|Year : 2021 | Volume
| Issue : 3 | Page : 80-84
Study of depressive, anxiety, and stress symptoms and their associated risk factors among undergraduate nursing students in central India: A cross-sectional study
Priyanka Verma1, Mamta Verma2, Brajesh Lahri3, Abhijit Pakhare4, Sebi Das2
1 College of Nursing, AIIMS Bhopal, Madhya Pradesh; MPH Student, IIPH-Delhi, India
2 College of Nursing, AIIMS Bhopal, Madhya Pradesh, India
3 Dr. R. P. Centre for Ophthalmic Sciences, AIIMS, New Delhi, India
4 Department of Community and Family Medicine, AIIMS, Bhopal, Madhya Pradesh, India
|Date of Submission||23-May-2021|
|Date of Decision||20-Jun-2021|
|Date of Acceptance||23-Jun-2021|
|Date of Web Publication||29-Sep-2021|
Dr. Brajesh Lahri
100/1A, Surya Apartment, Gautam Nagar, New Delhi - 110 049
Source of Support: None, Conflict of Interest: None
Background: Assessment of mental health of undergraduate Indian nursing students using Depression, Anxiety, and Stress Scale-21 (DASS-21) and determination of associated potential risk factors. Aims: The aim of the study was to find the prevalence of depressive, anxiety, and stress symptoms among undergraduate nursing students, in a tertiary care teaching hospital in Central India. The study also aimed to find out potential risk factors associated with depressive, anxiety, and stress symptoms in the study population. Methodology: The study was an analytical, cross-sectional, questionnaire-based study done on undergraduate nursing students at a tertiary care teaching hospital in Central India. Data about depressive, anxiety, and stress symptoms was collected by administering the DASS-21 questionnaire, to the participating individuals in English language. Prevalence of depressive, anxiety, and stress symptoms was done described in percentages. Binomial logistic regression analysis was done to find out factors associated with moderate-to-severe grade of symptoms. Results: Our study shows the prevalence of moderate to very severe depressive symptoms to be 34.1%. Similarly, prevalence of moderate to very severe anxiety and stress symptoms was found to be 61.9% and 17.7%, respectively. On doing binomial logistic regression analysis, family relationship was found to be significantly associated with depressive (P = 0.00, odds ratio [OR] 0.638 [95% confidence interval (CI) 0.877–0.464]) and stress (P = 0.002, OR 0.582 [95% CI 0.822–0.412]) symptoms. Similarly, adequate friend support was found to be significantly associated with anxiety (P = 0.04, OR 0.785 [95% CI 0.923–0.602]) and stress symptoms (P = 0.007, OR 0.645 [95% CI 0.885–0.469]). Conclusion: Our study concludes that the prevalence of depression, anxiety, and stress symptoms among nursing students is alarmingly high. In our study, lack of healthy family relations and lack of friend support were found to be two main risk factors associated with depression, anxiety, and stress. There is a need to acknowledge the mental health issues of nursing students and to devise strategies to tackle them efficiently.
Keywords: DASS-21, depression, India, nursing students, nursing
|How to cite this article:|
Verma P, Verma M, Lahri B, Pakhare A, Das S. Study of depressive, anxiety, and stress symptoms and their associated risk factors among undergraduate nursing students in central India: A cross-sectional study. J Prim Care Spec 2021;2:80-4
|How to cite this URL:|
Verma P, Verma M, Lahri B, Pakhare A, Das S. Study of depressive, anxiety, and stress symptoms and their associated risk factors among undergraduate nursing students in central India: A cross-sectional study. J Prim Care Spec [serial online] 2021 [cited 2022 Jan 21];2:80-4. Available from: http://www.jpcs.com/text.asp?2021/2/3/80/327054
| Introduction|| |
Depression is considered to be the leading psychiatric disorder among university students and is a major risk factor for students attempting suicide., Its consequences include academic, social derailment, and most seriously, attempted and completed suicide. Depression is characterized by sadness, loss of interest or pleasure, feelings of guilt or low self-esteem, disturbed sleep or appetite, fatigue, and poor concentration. Depression is a common mental disorder that lowers the quality of life among adult individuals. These problems lead to poor psychological well-being that interfere with learning and limit the academic performance of students and lower their productivity.,,, Depression, Anxiety, and Stress Scale-21 (DASS-21) has been commonly used to assess the relationship and effect of depression, anxiety, and stress among various populations, age groups, clinical, and nonclinical respondents and for differentiation between anxiety and depression. Several studies support its validity, feasibility, and its capacity to detect changes of depressive symptoms over time.,, Furthermore, anxiety and stress form a major part of common mental disorders and are an important cause of long-term mental health morbidity.. Nursing is one of the most stressful professions in the world. Nursing students are a valuable human resource because they play a main role in providing patient care. Nursing students face stressful events in their study period that lead to negative consequences in their academic, professional, and personal life. There are various stress factors such as staying away from home, pressure in academics, vigorous professional training, socioeconomic background, friend support, and relations with family members, which affect their mental health. Such psychological distress among them leads to less productivity, reduced quality of life, and learning difficulties and may negatively affect patient care. At global level, there are multiple studies related to stress, anxiety, and depressive symptoms among nursing students, but studies from India on the epidemiology of psychiatric disorders among nursing students are limited. These studies show that stress, anxiety, and depression symptoms are highly prevalent among nursing students.,, As far as Central India is concerned, there is a lack of studies concerned with depression and anxiety disorders among nursing and medical students. Hence, this study was carried out to assess the prevalence and associated risk factors of depression and anxiety disorders among nursing students at a tertiary care teaching hospital of central India.
- To determine the prevalence of depression, anxiety, and stress among nursing students of a tertiary care teaching hospital of Central India
- To find out the association of various factors associated with depression, anxiety, and stress among nursing students of a tertiary care teaching hospital of Central India.
| Methodology|| |
The study design used in this study was cross-sectional study.
A study was done at Nursing College of a tertiary care teaching hospital of Central India.
BSc nursing students of a tertiary care teaching hospital of Central India, i.e., AIIMS Bhopal.
In this study, a DASS-21 questionnaire was administered to 180 BSc nursing students. Out of these, 176 participants submitted completely filled questionnaires and four questionnaires received were incomplete and so, were excluded from the analysis. The response rate for the study was 97.77% (176/180).
Mode of selection
One hundred and eighty nursing (BSc nursing) students studying at a tertiary care teaching hospital of Central India, i.e., AIIMS Bhopal.
- Individuals who deny participation in the study
- Individuals who do not fill the administered questionnaire or submit an incompletely filled questionnaire.
Data collection procedure
Written informed consent was taken from all the participants and then data about depression and anxiety disorders was collected by administering the DASS-21 questionnaire, a 21-item self-reported questionnaire, to the participating individuals in English language.
Depression, Anxiety, and Stress Scale-21 questionnaire
Originally DASS consisted of 42 items, and later this 42-item DASS of Lovibond was modified into a shorter 21-item version. Previously published studies have confirmed its reliability and validity worldwide, all showing the DASS-21 is a well-established instrument to measure symptoms of depression, anxiety, and stress in both clinical and nonclinical samples of adults.,
Plan of analysis
Data was analyzed using IBM SPSS Statistics software (Ref: IBM Corp. Released 2017. IBM SPSS Statistics for Windows, version 25.0. IBM Corp., Armonk, NY, USA). Categorical variables were summarized using frequency and percentage. Numerical variables were summarized with mean and standard deviation or median and interquartile range. DASS-21 scoring was done as per standard guidelines and scores on depression, anxiety, and stress components were further categorized into severity as per suggested cutoffs. On the basis of DASS-21 score, two categories were made, i.e., symptoms present or absent. It was done by putting normal to mild severity scores in one and moderate to very severe in the other category. Binomial regression analysis was done to identify determinants of severity of anxiety, depression, and stress symptoms.
- Study was done after getting a letter of permission from the Institutional Human Ethics Committee. Reference No. AIIMS Bhopal/IHEC-LOP/2017/STS0131
- All the individuals participating in the study were well informed about the nature, need, and implications of the study. Written informed consent form (provided in English) was filled by each participating individual.
Confidentiality of the informants/participating volunteers was maintained. No personal data were disclosed during the study, and any personal detail will not be taken into consideration during data analysis.
| Results|| |
A total number of questionnaires administered in our study were 180 and the final number of participants after excluding incompletely filled questionnaires was 176. Thus, the response rate in our study was 97.77%.
The mean age of participants in our study was 20.62 years with a standard deviation of ±1.46 years. All the participants were females (n = 176) [Table-1].
Out of total 176 participants, 122 (69.32%) were Hindus, 5 (2.84%) were Muslim, 5 (2.84%) were Sikhs, 40 (22.73%) were Christians, and 4 (2.27%) students belonged to other religions such as Buddhism and Jainism (n = 176) [Table-1].
Out of total 176 participants, 57 (32.40%) were from general category, 60 (34.1%) belonged to other backward classes, 38 (21.6%) from scheduled castes, and 21 (11.9%) belonged to scheduled tribe category (n = 176) [Table-1].
We used a DASS-21 questionnaire for collecting data about participant's depressive, anxiety, and stress symptoms. In all the three categories, the maximum possible score is 42. Out of 42, based on score, patients are classified into various categories such as normal, mild, moderate, severe, and extremely severe.
On analyzing data about depressive symptoms, 53.4% (n = 94) participants were normal. The prevalence of mild depression was 12.5% (n = 22), of moderate depression was 23.9% (n = 42), of severe depression was 6.8% (n = 12), and participants under extremely severe category were 3.4% (n = 6) [Table-2].
|Table 2: Prevalence of depressive, anxiety and stress symptoms based on Depression, Anxiety, and Stress Scale 21 scores|
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On analyzing data about anxiety symptoms, 27.8% (n = 49) of participants were normal. The prevalence of mild anxiety was 10.2% (n = 18), of moderate anxiety was 27.8% (n = 49), of severe anxiety was 14.8% (n = 26), and participants under extremely severe anxiety symptoms category were 19.3% (n = 34) [Table-2].
On analyzing data about stress symptoms, 65.3% (n = 115) of participants were normal. The prevalence of mild stress was 17.0% (n = 30), of moderate stress was 9.1% (n = 16), of severe stress was 6.3% (n = 11), and participants under extremely severe stress symptoms category were 2.3% (n = 04) [Table-2].
We also looked for association between various sociodemographic factors under study and severity of depressive, anxiety, and stress symptoms, using binomial regression after categorizing the subjects based on their score in normal, mild, in one category, as no symptoms and moderate, severe, and extremely severe categories into other category with presence of symptoms.
On doing binomial logistic regression analysis for depressive symptoms, statistically significant correlation was seen between severity of depressive symptoms and family relations. Odds ratio (OR) of 0.78 in this significant variable indicates a decrease in chances of getting moderate-to-severe symptoms of depression; with higher score on family relations variable, i.e., better intrafamily relationship [Table-3].
|Table 3: Factors associated with self-reported mental health assessment on Depression, Anxiety, and Stress Scale 21, according to the binomial logistic regression analysis|
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On doing binomial logistic regression analysis for anxiety symptoms, statistically significant correlation was seen between severity of anxiety symptoms and friend support; rest all factors were found statistically nonsignificant. On doing binomial logistic regression, OR of 0.78 in this significant variable, i.e., friend support indicates 0.78 times reduced chances of getting moderate-to-severe anxiety symptoms with better friend support [Table-3].
On doing binomial logistic regression analysis for stress symptoms, statistically significant correlation was seen between the presence of stress symptoms and family relations and friend support; rest of all factors were found statistically nonsignificant. On doing binomial logistic regression, OR of 0.58 and 0.64 was found for family relationship and friend support, respectively. It indicates a 0.58 and 0.64 times decreased chances of getting moderate-to-severe stress symptoms, with better family relations and friend support, respectively [Table-3].
| Discussion|| |
Our study reveals the prevalence of moderate-to-severe depressive symptoms to be 34.1% in undergraduate nursing students, which corroborates with the findings of previous studies. If we include students suffering from mild depression too, then the prevalence rises to 46.6%. In a study conducted by Basu et al., among undergraduate nursing students in Kolkata, prevalence of depressive symptoms as 33.33% was seen. Similarly, a study by Manpreet and Maheshwari among postgraduate nursing students have revealed prevalence of depression as 38%. A cross-sectional study by Kishore et al. among nurses working in a tertiary care hospital in South India has showed the prevalence of anxiety as 63.3%, of depression 56.05%, and of stress symptoms as 36.17% in participants. Similarly Kadappuran had conducted a study to assess the burden of depressive, anxiety, and stress symptoms in nursing students in Kerala and reported moderate level of depression in 53.6%, anxiety in 37.9%, and stress in 46.4% participants, respectively. A meta-analysis by Tung et al. has shown the prevalence of depression as 34.0% among nursing students, which corroborates with the findings of our study. They have also found a significant difference in the prevalence of depression with age of students, higher prevalence in younger students. Our study also shows the prevalence of moderate-to-very severe anxiety symptoms to be 61.9% and including students reporting mild anxiety symptoms too, prevalence rises to a surprising 72.1%. The prevalence of anxiety symptoms in nursing students in our study is higher as compared to previous studies by Basu et al. and Manpreet and Maheshwari, which have shown a prevalence of anxiety symptoms as 56.59% and 55%, respectively. The prevalence of stress symptoms in our study was found to be 34.7%. The students having moderate to extremely severe stress symptoms were found to be 17.7%. Cheung et al. have shown the prevalence of moderate to extremely severe depressive, anxiety, and stress symptoms among undergraduate nursing students to be 24.3%, 39.9%, and 20.0%, respectively. These findings are similar to our study in terms of prevalence of depressive, anxiety, and stress symptoms and also reinforce the finding of more prevalence of anxiety symptoms as compared to depression and stress. A study by Risal et al. among undergraduate nursing students in Nepal has shown a prevalence of depression as 38%, which is similar to our study. A meta-analysis and systematic review by Pacheco et al. have shown the prevalence of depression, anxiety, and stress as 30.6%, 32.9%, and 49.9%, respectively, among medical students in Brazil.
We also conducted a binomial logistic regression analysis, after dividing the students based on the DASS score into two categories, namely Category 1 consisted of normal to mild symptoms, and the second category included moderate, severe, and extremely severe groups. Assessment of association between risk factors such as friend support, family relationship, pressure in academics, study satisfaction, and self-perceived adequacy of study resources available to the student with severity of depressive, anxiety, and stress symptoms was done. In doing binomial logistic regression analysis, in our study, we found good interpersonal relations in the family to be the single most important factor associated with depression and stress. Adequate friend support was another factor which was found significantly associated with anxiety and stress. Both the factors have OR <1, indicating a higher score on Likert scale,,,,,, is associated with a lower DASS score, indicating more less chances of getting severe depressive, anxiety, and stress symptoms, in the presence of good family relations and friend support. Pössel et al. have shown that adolescents facing depressive and stress symptoms who have better family relations and support are more likely to show improvement in their symptoms as compared to their peers who have poor family support. A study by Nasser and Overholser has also shown that patients suffering from major depression who have better family relationships and friend support show better and fast recovery, as compared to patients who reported poor family and friend support. Other risk factors under the study showed no statistically significant association on regression analysis. Due to increasing burden and increasing awareness about mental health disorders, number of these patients presenting to primary care specialists is also bound to increase. Patients with coexisting mental health disorders can present with somatic symptoms such as headache or chest discomfort, or other nonspecific symptoms. The association of these symptoms with underlying depressive, anxiety, or stress symptoms may be overlooked by Primary Care Specialists because of less suspicion about mental health disorders and sometimes because of time constraints. Despite these difficulties, primary care providers can play an important role in the early diagnosis and management of patients suffering from mental health disorders.
Our study results show the high prevalence of depressive, anxiety, and stress symptoms among nursing students in Central India. It also recognizes association with underestimated potential modifiable risk factors, i.e., family support and friend support. Multiple studies around the world have shown similar results, indicating a need to improvise the nursing education curriculum, and also calls for a policy level decision to give due attention to the mental health of budding health-care professionals, especially nursing students.
Limitations of our study include a relatively small sample size and inclusion of nursing students from only a single tertiary care teaching hospital. There is a need for more number of studies, involving a larger sample size and nursing students from multiple institutions to give a better understanding and data about this important issue of mental health of nursing students.
| Conclusion|| |
Our study concludes that the prevalence of depression, anxiety, and stress symptoms among nursing students is alarmingly high. In our study, lack of healthy family relations and lack of friend support were found to be two main risk factors associated with depression, anxiety, and stress. Nursing students being the important pillars of the future of our country's health care, major steps need to be taken at both teaching institutes and policy level to safeguard and improve their mental health.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]