INTRODUCTION
Medical school programme for undergraduate is divided into two phases: pre-clinical and clinical. The clinical phase is when they will visit the clinics, wards and even patients’ home in order to get contact with the patients. The study techniques, ward rounds, tutorial, lectures and seminars are are very demanding that can lead to psychological distress among the students (Zaid et al. 2007). Psychological distress is to define as emotional instability which includes studentstress, anxiety and depression (Drapeau et al. 2012).
Anxious students may have palpitation, difficulty in breathing, numbness and gastrointestinal symptoms which can affect their attention and study (Desrosiers & Miller 2007). More than half of our university students (non-medical and also medical) were found to suffer from anxiety while studying the undergraduate course (Shamsuddin et al. 2013; Yusoff et al. 2013). Students become anxious especially when they are worried about failing an exam. Students who are anxious may easily become distressed with their anxiety symptoms.
Stress is very common among medical students. It is described as a fearful anticipation accompanied by sweating and increased heart beating (Benjamin & Virginia 2005). Shah et al. (2010) stated that the stressors are parental expectations, frequent examinations, the enormous academic curriculum, worry about their future and academic performance. Females are found to be more stressed than males. It is possibly due to their personalities and different coping mechanism. An earlier study established that most students perceived examination as the main stressor (Shah et al. 2010). The academic stressors may lead to psychological stress and subsequently depression if they do not have good stress management.
Depression is a psychopathological mood occured for more than two weeks disturbing the student’s work and social function (Benjamin & Virginia 2005). About 15% of medical students was found to be depressed.Since feeling depressed was associated with increased risk of suicide, it is not surprised that one fifth of them had suicidal ideation (Fan et al. 2012; Tija et al. 2005).
Medical course is well known with its stressful pursuit that often causes a negative impacts on physical and mental health of the students. Students might not be able to face all the stressors in their medical life; hence, they should seek help from the right sources. The sources of help can be divided into formal (counsellors, lecturers, health professionals, social workers, religious personnel or youth programmes) and informal (friends, family members and peer groups) (Tuisku et al. 2006).
Hence, the present study was performed to identify psychological disorders among our medical students who were in their clinical years. Their help seeking behavior was also explored.
MATERIALS AND METHODS
This was a cross-sectional study conducted in UKM Medical Centre, Malaysia. Participants in this study were in their third to fifth year of medical school. By using proportional sampling method, students from each academic year were selected randomly. The students were approached individually (before or after the formal teaching, or in their dormitories). The students were briefed about the study and they were provided with a set of self-administered questionnaire and a consent form.This questionnaire consisted socio-demographic items, BM DASS-21 and questions on help-seeking behaviour.
The validated BM DASS-21 comprised of 21 questions that gauge the severity level of depression, anxiety and stress. However, it is not a diagnostic tool. The internal consistencies for each domains of BM DASS-21 were very good: depression (0.84), anxiety (0.74) and stress (0.79) (Ramli et al. 2007).
The questions on help-seeking behaviour assessed the use of medical facilities and other help-seeking sources. It was adapted from previous study by Aida et al. (2010). Face validity was done to improve its clarity and comprehensibility.
The collected data was analyse dusing the Statistical Package for Social Sciences version 18.0 (SPSS 18.0). Descriptive analysis in frequency and percentage were used to present the data of socio-demographic and BM DASS-21. Pearson’s Chi-Square with Yates Correction was used to analyse the association between the students’ psychological disorders and their help-seeking behavior. The statistical significance was established when p value of <0.05.
Ethical approval from the Research Committee of Universiti Kebangsaan Malaysia was obtained prior to the study. Written consent was also obtained from the students prior to their participation.
RESULTS
There were 458 medical students approached but only 380 students agreed to participate in this study (82.9% response rate). There were 221 females (58.2%) and 159 males (41.8%) with their age ranged between 20 and 25 years old (SD 1.049). Majority of the students were Malays (243; 63.2%), followed by Chinese (132; 34.7%), Indian (5;1.3%) and others (3; 0.8%). The respondents were third year (147; 38.7%), fourth year (118; 31.1%) and fifth year (115;30.3%) medical students. Majority of them had good Cumulative Grade Point Average (313; 82.4%). More than half of the respondents stayed in dormitories (311; 81.8%) and were active in co-curriculum activities (190;50%). Majority of the students stated that they had good relationship with their parents (374; 98.4%) (Table 1).
It was found that only minority of the students had depression (1.3%), anxiety (2.4%) and stress (2.4%) (Table 2). Majority of them preferred to seek help from friends (283; 74.5%) followed by parents (275; 72.4%) and siblings (203; 53.4%) (Table 2). Among formal sources of help, religious personnel (71; 18.7%), psychiatrists (64; 16.8%) counselors (45; 11.8%) were the top three preferred sources by the students (Table 3).
When we analysed the associations between students psychological disorders (depression, anxiety and stress) and their help seeking behaviour (Table 4 and 5), we found that there was a significant association between the presence of anxiety and help-seeking behaviour from the formal sources: counsellor (p=0.001) and religious personnel (p=0.03) (Table 5). However, there was no significant associations between the other psychological disorders (depression and stress) and other sources of help (Table 4 and 5).
DISCUSSION
This cross-sectional study had a good response rate, particularly among the third year medical students. Moderate response rate from the fourth and fifth year students might be due to their heavier clinical work as compared to the third year students. This is similar to a study by Abdul Ghani (2008). Most of the respondents in this study were Malay (63.2%), followed by Chinese (34.7%) and Indian (1.3%). This trend is similar to that of the national ethnicity trend in which Malays is the biggest ethnic, followed by Chinese and Indian.
An interesting finding in this study was a low prevalence of psychological disorders among the UKM medical students (depression: 1.3%, anxiety: 2.4% and stress: 2.4%). The prevalence was lower compared to a previous study done in Northern Europe where 14% of their medical students were depressed and 43% of them were anxious (Bunevicius et al. 2008). This could be due to post-exam sampling of the students in our study. The UKM medical students could also have good strategies to cope with their emotional problems. Another possible reason is implementation of mentoring programme during the clinical years. This programme involves assigning four to five students to one lecturer who acts as a mentor. They have scheduled meetings to discuss about their academic performance and any psychosocial issues with their mentors.
There are two types of help seeking behaviour, formal and informal (Tuisku et al. 2006). In this study, medical students preferred informal sources of help such as friends (74.5%), parents (72.4%) and siblings (53.4%) compared to formal sources of help. This finding was similar to another local study that involved adolescents from a secondary school (Aida et al. 2010). This could be due to their good relationships with their friends (98.7%), parents (98.4%) and siblings (98.7%). Other studies also reported that many medical students shared their problems with their friends as their coping mechanism (Sherina et al. 2003; Zaid et al. 2007).
Staying together with friends, sharing similar academic stressors and having good friendships could explain their preference to seek each others’ help to deal with any problems including emotional disturbances. In addition, parents are found to be an important source of support particularly when their emotional distress arises from financial problems (Sherina et al. 2003).
Very few of them trusted people they met in the internet chat rooms to share their problems. However, Gould et al. (2002) reported a higher proportion of adolescents sought support from people in the internet. The low use of internet chat rooms as a source of help in our study could be because they were well connected with their friends through social media such as Facebook, WhatsApp and Twitters. The medical students should also be informed about the reliable websites, for instance Café@Teen by Natural Population and Family Development Board Malaysia that provide help in managing their emotional problems (LPPKN 2008).
With regard to the formal sources of help, majority of the students did not seek support from the psychiatrists, counsellors, religious personnel and other healthcare providers. They might be afraid that these healthcare providers could have negative perception towards them. Since there is a possibility that they will be working with these healthcare providers, the negative perceptions could jeopardise their future relationships with them. In addition, they also might have doubt that their confidentiality would be breached. Furthermore, meetings the healthcare providers for help could cause them to miss their classes, lectures and clinical teaching sessions. Thus, their performance might be affected and could make them more distress.
Interestingly, there was a significant association between the presence of anxiety and help seeking behaviour from the formal sources. Significantly more students who had anxiety sought help from the counsellors and religious personnel compared to those who were not anxious. These results were similar to an earlier study done by Eisenberg et al. (2007). There was no significant association between emotional distress and help that these students sought from informal sources. Rosenthal and Okie (2005) found that many students perceived stress in medical school was common. Hence, there was no need for them to seek help from others.
Limitations of the study were related to the cross-sectional design and the timing of data collection which was done following an examination. Students might have less emotional distress during this period. Therefore, we recommend future studies to be performed prospectively.
CONCLUSION
Prevalence of psychological disorders among UKM medical students was low. Significantly more students who were anxious sought formal help from counsellors and religious personnel. Good relationships with friends and parents were essential for their psychological well beings. Eventhough the prevalence was low, the students’ awareness on these disorders cannot be determined. An effective screening programme is still needed to recognise students with possible psychological disorders.
ACKNOWLEDGEMENTS
I would like to thank Universiti Kebangsaan Malaysia for funding this research. I would also like to express gratitude to Professor Dr Ramli Musa for sharing the validated BM DASS 21.