ASSRJ-7044.pdf

Page 1 of 11

360

Advances in Social Sciences Research Journal – Vol.7, No.8

Publication Date: August 25, 2020

DOI:10.14738/assrj.77.7044.

Muriungi, S. K., & Menecha, J. B. (2020). Comorbidity Of Depression And Anxiety Among Students At The Kenya Medical Training

Colleges In Kenya. Advances in Social Sciences Research Journal, 7(8) 360-370.

Comorbidity Of Depression And Anxiety Among Students At The

Kenya Medical Training Colleges In Kenya

Susan K. Muriungi

Daystar University

Jared B. Menecha

Daystar University

ABSTRACT

Objectives: To determine comorbidity of depression and anxiety among

students at the Kenya Medical Training College, Kenya. Methodology:

This was a cross-sectional descriptive study design. Study participants

were basic diploma students in a middle level college in Kenya. Data was

collected using a researcher designed self-administered questionnaire

for socio-demographic characteristics, the Beck Depression Inventory

(BDI) for severity of depression and the Beck Anxiety Inventory (BAI)

for the severity of anxiety in all the students in the seven largest KMTC

campuses. All the participants gave informed consent. Results: 18.4%

and 20.2% of group A and B respectively had moderate depression while

48.5% and 45.8% respectively had severe depression. The equivalents

for anxiety in groups A and B were 24.4% and 23.6% for moderate

anxiety and 32.1% and 31.5% for severe anxiety. There was a higher

rate of depression and anxiety in the second year; with a statistically

significant association between depression and anxiety and the year of

study in the two groups (p<0.0001 each respectively). All the other

social demographic characteristics had no statistically significant

association with depression or anxiety in the two groups. There was a

higher prevalence of depression and anxiety co-morbidity in both

groups which was statistically significant (p<0.0001). Conclusion:

Depression and anxiety were highly prevalent and significantly co- existent among the KMTC students. These mental conditions seemed to

vary with the level of study training among college students. Therefore,

the psychological well-being of college students need to be carefully

addressed. There is need to closely monitor anxiety and depression to

eliminate the risk factors and consequently prevent the development of

adverse outcomes.

Keywords: KMTC, Beck’s Anxiety Inventory, Beck’s Depression Inventory

INTRODUCTION

Depression and anxiety disorders, either alone or co morbid, are found among the general

population (1, 2, 3). They contribute significantly to the aggregate point prevalence of about 10% of

neuropsychiatric disorders among adults (4, 5, 15).

Page 2 of 11

Muriungi, S. K., & Menecha, J. B. (2020). Comorbidity Of Depression And Anxiety Among Students At The Kenya Medical Training Colleges In Kenya. Advances

in Social Sciences Research Journal, 7(8) 360-370.

URL: http://dx.doi.org/10.14738/assrj.78.7044 361

Depression and anxiety are debilitating. When left unmanaged, they affect one’s general functioning

making it hard for them to perform everyday tasks completely, competently and efficiently (6, 7).

This ultimately affects their general well-being, productivity and quality of life in relation to

themselves and others (8). The average age of onset for many mental health conditions is the typical

college age of 18-24 years.

This is contributed to by the many first encounters in life. Common stressors include: adjustment

to college environment, educational debt, heavy workload, sleep deprivation, difficult patients, poor

learning environments, financial concerns, information overload and career planning, new

friendships, distance from parents, new cultures and alternative ways of thinking (9,10,11,12].

These stressors can lead to catastrophic consequences such as anxiety, depression, impaired

academic performance, impaired competency, medical errors and attrition from medical schools (9,

10, 12, 13). Existence of depression and anxiety among students undertaking health training at

different cadres not only affects the individual’s life negatively but may also have repercussions for

patient care in the long run (14, 15). The medical professionals may become reluctant to be screened

and treated for depression, anxiety or other common mental disorders due to fear of being revealed

that they have the condition(s) and become stigmatised (16, 17,18).

Studies have documented that at the start of medical school, medical students have mental health

similar to their nonmedical peers [16], however, students’ mental health worsens during the

medical training.[14,16,19]

In a study involving 1st and 2nd year medical students in a Californian University to investigate the

use of mental health services and its barriers, Givens et al. (20) found out that about one fourth of

the respondents were depressed. He noted that there was a negative attitude towards mental illness

among the respondents and therefore their unwillingness to openly seek help. He further noted that

medical students encounter severely sick patients many of whom may end up dying. He further

noted that the challenge of dealing with severe illness and death can challenge them emotionally

and may evoke unresolved episodes of loss or trauma from their past and cause them anxiety or

depression.

Givens et al. (20) also found that the students had poor coping strategies in the face of high stress

levels inherent in a student’s life due to inadequate sleep hours, reduced social life, fatigue and

academic challenges involved. As these students encounter serious illness and deaths within their

practical learning sessions, their emotional balance may be put to task and unmask their

vulnerability to either anxiety or depression.

In a cross sectional study to assess prevalence of depression and anxiety among paramedical 1st, 2nd

and 3rd year students of medicine in a Saudi Arabia a significant difference between males and

females was found with 66.6% of the females and 44.4% of the males found to be depressed. Similar

studies found co-existence of depression and anxiety among college students but with no

statistically significant differences between males and females (21).

In a Swedish study (22) to assess the exposure to different stressors and the prevalence of

depression among medical students at different levels of education, the Higher Education Stress

Page 3 of 11

362

Advances in Social Sciences Research Journal (ASSRJ) Vol.7, Issue 8, August-2020

Inventory (HESI), and the Major Depression Inventory (MDI) were used. This study found out that

the prevalence of depressive symptoms among the students was 12.9%, significantly higher than in

the general population, and was 16.1% among female students versus 8.1% among males. Another

study from Turkey used the General Health Questionnaire (GHQ-12) and found out that 47.9% of

the second-year medical students experienced emotional disorders, compared to economics

(29.2%) and physical education students (29.2%). [23] A study from Malaysia also reported that

41.9% of medical students experienced emotional disturbances. [24].

In an earlier study to determine the association and implications of anxiety and depression in

university medical and paramedical students in Kenya, Ndetei et al (25) found 43% of the student

nurses felt they needed to seek help for their symptoms, 14.3% had sought help and there was a

significant correlation between individual symptoms of anxiety and depression in over 50% of all

the pairs of individual symptoms. Out of 364 respondents, 48.9% required medical attention for

their depression and anxiety symptoms. This was the only study found on prevalence of depression

and anxiety among college students in Kenya.

However, there is paucity of information in the literature documenting the prevalence of anxiety

and depression among college students in Kenya. Hence, the aim of this cross-sectional study was

to determine prevalence of depression and anxiety among 1st and 2nd year basic Diploma students

at the Kenya Medical Training Colleges. It was hoped that the study could contribute to the existing

literature on the topic and provide information for possible future interventions.

METHODOLOGY

The study participants were drawn from seven of Kenya Medical Training Colleges. These were: The

Nairobi, Nakuru, Port Reize, Mombasa, Kisumu, Muranga and Meru campuses.

All participants were recruited from seven of the KMTC colleges spread out across the country.

Students involved in the study were pursing any of the courses offered at basic diploma level:

Nursing, Medical Records and information sciences, Community Oral Health, Laboratory sciences,

Public Health Sciences, Medical Imaging sciences, Neurophysiology, Clinical medicine, Dental

technology, Occupational Therapy, Optometry, Orthopaedics Technology, Physiotherapy, pharmacy

and Medical engineering Sciences.

All the students from the colleges who gave informed consent were recruited into the study.

Inclusion criteria was all the 1st and 2nd year basic diploma students in all the academic departments

in the selected KMTCs who gave informed consent while the exclusion criteria was any student in

all the academic departments who was undertaking a post basic course or any 1st or 2nd year student

who had not given consent.

Students were asked to complete self-rated instruments measuring severity of depression and

anxiety as well as a researcher designed questionnaire for socio-demographic characteristics.

Data Collection Instruments

The research instruments consisted of three self-administered questionnaires:

Page 4 of 11

Muriungi, S. K., & Menecha, J. B. (2020). Comorbidity Of Depression And Anxiety Among Students At The Kenya Medical Training Colleges In Kenya. Advances

in Social Sciences Research Journal, 7(8) 360-370.

URL: http://dx.doi.org/10.14738/assrj.78.7044 363

1. A researcher designed questionnaire for Socio-Demographic Characteristics: gender, age,

year of study, marital status, place of residence while in session, religion and the KMTC

campus;

2. The Beck’s Depression Inventory (BDI). This 21 items self-report inventory measures the

severity of depression in a general population in relation to the specified scores. It is a widely

used instrument, discriminates severities of depression, differentiates depression from non- depressed patients and it has a high coefficient alpha of 0.93 (p=0.001) for college students

as well as exhibiting validity and reliability of 90% (25). The cut off points for the BDI used

in this study were 0-9 minimal depression, 10-18 mild depression, 19-29 moderate

depression, 30-63 severe depression.

3. The Beck’s Anxiety Inventory (BAI). This 21 questions instrument was designed to measures

the severity of anxiety in a general population. It has proved to show high interval

consistency and test retest reliability over 1 week (26). In the general population,

respondents who score above 36 scores are considered to have anxiety. The cut off points

for BAI used for this study were 0-7 minimal anxiety, 8-15 mild anxiety, 16-25 for moderate

anxiety, and 26-63 severe anxiety.

The BDI and BAI have been validated against DSM-IV respective diagnostic criteria in the western

countries where they have been used extensively for similar and other relevant surveys as they

were used in this study (26, 27). All the three instruments were self-administered and took an

average of one hour to complete.

Ethical Consideration and data collection procedure

Ethical approval to conduct this study was obtained from Kenyatta National Hospital/University of

Nairobi ethical and research committee. Authority from the Director of KMTC to carry out research

in the selected KMTC campuses was officially communicated to the administrative heads of the

seven selected. All the study participants gave informed consent and confidentiality was maintained

throughout the study. The respondents were all given information on resources available for help.

Data was collected in self-administered questionnaire without any personal identification.

Data management

The collected data was analysed using SPSS version 16, utilizing descriptive and inferential

statistics. Results were presented in the form of tables and narratives. Statistical significance was

set at p < 0.05.

RESULTS

Description of the study population - background characteristics.

The table 1 below gives the socio-demographic characteristic of the 3107 students who consented

to participate in the study.

Page 5 of 11

364

Advances in Social Sciences Research Journal (ASSRJ) Vol.7, Issue 8, August-2020

Table 1. Socio-demographic characteristics of the study participants

Categories, n=3107 %

Gender

Male 53.4%

Female 46.6%

Age groups

<25 years 91.0%

> 25 years 9.0%

Year of study

1st year 57.0%

2nd year 43.0%

Place of Residence

Within college hostels 81.8%

Outside college hostels 18.2%

Marital Status

Single 94.6%

Married 4.9%

Separated, divorced, widowed and others 0.5%

Religion

Protestant 63.1%

Catholic 28.2%

Muslim 4.3%

Others 4.4%

Table 2 summarizes of the prevalence of depression and anxiety among respondents in the 2

groups. There was no significant association between the 2 groups and depression or anxiety in the

baseline evaluation study (p>0.05 respectively).

Table 2: Prevalence of Depression and Anxiety between the groups

Categories N=3107 Percentage (100%)

Depression

Minimal 646 20.8%

Mild 401 12.9%

Moderate 606 19.5%

Severe 1454 46.8%

3107 100%

Anxiety

Minimal 705 22.7%

Mild 673 21.7%

Moderate 743 23.9%

Severe 986 31.7%

3107 100%

Page 6 of 11

Muriungi, S. K., & Menecha, J. B. (2020). Comorbidity Of Depression And Anxiety Among Students At The Kenya Medical Training Colleges In Kenya. Advances

in Social Sciences Research Journal, 7(8) 360-370.

URL: http://dx.doi.org/10.14738/assrj.78.7044 365

Correlation between the social demographic data with depression and anxiety

Table 3 summarizes the associations between social demographic characteristics and depression

or anxiety in the two groups. There was higher prevalence of depression in the second years

compared to the first years. There was a significant association between level of study and the

prevalence of depression in group A and B, p<0.0001 and p<0.0001 respectively.

Table 3. Correlation between depression and anxiety with year of study

Outcomes Categories 1st year

N=1796

2nd year

n=1311

Depression

Minimal 25.3% 14.5%

Mild 14.9% 10.4%

Moderate 18.1% 20.8%

Severe 41.8% 54.3%

x2=37.352 df=3 p<0.0001

Anxiety

Minimal 27.4% 16.2%

Mild 23.8% 18.8%

Moderate 22.2% 26.0%

Severe 26.6% 39.0%

x2=31.345 df=3 p<0.0001

The social demographic characteristics that had no statistically significant association with

depression or anxiety and group A and B were; gender p=0.387 and p=0.071, age bracket p=0.073

and p=0.471, residence p=0.602 and p=0.856, marital status =0.387 and p=0.071 and religion

p=0.203 and p=0.869.

Table 4 summarizes the co-morbidity of depression and anxiety between the two groups. The

severities were similar for both anxiety and depression between the two groups. There was a

significant association between co-morbidity of depression and anxiety in the two groups,

p<0.0001, each with a skew toward moderate and severe conditions.

Table 4: Co-morbidity between Depression and Anxiety

DISCUSSION

Population studies

The high response rate is attributable to the fact that the PI had done sensitization before the data

collection period to both the respondents and the administrators of the campuses. Similar studies

Anxiety

Depression

Minimal Mild Moderate Severe

n 739 712 760 896

Minimal 9.85% 5.25 3.25% 2.4%

Mild 3.75% 3.5 3.15% 2.5%

Moderate 3.7% 4.55 5.45% 5.75%

Severe 5.15% 8.5 11.7% 21.45%

X2=227.057 df=9 p<0.0001

Page 7 of 11

366

Advances in Social Sciences Research Journal (ASSRJ) Vol.7, Issue 8, August-2020

carried out in institutions of learning in Kenya found high return rates of up to 100% (28) while

that from a medical University in Karachi was 90% (29). Majority of the respondents were below

24 years and were single since they are admitted in college after their high school examinations and

the majority of those above 24 years and were married, separated, divorced or widowed were

possibly those who were upgrading having undertaken a certificate course and worked for more

than 3 years. More than half of the respondents were Protestants.

Prevalence of depression and anxiety

The reported higher prevalence of depression compared to anxiety in the present study probably

overstates the case for depression and understates for anxiety (29, 30). However, given the fact that

anxiety was independently accessed with BAI, it probably reflects true prevalence of anxiety,

although at the time of the study, the anxiety had possibly already evolved to depression. Anxiety

symptoms are possibly more likely to precede depressive symptoms than the reverse as stated by

Leadbeater, Thompson, & Gruppuso (31). Results on a study on prevalence of depression and

anxiety among medical college students in a Pakistan University found that 70% of the respondents

suffered anxiety and depression which is consistent with what was found in other similar studies

(32,33).

The researchers in these studies concluded that new life styles, financial challenges and psycho

stressors, academic challenges experienced by the respondents might have posed a challenge to

them and precipitated them to develop depression or anxiety. Similar studies explained that the

high levels of severe depression and anxiety found among student respondents could be explained

by the fact students have to deal with unique stressors such as new lifestyles and cultures, new

friends and exposure to alternative ways of thinking. This is because these encounters required

them to develop new strategies to cope with the new circumstances/situations as they progressed

in their professional training and adjust to the new lifestyles different from their socializations.

Those who could not cope were likely to struggle and become susceptible to anxiety and/or

depression (13, 33).

In a similar study to investigate prevalence of depression, anxiety and their associated factors

among medical students in Karachi, a high prevalence, 70%, of anxiety and depression was found

among the respondents. Results indicated that the precipitating causes were not exclusively

academic but included psycho-stressors like loss, relationship problems, residence and substance

abuse among others (29).

In a similar study among Kenyan children and adolescents using the Multidimensional Anxiety Scale

for Children (MASC), 12.9% were found to have clinical anxiety with 80% having social anxiety (28).

Correlation of depression and anxiety with year of study

More 2nd year than 1st year students were found to have severe depression. It was inferred that 2nd

year students had unique issues that were not experienced by their counterparts in their first year.

Since the 2nd year students were undertaking both practical attachments in the various hospitals in

addition to classroom work, exposure to very sick people and death in the hospitals may have

stressed them and precipitated them to develop anxiety or depression. They may also have had no

spare time to get social support of their experiences from their peers because of their busy

schedules in both the classroom and practical learning. In a study by Inam et al (21), it was found

Page 8 of 11

Muriungi, S. K., & Menecha, J. B. (2020). Comorbidity Of Depression And Anxiety Among Students At The Kenya Medical Training Colleges In Kenya. Advances

in Social Sciences Research Journal, 7(8) 360-370.

URL: http://dx.doi.org/10.14738/assrj.78.7044 367

out that 66% of the 1st years with depression and anxiety while 73% of the 2nd years had the same.

Other similar studies found similar results (30).

These findings were different from those found in similar studies where 1st year students were

found to have higher prevalence of depression than the 2nd or 3rd years. This was attributed to the

ability of the seniors to cope better with emerging social issues than the 1st years as well as by the

introduction of taking more responsibility for their learning and a shift from the traditional spoon

feeding teaching methodology (31). The drop of prevalence rate in 2nd year may support the above

hypothesis since by then the students get used to the system (13, 14, 16).

The study found out that there were more males with depression compared to females while

prevalence of anxiety was similar among males and females is probably because females are more

likely able to cope better with possible psycho stressors since they are by nature more expressive

of their challenges and therefore more likely to get social support (21, 23). There may have been

other factors that caused more males than females to develop depression that were less prevalent

among the females. For instance, males having more risk to substance abuse than the females, which

may have predisposed them to develop substance-induced depression or anxiety as found in other

studies (34, 35). Other studies however have found more females with depression and anxiety than

the males.

Bazmi (38) in a similar study found 66.6% of the females with depression and anxiety while 44.4%

males had the same and there was a statistically significant difference of p=0.001. This could have

been due to more females complaining about the volume and complexity of the academic material

they had to cover or females were likely to report stress or a tendency of females to over report

medical and psychological symptoms. Nonetheless, male bias towards female complaints cannot be

ruled out. However, in our study, since the questionnaire was self-administered and anonymous,

therefore, further workup could not be carried out to tease out the factors related to higher reported

levels of anxiety and depression in females.

The higher percentage of respondents above 25 years in this study who had severe depression

compared to the younger age groups and the similar trend observed on the correlation between

anxiety and age group is probably because; those above 25 years were in their 2nd year of study

which posed greater academic demands, financial challenges or social/family related challenges

since they may have been married, divorced or widowed which meant added responsibilities as

they studied. It was observed that respondents who were from the Nairobi campus might have had

additional challenges of the city life compared to respondents who were drawn from KMTCs in less

hectic rural towns. These results were different from those of other studies where the younger age

groups were found to have higher levels of depression and anxiety (28) while other studies found

Page 9 of 11

368

Advances in Social Sciences Research Journal (ASSRJ) Vol.7, Issue 8, August-2020

in-expensive towns. This study did not seek to investigate specific possible psycho stressors that

may have precipitated the respondents to develop these conditions.

Co-morbidity between depression and anxiety

The high co-morbidity of depression and anxiety found in this study is similar to findings in other

studies (29, 38, 40), leading to the conclusion that cases of pure depression without anxiety were

rarer than cases of anxiety without concomitant depression (35, 36, 37), including the case of

students in colleges due to the new exposures that student’s encounter (35,39).

This study contributes to the global data base in general and the first Kenya data specifically on

scientifically based evidence on the high prevalence of depression and anxiety among these young

adult paramedical students. The results of the study provide baseline data for the institution’s

management to make evidence based policies for prevention, management and unveiled mental

health training needs for the students. This would in turn pave way for possible scientifically based

decisions to review the various curricula to incorporate a mental health component in all the

academic departments.

LIMITATION OF THE STUDY

A limitation of the current study is that it did not investigate whether or not any respondent had

suffered depression or anxiety previously as well as indentify definite possible psycho stressor,

which may have precipitated depression or anxiety.

Acknowledgement

All the KMTC student respondents who participated in the study. The principals and lecturers who

assisted with the study logistics. Grace Mutevu and my sister Lucy Gitonga for their prompt

typographical assistance whenever I needed it, Purity Ngagi my bio-statistician for her timely

analysis of the data, John Ng’ang’a and Esther Kariuki for their invaluable assistance.

References

1. Kessler, R. C., Gruber, M., Hettema, J. M., Hwang, I., Sampson, N., & Yonkers, K. A. (2008). Co-morbid major

depression and generalized anxiety disorders in the National Comorbidity Survey follow-up. Psychological

medicine, 38(3), 365-374.

2. Kroenke, K., Spitzer, R. L., Williams, J. B., Monahan, P. O., & Löwe, B. (2007). Anxiety disorders in primary care:

prevalence, impairment, comorbidity, and detection. Annals of internal medicine, 146(5), 317-325.

3. Chisholm, D., Sweeny, K., Sheehan, P., Rasmussen, B., Smit, F., Cuijpers, P., & Saxena, S. (2016). Scaling-up

treatment of depression and anxiety: a global return on investment analysis. The Lancet Psychiatry, 3(5), 415-

424.

4. Baxter, A. J., Scott, K. M., Vos, T., & Whiteford, H. A. (2013). Global prevalence of anxiety disorders: a systematic

review and meta-regression. Psychological medicine, 43(5), 897-910.

5. Kessler, R. C., Petukhova, M., Sampson, N. A., Zaslavsky, A. M., & Wittchen, H. U. (2012). Twelve-month and lifetime

prevalence and lifetime morbid risk of anxiety and mood disorders in the United States. International journal of

methods in psychiatric research, 21(3), 169-184.

6. Gulliver, A., Griffiths, K. M., Christensen, H., & Brewer, J. L. (2012). A systematic review of help-seeking

interventions for depression, anxiety and general psychological distress. BMC psychiatry, 12(1), 81.

7. Hofmann, S. G., & Smits, J. A. (2008). Cognitive-behavioral therapy for adult anxiety disorders: a meta-analysis of

randomized placebo-controlled trials. The Journal of clinical psychiatry, 69(4), 621.

Page 10 of 11

Muriungi, S. K., & Menecha, J. B. (2020). Comorbidity Of Depression And Anxiety Among Students At The Kenya Medical Training Colleges In Kenya. Advances

in Social Sciences Research Journal, 7(8) 360-370.

URL: http://dx.doi.org/10.14738/assrj.78.7044 369

8. Kanner, A. M., Barry, J. J., Gilliam, F., Hermann, B., & Meador, K. J. (2010). Anxiety disorders, subsyndromic

depressive episodes, and major depressive episodes: do they differ on their impact on the quality of life of

patients with epilepsy?. Epilepsia, 51(7), 1152-1158.

9. Gupta, S., Choudhury, S., Das, M., Mondol, A., & Pradhan, R. (2015). Factors causing stress among students of a

Medical College in Kolkata, India. Education for Health, 28(1), 92.

10. Pulido-Martos, M., Augusto-Landa, J. M., & Lopez-Zafra, E. (2012). Sources of stress in nursing students: a

systematic review of quantitative studies. International Nursing Review, 59(1), 15-25.

11. Cokley, K., McClain, S., Enciso, A., & Martinez, M. (2013). An examination of the impact of minority status stress

and impostor feelings on the mental health of diverse ethnic minority college students. Journal of Multicultural

Counseling and Development, 41(2), 82-95.

12. Shah, M., Hasan, S., Malik, S., & Sreeramareddy, C. T. (2010). Perceived stress, sources and severity of stress among

medical undergraduates in a Pakistani medical school. BMC medical education, 10(1), 2.

13. Ab Latif, R., & Mat Nor, M. Z. (2016). Stressors and coping strategies during clinical practices among diploma

nursing students. Education in Medicine Journal, 8(3), 21-33.

14. Dyrbye, L. N., Thomas, M. R., & Shanafelt, T. D. (2006). Systematic review of depression, anxiety, and other

indicators of psychological distress among US and Canadian medical students. Academic medicine, 81(4), 354-

373.

15. Puthran, R., Zhang, M. W., Tam, W. W., & Ho, R. C. (2016). Prevalence of depression amongst medical students: a

meta-analysis. Medical education, 50(4), 456-468.

16. Hope, V., & Henderson, M. (2014). Medical student depression, anxiety and distress outside North America: a

systematic review. Medical education, 48(10), 963-979.

17. Hegney, D. G., Craigie, M., Hemsworth, D., Osseiran-Moisson, R., Aoun, S., Francis, K., & Drury, V. (2014).

Compassion satisfaction, compassion fatigue, anxiety, depression and stress in registered nurses in Australia:

study 1 results. Journal of nursing management, 22(4), 506-518.

18. Bitsko, R. H., Holbrook, J. R., Ghandour, R. M., Blumberg, S. J., Visser, S. N., Perou, R., & Walkup, J. T. (2018).

Epidemiology and impact of health care provider-diagnosed anxiety and depression among US children. Journal of

developmental and behavioral pediatrics: JDBP, 39(5), 395-403.

19. Rotenstein, L. S., Ramos, M. A., Torre, M., Segal, J. B., Peluso, M. J., Guille, C., & Mata, D. A. (2016). Prevalence of

depression, depressive symptoms, and suicidal ideation among medical students: a systematic review and meta- analysis. Jama, 316(21), 2214-2236.

20. Givens, J. L., & Tjia, J. (2002). Depressed medical students' use of mental health services and barriers to use.

Academic medicine, 77(9), 918-921.

21. Inam, S. B. (2007). Anxiety and depression among students of a medical college in Saudi Arabia. International

journal of health sciences, 1(2), 295.

22. Dahlin, M., Joneborg, N., & Runeson, B. (2005). Stress and depression among medical students: A cross-sectional

study. Medical education, 39(6), 594-604.

23. Aktekin M, Karaman T, Senol Y, et al: Anxiety, depression and stressful life events among medical students: A

prospective study in Antalya, Turkey. Med Educ 2001;35:12–7.

24. Sidik MS, Rampal L, Kaneson N. Prevalence of emotional disorders among medical students in a Malaysian

university. Asia Pac Fam Med 2003; 2:213–7.

25. Ndetei DM: The association and implications of anxiety and depression in university medical and paramedical

students in Kenya. East African medical journal 1987; 64(3): 214-226

26. Osman, A., Hoffman, J., Barrios, F. X., Kopper, B. A., Breitenstein, J. L., & Hahn, S. K. (2002). Factor structure,

reliability, and validity of the Beck Anxiety Inventory in adolescent psychiatric inpatients. Journal of Clinical

Psychology, 58(4), 443-456.

Page 11 of 11

370

Advances in Social Sciences Research Journal (ASSRJ) Vol.7, Issue 8, August-2020

27. Sharp, L. K., & Lipsky, M. S. (2002). Screening for depression across the lifespan. Am Fam Physician, 66, 1001-

1008.

28. Ndetei DM, Khasakhala L., Nyabola, L., Ongecha, F., and Kokonya, D.A. Psychosocial and health aspects of drug use

by students in public secondary schools in Nairobi Kenya. Substance abuse 2009; 30:61-68

29. Munamad SK, Sajid M, Areef B, et al: Prevalence of depression, anxiety and their associated factors among Medical

students in Karachi, Pakistan. J Pak Med Assoc 2006; 12: 583-6

30. Bazmi SN: To assess prevalence of anxiety and depression among medical students in a medical college of Saudi

Arabia. International journal of health sciences 2007; 1(2): 295-300

31. Leadbeater, B., Thompson, K., & Gruppuso, V. (2012). Co-occurring trajectories of symptoms of anxiety,

depression, and oppositional defiance from adolescence to young adulthood. Journal of Clinical Child &

Adolescent Psychology, 41(6), 719-730.

32. Givens J, Tjia J: Depressed medical students’ use of mental health services and barriers to use. Acad med 2002; 77:

918 – 921.

33. Munamad SK, Sajid M, Areef B, et al: Prevalence of depression, anxiety and their associated factors among Medical

students in Karachi, Pakistan. J Pak Med Assoc 2006; 12: 583-6

34. Thornicroft G, Maingay S: The global response to mental illness, an enormous health burden is increasingly being

recognized. BMJ 2002; 325(9): 608-609.

35. Vaidya PM, Mulgaonkar KP: Prevalence of depression, anxiety and stress in undergraduate Medical students and

as correlation with their academic performance: Indian JOCC Ther 2007; 39(1): 7-10

36. Dahlin, M. E., & Runeson, B. (2007). Burnout and psychiatric morbidity among medical students entering clinical

training: a three year prospective questionnaire and interview-based study. BMC Medical education, 7(1), 6.

37. Beiter, R., Nash, R., McCrady, M., Rhoades, D., Linscomb, M., Clarahan, M., & Sammut, S. (2015). The prevalence and

correlates of depression, anxiety, and stress in a sample of college students. Journal of affective disorders, 173, 90-

96.

38. Bazmi SN: To assess prevalence of anxiety and depression among medical students in a medical college of Saudi

Arabia. International journal of health sciences 2007; 1(2): 295-300

39. Scot J, Dickey B: Global burden of depression: The intersection of culture and medicine. Br. J. Psychiatry 2003;

183: 92- 4

40. Tartakousky MS: Depression & anxiety among College Students. Depression and Anxiety 2008; 0: 1-10.