Stress and substance use among undergraduate medical students in a Government medical college in Northern Karnataka

Context: Medical education is highly stressful and demanding as a career. Although, only the academically-minded youth in the society tend to be selected for medical education, the stressful academic environment can exert a negative effect on the psychological and physical well-being. There is growing concern about substance use/dependence among medical students. While medical students and doctors help patients resolve substance dependency, they are not immune to these temptations themselves. In addition to negative effects on the individual’s physical and mental health, and on their families, substance abuse may threaten the ability to provide adequate patient care, and it may undermine the individual’s role as a role model for healthy lifestyles. Aims: To assess the stress and substance use and association among them among undergraduate medical students. Settings and Design: It was a cross sectional study with second, third and final year undergraduate medical students of a government medical college in Northern Karnataka as subjects. Materials and Methods: Basic demographical data was collected using a semi structured questionnaire, substance use was assessed using WHO ASSIST 3.0 scale, stress was assessed using Medical Student Stressor Scale (MSSQ). Statistical analysis used: Data was compiled and appropriate statistical tests were used to analyse the data with the help of SPSS 20. Results: Out of 450 second, third and final year undergraduate medical students, 403 participated in the study. The prevalence of substance use was about 34.7% with alcohol being the leading substance followed by marijuana. Few students reported inhalant/volatile substance use. 65% of the subjects reported high stress. Stress was almost equal in almost all domains. Conclusions: Effective interventions have to be planned and implemented to reduce stress levels among medical students and to address the issue substance use by promoting healthy life style and coping skills. Key Messages: There is association between stress and substance use among undergraduate medical students. Effective interventions have to be planned and implemented to reduce stress levels among medical students and to address the issue substance use by promoting healthy life style and coping skills.


Introduction
In a developing country like India, historically and culturally, medical profession is considered as one of the highly respected professions. It is a great dream for many of the pre university students to get into medical course. 1 But medical education is highly stressful and demanding as a career. Academic pressure producing stress in a student is not surprising, but this is not the only source of stress among them. 2 Many other factors namely the teaching style, inter and intrapersonal issues, drive and motivation related problems and social reasons may also contribute to the distressed state of the learner. In addition to stress, the students' social, emotional and physical as well as family problems may influence their learning ability and academic performance. 3 Previous studies have shown fairly high levels of distress, such as symptoms of depression 4,5 and suicide thoughts 6-7 among medical undergraduates. The potential negative effects of emotional distress on medical students include impairment of functioning in class-room performance, clinical practice and impaired mental health. [8][9] Higher levels of stress may have a negative impact on the students learning ability. Excessive stress may result in mental and physical problems and may diminish a student's sense of worth and might affect his/her academic achievement. 10,11 Studies from west, that have examined coping strategies of medical students with the stresses of undergraduate medical education have generally identified, use of alcohol as a coping strategy [12][13][14] but some studies have reported the use of other substances such as tobacco and drugs. 15,16 Studies from developing countries like Pakistan, India, Thailand and Malaysia have reported stress among medical students and have underscored the role of academics as a source of stress. 1,17,18 Stress may affect health by producing changes in behaviour and there is evidence that under high levels of stress, health-enhancing behaviour declines and healththreatening behaviour such as consumption of tobacco, alcohol, and other drugs may increase, so people are more likely to engage in behaviours that increase the risk of illness and injury. 19 There is considerable evidence from population-based and clinical studies supporting a positive association between psychosocial adversity, negative affect, and chronic distress and addiction vulnerability. Previous studies [20][21][22] have estimated a prevalence rate of substance abuse to be around 20-40 per cent among undergraduate medical students.
So, the present study assesses the prevalence of stress and substance use among undergraduate medical students and association between them.

Materials and Methods
A cross-sectional study was conducted among medical undergraduate students in a government medical college in Karnataka between June and July 2017 to assess the prevalence of stress and substance use among undergraduate medical students and association between them.
A total of 450 bachelor of medicine and bachelor of surgery (MBBS) students from second year to final year were studying in the institute. Institutional ethical committed permitted to conduct the study. All the undergraduate medical students from second year to final year MBBS were invited to participate in the study. The purpose of the study was explained to the participants, and a written informed consent was obtained during their theory class. The students who consented to participate in the study were included and were asked to complete a selfadministered pre structured anonymous questionnaire consisting of the following sections: (a) sociodemographic profile (b) medical students' stressor questionnaire (MSSQ-40) 23 (c) World Health Organization Alcohol, Smoking and Substance Involvement Screening Test v 3.0. (WHO ASSIST v 3.0). 24 They were given 50 minutes to complete the questionnaire and asked to put the questionnaire in a ballot box kind of set up in a predesignated place in the class room and their roll numbers were noted separately for their class attendance as well as to note down the absentees. Those who were absent in the class were later invited to be a part of the study. Data was compiled and appropriate statistical tests were used to analyze the data with the help of SPSS 20.

MSSQ-40 23
The MSSQ-40 is a rating tool developed in a medical institute in Malaysia and validated to measure stress and its sources among medical students. It assesses six domains of sources of stress namely academic-related stressors (ARS), intrapersonal and interpersonal-related stressors (IRS), teaching and learning-related stressors (TLRS), social-related stressors (SRS), drive and desire related stressors (DRS) and group activities related stressors(GRS). Participants are asked to respond to each item along a five point Likert scale (0-4), zero being no stress at all to four being severe stress. The scoring was done as per the instructions of the scale and the stress levels were graded as mild (<1), moderate (1.01-2), high (2.01-3), and severe (>3). The mean score obtained reflects on the overall stress status of the participant. Mild stress indicates a near absence of stress while moderate shows the ability of the student to manage well. High score shows that emotions maybe labile whereas severe stress indicates the difficulty in coping with day to day activities.

The Alcohol, Smoking and Substance Involvement
Screening Test (ASSIST) v 3.0 24 It was developed under the auspices of the World Health Organization (WHO) to be used in primary health care settings where hazardous and harmful substance use among clients may go undetected, or become worse. The ASSIST (version 3.0) is an eight item questionnaire designed to be administered by a health care professional to a client, and takes about five to ten minutes to administer. The ASSIST was designed to be culturally neutral and useable across a variety of cultures to screen for use of the following substances: tobacco products, alcohol, cannabis, cocaine, amphetamine-type stimulants, inhalants, sedatives and sleeping pills (benzodiazepines), hallucinogens and 'other' drugs.
The ASSIST determines a risk score for each substance. It obtains information from clients about lifetime use of substances, and use of substances and associated problems over the last three months. Scores in the mid-range on the ASSIST are likely to indicate hazardous or harmful substance use ('moderate risk') and higher scores are likely to indicate substance dependence ('high risk').

Results
Out of 450 students, 403 responded with response rate being 89.5%. As seen in Table 1 In the study, on MSSQ, scores of more than 1.01 were considered as having stress. 246 (61.1%) students, had collective score of >1.01 signifying stress among majority. As seen in table 2, among various stress domains, stress was high in academic related (78.4%), interpersonal and intrapersonal (70%) and group activity related (68.7%) domains. Drive and desire related domain had least stress (39.5%).
There was significant association (p <0.05) between the year of MBBS and stress. As the year of study progressed, the stress also increased, especially in the academic related domain.
While assessing substance use, 140 (34.7%) students reported use of either one of tobacco, alcohol, cannabis, cocaine, inhalants, sedatives, hallucinogens, and opioids at least once in their lifetime. Prevalence of substance use increased as the year of MBBS progressed. (Table 3) Among the respondents, 49 (12.6%) were at moderate to high risk for tobacco use, 40 (9.9%) for alcohol, 29 (7.2%) for cannabis, 14 (3.4%) for inhalants, and 11 (2.6%) for sedatives. (Table 4) The association of academic related stress was significant (p<0.05) with tobacco, alcohol, cannabis, inhalants and sedatives use (Table 5). Similarly, inter and intrapersonal, teaching and social related stress was significantly associated with tobacco, alcohol, cannabis and inhalants use. Drive and desire and group activity related stress was significantly associated with tobacco, alcohol and cannabis use.
There was no significant association of stress with gender, religion and place of stay. There was also no significant association between substance use and gender, religion and place of stay.

Discussion
The prevalence of stress among undergraduate medical students in our study was 61.1%, which is almost similar to the prevalence reported by previous studies. [25][26][27][28][29] However, Studies investigating stress among Indian medical students report wide variations in the prevalence of stress (37.3-97%). [30][31][32][33][34] This observed inconsistency can be explained by demographic differences in the samples, different academic years of the students studied, varying case definitions, and no uniformity in measuring tools. 31 The possible reasons for the variability in the levels of stress could be due to certain differences in the curricula, teaching facilities, qualification and experience of the instructors, and the levels of care given to the students. Academic counselling is not a common practice in the present setup because of a large number of medical students and limited number of the faculties that may contribute to high prevalence of stress. 31 Our subjects experienced more stress in academic related domain. In most of the previous studies, students reported similar academic related stress. 31 Few of the issues in which they were stressed were -tests /exams, selfexpectation, heavy workload, not enough skills, full of competition, having difficulty in understanding the content, getting poor marks, lack of time for revision, large syllabus to learn and unjustified grading system. Medical students are overloaded with a tremendous amount of information. The excessive amount of stress in medical training predisposes students to have difficulties in solving problems and reduced concentration and finally develop depression. 26 Furthermore, stress among medical students can break the mental stability, impaired judgments, and absenteeism from class lesson. In effect, all those things compromise academic achievement of students. 25 As the students progressed to higher classes in medical course the amount stress increased. This can be attributed to high volume of study material, expectation and increased competition. 21 A high prevalence of stress among medical students is a cause of concern as it may impair behaviour of students, diminish learning, and ultimately affect patient care after their graduation. 35,36 In our study, 34.7% of the subjects had used either one of tobacco, alcohol, cannabis, cocaine, inhalants, sedatives, hallucinogens, and opioids at least once in their lifetime. The result was the in the range of prevalence of substance use seen among undergraduate medical students in the previous studies. [37][38][39][40] There was significant association between year of study and substance use. As the year of study advanced, prevalence of substance use also increased. This may be attributed to increased syllabus, clinical postings and exams and increased self-expectation. 40 Most common substance of use was alcohol followed by tobacco and cannabis. In few other studies tobacco was the most common substance of use. 40,41 Interesting finding in our study was moderate to high risk of inhalant use in 3.4% of the subjects. In India Inhalant use is reported among school students and children belonging to lower socioeconomic strata. 42 But studies among medical undergraduate students don't mention inhalant abuse. But few studies from Greece and Brazil 43,44 do mention about inhalant abuse with prevalence being 3.1%-31%. As inhalants are not contraband and easily available, the usage of this substance is worrisome. This finding needs to be further investigated.
There was also no significant association between substance use and gender, religion and place of stay. It needs more structured and large scale studies to assess the relation between these factors.
Though our study did not assess the reasons for substance us, according to previous studies socialization, feeling of having grown up and relieving from tensions 41 to relieve of the stress and curiosity, academic stress, peer pressure, failure in love matters also accounted for initiation of substance use among majority of abusers. [40][41][42][43] The association of academic related stress was significant (p<0.05) with tobacco, alcohol, cannabis, inhalants and sedatives use. Similarly, inter and intrapersonal, teaching and social related stress was significantly associated with tobacco, alcohol, cannabis and inhalant use. Drive and desire and group activity related stress was significantly associated with tobacco, alcohol and cannabis use. These findings were similar to findings in the previous studies. [20][21][22] The previous studies haven't studied in detail about each substance of use and each domain of stress. But the specific association between type of stress and certain substances abuse needs to be investigated further.

Conclusion
Stress levels are very high among undergraduate medical students. Substance use is one of the coping mechanisms among them due to high level of stress. So, healthy management of stress is essential among undergraduate medical students.

1.
First year MBBS students were not involved in the study and all the participants belonged to one institute. So the results cannot be generalized. 2. The involved self-administered questionnaire so possibility of information bias cannot be ruled out. 3. This was a cross-sectional study, so cause-effect relationships could not be established. Some students might have over-or under-reported their stress and stressful factors. 4. Prospective studies are necessary to study the associations between occurrence of stressors and incidence of stress.

Source of Funding
None.

Conflicts of Interest
None.