SYSTEMATIC REVIEW/META ANALYSIS Prevalence of Depression, Anxiety, Stress and Suicide Ideation Among Undergraduate Medical Students in India: A Systematic Review and Meta-Analysis Harpreet Kaur1, Varsha Gupta2, Aseem Garg3*, Sangeeta4, Bijaya Kumar Padhi5 1,3,4Kalpana Chawla Government Medical College, Karnal, India Medical College, Alwar, India 5Postgraduate Institute of Medical Education & Research, Chandigarh, India 2Government DOI: 10.55489/njcm.151020244529 ABSTRACT Background: Studies reported significant levels of psychological morbidity from across the globe among undergraduate medical students. Present meta-analysis aimed to provide a most up to date comprehensive insight into the prevalence of depression, stress, anxiety and suicidal ideation among undergraduate medical students in India. Material and Methods: A systematic search was conducted in three databases PubMed, Scopus and Google Scholar from July 2023 to August 2023. Quality of included studies (43 studies, N=15557) was assessed using modified Newcastle-Ottawa scale and data was analyzed using MetaXL version 5.3. Pooled estimates with 95% confidence intervals were determined using the random-effects model. Results: The pooled prevalence of depression, anxiety, stress and suicide ideation was 48% (95% CI: 4155%) (P 0.000, I2 = 98%), 54% (95% CI 42-58%) (P =0.00, I2 = 98%), 50% (95% CI 45-63%) (P =0.001, I2 = 99%) and 21% (95% CI: 9-35%) (P =0.000, I2 = 98%) respectively. Subgroup analysis showed more females than males students were affected from depression, anxiety, stress and suicide ideation. Conclusion: High prevalence of psychological disorders in medical students in India emphasize the need for the counselling services to control this morbidity and implement long term policies and programs at institutional level. Keywords: India, Medical students, Mental health, Pooled prevalence, psychological disorders ARTICLE INFO Financial Support: None declared Conflict of Interest: None declared Received: 30-07-2024, Accepted: 20-09-2024, Published: 01-10-2024 *Correspondence: Dr. Aseem Garg (Email: aseemgarg1990@gmail.com) How to cite this article: Kaur H, Gupta V, Garg A, Sangeeta, Kumar Padhi BK. Prevalence of Depression, Anxiety, Stress and Suicide Ideation Among Undergraduate Medical Students in India: A Systematic Review and Meta-Analysis. Natl J Community Med 2024;15(10):868-883. DOI: 10.55489/njcm.151020244529 Copy Right: The Authors retain the copyrights of this article, with first publication rights granted to Medsci Publications. This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-Share Alike (CC BY-SA) 4.0 License, which allows others to remix, adapt, and build upon the work commercially, as long as appropriate credit is given, and the new creations are licensed under the identical terms. www.njcmindia.com│pISSN: 0976-3325│eISSN: 2229-6816│Published by Medsci Publications @2024 National Journal of Community Medicine│Volume 15│Issue 10│October 2024 Page 868 Kaur H et al. INTRODUCTION Medical education is widely regarded as one of the most demanding and psychologically taxing professional courses. Medical training has high academic and emotional requirements as compared to other graduate training programmes.1,2 Generally, the total time required to acquire the necessary professional knowledge and skills is greater for medical students than those with other majors which negatively affects the mental health of medical students.3,4 The demanding academic workload, strict schedules, significant performance expectations, distance from loved ones, and transition to clinical environments, sleep deprivation, financial concerns, minimal relaxation, and recreation time cause more stress in medical students.5 Increased stress levels result in an increased psychological problems such as depression, anxiety, drug abuse, and suicide ideation.6-8 Studies from across the globe have shown that medical students experience significant levels of psychological morbidity ranging from stress, depression, anxiety and suicidal ideation to psychiatric disorders.9-11 Existing research has emphasized the detrimental impacts of depression on young individuals, including impaired academic achievement, elevated substance abuse, and suicidal thoughts.12-16 Anxiety is another significant concern for medical students as studies reported that about one third (33.8%) of medical students were affected from this issue globally, with a higher prevalence observed among medical students from the Middle East and Asia.17 Medical doctors are one of the high-risk groups for suicide.18,19 It seems that this problem arises during medical school.20,21 The rates of suicidal ideation in medical students vary widely, ranging from 6.0% to 43.0%.20,22-24 Psychological morbidities in medical students are concerning as they can negatively impact their interpersonal relationships and future clinical practices like decrease in academic performance, professionalism, and empathy toward their patients; if left unnoticed and untreated.25-27 The medical education and healthcare work settings in India demonstrate some differences compared to those observed in Western or other Asian regions.Varying prevalence rates were reported in different epidemiological studies in India and there is a limited number of prevalence meta-analysis studies of mental health problems which makes generalization of prevalence rates difficult which are crucial for developing strategies to prevent, screen, treat, and support the mental well-being of medical students. In such a scenario, up-to-date pooled estimates are a need of the hour to estimate the burden of mental health disorders in medical students.12 Previous systematic review and meta-analysis conducted in 2015 on prevalence of depression, anxiety, and stress among medical students in India reviewed all the studies published from January 1970 to October 2015.28 So, present meta-analysis aimed to up- date the existing review and to provide most upto date comprehensive insight into the prevalence of depression, stress, anxiety and suicidal ideation among undergraduate medical students in India. METHODOLOGY The present systematic review and meta-analysis was conducted according to PRISMA checklist and Meta-analyses and Meta-analysis of Observational Studies in Epidemiology reporting guidelines.29,30 Before starting the literature search, we registered it in PROSPERO (CRD42023476411), an international database of prospectively registered systematic reviews. Two authors (VG, HK) conducted systematic searches in three databases PubMed, Scopus and Google Scholar from July 2023 to August 2023 and were blinded to each other’s’ decisions. For searching articles on the prevalence of depression, anxiety, stress and suicide ideation among undergraduate medical students we used the following search terms: “Mental Health Problems” OR “Mental Health disorder” OR “Mental Health” OR “Anxiety” OR “Stress” OR “Depression” OR “Suicide Ideation” AND “MBBS students” OR “Undergraduate Medical Students” OR “Medical Students” AND India (Table S1). All the original quantitative articles published from August 2015 to June 2023 that reported prevalence of at least one of the depression, anxiety and/or stress were included for the review. There were very few quantitative studies that reported the prevalence of suicide ideation among students in India and no meta-analysis was published earlier on the prevalence of suicide ideation among undergraduate medical students in India. So, all the studies published from January 2000 to June 2023 that reported prevalence of suicide ideation among undergraduate medical students in India were reviewed. The reference sections of pertinent reviews identified through the database search were examined to locate relevant studies. All available articles published in English during the study period that examined the prevalence of stress, anxiety, depression, and suicidal ideation among undergraduate medical students in India were retrieved. Inclusion criteria: Studies with cross sectional design, conducted among undergraduate medical students from India and reported at least one of the prevalence of stress, anxiety, depression and/ or suicide ideation were included in the review. Exclusion criteria: We excluded publications reporting reviews, discussions, single-case studies, systematic review and meta- analysis and qualitative studies. Studies that not accessible online were not included. Also, studies looking at psychological morbidities only due to examination were excluded. Moreover, studies related to only interns, paramedical students and studies related to physical or mental illness in undergraduate medical students due to the COVID-19 pandemic were excluded. National Journal of Community Medicine│Volume 15│Issue 10│October 2024 Page 869 Kaur H et al. Study selection: Rayyan (https://rayyan.qcri.org) software was used for the systematic review of the retrieved articles. Two investigators (HK, VG) independently screened title and abstract of the retrieved publications in-duplicate using Rayyan and decided whether they were appropriate for inclusion in the meta-analysis. Based on the above eligibility criteria, articles that considered to be relevant by two reviewers (VG, HK) were entered into full text screening process into in-duplicate Rayyan. Any disagreement was resolved by mutual discussion. PRISMA flow chart of study identification and selection processes is shown in Fig 1. Data Extraction: After the study selection according to inclusion and exclusion criteria, two researchers who conducted screening procedures independently conducted descriptive data extraction from the final set of included studies. Data was extracted using predesigned spreadsheet in Microsoft Excel which included the year of publication, first author’s name, study population region, study design, sampling technique, study period, age of participants, response rate, sample size, number of males and females, instrument used for assessing depression, anxiety, stress and suicide ideation, overall prevalence of at least one of the stress, anxiety, depression and suicide ideation and among male and female students. Risk of Bias Assessment: Modified version of New Castle Ottawa Quality Assessment Scale adapted for cross sectional study was used for quality assessment.31 Following characteristics were assessed. Q1: Representativeness of sample (The inclusion of all subject or use of random sampling) Q2: Appropriate Sample size Q3: Non-Response rate equal to or greater than 80% Q4: Valid screening tools to evaluate depressive, stress, anxiety, suicide ideation symptoms and cutoff values Q5: Appropriate statistical analysis (appropriate and clearly described statistical test). Assessment was done at study level. For each characteristic minimum sore 0 and maximum score 5 was given. Studies scoring ≥3 points and <3 points were regarded as having a low risk of bias and a high risk of bias respectively. Two researchers independently assessed the risk of bias for each included study. Any discrepancies were resolved by discussion with a third researcher (HK, VG and AG). Data Synthesis and Analysis: MetaXL version 5.3 was used for analysis of the data retrieved from the studies. The extracted data was utilized to determine the prevalence of depression, anxiety, stress and suicide ideation among medical students. Pooled estimates with 95% confidence intervals were calculated using a random-effects model because of substantial variation across studies.32 Cochran’s heterogeneity statistic (Q) was used to test if the effect sizes of different studies were similar or not. Q statistics with p-value < 0.10 was considered statistically significant heterogeneity. I² statistics were used to analyze the heterogeneity and I² >75% was considered as high heterogeneity.33 Subgroup analyses stratified by gender and screening tool was done to study the source of heterogeneity among subgroup. Forest plots were used to determine the prevalence of pooled estimates. To determine possible publication bias, evidence of asymmetry and other small study effect funnel plots were used. Publication bias was assessed using the Doi plot and the LFK index to validate the asymmetries observed in the funnel plot. Value of LFK index over ±1 is considered to be publication bias.34 Sensitivity analysis was performed by excluding each study and rerunning the meta-analysis to test the robustness of the pooled prevalence of stress, anxiety, depression and suicide ideation. Figure 1: PRISMA flowchart for the identification and selection of observational studies in systematic review and meta-analysis of anxiety, depression, stress and suicide ideation RESULTS Our search with the pre-specified search strategies resulted in an overall of 892 articles. We removed 40 duplicated studies before further screening. After screening titles and abstract of remaining 852 studies, 799 were excluded being irrelevant to the main subject; and repetitive publications. After screening full text for remaining 53 articles for eligibility to be included in the current systematic review and metaanalysis study; 10 articles were excluded due to various reasons (4 no prevalence estimates, 4 different target population, 1 inadequate information, 1 others). Finally, 43 eligible studies were included for the present meta-analysis (Figure 1). National Journal of Community Medicine│Volume 15│Issue 10│October 2024 Page 870 Kaur H et al. Table 1: Characteristics of Included Studies Author (year of Publication) citation Mandyam (2023)35 Merchant (2023)36 Shah (2023)37 Arun (2022)38 Karthik (2022)39 Lepcha (2022)40 Chakraborty (2021)41 Desai (2021)42 Jose (2021)43 Study design Sampling Technique Study period Age (years) Response rate Sample Male size Screening Tool and Cutoff Values Depression Anxiety Stress Suicide Ideation Cross sectional Complete enumeration - 17-25 100 588 - DASS 42>=10 DASS 42>=8 DASS 42>=15 - Cross sectional Consecutive Sampling Snowball Sampling Complete enumeration Stratified sampling Complete enumeration - Jan-March, 2023 Oct,2019 Nov,2019-Dec,2019 Jan,2020-Jan,2021 Jul,2106- Oct, 2016 17-30 18-24 - 99 100 - 1300 623 425 360 382 487 336 164 157 144 - DASS 21>=14 PHQ 9>=15 DASS 21>=10 HADS>=8 DASS 21>=10 Nov,2017 Nov,2020-Jan,2021 18-23 72 100 506 140 75 PHQ-9>=10 PHQ-9>=1 DASS 42>=10 DASS 42>=8 DASS 42>=15 - Karmakar (2021)44 Khan (2021)45 Kukreja (2021)46 Pandey (2021)47 Cross sectional Complete enumeration Non Probability Sampling Simple random sampling Complete enumeration Convenient sampling Jan, 2017- Dec,2017 18-25 100 310 163 DASS 42>=10 DASS 42>=8 DASS 42>=15 - Jan 2021-May,2021 2019 Feb, 2018-Jan,2019 18-25 21.28 19-24 100 100 100 264 301 150 131 148 103 BDI>=10 HAM-D>=7 Solanki (2021)48 Haritay (2020)49 Cross sectional Cross sectional June2019-Nov-2019 2019 17-28 17-25 82.8 - 395 148 154 - May,2017-Dec,2018 - 100 273 Sep,2019 21.33+1.98 - 96 - June-Aug,2017 Nov,2019-Dec,2019 Feb, 2018-Jan,2019 17-20 20.89+1.77 20.8+1.9 Dec, 2016- Feb,2017 Nov, 2017-July,2018 Jul-Sep, 2017 19.8+1.85 18-20 18-24 Cross sectional Cross sectional Cross sectional Cross sectional Cross sectional Cross sectional Cross sectional Cross sectional Cross sectional Kamthan (2021)50 Cross sectional Kumar (2020)51 Luthra (2020)52 Cross sectional Cross sectional Nesan (2020)53 Nezam (2020)54 Pattnaik (2020)55 Singh (2020)56 Cross sectional Cross sectional Cross sectional Cross sectional Gupta (2018)57 James (2018)58 Nivetha (2018)59 Cross sectional Cross sectional Cross sectional Complete enumeration Simple random &Systematic Random Sampling Simple Rrandom Sampling Simple Random Sampling Complete enumeration Complete enumeration Complete enumeration Complete enumeration Simple Random Sampling National Journal of Community Medicine│Volume 15│Issue 10│October 2024 DASS 21>=10 HAM-A>=18 GAD 7>=10 DASS 21>=8 HADS >=5 DASS 21>=8 DASS 21>=19 DASS 21>=15 DASS 21>=15 - SBQ-R>=7 - CES-D>=16 ADSS48>=3 PSS 10>=14 SSDQ>=1 Domain ADSS 48>=3 ADSS 48>=3 - - - - - 200 225 142 DASS 21>=10 DASS 21>=8 DASS 21>=15 DASS 21>=10 DASS 21>=8 DASS 21>=15 - 100 87.84 - 415 921 902 150 179 572 103 BDI>=10 PHQ 9>=5 HAM-D>=7 - 100 417 137 303 117 52 156 BDI>=10 - BAI>=16 - K 10>=20 SSDQ>=1 Domain GHQ 12>=4 PSS 10>=14 - BSSI>=9 - - Page 871 Kaur H et al. Author (year of Publication) citation Rebello (2018)60 Taneja (2018)61 Aggarwal (2017)62 Chellaiyan (2017)63 Chenganakkattil (2017)8 Hakim (2017)64 Study design Sampling Technique Study period Age (years) Response rate Sample Male size Screening Tool and Cutoff Values Depression Anxiety Stress Suicide Ideation Cross sectional Cross sectional Cross sectional Cross sectional Convenient sampling Complete enumeration Convenient sampling Complete enumeration Dec,2016 Sep,2017 April,2016-March,2017 17-19 18-25 18-25 >18 80.67 94 98 92.6 121 187 147 507 69 124 51 217 DASS 21>=10 BDI>=10 DASS 21>=8 GAD 7>=10 PSS 14>=28 DASS 21>=15 PSS 14>=28 PSS 14>=7 - Cross sectional - - 100 150 - SDS>=50 SAS>=45 PSS 10>=14 - Oct, 2016- April, 2017 - 100 426 249 PHQ 9>=5 GAD 7>=5 - - Kumar (2017)65 Samanta (2017)66 Chaudhary (2016)67 George (2016)68 Cross sectional Cross sectional Cross sectional Simple Random Sampling Simple Random Sampling Complete enumeration Complete enumeration Complete enumeration Jan,12-June,2013 March,2014-June,2015 Oct-Nov, 2014 17-24 20.64+1.19 17-32 88.8 76 90.4 444 225 452 228 137 243 BDI>=10 - - PSS 14>=12 PSS 10>=20 PSS 10>=20 - - 17-25 100 290 121 - - PSS 10>=26 - Kumar (2016)69 Rawat (2016)70 Cross sectional Cross sectional Sep- Nov,2015 - 100 332 300 137 187 DASS 42>=10 DASS 42>=8 DASS 42>=15 PHQ 9>=5 - Singh (2016)71 Yadav (2016)72 Cross sectional Cross sectional Feb-May,2014 18-22 - 100 512 330 244 223 HAM-D>=7 HAM-A>=7 DASS 42>=14 DASS 42>=8 - Naveen (2015)73 Cross sectional Oct-Nov, 2014 18-22 100 152 50 DASS 42>=14 DASS 42>=8 DASS 42>=15 - Suman (2015)74 Cross sectional Jul-Aug,2015 18-25 100 120 60 DASS 42>=14 DASS 42>=8 DASS 42>=15 - Goyal (2012)75 Cross sectional - 17-30 100 265 138 - - - TASR Jain (2012)76 Cross sectional Simple Random Sampling Convenient sampling Simple Random Sampling Complete enumeration Simple Random Sampling Simple Random Sampling Simple Random Sampling Simple Random Sampling Convenient sampling - - 87 - - - - - Custom questionnaire Cross sectional Cross sectional - Cells containing “-“ indicate that the study author did not provide any relevant information for that column. Abbreviations: HADS Hospital Anxiety and Depression Scale , PHQ-9 Patient Health Questionnaire, SDS Zung Self-Rating Depression Scale, BDI Beck Depression Inventory, DASS-21 Depression Anxiety Stress Scale 21 item, DASS-42 Depression Anxiety Stress Scale 42 item, ADSS Anxiety Depression Stress Scale, CES-D Centre for epidemiological studies depression scale, HAM-D Hamilton Depression Rating Scale, BAI Beck Anxiety Inventory , SAS Zung self-rating anxiety Scale, HAM-A Hamilton Anxiety Rating Scale, GAD-7 Generalized Anxiety Disorder 7 scale, SSDQ Students Stress Dimension Questionnaire, PSS Perceived Stress Scale, GHQ General Health Questionnaire, K 10 Kessler Psychological Distress Scale, SBQ-R Suicide Behaviors Questionnaire-Revised, BSSI Beck Scale for suicide Ideation, TASR Tool for Assessment of Suicide Risk National Journal of Community Medicine│Volume 15│Issue 10│October 2024 Page 872 Kaur H et al. Table 2: Quality ratings of included studies using the modified Newcastle-Ottawa Scale Sr No Author Representative (Year of Publication) Sample Non response Size Valid Statistical Tool Method Score 1 Mandyam 202335 Y Y Y Y Y 2 Merchant 202336 Y Y Y Y Y 5 5 3 Shah 202337 Y Y Y Y Y 5 4 Arun 202238 N N Y Y Y 3 5 Karthik 202239 Y Y Y Y Y 5 6 7 Lepcha 202240 Chakraborty 202141 Y N Y Y Y N Y Y Y Y 5 3 8 Desai 202142 Y Y N Y Y 4 9 Jose 202143 N Y Y Y Y 4 10 Karmakar 202144 Y Y Y Y Y 5 11 Khan 202145 N Y Y Y Y 4 12 Kukreja 202146 Y Y N Y Y 4 13 Pandey 202147 N Y N Y Y 3 14 Solanki 202148 Y Y Y Y Y 5 15 Haritay 202049 Y N N Y Y 3 16 Kamthan 202050 Y Y Y Y Y 5 17 Kumar 202051 N N Y Y Y 3 18 Luthra 202052 Y N N Y Y 3 19 Nesan 202053 Y Y N Y Y 4 20 21 Nezam 202054 Pattnaik 202055 Y Y Y Y Y Y Y Y Y Y 5 5 22 Singh 202056 N Y N Y Y 3 23 Gupta 201857 Y Y N Y Y 4 24 James 201858 N Y N Y Y 3 25 Nivetha 201859 Y Y Y Y Y 5 26 Rebello 201860 N Y Y Y Y 4 201861 27 Taneja Y Y Y Y Y 5 28 Aggarwal 201762 N Y Y Y Y 4 29 Chellaiyan 201763 Y Y Y Y Y 5 20178 30 Chenganakkattil Y N N Y Y 3 31 Hakim 201764 Y Y Y Y Y 5 32 Kumar 201765 Y Y Y Y Y 5 33 34 Samanta 201766 Chaudhary 201667 Y Y Y Y N Y Y Y Y Y 4 5 35 George 201668 Y Y Y Y Y 5 36 Kumar 201669 Y Y N Y Y 4 37 Rawat 201670 Y Y Y Y Y 5 38 Singh 201671 Y Y N Y Y 4 39 Yadav 201672 Y Y Y Y Y 5 40 Naveen 201573 Y Y Y Y Y 5 41 Suman 201574 Y Y Y Y Y 5 42 Goyal 201275 Y Y Y Y Y 5 43 Jain 201276 N N Y N Y 2 Modified version of New Castle Ottawa Quality Assessment Scale adapted for cross sectional study31 was used to assess quality of the studies. This scale is based on the following criteria: Q1: Representativeness of sample (The inclusion of all subject or use of random sampling); Q2: Appropriate Sample size; Q3: Non-Response rate equal to or greater than 80%; Q4: Valid screening tools to evaluate depressive, stress, anxiety, suicide ideation symptoms and cutoff value; and Q5: Appropriate statistical analysis (appropriate and clearly described statistical test) National Journal of Community Medicine│Volume 15│Issue 10│October 2024 Page 873 Kaur H et al. Depression Study Prev (95% CI) % Weight Mandyam 2023 0.35 ( 0.31, 0.39) 3.4 Merchant 2023 0.55 ( 0.52, 0.57) 3.4 Arun 2022 0.36 ( 0.31, 0.40) 3.4 Karthik 2022 0.48 ( 0.43, 0.54) 3.4 Lepcha 2022 0.23 ( 0.18, 0.27) 3.4 Chakraborty 2021 0.49 ( 0.44, 0.53) 3.4 Desai 2021 0.14 ( 0.11, 0.18) 3.4 Jose 2021 0.66 ( 0.58, 0.73) 3.3 Karmakar 2021 0.95 ( 0.92, 0.97) 3.3 Kukreja 2021 0.26 ( 0.21, 0.31) 3.3 Pandey 2021 0.52 ( 0.44, 0.60) 3.3 Solanki 2021 0.37 ( 0.32, 0.42) 3.4 Haritay 2020 0.63 ( 0.55, 0.70) 3.3 Kumar 2020 0.27 ( 0.21, 0.33) 3.3 Luthra 2020 0.24 ( 0.19, 0.30) 3.3 Nezam 2020 0.35 ( 0.32, 0.38) 3.4 Pattnaik 2020 0.67 ( 0.64, 0.70) 3.4 Singh 2020 0.52 ( 0.44, 0.60) 3.3 Gupta 2018 0.73 ( 0.69, 0.77) 3.4 Taneja 2018 0.32 ( 0.26, 0.39) 3.3 Chellaiyan 2017 0.50 ( 0.46, 0.55) 3.4 Chenganakkattil 2017 0.72 ( 0.65, 0.79) 3.3 Hakim 2017 0.58 ( 0.53, 0.63) 3.4 Kumar 2017 0.48 ( 0.44, 0.53) 3.4 Kumar 2016 0.38 ( 0.33, 0.43) 3.3 Rawat 2016 0.60 ( 0.54, 0.65) 3.3 Singh 2016 0.60 ( 0.55, 0.64) 3.4 Yadav 2016 0.57 ( 0.52, 0.62) 3.3 Naveen 2015 0.38 ( 0.31, 0.46) 3.3 Suman 2015 0.50 ( 0.41, 0.59) 3.2 Overall 0.48 ( 0.41, 0.55) 100.0 Q=1564.34, p=0.00, I2=98% 0.1 0.2 0.3 0.4 0.5 0.6 Prevalence 0.7 0.8 0.9 1 Figure 2: Forest plot of prevalence of Depression among undergraduate Indian medical students CI Confidence Interval Anxiety Study Prev (95% CI) % Weight Mandyam 2023 0.44 ( 0.40, 0.48) 4.6 Merchant 2023 0.66 ( 0.63, 0.69) 4.6 Shah 2023 0.27 ( 0.24, 0.31) 4.6 Arun 2022 0.20 ( 0.17, 0.24) 4.6 Karthik 2022 0.61 ( 0.55, 0.66) 4.6 Lepcha 2022 0.47 ( 0.42, 0.52) 4.6 Chakraborty 2021 0.58 ( 0.53, 0.62) 4.6 Karmakar 2021 0.97 ( 0.94, 0.98) 4.6 Jose 2021 0.66 ( 0.58, 0.73) 4.5 Haritay 2020 0.59 ( 0.51, 0.67) 4.5 Kumar 2020 0.30 ( 0.24, 0.37) 4.5 Luthra 2020 0.30 ( 0.24, 0.36) 4.5 James 2018 0.37 ( 0.29, 0.46) 4.5 Taneja 2018 0.40 ( 0.33, 0.47) 4.5 Chellaiyan 2017 0.49 ( 0.45, 0.53) 4.6 Chenganakkattil 2017 0.19 ( 0.13, 0.26) 4.5 Hakim 2017 0.47 ( 0.43, 0.52) 4.6 Kumar 2016 0.52 ( 0.47, 0.57) 4.6 Singh 2016 0.60 ( 0.55, 0.64) 4.6 Yadav 2016 0.71 ( 0.66, 0.76) 4.6 Naveen 2015 0.47 ( 0.39, 0.55) 4.5 Suman 2015 0.62 ( 0.53, 0.70) 4.4 Overall 0.50 ( 0.42, 0.58) 100.0 Q=1183.76, p=0.00, I2=98% 0.1 0.2 0.3 0.4 0.5 0.6 Prevalence 0.7 0.8 0.9 1 Figure 3: Forest plot for prevalence of Anxiety among undergraduate Indian medical students National Journal of Community Medicine│Volume 15│Issue 10│October 2024 Page 874 Kaur H et al. Stress Study Prev (95% CI) % Weight Mandyam 2023 0.30 ( 0.27, 0.34) 3.7 Merchant 2023 0.34 ( 0.32, 0.37) 3.8 Karthik 2022 0.27 ( 0.23, 0.32) 3.7 Chakraborty 2021 0.33 ( 0.29, 0.38) 3.7 Jose 2021 0.75 ( 0.67, 0.82) 3.7 Karmakar 2021 0.90 ( 0.86, 0.93) 3.7 Khan 2021 0.86 ( 0.82, 0.90) 3.7 Pandey 2021 0.67 ( 0.59, 0.74) 3.7 Haritay 2020 0.68 ( 0.60, 0.75) 3.7 Kamthan 2020 0.56 ( 0.50, 0.62) 3.7 Kumar 2020 0.43 ( 0.36, 0.50) 3.7 Luthra 2020 0.34 ( 0.28, 0.41) 3.7 Singh 2020 0.67 ( 0.59, 0.74) 3.7 Gupta 2018 0.49 ( 0.44, 0.53) 3.7 Nivetha 2018 0.80 ( 0.75, 0.84) 3.7 Rebello 2018 0.34 ( 0.26, 0.43) 3.6 Taneja 2018 0.44 ( 0.37, 0.51) 3.7 Aggarwal 2017 0.49 ( 0.41, 0.57) 3.7 Chellaiyan 2017 0.85 ( 0.82, 0.88) 3.7 Chenganakkattil 2017 0.72 ( 0.65, 0.79) 3.7 Kumar 2017 0.84 ( 0.80, 0.87) 3.7 Samanta 2017 0.38 ( 0.32, 0.45) 3.7 Chaudhary 2016 0.48 ( 0.43, 0.53) 3.7 George 2016 0.30 ( 0.25, 0.35) 3.7 Kumar 2016 0.34 ( 0.29, 0.39) 3.7 Naveen 2015 0.33 ( 0.26, 0.41) 3.7 Suman 2015 0.47 ( 0.38, 0.56) 3.6 Overall 0.54 ( 0.45, 0.63) 100.0 Q=1737.98, p=0.00, I2=99% 0.2 0.3 0.4 0.5 0.6 Prevalence 0.7 0.8 0.9 Figure 4: Forest plot for prevalence of Stress among undergraduate Indian medical students Suicide Ideation Study Prev (95% CI) % Weight Arun 2022 0.19 ( 0.15, 0.23) 20.1 Desai 2021 0.09 ( 0.06, 0.11) 20.1 Nesan 2020 0.13 ( 0.10, 0.16) 20.1 Goyal 2012 0.54 ( 0.48, 0.60) 19.9 Jain 2012 0.20 ( 0.16, 0.25) 19.9 Overall 0.21 ( 0.09, 0.35) 100.0 Q=204.10, p=0.00, I2=98% 0.05 0.1 0.15 0.2 0.25 0.3 0.35 Prevalence 0.4 0.45 0.5 0.55 0.6 Figure 5. Forest plot for prevalence of Suicide Ideation among undergraduate Indian medical students The characteristics of included studies are shown in Table 1; 30 studies reported prevalence rates of depression, 22 reported prevalence rates of anxiety, 27 studies reported prevalence of stress, and 5 reported prevalence of suicide ideation. Quality of Included studies: Table 2 shows the Quality score of included studies. Out of all included studies, 42 were of high quality with score ≥3 except one study [76] which had score equal to 2. Prevalence of Depression: The review of 30 studies (n= 11737) found that the prevalence of depression among medical students in India ranged from 14% to 95%, with a combined prevalence of 48% (95% CI: 41-55%). The significant heterogeneity between studies was present (I2= 98%, p=0.00) (Figure 2) Prevalence of Anxiety: According to the analysis of 22 studies (n=8011) which reported anxiety, the prevalence of anxiety among medical students in India was found to range from 19% to 97%, with an overall combined rate of 50% (95% CI 42-58%). There was significant heterogenicity (I2=98%, p=0.00). (Figure 3) Prevalence of Stress: The pooled prevalence of stress among the 27 included studies (n=8412) was 54% (95% CI 45-63%), with individual studies reporting prevalence rates ranging from 27% to 90%. There was significant heterogenicity (I2=99%, p=0.00). (Figure 4) National Journal of Community Medicine│Volume 15│Issue 10│October 2024 Page 875 Kaur H et al. Depression by Gender Subgroup Analysis Study or Subgroup Prev (95% CI) % Weight Male Karthik 2022 (Male) 0.52 ( 0.44, 0.59) 3.9 Lepcha 2022 (Male) 0.14 ( 0.09, 0.20) 3.9 Karmakar 2021 (Male) 0.93 ( 0.88, 0.96) 3.9 Kukreja 2021(Male) 0.22 ( 0.15, 0.29) 3.9 Solanki 2021 (Male) 0.39 ( 0.31, 0.47) 3.9 Patnaik 2020 (Male) 0.67 ( 0.63, 0.71) 4.0 Singh 2020 (Male) 0.48 ( 0.38, 0.57) 3.8 Gupta 2018 (Male) 0.69 ( 0.61, 0.77) 3.8 Kumar 2017 (Male) 0.48 ( 0.41, 0.54) 3.9 Kumar 2016 (Male) 0.37 ( 0.29, 0.46) 3.8 Rawat 2016 (Male) 0.55 ( 0.47, 0.62) 3.9 Yadav 2016 (Male) 0.54 ( 0.47, 0.60) 3.9 Suman 2015 (Male) 0.53 ( 0.41, 0.66) 3.7 Male subgroup 0.50 ( 0.38, 0.62) 50.1 Q=411.11, p=0.00, I2=97% Female Karthik 2022 (Female) 0.46 ( 0.39, 0.53) 3.9 Lepcha 2022 (Female) 0.28 ( 0.22, 0.34) 3.9 Karmakar 2021 (Female) 0.97 ( 0.93, 0.99) 3.9 Kukreja 2021 (Female) 0.29 ( 0.22, 0.37) 3.9 Solanki 2021 (Female) 0.35 ( 0.29, 0.41) 3.9 Patnaik 2020 (Female) 0.67 ( 0.61, 0.72) 3.9 Singh 2020 (Female) 0.62 ( 0.47, 0.75) 3.6 Gupta 2018 (Female) 0.76 ( 0.71, 0.81) 3.9 Kumar 2017 (Female) 0.49 ( 0.42, 0.56) 3.9 Kumar 2016 (Female) 0.38 ( 0.31, 0.45) 3.9 Rawat 2016 (Female) 0.64 ( 0.55, 0.72) 3.8 Yadav 2016 (Female) 0.64 ( 0.54, 0.72) 3.8 Suman 2015 (Female) 0.47 ( 0.34, 0.59) 3.7 Female subgroup 0.55 ( 0.42, 0.67) 49.9 0.53 ( 0.44, 0.61) 100.0 Q=449.62, p=0.00, I2=97% Overall Q=861.09, p=0.00, I2=97% 0.1 0.2 0.3 0.4 0.5 0.6 Prevalence 0.7 0.8 0.9 1 Figure 6: Subgroup analysis by Gender, Depression prevalence Anxiety by Gender Subgroup Analysis Study or Subgroup Prev (95% CI) % Weight Male Shah 2023 (Male) 0.35 ( 0.30, 0.40) 5.7 Karthik 2022(Male) 0.59 ( 0.51, 0.66) 5.6 Lepcha 2022 (Male) 0.47 ( 0.39, 0.55) 5.6 Karmakar 2021 (Male) 0.95 ( 0.91, 0.98) 5.6 James 2018 (Male) 0.25 ( 0.14, 0.38) 5.3 Hakim 2017 (Male) 0.47 ( 0.41, 0.54) 5.6 Kumar 2016 (Male) 0.48 ( 0.40, 0.57) 5.6 Yadav 2016 (Male) 0.72 ( 0.66, 0.78) 5.6 Suman 2015 (Male) 0.58 ( 0.46, 0.71) 5.4 Male subgroup 0.55 ( 0.40, 0.71) 49.9 Shah 2023 (Female) 0.19 ( 0.14, 0.24) 5.7 Karthik 2022 (Female) 0.62 ( 0.55, 0.69) 5.6 Lepcha 2022 (Female) 0.47 ( 0.41, 0.53) 5.6 Karmakar 2021 (Female) 0.99 ( 0.96, 1.00) 5.6 James 2018 (Female) 0.33 ( 0.23, 0.43) 5.5 Hakim 2017 (Female) 0.47 ( 0.40, 0.55) 5.6 Kumar 2016 (Female) 0.55 ( 0.48, 0.62) 5.6 Yadav 2016 (Female) 0.68 ( 0.59, 0.77) 5.5 Suman 2015 (Female) 0.65 ( 0.52, 0.77) 5.4 Female subgroup 0.57 ( 0.38, 0.75) 50.1 0.56 ( 0.44, 0.67) 100.0 Q=284.30, p=0.00, I2=97% Female Q=424.63, p=0.00, I2=98% Overall Q=711.52, p=0.00, I2=98% 0.1 0.2 0.3 0.4 0.5 0.6 Prevalence 0.7 0.8 0.9 1 Figure 7: Subgroup analysis by Gender, Anxiety prevalence National Journal of Community Medicine│Volume 15│Issue 10│October 2024 Page 876 Kaur H et al. Stress by Gender Subgroup Analysis Study or Subgroup Prev (95% CI) % Weight Male Karthik 2022 (Male) 0.29 ( 0.22, 0.36) 6.3 Karmakar 2021 (Male) 0.90 ( 0.84, 0.94) 6.3 Gupta 2018 (Male) 0.74 ( 0.66, 0.82) 6.3 Nivetha 2018 (Male) 0.79 ( 0.73, 0.85) 6.3 Rebello 2018 (Male) 0.39 ( 0.28, 0.51) 6.2 George 2016 (Male) 0.22 ( 0.15, 0.30) 6.3 Kumar 2016 (Male) 0.28 ( 0.21, 0.36) 6.3 Suman 2015 (Male) 0.55 ( 0.42, 0.67) 6.1 Male subgroup 0.53 ( 0.31, 0.74) 50.0 Karthik 2022 (Female) 0.26 ( 0.20, 0.32) 6.3 Karmakar 2021 (Female) 0.90 ( 0.84, 0.94) 6.3 Gupta 2018 (Female) 0.87 ( 0.83, 0.91) 6.3 Nivetha 2018 (Female) 0.80 ( 0.73, 0.86) 6.3 Rebello 2018 (Female) 0.27 ( 0.16, 0.40) 6.1 George 2016 (Female) 0.35 ( 0.28, 0.42) 6.3 Kumar 2016 (Female) 0.38 ( 0.31, 0.45) 6.3 Suman 2015 (Female) 0.38 ( 0.26, 0.51) 6.1 Female subgroup 0.54 ( 0.32, 0.76) 50.0 0.54 ( 0.39, 0.68) 100.0 Q=320.25, p=0.00, I2=98% Female Q=441.36, p=0.00, I2=98% Overall Q=766.67, p=0.00, I2=98% 0.2 0.3 0.4 0.5 0.6 Prevalence 0.7 0.8 0.9 Figure 8: Subgroup analysis by Gender, Stress prevalence Figure 9: Subgroup analysis by Gender, Suicide prevalence National Journal of Community Medicine│Volume 15│Issue 10│October 2024 Page 877 Kaur H et al. Prevalence of Suicide ideation: A total of 5 studies (n=1611) were identified which reported suicide ideation in medical students in India. The prevalence rate varied from 9% to 54%. The pooled prevalence of suicide ideation among medical students of 5 included studies was 21% (95% CI: 9-35%). There was significant heterogenicity (I2=98%, p=0.00). (Fig 5) Publication Bias: Publication bias for depression, anxiety, stress and suicide ideation, the DOI plot shows no asymmetry confirming the absence of bias for depression (LFK=.22), for anxiety (LFK=.61) and suicide ideation (LFK=0.86) (Figure S3) respectively but shows minor asymmetry for stress (LFK=1.84). (Figure: S1-S4) Sensitivity Analysis: Sensitivity analyses were conducted using the leave-one-out method. This involved sequentially removing one study at a time from the analysis and recalculating the pooled prevalence and I2 of the remaining studies. This allowed for the identification of individual studies that significantly impacted the pooled prevalence or heterogeneity. Depression: Seven studies [40,42,46,51,52,53,61] found to be the major determinants of the pooled prevalence of depression among undergraduate medical students and seven studies [39,41,47, 56,63,65,74] found to be the major source of heterogeneity. (Supplementary file: Table S2) Anxiety: Sensitivity analysis showed that six studies [37,38,51,52,58,64] severely affected the pooled prevalence of anxiety among undergraduate medical students. Six studies [40,49,63,8,65,73] found to be the major source of heterogeneity. (Supplementary file: Table S3) Stress: The sensitivity analysis revealed that nine studies [35,36,39,41,52,60,68,69,73] were the primary determinants of the pooled prevalence of stress among undergraduate medical students, and seven studies [50,51,57,61,62,67,74] substantially contributed to the observed heterogeneity. (Supplementary file: Table S4) Suicide Ideation: Sensitivity analysis showed that one study [42] comparatively the prime determinant of the pooled prevalence of suicide ideation and two studies [38,76] found to be major source of heterogeneity among undergraduate medical students. (Supplementary file: Table S5) Subgroup analysis by Gender Subgroup analysis of the prevalence of depression, anxiety, stress and suicide ideation by gender is listed in Figure 6-9 respectively. Depression: According to a synthesis of 13 studies that reported subgroup prevalence by gender, the pooled prevalence of depression was 50% (95% CI: 38-62%) for male medical students and 55% 55% (95% CI: 42-67%) for female medical students. (Figure 6) Anxiety: A total of 9 studies reported subgroup data by gender for the prevalence of Anxiety with pooled prevalence for male 55% (95% CI: 40-71%) and with pooled prevalence for female 57 % (95% CI: 3875%). (Figure 7) Stress: The pooled prevalence of stress was 53% (95% CI: 31-74%) for male medical students and 54% (95% CI: 32 -76%) for female medical students, as reported across 8 studies that provided subgroup data by gender. (Figure 8) Suicide Ideation: Only two studies reported subgroup data by gender for the prevalence of suicide ideation with pooled prevalence for male 26% (95% CI: 0-66%) and with pooled prevalence for female 34% (95% CI: 0 -92%). (Figure 9) Subgroup analysis by Screening Tools Subgroup analysis of the prevalence of depression, anxiety, stress and suicide ideation by screening tools is listed in Figure S5- S7 respectively. (Supplementary file) Screening tools for assessment of depression: All included studies used validated screening tools. The most common instrument used to identify depression was Beck Depression Inventory (BDI)>=10 and Depression Anxiety Stress Scale-21 (DASS-21)>=10 based on 5 studies each and resulting in pooled prevalence of 46% and 35% respectively. Other commonly used criteria included Depression Anxiety Stress Scale-42 (DASS 42)>=10 resulting in pooled prevalence of 61% based on 4 studies; Depression Anxiety Stress Scale-42 (DASS-42)>=14 resulting in pooled prevalence of 49% based on 3 studies; Patient Health questionnaire-9 (PHQ-9)>=5 resulting in pooled prevalence of 62% based on 3 studies and Hamilton Depression Rating Scale (HAM-D)>=7 based on 3 studies resulting in pooled prevalence of 55%. The results did not indicate a significant decrease in heterogeneity for any of the subgroups except for screening tool Hamilton Depression Rating Scale (HAM-D)>=7. (Supplementary file: Figure S5) Screening tools for assessment of anxiety: For anxiety symptom screening tools, all the studies used validated screening tools. 7 studies used the Depression Anxiety Stress Scale-42 (DASS-42)>=8 resulting in pooled prevalence of 64%; Depression Anxiety Stress Scale-21(DASS-21)>=8 resulting in pooled prevalence of 43% based on 5 studies; General Anxiety Disorder-7 (GAD-7) ≥10 yielded a pooled prevalence of 34% based on 2 studies. The results did not indicate a significant decrease in heterogeneity for any of the subgroups (Supplementary file: Fig.S6) Screening tools for assessment of Stress: All included studies used validated screening tools to evaluate stress. The most common instrument used to identify stress was Depression Anxiety Stress Scale-42 (DASS-42)>=15 based on 6 studies each and resulting in pooled prevalence of 52%. Other commonly used criteria included Depression Anxiety Stress Scale-21 (DASS 21)>=15 resulting in pooled National Journal of Community Medicine│Volume 15│Issue 10│October 2024 Page 878 Kaur H et al. prevalence of 35% based on 5 studies; Perceived Stress Scale-10 (PSS-10)>=14 resulting in pooled prevalence of 80% based on 3 studies; Perceived Stress Scale-10 (PSS-10)>=20 resulting in pooled prevalence of 43% based on 2 studies; Perceived Stress Scale-14 (PSS-14)>=28 resulting in pooled prevalence of 38% based on 2 studies; Students Stress Dimension Questionnaire (SSDQ)>=1 Domain based on 2 studies resulting in pooled prevalence of 67%. No meaningful reduction in heterogeneity was observed across the examined subgroups except for screening tool Students Stress Dimension Questionnaire (SSDQ)>=1 Domain. (Supplementary file: Figure S7) Screening tools for assessment of suicide ideation: Each of five included studies used different screening tools to evaluate suicide ideation. Four studies [37,41,52,75] used validated screening tools while one study conducted by Jain et al [76] used unvalidated custom questionnaire to evaluate suicide ideation. Excluding the study by Jain et al. did not substantially impact the overall reported prevalence (20%, according to the leave-one-out analysis). DISCUSSION This systematic review and meta-analysis provide the comprehensive estimate of the prevalence of depression, anxiety, stress and suicide ideation among undergraduate medical students in India derived from pooling data from 43 observational studies with a total of 15,557 students. Present review suggests that almost half (48%) of the undergraduate medical students in India were suffered from depression while individual studies reported prevalence varied from 14% to 95%. This meta-analysis also found that more females (55%) than males (50%) were affected from depression. These findings are similar to the findings of the systematic review conducted earlier in India that reported that half of the medical students in India were affected by depression and more females than males were affected.77 This variation of the depression among males and females may reflect the trend in the general population which reported that depression is widely prevalent in women in all age groups especially in India.78 All the studies included in present analysis to assess depression in undergraduate medical students used widely used validated tools. Most common tools used to assess depression were Beck Depression Scale (BDI); Depression Anxiety Stress Scale (DASS 21) and Depression Anxiety Stress Scale (DASS-42) with cutoff 10. Pooled prevalence of depression assessed by these tools was 46%, 35% and 61% respectively. The specific threshold selected to designate an individual as depressed can significantly impact the reported rates of depression. A common cutoff point utilized for both the Beck Depression Inventory and the Depression Anxiety Stress Scales is a score of 10 or higher. Raising the cutoff value would likely lead to a lower reported prevalence of depressive symptoms. Overall, pooled prevalence found to be high among undergraduate medical students in India which is a cause of concern. Several reasons may account for this result. Given the direct impact of the medical profession on human life, the educational requirements for aspiring medical professionals are particularly rigorous and demanding in comparison to other academic disciplines. In present meta-analysis, half (50%) of the medical students were found to be affected by anxiety while individual studies reported prevalence varied from 19% to 97%. Previous review reported a pooled prevalence of anxiety among medical students of 33.8% worldwide79 and a systematic review included undergraduate medical students conducted in 2015 in India had reported the pooled prevalence for anxiety 34.5%.28 Present meta-analysis suggests that incidence of anxiety has increased in recent years to a greater extent. Present review found that more females than males suffered from anxiety which is similar to the findings of another review which suggested that female medical students were more vulnerable to anxiety than male students.80 Most common tool to evaluate anxiety was Depression Anxiety Stress Scale-42 (DASS-42) and Depression Anxiety Stress Scale-21(DASS-21) with a cut off 8 resulting in pooled prevalence of 65% and 43% respectively. However, the difference in prevalence values of different screening tools may be due to substantial differences in sample size of subgroups. The results of our study indicate that anxiety disorders in medical students warrant serious consideration, prompt diagnosis, and supportive intervention by medical school faculty and administration. Present meta-analysis reported more than half (54%) of the undergraduate medical students in India were affected by stress while individual studies reported prevalence varied from 27% to 90%. These findings are similar to the findings of existing review which reported that more than half of the medical students were affected from stress and more females than males found to be affected.28 Similar results were reported from another systematic review that reported pooled prevalence of stress to be 49.9% among medical students in Brazil.81 Also, present review showed both the genders were almost equally affected by stress. The most common instrument used to identify stress was Depression Anxiety Stress Scale-42 (DASS-42) and Depression Anxiety Stress Scale-21 (DASS-21) with the cut off 15 resulting in pooled prevalence of 52% and 35% respectively. Present review reported considerably higher prevalence of suicide ideation (21%) among medical students in India as compared to another systematic review that reported prevalence of suicide ideation amongst medical students 11% around the world and 13% in China.82,83 Higher prevalence of suicide ideation among undergraduate medical students in India is a serious cause of concern. Suicidal ideation National Journal of Community Medicine│Volume 15│Issue 10│October 2024 Page 879 Kaur H et al. has been found to be closely associated with other mental health conditions, including depression and anxiety. The intense academic demands placed on medical students are believed to be a significant contributing factor to suicidal ideation among this population. Present analysis showed more females to be affected by suicide ideation than males. This result is similar to another meta-analysis which showed that more females than males had suicidal ideation.84 The observed gender disparity in suicidal ideation may be attributed to societal expectations, wherein males are anticipated to be self-reliant and resolute, while females are expected to be dependent and indecisive, often expressing their distress through rumination. Suicidal ideation carries a high risk of transitioning into actual suicidal attempts and actions, potentially resulting in fatal and irreversible outcomes.85 Therefore, providing increased access to mental health counselling and education on suicide prevention should be prioritized for medical students, in order to mitigate these adverse psychological outcomes. In India, government has taken various steps in this direction time to time to help medical students by implementing various program. Student mentorship program has been introduced by National Medical Commission (NMC) in India to provide career-related information, General support, counselling on handling job stress and anxieties and sharing the successful experiences by mentors in managing mental health challenges. Moreover, recently national medical commission has formed a Task Force aimed at supporting students dealing with depression and suicidal tendencies. Though the implementation success of these programs across various institutes needs to be evaluated. STRENGTHS Our study exhibits no evidence of publication bias, as demonstrated by the funnel plots and Egger's regression analyses. Moreover, the outcomes were not notably affected by leave-one-out sensitivity analyses. All the studies included in the analysis to evaluate depression, anxiety and stress used validated screening tools except one study. Lastly, all the studies used appropriate statistical methods and most of the studies have a low risk of bias with high response rates. All the studies except one study showed high quality assessment score. This systematic review and metaanalysis could be an important warning and reminder regarding the current status of psychological morbidities among undergraduate medical students in India. LIMITATIONS The use of self-assessment instruments to screen for mental health issues in the included studies may have affected the precision of the results. The absence of further evaluation of the individuals identi- fied as having positive mental health concerns could have influenced the reliability of the findings. Potential associated factors to mental health problems were not studied which are important to know the most contributing factors to mental health problems in medical students. CONCLUSION Almost half of the medical undergraduate students in India were found to be suffered by depression, anxiety and stress and almost one fifth of the students found to be affected by suicide ideation. More females than males found to be affected by these mental problems. This high prevalence of psychological disorders in undergraduate medical students in India emphasize the need for the counselling services to be made available to the students in the medical college to control this morbidity. To target the source of the students’ mental health issues, Institutes should implement long term policies and programs. Regular and Prompt mental health evaluations and support measures should be put in place to prevent these issues from escalating into more serious psychological conditions. REFERENCES 1. Guthrie EA, Black D, Shaw CM, Hamilton J, Creed FH, Tomenson B, et al. Embarking upon a medical career: Psychological morbidity in first year medical students. Med Educ. 1995;29:337-41. 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