ORIGINAL ARTICLE

Anxiety, depression and quality of life of medical students

in Malaysia

Gin-Gin Gan, FRCP1, Yuen-Ling Hue, MBBS2

1
Department of Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia, 2 Department of Obstetric, Tunku
Jaafar Hospital, Seremban, Negeri Sembilan, Malaysia

ABSTRACT
Background: Medical education is known to be highly
of anxiety varies between 7.7% to 65.5% and the prevalence

stressful and challenging. Many medical students suffer

rate of depression can range from 6% to 66%.4,5 In Malaysia,

from psychological stress which may lead to burnout and

44% and 34.9% of medical students attending a private

poor academic performances. Quality of life (QOL) of

university had been reported to have some level of anxiety

medical students is also affected. In this study, we aim to

and depression respectively.6 Another study by a public

determine the prevalence of anxiety and depression of the

university in Malaysia demonstrated that 48.6% of first and

senior medical students and to assess their QOL.

third year medical students have some level of psychological
stress.7 Psychological status of final year medical students,

Methods: This is a cross-sectional study which involved

who usually have major barrier examinations before

medical students in their final two years of study at a public

entering their internship programmes in Malaysia had also

university in Malaysia. Self-administered Hospital Anxiety

been studied and the prevalence rate of anxiety and

and Depression scale (HADS) and World Health

depression were reported to be as high as 56% and 21.7%

Organisation QOL questionnaire (WHOQOL-BREF) were

respectively.8,9

used to assess their psychological symptoms and QOL. Quality of life (QOL) is another aspect in one’s evaluation of

Results: A total 149 students participated. The prevalence

health status, which is increasingly becoming more relevant

rates of anxiety and depression were 33% and 11%

and important. Many studies which had consistently showed

respectively. Malay students had significantly more anxiety

that QOL is negatively affected by the presence of anxiety

compared to the other ethnic groups, P<0.05. Female

and depression.10-12 Previous studies from many countries had

students had significantly lower psychological score

demonstrated that medical students had lower QOL

compared to male; 70.73 vs 66.32(P<0.05). Anxiety and

compared to their peers.13,14 However, not many had

depression were associated with significantly poorer QOL.

specifically looked into the association of anxiety and

Students with depression symptoms were associated with

depression with QOL, especially within the Asian countries. It

lower physical, psychological and environmental domain

is usually thought that Asian students faced more pressure

score whereas those with anxiety had lower psychological,

from parents and teachers to perform well and this may

social and environmental scores, P<0.05. Overall QOL score

inadvertently cause more stress to the students.15 Therefore, it

was significantly lower in Chinese students (P<0.05) and

is critical to determine the prevalence of anxiety and

those with depression (P<0.001).

depression among medical students and to assess their QOL
in relation to these psychological symptoms. This is especially

Conclusion: QOL of medical students are significantly

pertinent as evidences had shown that mental disorders and

affected by the presence of anxiety and depression. It is

stress can lead to multitude of problems such as burnout,

recommended that medical schools implement measures

suicide and serious professional misconducts.16,17

which can identify students at risk and to offer

comprehensive intervention and preventive programmes to
This study aims to determine the prevalence of anxiety and

improve the students’ wellbeing.

depression of medical students in their final two years of
study in a public university in Malaysia. We also aim to

KEy WORDS:
assess the QOL of these medical students. The findings of this
study will hopefully provide useful information to the
Anxiety, depression, medical students university.

INTRODUCTION MATERIALS AND METHODS

It is a well-known fact that medical education is generally This is a cross-sectional study which included medical
more intensive and takes longer duration to complete students in their final two years of training at one of the
compared to many other courses. It is therefore not surprising public medical schools in Malaysia. The study was conducted
that medical students experience higher risk of anxiety and from May 2015 to August 2015. The study was approved by
depression compared to the general population.1-5 The the deputy dean of undergraduate study at that time and also
prevalence of anxiety and depression differs in different the institution ethic committee.
universities and countries, where the reported prevalence rate
This article was accepted: 20 August 2018
Corresponding Author: Dr Gin Gin Gan
Email: gangg@ummc.edu.my

Med J Malaysia Vol 74 No 1 February 2019 57

Original Article

Scoring for anxiety and depressive symptoms were made by psychological domain (68.09). Social domain had the
based on validated Hospital Anxiety and Depression Scale lowest mean score of 65.97. There was no significant
(HADS).18 HADS had a total of 14 items which were divided difference in the mean scores of all QOL domains amongst the
into two subscales, anxiety subscale (seven items) and three ethnic groups. (Table II)
depression subscale (seven items). A score of 0 to 7 indicates
absence of symptoms of anxiety or depression; HADS score of Female students had significantly lower psychological score
8-10 indicates presence of symptoms i.e. borderline or mild compared to male; 70.73 vs 66.32(P<0.05). Household income
and score of 11 or greater indicates significant symptoms. played a significant role in all QOL domains except for overall
health score. Students who exhibited anxiety and/or
WHO QOL-BREF is a validated questionnaire which is depression symptoms were associated significantly with lower
commonly used to evaluate QOL.19,20 The WHOQOL-BREF overall mean QOL score and all domains of QOL except for
contains a total of 26 questions. One question on overall overall health score. However, students who had clinically
perception of QOL, one question on overall perception of significant depression and/or anxiety (HADSA≥11 and
health and the remaining questions evaluate the four HADD≥11) did not significantly associate with lower social
domains of QOL; seven questions on physical health, six domain scores. (Table III)
questions on psychological domain, three questions on social
domain and eight questions on environmental domain. For After multivariate linear analysis, overall QOL score was now
question on overall perception of QOL and health, raw score found to be significantly affected by ethnicity and those with
was used. Whereas, scores of the four domains are calculated depression symptoms. Physical health, psychological and
and then transformed to a 0-100 scale; according to the environmental domain scores were significantly lower in
manual provided. The domain scores were scaled in a students with depression. Students with anxiety symptoms
positive direction whereby higher score denotes higher were associated with lower psychological, social and
quality of life. environmental scores. Students from well to do financial
background reported significantly better environmental score.
The questionnaires were delivered to the students after Gender did not play any significant role in the differences of
lectures and collected on the same day. Basic demographic QOL scores. (Table IV)
information is also collected at the same time. All the

DISCUSSION
information was anonymised.

Demographic characteristics including anxiety and According to a systematic review, 7.7% to 65.5% of medical
depression and mean score of QOL were analysed using chi- students outside of United States had anxiety.4 In this study,
square or t-test where appropriate. Multiple linear regression we found 33% of the students had anxiety symptoms and
analysis was used to determine any independent associations 14% had significant anxiety. On the other hand, 11% of our
when needed. P value of <0.05 was considered as clinically students had symptoms of depression and only 3.4% had
significant. Data was analysed using the Statistical Package significant symptoms of depression. It would appear that
for Social Sciences (SPSS) version 17.0. psychological stress in these students are lower than what
was reported in a private medical university and another

RESULTS
public university in Malaysia.6,9 The difference in the
prevalence rate was probably due to the different cohort of
A total of 154 students participated in this study but five were students recruited. The lower incidence of psychological stress
excluded due to incomplete information. Only 38 students in among the senior medical students was also consistently
year four participated in the study and the remaining 111 demonstrated in other studies and this was explained by the
students were in their final year. Majority of the students experience and the maturity of the final year medical
(97%) entered university after completion of matriculation or students in dealing with examinations and the skills they
basic science foundation programme. All students were have developed in coping with the curriculum.22,23 However,
staying in hostels provided by university at the time of when we compared with other Asian countries, the
participation. Other sociodemographic information of the prevalence rate of anxiety in our cohorts was also lower, for
medical students was summarised in Table I. Thirty-three example Pakistan reported a prevalence rate of anxiety to be
(33%) of the students had presence of anxiety symptoms with 60%.24 However, according to the systematic review by
14% of them complained of significant symptoms. On the Cuttilan et al, pooled prevalence rate of anxiety was 7.04%
other hand, 11% had symptoms of depression, of which 3.4% in Asia where China reported the lowest rate.25 The difference
had significant symptoms of depression. Malay students had in the prevalence rate of anxiety within countries and regions
more anxiety symptoms compared to the other two ethnic is interesting as many postulate that there may be different
groups, P<0.05. There was no difference in the prevalence of coping mechanism used by different populations.
depressive symptoms and ethnicity. Gender, marital status,
religion and household income did not significantly associate Malay students appeared to report more anxiety symptoms
with anxiety and depression. There was no significant when compared to the other two ethnic groups. Similar
difference in anxiety and depression in the two different years finding was reported by Shamsudin et al., where Malay
of students. students had the highest stress score compared to the other
two ethnicity groups, however the students they surveyed
The mean scores for QOL and health were 4.02 and 3.98. The were not limited to medical programmes.26 The difference
mean scores of all domains of QOL are showed in Table I. may be explained by the different coping mechanisms of
Physical domain had the highest mean score (70.44) followed each culture groups.

58 Med J Malaysia Vol 74 No 1 February 2019

 Anxiety, depression and quality of life of medical students in Malaysia

Table I: Characteristics of Medical Students

No (%)
Age Median (years) 23 (range 22-24)
Gender Male 64 (43)
Female 85 (57)
Ethnicity Malay 70 (47)
Chinese 72 (48.3)
Indians 7 (4.7)
Marital status Yes 2 (1.3)
No 147 (98.7)
Household monthly income (RM) <2000 41(27.5)
2000-4999 56(37.6)
5000-9999 29(19.5)
≥10000 23(15.4)
HADS Anxiety <8 100 (67)
8-10 28 (18.7)
≥11 21 (14)
HADS Depression <8 132 (88.6)
8-10 12(8)
≥11 5(3.4)
QOL mean score 4.02(±0.636)
Overall health mean score 3.98 (±0.688)
Physical domain mean score 70.58(±12.98)
Psychological domain mean score 68.21(±13.06)
Social relation mean score 66.07(±15.19)
Environment mean score 67.06(±12.81)

Table II: Anxiety, depression and QOL domains of the three ethnic groups of students
Malay (n=70) Chinese (n=72) Indian (n=7) P value
HADA≥8
N (%) 30(61) 19(39) 0(0) 0.02*
HADA≥11
N(%) 13(62) 8(38) 0(0) 0.15
HADD≥8
N(%) 10(59) 7(41) 0(0) 0.43
HADD≥11 N(%) 2(40) 3(60) 0(0) 0.67
Overall QOL
score 4.14 3.92 4.00 0.06
Overall health score 4 4 3.71 0.56
Physical score 70.13 70.91 71.57 0.68
Psychological score 68.73 67.75 67.85 0.68
Social score 68.2 63.58 70.42 0.27
Environment score 66.6 67.83 63.57 0.94
*significant P value

Table III: Association of anxiety and depression with QOL

HADA P value HADA P value HADD P value HADD P value
<8 ≥8 ≥11 <8 ≥8 ≥11
(n=100) (n=49) (n=21) (n=132) (n=17) (n=5)
Overall QOL 4.13 3.81 0.004 3.67 0.005 4.1 3.41 <0.001 2.6 <0.001
Overall health 4.01 3.94 0.5 3.98 0.92 4.01 3.76 0.55 4.0 0.9
Physical 73.11 65.41 <0.001 59.80 0.00 72.01 59.41 <0.001 56.4 0.01
Psychological 71.54 61.43 <0.001 55.76 0.00 70.22 52.64 <0.001 40.0 <0.001
Social 69.86 58.35 <0.001 61.38 0.127 67.67 53.71 <0.001 57.6 0.2
Environment 69.92 61.22 <0.001 58.14 0.00 68.54 55.53 <0.001 47.4 <0.001

Table IV: Multiple linear regression analysis with beta coefficient values of all QOL domains and students’ characteristics and
anxiety and/or depression symptoms
Variables Overall QOL Overall health Physical Psychological Social Environmental
Ethnicity -0.229* -- -- -3.28 -- --
Gender -- -- -- -- -- --
Household income 0.025 -- 1.266 -0.389 0.869 1.527*
HADA >8 -0.155 -- -3.95 -6.08* -8.66* -4.99*
HADD>8 0.317* -- -9.51* -12.27* -7.33 -9.11*
• * P value <0.05

Med J Malaysia Vol 74 No 1 February 2019 59

Original Article

Our results demonstrated that females had significantly to improve students’ resilience and mental health with
lower psychological domain, similar to reports elsewhere.28,29 encouraging results.38-40 Mentorship programmes which may
Females may be more sensitive to pressure and were more be useful in helping students in coping with life stressors and
emotional, maybe some of the possible reasons.2,28,30 Students academic training is currently implemented in our
from better financial background reported better university. Programme such as this has demonstrated
environmental scores which again were consistent with other positive effects on medical students’ mental wellbeing in
study.31 other countries.41 In addition, there are several studies which
have demonstrated that mindfulness training may be
In this study, students who had anxiety symptoms were more effective in increasing students’ resilience and reduce
likely to have lower scores in psychological, social and psychological stress.42-43 This may be one of the strategies
environmental domains. Whereas, students who had university may consider implementing.
depression symptoms had lower scores in all domains except
for overall health score. This finding highlights the impact of In conclusion, this study confirmed that QOL of medical
anxiety and depression on QOL which also concurs with students are affected by anxiety and depression and further
many other studies.32 highlights the importance of medical school to develop
strategies to identify students at risk of mental stress and to
Interestingly, we also found that ethnicity significantly perhaps improve the current support systems for students.
affected the scores of overall QOL where Chinese students

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