ORIGINAL ARTICLE

Efficacy of behavioral intervention in reducing

anxiety and depression among medical students
A B S T R A C T
Velayudhan A., Background: Now a days, college students frequently have more complex problems
S. Gayatridevi1, Rita Rani than they used to have over a decade ago greater difficulties in relationships;
and more severe problems, such as depression, anxiety and thoughts of suicide.
Bhattacharjee1 Counseling helps students to understand themselves and the world around them, and
Departments of Psychology, to adjust themselves more efficiently and appropriately to other fellow beings. Aim:
Bharathiar University, To determine as to what extent the medical students were able to cope up with their
Coimbatore; 1Avinashilingam anxiety and depression with the help of counseling. Materials and Methods: In the
University for Women, experimental design Before-and after with control design, Beck Anxiety Inventory
Coimbatore, Tamil Nadu, India
and Beck Depression Inventory were administered to 120 medical students who were
randomly selected from a private medical college, comprising of 30 males and 30
females in each of the two groups, viz., the experimental group and the control group.
Statistical analysis: Means, standard deviations, t test and one-way ANOVA were
used to analyze the data. Results: Anxiety and depression among the students were
found to be reduced after counseling. Male and female students in the experimental
Address for correspondence:
group showed decrease in the levels of anxiety and depression; whereas the control
Dr. A. Velayudhan, group, which did not get the benefit of counseling, continued to have the same
Department of Psychology, levels of anxiety and depression. Conclusion: Counseling is helpful in building self-
Bharathiar University, confidence and the capacity to adjust, by reducing anxiety and depression among
Coimbatore - 641 046, medical college students.
Coimbatore, India.
E-mail: avelayudham@rediffmail. Keywords: Anxiety, depression, intervention, relaxation, yoga
com

T oday, most societies, both in the developed and the

developing countries, view adolescents as immature
and ill-equipped individuals requiring guidance to help
them become responsible members of their communities.
In todays world, college students frequently have more
complex problems than they used to have over a decade
ago, including the typical or expected problems of college
student difficulties in relationships and developmental
issues; as well as the more severe problems, such as
depression, sexual assault and thoughts of suicide.
Counseling is, in its essence, a helping relationship. The
goal of counseling is to help individuals overcome many
of their future problems. Counseling service for adults
comprises a follow-up service, which may help counselees
secure continuing education and assistance for personal
Access this article online
Quick Response Code:
Website: www.industrialpsychiatry.org
DOI: 10.4103/0972-6748.77636
and occupational adjustments. Modern counseling is a
product of the educational system, which has deep roots
in terms of concern for the individuals freedom, rights,
dignity and worth as a human being. Counseling in the
educational context comprises a very important and vital
part of educational activities. Many students at different
levels of education have been found to function at levels
far below their capacities. Counseling would certainly
help brighten the lives of many young individuals. It
promotes emotional maturity, personality development,
self-responsibility, creativity and ability to solve problems.
Educational counseling has emerged as a discipline to
provide help to students on campus of schools, colleges
and universities, such that they are not tormented by their
internal conflicts, do not become cynical and do not resort
to self-destructive strategies. In recent times, education
has come to have a wider meaning, namely, counseling,
for it has increasingly been realized that learning in the
ultimate analysis is individual learning or self-learning. The
collegiate student is, for all practical purposes, an adult with
no adult responsibilities. Thus, a total counseling program
at the collegiate level would comprise an extension of the
various services provided to the pupils at the earlier stages
of their lives.

Industrial Psychiatry Journal  41 Jan-Jun 2010 | Vol 19 | Issue 1

 Velayudhan, et al.: Reducing anxiety and depression
Anxiety is experienced by every individual at some point or
the other in his/ her life. According to Coleman, Anxiety
is an internalized fear aroused by an impulse to commit
mistakes.[1] It is a series of symptoms, which arise from
faulty adaptation to the stresses and strains of life. Anxiety
is one of the most common problems faced by college
students. An author investigated examination-related
anxiety experienced by medical students, with the Visual
Analogue Scale for Anxiety (VASA) for three situational
cues usual day-to-day anxiety, highest anxiety associated
with major exams the previous year and anxiety experienced
during the end-of-term examination just completed.[2,3]
Twenty-eight weeks later, the students rated the anxiety
experienced by them during a subsequent end-of-term
psychiatry examination. For day-to-day anxiety, most
students rated themselves toward the lower end of the
VASA, though not markedly higher anxiety during the
end-of-term psychiatry examination.
According to Coleman, depression is an emotional state
characterized by extreme dejection, gloomy ruminations,
feelings of worthlessness, loss of hope, and often of
apprehension.[1] The World Health Organization has
declared depression as the leading cause of disability because
of its physical, psychological and social impacts.[4] The
researchers conducted a study on depression among 129
first year psychology students in South Africa.[5] The results
revealed that psychology students reported significantly
lower levels of depression than non-psychology students on
the Beck Depression Inventory. Students who experience
depression may feel an oppressive sense of sadness,
fatigue, guilt and hopelessness. Depression is a common
experience among college students, with one in seven
students experiencing it. Brought on by a combination of
students vulnerable age and the stress and demands of
college life, depression and related conditions can strike
for the first time in college, or come back to haunt those
who had first battled it in high school. Medical students are
more prone to depression than their non-medical peers.
Researchers noted that depression gets doubled among
medical students between the beginning and end of an
academic year.[6] Most people experience feelings of being
stressed out or anxious before an important event such
as an exam or a class speech. An author pointed out that
fear of failure is one of the sources of stress in a medical
school.[7] But many students face more than just normal
stress; their lives are filled with overwhelming worrying
and fear that are chronic and debilitating.
A researcher studied the relationship between depression and
anxiety among undergraduate students in 18 Arab countries
by a cross-cultural study.[8] Beck Depression Inventory was
administered to 9,168 participants, comprising 4,230 males
and 4,938 females, their ages ranging from 18 to 25 years.[9]
Findings indicated that depression was positively significant
Jan-Jun 2010 | Vol 19 | Issue 1 42
and correlated with anxiety. Authors studied the relation
of depression and anxiety to life stress and achievement
in students.[10] The result showed that 9% of previously
symptom-free students became depressed, and 20% became
anxious at a clinically significant level. The explosion in
medical knowledge means that every year they need to learn
more to update themselves.
The pace of receiving knowledge is faster in a medical
college than the student ever faced before. Authors stated
that stress, health-related and emotional problems increase
during the period of undergraduate medical education.[11]
This can lead to mental distress and has a negative impact
on cognitive functioning and learning. Any student who
has a scintilla of self-doubt will find that self-doubt got
activated and magnified during his/ her education in a
medical college. Countless hours spent in the library, harsh
exams, competitions, stress and a small-tonon-existent
income for several years, sum up the everyday life of many
medical students. Researchers found that unlike residents,
medical students are not protected by limits on work hours.[12]
Exam anxiety is the emotional reaction that some students
face before exams. It has been observed by Morrison that
medical students have marked undue stresses during pre-
examination and examination period.[13] Studying itself can
be stressful, but researchers found that there were specific
health-related effects of medical education, including high
levels of anxiety and depression. Suicidal ideation among
medical trainees has been investigated less often and only
periodically. The National College- Health Assessment Survey
found that 9.5% of students preparing for health-related fields
reported that they had experienced suicidal ideation.[14] Emotional
intelligence is highly associated with better psychological
adjustment. Individuals reporting greater emotional clarity
and a greater ability to repair their own emotional states report
higher levels of self-esteem, another important indicator of
mental health.[15] Researchers studied the prevalence of
emotional disorders using the English version of the General
Health Questionnaire-12 among respondents who were
medical students at a private medical school in Ipoh, Perak,
Malaysia.[16] The researchers indicated that the prevalence
of emotional disorders among the medical students was
high (46.2%). Previous studies on the psychological health
of physicians shows the medical community exhibits a
relatively high level of certain mental health problems,
particularly depression, which may lead to drug abuse and
suicide.[17] Counseling programs are essential among students
for subjective well-being and mental health. The positive
effects of such counseling services and stress management
programs are frequently reported.[18] The authors illustrated
the behavioral treatment of medical students and physicians
whose debilitating test-related anxiety was associated with
their failure to pass the United States Medical Licensing
Examination (USMLE).[19] Treatment featured progressive
Industrial Psychiatry Journal
 Velayudhan, et al.: Reducing anxiety and depression
muscle relaxation, systematic desensitization, the self-
control triad, behavioral rehearsal and a psycho-educational
component. Ninety-three percent of the clients eventually
passed the examination while in treatment. Pass rates for
this group were substantially higher than the national
average for repeat USMLE test takers.
OBJECTIVES
1. To analyze the levels of anxiety and depression among
medical students (pre-test and post-test).
2. To provide counseling sessions for depression and
anxiety.
3. To find out the differences in the levels of anxiety and
depression among the male and female students before
and after the counseling session.
Hypotheses
1. There will be no significant difference in anxiety
between the experimental and control groups before
counseling.
2. There will be no significant difference in anxiety
between the experimental and control groups after
counseling.
3. There will be no significant difference in depression
between the experimental and control groups before
counseling.
4. There will be no significant difference in depression
between experimental and control groups after
counseling.
5. There will be no significant difference in anxiety among
the boys of the experimental and control groups before
and after counseling.
6. There will be no significant difference in anxiety among
the girls of the experimental and control groups before
and after counseling.
7. There will be no significant difference in depression
among the boys of the experimental and control groups
before and after counseling.
8. There will be no significant difference in depression
among the girls of the experimental and control groups
before and after counseling.
MATERIALS AND METHODS
Sample
The sample consisted of 120 medical students; of them,
30 males and 30 females constituted the control group,
and 30 males and 30 females constituted the experimental
group. These students were randomly selected from the
population of a private medical college affiliated to a
foreign university.
Industrial Psychiatry Journal 
Tools
Beck anxiety inventory (1993):
Aaron Beck devised the Beck Anxiety Inventory in 1993.[20] It
is an inventory of 33 items; it evaluates the most common
symptoms of anxiety and panic, such as worry, fear of
dying, and a racing heart. The alternatives provided for each
statement or symptoms were, not at all, somewhat,
moderately and a lot. The scale consisted of 6
questions on anxious feelings; 11, on anxious thoughts;
and 16, on the physical symptoms of anxiety.
Beck depression inventory (1996):
Aaron Beck devised the revision format of Beck
Depression Inventory (BDI) in 1996.[9] The BDI is a 21-
item self-report inventory; it assesses emotional, cognitive
and physiological aspects of depression. The questionnaire
is composed of items relating to symptoms of depression,
such as hopelessness and irritability; of cognition, such as
guilt or feelings of being punished; and physical symptoms
such as fatigue, weight loss. Each of the 21 items of the
BDI attempts to assess an attitude that appears to be
specific to depressed people.
Procedure
The above two questionnaires were administered to the
subjects (n= 120) of experimental and control groups
before and after counseling. To the experimental group,
Counselling, relaxation techniques and meditation
were taught and it was ensured that it was practiced.
After 1 month, the two questionnaires were once again
administered to the subjects of both the groups.
Statistical analysis
Statistical analysis was done with the help of Statistical
Package for Social Sciences [SPSS]. The means and
standard deviations, t test and ANOVA were used to find
if there were significant difference between the groups.
RESULTS AND DISCUSSION
The mean scores and standard deviations with regard to
anxiety and depression were obtained for both the groups
of medical students before and after intervention, during
which counseling was provided for the experimental group.
One-way analysis of variance (ANOVA) was used to test
the significance of the difference between the mean scores
obtained by medical students in the areas of anxiety and
depression. The efficacy of counseling was also compared
using a control group. The following results were obtained
from the present study.
The means, standard deviations and the F ratio were
43 Jan-Jun 2010 | Vol 19 | Issue 1
 Velayudhan, et al.: Reducing anxiety and depression

calculated to find out if the difference in the level of Table 1: Anxiety among students of experimental
anxiety between the experimental and control groups and control groups before counseling
before counseling was significant. Table 1 shows that Anxiety n Mean Standard F
there was no significant difference between the two deviation
groups (experimental and control groups). It shows that Experimental group 60 24.07 11.04
0.46 NS
the groups were homogeneous. Therefore, the hypothesis Control group 60 25.13 5.07
There will be no significant difference in anxiety between NS= Not significant
the experimental and control groups before counseling.
is accepted. Table 2: Anxiety among experimental and control
groups after counseling
Table 2 shows the F ratio in one-way analysis of variance. Anxiety n Mean Standard F
Results showed there was significant difference in the anxiety deviation
level after counseling between the experimental and control Experimental group 60 8.07 4.89
301.33**
groups. Since the experimental group was given counseling, Control group 60 23.57 4.89
they were able to overcome the problems faced by them. The **= Significant at .01 level
control group did not receive any counseling; their problems
remained the same after the test. Therefore, the hypothesis Table 3: Depression among experimental and
There will be no significant difference in anxiety between the control groups before counseling
experimental and control groups after counseling. is rejected. Depression n Mean Standard F
deviation
Table 3 shows the values of mean, standard deviation Experimental group 60 35.77 7.16
1.46 NS
and the F ratio of the experimental and control groups Control group 60 34.40 5.08
before intervention, to find out if there was any significant NS= Not significant
difference in depression between the two groups. The
above table shows there was no significant difference Table 4: Depression among experimental and
between the two groups (control and experimental) with control groups after counseling
regard to depression before counseling. As both the groups Depression n Mean Standard F
belong to the same institution and suffer from more or deviation
less similar problems, the result indicated that there was Experimental group 60 25.47 3.29
133.56 **
no significant difference between them before counseling. Control group 60 33.60 4.35
Therefore, the hypothesis There will be no significant **= Significant at .01 level
difference in depression between the experimental and
control groups before counseling. is accepted. Table 5: Anxiety among boys in the experimental
and control groups before and after counseling
Table 4 shows the values of mean, standard deviation Anxiety n Before: After: 't'
and the F ratio, which reveals a significant difference mean mean
in depression between the experimental and control (SD) (SD)
groups. Because of counseling, depression was reduced Experimental group 30 24.07 8.07 7.20 **
(11.13) (4.94)
to a great extent for the experimental group. Therefore,
Control group 30 25.13 22.97 1.67 NS
the hypothesis There will be no significant difference in (5.11) (4.91)
depression between the experimental and control groups **= Significant at .01 level. NS= Not significant. SD = Standard Deviation
after counseling. is rejected.
the hypothesis There will be no significant difference in
Table 5 shows that there is a significant difference
anxiety among the boys of the experimental and control
between the level of anxiety experienced before and after
counseling among boys. This could be due to guidance and groups before and after counseling. is partially accepted.
support provided to the boys. The responses were quite
similar, both pre-test and post-test. Almost all students Table 6 shows the t values for the levels of anxiety
had problems regarding their coping up with the foreign experienced by the girls of the medical college before and
syllabus of their MBBS course except a few students who after counseling for both experimental and control groups.
had personal problems also. Without proper support and The results showed a significant difference in the anxiety
guidance, the boys in the control group had the same levels among the girls in the experimental group before and
problems as seen in the responses post-test, showing no after counseling, as an effect of counseling. But the control
significant difference before and after the test. Therefore, group remained the same with regard to anxious feelings.

Jan-Jun 2010 | Vol 19 | Issue 1 44 Industrial Psychiatry Journal

 Velayudhan, et al.: Reducing anxiety and depression

Therefore, the hypothesis There will be no significant Table 6: Anxiety among girls in experimental and
difference in anxiety among the girls of the experimental control groups before and after counseling
and control groups before and after counseling. is partially Anxiety n Before: After: 't'
accepted. mean mean
(SD) (SD)

Table 7 shows that there is a significant difference in the Experimental group 30 25.7 9.67 8.88 **
(8.99) (4.11)
levels of depression among boys in the experimental group Control group 30 26.83 23.57 1.70 NS
before and after counseling. They were given guidance with (4.08) (4.93)
regard to learning and routine work in the course of their **= Significant at .01 level. NS= Not Significant. SD= Standard deviation
day-to-day activities. There was no significant difference
in the pre-test and post-test levels of depression among Table 7: Depression among boys in experimental
boys of the control group. Boys of the medical college and control groups before and after counseling
seemed to be depressed regarding their academic level, Anxiety n Before: After: 't'
their surroundings, as well as the course that they were mean mean
undergoing due to their lack of confidence, decision- (SD) (SD)
making ability and willpower as a whole. Therefore, the Experimental group 30 35.77 25.47 7.08 **
hypothesis There will be no significant difference in (7.22) (3.32)
Control group 30 34.4 34.93 0.78 NS
depression among the boys of the experimental and control (5.12) (4.03)
groups before and after counseling. is partially accepted. **= Significant at .01 level. NS= Not significant. SD= Standard deviation

Table 8 shows the t values for the girls in experimental

Table 8: Depression among girls in experimental
and control groups before and after counseling. Medical
and control groups before and after counseling
students are prone to depression due to hard work, no
resting time, Inadequate sleep, fatigue, etc. It is believed Depression n Before: After: 't'
mean mean
that, students coping strategies and personal health (SD) (SD)
deteriorate as they progress through medical school. Experimental group 30 35.47 22.8 10.57 **
Students often dismiss their feelings of despondency as a (5.48) (3.61)
normal emotional response to medical school education, Control group 30 35.27 33.6 1.36 NS
(5.07) (4.38)
where they live from test to test and dont take time off
for themselves. Almost similar problems were faced by **= Significant at .01 level. NS= Not significant. SD= Standard deviation

the medical students in this study, wherein it was found

that they needed help to overcome such depression, and
it was also found that counseling was effective for the
students in considerably relieving them from depression
and finding solutions of their choice. Table 8 shows that
there was a significant difference in the levels of depression
among girls in the experimental group before and after
counseling; and there was no significant difference in the
pre-test and post-test levels of depression among girls of
the control group. Therefore, the hypothesis There will
be no significant difference in depression among the girls
of the experimental and control groups before and after
counseling. is partially accepted.
CONCLUSION
The medical students who got the benefit of counseling
during the intervention program were found to have
lower levels of anxiety and depression at the end of the
intervention program when compared to the start of the
intervention program. Counseling certainly helped to
increase the levels of self-confidence and the ability of
adjustment of the medical students. It is suggested that
counseling should be an integral part of any educational
course, especially professional courses, in order to boost
self-confidence and adjustment ability of the students.
Relaxation techniques have time and again proved that they
are adjunct to medicine in a number of ways; thus they
have to be imbibed as a way of life for many to overcome
such problems.
REFERENCES
1. Coleman JC. Abnormal Psychology and Modern Life. Los
Angles: Scott Foresman and Co.; 1988.
2. Kidson M, Hornblow A. Examination anxiety in medical
students: Experiences with the visual analogue scale for
anxiety. Med Educ 1982;16:247-50.
3. Vogelsang J. The visual analog scale: An accurate and
sensitive method for self-reporting preoperative anxiety. J
Post Anesth Nursing 1988;3:235-9.
4. WHO department of non communicable disease surveillance
(August 18th 2006). Available from: http://www.who.int
[Last accessed on 2007 Mar 20].
5. Pillay AL, Edwards SD, Gambu SQ, Dhlomo RM. Depression
among university students in South Africa. Psychol Rep
2002;91:725-8.
6. Vitaliano PP, Maiuro RD, Russo J, Mitchell ES, Carr JE, Van
Citters RL. A Biopsychosocial model of medical student

Industrial Psychiatry Journal  45 Jan-Jun 2010 | Vol 19 | Issue 1

 Velayudhan, et al.: Reducing anxiety and depression

distress. J Behav Med 1988;11:311-31.
7. Sherina MS, Lekhraj R, Nadarajan K. Prevalence of emotional
disorders among medical students in a Malaysian university.
Asia Pac Fam Med 2003;2:213-7.
8. Alansari BM. Relationship between depression and anxiety
among undergraduate students in eighteen Arab countries: A
cross-cultural study. Soc Behav Personal 2005;33:503-12.
9. Beck AT, Steer RA, Brown GK. Manual for the Beck
Depression Inventory-II. San Antonio, TX: Psychological
Corporation; 1996.
10. Andrews B, Wilding JM. The relation of depression and
anxiety to life-stress and achievement in students. Br J
Psychol 2004;95:509-21.
11. Dahlin M, Joneborg N, Runeson B. Stress and depression
among medical students: A cross-sectional study. Med Educ
2005;39:594-604.
12. Golub JS, Weiss PS, Ramesh AK, Ossoff RH, Johns MM 3rd.
Burnout in residents of otolaryngology-head and neck surgery:
A national inquiry into the health of residency training. Acad
Med 2007;82:596-601.
13. Morrison J, Moffat K. More on Medical Student stress. Med
Educ 2001;35:617-8.
14. Kisch J, Leino EV, Silverman MM. Aspects of suicidal behaviour,
depression, and treatment in college students: Results from
the spring 2000 national college health assessment survey.
Suicide Life Threat Behav 2005;35:3-13.
15. Salovey P, Woolery A, Stroud L, Epel E. Perceived emotional
intelligence, stress reactivity and symptom reports: Furthers
explorations using the Trait Meta-Mood Scale. Psychol Health
2002;77:611-27.
16. Zaid ZA, Chan SC, Ho JJ. Emotional Disorders among Medical
Students in a Malaysian Private Medical School. Sigapore
Med J 2007;48:895-9.
17. Tyssen R, Vaglum P. Mental health problems among young
doctors: An updated review of prospective studies. Harv Rev
Psychiatry 2002;10:154-65.
18. Edelman M, Ficorelli C. A measure of success: Nursing
students and test anxiety. J Nurses Staff Dev 2005;21:55-9
19. Powell DC. Behavioral treatment of medical students and
physicians whose debilitating test anxiety was associated
with their failure to pass the United States Medical Licensing
Examination. USA: USMLE; 2006.
20. Beck AT, Steer RA. Beck Anxiety Inventory Manual. San
Antonio, TX: The Psychological Corporation Harcourt Brace
and Company; 1993.
How to cite this article: Velayudhan A, Gayatridevi S, Bhattacharjee
RR. Efficacy of behavioral intervention in reducing anxiety and depression
among medical students. Ind Psychiatry J 2010;19:41-6.
Source of Support: Nil. Conflict of Interest: None declared.

Author Help: Reference checking facility

The manuscript system (www.journalonweb.com) allows the authors to check and verify the accuracy and style of references. The tool checks
the references with PubMed as per a predefined style. Authors are encouraged to use this facility, before submitting articles to the journal.
The style as well as bibliographic elements should be 100% accurate, to help get the references verified from the system. Even a
single spelling error or addition of issue number/month of publication will lead to an error when verifying the reference.
Example of a correct style
Sheahan P, Oleary G, Lee G, Fitzgibbon J. Cystic cervical metastases: Incidence and diagnosis using fine needle aspiration biopsy.
Otolaryngol Head Neck Surg 2002;127:294-8.
Only the references from journals indexed in PubMed will be checked.
Enter each reference in new line, without a serial number.
Add up to a maximum of 15 references at a time.
If the reference is correct for its bibliographic elements and punctuations, it will be shown as CORRECT and a link to the correct
article in PubMed will be given.
If any of the bibliographic elements are missing, incorrect or extra (such as issue number), it will be shown as INCORRECT and link to
possible articles in PubMed will be given.

Jan-Jun 2010 | Vol 19 | Issue 1 46 Industrial Psychiatry Journal

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.