Mental health is an essential component of overall health. Physical health and mental health are inter-linked, and a deterioration in any of them can have an impact on the other one. Many studies have demonstrated the role of psychosocial and behavioral risk factors in the etiology and pathogenesis of various disorders[1-4]. For maintaining a positive health, an intricate balance between all aspects of health is necessary. 

Medical students face significant academic pressure, psychological stress and existential crisis. Medical Undergraduates are mostly in the age group of 17-24 years and are commonly confronted with significant burden in various domains. Difficulties faced by medical undergraduates include long study hours, language related problems, living in hostels instead of their home which students find difficult to cope, hectic schedule, feeling of loneliness and home sickness. Factors like academic burden, duration of the degree course which has an impact on student’s health cannot be modified. An insight into the modifiable contributing factors, as well as the circumstantial reaction of students can be beneficial. Depression is a common mental health disorder, which is both preventable and curable. It manifests in various forms and affects a wide age range. A number of determinants influence the occurrence of depression, as biochemical factors, genetic, environmental factors and personality traits. Depression among medical students is found to be higher as compared to the general population [5,6]. In a study conducted  the overall prevalence of depression in Indian Medical undergraduates was found to be 30%

An individual’s personality is reflected in their thoughts, emotions and behavior, which influence the health of person[7]. Personality guides how an individual handle and reacts to a situation. Personality type refers to psychological classification of different types of individuals. The most well- known of these personalities is type A personality which includes ambitiousness, aggressiveness, competitiveness, impatience, alertness, irritation, hostility and increased potential for anger. Type A individuals are at increased risk for developing coronary heart diseases. The other personality type is type B personality. Type B personality individuals on the other hand possess a calm and relaxed behavior, work in a steady pace for their achievement and are more accepting towards failure. Recently a new personality construct, Type D personality has been proposed in which D stands for distress as reflected by the mood status [8,7,9,10]. Mood plays a mediating role in the relation between stressful events and cortisol secretion [11,7,12]. Type D personality is defined as the joint tendency towards negative affect and social inhibition.

Negative affect means people have negative emotions towards themselves and others. They tend to experience difficulty in expressing themselves appropriately in social situations and this results in social inhibition. The prevalence of type D personality is found to be 31% in the medical undergraduate students[13]. Type D personality is a vulnerability factor for general psychological distress that affects physical health status and people with type D personality are at increased risk of developing psychiatric disorders like depression, anxiety, post-traumatic stress disorder, panic or phobic disorder, and medical disorders like cardiovascular disease and stroke[14]. 

Therefore, mental health being an important determinant for a student’s health and academic performance the current study was planned to assess the prevalence of Type D personality, depression and it’s association, with the following objectives:

1. To find the Prevalence of Type D personality among undergraduate students of a medical college of Delhi.

2. To find the Prevalence of Depression among the same students

3. To find the associated factors with type D Personality among them. 

STUDY AREA 

Vardhman Mahavir Medical College and Safdarjung Hospital is a prominent medical institution in India under the Ministry of Health and Family Welfare and is well known for its quality of health services to all strata of society. This cross-sectional study was conducted by the Department of Community Medicine, Vardhman Mahavir Medical College and Safdarjung Hospital, among undergraduate medical students.

STUDY POPULATION 

Inclusion criteria were undergraduate medical students of 1^st, 3^rd, 5^th, 7^th and 9^th semester. Students who were absent on the day of study and those who did not give consent were excluded from the study. 

SAMPLE SIZE

According to a study conducted [13] among undergraduate medical students of West Bengal, the prevalence of type-D personality was found to be 31.0%. So, taking the prevalence of type-D personality as 31.0%, the sample size according to formula 4PQ/L² and taking absolute error of 5 the sample size comes out to be 342. So, if we added 10% as loss to follow up, the sample size to be covered came out to be 376. So, we covered a sample of 380 undergraduate medical students from five semesters and intern batch of Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi.

SAMPLING METHOD:  STRATIFIED RANDOM SAMPLING

According to the list from the academic section of the college, the total number of currently enrolled undergraduate medical students were 900 (5 semesters + interns). The five semesters were 1^st, 3^rd, 5^th, 7^th and 9^th and each semester had strength of 150 students. The sample size of 380 was covered in these five semesters and interns by stratified random sampling technique. A sample of 64 students was covered from each semester and intern batch. List of students according to university roll number of each semester was taken from the academic section. Random number tables were used in selecting participants from each semester. 

STUDY TOOLS

 A predesigned, pretested, semi structured questionnaire along with DS14 and PHQ9 was used. The DS14 Questionnaire is the most accepted and widely used diagnostic instrument for the assessment of Type D personality. This tool was developed [7]and established as valid and reliable instrument both in clinical samples and in general population. The PHQ9 is an established multipurpose instrument for screening, diagnosing, monitoring and measuring the severity of depression. Both DS14 and PHQ9 are freely accessible.

DATA COLLECTION

Before administering the questionnaire to the study participants in their respective lecture halls, the importance of study was explained to them. A predesigned, pretested, semi structured questionnaire was filled by the study participants after explaining the questionnaire in detail to them. Students were encouraged to fill all the particulars of the questionnaire and were instructed not to leave any question unanswered. The data was collected in September 2018. 

DEFINITIONS USED IN THE STUDY

The DS14 questionnaire had 14 questions which was divided into two parts, first is negative affectivity questionnaire consist of seven questions and second is social inhibition questionnaire which also consist of seven questions. This questionnaire was assessed on a Likert scale from 0(false) to 4(true). The scoring of negative affectivity equal to sum of scores of questions 2+4+5+7+9+12+13 and social inhibition scoring equal to sum of scores of questions 1(reversed)+3(reversed)+6+8+10+11+14. Scores on both scales were range from 0-28. Participants were classified as having type D personality if both negative affectivity and social inhibition scores are greater than or equal to 10. The PHQ9 questionnaire had 9 questions with minimum score of 0 and maximum score of 27. Based on this questionnaire participants were classified as having no depression (0-4), mild depression (5-9), moderate depression (10-14), moderately severe (15-19) and severe depression (20-27). 

STATISTICAL ANALYSIS

The data was entered in a master sheet on MS Excel and later transferred from MS Excel to SPSS 

licensed Software version 20.0 for analysis. Data validation checks were performed at regular interval for the data entered in the worksheet of MS Excel. Simple tables and cross tables were made. Appropriate diagrams were made to illustrate the results e.g. Bar Diagrams, Pie Charts. For qualitative data analysis Chi-square test was used.

ETHICAL ISSUES

Ethical clearance was taken from institutional ethical committee

The study was conducted among 380 undergraduate medical students. Mean age of study participants was 20.69 ±1.98. The age of study participants ranged between a minimum age of 20 years and maximum age of 22 years. Among 380 participants studied, male students were 213 (56%) and females were 167 (44%). Majority (51.5%) of students were in the age group 20-22 years. Around three fourths of the participants belonged to nuclear families and around 80% were currently staying in hostels. Almost all the participants belonged to upper and upper middle-class socioeconomic status. Most of the participants did not have any chronic medical condition. Half of the students spent less than 2.5 hours per week on yoga, sports or exercise. Nearly 320(84%) of the students did not report any sleeping difficulty. There was history of alcohol consumption among 43(11%) of the students. Approximately 52(14%) students felt they had a stressful relationship with their parents, siblings, friends, colleagues, or partnerOut of 380 students 116 (30.5%) students had Type D personality and 264 (69.5%) students did not have Type D personality.

Table 1. Distribution of Type D personality according to associated factors in the study population

Table 1 shows that on analyzing Type D personality with various associated factors, it was observed that performing physical exercise/yoga/sports for less than 2.5 hours per week, presence of sleeping disorder, presence of a stressful relationship and being a hosteller was significantly associated with Type D personality. No significant association was found between Type D personality and gender, family type and presence of chronic medical condition.

Table 2. Distribution of study participants according to prevalence of depression. (N=380)

Table 2 Shows that the overall prevalence of depression was found to be 44.5% among the study participants, that accounts to be approximately half (169) of the students. Around one third (28.7%) of the students (109) suffered from mild depression. Only 4 students (1.1%) had severe depression. 

Table 3. Association of Type D Personality and Depression. (N=380)

* Chi square statistic=40.55, p-value was <0.05, df =1

Table 3 Shows that 68.9% of study participants with Type D personality also had depression and there is a statistically significant association present between Type D personality and depression.

In the present study, majority (51.5%) of the participants were in the age group of 20-22 years. Similar study conducted [14]A in the year 2017 also reported that 59% of the participants were in the age group of 19-21 years[14]. In our study, the percentage of male participants were 56% which was higher than females (44%). Similar results were observed in a study conducted in 2008 [13]in which they found that 69% were males and 31% were females. In another study conducted [14]]A in 2017 among college going students conducted in Delhi also found that 54% of the participants were males and 46% were females[14].

The prevalence of Type D personality among the study participants in this study was found to be 30.5%. Similar results were found in a study conducted [14]A in Delhi[14], where prevalence of Type D personality was found to be 39.6%. Although the results are in contrast to a study conducted in Midnapore [13]where the prevalence of Type D personality was as high as 70%. This can be due to the fact that assessment in our study was done by a self-administered questionnaire, leading to underestimation of the prevalence of Type D. 

About 22.4% of those students having Type D personality also had sleeping disorder in the present study. This was in accordance with the studies evaluating Type D personality and sleep disturbances, where individuals with Type D personality reported to have fewer sleeping hours [15,16]. 

In our study, it was found that 45.5% of study participants had depression. Students in this age face academic and social pressure, which makes them more prone to depression. Similar results were reported from a study conducted among undergraduate medical students of Midnapore  [13], where prevalence of depression was 45.3%. In another study conducted [17]among Punjab university students found that prevalence of depression was 59.3%[17].  Relatively lower prevalence of 24.2% was reported among medical students in Sweden[18]. This difference can be attributed to the wide difference in the settings of these participants.

Students with Type D personality have higher incidence of anxiety, hostility and stress. In this study also, it was found that 68.9% of the participants with Type D personality also had depression, and type D personality was significantly associated with depression (P <0.05). Almost similar results were found in a study among college students of Delhi University, where a significant association was found between Type D personality and depression[14]. Another study conducted among medical undergraduates also reported occurrence of depression along with Type D personality[13].

Data collection was done by self-administered questionnaire which was a limitation in our study due to which under reporting or over reporting of some determinants can be there especially those which are socially sensitive. Second limitation, as this was a cross sectional study, therefore we can conclude only the association between depression and Type D personality, and no temporal association can be proved. 

This study suggests that about one third of study participants had Type D personality and almost half of participants had depression, along with a significant association between the two determinants.

This study reports high prevalence of Type D personality and depression among medical undergraduate students. Timely intervention in the form of diagnosis, treatment and counselling for students having Type D personality, depression and other associated factors can prove to be beneficial.

Healthy mind and healthy body are required for overall development of the student, which will require regular assessment of depression and other psychological stressors and its treatment. The mental health of the students can be promoted by personal mentoring sessions, which would ensure confidentiality, and further it can be used as an opportunity to sensitize the student’s parents, as the overall environment and relationships build a student’s personality.

The authors declare that they have no conflict of interest

No funding sources

The study was approved by the Vardhman Mahavir Medical College, India

1. Williams, R. B., & Littman, A. B. (1996). Psychosocial factors: role in cardiac risk and treatment strategies. Cardiology clinics, 14(1), 97-104.

2. Musselman, D. L., Evans, D. L., & Nemeroff, C. B. (1998). The relationship of depression to cardiovascular disease: epidemiology, biology, and treatment. Archives of general psychiatry, 55(7), 580-592.

3. Sher, L. (1999). Effects of psychological factors on the development of cardiovascular pathology: role of the immune system and infection. Medical hypotheses, 53(2), 112-113. 

4. Chapman, B. P., Roberts, B., & Duberstein, P. (2011). Personality and longevity: knowns, unknowns, and implications for public health and personalized medicine. Journal of aging research, 2011. 75, 9170.

5. Cameron, I. M., Crawford, J. R., Lawton, K., & Reid, I. C. (2008). Psychometric comparison of PHQ-9 and HADS for measuring depression severity in primary care. British Journal of General Practice, 58(546), 32-36.

6. Haddad, M., Walters, P., Phillips, R., Tsakok, J., Williams, P., Mann, A., & Tylee, A. (2013). Detecting depression in patients with coronary heart disease: a diagnostic evaluation of the PHQ-9 and HADS-D in primary care, findings from the UPBEAT-UK study. PloS one, 8(10), e78493.

7. Denollet, J. (2005). DS14: standard assessment of negative affectivity, social inhibition, and Type D personality. Psychosomatic Med, 67(1), 89–97.

8. Pedersen, S. S., & Denollet, J. (2003). Type D personality, cardiac events, and impaired quality of life: a review. European Journal of Preventive Cardiology, 10(4), 241-248.

9. Buchanan, T. W., Al'Absi, M., & Lovallo, W. R. (1999). Cortisol fluctuates with increases and decreases in negative affect. Psychoneuroendocrinology, 24(2), 227-241. 

10. Smyth, J., Ockenfels, M. C., Porter, L., Kirschbaum, C., Hellhammer, D. H., & Stone, A. A. (1998). Stressors and mood measured on a momentary basis are associated with salivary cortisol secretion. Psychoneuroendocrinology, 23(4), 353-370. 

11. Van Eck, M., Berkhof, H., Nicolson, N., & Sulon, J. (1996). The effects of perceived stress, traits, mood states, and stressful daily events on salivary cortisol. Psychosomatic medicine, 58(5), 447-458. 

12. Vaidya, P. M., & Mulgaonkar, K. P. (2007).  Prevalence of depression, anxiety and stress in undergraduate medical students and its correlation with their academic performance. Indian J of Occup Ther 39.7–10.

13. Gupta, S., & Basak, P. (2008). Depression and type D personality among undergraduate medical students. Indian J of Psychiatry 10(6), 187-15.

14. Khan, Z.H., & Khokhar, A. (2017).Prevalence of Type D personality, depression and their association amongst college going students of Delhi. Int J of Curr Res.;9(06), 53186-53189.

15. Akram, U., McCarty, K., Akram, A., Gardani, M., Tan, A., Villarreal, D., ... & Allen, S. (2018). The relationship between type D personality and insomnia. Sleep Health, 4(4), 360-363.

16. Condén, E., Ekselius, L., & Åslund, C. (2013). Type D personality is associated with sleep problems in adolescents. Results from a population-based cohort study of Swedish adolescents. Journal of Psychosomatic Research, 74(4), 290-295.

17. Singh, M., Goel, N. K., Sharma, M. K., & Bakshi, R. K. (2017). Prevalence of Depression, Anxiety and Stress among Students of Punjab University, Chandigarh. National J of Com Med. 8(11), 666-671.

18. Dahlin, M., Joneborg, N., & Runeson, B. (2005). Stress and depression among medical students: A cross‐sectional study. Medical education, 39(6), 594-604.