Medical education is among the most demanding academic programs, characterized by rigorous curriculum, extensive study hours, and immense responsibility for human life.1 The transition to clinical years brings additional stressors including patient interaction, fear of errors, and exposure to suffering.2 These stressors place medical students at heightened risk for anxiety disorders, particularly Generalized Anxiety Disorder. GAD is characterized by excessive worry accompanied by physical symptoms including restlessness, fatigue, and difficulty concentrating.3 Studies report GAD prevalence of 18-45 % among medical students, substantially higher than the general population prevalence of 3.1 %.4,5 In India, medical education follows a five-and-a-half-year MBBS program with varying stress across preclinical, clinical, and internship phases.6 While research exists on general stress among medical students, specific studies on GAD using validated tools like GAD-7 remain scarce in India. The relationship between GAD and clinical posting stress has not been adequately explored. This study aimed to determine GAD prevalence among Chennai medical students, compare across academic years, correlate with examination performance, and identify predictors through multivariate analysis.

Study Design and Setting This cross-sectional study was conducted at Tagore Medical College and Hospital, Chennai, in collaboration with three other medical colleges during January to March 2018. The study population comprised MBBS students from all five academic years. Students with pre-existing psychiatric disorders on treatment and those with incomplete responses were excluded. Sample size was calculated using n = Z²pq/d², with expected prevalence 34 % and 5 % precision, yielding 344 students. Accounting for 20 % non-response, 420 were targeted. Using stratified random sampling by academic year, 520 students were approached and 450 completed questionnaires (response rate 86.5 %). A structured questionnaire collected demographics, academic data, and lifestyle factors. GAD was assessed using the validated GAD-7 scale (cut-off ≥10, sensitivity 89 %, specificity 82 %).7 For clinical year students, clinical posting stress was assessed through questions on patient interaction anxiety, fear of errors, and skill performance difficulty. Sleep quality was measured using Pittsburgh Sleep Quality Index (PSQI >5 indicates poor sleep). After ethical clearance (IEC/TMC/2017/124), questionnaires were self-administered in classroom settings with informed consent. Data were analyzed using SPSS 26.0. Descriptive statistics, chi-square test, t-test, ANOVA with Tukey post-hoc, Pearson correlation, and multiple logistic regression were performed. Significance was set at p<0.05.

Of 520 students approached, 450 completed questionnaires (86.5 % response). Mean age was 21.3±2.1 years. Overall GAD prevalence was 42.7 % (95 % CI: 38.1-47.3). Distribution: minimal anxiety 29.6 %, mild 27.8 %, moderate 24.9 %, severe 17.8 %. Table 1 presents demographic characteristics and GAD prevalence. Table 1: Demographic Characteristics and GAD Prevalence Among Study Participants (N=450) Variable Category n (%) GAD Present n (%) GAD-7 Score Mean ± SD Test Statistic p-value Gender χ²=8.92 0.003* Male 188 (41.8) 65 (34.6) 8.5 ± 5.2 Female 262 (58.2) 127 (48.5) 10.4 ± 5.2 Academic Year χ²=34.67 <0.001* First year 95 (21.1) 28 (29.5) 7.8 ± 4.6 Second year 89 (19.8) 32 (36.0) 8.9 ± 4.8 Third Part-I 92 (20.4) 40 (43.5) 10.2 ± 5.1 Third Part-II 88 (19.6) 50 (56.8) 11.7 ± 5.4 Internship 86 (19.1) 42 (48.8) 10.8 ± 5.6 Residence χ²=12.34 <0.001* Hostel 298 (66.2) 142 (47.7) 10.3 ± 5.4 Day scholar 152 (33.8) 50 (32.9) 8.3 ± 4.9 Family History χ²=15.78 <0.001* Present 67 (14.9) 41 (61.2) 12.4 ± 5.7 Absent 383 (85.1) 151 (39.4) 9.2 ± 5.1 *Statistically significant at p<0.05; χ² - Chi-square test Female students demonstrated significantly higher prevalence (48.5 vs 34.6 %, OR=1.77, 95 % CI: 1.21-2.59). Mean GAD-7 scores increased progressively across years (First 7.8±4.6 to Third Part-II 11.7±5.4, F=12.34, p<0.001). Figure 1 illustrates the distribution of GAD severity levels across academic years, demonstrating progressive increase in moderate and severe categories from First year to Third year Part-II. Figure 1: Distribution of GAD Severity Levels Across Academic Years Table 2 presents year-wise comparison showing significant differences across academic years. Post-hoc analysis revealed Third Part-II significantly higher than First year (mean difference 3.9, 95 % CI: 2.1-5.7, p<0.001). Among clinical students (n=266), 71.4 % reported clinical posting stress with GAD prevalence markedly higher (52.6 vs 23.7 %, OR=3.58, p<0.001). Table 2: Year-wise Comparison of GAD Prevalence and Associated Factors Academic Year n GAD n (%) Mean GAD-7 ± SD Clinical Stress (%) Sleep Problems (%) Mean Exam Score % ± SD First Year 95 28 (29.5) 7.8 ± 4.6 - 48 (50.5) 69.4 ± 9.2 Second Year 89 32 (36.0) 8.9 ± 4.8 - 52 (58.4) 66.8 ± 10.1 Third Part-I 92 40 (43.5) 10.2 ± 5.1 61 (66.3) 62 (67.4) 63.2 ± 8.7 Third Part-II 88 50 (56.8) 11.7 ± 5.4 71 (80.7) 68 (77.3) 60.5 ± 9.4 Internship 86 42 (48.8) 10.8 ± 5.6 58 (67.4) 64 (74.4) 62.8 ± 8.9 Total 450 192 (42.7) 9.6 ± 5.3 190/266 (71.4) 294 (65.3) 64.5 ± 9.5 GAD Prevalence: χ²=34.67, p<0.001; Mean GAD-7: F=12.34, p<0.001; Clinical stress applicable for clinical years only Significant negative correlation existed between GAD-7 and examination scores (r=-0.456, p<0.001). Students with severe anxiety scored 12.9 % lower (58.3±8.7 vs 71.2±7.4 %, t=11.24, p<0.001, Cohen's d=1.56). Figure 2 demonstrates this inverse relationship. Figure 2: Scatter Plot Showing Correlation Between GAD-7 Scores and Examination Performance Table 3 presents the relationship between GAD severity and academic performance indicators. Concentration problems were reported by 83.8 % of severe anxiety students compared to 9.0 % with minimal anxiety (χ²=127.45, p<0.001). Table 3: Association Between GAD Severity and Academic Performance Indicators Performance Indicator Minimal (0-4) n=133 Mild (5-9) n=125 Moderate (10-14) n=112 Severe (≥15) n=80 p-value Mean Exam Score % 71.2 ± 7.4 66.3 ± 8.2 61.8 ± 8.9 58.3 ± 8.7 <0.001* Academic Failure 8 (6.0%) 11 (8.8%) 18 (16.1%) 23 (28.8%) <0.001* Attendance % 87.6 ± 6.2 84.3 ± 7.1 79.8 ± 8.4 75.2 ± 9.3 <0.001* Frequent Concentration Problems 12 (9.0%) 34 (27.2%) 68 (60.7%) 67 (83.8%) <0.001* Missed Exams Due to Anxiety 2 (1.5%) 8 (6.4%) 21 (18.8%) 28 (35.0%) <0.001* *Statistically significant at p<0.05 Figure 3 illustrates GAD prevalence by clinical posting stress levels and number of stressors. Students with 4+ stressors showed 64.5 % GAD prevalence compared to 23.7 % with 0-1 stressors (χ²=31.45, p<0.001). Figure 3: GAD Prevalence by Clinical Posting Stress Level and Number of Stressors Table 4 presents multiple logistic regression analysis. The final model showed good fit (Hosmer-Lemeshow χ²=8.34, p=0.401, Nagelkerke R²=0.412) with clinical posting stress showing the highest odds (OR=3.12, 95 % CI: 1.89-5.14, p<0.001). Table 4: Multiple Logistic Regression Analysis for Independent Predictors of GAD (N=450) Predictor Variable Adjusted OR 95% CI p-value Female gender 1.86 1.21 - 2.87 0.004* Clinical years (vs preclinical) 2.34 1.52 - 3.61 <0.001* Hostel residence 1.63 1.03 - 2.58 0.037* Academic failure history 2.91 1.64 - 5.18 <0.001* Clinical posting stress 3.12 1.89 - 5.14 <0.001* Poor sleep quality (PSQI>5) 2.28 1.46 - 3.56 <0.001* Family psychiatric history 2.45 1.33 - 4.52 0.004* Irregular physical activity 1.89 1.22 - 2.92 0.004* Screen time >6 hours/day 1.67 1.09 - 2.56 0.019* *Statistically significant at p<0.05; Model fit: Nagelkerke R²=0.412, Hosmer-Lemeshow χ²=8.34, p=0.401 Students with GAD had poorer sleep quality (PSQI 8.7±3.2 vs 5.4±2.8, t=11.34, p<0.001) and shorter duration (5.8±1.2 vs 6.9±1.1 hours, t=8.76, p<0.001). Among 192 GAD students, only 23.4 % sought help. Barriers: stigma (68.7 %), lack of awareness (54.4 %), fear of consequences (47.6 %).

This study revealed 42.7 % GAD prevalence among Chennai medical students, substantially higher than the general population (3.1 %).8 Our finding aligns with international studies. Quek et al reported pooled global prevalence of 33.8 %.9 Gazzaz et al found 49.0 % anxiety in Saudi medical students.10 The higher prevalence reflects intense competitive environment in Chennai medical colleges and use of validated diagnostic tools. The progressive increase across academic years, peaking at Third Part-II (56.8 %), aligns with research documenting heightened clinical year stress.11 This critical transition requires integrating theoretical knowledge with patient care while managing emotional demands. Clinical responsibilities including direct patient interaction, procedural performance under supervision, error fears, and hierarchical navigation substantially contribute to anxiety burden. Our strong association between clinical posting stress and GAD (OR=3.12) is concerning. With 71.4 % reporting clinical stress, this represents a major modifiable risk factor. These findings resonate with previous research highlighting patient-related responsibilities as major stressors.1 The clinical environment presents unique challenges: exposure to suffering and death, ethical dilemmas, and clinical responsibility weight. The significant negative correlation between GAD and academic performance (r=-0.456) has critical implications. Students with severe anxiety scored 12.9 % lower, creating a vicious cycle. Similar findings were reported by Puthran et al and Mazurkiewicz et al.12,13 The concentration problems in 83.8 % of severe anxiety students mechanistically explain this impairment. Gender differences (females 48.5 vs males 34.6 %) reflect global epidemiological patterns.9 Contributing factors include biological stress response differences, hormonal influences, differential sociocultural expectations, and varying coping strategies. Poor sleep emerged as a strong predictor (OR=2.28). Students with GAD slept 1.1 hours less nightly, representing chronic sleep deprivation impairing cognitive function and emotional regulation. Academic failure history showed the highest modifiable risk OR (2.91), emphasizing early academic support system needs. Family psychiatric history (OR=2.45) suggests genetic and environmental familial vulnerability, highlighting screening importance. Lifestyle factors including irregular physical activity (OR=1.89) and excessive screen time (OR=1.67) represent modifiable intervention targets.14 Most concerning is only 23.4 % sought professional help despite service availability. Primary barriers were stigma (68.7 %) and academic consequence fears (47.6 %). This high-need, low-help-seeking phenomenon is well-documented globally.15,16 Medical culture must normalize mental health care. Study strengths include validated diagnostic instrument use, adequate sample size, all academic year inclusion, and robust multivariate analysis. Limitations include cross-sectional design precluding causation, potential self-report bias, Chennai-specific generalizability limits, and absence of clinical diagnostic interviews. Findings necessitate: routine mental health screening during vulnerable periods; comprehensive support systems including accessible counseling; curriculum modifications reducing unnecessary stress; specific clinical posting stress interventions; active stigma reduction efforts; and healthy lifestyle promotion.

GAD prevalence among Chennai MBBS students is alarmingly high (42.7 %), progressively increasing across academic years and peaking during clinical postings. Strong negative correlation with academic performance and low help-seeking (23.4 %) despite available services underscore urgent comprehensive mental health support system needs. Medical colleges must prioritize student mental health through routine screening, accessible counseling, curriculum modifications, clinical transition support, stigma reduction, and lifestyle interventions. Addressing this crisis is essential for student wellbeing and developing healthy, resilient physicians capable of optimal patient care. ACKNOWLEDGEMENTS The authors acknowledge cooperation from Principals and faculty of participating medical colleges. We thank all MBBS students who participated and Department of Psychiatry staff at Tagore Medical College for data collection assistance.

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