feliz
feliz
  • Users Online: 622
  • Print this page
  • Email this page


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 6  |  Issue : 2  |  Page : 142-148

Perceived stress and insomnia among medical residents in South India: A cross-sectional study


1 Department of Psychiatry, JJM Medical College, Davangere, India
2 Department of Psychiatry, S. Nijalingappa Medical College, Bagalkot, India
3 Department of Psychiatry, KJ Somaiya Medical College and Research Centre, Mumbai, Maharashtra, India
4 Department of Psychiatry, Punyakoti Foundation, Hospete, Karnataka, India

Date of Submission19-Nov-2021
Date of Decision07-Dec-2021
Date of Acceptance15-Dec-2021
Date of Web Publication15-Mar-2022

Correspondence Address:
Dr. Harish Kulkarni
#10, Department of Psychiatry, S. Nijalingappa Medical College, Navanagar, Bagalkot, Karnataka
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aip.aip_140_21

Rights and Permissions
  Abstract 


Background: The ever-expanding medical knowledge, longer work schedule and the work atmosphere ridden with litigations make the medical education a stressful phase. Stress in resident doctors goes unattended many a times. Residents also face difficulty in sleep owing to their heavy work and erratic routine. Insomnia is noted to be a common accompaniment of stress. In this background, the present study is aimed to estimate the prevalence of stress levels and the presence of insomnia among resident doctors and to assess the association between them along with their socio-demographic correlates. Methodology: Resident doctors working in three different hospitals attached to a medical college were approached; consenting participants were administered Sociodemographic pro forma, Perceived Stress Scale, and Bergen's Insomnia scale. Statistical analysis was done using SPSS software. Results: A total of 251 residents participated in the study, of which majority were females, Hindu, from an urban background, unmarried and used no psychoactive substance. Of all the residents 80% reported to be stressed and 62% had insomnia. Bergen's Insomnia scores had moderate correlation with Perceived stress scores (r = 0.453, P < 0.001). Female and sleep-deprived residents had higher stress. Residents in clinical branches and residents with long work hours had significant insomnia than their counterparts. On logistic regression analysis, duration of work hours and problem adjusting to the current place of residence significantly predicted insomnia. Conclusion: Most residents reported to be having stress and the stressed individuals had associated insomnia. Given the serious health effects of stress, there is a need to detect it early. Insomnia could be viewed as an early and soft indicator of underlying stress.

Keywords: Medical education, residency, sleep disorder, stress, students


How to cite this article:
Anupama M, Kulkarni H, Nisarga V, Sushravya. Perceived stress and insomnia among medical residents in South India: A cross-sectional study. Ann Indian Psychiatry 2022;6:142-8

How to cite this URL:
Anupama M, Kulkarni H, Nisarga V, Sushravya. Perceived stress and insomnia among medical residents in South India: A cross-sectional study. Ann Indian Psychiatry [serial online] 2022 [cited 2022 Sep 25];6:142-8. Available from: https://www.anip.co.in/text.asp?2022/6/2/142/339661




  Introduction Top


Medical education has increasingly become complex over years, technological advancements and newer studies are adding to our understanding of illnesses and changing our treatment protocols. The resultant ever-expanding medical literature and necessary knowledge assimilation are burdening the young minds. To further add to this, resident doctors witness long exhausting work hours in hospital, emotionally challenging work environment, expectation of higher proficiency which collectively cause stress in residents.[1] Residents' personal struggles in life also add to the situation, thus making the residency period the most stressful phase in the entire medical profession.[2]

Studies that have been done so far support the fact that medical students face stress commonly. In a study done in Saudi Arabia, 53.2% of medical students reported stress, of those 16.7% had severe stress.[3] In Brazil, 40.9% of medical students reported being stressed to a significant extent.[4] A study among resident doctors in India reported 37.3% of resident doctors were significantly stressed.[5] Various factors were claimed to be associated with higher stress levels such as female gender,[6] being married, longer working hours,[7] and interpersonal problems.[8] Stress in medical students leads to not only academic failures but also various health hazards such as anxiety, depression, substance abuse, and even suicide.[9],[10] These factors increase the morbidity levels in professionals, affect the cost-effectiveness of medical education, and burden the families. It also negatively impacts patient care by reducing the efficiency of the doctor, especially judgment-making capacity and the reaction time.[11]

Given the negative consequences of stress in the residents both on self and the patient care, early identification of stress becomes particularly important. Early detection and management with prevention of work-related stress in medical profession can improve the quality of patient care. However, in most scenarios stress remains unidentified either because of the ignorance or due to stigmatizing attitude toward work-related stress, thus failing in preventing it.[12] Some studies reported that disturbances in sleep were noticed quite early in people with stress.[3],[13],[14] Insomnia is easily identified both subjectively and on objective assessment. Given this, if it is possible to detect insomnia among postgraduate residents and correlate it with perceived stress, it could serve as an early indicator of stress: a state marker for stress.

Existing studies differ widely in the prevalence of stress. Most of them restricted to undergraduate medical students and hardly few studies looked for the association between sleep and stress. Hence, the current study was planned to estimate the prevalence of stress and insomnia; the association between them along with their socio-demographic correlates in postgraduate residents in a premier postgraduate medical institution in South India.


  Methodology Top


The study was conducted on medical residents who were undergoing their postgraduate training in various medical specialties. Residents were working in three hospitals; two government hospitals and one private hospital, all attached to a Medical College. Ethical clearance was obtained from Institutional Ethical Committee Review board. Head of the institution and Heads of the respective departments permitted conductance of the study. Each resident was approached and briefly explained about the study. Written consent was sought before starting the study. Consenting residents were administered the scales. All the residents were approached for participation and unwilling residents opted out of the study. The assessment was cross-sectional using self-rated scales.

Assessment tools

Self-designed proforma was used for collection of sociodemographic and work details. It included: age, gender, marital status, residence, year of postgraduate training, specialty, average working hours, leisure time, number of night shifts, difficulties faced at workplace, presence of interpersonal problems, and adjustment difficulties in personal life. Stress was assessed using Cohen's perceived stress scale (PSS). It is commonly used scale worldwide and in India. The test has internal consistency of 0.82 and test-retest reliability is 0.77 and Cronbach's alpha is 0.78. Scoring on PSS ranged from 0 to 40. Score of less than 13 indicated low or normal levels of stress, 14–26 shows stress of moderate intensity, and more than 27 suggests severe stress.[15] For insomnia assessment, Bergen Insomnia Scale was used. It is a 6 item scale, easy and quick to administer. Score ranges from 6 to 42. Cronbach's alpha for the scale is 0.79, test-retest reliability is 0.77. Total Score of 6 or more is considered as positive, in which 3 should be on questions 1–4 and 3 on questions 5 and 6, respectively.[16]

Statistical analysis

Statistical analysis was done using IBM SPSS statistics licensed version 23 (IBM SPSS Statistics for Windows, Armonk, New York, USA). The data were checked for normality of distribution using Kolmogorov–Smirnov test. Parametric statistics such as Independent t-test, one-way analysis of variance, and nonparametric statistics such as Chi-square, Mann–Whitney U test, Kruskal–Wallis were used to compare groups on different variables. Pearsons and Spearmans's rho were both used to find a relationship between different variables. Logistic regression was done to look for the predictors of insomnia.


  Results Top


A total of 267 residents participated in the study; of which 16 pro forma were excluded from analysis due to incomplete information and 251 pro forma were finally analyzed. The mean age of the sample was 27 (±2) years. There were more females 137 (54.6%) in the sample. Majority of the residents belonged to Hindu religion 223 (88.8%), were staying alone 177 (70.5%), were single 177 (70.5%), from urban background 168 (66.8%) and were not using any psychoactive substance 212 (83.3%). Sociodemographic details are given in [Table 1].
Table 1: Sociodemographic variables

Click here to view


Work environment

Residents were dispersed over seventeen departments including clinical and nonclinical branches. The mean working duration was 65 h per week; 9.6 h per day and ranged from 30 to 140 h per week with respect to the departments. Some residents were working for 18–20 h at a stretch in a day. A total of 181 (72%) residents were working in night shifts/night call duty at the time of assessment. Average number of night shift duties per person was 6 per month. Mean hours of sleep per night was 6 h with a minimum of 2 h for some residents. The mean leisure time a resident would get per week was 14 h; few residents reported that they got no leisure time at all. More than one-fourth of residents (27%) found their work environment difficult to handle. They reported facing difficulties in either academic work or clinical work. Inter-personal problems were reported by 33 (13%) at work place with the teachers, colleagues, and other hospital staff. A significant proportion of residents (48%) had adjustment problems at their workplace. Details about workplace are depicted in [Table 2].
Table 2: Work details

Click here to view


Stress and insomnia

Mean scores of perceived stress were 18.45(±6.94). Stress was present in 201 (80%) of the residents as indicated by scores above 13 on PSS. Of these, 173 (69%) had moderate and 28 (11%) had severe stress. PSS scores were higher in females (Z = 4.51, P < 0.001), in those who faced difficulties at work (Z = 3.778, P < 0.001), in those who were poorly adjusted to current environment (Z = 3.232, P = 0.001) and in those who had lesser opportunity to sleep (depicted as hours of sleep) (r = 0.163, P = 0.01). Overall scores on Stress and Insomnia are given in [Table 3] and [Table 4], respectively.
Table 3: Perceived Stress Scale

Click here to view
Table 4: Bergen's Insomnia scores

Click here to view


Mean scores on Bergen's Insomnia scale was 12.86(±9.57). 156 (62%) residents scored above the cut-off, i.e., score of 6 or more on the scale. Residents staying with family had significantly lesser insomnia than others (F = 4.50, P = 0.012). Residents who were having difficulty at workplace (t = 3.539, P < 0.001) and difficulty adjusting to current place of residence (Z = 3.028, P = 0.002) had higher insomnia scores. Also, residents who worked in clinical branches had significant insomnia than nonclinical branches (Z = 2.199, P = 0.03). Post hoc analysis by Games-Howell method showed that residents of the pediatric department had significantly higher scores on insomnia than residents from pathology (P = 0.01) and surgery department (P = 0.01). Insomnia scores had a significant positive correlation with number of working hours (P = 0.001), number of night duties per month (P = 0.002). Logistic regression analysis was done on work variables showed that duration of work hours and problem adjusting to the current place of residence significantly predicted insomnia (P < 0.001). Perceived stress scores had a significant correlation with insomnia scores (r = 0.453, P < 0.001 Spearman's rho), the graphical representation of relation is depicted in [Figure 1].
Figure 1: Scatter plot graph of correlation between Insomnia and Perceived stress scores.

Click here to view



  Discussion Top


In our study, 80% of the resident doctors reported stress of which 11% had severe stress. Sixty-two percent of residents reported insomnia. Previous studies also have reported high rates of stress ranging from 37% to 80% in resident doctors, with one study reporting 17% of resident doctors having a severe amount of stress.[3],[4],[5],[17],[18] These findings are cause of great concern. Such a major proportion of students were suffering from stress and insomnia and they were hitherto undetected and untreated. This could have been because of ignorance in the residents about their own mental health, ignorance among the hospital administrators regarding work burden and stress, or it could also be due to stigmatizing attitude of people towards psychological issues such as stress which led to its underreporting. Stress could have had a huge impact on the health and wellbeing of residents.[9] Two-thirds of the sample was having clinically detectable insomnia. Sleep is a basic necessity of life and its impairment impacts physical and mental health.

Perceived stress significantly correlated with insomnia, suggesting that the residents who were stressed had insomnia. Although stress was more prevalent than insomnia in the sample those who had insomnia invariably had stress. Hence, the presence of insomnia could mean the presence of stress. Hence, insomnia could be used as indicator to detect underlying stress in otherwise healthy at risk individuals. Especially when residents shy out reporting psychological problems, insomnia was quite easily reported and sought treatment. An earlier study also has reported this association between stress and insomnia.[3]

Female residents, in our study, had significantly higher amount of stress as compared to male residents (Z = 4.511, P < 0.000). A similar gender difference was also reported in earlier studies,[6],[19] while few other studies found no gender difference in stress.[3],[5] This could be explained as female doctors usually carry the burden of both professional and family responsibilities more than males, which could be a source of stressors. Furthermore, females in comparison with males appreciate and express their emotional states often, including stress.[20] The important reasons that could explain high-stress levels in our study were experiencing of difficulties in carrying out academic and clinical work, problem adjusting to their current environment, and sleep deprivation. These factors had a significant correlation with stress.

Residents in our study worked for a mean duration of 65 h per week. Work hours ranged from 30 to 140 h in a week. Work hours spanned 18–20 h at a stretch in a day with short or no official breaks. This was clearly in excess of the recommended 48 h per week and 12 h at a stretch in medical professionals.[21] Pediatrics followed by Obstetrics and Gynecology residents had the highest mean work duration per week of 115 and 96 h respectively whereas most nonclinical branch residents had 42 h per week. Work hours in rest of the departments fell in between these two extremes. Some residents reported to be working for 140 h per week which is nearly 3 times more than the recommended. Working overtime neglecting their personal life, leisure, daily routines, and biological functions is definitely detrimental to their health.

Recreational activities in leisure time play a revivable role by relieving fatigue, preventing burnout, and improving the work efficiency.[18] In this study, availability of leisure time varied widely with a range of 0–28 h per week (average 14 h) across different departments. As expected, residents working in clinical specialties had lesser leisure time than nonclinical specialties. Overall many residents had adequate leisure time except residents in Pediatrics and OBG departments, who reported of having very less to no leisure time. This stands in contradiction to the directions of the honorable Supreme Court of India, which stated that resident doctors should have mandatory 1 day weekly-off.[21] Similar regulations regarding resident doctors' working hours exist in other countries too; European Union permits maximum of 48 h per week with 11 h continuous rest in a day and 1 day off each week, with 20 min of rest every 6 h. The Accreditation Council for Graduate Medical Education of the USA differs from EU in extending the number of work-hours. The maximum of 80 h weekly with 30-h maximum straight shifts and at least 10 h off between shifts are permitted in the USA. The scenario of residents overworking is common in middle-low income countries as very few trained personnel are available to cater to a large number of people who access these services.[22] However, justifiable and nonexploitative work schedule is a requirement for medical professionals so that it prevents them from being pushed into stress and burnout. An earlier study found association between stress and the duration of work in resident doctors[18] but our study did not find this association.

In this study, mean hours of sleep per day was 6 h (ranged from 2 to 12 h), and was in concordance with the night shift duties of the resident and varied according to specialties. All clinical departments had night shifts/calls, with an average of 6-night shifts in the past month. The residents of nonclinical branches had adequate of 7-8 h of sleep whereas residents of clinical branches had wide variations in sleep duration. Residents of clinical departments such as ENT, psychiatry, dermatology, ophthalmology, radiology, pulmonology, anesthesia, and general surgery enjoyed 6 plus hours of sleep on most nights. Residents of departments like Medicine, OBG, Orthopedics, Emergency Medicine and Pediatrics where there was high patient turnout had <6 h of sleep. Some residents in Pediatrics and OBG departments reported just 2–4 h of sleep per night for most nights in the past week. The same work schedule was running for several months at the time of assessment. Sleep duration was significantly lesser than the recommended 7–9 h per day (by the American Sleep Association). Sleep deprivation was significantly associated with higher stress. Sleep deprivation, in our study, was defined as “deficiency in hours of sleep from their normal regular sleep due to work schedule” recorded by self-reporting. This was irrespective of their ability to fall asleep. This is not same as insomnia, which was “inability to sleep when ample opportunity and soporific environment was available.” Hence, insomnia was not due to a lack of opportunity or time to sleep. Earlier studies remarked that doctors often ignore sleep and do not consider sleep as one of their priorities.[23] Those who ignore the fact that they are sleep-deprived also underestimate their health problems.[24] Long-standing sleep deprivation is known to impair cognitive functioning and increase impulsivity.[25] Insomnia, in addition to its correlation with stress, had robust relationship with factors that had association with stress, including long work hours, number of night duties, difficulties at work, and trouble adjusting to the new place. This is in contrast to popular belief that heavy work would induce tiredness and facilitate sleep. The probable explanation could be; stress along with alternating night and day shift duties lead to disturbance in various homeostatic mechanisms thus resulting in insomnia.

In our study, stress and insomnia had no association with age, marital status, leisure time, year of postgraduation. Working on night shift duties per se or number of work hours failed to show association with stress while insomnia had no association with gender. Earlier studies have shown mixture of results in this regard.[5],[12],[22] This could be because of other psychological constructs like personality of the residents, social support system, indulgence in stress-relieving activities like sports, hobbies, etc., Although there is no easy way to escape from the stressors of medical residency training, the resultant serious effects such as burnout, depression, suicide, and substance use can be prevented. Early identification of the stress and addressing issues aiming for its reduction would be important. Our medical education system does not include teaching of various soft skills like recognition of stress and stress management despite a high prevalence of stress in medical students. It often goes unrecognized due to probable ignorance, denial, or stigma associated with stress. On the background of increasing number of premature deaths in young doctors, belittling stress in doctors puts them at serious risk for various health hazards. Students at undergraduate and postgraduate levels of medical education, their teachers, and the management need to be educated about the rampant prevalence of stress and practical ideas to prevent it. One such step recommended is to reduce resident's work hours, which has shown to reduce stress levels.[26] Creating awareness about stress, reduction of environmental stressors, personality development workshops, early detection, and prompt management may have a role in stress management. With the widely replicated finding that insomnia is strongly related to stress, as this study also shows, we would like to propose that insomnia is a soft and early indicator of stress. In addition, sleep-related symptoms are less stigmatizing for doctors and are often reported. Therefore a careful evaluation is necessary for detecting the presence of stress in this group. Objective methods like questionnaires or inventories can be used to detect stress accurately and overcome the stigma in reporting stress.

Therefore, a resident presenting with insomnia should be evaluated for the presence of stress, to be effectively managed if present. This improves mental well-being and quality of life of resident doctors which in turn improves quality of patient care.

Strengths and limitations

Strengths of the study are large number of residents were approached. Residents from 17 departments which include almost all clinical and most nonclinical specialties were recruited. The residents were working in both private and government setups thus were exposed to problems of either setting. Residents from different geographical location and socio-economic background were included in the study. Different sociodemographic characteristics had a representation in the sample. There are some limitations of the study. The response rate was only 48%. Studies aiming to assess psychological morbidity in doctors are countered with poor response rate.[18] This could be due to several reasons such as relative lack of free time, stigmatizing attitude, or discomfort expressing psychological problems. Residents who were more psychologically oriented and felt the need for assessment were more likely to have taken part in the study. Since the study is a cross-sectional one and self-reported based on recall, it is not possible to assess causality between stress and the various correlates examined. And as this study reports findings from a single institution, it has limited generalization.

Implications

The study intended to assess the prevalence of stress in residents working in hospitals/medical colleges. The high prevalence of stress and its invariable accompaniment with insomnia needs highlighting. The proposition of insomnia being soft sign of underlying stress need further validation by more number of similar studies, covering the limitation of the present study. Managing stress along with associated features like insomnia would take paramount importance in preventive psychiatry and also improve quality of life and better patient care when observed in doctors. In order to prevent the stress and its aftermath, there is a need for robust stress management strategies in medical students. This calls for programs aimed at early detection of stress and interventions for prevention as well as reduction of stress in resident doctors such as judicious work schedules, adequate leisure and sleep timings, grievance addressing committees, counseling cells to begin with.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Firth J. Levels and sources of stress in medical students. Br Med J (Clin Res Ed) 1986;292:1177-80.  Back to cited text no. 1
    
2.
Abodunrin OL, Ilori OR, Temitayo-Obor AA, Adeomi AA, Folorunso ES, Adeoye OA, et al. Stress and coping strategies during residency training: Survey of a teaching hospital in Southwestern Nigeria. Int J Innov Res Dev 2017;6:99-105.  Back to cited text no. 2
    
3.
Almojali AI, Almalki SA, Alothman AS, Masuadi EM, Alaqeel MK. The prevalence and association of stress with sleep quality among medical students. J Epidemiol Glob Health 2017;7:169-74.  Back to cited text no. 3
    
4.
Bassols AM, Carneiro BB, Guimarães GC, Okabayashi LM, Carvalho FG, da Silva AB, et al. Stress and coping in a sample of medical students in Brazil. Arch Clin Psychiatr 2015;42:1-5.  Back to cited text no. 4
    
5.
Sahasrabuddhe AG, Suryawanshi SR, Bhandari SR. Stress among doctors doing residency: A cross-sectional study at a tertiary care hospital in the city of Mumbai. Natl J Community Med 2015;6:21-4.  Back to cited text no. 5
    
6.
Gobbur SB, Nigudgi SR, Reddy S. International journal of community medicine and public health. Int J Community Med Public Health 2016;3:576-80.  Back to cited text no. 6
    
7.
Landrigan CP. Sliding down the bell curve: Effects of 24-hr work shifts on physicians's cognition and performance. Sleep 2005;28:1351-3.  Back to cited text no. 7
    
8.
Ojo EO, Chirdan OO, Ajape AA, Agbo S, Oguntola AS, Adejumo AA, et al. Post-graduate surgical training in Nigeria: The trainees' perspective. Niger Med J 2014;55:342-7.  Back to cited text no. 8
[PUBMED]  [Full text]  
9.
Ray I, Joseph D. Stress in Medical Students. Vol. 12; 2010. p. 4. Available from: https://www.jkscience.or. [Last accessed on 2018 Nov 23].  Back to cited text no. 9
    
10.
Jaisoorya TS, Rani A, Menon PG, Jeevan CR, Revamma M, Jose V, et al. Psychological distress among college students in Kerala, India-prevalence and correlates. Asian J Psychiatr 2017;28:28-31.  Back to cited text no. 10
    
11.
Dixit A, Thawani R, Goyal A, Vaney N. Psychomotor performance of medical students: Effect of 24 hours of sleep deprivation. Indian J Psychol Med 2012;34:129-32.  Back to cited text no. 11
[PUBMED]  [Full text]  
12.
Saini NK, Agrawal S, Bhasin SK, Bhatia MS, Sharma AK. Prevalence of stress among resident doctors working in medical colleges of Delhi. Indian J Public Health 2010;54:219-23.  Back to cited text no. 12
[PUBMED]  [Full text]  
13.
Bamuhair SS, Al Farhan AI, Althubaiti A, Agha S, Rahman SU, Ibrahim NO. Sources of stress and coping strategies among undergraduate medical students enrolled in a problem-based learning curriculum. J Biomed Educ 2015. https://doi.org/10.1155/2015/575139.  Back to cited text no. 13
    
14.
Priya J, Singh J, Kumari S. Study of the factors associated with poor sleep among medical students. Indian J Basic Appl Med Res 2017;6:422-9.  Back to cited text no. 14
    
15.
Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav 1983;24:385-96.  Back to cited text no. 15
    
16.
Pallesen S, Bjorvatn B, Hilde I, Sivertsen NB, Hjørnevik M, Morin CM. A new scale for measuring insomnia: The Bergen insomnia scale, perceptual and motor skills 2017;107:691-706.  Back to cited text no. 16
    
17.
Nair P. Most Young GMC Doctors are Stressed. The Times of India Newspaper Dated; 2009. Available from: https://www.timesofindia.indiatimes.com/city/goa/Most-young-GMC-docs-are-stressed/articleshow/4412126.cms. [Last accessed on 2020 Oct 25].  Back to cited text no. 17
    
18.
Grover S, Sahoo S, Bhalla A, Avasthi A. Psychological problems and burnout among medical professionals of a tertiary care hospital of North India: A cross-sectional study. Indian J Psychiatry 2018;60:175-88.  Back to cited text no. 18
[PUBMED]  [Full text]  
19.
Alosaimi FD, Kazim SN, Almufleh AS, Aladwani BS, Alsubaie AS. Prevalence of stress and its determinants among residents in Saudi Arabia. Saudi Med J 2015;36:605-12.  Back to cited text no. 19
    
20.
Doherty EM, Cronin PA, Offiah G. Emotional intelligence assessment in a graduate entry medical school curriculum. BMC Med Educ 2013;13:38.  Back to cited text no. 20
    
21.
The Directives of the Supreme Court of India in its Judgment Dt. 25.9.87 in Writ Petition No. 348-352 of 1985, The Instruction No. 13 of this Letter 'Hours of Work'; 1985.  Back to cited text no. 21
    
22.
Parshuram CS, Dhanani S, Kirsh JA, Cox PN. Fellowship training, workload, fatigue and physical stress: A prospective observational study. CMAJ 2004;170:965-70.  Back to cited text no. 22
    
23.
Ahrberg K, Dresler M, Niedermaier S, Steiger A, Genzel L. The interaction between sleep quality and academic performance. J Psychiatr Res 2012;46:1618-22.  Back to cited text no. 23
    
24.
van Dongen HP, Dinges DF. Circadian rhythm in sleepiness, alertness and performance. In: Kryger MH, Roth T, Dement WC, editors. Principles and Practice of Sleep Medicine. Philadelphia, PA: Saunders; 2005. p. 435-43.  Back to cited text no. 24
    
25.
Choshen-Hillel S, Ishqer A, Mahameed F, Reiter J, Gozal D, Gileles-Hillel A, et al. Acute and chronic sleep deprivation in residents: Cognition and stress biomarkers. Med Educ 2021;55:174-84.  Back to cited text no. 25
    
26.
Dyrbye LN, Thomas MR, Shanafelt TD. Systematic review of depression, anxiety, and other indicators of psychological distress among U.S. and Canadian medical students. Acad Med 2006;81:354-73.  Back to cited text no. 26
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Methodology
Results
Discussion
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed556    
    Printed24    
    Emailed0    
    PDF Downloaded26    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]