Hypochondriasis and self-medication among medical sciences students during the COVID-19 pandemic: A descriptive cross-sectional study in Northwestern Iran

1 Introduction

Self-medication is a form of self-management in which individuals, families, and communities take medications to treat and improve their health without consulting a physician [1]. The World Health Organization (WHO) defines self-medication as the acquisition and use of one or more industrial or herbal medicines without the use of a physician’s opinion or diagnosis and without a prescription or medical supervision [2]. Indiscriminate drug usage causes disruption of the drug market, cost wastage, per capita increase in drug use [3], and the spread of factors such as bacterial resistance, lack of optimal treatment, drug poisoning and side effects [4]. According to studies, the prevalence of self-medication in different parts of the world varies depending on various cultural, political and economic factors and it has been reported between to be 32.5–81.5% [5]. For example, the prevalence of self-medication has been reported to be 21.5% in rural areas of Portugal [6], 14.9% in the adult population of Brazil [7], 11.9–50% in rural India [8], 62.7% in the adult population of Kuala Lumpur [9], and 42.5% in the general population of Oman [10]. One of the most important reasons for self-medication is the popular culture and public belief that they should be prescribed a lot of drug since people think that any doctor who prescribes more drugs is a better doctor [11]. In addition, many people take medication for prevention and treatment as well as self-enhancement [12]. This has caused half of the drugs used to be useless [12].

In Iran, the country’s pharmaceutical system is facing with inappropriate and indiscriminate use of drugs and efforts have not been very successful to correct this trend [13]. The prevalence of self-medication has been reported to be 68% in the elderly population [14]. According to studies, indiscriminate drug use is very common among Iranian students, especially medical students [15–18]. In some studies, its prevalence has been reported to be above 50% [15, 16], and in some cases even above 80% [17, 18]. In a review study conducted in Iran, it was found that analgesics, eye drops and antibiotics included the highest indiscriminate drug use, respectively [19]. Factors such as keeping medicine at home, believing that self-medication is safe, not having enough time to see a doctor to solve the problem, delivery of medicine without a doctor’s prescription by pharmacies, distrust of the quality of medicine and preferring foreign drugs to Iranian type was mentioned as important factors related to indiscriminate use of drugs [19].

Hypochondriasis is a type of mental disorder, the person is suspicious of the doctor’s diagnosis and believes that he has a serious illness and seeks excessive medical care, despite having physical health and not observing the problem and disease in clinical and laboratory examinations [20]. Therefore, the person seeks excessive medical care or requests frequent changes of medical care and may even refuse medical care for fear of developing the disease [21]. Hypochondriasis can arise after a serious illness or the death of a relative, or because of a physical illness in a person who has recovered but left him/her in the same state of mind [21]. Another reason for this disorder is the patient’s hypersensitivity to bodily sensations and his/her low tolerance threshold for pain and physical discomfort [22]. According to studies, the prevalence of this disorder is about 6% [23, 24]. The symptoms of hypochondriasis can start at any age; but this disorder is more reported in people aged 20–30 [25]. In the studies conducted by Ghasemnejad et al. and Ajezi, the prevalence of severe hypochondriasis was reported in one third of the studied Iranian students [26, 27].

The outbreak of coronavirus 2019 (COVID-19) posed new challenges in the field of healthcare worldwide [28]. One of these challenges was the lack of specific drugs at the beginning of the outbreak [29]. On the other hand, the spread of social media and sometimes the presentation of inaccurate information about drugs led to an increase in self-medication and home remedies without confirmation of sufficient safety and effectiveness [30, 31]. This is evidenced by the dramatic increase in internet searches for COVID-19 drugs, as well as the availability of online information on COVID-19 drugs by 2020 worldwide [32]. In some developing countries, including India, self-medication with hydrochloroquine and chloroquine has been observed against COVID-19 [33]. In the United Kingdom (UK), indiscriminate use by dexamethasone has been increased after researchers introduced dexamethasone as a life-giving drug against COVID-19 [34]. On the other hand, previous research on epidemics, such as the 2009 swine flu crisis, has shown that hypochondriasis is positively correlated with depression and anxiety [35]. People with hypochondriasis are more likely to experience psychological distress during an outbreak of an infectious disease because they interpret their symptoms of physical discomfort as signs of infection [36]. Almhdawi et al. reported that healthcare students had a relatively low level of Health-related Quality of life (HRQOL) during COVID-19 pandemic in Jordan [37]. Hence, it is expected that this vulnerability and fear factor could predict psychological pathology [37].

Considering the results of the afore-mentioned studies, it is very important to pay attention to the side effects of self-medication and hypochondriasis. In addition, studies show that the incidence of self-medication and hypochondriasis among the young population, especially students, is high and it needs to be investigated. Meanwhile, students are of special importance due to their social position and they have more contact with community members in their future job positions as role models and examples of health behaviors for other people. On the other hand, the increase in fear and anxiety among the public following the prevalence of the emerging COVID-19 pandemic can aggravate the two disorders (self-medication and hypochondriasis) because a person may mistakenly consider themselves sick and this feeling makes them take medicine. It seems, in order to change the society’s behavior, preliminary studies on the prevalence and influencing factors on health-related phenomena should be conducted to provide the basis for effective interventions. Therefore, collecting information about the causes and types of drugs taken for self-medication, as well as the prevalence of hypochondriasis disorder, can be helpful in dealing with these disorders because based on this information, the necessary training and awareness can be provided to the students. This study aims to identify the frequency and causes of self-medication and hypochondriasis among students of Khalkhal University of Medical Sciences.

2 Methods

3 Results

This study was performed to identify the frequency and causes of self-medication and hypochondriasis among students. The results confirmed the prevalence of self-medication among roughly 50% of the participants. Previous studies also showed a high prevalence of self-medication among Iranian students [15–18]. The total mean score of hypochondriasis among the participants also indicated that most of the individuals were in the borderline group of hypochondriasis and therefore being at risk. The temporary hypochondriasis is often seen among medical students. A bodily feeling, which was unimportant to a person in the past, is now mistakenly considered as a disease. Because the student now has a newly acquired cognitive body of information about pathology and clinical medicine [42].

Students, especially those of various medical sciences, seem to try self-medication or recommend medication based on what they know and have learned. A high proportion of self-medication was found among students according to results. Of course, this problem has also been reported in other parts of the world, including among Oman (78.5%) and Ethiopian (38.5%), Karachi (76%) and Kuwait (92%) students [43–46]. According to these finding, it can be stated that the rate of self-medication among students is high and it is necessary to give the necessary information to them through books, professors, media, internet and publishing related specialized articles. In addition, the findings indicated a high percentage of students in the basic sciences had self-medication, which is a very high rate considering the lack of direct contact of this group of students with the patient and the hospital and overall clinical work. This can be a sign of the influence and prescription of other classmates and friends, or lack of awareness of the side effects of drugs.

In this study, the highest rate of self-medication was in the form of tablets and capsules and the highest type of medication was herbal medicine, multivitamins, and supplements. The most common reason for self-medication was the previous use and effectiveness of the drug in the past. Similarly, Najafipour et al. in their study on medical students concluded that the most common form of medication usage was taking the tablets, and painkillers. They argued that previous experience of drug use, ignoring the disease’s significance and self-diagnosis were the main causes of self-medication [17]. Khadem et al. in their study on medical students in Rafsanjan reported about 76.4% prevalence of self-medication, mostly in the form of tablets. In addition, analgesia was the most commonly used drug and the previous drug usage was the most important cause of self-medication [16]. A study by Alshogran et al. in Jordan showed that self-medication was very common among medical and non-medical students (96%). In their study, self-medication with analgesics and anti-allergy drugs was reported to be significantly higher among medical students. Non-medical students, in contrast to medical students, were significantly more dependent on friends as a source of self-medication counseling and personalexperience [47].

There are several points to consider in results. First, unlike previous studies where painkillers were the most commonly used drugs, in this study herbal drugs and multivitamins were more common. Herbal medicine has been common in all parts of Iran for many years [48]. On the one hand, this may be influenced by the location of the study, where the use of herbal medicines is common. In addition, it may be related to the time of the study, which emphasized the effect of vitamins during the outbreak of Corona. Also, the use of herbal medicine became more common. Afshari and Jouki found out that diets containing vitamin A, C, D, E, and omega 3 could be used as promising options to prevent lung infection with COVID-19 [49]. The use of herbal medicine is very common among the people of China to reduce visits to the hospital during the COVID-19 pandemic [50].

Another issue is keeping medicine at home in all countries of the world and it is not unique to Iran. Many researches in different provinces of Iran show the increase of drug resistance to all kinds of antibiotics, the lack of attention of doctors to drug interactions and the imposition of exorbitant costs on patients [51]. Soudi et al. in their study on 500 households found that 90% of them keep medicine at home. The most pharmaceutical forms were tablets, ampoules, capsules, and syrups, respectively [52]. Certainly, the accumulation of easily available drugs is the basis of self-medication, which, with its repetition, also leads to drug resistance. The results of a study showed that many students believe that drugs are not dangerous and they have obtained good results from self-medication. As a result, they take medicine without a doctor’s prescription [53]. Therefore, correcting self-medication behavior requires information and necessary training. Salami et al. promoted self-medication behavior in medical students with the help of an educational intervention based on the health belief model [54]. The issue that should be considered in training is that using a certain drug in the past cannot be a strong reason to use it again because the conditions of the body change and the same symptoms may be caused by a different disease or problem.

According to the findings, a statistically significant association was found between residence status, academic year, and self-medication. It seems that students at lower academic levels and students who lived far from their families did more self-medication. Respiratory allergies and joints disease or problems, were also associated with self-medication. In the study of Nahimana et al. on nursing students, self-medication was influenced by relatives’ advice, low income, level of study and religion [55]. Mohammad et al. in their study stated that age, rural residence, female gender, inadequate access to health care, the presence of chronic diseases and income (1000–2,000 pound) per month were strong predictors of self-medication [56]. In Gholipour et al.’s study on students of Tabriz University of Medical Sciences, in contrast to our results, a statistically significant association was found between gender and field of study and self-medication [57]. We found a statistically significant association between fear of COVID-19 and a history of infection in the individuals and their family and relatives and self-medication. According to the number of Google searches, the rate of self-medication has increased since the outbreak of the new pandemic [32]. In a multicenter study in Peru, Quispe-Cañari et al. reported self-medication with acetaminophen, ibuprofen, azithromycin, penicillin, antiretroviral drugs, and hydroxychloroquine during the COVID-19 pandemic [58]. Romano et al. reported that acetaminophen sales increased significantly during the COVID-19 pandemic [59]. Wegbom et al. showed that the prevalence of self-medication for the protection or treatment of COVID-19 in Nigeria was 41%. Fear of discrimination or stigma, fear of being quarantined, fear of contact with a suspicious infected person, and infection were important self-medication factors in their study [60].

In this study, most students were in the mild group in terms of hypochondriasis. However, the number of people in mild to moderate groups was about 20% of the participants. In addition, a statistically association was found between hypochondriasis and father’s level of education and some problems and diseases related to heart, gastrointestinal nerves, headaches and hypochondriasis. Previous studies also confirmed the prevalence of hypochondriasis in the third decade of life and to an almost equal extent among men and women [25, 62]. The study of Meng et al. showed a 28% prevalence of hypochondriasis among health students. This rate was higher in women than men, but it was not statistically significant [63]. Ahmed et al. reported a worrying rate of hypochondriasis among medical students. More than 60% of the participants were dissatisfied with their general health and more than two-thirds, most of whom were women, admitted that they were affected by unexplained pain in their body [64]. In the study by Talaei et al., the prevalence of borderline hypochondriasis symptoms was 36.8% and the prevalence of its disorder in the studied students was 16%. The disorder was significantly more common in girls. In addition, the association between hypochondriasis and different fields and levels of education was reported to be significant [41]. Akhavan et al. in their study on operating room staff found that as people got older, the prevalence of hypochondriasis increased [65]. It should be noted that the demographic variables studied in the studies are very diverse and this is the main reason for the difference between their results and the present study. On the other hand, in this research, age, levels and fields of study are largely similar.

In this study, a statistically significant association was found between hypochondriasis and self-infection of individuals and family and relatives with COVID-19 and fear of COVID-19. It is clear that the association between hypochondriasis and self-medication is two-way. The feeling of being sick increases the desire to take medicine, and on the other hand, excessive use of medicine and not getting results from it induces the feeling of being sick. In Okoi et al.’s study, 91% of respondents reported phobia and hypochondriasis. The phobia was mostly attributed to COVID-19 and the human immunodeficiency virus [66]. Mousavi et al. concluded that hypochondriasis can be predicted by variables of using protective equipment, experience of COVID-19 infection and awareness of this disease [67]. It is true that, as studies have emphasized, the fear of COVID-19 may increase hypochondriasis, but the psychological roots affecting this behavior should not be ignored. Scrignar recommended that panic disorder should be ruled out before diagnosing patients with hypochondriasis, because patients may have symptoms of panic disorders that can be similar to the fear and worries of hypochondriacs [68]. Sakai et al. confirmed a high prevalence of personality disorders among patients with hypochondriasis. The most common associated type of personality disorder with hypochondriasis was obsessive-compulsive personality disorder [69]. Hypochondriasis has long been recognized as an incurable problem, but later the beneficial effects of cognitive-behavioral therapies were identified [70]. A 5-year study in the UK found that cognitive-behavioral therapies significantly reduced stress and its symptoms among 444 patients with hypochondriasis [71]. In two studies, the effect of psychotherapy, cognitive therapy and paroxetine in reducing symptoms and treating symptoms of hypochondriasis has been confirmed [72, 73]. Hypochondriasis sometimes is related to problems and chronic pain, as was observed among study participants. The association between pain and hypochondriasis was confirmed in a review study, while pain treatment improved patients with hypochondriasis [74]. On the other hand, the fear of COVID-19 has been related to both phenomena, so giving the necessary awareness in this case can also help and reduce fear and anxiety. Izzeddin Sarsak reported more than 30% of medical and rehabilitation sciences students experienced sleep and appetite distribution during the pandemic. Students with adequate knowledge about the COVID-19 pandemic reported a significant decrease in anxiety level [75].

5 Conclusion

According to the findings, more than half of the participants in the study had self-medication. Prevalence of indiscriminate drug use among the educated classes can cause indiscriminate drug use and self-medication to become normal behavior among people, because community choose educated people as role models. It is necessary to design programs at the university level by holding workshops and scientific discourses so that students can conclude that indiscriminately taking drugs can have irreparable side effects. Previous experience of drug use was the most important cause of self-medication. It seems necessary to control the sale of drugs in pharmacies, as well as the proper prescription of drugs by doctors. In addition, training provided by pharmacies and pharmacists can reduce the complications of indiscriminate drug use. About 20% of students also experienced mild to moderate hypochondriasis. Fear of COVID-19 infection and a history of the disease among individuals, family and relatives exacerbated both phenomena. Since the exact time for the end of the COVID-19 pandemic has not been determined, and self-medication and hypochondriasis may cause physical and psychological harm, especially for university students who are the human capital of a country, it is suggested that the necessary training and support be provided to deal with these two phenomena. Since chronic pains and mental disorders aggravate the symptoms of hypochondriasis and even self-medication, accurate identification of causes and symptoms can be helpful in planning for education, counseling and drug prescription. The association between hypochondriasis and self-medication is two-way. The feeling of being sick increases the desire to take medicine, and on the other hand, excessive use of medicine and not getting results from it induces the feeling of being sick. Therefore, effective measures in each case can improve the other case as well.

Ethical approval

Ethical permission was obtained from the Ethics Committee of Khalkhal University of Medical Science (IR.KHALUMS.REC.1400.004).

Informed consent

Informed consent was obtained from all participants prior to participation in the study.

Conflict of interest

None to report.