Half the Room

What PHQ-9 and GAD-7 actually measure

This is the part most news coverage gets wrong. The PHQ-9 and GAD-7 are not diagnostic instruments. They are screening instruments. The distinction matters enormously.

A screening instrument identifies people who are likely to have a condition and who should receive further evaluation. It does not confirm a diagnosis. A positive screen on PHQ-9 does not mean a student has clinical depression. It means they reported a pattern of symptoms — low mood, loss of interest, sleep disturbance, difficulty concentrating, feelings of worthlessness — that is consistent with a depressive episode and warrants clinical follow-up.

PHQ-9 (Patient Health Questionnaire, 9 items) asks respondents how often in the past two weeks they have experienced nine symptoms: low mood, anhedonia, sleep problems, fatigue, appetite change, low self-worth, concentration difficulty, psychomotor changes, and suicidal ideation. Each symptom is scored 0 (not at all) to 3 (nearly every day). Total scores run 0 to 27. The commonly used cut-offs are: 5–9 (mild), 10–14 (moderate), 15–19 (moderately severe), 20–27 (severe). A score of 10 or above is typically used as a positive screen for major depressive disorder.

GAD-7 (Generalised Anxiety Disorder scale, 7 items) works similarly, asking about anxiety symptoms over the past two weeks: feeling nervous, inability to control worrying, worrying too much, difficulty relaxing, restlessness, irritability, and fear that something awful might happen. Scores of 10 or above indicate moderate to severe anxiety warranting clinical evaluation.

When the TISS study reported that 49.3 per cent of students showed anxiety symptoms and 32 per cent showed depression symptoms, it meant: those percentages of students scored above the validated clinical threshold on these instruments. Not that nearly half of Kota is clinically depressed. But that nearly half of Kota's students reported a symptom burden that clinicians would want to investigate further.

The difference sounds technical. It has real consequences for how the finding should be reported — and for what the appropriate response is.

What else they found

Beyond the headline numbers, the TISS study documented a set of findings that paint a more detailed picture of student life in Kota.

On financial pressure: 27.6 per cent of students reported significant distress linked to the financial debt their families had taken on to fund their coaching. This is not simply distress about exams. It is distress about the weight of a family's economic bet resting on one outcome. Researchers noted that this financial stress was correlated with higher anxiety and depression scores — students who reported debt-related distress showed elevated symptom burden on both instruments.

On social isolation: A significant proportion of students reported reduced contact with family and friends since arriving in Kota. The city's boarding model — students living in hostels, attending classes from early morning until late evening, preparing in study halls at night — structurally limits social interaction. Researchers found that students with lower perceived social support had meaningfully higher distress scores.

On help-seeking: This may be the finding with the most immediate policy relevance. The study found that very few students — the precise figure varied across sub-groups, but was consistently below 10 per cent — had sought any professional mental health support despite experiencing significant symptoms. The barriers cited were: stigma (believing seeking help was a sign of weakness), lack of awareness that support was available, cost, and time constraints. Students in the highest distress categories were not more likely to seek help; if anything, the most severely symptomatic students were the least likely to have accessed any support.

On academic performance fears: Students who reported fear of academic failure — not just the exam itself, but the prospect of returning home without success, of facing their families — showed significantly higher distress scores than those who did not. The researchers interpreted this as evidence that the psychological stakes of Kota extend beyond personal ambition into family obligation and social identity.

The causation question: does Kota create this distress?

The TISS study cannot answer the question that its numbers most naturally invite: does Kota cause this?

The study is cross-sectional. It measured students' mental health at one point in time. It did not measure students before they arrived in Kota and after — a longitudinal design that would be necessary to show whether distress increased over the course of coaching. It did not compare Kota students with matched students preparing for the same exams elsewhere, which would be necessary to show whether Kota's particular environment drives distress above what exam preparation alone would generate.

This is not a criticism of the study's design. A government-commissioned field survey has practical constraints — time, budget, access. The researchers acknowledge this limitation explicitly.

What the limitation means is that three explanations for the high prevalence numbers are all consistent with the data:

Kota causes distress. The hostel environment, the extreme study hours, the competition, the distance from family, and the financial pressure combine to produce elevated mental health problems in students who would otherwise be fine.

Distress selects into Kota. Students who are already more anxious, more perfectionistic, more driven — and thus more vulnerable to distress — are the ones most likely to uproot and move to Kota in the first place. The population in Kota is not a random sample of Indian 17-year-olds; it is a self-selected group of the most intensely exam-focused students in the country.

Both are true simultaneously. Students who arrive already at elevated risk encounter an environment that amplifies that risk. The two mechanisms compound.

The study's numbers are real. The mechanism that produced them is uncertain. That uncertainty should be stated — and it should shape how policy responds.

What this evidence means

Here is what the TISS study does establish, even with its limitations:

A large proportion of students in Kota's coaching institutes are carrying a symptom burden that, in any clinical or public health context, would be considered significant. Whether Kota caused it or not, it exists. It is measurable. And it is largely untreated.

The finding that fewer than 10 per cent of symptomatic students sought help is, in some ways, more consequential than the headline prevalence numbers. High prevalence numbers might prompt debate about coaching culture and policy. Low help-seeking numbers point to something more immediate and actionable: these students are in distress, they are not accessing support, and the barriers to access are not principally logistical. They are cultural — stigma, shame, the belief that distress is weakness rather than a condition with legitimate treatment.

The Rajasthan government's response to the study was to mandate mental health counsellors in Kota's coaching institutes. Whether that response was adequate, and whether the mandate was effectively implemented, is a separate question. The study created the evidence base that made that policy response possible.

What the study cannot do — and what no cross-sectional field survey can do — is tell us whether the solution is better mental health support within the coaching system, or whether the system itself needs to change. That is not a research question. It is a values question about what a society owes its 17-year-olds, and what it is willing to ask of them in exchange for a medical degree.

What this study doesn't prove

That 49% of Kota students have clinical depression or anxiety. The PHQ-9 and GAD-7 are screening tools, not diagnostic instruments. A positive screen is a threshold crossed on a self-report questionnaire, not a clinical diagnosis. The appropriate reading is: nearly half the students surveyed reported symptoms consistent with anxiety disorder at a level that warrants clinical follow-up.

That coaching causes mental health problems. This cross-sectional study cannot establish causation. It shows prevalence at a single point in time, in a self-selected population, without a comparison group. Students who move to Kota may already be more anxious than the general population. The environment may make it worse. Both may be true. The data does not distinguish between these explanations.

That Kota is uniquely harmful compared to other forms of competitive exam preparation. The study did not compare Kota students with students at coaching centres in other cities, students self-studying at home, or students in the same exam cycle not enrolled in coaching. Without that comparison, we cannot say whether Kota's rates are higher or lower than alternatives.

That these findings have gotten worse or better over time. This was a 2018 study. Kota's coaching ecosystem has changed since then — new regulations, mandatory counsellors, some institutes limiting student intake. Whether mental health outcomes have improved, worsened, or stayed the same is unknown.

That the Rajasthan government's policy response — mandatory counsellors — was effective. The study recommended action. Whether the action worked is an empirical question that requires a follow-up study, which, as of the time of this writing, has not been published.