Anxiety and Depression and Associated Stressors among Health Science Students in the Middle East

By Sridevi Adivi

Independent Public Health Consultant, ISECN Eastern Mediterranean Regional Editor

Anxiety and depression are good indicators for mental health assessment.  Students of health sciences universities are no exception to the growing global phenomenon of stress causing anxiety and depression. Medical education is dynamic with expanding knowledge and evolving therapies. The objective is to acquire knowledge, gain proficiency and become competent. (1) Studies have been conducted worldwide while the region of the Middle East is understudied and the few studies conducted report high level of anxiety and depression. First year students are a unique population with a transition to a complex environment followed by dynamic academic stressors. (2) An exclusive feature of the region is a diverse student population from multiethnic backgrounds and from different languages of instruction in high schools.  Diversity is prominent as children of expatriates and students of neighboring countries secure admission and a primary reason for studies in the region focusing on the first year students. Stress in the first year is attributed to emotional and academic components, and in the ensuing years, to physical factors and patient care. Academic evaluations, lack of leisure time and peer support, living away from families and financial issues, all stimulate fear, lack of ability and anger causing anxiety and depression. (3)

This paper is a compendium of the studies conducted in Arab Countries namely United Arab Emirates, Saudi Arabia, Oman, Bahrain and Egypt. The cross-sectional surveys studied the prevalence of anxiety and depression among medical, pharmaceutical and nursing students.  Participation in the surveys was voluntary, anonymous and students were administered questionnaires. Influence of demography, psychosocial, behavioral, health and academic factors on the mental health of student population was evaluated. Majority of the participants constituted of first year students except in two studies that had first, sixth year, pre-clinical and clinical stages to assess difference in prevalence.

In Egypt, United Arab Emirates and Saudi Arabia, participants belonged to first year of medicine, pharmaceutical, nursing and dental. The volunteers answered a self-administered questionnaire for the analysis of stressors. The nursing students were of two categories; direct admission from high school and after graduation. Data analyzed showed uniformity and no distinction among the categories. Analysis demonstrated academics as the highest stressor followed by environmental and interpersonal factors for anxiety and depression. Incidence of depression worsened from beginning of the year to the end. (2) The first survey in Egypt was conducted with a two part questionnaire completed by 379 first year medical students.

The first part was a data collection instrument identified the demographic and risk factors of psychological health. Second part was an Arab version of Depression Anxiety Stress Scale (DASS). Major percentages of participants were living with families and perceived moderate socio-economic standard. Only 8.7% suffered from single psychological illness. Alarmingly, 34.6% and 46.9% suffered from triple concomitant and double concomitant psychological illnesses**. Men were prone to depression and women were prone to anxiety and stress. Behavioral and existing medical conditions were considered for associated psychological illnesses. Depression was associated with insomnia, physical illness and frequent consumption of coffee and tea. Education in English was an associated stress factor. (1)

In Egypt, Equal number of subjects from the first year of two streams; medical and pharmaceutical, showed that anxiety and depression were significant in both streams. Arabic version of Beck’s Anxiety Index and Beck’s Depression Inventory acted as tools of measurement with 21 multiple choice answers. Predominant levels of anxiety and depression exhibited in medical stream compared to pharma stream. This was attributed to medical students passing through several examinations, being critical about self and socially isolated when compared to the pharmaceutical students.  Gender differences were noted showing that symptoms are more visible among women. Women voice out their stress due to high load curriculum, physical and psychological distress and less job opportunities in comparison to men. (2)

In Bahrain, comparative analysis of first and sixth year students was conducted utilizing the Hospital Anxiety and Depression Scale. Gender played no significant role among the first and sixth year students. Based on HADS scoring the subjects were segregated into three groups- normal, mild and severe. Figures from the ANOVA test demonstrated prevalence of anxiety and depression was higher among participants from the sixth year than the first year.  Lesser number of students classified as normal in comparison to the first year.  It also suggests that medical students experience more stressors in addition to everyday life. (5) The cross sectional study from Oman had voluntary participation of pre-clinical and clinical graduate students. Majority of the subjects were women and urban residents. Stress factors varied such as mild stress when discussing personal problems with patients, abuse as secondary and severe stress for lack of family time. Students were stressed by poor marks, large burden of study material, assessments and time constraints. Coping strategies varied from planning things ahead and religion. (4)

In United Arab Emirates, all students of the first year from professional courses were contacted for the survey.  Student population consisted of 35 nationalities and many were in the Emirates for the first time. The first two parts of the questionnaire obtained demographic details and general health using the validated GHQ-12 (General Health Questionnaire with 12 questions). The third part for sources of stress was validated and tested prior to application. The stressors were classified into academic, psychological and health. Frequency of assessments, overload of work and managing time are the academic components. Worry about future, high expectations by parents and interactions with members of opposite sex were the psychosocial components. Health related components were lack of physical activity and lack of healthy diet combined with irregular eating habits are the associated stressors. Psychosocial morbidity was higher among students with other languages of instruction in high school. Coping with English is a stressor irrespective of the demographic group. The GHQ-12 revealed that one in 3 students exhibited psychological morbidity. Psychosocial components precede other factors though no significant differences were found among the genders or the students of different faculties. (6)

Conclusion

Anxiety and depression have negative effects on the physical and mental health of the students, which in turn, impacts their education. (2) The cross-sectional studies show that medical students are burdened by anxiety and stress owing to different stressors. Academic stressors rank first, psychosocial rank second and demography impacts minimally. Subsequently, the disability to perform in class and impairment to technical procedures can cause harm to patients, relationship with peers, faculty and family. The stress and deteriorating performance can prolong into their internship and clinical practice. (4) Early detection and treatment can shorten the duration the episodes of depression and reduces the impact. (1)  Physical activity, meditation, planned time outs and other coping methods aid in stress management. Counselling and teaching stress management from first year is imperative to enhance the standards of healthcare in the region.

Limitations to these surveys are smaller populations and larger number of female students to express significant differences among gender or year of study. These countries have produced little research in the area of medical education and stress. Sensitivity of the student population to traditional and cultural beliefs is an important influencer to be considered in future research. Improved research with the inclusion of criteria like tobacco use, internet and social media addiction are suggested for complete assessment of information.

** Percentage quoted due to presence of more than one psychological illness.

References

  1. Depression, anxiety and stress among first year medical students in an Egyptian public university Ayat R. Abdallah1 * and Hala M. Gabr, International Research Journal of Medicine and Medical Sciences Vol. 2(1), pp. 11-19, February 2014 ISSN: 2354-211X
  2. Stress/ Stressors as Perceived by Baccalaureate Saudi Nursing Students Abeer Saad Eswi, Sahar Radi and Hanaa Youssri, Middle-East Journal of Scientific Research 14 (2): 193-202, 2013 ISSN 1990-9233 © IDOSI Publications, 2013 DOI: 10.5829/idosi.mejsr.2013.14.2.734
  3. Prevalence of anxiety and depression among medical and pharmaceutical students in Alexandria University ;Motaz B.Ibrahim and.Moataz H.Abdelreheem,   Alexandria Journal of Medicine,Volume 51, Issue 2, June 2015, Pages 167-173, https://doi.org/10.1016/j.ajme.2014.06.002
  4. Perception of stress, anxiety, depression and coping strategies among medical students at Oman Medical College, Firdous Jahan (1) Muhammad A Siddiqui (2) Mohammed Mitwally (3) Noor Said Jasim Al Zubidi (4) Huda Said Jasim Al Zubidi , MIDDLE EAST JOURNAL OF FAMILY MEDICINE VOLUME 14 ISSUE 7, SEPTEMBER 2016
  5. Comparison between the First and Sixth Year Medical Students in the Arabian Gulf University of Bahrain Regarding Anxiety and Depression Hasfa M. Ali1 , Duaa M. Attar1 , Fatma Al-Abdulwahid1 , Fatema A. Juma1 , Hussah I. Al-Mezail1 , Jawaher A. Al-Jalahma1 , Raneem R. Al-Shaikh1 , Samar S. Hussain1 , Sara A. A. Al-Mail1 , Wafa A. T. Al-Omari1 and Amer Kamal, International Neuropsychiatric Disease Journal 2(2): 85-93, 2014
  6. Psychological Health of First-Year Health Professional Students in a Medical University in the United Arab Emirates, Kadayam G Gomathi,1,* Soofia Ahmed,2 and Jayadevan Sreedharan  , Sultan Qaboos Univ Med J. 2012 May; 12(2): 206–213.
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