Pakistan Journal of Medical Sciences


ISSN 1681-715X





Volume 24

 January - March 2008

Number  1



PDF of this Article

Stress and depression among medical students:
A cross sectional study at a medical college in Saudi Arabia

Hamza Mohammad Abdulghani1


Objectives: To determine prevalence of stress among undergraduate medical students and to observe an association between stress and academic year, grades, regularity and physical problems.

Methodology: All 600 registered students at College of Medicine, King Saud University in years 1,2,3,4 and 5 were enrolled in the study, and asked to complete a stress inventory called Kessler10.

Results: There were 494 responses with the response rate of 83%. The prevalence of stress of all types was found among 57% and severe stress among 19.6% study subjects. There was highly statistically significant association between year of study and stress levels, (p<0.0001). The association between academic grades of study subjects and their stress levels is not statistically significant, as distribution of prevalence of stress is not significantly different across each of the four academic grades (p=0.46).The main source of stress found to be their studies (60.3%), followed by home environment (2.8%) and 36.9% of study population did not mention any source of stress.

Conclusion: High levels of psychosocial distress was found in our students during the initial three years of their course. It poses additional challenges for students’ support services delivery which may require to address mental health problems along with common health strategies for our students.

KEY WORDS: Educational Achievements, Medical Student, Stress, Depression, Saudi Arabia.

Pak J Med Sci    January - March 2008    Vol. 24 No. 1    12-17

1. Dr. Hamza Mohammad Abdulghani, DPHC, ABFM, MRCGP,
Assistant Professor,
Department of Family Physician and
Community Medicine,
College of Medicine,
King Saud University,
Saudi Arabia.


Dr. Hamza Mohammad Abdulghani,
Assistant Professor & Consultant Family Physician,
Dept. of Family & Community Medicine,
College of Medicine,
King Saud University,
P.O. Box: 230155,
Saudi Arabia.

* Received for Publication: September 25, 2007

* Accepted: December 1, 2007


Medical education is perceived as being stressful. It is characterized by many psychological changes in students. Medical students encounter multiple anxieties in transformation from insecure student to young knowledgeable physician. There is a growing concern about stress in medical training. Studies have observed that medical students experience a high incidence of personal distress during their undergraduate course. High levels of stress may have a negative effect on mastery of the academic curriculum. Stress, health and emotional problems increase during the period of undergraduate medical education. This can lead to mental distress and has a negative impact on cognitive functioning and learning.1

In most medical schools, the environment itself is an all prevailing pressure providing an authoritarian and rigid system; one that encourages competition rather than cooperation between learners.2 Studies suggest that mental health worsens after student begins medical school and remains poor throughout training. The majority of the studies on stress in medical education focus on the documentation of stress and information on the correlation of stress.3-6 It is not just undergraduate study period which brings the stress but it may continue later in internship, postgraduate study period and later in physicians’ practical life7-9 and it may reach burnout level.10 The estimated prevalence of emotional disturbance was found in different studies higher than in general population. In three British universities, the prevalence of stress was 31.2%,11 in a Malaysian medical school 41.9%12 and 61.4% is a Thai medical school.13 Medical school stress is likely to predict later mental health problems, but students seldom seek help for their problems.14 In a Swedish study, the prevalence of depressive symptoms among students was 12.9% and a total of 2.7% of students had made suicidal attempts.1 It is important for medical educators to know the prevalence and causes of student distress, which not only affects his health, but also his academic achievement at different time points of their study period.

An extensive electronic internet based search failed to locate any study which shows the prevalence of stress in undergraduate medical students in Saudi Arabia. This study was carried out with the following objectives:

1. To determine the prevalence of self-perceived stress among under graduate medical students.

2. To observe an association between the levels of stress and study variables: (i) academic year (ii) academic grades (iii) regular to course and (iv) physical problems.


Instrument: A wide range of different measures has been used to address stress and depressive symptomatology in medical students. It has been assessed with different tools like Beck’s Depression Inventory,12 General Health Questionnaire (GHQ)11 and as well as well other common and less common instruments.1,15

The instrument Kessler10 Psychological Distress (K10) has been developed by Kessler and colleagues, which widely used in population-based epidemiologic studies to measure current (1-month) distress. It has been shown to be without substantial bias with respect to sex and educational level. It has been designed to measure the level of distress and severity associated with psychological symptoms in population surveys. It is being used widely, including in the World Health Organization World Mental Health Survey, and as a clinical outcome measure.16-20 The K10 comprises 10 questions of the form, "how often in the past month did you feel ..." and offers specific symptoms such as "tired out for no good reason," "nervous", and "sad or depressed". The five possible responses range from "non of the time" to "all of the time" and are scored from 2 to 5; the items are assumed to obtain a total score. A score of less than 20 was considered not to represent a ‘case’ possibility of mental illness. A score of 20-24 was considered to present a mild stress, 25-29 was considered to present moderate stress and 30-50 was considered to represent as severe stress. These coding was used according to the instructions of the authors.21 This K10 questionnaire is observed to have good psychometric properties with Cronbach’s alpha of 0.8938 (95% Confidence Interval (C.I.): 0.8793-0.9072).

Study Sample: All the five-year male undergraduate students in the College of Medicine were asked to complete the K10 self-administered Arabic version questionnaires during the academic year 2006. Filled questionnaires were collected before one month of the examination period so as minimize the extra stress symptoms. Additional questions relating to academic achievement, source of stress, medical illness in past 4 weeks and how many days a student was not able to work were also collected. All students who participated in the study were informed about the objectives of the study and information about the instrument was explained by well trained research assistants. The students were allowed to respond in their own time and privacy. The participation was entirely on voluntary basis. All students were guaranteed the confidentiality. The study was approved by research ethical committee.

Statistical Analysis: Data were entered in Microsoft Excel and analyzed using SPSS version 12.0 statistical software. Prevalence of an outcome variable along with 95% confidence interval was calculated. Pearson’s chi-square test and odds ratio were used to observe and quantify an association between the categorical outcome and different study variables. Student’s t-test for independent samples was used to compare the mean values of study variables in relation to stress. A p-value of < 0.05 was considered statistically significant. The outcome variable stress was categorized into dichotomous as stress (no/yes) by considering the three levels (mild, moderate and severe) of stress as presence of stress.


There were 494 responses from a total student population of approximately 600 with the response rate of 83%. The mean (± standard deviation) age of study sample was 21.4(± 1.9) years. The prevalence of stress of all types was found to be about 57% (95% Confidence Interval (C.I.): 52.6-61.4) and the severe stress prevalence was 19.6% (95% C.I.: 16.1-23.1) (Table-I). The distribution of study variables are given in Table-II.

The prevalence of stress was higher (74.2%) in first year of study followed by second year (69.8%), third year (48.6%), fourth year (30.4%) and 49% was observed in fifth year of the study. There is highly statistical significant association between the year of study subjects and the stress levels. As the year of study was increasing, the prevalence of stress was decreasing, which is statistically significant (X2 = 45.9, p <0.0001). The odds ratios 6.4(for 1st year), 5.2 (2nd year), 2.4 (3rd year) and 2.1 (5th year), when 4th year is considered as reference category also indicates highly statistically significant association. The odds of student having stress is higher in 1st and 2nd year, where as the odds are decreasing in 3rd and 5th year. (Table-III)

The association between academic grades of study subjects and their stress levels is not statistically significant, as the distribution of prevalence of stress is not significantly different across each of the four academic grades (X2 = 2.57, p =0.46). There is no statistical significant association between the regularity (Yes/No) to the academic course and the stress levels of study subjects. The distribution of stress levels is not significantly different, being a student either regular or irregular to the academic course (X2 = 0.78, p =0.37). The corresponding odds ratios also show non significant association. But the prevalence of physical problems is statistically significantly associated with the stress levels (X2 = 19.78, p <0.001). The odds ratios 2.5 and 2.0 shows the odds of getting into stress is higher with mild to moderate and severe physical problems when compared with no physical problems (Table-IV). The mean number of days unable to work(9.5 days) was higher in subjects who had stress, when compared with the subjects with no stress (2.3 days) which is statistically significant (t = 9.75, p< 0.0001). The mean number of days cut down (10.7 days) was higher in subjects, who had stress, when compared with subjects with no stress (5.2 days) which is statistically significant (t = 5.3, p<0.0001).

The main source of stress stated by the study subjects was their studies (60.3%), followed by home environment (2.8%) and 36.9% of study population did not mention any source of stress.


A descriptive self administered questionnaire based study got a response rate of 83%, which provides an adequate sample size to fulfill the objectives of this study. The results of this study indicates higher prevalence of stress in our undergraduate medical students. The level of stress or depression varied between stages of education. This increased level of stress indicates a decrease of psychological health in our students which may impair students’ behaviour, diminish learning, and, ultimately, affect patient care. Overall prevalence of stress in this study is 57% which is similar to the Thai study; 61.4%13 but higher than Malaysian; 41.9%12 and British study;31.2%.11 The increase in stress level in fifth year is expected as it is the clinical teaching where students are loaded with clinical schedules at the hospital.

An interesting finding of this study is that the level of stress decreases as the year of study is increasing. This is contradicting to the finding of a study where the level of stress increased progressively during the course, to as much high as 40% by the end of the clinical training period.22 Other studies also suggest that mental health worsens after students are admitted to medical school and remains poor throughout the training23 especially in the transition from basic science teaching to clinical training.24 Only one study goes in line with our finding that, students found medical course stressful during the first year but not in subsequent years.25 Our finding could be explained by many factors. Our students may be able to develop coping mechanism with the help of our students support system. Other factor could be that our education is free and a small amount of monthly stipend given to each student during their under graduate course. In many different foreign schools students are plagued by financial worries, which is an important cause of their stress3,26 which is not the case in our college, as it is funded by the Government agency (Ministry of Higher Education).

This study did not show any association of stress with academic grades and being regular to courses. But stress is found to be significantly associated with physical problems. It is difficult to understand and could not be answered from this study, whether stress is causing physical problems or vice versa.

The negative effects of long and tiring medical education on the psychological status of students have been shown in several studies. A study from UK showed that one third of psychiatrically ill students did not graduate from the college.27 The changes appear to be significant during the first year. Therefore with early identification and with effective psychological services, possible future illness may be prevented. Besides educational demands, social and friendship-related factors are reasons for psychological disturbance in our students. Our data suggest that first and second year students who have the higher level of stress should be supported well by student support system as they may be able to cope up with the stress properly in later years and at higher level of education. It is also important to target prevention strategies at the students who have mild or moderate level of psychological stress in order to prevent the development of more serious conditions.

Wellness and mental health programmes are needed to help students to make smooth transitions between different learning environments with changing learning demands and a growing burden. Medical schools in the United States and Canada have initiated health promotion programmes and have reported positives results in reducing the negative effects of stress upon medical students’ health and academic performance.28-30

Our students must be taught to look for any cardinal signs and symptoms of stress such as recent weight change, sleeping and concentration difficulties, depression, or increasing cigarette smoking and so forth. If such signs and symptoms are present, they should seek medical advice. On the other hand, a minimal amount of stress is necessary to add spice to one’s life. An element of stress is involved with growth and is essential for sound personal functioning.

Limitations of the study: We acknowledge that this is a cross-sectional study with sample drawn from only male students as our college regulation has different system for male and female students. It could be considered as one of the limitation of this study. But other studies showed that gender differences in specific stress symptoms and overall prevalence or mean scores of stress were not much and did not turn out to be a significant factor in stress reporting.11,20,22 Furthermore, the findings of this study are based on self reported information provided by students and some potential for reporting bias may have occurred because of respondents’ interpretation of the questions or desire to report their emotions in a certain way or simply because of inaccuracies of responses. Low response was evident in 4th and 5th year students as they were occupied with clinical works. A prospective study could be carried out with a cohort of all five year students to look at the different levels of stress.


This study presents empirical evidence regarding the psychological health of students in our college. These findings suggest that high levels of psychosocial distress exists in our students during the initial three years of their course, and pose additional challenges for students’ support services delivery. This suggests that when students are taken into colleges, special care has to be taken to find out obvious psychiatric problems or just psychological distress in them. The major finding is that psychological distress in students is more common than population based estimates; therefore, it may require to address mental health problems along with common health strategies for our students.


The author would like to thank the medical students at the college of medicine for their participation in the study. Also special thanks to Dr. Sheikh Shafi Ahmad, Assistant Professor and consultant statistician in the department of family and community medicine, for his valuable analysis and advice on statistics and reviewing whole manuscript.


1. Dahlin M, Joneborg N, Runeson B. Stress and depression among medical students: a cross-sectional study. Med Educ 2005;39:594-604.

2. Styles WM. Stress in undergraduate medical education: the mask of relaxed brilliance. Br J Gen Pract 1993;43:46-7.

3. Ross S, Cleland J, Macleod MJ. Stress, debt and undergraduate medical performance. Med Edu 2006;40:584-9.

4. Stewart SM, Lam TH, Betson CL, Wong CM, Wong AMP. A prospective analysis of stress and academic performance in the first two years of medical school. Med Educ 1999;33:243-50.

5. Singh G, Hankins M, Weinman JA. Does medical school cause health anxiety and worry in medical students? Med Educ 2004;38:479-81.

6. Wilkinsos TJ, Gill DJ, Fitzjohn J, Palmer CL, Mulder RT. The impact on students of adverse experiences during medical school. Med Teach 2006;28(2):129-35

7. Roberts I. Junior doctors’ years: training not education. BMJ 1991;302:225-8.

8. Firth-Cozen J. Emotional distress in junior hospital doctors. BMJ 1987;295:533-6.

9. Tyssen R, Valglum P, Gronuold T, Nina T. The relative importance of individual and organizational factors for the prevention of job stress during internship: a nation wide and prospective study. Med Teach 2005;27(8):726-31.

10. Willcock S, Daly M, Tennant C, Allard B. Burnout and Psychiatric morbidity in new medical graduates. Med J Malaysia 2004;181(&):357-60.

11. Firth J. Levels and sources in medical students. BMJ 1986;292:1177-80.

12. Sherina MS, Rampal L, Kaneson N. Psychological stress among undergraduate medical students. Med J Malaysia 2004;59:207-11.

13. Saipanish R. Stress among medical students in a Thai medical school. Med Teach 2003;25(5):502-6.

14. Tyseen R, Vaglum P, Gronvold, NT, Bkeberg O. Factors in medical school that predict postgraduate mental health problems in need of treatment. A nationwide and longitudinal study. Med Edu 2001;35:110-20.

15. Aktekin M, Karaman T, Senol YY, Erdem S, Erengin H, Akaydin M. Anxiety, depression and stressful life events among medical students: a prospective study in Antalya, Turkey. Med Edu 2001;35:12-17.

16. Kessler RC, Andrews G, Colpe LJ, Hiripi E, Mroczek DK, Normand SL, et al. Short screening scales to monitor population prevalences and trends in non-specific psychological distress. Psychol Med 2002;32(6):959-76.

17. Cairney J, Veldhuizen S, Wade TJ, Kurdyak P, Streiner DL. Evaluation of 2 measures of psychological distress as screeners for depression in the general population. Can J Psychiatry 2007;52:111-20.

18. Brooks RT, Beard J, Steel Z. Factor structure and interpretation of the K10. Psychol Assess 2006;18(1):62-70.

19. Forero R, Young L, Hillman KM, Bauman AE, Leraci S. Prevalence of psychological stress assessed in emergency departments. Emerg Med J 2006;23:489.

20. Kilkkinen A, Kao-Philpot A, O’Neil A, Philpot B, Reddy P, Bunker S, et al. Prevalence of psychological distress, anxiety and depression in rural communities in Australia. Aust J Rural Health 2007;15:114-19.

21. Kessler_10_measure (Retrieved on Jan 2006)

22. Niemi PM, Vainiomarki PT. Medical students’ distress – quality, continuity and gender differences during a six-year medical program. Med Teach 2006;28(2):136-41.

23. Dyrbye L, Thomas M, Shanafelt T. Medical student distress: causes, consequences, and proposed solutions. Mayo Clin Proc 2005;80(12):1613-22.

24. Helmers KF, Danoff D, Steinert Y, Leyton M, Young SN. Stress and depressed mood in medical students, law students and graduate students at McGill Unviersity. Acad Med 1997;72:708-14.

25. Guthire E, Black D, Bagalkote H, Shaw C, Campbell M, Creed F. Psychological stress burnout in medical students: a five-year prospective longitudinal study. J R Soc Med 1998;91:237-43.

26. Gushae J. Financial worries part of education for Memorial’s medical students. Can Med Assoc J 1997;157(5):559-62.

27. Salmons PH. Psychiatric illness in medical students. Br J Psychiatry 1983;143:505-8.

28. Abramovitch H, Schreier A, Koren N. American medical students in Israel: Stress and coping-a follow-up study. Med Edu 2000;34:890-6.

29. Lee J, Graham A. Students’ perception of medical school stress and their evaluation of a wellness elective. Med Ed 2001;35:658-9.

30. Wolf TM, Randall HM, Faucett JM. A survey of health promotion programs in U.S. and Canadian Medical Schools. Am J Health Promot 1988;3:33-6.


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