Abstract
Depression and anxiety are prevalent psychiatric illnesses worldwide. This study aimed to estimate the prevalence of these illnesses and their associated sociodemographic factors among medical students at King Saud University, Riyadh, Saudi Arabia, by comparing first- and non-first-generation students. This cross-sectional study included 367 participants. The study tool, distributed in December 2023, consisted of a questionnaire developed by the research team to assess sociodemographic factors, the Patient Health Questionnaire-9 (PHQ-9), and the Generalized Anxiety Disorder 7-Item scale (GAD-7). Among the participants, 33.5% had a first-degree relative who attended medical school. The mean GAD-7 score was 8.30 for first-generation students and 7.48 for non-first-generation students, suggesting a trend toward higher anxiety in first-generation students, although the differences between the 2 groups were not statistically significant (P = .170). The mean PHQ-9 score was 9.54 for first-generation and 8.10 for non-first-generation students (P = .042). Women had significantly higher mean scores than men on both the GAD-7 and PHQ-9 (P=<.001). First- and third-year students had the highest mean scores on both the GAD-7 and PHQ-9 (P < .001). A statistically significant (P < .001) association was observed between anxiety and depression. Future research should focus on identifying, developing, and examining interventions that target at-risk groups of medical students. Multicenter studies with more rigorous research methodologies are warranted to validate these results.
Keywords: anxiety, depression, first-generation, King Saud University, medical students, non-first-generation, Saudi Arabia
1. Introduction
Anxiety and depression are among the most prevalent psychiatric illnesses, both globally and locally.[1,2] The prevalence of anxiety disorders in the general global population ranges from 4.05% to 7.3%,[3,4] and that of depression ranges from 4.1% to 8%.[5,6] In Saudi Arabia (SA), the prevalence of anxiety disorders among the general population is 12%, while that of depression is 3.8%.[1]
Medical education places extraordinary demands on medical students.[7–9] A comprehensive study conducted in SA (2021) revealed that an overwhelming majority of medical students, surpassing 72%, dedicated a minimum of 3 hours to their daily studies.[7] Another study in SA demonstrated that 75% of medical students, particularly when their examinations were approaching, committed themselves to a demanding schedule of studying for 10 hours or more per day.[8] These studies[7,8] emphasize the significant time commitment required in the context of medical school. Medical school’s potential impact on students’ social aspects is equally noteworthy. A recent publication from SA examined social aspects among a group of 675 medical students, revealing that only 37% of the participants expressed satisfaction with their social lives.[9]
An extensive global meta-analysis estimated that 27.2% of medical students worldwide experience depression or exhibit depressive symptoms.[10] Another meta-analysis of mental health among medical students revealed a slightly higher percentage, indicating a prevalence of 28% for depression within this population.[11] A meta-analysis on anxiety levels among medical students revealed them to be 33.8%[12] and a relatively recent study in SA targeting medical students reported a notable prevalence of 53% for anxiety.[13] When considering sex differences in mental health outcomes among medical students, women appear to exhibit a higher susceptibility to anxiety and depression than men.[14,15] Moreover, a pattern emerged when examining the impact of the academic year on mental health. Students of both sexes experienced the highest levels of depression during their first year of medical education.[15]
“First-generation medical students” refers to individuals pursuing medical education who represent the first generation within their families to start on this academic path.[16] A pilot survey published in 2014 examined the experiences of first-generation medical students, revealing significantly elevated levels of fatigue, stress, financial apprehension, and a discernible decline in their overall quality of life.[17] Similarly, a study conducted in the United States (US) unveiled evidence that first-generation college students, including those enrolled in medical programs, exhibit a higher tendency to experience physical, cognitive, and emotional symptoms associated with anxiety than their counterparts.[18] A study conducted in Taif, SA that examined the effect of generational status on the prevalence of depression found no statistically significant association.[19]
This study was conducted to examine the challenges faced by medical students in terms of anxiety and depressive disorders that may affect their mental well-being. The primary objectives of this study were to estimate the prevalence of depression and anxiety among medical students at King Saud University (KSU), compare the levels of depression and anxiety among first- and non-first-generation medical students, and assess the sociodemographic factors associated with these illnesses among the participants. Our findings could provide mental health professionals and policymakers with the knowledge and evidence-based insights required to implement policies that facilitate and optimize the well-being of medical students. We hypothesize that depression and anxiety are higher in first-generation compared to non-first-generation medical students. We also hypothesize that depression and anxiety are associated with certain sociodemographic factors such as sex and the current academic year.
2. Materials and methods
2.1. Study design, setting, and participants
A quantitative cross-sectional study was conducted among the target population, namely all medical students, men and women, from the first to fifth year attending KSU Medical College in Riyadh, SA. Students with any communication barriers or who were in the preparatory or internship year during the study period, were excluded. The research team distributed the study tool among the participants during the month of December, 2023; it was distributed electronically, via social media channels such as WhatsApp, to reduce costs and time. The number of medical students at KSU Medical College was estimated to be approximately 1494, including men and women. Using the Raosoft sample size calculator (http://www.raosoft.com/samplesize.html) with a margin of error of 5% and a confidence level of 95%, the estimated required sample size was 306 participants. An additional 20% was added to account for nonrespondents; therefore, 367 students were included.
2.2. Study instruments
The study instrument consisted of 3 sections: a questionnaire developed by the research team, the Patient Health Questionnaire-9 (PHQ-9), and the Generalized Anxiety Disorder 7-Item scale (GAD-7).
The research team developed a questionnaire to assess sociodemographic factors, including age, sex, current academic year, generational status (i.e., whether the participant had any first-degree relatives who attended a medical school before him/her), living conditions, and current grade point average (GPA).
The PHQ-9 is a brief, self-administered questionnaire that is reliable and valid in measuring depression and its severity,[20] with a Cronbach α coefficient of 0.89 in the PHQ Primary Care study and an α = 0.86 in the PHQ Ob-Gyn Study.[21,22] It consists of 9 multiple-choice questions and has a raw scoring of (0–27); a score of 10 or above shows 88% sensitivity and 88% specificity.[20,22] The scores were classified into the following severity categories: minimal depression: 0 to 4, mild depression: 5 to 9, moderate depression: 10 to 14, moderately severe depression: 15 to 19, and severe depression: 20 to 27. The PHQ-9 is in the public domain, meaning that it can be used freely and without permission from authors.[23]
The GAD-7 scale is a valid and reliable tool[24] for screening and assessing the severity of generalized anxiety disorder (GAD) in clinical practice and research, using 10 points or more as a cutoff point yielding a sensitivity of 89% and a specificity of 82%[24] with a reliability coefficient Cronbach α of 0.895.[25] The scale has 7 multiple-choice items assessing the previous 2 weeks for the participant. The scores are summed, and the participant is classified into 1 of these 4 categories based on their score: 0 to 4, minimal anxiety; 5 to 9, mild anxiety; 10 to 14, moderate anxiety; and 15 to 21, severe anxiety. Hence, the scale has 7 multiple-choice items, with a raw score between 0 and 21. The GAD-7 is also available in the public domain.[23]
2.3. Descriptive statistics
Statistical analyses were performed using IBM SPSS for Windows, version 29 (IBM Co., Armonk, NY). The PHQ-9 and GAD-7 scales were used to assess the severity of depression and anxiety, respectively. We used a cutoff of 10 points or more for both scales (PHQ-9 and GAD-7), as this cutoff yielded the highest specificity and sensitivity in measuring depression and anxiety, respectively, according to the available literature.[20,24,26,27] Categorical variables were presented as frequency and percentage (%) and analyzed using the chi-square test. Numerical data were presented as mean and standard deviation, analyzed using the independent-samples t-test and one way ANOVA. Testing for normality of the distribution was conducted using the Shapiro–Wilk test, and post hoc testing was performed using Bonferroni adjustment. Pearson correlation was used to study the association between different numerical variables. Multiple linear regression was used to study the factors associated with GAD-7 scale and PHQ-9 among KSU medical students. P ≤ .05 was considered statistically significant.
2.4. Ethical consideration
This study was approved by the Institutional Review Board of the College of Medicine at KSU on December 07, 2023 (Research Project No. E-23-8330). The informed-consent statement was read by the participants, who then selected “Next” to access the study’s survey. An explanation of confidentiality and data anonymity was provided to the participants along with information on the study’s scope and the principal investigator’s contact information. The right to participate was granted by clicking on the link to provide informed consent.
3. Results
Table 1 presents the characteristics of the participants. A total of 367 medical students participated in this study to assess the prevalence of depression and anxiety among first- and non-first generation medical students. The mean age of the participants was 21.24 years, standard deviation = 1.65 years. Of the participants, 244 (66.5%) were men and the rest (123 (33.5%)) were women. Seventy-three (19.9%) participants were first-year students and 74 (20.2%) were second-year students. A total of 123 (33.5%) participants had a first-degree relative who had attended medical school, 19 (5.2%) lived alone, and the majority (348 (94.8%)) lived with others. The highest proportion of participants (133 [36.2%]) had an excellent GPA, and 85 (23.2%) had a very good GPA.
Table 1.
Participant characteristics (N = 367).
| N (%) | ||
|---|---|---|
| Age | Mean (SD) | 21.24 (1.65) |
| Range | 18–27 | |
| Sex | Male | 244 (66.5%) |
| Female | 123 (33.5%) | |
| Academic year | First year | 73 (19.9%) |
| Second year | 74 (20.2%) | |
| Third year | 71 (19.3%) | |
| Fourth year | 74 (20.2%) | |
| Fifth year | 75 (20.4%) | |
| Having a first-degree relative who attended medical school | No | 244 (66.5%) |
| Yes | 123 (33.5%) | |
| Living condition | Alone | 19 (5.2%) |
| With others | 348 (94.8%) | |
| Current GPA | Exceptional (5.0) | 20 (5.4%) |
| Excellent (≥4.75) | 133 (36.2%) | |
| Superior (≥4.5) | 91 (24.8%) | |
| Very good (≥4.0) | 85 (23.2%) | |
| Above average (≥3.5) | 32 (8.7%) | |
| Good (≥3.0) | 5 (1.4%) | |
| High pass (≥2.5) | 1 (0.3%) | |
GPA = grade point average, SD = standard deviation.
Table 2 shows the distribution of students across different categories of anxiety and depression. The mean GAD-7 score for all participants was 8.02 (5.37), while for men it was 7.19 (5.26), and for women it was 9.67 (5.23). Among all participants, 111 (30.3%) had minimal anxiety, 119 (32.4%) had mild anxiety, 92 (25.1%) had moderate anxiety, and 45 (12.2%) had severe anxiety. Among the men, 89 (36.5%) had minimal anxiety, 79 (32.4%) had mild anxiety, 52 (21.3%) had moderate anxiety, and 24 (9.8%) had severe anxiety. Among the women, 22 (17.9%) had minimal anxiety, 40 (32.5%) had mild anxiety, 40 (32.5%) had moderate anxiety, and 21 (17.1%) had severe anxiety.
Table 2.
Generalized Anxiety Disorder-7 and Patient Health Questionnaire-9 scores for King Saud University medical students.
| Total N (%) | Men N (%) | Women N (%) | ||
|---|---|---|---|---|
| GAD-7 score | Mean (SD) | 8.02 (5.37) | 7.19 (5.26) | 9.67 (5.23) |
| Range | 0–21 | 0–21 | 0–21 | |
| Anxiety categories | Minimal anxiety | 111 (30.3%) | 89 (36.5%) | 22 (17.9%) |
| Mild anxiety | 119 (32.4%) | 79 (32.4%) | 40 (32.5%) | |
| Moderate anxiety | 92 (25.1%) | 52 (21.3%) | 40 (32.5%) | |
| Severe anxiety | 45 (12.2%) | 24 (9.8%) | 21 (17.1%) | |
| PHQ-9 score* | Mean (SD) | 9.06 (6.43) | 7.96 (6.27) | 11.23 (6.21) |
| Range | 0–26 | 0–26 | 0–26 | |
| Depression categories | Minimal depression | 104 (28.4%) | 83 (34.0%) | 21 (17.1%) |
| Mild depression | 97 (26.4%) | 71 (29.1%) | 26 (21.1%) | |
| Moderate depression | 97 (26.4%) | 52 (21.3%) | 45 (36.6%) | |
| Moderately severe depression | 43 (11.7%) | 26 (10.7%) | 17 (13.8%) | |
| Severe depression | 26 (7.1%) | 12 (4.9%) | 14 (11.4%) | |
| Anxiety prevalence | Score ≥ 10 | 137 (37.3%) | 76 (31.1%) | 61 (49.6%) |
| Depression prevalence | Score ≥ 10 | 166 (45.2%) | 90 (36.9%) | 76 (61.8%) |
GAD-7 = Generalized Anxiety Disorder-7, PHQ-9 = Patient Health Questionnaire-9, SD = standard deviation.
The PHQ-9 score can range from 0–27; however, in this sample, the maximum score achieved was 26.
The mean PHQ-9 score for all participants was 9.06 (6.43), while that in men was 7.96 (6.27), and in women it was 11.23 (6.21). Among the participants, 104 (28.4%) had minimal depression, 97 (26.4%) had mild depression, 97 (26.4%) had moderate depression, 43 (11.7%) had moderately severe depression, and 26 (7.1%) had severe depression. Among the men, 83 (34.0%) had minimal depression, 71 (29.1%) had mild depression, 52 (21.3%) had moderate depression, 26 (10.7%) had moderately severe depression, and 12 (4.9%) had severe depression. Among the women, 21 (17.1%) had minimal depression, 26 (21.1%) had mild depression, 45 (36.6%) had moderate depression, 17 (13.8%) had moderately severe depression, and 14 (11.4%) had severe depression.
The cutoff point used for the presence of anxiety was a score of ≥10, so the prevalence of anxiety was 37.3% for all participants. Seventy-six (31.1%) of the men and 61 (49.6%) of the women suffered from anxiety. The cutoff point used for depression was a score of ≥10, so the prevalence of depression was 45.2% for all participants. Ninety (36.9%) of the men and 76 (61.8%) of the women experienced depression.
Table 3 shows a comparison of the GAD-7 and PHQ-9 scores across participant characteristics. Sex, academic year, age, and PHQ-9 score showed significant associations with the GAD-7 score. The mean GAD-7 score in men 7.19 (5.26) was lower than that in women 9.67 (5.23); (P < .001). The mean GAD-7 score in first-year students 10.38 (5.29) was higher than that in second-, fourth-, and fifth-year students (7.00 [4.99], 6.88 [5.65], and 7.05 [4.84], respectively) (P < .001). The correlation coefficient between age and GAD-7 score was r = −0.146 (P = .005), indicating a weak negative correlation. The correlation coefficient between the PHQ-9 and GAD-7 scores was R = 0.722 (P < .001), indicating a strong positive correlation.
Table 3.
Comparison of Generalized Anxiety Disorder-7 and Patient Health Questionnaire-9 scores across participant characteristics.
| N | GAD-7 score | PHQ-9 score | ||||||
|---|---|---|---|---|---|---|---|---|
| Mean | SD | P-value | Mean | SD | P-value | |||
| Sex | Male | 244 | 7.19 | 5.26 | <.001 * | 7.96 | 6.27 | <.001 * |
| Female | 123 | 9.67 | 5.23 | 11.23 | 6.21 | |||
| Academic year | First year | 73 | 10.38 | 5.29 | <.001 * | 11.79 | 6.10 | <.001 * |
| Second year | 74 | 7.00 | 4.99 | 8.58 | 6.94 | |||
| Third year | 71 | 8.87 | 5.30 | 10.08 | 5.90 | |||
| Fourth year | 74 | 6.88 | 5.65 | 7.03 | 6.46 | |||
| Fifth year | 75 | 7.05 | 4.84 | 7.89 | 5.72 | |||
| Having a first-degree relative who attended medical school | No | 244 | 8.30 | 5.45 | .170 | 9.54 | 6.50 | .042 * |
| Yes | 123 | 7.48 | 5.19 | 8.10 | 6.21 | |||
| Living conditions | Alone | 19 | 8.16 | 5.13 | .910 | 11.84 | 6.51 | .052 |
| With others | 348 | 8.01 | 5.39 | 8.91 | 6.40 | |||
| Current grade point average (GPA) | Exceptional (5.0) | 20 | 8.75 | 5.66 | .183 | 10.15 | 6.29 | .174 |
| Excellent (≥4.75) | 133 | 8.58 | 5.57 | 9.59 | 6.38 | |||
| Superior (≥4.5) | 91 | 7.01 | 4.86 | 7.76 | 5.83 | |||
| Very good (≥4.0) | 85 | 7.69 | 5.46 | 8.87 | 6.56 | |||
| Above average or less (2.5–4) | 38 | 8.84 | 5.37 | 10.13 | 7.52 | |||
| Age | Pearson correlation coefficient | -0.146 | .005 * | -0.17 | .001 * | |||
| GAD-7 and PHQ-9 | Pearson correlation coefficient | 0.722 | <.001 * | |||||
GAD-7 = Generalized Anxiety Disorder 7-Item, PHQ-9 = Patient Health Questionnaire-9, SD = standard deviation.
Significance was set at P≤.05.
Sex, academic year, having a first-degree relative who had attended medical school before, age, and GAD-7 showed statistically significant associations with PHQ-9 scores. The mean PHQ-9 score in men 7.96 (6.27) was lower than that in women 11.23 (6.21) (P < .001). The mean PHQ-9 score in first-year students 11.79 (6.10) was higher than that in second-, fourth-, and fifth-year students 8.58 (6.94), 7.03 (6.46), and 7.89 (5.72), respectively. The mean PHQ-9 score in third-year students 10.08 (5.90) was higher than that in fourth-year students 7.03 (6.46) (P < .001). The mean PHQ-9 score in participants who had a first-degree relative who had attended medical school 8.10 (6.21) was lower than that in participants who did not have a first-degree relative who attended medical school 9.54 (6.50), (P = .042). The correlation coefficient between age and the PHQ-9 score (r = −0.17) (P = .001) indicated a weak negative correlation.
Table 4 shows the comparison of anxiety categories across participant characteristics. Sex and current academic year showed a statistically significant association with the anxiety categories. The percentage of men who had minimal anxiety (89 [36.5%]) was higher than that in women (22 [17.9%]); the percentage of men with moderate anxiety (52 [21.3%]) was lower than that in women (40 [32.5%]); the percentage of men with severe anxiety, 24 (9.8%) was lower than that in women (21 [17.1%]) (P = .001).
Table 4.
Comparison of anxiety categories across participant characteristics.
| Anxiety categories | P-value | |||||
|---|---|---|---|---|---|---|
| Minimal anxiety N (%) | Mild anxiety N (%) | Moderate anxiety N (%) | Severe anxiety N (%) | |||
| Sex | Male | 89 (36.5%) | 79 (32.4%) | 52 (21.3%) | 24 (9.8%) | .001 * |
| Female | 22 (17.9%) | 40 (32.5%) | 40 (32.5%) | 21 (17.1%) | ||
| Academic year | First year | 7 (9.6%) | 30 (41.1%) | 19 (26%) | 17 (23.3%) | <.001 * |
| Second year | 29 (39.2%) | 24 (32.4%) | 17 (23%) | 4 (5.4%) | ||
| Third year | 19 (26.8%) | 17 (23.9%) | 26 (36.6%) | 9 (12.7%) | ||
| Fourth year | 32 (43.2%) | 19 (25.7%) | 15 (20.3%) | 8 (10.8%) | ||
| Fifth year | 24 (32%) | 29 (38.7%) | 15 (20%) | 7 (9.3%) | ||
| Having a first-degree relative who attended medical school | No | 71 (29.1%) | 77 (31.6%) | 62 (25.4%) | 34 (13.9%) | .536 |
| Yes | 40 (32.5%) | 42 (34.2%) | 30 (24.4%) | 11 (8.9%) | ||
| Living condition | Alone | 5 (26.3%) | 6 (31.6%) | 5 (26.3%) | 3 (15.8%) | .956 |
| With others | 106 (30.4%) | 113 (32.5%) | 87 (25%) | 42 (12.1%) | ||
| Current grade point average (GPA) | Exceptional (5.0) | 5 (25%) | 8 (40%) | 3 (15%) | 4 (20%) | .621 |
| Excellent (≥4.75) | 36 (27.1%) | 43 (32.3%) | 34 (25.6%) | 20 (15%) | ||
| Superior (≥4.5) | 32 (35.1%) | 31 (34.1%) | 22 (24.2%) | 6 (6.6%) | ||
| Very good (≥4.0) | 29 (34.1%) | 25 (29.4%) | 23 (27.1%) | 8 (9.4%) | ||
| Above average or less (2.5–4) | 9 (23.7%) | 12 (31.6%) | 10 (26.3%) | 7 (18.4%) | ||
Significance was set at P ≤ .05.
Regarding academic year, the percentage of fourth-year students who had minimal anxiety (32 [43.2%]) was higher than that in first- and third-year students (7 [9.6%]; 19 [26.8%]). The percentage of first-year students who had mild anxiety (30 [41.1%]) was higher than that of third and fourth-year students (17 [23.9%]; 19 [25.7%]). The percentage of third-year students with moderate anxiety (26 [36.6%]) was higher than that for fourth- and fifth-year students (15 [20.3%]; 15 [20%]). The percentage of first-year students who had severe anxiety (17 [23.3%]) was higher than that of second- and fifth-year students (4 [5.4%]; 7 [9.3%]) (P < .001).
Table 5 shows a comparison of depression categories across participant characteristics. Sex and academic year were significantly associated with depression categories. The percentage of men with minimal depression (83 [34%]) was higher than that in women (21 [17.1%]). The percentage of men who had mild depression (71 [29.1%]) was higher than that in women (26 [21.1%]). The percentage of men who had moderate depression (52 [21.3%]) was lower than that in women (45 [36.6%]). The percentage of men who had moderately severe depression (26 [10.7%]) was lower than that in women (17 [13.8%]) and the percentage of men who had severe depression (12 [4.9%]) was lower than that in women (14 [11.4%]) (P < .001).
Table 5.
Comparison of depression categories across participants’ characteristics.
| Depression categories | P-value | ||||||
|---|---|---|---|---|---|---|---|
| Minimal depression | Mild depression | Moderate depression | Moderately severe depression | Severe depression | |||
| Sex | Male | 83 (34%) | 71 (29.1%) | 52 (21.3%) | 26 (10.7%) | 12 (4.9%) | <.001 * |
| Female | 21 (17.1%) | 26 (21.1%) | 45 (36.6%) | 17 (13.8%) | 14 (11.4%) | ||
| Academic year | First year | 10 (13.7%) | 14 (19.2%) | 29 (39.7%) | 10 (13.7%) | 10 (13.7%) | .002 * |
| Second year | 24 (32.4%) | 19 (25.7%) | 15 (20.3%) | 9 (12.1%) | 7 (9.5%) | ||
| Third year | 14 (19.7%) | 19 (26.8%) | 24 (33.8%) | 10 (14.1%) | 4 (5.6%) | ||
| Fourth year | 32 (43.2%) | 19 (25.7%) | 14 (18.9%) | 6 (8.1%) | 3 (4.1%) | ||
| Fifth year | 24 (32%) | 26 (34.7%) | 15 (20%) | 8 (10.7%) | 2 (2.6%) | ||
| Having a first-degree relative who attended medical school | No | 62 (25.4%) | 63 (25.8%) | 69 (28.3%) | 31 (12.7%) | 19 (7.8%) | .359 |
| Yes | 42 (34.1%) | 34 (27.6%) | 28 (22.8%) | 12 (9.8%) | 7 (5.7%) | ||
| Living condition | Alone | 3 (15.8%) | 3 (15.8%) | 9 (47.4%) | 2 (10.5%) | 2 (10.5%) | .226 |
| With others | 101 (29%) | 94 (27%) | 88 (25.3%) | 41 (11.8%) | 24 (6.9%) | ||
| Current grade point average (GPA) | Exceptional (5.0) | 5 (25%) | 2 (10%) | 9 (45%) | 1 (5%) | 3 (15%) | 0.444 |
| Excellent (≥4.75) | 34 (25.5%) | 36 (27.1%) | 35 (26.3%) | 19 (14.3%) | 9 (6.8%) | ||
| Superior (≥4.5) | 29 (31.9%) | 25 (27.4%) | 26 (28.6%) | 8 (8.8%) | 3 (3.3%) | ||
| Very good (≥4.0) | 25 (29.4%) | 26 (30.6%) | 19 (22.4%) | 8 (9.4%) | 7 (8.2%) | ||
| Above average or less (2.5–4) | 11 (28.9%) | 8 (21.1%) | 8 (21.1%) | 7 (18.4%) | 4 (10.5%) | ||
Significance was set at P ≤ .05.
Regarding the academic year, the percentage of fourth-year students who had minimal depression (32 [43.2%]) was higher than that in first- and third-year students (10 [13.7%]; 14 [19.7%]). The percentage of fifth-year students who had mild depression (26 [34.7%]) was higher than that in first-year students (14 [19.2%]). The percentage of first-year students who had moderate depression (29 [39.7%]) was higher than that in second- and fifth-year students (15 [20.3%] and 15 [20%], respectively). The percentage of third-year students who had moderately severe depression (10 [14.1%]) was higher than that in fourth-year students (6 [8.1%]). The percentage of first-year students who had severe depression (10 [13.7%]) was higher than that in third-, fourth- and fifth-year students (4 [5.6%], 3 [4.1%], and 2 [2.6%], respectively) (P = .002).
Table 6 shows the association between anxiety and depression categories. The depression categories showed statistically significant associations with the anxiety categories: the percentage of students who suffered from mild depression and mild anxiety (47 [39.5%]) was higher than that of students who suffered from mild depression and minimal, moderate, and severe anxiety ((29 [26.1%], 18 [19.6%], and 3 [6.6%], respectively). Furthermore, the percentage of students who suffered from minimal depression and minimal anxiety (73 [65.8%]) was higher than that of students who suffered from minimal depression, mild, moderate, and severe anxiety) (24 [20.2%], 6 [6.5%], and 1 [2.2%], respectively). Moreover, the percentage of students who experienced moderate depression and moderate anxiety (41 [44.6%]) was higher than that of students who experienced moderate depression and mild, minimal, and severe anxiety (37 [31.1%], 7 [6.3%], and 12 [26.7%], respectively). The percentage of students who suffered from moderately severe depression and severe anxiety (12 [26.7%]) was higher than that of students who suffered from moderately severe depression, mild anxiety, and minimal anxiety (9 [7.6%] and 1 [0.9%], respectively). Furthermore, the percentage of students who suffered from severe depression and anxiety (17 [37.8%]) was higher than that of students who suffered from severe depression and mild, minimal, and moderate anxiety (2 [1.7%], 1 [0.9%], and 6 [6.5%], respectively) (P < .001).
Table 6.
Association between anxiety and depression categories.
| Anxiety categories | Total | P-value | |||||
|---|---|---|---|---|---|---|---|
| Minimal N (%) | Mild N (%) | Moderate N (%) | Severe N (%) | ||||
| Depression categories | Minimal | 73 (65.8%) | 24 (20.2%) | 6 (6.5%) | 1 (2.2%) | 104 (28.4%) | <.001 * |
| Mild | 29 (26.1%) | 47 (39.5%) | 18 (19.6%) | 3 (6.6%) | 97 (26.4%) | ||
| Moderate | 7 (6.3%) | 37 (31.1%) | 41 (44.6%) | 12 (26.7%) | 97 (26.4%) | ||
| Moderately severe | 1 (0.9%) | 9 (7.5%) | 21 (22.8%) | 12 (26.7%) | 43 (11.7%) | ||
| Severe | 1 (0.9%) | 2 (1.7%) | 6 (6.5%) | 17 (37.8%) | 26 (7.1%) | ||
| Total | 111 (100%) | 119 (100%) | 92 (100%) | 45 (100%) | 367 (100%) | ||
Significance was set at P ≤ .05.
Table 7 shows the multiple linear regression analysis for factors affecting the GAD-7 and PHQ-9 scores. There was a significant association between sex, academic year, and current GPA and GAD-7 score. Women had a higher GAD-7 score by an average of 1.86 (P = .005, 95% confidence interval (95%CI) = 0.56–3.17) than men. Compared with first-year students, second-, fourth-, and fifth-year students had a lower GAD-7 score by an average of −3.25, (P = .003, 95%CI = ‐5.4 to ‐1.09), ‐3.28, (P = .029, 95%CI = ‐6.22 to ‐0.34) and −3.3, (P = .05, 95%CI = ‐6.61 to 0) respectively. Compared with students with exceptional (5.0) GPA, students with an above average or lower (2.5–4) GPA had higher GAD-7 scores by an average of 3.88 (P = .019, 95%CI = 0.64–7.13).
Table 7.
Multiple linear regression for the factors affecting Generalized Anxiety Disorder 7-Item and Patient Health Questionnaire-9 score among medical students.
| GAD-7 score | PHQ-9 score | |||||||
|---|---|---|---|---|---|---|---|---|
| Coefficient | P-value | 95%CI of the coefficient | Coefficient | P-value | 95%CI of the coefficient | |||
| Age | -0.05 | .887 | ‐0.75 | 0.65 | ‐0.2 | .636 | ‐1.01 | 0.62 |
| Sex | ||||||||
| Male | Ref. | Ref. | ||||||
| Female | 1.86 | .005 * | 0.56 | 3.17 | 2.6 | .001 * | 1.07 | 4.13 |
| Current academic year: | ||||||||
| First year | Ref. | Ref. | ||||||
| Second year | ‐3.25 | .003 * | ‐5.4 | ‐1.09 | ‐2.83 | .029 * | ‐5.36 | ‐0.29 |
| Third year | ‐1.25 | .32 | ‐3.71 | 1.22 | ‐1.07 | .467 | ‐3.96 | 1.82 |
| Fourth year | ‐3.28 | .029 * | ‐6.22 | ‐0.34 | ‐4.27 | .016 * | ‐7.71 | -0.82 |
| Fifth year | ‐3.3 | .05 * | ‐6.61 | 0 | ‐3.47 | .079 | ‐7.35 | 0.41 |
| Having a first-degree relative who attended medical school | ||||||||
| No | Ref. | Ref. | ||||||
| Yes | ‐0.3 | .609 | ‐1.45 | 0.85 | ‐0.75 | .272 | ‐2.1 | 0.59 |
| Living condition | ||||||||
| Alone | Ref. | Ref. | ||||||
| With others | -0.84 | .5 | -3.29 | 1.61 | -3.99 | .007 * | -6.87 | -1.11 |
| Current GPA | ||||||||
| Exceptional (5.0) | Ref. | Ref. | ||||||
| Excellent (≥4.75) | 1.84 | .163 | -0.75 | 4.44 | 1.72 | .269 | -1.33 | 4.77 |
| Superior (≥4.5) | 2.05 | .168 | -0.87 | 4.96 | 2.17 | .213 | -1.25 | 5.59 |
| Very good (≥4.0) | 2.7 | .072 | -0.24 | 5.64 | 3.27 | .063 | -0.18 | 6.72 |
| Above average or less (2.5–4) | 3.88 | .019 * | 0.64 | 7.13 | 4.47 | .022 * | 0.65 | 8.28 |
95%CI = 95% confidence interval, GAD-7 = Generalized Anxiety Disorder 7-Item, GPA = grade point average, PHQ-9 = Patient Health Questionnaire-9.
Significance was set at P≤.05.
The associations between sex, current academic year, living conditions, current GPA, and PHQ-9 score were statistically significant. Women had higher PHQ-9 scores than men by an average of 2.6 (P = .001, 95%CI = 1.07–4.13). Compared with first-year students, second- and fourth-year students had lower PHQ-9 scores by an average of −2.83, (P = .029, 95%CI = ‐5.36 to ‐0.29) and −4.27, (P = .016, 95%CI = ‐7.71 to ‐0.82), respectively. Students who lived with others had lower PHQ-9 scores by an average of −3.99, (P = .007, 95%CI = ‐6.87 to ‐1.11) than those who lived alone. Students with above average or lower (2.5–4) GPA had higher PHQ-9 scores by an average of 4.47, (P = .022, 95%CI = 0.65–8.28) than students with exceptional (5.0) GPA.
4. Discussion
This study was conducted to examine the challenges faced by medical students in terms of anxiety and depressive disorders that may affect their mental well-being. The prevalence of depression among our participants was 45.2%. Another Saudi study conducted among medical students found a depression prevalence of 83.4% among the participants.[28] The variance in prevalence between our study and the other[28] may be attributed to the different cutoff PHQ-9 scores used to estimate prevalence; the other study[28] used a cutoff of ≥ 5 (i.e., mild depression severity and above), while in our study, we used a cutoff of ≥10 (i.e., moderate depression severity and above). Despite these variations, our study and the other[28] both indicated a high prevalence of depression among medical students. Therefore, we recommend that the awareness of depression among students be improved through the implementation of screening strategies, and that mental health care services be provided.
In our study, women had higher PHQ-9 scores than men. This finding is supported by multiple studies conducted among medical students, in which a higher prevalence of depression was detected in women than in men.[29,30] Furthermore, our results indicated that men had a lower percentage of moderate, moderately severe, and severe depression than women, aligning with the existing literature stating that being female is a well-established risk factor for depression.[31,32] Our findings highlight the importance of keeping sex variation in mind when it comes to depression among medical students and the need to place more emphasis on female students.
In our study, students living with others displayed lower PHQ-9 scores than those living alone, a finding supported by another study conducted among medical students in Indonesia.[33] We hypothesized that this finding might be attributed to the social support and companionship gained by living with others, which could alleviate feelings of loneliness and depression.[34] Our findings also emphasize the need to provide psychosocial support to students living alone.
The highest prevalence of depression in our study was observed in first-year students, followed by third-, second-, fifth-, and fourth-year students. An Ethiopian study examining the prevalence of depression among medical students found that first- and second-year students were most susceptible to depression.[29] The findings of this study are consistent with our findings regarding the first year but inconsistent with our findings concerning the third and second years. Curricular differences between SA and Ethiopia may explain these inconsistent results. In addition, we hypothesized that, for first-year students, the higher prevalence of depression is related to a shift in the environment, namely joining medical school. For third-year students, we hypothesized that it is related to experiencing a more clinically oriented setting, as per the KSU medical college curriculum, which could impose new challenges. We encourage screening for depression in high-risk groups, such as first- and third-year students, to increase awareness of the illness. It is also worth mentioning that our findings differ from those of a study of medical students conducted in the US, where depressive symptoms significantly increased during the second, third, and fourth years.[35] We hypothesize that the discrepancy between our findings and those of this study[35] could be explained, at least in part, by the fact that medical students in the US commonly contend with substantial student debt,[36] which could contribute to the observed escalation in depressive symptoms over time.
In our study, multiple regression analysis of the factors affecting PHQ-9 scores indicated that students with 2.5 to 4 GPAs had higher PHQ-9 scores than students with exceptional (5.0) GPAs. Our findings suggest a plausible correlation between academic performance and mental health, wherein students who encounter academic hurdles or who achieve lower grades may experience higher levels of depressive symptoms. Our findings demonstrate the importance of implementing comprehensive support methods to address students’ psychological well-being and promote their academic performance.
Unsurprisingly, in our study, we found a statistically significant association between anxiety and depression categories. We hypothesized that this association stems from possible shared biological, psychological, and environmental mechanisms triggering and influencing the manifestation and co-occurrence of anxiety and depression symptoms among individuals.[37] Hence, it is essential to screen for depression among students displaying symptoms of anxiety and vice versa.
We also examined the variables related to anxiety. Our results revealed a prevalence of 37.3% for anxiety among the participants. Another study conducted in SA on medical students reported an anxiety prevalence of 31.7%.[38] Therefore, we recommend that the awareness of this illness among students also be improved through the implementation of screening strategies, and that access to mental healthcare services be provided.
In our study, women had significantly higher GAD-7 scores than men. Our result is consistent with another study conducted among medical students in the US.[39] This trend aligns with the existing knowledge that anxiety disorders, including GAD, are more common in women than in men.[40] Therefore, our findings underscore the need to enhance the awareness of anxiety and to cultivate coping strategies among female students. Furthermore, our study found that women experienced higher levels of moderate and severe anxiety than men, which corresponds with another study conducted in SA.[38] Our findings and those of this study[38] are also aligned with the available knowledge, showing that women are more likely to develop anxiety disorders than men.[40]
The multiple linear regression analysis in our study revealed that second-, fourth-, and fifth-year students had lower GAD-7 scores than first-year students. This is supported by the findings of the study conducted in Ethiopia, which revealed that anxiety scores across all other academic years were lower than those of first-year students.[29] We hypothesized that the rise in anxiety in the first year could be attributed to the new and more demanding environment of joining medical school. We urge academic institutes to introduce guidance programs for students in earlier years to help them adjust to the new environment, to provide anxiety management interventions and healthy coping skills, and to provide mental health services. These interventions could improve students’ general well-being and, hence, their academic achievement.
In our study, students with (2.5–4) GPAs had higher GAD-7 scores than students with “exceptional” GPAs, indicating a plausible correlation between academic performance and anxiety levels, with individuals facing academic challenges experiencing heightened anxiety levels. Our findings are consistent with those of another study conducted in SA among health science students, which found that students with higher GPAs tended to have lower GAD-7 scores.[41] The relationship between GPA and anxiety may be complex and influenced by academic pressure, coping strategies, and individual responses to educational demands, highlighting the need for future studies to examine this relationship.
Finally, our results, as per the multiple linear regression, showed that generational status had no statistically significant effect on depression or anxiety. Our results are similar to those of another study conducted in Taif, SA, aiming to assess the differences between first- and non-first-generation medical students, which showed no statistically significant difference between the 2 groups in terms of depression.[19] Unfortunately, literature examining the effects of generational status and anxiety is limited. However, our results and those of this study[19] are surprising as, according to the literature, first-generation students, in general, are more prone to stress, fatigue, and an overall reduction in quality of life.[17] They also have a higher tendency to develop physical, cognitive, and emotional symptoms associated with anxiety than their counterparts.[18]
5. Conclusions
Our study examined depression, anxiety, and their associated sociodemographic factors among medical students at KSU, comparing first- and non-first-generation students. First-generation medical students exhibited higher levels of anxiety and depression; however, these differences were not statistically significant regarding anxiety. While female and first- and third-year medical students were more vulnerable to depression and anxiety, their GPA and living arrangements had no impact on these mental illnesses. To support the mental health of medical students, we recommend that educational institutions increase awareness regarding depression and anxiety among students. Such a goal could be achieved by implementing screening strategies for depression and anxiety and, nonetheless, screening for depression among students displaying symptoms of anxiety and vice versa. Another way to accomplish this goal is by further emphasizing the negative consequences of these illnesses in the curriculum of the psychiatric course during the medical school years. Another aspect we recommend is to ensure providing access to mental health care services for students, especially for high-risk groups such as women and first-year medical students. Considering the plausible correlation between academic performance and mental health is also essential.
6. Strengths and limitations
This study had several strengths and limitations. In terms of strengths, widely validated scales were used and the sample size was large enough to identify statistically significant findings. The sample was representative of the target population with a 2:1 male-to-female ratio, which was consistent with the distribution of KSU medical students. In terms of limitations, the study was conducted at a single site, KSU, making it challenging to generalize the results to other locations. Convenience sampling was also performed. Future multicenter studies with more rigorous research methodologies are required to address these limitations. Another limitation of this study is that certain variables that could be relevant to depression and anxiety, such as comorbidities and medications, were not explored. Exploring such variables in future research studies could add to our knowledge.
Acknowledgments
The authors extend their appreciation to the Deanship of Scientific Research, King Saud University, for funding through the Vice Deanship of Scientific Research Chairs; SABIC Psychological Health Research and Applications Chair (SPHRAC), Department of Psychiatry, College of Medicine, King Saud University, Riyadh 12372, Saudi Arabia.
Author contributions
Conceptualization: Ahmad H. Almadani, Abdullah A. Alsubaihi, Hesham A. Alsqabi, Mohammed A. Alkathiri, Meshal I. Alassaf, Osama A. Alagel, Sulaiman S. Alshowihi, Mohammad A. Alolayan.
Data curation: Ahmad H. Almadani, Abdullah A. Alsubaihi.
Formal analysis: Ahmad H. Almadani, Abdullah A. Alsubaihi.
Funding acquisition: Ahmad H. Almadani.
Methodology: Ahmad H. Almadani, Abdullah A. Alsubaihi, Hesham A. Alsqabi, Mohammed A. Alkathiri, Meshal I. Alassaf, Osama A. Alagel, Sulaiman S. Alshowihi, Mohammad A. Alolayan.
Project administration: Ahmad H. Almadani, Abdullah A. Alsubaihi, Hesham A. Alsqabi, Mohammed A. Alkathiri, Meshal I. Alassaf, Osama A. Alagel, Sulaiman S. Alshowihi.
Resources: Ahmad H. Almadani, Abdullah A. Alsubaihi, Hesham A. Alsqabi, Mohammed A. Alkathiri, Meshal I. Alassaf, Osama A. Alagel, Sulaiman S. Alshowihi.
Software: Ahmad H. Almadani, Abdullah A. Alsubaihi, Hesham A. Alsqabi, Mohammed A. Alkathiri, Meshal I. Alassaf, Osama A. Alagel, Sulaiman S. Alshowihi.
Supervision: Ahmad H. Almadani.
Validation: Ahmad H. Almadani, Abdullah A. Alsubaihi, Hesham A. Alsqabi, Mohammed A. Alkathiri, Meshal I. Alassaf, Osama A. Alagel, Sulaiman S. Alshowihi, Mohammad A. Alolayan.
Visualization: Ahmad H. Almadani.
Writing – original draft: Ahmad H. Almadani, Abdullah A. Alsubaihi, Hesham A. Alsqabi, Mohammed A. Alkathiri, Meshal I. Alassaf, Osama A. Alagel, Sulaiman S. Alshowihi.
Writing – review & editing: Ahmad H. Almadani, Mohammad A. Alolayan.
Abbreviations:
- 95%CI
- 95% confidence interval
- GAD-7
- Generalized Anxiety Disorder 7-Item scale
- GPA
- grade point average
- KSU
- King Saud University
- PHQ-9
- Patient Health Questionnaire-9
- SA
- Saudi Arabia
- US
- United States
This research was funded by the Deanship of Scientific Research, King Saud University, through the Vice Deanship of Scientific Research Chairs; SABIC Psychological Health Research and Applications Chair (SPHRAC), Department of Psychiatry, College of Medicine, King Saud University, Riyadh 12372, Saudi Arabia. The funding sources had no involvement in the study.
Informed consent was obtained from all participants.
The authors have no conflicts of interest to disclose.
The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.
The study was approved by the Institutional Review Board at the College of Medicine at King Saud University, Riyadh (Research Project No. E-23-8330).
How to cite this article: Almadani AH, Alsubaihi AA, Alsqabi HA, Alkathiri MA, Alassaf MI, Alagel OA, Alshowihi SS, Alolayan MA. Comparison of depression and anxiety in first- versus non-first generation Saudi medical students: A cross-sectional study. Medicine 2024;103:30(e39115).
Contributor Information
Abdullah A. Alsubaihi, Email: AbdullahAAlsubaihi@gmail.com.
Hesham A. Alsqabi, Email: Heshamalsqabi@gmail.com.
Mohammed A. Alkathiri, Email: mohammed0alkathiri@gmail.com.
Meshal I. Alassaf, Email: meshalalassaf2@gmail.com.
Osama A. Alagel, Email: osama4921@gmail.com.
Sulaiman S. Alshowihi, Email: sulaimanalshowihi@gmail.com.
Mohammad A. Alolayan, Email: malolayan@ksu.edu.sa.
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