Abstract
Objectives:
To determine the prevalence of symptoms of depression, anxiety and stress among secondary school girls.
Methods:
A cross- sectional study was carried out on secondary school girls in Abha city, Aseer Region, Saudi Arabia, using the Arabic version of the Depression, Anxiety, and Stress Scale (DASS-42).
Results:
Of 545 female students recruited in this study, 73.4% had the symptoms of at least one of the three studied disorders; 50.1% had at least two disorders. The prevalence of symptoms of depression, anxiety and stress was 41.5 %, 66.2% and 52.5% respectively. The majority of symptoms were mild to moderate in severity. The scores for depression, anxiety, and stress were positively and significantly correlated. No significant association was found between the girls’ sociodemographic characteristics and the scores of the three studied disorders.
Conclusion:
One of the most important aspects of a primary care physician’s care of females is to screen for and treat common mental disorders.
Keywords: DASS-42, Depression, Anxiety, Stress, Adolescent, Secondary school girls, Saudi Arabia
Advances in Knowledge
Symptoms of negative emotional syndromes (depression, anxiety and stress) are highly prevalent among Saudi female secondary school students.
These symptoms are higher among female than male secondary school students and do not differ significantly according to girls’ sociodemographic characteristics.
Application to Patient Care
It is important to screen adolescents for negative emotional syndromes and to refer those with morbid symptoms for psychiatric consultation.
School health unit staff and primary health care physicians can play a major role in the diagnosis and management of mental disorders.
Adolescence (11–21 years old) is a transitional stage from childhood to adulthood.1,2 During this stage, many psychological changes take place.1–3 Psychiatric disorders in this period constitute a major public health concern and can result in serious consequences.1,2 Research has shown that the majority of adult sufferers of mental disorders indicate that their symptoms began in childhood and adolescence.1–3 The appropriate identification and treatment of mental disorders in this period provide teenagers with immediate positive benefits, and serve to counteract consequences such as poor academic performance, substance abuse and suicidal behaviour.3–6
Globally, Roberts et al.7 reported that the prevalence rates of mental disorders among children and adolescents range from 1% to 51% with a mean rate of 15.8% for adolescents. In the USA and Australia, one in five teenagers suffers from mental health problems.8, 9 In developing countries, the prevalence of mental disorders among adolescents attending primary health care facilities ranges between 12% and 29%.10 Several studies indicate that prevalence rates of the individual disorders: depression, anxiety and stress are growing among adolescents.8, 9, 11 Harrington and Clark12 reported that 60% of adolescents experience depressive symptoms. An earlier study on Saudi secondary school boys indicated that 38.2% had depression, while 48.9% experienced anxiety and 35.5% suffered from stress.13
The Saudi community is undergoing great economic and social changes. It has a young population, with 60% under 30 years old, and 47% under 15 years;14 however, very little is known about the extent of psychiatric illnesses among Saudi female adolescents. Therefore, this study aimed to evaluate the extent of depression, anxiety, and stress among secondary school girls in Abha City, Saudi Arabia.
Methods
This cross-sectional study was conducted during the school year, in October 2007, in Abha, the capital city of Aseer Region, in the southwest of Saudi Arabia with a total population of 300,000.
Through the School Health Unit for Girls (SHU-G), all secondary schools for girls located in Abha City (n=10) were invited to participate in this study. Principals and directors of these schools were provided with the important information about this study. All of them agreed to cooperate and to participate.
In Saudi Arabia, general education of children starts at 7 years old. Girls have separate schools from boys. Each secondary school has three teaching levels, which represent the 10th, 11th, and 12th years of education.
Data were collected using the Arabic version of the Depression Anxiety Stress Scale (DASS),15 while demographic and environmental data, as well as the presence of associated psychological factors, were collected via a questionnaire devised for the study. The DASS-42 is used for data collection to assess the negative emotional symptoms among students. It is a 42-item self-report inventory designed to measure the presence and severity of symptoms of depression, anxiety and stress among people as young as 12 years of age.15 This scale was psychometrically validated to the Arabic culture by Taouk et al.16 This screening and outcome measure reflects the experience of the person over the previous 7 days. Gamma coefficients that represent the loading of each scale on the overall factor (total score) are 0.71 for depression, 0.86 for anxiety, and 0.88 for stress. One would expect anxiety and stress to load higher than depression on the common factors as they are more highly correlated and, therefore, dominate the definition of this common factor. The reliability of the test is considered adequate and test-retest reliability is likewise considered adequate with 0.71 for depression and 0.79 for anxiety. Exploratory and confirmatory factor analyses have sustained the proposition of its factors (p <0.05).15 Table 1 shows the scoring and grading of the DASS.
Table 1:
Scoring and grading of the Depression, Anxiety and Stress Scale (DASS)15
| Category | Depression | Anxiety | Stress |
|---|---|---|---|
| Normal | 0–9 | 0–7 | 0–14 |
| Mild | 10–13 | 8–9 | 15–18 |
| Moderate | 14–20 | 10–14 | 19–25 |
| Severe | 21–27 | 15–19 | 26–33 |
| Extremely severe | 28+ | 20+ | 34+ |
At each school, one classroom from each year level was selected by simple random sampling. Prior to administration of the questionnaire, the purpose of the study was briefly and clearly described to the students. They were informed that they could choose not to participate and were assured of the full confidentiality of their data. A total of 545 secondary school girls participated in this study, their age ranged from 14–20 years with an average of 17.13 ±1.12 years and a median of 17.0 years.
Data were collected by 4th year trained female medical students (n=20), under the supervision of their college professors (n=5). These medical students were trained on practical research methodology, as a part of their community medicine course.
Statistical analysis was conducted by the staff of the Department of Family and Community Medicine, College of Medicine, King Khalid University, using the Statistical Package for the Social Sciences (SPSS, Version 15 for Windows). The significance of differences was tested using the χ2 test at the 5% level of probability significance. Students who obtained high DASS scores (i.e. severe or extremely severe symptoms) were referred to the research psychiatrist to confirm the diagnosis and to provide proper psychiatric consultation and management.
Results
Table 2 shows the distribution of students’ age groups and scholastic years. About 60% of the students were enrolled in the 2nd and 3rd year, while 40.2% were enrolled in the first year.
Table 2:
Distribution of secondary school girls in Abha, Saudi Arabia according to their age, scholastic year and type of study (n=545)
| Student characteristics | No. | % |
|---|---|---|
| Age groups (in years) | ||
| 14–15 | 22 | 4 |
| 16– 17 | 333 | 61.1 |
| 18– 20 | 190 | 34.9 |
| School year | ||
| First year | 219 | 40.2 |
| Second year | 163 | 29.9 |
| Third year | 163 | 29.9 |
| Total | 545 | 100 |
Table 3 shows that the majority of girls lived with both their parents (89.0%). The most frequent level of education among fathers was university education (39.4%), while only 7.9% were illiterate. On the other hand, the most frequent mothers’ education level was primary education (29.9%) followed by illiterates (28.3%). The most frequent fathers’ occupations of the studied sample were retired or currently not working (34.5%) followed by governmental civil employee (29.7%), while most mothers were housewives (87.9%).
Table 3:
Socio-demographic characteristics of secondary school girls, Abha, Saudi Arabia (n=545)
| Characteristics | No. | % |
|---|---|---|
| Parents’ status | ||
| Living within the family | 485 | 89.0 |
| Divorced/separated | 24 | 4.4 |
| Deceased father | 28 | 5.1 |
| Deceased mother | 5 | 0.9 |
| Both parents deceased | 3 | 0.6 |
| Father’s education | ||
| Illiterate | 43 | 7.9 |
| Primary | 87 | 16.0 |
| Intermediate | 93 | 17.1 |
| Secondary | 107 | 19.6 |
| University | 149 | 27.3 |
| Postgraduate | 66 | 12.1 |
| Father’s employment | ||
| Unemployed | 25 | 4.6 |
| Military | 89 | 16.3 |
| Governmental employee | 162 | 29.7 |
| Private business | 106 | 19.5 |
| Retired | 163 | 29.9 |
| Mother education | ||
| Illiterate | 154 | 28.3 |
| Primary | 163 | 29.9 |
| Intermediate | 88 | 16.1 |
| Secondary | 69 | 12.7 |
| University | 54 | 9.90 |
| Post graduate | 17 | 3.10 |
| Mother’s employment | ||
| Housewife | 479 | 87.9 |
| Employed | 66 | 12.1 |
Table 4 shows that 73.4% of the girls had at least one of the three studied disorders (depression, anxiety or stress). Moreover, 50.1% of subjects had at least two disorders, and more than one-third of the students (35.5%) had all the three disorders under study. Depression, anxiety, and stress were found in 41.5 %, 66.2% and 52.5% of the subjects respectively. Table 5 reveals that depression, anxiety, and stress were positively and significantly correlated. Table 6 shows that the prevalence of symptoms of depression, anxiety and stress among secondary school girls did not differ significantly according to their sociodemographic characteristics.
Table 4:
Prevalence and intensity of Depression, Anxiety, and stress among secondary school girls, Abha, Saudi Arabia. (n=545)
| Psychological traits | No. | % |
|---|---|---|
| Depression | 226 | 41.5 |
| Mild | 92 | 16.9 |
| Moderate | 77 | 14.1 |
| Severe | 39 | 7.20 |
| Extremely severe | 18 | 3.30 |
| Anxiety | 361 | 66.2 |
| Mild | 75 | 13.8 |
| Moderate | 144 | 26.4 |
| Severe | 81 | 14.8 |
| Extremely severe | 61 | 11.2 |
| Stress | 286 | 52.5 |
| Mild | 108 | 19.8 |
| Moderate | 114 | 20.9 |
| Severe | 50 | 9.20 |
| Extremely severe | 14 | 2.60 |
| Morbidity | ||
| One symptom or more | 400 | 73.4 |
| More than one symptom | 273 | 50.1 |
| Free of symptoms* | 145 | 26.60 |
| Total | 545 | 100 |
Depression, anxiety or stress
Table 5:
Correlation matrix between severities of depression, anxiety, and stress among secondary school girls, Abha, Saudi Arabia (n =545)
| Depression | Anxiety | Stress | ||||
|---|---|---|---|---|---|---|
| r | p-value | r | p-value | r | p-value | |
| Depression | -- | -- | 0.693 | < 0.001 | 0.691 | < 0.001 |
| Anxiety | 0.691 | < 0.001 | -- | -- | 0.728 | < 0.001 |
| Stress | 0.694 | < 0.001 | 0.728 | < 0.001 | -- | -- |
Table 6:
Prevalence of depression, anxiety and stress among secondary school girls according to their sociodemographic characteristics (n=545)
| Depression | Anxiety | Stress | |||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Normal | Depression | p Value | Normal | Anxiety | p Value | Normal | Stress | p Value | |||||||
| No. | % | No. | % | No. | % | No. | % | No. | % | No. | % | ||||
| Age groups (in years) | |||||||||||||||
| 14–15 | 15 | 68.2 | 7 | 31.8 | - | 7 | 33.3 | 14 | 66.7 | - | 12 | 54.5 | 10 | 45.5 | - |
| 16–17 | 195 | 59.3 | 134 | 40.7 | - | 106 | 32.2 | 223 | 67.8 | - | 153 | 46.8 | 174 | 53.2 | - |
| 18–19 | 109 | 58.9 | 76 | 41.1 | 0.697 | 71 | 38.6 | 113 | 61.4 | 0.345 | 94 | 50.3 | 93 | 49.7 | 0.627 |
| School year | |||||||||||||||
| First | 126 | 58.3 | 90 | 41.7 | - | 71 | 32.9 | 145 | 67.1 | - | 103 | 48.1 | 111 | 51.9 | - |
| Second | 93 | 57.4 | 69 | 42.6 | - | 55 | 34.6 | 104 | 65.4 | - | 70 | 42.9 | 93 | 57.1 | - |
| Third | 100 | 63.3 | 58 | 36.7 | 0.507 | 58 | 36.5 | 101 | 63.5 | 0.767 | 86 | 54.1 | 73 | 45.9 | 0.135 |
| Parents’ status | |||||||||||||||
| Living within the family | 288 | 60.4 | 189 | 39.6 | - | 163 | 34.3 | 312 | 65.7 | - | 234 | 49.1 | 243 | 50.9 | - |
| Divorced/separated | 10 | 43.5 | 13 | 56.5 | - | 11 | 47.8 | 12 | 52.2 | - | 9 | 39.1 | 14 | 60.9 | - |
| Deceased father | 15 | 53.6 | 13 | 46.4 | - | 7 | 25.0 | 21 | 75.0 | - | 13 | 46.4 | 15 | 53.6 | - |
| Deceased mother | 4 | 80.0 | 1 | 20.0 | - | 1 | 20.0 | 4 | 80.0 | - | 1 | 20.0 | 4 | 80.0 | - |
| Both parents deceased | 2 | 66.7 | 1 | 33.3 | 0.413 | 2 | 66.7 | 1 | 33.3 | 0.311 | 2 | 66.7 | 1 | 33.3 | 0.569 |
| Father’s education | |||||||||||||||
| Illiterate | 26 | 60.5 | 17 | 39.5 | - | 19 | 44.2 | 24 | 55.8 | - | 24 | 57.1 | 18 | 42.9 | - |
| Primary | 37 | 43.0 | 49 | 57.0 | - | 22 | 25.9 | 63 | 74.1 | - | 36 | 41.4 | 51 | 58.6 | - |
| Intermediate | 53 | 58.2 | 38 | 41.8 | - | 19 | 20.7 | 73 | 79.3 | - | 40 | 43.5 | 52 | 56.5 | - |
| Secondary | 68 | 65.4 | 36 | 34.6 | - | 43 | 41.7 | 60 | 58.3 | - | 54 | 52.4 | 49 | 47.6 | - |
| University | 94 | 63.9 | 53 | 36.1 | - | 58 | 39.5 | 89 | 60.5 | - | 73 | 49.7 | 74 | 50.3 | - |
| Postgraduate | 41 | 63.1 | 24 | 36.9 | 0.125 | 23 | 35.9 | 41 | 64.1 | 0.106 | 32 | 49.2 | 33 | 50.8 | 0.457 |
| Mother’s education | |||||||||||||||
| Illiterate | 56 | 36.6 | 97 | 63.4 | - | 76 | 49.7 | 77 | 50.3 | - | 11 | 45.8 | 13 | 54.2 | - |
| Primary | 52 | 32.5 | 108 | 67.5 | - | 89 | 55.3 | 72 | 44.7 | - | 49 | 55.1 | 40 | 44.9 | - |
| Intermediate | 25 | 29.1 | 61 | 70.9 | - | 37 | 42.5 | 50 | 57.5 | - | 88 | 55.3 | 71 | 44.7 | - |
| Secondary | 25 | 36.2 | 44 | 63.8 | - | 26 | 38.2 | 42 | 61.8 | - | 65 | 61.9 | 40 | 38.1 | - |
| University | 20 | 40.0 | 30 | 60.0 | - | 22 | 43.1 | 29 | 56.9 | - | 106 | 66.7 | 53 | 33.3 | - |
| Postgraduate | 6 | 37.5 | 10 | 62.5 | 0.772 | 9 | 56.3 | 7 | 43.8 | 0.150 | 319 | 59.5 | 217 | 40.5 | 0.118 |
| Father’s occupation | |||||||||||||||
| Unemployed | 11 | 45.8 | 13 | 54.2 | - | 8 | 32.0 | 17 | 68.0 | - | 13 | 52.0 | 12 | 48.0 | - |
| Military | 49 | 55.1 | 40 | 44.9 | - | 31 | 35.2 | 57 | 64.8 | - | 45 | 51.7 | 42 | 48.3 | - |
| Governmental employee | 88 | 55.3 | 71 | 44.7 | - | 52 | 33.1 | 105 | 66.9 | - | 66 | 41.5 | 93 | 58.5 | - |
| Private business | 65 | 61.9 | 40 | 38.1 | - | 39 | 37.1 | 66 | 62.9 | - | 54 | 51.4 | 51 | 48.6 | - |
| Retired | 106 | 66.7 | 53 | 33.3 | 0.118 | 54 | 34.0 | 105 | 66.0 | 0.967 | 81 | 50.6 | 79 | 49.4 | 0.375 |
| Mother’s employment | |||||||||||||||
| Housewife | 289 | 61.4 | 182 | 38.6 | - | 165 | 35.0 | 306 | 65.0 | - | 236 | 50.1 | 235 | 49.9 | - |
| Employed | 30 | 46.2 | 35 | 53.8 | 0.119 | 19 | 30.2 | 44 | 69.8 | 0.483 | 23 | 35.4 | 42 | 64.6 | 0.126 |
Discussion
DASS-42 was utilised in this research.15,16 It has the advantage that it can discriminate between the negative emotional symptoms of depression, anxiety, and stress; it is suitable for screening adolescents as young as 12 years of age; it is freely available in the public domain, and it is a short and easily answered questionnaire.
The present study indicated high prevalence rates for symptoms of depression, anxiety and stress among Saudi secondary school girls. About 10% of students showed severe or extremely severe symptoms of depression and stress while 25% of them showed severe or extremely severe symptoms of anxiety.
Moreover, results revealed that about 75% of the female Saudi secondary school students reported the symptoms of at least one of the three studied disorders. This is higher than those reported by several national, regional and international studies7–10,12,13,17,18 A review of the literature reveals a considerable disparity in figures on the prevalence of psychiatric disorders in adolescents. This could be due to the diversity in methods, definitions used, or geographical locations.7 In 1998, Robert et al.,7 reviewed 52 studies carried out in over 20 countries over the past four decades, and found that prevalence estimates of psychopathology ranged from 1 to 51%, (mean 15.8%), with a median rate of 15% among adolescents. In Taif City, Saudi Arabia, Abdel-Fattah et al.17 reported that 8.3% of male pupils in primary and secondary schools (5.6% of the sample was adolescent) were emotionally disturbed as measured by the Child Behavior Checklist “parent form”. Using the “Child Behavior Checklist”, Eapen et al.18 conducted a study on schoolchildren aged 6 to 15 years in the United Arab Emirates, a neighbouring country which has a similar culture to Saudi Arabia, and found that 23.9% of children had a mental health problem. The prevalence estimate for behavioural disorders was 16.5%.
Of the individual disorders, anxiety was the most prevalent (66.2%), followed by stress (52.5 %), then depression (41.5%). This finding is in agreement with that of Pelcovitz et al.,19 who found that anxiety disorders are the main psychiatric diagnosis in adolescents. In a previous study on Saudi male adolescents, symptoms of anxiety were the most prevalent (48.9%), followed by depression (38.2%), then symptoms of stress (35.5%).13 These high prevalence rates of symptoms of depression, anxiety and stress among Saudi female students can be attributed to the increasing stresses on Saudi females related to the social and cultural transformations in Saudi society. In addition, choosing a career has grown more difficult as the job market for women has become more complex. Furthermore, high psychological distress among students can be related to their study problems during the secondary school study period.
In agreement with previous studies, where comorbidity among adolescents ranged from 25% to 68 %,20,21 the comorbidity in this study was 50.1%. Psychiatric morbidity and comorbidity among girls in this study is higher than that reported in a study of 1,723 Saudi secondary school boys in the same region using the same methodology where 59.4% had at least one of the three disorders, (38.2%) had depression, while 48.9% had anxiety and 35.5% had stress.13 In a study conducted at four primary care clinics affiliated to university hospitals throughout the eastern United States, women were more likely than men to have at least one mental disorder (43% versus 33%; p <0.05). Psychiatric comorbidity was also more common in women (26% of women had two or more mental disorders versus 15% of men, p <0.05).22
Unlike previous studies19,23,24 this research failed to find any association between psychiatric morbidity and the socio-demographic characteristics of the participants. In a study of 8,934 Norwegian adolescents, those with a family history of divorce and parental distress were more vulnerable to symptoms of anxiety than those without such distress.24 Vazsony looked at 6,935 adolescents from Hungary, Switzerland and the United States and found that increased anxiety occurred in the presence of extreme maternal and paternal closeness to the adolescents, possibly caused by parental over intrusiveness.
The World Health Organization (WHO)25 noted that there are increasing numbers of people in the Eastern Mediterranean Region, who are now entering the age of risk for development of mental disorders, i.e. adolescence/early adulthood and old age. Existing conditions of social and physical strife provide fertile grounds for an upsurge in mental health problems and their consequences such as suicide and substance dependence. The school environment can offer an excellent opportunity to promote sound principles of mental health and healthy lifestyles. Consequently, further national studies are needed to explore the ability of school health unit staff and primary health care physicians to diagnose and manage mental disorders.
LIMITATIONS
This study has the following limitations: it was performed exclusively in the City of Abha, hence, its results exclusively reflect the psychiatric status of urban adolescents; it was restricted to female students only, which prevented the determination of sex-specific prevalence rates; it was a school-based study, which might therefore miss adolescents in the community who do not attend school. In addition, there is no built-in lie scale in DASS, as it is just a self-reporting data collection tool (with triangulation). Finally, no information on suicidal ideation can be picked up in DASS.
Conclusion
The present study confirms the high prevalence of depression, anxiety, and stress among Saudi female adolescent students. The challenges ahead include the need to carry out extensive further research, and to develop national intervention programmes to promote mental health.
Acknowledgments
The authors would like to thank 4th year female medical students for collecting the data and their professors at the Department of Family and Community Medicine, College of Medicine, King Khalid University, Saudi Arabia for their great help in supervising the data collection and conducting the statistical analysis.
Footnotes
Conflict of Interest
The authors report no conflit of interest.
References
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