Abstract
Background
Mental health issues are increasing in severity and number on college campuses. Improving adolescent mental well-being remains a challenge for most societies.
Objectives
The objectives of this study was to study the prevalence of psychological mood disorders and its association with some factors.
Methods
A cross-sectional-questionnaire based study was conducted among medical students in Fayoum University. Propensity to Psychological mood disorders was assessed by using a short version Depression, Anxiety and Stress Scale-21 (DASS-21), along with a pretested Sociodemographic questionnaire.
Results
A total of 442 students participated in the study with the mean age of 20.15 ± 1.9 years. Overall, the prevalence of stress, anxiety and depression with various degrees was 62.4%, 64.3%, and 60.8% among studied sample respectively. Higher stress and anxiety scores were significantly associated with female sex, older age, and BMI ⩾ 25 kg/m2. Higher depression score was associated with increasing age, low socioeconomic standard and among students from other governorates.
Conclusion
A substantial proportion of medical students are suffering from depression, stress, and anxiety. Female sex, increasing age, overweight and obesity are significant associated factors. Further studies need to be carried to identify other associated factors related to academic medical education.
1 Introduction
Mental health disorders according to the World Health Organization (WHO) are one of the leading causes of disability worldwide. Three of the ten leading causes of disability in people between the ages of 15 and 44 are mental disorders, and the other causes are often associated with mental disorders.Citation1 The mental health action plan for 2013–2020, recently published by the WHO, demonstrated the need for a collective evidence based effort to improve mental health.Citation2
Stress is anything that poses a challenge or a threat to our well-being. It has been defined as a process in which environmental demands exceed the adaptive capacity of an organism, resulting in psychological and biological changes that may place persons at risk for disease.Citation3 Anxiety is a psychological and physiological state characterized by cognitive, somatic, emotional, and behavioral components. These components combine to create an unpleasant feeling that is typically associated with uneasiness, fear, or worry. Anxiety is a generalized mood condition that occurs without an identifiable triggering stimulus,Citation4 while many symptoms of depression include, persistent sad, anxious or “empty” feelings, feelings of hopelessness, feelings of guilt, worthlessness and/or helplessness, irritability, restlessness, and loss of interest in activities or hobbies once pleasurable.Citation5
University students are a special group of people that are enduring a critical transitory period in which they are going from adolescence to adulthood and can be one of the most stressful times in a person’s life.Citation6 Several studies have reported high rates of psychological morbidity among medical students using various instruments. Both retrospective and prospective researches have shown that most adulthood mental disorders begin in childhood and adolescence.Citation7
The psychological health complaints and symptoms, mental health issues are increasing in severity and number on college campuses.Citation8,Citation9 Because, up to 60% of university students left university without finishing their studies because of depression, anxiety and maladjustment.Citation8,Citation10 A review of psychological distress among medical students found a high prevalence of depression and anxiety, with levels of psychological distress consistently higher than in the general population and age-matched peers by the later years of training.Citation11–Citation13 In Arab countries, recent studies from Egypt, Saudi Arabia, and United Arab Emirates reported high rates of anxiety and depression.Citation14–Citation17
It is important to identify the prevalence, and risk factors of stress among medical students, which not only affect their health but also their academic achievements at different points of time in their study period.Citation18,Citation19 In addition patients care is affected by psychological distress among physicians such as Poor communication, diminished quality of care and medical errors have been found to be associated with physical stress.Citation20
The association of mental illness and obesity especially depression has been concluded in previous research.Citation21,Citation22 The prevalence of obesity has tripled concurrently with the rate of depression in many countries of the World Health Organization (WHO) European Region since 1980 s, and continues to rise at an alarming rate.Citation23 We study through this research this relation among university students. This help to identify special at risk group, and to develop and evaluate more effective preventive and therapeutic interventions to these conditions.
High rates of psychological problem among medical students are most likely related to academic, financial and social demands that college environments place on students at a time when they are also involved in issues related to lifestyle and careers.Citation24 Much of the literature on risk factors among students has focused on suicidality and has found higher risks for students who are over age 25 or male undergraduates.Citation25 In Egypt, Mental disorders were associated with social, demographic, behavioral, and educational factors.Citation14
The current study aimed to explore the magnitude of psychological mood disorders (stress, anxiety and depression) among Fayoum university medical students. The study also aimed to explore the association between these disorders and some factors such as sex, age, socioeconomic standard, and obesity.
2 Methods
2.1 Study design and setting
A cross-sectional study was conducted in Fayoum University of Egypt from January to April, 2015, among the first to fourth academic year students of medicine who were available in teaching classes in the main faculty building. Fayoum is a large depression or basin in the southwest of Cairo, and Fayoum Governorate’s population amounts to 3.07 millions persons.Citation26 Most of them live in rural communities and work in agriculture and its related industries. The average family size ranges from 4.1 to 4.5 from urban to rural communities respectively.Citation27
2.2 Ethical consideration
This study was approved by the Medical Research and the Ethical Committee of Faculty of Medicine, Fayoum University. A verbal consent was obtained from all participants before filling the questionnaire.
2.3 Sample population
The total number of Fayoum medical students in year 2014/2015 was 834 (509 females and 325 males) and the number in the four first academic years was 703 students (420 females and 283 males) distributed across the academic years as follows: 215 in the 1st academic class, 190 in the 2nd academic class, 166 in 3rd academic class and 132 in the 4th academic class. All were invited to participate, and of those, 442 gave verbal consent and participated in this study. They were distributed across academic years as follows: 120.106, 118 and 98 students in the 1st, 2nd, 3rd, and 4th academic years respectively. A purposive sample was chosen from first to fourth academic years students who were available in classes and gave verbal consent.
Sample size was calculated using stat- Calc, by using the following data; prevalence rate 50%, significance level 0.05 and power of the study is 80%. Thus in this study, the minimum size required was 377. The size taken was 442 students.
2.4 Study tools
2.4.1. A predesigned self-administered questionnaire was used to assess demographic data, socioeconomic condition, and lifestyle, of students.
2.4.2. Psychological disorders were assessed by using the Arabic short version of the standardized Depression Anxiety Stress Scale-21 Items (DASS21). DASS21 is a set of three self-report scales designed to measure the negative emotional states of depression, anxiety and stress with 7 items per scale, the depression scale assesses dysphoria, hopelessness, self-deprecation and lack of interest. The Anxiety scale assesses autonomic arousal, skeletal muscle effect. The stress scale assesses relaxing difficulty, nervous arousal and being easily agitated.Citation28
2.4.3. Tools for measuring: weight, height and waist circumference; the weight was measured in kilogram without shoes using a standing weighing machine. Checks on the scale were made routinely before recording the weight of each student and the pointer was adjusted to zero using the screw provided; reading was taken to the nearest 1 kg. The height was taken barefooted in centimeter using standard measuring tape, and reading was taken to the nearest 1 cm. The waist circumference is measured by a measure tape at a level midway between the lowest rib and the iliac crest. The measuring tape should be snug but not compressing the skin and held parallel to the floor.Citation29
All selected students were invited to participate in the study after explaining purpose of study, and confidentiality was ensured. The self-administered questionnaires were distributed in and at the end of their classes. Filling questionnaire was taking about fifteen minutes of time. From a total of 500 distributed questionnaires, 442 completed questionnaires were returned with participation rate 88.4%. Body measurements: weight, height, and WC were taken from every student completed questionnaire.
2.5 Data manipulation and scoring system
2.5.1. Collected data were checked for completeness and manipulated as follows: –Body mass index was calculated by dividing the weight in kilograms by the square of the height in meters. A BMI over 25 kg/m2 is defined as overweight and a BMI of over 30 Kg/m2 as obese.Citation30- Reference levels for desirable waist circumference (for men <102 cm and for women <88 cm).
2.5.2. The socioeconomic score was calculated according to (the modified Fahmy and El-sherbini Social Score).Citation31 This system includes the following:
2.5.2.1. Crowding Index (persons per room)<2 = 3, 2- = 2, Occupation for father or mother → Working = 2 and not working =
2.5.2.2. Education for father or mother: → Illiterate or read and write = 1, Primary = 2, Preparatory = 4, Secondary = 6, University or higher = 8.
2.5.2.3. Family income meets expenses → Yes and Save = 4, Yes = 3, Sometimes = 2, No = 1 -Sanitation → all of Three (water, electricity and waste disposal) = 3, two of three = 2, one of three = 1.
2.5.2.4. The overall Social Scoring is classified into four levels: Less than 15 Very Low Social Standards. 15–19 low social standards. 20–24 middle social standards 25–30 high social standards.
2.5.3. Lovibond scoring scale for psychological mood. Items are scored on 0–3 scale scoring for Depression, Anxiety and Stress, scale are derived by summing the item in each scale (range 0–42). Scores obtained on the DASS 21 will need to be multiplied by 2 to calculate the final score ().
Table 1 Lovibond scoring scale for psychological mood.
2.6 Statistical analysis
Data were analyzed using Statistical Package for Social Science version 16.0 software, SPSS, Inc., Chicago, IL Data were summarized using mean and standard deviation values of age, median and interquartile range (IQR) for stress, anxiety and depression scores, number and percentage for qualitative variables. Comparison between groups was done using chi-square and Fisher’s exact test for qualitative variables and Mann-Whitney and Kruskal–Wallis tests for scores. Logistic regression analysis was done to test for risk factors of stress, anxiety, and depression. A p value less than or equal to 0.05 was considered statistically significant.
3 Results
3.1 Sociodemographic characteristics of the students
revealed the distribution of the studied students who have shared in the study. The total number was 442 students with the mean age of 20.15 ± 1.9 years. They were divided into two age groups: the first age group (17–19) years with a percentage of 33.9%, and the other age group (20–22) years by 66.1%. The male students were represented by 38.9% where the female students were represented by 61.1%. Rural residence was represented by 56% of students; those from other governorates were represented by low percent (7.7%). The percent of students with very low and low socioeconomic standard represented over 30% of students.
Table 2 Sociodemographic characteristics of the students (total number 442).
3.2 Prevalence of psychological mood disorders among study participants
and show the prevalence of stress among study participants over 60% with increasing prevalence among females compared to males (p value = 0.001); the percent of stress represented 65.9%, in females (mild and moderate 29.6%, severe and very severe 36.3%) and 57% in males. The prevalence of anxiety among students was near 65% with increasing prevalence in females (70.4%) than males (54.7%). Depression was detected in 60% of students with no significant difference between males and females. The proportion of overweight and obese students was 23.5% and 14.5% respectively with no significant difference between males and females. Regarding abdominal obesity detected by WC, a higher proportion of females 22.2% than males 14.0% was in obese classes (p = 0.03). shows that a significant association between stress and student age more than > 20 years has been recorded (p 0.049); they represented higher percentages in stressed students than normal. Also significant association between stress, anxiety, and depression and higher academic classes was detected with p values, 0.023, 0.001, and 0.023. Significant association between stress and marital status has also been reported (p 0.00); married students were less prone to stress. Significant association between the presence of anxiety and age and body weight has been detected; the prevalence of anxiety was significantly higher among older and overweight and obese students. Regarding depression, a significant association has been reported between the presence of depression and age (p 0.04).
Figure 1 Prevalence of stress, anxiety, and depression among study participants.
Table 3 Psychological disorders and weight measurements of student by sex.
Table 4 Demographic, physical activity and body weight risk factors of stress, anxiety, and depression among study participants.
3.3 Psychological disorders associated factors
3.3.1. shows median and IQR of stress, anxiety, and stress scores according to Sociodemographic, weight and lifestyle characters;
Table 5 Factors affecting psychological illness among students.
3.3.1.1. Sex: the median stress and anxiety scores were significantly higher in females than male students, p value 0.00 and 0.009 respectively with no association between depression and sex.
3.3.1.2. Age: the median stress and depression scores were significantly higher among older students aged from 21 to 23 years, p value 0.015 and 0.011 respectively.
3.3.1.3. It was shown also that there was a significant association between socioeconomic standard and stress and depression scores, p value 0.045 and 0.029 respectively, with higher scores detected among those with lower socioeconomic classes.
3.3.1.4. A higher depression score was detected among students from other governorates than those from Fayoum governorate p = 0.002. A significant association also was detected between anxiety and unmarried students.
3.3.1.5. A significant association between obesity and stress and anxiety scores: a higher stress and anxiety scores were detected among obese and overweight than normal students (p value 0.002 and 0.04). No association of depression and obesity was detected in our results. Abdominal obese students detected by WC showed higher stress score than normal students (p 0.00).
3.3.2. shows that age > 20y was a significant predictor for stress, anxiety and depression. Female sex was a predictor for both stress and anxiety. BMI ⩾ 25 kg/m2 was an important predictor for stress and anxiety.
Table 6 Multivariate stepwise logistic analysis of predictors.
4 Discussion
The present study aimed at identifying different psychological disorders and associated factors among medical Fayoum university students. The data were collected from 442 students aged from 18 year to 22 years old from first to fourth academic years from different socioeconomic levels ().
The result of this study showed that the overall prevalence of stress was 62.5% among medical students. Similar studies from other countries showed a wide variety of rates; two studies in Saudi Arabia reported prevalence stress rates of 71.9% and 57%.Citation32,Citation33 In Malaysian, it was 41.9%, and in Thai it was 61.4% Citation34,Citation35. This variation has been explained to be due to cultural differences, differences in the healthcare system, and differences in the population and the tools used in the study. Regarding our tools, DASS-21 questionnaire is used. The validity and reliability of the DASS-21 questionnaire in measuring the dimensions of depression, anxiety, and depression have been proved in different studies Citation36,Citation37. This tool is only an indicator that couldn’t replace clinical examination; it is suitable for screening normal adolescents and adults. This scale was psychometrically validated to the Arabic culture by Taouk et al. Citation38.
The present study showed a significant association of stress score with increasing age (). Neimi and Vainiomaki reported that the level of stress increased progressively during the course to reach as high as 40% by the end of clinical training period.Citation39 Results of other studies in North America also suggest that mental health worsens after students join a medical school and remain poor throughout the course, especially in the transition from basic science teaching to clinical training.Citation40, but contrary to this finding, other studies concluded that the prevalence of stress was decreased as the students progressed in their years of study.Citation35,Citation36
Our results revealed also an association of stress score with lower socioeconomic standard, and increased BMI and WC () while factors such as, residence and exercise did not show any statistically significant association with stress. These findings are in accordance with some findings of other studies; Jizan University study reported that factors such as BMI and the gender showed statistical association with stress.Citation35 In study conducted in Menoufiya University, Egypt, stress was significantly associated with gender, residence, perceived socioeconomic standard, feeling loneliness, and sharing family in social activities,Citation14 while Labib et al. in Fayoum University reported that academic and family sources of stress were statistically significantly more in medical than in nonmedical students.Citation41
In our study the prevalence of depression and anxiety was detected among 60.2% and 64.3% of medical students (). Similar studies conducted in Egypt universities reported other figures; in Menoufiya University, the prevalence of depression and anxiety, was 63.6% and 78.4% respectively,Citation14 in Alexandria University; 43.9% and 57.9% of medical students were suffering from anxiety and depression respectively.Citation42 Another study conducted in Mansoura University among medical students has reported lower figures; prevalence of depressive and anxious symptoms was 28.3% and 21.2%.Citation43 Our findings are also similar to what is reported in other countries; in Pakistan, a prevalence of 70% anxiety and depression was reported among medical students.Citation44 On the other hand, Jadoon et al. Citation24 have reported a prevalence of 43.89% of anxiety and depression among 482 medical students. In Beirut (27.63% and 69%),Citation45 and in Iran was 33%.Citation46
Depressive, anxiety disorders and obesity are among the leading public health concerns globally causing disability, reduced quality of life, increased mortality and comorbid conditions; however, the relationship between obesity and psychiatric disorders has not been clear. Methodological differences across studies have contributed to inconsistent observations. In our finding, the Anxiety score was significantly higher with increasing BMI and the BMI >=25 was a predictor of anxiety, however the depression score was not ( and ). Some studies found positive association between obesity and psychiatric morbidity (depression and/or anxiety), especially among women,Citation21 but others didn’t find association between obesity and mental healthCitation47 while, others reported the prevalence of depression and/or anxiety was higher in underweight men and womenCitation48 and in underweight men.Citation47 Prospective research done by Nigatu et al. Citation22 added evidence that obesity is associated with the subsequent onset of recurrent major depressive disorder (MDD-R) but not of single episode MDD among adults in the general population. Although the reverse association was not found, MDD-R tends to be also associated with subsequent development of obesity.
The current study revealed gender difference in self-reported anxiety and stress with significantly higher stress and anxiety among females than males (, ). This was consistent with Menoufyia university study; it was reported that females were more vulnerable to anxiety and stress.Citation14 Amr et al., in Mansoura University, Egypt, reported no significant difference in stress between male and female medical students.Citation49 Previous epidemiological studies have concluded that females were more prone to psychological symptoms than males.Citation37,Citation42,Citation43 This is possibly due to the fact that females complain more about the high load of the curriculum, are more liable to over complaint about physical and psychological symptoms and face less job opportunities than males in eastern countries.Citation43 Stressors such as Exams, contacts with patients and autopsy were described as a high stressors that are significantly more frequent in female students.Citation50 Regarding depression, our results showed no gender difference. Amr et al. found that among medical student in Mansoura, females scored higher on a depression and neuroticism scale than males. Sarokhani et al. Citation46 reported an opposite finding that prevalence of depression was higher among boys (28%) than among girls (23%). Tyssen et al. found a higher prevalence of mental problems among male doctors than the general male population, but findings about female doctors did not differ from the generally high prevalence rates among the general female population.Citation51 The inconsistent data about gender difference are most likely explained by multifactorial, including biological, sociocultural, or variable combinations of each.Citation49
The current study showed significant association of Depression and stress scores with lower socioeconomic class with higher score detected in low and very low socioeconomic () and the low and very low socioeconomic standard was a predictor of anxiety (). This was in accordance with what was reported by Eisenberg et al.Citation52, that the students who grew up in poor families were substantially more likely to screen positive for depression or anxiety disorders and to report suicidal thoughts.
The prevalence of stress, anxiety and depression scores was higher among unmarried students (). Sarokhani et al. Citation46 reported similar findings; the prevalence of depression among single students (39%) was higher than married students 20%. Contrary to our study, Bayram and Bilgel Citation53 showed that married students reported higher levels of depression.
4.1 Conclusion and recommendation
A substantial proportion of Fayoum medical university students are suffering from Psychological disorders. The prevalence is more among females than males, with increasing age and with increasing BMI. Counseling and preventive mental health services should be an essential part of the routine investigation of medical students. Actions should be taken to encourage the students to seek help on exposure to distress. Further studies should be done to identify different sources and causes of stress especially related to academic and educational factors, and the effect of different intervention measures to avoid or cope with the psychological effect of the life tension.
Limitation
In this study, some limitation should be considered. Some factors are not studied as academic and educational factors, and fifth and sixth academic years even other faculties are not included in this study. Further studies should take these limitations into consideration.
Fund statement
The whole study was funded by the authors.
Conflict of interest
The authors declare that there are no conflicts of interest.
Acknowledgment
We thank students who shared in the study.
Notes
Peer review under responsibility of Alexandria University Faculty of Medicine.
Available online 20 February 2016
Related Research Data
References
- Murray C, Lopez A. World Health Report 2002: Reducing Risks, Promoting Healthy Life. Geneva, Switzerland: World Health Organization
- WHO. World Health Organization Mental health action plan 2013–2020. Geneva: available at <http://apps.who.int/%20iris/bit%20stream/10665/89966/1/9789241506021_eng.pdf>.
- S.CohenR.C.KesslerL.Underwood-GordonStrategies for measuring stress in studies of psychiatric and physical disordersS.CohenR.C.KesslerL.Underwood-GordonMeasuring stress1995Oxford University PressNew York328
- M.E.SeligmanE.F.WalkerD.L.RosenhanAbnormal psychology4th ed.2001W.W. Norton & Company, Inc.New York
- NIMH. National Institute of Mental Health; 2008. <http://www.nimh.nih.gov>.
- J.L.BuchananPrevention of depression in the college student Population: a review of the literatureArch Psychiatric Nurs26120122142
- R.C.KesslerG.P.AmmingerS.Aguilar-GaxiolaJ.AlonsoS.LeeT.B.UstunAge of onset of mental disorders: a review of recent literatureCurr Opin Psych202007359364
- L.E.RubinStudent mental health in a chiropractic university settingJ Chiropr Educ2220081216
- E.OvugaJ.BoardmanD.WassermanUndergraduate student mental health at Makerere University, Uganda: research reportWorld Psychiatry520061
- O.F.PorterUndergraduate completion and persistence at four-year colleges and universities1990National Institute of Independent Colleges and UniversitiesWashington
- L.N.DyrbyeM.R.ThomasT.D.ShanafeltSystematic review of depression, anxiety, and other indicators of psychological distress among U.S. and Canadian medical studentsAcad Med812006354373
- M.DahlinN.JoneborgB.RunesonStress and depression among medical students: a cross-sectional studyMed Educ392005594604
- J.M.RosenthalS.OkieWhite coat, mood indigo: depression in medical studentsN Engl J Med353200510851088
- A.R.Abdallah1H.M.GabrDepression, anxiety and stress among first year medical students in an Egyptian public universityInt Res J Med Med Sci2120141119
- A.H.El-GilanyM.AmrS.HammadPerceived stress among male medical students in Egypt and Saudi Arabia: effect of sociodemographic factorsAnn Saudi Med282008442448
- M.AmrA.El-GilanyM.El-SayedE.El-SheshtawyStudy of stress among medical students at Manssoura UniversityBanha Med J20073720072531
- A.O.CarterM.ElzubeirY.M.AbdulrazzaqA.D.RevelA.TownsendHealth and lifestyle needs assessment of medical students in the United Arab EmiratesMed Teacher2552003492496
- H.AbdulghaniA.AlKanhalE.MahmoudG.PonnamperumaE.AlfarisStress and its effects on medical students. A cross-sectional study at a College of Medicine in Saudi ArabiaJ Health Popul Nutr2952011516522
- A.HysenbegasiS.L.HassC.R.RowlandThe impact of depression on the academic productivity of university studentsJ Ment Health Policy Econ832005145151
- J.Firth-CozensJ.GreenhalghDoctors’ perceptions of the links between stress and lowered clinical careSoc Sci Med44199710171022
- K.M.CarpenterD.S.HasinD.B.AllisonM.S.FaithRelationships between obesity and DSM-IV major depressive disorder, suicide ideation, and suicide attempts: results from a general population studyAm J Public Health9022000251257
- Y.T.NigatuU.BültmannS.A.ReijneveldThe prospective association between obesity and major depression in the general population: does single or recurrent episode matter?BMC Public Health Sample15201535010.1186/s12889-015-1682-9
- World Health Organization. Nutrition; 2015; Available at: <http://www.euro.who.int/en/what-we-do/health-topics/disease-%20prevention/nutrition/a-healthylifestyle/%20body-mass-index-bmi>.
- N.A.JadoonR.YaqoobA.RazaM.A.ShehzadZ.S.ChoudhryAnxiety and depression among medical students: a cross-sectional studyJ Pak Med Assoc6082010699702
- M.M.SilvermanP.M.MeyerF.SloaneM.RaffelD.M.PrattThe big ten student suicide study: A 10-year study of suicides on midwestern university campusesSuicide Life Threat Behav271997285303
- Official Fayoum Web Site: <http://www.fayoum.gov.eg>.
- CAPMAS. Statistical data and records of El-Fayoum Governorate. Egypt, Central Agency for Public Mobilization and Statistics; 2009.
- S.H.LovebirdLovibondManual for the depression anxiety stress scales2nd. Ed.1995Psychology FoundationSydney
- T.HanLeer E.VanJ.SeidellM.LeanWaist circumference action levels in the identification of cardiovascular risk factors: prevalence study in a random sampleBMJ3117017199514011405
- WHO. Obesity and overweight, Global Strategy on diet, physical activity and health; 2003.
- S.I.FahmyA.F.El SherbiniDetermining simple parameters for social classification for health researchBull High Inst Publ Health13198395108
- M.SaniM.S.MahfouzI.BaniA.H.AlsomilyD.AlagiN.Y.AlsomilyPrevalence of stress among medical students in Jizan University, Kingdom of Saudi ArabiaGulf Med J1120121925
- H.AbdulghaniStress and depression among medical students: a cross sectional study at a medical college in Saudi ArabiaPak J Med Sci2420081217
- M.S.SherinaL.RampalN.KanesonPsychological stress among undergraduate medical studentsMed J Malaysia592004207211
- R.SaipanishStress among medical students in a Thai medical schoolMed Teach252003502506
- J.D.HenryJ.R.CrawfordThe short-form version of the Depression Anxiety Stress Scales (DASS-21): construct validity and normative data in a large non-clinical sampleBr J Clin Psychol442005227239
- Psychology Foundation of Australia. DASS publications. Available online at: <http://www2.psy.unsw.edu.au/groups/dass/%20pub.htm>. [last accessed: February 15, 2009].
- Taouk M, Lovibond PF, Laub R. Psychometric Properties of an Arabic Version of the Depression Anxiety Stress Scale (DASS); 2001. From <http://www2.psy.unsw.edu.au/Groups/Dass/Arabic/Arabic.htm>.
- P.M.NiemiP.T.VainiomakiMedical students’ distress—quality, continuity and gender differences during a six-year medical programmeMed Teach2822006136141
- L.DyrbyeM.R.ThomasT.D.ShanafeltMedical student distress: causes, consequences, and proposed solutionsMayo Clin Proc80200516131622
- N.A.LabibA.A.BarakatN.El SherbinyE.EbrahimStress Profile among Fayoum University StudentsEgypt J Commun Med2820105971
- M.B.IbrahimM.H.AbdelreheemPrevalence of anxiety and depression among medical and pharmaceutical students in Alexandria/University Faculty of Medicine, Alexandria UniversityAlexandria J Med512015167173
- M.AmirA.H.El GillanySelf-reported depression and anxiety by students at an Egyptian Medical SchoolJ Pakist Psych Soc (JPPC)2201071
- M.S.KhanS.MahmoodA.BadshahS.U.AliY.JamalPrevalence of depression, anxiety and their associated factors among medical students in Karachi, PakistanJ Pak Med Assoc562006583586
- Z.MehannaS.RichaPrevalence of anxiety and depressive disorders in medical students. Transversal study in medical students in the Saint-Joseph University of BeirutEncephale322006976982
- D.SarokhaniA.DelpishehY.VeisaniM.T.SarokhaniR.E.ManeshK.SayehmiriPrevalence of depression among university students: a systematic review and meta-analysis studyvol. 20132013Hindawi Publishing Corporation Depression Research and Treatment37385710.1155/2013/373857p.7
- T.S.HanM.A.TijhuisM.E.LeanJ.C.SeidellQuality of life in relation to overweight and body fat distributionAm J Public Health88199818141820
- G.ZhaoE.S.FordS.DhingraC.LiT.W.StrineA.H.MokdadDepression and anxiety among US adults: associations with body mass indexInt J Obes332009257266;10.1038/ijo.2008.26
- M.AmrA.El GilanyA.El-HawaryDoes gender predict medical students’ stress in Mansoura, Egypt?Med Educ Online13200812 doi;10 Available from <http://www.med-ed-online.org>.
- D.Backović1J.Živojinović1J.MaksimovićM.MaksimovićGender difference in academic stress and burnout among medical students in final years of educationPsychiat Danubina2422012175181
- R.TyssenP.VaglumN.T.GronvoldO.EkebergSuicidal Nationwide and prospective study of prevalence and ideation among medical students and young physicians: a predictorsJ Affect Disord6420016979
- D.EisenbergS.E.GollustE.GolbersteinJ.L.HefnerPrevalence and correlates of depression, anxiety, and suicidality among university students mph university of michiganAm J Orthopsych7742007534542 Copyright by the American Psychological
- N.BayramN.BilgelThe prevalence and sociodemographic correlations of depression, anxiety and stress among a group of university students”Social Psychiat Psychiat Epidemiol4382008667672