An empirical investigation of the incidence of negative psychological symptoms among Chinese international students at an Australian university

Abstract

Objective

To examine comparative levels of depression, anxiety, and stress among a sample of Chinese international students and local Australian students studying at a major Australian university, and to elicit the main sources of symptoms in these groups.

Method

The study used the Depression, Anxiety and Stress Scale (DASS‐42) to measure scores on each of the subscales in a sample of 201 undergraduate students. Differences between the local students, Australian students, and Chinese international students are reported. Qualitative data are analysed to determine the main sources of students' psychological symptoms.

Results

Australian students' stress levels fell between the ‘mild’ to ‘moderate’ categories, while Chinese students' stress levels fell within the ‘moderate’ category. Anxiety levels were between ‘normal’ and ‘mild’ for Australian students, and between ‘moderate’ and ‘severe’ for Chinese students. Depression levels fell in the upper range of ‘normal’ for both groups. Chinese students' levels of both stress and anxiety were significantly higher than for local students. Academic, life balance, and family factors were found to be the main sources of stress for Chinese students.

Conclusions

Chinese international students experience significantly higher levels of anxiety and stress than their Australian counterparts, and the causes of these appear to be culture‐specific. Universities have a duty of care to address the phenomena of psychological morbidity among Chinese international students. Approaches to psychological support services, including counselling and academic support, should be culturally specific and must be reinforced constantly during the semester as stress and anxiety accumulate.

Key words:

• cross‐cultural comparison
• individual differences
• psychological testing and measurement
• stress

What is already known about the topic

• Academic performance is related to the psychological well‐being of students.

• Chinese traditional culture places a strong emphasis on academic success, and as such academic factors may be a large contributor to the psychological health of Chinese international students.

• There appears to be empirical support for a higher incidence of psychological morbidity among international students from the Asian region who experience greater difficulty acculturating to life in Western countries compared with students from European countries.

What this topic adds

• Further support for the notion that Chinese international students experience higher psychological morbidity than local students, and this is evident in an Australian university context.

• Moderate to high levels of stress and anxiety in Chinese international students have substantial implications for the capacity of these students to cope with the demands of academic life.

• Sources of stress and anxiety vary according to cultural group—for Chinese students, it is more likely to relate to academic, family, and life balance issues.

China is the largest single nation contributor to Australia's international student population, with one fifth of all lodged and granted visa applications coming from Chinese students (Australian Bureau of Statistics, 2011). A recent study found that the number of Chinese choosing to study overseas is estimated to increase seven times within the next 5–10 years, with Australia the most popular destination in the Asian region (HSBC Bank Australia, 2013). Many students choose to return to China upon completion of their studies, while others stay for the long term, working for Australian organisations and contributing to the development of our cultural ties between Australia and the Asian region.

As the proportion of Chinese students in our universities continues to grow, it is critical for universities to understand the challenges of adjustment facing these students and to assist them to cope with the demands of studying in a foreign country. Aside from a new and very different educational system, these students are faced with a new social environment, culture shock, financial difficulties, language barriers, discrimination, and homesickness, all of which can be a potential source of stress and place students at an increased risk for psychological disorders (Hyun, Quinn, Madon, & Lustig, 2007; Mori, 2000; Ward & Low, 2004).

The period of undergraduate education is often regarded as critical in the development of an autonomous personal life—a transitory phase between adolescence and adulthood when students struggle to cope with academic and social demands and prepare for their professional careers (Bayram & Bilgel, 2008). There is evidence, however, to suggest high rates of psychological morbidity in students during their undergraduate years, especially in relation to the symptoms of depression and anxiety (Stanley & Manthorpe, 2001). Given the very significant transition from high school to university life and the specific personal challenges posed by, for example, moving away from the family home and transitioning to different study modes and new environments, most studies examining psychological morbidity in students have tended to focus on the undergraduate years. One study by Wyatt and Oswalt (2013) compared undergraduate students with postgraduate students, finding that undergraduate students experienced higher rates of feelings and behaviours related to poor mental health than postgraduates. While postgraduate students experienced more incidents of ‘very high stress’, average levels of stress were more likely experienced in undergraduates.

Similarly, in a study of 2,843 students at a large US university, Eisenberg, Gollust, Golberstein, and Hefner (2007) found higher levels of depressive and anxiety disorders among undergraduate students compared with graduate students, using the Patient Health Questionnaire (PHQ‐9) (Kroenke, Spitzer, & Williams, 2001). Specifically, the study found that over 15% of undergraduate and 13% of postgraduate students suffer from an anxiety or depressive disorder. These results, however, are still well below those found in a later study using the same measure in a sample of Chinese international students studying at Yale University (Han, Han, Luo, Jacobs, & Jean‐Baptiste, 2013). Further, it has been reported that when compared with the general population, university students exhibit higher levels of depression and anxiety (McLennon, 1992).

The accumulation of stressors over time depletes international students' physical and psychological resources, thus compromising their capacity to cope with the demands of academic life (Misra & Castillo, 2004). Stress and anxiety may manifest as physiological symptoms, including a lack of energy, loss of appetite, headaches, or gastrointestinal complaints (Winkelman, 1994). According to Mori (2000), international students may somaticise their feelings of stress in order to avoid the cultural stigma associated with seeking professional psychological help. For example, these students may attribute headaches or sleep problems to physical illnesses despite the fact that such symptoms have no organic basis (Khoo, Abu‐Rasain, & Hornby, 1994). While there is much knowledge about international students' perceptions of academic challenges, much less is known about their mental and physical well‐being. There is increasing evidence in the literature to support the view that academic performance is related to the psychological well‐being of students, and that successful coping strategies not only influence positive adaptation but also reduce psychological distress and contribute to improved performance (Grey, 2002; Rosenthal, Russell, & Thomson, 2008).

Chinese traditional culture places a strong emphasis on academic success, and as such academic factors may be a large contributor to the psychological symptoms of Chinese international students (Han et al., 2013). Since the one child policy was implemented in Mainland China in the 1970s, most students are the only children in their family, and this creates added pressure for the child to live up to the high expectations of their parents in terms of academic success. This, along with Chinese cultural emphasis on strong family ties, means that students studying abroad have difficulty establishing independence from their parents (Settles, Sheng, Zang, & Zhao, 2012). Acculturation, or negotiating the conflicting demands of home and new culture, is thus a crucial factor in determining international students' psychological adjustment to studying in a foreign country. Yeh (2003) found that Asian immigrant youths who were less acculturated to the American environment reported more psychological symptoms than more acculturated ‘American‐Asian’ (‘Asian’ descent, born in America) youths. Such findings may be partly explained by the fact that more assimilated immigrants experience less cultural conflict due to higher proficiency in language and a greater level of comfort with local culture.

A number of studies have demonstrated a high incidence of psychological morbidity and among international students from the Asian region, who often experience more difficulty acculturating to life in Western countries than those coming from European countries (Cross, 1995; Han et al., 2013; Leung, Cheung, & Tsui, 2012).

In a recent study conducted at Yale University, Han et al. (2013) found a high incidence of depressive symptoms (45%) and anxiety (29%) among a sample of 130 Chinese international students. The study used a Chinese version of the PHQ‐9 (Kroenke et al., 2001) to measure depression levels, and the Generalised Anxiety Disorders (GAD‐7) (Spitzer, Kroenke, Williams, & Lowe, 2006) to measure anxiety. The students identified several factors as being associated with their depressive and anxiety symptoms, including academic stress, social isolation, culture shock, and language difficulties.

Similarly, in a very large study of 7,915 first‐year tertiary education students in Hong Kong using the 42‐item Depression Anxiety Stress Scales (DASS‐42) (Lovibond & Lovibond, 1995a), depression, anxiety, and stress levels of moderate severity and above were found in 21%, 41%, and 27% of the sample, respectively (Wong, Cheung, Chan, Ma, & Tang, 2006). These levels were well above the means of previously published normative data in non‐clinical populations (Crawford & Henry, 2003; Lovibond & Lovibond, 1995b).

Only a handful of studies have examined the psychological symptoms of international students from China or the Asian region in the Australian tertiary education context. In a large study of 979 international students in an Australian university, Rosenthal et al. (2008) found students from Asia to exhibit higher mean scores for the DASS‐42 (Lovibond & Lovibond, 1995b) subscales of depression (8.7), anxiety (7.6), and stress (11.7) than non‐Asian students. These scores were also above the normative scores established in a non‐clinical Australian sample (Lovibond & Lovibond, 1995a). In addition, the study found stress to be most strongly associated with student self‐perceptions of low academic progress.

In a sample of 172 Australian university students, Khawaja and Dempsey (2008) examined differences in psychological morbidity and coping capacity among domestic and international students. The study employed a battery of tests, including the Academic Situation Scale (Sam, 2001) to measure stress, the Hopkins Symptom Checklist (Derogatis, Lipman, Rickels, Uhlenhuth, & Covi, 1974) to measure psychological distress, and the Brief Cope Scale (Carver, 1997) to assess an individual's response to stress. Results showed that international students experienced more symptoms of stress due to lack of social support, used more dysfunctional coping strategies, and had greater incongruence between their expectations and experiences of university life, than local students.

Finally, in a report summarising findings of a decade of national studies on the first‐year university experience in Australia, students from Southeast Asia, Hong Kong, and China were more likely to have below average scores on a five‐item ‘comprehending and coping’ scale developed by the authors, containing items such as ‘I frequently feel overwhelmed by all I have to do’ and ‘I have difficulty adjusting to the style of teaching at University’ (Krause, Hartley, James, & McInnis, 2005).

While a number of studies described above suggest that international students appear to experience more negative psychological symptoms than their domestic counterparts, and that this phenomenon may be more prevalent in the case of students from the Asian region, there are very few studies that have utilised comparison groups. Further, most studies have simply compared domestic with international students, choosing to include students from any foreign country in the ‘international’ group (e.g., Khawaja & Dempsey, 2008). Other studies have compared domestic students to those from ‘Asia’ more generally (e.g., Rosenthal et al., 2008), despite the very different economic and cultural conditions students from China may have experienced compared with, for example, those from Singapore or Malaysia.

The current study aims to address these deficiencies in the literature by providing a single comparative study of international students from Mainland China and local, Australian students. The study will examine the prevalence of negative psychological symptoms, specifically stress, anxiety, and depression among a group of undergraduate business students at a major Australian university. Specifically, the study aims to identify any differences in the levels of symptoms between the local Australian and Chinese international students. Second, the study examines the main contributors, or stressors, leading to negative psychological symptoms in these students and offers suggestions for addressing these issues at the institutional level.

Methodology

Participants

The participants in this study were 201 students enrolled in a business management subject at a major Australian university. A statistical power analysis was performed for sample size estimation. The effect size was 0.5, or medium (Cohen, 1988), alpha = 0.5 and power = 0.8. Projected sample size required for this effect size using the GPower software (Faul, Erdfelder, Lang, & Buchner, 2007) is N = 128. In order to reduce the effect of unequal variances, data collection continued until roughly equal sample sizes were achieved. Thus, our sample size of 201 was considered more than adequate for the study. The final sample comprised 98 local Australian students and 103 international Chinese students. Eighty‐two students were male (40.8%) and 119 were female (59.2%).

As the purpose of the study was to compare international students from China with local Australian students, only students who indicated that they were local Australian students or Chinese international students were included. To qualify as a local Australian student, participants needed to indicate that they had spent the majority of their primary and high school education in Australia. For qualification as a Chinese international student, participants needed to indicate that they held international student status, they were born in Mainland China, and they had been in Australia for less than 5 years.

Procedure

As part of the curriculum of a specific unit on understanding the self, students focus on developing skills and knowledge in self‐awareness, including awareness of their own vulnerability to stress, anxiety, and depression. Students in this unit were provided with the survey during small group tutorial class time. They were given ample time to complete and self‐score the survey, which was followed by small group discussion. The survey was anonymous, and students were provided with the option to hand in their survey to the lecturer for research purposes. Class lecturers strongly encouraged students to complete the open‐ended item (relating to their sources of stress, etc.). Chinese students were provided with the option of filling in the Chinese language version of the survey. However, interestingly, all students opted to complete the English version. Students were also informed that their results were not indicative of a clinical diagnosis, and if they were concerned about their results they should seek the advice of a qualified practitioner for further evaluation.

Instrument

The survey instrument comprised a number of demographic items and questions relating to students' international student status, their length of time in Australia, work experience, and so on. Also included was a self‐report item on the level of life stress relative to other individuals' age, an open‐ended item allowing subjects to describe the main sources of stress and anxiety in their life, and Lovibond and Lovibond's (1995b) 42‐item Depression Anxiety Stress Scale (DASS‐42).

The DASS‐42 is a self‐administered survey comprising 42 negative emotional symptoms. Subjects are asked to rate the extent to which they have experienced each symptom over the past week, on a 4‐point severity/frequency scale. Scores for the subscales of depression, anxiety, and stress are then determined by adding the scores for the relevant 14 items.

The DASS‐42 has very well‐established psychometric properties in clinical and community samples, with the factor structure being substantiated by both exploratory and confirmatory factor analysis (Lovibond & Lovibond, 1995a, 1995b). It measures three subscales of depression, anxiety, and stress, and has been found to differentiate between these three states. The depression scale assesses dysphoria, hopelessness, devaluation of life, self‐depreciation, lack of interest or involvement, anhedonia, and inertia. The anxiety scale assesses autonomic arousal, skeletal muscle effects, situational anxiety, and subjective experience of anxious affect. Finally, the stress scale assesses difficulty relaxing, nervous arousal, being upset or agitated easily, irritability, over‐reactivity, and impatience (Lovibond & Lovibond, 1995b).

The internal reliability (coefficient alpha) for each scale for the DASS‐42 normative (non‐clinical) sample is: depression 0.91, anxiety 0.84, and stress 0.90 (Lovibond & Lovibond, 1995b). Strong convergent validity and moderate discriminant validity have been established (Crawford & Henry, 2003). While the scale discriminates between the three negative emotional syndromes, Lovibond and Lovibond (1995b) found the subscales to be moderately highly correlated with each other, and in particular the stress scale to be more highly correlated with anxiety than with depression.

There is limited evidence on the psychometric properties of the DASS scale in Chinese populations. Chan et al. (2012) confirmed the three‐factor model of the Chinese language version of the DASS‐21 with Cronbach's alphas all above 0.90 in a sample of 605 Chinese students living in China. Mean scores were comparable to normative data in Western populations, with the exception of the stress scale where the Chinese sample was higher.

Analysis

Quantitative data were entered and analysed using SPSS version 21 (IBM, Armonk, NY, USA). Only completed surveys and surveys that met the criteria set for ‘Australian’ or ‘Chinese’ groups were included in the analysis. Surveys from students of other national backgrounds were not included in the current study. Means and standard deviations were calculated for the overall sample. Subscales for depression, anxiety, and stress were calculated by adding the data for the 14 relevant items in each subscale. t‐Tests were conducted to evaluate differences in means for the three subscales according to nationality (Australian or Chinese). Analysis of covariance (ANCOVA) was also conducted to determine whether mean differences remained significant after controlling for the effects of age and gender.

Qualitative information from the open‐ended item relating to the main sources of stress in the student's life was encoded using a thematic analysis (Boyatzis, 1998). This involved identifying dominant themes within the data and manually coding the number of occurrences for each theme. A theme was considered ‘dominant’ and included in the results table if it occurred more than 10 times for one of the two groups of students. Frequencies for the two groups of students (Chinese and Australian) were then recorded for each of the dominant themes.

Results

In order to determine the levels of depression, anxiety, and stress in the overall student sample and within the two student groups, the mean scores for the three DASS‐42 subscales were calculated (see Table 1). For the whole sample, the mean score for anxiety was 10.91 (standard deviation (SD) = 7.76). Using guidelines of severity based on Lovibond and Lovibond's (1995b) normative sample (see Table 2), this indicates ‘moderate’ levels of anxiety. For the stress subscale, overall mean score was 20.14 (SD = 9.42), indicating ‘moderate’ levels of stress. For the depression subscale, overall mean score for the total sample was 8.80 (SD = 7.36). This sits in the upper limit of ‘normal’, according to Lovibond and Lovibond's (1995b) classifications.

Table 1. Descriptive statistics and national differences for DASS‐42 subscales

Scale	Whole sample (n = 201)	Australian (n = 98)	Chinese (n = 103)	t, df
	Mean (SD)	Mean (SD)	Mean (SD)
Anxiety	10.91 (7.76)	7.49 (4.74)	14.17 (8.65)	6.83***, 159.83
Stress	20.14 (9.42)	18.26 (7.83)	21.94 (10.44)	2.84**, 188.85
Depression	8.80 (7.36)	9.06 (8.73)	8.54 (5.79)	0.49, 167.27

Notes. Equal variances not assumed (using Levene's test).

*p < .05, **p < .01, ***p < .001.

Table 2. Cut‐off scores for ‘severity’ labels (adapted from Lovibond & Lovibond, 1995b)

	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+

The main aim of the study was to examine any differences between the two student groups with respect to their levels of depression, anxiety, and stress. To this end, independent sample t‐tests (two‐tailed, equal variances not assumed) were conducted to examine the differences in mean scores between local Australian and Chinese international students on the three subscales of the DASS‐42, that is depression, anxiety, and stress (see Table 1). Australian (local) students showed lower levels of anxiety (M = 7.49, SD = 4.74) than Chinese international students (M = 14.17; SD = 8.65), and this difference was significant, (t(159.83) = 6.83, p < .001). Using Lovibond and Lovibond's (1995b) cut‐off scores for ‘severity’ labels (Table 2), anxiety levels for Chinese students fell between the ‘moderate’ and ‘severe’ categories, while Australian students' scores fell between ‘normal’ and ‘mild’ categories. ANCOVA was conducted to test whether these country differences were significant after controlling for the effects of gender and age. Results showed the main effect of country on anxiety scores remained significant (F(1, 197) = 75.07, p < .001).

In relation to students' stress levels, Australian students scored lower on average (M = 18.26, SD = 7.83) than Chinese students (M = 21.94, SD = 10.44) on the stress subscale, and this difference was statistically significant (t(188.85) = 2.84, p < .01). Stress levels for Australian students fell between the ‘mild’ and ‘moderate’ categories, while Chinese students' levels fell within the ‘moderate’ severity category for stress. ANCOVA was conducted to test whether these country differences were significant after controlling for the effects of gender and age. Results showed the main effect of country on stress scores remained significant (F(1, 197) = 20.58, p < .001).

Differences between groups in relation to the levels of depression were examined using the depression subscale. Mean scores for the depression subscale fell between the ‘normal’ and ‘mild’ categories for the Australian students (M = 9.06; SD = 8.73) and in the upper limit of the ‘normal’ category for the Chinese students (M = 8.54; SD = 5.79). There was no significant difference between the scores for the two student groups.

It was also of interest in the current study to examine student perceptions relating to the main sources of stress and anxiety in their lives. Table 3 presents the results for the qualitative, or open‐ended item, where students were asked to describe the main sources of stress or anxiety in their lives. A total of 105 students responded to this item, with some providing more than one source of stress. The high response rate is best explained by the fact that students were given ample time in class to complete the survey. There were seven main themes arising from the thematic content analysis, and these were labelled as ‘academic/study stressors’ (e.g., understanding assessments, heavy workload, poor grades), ‘work stressors’ (e.g., stress associated with part‐time or full‐time work), ‘financial stressors’ (e.g., strain on parent's income, loans and debt), ‘life balance stressors’ (e.g., not having time for girlfriend, friendships, sports, travel, hobbies), ‘family stressors’ (e.g., expectations of parents), and ‘personality/personal stressors’ (e.g., self‐esteem, perfectionism, attention deficit hyperactivity disorder (ADHD), shyness, fear of failure). The greatest stressors identified by the local Australian students were ‘academic/study stressors’ (30%), ‘work stressors’ (19%), and ‘life balance’ (13%), while the greatest stressors identified by the Chinese international students were ‘academic/study stressors’ (41%), ‘life balance stressors’ (23%), and ‘family stressors’ (17%). Clearly, Chinese students experience significant amounts of stress from high parental expectations with respect to academic performance.

Table 3. Main sources of stress identified by Australian and Chinese students

Source of stress	Examples from the survey	Chinese students n (%)	Australian students n (%)
Academic/study	Assignments, examinations, keeping up with workload, achieving good grades, understanding requirements of assessment	42 (41%)	30 (31%)
Work	Demands of outside work, balancing work and study demands, difficult people/boss at work, switching from part‐time to full‐time work	0 (0%)	19 (19%)
Financial	Insufficient funds for study, living, extracurricular activities; worries about strain on family/parent's finances, student loans, debts	12 (12%)	8 (8%)
Life balance	Lack of time or trouble balancing priorities—for friends, relationships, family, hobbies, sports; looking after children, parents or elderly/sick relatives	23 (22%)	13 (13%)
Family	Managing expectations of parents/family (esp. in relation to achieving good grades)	17 (17%)	3 (3%)
Personal/personality factors	Low self‐esteem, perfectionism, fear of failure, inability to make friends, anxious personality, biological/clinical factors, for example, diagnosed depression, attention deficit hyperactivity disorder	11 (11%)	6 (6%)

Note. Students often gave more than one main stressor; others did not respond at all.

With respect to the ‘academic/study’ stressors, a number of Chinese students mentioned ideas of not understanding what was required or differences in expectations across the two countries. For example, one student wrote: ‘Australian teachers expect students to do more research’. Another student commented: ‘We are not given enough examples for how to do the essay’. Australian students, on the other hand, tended to cite heavy workload more often, for example ‘all the assignments are due at once and then the exams altogether as well, it is too much at once’. In the ‘life balance’ category, many Chinese students specifically mentioned a lack of time for social pleasures and friendships, while Australian students focused more on relationships with partners and troubles pursuing sport and exercise goals. The ‘family’ category was derived mostly from the responses of Chinese students. One student wrote ‘my parents use Skype to watch me study and tell me work harder and late at night’. Another wrote: ‘if I fail my subjects, my parents will not talk to me’, and another ‘I need to make my family feel proud and happy’. Interesting responses were also found within the ‘personal/personality’ category where students described the source of their stress as arising from their own low self‐esteem, sense of perfectionism, fears of failure, and inability to make friends. Others described themselves as having an ‘anxious personality’, or being clinically diagnosed with depression or ADHD. There were no obvious differences in the responses for this category between the two student groups.

Limitations

There are several limitations to the current study that should be highlighted. While the DASS‐42 measure is considered a reliable and valid measure for investigating the incidence of depression, anxiety, and stress in non‐clinical populations, there remains a lack of appropriate validation of the scale within Asian populations. An individual's culture will affect the way in which one experiences symptoms such as depression and anxiety, as well as their emotional expression of these symptoms (Kirmayer, Robbins, Dworkind, & Yaffe, 1993). For example, Kirmayer et al. (1993) found Asians were more prone to somatisation than North Americans. Further work investigating the psychometric properties of the scale in specific cultural populations in Asia is warranted.

The sample used for the current study was drawn from a single university in a large Australian city. Students were all studying a business degree. While this university is typical of large metropolitan Australian universities with high numbers of international, especially Chinese, students, results may not be generalisable to smaller colleges or to universities outside of Australia. The university in this study is located proximally very close to Chinatown, providing ready access to Chinese shops, restaurants, and Chinese‐language medical services. These services may assist with students' acculturation to the ‘Western’ culture and would not be available in the more rural‐based universities. Finally, while the study highlights some differences in negative psychological health symptoms between Australian and Chinese students, and provides some perceptions from students as to the sources of these symptoms, there is no causal relationship established. The underlying causes of depressive symptoms, for example, are varied and complex, and can include both genetic and environmental factors. Students' self‐assessments of the causes of their symptoms are not always accurate, and yet an understanding of the source of symptoms is critical to treatment and recovery.

Discussion and Conclusions

The purpose of this study was to examine the incidence of depression, stress, and anxiety in a group of undergraduate students, and to observe and describe differences between local Australian students and Chinese international students. While many studies have examined psychological symptoms in international students generally (e.g., Misra & Castillo, 2004; Mori, 2000; Rosenthal et al., 2008) or students from the ‘Asian’ continent (e.g., Yeh, 2003), few studies have specifically targeted international students from Mainland China. Given the unique sources of stress derived from cultural influences, such as family expectations, the one child policy, and a strong emphasis on academic success (Han et al., 2013), it appears critical that empirical research focus specifically on students from Mainland China rather than grouping them with other international students.

Results from this study showed Australian students to have, on average, ‘normal’ to ‘mild’ levels of depression and anxiety, while stress levels were found to be ‘mild’ to ‘moderate’ in severity. Chinese international students had significantly higher levels of stress and anxiety than local students, and these levels both fell within the ‘moderate’ severity category established by Lovibond and Lovibond (1995b). Differences remained significant after controlling for the effects of gender and age. These results are consistent with those of previous studies that have found higher levels of negative psychological symptoms among international students from Asia or China specifically (Cross, 1995; Han et al., 2013; Leung et al., 2012; Settles et al., 2012; Yeh, 2003). Qualitative data suggested that the main sources of anxiety and stress for the Chinese students were academic factors, such as study workload and ambiguity over assessment tasks or teaching styles; life balance stressors, such as lack of time for relationships and social activities; and family stressors, including high expectations and pressure to succeed from parents.

Although the DASS‐42 is not a diagnostic instrument, there are a number of potentially significant outcomes associated with negative psychological symptoms. Levels of anxiety and stress at or above moderate severity are likely to be associated with functional impairment, and in some cases may warrant attention from a mental health practitioner (Wong et al., 2006). Furthermore, prolonged exposure to the symptoms of anxiety and stress also makes these individuals more vulnerable to developing depression as well as physiological complaints such as cardiovascular concerns (Misra & Castillo, 2004). In students, anxiety and depression can contribute to learning difficulties and reduced academic performance (Dyrbye, Thomas, & Shanafelt, 2006; Rosenthal et al., 2008) and occupational success (Bayram & Bilgel, 2008). Mental health in young adults has also been associated with an increase in alcohol and substance abuse (Weitzman, 2004) and future employment and relationships (Ettner, Frank, & Kessler, 1997). Further, there is some evidence that anxiety and depression may be causally linked, suggesting that students experiencing higher levels of anxiety may have an increased risk of developing depression in later years (Muris, Merckelbach, Schmidt, Gadet, & Bogie, 2001). As such it is clear that psychological morbidity may impact upon the student's current well‐being and performance, but also on longer term health and quality of life.

Academic success appears to be a major cause of concern among Chinese international students, and this is consistent with Chinese cultural norms that place considerable emphasis on academic achievement (Han et al., 2013). An academic failure for a Chinese student could mean a loss of face, a sense of shame, severe criticism from one's family, and a lifelong sense of failure (Settles et al., 2012). Unlike in Western countries where mental illness is a separate and distinct field of treatment, Chinese culture does not define mental illness as a separate entity. Rather, somatic symptoms such as headaches and gastrointestinal symptoms may be interpreted as physiological, and many Chinese will visit their regular physician for treatment (Mori, 2000; Winkelman, 1994). As such, the underlying psychological causes are not addressed and the cycle of physiological symptoms will likely continue and perhaps worsen.

Universities have a duty of care to address the phenomena of psychological morbidity among Chinese international students. It has been suggested that Chinese international students often do not seek psychological help because of cultural stigmas or lack of awareness of available services (Pedersen, 1991). Psychological support services, including counselling and academic support, should be advertised to students during orientation and reinforced constantly during the semester as stress and anxiety accumulate. Students applying for special consideration on the basis of headaches, gastrointestinal symptoms, insomnia, and other physiological complaints require regular follow‐up and encouragement to seek help from a mental health practitioner. Finally, academics need to be educated about the specific psychological issues that pertain to Chinese students, and university counselling services should recruit Chinese‐speaking counsellors.

This study has important implications for clinical practitioners working with international students, especially those from the Asian region. For example, these individuals may present with somatisation of symptoms, making diagnosis more complex. A tendency to delay seeking treatment could translate to an increased severity of symptoms and more intensive interventions than may have been necessary. Approaches to treatment and counselling must start with a thorough understanding of the cultural nuances of this student group, including a multifaceted approach to assisting the student transition to Western lifestyle and education.

The current study has provided important insight into the psychological symptoms of undergraduate students specifically those from Mainland China. Future research should investigate the cultural moderators influencing anxiety and stress levels in these students and explore potential initiatives for addressing the phenomena, especially those that are culture‐specific.