Assessment of Anxiety Severity and Determinants among Undergraduate

Pharm-D students: A Cross Sectional Study

Chapter 1

Introduction
Medical education is universally considered to be an extremely strenuous and mentally
challenging process. Aspiring physicians and pharmacists are set to go through a multi-year
academic and clinical training program aimed at providing them with knowledge, skills, and
ethical foundation to support humanity. But the cost of this transformative process is not without
its huge psychological costs. The predisposed stressors inherent in the medical curriculum often
have a significant impact on the psychological health of the undergraduate student, which results
into increased rates of all sorts of psychological problems. Among them, anxiety is one of the
most widespread issues, which occurs as consistent feelings of anxiety, stress, and concern,
which can significantly hinder the normal functioning, academic results, and quality of life in
general [1].
A high-pressure environment of overload of information, a hectic timetable of exams, and the
high stakes, frequently life-and-death, aspect of clinical duties are systematically subjected to
Pharm-D students. All these factors culminate into a considerably high risk of developing
anxiety disorders and the mental health of Pharm-D students is one of the most important spheres
of modern research and interventions [2]. Epidemiological observations of anxiety in Pharm-D
students all over the world show that the incidence of anxiety in these students is much higher
than in the general population, or in those studying other subjects. A groundbreaking meta-
analysis, which involved sixty-nine separate studies carried out in different global contexts,
approximated the overall prevalence of anxiety among the Pharm-D students at about 33.8% [1].
This disturbingly elevated level of psychological distress is not a temporary or intermittent event
concerning the stress of the student experience; but a systemic problem with implications
extending to the future effectiveness and sustainability of the medical workforce worldwide.
Prolonged anxiety during the early years of medical education has been strongly associated with
a chain of adverse events, such as a lack of academic interest, impaired clinical decision-making
skills, and a higher predisposition to burnout in the profession and loss of empathy-
characteristics that are inherently opposite to effective patient care [3].
In the particular case of Pakistan, the situation is an even more urgent one in terms of the mental
health of Pharm-D students. Pakistan is typified by a medical education system that is marked by
a highly competitive admission strategy, a curriculum that tends to encourage rote memorization
and the use of high-stakes summative assessments. These pedagogical and structural factors
cause an academic stressing environment that is ever-present. Studies have been carried out in
various urban centres in Pakistan such as Karachi, Multan, and Peshawar, and have always
reported high rates of anxiety and depression among undergraduate Pharm-D students. As an
example, a seminal study done at Nishtar Medical College in Multan showed that a significant
percentage of 43.89 of its Pharm-D students sample portrayed symptoms suggestive of anxiety
and depression [2]. Such striking results highlight the urgent and critical need to conduct a
systematic evaluation of the magnitude of anxiety severity and thoroughly determine the exact
risk factors that lead to such a significant mental health burden under the unique local socio-
cultural and academic contexts in Pakistan.
Medical education has its own special environment, which is both intense and demanding.
Contrary to most other undergraduate courses, medical education requires a tremendous and
sometimes startling shift in the underlying principles of classroom education to an extremely
high-stakes clinical setting. The lives and welfare of real patients are on the line in such
environments, bringing in a new standard of responsibility and emotional stress. This is a highly
demanding shift that normally takes place in the third and fourth year of the medical program
and introduces new and extreme stressors including the fear of committing medical errors, the
emotional burden of suffering and death and the ever-present expectation to deliver perfectly
under scrutiny.
The hidden curriculum of rules, values and social norms that permeate medical schools and can
easily lead a medical school student to think that vulnerability is undesirable, that emotional
distress is unfamiliar and that seeking help to improve mental health is a weakness only adds to
these overt stressors [4]. The culture of medical profession has long been dominated by a
romanticized view of resilience, stoicism and self-sacrifice that occasionally led to the physical
and mental health of the student being negatively affected. The anticipation of working too long
hours, too long of a study, and too little sleep has often been painted as an inevitable rite of
passage- a trial through which would-be doctors have to go.
Nevertheless, modern psychological and educational studies have shown without any doubts that
such conditions are not merely not conducive to the most effective learning and acquisition of
clinical competence, but are actually detrimental. Unchecked, chronic stress causes severe
cognitive deficits such as memory, attention and executive impairment, all of which are essential
cognitive abilities of a medical student. Therefore, it is not only that the high rates of anxiety
among Pharm-D students are a personal health problem in the sense that they affect the
individual directly, but also it is a systemic professional matter and directly influences the
quality, safety, and humanistic nature of the future healthcare system [5].
The intensity and frequency of the anxiety in Pharm-D students is rather diverse in terms of the
geographical location and culture. These differences are a complicated combination of cultural
norms, socio-economical situation, and peculiarities of national education systems. Anxiety
among Pharm-D students in Western countries (United States, Canada, and the United Kingdom)
has been reported to have a typical range of 20% to 25% [6] in the literature. These figures are
quite important but they are often contrasted with those reported in most Asian and Middle
Eastern countries where prevalence rates can often be above 40 or even above 50 [7].
Such a remarkable gap can be explained by a set of factors that are all interrelated, including, but
not limited to, highly competitive academic settings, increased family and societal pressure to
achieve success in some highly-regarded professions such as medicine, and a more significant
cultural taboo attached to mental health concerns, which commonly prevents people to seek help
or even admit that they are struggling. The medical profession in Pakistan is characterized by a
very high level of social prestige and regarded as the highest academic and professional success.
Therefore, medical colleges are highly competitive in their admissions where thousands of
students compete to secure a few seats. To most students, getting into a medical program is the
culmination of a life long dream, which in many cases is shared and fostered by the whole
family. Such collective investment and expectation cause a huge pressure, even overwhelming,
to achieve success by any means necessary.
The curriculum of Pakistani medical schools and colleges tends to follow more traditional
pedagogical schemes, in which a major source of student advancement is the annual or modular
examinations, which are viewed as gatekeepers. This culture of examination which is all-or-
nothing is one of the main and powerful sources of anxiety especially when test dates are
approaching. Moreover, a systemic deficiency of widespread access, lack of formal, and
destigmatized mental health support services is a critical issue in many Pakistani medical
institutions. This lack implies that students are often left alone to cope with their deep distress,
which unintentionally creates a climate of high stress and competition and not co-education and
support. This competitive environment might, unfortunately, undermine critical social support
systems among students, which would otherwise be extremely important in protecting against the
impact of psychological stress and promote resilience [12].
Medical education is associated with a stressful lifestyle, which frequently results in a
widespread tendency of unhealthy behaviors the most evident of them being low sleep hygiene
with a high decline in physical activities. Sleep depletion is a long-standing and powerful risk of
the onset and worsening of anxiety and depression. Countless studies have conclusively shown
that a large percentage of Pharm-D students continuously get less than the advised seven and
eight hours of sleep per night, a scenario which is quite critical during high examination times.
This chronic state of insufficient sleep does not only directly increase the level of anxiety, but
also greatly undermines the cognitive and emotional ability of a student to cope with stress in a
positive and self-perpetuating vicious cycle [13].
Exercise, and physical exercise, which is well known as a strong protective mechanism against
anxiety and an enhancer of mental health, is often the first victim when the academic demands
on the students increase. The perceived energy shortage and time constraints will often cause one
to give up on the exercise routines. Equally, a strong social support of family, friends, and peers
is a very important psychological buffer of the harmful impact of stress. Yet the exceptionally
time-consuming quality of medical research tends to lead to social seclusion. Students can
become more disconnected to the support systems that they had previously, further increasing
their susceptibility to anxiety and other mental health issues [14].
The unified and persuasive conclusions of the research on the anxiety of Pharm-D students
unambiguously indicate a great and immediate necessity of a systematic change of the
philosophy of medical education and its practical implementation. This is not only the need to
provide reactive counseling services, but also wholesale changes in the curriculum design,
teaching methods, and evaluation procedures. Strategic reduction of the frequency and stakes of
high-pressure exams, grading systems that are more progressive, including mental health
awareness and training on coping skills, as part of the core curriculum, are some of the evidence-
based practices that have been suggested and effectively applied in other contexts to reduce
student stress and anxiety [15].
Moreover, it is crucially important to create a culture of wellness which is pervasive in medical
colleges. This is a multi-pronged strategy: education of faculty members to sensitively identify
the first symptoms of psychological distress in students, building an institutional culture in which
reaching out to a specialist in relation to mental health issues is not only accepted, but positively
encouraged, and eradication of the stigma that surrounds mental illness in the medical
profession, which is deeply rooted. With a holistic approach towards the problem of anxiety and
willingness to build a supportive and health promoting educational environment, medical
institutions will be able to know that they are not only creating technically competent doctors,
but also healthy, resilient, and compassionate individuals that will be well-prepared to manage
the intricacies of their future profession and deliver high-quality patient care.
Statement of the Problem
Although the international literature on the subject of mental health of Pharm-D students is on
the rise, a noticeable and considerable gap still lies in our overall solid knowledge on the specific
factors that define the degree of anxiety in undergraduate Pharm-D students in Pakistan. This gap
is especially significant in the post-pandemic period, during which the global health crisis has
probably changed the paradigms of education and presented new stressors. Educational
environment has experienced significant changes at a very high rate and hence, the kind and
degree of stressors that students are facing might have changed in a manner that has not been
well comprehended. Many students have to struggle with a tricky combination of unceasing
academic stress, unforgiving social norms, and intrinsic personal weaknesses. However, the
definite set of risk factors, which trigger intense anxiety, is not well-explored and described in
most of the institutions of Pakistan.
The essence of the issue that this cross sectional study will deal with is the appallingly high rates
of anxiety prevalence and the fluctuating, and often crippling, severity of anxiety in medical
undergraduates. This widespread problem is often not managed and, as a result, not diagnosed,
which results in prolonged misery and poor academic and personal performance. In the absence
of a systemic and evidence-based evaluation of the severity of anxiety and its multifactorial risk
factors, which include demographic factors, the strength of academic workload, and key lifestyle
decisions, it becomes extremely difficult to develop and implement specific and functional
intervention strategies on the side of educational authorities, curriculum developers, and mental
health professionals. In this study, the researcher attempts to close this essential gap in
knowledge, through a detailed cross-sectional examination of the anxiety levels and a careful
listing of the main risk factors that are widespread among Pharm-D students. In that way, the
study will hopefully offer practical recommendations that will help proactively build and develop
a strong implementation of supportive mental health structures in medical colleges across
Pakistan and eventually help create a healthier and productive learning environment.
Significance of the Study
The study has far-reaching and significant implications on a large number of stakeholders in the
medical education industry and the healthcare ecosystem in general. Its implications are
revolutionary, and it is beneficial to the individual, institutional, and society levels. To the
Pharm-D students themselves, the results of this study can be a priceless resource, as it will help
them to gain a better idea of their own mental health and shed some light on which factors
exactly are potentially causing their distress. This increased self awareness is essential because it
might enable students to be aware of the initial symptoms of anxiety and pursue professional
assistance in a timely manner, eliminating the possibility of the condition developing to even
greater heights. Their experiences can also be justified by the insights of the study and make
their experiences seem normal, instead of isolating them.
Secondly, in the case of medical college administrators and faculty, the empirically acquired,
evidence-based information about this particular feature of the curriculum, methods of teaching,
or the institutional setting that is perceived to be the most stressful by students is provided by this
research. With such fine grained knowledge institutions will be able to embark on considered
and calculated reforms in the teaching practices, assessment processes as well as student support
services. To illustrate, when workload is found to be a major stressor, the administrator could
think through curriculum restructuring or workload management policies. In case exam formats
are anxiety provoking, alternative assessment strategies may be considered.
Moreover, the research is also a significant contribution to the general area of the psychiatric
research in Pakistan. It complements the current body of knowledge by creating up-to-date and
localized information about the mental health of a vital section of the youth population, who will
be the backbone of the future healthcare system of the country. Students in certain years of study,
students with specific socio-economic backgrounds, or students with specific demographic
profiles can be identified as among the high-risk groups, which allows the prioritization of
resources to be directed towards counseling, psychological support, and preventative mental
health programs more effectively and efficiently. Finally, it is not just a kind deed to counteract
and prevent anxiety among Pharm-D students, but a necessity to promote a sense of personal
well-being, maintain professional growth, and, most importantly, ensure the quality and integrity
of the care to be offered by future-physicians as they engage in the profession.
The justification of conducting such a study is strong and multi-dimensional, as based on ethical,
professional, and social imperatives. To begin with, there is an inherent moral and professional
duty to protect and ensure the well-being of a group of individuals who are bound to become the
guardians of national health. Pharm-D students are a precious asset of human capital and huge
amounts of money; their mental anguish and possible failure would mean an irreversible loss not
just to themselves, but also to the society that they are being trained to serve. It is therefore a
question of human rights and professional responsibility to address their mental health needs.
Secondly, the modern medical education environment in Pakistan is marked with excessive
pressures and fast changes. The growth of public and private medical colleges, the rising cost of
medical education and the growing competitive nature of the job market of medical graduates,
have all contributed to a climate of stress among the students. Although there has been a growing
body of research on the mental health of Pharm-D students in big urban centers like Karachi and
Lahore in Pakistan, there is an urgent and constant need to localize and update data. These data
should be a true reflection of the existing socio-economic reality, of the cultural peculiarities,
and, in particular, of the psychological consequences of the recent global pandemic, which have
certainly put new layers of complexity and stress on the educational process.
Thirdly, the research is well-grounded by its huge potential of practical implementation and
practical influence. The clear definition of the exact risk factors of anxiety in Pharm-D students
will enable institutions of higher learning to design and adopt evidence-based interventions that
are highly specific. An example is that in case the research conclusively proves that first year
students are disproportionate targets of terror-inducing anxiety, colleges can be proactive in
implementing more holistic orientation programs, peer-mentoring programs, and early screening
of psychological disorders. Equally, when an academic workload becomes overwhelming, as one
of the major causes of distress, faculty and curriculum designers can consider approaches to
streamlining.
Objectives of the Study
This study is carefully planned and will accomplish a list of precise and quantifiable objectives,
which altogether will help in gaining a holistic picture of anxiety in undergraduate Pharm-D
students. Its main goals are as follows:
 To estimate anxiety prevalence and severity among undergraduate Pharm D students in
Punjab, Pakistan using standardized scales (GAD-7 or HAM-A).
 To identify the demographic, academic, and socio-lifestyle determinants (such as gender,
academic workload, examination frequency, sleep patterns, and social support)
significantly associated with anxiety levels.

Research Questions
In order to methodically answer the mentioned objectives, the given study aims to provide the
answers to the following specific research questions:
• What is the general prevalence of anxiety in the study population (undergraduate Pharm-D
students) and how is the anxiety divided into different levels of anxiety (minimal, mild,
moderate, severe) according to standardized scales?
• Do male and female Pharm-D students differ significantly in terms of anxiety levels and, in
that case, what are the possible contributing factors that might lead to the gender gap in the
local environment?
• Does the year of study (e.g. of first, clinical, final year) have any effect on the prevalence
and severity of anxiety in medical undergraduates? Are there any particular academic
changes or times relating to an anxiety peak?
• Which academic determinants (e.g., perceived workload, examination pressure, curriculum
design) and lifestyle determinants (e.g., sleep deprivation, lack of physical activity,
inadequate social support) are most closely and independently related with greater levels of
anxiety among Pharm-D students?
• What intervention and strategies can be successfully applied to medical colleges and
universities to reduce the risk factors identified to cause anxiety and improve the general
mental health of the population of undergraduate Pharm-D students in these institutions?
Assumptions
There are some underlying assumptions that underlie this study that are essential to the validity
and interpretation of the findings. The following are these assumptions:
• Honest and Accurate Responses: It is anticipated that all the study participants will be
honest, candid, and truthful as well as have accurate answers to the questionnaires and
 assessment tools in the survey. The results are based on self-reported data, and the
credibility of the results will depend on how willing the participants are to share their
experiences and perceptions without bias or social desirability factors.
• Validity and Reliability of Instruments: The standardized psychometric measures chosen to
measure anxiety (e.g., GAD-7, HAM-A) are presumed to be the valid and reliable measures
of the level of anxiety in the chosen specific population of undergraduate medical and
pharmacy students in Pakistan. This means that these tools are valid in what they are
intended to measure and that they will give the same results in the same conditions.
• Representativeness of the Sample: It is believed that the sample of undergraduate Pharm-D
students that will be recruited to participate in the study is representative to the rest of the
population of the medical and pharmacy students studying in colleges and universities that
are affiliated with the University of the Punjab. This representativeness is essential in the
generalization of the findings of the study to the larger student body.
• Fit of Cross-Sectional Design: The cross-sectional research design is deemed to be suitable
in determining the associations and prevalence of anxiety and its risk factors at a given
point in time. Although this design does not identify causality, it is appropriate to
investigate relationships between variables as they are present at the same time.
Limitations
In order to maintain a sharp and controllable scope, this paper is limited to certain constraints,
which delimit it and set its boundaries and area of investigation:
• Geographical Scope: The geographical scope of the study is restricted to the undergraduate
medical and pharmacy colleges which are formally part of the University of the Punjab,
Lahore, Pakistan. It implies that the results might not be generalizable directly to Pharm-D
students in other parts of Pakistan or to other countries with other educational systems and
cultural backgrounds.
• Target Population: The researcher only targets undergraduate students pursuing MBBS and
Pharm-D courses. It excludes postgraduate residents, medical interns, faculty members and
students of other health-related fields. This will be confined to a more detailed examination
of the particular stressors experienced by undergraduate Pharm-D students.
• Assessment Method: The measurement of the anxiety and its risk factors is mainly
grounded on self-reported data which is gathered by questionnaires and standardized scales.
Although these methods are most common and tested, they can be exposed to social
desirability bias and recall bias or subjective interpretation by respondents. The researchers
have not used clinical interview and objective physiological measures of anxiety.
• Temporal Scope (Cross-Sectional Nature): The research design will be a cross-sectional
one, i.e., data will be obtained at one point in time. As a result, it is able to come up with
associations between variables but not cause-and-effect relationships or trace changes of
mental health throughout the longitudinal course of the medical program. It represents a
snapshot and not dynamic view of development of anxiety.
Operational Definitions of Key Terms
In order to secure optimal clarity, accuracy and consistency in the whole body of this research,
the following operational definitions are carefully outlined of the major terms and constructs to
be used in this research:
• Anxiety: To the extent of the current investigation, the operationally defined notion of
anxiety is a multifaceted psychological, physiological condition that is defined by the
complex of somatic, emotional, cognitive, and behavioral elements. It comes in form of a
bad emotion of fear, apprehension or dread with regard to things that are expected to happen
in the future or perceived threats. In the research in question, the level of anxiety will be
measured quantitatively based on the scores achieved with the help of valid and
standardized psychometric instruments, i.e., the Generalized Anxiety Disorder-7 (GAD-7)
scale or the Hamilton Anxiety Rating Scale (HAM-A), which have become well-established
in addressing the level of anxiety severity in both clinical and research environments.
• Anxiety Severity: This term is used to determine the measurable magnitude and clinical
effects of the anxiety symptoms in a particular student. Depending on the scores of the
above standardized psychometric tools, the severity of anxiety will be divided into different
levels which usually involve minimal, mild, moderate, and severe. These groups permit a
more detailed perception of the anxiety burden among the students.
• Undergraduate Pharm-D students: This term accurately indicates the target population of
this study. It is used to refer to any students who are currently pursuing either a five-year
Bachelor of Medicine and Bachelor of Surgery (MBBS) program or a five-year Doctor of
Pharmacy (Pharm-D) program in any of the recognized medical or pharmacy colleges that
are members of the Quaid-e-Azam College of Pharmacy Pattoki, Lahore, at the time of data
collection.
• Risk Factors: operationally, they are considered to be those characteristics, traits, exposures
or situations that in the presence of risk factors, significantly raise the chances or probability
of a person developing greater levels of anxiety or developing more severe symptoms of
anxiety. Risk factors identified within the framework of this study will include a mix of
variables, such as demographic factors (e.g., age, gender, marital status), academic stressors
(e.g., perceived academic workload, frequency of examinations, performance pressure), and
other important lifestyle factors (e.g., sleep patterns, dietary habits, physical activity levels,
quality of social support).
• Cross-Sectional Study: This is a particular form of observational research design that is
used in this study. A cross-sectional study is the study of data whose data collection has
been done on a population or a representative group of the population at a single, particular
time. The design enables one to test prevalence and identify the association between
variables but not causality.
Conceptual Framework
The theoretical framework that forms the basis of this study is deeply entrenched in the popularly
adopted, the Transactional Model of Stress and Coping, first put forward by Lazarus and
Folkman. This model assumes that psychological stress is not an intrinsic feature of an event, but
rather a result of a dynamic and ongoing process of interaction between a person and his or her
surrounding environment. In particular, stress is theorized as the result of the lack of balance
between the demands imposed on a person and the subjective evaluation of the resources at
his/her disposal to successfully handle the demands [16].
The “demands” in the very challenging setting of medical education are multi-fold and comprise
both the academic and clinical demands, the pressure to perform extremely well and the
emotional demands of working with patients. On the other hand, the resources include various
internal and external aspects, including individual resilience, effective coping mechanisms, a
strong social support system, and institutional access to mental health services. In this context,
this research determines a number of major independent variables which are theorized to serve as
potential risk factors in determining the dependent variable. These are independent variables that
will be systematically classified to be analysed in detail:
• Demographic Factors: This group entails intrinsic attributes of the student population like
gender (male/female), age (classified into appropriate age groups), year of study (e.g. first,
second, clinical, final year) and residential status (e.g., living in a hostel, living with family,
living independently). These are the factors that tend to be unchangeable though they can
drastically alter exposure to stressors and availability of resources.
• Academic Factors: This includes those that are directly related to the academic experience
such as satisfaction of the students with the career they have chosen, their own subjective
view of the academic workload (e.g., overwhelming, manageable), the frequency and
intensity of examinations, and their perception of the relationship they have with faculty
members and mentors. The perceived academic pressure and performance expectation are
the key to this category.
• Lifestyle and Social Factors: This group encompasses modifiable behavior and
environmental resources, including the number of hours of sleep received on average per
night, physical activity frequency and intensity, nutrition (e.g., balanced, irregular), and
most importantly, the perceived quality and access to social support provided by family,
peers, and important others. Participation in extracurricular activities and hobbies would
also be included in this domain, which is an area of stress relief and social bonding.
The Severity of Anxiety serves as the dependent variable in this holistic model and is perceived
to be a dynamic process that is determined by the complex interaction of these risk factors
identified. The hypothesis is that, students exposed to greater academic demands, declare poor
sleep, do little physical exercises, and feel less social support will have significantly larger scores
of anxiety severity. On the other hand, learners with good coping strategies, good lifestyle
choices, and good and supportive social support are likely to portray low anxiety levels even in
the face of the natural demands and pressures of medical education. This framework informs the
empirical investigation as it is possible to explore these relations systematically and identify
main areas of intervention.

Chapter 2
Litrature Review
This study aimed to assess the level of anxiety among medical students across different academic
years. A self-administered questionnaire was distributed through Google Forms via WhatsApp
and email. The tool included demographic information and the Hamilton Anxiety Rating Scale to
measure anxiety, with a maximum score of 56. Participation was voluntary, and informed
consent was obtained from all respondents. Data were collected anonymously and analyzed
using Microsoft Excel 2007 and Epi Info 7.2. The calculated sample size was 381, based on a
previously reported anxiety prevalence of 19.8%. However, a total of 623 students participated in
the study. Results showed that 73% of students had minimal to mild anxiety levels. Additionally,
15% had mild to moderate anxiety, while 13% experienced moderate to severe anxiety. Severe
anxiety was more prevalent in male students (16.07%) compared to females (8.71%). Final-year
students and day scholars exhibited the highest levels of severe anxiety.(Vidhi Vijaykumar,
Sanjay et al. 2023)
A multicenter cross-sectional study was conducted between August 2011 and August 2012 to
evaluate personal and institutional factors associated with depression and anxiety among medical
students. The study was carried out in 22 Brazilian medical schools. A total of 1,650 students
were randomly selected, out of which 1,350 completed the study, giving a response rate of
81.8%. The Beck Depression Inventory and State-Trait Anxiety Inventory were used to assess
depressive and anxiety symptoms. The study analyzed personal factors such as age, sex, housing,
and tuition scholarship, as well as institutional factors including year of training, school status,
location, and support services. The results showed that depressive symptoms were present in
41% of students, while state anxiety and trait anxiety were reported in 81.7% and 85.6% of
students respectively. The study also found a significant positive correlation between anxiety and
depression scores. Female gender, capital city location, and tuition scholarships were associated
with higher levels of anxiety and depression. However, the study was limited by its cross-
sectional design and reliance on self-reported data, which restricts causal interpretation and may
affect the accuracy of the findings.(Brenneisen Mayer, Souza Santos et al. 2016)
This study aimed to assess the levels of perceived stress, anxiety, and their predictors among
medical students at Helwan University. A cross-sectional study design was conducted on 1696
undergraduate medical students. Data were collected using a structured self-administered
questionnaire. Psychological assessment tools included the Perceived Stress Scale, the Medical
Students Stressor Questionnaire, and the Beck Anxiety Inventory. The study evaluated stress
levels, anxiety levels, and associated stressors. Results showed that 93% of students experienced
moderate to high stress levels. Additionally, 54.9% of students had moderate to concerning
anxiety levels. Major stressors included academic, social, intrapersonal, and group activity-
related factors. Significant predictors of stress and anxiety included female gender, younger age,
living away from family, lower academic performance, and chronic illness. The study concluded
that medical students experience high psychological distress, highlighting the need for structured
stress management and counseling programs.(Ebrahim, Sayed et al. 2024)
A cross-sectional study was conducted between September and December 2017 to investigate the
prevalence and determinants of mental health issues among undergraduate students at a recently
established remote campus in Banyuwangi, East Java, Indonesia. The study included 229
undergraduate students selected through cluster sampling. Psychological status was measured
using the Depression, Anxiety, and Stress Scale. The findings showed a considerable burden of
mental health problems among students, with anxiety reported in 51.1%, stress in 38.9%, and
depression in 25.0% of participants. Multivariable logistic regression showed that level of
education was an important determinant of depression and stress. Fifth-semester students had
significantly higher odds of depression and stress compared to seventh-semester students, while
no significant predictors were found for anxiety. The study concluded that newly established
university settings need regular and strong counseling policies to support students during
stressful academic periods. However, the cross-sectional design limits the ability to identify
long-term trends or establish direct causal relationships. (Erni Astutik1 2020)
Deepak et al. (2017) conducted a cross-sectional study at Dow Medical College, Karachi, to
determine the prevalence of depression and anxiety among undergraduate medical students and
to evaluate its association with gender, academic year, and family history of depression. The
study was carried out from May to July 2016 and included 325 undergraduate medical students
selected through convenience sampling. Data were collected using a self-administered structured
questionnaire incorporating the Aga Khan University Anxiety and Depression Scale (AKUADS),
a validated screening instrument for anxiety and depression. The findings demonstrated that
36.3% of participants were at risk of depression and anxiety according to the established cutoff
score. Statistical analysis revealed no significant association between depression/anxiety and
either gender or academic year of study; however, a significant relationship was observed with
positive family history of depression (p=0.002), indicating that students with familial
predisposition were more likely to experience psychological distress. The authors concluded that
a considerable proportion of medical students were at risk of depression and anxiety during
undergraduate training. Nevertheless, the study was limited by its single-center setting,
convenience sampling technique, unequal gender representation, relatively small sample size,
and the inability of the cross-sectional design to establish causal relationships. (Pooja Deepak1
2017)
The study aimed to assess depression among Doctor of Pharmacy (Pharm.D) students in Pakistan
using a descriptive cross-sectional design. It was conducted at Hamdard University, Islamabad
campus, with a sample size of 400 students. Data were collected through a pre-validated Patient
Health Questionnaire (PHQ-9) and analyzed using SPSS version 21.0, applying descriptive
statistics along with non-parametric tests such as Mann-Whitney and Kruskal-Wallis. The results
revealed mild depression among students, with a significant difference (p ≤ 0.05) observed
across different professional years, while no significant differences were found based on gender,
age, city, medium of instruction, or parental income. However, the study is limited by its cross-
sectional nature and single-institution setting, which may limit the generalizability of the
findings. (Madeeha Malik1 2018)
Shah et al. (2010) conducted a cross-sectional questionnaire-based study at CMH Lahore
Medical College, Pakistan, to assess perceived stress, sources and severity of stress, and
determinants of stressed cases among undergraduate medical students. The study was carried out
from January to March 2009 and involved first- and second-year MBBS students, with 200
students invited to participate and 161 completing the survey, yielding a response rate of 80.5%.
Data were collected using the Perceived Stress Scale (PSS-14) along with a 33-item
questionnaire evaluating potential stressors and their severity. The findings revealed a high mean
perceived stress score of 30.84 ± 7.01, with female students reporting significantly higher stress
levels than males. Academic and psychosocial factors emerged as the predominant sources of
stress, with high parental expectations, frequency of examinations, vast academic curriculum,
sleeping difficulties, and concerns about the future being the most frequently reported stressors.
Logistic regression analysis demonstrated that psychosocial and academic stressors were
significant predictors of stressed cases. However, the correlation between perceived stress and
academic performance was negative but statistically insignificant. The study concluded that
medical students experienced substantial levels of stress during undergraduate training.
Nonetheless, its limitations included single-center design, self-reported data collection, potential
response bias, limited generalizability, and the inability of the cross-sectional design to establish
temporal or causal relationships. (Mohsin Shah1 2010)
A descriptive cross-sectional study conducted by Bilal Saeed et al. (2018) at various educational
institutions in Abbottabad, Pakistan, from December 2016 to August 2017, assessed the
prevalence of anxiety and associated factors among undergraduate students, with a specific focus
on comparing medical and non-medical students. The main objective of the study was to
determine the prevalence of anxiety and identify various socio-demographic and academic
factors linked with it among undergraduate students. Using non-probability convenient sampling,
the researchers collected data from a sample of 137 undergraduate students (31 males and 106
females, mean age 20.80 ± 1.5 years), consisting of 45% boarders and 55% day scholars. A self-
administered questionnaire was used as the data collection tool, and the data was analyzed using
SPSS version 21.0. The results revealed a high prevalence of anxiety, with only 30.7% of
students having normal anxiety levels, while 19.7% had mild, 35.0% moderate, and 14.6%
severe anxiety. Anxiety was found to be significantly more prevalent among female students
compared to males. Important associated factors included homesickness, financial difficulties,
self-medication during examinations, and cigarette smoking. The study also noted higher anxiety
levels among day scholars and medical students. The authors concluded that anxiety is highly
prevalent among undergraduate students in Pakistan, particularly among females, day scholars,
and medical students. However, the study has limitations including the use of convenient
sampling from selected institutions in one city, which restricts its generalizability, along with
potential response bias due to reliance on self-reported data. (Bilal Saeed 2017)
The study aimed to evaluate anxiety, depression, and stress (AD&S) among pharmacy
undergraduates studying under semester and annual academic systems. A questionnaire-based
cross-sectional design was employed at the Faculty of Pharmacy and Health Sciences, University
of Balochistan, Quetta, with a sample size of 289 students. Data were collected using the
Depression, Anxiety and Stress Scale (DASS), and analyzed through SPSS version 20.0 using
both descriptive and inferential statistics. The results indicated moderate levels of anxiety
(14.15±9.3), depression (13.61±7.9), and stress (18.18±8.2) among students, with significantly
higher AD&S levels observed in the semester system compared to the annual system (p<0.05).
However, the study was limited by its cross-sectional nature and single-institution setting, which
may restrict generalizability. Overall, the findings emphasize the need for appropriate
interventions to reduce psychological distress and enhance academic performance among
pharmacy students.(Saeed, Saleem et al. 2017)
The study aimed to evaluate anxiety and depression among university students enrolled in annual
and semester systems in Lahore, Pakistan. A cross-sectional study of 7 months duration was
conducted across two private and two public sector universities, including a total sample size of
404 students. Data were collected using a structured assessment tool for anxiety and depression,
and analyzed through univariate and multivariate statistical methods. The findings revealed
significant differences between annual and semester system students in terms of age (p=0.003),
marital status (p=0.01), living status (p=0.004), and factors affecting mental health (p=0.004).
Students in the annual system showed higher odds of anxiety, including mild (OR 2.7, p=0.019)
and extremely severe (OR 2.6, p=0.002), compared to those in the semester system. Furthermore,
depression was significantly associated with male gender (OR 2.3), age ≤22 years (OR 2.8), and
living status (OR 5.96). However, the study was limited by its cross-sectional design and focus
on a specific geographic area, which may affect the generalizability of the results.(Azam, Ishaq
et al. 2020)

Refrences
Azam, M., et al. (2020). "Frequency of Anxiety, Depression and Stress among Pharmacy
Undergraduates of Annual and Semester System: A Cohort-Based Comparison." Journal of
Pharmacy Practice and Community Medicine 6(3): 35–39.

Bilal Saeed, I. A., Junaid Zeb, Marwa zeb (2017). "Anxiety among undergraduate students
"comparing medical with non medical students"." Pakistan Journal of medicine and dentistry

Brenneisen Mayer, F., et al. (2016). "Factors associated to depression and anxiety in medical
students: a multicenter study." BMC Med Educ 16(1): 282.

BACKGROUND: To evaluate personal and institutional factors related to depression and

anxiety prevalence of students from 22 Brazilian medical schools. METHODS: The
authors performed a multicenter study (August 2011 to August 2012), examining
personal factors (age, sex, housing, tuition scholarship) and institutional factors (year of
the medical training, school legal status, location and support service) in association
with scores of Beck Depression Inventory (BDI) and State Trait Anxiety Inventory (STAI).
RESULTS: Of 1,650 randomly selected students, 1,350 (81.8 %) completed the study. The
depressive symptoms prevalence was 41 % (BDI > 9), state-anxiety 81.7 % and trait-
anxiety in 85.6 % (STAI > 33). There was a positive relationship between levels of state (r
= 0,591, p < 0.001) and trait (r = 0,718, p < 0.001) anxiety and depression scores. All
three symptoms were positively associated with female sex and students from medical
schools located in capital cities of both sexes. Tuition scholarship students had higher
state-anxiety but not trait-anxiety or depression scores. Medical students with higher
levels of depression and anxiety symptoms disagree more than their peers with the
statements "I have adequate access to psychological support" and "There is a good
support system for students who get stressed". CONCLUSIONS: The factors associated
with the increase of medical students' depression and anxiety symptoms were female
sex, school location and tuition scholarship. It is interesting that tuition scholarship
students showed state-anxiety, but not depression and trait-anxiety symptoms.

Ebrahim, O. S., et al. (2024). "Perceived stress and anxiety among medical students at Helwan
University: A cross-sectional study." J Public Health Res 13(1): 22799036241227891.
 BACKGROUND: Medical students are prone to high levels of perceived stress and
anxiety, which can negatively impact their academic performance, as well as their
physical and mental health. This study aimed to assess the main stressors, levels of
perceived stress and anxiety, and their predictors among medical students. DESIGN AND
METHODS: A structured questionnaire was used to collect data from 1696 medical
students at Helwan University. A cross-sectional study was designed to evaluate their
perceived stress, stressors, and anxiety using the Perceived Stress Scale, Medical
Students Stressor Questionnaire, and Beck Anxiety Inventory, respectively. RESULTS:
Approximately 93% of medical students experienced moderate to high levels of stress,
while 54.9% of medical students experienced moderate to concerning levels of anxiety.
The main stressors were academic, teaching, social, intrapersonal, group activity, and
desire-related stressors. Risk factors associated with higher perceived stress included
being female, young age, living away from the family, obtaining lower academic
percentages, having psychiatric, neurological, or other chronic medical illnesses, and
experiencing higher levels of academic, intrapersonal, drive, and group activities-related
stressors. Risk factors for higher anxiety included being female, residing in rural areas,
having psychiatric, neurological, or other chronic medical illnesses, perceiving a high
level of stress, and experiencing higher levels of academic, intrapersonal, and social-
related stressors. CONCLUSIONS: The findings indicate that a significant proportion of
medical students experience various levels of stress and anxiety. These results
underscore the urgent need for a stress management program, to help medical students
to cope with different stressors.

Erni Astutik1, S. K. S., Septa Indra Puspikawati3, Tika Dwi Tama4, Desak Made Sintha (2020).
"Depression, Anxiety, and Stress among Students in Newly Established Remote University
Campus in Indonesia " Malaysian Journal of Medicine and Health Sciences (eISSN 2636-9346).

Madeeha Malik1, A. H., Azhar Hussain3 (2018). "PREVALENCE OF DEPRESSION AMONG DOCTOR
OF PHARMACY (PHARM.D) STUDENTS: A DESCRIPTIVE CROSS-SECTIONAL STUDY FROM
PAKISTAN " Panacea Journal of Pharmacy and Pharmaceutical Sciences

Mohsin Shah1, S. H., Samina Malik2, Chandrashekhar T Sreeramareddy3 (2010). "Perceived

Stress, Sources and Severity of Stress among medical undergraduates in a Pakistani Medical
School." BMC Medical Education.

Pooja Deepak1, U. U. N. U., Washdev Washdev3, Daniyal Mirza4, Farah Naz5, (2017).
"PREVALENCE OF DEPRESSION AND ANXIETY AMONG UNDERGRADUATE MEDICAL STUDENTS
IN A GOVERNMENT MEDICAL COLLEGE OF KARACHI " Original Article.
Saeed, H., et al. (2017). "Determinants of Anxiety and Depression Among University Students of
Lahore." International Journal of Mental Health and Addiction 16(5): 1283–1298.

Vidhi Vijaykumar, S., et al. (2023). "Anxiety level among undergraduate medical students: A
cross-sectional study using the Hamilton: A scale." Magna Scientia Advanced Research and
Reviews 8(1): 068–072.