Level of anxiety and depression among undergraduate dental students of University of Hail,Saudi Arabia

Abstract

BACKGROUND:

Dental students have been identified as having a high level of stress.

OBJECTIVE:

This study aimed to assess the prevalence of anxiety and depression among undergraduate dental students of university of Hail and to determine the association of anxiety and depression in terms of gender and respective year of study.

METHODS:

This was an observational cross-sectional study. Nonprobability sampling technique was used to assess the prevalence and association of anxiety and depression among male and female dental students of preclinical and clinical years of College of Dentistry, University of Hail, Saudi Arabia. Students were contacted personally, explained the purpose of the study and asked to participate in the study. Students were asked to complete both Beck’s depression inventory and Beck’s anxiety inventory to assess the level of their respective status.

RESULTS:

The results of the survey revealed that a greater number of females suffered from ‘moderate’ level of anxiety (12.3%) as compared to males (3.2%). Additionally, the percentage for females to experience ‘borderline’ (11.6%) and ‘moderate’ (9.7%) level of depression was higher than their male counterparts –‘borderline’ (7.7%) and ‘moderate’ (2.6%). The level of anxiety and depression compared with genders was found to be statistically significant. It was noted that final year students (8.4%) experienced ‘moderate’ level of anxiety and there was a peak rise in level of depression among 4th year (6.5%) and 6th year (5.8%) students as compared with other years.

CONCLUSION:

The finding of the study emphasizes that the overall percentage of level of depression is comparatively higher than level of anxiety among dental students.

Keywords

Beck’s anxiety inventory Beck’s depression inventory college of dentistry Hail undergraduate students

1 Introduction

Anxiety and depression often go concurrently. Many people who have experienced one will be affected with the other at some point in their life. It is no doubt that dentistry is a high stress career with high rates of depression and anxiety where the students endure significant stress trigger stimulants every day [1]. These can lead to emotional, psychological, and sometimes physical hardships for students [2].

Dental students have been identified as having a higher level of stress than medical students with higher levels of stress-related psychosomatic activity and increased mood disturbance [3, 4]. If stress is to be defined, it is an extra effort that accompanies a demand thought to be either very challenging (positive) or threatening (negative) depending on the assessment. Anxiety is an adverse response to stress, which to date is the only measure of stress that has been tested with academic performance in dental students.

Although the sources of stress in dental students are multifactorial, some of the crucial factors contributing to student’s exposure to stress are on campus (time and scheduling pressures, examination phobia and grades, expertise in clinical decision-making scenarios, group competencies and maintaining interpersonal skills) [5 –7]. Many of the studies have been conducted on stress level among dental students in different parts of the world and in Saudi Arabia as well. In addition to the above determinants, the other most cited stressors are gender, year of study, marital status, first choice of admission, financial problems, living arrangement [8 –11]. For example, several studies found that students living with their parents had lower stress levels than those residing in student dormitories or with roommates [5]. Nevertheless, increase in anxiety and depression have been associated with negative effect on proficiency of academic study program suggested by the university [12]. Gender differences in anxiety and depression have been found in other studies indicating that female students had higher levels of anxiety and depression level than their male counterparts [13, 14]. The current view is that anxiety and depression is rising in undergraduate dental students where females are the most sufferers [14].

Hence, the objective of our study was (1) to measure the level of depression and anxiety among dental students of University of Hail; (2) to find out the association between gender and anxiety/depression among dental students of University of Hail; and (3) to assess the association between anxiety/depression and students of respective years in College of Dentistry of University of Hail.

Since the inception of College of Dentistry in University of Hail is recent, so carrying out this study may help in designing appropriate intervention strategies; allow programmatic changes designed to minimize stress through anxiety and depression attenuation, to enhance students’ psychosocial well-being and improve academic performance.

2 Materials and methods

The dental bachelor degree at the University of Hail is a six-year program. The first 2 years are basic years i.e. the core science component followed by 3rd year, which is preclinical, and the beginning of most of the dental courses. The 4th year is partly a pre-clinical and clinical program; the students are able to deal with the patients in the second semester. The next two years are completely clinical, the modules focus mainly on clinical subjects and skills. Our study was an observational cross-sectional study. It was approved by the institutional review board (H-2018-094) of University of Hail, Saudi Arabia.

During the academic year of 2017–2018, all the students of College of Dentistry from 3rd to final year were contacted personally.The purpose of the study was clearly explained to the students.The questionnaire was given to all the students and asked to participate in the study. Confidentiality was ensured and it was made clear to them that participation was voluntary and anonymous. The total sample of the study consisted of 155 undergraduate dental students including both males and females with the age range 20–25 years. The data were collected from the students at the beginning of second semester of the specified academic year. All students were contacted directly at the beginning and end of the class. They were informed that filling the questionnaire would not take more than fifteen minutes. All questionnaires were presented in the English language since the official language of teaching at the dental school is English.

The twenty-one questions of Beck’s anxiety inventory (BAI) and Beck’s depression Inventory (BDI) designed by Dr. Aron T. Beck [15, 16] is a validated and effective tool to measure the anxiety and depression of the students.

Beck’s depression inventory (BDI) comprises of twenty-one multiple-choice questions with four possible answers, graded from zero to three indicating how severe the symptoms are. It is considered as one of the best used tools to measure depression and its severity. BDI scores were categorized as normal (1–10), mild mood disturbance (11–16), borderline clinical depression (17–20), moderate depression (21–30), severe depression (31–40) and extreme depression (more than 40).

Beck’s anxiety inventory (BAI) is also twenty-one multiple-choice questions self-report inventory with four possible answers like that of BDI, measuring the common symptoms of anxiety. The questions were arranged in columns and the students were asked to mark the most appropriate answer. BAI scores were formulated into very low anxiety (1–21), moderate anxiety (22–35) and severe anxiety (more than 35). Additionally, the demographic variables included gender; age (20–25 years) and year of study were noted.

Data was displayed as number and percentage and analyzed by Chi-square test and p-value < 0.05 was considered significant. SPSS software (release 20.0, SPSS Inc., Chicago, U.S) was used for statistical analysis.

3 Results

3.1 Demographic characteristics

The questionnaire was given to all undergraduate dental students from 3rd year to final year which comprise of the total sample size. The demographic characteristics of the respondents are shown in Table 1. The data were collected from all155 participants of which (n = 77, 49.7%) were males and (n = 78, 50.3%) were females with the age group of 20–25 years. In terms of students per year, 21.9%students were in 3rd year, 26.5%were in 4th year and an equal percentage of students (25.8%) were in 5th and final year respectively.

Table 1
Distribution of dental students according to age, sex and year of study

Variable Frequency Percentage (%)

Age (years)

20 7 4.5

21 25 16.1

22 43 27.7

23 33 21.3

24 37 23.9

25 10 6.4

Gender

Female 78 50.3

Male 77 49.7

Class year

Third year 34 21.9

Fourth year 41 26.5

Fifth year 40 25.8

Sixth year 40 25.8

Variable	Frequency	Percentage (%)
Age (years)
20	7	4.5
21	25	16.1
22	43	27.7
23	33	21.3
24	37	23.9
25	10	6.4
Gender
Female	78	50.3
Male	77	49.7
Class year
Third year	34	21.9
Fourth year	41	26.5
Fifth year	40	25.8
Sixth year	40	25.8

3.2 Gender differences in level of anxiety and depression

Table 2 shows the association between anxiety and gender and are arranged from “low to severe” level of anxiety in order. It was reported that majority of the male students (46.5%) had “low level” of anxiety (83.9%). On the other hand, more than double the number of females (12.3%) had “moderate level” of anxiety, with significant gender differences (p = 0.005) observed.

Table 2
Association between anxiety and gender

Gender Anxiety Total p-value

Low No. (%) Moderate No. (%) Severe No. (%) No. (%)

Female 58 (37.4) 19 (12.3) 1 (0.6) 78 (50.3)

Male 72 (46.5) 5 (3.2) 0 (0.0) 77 (49.7) 0.005

Total 130 (83.9) 24 (15.0) 1 (0.6) 155 (100.0)

Gender	Anxiety	Total	p-value
Female	58 (37.4)	19 (12.3)	1 (0.6)	78 (50.3)
Male	72 (46.5)	5 (3.2)	0 (0.0)	77 (49.7)	0.005
Total	130 (83.9)	24 (15.0)	1 (0.6)	155 (100.0)

The association between depression and gender are displayed in Table 3, categorized from “normal” to “severe” depression. It was found that 17.4%of the males had “mild” depression but females were found to have “borderline” (11.6%) and “moderate” (9.7%) level of depression. Also 0.6%of the female students suffered from ‘severe’ level of depression and the results were statistically significant (p = 0.012).

Table 3

Association between depression and gender

Gender	Depression					Total	p-value
	Normal No. (%)	Mild No. (%)	Borderline No. (%)	Moderate No. (%)	Severe No. (%)	No. (%)
Female	30 (19.4)	14 (9.0)	18 (11.6)	15 (9.7)	1 (0.6)	78 (50.3)
Male	34 (21.9)	27 (17.4)	12 (7.7)	4 (2.6)	0 (0.0)	77 (49.7)	0.012
Total	64 (41.3)	41(26.5)	30 (19.4)	19 (12.3)	1 (0.6)	155 (100)

3.3 Level of anxiety and depression in terms of respective years

Table 4 displayed the association between anxiety in terms of dental students of respective years. Compared to other years, most of the students in final year were found to suffer from ‘moderate’ level of anxiety and were statistically significant (p = 0.02).

Table 4
Association between anxiety and respective dental year students

Class year Anxiety Total p-value

Low No. (%) Moderate No. (%) Severe No. (%) No. (%)

3rd year 30 (19.4) 4 (2.6) 0 (0.0) 34 (21.9) 0.020

4th year 38 (24.5) 3 (1.9) 0 (0.0) 41 (26.5)

5th year 35 (22.6) 4 (2.6) 1 (0.6) 40 (25.8)

6th year 27 (17.4) 13 (8.4) 0 (0.0) 40 (25.8)

Total 130 (83.9) 24 (15.5) 1 (0.6) 155 (100.0)

Class year	Anxiety	Total	p-value
3rd year	30 (19.4)	4 (2.6)	0 (0.0)	34 (21.9)	0.020
4th year	38 (24.5)	3 (1.9)	0 (0.0)	41 (26.5)
5th year	35 (22.6)	4 (2.6)	1 (0.6)	40 (25.8)
6th year	27 (17.4)	13 (8.4)	0 (0.0)	40 (25.8)
Total	130 (83.9)	24 (15.5)	1 (0.6)	155 (100.0)

Table 5 demonstrates the level of depression among dental students per respective years. The results showed that apparently all students from 3rd to final year had some degree of “mild” depression but the peak change was observed in 4th year students to have ‘borderline’ depression (6.5%) as well as 6th year students to suffer from ‘borderline’ depression (5.2%) and ‘moderate’ depression (5.8%). Despite some decrease in overall level of depression was noted among 5th year students but 0.6%of the students were found to have ‘severe’ depression.

Table 5

Association between depression and respective dental year students

Class year	Depression					Total	p-value
	Normal No. (%)	Mild No. (%)	Borderline No. (%)	Moderate No. (%)	Severe No. (%)	No. (%)
3rd year	12 (7.7)	10 (6.5)	7 (4.5)	5 (3.2)	0 (0.0)	34 (21.9)	0.279
4th year	18 (11.6)	11 (7.1)	10 (6.5)	2 (1.3)	0 (0.0)	41 (26.5)
5th year	22 (14.2)	9 (5.8)	5 (3.2)	3 (1.9)	1 (0.6)	40 (25.8)
6th year	12 (7.7)	11 (7.1)	8 (5.2)	9 (5.8)	0 (0.0)	40 (25.8)
Total	64 (41.3)	41 (26.5)	30 (19.4)	19 (12.3)	1 (0.6)	155 (100.0)

Figure 1 represents that most of the students had ‘low’ level of anxiety (85.20%), whereas 14.2%in ‘moderate’ level of anxiety and 0.6%of the total population were suffering from ‘severe’ level of anxiety respectively. However, there is more distinct variation in level of depression among students as shown in Fig. 2. According to the study, it was found that more than a quarter (27.1%) of the total population had ‘mild’ depression, while 19.4%had ‘borderline’ depression and the rest 12.3%had ‘moderate’ level of depression.

Fig. 1

Prevalence of anxiety among dental students.

Fig. 2

Prevalence of depression among dental students.

4 Discussion

While anxiety and depression are very common with symptoms and causes often can overlap but these are two different medical conditions with unique distinguishing features. The rise in anxiety and depression is more prevalent in students of health fields and is an added major source of concern during these worst pandemic days of COVID-19. It not only threatens our existence and health status but also adds a heavy burden on the students with regards to the newly adopted teaching and assessment procedures. Not to mention the stress of being able to keep up and cope with the materials and guidelines [17, 18].

A variety of studies have shown that college students in Saudi Arabia experienced the symptoms of anxiety and depression; recorded a prevalence ranging from 14 to 50%[19]. The documented anxiety and depression level experienced by dental students was further highlighted in our studies by comparing between males and females. Majority of the male participants (46.5%) reported to suffer from ‘low’ level of anxiety and 17.4%having ‘mild’ depression when compared with females. This result is similar to the finding of the study [19] where males suffer more from anxiety and depression. However, we found that a greater number of female students experienced ‘moderate’ level of anxiety (12.3%) with 11.6%and 9.7%suffering from ‘borderline’ and ‘moderate’ level of depression respectively. Statistically significant differences were found between genders and level of anxiety and depression. This finding is in agreement with other previous studies that shows the intrinsic psychological differences between genders [5 , 14]. An explanation for this pattern is females are more sensitive, are naturally more vulnerable to psychological stress and depression due to differences in how their brain response to certain hormones and adapt to stressful situation. Moreover, in our study 0.6%of the females reported to suffer from ‘severe’ anxiety and depression. It is clear that more research with a larger sample over a period of successive academic years is needed to scrutinize the actual number of students suffering from ‘severe’ anxiety and depression level. Anxiety and depression level may vary a lot among the dental students depending on their year of study and the time during the academic year [8 , 11].

The majority of the students based on their year of study were marked to ‘low’ level of anxiety. Responses of preclinical year (3rd year) and clinical years (4th, 5th year) to ‘moderate’ level of anxiety were found to be very similar except comparatively a greater number of 6th year students (8.4%) were observed to have ‘moderate’ level of anxiety. Statistically significant differences were found between the years of study and level of anxiety. It is evident that the final year students have more anxiety for the extra responsibilities including but not limited to examination, grades, completing assignments and difficulty in accomplishing their clinical quota as per their requirement [20].

It has been shown that students in clinical years experienced different depression level as compared to preclinical years. This was reported by utilizing Beck’s depression inventory (BDI) [15, 16] to measure depression and its severity. Here, our analysis indicated that 4.5%of students in 3rd year and 6.5 %of 4th year students have ‘borderline’ depression level. This replicate previous research in that students in the transition from preclinical to clinical training tended to report high levels of psychological distress [5 , 21]. In addition, based on BDI scores, the results revealed that the ‘moderate’ level of depression increased overtime in students from 4th year to 6th year. We also need to mention that we observed a decrease in depression level in 5th year students but it is noteworthy to refer that 0.6%of students in 5th year experienced ‘severe’ level of depression. These findings were in contrast with the findings where 4th [22, 23] and 5th years [24] were reported to be more stressed.

Besides the main stressor like examination and grades, the intimidation and thought to be able to cope with all dental subjects as they progress from one year to other remain an additional challenge for them. Fear of being unsuccessful in a course, swamped with an exaggerated sense of responsibility to complete assigned works, presentation and clinical requirements, patient management and lack of proper relaxation could be the possible reasons for distress in final year dental students. This may explain why dental students’ sufferers of anxiety and depression from a very early life are [25 –27].

In general, the majority of students reported having ‘low’ level of anxiety compared to overall percentage of level of depression. There could be some of the possible explanations. This could be because of the fact that the level of anxiety or depression depends on when the data was collected. In our study the data has been collected from the students at the beginning of the second semester after a short break; and it is obvious that the students might have been less pressurized and more relaxed compare to the time before exam. Other credible reasons, close professional relationship with faculties and a satisfactory peer relationship acting as mentors for each other [28 –30] have reported to develop a positive, long lasting effect on students’ academic success with reduced stress load [31, 32]. However, longitudinal studies should be carried out among dental students of successive academic years to compare the differences between level of anxiety and depression.

There are a number of limitations restricting the generalizability of this study. First, the results of this study are limited by a relatively small sample size and data representation of only one academic year which might have narrowed our statistical inferences. Second, the study was carried out only at the beginning of a semester of that academic year, it might be beneficial if the study could be conducted again just before the exam time to compare our findings. Third, it was also imperative to explore the relationships between the factors causing anxiety and depression and how these may vary based on gender and year of study. Future longitudinal studies should aim to include students of successive academic years in order to compare the differences over a period of years. Also, the factors causing stress including academic and environmental domains need to be further tested by prospective studies.

5 Conclusion

The finding of the study showed that the overall percentage of level of depression was comparatively higher among students than level of anxiety. Despite the anxiety level in overall students was low, but a higher percentage of females were sufferers and clinical students as compared to other years were found to be in more stress. It can be assumed that the actual percentage of the symptoms of anxiety and depression may be even higher than those reported herein. This is important to conduct analytical study at times to determine the provoking factors for anxiety and depression and also to review the course curriculum and examination pattern in order to overcome much stress among students.

Conflict of interest

None to report.

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Level of anxiety and depression among undergraduate dental students of University of Hail,Saudi Arabia

Abstract

BACKGROUND:

OBJECTIVE:

METHODS:

RESULTS:

CONCLUSION:

Keywords

1 Introduction

2 Materials and methods

3 Results

3.1 Demographic characteristics

Table 2 Association between anxiety and gender Gender Anxiety Total p-value Low No. (%) Moderate No. (%) Severe No. (%) No. (%) Female 58 (37.4) 19 (12.3) 1 (0.6) 78 (50.3) Male 72 (46.5) 5 (3.2) 0 (0.0) 77 (49.7) 0.005 Total 130 (83.9) 24 (15.0) 1 (0.6) 155 (100.0)

5 Conclusion

Conflict of interest

References

Table 2
Association between anxiety and gender

Gender Anxiety Total p-value

Low No. (%) Moderate No. (%) Severe No. (%) No. (%)

Female 58 (37.4) 19 (12.3) 1 (0.6) 78 (50.3)

Male 72 (46.5) 5 (3.2) 0 (0.0) 77 (49.7) 0.005

Total 130 (83.9) 24 (15.0) 1 (0.6) 155 (100.0)