PREVALENCE OF DEPRESSION AND ANXIETY IN UNDERGRADUATE STUDENTS

STUDING IN THE FACULTY OF PHARMACY, MADONNA UNIVERSITY, ELELE,

NIGERIA

IGWEZE ZELINJO NKEIRUKA

20175613
FACULTY OF PUBLIC HEALTH PHARMACY
WEST AFRICN POSTGRADUATE COLLEGE OF PHARMACISTS
2021

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PREVALENCE OF DEPRESSION AND ANXIETY IN UNDERGRADUATE STUDENTS
STUDING IN THE FACULTY OF PHARMACY, MADONNA UNIVERSITY, ELELE,
NIGERIA

IGWEZE ZELINJO NKEIRUKA

20175613
A PROJECT SUBMITTED IN PARTIAL FULLFILMENT OF THE REQUIREMENT FOR
THE AWARD OF FELLOWSHIP OF THE WEST AFRICAN POSTGRADUATE COLLEGE
OF PHARMACISTS

2021

ii
 DECLARATION
I THE UNDERSIGNED DECLARE THAT I HAVE WHOLLY UNDERTAKEN THIS
RESEARCH REPORTED HEREIN UNDER SUPERVISION AND I HAVE NOT
SUBMITTED IT FOR THE AWARD OF ANY DEGREE ELSEWHERE

Student’s Name: ………………………………………………..

Signature and Date: …………………………………………

I the undersigned declare that I have supervised the above student to undertake the study
reported herein and she has my permission to submit it for assessment.
Supervisor ……………………………………………………………………
Signature and Date …………………………………………………………….

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 Acknowledgement

I wish to thank God almighty, for His grace that enabled me to finish this work. To my husband, Ikem for
all the support and encouragement which kept my determination optimal .To my supervisor, Dr Ezeudo
Nwaozuzu, I will ever remain grateful. Finally to my children Nnenna, Chidera, Udochukwu,
Kosaluchukwu and Onyekachukwu .Thank you for all your support and your advice that it’s time to quit
formal education

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 TABLE OF CONTENTS

Declaration iii

Acknowledgement iv

Table of Contents v

List of Tables vi

Abstract vii

CHAPTER ONE INTRODUCTION AND LITRATURE REVIEW. 1

1. Introduction 1

1.2 Literature review 5

1.2.1 Prevalence of depression and anxiety in university students. 5

1.2.2 Causes of depression 6

1.2.3 The Influence of the Transition Experience to University Student Status. 7

1.2.4 Most Prevalent Mental Disorders among University Students 9

1.2.4.1 Depression 9

1.2.4.2 Anxiety 10

1.2.4.3 Stress 10

1.2.5 Factors Leading to Mental Health Disorders among University Students 11

1.2.6. Risk Factors Associated with Anxiety and Depression 13

1.2.6.1 Psychological factors 13

1.2.6.2 Academic factors 14

1.2.6.3 Biological factors 17

1.2.6.4 Lifestyle factors 18

1.2.6.5 Social factors 19

1.2.6.6 Economic factors 21

1.2.6.7 Stigma associated with mental health 22

1.2.7 Justification 22

1.2.8 Aim 23

1.2.9 Specific Objectives 23

1.2.10 Significance of Study 23

CHAPTER TWO METHOD 24

2.1 Research Design 24

2.2 Research Setting 24

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2.3 Target Population 24

2.4 Sampling 24

2.5 Sampling Technique 25

2.6 Instruments for Data Collection 26

2.7 Validity of Instrument 27

2.8 Method of Data Collection 27

2.9 Method of Data Analysis 27

CHAPTER THREE RESULTS 28

3.1 Participant Characteristics: Descriptive findings 28

3.2 Interpreting the Beck Depression Inventory 32

3.3 Hamiltons Anxiety Rating Scale (HAM-A) 38

CHAPTER FOUR 43

Discussion 43

CHAPTER FIVE 48

Conclusion 48

References 50

Appendix 62

LIST OF TABLES

Table 3.1 Demographic characteristics of Pharmacy students 29

Table 3.2 Prevalence of depression among Pharmacy students on the Becks Depression Inventory 33

Table 3.3 Association of Becks Depression Inventory with various socio-demographic 34

Variables

Table 3.4 Prevalence of anxiety among Pharmacy students on the Hamilton Anxiety 38

Rating Scale

Table 3.5 Association of Hamilton Anxiety Rating Scale with various socio-demographic 40

Variables

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 Abstract

Background/Objectives: Depression is one of the most common health problems for university
students. Several studies have tended to focus on common mental disorders among medical
students and have largely ignored university students in other fields. The purpose of this study
was to determine the Prevalence of Depression and Anxiety in Undergraduate students studying
in the Faculty of Pharmacy, Madonna University, Elele, Nigeria and their relationships to
sociodemographic variables.
Method: A cross-sectional study was carried out at Faculty of Pharmacy, Madonna University,
Elele, Nigeria. The questionnaire was administered to 614 Pharmacy students in 200,300,400,
and 500L .They were present at the time of distribution of the questionnaires and consented.
Prevalence of anxiety and depression were measured by the Beck depression inventory (BDI)
and Hamilton Anxiety Rating Scale (HAM-A) using a structured validated questionnaire having
some a sociodemographic variables. The Pearson’s chi-square test Student t-tests were applied to
estimate associations between socio-demographic data, anxiety and depression outcomes in
different cutoffs. For all the analyses, the significance level was 5% (0.05).
Results: In the present study, prevalence for moderate to extremely severe depression and
anxiety were 50.1 and 52.1% respectively. Study participants were predominantly female (n =
372, 60.6%) and 39.4% (n = 242) were males. Females were more at risk and year of study
appear to be a factor for anxiety and depression. The prevalence of anxiety among the study
participants according to the Hamilton Anxiety Rating scale was (n = 294), 47.9% considered to
have no anxiety, 303 students (49.3%) had mild to moderate anxiety, and 17(2.8%) had severe
anxiety. It was seen that ethnicity, class level, Religion, Current Parent household status, Number
of children, Position in family and Family background settlement did not affect the prevalence of
anxiety and depression. For Beck’s depression scale, there were significant correlation between
number of students sharing residence (p=0.02), Age (p=0.001), Gender (p=0.001) and Marital
status (p=0.001) and Hamilton Anxiety Rating scale for class level (p=0.04).
Conclusions: The results showed that Pharmacy students constitute a vulnerable group that has a
high prevalence of anxiety and depression.

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 CHAPTER ONE
INTRODUCTION AND LITRATURE REVIEW.
1. Introduction

Background

Depression is one of the most common health problems for university students (Lyubomirsky et
al., 2003; Vredenburg et al., 1988). Depression is considered as a multi-problematic disorder that
leads to impairment in inter-personal, social, and occupational functioning (Sadock and Kaplan,
2007). The basic characteristic of depression is a loss of positive affect which manifests itself in
a range of symptoms, including sleep disturbance, lack of self-care, poor concentration, anxiety
and lack of interest in everyday experiences (NICE, 2009). Level of impairment can be classified
clinically by standardized diagnostic interview but in prevalence studies depression is typically
identified through a validated, self-report screening instrument. The prevalence of depression
seems to be affected by many factors including; population studied, socio-demographic factors
(e.g. sex, age) (Steptoe et al., 2007; Kaplan et al., 2008), place of study (Weissman et al.,1996;
Steptoe et al., 2007) diagnostic tool and sampling used (Weissman et al., 1996; Marsella, 1978).
Although there has been an increasing concern about depression in specific groups such as
adolescents or the elderly (Winter et al., 2011; Springer et al., 2011; Lim et al., 2011; Gladstone
et al., 2011; McKenzie et al., 2010), the problem of university students’ depression has received
relatively little attention, despite evidence of a steady rise in the number of depressed university
students (Ceyhan et al., 2009). Studies have reported wide variations in the proportion of
students identified as depressed, from relatively low rates around 10% (Goebert et al.,
2009;Vazquez and Blanco, 2006; Vazquez and Blanco, 2008) to high rates of between 40% and
84% (Bayati et al., 2009; Garlow et al., 2008; Khan et al., 2006). This wide variation appears to
be influenced by many factors including methods of assessment (Weissman et al., 1996;
Marsella, 1978), geographical location (Steptoe et al., 2007;Weissman et al.,1996) and
demographic factors such as SES (Kaplan et al., 2008; Steptoe et al., 2007). The cost of affective
disorders can be particularly high in young people because they represent the future of any
community, its hope and potential leaders (El-Gendawy et al., 2005). Depression in this early life
stage can lead to an accumulation of negative consequences through adult life through its impact
on career prospects and social relationships (Denise et al., 1996; Aalto-Setälä et al., 2001).

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Depression has been linked to poorer academic achievements (Hysenbegasi et al., 2005),
relationship instability (Whitton and Whisman, 2010), suicidal thoughts and attempts (Jeon,
2011) and poorer work performance (Harvey et al., 2011).

Although arguably university students are more likely to be advantaged in socioeconomic terms
which is considered protective against depression (Lowe et al., 2009), there are many factors that
might increase students’ vulnerability to depression. These factors include changes in life style
resulting in sleep and eating disturbances, financial stressors, family relationship alterations,
academic worries and preoccupation with post-graduation life (NIMH, 2003)

Depressive disorders are characterized by sadness, loss of interest or pleasure, feelings of guilt or
low self-worth, disturbed sleep or appetite, feelings of tiredness, and poor concentration.
Depression can be long lasting or recurrent, substantially impairing an individual’s ability to
function at work or school or cope with daily life. At its most severe, depression can lead to
suicide. Depressive disorders include two main sub-categories: major depressive disorder /
depressive episode, which involves symptoms such as depressed mood, loss of interest and
enjoyment, and decreased energy; depending on the number and severity of symptoms, a
depressive episode can be categorized as mild, moderate, or severe; and dysthymia, a persistent
or chronic form of mild depression; the symptoms of dysthymia are similar to depressive
episode, but tend to be less intense and last longer. A further important distinction concerns
depression in people with or without a history of manic episodes. Bipolar affective disorder
typically consists of both manic and depressive episodes separated by periods of normal mood.
Manic episodes involve elevated mood and increased energy, resulting in over-activity, pressure
of speech and decreased need for sleep.

Depression is the third leading contributor to the global disease burden, and alcohol and illicit
drug use account for more than 5% (WHO, 2010). Every seven seconds, someone develops
dementia (Ferri, C. P. et al., 2005), costing the world up to US$609 billion in 2009 ( Wimo et al.,
2010 ). In 2002, Bertolote, & Fleischmann estimated that by 2020, 1.5 million people will die
each year by suicide, and between 15 and 30 million will make the attempt.

Anxiety disorders refer to a group of mental disorders characterized by feelings of anxiety and
fear, including generalized anxiety disorder (GAD), panic disorder, phobias, social anxiety
disorder, Obsessive-compulsive disorder (OCD) and post-traumatic stress disorder (PTSD). As

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with depression, Symptoms can range from mild to severe. The duration of symptoms typically
experienced by people with anxiety disorders makes it more a chronic than episodic disorder
(WHO, 2017)

Mental, neurological and substance-use disorders (MNS) constitute 13% of the global burden of
disease, surpassing both cardiovascular disease and cancer (WHO, 2008).Globally, it is
estimated that 4.4% of the global population suffer from depressive disorder, and 3.6% from
anxiety disorder. In 2015 WHO reported 7, 079, 815 cases of depressive disorders representing
3.9% and 4, 894, 557 of anxiety disorders representing 2.7% of the population in Nigeria (Global
Burden of Disease study, 2015).

The absence of cures, and the dearth of preventive interventions for mental and neurological
disorders, in part reflects a limited understanding of the brain and its molecular and cellular
mechanisms. Where there are effective treatments, they are frequently not available to those in
greatest need. Unequal distribution of human resources — between and within countries —
further weakens access: the World Health Organization’s European region has 200 times as
many psychiatrists as in Africa (WHO, 2005). Across all countries, investment in fundamental
research into preventing and treating MNS disorders is disproportionately low relative to the
disease burden (Saxena, et al., 2007)

The university brings big changes for students’ life. The pace of life becomes more intense, the
workload of studies is increased, and often the geographical distance of the family, as well as the
imposition of charges by the society, by the institution and by the student himself may provoke
feelings such as disappointment, irritability, anxiety and impatience (Chatterjee et al., 2014;
Ibrahim et al.,2013). Such situations are, in many cases, anxiety factors and possible triggers for
depression. High prevalence of depression in University students is observed, on average 30.6%,
while for the population in general, this prevalence corresponds to 9%. Some studies indicate a
prevalence of anxiety in college students varying between 63% and 92 % ( Shamsuddin et
al.,2013; Herrero et al., 2014).

Considered a public health issue, depression is a multifactorial disease that interfere with the
interpersonal, social and professional functioning of the individual. It consists of mood changes,
loss of initiative, general lack of interest, sleep disorders, lack of self-care, decreased ability to
concentrate, anxiety, among other symptoms (Ibrahim et al.,2013). Among the risk factors most

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associated with depression, family history, personality-related aspects, as well as unpleasant
experiences in the daily lives of the person may be highlighted. Studies show mental disorders,
particularly depression, are among the strongest risk factors for suicide attempt (Chatterjee et al.,
2014; Herrero et al., 2014 ). Anxiety, also considered a common mental disorder, consists of a
physiological response of human beings to the environment into which they are inserted and the
situations they experience; however, it can become pathological, characterized by distress,
difficulty in concentrating, sleep disorders, fatigue, trembling, among others (Chaves et
al.,2015). When compared with other university students, Pharmacy students have additional
factors that may cause anxiety: the workload, the relationship with the students and lecturers, the
distress and the fear of making mistakes are singled out as key factors triggering anxiety.

Besides facing a heavy academic overload and an increasingly competitive environment,

professional students must strive for academic excellence to meet the demands from the labor
market (Lamis et al.,2016). The common mental disorders in this population are emerging
problems and its prevalence is a concerning factor, as well as its deleterious effects on the
students’ health. Moreover, suicide cases in this population group draws attention for their
upward trends. Given the magnitude of this problem, knowing the prevalence of anxious and
depressive symptoms in students is relevant to develop prevention plans and other mechanisms
for strengthening the mental health of these university students.

The prevalence of anxiety and depression symptoms was quite expressive; 62.9% and 30.2%,
respectively, occurring mainly in mild levels. The socio demographic and occupational analysis
revealed that females are more prone to develop depressive symptoms and that factors such as
work and leisure are also related to depression. In relation to the reported symptoms,
nervousness, feeling of being scared, indigestion or abdominal discomfort, fear of the worst to
happen, fatigue and irritability were the most evident (Fernandes et al.,2018)

Depression is a mental disorder characterized by persistent loss of interest, pleasure feeling of

sadness and, which are accompanied by somatic and cognitive changes that substantially affect
the day-to-day living of the sufferer (Mehta et al.,2015; Paykel ,2008). Depression can result
from stress due to negative life experiences, including traumatic events, lack of social support,
financial problems, interpersonal problems, and conflicts as well as diseases of nervous and

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associated systems including neurodegenerative disorders and cancer (January et al.,2018).
Accumulating evidences indicate that depression is one of the leading causes of disability,
affecting people in all countries across the world with a global prevalence of 3.2% (Moussavi et
al.,2008; Sweetland et al.,2014). Depression usually starts at a young age and often is recurrent
throughout life. For these reasons, depression is considered the leading cause of disability across
the world in terms of total years lost due to disability (Moussavi et al.,2008).

1.2 Literature review

1.2.1 Prevalence of depression and anxiety in university students.

Emerging reports indicate that University students are among the population with higher
prevalence of depression (Dessie et al .,2013; Nwobi et al .,2009 ; Hersi et al ., 2017).
According to available data, University students have higher prevalence of mental disorder than
the general population (Hersi et al., 2017). A multi-center study of mental disorders conducted
among youths in Europe showed that 5.8% had anxiety disorders, 10.5% had depressive disorder
and 32.3% reported suicidal thoughts (Balaƴzs et al., 2013). In another study, conducted in
Adama University in Ethiopia, Dessie et al. reported 21.6% prevalence of depression among 413
students. Melese et al.,(2016) reported 30% prevalence of depression among 240 students of
Hawassa University in Southern Ethiopia. Though data are scanty, a few studies conducted in
Nigeria have showed that the prevalence of depression is higher among University students
(Adewuya et al.,2016; Tamunosik et al.,2017) compared to the general population-3.1% (Gureje
et al ., 2010). Out of 1,206 Federal University students in Western Nigeria, 8.3% reportedly had
depressive disorder (Adewuya et al.,2016 ). In another study conducted among 762 seniors of
University of Nigeria, Enugu Campus, about 62% were observed to have depression (Nwobi et
al .,2009). A higher prevalence of depression (84%) was reported among students of Obafemi
Awolowo University, Ile Ife Nigeria (Ayeni,2005).

From the above studies outlined, it appears that education level is inversely proportional to
mental disorders. Indeed a recent study revealed a weak inverse relationship between depression
and education (Kranjac et al., 2017). Bjelland et al.,(2008) reported that higher educational level
confer a protective effect against depression. Similar findings were reported in individuals who
had higher education, but were shown to experience lower levels of depression (Adler et al.,
1994; Kessler et al., 1994). However, diminishing mental health status secondary to educational

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level has been reported (Bracke et al., 2013). Consequently, overeducated people are expected to
experience more episodes of depression. Some authors did not find any association between
education and depression among African Americans (Williams et al., 2007; Gavin et al.,2010). It
will be important for future studies to address these inconsistencies using robust replications with
larger sample size.

1.2.2 Causes of depression

Literature evidences suggest that depression is associated with fatigue, poor appetite,
concentration/ attention disorder, psychomotor disturbances, sleep disorders, vague aches and
pain, feelings of guilt or low self-worth, and suicidal thoughts (Chand and Arif,2019 ;Paykel ,
2008; Marcus et al., 2012; Salle et al., 2012). Adewuya et al., (2016) reported poor or lack of
accommodation, very large family size, heavy cigarette smoking and high level of alcohol
consumption as factors that were associated with depression. Adewuya et al., also reported
association between depression and female gender. However, Melese et al.,(2016) did not
observe any significant difference . The authors also reported that crowded living environment
and feeling of insecurity had been associated with depression. A recent investigation by Hersi et
al.,( 2017) showed that such factors as female gender, financial problems, poor prospect of
finding a job, conflicts with family and friends. The association between somatic (or physical)
disorders and depression has been reported among University students in Nigeria. Despite the
high prevalence of depression and its negative consequences among university students in
Nigeria, little has been done to investigate the factors associated with depression. It is also
necessary to step up intervention programs aimed at reducing the prevalence or associated
consequences of this mental disorder. Bjelland et al., (2008) showed that the strongest influence
on mental health was exerted by somatic disorders, followed by socio-demographic factors. The
association between depression and somatic defects has been observed a couple of studies
conducted in different part of the world (Abdelaziz et al.,2017; Goodwin,2006; Kang et al.,
2015). Whitney et al.,( 2018.) recently showed that pain was a major risk factor associated with
depression. Pain and vague aches are often the presenting symptoms of depression (Trivedi,
2004). Research data have shown that a high percentage of individuals suffering from
depression, who seek treatment in health care facilities, often report only physical symptoms,

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suggesting that somatic disorders are important factors associated with mental disorders
(Trivedi,2004).

Mental health disorders form up to 15% of all recognized diseases worldwide (Sakellari et
al.,2011). According to the World Health Organization (WHO) (W.H.O,2014), over 450 million
people live with a mental disorder. The WHO indicates that poor mental health is associated with
certain determinants such as: “rapid social change, stressful work conditions, gender
discrimination, social exclusion, and unhealthy lifestyle, risks of violence and physical ill-health,
and human rights violations”. Because the transition from being a high school student to being a
university student is a stressful or very challenging; university students worldwide are at risk for
mental health disorders (Corley,2013). MacKean (2011) and Gallagher (2008) showed that
compared to the general population, university students on average have increased mental health
problems such as: depression, anxiety, suicidal thoughts, psychosis, addictions, risk for suicide,
use of psychiatric medications, and other chronic psychiatric disorders. Studies have indicated
that the prevalence is particularly high among female students in the first year of their program
compared to their male counterparts (Field et al., 2012; Price et al.,2006). According to Storrie et
al. (2010), “given the global prevalence and burden of mental illness, it is likely there would be a
significant number of students with emotional problems enrolled in university both with a formal
diagnosis and also with no formal diagnosis but with disabling symptoms”

1.2.3 The Influence of the Transition Experience to University Student Status.

Although University students share similarities with individuals in the general population,
MacKean (2011) found them to be more at risk for negative mental health outcomes because
they are exposed to two sources of transitional stressors: stress related to the transition from high
school to university student status, and stress related to the transition from adolescence to
adulthood. Support for that assumption has been expressed by Kessler et al., (2005), who
maintain that it is during this developmental phase that university students are most at risk for the
development of mental illness. Moreover, there is evidence that there are factors present within
academic institutions that are negatively influencing the mental wellbeing of university students.
For example, an increase in stressful events such as not passing an exam, or financial worries
related to student loans, or finding a part-time job to help cover the costs of books or other
course materials, and for first year students, moving into unknown environments may result in

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the development of psychiatric symptoms (Corley, 2013; Hicks and Heastie, 2008; Lund et al.,
2010; Reifler, 2006). Verger et al., (2009) found that the first-year students are more vulnerable
to increased levels of stress because they often have ineffective coping abilities and lack of
autonomy when compared to students in subsequent years of study.

The stress and anxiety experienced by first-year students also appears to be influenced by the
isolative nature of the university environment now that students have moved away from family
and friends, and thus now have to self-sufficient and function independently (Verger et al.,
2009). In other words, they may demonstrate an inability to adapt appropriately to the stress and
anxieties related to school demands and expectations, and eventually develop mental health
problems (Chen et al., 2009). Many university students who are experiencing stress use
ineffective coping mechanisms to deal with their stressors.

According to Burris et al., (2009), a considerable number of university students use

addictive behaviors to cope with stressors related to the academic environment. Support for this
assumption has been provided by Hughes (2012) who found alcohol consumption was the
highest during the initial part of the first semesters, and late into the second semesters. In
addition, tobacco use has been identified as another way that students cope with salient stressors
within their social and academic environment (Samouilhan and Seabi, 2010; Su et al., 2011).
Hamdan-Mansour and Marmash (2007) found that tobacco use among university students was
related to boredom, little interest in life, and an inability to develop positive behaviors. Outcomes
of this substance use were an increased number of suicidal thoughts and behaviors among
university students, culminating in an increase in depressive symptoms and increased feelings of
anger and fatigue (Lund et al., 2010; Skala et al., 2012).

The time span allotted for sleeping is often very limited among first year university
students, which in turn can negatively influence their mental health status and psychological
well-being. Lund et al., (2010) showed that the increasing levels of stress can lead to changes in
sleep patterns among this population. In contrast to students enrolled in second, third and fourth
year of the program, the authors found that the first year students were losing over two hours of
sleep a night during weekends. Lund et al., (2010) concluded that this lack of sleep led to
increasing amounts of alcohol consumption within the student population. Furthermore, these
students often used alcohol, along with stimulants and other non-prescription drugs to help

8
improve fractured sleep patterns and fight feelings of fatigue in order to perform academically.
Chronic poor quality and quantity of sleep led to the development of mental health issues
problems, including increased agitation, depressive symptoms, feelings of fatigue, as well as
negatively affecting their ability to function academically and socially (Lund et al., 2010).
According to Field et al. (2012) their limited time spent sleeping was listed as the single “most
significant predictor” for depression among university students.

1.2.4 Most Prevalent Mental Disorders among University Students

1.2.4.1 Depression

Depression is the most commonly diagnosed mental illness among university students within
several countries, including Spain, England, Australia and the United States. The prevalence of
depression among first year female students in Canada and United States was double that of their
male counterparts: 14% and 7% respectively (Field et al., 2012; Price et al., 2006).

However, Vaez and Laflamme (2008) found that female university students accessed health
services in higher proportions when compared to male students. The authors concluded: “of
those who had sought care, the proportion of females was significantly higher than that of males
(64.8% compared with 35.2%)”. The authors also found that male students often denied, or failed
to verbalize whether they had accessed mental health services during their university program.
Their results were supported by a study conducted by Burris et al. (2009) who found that female
students had perceived poorer mental health status compared to male students, and were at a
greater risk for depression during university. In their literature review, Miller and Chung (2009)
found that 43.2% of university students had such severe depressive symptoms that functioning
within the academic setting was a challenge. They put it this way: …”more than 3,200 university
students reported being diagnosed as having depression, with 39.2% of those students diagnosed
in the past 12 months, 24.2% currently in therapy for depression, and 35.8% taking
antidepressant medication”). According to Field et al. (2012), as many as 86% of universities
surveyed within the United States identified increasing rates of depression within academic
institutions. They found that depressive symptoms led to poorer academic performances among
affected students and increased their vulnerability for experiencing additional mental health
problems, including “anxiety, intrusive thoughts, controlling intrusive thoughts and sleep
disturbances”.

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1.2.4.2 Anxiety

According to the Anxiety and Depression Association of America (Ibrahim et al., 2013), anxiety
disorder is widely prevalent and one of the most common types of mental health problems
among college students. They indicated that 75% of 40 million Americans diagnosed with
anxiety reported they experience their first episode of anxiety at age 22. The prevalence of
depression and anxiety was 15.6% among undergraduates and 13% among graduate students
(Eisenberg et al.,2007). The authors found that panic disorder and generalized anxiety disorder
were less prevalent among undergraduates and graduate students:4.2% and 3.8% respectively.
The rate of Anxiety disorders among females was double that of male students. Ibrahim et al.
(2013) conducted a study to determine the prevalence and predictors of anxiety and depression
among female medical students in King Abdulaziz University, Jeddah, Saudi Arabia. Their
findings indicated that the prevalence of anxiety was 34.9%. The major causes of the anxiety
were found to be associated with the condensed academic courses, academic failures and
emotional factors during the 6 months preceding the study. The major conclusion of the these
studies was that anxiety can lead to suicidal ideation, substance abuse, physical illness, risky
sexual behavior, and it has a negative impact on the cognitive and learning abilities among
university students (Ibrahim et al.,2013).

1.2.4.3 Stress

Although stress is not classified or identified as a mental disease, it is considered one of the most
risk factors that leads or associate with mental illness (Seedat et al.,2009). Stress occurs “ when
an individual perceives that environmental demands tax or exceed his or her adaptive capacity”
(Cohen et al.,2007 ) . Stress is considered as one of the most prevalent risk factor for mental
illness among university students because they have to deal with a vast range of different
academic, social, and personal challenges (Bray and Born,2004; Oman et al.,2008;
Waghachavare et al.,2013). According to the American College Health Association (2006),
although 36% of national American university students are overwhelmed, 36% of all students are
mentally exhausted. A Saudi study conducted by Sani et al. (2012) to investigate the prevalence

10
of stress among medical students in Jizan University in Saudi Arabia revealed the “prevalence of
stress among medical students was 71.9%, with females being more stressed (77%) than the
males (64%). The major factors associated with perceived stress among students were “long
hours of study, examinations and very tight time schedules, psychological and family issues, lack
of entertainment in the campus; and the education system itself”. In conclusion, continuing
stressors have negative influence on both physical and mental health, which exhausts
individuals’ energy and may lead to less functional productivity (Oman et al., 2008). According
to Waghachavare et al. (2013), integrating stress management skills into university curricula will
be helpful in reducing the prevalence of this problem and other mental health disorders related to
stress.

1.2.5 Factors Leading to Mental Health Disorders among University Students

Flatt (2013) has provided an in-depth discussion of six factors identified in the literature that
allegedly lead to mental health disorders among university students. Academic pressure was the
first factor, which elevates the stress level and leads to mental health problems (e.g., stress,
anxiety and depression) because students fail to cope effectively with low academic achievement
at university, and because of the difficulty to achieve the high grades they desire. Financial
burden was the second factor which Flatt identified as leading to depression, anxiety, stress, and
psychosis, as well as to academic failure among university students. This factor was the result of
increased tuition fees, decreased governmental financial support, increased students loans with
high interest rates and related causes. Two additional factors were found to trigger mental health
issues. The third factor was limited accessibility to higher education for many minority group
students from different cultural, social, and economic backgrounds.

As it has been reported previously by several authors, female students have a higher risk
for mental health disorders than male students. Because the ratio of female students is higher
than that of male students, this imbalance between the two genders constitutes the fourth factor.
Technology (e.g., internet and cellphone) is a double edged weapon. The negative or harmful
effect of the overuse of technology is the fifth factor that has been found to create mental health
issues among university students. According to Flatt (2013), “the harmful effects of technology
overuse include internet addiction or problematic internet use, mobile phone use, and overuse of
internet pornography lead to depression, anxiety, social isolation, shyness, low self-esteem, and

11
lack of social and emotional skills”. The final factor was the change in life style of students,
which leads to mental health problems such as depression, anxiety, and panic disorders, as well
as, physical health problems such as gaining body weight. Life style change includes eating
unhealthy or poor diet, decreasing physical exercises, and neglecting managing stress and
depression using effective coping mechanisms. Because this factor is a very significant one, a
detailed discussion about it has been afforded at the beginning of this paper. In summary, the
above mentioned six factors shed the light on most risk factors that make university students
vulnerable to mental health disorders where administrators, educators, and healthcare providers
at universities have to take these factors in consideration to prevent and treat metal health
problems among students. Most of previous studied

In the context of education and learning, healthcare students can experience high levels of stress
in their everyday activities due to a variety of factors such as study burden, high amount of
content to be learned in relatively short periods, and continuous exams and tests (Bieling et al.,
1998;, Abdel Rahman et al., 2013). This continuous stress can lead to anxiety, nervousness, and
worry associated with the arousal of the nervous system (Bieling et al., 1998; Abdel Rahman et
al., 2013; Vitasari et al., 2010; Alzahran et al., 2017). Anxiety is a psychological condition as
well as an emotional and behavioral disorder characterized by extreme worrying, a sense of fear,
agitation, excessively sensitive responses, and deleterious thinking (Callahan, 2001; Mohd Ghani
et al., 2010). It was evidenced that anxiety may decrease student’s academic interest, due to its
physiological symptoms which include sweaty palms, cold hands and feet, panic attacks, fast
breathing, racing heartbeat, and upset stomach (Vitasari et al.,2010). Previous studies from
different countries and discipline revealed that anxiety and its associated symptoms greatly
influence students’ academic performance (Pillay et al., 2016; McCraty et al., 2000; McCraty,
2007; Vogel and Collins, 2006). Moreover, several studies reported that most students (75%)
during their under graduation and post graduations at universities and colleges experienced some
degree of anxiety symptoms (Mohd Ghani et al., 2010; Tartakovsky, 2008).

A large number of studies revealed the association between higher levels of anxiety and poorer
academic performance among students (McCraty, 2007; Vogel and Collins, 2006; Luigi et al.,
2007). Moreover, earlier data also showed that increased levels of anxiety were associated with
decreased memory, loss of concentration, and cognitive decline (Cassady, 2004). Numerous

12
studies reported that the prevalence of anxiety was found to be higher in students compared to
the general public (January et al., 2018; Dyrbye et al., 2006; Oppong Asante and Andoh-Arthur,
2015; Othieno et al., 2015; Ovuga et al., 2006). The most common form of reported anxiety
among the general community was specific phobias with a prevalence rate of 13.2%, followed by
social anxiety disorder (5.8%) and generalized anxiety disorder (GAD) (5.1%) (Baldwin et al.,
2016). However, the most common prevalent form of anxiety among students was social phobia
with 11.9%, showing an early age of onset while panic disorder and GAD had somewhat later
onset (Blanco et al., 2008; Kessler et al., 2005).

Another recent systematic review evaluated the prevalence of depression and anxiety and
reported that an estimated prevalence of anxiety was 35% among college students (January et al.,
2018). With regard to Saudi Arabia, a study indicated that the prevalence of anxiety among
graduate and undergraduate medical students was 31.8%; however, the prevalence was higher in
first year students compared to those in other years (Alzahrani et al., 2017). Another study
conducted among undergraduate students in the south region of Saudi Arabia reported a
prevalence of 47.2% for mild anxiety, 42.3% for moderate, and 10.5% for severe anxiety
(Hakami et al., 2018). Similarly, a study conducted in the central region of Saudi Arabia with a
multiethnic sample of medical students from Al Faisal University reported a high prevalence of
63% of anxiety. In a study of the prevalence and socioeconomic correlates of anxiety among
pharmacy students at Saudi University, Riyadh Saudi Arabia, the total prevalence of anxiety was
found to be 49% (Sana Samreen et al., 2020).The authors revealed that half of the pharmacy
students suffered from anxiety during their studies at university, with the majority of them
experiencing mild to moderate anxiety. The study found no significant differences in anxiety
according the year of study.

1.2.6. Risk Factors Associated with Anxiety and Depression

Anxiety and Depression (AD) are multifactorial, complex psychological issues which can have
underlying biopsychosocial reasons. Multiple risk factors which affect the formation of SAD
among undergraduate university students in developed and developing countries were identified
in this review. These factors can be categorized into multiple themes including psychological,
academic, biological, lifestyle, social and financial.

1.2.6.1 Psychological factors

13
 Self-esteem, self-confidence, personality types, and loneliness can be associated with SAD
among university students. Students who have a lower level of self-esteem are more susceptible
to develop anxiety and depression (Ratanasiripong et al., 2018). Also, students with high
neuroticism and low extraversion in five-factor personality inventory (McCrae and John, 1992)
are more likely to develop AD during university years (Kawase et al., 2008). Other
psychological factors such as feeling of loneliness plays important roles in increasing AD risk
factors (Kawase et al., 2008). Moving away from family and beginning an independent life can
pose challenges for fresher students such as loneliness until they adjust to university life and
expand their social network. Indeed, Kawase et al.,(2008) showed that students who live in other
cities than their hometown for studying purposes are more likely to develop anxiety and
depression. Some students enter the university with underlying mental conditions, which can
become exacerbated as they transition into the independent life at university. While depression is
higher among university and college students compared to the general public, students with a
history of mental health problems, such as post-traumatic stress disorder (PTSD), are more prone
to development of anxiety and depression during their university lives compared to students who
did not have such experience before starting their degrees (Fortney et al.,2016). Furthermore,
exposure to violence in childhood either at the household or the community correlates with AD
formation later in life and at University (Miller-Graff et al., 2015). Therefore, low self-esteem
and self-confidence, having an underlying mental health condition before beginning the
university, personality type (high neuroticism and low extravasation), and loneliness can increase
the probability of AD formation in students.

1.2.6.2 Academic factors

Multiple university-related academic stressors can lead to AD among students. One of these
factors which was strongly present in many studies evaluated in a review was the subject of the
degree. Medical, nursing, and health-related students have a higher prevalence of depression and
anxiety compared to their non-medical peers (Kawase et al., 2008; Wanda & Carla, 2013;
Ghodasara et al., 2011). Medical and nursing students who have both theoretical duties and
patient-related work usually have the highest level of workload among university students,
consequently deal more with anxiety and depression (Wanda & Carla, 2013; Fares et al., 2016).
In addition, students who major in psychology and philosophy, similar to nursing and medical

14
students, are more likely to develop depression during their studies compared to others (Kawase
et al., 2008). These studies did not identify whether students who have underlying mental health
conditions are more likely to choose certain subjects such as philosophy, psychology, or subjects
which lead to caring roles such as nursing and medicine. Because of the nature of their work,
medical and nursing students who deal with people’s health can experience depression and
anxiety as a result of fears of making mistakes which can result in harming patients (Wanda &
Carla, 2013). Students with practical components in their degree are required to travel to
unfamiliar places for fieldwork and work experience which can add to their stress and anxiety
(Wanda & Carla 2013).

Also, some prospective students, especially those who study nursing and medicine, usually do
not have a clear understanding of the curriculum and workload associated with the subject before
entering the university, therefore, they can face a state of disillusionment once they begin their
studies at university (Wanda & Carla ,2013; Ghodasara et al.,2011; Fares et al.,2016). It is worth
mentioning that not all studies found a significant correlation between the subject of study and
AD development (Macaskill, 2013). This can be explained by differences in sample type and size
which results in variations existing in the amount of workload and curriculum in similar subjects
taught in various universities in different countries. Studying a higher degree can be a
challenging task which requires mental effort. Mastery of the subject can negatively correlate
with self-esteem, anxiety, and depression among university students with students who have a
mastery of subject demonstrating a lower level of stress and anxiety (Bovier et al., 2004). Also,
students who study in a non-native language report the highest level of anxiety and depression
during their freshman years, and their stress levels decrease during the subsequent study years
(Lee et al. 2012). This can be explained by the fact that students who are studying in a foreign
language usually are those who have migrated abroad, therefore, require some time to adjust to
their new lives. Different studies have showed that the level of anxiety and depression among
both international and home students could correlate with the year of study with fresher students
who enter the university and students at the final year of their studies experiencing the greatest
amount of anxiety and depression with different risk factors (Ratanasiripong et al.,2018; Lee et
al.. 2012). While fresher students experience AD because of challenges in adjustments to
university life, past negative family experience, social isolation and not having many friends,
final year students report uncertainty about their future, prospective employment, university debt

15
repayment and adjusting to the life after university as major risk factors for their AD
(Ratanasiripong et al.,2018, Lee et al. 2012). Therefore, a shift in AD risk factors themes are
observed as students make a progress in their degrees. Students spend a significant portion of
their time at university being engaged with their academic activities, and unpleasant academic
outcomes can influence their mental health. Receiving lower grades during the time of studies
can negatively influence students’ mental health, causing them to develop SAD (Ishii et al. 2018;
Stallman,2010).

Academic performance during undergraduate studies can determine the degree

classification, which can, subsequently, influence students’ opportunities such as employment
success rate or access to postgraduate courses (Wanda & Carla, 2013). Conversely, both the
number of students with mental health problem symptoms and the severity of students’ AD
increase during exam time (Scholz et al., 2016), reflecting a direct relationship between
academic pressure and students’ mental health states. However, the causal relationship is not
well-established; it is possible that depression and associated problems such as temporary
memory loss and lack of concentration (Schweizer et al., 2018) are reasons for poor academic
grades or inversely, students feel stressed leading to depression because of their poor
performance in their exams.

A mutual relationship can exist between grades and mental health, as having a poor
mental health can reciprocally cause students to get lower grades (Stallman ,2010), leading to a
vicious cycle of mental health and academic performance. Interestingly, students’ sense of social
belonging and coherence to the university community was reduced during exam periods (Scholz
et al.,2016). This can be explained by the reduced participation rate of students in university
social activities and clubs as well as an increased sense of competition with their peers.
Furthermore, students interact directly and indirectly with teachers, lecturers, tutors, and other
staff; therefore, the relationship between students and academic staff can influence students’
mental health. A negative and abusive relationship with teachers and mentors can be another
factor causing SAD among undergraduate students (Wanda & Carla, 2013). On the other hand,
being a part-time student is a protective factor for anxiety and depression, and part-time students
have better mental health compared to students with full-time status (Stallman, 2010).This can be
explained by financial securities which have a source of income can bring or because part-time

16
students are usually older than full-time students (Stallman, 2010), and therefore, more
emotionally stable. In conclusion, risk factors increasing AD among university students include
high workload pressure, fear of poor performance in exams and assessments, wrong expectations
from the course and university, insufficient mastery in the subject, year of study, and a negative
relationship with academic staff.

1.2.6.3 Biological factors

Mental health can be influenced by ones’ physical health. Presence of an underlying health
condition or a chronic disease before entering the university can be a predictor of having AD
during university years (Bovier et al., 2004; Ishii et al., 2018). Students with physical and mental
disabilities can be in a more disadvantaged position and do not fully participate in university life
leading to AD formation (Ishii et al., 2018). An association between gender and depressive
disorders have been observed in several studies (Maser et al. 2019; Wanda & Carla, 2013;
Stallman, 2010, Usher and Curran, 2017). Female students had a higher prevalence of AD
compared to male students. Interestingly, while female students demonstrated a higher level of
AD, the dropout rate of female students with a mental health problem from university was lower
compared to their male counterparts (Ishii et al., 2018). On the other hand, while females are at a
higher risk of developing depressive disorders, males with depressive disorders are less willing
to seek professional help and ask for support due to the stigma attached to mental health (Call
and Shafer,2018), causing exacerbation of their problem over time (Turner et al., 2007).

Age can be another factor related to AD. Younger students report a higher level of AD
compared to older students (Stallman, 2007; Usher and Curran, 2017). However, other meta-
analysis studies did not find a significant correlation between students’ age and their mental
health which can be due to sampling differences. (Zeng et al., 2019). Some studies showed that
while older undergraduate students have a higher determination to do well in the university
(Brockelman, 2009), those who have family commitments are more prone to develop AD during
their degrees (Wanda & Carla, 2013). These discrepancies in findings can be explained by
different sample sizes and types of studies which can be influenced by various confounding

17
factors such as nationality, country of study, degree of studies, gender, and socioeconomic status.
Similarly, a lack of correlation between depression prevalence and year of study is observed as
some studies have reported a higher prevalence among earlier years of studies, while others have
shown a higher prevalence among students as they move closer to the end of their studies
(Roberts et al., 2010). These differences can be explained by different causes of depression in a
different age; for example, while depression in younger adults can be due to changes in their
environment and difficulties in adapting to a new life, older adults can have depression
symptoms because of a lack of certainty for their future and employment. Nevertheless,
differences exist between SAD risk factors associated with young and older students. Overall,
biological risk factors affecting SAD include age of students, gender, and underlying physical
conditions before entering the university.

1.2.6.4 Lifestyle factors

Moving away from families and beginning a new life requires flexibility and adaptation to adjust
to a new lifestyle. As most undergraduate students leave their family environment and enter a
new life with their peers, friends, and classmates, their behaviour and lifestyle change too.
Multiple lifestyle factors such as alcohol consumption, tobacco smoking, dietary habits, exercise,
and drug abuse can affect AD. Alcohol consumption is high among students with AD
(Ghodasara et al., 2011) a causal relationship was not been established in this study though.
Tobacco smoking is another risk factor associated with AD which is common among students,
especially students who study in Eastern developed and developing countries such as China,
Japan and South Korea (Kawase et al., 2008, Cai et al., 2015). Most students, especially male
students, smoke because of social bonding and the rate of social smoking is directly correlated
with AD (Kawase et al., 2008, Cai et al., 2015). Social smokers are less willing to quit smoking,
and more likely to persist in their habit, resulting in long term negative physical and
psychological health consequences (Cai et al., 2015). Illegal substance abuse can be another
factor important in AD among young people (Tountas and Dimitrakaki, 2006). Academic-related
stress and social environment in university dormitories and student accommodations can
encourage students to use illegal drugs, smoke tobacco and consume alcohol excessively as a
coping mechanism, resulting in AD (Tavolacci et al., 2013). Interestingly, students who
perceived they had support from the university were feeling less stressed and were less at the risk

18
of substance abuse (Boulton and O'Connell,2017), indicating the important role of social support
in preventing and alleviating depression symptoms. This is of particular importance as a new
social habit and behaviour adapted early during life can last for a long time. Furthermore,
students who do not have a healthy lifestyle can feel guilt, which can worsen their AD condition
(Jenkins et al., 2019). Interestingly, Rosenthal et al., (2018) showed that negative behaviours
resulting from alcohol consumption such as missing the next day class, careless behaviour and
self-harm, verbal argument or physical fight, being involved in unwanted sexual behaviour, and
personal regret and shame could be the main reasons for depression associated with drinking
alcohol, rather than the amount of alcohol consumed. In contrast, a moderate to vigorous level of
physical activity can be a protective factor against developing SAD during university life (Usher
and Curran, 2017; Terebessy et al., 2016). Students who have a perception of having inadequate
time during their studies do not spend enough time for exercise and can develop AD symptoms
(Wanda and Carla, 2013).

Another lifestyle-related risk fact associated with AD is sleep. Many young people do not
receive sufficient sleep, and sleep deprivation is a serious risk factor for low mood and
depression (Ghodasara et al., 2011; Rosenthal et al., 2018). Self-reported high level of stress and
sleep deprivation is common among American students (Bovier et al., 2004; Wallace et al.,
2017). Insufficient sleep can act as a vicious cycle- academic stress can cause sleep deprivation,
and insufficient sleep can cause stress due to poor academic performance since both sleep quality
and quantity is associated with academic performance (Ghodasara et al., 2011). Overall, poor
sleeping habit is associated with a decreased learning ability, increase in anxiety and stress,
leading to depression. Different negative lifestyle behaviours such as tobacco smoking, excessive
alcohol consumption, unhealthy diet, lack of adequate physical activity, and insufficient sleep
can increase the risk of SAD formation among university students.

1.2.6.5 Social factors

Having a supportive social network can influence students’ social and emotional wellbeing, and
subsequently lower their probability of having anxiety and depression in university (Wanda and
Carla, 2013; Usher and Curran, 2017; Hefner and Eisenberg, 2009). The quality of relationship
with family and friends is important in developing AD. Having a well-established and supportive
relationship with family members can be a protective factor against AD development, which, in

19
turn, can affect the sense of students’ fulfilment from their university life (Wanda and Carla,
2013). The frequency of family visits during university years negatively correlates with SAD
development (Ishii et al., 2018). Family visits can be more challenging for international students
who live far away from their families, therefore adding to existing problems of international
students who live and study abroad. In contrast, having a negative relationship with family
members, especially parents, can cause AD formation among students in university (Meng et al.,
2011). Similarly, having a strict family who posed restrictions on behaviours and activities
during childhood can be a predictor of developing AD during university years (Meng et al.,
2011). Also, it is shown that being in a committed relationship has a beneficial protective factor
against developing depressive symptoms in female, but not male, students (Whitton et al., 2013).
Interestingly, both male and female students who were in committed relationships reported a
lower alcohol consumption compared to their peers who were not in committed relationships
(Whitton et al., 2013). Involvement in social events such as participating in sporting events and
engaging in club activities can be a protective factor for mental health (Lee et al., 2012; Usher
and Curran, 2017). Assessing preclinical medical students’ social, mental, and psychological
wellbeing showed that while first year students demonstrate a decrease in their mental wellbeing
during the academic year, they have an increase in their social wellbeing and social integration
(Michalec and Keyes, 2013). This can be explained by the time period required for fresher
students who enter the university to adjust to the social environment, make new friends, and
integrate into the social life of the university.

Access to social support from university is another factor which is negatively correlated with
developing anxiety and depression (Bovier et al., 2004). It is worth mentioning that different
universities provide different degrees of social support for students which can reflect on different
anxiety and depression observed among students of different universities. Importantly, sexual
victimization during university life can be a predictor of depression. By surveying female
Canadian undergraduate students, McDougall et al., (2016) found that students who were
sexually victimized and had non-consensual sex were at a higher chance of developing
depression following their experience, emphasizing the importance of safeguarding mechanism
for students at university campuses. While the internet and social media can be great tools for
maintaining a social relationship with classmates, pre-university friends and family members, it
can have negative mental health effects. Excessive usage of social media and the internet during

20
freshman year can be a predictor of developing AD during the following years. Students who
have a higher dependence on the social media report a higher feeling of loneliness, which can
result in AD. Students with internet addiction and excessive usage of social media are usually in
first year of their degrees (Yao et al., 2013; Thomas et al., 2020) which can reflect a lack of
adjustment to university life and forming a social network. Also, students who use social media
more often have a lower level of self-esteem and prefer to recreate their sense of self (Thomas et
al.,2020), indicating an intertwined relationship between biopsychosocial factors in developing
AD among students. Demographic status, ethnic and sexual minority groups including
international Asian students, black and bisexual students were at an elevated risk of depression
and suicidal behaviour (Goodwill and Zhou, 2020; Hefne rand Eisenberg, 2009). The frequency
of mental health is usually more common among ethnic minorities. For example, Turner et al.,
(2007) showed that ethnic minority students report a higher level of anxiety and depression
compared to their white peers; however, they do not ask for help as much. Other studies
supported these findings by showing that students from ethnic and religious minorities,
regardless of their country of origin and country in which they study, have a higher prevalence of
anxiety and depression compared to their peers (Hefner and Eisenberg, 2009). Also, students’
expectations from university can be different among ethnic minorities students, and most of them
do not have a sufficient understanding of the services that university can provide for them
(Brockelman, 2009). Therefore, lack of support from family and university, adverse relationships
with family, lack of engagement in social activities, sexual victimization, excessive social media
usage, belonging to ethnic and religious minority groups, and stigma associated with the mental
health are among risk factors for AD in university students.

1.2.6.6 Economic factors

Students’ family economic status can influence their mental health. A low family income and
experiencing poverty can be predictors of AD development during university years
(Ratanasiripong et al., 2018; Hefner and Eisenberg, 2009; Li et al., 2019; Sznitman et al., 2011).
A higher family income can even ameliorate negative psychological experiences during
childhood, which can have long-term negative consequences on the mental health of students
once they enter university (Li et al., 2019). Also, experiencing poverty during childhood can
have negative long-term consequences on adults, leading to AD development during university

21
life (Sznitman et al., 2011). Some students take up part-time job to partially fund their studies.
Vaughn et al., (2016) showed that relationship of employed students with their colleagues in the
workplace could affect students’ mental health; and those students who had a poor relationship
with their colleagues had worse mental health. However, it is worth mentioning that a causal
relationship was not established. It can be possible that students who have poor mental health
cannot get along with their co-workers, resulting in an adverse working relationship. Because of
paying higher tuition fees and less access to scholarships and bursaries available, international
students can have more financial problems, causing a higher degree of anxiety and depression
compared to home students (Bradley, 2000). Lack of adequate financial support, low family
income and poverty during childhood are risk factors of AD in students of undergraduate courses
in developed and developing countries.

1.2.6.7 Stigma associated with mental health

While efforts have been put to reduce the stigma associated with receiving help for mental health
problems, this still remains a challenge. For example, more than half of students who had AD did
not receive any help or treatment for their condition because of the stigma associated with mental
health (Zivin et al., 2009; Park et al., 2020). This is not related to the awareness of the
availability of mental health resources which was ruled out by the authors, as most of the
students who did not receive any help for their mental health problem were aware of available
help and support to them (Zivin et al., 2009). Furthermore, the social stigma associated with
receiving help for mental health problems was significantly associated with suicidal behaviour,
acting as a preventive barrier to seek help i.e. planning or attempt (Goodwill and Zhou, 2020).
Among students, those with a history of mental health problem such as veterans with PTSD are
less likely to seek for help compared to non-veteran students (Fortney et al., 2016), making them
more susceptible to struggling with untreated mental health.

1.2.7 Justification of Study

So many studies have tended to focus on common mental disorders among medical students and
have largely ignored university students in other fields. Understanding the burden of
psychological morbidity among university students is imperative as there is evidence showing
that cognitive, behavioral, and mindfulness interventions can be effective in reducing anxiety and
depressive symptoms in these groups .Such interventions are particularly useful in resource-

22
limited settings such as low- and middle-income countries which Nigeria belongs to, where
antidepressants although may be available, but not the appropriate solution.

In light of the risks and consequences of psychological morbidity on students and the remarkable
growth in University student numbers in Private Universities in Sub-Saharan Africa within the
last 30 years, there is a need to understand the prevalence and antecedents of common mental
disorders among University students in an institution such as Madonna University. University
based mental health well-being programs and interventions may become increasingly imperative
as they contribute to prevention and minimization of psychological morbidity. Additionally,
there is a need to create supportive environments for students who may be having mental health
difficulties during their training

1.2.8 Aim

The purpose of this study is to determine the Prevalence of Depression and Anxiety in
Undergraduate students studying in the Faculty of Pharmacy, Madonna University Elele, Nigeria

1.2.9 Specific objectives of this study are:

1. To determine the prevalence of depression and anxiety among students in the Faculty of
Pharmacy, Madonna university, Elele. Nigeria

2. To determine the prevalence of depression and anxiety among the 200,300,400 and 500 L
students of Faculty of Pharmacy, Madonna university, Elele. Nigeria

3. To determine which level, socio demographic and factors are associated with depression
among students of the Faculty of pharmacy, Madonna University, Elele. Nigeria

5. To assess gender differences and discrepancies between class years.

1.2.10 Significance of Study

This study can be used to better inform the school management, hostel supervisors, staff at
Madonna University to better serve their students experiencing Anxiety and depressive

23
 symptoms .This can help in management and control of the increase in the rate of depression
and anxiety among its students after the case study of Pharmacy students.

CHAPTER TWO

METHOD

2.1 Research Design

Research design is defined as development of the framework of the study or the overall plan,
strategy or structure that will assist the researcher to pursue and accomplish the objectives of a
study through responses to the research question. The researcher will use a descriptive research
design for this study. A descriptive design is a non-experimental design used to describe the
variables without manipulating the situation. Pharmacy students who qualify for the study will be
chosen to participate in the data collection process on the prevalence of anxiety and depression in
students in Madonna University Elele, Rivers State.

2.2 Research Setting

The setting for this study is Madonna University, Elele Campus in Rivers state. The Faculty has
six Departments.

2.3 Target Population

24
The study population consists of male and female students currently enrolled in Faculty of
Pharmacy for the Bachelor of Pharmacy (B.Pharm) program from Madonna University, Elele
Campus in Rivers state, Nigeria.

2.4 Sampling

Cross-sectional study in which, 614 students participated during the academic year 2020–2021
by completing a self-administered questionnaire. This cross-sectional survey was administered at
Madonna University Elele, Rivers State. All students (n = 614) included were students who have
spent at least a session in the University, and are in the Faculty of Pharmacy. The University
Institutional Review Board (IRB) approved the study. The sample size will be determined using
the Taro Yamane’s formula for calculating sample size. Taro Yamane was a statistician who
developed a statistical formula to aid the calculation and determination of sample size given a
study population. The Taro Yamane’s statistical formula is stated as follows;

n = N / (1 + Ne2)

n= corrected sample size,

N = population size (N = 244)

e = Margin of error, e = 0.05 based on the research condition.

From the class records and attendance sheets compiled by the Faculty officer, the population of
the students is shown below.

200 Level - 165 students

300 Level - 190 students

400 Level - 130 students

500 Level - 352 students

Total Population 837 students

25
Therefore,

n = 837 / 1 + (837 x 0.052)

n = 837 / (1 + 2.0925)

n = 837 / 3.0925

n = 270.65

The students that will be participants to be used for the data collection procedure for analysis

Therefore, the minimum sample size for this study will be 280 Pharmacy students.

2.5 Sampling Technique

The sampling technique that will be used for this study is the convenience non probability
sampling technique. This is chosen because technique involves random selection of study
elements in such a way that each member of the study population has an equal chance of being
selected into the study. The inclusion criterion includes willingness to participate in the study;
availability at the time of data collection; and respondents must be in their second to fifth year of
study in the Faculty of Pharmacy. Exclusion criteria will be all other students that do not belong
to the Faculty of Pharmacy irrespective of their year of study.

2.6 Instruments for Data Collection

The researcher will use a self-structured questionnaire to collect data that will be used for
analysis in the study. The first section of the questionnaire consisted of demographics and other
participant characteristics Demographic information included age (recorded as continuous
variable), Gender (male, female, ),Marital status( married ,single) ethnicity (Yoruba,Hausa,Igbo
others), class level (200L,300L,400L,500L), Religion(Christianity,Islam,others),Current Parent
household status(one parent household, two parents household, others) Number of children
(1,2,3,4,5,6,>7)Position in family(1,2,3,4,5,6,>7) Family background settlement(rural,
urban),number of students living in a room.
Mental health outcomes were measured by different batteries of depression and anxiety .Beck
depression inventory (BDI) and Hamilton Anxiety Rating Scale (HAM-A).

26
The researcher adopted the Hamilton Anxiety Rating Scale, which is a psychological
questionnaire used by clinicians to rate the severity of a patient's anxiety. The scale consists of
14 items designed to assess the severity of a patient's anxiety. Each of the 14 items contains a
number of symptoms, and each group of symptoms is rated on a scale of zero to four, with four
being the most severe. All of these scores are used to compute an overarching score that
indicates a person's anxiety severity.

The BDI is a well-established questionnaire used to screen for depression.(Beck et

al.,1988;Becks et al.,1961) .The BDI is the most commonly used depression inventory in both
research and clinical practice. Questions on the 21-item BDI assess various cognitive,
physiological, and effect-related symptoms of depression .BDI symptoms and are classified into
four levels of intensity- as sadness, feelings about the future, irritability; loss of pleasure, fatigue,
and changes in appetite. Each item has four answers (0, 1, 2 or 3), being possible to have more
than one answer in each question, but only the one with higher value is validated. The total
scores can range from 0 to 63, suggesting the following severity level: 0-13, minimum/no
depression; 14-19, mild depression; 20-28, moderate depression; and 29-63, severe depression.
The cut-off score for BDI was ≥ 17 (Ceylan et al., 2003; Karakaya et al., 2004; Bostancı et al.,
2005; Güleç et al., 2005).
2.7 Validity of Instrument

Validity refers to the degree to which a measurement represents a true value. Focus is put on the
usability of the instrument chosen. In this study, to ensure validity of the instrument, the
questionnaire to be used will be approved and validated by Psychiatrists at Psychiatrist at the
Madonna University Teaching Hospital. My supervisor also read through to ensure that the
instrument measures what it ought to measure by considering the stated aims and objectives.

2.8 Method of Data Collection

Data collection is a process that includes subject selection and collection of data from these
subjects. Data maybe collected using different approaches, depending on research design and
measurement methods. The direct approach will be used for this study. The researcher will select
the student free period to distribute the questionnaires to ascertain their response. Research
assistants were also be carefully selected and trained on how to administer the questionnaires to
the respondents. Further, the data collection instrument was carefully administered, discussed

27
and explained to the respondents for ease of understanding. This will be done in the premises of
Madonna University for ease of distribution and will also be collected on the spot of
administration to ensure complete responses.

2.9 Method of Data Analysis

The data obtained was entered into Microsoft Excel spreadsheet, rechecked for accuracy and
completeness and uploaded into statistics Software IBM® SPSS®, version 23.0, which was used
to process the data. Descriptive analyses examined the distribution of all variables of interest.
Frequency and percentage was used to represent socio-demographic variables. Responses for the
21 and 14 item standard questions on Beck’s Depression Inventory and Hamilton Anxiety Rating
Scale was added up as required by this analytical tool and analyzed in terms of frequency and
percentage. The Pearson’s chi-square test was performed to verify associations between the
characteristics of pharmacy students and the classifications regarding the level of depressive and
anxiety symptoms in different cutoffs. For all the analyses, the significance level was 5% (0.05)
Statistical Chi2 and Student t-tests were applied to estimate associations between socio-
demographic data, anxiety and depression outcomes.

CHAPTER THREE

RESULTS

3.1 Participant Characteristics: Descriptive findings

A detailed description of participant characteristics is provided in Table 1. A total of 614 male and
female pharmacy students from the second, third, fourth and fifth year of bachelor of pharmacy degree
programs completed the survey. Study participants were predominantly female (n = 372, 60.6%) were
females, and about 39.4% (n = 242) were males. A very large number of the students (n = 602, 98%) are
single. The majority (n = 378, 61.2%) were in the age range of 21-25 years, 214(34.9%) were of the ages
15-20 years and only 24(3.9 %) were in the age range of 26-30 years (Table3.1).

Most of the students were of the Igbo ethnic extraction (n = 362, 59%), 114(18.6%) were Yoruba, 129
(21%) were from other tribes, while only 9(1.5%) were Hausa. Of the 614 students who completed the
questionnaire, 76 (12.4%) were second year, and 182 (29.6%) were third and 133 (21.7%) fourth year,

28
and 223(36.3%) were fifth year students. The majority of the students (n = 587, 95.6%) were Christians,
3.9% (n = 24) were of the Islamic religion and only 0.5 %( n=3) were of other unstated religion afflation.

With regard to how many parent in the household, only 5.4% (n = 33) lived in a household with more
than two parents; 14% (n = 86) lived with only one parent, and 80.6% (n = 495) lived with two parents.

The number of children in the family as obtained from the participants were as follows :
1(n=31,5%),2(n=56,9.1%),3(n=76,12.4%),4(n=127,20.7%),5(n=95,15.5%),6(n=120,19.5%),7(n=66,10.7%),
8(n=30,4.9%),9(n=12,2%) and10 (n=1,0.2%).

The position in the family were also computed from the questionnaire.

1(n=13,21.2%),2(n=139,22.6%),3(n=107,17.4%),4(n=104,16.9%),5(n=64,10.4%),6(n=44,7.2%),7(n=13,2.1
%),8(n=11,1.8%) and 9(n=2,0.3%).

29
 Table3. 1. Demographic characteristics of Pharmacy students.

Sociodemographic characteristics Frequency(n) Percentage (%)

Gender 242 39.4

Male 372 60.6
Female
Marital status
Single 602 98
Married 12 2
Age(years)
15 – 20 214 34.9
21 – 25 376 61.2
26 – 30 24 3.9
Pharmacy Level
200L 76 12.4
300L 182 29.6
400L 133 21.7
500L 223 36.3
Religion
Christianity 587 95.6
Islam 24 3.9
Others 3 0.5
Ethnicity
Yoruba 114 18.6

29
Hausa 9 1.5
Igbo 362 59
Others 129 21
Current parent household status
One parent household 86 14
Two parent household 495 80.6
More than 2 parent household 33 5.4
Number of children in the family
1 31 5
2 56 9.1
3 76 12.4
4 127 20.7
5 95 15.5
6 120 19.5
7 66 10.7
8 30 4.9
9 12 2
10 1 0.2

Position in the family

1 130 21.2
2 139 22.6
3 107 17.4
4 104 16.9
5 64 10.4
6 44 7.2
7 13 2.1
8 11 1.8

30
 9 2 0.3
Family Residence
Rural 8 1.3
Urban 606 98.7
Number of persons living in the hostel
1–4 130 21.2
5–8 390 63.5
More than 8 94 15.3

31
3.2 Interpreting the Beck Depression Inventory

The scores for each of the twenty-one questions from the completed questionnaire were added up by
counting the number to the right of each question that was marked. Details are presented in Table 3.2.

Key:

1-10 These ups and downs are considered normal

11-16 Mild mood disturbance
17-20 Borderline clinical depression
21-30 Moderate depression
31-40 Severe depression

Responses from the Beck’s Depression Inventory rating was compiled, the most prevalent was 17 – 20
(18830.6%)-Borderline clinical depression,1-10(n=127,20.7%)–normal,11-16(n=179,29.2%)- Mild mood
disturbance,21-30(n=110,17.9%)- Moderate depression and 31-40 (n=10,1.6%) - Severe depression.
Details are in Table 3.2.
As shown in Table 3.3, there is no significant correlation between the Beck’s depression scale
and Demographics of ethnicity (Yoruba,Hausa,Igbo, others), class level(200L,300L,400L,500L),
Religion(Christianity,Islam,others),Current Parent household status(one parent household, two
parents household, others) Number of children (1,2,3,4,5,6,7,8,9,10)Position in
family(1,2,3,4,5,6,7,8,9) and Family background settlement(rural, urban) .There were significant
correlation between number of students sharing residence (p=0.02), Age(p=0.001) , Gender
(male, female, ) p=0.001), Marital status( married ,single)( p=0.001). Details in Table 3.3

Table 3.2 Prevalence of depression among Pharmacy Students on the Becks Depression Inventory

Scale Frequency(n) Percentage (%)

1--10 127 20.7

11--16 179 29.2
17-20 188 30.6
21-30 110 17.9
31-40 10 1.6

32
33
 Table 3.3: Association of Beck’s Depression Scale with various socio-demographic variables

Sociodemographic characteristics Becks Depression Inventory ꭓ2 P

Frequency(n) 1--10 11--16 17-20 21-30 31-40
Gender
Male 242(39.4) 74(12.1) 77(12.5) 58(9.4) 26(4.2) 7(1.1) 41.053 0.001
Female 372(60.6) 53(8.6) 102(16.6) 130(21.2) 84(13.7) 3(0.5)

Marital status
Single 602(98.0) 125(20.4) 177(28.8) 182(29.6) 108(17.6) 10(1.6) 2.462 0.652
Married 12(2.0) 2(0.3) 2(0.3) 6(1.0) 2(0.3) 0(0.0)

Age(years)
15 – 20 214(34.9) 64(10.4) 72(11.7) 54(8.8) 19(3.1) 5(0.8) 44.558 0.001
21 – 25 376(61.2) 58(9.4) 105(17.1) 121(19.7) 88(14.3) 4(0.7)
26 – 30 24(3.9) 5(0.8) 2(0.3) 13(2.1) 3(0.5) 1(0.2)

Pharmacy Level
200L 76(12.4) 29(4.7) 26(4.2) 14(2.3) 3(0.5) 4(0.7) 82.997 0.001
300L 182(29.6) 48(7.8) 72(11.7) 44(7.2) 16(2.6) 2(0.3)
400L 133(21.7) 19(3.1) 36(5.9) 47(7.7) 29(4.7) 2(0.3)
500L 223(36.3) 31(5.0) 45(7.3) 83(13.5) 62(10.1) 2(0.3)

Religion
Christianity 587(95.6) 122(19.9) 172(28.0) 180(29.3) 103(16.8) 10(1.6) 5.56 0.696
Islam 24(3.9) 4(0.7) 7(1.1) 6(1.0) 7(1.1) 0(0.0)

34
Others 3(0.5) 1(0.2) 0(0.0) 2(0.3) 0(0.0) 0(0.0)

Ethnicity
Yoruba 114(18.6) 25(4.1) 29(4.7) 33(5.4) 25(4.1) 2(0.3)
Hausa 9(1.5) 0(0.0) 3(0.5) 2(0.3) 4(0.7) 0(0.0)
Igbo 362(59) 73(11.9) 110(17.9) 116(18.9) 58(9.4) 5(0.8)
Others 129(21) 29(4.7) 37(6.0) 37(6.0) 23(3.7) 3(0.5)

Current parent household status

One parent household 86(14) 18(2.9) 25(4.1) 32(5.2) 9(1.5) 2(0.3) 15.654 0.048
Two parent household 495(80.6) 95(15.5) 147(23.9) 150(24.4) 95(15.5) 8(1.3)
More than 2 parent household 33(5.4) 14(2.3) 7(1.1) 6(1.0) 6(1.0) 0(0.0)

Number of children in the family

1 31(5) 7(1.1) 7(1.1) 10(1.6) 7(1.1) 0(0.0) 18.679 0.992
2 56(9.1) 14(2.3) 16(2.6) 16(2.6) 9(1.5) 1(0.2)
3 76(12.4) 12(2.0) 24(3.9) 23(3.7) 17(2.8) 0(0.0)
4 127(20.7) 28(4.6) 38(6.2) 37(6.0) 20(3.3) 4(0.7)
5 95(15.5) 19(3.1) 28(4.6) 29(4.7) 18(2.9) 1(0.2)
6 120(19.5) 25(4.1) 31(5.0) 38(6.2) 22(3.6) 4(0.7)
7 66(10.7) 15(2.4) 18(2.9) 23(3.7) 10(1.6) 0(0.0)
8 30(4.9) 5(0.8) 11(1.8) 10(1.6) 4(0.7) 0(0.0)
9 12(2) 2(0.3) 5(0.8) 2(0.3) 3(0.5) 0(0.0)
10 1(0.2) 0(0.0) 1(0.2) 0(0.0) 0(0.0) 0(0.0)

Position in the family

1 130(21.1) 24(3.9) 34(5.5) 46(7.5) 21(3.4) 5(0.8) 32.561 0.439
2 139(22.6) 25(4.1) 43(7.0) 43(7.0) 27(4.4) 1(0.2)

35
 3 107(17.4) 25(4.1) 36(5.9) 23(3.7) 22(3.6) 1(0.2)
4 104(16.9) 21(3.4) 33(5.4) 34(5.5) 14(2.3) 2(0.3)
5 64(10.4) 19(3.1) 13(2.1) 18(2.9) 13(2.1) 1(0.2)
6 44(7.2) 8(1.3) 11(1.8) 18(2.9) 13(2.1) 0(0.0)
7 13(2.1) 3(0.5) 2(0.3) 4(0.7) 4(0.7) 0(0.0)
8 11(1.8) 2(0.3) 7(1.1) 1(0.2) 1(0.2) 0(0.0)
9 2(0.3) 0(0.0) 0(0.0) 1(0.2) 1(0.2) 0(0.0)

Family Residence
Rural 8(1.3) 3(0.5) 3(0.5) 1(0.2) 1(0.2) 0(0.0) 2.436 0.656
Urban 606(98.7) 124(20.2) 176(28.7) 187(30.5) 109(17.8) 10(1.6)

Number of persons living in the

hostel
1–4 130(21.2) 27(4.4) 38(6.2) 36(5.9) 27(4.4) 2(0.3) 18.211 0.02
5–8 390(63.5) 89(14.5) 114(18.6) 124(20.2) 55(9.0) 8(1.3)
More than 8 94(15.3) 11(1.8) 27(4.4) 28(4.6) 28(4.6) 0(0.0)

˂ 0.05 is significant Values in

parenthesis Percentage(%)

36
37
3.3 Hamilton Anxiety Rating Scale (HAM-A)

Table 3.4 below indicates the frequency of anxiety among the students involved in this study
using Hamilton’s anxiety rating scale.

The HAM-A was one of the first rating scales developed to measure the severity of anxiety symptoms,
and is still widely used today in both clinical and research settings. The scale consists of 14 items, each
defined by a series of symptoms, and measures both psychic anxiety (mental agitation and psychological
distress) and somatic anxiety (physical complaints related to anxiety). Although the HAM-A remains
widely used as an outcome measure in clinical trials, it has been criticized for its sometimes poor ability
to discriminate between anxiolytic and antidepressant effects, and somatic anxiety versus somatic side
effects. The HAM-A does not provide any standardized probe questions. Despite this, the reported levels
of interrater reliability for the scale appear to be acceptable.

Each item is scored on a scale of 0 (not present) to 4 (severe), with a total score range of 0–56, where

<17 Mild severity

18-24 Mild to moderate severity
25-30 Moderate to severe

The prevalence of anxiety among the study participants according to the Hamilton Anxiety Rating scale
was(n = 294), 47.9% considered to have no anxiety, 303 students (49.3%) had mild to moderate anxiety,
and 17(2.8%) had severe anxiety Table 3.4.

Table 3.4 Prevalence of anxiety among Pharmacy Students on the Hamilton Anxiety Rating Scale

Scale Frequency(n) Percentage (%)

<17 294 47.9

18-24 303 49.3
25-30 17 2.8

Regarding anxiety, a detailed description of the characteristics frequencies of anxiety rating

parameters is given in Table 3.5 As seen in Table 3.5, there were no differences in total anxiety
scores between the different variables (p >0.05) .
38
As shown in Table 3.5, there is no significant correlation between the Hamilton Anxiety Rating
scale and Demographics of ethnicity (Yoruba,Hausa,Igbo, others), ,
Religion(Christianity,Islam,others),Current Parent household status(one parent household, two
parents household, others) Number of children (1,2,3,4,5,6,7,8,9,10)Position in
family(1,2,3,4,5,6,7,8,9) , Family background settlement(rural, urban) )number of students
sharing residence Age, Gender (male, female, ) , Marital status( married ,single) . There were
significant correlation between class level (200L, 300L, 400L, 500L) (p=0.04). Details in Table
3.5

39
 Table 3.5 Association of Hamilton Anxiety Rating scale with various socio-demographic variables

Frequency(n) Hamilton Anxiety Rating Scale ꭓ2 P

<17 18-24 25-30

Gender

Male 242(39.4) 120(19.5) 116(18.9) 6(1.0) 0.525 0.769

Female 372(60.6) 174(28.3) 187(30.6) 11(1.8)

Marital status

Single 602(98.0) 287(46.7) 298(48.5) 17(2.8) 0.764 0.682

Married 12(2.0) 7(1.1) 5(0.8) 0(0.0)

Age(years)

15 – 20 214(34.9) 115(18.7) 91(14.8) 8(1.3) 8.045 0.09

21 – 25 376(61.2) 166(27.0) 202(32.9) 8(1.3)

26 – 30 24(3.9) 13(2.1) 10(1.6) 1(0.2)

Pharmacy Level

40
200L 76(12.4) 50(8.1) 33(3.7) 3(0.5) 13.207 0.04

300L 182(29.6) 85(13.8) 93(15.1) 4(0.7)

400L 133(21.7) 60(9.8) 70(11.4) 3(0.5)

500L 223(36.3) 99(16.1) 117(19.1) 7(1.1)

Religion

Christianity 587(95.6) 276(45) 295(48) 16(2.6)

Islam 24(3.9) 18(2.9) 5(0.8) 1(0.2)

Others 3(0.5) 0(0.0) 3(0.5) 0(0.0)

Ethnicity

Yoruba 114(18.6) 53(8.6) 58(9.4) 3(0.5)

Hausa 9(1.5) 6(1.0) 3(0.5) 0(0.0)

Igbo 362(59) 169(27.5) 185(30.1) 8(1.3)

Others 129(21) 66(10.70 57(9.3) 6(1.0)

Current parent household status

One parent household 86(14) 42(6.8) 40(6.5) 4(0.7) 1.744 0.783

41
Two parent household 495(80.6) 235(38.3) 248(40.4) 12(2.0)

More than 2 parent household 33(5.4) 17(2.8) 15(2.4) 1(0.2)

Number of children in the family

1 31(5) 14(2.3) 16(2.6) 1(0.2) 16.663 0.546

2 56(9.1) 26(4.2) 29(4.7) 1(0.2)

3 76(12.4) 46(7.5) 29(4.7) 1(0.2)

4 127(20.7) 49(8.0) 72(11.7) 6(1.0)

5 95(15.5) 48(7.8) 44(7.2) 3(0.5)

6 120(19.5) 55(9.0) 63(10.3) 2(0.3)

7 66(10.7) 38(6.2) 26(4.2) 2(0.3)

8 30(4.9) 13(2.1) 16(2.6) 1(0.2)

9 12(2) 5(0.8) 7(1.1) 0(0.0)

10 1(0.2) 0(0.0) 1(0.2) 0(0.0)

Position in the family

1 130(21.1) 60(9.8) 68(11.1) 2(0.3) 2.436 0.656

42
 2 139(22.6) 67(10.9) 67(10.9) 5(0.8)

3 107(17.4) 47(7.7) 58(9.4) 2(0.3)

4 104(16.9) 45(7.3) 54(8.8) 5(0.80)

5 64(10.4) 43(7.0) 21(3.4) 0(0.0)

6 44(7.2) 21(3.4) 21(3.4) 0(0.0)

7 13(2.1) 8(1.3) 5(0.8) 0(0.0)

8 11(1.8) 3(0.5) 7(1.1) 1(0.2)

9 2(0.3) 0(0.0) 2(0.3) 0(0.0)

Family Residence

Rural 8(1.3) 5(0.8) 3(0.5) 0(0.0) 0.817 0.665

Urban 606(98.7) 289(47.1) 300(48.9) 17(2.8)

Number of persons living in the

hostel

1–4 130(21.2) 57(9.3) 69(11.2) 4(0.7) 4.265 0.371

5–8 390(63.5) 194(31.6) 188(30.6) 8(1.3)

More than 8 94(15.3) 43(7.0) 46(7.5) 5(0.8)

43
˂ 0.05 is significant

Values in parenthesis Percentage(%)

44
 CHAPTER FOUR

DISCUSSION

This study identified the prevalence of depression and anxiety among pharmacy students from
Madonna University, Elele. A large number of previous studies from different countries utilizing
diverse study populations, including both medical and pharmacy students, have investigated the
prevalence of anxiety and depression (Dessie et al .,2013; Nwobi et al .,2009 ; Hersi et al .,
2017 Balaƴzs et al.,2013). In the present study, prevalence for moderate to extremely severe
depression and anxiety were 50.1 and 52.1% respectively. The present results indicated that
pharmacy students suffered from some form of anxiety and depression, ranging from mild to
severe. Anxiety contributes to depression, which in turn may lead individuals to entertain
suicidal thoughts. Medical, nursing, and health-related students have a higher prevalence of
depression and anxiety compared to their non-medical peers (Kawase et al., 2008; Wanda &
Carla, 2013; Ghodasara et al.,2011).

Numerous studies reported that the prevalence of anxiety was found to be higher in students
compared to the general public (January et al., 2018; Dyrbye et al., 2006; Oppong Asante and
Andoh-Arthur, 2015; Othieno et al., 2015; Ovuga et al., 2006). In one study, the prevalence of
anxiety in college students varied between 63% and 92 % (Shamsuddin et al., 2013; Herrero et
al., 2014). Another study by Bayram and Bilgel in 2008 among Turkish University students (n =
1617) found 47.1% of anxiety. Consistently, another study by Shamsuddin et al. among
Malaysian students reported 34% of anxiety. Our study findings were lower than a previous
study by Yusoff et al., among medical students (n = 442) who reported a high prevalence of
anxiety of 64.3%.

We found that the prevalence in anxiety was 52.1% .This is in agreement with a study of the
prevalence and socioeconomic correlates of anxiety among pharmacy students at Saudi
University, Riyadh Saudi Arabia, in which the total prevalence of anxiety was found to be 49%
(Sana Samreen et al., 2020).The authors revealed that half of the pharmacy students suffered
from anxiety during their studies at university, with the majority of them experiencing mild to
moderate anxiety

43
On the whole, variation in anxiety is expected and can be attributed to the difference in the used
study tool and risk factors of anxiety, among which university and home environments
(including household number, urban or rural dwelling and student residential status) are critical
players. According to previous reports, students from various disciplines such as pharmacy and
allied healthcare professions are more likely to be affected by high stress levels related to
educational strategies, which results in different levels of consequences in students’ academic
and social life.

High prevalence of depression in University students is observed, on average 30.6%, while for
the population in general, this prevalence corresponds to 9%.Though data are scanty, a few
studies conducted in Nigeria have showed that the prevalence of depression is higher among
University students (Adewuya et al., 2016).A higher prevalence of depression (84%) was
reported among students of Obafemi Awolowo University, Ile Ife Nigeria (Ayeni, 2005).

Studies have reported wide variations in the proportion of students identified as depressed, from
relatively low rates around 10% (Goebert et al., 2009;Vazquez and Blanco, 2006; Vazquez and
Blanco, 2008) to high rates of between 40% and 84% (Bayati et al., 2009; Garlow et al., 2008;
Khan et al., 2006). This wide variation appears to be influenced by many factors including
methods of assessment (Weissman et al., 1996; Marsella, 1978), geographical location (Steptoe
et al., 2007; Weissman et al., 1996) and demographic factors (Kaplan et al., 2008; Steptoe et al.,
2007).

An association between gender and depressive disorders have been observed in several studies
(Maser et al. 2019; Wanda & Carla, 2013; Stallman, 2010, Usher and Curran, 2017). Female
students had a higher prevalence of anxiety and depression compared to male students. This
study found that females (52%) had more depression than the males (27.2%) and there was a
significant relationship with the Becks Depression Inventory. However, although the anxiety
levels were also greater in females (32.4%) there was no significant relationship with the
Hamilton Anxiety Rating Scale. Several other studies have revealed that females are more likely
to report anxiety in comparison to males.

The socio demographic analysis revealed that females are more prone to develop depressive
symptoms .Adewuya et al., (2016) reported an association between depression and female
gender. This is in agreement with our findings. However, this study did not find any significant

44
association between anxiety and being female. This observation is in agreement with various
authors that did not observe any significant difference (Melese et al., 2016; Balaƴzs et al., 2013;
Dessie et al 2013).

Sexual victimization during university life can be a predictor of depression. By surveying female
Canadian undergraduate students, McDougall et al.,(2016) found that students who were
sexually victimized and had non-consensual sex were at a higher chance of developing
depression following their experience, emphasizing the importance of safeguarding mechanism
for students at university campuses. These experiences are also dominant in Nigerian
universities, both private and federal.

Also our study results revealed no significant differences in students’ anxiety according to
demographic characteristics. However, this study found significant differences in anxiety
according to the year of the study. Final students had more anxiety issues than the 200- 400 L.
This may be due to the reality that students in higher level of study are more likely to have
depression due to the fact that they have a large part of their curriculum to cover.

It has been suggested that rates of depression in undergraduate student have increased over time
(Ceyhan et al., 2009; Denise et al., 1996), but in a review, the authors could not detect this trend
(Ibrahim et al., 2013) .They suggested that the differences could be explained by differences in
the study methods, tools used, or the cultural differences of the studied population. Still a
growing concern has been expressed about university students’ mental health (Ceyhan et al.,
2009).

The high prevalence of depression and anxiety in this study could be attributed to the fact that
enormous restrictions in freedom of the students, Madonna University is a complete residence
University. From the data collected, students live in crowded conditions where each student live
with between 3-8 students in a room and this may be contributing factors. Adewuya et al.,
(2016) and Melese et al., (2016) also reported that crowded living environment and feeling of
insecurity had been associated with depression. Furthermore, social stress such as relationship
with peer groups, hostel friends, displacement from home and financial problem have also
potentially psychologically influence undergraduate students greatly

45
No study has found association between number of children in the family, religion, position in
family with anxiety and depression. This study did not find any significant association between
age, marital status, where family resides with depression and anxiety.

Age can be another factor related to anxiety and depression. This study found that the age group
of 21-25years were more prone to anxiety and depression. Younger students report a higher level
of anxiety and depression compared to older students (Stallman, 2007; Usher and Curran, 2017).
However, one meta-analysis studies did not find a significant correlation between students’ age
and their mental health, which the authors reported could be due to sampling differences (Zeng et
al., 2019). Some studies showed that older undergraduate students have a higher determination to
do well in the university (Brockelman, 2009).

Another systematic review evaluated the prevalence of depression and anxiety and reported that
an estimated prevalence of anxiety was 35% among college students (January et al.,2018). With
regard to Saudi Arabia, a study indicated that the prevalence of anxiety among graduate and
undergraduate medical students was 31.8%; however, the prevalence was higher in first year
students compared to those in other years (Alzahrani et al., 2017). This study found the
prevalence of depression and anxiety to be significantly different according the year of study.
The study showed that students in higher levels had a higher prevalence of depression and
anxiety. However, it is not in agreement with the study by Sana Samreen et al., (2020) that
reported no significant differences in anxiety according the year of study.

Different studies have showed that the level of anxiety and depression among both international
and home students could correlate with the year of study with fresher students who enter the
university and students at the final year of their studies experiencing the greatest amount of
anxiety and depression with different risk factors (Ratanasiripong et al.,2018; Lee et al. 2012).
While fresher students experience anxiety and depression because of challenges in adjustments
to university life, past negative family experience, social isolation and not having many friends,
final year students report uncertainty about their future, prospective employment, university debt
repayment and adjusting to the life after university as major risk factors for their anxiety and
depression (Ratanasiripong et al., 2018, Lee et al., 2012).

Similarly, a lack of correlation between depression prevalence and year of study is observed as
some studies have reported a higher prevalence among earlier years of studies, while others have

46
shown a higher prevalence among students as they move closer to the end of their studies
(Roberts et al., 2010). These differences can be explained by different causes of depression in a
different age; for example, while depression in younger adults can be due to changes in their
environment and difficulties in adapting to a new life, older adults can have depression
symptoms because of a lack of certainty for their future and employment. Nevertheless,
differences exist between anxiety and depression risk factors associated with young and older
students. Overall, biological risk factors affecting anxiety and depression include age of students,
gender, and underlying physical conditions before entering the university

Turner et al., (2007) showed that ethnic minority students report a higher level of anxiety and
depression compared to their white peers; however, this study could not buttress this findings.
Other studies supported these findings by showing that students from ethnic and religious
minorities, regardless of their country of origin and country in which they study, have a higher
prevalence of anxiety and depression compared to their peers (Hefner and Eisenberg, 2009).

47
 CHAPTER FIVE

CONCLUSION

The findings of this study revealed that a majority of the Pharmacy students studying at
Madonna University suffered from mild to moderate anxiety and depression. In addition, our
study found no significant differences in anxiety according to participant characteristics. The
high burden of studying along with other factors such as expanse of the curriculum and living
conditions are likely to be the major reasons for anxiety and depression. Besides, lack of baseline
information concerning mental status of Pharmacy students has become a limitation of our study.
We were only able to determine the prevalence of the psychological distress among the students.

Our study has several potential limitations. First, it included only second, third, and fourth year
Pharmacy students; secondly, this study was carried out in a single private operated university in
Nigeria; the results may not completely reflect the anxiety of all Pharmacy students. The
generalizability of our findings should thus be evaluated in future studies. Also, because this
study was done only among the Pharmacy students from a single private university, who are
more likely to have high levels of stress, selection bias might be present, and therefore might not
represent the general picture in Nigerian Universities. Associations among all these might not be
representative of the general population also, because this study is only focus on undergraduates.

Although there is a need for more in-depth research to confirm the findings of this study, there is
accumulating evidence to suggest that depression and anxiety represents a significant health
concern in University populations. Although females are more at risk, the high rates for male
students are particularly concerning since they are typically less willing to access support. The

48
results of this study suggest that more attention should be given to the identification and
management of depression and anxiety in University settings. With current economic pressures,
vulnerability may increase further unless research is conducted to establish effective
interventions for management of depression and anxiety in students.

Students’ psychological problems such as depression and anxiety, if recognized in early stages,
can be treated with behavioral therapy, emotional support, and social skills training. This may
help future graduates to overcome their difficulties and lead a healthier life. The present study
results also highlight the need for further research including larger groups of students in different
fields.

In conclusion, depression and anxiety have a high detrimental effect to individual and society,
which can lead to negative outcomes including dropouts and increased suicidal tendency. With
that, there is a need for greater attention to the psychological wellbeing of undergraduate
students to improve their quality of life. Additionally, we recommend the importance of
assessment of anxiety, depression, other behavioral and mental illness using noninvasive tools
like questionnaires. This type of assessment may help the policymakers to assess the problems of
society timely and make necessary recommendations.

49
 REFRENCES
Aalto-Setälä T, Marttunen M, Tuulio-Henriksson A, Poikolainen K, Lönnqvist J.
(2001).Prevalence of depression and other DSM-IV disorders among young adults.
Psychological Medicine, 31:791-801.
Abdel Rahman AG, Al Hashim BN, Al Hiji NK and AlAbbad Z (2013). “Stress among medical
Saudi students at College of Medicine, King Faisal University,” Journal of Preventive Medicine
and Hygiene, 54, (4):195–199.
Abdelaziz AM, Alotaibi KT, Alhurayyis JH et al (2017).The association between physical
symptoms and depression among medical students in Bahrain. Int J Med Educ; 8:423.
Adewuya AO, Ola BA, Aloba OO, et al (2006). Depression amongst Nigerian university
students. Soc Psychiatry Psychiatr Epidemiol; 41:674-8.
Adler NE, Boyce T, Chesney MA, et al (1994). Socioeconomic status and health: The challenge
of the gradient. Am Psychol; 49:15.
Alzahrani AH, Alzahrani AK, Alharithy M et al (2017). “Prevalence of anxiety and generalized
anxiety disorder among male medical students at Taif University, Saudi Arabia,” World Journal
of Pharmaceutical Research, 3:18– 22.
Ayeni EA (2005). Epidemiological study of depression among students in a tertiary institution:
A case study at Obafemi Awolowo University, Ile-Ife. Nigerian J Health Biomed Sci; 4:82-7.
Balaƴzs J, Mikloƴsi M, Kereszteƴny A et al (2013). Adolescent sub threshold depression and
anxiety: Psychopathology, functional impairment and increased suicide risk. J Child Psychol
Psychiatry; 54:670-7.
Baldwin D S, Anderson IM, Nutt DJ et al., (2016). “Evidence based guidelines for the
pharmacological treatment of anxiety disorders: recommendations from the British Association
for Psychopharmacology,” Journal of Psychopharmacology, 19(6):567–596.

50
Bayati A, Beigi M, Salehi M (2009). Depression prevalence and related factors in Iranian
students. Pakistan Journal of Biological Sciences, 12:1371-5.
Beck AT, Steer R, Garbin M(1988).Psychometric properties of the Beck Depression Inventory:
twenty-five years of evaluation. Clin Psychol Rev, 8:77–100.

Beck AT, Ward CH, Mendelson M et al (1961). An inventory for measuring depression. Arch
Gen Psychiatry, 4:561–71.

Bertolote J and Flieschmann A (2002).Suicidologi7, 6–8

Bieling PJ, Antony MM and Swinson RP (1998). “The state-trait anxiety inventory, trait version:
structure and content reexamined,” Behaviour Research and Therapy, 36, (7-8): 777–788.
Blanco C, Okuda M, Wright C et al., (2008). “Mental health of college students and their non-
college-attending peers: results from the National Epidemiologic Study on Alcohol and Related
Conditions,” Archives of General Psychiatry, 65(12)1429–1437.
Boulton M, O'Connell KA (2017) .Nursing Students’ Perceived Faculty Support, Stress, and
Substance Misuse. J Nurs Educ 56: 404–411.
Bovier PA, Chamot E, Perneger TV (2004) .Perceived stress, internal resources, and social
support as determinants of mental health among young adults. Qual Life Res 13: 161–170.
Bracke P, Pattyn E, von dem Knesebeck O (2013).Overeducation and depressive symptoms:
Diminishing mental health returns to education. Sociol Health Illn; 35:1242-59.
Bradley G (2000). Responding effectively to the mental health needs of international students.
High Educ 39: 417–433.
Bray SR and Born HA (2004). Transition to university and vigorous physical activity:
implications for health and psychological well-being. Journal of American college health; 52 (4):
181-188.
Brockelman KF (2009). The interrelationship of self-determination, mental illness, and grades
among university students. J Coll Student Dev 50: 271–286.
Burris JL., Brechtin EH, Salsman J, Carlson CR (2009). Factors associated with the
psychological well-being and distress of university students. Journal of American college health;
57 (5): 536-543.
Cai L, Xu F, Cheng Q, et al (2015) Social Smoking and Mental Health Among Chinese Male
College Students. Am J Health Promot 31: 226–231.
Call JB, Shafer K (2018) .Gendered Manifestations of Depression and Help Seeking Among
Men. Am J Mens Health 12: 41–51.

51
Callahan RJ (2001). “The impact of thought field therapy on heart rate variability (HRV),”
Journal of Clinical Psychology, 57(10): 1153-1170.
CassadyJC (2004). “The influence of cognitive test anxiety across the learning–testing cycle,”
Learning and Instruction, 14(6):569–592.
Ceyhan A, Ceyhan E, Kurty Y (2009). Investigation of university students’ depression. Eurasian
Journal of Educational Research 36:75-90.
Chand SP, Arif H (2019). Depression. Treasure Island (FL): StatPearls Publishing
Chatterjee S, Saha I, Mukhopadhyay S, Misra R, Chakraborty A, Bhattacharya A (2014).
Depression among nursing students in an Indian government college. Br J Nurs. 23(6):316-20.
Chaves ECL, Lunes DH, Moura CC, Carvalho LC, Silva AM, Carvalho EC (2015). Anxiety and
spirituality in university students: a cross sectional study. Rev Bras Enferm, 68(3):444-9.
Chen H, Wong Y, Ran M, Gilson C (2009). Stress among Shanghai University Students.
Journal of social work; 9(3): 323-344.
Cohen S, Janicki-Deverts D, Miller G (2007). Psychological stress and disease. JAMA; 298(14):
1685-1687.
Corley L (2013). Prevalence of mental health issues among college students: How do advisers
equip themselves? The Mentor an Academic Advising Journal; Available from 2020/09/mental-
health-college-students.
Denise L, Terrie M, Avshalom C, Lynn M, Phil S, Warren S (1996). Psychiatric disorder in a
birth cohort of young adults: prevalence, comorbidity, clinical significance, and new case
incidence from ages 11-21. Journal of Consulting and Clinical Psychology, 64:552-62.
Dessie Y, Ebrahim J, Awoke T (2013). Mental distress among university students in Ethiopia: A
cross sectional survey. Pan Afr Med J; 15.
Dyrbye LN, Thomas MR and Shanafelt TD (2006). “Systematic review of depression, anxiety,
and other indicators of psychological distress among U.S. and Canadian medical students,”
Academic Medicine, 81, (4):354–373.
Eisenberg D, Gollust SE, Golberstein E, Hefner JL (2007). Prevalence and correlates of
depression, anxiety and suicidality among university students. American journal of
orthopsychiatry; 77(4): 534-542
El-Gendawy S, Hadhood M, Shams R, Ibrahim A. Epidemiological aspects of depression among
Assiut University students. Assist Medical Journal 2005; 29:81-9.
Fares J, Al Tabosh H, Saadeddin Z, et al (2016). Stress, Burnout and Coping Strategies in
Preclinical Medical Students. North Am J Med Sci 8: 75–81.

52
Fernandes MA, Vieira FER, Silva JS, Avelino FVSD, Santos JDM (2018). Prevalence of anxious
and depressive symptoms in college students of a public institution. Rev Bras Enferm 71(Suppl
5):2169-75.
Ferri C, Prince M, Brayne C, Brodaty H, Fratiglioni L, Ganguli M, et al. (2005). Global
Prevalence of Dementia: A Delphi Consensus Study. Lancet, 366, 2112-2117.
Field T., Diego M., Pelaez M., Deeds O., Delgado J (2012). Depression and related problems in
university students. College student journal; 46(1):193-202.
Flatt A (2013). A Suffering Generation: Six factors contributing to the mental health crisis in
North American higher education. College quarterly16 (1).
Fortney JC, Curran GM, Hunt JB et al (2016). Prevalence of probable mental disorders and help
seeking behaviors among veteran and non-veteran community college students. Gen Hosp
Psychiat 38: 99–104.
Gallagher R. P. National survey of counseling center directors. The International Association of
Counseling Services, Inc.; (2008),
Available from http://www.collegecounseling.org/pdf/2008_survey.pdf
Garlow S, Rosenberg J, Moore J, Haas A, Koestner B, Hendin H, et al., (2008).Depression,
desperation, and suicidal ideation in college students: results from the American Foundation for
Suicide Prevention College screening project at Emory University. Depress and Anxiety, 25:482-
8.
Gavin AR, Walton E, Chae DH, et al (2010). The associations between socio-economic status
and major depressive disorder among Blacks, Latinos, Asians and non-Hispanic Whites:
Findings from the collaborative psychiatric epidemiology studies. Psychol Med; 40:51-61.
GBD (2015). Disease and Injury Incidence and Prevalence Collaborators, and others. Global,
regional, and national incidence, prevalence, and years lived with disability for 310 diseases and
injuries, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. The
Lancet, 388: 10053.
Ghodasara SL, Davidson MA, Reich MS, et al (2011). Assessing Student Mental Health at the
Vanderbilt University School of Medicine. Acad Med 86:18-46.
Gladstone T, Beardslee W, O’Connor E (2011). The prevention of adolescent depression.
Psychiatric Clinics of North America, 34:35-52.
Goebert D, Thompson D, Takeshita J, Bryson P (2009).Depressive symptoms in medical
students and residents: a multischool study. Academic Medicine 84: 236-41.
Goodwill JR, Zhou S (2020). Association between perceived public stigma and suicidal
behaviors among college students of color in the U.S. J Affect Disord 262: 1–7.
Goodwin GM (2006). Depression and associated physical diseases and symptoms. Dialogues
Clin Neurosci; 8:259.
53
 Hakami RM, Mahfouz MS, Adawi AM et al (2018). “Social anxiety disorder and its impact in
undergraduate students at Jazan University, Saudi Arabia,” Mental illness, 9(2):7274.
Hamdan-Mansour A and Marmash LR (2007).Psychological well-being and general health of
Jordanian university students. Journal of psychosocial nursing and mental health services; 45
(10): 31-39.
Harvey S, Glozier N, Henderson M, Allaway S, Litchfield P, Holland-Elliott K, et al
(2011).Depression and work performance: an ecological study using web-based screening.
Occupational Medicine, 61:209-11.
Hefner J, Eisenberg D (2009) .Social support and mental health among college students. Am J
Orthopsychiat 79: 491–499.
Herrero AA, Sábado JT, Benito JG. (2014).Associations between emotional intelligence,
depression and suicide risk in nursing students. Nurse Educ Today,34(4):520–5.
Hersi L, Tesfay K, Gesesew H et al (2017). Mental distress and associated factors among
undergraduate students at the University of Hargeisa, Somaliland: A cross-sectional study. Int J
Ment Health Sys; 11:39.
Hicks T and Heastie S (2008). High school to college transition: A profile of the stressors,
physical, and psychological health issues that affect the first-year on-campus college student.
Journal of cultural diversity; 15: 143–147.
Hughes C (2012). All beer and skittles? A qualitative pilot study of the role of alcohol in
university college life. Australian universities review; 54 (2): 22-28.
Hunt J and Eisenberg D (2010).Mental health problems and help-seeking behavior among
college students. Journal of Adolescent Health, 46:3-10.
Hysenbegasi A, Hass S, Rowland C (2005).The impact of depression on the academic
productivity of university students. Journal of Mental Health Policy and Economics 8:145-51.
Ibrahim AK, Kelly SJ, Adams CE, Glazebrook C. (2013).A systematic review of studies of
depression prevalence in university students. JPsychiatr Res47 (3):391–400.
Ibrahim N, Al- Kharboush D, El-Khatib L, Al –Habib A, Asali D (2013). Prevalence and
predictors of anxiety and depression among female medical students in King Abdulaziz
University, Jeddah, Saudi Arabia. Iranian journal of public health; 42 (7): 726-736.
Ishii T, Tachikawa H, Shiratori Y, et al (2018). What kinds of factors affect the academic
outcomes of university students with mental disorders? A retrospective study based on medical
records. Asian J Psychiat 32: 67–72.
January J, Madhombiro M, Chipamaunga S, Ray S, Chingono A, and Abas M (2018).
“Prevalence of depression and anxiety among undergraduate university students in low and
middle-income countries: a systematic review protocol,” Systematic Reviews,7(1)57.

54
Jenkins EK, Slemon A, O’Flynn-Magee K et al (2019). Exploring the implications of a self-care
assignment to foster undergraduate nursing student mental health: Findings from a survey
research study. Nurs Educ Today 81: 13–18.
Jeon H (2011). Depression and suicide. Journal of the Korean Medical Association, 54: 370-5.
Kang HJ, Kim SY, Bae KY, et al (2015). Comorbidity of depression with physical disorders:
Research and clinical implications. Chonnam Med J; 51:8-18.
Kaplan G, Shema S, Leite C (2008). Socioeconomic determinants of psychological wellbeing:
the role of income, income change, and income sources during the course of 29 years. Annals of
Epidemiology, 18:531-7.
Kawase E, Hashimoto K, Sakamoto H, et al (2008). Variables associated with the need for
support in mental health check-up of new undergraduate students. Psychiat Clin Neurosci 62:
98–102.
Kessler R, Bergland P, Demler O, Jin R, Walters E E (2005). Lifetime prevalence and age-of-
onset distributions of DSM-IV disorders in the National comorbidity survey replication.
Archives of general psychiatry; 62: 593-602.
Kessler, RC, McGonagle, et al (1994). Life-time and 12-month prevalence of DSM-JJJ-R
psychiatric disorders in the United States. Arch Gen Psychiatry; 51:8-19.
Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR and Walters E E (2005). “Lifetime
prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity
Survey Replication,” Archives of General Psychiatry, 62(6)593–602.
Khan M, Mahmood S, Badshah A, Ali S, Jamal Y (2006).Prevalence of depression, anxiety and
their associated factors among medical students in Karachi, Pakistan. Journal of the Pakistan
Medical Association, 56:583-6.
Kranjac AW, Nie J, Trevisan M et al (2017). Depression and body mass index, differences by
education: Evidence from a population-based study of adult women in the US Buffalo-Niagara
region. Obes Res Clin Pract; 11:63-71.
Lamis DA, Ballard ED, May AM, Dvorak RD (2016). Depressive symptoms and suicidal
ideation in college students: the mediating and moderating roles of hopelessness, alcohol
problems, and social support. J Clin Psychol, 72(9):919–32.
Lee KH, Ko Y, Kang KH, et al (2012).Mental Health and Coping Strategies among Medical
Students. Korean J Med Educ 24: 55–63.
Li M, Li WQ, Li LMW (2019). Sensitive Periods of Moving on Mental Health and Academic
Performance among University Students. Front Psychol 10: 1289.
Lim M, Chang W, Yu X, Chiu H, Chong M, Kua E (2011). Depression in Chinese elderly
populations. Asia-Pacific Psychiatry, 3:46-53.
Lima R (2013). Os suicídios e a universidade produtivista. Rev Esp Acad; 13(149):78-86.
55
Lowe G, Lipps G, Young R (2009). Factors associated with depression in students at the
University of the West Indies, Mona, Jamaica. West Indian Medical Journal, 58:21-7.
Luigi M, Ducci F, Scoto MC, Passaniti E, D'Arrigo VG and Vitiello B (2007). “The role of
anxiety symptoms in school performance in a community sample of children and adolescents,”
BMC Public Health, 7(1): 347.
Lund HG, Reider BD, Whiting AB, Prichard JR (2010). Sleep patterns and predictors of
disturbed sleep in a large population of college students. Journal of adolescent health; 46(2):
124-132.
Lyubomirsky S, Kasri F, Zehm K (2003). Dysphoric rumination impairs concentration on
academic tasks. Cognitive Therapy and Research, 27:309-30
Macaskill A (2013) .The mental health of university students in the United Kingdom. Brit J
Guid Couns 41: 426–441.
MacKean G (2011). Mental health and well‐being in postsecondary education settings: A
literature and environmental scan to support planning and action in Canada. Canadian
association of college and university student services; Available from
http://www.cacuss.ca/_Library/documents/Post_Sec_Final_Report_June6.pdf
Marcus M, Yasamy MT, van Ommeren M et al (2012). Depression: A global public health
concern. WHO MSD; 1:6-8.
Marsella A (1978). Thoughts on cross-cultural studies on the epidemiology of depression.
Culture, Medicine and Psychiatry, 2:343-57.
Maser B, Danilewitz M, Guérin E, et al (2019) .Medical Student Psychological Distress and
Mental Illness Relative to the General Population: A Canadian Cross-Sectional Survey. Acad
Med 94:34-38.
McCrae RR, John OP (1992). An introduction to the five-factor model and its applications. J
Pers 60: 175–215.
McCraty R (2007). When Anxiety Causes Your Brain to Jam, Use Your Heart, Institute of Heart
Math, Heart Math Research Center, Institute of HeartMath Boulder Creek, CA.
McCraty R, Tomasino D, Atkinson M, Aasen P and Thurik SJ (2000). Improving test-taking
skills and academic performance in high school students using HeartMath learning enhancement
tools, Boulder Creek, CA: HeartMath Research Center, Institute of HeartMath,
McDougall EE, Langille DB, Steenbeek AA, et al (2016) .The Relationship Between
Nonconsensual Sex and Risk of Depression in Female Undergraduates at Universities in
Maritime Canada. J Interpers.
McKenzie M, Olsson C, Jorm A, Romaniuk H, Patton G (2010).Association of adolescent
symptoms of depression and anxiety with daily smoking and nicotine dependence in young
adulthood: findings from a 10-year longitudinal study. Addiction 105:1652-9.

56
 Mehta K, Kaur S, Girgla KK et al., (2015). A study of mental distress in medical students. Natl
J Physiol Pharm Pharmacol; 5:190.
Melese B, Bayu B, Wondwossen F et al., (2016). Prevalence of mental distress and associated
factors among Hawassa University medical students, Southern Ethiopia: A cross-sectional study.
BMC Res Notes; 9:485.
Meng X, Kou C, Shi J, et al (2011). Susceptibility genes, social environmental risk factors and
their interactions in internalizing disorders among mainland Chinese undergraduates. J Affect
Disord 132: 254–259.
Michalec B, Keyes CLM (2013). A multidimensional perspective of the mental health of
preclinical medical students. Psychol Health Med 18: 89–97.
Miller E and Chung H (2009). A literature review of studies of depression and treatment
outcomes among U.S. college students since 1990. Psychiatric services; 60 (9): 1257-1260.
Miller-Graff LE, Howell KH, Martinez-Torteya C, et al (2015). Typologies of Childhood
Exposure to Violence: Associations with College Student Mental Health. J Am Coll Health 63:
539–549.
Mohd GhaniA, Nubli M, Wahab A, Ahmad O and Prima V (2010). “The use of study anxiety
intervention in reducing anxiety to improve academic performance among university students,”
International Journal of Psychologica, 2(1):89–95.
Moussavi S, Chatterji S, Verdes E, et al (2007). Depression, chronic diseases, and decrements in
health: Results from the World Health Surveys. Lancet; 370:851-8.
NICE (2009). Depression: the treatment and management of depression in adults, NICE clinical
guideline 90. NICE clinical guideline 23. London: National Institute for Health and Clinical
Excellence.
NIMH (2003). National Institute of Mental Health: depression and college students. New York:
NIMH (NIH Publication)
Nwobi EA, Ekwueme OC, Ezeoke UE (2009). Mental depression and coping strategies among
medical students of University of Nigeria, Enugu campus. Int J Med Health Develop; 14:42-8.
Oman D, Shapiro SL, Thoresen CE, Plante TG, Flinders T (2008). Meditation Lowers Stress
and supports forgiveness among college students: A randomized controlled trial. Journal of
American college health; 56(5): 569-578.
Oppong Asante K and Andoh-Arthur J (2015). “Prevalence and determinants of depressive
symptoms among university students in Ghana,” Journal of Affective Disorders, 171:161–166.
Othieno C J, Okoth R, Peltzer K, Pengpid S and Malla LO (2015). “Risky HIV sexual behaviour
and depression among University of Nairobi students,” Annals of general psychiatry, 14 (1):16,
Ovuga E, Boardman J and Wasserman D (2006). “Undergraduate student mental health at
Makerere University, Uganda,” World Psychiatry, 5(1):51-52,
57
Park SY, Andalibi N, Zou Y et al (2020) .Understanding Students’ Mental Well-Being
Challenges on a University Campus: Interview Study. JMIR Form Res 4: 15962.
Paykel ES (2008). Basic concepts of depression. Dialogues Clin Neurosci; 10:279.
PillayN, Ramlall S and Burns JK (2016). “Spirituality, depression and quality of life in medical
students in KwaZulu-Natal,” South African Journal of Psychiatry, 22(1): 731.
Price EL, McLeod PJ, Gleich SS, Hand D (2006). One-year prevalence rates of major
depressive disorder in first-year university students. Canadian journal of counseling, 40: 68–81.
Ratanasiripong P, China T, Toyama S (2018). Mental Health and Well-Being of University
Students in Okinawa. Educ Res Int 2018: 4231836.
Reifler CB (2006). Epidemiologic aspects of college mental health. Journal of American college
health; 54(6): 372-376.
Roberts SJ, Glod CA, Kim R, et al (2010) Relationships between aggression, depression, and
alcohol, tobacco: Implications for healthcare providers in student health. J Am Acad Nurse Pract
22: 369–375.
Rosenthal SR, Clark MA, Marshall BDL, et al. (2018) Alcohol consequences, not quantity,
predict major depression onset among first-year female college students. Addict Behav 85: 70–
76.
Sadock B, Kaplan H. Kaplan and Sadock (2007).synopsis of psychiatry: behavioral
sciences/clinical psychiatry. Baltimore: Lippincott Williams & Wilkins.
Sakellari E, Leino-Kilpi H, Kalokerinou-Anagnostopoulou A (2011). Educational interventions
in secondary education aiming to affect pupils’ attitudes towards mental illness: A review of the
literature. Journal of psychiatric & mental health nursing; 18: 166-176.
Samouilhan T and Seabi J (2010). University students' beliefs about the causes and treatments of
mental illness. South Africa journal of psychology; 40(1): 74-89.
Sana Samreen, Nasir A. Siddiqui, and Ramzi A. Mothana (2020).Prevalence of Anxiety and
Associated Factors among Pharmacy Students in Saudi Arabia: a Cross-Sectional Study. BioMed
Research International .Article ID 2436538 | https://doi.org/10.1155/2020/2436538
Sani M, Mahfouz MS, Bani I, Alsomily AH., Alagi D, Alsomily N, Asiri S, et al
(2012).Prevalence of stress among medical students in Jizan university, Kingdom of Saudi
Arabia. Gulf medical journal; 1 (1): 19-25.
Saxena S, Thornicroft G, Knapp M and Whiteford H (2007). Lancet 370, 878–889
Scholz M, Neumann C, Ropohl A, et al (2016). Risk factors for mental disorders develop early
in German students of dentistry. Ann Anat Anz 208: 204–207.

58
Schweizer S, Kievit RA, Emery T et al., (2018). Symptoms of depression in a large healthy
population cohort are related to subjective memory complaints and memory performance in
negative contexts. Psychol Med 48: 104–114.
Seedat S, Stein D, Jackson P, Heeringa S, Williams D (2009). Myer Life stress and mental
disorders in the South African stress and health study. SAMJ; 99 (5), 375-382.
Shamsuddin K, Fadzil F, Ismail WSW, Shah SA, Omar K, Muhammad NA, et al.(2013)
Correlates of depression, anxiety and stress among Malaysian university students. Asian J
Psychiatr; 6(4):318–23.
Skala K, Kapusta ND, Schlaff G, Unseld M, Erfurth A, Lesch OM, Akiskal HS (2012). Suicidal
ideation and temperament: an investigation among college students. Journal of affective
disorders; 141(2–3): 399–405.
Springer D, Rubin A, Beevers C (2011). Treatment of depression in adolescents and adults:
clinician’s guide to evidence-based practice. In: Clinician’s guide to evidence based practice
series. West Sussex: John Wiley & Sons.
Stallman HM (2010). Psychological distress in university students: A comparison with general
population data. Aust Psychol 45: 249–257.
Steptoe A, Tsuda A, Tanaka Y, Wardle J (2007). Depressive symptoms, socio-economic
background, sense of control, and cultural factors in university students from 23 countries.
International Journal of Behavioral Medicine, 14:97-107.
Storrie K, Ahern K, Tuckett A (2010). A systematic review: Students with mental health
problems–a growing problem. International journal of nursing practice; 16(1): 1-6.
Su J, Buys N, Stewart D, Shum D, Farquhar L (2011). Smoking in Australian university
students and its association with socio-demographic factors, stress, health status, coping
strategies, and attitude. Health education; 111: 117-132.
Sweetland AC, Belkin GS, Verdeli H (2014). Measuring depression and anxiety in sub-Saharan
Africa. Depress Anxiety; 31:223-32.
Sznitman SR, Reisel L, Romer D (2011).The Neglected Role of Adolescent Emotional
WellBeing in National Educational Achievement: Bridging the Gap between Education and
Mental Health Policies. J Adolesc Health 48: 135–142.
Tamunosiki CA, Chinawa JM, Aniwada EC, et al (2017). Determinants of depression among
medical students in two medical schools from South East Nigeria: A screening test. Ann
Nigerian Med; 11:27.
Tavolacci MP, Ladner J, Grigioni S, et al (2013). Prevalence and association of perceived stress,
substance use and behavioral addictions: a cross-sectional study among university students in
France, 2009–2011. BMC Public Health 13: 724.

59
 Terebessy A, Czeglédi E, Balla BC et al (2016). Medical students’ health behaviour and self-
reported mental health status by their country of origin: a cross-sectional study. BMC Psychiat
16: 171
The American College Health Association (2006). American college health association national
college health assessment Spring 2006 reference group data report (Abridged). Journal of
American college health; 54 (4): 195-206
Thomas L, Orme E, Kerrigan F (2020). Student Loneliness: The Role of Social Media through
Life Transitions. Comput Educ 146: 103754. Violence 34: 4597–4619.
Tountas Y, Dimitrakaki C (2006) .Health education for youth. Pediat Endocrinol Rev P 3: 222–
225.
Trivedi MH (2004).The link between depression and physical symptoms. Prim Care Companion
J Clin Psychiatry; 6:12.
Turner AP, Hammond CL, Gilchrist M, et al (2007). Coventry university students’ experience of
mental health problems. Couns Psychol Q 20: 247–252.
Usher W, Curran C (2017). Predicting Australia’s university students’ mental health status.
Health Promot Int 34: 312–322
Vaez M and Laflamme L (2008). Experienced stress, psychological symptoms, self-rated health
and academic achievement: A longitudinal study of Swedish university students. Social behavior
and personality; 36(2): 183-196.
Vaughn AA, Drake RR, Haydock S (2016) College student mental health and quality of
workplace relationships. J Am Coll Health 64: 26–37.
Vazquez F, Blanco V (2006).Symptoms of depression and related factors among Spanish
university students. Psychological Reports 99:583-90.
Verger P, Combes JB, Kovess-Masfety V, Choquet M, Guagliardo V, Rouillon F, Peretti-Watel,
P(2009). Psychological distress in first year university students: Socioeconomic and academic
stressors, mastery and social support in young men and women. Social Psychiatry and
psychiatric epidemiology; 44(8): 643-650.
Vitasari P, Wahab MNA, Othman A, Herawan T and Sinnadurai SK (2010). “The relationship
between study anxiety and academic performance among engineering students,” Procedia-
Social and Behavioral Sciences, 8: 490–497.
Vogel H L and Collins AL (2006). “The relationship between test anxiety and academic
performance,” Journal of Abnormal and Social Psychology, 67: 523–532.
Vredenburg K, O’Brien E, Krames L (1988). Depression in college students: personality and
experiential factors. Journal of Counseling Psychology, 35:419-25.

60
 Waghachavare VB, Dhumale GB, Kadam YR, Gore AD (2013). A study of stress among
students of Professional Colleges from an urban area in India. Sultan Qaboos University Medical
Journal; 13 (3): 429-436.
Wallace DD, Boynton MH, Lytle LA (2017). Multilevel analysis exploring the links between
stress, depression, and sleep problems among two-year college students. J Am Coll Health 65:
187–196
Wanda MC, Carla S (2013) .Stress, Depression, and Anxiety among Undergraduate Nursing
Students. Int J Nurs Educ Scholarship 10: 255–266.
Weissman M, Bland R, Canino G, Faravelli CEA (1996).Cross-national epidemiology of major
depression and bipolar disorder. JAMA 276:293-9.
Whitton S, Whisman M (2010).Relationship satisfaction instability and depression. Journal of
Family Psychology, 24:791-4.
Whitton SW, Weitbrecht EM, Kuryluk AD et al (2013). Committed Dating Relationships and
Mental Health Among College Students. J Am Coll Health 61: 176–183.
WHO (2017) Depression and Other Common Mental Disorders Global Health Estimates.
WHO/MSD/MER/2017.2
WHO Atlas on Substance Use (WHO, 2010).
WHO Mental Health Atlas (WHO, 2005).
Williams DR, Gonzalez HM, Neighbors H, et al., (2007). Prevalence and distribution of major
depressive disorder in African Americans, Caribbean blacks, and non-Hispanic whites: Results
from the national survey of American life. Arch Gen Psychiatry; 64:305-15.
Wimo A, Winblad B and Jönsson L (2010). Alzheimer’s & Dementia 6, 98–103
Winter Y, Korchounov A, Zhukova T, Bertschi N (2011). Depression in elderly patients with
Alzheimer dementia or vascular dementia and its influence on their quality of life. Journal of
Neurosciences in Rural Practice, 2: 27-32.
World Health Organization .The Global Burden of Disease: 2004 Update (WHO, 2008).
World Health Organization. Mental health: strengthening our response. Geneva, World Health
Organization (Fact sheet no. 220)(updated 2020). Available from: http://www.who.int/me
diacentre/factsheets/fs220/en/index.html.
Yao B, Han W, Zeng L, et al (2013). Freshman year mental health symptoms and level of
adaptation as predictors of Internet addiction: a retrospective nested case-control study of male
Chinese college students. Psychiat Res 210: 541–547.
Zeng W, Chen R, Wang X, et al (2019). Prevalence of mental health problems among medical
students in China: A meta-analysis. Medicine 98: 15337–15337.

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 Zivin K, Eisenberg D, Gollust SE et al., (2009).Persistence of mental health problems and needs
in a college student population. J Affect Disord 117: 180–185.

APPENDIX

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TOPIC: Prevalence of Depression and Anxiety in Undergraduate students studying in the
Faculty of Pharmacy ,Madonna University, Elele, Nigeria …
Background: Depression and anxiety symptoms are reported to be common among university students in
many regions of the world and impact on quality of life and academic attainment. Poor mental health
among university students has been a cause of concern globally. An exhaustive systematic review
indicated that university students have higher rates of depression than the general population. Prevalence
of depression or anxiety among health professions’ students have also been reported to be higher than in
the general population in resource-constrained settings and resource-rich settings. Most of these studies
have reported prevalence of depression or anxiety above 35%.

DEMOGRAPHIC INFORMATION

Gender: Male Female Marital status: Married

Level: Single
200
300
400
500

Age Range: 15 -20 21 – 25 26 – 30 >30

CHRISTAINITY ISLAM OTHERS YORUBA HAUSA IGBO OTHERS

RELIGIO ETHNICITY
N

FAMILY INFORMATION

CURRENT PARENT
HOUSEHOLD STATUS
ONE Number of children: 1 2 3 4 5 6 >7
PARENT HOUSEHOLD
TWO
PARENT HOUSEHOLD
OTHERS

Position in the family: 1 2 3 4 5 6 >7

FAMILY BACKGROUND SETTLEMENT

RURAL URBAN

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Accommodation 1 2 3 4 5 6 7>

BECKS DEPRESSION INVENTORY

1- I do not feel sad , I feel sad , I am sad all the time and I can’t snap out of it ,
I am so sad and unhappy that I can’t stand it

2- I am not particularly discouraged about the future , I feel discouraged about the future , I
feel I have nothing to look forward to , I feel the future is hopeless and that things cannot
improve

3- I do not feel like a failure , I feel like I have failed more than the average person ,
As I look back on my life all I can see is a lot of failures ,I feel I am a complete failure as a
person

4- I get as much satisfaction out of things as I used to , I don’t enjoy things the way I used to ,I
don’t get real satisfaction out of anything anymore , I am dissatisfied or bored with everything

5- I don’t feel particularly guilty , I feel guilty a good part of the time , I feel quite guilty most of
the time , I feel guilty all of the time

6- I don’t feel disappointed in myself , I am disappointed in myself ,I am disgusted with myself ,

I hate myself

7- I don’t feel I am any worse than anybody else , I am critical of myself for my weaknesses or
mistakes ,I blame myself all the time for my faults , I blame myself for everything bad that
happens

8- I don’t have any thoughts of killing myself , I have thoughts of killing myself, but I would not
carry them out , I would like to kill myself , I would kill myself if I had the chance

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9- I don’t cry any more than usual , I cry more than I used to , I cry all the time now , I used to
be able to cry, but now I can’t cry even though I want to

10- I am no more irritated by things than I ever was , I am slightly more irritated now than usual ,
I am quite annoyed or irritated a good deal of the time , I feel irritated all the time

11- I have not lost interest in other people , I am less interested in other people than I used to be
, I have lost most of my interest in other people , I have lost all of my interest in other people

12- I make decisions about as well as I ever could , I put off making decisions more than I used
to , I have greater difficulty in making decisions more than I used to , I cant make decisions at
all anymore

13- I don’t feel that I look any worse than I used to , I am worried that I am looking old or
unattractive ,I feel there are permanent changes in my appearance that make me look
unattractive , I believe that I look ugly

14- I can work about as well as before , It takes an extra effort to get started at doing something ,
I have to push myself very hard to do anything , I can’t do any work at all

15- I can sleep a well as usual , I don’t sleep as well as I used to , I wake up 1-2 hours earlier than
usual and find it hard to get back to sleep , I wake up several hours earlier than I used to and
cannot get back to sleep

16- I don’t get more tired than usual , I get tired more easily than I used to , I get tired from doing
almost anything , I am too tired to do anything

17- My appetite is no worse than usual , My appetite is not as as good as it used to be , My

appetite is much worse now , I have no appetite at all anymore

18- I haven’t lost much weight, if any lately , I have lost more than five pounds , I have lost more
than ten pounds , I have lost more than fifteen pounds

19- I am no more worried about my health than usual , I am worried about physical problems like
aches, pains, upset stomach, or constipation , I am very worried about physical problems and
it’s hard to think of much else , I am so worried about my physical problems that I cannot think
of anything else

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 20- I have not noticed any recent change in my interest in sex , I am less interested in sex than I
used to be , I have almost no interest in sex , I have lost interest in sex completely

21- I don’t feel I am being punished , I feel I may be punished , I expect to be punished I feel I
am being punished

HAMILTON ANXIETY RATING SCALE (HAM-A)

Anxious mood
This item covers the emotional condition of uncertainty about the future, ranging from worry,
insecurity irritability and apprehension to overpowering dread.
0-The patient is neither more of less insecure or irritable than usual.

1-Doubtful whether the patient is more insecure or irritable than usual.

2-The patient expresses more clearly to be in a state of anxiety, apprehension or
irritability, which he may find difficult to control. However, the worrying still is about
minor matters and thus without influence on the patient’s daily life.
3-At times the anxiety or insecurity is more difficult to control because the worrying is
about major injuries or harms which might occur in the future. Has occasionally interfered
with the patient daily life.
4-The feeling of dread is present so often that it markedly interferes with the patient’s
daily life.

Fears 
This item includes fear of being in a crowd, of animals, of being in public places of being alone

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of traffic, of strangers, of dark etc. it is important to note whether there has been more phobic
anxiety during the present episode than usual.

0-Not present

1-Doubtful whether present

2-The patient experiences phobic anxiety but is able to fight it

3-It is difficult to fight or overcome the phobic anxiety which thus to some extent
interferes with the patient daily life and work.

4-The phobic anxiety clearly interferes with the patient’s daily life and work.

Insomnia 
This item covers the patients subjective experience of sleep duration and sleep depth during
the three preceding nights. Note; Administration of hypnotics or sedatives is disregarded.

0-Usual sleep duration and sleep depth.

1-Sleep duration is doubtfully or slightly reduced (e.g. due to difficulties falling asleep),
but no change in sleep depth.
 
2-Sleep depth is also reduced, sleep being more superficial. Sleep as a whole is somewhat
disturbed

3-Sleep duration and sleep depth is markedly changed. Sleep periods total only a few
hours per 24 hours

4-Sleep depth is so shallow that the patient speaks of short periods of slumber or dozing
but no real sleep

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Tension
This item includes inability to relax, nervousness, bodily tensions, trembling and restless

fatigue.

0-The patient is neither more nor less tense than usual.

1-The patient seems somewhat more nervous and tense than usual.

2-Patient expresses clearly unable to relax and full of inner unrest, which he finds difficult
to control, but it is still without influence on the patients daily life.

3-The inner unrest and nervousness is so intense or frequent that it occasionally

interferes with the patient’s daily work.

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4-Tension and unrest interfere with the patient’s life and work at all times.

Difficulties in concentration and memory 

This item covers difficulties in concentration, making decision about everyday matters and
memory

0-The patient has neither more nor less difficulty in concentration and/or memory that
usual.

1-Doubtful whether the patient has difficulty in concentration and/or memory.

2-Even with a major effort it is difficult for the patient to concentrate on his daily routine.

3-The patient has pronounced difficulties with concentration, memory, or decision

making, e.g. in reading newspaper article or watching a television programme to the
end .

4-During the interview the patient shows difficulty in concentration memory or decision
making.

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Depressed mood 
This item covers both the verbal and non-verbal communication of sadness, depression,
despondency, despondency, helplessness

0-Not present

1-Doubtful whether the patient is more despondent or sad than usual or is only
vaguely so.

2-The patient is more clearly concerned with unpleasant experiences, although he

still lacks hopelessness or helplessness

3-The patient shows clear nonverbal signs of depression and/or hopelessness.

4-The patient remarks on despondency and helplessness or nonverbal signs

dominate the interview and the patient cannot be distracted.

General somatic symptoms; muscular

Weakness, stiffness, soreness, or real pain, more or less diffusely localized in the muscles,
such as jaw ache or neck ache

0-The patient is neither more or less stiff nor sore in the muscles than usual.

1-The patient seems somewhat more stiff or sore in the muscles than usual.

2-The symptoms have the character of pain.

3-Muscle pain interferes to some extent with the patient’s daily work and life.

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4-Muscle pain is present most of the time and clearly interferes with the patients daily
work and life

Cardiovascular symptoms
This item includes tachycardia, palpitation, oppression, chest pain, throbbing in the blood vessels, and
feelings of faintness

0-Not present

1-Doubtful whether present.

2-Cardiovascular symptoms are present, but the patient can still control them.

3-The patient has occasional difficulty controlling the cardiovascular symptoms, which thus to
some extent interfere with his daily life and work.

4-Cardiovascular symptoms are present most of the time and clearly interfere with the patients’
daily life and work.

Respiratory symptoms
Feelings of constriction or contraction in throat or chest, dyspnea or choking sensation and sighing
respiration

0-Not present

1-Doubtful whether present

2-Respiratory symptoms are present, but the patient can still control them

3-The patient has occasional difficulty controlling the respiratory symptoms which thus to
some extent interfere with his daily life and work

4-Respiratory symptoms are present most of the time clearly interfere with the patients daily
life and work.

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Gastro-intestinal symptoms
This item covers difficulties in swallowing, sinking sensation in stomach dyspepsia (heart burn or
burning sensation in the stomach, abdominal pains related to meals, fullness, nausea and
vomiting).

0-Not present

1-Doubtful whether present (or doubtful whether different from usual).

2-One or more gastro-intestinal symptoms are present, but the patient can still control them

3-The patient has occasional difficulty controlling the gastro-intestinal symptoms, which to
some extent interfere with his daily life and work

4-The gastro-intestinal symptoms are present most of the time and interfere clearly with the
patients daily life and work

Genito-urinary symptoms
This item includes non-organic or psychic symptoms such as frequent or more pressing passing of
urine menstrual irregularities, anorgasmia, dyspareunia, premature ejaculation, loss of erection.

0-Not present

1-Doubtful whether present (or doubtful whether different from usual)

2-One or more genito-urinary symptoms are present, but do not interfere with the patients
daily life and work

3-Occasionally, one or more genito-urinary symptoms are present to such a degree that they
interfere to some extent with the patients daily life and work

4-The genito-urinary symptoms are present most of the time and interfere clearly with the
patients daily life and work.

Other autonomic symptoms

This item includes dryness of mouth, blushing or pallor, sweating and dizziness

0-Not present

1-Doubtful whether present

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 2-One or more autonomic symptoms are present, but they do not interfere with the patients
daily life and work

3-Occasionally, one or more autonomic symptoms are present to such a degree that they
interfere to some extent with the patient daily life work

4-Autonomic symptoms are present most of the time and clearly interfere with the patients’
daily life and work.

Behavior during interviews

The patient may appear tense, nervous, agitated, restless, tremulous, pale, hyperventilating or
sweating during the interview. Based on such observations a global estimate is made. If you have
attended any form of interview, please pick one of the options that well describes your state at that
time (e.g. Madonna entrance interview)

0-I appeared anxious

1-I doubt I appeared anxious

2-I was moderately anxious

3- I was markedly anxious

4-I was overwhelmed in anxiety, for example with shaking and trembling all over

General somatic symptoms; sensory

This item includes increased fatigue and weakness or real functional disturbances of the
senses, including tinnitus, blurring of vision, hot and cold flashes and prickling sensations

0-Not present

1-Doubtful whether the patient indications of symptoms are more pronounced than usual
 
2-The sensation of pressure reach the character of buzzing in the ears, visual disturbances
and prickling or itching sensations in the skin

3-The generalized sensory symptoms interfere to some extent with the patients’ daily life
and work.

4-The generalized sensory symptoms are present most of the time and clearly interfere
with patients daily life and work

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