To measure the occurrence and levels of depression, anxiety and stress in undergraduate dental students using the Depression, Anxiety and Stress Scale (DASS-21).
This cross-sectional study was conducted in November and December of 2014. A total of 289 dental students were invited to participate, and 277 responded, resulting in a response rate of 96%. The final sample included 247 participants. Eligible participants were surveyed via a self-reported questionnaire that included the validated DASS-21 scale as the assessment tool and questions about demographic characteristics and methods for managing stress.
Abnormal levels of depression, anxiety and stress were identified in 55.9%, 66.8% and 54.7% of the study participants, respectively. A multiple linear regression analysis revealed multiple predictors: gender (for anxiety b=-3.589, p=.016 and stress b=-4.099, p=.008), satisfaction with faculty relationships (for depression b=-2.318, p=.007; anxiety b=-2.213, p=.004; and stress b=-2.854, p<.001), satisfaction with peer relationships (for depression b=-3.527, p<.001; anxiety b=-2.213, p=.004; and stress b=-2.854, p<.001), and dentistry as the first choice for field of study (for stress b=-2.648, p=.045). The standardized coefficients demonstrated the relationship and strength of the predictors for each subscale. To cope with stress, students engaged in various activities such as reading, watching television and seeking emotional support from others.
The high occurrence of depression, anxiety and stress among dental students highlights the importance of providing support programs and implementing preventive measures to help students, particularly those who are most susceptible to higher levels of these psychological conditions.
Dental education can be a significant source of stress among dental students, and studies have observed higher levels of stress among dental students than in the general population.
In their systematic review, Alzahem and colleagues
Long-term stress has been linked to the development of other disorders. A study conducted in a Swedish population found an association between different stress levels and mental health: high levels of stress were associated with depression, whereas low and moderate stress levels were associated with anxiety.
Despite their interrelationship, anxiety and depression in dental students have not been explored as frequently as stress. Previous studies have implemented specific tools designed to evaluate the construct of stress only, such as the commonly used Dental Environmental Stress (DES) Scale.
Although several studies have assessed levels of stress and identified stressors in the dental environment in Saudi Arabia, no studies have used measures of depression and anxiety to assess the psychological well-being of undergraduate dental students specifically. Therefore, our aim was to measure the levels of depression, anxiety and stress in dental students at King Saud University (KSU) using the DASS-21 and to investigate the relationship between these levels and previously reported stressors.
This cross-sectional study was conducted at the College of Dentistry of KSU in Riyadh City, Saudi Arabia, during November and December of 2014. All undergraduate dental students were eligible to participate. First-year dental students who had not yet completed one year of dental school and students receiving any psychological management (cognitive or behavioral therapy, medication or a combination; whose responses could be biased due to the effect of treatment on their psychological status) were excluded from the study. Ethical approval was obtained from the Ethics Committee of the College of Dentistry Research Center (CDRC) at KSU (CDRC NO: IR0096).
In total, 289 of 595 students from all study years were invited to participate. The questionnaire was completed by 277 students, resulting in a response rate of 95.8%. Of the surveyed participants, 30 (10.83%) disclosed receiving psychological management and were excluded from the study; thus, the final sample size was 247 participants. The demographic characteristics of the study participants are presented in
% | No. | Demographic variable | |
---|---|---|---|
54.2 | 134 | Male | Gender |
45.7 | 113 | Female | |
89.1 | 220 | Single | Marital status |
8.9 | 22 | Married | |
0 | 0 | Widowed | |
2 | 5 | Divorced | |
19 | 47 | 2nd year | Year of study |
21.4 | 53 | 3rd year | |
19.4 | 48 | 4th year | |
19.0 | 47 | 5th year | |
21 | 52 | Interns | |
13.8 | 34 | 2.75 - < 3.75 | GPA (of previous year) |
44.1 | 109 | 3.75 - < 4.5 | |
42.1 | 104 | 4.5 - 5 | |
36.4 | 90 | No | Dentistry 1st choice |
63.5 | 157 | Yes | |
83.0 | 205 | No | Financial responsibilities |
17.0 | 42 | Yes | |
79.8 | 197 | Satisfied | Satisfaction with peer relationships |
7.3 | 18 | Dissatisfied | |
12.9 | 32 | Neither | |
60.3 | 149 | Satisfied | Satisfaction with faculty relationships |
19.4 | 48 | Dissatisfied | |
20.2 | 50 | Neither | |
51.8 | 128 | Satisfied | Satisfaction with college overall |
34.0 | 84 | Dissatisfied | |
14.2 | 35 | Neither |
A two-part, self-administered questionnaire was developed in English. The first section included 11 questions related to demographic characteristics such as gender, marital status, year of study, grade point average (GPA), and whether dental school was the student’s first admission choice. Subsequently, the students answered questions scored on a Likert scale (from 0 to 5) assessing their satisfaction with their peer and faculty relationships and the academic environment in general. A final question addressed the students’ stress coping methods (more than one option could be selected). The second section of the questionnaire contained the 21 items from the short-form version of the DASS.
The DASS was developed by Lovibond and Lovibond
The DASS-21 is the short-form version of the original self-reported 42-item questionnaire and has demonstrated good to excellent internal consistency,
Stress N (%) | Anxiety N (%) | Depression N (%) | Levels |
---|---|---|---|
112 (45.3) | 82 (33.2) | 109 (44.1) | Normal |
36 (14.6) | 28 (11.3) | 35 (14.2) | Mild |
49 (19.8) | 53 (21.4) | 53 (21.4) | Moderate |
30 (12.1) | 22 (8.9) | 21 (8.5) | Severe |
20 (8.1) | 62 (25.1) | 29 (11.7) | Extremely severe |
Class leaders were contacted, and a 10-minute meeting after a lecture was arranged for each student year. One of the authors briefly explained the project, and hard copies of the questionnaires were then distributed. Participation was voluntary, the purpose of the research was stated on the first page of the questionnaire, confidentiality and anonymity were assured, and written informed consent was obtained from all participants.
The statistical analysis was performed using Statistical Package for Social Sciences software (SPSS version 20) (IBM Corporation, New York, USA). Descriptive statistics (means, standard deviations, percentages and frequencies) were calculated to assess the percentages and levels of depression, anxiety and stress among the study participants. Multiple linear regression was used to test whether depression, anxiety and stress could be predicted by the different variables in the questionnaire.
Abnormal levels of depression, anxiety and stress were observed in 55.9%, 66.8% and 54.7% of the respondents, respectively (
The Cronbach’s alphas for each of the 7-item subscales (Depression = .889, Anxiety = .822, Stress = .865) indicated the high internal consistency and reliability of the questionnaire. The residual plot distribution revealed a slight positive skew towards depression (K-S test, p = .042; skewness = .654) and anxiety (K-S test, p = .251) but no marked inflation due to collinearity.
A significant regression equation was found (R2Adjusted = .129. F(9,237) = 5.044, p < .001). Satisfaction with relationships with peers significantly predicted depression (b = -3.527, t(237) = -3.592, p < .001), as did satisfaction with relationships with college faculty (b = -2.318, t(237) = -2.709, p = .007). Depression decreased when satisfaction with peer and faculty relationships increased. Low satisfaction with relationships with peers was a stronger predictor of depression (β = -.229) than low satisfaction with relationships with faculty (β = -.174) (
A significant regression equation was found (R2Adjusted = .123, F(9,237) = 4.825, p < .001). Gender significantly predicted anxiety (b = -3.589, t(237) = -2.424, p = .016), as did satisfaction with relationships with peers (b = -2.119, t(237) = -2.432, p = .016) and satisfaction with relationships with faculty (b = -2.213, t(237) = -2.914, p = .004). Anxiety decreased when there was an increase in satisfaction with peer and faculty relationships and when the student was male. Gender was a slightly stronger predictor of anxiety (β = -.189) than low satisfaction with relationships with faculty (β = -.188), while low satisfaction with relationships with peers (β = -.155) was the weakest predictor (
A significant regression equation was found (R2Adjusted = .163, F(9,237) = 6.305, p < .001). Gender significantly predicted stress (b = -4.099, t(237) = -2.683, p = .008), as did dentistry as the student’s first choice of study (b = -2.648, t(237) = -2.011, p = .045), satisfaction with relationships with peers (b = -2.096, t(237) = -2.331, p = .021), and satisfaction with relationships with faculty (b = -2.854, t(237) = -3.642, p < .001). Stress decreased when (a) the student was male; (b) there was an increase in satisfaction with relationships with peers; (c) there was an increase in satisfaction with relationships with college faculty; or (d) dentistry was the student’s first choice of study. The strongest predictor of stress was low satisfaction with faculty relationships (β = -.229), followed by gender (β = -.204) and low satisfaction with relationships with peers (β = -.145), and the weakest predictor was when dentistry was not the student’s first choice of study (β = -.127) (
Predictor | Subscale | Unstandardized Coefficients | Standardized Coefficients | t | p | Collinearity Statistics | ||
---|---|---|---|---|---|---|---|---|
b | SE | β | Tolerance | VIF | ||||
Constant | D | 33.597 | 8.272 | 4.062 | .000* | |||
A | 22.598 | 5.559 | 4.065 | .000* | ||||
S | 29.473 | 5.737 | 5.137 | <.001* | ||||
Gender (1 = Male, 0 = Female) | D | -2.275 | 1.668 | -.106 | -1.364 | .174 | .586 | 1.705 |
A | -3.589 | 1.480 | -.189 | -2.424 | .016* | .586 | 1.705 | |
S | -4.099 | 1.528 | -.204 | -2.683 | .008* | .586 | 1.705 | |
Marital status (1 = Married, 0 = Not Married) | D | 0.324 | 2.310 | .009 | 0.140 | .889 | .937 | 1.067 |
A | 3.331 | 2.049 | .100 | 1.625 | .105 | .937 | 1.067 | |
S | 2.762 | 2.115 | .079 | 1.306 | .193 | .937 | 1.067 | |
Year of study (1 to 5) | D | 0.880 | .496 | .117 | 1.774 | .077 | .821 | 1.218 |
A | 3.331 | 2.049 | .100 | 1.625 | .105 | .937 | 1.067 | |
S | 0.573 | .454 | .081 | 1.261 | .209 | .821 | 1.218 | |
GPA of the previous year (2 to 4) | D | 0.893 | 1.221 | .058 | 0.731 | .465 | .569 | 1.758 |
A | 3.331 | 2.049 | .100 | 1.625 | .105 | .937 | 1.067 | |
S | 1.318 | 1.118 | .091 | 1.179 | .240 | .569 | 1.758 | |
Was studying dentistry your first choice? (1 = Yes, 0 = No) | D | -1.640 | 1.438 | -.074 | -1.140 | .255 | .847 | 1.181 |
A | -2.430 | 1.276 | -.124 | -1.904 | .058 | .847 | 1.181 | |
S | -2.648 | 1.317 | -.127 | -2.011 | .045* | .847 | 1.181 | |
Do you have financial responsibilities towards your family? (1=Yes, 0 = No) | D | -0.401 | 1.800 | -.014 | -0.223 | .824 | .887 | 1.127 |
A | -2.430 | 1.276 | -.124 | -1.904 | .058 | .847 | 1.181 | |
S | -0.756 | 1.648 | -.028 | -.459 | .647 | .887 | 1.127 | |
How satisfied are you with your relationship with your peers? (1 to 3) | D | -3.527 | .982 | -.229 | -3.592 | <.001* | .875 | 1.143 |
A | -2.119 | .871 | -.155 | -2.432 | .016* | .875 | 1.143 | |
S | -2.096 | .899 | -.145 | -2.331 | .021* | .875 | 1.143 | |
How satisfied are you with your relationship with college faculty? (1 to 3) | D | -2.318 | .856 | -.174 | -2.709 | .007* | .859 | 1.165 |
A | -2.213 | .759 | -.188 | -2.914 | .004* | .859 | 1.165 | |
S | -2.854 | .784 | -.229 | -3.642 | <.001* | .859 | 1.165 | |
Overall, are you satisfied with your experience at college?(1 to 3) | D | -0.433 | .921 | -.029 | -0.470 | .639 | .923 | 1.084 |
A | 0.793 | .817 | .060 | .971 | .333 | .923 | 1.084 | |
S | -0.017 | .843 | -.001 | -.020 | .984 | .923 | 1.084 |
*Significant predictor (p < .05)
D=depression, A=anxiety, S=stress, SE=standard error, VIF=variance inflation factor
The most frequently mentioned coping method for relieving stress was "activities such as watching television, reading, sleeping and shopping" (71%), followed by "emotional support from others" (53%). Under “other” mechanisms, eating, traveling and smoking were mentioned by some students as stress coping methods. Two students mentioned using recreational drugs to relieve stress (
Undergraduate dental education in Saudi Arabia is a seven-year program. The first year is a general preparatory year that is common to all health colleges, followed by 5 years of dental school. The final year is a 12-month internship program. The first year consists mainly of courses in basic, medical, and dental science. Students enroll in dental school directly from high school; the level of competition is very high, and only the best students with the highest grades and performance indicators at school and on admission exams and interviews are accepted. This competition persists throughout dental education, as high grades and above-average performance are expected and represent the norm. Additional pressure stems from the large amount of new information that students must learn and the technical skills they must master. Schmitter and colleagues
In this study, the occurrence of depression, anxiety, and stress among dental students was high, and the levels of these conditions were abnormal in more than half the students. The figures in this study were comparable to those of Aboalshamat and colleagues
The higher rate of and scores for anxiety (compared with depression and stress) confirm the observation that anxiety has become the most common mental health problem among college students.
Students’ methods of stress reduction
The high levels of depression, anxiety and stress could be attributed to the pressure exerted on students during dental education by their workload, clinical requirements, examinations and grades.
Female students universally report higher levels of stress and anxiety,
Marital status and financial responsibilities were not significant predictors of depression, anxiety, or stress in the current research. Other studies have also found that students’ marital status is not a significant predictor.
Study year and academic achievement (measured by GPA in this study) are the most commonly reported academic factors that significantly affect dental students’ psychological health. Studies have reported higher stress levels among students with the lowest GPAs and among students with average GPAs than among other students.
The most significant and strongest predictors in this study were students’ satisfaction with their faculty and peer relationships, followed by their overall experience at the college. Therefore, factors related to human relationships appear to have a greater impact on psychological health than other academic factors. Similarly, Wayt
Students’ satisfaction with their learning environment has been discussed in the literature. In previous studies, students have either been unsatisfied with faculty support
Previous studies have focused more on students’ relationships with staff than their relationships with fellow students. In this study, we found that one of the strongest predictors of stress was peer relationships; satisfactory peer relationships protected against distress. Previous studies have reported that the higher students’ social support is, the lower their symptoms of stress.
Stressed individuals typically adopt certain coping patterns as a natural response to stress and to alleviate the associated psychological tension. In our study, the majority of the students actively engaged in activities unrelated to the profession of dentistry to relieve stress. Previous studies have found that the most common coping method is emotional support from others, specifically, talking to friends and family.
Research has also suggested that students with certain personality traits are more prone to distress. Specifically, the risk of depression may increase with maladaptive perfectionism,
Several strategies for stress management among dental students have been introduced and discussed in the literature, including relaxation strategies, interpersonal approaches such as counseling systems, programs designed to improve studying and test-taking skills and stress management workshops.
Although this study has several strengths, such as the excellent response rate, random sampling method, and the simple and concise test tool, it also has some limitations. The cross-sectional design does not allow for assessments of changes in psychological status over time. In addition, given the self-reported nature of the assessment tool, we cannot rule out response bias. Furthermore, our literature review was limited to articles published in English, which may preclude comparisons with significant findings reported in other languages. To improve the accuracy of the outcomes, studies using a longitudinal design that include more schools at the national or international level are recommended for future research.
This study aimed to assess the levels of depression, anxiety and stress in undergraduate dental students and found that despite excluding participants currently undergoing psychological management, the levels of these conditions were relatively high. The actual numbers may be even higher than those reported herein. Participants with abnormal depression and anxiety scores require a clinical diagnosis to receive prompt treatment. Furthermore, to ensure early identification of and intervention for psychological conditions, both students and faculty should be educated regarding the physical and psychological signs and symptoms of anxiety and depression. More attention should be devoted to susceptible individuals, such as female students, with the aim of improving relationships and satisfaction levels. Strategies for stress prevention and management should be implemented in dental schools to improve students’ well-being, prevent drop out and ensure proper patient care. The persistence of these problems may lead to further physical and psychological complications that could continue after graduation, resulting in unhealthy dentists or early retirement and thereby affecting both the quantity and quality of the workforce.
The authors would like to acknowledge the efforts of Dr Manal Alkadi, who had an important role and contributed to this study but humbly chose not to share co-authorship of this article.
The authors declare that they have no conflict of interest.