A high prevalence of stress among medical students is a cause of concern as it may impair behaviour of students, diminish learning, and ultimately affect patient care after their graduation. The overall prevalence of stress in the study (63.7%) is similar to the Thai study (61.4%) (14
) but higher than a study in Egypt (43.7%) (16
), or a Malaysian study (41.9%) (13
), and a British study (31.2%) (12
). This could be either due to the different instruments used in other studies or it could be a real difference.
An interesting finding of the present study was that the level of stress decreased as the year of study progressed. This is contradictory to the finding of another study where the level of stress increased progressively during the course, to reach as high as 40% by the end of the clinical training period (24
). Results of other studies in North America also suggest that mental health worsens after students join a medical school and remains poor throughout the course (25
), especially in the transition from basic science teaching to clinical training (26
). Only one study falls in line with the finding of this study that the students found medical course stressful during the first year of study but less so in subsequent years (27
). This finding could be explained by many factors. First, that this is a cross-sectional and not a cohort study to be sure that the stress is really decreasing in the study subjects. This finding could be just due to chance as the study shows the increase of stress in different groups and not the same student groups. Another explanation could be that the students may have been able to develop coping mechanisms with the help of the students' support system. Also, usually low failure rates
in later years of courses make students more confident and less stressed. Another factor could be that our medical education is free of charge for the students in the governmental medical colleges. In many countries, medical students are plagued by financial worries, which is an important cause of their stress (7
The present study did not show any association of stress with grade point average (academic grade) and regularity of attendance in the courses. However, stress was significantly associated with the students' perception of physical problems. This aspect is difficult to explain based on the findings of the study. It is possible that stress is the cause of the physical symptoms, or the physical symptoms could cause the stress—both are possible.
The prevalence of stress in the study was higher among the female students compared to their male counterparts but other studies have shown that the gender differences in specific stress symptoms and overall prevalence or mean scores of stress were scarce and did not turn out to be a significant factor in reporting of stress (12
). As male and female students in their studies have separate campuses, it could be speculated that relatively a poor learning environment exists in the female campus with lesser educational facilities and recreation opportunities. However, this issue could not appropriately be explained by our study and requires further investigation.
The negative effects of long and tiring medical education on the psychological status of students have been shown in several studies. Results of a study in the UK showed that one-third of psychologically-ill students did not graduate from the college (29
). The changes relating to becoming a medical student appear to have a significant impact on the psychological status of students during the first year in their study. Therefore, with early identification and effective psychological services, possible future illnesses may be prevented. As the study findings showed a high level of stress among the first-year and second-year students, we suggest supporting them and taking care of this group by the student support system. This will also help them cope well with stress in the later years. It is very important to target stress-prevention strategies at students who have any level of psychological stress to prevent the development of more serious conditions relating to stress. Wellness and mental health programmes are also needed to help students make smooth transition between different learning environments with changing learning demands and a growing burden on their mental and physical capacity. Medical schools in the United States and Canada have initiated health-promotion programmes and have reported positive results in reducing the negative effects of stress upon health and academic performance of medical students (30
). A similar approach to reduce the level of stress could be used for the students of the College of Medicine, King Saud University. On the other hand, a minimal amount of stress is necessary to add spice to one's life and to achieve optimal performance at examinations. An element of stress is involved with growth and is essential for sound personal functioning.
This cross-sectional study was based on self-reported information provided by students. Therefore, there is some potential for reporting bias which may have occurred because of the respondents' interpretation of the questions or desire to report their emotions in a certain way or simply because of inaccuracies of responses. Another longitudinal study could be carried out with a cohort of students to investigate the levels of stress among students in all the five years of undergraduate medical years and the associated factors.
The findings of the study suggest that the level of psychosocial stress was higher in the female students compared to the male students. The stress level in the initial three years of the course was higher than the last two years of the course. Physical problems might have led to extra stress. The study did not find a significant association between academic grades and regularity of attendance in the course on one hand and the presence of stress on the other hand. The findings of high level of stress among the medical students in the initial years also suggest that, when students are admitted to the medical school, special care must be taken to find out obvious psychiatric problems or psychological stress among them. The major finding of high psychological stress in the students of the medical college of King Saud University points to the need for establishing counselling and preventive mental health services as an integral part of routine clinical services being provided to the medical students.