The general health and well-being of medical students have become a matter of concern as the demands of medical schools become increasingly more stressful. Stress is omnipresent and drives people to perform to the best of their ability. However, excessive or persistent stress leads to psychological and physical ill-health. A previous systematic review showed that stress is prevalent in university students and has significant negative effects on their quality of life. Multiple factors such as tight time schedules, increased workload, fears of failing, and highly competitive environments are associated with higher stress and psychological illnesses in students.
The prevalence of psychological distress is higher in medical students than in their nonmedical peers[5-7] with a 33.8% global prevalence of anxiety in medical students. The prevalence of stress is even greater in first year medical students since they need to cope with all sorts of stressors in a short period. Long-standing stress can lead to serious outcomes, such as burnout, depression, anxiety, poor mental or physical quality of life, and adjustment disorder.[9,10] Moreover, the inability to cope with such stressors may lead to adjustment disorder.
According to DSM-IV, the adjustment disorder is defined as “the presence of emotional or behavioral symptoms in response to an identifiable stressor, occurring within 3 months of the onset of the stressor, these symptoms are clinically demonstrated as either of the following: marked distress, in excess to what would be expected from exposure to the stressor, or significant impairment of social, occupational, or academic functioning.” In addition to impacting the quality of life and psychological health, adjustment disorder also significantly increases suicidal ideation. According to the American Psychiatric Association, the prevalence of adjustment disorder was in the range of 5%–20% in outpatient mental health treatment. Clinically, adjustment disorder can be classified into six main subtypes: depressed mood, anxiety, mixed anxiety and depression, disturbance of conduct, mixed disturbance of conduct and emotions, and an unspecified subtype. A scale known as the adjustment disorder-new model 20 (ADNM-20), has been developed to easily assess adjustment disorder and improve conceptualization. This scale measures both core and accessory symptoms including preoccupation with the stressor, failure to adapt, avoidance, depression, anxiety, and impulsivity to determine the patient’s subtype.
Medical students have the propensity to develop adjustment disorder since they experience multiple risk factors such as homesickness, change in living conditions, difficulty in making new friends, education pressure, and expectation. Therefore, every university and education ministry should investigate and assess the magnitude of the problem of adjustment disorder and its associated risk factors. The aim of this study was to estimate the proportion of first year medical students who have adjustment disorder and explore its possible risk factors.
Materials and Methods
A cross-sectional observational study was conducted on all first year medical students at King Saud University, College of Medicine, Saudi Arabia, to assess the proportion that had adjustment disorder and explore the possible risk factors. Ethical approval was obtained from the Institutional Review Board (IRB) vide Letter No. 19/0156/IRB dated 08/12/2019 and informed written consent was taken from all participants.
A questionnaire was distributed to the students through an online survey during their break. Data collection started on January 27, 2020, and lasted for 1 month. The dates were determined specifically to avoid examination periods. The estimated time for completion of the questionnaire was 7–10 min. The study objectives and methods were explained to the participants, who were also instructed on how to complete the questionnaire.
ADNM-20 is a self-reported measurement of assessing adjustment disorder with a stressor list and an item list. In the stressor list, the participants had the option to select out of a list of life stressors that which they had experienced recently and which was the most impactful/stressful. The item list consisted of multiple questions related to the most distressing event in the last 6 months on a four-point Likert scale from 1 (never) to 4 (often). The ADNM-20 item scores were summed, and a cut-off point >47.5 was designated as a high risk of developing an adjustment disorder. The ADNM-20 is divided into core symptoms of adjustment disorder and accessory symptoms. The core symptoms consisting of preoccupation and the failure to adapt were assessed by four items. The accessory symptoms included avoidance, depressive mood, anxiety, and impulse disturbances. Incomplete surveys were excluded. Demographic questions included age, gender, marital status, nationality, and permanent residence.
Statistical data analysis: The mean and standard deviation were used to describe the continuous variables, while categorical variables were described as frequency and percentages. The multiple response dichotomy analysis was applied to describe the variables with more than one option (e.g., experienced recent stressors). The Kolmogorov–Smirnov test of statistical normality was used to assess the metric variables. The Bivariate Chi-squared test of association was used to assess the correlations between categorical variables. The students perceived ADNM-20 score and its sub-scale scores were computed according to the author’s scoring manual, and the total score was dichotomized into low- versus high-adjustment disorder based on a cutoff value of 47.5 points. Multivariate binary logistic regression analysis was applied to assess the student’s odds of having an adjustment disorder and the stress of attending a medical school; the association between predictor-independent variables was expressed as a multivariate-adjusted odds ratio (OR) with 95% confidence intervals. Figures were created using Excel spreadsheets Version 2010, and the SPSS IBM v21 (Armonk, NY) statistical data analysis program was used for data analysis with the alpha significance level of 0.050 level.
Enrolled in this study were two hundred and sixty-seven medical students, 155 of whom had experienced a recent stressor. However, only 128 of them completed the ADNM-20 survey. Table 1 displays the descriptive analysis of the students’ sociodemographic characteristics. Most of the medical students (56.2%) were male, only a few of whom (4.6%) were ever married; 3.7% were non-Saudi expatriates, and 92.5% were Riyadh residents. Some (13.9%) students had previously been diagnosed with a mental illness, but most (66.3%) revealed that they experienced stress as a result of attending medical school.
Out of 267 students participating in the survey, only 155 reported recent stressors. The most recently experienced stressor was too much/too little work for 52.9% of the students [Table 2 and Figure 1], followed by time pressures and the difficulty of meeting deadlines both experienced by 52.8% of the students. The most impactful/stressful events for 28.9% of the students were too much/too little work followed by time pressures and the difficulty of meeting deadlines for 27.2% of the students.
Table 3 displays the descriptive analysis of the medical students’ overall perceptions of adjustment disorder ADNM-20 scale score and its sub-scale scores. The medical students’ overall mean perceived adjustment disorder ADNM-20 score was 44.16 ± 11.30, maximum possible score = 80, which highlights a moderate level of perceived adjustment difficulty. However, with a cutoff point of 47.5% to determine the high risk of adjustment disorder, most (44.5%) medical students fell into the high-risk category. Furthermore, the medical students’ mean perceived preoccupation with stressors subscale score was 10.66 ± 3.10 points, suggesting that the students could experience substantive preoccupation with stressful thoughts in general. Furthermore, the students’ failure to adapt sub-scale score was 9.91 ± 3.34 points, indicating that they had substantial difficulty adapting. In addition, the students’ mean perceived depressive mood subscale score of 7.51 ± 2.32 points is indicative of a high probability density of depression. The students’ anxiety subscale score of 5.23 ± 1.71 points suggests high perceived anxiety and their impulsive disturbance subscale score of 7.47 ± 2.57 points suggests substantive perceived impulsiveness as result of stressful events.
Multivariate binary logistic regression analysis was applied to explain why medical students perceived less or more adjustment failure/disorder [Table 4]. It showed that female medical students were more likely to have a high risk of adjustment disorder with the OR of 2.48 compared to male students (P = 0.030), accounting for the other independent predictor variables in the analysis model. Furthermore, the students’ age correlated significantly but negatively with their odds of having an adjustment disorder; for each year of increase in the students’ age, their odds of having an adjustment disorder declined by a factor equal to 60.3% times less than the average P = 0.013. Figure 2 illustrates that across all age groups, the mean predicted probability of being at high risk for adjustment disorder in general (the dashed lines) of female students exceeded that of males. Furthermore, the analysis showed that the students’ experience of the recent illness of a loved one correlated positively but not statistically significantly with their odds of being at high risk of an adjustment disorder (P = 0.055). Moreover, students who experienced family conflicts were at increased odds of 2.84 times of being at high risk for adjustment disorder compared to those who had had no recent family conflicts. However, this association was not statistically significant (P = 0.072). Students who reported that they had been under stress as result of too much/too little work were 2.72 times more at risk of adjustment disorder compared to those who had not experienced any stress (P = 0.037).
The aim of this cross-sectional study was to assess the proportion of students with adjustment disorder and explore the associated risk factors in students in their first year at medical college (Foundation year). The general prevalence of stressors in first year medical students was 58.1%, and 21.3% of the students were at high risk for adjustment disorder, indicating adjustment problems in medical students.
According to the ADNM-20 scale, 21.3% of first year medical students were at high risk for adjustment disorder, which is in contrast to a previous study that used the ADNM-20 scale during the COVID-19 pandemic that reported 57.6% of their study participants at high risk of adjustment disorder. Another study that assessed adjustment problems in students showed that 42.5% of the students at Ethiopian University, and 48% of the students at Jimma University, Ethiopia, had adjustment problems.[17,20] In addition, a previous local study conducted at the Gulf University of Bahrain found that 36.8% of the medical students had potential adjustment disorders, the highest prevalence being in first year medical students.
The stressors most reported by the students were too much/too little work, followed by time pressures and the difficulty of achieving time deadlines. The most common core symptom of adjustment disorder reported by the participants was a preoccupation with stressors, which is in line with previous local studies. At King Saud University, the prevalence of the medical students’ stress was 63.7% which was even higher in first year students at 78.7%. Furthermore, at a neighboring college in Riyadh, King Saud Bin Abdulaziz University for Health Sciences, the prevalence of medical students’ stress was 53.2%. The most commonly reported accessory symptoms, which could play an important role in the degree of suspicion of adjustment disorder in college students experiencing stress, was avoidance. Furthermore, the medical students exhibited a high probability density of depression and anxiety. First-year students were more affected by the depressive category of adjustment disorders.
Based on the literature review, it was hypothesized that sex, age, and family issues were risk factors for adjustment disorder.[25,26] Indeed, females were at a high risk for adjustment disorder. A previous study that used the ADNM-20 scale also reached a similar conclusion. Regarding age, 64% of the students were 19-year-old, 27% were 20-year-old and the rest were either 18 or 21 years and above, and there was a statistically significant inverse relationship between adjustment disorder and age.
Personal issues are as important as the demographics, but the death of a loved one, family conflicts, and the illness of a loved one were the most reported stressors not related to the medical school or demographics. This result is comparable to that of the Duhok University study in which personal illness or that of a loved one and family issues were the leading stressors. In our study, the illness of a loved one and family conflicts were only slightly positively correlated with adjustment disorder. However, all personal factors could influence a student’s ability to adjust to medical school.
We recommend that preventive measures such as screening and awareness programs should be considered for medical students to help them adapt to their new environment. Increased student-staff interactions could provide support to adapt to reduce social adjustment difficulties.
Our findings should be limited to the setting of the study, King Saud University. Since the study design was cross-sectional, a true causal relationship could not be established. Further longitudinal studies on a national scale are necessary to establish the causal relationships between adjustment disorder and medical students.
Medical students are exposed to tremendous amounts of stress, making them susceptible to developing an adjustment disorder. This study improves our understanding of adjustment disorder in first year medical students at King Saud University and adds to our knowledge that females and younger students, as well as those under too much stress, are at an increased risk of developing an adjustment disorder. The symptoms of adjustment disorder in first year medical students are mainly characterized by avoidance, followed by depression and anxiety.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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