The medical school curriculum of the College of Medicine, King Saud University, Riyadh, Saudi Arabia, has been developed to graduate competent and professional physicians to serve their community efficiently. Medical education is perceived as being stressful, as it is characterized by many psychological changes in students.

Studies have shown that medical students experience a high level of stress during their undergraduate course (^1-5). High level of stress may have a negative effect on cognitive functioning and learning of students in the medical school (⁶). Results of studies suggest that mental health worsens after students begin medical school and remain poor throughout the training (¹). The majority of studies on stress in medical education focus on the documentation of stress and information on the correlates of stress (⁴,⁷).

In many medical schools, the environment itself is an all prevailing pressure situation, providing an authoritarian and rigid system, one that encourages competition rather than cooperation between learners (⁵). It is not just the undergraduate study period which brings stress but it may continue during the internship, postgraduate study period, and later into physician's practical life (^8-10). The stress may also reach burnout levels (¹¹).

The estimated prevalence of emotional disturbance found in different studies on medical students was higher than that in the general population. In three British universities, the prevalence of stress was 31.2% (¹²), and it was 41.9% in a Malaysian medical school (¹³) and 61.4% in a Thai medical school (¹⁴). Stress in medical school is likely to predict later mental health problems but students seldom seek help for their problems (¹⁵). In a Swedish study, the prevalence of depressive symptoms among medical students was 12.9%, and 2.7% of students had made suicidal attempts (⁶). It is important for medical educators to know the prevalence, causes, and levels of stress among students, which not only affect their health but also their academic achievements at different points of time of their study period.

In Saudi Arabia, local epidemiological data about psychological morbidity among medical undergraduate students are scarce. Results of two recent studies from Egypt and Saudi Arabia suggest high rates of anxiety and depression among medical students (¹⁶,¹⁷). An extensive electronic Internet-based search failed to locate any study which shows an association between stress and academic achievement in undergraduate medical students in Saudi Arabia. The present study was, therefore, carried out to determine the prevalence of self-perceived stress among medical students and to observe any possible association between the levels of stress and (a) gender, (b) academic year, (c) academic grades, (d) regularity of course attendance, and (e) presence of perceived physical problems.

In total, 775 (87%) of approximately 892 students completed the questionnaire Their mean (±standard deviation) age was 21.3 (±1.7) years. The characteristics of the study subjects are shown in Table 1. The prevalence of stress of all levels was about 63.8%, and the prevalence of severe stress was 25.2% (Table 2).

The proportion of female students who had stress was higher (75.7%) than their counterpart males (57%) [χ²=27.2, odds ratio (OR)=2.3, p<0.0001].

The prevalence of stress was the highest among the first-year students (78.7%), followed by the second-year (70.8%), third-year (68%), fourth-year (43.2%), and fifth-year students (48.3%). There was a high significant association between the study year and the stress levels (χ² test for trend=47.9, p<0.0001). The odds ratios were 3.96 (first year), 2.6 (second year), 1.9 (third year), and 0.82 (fourth year) respectively while the fifth year was considered the reference category. It also indicated a high significant association. The association between the academic grades of the students and the rate of stress was not significant (χ² test for trend=1.01, p=0.31).

There was no significant association between the regularity of attendance in the academic course (yes/no) and the level of stress among the students. The distribution of stress levels was not significantly related to a student being either regular or irregular in attending the academic course work (χ²=0.037, OR=1.05, p=0.85). Students who reported physical symptoms were more likely to be stressed than those who did not perceive physical symptoms.

The presence of physical problems had a significant association with a higher level of stress among the students (χ²=20.3, OR=2.1; p<0.0001) (Table 3). The study variables, including being female (p<0.0001), year of study (p<0.001), and presence of perceived physical problems (p<0.0001), were found as independent significant risk factors for the outcome variable of stress (Table 4). The mean number of days (9.5 days) being unable to study or work was higher among students who had stress than students with no stress (2.3 days) (t=9.75, p<0.0001). The mean number of days that the respondents managed to work only partially was higher among students who had stress (10.7 days) than students with no stress (5.2 days) (t=5.3, p<0.0001).

The main sources of stress stated by the students were coping with their studies (60.3%), followed by home environment (2.8%). However, 36.9% of the students did not mention any source of stress.

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 (⁷,²⁸).

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 (¹²,²³,²⁴). 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 (^30-32). 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.

The authors gratefully acknowledge all those medical students who participated in and contributed to the study. They also thank Dr. Shaffi Ahamed Shaikh for statistical analysis and Prof. Riaz Qureshi for revising and editing the manuscript.