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Relation between insomnia and stress, anxiety, and depression
among Egyptian medical students
Doaa Barakat
a
, Mohamed Elwasify
b
, Mahmoud Elwasify
b
and Doaa Radwan
a
a
Department of Psychiatry, Faculty of Medicine,
Ain Shams University, Cairo and
b
Department of
Psychiatry, Faculty of Medicine, Mansoura University,
Mansoura, Egypt
Correspondence to Doaa Barakat, MD, PhD,
Department of Psychiatry, Ain Shams University
Hospitals, 22 Dair Almalak, Abbassia, 11657 Cairo,
Egypt
Tel: + 201006935895; fax: + 20226836379;
e-mail: doaab@hotmail.com
Received 14 March 2016
Accepted 12 May 2016
Middle East Current Psychiatry
2016, 23:119–127
Background
There has been a growing attention paid to depression, anxiety, and stress among
college students. Only few studies have assessed these topics among medical
students, and fewer still have been conducted in Arab countries. Furthermore, the
relation of depression, anxiety, and stress to insomnia has not been thoroughly
investigated.
Participants and methods
This cross-sectional, questionnaire-based observational study explored the prevalence
of stress, anxiety, and depression and their relationship to insomnia among 980
undergraduate medical students of Mansoura University. The data were gathered
using a demographic questionnaire, the Insomnia Severity Index, and the Depression
Anxiety Stress Scale.
Results
The prevalence of symptoms of stress, anxiety, and depression was 63.7, 66.9, and
59.2%, respectively. There were significant associations with multiple demographic
variables. There was a significant positive correlation between Insomnia Severity Index
score and stress, anxiety, and depression scores. Different stressors were identified by
the students, including residence, working while being educated, studying more than
4 h a day, difficulty studying in English, problems communicating with the teaching
staff, fear of failure in the future, death of a family member, chronic illness of a family
member, physical health problems, and problems due to coping with academic
demands.
Conclusion
Stress, anxiety, and depression are common among medical students in Egypt, and are
correlated with insomnia.
Keywords:
anxiety, depression, Depression Anxiety Stress Scale, Insomnia Severity Index,
insomnia, medical students, stress
Middle East Curr Psychiatry 23:119–127
&2016 Institute of Psychiatry, Ain Shams University
2090-5408
Introduction
Several studies have investigated different sleep practices
and difficulties among college students [1–3] and
medical residents [4], but only few were conducted on
medical students. Depression, anxiety, and stress were
assessed among university students in several stu-
dies [1,5,6], and among medical students in few studies
as well [7–9], but their relation to insomnia is still under-
investigated.
Medical students face tremendous stress because of
enormous and continuous academic demands that alter
their sleep habits. The quality and quantity of sleep may
change after enrollment in a medical school because
of exam anxiety, a tense environment, and irregular
schedules [10].
Dyssomnia reduces an individual’s ability to cope with
daily tensions and increases the incidence of depressive
and anxiety disorders. Irregularity in sleep–wake pattern
not only causes manifest mental and physiological
depression but also leads to derangements of social and
occupational activities [11].
Sleep disturbances are important symptoms in many
psychiatric illnesses, such as mood and anxiety disorders.
Because sleep disturbances usually precede other symp-
toms of depression, it has been speculated that a depressed
mood may be a consequence of sleep disturbance or that a
hormonal or neurotransmitter change causes both a
depressive state and sleep disturbance [12]. Sleep
disturbance can be a comorbidity, a cause, or a symptom
of psychiatric disorders [13]. The presence of psychiatric
illness may also complicate the diagnosis and prognosis of
sleep disorders [14].
Some researchers have advocated that a diagnosis of
depression in the absence of sleep disturbance should be
made cautiously. Sleep disturbance is a risk factor for
suicide, and persistent sleep problems increase the risk
for relapse and recurrence of depression. While difficulty
in initiating or maintaining sleep (including early morning
Original article 119
2090-5408 &2016 Institute of Psychiatry, Ain Shams University DOI: 10.1097/01.XME.0000484345.57567.a9
Copyright r2016 Institute of Psychiatry, Ain Shams University. Unauthorized reproduction of this article is prohibited.
awakening) has been broadly described in depressed
patients, hypersomnia is less common and could be a
feature of atypical depression [15].
A long-term prospective study was conducted on 1053
men who provided information on sleep habits during
medical school. The authors concluded that insomnia in
young men was an indicator of a high risk for subsequent
clinical depression and psychiatric distress that continued
for at least 30 years [16].
A study among 572 Mexican medical students concluded
that sleep difficulties were associated with stress, anger,
worry, cognitive hyperarousal, and hypervigilance [17].
Changes in the sleep architecture in patients with
depression and anxiety has been established [18,19].
Disruption in circadian rhythm and hypothalamic–
pituitary–adrenal axis activity have been identified in
patients with sleep disorders, as well as in patients with
anxiety and depression [15,20].
Hypothesis
We hypothesize that symptoms of depression, anxiety,
and stress are common among Egyptian medical students,
and are related to insomnia.
Aim
This study sought to evaluate the prevalence of
symptoms of stress, anxiety, and depression and their
relationships to insomnia in different academic classes of
undergraduate medical students in Mansoura University,
and to explore whether certain variables or stressors could
be associated with these symptoms.
Participants and methods
Study design
This was a cross-sectional, questionnaire-based, descrip-
tive study conducted from May 2015 to September 2015.
Participants
The study sample consisted of undergraduate medical
students who were enrolled at Mansoura University in
Egypt.
Sample size was calculated based on the prevalence of
depression, anxiety, and stress among Egyptian medical
students stratified by the grade. In the reviewed
literature, the prevalence for the three disorders was
found to be 63.6, 78.8, and 57.8%, respectively [21]. By
setting aat 0.05 and maximum accepted error as 5%, we
calculated 140 students to be the minimum proper
sample size to achieve 80% statistical power. Thus, the
minimum number of students from each educational year
was 140 students. Sample size calculation was done using
the StatCalc software (Epi Info, version 7.0.8.3 for MS
Windows, 2011; CDC, Atlanta, Georgia, USA).
We recruited 980 medical students, including 140
students from each educational year from the first year
till the internship year. We used a systematic random
sampling technique by skipping each third and fourth
name on the class list. The recruitment and collection of
data continued for 7 weeks. We excluded students who
were on sedatives or narcotics for any acute or chronic
medical condition.
This study was approved by the research and ethics
committees of the university. Informed consent was
obtained from all participants, and confidentiality of the
information collected was assured.
Instruments
(1) The students were asked to complete a self-
administered questionnaire written in Arabic and
developed by the authors. Questions were related to
social and demographic profile and different possible
stressors including problems with studying in the
English language, fear of failure, death of a family
member, chronic illness of a family member, physical
health problems, problem due to coping with
academic demands, problems in communication with
the teaching staff, and student residence during the
study.
(2) The Depression Anxiety Stress Scale 21 (DASS 21) is
a condensed 21-item version of the full DASS, which
originally consisted of 42 items. The three scales
contain seven items that evaluate the dimensions of
depression, anxiety (symptoms of psychological
arousal), and stress (the more cognitive, subjective
symptoms of anxiety). The severity ratings are based
on percentile scores with 0–78 classified as normal,
78–87 as mild, 87–95 as moderate, 95–98 as severe,
and 98–100 as extremely severe [22]. The scale was
psychometrically validated for the Arabic culture [23].
(3) The DASS is a quantitative measure not a categorical
measure of clinical diagnoses. Emotional syndromes
such as depression and anxiety are intrinsically
dimensional; they vary along a continuum of severity
(independent of a specific diagnosis). It can lead to a
useful assessment of disturbance, for example, a mild
score means that the person is above the population
mean but probably still way below the typical severity
of someone seeking help; it does not mean a mild
level of disorder [22].
(4) Insomnia Severity Index
The Insomnia Severity Index (ISI) is a seven-item self-
reported questionnaire assessing the nature, severity,
and impact of insomnia. The usual recall period is the
‘last month’ and the dimensions evaluated include
severity of sleep onset, sleep maintenance, early
morning awakening problems, sleep dissatisfaction,
interference of sleep difficulties with daytime function-
ing, noticeability of sleep problems by others, and
distress caused by the sleep difficulties. A five-point
Likert scale is used to rate each item (e.g. 0 = no
problem; 4 = very severe problem), yielding a total
score ranging from 0 to 28. The total score is
interpreted as follows: absence of insomnia (0–7);
subthreshold insomnia (8–14); moderate insomnia
120 Middle East Current Psychiatry
Copyright r2016 Institute of Psychiatry, Ain Shams University. Unauthorized reproduction of this article is prohibited.
(15–21); and severe insomnia (22–28). Three versions
of this scale are available – patient, clinician, and
significant others – but the present study focused on
the patient version only [24]. We used the Arabic
version of the questionnaire [25].
Statistical analysis
The data were collected, coded, revised, and fed into the
statistical package for the social sciences (SPSS) (version
20, 2011; IBM Corp., New York, New York, USA).
Qualitative data were presented as numbers and percen-
tages. Quantitative data with parametric distribution
were presented as means, SDs, and range. The w
2
-test
using qualitative data was performed to compare the two
groups, and the Fisher exact test was used when the
expected count in any cell was less than 5. Comparisons
between more than two groups were conducted using the
one-way analysis of variance. Spearman’s correlation
coefficients were used to assess the relation between
two quantitative parameters, and the criterion for
assessing significance was set at less than 0.05.
Results
Demographic and clinical characteristics of the
participants
Demographic characteristics of our sample are shown
in Table 1. The participants comprised 980 medical
students, 66.3% of whom were women. The mean age of
the participants was 21.9 ± 2.08 years, and the age range
was 18–25 years.
Clinical characteristics of our sample are shown
in Table 2. Out of the included students, 624 (63.7%)
reported symptoms of stress, 656 (66.9%) reported
symptoms of anxiety, and 580 (59.2%) reported symptoms
of depression.
Stress symptoms were mild in 13.2%, moderate in 20.1%,
severe in 19.8%, and extremely severe in 10.3% of the
students.
Anxiety symptoms were mild in 14.9%, moderate in 14%,
severe in 11.8%, and extremely severe in 26.2% of the
students.
Depression symptoms were mild in 14.4%, moderate in
27.4%, severe in 13%, and extremely severe in 4.4% of the
students.
There were more students reporting significant stress in
the early years of education. A higher percentage of
second-year students reported stress (75.3%), whereas
severe and extremely severe stress were more common
among the first-year students (40.3%).
A higher percentage of third-year students reported anxiety
(79.8%). Severe and extremely severe anxiety were more
prevalent among first-year students (47.9%), second-year
students (46.8%), and third-year students (45.8%).
A higher percentage of second-year students reported
depression (85.3%), with severe and extremely severe
depression more common among sixth-year students
(42.7%) and among second-year students (41.2%).
Mean insomnia score was 10.84 ± 7.15. According to the
ISI, insomnia was present in 27.7% of the students. It was
moderate in 18%, severe in 9.7%, and subthreshold in
41% of the students.
Initial insomnia was mild in 29.3%, moderate in 20.9%,
severe in 16.5%, and extremely severe in 5.7% of the
students.
Maintenance insomnia was mild in 29.4%, moderate in
19.6%, severe in 15.7%, and extremely severe in 6.3% of
the students.
Late insomnia was mild in 30.3%, moderate in 19.4%,
severe in 15.2%, and extremely severe in 4.2% of the
students.
There was a statistically significant difference regarding
the presence or absence of insomnia according to the ISI
in different years of education. Among first-year students,
50% had moderate to severe insomnia, compared with
39.3, 22.9, 14.3, 29.3, 18.6, and 19.3% of second, third,
Table 1 Demographic characteristics of the study sample
N(%)
Sex
Male 330 (33.7)
Female 650 (66.3)
Age
Mean ± SD 21.9 ± 2.08
Range 18–25
Regular physical exercise
No 596 (60.9)
Yes 383 (39.1)
Caffeine intake
o6 cups/day 144 (14.7)
46 cups/day 836 (85.3)
Work while educated
No 806 (82.3)
Sometime 138 (14.1)
Part-time 24 (2.4)
Full-time 11 (1.1)
Studying hours
o4 h/day 459 (46.8)
44 h/day 521 (53.2)
Student residence during study
With family 639 (65.2)
University campus 215 (21.9)
Outside campus 126 (12.9)
Problems with studying in English language
No 809 (82.6)
Yes 171 (17.4)
Fear of failure in future
No 729 (74.4)
Yes 251 (25.6)
Death of a family member
No 764 (77.2)
Yes 223 (22.8)
Chronic illness of a family member
No 705 (71.9)
Yes 275 (28.1)
Physical health problems
No 898 (91.6)
Yes 82 (8.4)
Problem coping with academic demands
No 724 (73.9)
Yes 256 (26.1)
Problems in communication with teaching staff
No 790 (80.7)
Yes 189 (19.3)
Students insomnia, anxiety and depression Barakat et al. 121
Copyright r2016 Institute of Psychiatry, Ain Shams University. Unauthorized reproduction of this article is prohibited.
fourth, fifth, sixth-year students, and interns, respec-
tively.
Different variables in relation to stress, depression, and
anxiety
Different variables in relation to stress, anxiety, and
depression are shown in Table 3. There was a significant
association between stress and each of the following: sex,
with more stress in females; caffeine intake, with more
stress in those consuming more than six cups/day; and
problems in communication with the teaching staff
(P= 0.008, 0.003, and 0.000, respectively).
There was also a significant association between anxiety and
eachofthefollowing:sex,withmoreanxietyamong
females; death of a family member; problems in commu-
nication with the teaching staff; and working during
educated (P= 0.007, 0.000, 0.000, and 0.001, respectively).
Different stressors in different years of education
Different stressors among students in different years of
education are shown in Table 4. Working during educa-
tion was reported as stressful by 172 (17.6%) students,
with 14.1% of the students working sometimes, 2.4%
working part-time, and 1.1% working full-time. There was
a statistically significant difference in working during
education among different academic years, with more
working students during internship (P= 0.000).
Studying more than 4 h a day was reported as stressful by
30% of the students, with a greater number of sixth-year
students studying more than 4 h a day and reporting that
as stressful. There was a statistically significant differ-
ence regarding studying hours per day in different
academic years (P= 0.000).
Residence was considered as stressful by 20% of the
students, with 21.9% of the students living in the
university campus and 12.9% living outside the campus.
There was a statistically nonsignificant difference be-
tween student residence in different years of education
(P= 0.080).
Difficulty studying in English was reported as stressful by
17.4% of the students, with higher prevalence among the
first 3 years of education (64.3% of first-year students,
22.1 of second-year students, and 22.9% of third-year
students). There was a statistically significant difference
in difficulty studying in English among different educa-
tional years (P= 0.000).
Fear of failure in the future was reported as stressful by
25.6% of the students. It was more prevalent among
interns (40%). There was a statistically significant
difference regarding fear of failure in the future in
different years of education (P= 0.000).
Death of a family member was reported as a stress by
22.8% of students. It was more prevalent among interns
(40%). There was a statistically significant difference
regarding death of a family member in different years of
education (P= 0.000).
Chronic illness of a family member was reported as a
stress by 28.1% of the students. It was more prevalent
among the sixth-year students (43.6%). There was a
statistically significant difference regarding chronic ill-
ness of a family member in different years of education
(P= 0.043).
Chronic physical health problem was reported as a stress
by 8.4% of the students. It was more prevalent among
Table 2 Clinical characteristics of the study sample
N(%)
Depression severity
Normal 400 (40.8)
Mild 141 (14.4)
Moderate 269 (27.4)
Severe 127 (13.0)
Extremely severe 43 (4.4)
Stress severity
Normal 359 (36.6)
Mild 129 (13.2)
Moderate 197 (20.1)
Severe 194 (19.8)
Extremely severe 101 (10.3)
Anxiety severity
Normal 324 (33.1)
Mild 146 (14.9)
Moderate 137 (14.0)
Severe 116 (11.8)
Extremely severe 257 (26.2)
Stress present/absent
Absent 356 (36.3)
Present 624 (63.7)
Anxiety present/absent
Absent 324 (33.1)
Present 656 (66.9)
Depression present/absent
Absent 400 (40.8)
Present 580 (59.2)
Stress score
Mean ± SD 9.46 ± 5.30
Range 0–21
Anxiety score
Mean ± SD 6.40 ± 4.73
Range 0–21
Depression score
Mean ± SD 6.57 ± 3.99
Range 0–21
Initial insomnia
Absent 270 (27.6)
Mild 287 (29.3)
Moderate 205 (20.9)
Severe 162 (16.5)
Extremely severe 56 (5.7)
Maintenance insomnia
Absent 284 (29.0)
Mild 288 (29.4)
Moderate 192 (19.6)
Severe 154 (15.7)
Extremely severe 62 (6.3)
Late insomnia
Absent 303 (30.9)
Mild 297 (30.3)
Moderate 190 (19.4)
Severe 149 (15.2)
Extremely severe 41 (4.2)
ISI score
Mean ± SD 10.84 ± 7.15
Range 0–28
ISI interpretation
Absence of insomnia 307 (31.3)
Subthreshold insomnia 402 (41.0)
Moderate insomnia 176 (18.0)
Severe insomnia 95 (9.7)
Insomnia present/absent
Absent 709 (72.3)
Present 271 (27.7)
ISI, Insomnia Severity Index.
122 Middle East Current Psychiatry
Copyright r2016 Institute of Psychiatry, Ain Shams University. Unauthorized reproduction of this article is prohibited.
sixth-year students (15%). There was a nonsignificant
difference regarding chronic physical health problem in
different years of education (P= 0.063).
Problems due to coping with academic demands was
reported as a stress in 26.1% of the students. It was more
prevalent among the sixth-year students (60%), and fifth-
year medical students (42.9%). There was a statistically
significant difference regarding problem while coping
with academic demands in different years of education
(P= 0.000).
Problems in communications with teaching staff was
reported as a stress in 19.3% of the students. It was more
prevalent among fifth-year students (36%) and first-year
medical students (25.7%). There was a statistically
significant difference regarding problems in communica-
tion with the teaching staff in different years of education
(P= 0.000).
Relation between insomnia and stress, anxiety and
depression
There was a significant association between stress,
anxiety, and depression and the presence of insomnia as
identified by the ISI, as well as between different types
of insomnia, including initial insomnia, maintenance
insomnia, and late insomnia, and stress, anxiety, and
depression (P= 0.000).
Initial insomnia was moderate to extremely severe in
61.4% of those with stress, 56.7% of those with anxiety,
and 44.5% of those with depression.
Maintenance insomnia was moderate to extremely severe
in 59.9% of those with stress, 57% of those with anxiety,
and 42.4% of those with depression.
Late insomnia was moderate to extremely severe in 47.8%
of those with stress, 40.5% of those with anxiety, and
42.4% of those with depression.
Table 3 Different variables in relation to stress, anxiety, and depression
Stress N(%) Anxiety N(%) Depression N(%)
Absent
(N= 356)
Present
(N= 624)
P-
value
Absent
(N= 324)
Present
(N= 656)
P-
value
Absent
(N= 400)
Present
(N=580)
P-
value
Sex
Male 139 (39.0) 192 (30.7) 0.008 128 (39.5) 202 (30.8) 0.007 127 (31.8) 203 (35.0) 0.290
Female 217 (61.0) 432 (69.2) 196 (60.5) 454 (69.2) 273 (68.2) 377 (65.0)
Regular physical exercise
No 202 (56.7) 393 (62.9) 0.047 186 (57.6) 410 (62.5) 0.138 234 (58.5) 362 (62.5) 0.205
Yes 154 (43.3) 231 (37) 137 (42.4) 246 (37.5) 166 (41.5) 217 (37.5)
Caffeine
o6 cups/day 68 (19.1) 76 (12.2) 0.003 56 (17.3) 88 (13.4) 0.108 59 (14.8) 85 (14.7) 0.967
46 cups/day 288 (80.9) 548 (87.8) 268 (82.7) 568 (86.6) 341 (85.2) 495 (85.3)
Work while educated
No 277 (77.8) 530 (84.9) 0.027 246 (75.9) 560 (85.5) 0.001 320 (80.2) 486 (83.8) 0.153
Sometime 66 (18.5) 72 (11.5) 64 (19.8) 74 (11.3) 62 (15.5) 76 (13.1)
Part-time 9 (2.5) 15 (2.4) 12 (3.7) 12 (1.8) 14 (3.5) 10 (1.7)
Full-time 4 (1.1) 7 (1.1) 2 (0.6) 9 (1.4) 3 (0.8) 8 (1.4)
Studying hours
o4 h/day 170 (47.8) 289 (46.3) 0.681 167 (51.5) 292 (44.5) 0.038 191 (47.8) 268 (46.2) 0.634
44 h/day 186 (52.2) 335 (53.7) 157 (48.5) 364 (55.5) 209 (52.2) 312 (53.8)
Student residence during study
With family 221 (61.8) 418 (66.9) 0.201 204 (63.0) 435 (66.3) 0.583 267 (66.8) 372 (64.1) 0.566
University
campus
83 (23.3) 132 (21.2) 76 (23.5) 139 (21.2) 81 (20.2) 134 (23.1)
Outside
campus
52 (14.9) 74 (11.9) 44 (13.6) 82 (12.5) 52 (13.0) 74 (12.8)
Problems with studying in English language
No 304 (85.4) 505 (80.9) 0.085 276 (85.2) 533 (81.2) 0.127 328 (82.0) 481 (82.9) 0.706
Yes 52 (14.6) 119 (19.1) 48 (14.8) 123 (18.8) 72 (18.0) 99 (17.1)
Fear of failure
No 266 (74.7) 463 (74) 0.846 235 (72.5) 494 (75.3) 0.349 309 (77.2) 420 (72.4) 0.088
Yes 90 (25.3) 161 (25.9) 89 (27.5) 162 (24.7) 91 (22.8) 160 (27.6)
Death of a family member
No 270 (75.8) 494 (79) 0.232 230 (71.0) 534 (81.4) 0.000 317 (79.2) 447 (77.1) 0.418
Yes 86 (24.2) 130 (20.9) 94 (29.0) 122 (18.6) 83 (20.8) 133 (22.9)
Chronic illness of a family member
No 258 (72.5) 447 (71.5) 0.767 226 (69.8) 479 (73.0) 0.285 303 (75.8) 402 (69.3) 0.027
Yes 98 (27.5) 177 (28.5) 98 (30.2) 177 (27.0) 97 (24.2) 178 (30.7)
Physical health problems
No 340 (91.9) 558 (91.5) 0.103 400 (92.4) 498 (91.0) 0.011 448 (91.8) 450 (91.5) 0.637
Yes 30 (8.1) 52 (8.5) 33 (7.6) 49 (8.9) 40 (8.2) 42 (8.5)
Problem coping with academic demands
No 265 (74.4) 458 (73.4) 0.752 253 (78.1) 471 (71.8) 0.035 307 (76.8) 417 (71.9) 0.089
Yes 91 (25.6) 165 (26.6) 71 (21.9) 185 (28.2) 93 (23.2) 163 (28.1)
Problems in communication with teaching staff
No 320 (89.9) 469 (75.1) 0.000 288 (89.2) 502 (76.5) 0.000 318 (79.7) 472 (81.4) 0.513
Yes 36 (10.1) 155 (24.8) 35 (10.8) 154 (23.5) 81 (20.3) 108 (18.6)
Students insomnia, anxiety and depression Barakat et al. 123
Copyright r2016 Institute of Psychiatry, Ain Shams University. Unauthorized reproduction of this article is prohibited.
Correlation between Insomnia Severity Index score and
stress, anxiety, and depression scores
There was a significant positive correlation between the
ISI score and the stress score (r= 0.710, P= 0.000), the
anxiety score (r= 0.655, P= 0.000), and the depression
score (r= 0.284, P= 0.000).
Discussion
To our knowledge, this was the largest study assessing the
prevalence of symptoms of depression, anxiety, and stress
in relation to insomnia in medical students in the Arab
world.
The current study established the high prevalence of
symptoms of stress, depression, and anxiety among
medical students and the clear association of these
conditions with insomnia.
In the current study, 63.7% of the students had symptoms
of stress, 66.9% had symptoms of anxiety, and 59.2% had
symptoms of depression. These findings are in agreement
with those of several studies that have reported a higher
prevalence of stress, anxiety, and depression among
medical students than in the general population [26,27].
In Arab countries, three studies from Egypt, Saudi Arabia,
and the United Arab Emirates, respectively, reported high
rates of anxiety and depression among medical stu-
dents [21,28,29]; however, the studies did not correlate
these findings with insomnia.
Our results are similar to those of a 2014 study on first-
year medical students at Egypt’s Menoufiya University. In
that study, depression, anxiety, and stress were reported
in 63.6, 78.4, and 57.8% of the participants, respec-
tively [21].
Studies from around the world have reported prevalence
rates of stress among medical students ranging from 30 to
50% [26,30]; these levels are higher than those found in
students of other schools [31,32].
During the initial years of medical school enrollment, the
reasons for stress are related primarily to academic and
social factors, whereas in the later years, physical factors
generate more stress. Typically, the excessive study hours,
high academic demands, lack of time for leisure activities,
lack of peer support, distance from family, lack of
communication with the teaching staff, high parental
expectations, and economic difficulties are causes of
anxiety and stress among medical students [5,33]. The
presenting result could manifest itself in various ways,
including failure to cope in stressful situations, perfor-
mance anxiety, social phobia, depression, or panic
disorders [34].
Some college students are still learning to cope with
stress [35]. Without adequate restorative sleep, they may
Table 4 Different stressors in different years of education
N(%)
First year Second year Third year Fourth year Fifth year Sixth year Internship w
2
P-value
Work
No 127 (90.7) 134 (95.7) 130 (92.9) 120 (85.7) 126 (90.0) 101 (72.1) 69 (49.2) 153.889 0.000
Sometime 9 (6.4) 5 (3.6) 7 (5.0) 12 (8.6) 13 (9.3) 35 (25) 57 (40.7)
Part-time 3 (2.1) 0 (0.0) 1 (0.7) 8 (5.7) 1 (0.7) 2 (1.4) 9 (6.4)
Full-time 1 (0.7) 1 (0.7) 2 (1.4) 0 (0.0) 0 (0.0) 2 (1.4) 5 (3.6)
Studying hours
o4 h/d 81 (57.9) 57 (40.7) 56 (40.0) 67 (47.9) 52 (37.1) 38 (27.1) 108 (77.1) 90.353 0.000
44 h/d 59 (42.1) 83 (59.3) 84 (60.0) 73 (52.1) 88 (62.9) 102 (72.9) 32 (22.9)
Residence
With family 91 (65) 102 (72.9) 107 (76.4) 109 (77.9) 103 (73.6) 75 (53.6) 52 (37.1) 110.622 0.080
University campus 21 (15.0) 26 (18.6) 14 (10.0) 17 (12.1) 23 (16.4) 52 (37.1) 62 (44.3)
Outside campus 28 (20) 12 (8.6) 19 (13.6) 14 (10.0) 14 (10.0) 13 (9.3) 26 (18.6)
Problems with studying in English language
No 50 (35.7) 109 (77.9) 108 (77.1) 131 (93.6) 134 (95.7) 137 (97.9) 140 (100.0) 469.686 0.000
Yes 90 (64.3) 31 (22.1) 32 (22.9) 9 (6.4) 6 (4.3) 3 (2.1) 0 (0.0)
Fear of failure in future
No 120 (85.7) 120 (85.7) 93 (66.4) 100 (71.4) 110 (98.6 102 (72.9) 84 (60.0) 74.489 0.000
Yes 20 (14.3) 20 (14.3) 47 (33.6) 40 (28.6) 30 (21.4) 38 (27.1) 56 (40.0)
Death of a family member
No 115 (82.1) 108 (77.1) 120 (85.7) 98 (70.0) 130 (92.9) 102 (72.9) 84 (60.0) 72.201 0.000
Yes 25 (17.9) 32 (22.9) 20 (14.3) 42 (30.0) 10 (7.1) 38 (27.1) 56 (40.0)
Chronic illness of a family member
No 120 (85.7) 95 (67.9) 93 (66.4) 109 (77.9) 114 (81.4) 79 (56.4) 95 (67.9) 42.935 0.043
Yes 20 (14.3) 45 (32.1) 47 (33.6) 31 (22.1) 26 (18.6) 61 (43.6) 45 (32.1)
Physical health problems
No 132 (94.3) 130 (92.9) 128 (91.4) 129 (92.1) 130 (92.9) 119 (85.0) 130 (92.9) 117.527 0.063
Yes 8 (5.7) 10 (7.1) 12 (8.6) 11 (7.9) 10 (7.1) 21 (15.0) 10 (7.1)
Problem coping with academic demands
No 102 (72.9) 126 (90.0) 91 (65.0) 129 (92.1) 80 (57.1) 56 (40.0) 140 (100.0) 201.928 0.000
Yes 38 (27.1) 14 (10.0) 49 (35.0) 11 (7.9) 60 (42.9) 84 (60.0) 0 (0.0)
Problems in communication with teaching staff
No 104 (74.3) 107 (76.4) 107 (76.4) 112 (80.0) 90 (64.0) 131 (93.6) 140 (100.0) 80.183 0.000
Yes 36 (25.7) 33 (23.6) 33 (23.6) 28 (20.0) 50 (36.0) 9 (6.4) 0 (0.0)
124 Middle East Current Psychiatry
Copyright r2016 Institute of Psychiatry, Ain Shams University. Unauthorized reproduction of this article is prohibited.
not have adequate resources to cope with academic
stress [36].
Different stressors identified in our study were problems
in communications with the teaching staff, problem while
coping with academic demands, difficulty studying in
English, residence, studying more than 4 h a day, working
during education, chronic physical health problem,
chronic illness of a family member, death of a family
member, and fear of failure in the future. The first six of
these stressors directly relate to college life and their
effect may be more amplified among medical students.
In Egypt, undergraduate medical students who get poor
grades will obtain their postgraduate training outside the
residency programs offered by medical schools at
Egyptian universities, which diminishes their career
prospects compared with those of their more academi-
cally successful classmates, who can enter the residency
program. Consequently, students develop insomnia in the
process of prolonging their study hours [37].
One of the stressors for medical students identified in our
study was that they has to study in English, although
most students had studied in Arabic in high school. The
fact that most of the scientific and academic material
worldwide is presented in English justifies the need to
study medicine in English [38].
Living in a campus was identified as stressful by some of
the students. This could be attributed to poor dormitory
conditions, more economic stress, distance from the
family, less structured environment, and problems dealing
with roommates.
Studying more than 4 h a day and having to work during
medical education could impair the quality of their life of
students, affecting the leisure time, time to practice
regular physical exercise, time to interact with family and
friends, and time allowed for sleep.
In our study, there was no significant association between
stress, anxiety, or depression, and physical exercise. This
was in contrast to the findings of different researches –
that exercise not only improves self-esteem and reduces
social withdrawal but also reduces anxiety and depression
and improves cognitive functioning. These effects could
result from an exercise-induced increase in the cerebral
blood flow and from the effect on the hypothalamic–
pituitary–adrenal (HPA) axis, which connects with the
limbic system, which in turn controls motivation and
mood, the amygdala, which generates fear in response to
stress, and the hippocampus, which plays an important
role in memory formation, mood, and motivation [20].
In our study, there was a significant association between
stress and caffeine consumption. Caffeine causes dopa-
mine release in the prefrontal cortex, the principal area
involved in reward, and thus increases alertness, reduces
fatigue, and elevates mood. Thus, moderate caffeine
intake (o6 cups/day) is associated with less depressive
symptoms [39].
Symptoms of excessive caffeine consumption are similar
to those of anxiety, and both could be due to sympathetic
nervous system over activity. Because caffeine may be
involved in the precipitation, exacerbation, and main-
tenance of anxiety disorders, anxiety symptoms could be
reduced by caffeine withdrawal or restriction. Caffeine
reduces slow–wave sleep (SWS) in the early part of the
sleep cycle, can reduce rapid eye movement (REM) sleep
later in the cycle, and leads to initial and intermittent
insomnia [39].
The higher prevalence and higher levels of stress, anxiety,
and depression among students in their initial years of
education could be explained by the fact that students
acquire better coping strategies over time.
In our study, stress, depression, and anxiety were more
prevalent among females, a finding that was consistent
with those of other studies that have found that female
students reported more stress [26,40], although in one of
these studies the mean number of stressors was similar
for both male and female students [40]. While this
difference could be real, it could also be due to the fact
that females are more likely to report concerns or tend to
over report symptoms. Some researchers have also
suggested that sex may influence how medical students
perceive stress [30].
In our sample, insomnia was present in 27.7% of the
participants. This is comparable to what Loayza et al. [41]
found in their study among medical students, where
28.15% of the medical students had insomnia.
The current study establishes a clear association between
insomnia and stress, depression, and anxiety. Higher
insomnia scores were associated with higher stress,
depression, and anxiety scores. This finding is in
agreement with what Ford and Kamerow [13] concluded
in their study in 1989, that insomniacs are more likely to
present with depression and anxiety than are noninsom-
niacs. This is also similar to what Chang et al. [16] found
in their study among medical students, that insomnia is a
risk factor for clinical depression.
Changes in the objective sleep architecture of depressed
patients include impaired sleep continuity, increased
wakefulness, reduced sleep efficiency, increased sleep
onset latency, reduced total sleep time, shortened REM
latency, increased duration of the first REM period, and
increased REM density [42]. The normal decrease in
slow–wave activity from the first to the last non-REM
episode is also disrupted [18]. Some of these abnormal-
ities are present during remission and are associated with
an increased risk for relapse [19].
Reduced SWS in those with depression may be due to
abnormalities in the orbitofrontal and anterior cingulate
cortex or due to decreased regional cerebral blood flow, as
observed in imaging studies in these areas during
SWS [43,44].
The sleep–wake cycle is regulated by two processes, the
circadian process and the homeostatic process. The
homeostatic drive to sleep is wake-dependent and thus
increases in proportion to the amount of time since the
last sleep [45]. The timing of REM sleep is linked to the
Students insomnia, anxiety and depression Barakat et al. 125
Copyright r2016 Institute of Psychiatry, Ain Shams University. Unauthorized reproduction of this article is prohibited.
circadian rhythm, and slow–wave activity is a marker of
the homeostatic drive. Sleep abnormalities in those with
depression indicate a disruption in both homeostatic and
circadian drives [46].
Whether circadian rhythm disruption is a cause, a result,
or comorbid with depression requires more research. An
alternative explanation is that deficiencies in neurotrans-
mitters, such as serotonin, noradrenaline, or acetylcho-
line, lead to the phase advance of sleep rhythms in
depression [15].
Anxiety, which may be a state or a trait, includes
increased arousal, which could affect sleep. Studies have
found a significant decrease in total sleep time, an
increase in waking after sleep onset, and a prolongation
of sleep onset latency in patients with anxiety
disorders [47].
Patients with chronic insomnia are in a state of
continuous emotional arousal. They handle stress through
internalizing emotions, resulting in emotional arousal. At
bedtime, they are anxious and ruminate about different
stressors in their lives. Emotional arousal causes physio-
logical arousal, which then causes difficulties in sleep
initiation or maintenance. They develop ‘fear of sleep-
lessness’, which then further heightens their emotional
arousal and exacerbates their sleep difficulties [48].
In our study, stress levels correlated with ISI scores.
Stress affects sleep architecture and circadian rhythms.
Both sleep and stress are closely linked to the HPA axis
and the autonomic nervous system, which can explain the
relationship between sleep and stress. Stress has been
associated with the activation of the HPA axis. Cortico-
tropin-releasing hormone and cortisol are known to cause
arousal and sleeplessness. Stress-induced elevation of
plasma adrenocorticotropic hormone is associated with
increased REM sleep. Sleep deprivation results in
reduced amplitude of the cortisol profile in the morning
and elevated cortisol the following evening [12].
During SWS, sympathetic activity is reduced and the
HPA axis is subject to a marked inhibition. During REM
sleep, HPA activity increases to reach a diurnal maximum
shortly after morning awakening. Because the onset and
end of sleep involve HPA axis activity, the temporal
relationship between the axis and sleep indicates the
effect of stress on sleep [48].
The immune system also influences the relationship
between stress and sleep. This link is established by the
cytokines, such as interleukin-1b, tumor necrosis factor,
and interferon, all of which participate in the regulation
of sleep. In the absence of interleukin-1bor tumor
necrosis factor, sleep is interrupted, and if these
cytokines are injected, non-REM sleep increases. Inter-
leukin-1bcontributes to the immune-regulating feedback
chain, which activates the HPA axis, a possible mechan-
ism linking stress and sleep. Blood IL-1blevels vary in
the sleep–wake cycle, and blood tumor necrosis factor is
related to the slow–wave activity of the brain. While
chronic stress reduces natural killer cell activity, there
further exists a strong correlation between the degree of
loss of sleep continuity and natural killer cell func-
tion [49].
Conclusion
Stress, anxiety, and depression are prevalent among
medical students in Egypt, and are positively correlated
to insomnia. Symptoms are more common among females
and during initial years of education. Different stressors
were identified among medical students, including
residence, working while educated, studying more than
4 h a day, difficulty studying in English, problems
communicating with the teaching staff, fear of failure in
the future, death of a family member, chronic illness of a
family member, physical health problems, and problems
due to coping with academic demands. Stressors varied in
different years of education.
Limitations
The present study had some limitations. First, we could
not compare the mental status of the students before and
after joining medical school due to the absence of
baseline data about mental status of students at the
time of enrollment to medical schools in Egypt. Second,
not including subjects from private medical schools
limited the generalizability of our results. In addition,
the study did not use a tool to diagnose depression or
anxiety as the scale we used was a quantitative and not a
categorical measure of clinical diagnoses.
Recommendations
Assessment of the mental state of medical students upon
their enrollment in medical schools and during the first 3
years of their education is highly recommended. Failure
to detect mental illness among medical students can
increase morbidity and affect their academic perfor-
mance, careers, and quality of life. Early detection of
mental illness can shorten the duration of the illness and
reduce social and functional impairments. Incorporating
educational material about good sleep hygiene and the
effect of sleep on one’s mental state is recommended.
Moreover, coping with stress should be integrated into
the curriculum. Establishing student counseling units in
medical schools to provide support and guidance and
early detection of mental illness among students are
critical.
Acknowledgements
The authors are extremely grateful to the study participants who took
the time to participate in this study. Without their participation, this
study would not have been possible.
Conflicts of interest
There are no conflicts of interest.
126 Middle East Current Psychiatry
Copyright r2016 Institute of Psychiatry, Ain Shams University. Unauthorized reproduction of this article is prohibited.
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