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.
MATERIALS AND METHODS
A wide range of different measures have been used for addressing psychological distress and depressive symptomatology among medical students, such as Beck's Depression Inventory (13), General Health Questionnaire (GHQ) (11), and other common and less common instruments (6,18).
We used the Kessler10 Psychological Distress instrument (K10) developed by Kessler and colleagues (19). This instrument has been used widely in population-based epidemiological studies to measure current (1-month) distress and was translated in different languages, including Arabic, to measure the level of stress and severity associated with psychological symptoms in population surveys. The World Mental Health Survey of the World Health Organization used it as a clinical outcome measure (20-23). The K10 consists of 10 questions in the form of "how often in the past month did you feel ..." and offers specific symptoms, such as 'tired out for no good reason', 'nervous', and 'sad or depressed'. The five possible responses for each question range from 'none of the time' to 'all of the time' and were scored from 1 to 5 respectively. …