Int J Ment Health Addiction

https://doi.org/10.1007/s11469-017-9859-3

O R I G I N A L A RT I C L E

Determinants of Anxiety and Depression

Among University Students of Lahore

Hamid Saeed 1 & Zikria Saleem 1 & Mariam Ashraf 1 &

Nida Razzaq 1 & Kubra Akhtar 1 & Ammarah Maryam 1 &
Nasir Abbas 2 & Ali Akhtar 3 & Nazeeha Fatima 1 &
Kalsoom Khan 1 & Fawad Rasool 4

# Springer Science+Business Media, LLC, part of Springer Nature 2017

Abstract Benefits from an improved understanding of mental health of young adults, partic-
ularly students, affecting their academic performance are likely to be numerous. Thus, we
aimed at evaluating anxiety and depression among annual and semester university students of
Lahore, Pakistan. A cross-sectional study of 7 months duration was designed by enrolling a
total of 404 students from two private and two public sector universities of Lahore. We found
significant differences in frequency distribution with regard to age (p = 0.003), marital status
(p = 0.01), living status (p = 0.004), and reasons affecting of mental health (p = 0.004) between
annual and semester system students. Students enrolled in annual system exhibited higher odds
of anxiety, mild (OR 2.7, p = 0.019), and extremely severe (OR 2.6, p = 0.002), compared to
semester students. In overall assessment of university students, after univariate analysis,
multivariate analysis demonstrated significant association of depression with male students
(OR 2.3, p = 0.001), age ≤ 22 years (OR 2.8, p = 0.0005) and living status (OR 5.96, p =

* Hamid Saeed
hamid.pharmacy@pu.edu.pk

Zikria Saleem
zikria.pharmacy@pu.edu.pk

Mariam Ashraf
mariampharmd@gmail.com

Nida Razzaq
nidarazzaq12@yahoo.com

Kubra Akhtar
Kubra_akhtar@hotmail.com
Ammarah Maryam
rose.44merry@gmail.com

Nasir Abbas
nasirabbas77@gmail.com
 Int J Ment Health Addiction

0.0005). Similarly, as for anxiety, only male students demonstrated higher odds of anxiety (OR
2.8, p = 0.0005). As expected, compared to a single reason, multiple reasons affecting student’s
mental health demonstrated significant association with all three determinants of mental health,
i.e., stress (OR 0.36, p = 0.0005), anxiety (OR 0.31, p = 0.0005), and depression (OR 0.5, p =
0.0005). Taken together, these data suggested higher prevalence of anxiety among annual
system students, mainly because of studies, while in overall assessment male students and
students at an early stage of their life at the university were susceptible to anxiety and
depression, probably due to multiple reasons affecting their mental health.

Keywords Anxiety . Depression . Stress . Students . Pharmacy . University . Lahore

Depression is common throughout the world affecting almost 350 million people of all ages
(Pilania et al. 2013). Worldwide, among adolescents and young adults, the lifetime prevalence
of anxiety and depression is currently estimated to range from 5 to 70% (Sahoo and Khess
2010). It is estimated that 18% among youths have depressive symptoms and the tendency is
increasing in both males and females with advance aging (Saluja et al. 2004). However,
depression rate is estimated to be double in females compared to males (Saluja et al. 2004).
Additionally, the prevalence of depressive symptoms may vary among diverse ethnic groups,
for example in the USA, the frequency of depression is about 29% in American Indian youths,
22% in Hispanics, 18% among whites, 17% among Asian Americans, and 15% in African
American youths, though with higher frequency among females (25%) than males (10%)
(Saluja et al. 2004). However, if anxiety and depression affects studying youth, it becomes
more alarming and needs prompt attention not only because it affects their future but also it
may deprive society from potential intelligentsia and brilliant minds.
Among student population, anxiety and depression are considered the most commonly
recognized disturbances affecting numerous functions, such as motivation, concentration,
perception of self-worth and mood (Andrews and Wilding 2004). Seemingly, most of the
lifetime mental disorders, normally starting with depression, have their first onset during

Ali Akhtar
aliakhtar5657@gmail.com
Nazeeha Fatima
Nazeeha.fatimah@hotmail.com
Kalsoom Khan
Kalsoomkhan1991@gmail.com
Fawad Rasool
fawadrasool@bzu.edu.pk

1
Section of Clinical Pharmacy, University College of Pharmacy, University of the Punjab, Allama
Iqbal Campus, Lahore 54000, Pakistan
2
Section of Pharmaceutics, University College of Pharmacy, University of the Punjab, Allama Iqbal
Campus, Lahore 54000, Pakistan
3
Division of Pharmacy, School of Medicine, University of Tasmania, Hobart, Australia
4
Department of Pharmacy, Bahauddin Zakariya University, Multan, Pakistan
Int J Ment Health Addiction

university age, with estimated range of depression from 85% to as low as 8% among university
students (Ibrahim et al. 2013; Said et al. 2013). Likewise, university students are a special
group of population constantly coping and adapting to various psychosocial challenges,
academic and social, while preparing for their professional careers (Uehara et al. 2010).
However, the exposure and duration of risks might vary from one study area or system to
another. Numerous literature evidences suggest that medical students experience mental health
problems due to constant exposure to stressful conditions, such as academic burden to study a
vast field, pressure from parents, fear of failure, labor market challenges, and vulnerability to
diverse emotional outbreaks (Eisenberg et al. 2007; Tabalipa et al. 2015). It is believed that
medical and pharmaceutical studies are often laborious with multiple demands related to
learning and training that might adversely affect student’s physical and mental health (Ahmed
et al. 2009; Benevides-Pereira and Gonçalves 2009; Sun and Zoriah 2015). According to
literature reports several instigating factors have been identified that might contribute towards
anxiety and depression among the students, such as academic matters, life in seclusion away
from family and friends, amount of workload, intimidation from faculty, exposure to human
sufferings, and finances (Dyrbye et al. 2006; Tabalipa et al. 2015).
Moreover, anxiety and depression affect student’s professional and personal traits. Profes-
sional concerns include compromised academic performance and honesty, decline in empathy
and ethics, and higher incidences of medical errors, while personal effects include strained
relationships, substance abuse and health deterioration (Dyrbye et al. 2005; Tabalipa et al.
2015). Nevertheless, it has been reported that among health care students, medical, dental, and
pharmacy, pharmacy students had higher rates of stress in comparison to other health care
students (Henning et al. 1998).
Studies from Pakistan have reported several contributing factors of stress, anxiety,
and depression, majorly among medical students, notably socio-demographic factors—
age, gender, examination criteria, dissatisfaction, and endless test schedules (Alvi
et al. 2010). Besides, numerous academic and psychosocial apprehensions, such as
high expectations of parents, vastness of academic curriculum, sleeping difficulties,
future worries, loneliness (Shah et al. 2010), strained relationships, living in university
dormitories (Rab et al. 2008), and initial academic years (Inam et al. 2003) were the
main contributors of anxiety and depression among medical students of Pakistan. Yet,
not a single study from Lahore, Pakistan, has been reported that evaluated and
examined the level of anxiety and depression among students enrolled in annual
and semester system degree programs. Thus, the aim of present study is to determine
the prevalence of anxiety, depression, and stress among students enrolled in annual
and semester system of examination registered at various public and private univer-
sities of Lahore, Pakistan.

Methods

Ethical Approval

The study was approved by ethical committee for human research, University College of
Pharmacy, University of The Punjab, reference # EC/UCP/092/2015. The same approval was
used for permission from various universities of Lahore to enroll students for data collection at
their premises. Informed consent was obtained from all the enrollees—verbal/written.
 Int J Ment Health Addiction

Study Design

A cross-sectional study was designed, and data was collected for a period of 7 months,
December 2015–May 2016, and it was conducted in two public and two private universities
of Lahore, Pakistan, having both annual and semester system of examination. Filed adminis-
trators, Pharm D students, distributed the questionnaires to eligible participants. Later, data was
segregated to annual examination system (n = 270) and semester examination system students
(n = 134). The questionnaire was divided into two sections, i.e., basic demographics including
age, gender, marital status, area of residence, study system, and area of study, and in the second
section, Depression Anxiety and Stress Scales (DASS-42), 42-item multiple choice question-
naire, was administered to estimate the scores of stress, anxiety, and depression.

Data Collection

A self-administered validated questionnaire, DASS-42, was utilized for data collection. Ques-
tionnaires were distributed among students belonging to annual and semester examination
system studying at various departments, i.e., social sciences, pharmacy, arts, and information
technology. The field administrators offered assistance to fill the questionnaire and were
involved in face to face interviews wherever deemed necessary. DASS 42-item questionnaire,
previously validated and standardized survey instrument, a set of three self-reported scales
designed to estimate the clinically significant negative emotional states of stress, anxiety and
depression and has been utilized in Pakistani population before (Rizvi et al. 2015). Depression
scale assess devaluation of life, dysphoria, lack of involvement, anhedonia and inertia, stress
scale assess nervous arousal, agitation, irritability and impatience, and anxiety scale assess
skeletal muscle effects, situational anxiety, and shaky and panicky behavior. DASS question-
naire severity rating index was used to define levels of stress (normal 0–14, mild 15–18,
moderate 19–25, severe 26–33, and extremely severe +34), anxiety (normal 0–7, mild 8–9,
moderate 10–14, severe 15–19, and extremely severe +20), and depression (normal 0–9, mild
10–13, moderate 14–20, severe 21–27, and extremely severe +28). Informed consent was
obtained from the students at the time of data collection.

Study Population

A total of 753 students, annual and semester system, from two public and two private
universities of Lahore, Pakistan, were found eligible as the per inclusion and exclusion criteria.

Inclusion Criteria All students enrolled in annual and semester system of examination,
irrespective of age, gender, any mild disease conditions not affecting cognitive functions,
ethnicity, financial status, and area of residence were enrolled in the study.

Exclusion Criteria Students having mental health issues and taking medicine for
anxiety and depression and failed to provide the informed consent were excluded
from the study.
Questionnaires were distributed among the eligible students along with informed consent.
Out of 753 students, 153 students failed to provide the informed consent, 87 students were
found absent at the time of data collection and another 109 students returned half-filled
questionnaires. Thus, the data of only 404 students, 193 males and 211 females, enrolled in
Int J Ment Health Addiction

degree programs having annual examination system (n = 270) and semester system of exam-
ination (n = 134), were further processed and analyzed.

Data Analysis

All the data were analyzed using Graphpad (Prism5) and SPSS (IBM, version 21).
Descriptive statistics were performed to estimate the frequencies of all socio-
demographic variables, while study area wise (pharmacy and non-pharmacy) associa-
tions among various socio-demographic characteristics were estimated using chi-square
test. Additionally, odds ratios for stress, anxiety, and depression levels for each socio-
demographic variables were estimated in univariate and multivariate logistic regression
models. Moreover, linear regression model was used to estimate the socio-
demographic predictors of anxiety, stress, and depression among students. An alpha
value of less than 0.05 was considered statistically significant.

Results

Sample Population Basic Demographics

Basic demographics of the sample population, annual and semester students, are
summarized in Table 1. Data suggested that there was statistically significant differ-
ence in frequency distribution among various demographic variables between annual
and semester students, such as age (p = 0.003), marital status (p = 0.01), living status
(p = 0.004), and reasons contributing towards stress, anxiety, and depression (p =
0.004) (Table 1). Similarly, frequency distribution for anxiety levels was significantly
different between annual and semester students (p = 0.004) (Table 1). Moreover, no
difference in rest of the variables was observed between students enrolled in annual
and semester system of examination (Table 1).

Association of Student’s Socio-Demographic Variables with Stress, Anxiety,

and Depression

For these associations all levels of stress, anxiety and depression were considered in one
category to determine the associations of various variables with that of stress, anxiety, and
depression using normal scores as reference category.

Stress

Student’s demographic variables, such as living status, study area and reasons were
examined for possible association with stress levels (Table 2). When estimated using
univariate regression model, no considerable association was observed in most of the
variables, such as age, gender, marital status, and area of residence, while students
having multiple reasons contributing towards stress are more likely to develop stress
(OR 0.376, p = 0.0005) (Table 2). Variables exhibiting significant associations as
observed by univariate analysis were then tested using multivariate analysis. In this
 Int J Ment Health Addiction

Table 1 Basic demographics of university students of Lahore

Characteristics Annual system (n = 270) Semester system (n = 134) p value

Age
≤ 22 204 (75.5%) 82 (61.2%) 0.003*
> 22 66 (24.4%) 52 (38.8%)
Gender
Male 127 (47%) 66 (49.2%) 0.67
Female 143 (53%) 68 (50.7%)
Marital status
Single 260 (96.2%) 121 (90.2%) 0.01*
Married 10 (3.7%) 13 (9.7%)
Living status
Day scholar 139 (51.4%) 89 (66.4%) 0.004*
Hostelite 131 (48.5%) 45 (33.5%)
Area of residence
Urban 181 (67%) 97 (72.3%) 0.274
Rural 89 (33%) 37 (27.6%)
Depression
Normal 111 (41%) 59 (44%) 0.941
Mild 83 (30.7%) 38 (28.3%)
Moderate 58 (21.5%) 29 (21.6%)
Severe 17 (6.3%) 7 (5.2%)
Extremely severe 1 (0.03%) 1 (0.07%)
Anxiety
Normal 102 (37.7%) 67 (50%) 0.004*
Mild 33 (12.2%) 8 (6%)
Moderate 40 (14.8%) 26 (19.4%)
Severe 23 (8.5%) 15 (11.1%)
Extremely severe 72 (27%) 18 (13.4%)
Stress
Normal 199 (73.7%) 106 (79%) 0.521
Mild 39 (14.4%) 18 (13.4%)
Moderate 22 (8.1%) 7 (5.2%)
Severe 7 (2.6%) 3 (2.2%)
Extremely severe 3 (1.1%) 0 (0%)
Types of reasons
Family 19 (7%) 14 (10.4%) 0.004*
Finances 28 (10.3%) 11 (8.2%)
Health 12 (4.4%) 9 (6.7%)
Relationship 22 (8.1%) 16 (12%)
Hostel life 14 (5.2%) 4 (2.98%)
Studies 103 (38%) 34 (25.4%)
2 59 (21.9%) 46 (34.3%)
>3 13 (4.8%) 0 (0%)

*p ≤ 0.05–0.002; **≤ 0.001–0.0001

context, multiple reasons contributing towards stress were significantly associated with
stress (OR 0.36, p = 0.0005) among university students compared to single or a few
reasons worrying them (Table 2).

Anxiety

Furthermore, associations were estimated between anxiety and student’s demographic

variables employing univariate and multivariate logistic regression (Table 3).
Int J Ment Health Addiction

Table 2 Association of stress with student’s demographic variables

Characteristics Stress Univariate logistic regression Multiple logistic regression

Yes No OR (95% CI) p value OR (95% CI) p value

( s c o r e 1 5 – (score 0–
34+) 14)

Age
≤ 22 (286) 65 (22.7%) 221 0.73 (0.44–1.2) 0.247 – –
(77.3%)
> 22 (118) 34 (28.8%) 84 (71.2%)
Gender
Male (193) 48 (24.9%) 145 1.06 (0.68–1.71) 0.813 – –
(75.1%)
Female (211) 51 (24.1%) 160
(75.8%)
Marital status
Unmarried (381) 91 (23.9%) 290 0.796 (0.24–1.6) 0.648 – –
(76.1%)
Married (23) 8 (34.8%) 15 (65.2%)
Living Status
Day scholar 51 177 0.979 (0.6–1.6) 0.98 – –
(228)
Hostelite (176) 48 128
Area of residence
Urban (278) 64 (23%) 214 (77%) 0.833 (0.53–1.36) 0.476 – –
Rural (126) 35 (27.8%) 91 (72.2%)
Examination system
Annual (270) 71 (26.3%) 199 1.5 (0.89–2.5) 0.098 – –
(73.7%)
Semester (134) 28 (20.9%) 106
(79.1%)
Reasons
Single (285) 54 (18.9%) 231 0.376 (0.22–0.613) 0.0005** 0.36 0.0005**
(81.4%) (0.24–0.61)
Multiple (118) 45 (38.1%) 73 (61.9%)

*p ≤ 0.05–0.002; **≤ 0.001–0.0001

Univariate analysis demonstrated that male students (OR 3.32, p = 0.0005), pharmacy
students (OR 2.27, p = 0.001), and students having multiple reasons of anxiety (OR
0.30, p = 0.0005) were more likely to experience anxiety in comparison to female and
non-pharmacy students and students having single reason of anxiety (Table 3). Be-
sides, using multiple regression model, only gender, pharmacy students, and multiple
reasons of anxiety demonstrated significant associations (Table 3).

Depression

The next obvious question was to find out the demographic variables most likely to
associate with depression. Same variables, as used in stress and anxiety, were con-
sidered to estimate likely associations between these variables and depression. Uni-
variate analysis suggested that depression was more likely to affect students below or
equal to 22 years of age (OR 2.6, p = 0.0005), males (OR 3.2, p = .0.0005), day
scholars (OR 6.5, p = 0.0005), and students having multiple reasons of depression (OR
 Int J Ment Health Addiction

Table 3 Association of anxiety with student’s demographic variables

Characteristics Anxiety Univariate logistic regression Multiple logistic regression

Yes No OR (95% CI) p value OR (95% CI) p value

( s c o r e 8 – (score 0–7)
20+)

Age
≤ 22 (286) 170 (59.4%) 116 1.17 (0.723–1.92) 0.509 1.2 (0.78–2.01) 0.413
(40.1%)
> 22 (118) 65 (55.1%) 53 (44.9%)
Gender
Male (193) 135 (70%) 58 (30%) 3.32 (2.09–5.27) 0.0005** 2.8 (1.86–4.41) 0.0005**
Female (211) 100 (47.4%) 111
(52.6%)
Marital status
Unmarried (381) 219 (57.5%) 162 0.388 (0.137–1.10) 0.076 0.404 (0.143–1.14) 0.091
(42.5%)
Married (23) 16 (69.5%) 7 (30.4%)
Living status
Day scholar 130 (57%) 98 (43%) 1.5 (0.97–2.44) 0.067 1.87 (1.26–3.17) 0.01*
(228)
Hostelite (176) 105 (60%) 71 (40%)
Area of residence
Urban (278) 155 (55.8%) 123 0.80 (0.49–1.28) 0.347 0.88 (0.53–1.35) 0.489
(44.2%)
Rural (126) 68 (54%) 58 (46%)
Examination system
Annual (270) 168 (62.2%) 102 2.27 (1.42–3.63) 0.001** 2.07 (1.32–3.24) 0.002*
(37.8%)
Semester (134) 67 (50%) 67 (50%)
Reasons
Single (285) 147 (51.2%) 138 0.30 (0.17–0.50) 0.0005** 0.31 (0.18–0.51) 0.0005**
(48.5%)
Multiple (118) 87 (73.7%) 31 (26.3%)

*p ≤ 0.05–0.002; **≤ 0.001–0.0001

0.55, p = 0.024), and the same variables demonstrated significant associations when
examined using multivariate analysis (Table 4).

Socio-Demographic Predictors of Stress, Anxiety, and Depression Among Students

Furthermore, using linear regression model, we studied various socio-demographic

variables to predict association of variables with stress, anxiety, and depression among
the students. Interestingly, in all the observed mental states, i.e., stress, anxiety, and
depression, age, below or equal to 22 years, was the sole predictor of stress, anxiety,
and depression among students (Table 5), even after adjusting for all the variables.
However, variable, i.e., reasons (multiple), affecting anxiety and stress levels, was
significantly associated with anxiety and stress as shown by un-adjusted p values;
nevertheless, when adjusted for age, gender, marital status and area of residence, only
two predictors were found to contribute significantly in anxiety only, i.e., study area,
pharmacy vs non-pharmacy, and reasons (multiple) contributing towards anxiety
(Table 5).
Int J Ment Health Addiction

Table 4 Association of depression with student’s demographic variables

Characteristics Depression Univariate logistic regression Multiple logistic regression

Yes No OR (95% CI) p value OR (95% CI) p value

( s c o r e 1 0 – (score 0–9)
28+)

Age
≤ 22 (286) 183 (64%) 103 (36%) 2.6 (1.57–4.25) 0.0005** 2.3 (1.43–3.64) 0.001*
> 22 (118) 51 (43.2%) 67 (56.8%)
Gender
Male (193) 122 (63.2%) 71 (36.8%) 3.21 (1.95–5.29) 0.0005** 2.8 (1.74–4.59) 0.0005*
Female (211) 99 (46.9%) 112
(53.1%)
Marital status
Unmarried (381) 218 (57.2%) 163 0.22 (0.07–0.66) 0.007* 0.25 (0.087–0.72) 0.01*
(42.8%)
Married (23) 16 (69.5%) 7 (30%)
Living status
Day scholar 164 (72%) 64 (28%) 6.5 (3.88–10.79) 0.0005** 5.96 (3.6–9.8) 0.0005**
(228)
Hostelite (176) 70 (40%) 106 (60%)
Area of residence
Urban (278) 166 (59.7%) 112 1.06 (0.65–1.73) 0.228 1.29 (0.83–2) 0.256
(40.3%)
Rural (126) 68 (53.9%) 58 (46%)
Examination system
Annual (270) 159 (58.9%) 111 1.59 (0.96–2.61) 0.073 1.1 (0.71–1.72) 0.674
(41.1%)
Semester (134) 75 (56%) 59 (44%)
Reasons
Single (286) 160 (56%) 126 (44%) 0.55 (0.33–0.92) 0.024* 0.6 (0.35–0.96) 0.034*
Multiple (118) 73 (61.9%) 45 (38.1%)

*p ≤ 0.05–0.002; **≤ 0.001–0.0001

Discussion

Anxiety and depression in young adults is a serious public health problem and a source of
colossal human sufferings (Adewuya et al. 2006). But when it comes to students the situation
becomes more alarming and dilapidating, affecting almost all areas of daily functioning,
including motivation, concentration, perception, self-worth, and mood (Andrews and
Wilding 2004). The present study is the first assiduous effort evaluating anxiety, depression,
and stress among students enrolled in degree programs having annual and semester system of
examination at various public and private sector universities of Lahore, Pakistan. Our data
suggested that students studying in annual system are more prone to develop mild and
extremely severe anxiety levels with no signs of stress and depression. Moreover, university
students, irrespective of study area, demonstrated strong association between mental condi-
tions, such as stress, anxiety, and depression with multiple reasons affecting mental health.
Similarly, males are more likely to experience anxiety and depression, while students of annual
system studies and day scholars are more susceptible to anxiety and depression, respectively.
Among students’ anxiety and depression might be associated with several contributing
factors such as age, gender, living conditions, strained relationships, negative life events,
family issues, social and educational concerns, high parental expectations, psychosocial
 Int J Ment Health Addiction

Table 5 Predictors of stress, anxiety, and depression in university students

Predictors Un-adjusted Adjusted

Depression Beta-coefficients p values Beta-coefficients p values

Age 0.212 0.033* 0.205 0.043*

Gender 0.052 0.438 0.045 0.494
Marital status − 0.098 0.169 − 0.097 0.168
Area of residence 0.022 0.739 0.007 0.919
Study Area 0.003 0.964 − 0.025 0.717
Reasons 0.053 0.435 0.029 0.671
Anxiety
Age 0.561 0.0005** 0.505 0.0005
Gender − 0.263 0.0005 − 0.282 0.0005
Marital status 0.042 0.531 0.037 0.531
Area of residence 0.113 0.070 0.049 0.379
Study area − 0.074 0.235 − 0.175 0.002**
Reasons 0.291 0.0005** 0.232 0.0005**
Stress
Age 0.153 0.004** 0.251 0.011*
Gender 0.130 0.051 0.120 0.065
Marital status − 0.079 0.264 − 0.082 0.239
Area of residence 0.014 0.813 − 0.019 0.771
Study area − 0.057 0.387 − 0.019 0.101
Reasons 0.153 0.022* 0.124 0.065

*p ≤ 0.05–0.002; **≤ 0.001–0.0001

Adjusted for age, gender, marital status, and area of residence

stressors, and financial concerns. These factors may not only affect student’s academic and
professional life but also have detrimental effects on their physical, mental, and psychological
health—impairing their quality of life and carrier development (Ibrahim and Abdelreheem
2015), (Sokratous et al. 2014). Our data suggested that majority of students in annual and
semester system degree programs were ≤ 22 years of age, unmarried and day scholars. Yet
only annual system enrollees had significantly higher anxiety levels, moderate (M) to ex-
tremely severe (ES 27%) compared to semester system enrolled students (ES 13.4%). Similar
findings have been reported before, demonstrating increased anxiety among medical and
pharmaceutical students, between 18 and 22 years of age, enrolled in annual system degree
programs (Ibrahim and Abdelreheem 2015). Moreover, in our study, the prevalence of
moderate and severe depression was 21 and 6.3%, respectively, in students of annual system
was found to be similar to students of semester system, i.e., 21.6 and 5.2%, respectively.
However, in developed countries, such as of Europe and the USA the prevalence of depression
was 23% in Germany, 34% Poland, 37% in Bulgaria, and 52% in Greece and 17.3% in the
USA, respectively (Bayram and Bilgel 2008; Christensson et al. 2011; Mikolajczyk et al.
2008), yet with no well-defined severity levels.
Nevertheless, these prevalence rates cannot be compared directly with our study due to
several reasons, differences in the scoring scales/questionnaires used for the assessment of
depression, differences in culture and religious beliefs. Interestingly, we also found that the
most frequently observed reasons of anxiety among the annual system students were their
studies in comparison to limited syllabus content of semester system students. This academic/
studies related anxiety in students of annual system can be attributed to several study related
factors and have been reported by numerous studies (Ibrahim and Abdelreheem 2015; Sun and
Int J Ment Health Addiction

Zoriah 2015; Tabalipa et al. 2015) such as intensity of the degree program, demanding utmost
dedication, amount of content to be studied, intimidation or pressure from the faculty,
transition to a university life, and pressure to succeed (Simić-Vukomanović et al. 2016).
Though, we did not observe significant differences in the levels of stress between annual
and semester system students, yet, during data collection, we observed that the annual system
students were complaining about study related stress. Therefore, the significant levels of mild
and severe anxiety levels in students of annual system can be attributed to stressful life events
in form of transition to university education and academic factors, such as study content and
area, performance, and demands related to more focused and independent learning.
Moreover, when it comes to stress and anxiety levels among overall university students,
annual and semester system combined, no significant associations were observed for various
socio-demographic variables, except for reasons of stressful life—students with multiple
reasons and enrolled in annual system (pharmacy degree program) are more susceptible to
stress and anxiety, respectively, compared to those having single reason and are semester
system students (non-pharmacy). Similar findings have been reported to males (Eisenberg
et al. 2007; Tabalipa et al. 2015). However, we did not observe any significant differences
between male and female students with regard to stress levels, probably because parents,
teachers, and even siblings are more care conscious and sympathetic towards female students
rather than male students in a Pakistani society. Other explanation could be that females are
more likely to share and express concerns related to competency, stress and academic
performance (Simić-Vukomanović et al. 2016). Surprisingly, we found that male students
exhibited higher anxiety levels compared to female students, probably because in a Pakistani
society, males are considered self-reliant for many routine matters and are self-sufficient to
cope with stressful life events. However multiple reasons could contribute towards developing
stress, anxiety, and depression among annual and semester system students making it more
complex and difficult to attribute a particular reason as the sole reason of mental worries, yet
studies alone stood conspicuous among all the reasons of mental health problems. In this
context, among various reasons, next to studies, finances and relationships were significant
contributors of stress, anxiety, and depression among the University students, and has been
reported previously (Simić-Vukomanović et al. 2016; Sokratous et al. 2014). We observed that
studies alone contributed majorly in mental health problems; however, combination of other
factors such as separation from family, financial issues, and health could further aggravate the
mental health issues affecting academic performance. Besides, similar to other reports
(Eisenberg et al. 2007; Simić-Vukomanović et al. 2016), our data suggested significant
association between age and levels of depression and anxiety.
When it comes to the studies from Pakistan, number of studies have reported the
prevalence of anxiety and depression among medical students ranging from 40 to
70%, yet, significantly higher among female students than males (Abrar et al. 2014;
Jadoon et al. 2010; Khan et al. 2006). Similar to the findings mentioned above,
mostly on medical students, when anxiety and depression levels were combined, mild
to extremely severe, the levels of anxiety and depression were ~ 62 and ~ 58%,
respectively, but only in annual system university students of Lahore. However, a
direct comparison cannot be made due to differences in assessment scales/
questionnaires utilized in all these studies—most of the studies used AKUADS, while
our study, the first one to utilize DASS, identify various levels of stress, anxiety, and
depression rather than a cumulative YES. Moreover, only one study from Pakistan
reported the prevalence of depression among pharmacy students (annual system),
 Int J Ment Health Addiction

59.49% in males and 64% in females utilizing seven-item social distance scale (SDS)
(Abbas et al. 2015). Despite overt mental health issues among students of Lahore,
Pakistan, no separate center exists at the University or at departmental level to deal
with alarming situation related to mental health and to better quip the future gener-
ations to cope with the battered situation.

Study Limitations

The study findings should be interpreted with care in context of several methodolog-
ical and recourse based limitations. Primarily, the cross-sectional design of the study
that precludes the inferences with regards to plausible relationship between explana-
tory variables with mental health issues, stress, anxiety, and depression. Moreover, we
enrolled students from four universities, two public and two private; thus, data cannot
be generalized to students from all the universities of Lahore, though, we tried to
represent both private and public universities. Additionally, we are unable to assess
the impact of study years and duration of stay at the university and its impact on the
mental status of the students. Besides, we are unable to report regarding the impact of
transition to University life and adapting to a new environment, along with the
contribution of parental factors affecting student’s mental health, such as single parent,
parent’s education and number of children/siblings. Importantly, due to number of
different scales/questionnaires utilized in the various studies, a direct comparison is
difficult even for studies from the same country or region.

Conclusion

In conclusion, our data suggested that annual system students had higher prevalence
of anxiety, mild and extremely severe, compared to semester system students. Overall,
university students demonstrated significant association of depression with male gen-
der and age ≤ 22 years. Similarly, males exhibited higher odds of having anxiety
compared to females. Only multiple reasons behind mental health issues, such as
studies, strained relations, away from home, and finances contributed significantly in
severity ratings of all three mental states, i.e., stress, anxiety, and depression. There-
fore, training and educational programs along with mental health counseling sessions
should be offered to the University students at the departmental and University level.
Seminars and sessions should be held in departments having difficult course contents
(pharmacy) demanding rigorous and extensive study hours to equip and train the
students to better cope and manage the instigators of stress, anxiety, and depression.

Acknowledgements Authors are extremely thankful to University administration for allowing us to collect the
data to the students for their participation.

Author’s Contribution HS: designed the study, did analysis, and wrote the manuscript, ZS: data entry and data
analysis, MA: write the manuscript, NR: data collection, KA: data collection, AM: data collection, NA: edited the
manuscript and assisted in data collection at private universities, AA: data analysis, NF: data collection, KK: data
collection, ZD: assisted in data collection from public universities and design of the study, NIB: edited the
manuscript and data analysis, FR: assisted in data collection from private university and ethical approval.
Int J Ment Health Addiction

Compliance with Ethical Standards

Ethical Statement All procedures followed were in accordance with the ethical standards of the responsible
committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as
revised in 2000. Informed consent was obtained from all patients for being included in the study.

Conflict of Interest The authors declare that they have no conflict of interest.

Annexure

Depression Anxiety and Stress Scale (DAAS)

Scoring:
Scores of depression, anxiety, and stress are calculated by summing the scores for the
relevant items.
The depression scale items are 3, 5, 10, 13, 16, 17, 21, 24, 26, 31, 34, 37, 38, and 42.
The anxiety scale items are 2, 4, 7, 9, 15, 19, 20, 23, 25, 28, 30, 36, 40, and 41.
The stress scale items are 1, 6, 8, 11, 12, 14, 18, 22, 27, 29, 32, 33, 35, and 39.
To use the Scoring Template (below) print on to a plastic overhead.
The scores for each of the respondents over each of the sub-scales are then evaluated as per
the severity rating index below.
Severity rating index
Depression Anxiety Stress
Normal 0–9 0–7 0–14
Mild 10–13 8–9 15–18
Moderate 14–20 10–14 19–25
Severe 21–27 15–19 26–33
Extremely severe 28+ 20+ 34+

DASS Name: Date:

Please read each statement and circle a number 0, 1, 2 or 3 which indicates how much the
statement applied to you over the past week. There are no right or wrong answers.
Do not spend too much time on any statement.
The rating scale is as follows:
0 Did not apply to me at all
1 Applied to me to some degree, or some of the time
2 Applied to me to a considerable degree, or a good part of time
3 Applied to me very much, or most of the time
Sr. # Questions Scoring

1 I found myself getting upset by quite trivial things 0 1 2 3

2 I was aware of dryness of my mouth 0 1 2 3
3 I couldn’t seem to experience any positive feeling at all 0 1 2 3
4 I experienced breathing difficulty (eg, excessively rapid breathing,ıbreathlessness in the 0 1 2 3
absence of physical exertion)
5 I just couldn’t seem to get going 0 1 2 3
6 I tended to over-react to situations 0 1 2 3
7 I had a feeling of shakiness (eg, legs going to give way) 0 1 2 3
8 I found it difficult to relax 0 1 2 3
 Int J Ment Health Addiction

Sr. # Questions Scoring

9 I found myself in situations that made me so anxious I was mostırelieved when they 0 1 2 3
ended
10 I felt that I had nothing to look forward to 0 1 2 3
11 I found myself getting upset rather easily 0 1 2 3
12 I felt that I was using a lot of nervous energy 0 1 2 3
13 I felt sad and depressed 0 1 2 3
14 I found myself getting impatient when I was delayed in any way ı(eg, lifts, traffic lights, 0 1 2 3
being kept waiting)
15 I had a feeling of faintness 0 1 2 3
16 I felt that I had lost interest in just about everything 0 1 2 3
17 I felt I wasn’t worth much as a person 0 1 2 3
18 I felt that I was rather touchy 0 1 2 3
19 I perspired noticeably (eg, hands sweaty) in the absence of high temperatures or physical 0 1 2 3
exertion
20 I felt scared without any good reason 0 1 2 3
21 I felt that life wasn’t worthwhile 0 1 2 3
22 I found it hard to wind down 0 1 2 3
23 I had difficulty in swallowing 0 1 2 3
24 I couldn’t seem to get any enjoyment out of the things I did 0 1 2 3
25 I was aware of the action of my heart in the absence of physical exertion (eg, sense of 0 1 2 3
heart rate increase, heart missing a beat)
26 I felt down-hearted and blue 0 1 2 3
27 I found that I was very irritable 0 1 2 3
28 I felt I was close to panic 0 1 2 3
29 I found it hard to calm down after something upset 0 1 2 3
30 I feared that I would be Bthrown^ by some trivial 0 1 2 3
but unfamiliar task
31 I was unable to become enthusiastic about anything 0 1 2 3
32 I found it difficult to tolerate interruptions to what I was doing 0 1 2 3
33 I was in a state of nervous tension 0 1 2 3
34 I felt I was pretty worthless 0 1 2 3
35 I was intolerant of anything that kept me from getting on 0 1 2 3
With what I was doing
36 I felt terrified 0 1 2 3
37 I could see nothing in the future to be hopeful about 0 1 2 3
38 I felt that life was meaningless 0 1 2 3
39 I found myself getting agitated 0 1 2 3
40 I was worried about situations in which I might panic and make a fool of myself 0 1 2 3
41 I experienced trembling (eg, in the hands) 0 1 2 3
42 I found it difficult to work up the initiative to do things 0 1 2 3
TOTAL

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