Definition and Conceptualization of Depression, Anxiety and Stress (DAS)
The concepts of mental disorder in general and depression in particular remain unclear and no consensual definitions are yet well-known although broadly discussed in various studies (Widiger and Sankis, 2000). However, scholars define depression differently according to their intent, contexts and their perceptions. For instance, Ness and Ellsworth (2009) contested that depression embodies a break dawn in a progressed and otherwise adaptive response to shortage or loss; it is a mental state in which one suffers sadness (Sharma and Pandey, 2017); it is a form of mental health problem (Zivin, 2009) and it is a common but serious mental illness typically marked by sad or anxious feelings (National Institute of Mental Health (NIMH), 2009). APA (2013) describes the word “depression” as a condition that is manifested in un happiness, shallow, uselessness and out of being worth.
There are many symptoms of depression though differ from person to person. However, Eller and Veldi (2006) described depression as continuous worried or absence of good feelings, feelings of desperateness, feelings of wrong, worthlessness and/or helplessness, bad temper, anxiety, and loss of interest in activities or hobbies once enjoyable. In addition, Kumer et al. (2009) also contested that depression is considered as a mood disorder. According to Marcus et al. (2012), there are 4 groups of symptoms of depression on which the problem is appeared: emotional, cognitive, motivation and physical. They also latter described the term “depression” as absence of interest or happiness, sadness, feelings of fault or low self-worth, disturbed sleep or hungriness, dangerous sleepiness, and lack of concentration. A person could be referred to be depressed if he/she displays one or amalgamation of the following variables-absence of good mood, lack of pleasure, feelings of in responsibility, lack of self-confident, loss of drinking and eating feelings, unable to get enough sleep or loos of giving focus on things (Marcus et al., 2014).

Like depression, no consensus definition given to anxiety. However, Prior scholars in the field of psychology define “anxiety” as their understanding on the issue itself. To this effect, Stossell (2006) defined anxiety as a function of biology and view point, physique and attention, nature and motive, behavior and values. It is also experienced at psychic and psychological levels. It is scientifically measurable at the molecular level and the physiological level. It is produced by nature and nurture. It is also refers to a psychological phenomenon and cultural occurrence. In computer terms, it is both external constraints (wired badly) and a software problem (run faulty logic that make think anxiously)
Seligman and his colleagues (2000) defined anxiety as a psychological and physiological state characterized by mental, somatic, emotional, and social modules. These components combine to create an unpleasant feeling that is typically associated with discomfort, distress, or worry and stress.
Anxiety is more associated with involuntary provocation, body stress and conditional facets, whereas stress is more related to touchiness, annoyance and un able to be free. It is a response of body to a perceived threat which is triggered by once principles, state of mind, and views and it is manifested by anxious feelings, strain, rapid blood circulation, disturbed heartbeat, perspiring, and unable to swallow food, weakness and strong pain above the abdomen. Worldwide about 272.2 million people have anxiety disorder about 14.0% of the European population (Wittchen et al., 2011). Literatures indicated that there are various predictors of anxiety. For instance, Yeshaw and Mosie (2016) dectated that anxiety was found to be associated with age, educational status, matrimonial level, income, intesity of resting period, occupational pleasure, dis agreement with friends, alcohol use andhewing chat. Nevertheless, income, taking chat regularly, dis agreement with friends, and ocupational pleasure of respondents were significantly related with anxiety at their final model.

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Like the other psychological disorders, stress also lacks standard definition because of subjectivity, multidimensionality and lack of demarcation in the concept. Despite these facts, prominent scholars tried their best to define the word stress. For instance Quyen (2007) explain the word stress as the aggregate of physical, mental and emotional tension on a person in specified period. The association or interaction between human being and their surroundings resulted in stress. Although stress is one of the mental disorders of human being prevails all over the world and we all talk frequently about stress, still now absence of what stress really is about, the contraction related to it and its long term effect on once life. In addition scholars know some terms which have similar meaning with stress. These terms are worry, struggle, exhaustion, despair and burden. Many people consider stress is something that happens to them, an event such as injury or inspiration. Whereas others think stress is what happens to our bodies, essence and our performance in response to an event in all activities.
Stress also refers to the mental state which derives from the person’s appraisal of the success with which he or she can adjust to the demands of the surrounding environment (Kumaraswamy, 2013). When something happens to us, we as a reflex action start evaluating the situation mentally, then we try to come to a decision, if it is threatening to us, how we need to deal with the situation and what skills and strategies we can use. As a result, if we come to conclusions that the demands of the situation overshadow the skills we have, then we label the circumstances as “stressful” and need to react it with the classic “stress response”. If we trust that our coping skills prevail over the demands of the situation, then we don’t see it as “stressful”. Some situations in life are stress-provoking, but they are our thoughts about situations that determine whether they are a problem to us or not. How we look it and perceive a stress-inducing event and how we react to it determines its impact on our health. If we respond in a negative way our health and happiness suffer. When we understand ourselves and our reactions to stress-provoking situations, we can learn to handle stress more effectively (Abraham, 2000).

Stress may be understood as a state of tension experienced by individuals facing extraordinary demands, constraints or opportunities. The pressures of modern life, coupled with the demands of a job, can lead to emotional imbalances that are collectively labeled ‘Stress’. However, stress is not always unpleasant. Stress is the spice of life and the absence of stress makes life dull, monotonous and spiritless (Alexander and wells, 1999).
With regard to the classification of stress, some scholar’s identified three common groups of definitions: the first class is a stimulus, an environmental event, usually a threat that affects the body in complex ways; in this interpretation, stress is referred to as a “stressor”, one that evokes complex reactions of the various systems of the body. A second class of definition is that stress is a bodily reaction to stressors; consequently, complex interaction of systems of the body can result in deleterious consequences to those systems and organs to the point of a person becoming “stressed out”; and serious illness can follow. These groups of definition was accepted by some contemporary scholars in the field of psychology.

A third type is an interactive one lies between environmental proceedings (stressors) and bodily reactions such that stressors affect systems of the body and the resulting behavior feeds back to affect the environmental stressors. However, they can also lead in complex ways to a variety of mental or physical problems.
Global over view of Psychological Health Problems (Depression, Anxiety and Stress)
Worldwide about 450 million people suffer from mental health problems, of which, about 150 million are affected with depression (American Psychiatric Association, 2013). Depression is predicted to be the world’s largest health problem by the year 2020 (Murray and Lopez, 1996). Mental health is essential to be well-maintained as without good health we will not be able to live in a state of synchronization. According to World Health Organization (2014) mental health is “a state of wellbeing in which individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community”.

Mental health is about how we feel about ourselves, others, and also how we are able to meet the demands of life (WHO, 2014). It is an escalating issue among professional accountants internationally, which requires serious attention from the community (Griffin, 2014). Mental health may impact the development and productivity of people, and will ultimately affect a person’s livelihood at home, at work and with others (Eisenberg, Golberstein, ; Hunt, 2009).
Depression, Anxiety and Stress (DAS) among students in Tertiary institutions (University)
Scholars in the field of psychology claimed that university students have long been experienced all or either of the well-known psychological morbidities- Depression, Anxiety and Stress. In this regard, Stanley and Manthorpe (2001) indicated that university students are vulnerable to mental health problems. There are high rates of psychological morbidity, especially depression and anxiety, among university students all over the world (Adewuya et al., 2006; Nerdrum et al., 2006; Ovuga et al., 2006). Edwards and Holden (2001) also acknowledged that among college students seeking counseling services, anxiety and depression were ranked first and third as presenting problems, respectively; whereas academic and work-related concerns were ranked second. Moreover, Brackney and Karabenick (1995) noted that high levels of distress, concomitant with limited coping resources, render students less able to meet academic demands. The higher level of psychiatric morbidity-depression 29.9%, anxiety 41.1% and stress 27% among undergraduate Nepanes medical students (Kunwar et al., 2016).

Kumarswamy (2013) also found that stress was more in second year medical students and this may be due to greater fear of not attaining their goal of being a doctor. Research survey on college students’ reports at any given time there will be 10 to 20 % of student population suffering from psychological problems (Stress, Anxiety & Depression). A recent study conducted by Mohammed et al., (2016) on depression, anxiety and stress among science and art students showed that girls are more depressed, anxious and stressed than male, meanwhile science students are more depressed, anxious and stressed than art students.

According to a Korean study, the prevalence of depression is 26.1% in men and 28.7% in women employees (Baxter, 2014). The study conducted in Ethiopia by Yigizie and Andualem (2017) on depression, anxiety, stress, and their associated factors among Jimma University staff demonstrated that depression, anxiety, and stress were found to be high among university staffs. All of those disorders (DAS) were found to be more common among khat chewers, those with no job satisfaction, and those who had conflict with their colleagues at the workplace. Depression and stress were more common in females than males. Prevalence of stress was also more common in widowed staff. From this finding it might be fair to conclude that the severity of depression, anxiety, stress could be too high if the target population could have been medical students though no study is conducted over them.

Since medical education is intended to prepare graduates for a personally rewarding and socially meaningful career promoting health and caring for the sick (Vaidya and Mulgaonkar, 2007), students are often confronted with significant stressors (Aktekin et al., 2001).

Depression, Anxiety and Stress (DAS) among Medical Students
Medical education throughout the world is considered as being somewhat hard and demanding. Studies on psychological problems such as stress, depression and anxiety among medical students showed that these problems are not considered properly at all (Manjunath et al., 2013). However, some studies gave great emphasis to investigate these common psychological problems. For example, Khan et al. (2017) conducted a research on psychosocial well-being of Undergraduate Medical Students of King Edward Medical University, Lahore using DASS 21 scoring questionnaire and found that 36.6% were categorized as normal stress, 17.4% as mild stress, 23.6% as moderate stress, 16.6% as severe and 5.7% as extremely severe stress. With regard to severity of anxiety, 21.4% were categorized as normal. 6.3% were suffering from mild anxiety; 22.4%, 19.0% and 30.9% were suffering from moderate, severe and extremely severe anxiety respectively. Severity of depression scale showed that 30.5% students were normal, 13.1%, 26.1%, 13.7% and 16.6% were categorized as suffering from mild, moderate, severe and extremely severe depression respectively. Females were found to be suffering from slightly more stress as compared to males, whereas the gender difference for anxiety and depression was not significant.

A study by Kunwar et al. (2016) on Study of Depression, Anxiety and Stress among the Medical Students in two Medical Colleges of Nepal demonstrated that the overall prevalence of depression, anxiety and stress (DAS) was 29.9%, 41.1% and 27% respectively. Similarly, Kulsoom and Afser (2015) in there study of stress, anxiety, and depression among medical students in a multiethnic setting in Saudi Arabia displayed that the students had high “baseline” traits of depression, anxiety, and stress, and these were higher if an examination was near, especially among Saudis and those who had attended a premedical university preparatory program. Smoking and female sex predicted higher levels of “baseline” depression, anxiety, or stress.

Moreover, a critical study by Ghada et al. (2016) entitled Prevalence and Predictors of Depression, Anxiety and Stress among Zagazig University Students in Egypt showed that the overall prevalence of depression, anxiety and stress among their studied samples was found to be 40%, 45%, 33.6% respectively. Multiple socio-demographic, life style, family and academic factors have been significantly associated (p<0.05) with depression, anxiety and stress like type of college, gender, age, housing, academic achievement, regular exercise, daily sleeping hours, smoking habit and other family and academic factors.

A study in India on depression, anxiety and stress levels among medical students in Mysore by Kumar et la. (2016) displayed that prevalence of mental health problems like depression, anxiety and stress were more than 30% among medical students. As the majority of the students were having milder degrees of illnesses they need to be addressed immediately before they manifest into severe forms. The study also concluded that Students’ distress may influence professional development and adversely impact academic performance contributing to academic dishonesty and substance abuse, and may play a role in attrition from medical school.

A cross-sectional study entitled on Depression, Anxiety, and Stress in Sudanese Medical Students on the role of quality of life and social support by Mohamed et al. (2016) depicted that medical students expressed high prevalence of depression, anxiety, and stress of different grades. The quality of surrounding environment and maintenance of physical health seems to play a key role in preservation of student mental health. Likewise, a comparative study by Navees et al. (2015) on Stress, Anxiety and Depression among Students of Selected Medical and Engineering Colleges, Bangalore demonstrated that among their sample students 33.6 % suffered from stress, 49.3% suffered from anxiety and 37.8% suffered from depression in varying levels of severity.
Roy et al. (2015) done a research on Depression, anxiety and stress among first year undergraduate medical students in India and found that significant increase in depression, anxiety and stress scores during pre-examination period in both males and females. However we have observed higher depression scores in female students in both relaxed state as well as stressed state. Anxiety scores were not significantly different in male and female students in both relaxed and stressed states. Stress scores were significantly different in stressed state in male and female students.

Patnaik et al. (2015) conducted a research on Depression, anxiety ; stress among first year medical students using cross sectional study design and reported that high prevalence of anxiety and considerable amount of stress ; depression among first year medical students. Iqbal and his friends (2015) also done a research entitled stress, anxiety ; depression among medical undergraduate students ; their socio-demographic correlates. They found that more than half of the respondents were affected by depression (51.3%), anxiety (66.9%) and stress (53%). Morbidity was found to be more in 5th semester students rather than students of 2nd semester. Females reported higher score as compared to their male counterparts.

All in all, Dyrbye et al. (2006) systematically reviewed over 40 articles of Psychological distress among medical students in their work of “Systematic Review of Depression, Anxiety, and Other Indicators of Psychological Distress Among U.S. and Canadian Medical Students”. The studies suggest a high prevalence of depression and anxiety among medical students, with levels of overall psychological distress consistently higher than in the general population and age-matched peers by the later years of training. Overall, the studies suggest psychological distress may be higher have some experience caring for patients through employment or volunteer work prior to applying to medical school and must undergo standardized examinations and a rigorous application and interview process.

In addition to identifying individuals with the necessary aptitude and commitment to pursue a career in medicine, this process is intended to identify individuals who choose to pursue a career in medicine based on significant insight into the demands, challenges, and rewards of the profession. Once enrolled, students and schools make a mutual commitment intended to prepare students for a socially useful and personally fulfilling career. Based on these characteristics, one may anticipate medical school would be a time of personal growth, fulfillment, and well-being despite its challenges. Unfortunately, studies suggest the current educational process may have an inadvertent negative effect on students’ mental health, with a high frequency of depression, anxiety, and stress among female students. Limited data were available regarding the causes of student distress and its impact on academic performance, dropout rates, and professional development.

Predictors of Academic Performance of Students
Academic performance has become relevant in all levels of education, that is, from kindergarten (KG) to University. For instance, in kindergarten, primary and secondary school levels of education, students are given report cards to inform their parents on how they are doing. After high school this pattern also continues in different form. Students in the higher institutions (colleges and universities) are given their grade report having cumulative grade point (CGPA) showing their performance in each semester.

Higher educational settings reinforce the message that performing well academically is critical to being successful. Many universities invest resources to assist students to succeed such as tutoring, supplemental instruction, connects students to available resources or other support services (Bisson, 2017). By doing these, some students perform better than others depending on their back ground knowledge, intellectual aptitude, cognitive ability, physical health, motivation mental health and so on (Dusselier, Dunn, Wang, Shelley, & Whalen, 2005). Past academic performance and standardized testing influence academic performance of university students (Larson, Orr, & Warne, 2016). Thus, most of the time, standardized test scores and GPA are frequently used to measure intellectual aptitude.

However, because of the subjectivity nature of grade, there is much debate as how effectively grades measure academic performance. Some of the scholars argued that grades given by different professors can vary significantly for the same level of work. Some may even say that this subjectivity undermines a GPA as a reliable measurement of academic achievement (Koper, Felton, Sanney, & Mitchell, 2015). Therefore, GPA is not shown the exact performance of students in the school. Others argued that in every circumstance students are judged as per their GPA. For instance, to get scholar ship, to earn funds or financial aid, to promote to the next higher level, to pursue their education and to elite, the critical and fundamental base is their GPA. Of course, it is often a flawed system, but grading as a measurement has been used by some colleges and universities as early as the 1860s (Bluemle, 2002). Felton and Koper (2005) also reported that as the educational establishment requires some assessment of educational performance, the focus of the effort should be on grades since other forms of assessment are subject to the same limitations and political pressures that generate in?ated grades. Other forms of assessment will be no less corrupt than grades and would be redundant if relatively meaningful grading standards were in effect.

The Nexus Between Medical Students’ Depression, Anxiety and Stress, and Academic achievements
Depression, anxiety, and stress were found to be interrelated to each other. The overlapping symptoms of these three psychological distresses can lead to all sorts of academic problems that can give impact to academic achievement among student. Saravana and Wilks (2014) reported that medical school is recognized as a stressful environment that often has a negative effect on students’ academic performance, physical health, and psychosocial well-being. It has also been found that students’ performance in school, college, and university is influenced by the symptoms of depression ( Stark ; Brookman 1994), stress (Dusselier, Dunn, Wang, Shelly, ; Whalen, 2005), and anxiety (Anson, Bernstein, ;Hobfoll, 1984) which could lead to difficulties in concentration, lack of motivation and interest, poor attendance, and physical health such as headache and fatigability. These conditions will influence students’ academic achievement.

Depression shows the largest effect on the mental health problem that influenced the academic performance of the students compared to other factors (Showalter, 2010). Depression interferes with daily life and causes pain to the depressed and people around him. University students face many problems such as separation from their families, entrance into a new environment and adaptation to educational standards causes high level of depression (Nasrin, 2010). When a student was too worried about his exams’ result, he/she would be depressed. If this depression continues, it would affect his/her performance in education (Achar, 2000). Chronic stress among medical students affects academic performance of students and leads to depression, substance use, and suicide (Leta et al., 2015). They further acknowledged that stress was a significant problem among medical students and had a negative impact on their academic performance.

Academic performance of university students (their cumulative GPA) is influenced by a variety of factors like cognitive ability, physical health and mental health. Intellectual aptitude and other cognitive factors can have an influence on how students perform academically in a higher educational setting. Only approximately twenty-five percent of variance in academic performance is attributed to cognitive factors (Wolfe ; Johnson, 1995 cited in Bisson, 2017). The rest of variance in academic performance can be attributed to factors related to physical and mental health. To understand mental health of college as well as university students, it is important to be aware of the developmental challenges and strengths that this demographic faces.
Larson et al. (2016) in their study on “using student health data to understand and promote academic success in higher education settings” demonstrated that both physical and mental health issues threats the academic status of tertiary level students. Some of the physical health difficulties the study measured included asthma, allergies, mononucleosis, strep throat, and urinary tract infections. The study also reported that mental health issues were significantly and negatively associated with GPA. The results of the study also showed that physical health issues were often correlated with mental health issues. For example, students who had high levels of stress, or difficulties handling stress, reported physical health issues affecting their diet and sleep. In working with students with anxiety and depression, the physical health symptoms are often reported as the presenting problem because they are the symptoms that are externalized (Hartley, 2011).

Recently, Bisson (2017) conducted a research on the effect of Anxiety and Depression on College Students’ Academic Performance and found that after eliminating an insignificant moderating effect of social support on the relationship between anxiety and academic performance, the total effect of anxiety on academic performance was not significant. The findings show gender was the strongest predictor and females performed higher than males. Past academic performance had a positive effect on current academic performance.

To sum up, psychological distress, including depression and anxiety, has been associated with lower GPAs (Drybye, Thomas, & Shanafelt, 2006; Holliday et al., 2016). Depression, anxiety and stress are found to be the most common mental health issues that are reported by most tertiary level students. Difficulties with mental health symptoms can become serious and even fatal if they go untreated. For instance, Duram (2009) reported that more than 80% of college students that committed suicides had no current or prior counseling.

777240318135Psychological Distress
00Psychological Distress
Fig.2.1 Conceptual Framework of the Study
3057525186690Intervening Variables
00Intervening Variables
313055023495Peer pressure
School environment
Course load
00Peer pressure
School environment
Course load



2845435374650Control Variables
00Control Variables

2940685226060Demographic and other known predictors of performance
00Demographic and other known predictors of performance
Source: Modified from Bisson (2017)