Depression Research and Treatment
Volume 2020 (2020), Article ID 7836296, 7 pages
https://doi.org/10.1155/2020/7836296

Research Article

Prevalence of Mental Distress and Associated Factors among Samara University Students, Northeast Ethiopia

Robel Tesfaye Kelemu,¹ Alemayehu Bayray Kahsay,² and Kedir Y. Ahmed3,4

¹Afar Regional Health Bureau, Afar National and Regional, PO Box: 28, Semera, Ethiopia
²School of Public Health, College of Health Sciences, Mekelle University, Ethiopia
³Department of Public Health, College of Medicine and Health Science, Samara University, PO Box: 132, Samara, Ethiopia
⁴Translational Health Research Institute, Western Sydney University, Campbelltown Campus, NSW, Australia

Correspondence should be addressed to Kedir Y. Ahmed; kedirymam331@gmail.com

Received 6 July 2019; Revised 22 September 2019; Accepted 8 October 2019; Published 24 January 2020

Academic Editor: Bettina F. Piko

Copyright © 2020 Robel Tesfaye Kelemu et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract.

Background. Empirical findings have indicated that higher institution students experience a higher prevalence of mental distress compared to the general population. Understanding the magnitude and associated factors of mental distress in university students would be helpful to practitioners and policymakers in Ethiopia. The aim of the present study was to examine the prevalence and associated factors of mental distress among Samara university students, Northeast Ethiopia. Methods. Institution based cross-sectional study design was conducted in Samara university from December to June 2018. A simple random sampling technique was employed to select the study participants. Self-Reporting Questionnaire-20 (SRQ-20) was used to measure the mental distress of students. Multivariable logistic regression modeling was used to examine the association between sociodemographic and psychosocial factors with the mental distress of students. Results. The proportion of students with mental distress were found to be 53.2% (95% confidence interval [CI]: 48.0%, 58.0%). Female students were more likely to be mentally distressed compared to male students (adjusted odds ratio [AOR]: 4.66; 95% CI: 2.81, 7.71). Ever khat use (AOR: 3.09; 95% CI: 1.74, 5.50) and poor sleep quality (AOR: 2.23; 95% CI: 1.12, 3.66) were significantly associated with mental distress of students. Conclusion. Our study indicates that the proportion of mental distress was found to be higher among Samara university students as compared to previously published studies in Ethiopia. Female students, ever khat users and those with poor sleep quality were associated with mental distress. There is a need for evidence-based interventional strategies such as self-help measures, sleep hygiene and peer support, as well as professional mental health services as part of student health services that would be helpful to reduce the burden of mental distress of students.

1. Background

Mental distress is a syndrome characterized by a clinically significant disturbance in cognition, emotion regulation, or behaviour accompanied by psychological, biological, or developmental processes dysfunction [1, 2]. Empirical findings have indicated that students experience a higher prevalence of mental disorders than the general population [3]. This is, even more, higher among students of higher institutions. There are several possible explanations for the increased mental distress of university students. First, students have to make significant adjustments to college life. Second, because of the pressure of studies, there is strain placed on interpersonal relationships. Third, housing arrangements and changes in lifestyle also contribute to the stress experienced by college/university students. Furthermore, students in college experience stress related to academic requirements, support systems, and ineffective coping mechanisms [4, 5].

Mental distress can lead to temporary effects as well as consequences that affect the individual in the long term. Common consequence of college students mental distress are a feeling of being overwhelmed [4, 5]; inability to concentrate and to focus the attention on a certain task which can result in being unable to answer questions in an exam [4, 6, 7], and finally may result in withdrawal from their college or university. In the long term, if mental distress is perceived as negative and excessive, it can result in physical and psychological impairment [8]. Studies showed that excessive stress is associated with both sleep problems and substance use, and mental health symptoms in young adolescents [6, 7].

In Ethiopia, however, despite more than one-third of the university students affected by mental distress at least once during their campus life, mental health has been one of the most disadvantaged health programs in higher institutions, both in terms of facilities and trained manpower [9–12]. To institutionalize policies and strategies for intervention and control of the mental distress of students, understanding the magnitude and predictors of mental distress in university students would be helpful to practitioners and policymakers in Ethiopia. Moreover, Samara university is located in one of the hottest areas in the country which might exacerbate the living condition of students. Therefore, the aim of this study was to examine the prevalence and associated factors of mental distress among Samara university students in Ethiopia.

2. Methods

2.1. Study Design and Study Setting

Institution based cross-sectional study design was used to assess the prevalence and associated factors of mental distress among Samara University students from February to March 2018. The study was conducted in Samara university, which is found at Semera-Logia town of Afar National and Regional State (ANRS). Semera-Logia town of Afar National and Regional State (ANRS) is located 583 km away from the capital of Ethiopia, Addis Ababa. In the 2017/2018 academic year, a total of 8,777 students were enrolled in regular, extension, the summer and post-graduate programs [13].

2.2. Source and Study Population

All regular Samara university students who were registered during the 2017/2018 academic year were the source population. Students selected by simple random sampling technique were the study population. Students who are unable to see and were out of the campus during the data collection period were excluded from the study.

2.3. Sample Size Determination and Sampling Procedure

A single population proportion formula assuming 95% confidence interval (CI), 5% margin of error, and 49.1% proportion of mental distress [14] was used to calculate the sample size. Considering a non-response rate of 10%, the final sample size of the study was found to be 422. After we select one department from each college, we used simple random sampling technique (table of random number) to select students from each department.

2.4. Data Collection

The data were collected using a self-administered questionnaire with four parts. First, a socio-demographic characteristic of students was asked. Second, the Self-Reporting Questionnaire (SRQ₂₀) was used to measure the prevalence of mental distress. SRQ₂₀ is originally developed by the World Health Organization (WHO) [15] designed to indicate common mental disorders or mental distress. The tool was validated in low and middle-income countries (including Ethiopia) [15]. In this study, students who are found to have eight or more symptoms of SRQ₂₀ questions in the last four weeks were considered as having mental distress. This cutoff point was used based on a validation study of the questionnaire which gave the highest sensitivity and specificity [9]. Third, ever and current substance use (i.e. Alcohol, khat, and cigarette) were asked. The last part of the questionnaire measured sleep quality and patterns of students using the Pittsburgh Sleep Quality Index. The PSQI is an effective instrument used to measure the quality and patterns of sleep in adults. It differentiates “poor” from “good” sleep by measuring seven areas (components) : subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medications, and daytime dysfunction over the last month [10].

One Psychologist as a supervisor and three diploma nurses as data collector participated in the data collection process. The distribution of the questionnaire was conducted to students while they were in the classroom.

2.5. Data Quality Control

Training was provided for the data collection team on the objective and overall data collection procedures on a day before the pretest. The pretest was also conducted on 10% of students of Samara university from non-selected departments. The daily meeting was conducted among the principal investigator, supervisor and data collectors to check completeness and clarity of the questionnaire and to resolve unanticipated problems.

2.6. Operational Definitions

Mental distress: Having eight or more symptoms of the 20 SRQ20 questions in the last four weeks. Current substance use: a history of substance use (for non-medical purposes) in the last four weeks. Ever substance use: using the specified substance (for non-medical purposes) even once in their lifetime. Students who scored >5 for PSQI were categorized under poor sleep quality otherwise they were catagorized under good sleep quality [10].

2.7. Data Processing and Analysis

After checking the consistency and completeness of the questionnaires, the data were entered into Epi info version 7.1.1.14, and then exported to SPSS version 20 for further analysis. Frequency, mean, and standard deviation were employed for descriptive analysis. Multivariable logistic regression modeling was used to examine the relationship between sociodemographic and psychosocial factors with the mental distress of students. Adjusted Odds Ratio with a 95% confidence interval was used as a measure of association. A P-value of <0.05 was used to declare statistical significance.

2.8. Ethical Consideration

Ethical clearance was obtained from the Samara university College of Medical and Health Sciences Ethical Review Committee. Voluntary informed consent was also obtained from each study participant after the purpose and importance of the study was communicated. The name of the participant and any personal identifier were omitted from the questionnaire to ensure confidentiality.

3. Results

3.1. Socio-Demographic and Academic Characteristics

Out of 404 respondents, 230 (56.9%) of them were male, and 255 (63.1%) of them were less than or equal to 21 years of age. The majority of the students were single in their marital status [380 (94.1%)], and 219 (54.2%) of them were originated from urban areas. A family history of mental illness was reported in 99 (24.5%) of students. About 97 (24.0%) of them were from the College of Engineering and Technology and 152 (37.6%) of them were second-year students (Table 1).

Table 1: Socio-demographic and academic characteristics of Samara university students, Northeast Ethiopia, 2018 ().

Variables
Frequency
Percentage (%)

Sex

Male
230
56.9

Female
174
43.1

Age

≤21 years
255
63.1

>21 years
149
36.9

Marital status

Single
380
94.1

Married
18
4.5

Divorced
6
1.5

Religion

Orthodox
242
59.9

Muslim
102
25.2

Protestant
51
12.6

Other
9
2.2

Origin of residence

Rural
219
54.2

Urban
185
45.8

College

Engineering and technology
97
24.0

Veterinary medicine
55
13.6

Business and economics
51
12.6

Law school
50
12.4

Medical and health sciences
49
12.1

Natural and computational science
41
10.1

Social science and humanity
35
8.7

Dryland agriculture
26
6.4

Year of study

1st year
98
24.3

2nd year
152
37.6

3rd year
83
20.5

4th year
15
3.7

5th year
46
11.4

6th year
10
2.5

CGPA

>3.5
76
18.8

3.00–3.49
129
31.9

2.50–2.99
121
30.0

2.00–2.49
77
19.1

<1.99
1
0.2

Family history of mental distress

Yes
99
24.5

No
305
75.5

CGPA: Cumulative grade point average.

3.2. Psycho-Social Characteristics

The current use of khat, alcohol, and tobacco was reported in 64 (15.4%), 86 (21.3%) and 16 (4%) of students (Table 2). The majority (77.2%) of them reported the sleeping duration of fewer than six hours. One hundred sixty-nine (41.8%) of students reported sleep latency and day time dysfunction of less than once in a week. Sleep medication was reported by 45 (11.1%) of students. Overall, 319 (79%) of students were classified as having poor sleep quality (total PSQI score >5) (Table 2).

Table 2: Distribution of psychosocial factors in Samara university students, Northeast Ethiopia, 2018 ().

Variables
Frequency ()
Percentage (%)

Sleep duration [mean (+SD) = 5.3(±0.96)]

Greater than 7 hours
50
12.4

6-7 hours
42
10.4

5-6 hours
181
44.8

<5 hours
131
32.4

Sleep latency

Not during the past month
51
12.6

Less than once a week
169
41.8

Once or twice a week
143
35.4

Three or more times a week
41
10.1

Day time dysfunction

Not during the past month
118
29.2

Less than once a week
169
41.8

Once or twice a week
91
22.5

Three or more times a week
26
6.4

Sleep efficiency

>85%
151
37.4

75–84%
87
21.5

65–74%
92
22.8

<65%
74
18.3

Subjective sleep quality

Very good
89
22

Fairly good
122
30.2

Fairly bad
144
35.6

Very bad
48
11.9

Sleep disturbance

Not during the past month
119
29.5

Less than once a week
107
26.5

Once or twice a week
100
24.8

Three or more times a week
78
19.3

Use of sleep medication

Not during the past month
359
88.9

Less than once a week
25
6.2

Once or twice a week
17
4.2

Three or more times a week
3
0.7

Sleep quality [mean (SD) = 7.91(±3.57)]

Good sleep quality
85
21

Poor sleep quality
319
79

Ever use of khat []

Yes
112
27.7

No
292
72.3

Current use of khat []

Yes
64
57.1

No
48
42.8

Frequency of khat chewing []

Once in a week
18
28.1

Two-three times in a week
31
48.4

More than three times a week
15
23.4

Ever drink alcohol

Yes
154
38.1

No
250
61.9

Currently drinking alcohol

Yes
86
55.8

No
68
44.2

Frequency of alcohol drinking

Once in a week
46
53.5

Two-three times in a week
32
37.2

More than three times a week
8
9.3

Ever smoke tobacco products

Yes
37
9.2

No
367
90.8

Current smoker

Yes
16
43.2

No
21
56.7

3.3. Prevalence of Mental Distress

Prevalence of mental distress among students was found to be 53.2% [95% confidence interval [CI]: 0.48, 0.58]. About 58.1% and 41.7% of female and male students had mental distress respectively.

3.4. Factors Associated with Mental Distress

In multivariable logistic regression, female sex, ever use of khat, and sleep quality were associated with a higher odds of mental distress among students. The P-value of the Hosmer and Lemshow model fitness test was 0.93. The odds of mental distress of female students was significantly higher (adjusted odds ratio [AOR]: 4.67; 95% CI: 2.81, 7.71) as compared to male students. Students who reported ever use of khat had higher odds (AOR: 3.09; 95% CI: 1.74, 5.50) of mental distress compared to their counterparts. The prevalence of mental distress was significantly higher (AOR: 2.02; 95% CI: 1.12, 3.66) among students with poor sleep quality than those who had poor sleep quality (Table 3).

Table 3: Factors associated with mental distress of Samara university Students, Northeast Ethiopia, 2018 ().

Variable
Mental distress
ORs with 95% CI

Yes
No
Crude
Adjusted

Sex

Male
90
140
1.00
1.00

Female
125
49
3.97 (2.6, 6.06)
4.66 (2.81, 7.71)

Year of study

1st year
80
18
7.16 (3.91, 13.12)
4.28 (0.85, 21.466)

2nd year
76
76
1.61 (1.02, 2.54)
0.78 (0.17, 3.65)

≥3rd year
59
95
1.00
1.00

Family history of mental illness

Yes
65
34
1.98 (1.23, 3.17)
1.69 (0.97, 2.96)

No
150
155
1.00
1.00

Ever used khat

Yes
70
41
1.74 (1.11, 2.73)
3.09 (1.74, 5.5)

No
145
148
1.00
1.00

Ever used alcohol

Yes
73
81
0.69 (0.58, 1.03)
0.9 (0.55, 1.47)

No
142
108
1.00
1.00

Sleep quality and quantity

Good sleep quality
32
53
1.00
1.00

Poor sleep quality
183
136
2.23 (1.36, 3.66)
2.02 (1.12, 3.66)

ORs = Odds ratio. The bold values indicate statistical significance.

4. Discussion

The present study investigated the prevalence and associated factors of mental distress among Samara University students. Our findings showed that the prevalence of mental distress among Samara University students was found to be 53.2%, indicating the higher magnitude of mental distress among higher education students in Ethiopia. The proportion of mental distress found to be higher than previously published studies conducted among university students from Adama, Gondar, and Hawassa [12, 16, 17]. The possible explanation for the difference with the above studies can be that Samara University is located in one of the hottest areas of the country which increases student's risk of heat exhaustion and heat stress [18]. Additionally, poor infrastructure and lack of recreational facilities either inside or outside of the campus could also probably explain the observed difference in the magnitude of mental distress. The proportion of mental distress was also higher than studies conducted in higher-income countries such as France (25.7%) [19], Norway (22.9%) [20], Iceland (22.5%) [21] and Australia (19.2%) [22]. The findings of this study suggested the need for interventions targeted to reduce the mental distress of Samara University students in Ethiopia.

International evidence indicates that the magnitude of mental distress is higher in female students than male students [19, 20]. Consistent with this evidence, our study showed that the odds of mental distress was found to be higher among female students compared to male students. This finding was also supported by previously published studies in Australia [22, 23], France [24], Norway [20] and Turkey [25]. The susceptibility to stressors due to domestic violence and hormonal changes during menstruation could probably explain the higher prevalence of mental distress among female students [26]. Additionally, the structural determinants of mental health such as income and social roles and rank of women may explain the observed relationship between female students and mental distress. There is a need for a public health primary prevention approach and gender-specific interventions that address gender-specific risk factors in Ethiopia.

Researchers have indicated the bi-directional relationships between substance use and common mental disorders of students [27, 28]. Our study also supported this relationship which showed the positive association between ever use of khat and mental distress of students. Similarly, previously published studies in Ethiopia also reported that substance use was associated with increased risk to mental distress of students [12, 29]. This result may be explained by the fact that people may use psychoactive substances as a self-regulation strategy to alleviate the distressful experience [28]. Another possible explanation for the observed association between substance use and mental distress could be that people with substance use and mental disorder may have an overlapping genetic susceptibility to both disorders [30]. The evidence from this study suggests that it is imperative that practitioners and policymakers work collaboratively to establish multi-pronged strategies to reduce the co-occurring substance use and mental distress of students.

The present study demonstrated that students who had poor sleep quality were more likely to experience mental distress as compared to those who had good sleep quality. This finding was supported by similar studies conducted among university students [31–33]. The relationship between poor sleep quality and mental distress can be explained by that students with sleep disturbances are more likely to complain a high level of stress, which might, in turn, be changed to mental distress [34]. There are, however, other possible explanations. The sleeping disturbance can be either a cause or a symptom of mental distress or simply co-morbidity [32]. We recommend high-quality longitudinal studies that might be helpful to investigate the relationship between mental distress and sleep quality of university students.

This study has some important limitations that should be kept in mind when interpreting the results. First, the cross-sectional nature of the study design may not allow confirming a definitive cause and effect relationship. Second, it is important to bear in mind that SRQ₂₀ is a screening instrument in measuring the mental distress of students. Nevertheless, the findings of this study can be used as a first step to understand the current situation of mental distress among university students. Third, the scope of this study was limited in terms of measuring the distressful experience of students. We recommend for qualitative investigations that explore the experience and perception of students towards the distressful experience. Last, the study may be prone to recall bias since the data were collected based on self-reported information. Despite the above limitation, the use of a validated standardized instrument can be considered as a potential strength of this study.

5. Conclusion

The result of the present study shows that more than half of Samara university students were mentally distressed. This proportion was higher as compared to similar studies conducted in Adama, Gondar and Hawassa university students. Being female in sex, ever use of khat and poor sleep quality were independent predictors of student’s mental distress. We recommended that students mental distress needs due attention and remedial action from both government and non-governmental organizations and any program aimed at preventing mental distress of students. For example, evidence-based interventional strategies such as self-help measures, sleep hygiene, and peer support, as well as professional mental health services as part of student health services, would be helpful to reduce the burden of mental distress of students.

Abbreviations

ANRS: | Afar national and regional state
AOR: | Adjusted odds ratio
CI: | Confidence interval
CGPA: | Cumulative grade point average
PSQI: | Pittsburgh sleep quality index
SRQ: | Self-reporting questionnaire
WHO: | World Health Organization.

Data Availability

The data set will not be shared in order to protect the participants’ identities.

Ethical Approval

The study was reviewed and approved by the Ethical review committee of Samara university, College of Medical and Health Science. All participants were pre-informed of the aim of the study and their full right to withdraw or refuse to participate before their verbal consent was obtained.

Conflicts of Interest

The authors declared no conflicts of interest.

Authors’ Contributions

Robel Tesfaye Kelemu conceived and designed the study, performed analysis and interpretation of data and drafted the manuscript. Alemayehu Bayray Kahsay and Kedir Y. Ahmed supervised the design, conception, analysis, interpretation of data and made critical comments at each step of research. All authors read and approved the final Manuscript.

Acknowledgments

We would like to express our heartfelt gratitude and sincere appreciations to all data Collectors and study participants in this study; without them, this research wouldn’t have been possible. We would like to extend our sincere appreciation to the dedicated staff working in Samara university student service as they have provided us the relevant data and information related to our research work. We would like to express our deeper thanks to Samara university, College of Medical and Health Sciences for facilitating the research work.

References

Y. G. Haile, S. M. Alemu, and T. D. Habtewold, “Common mental disorder and its association with academic performance among Debre Berhan university students Ethiopia,” International Journal of Mental Health Systems, vol. 11, no. 1, p. 34, 2017.

V. N. Vahia, “Diagnostic and statistical manual of mental disorders 5: a quick glance,” Indian Journal of Psychiatry, vol. 55, no. 3, pp. 220–223, 2013.

S. Svanum and Z. B. Zody, “Psychopathology and college grades,” Journal of Counseling Psychology, vol. 48, no. 1, pp. 72–76, 2001.

B. K. M. Mane Abhay, C. Niranjan Paul, and G. Hiremath Shashidhar, “Differences in perceived stress and its correlates among students in professional courses,” Journal of Clinical and Diagnostic Research, vol. 5, no. 6, pp. 1228–1233, 2011.

M. P. Tavolacci, J. Ladner, S. Grigioni, L. Richard, H. Villet, and P. Dechelotte, “Prevalence and association of perceived stress, substance use and behavioral addictions: a cross-sectional study among university students in France, 2009–2011,” BMC Public Health, vol. 13, no. 1, pp. 724–2011, 2013.

A. Sadeh, G. Keinan, and K. Daon, “Effects of stress on sleep: the moderating role of coping style,” Health Psychology, vol. 23, no. 5, pp. 542–545, 2004.

W. M. Sweileh, I. A. Ali, A. F. Sawalha, A. S. Abu-Taha, S. H. Zyoud, and S. W. Al-Jabi, “Sleep habits and sleep problems among palestinian students,” Child and Adolescent Psychiatry and Mental Health, vol. 5, no. 1, p. 25, 2011.

S. Cohen, G.W. Evans, D. Stokols, and D. S. Krantz, Behaviour, Health and Envirnmental Stress, Plenum Press, New York, NY, USA., 1986.

T. W. Harding, M. V. de Arango, J. Baltazar et al., “Mental disorders in primary health care: a study of their frequency and diagnosis in four developing countries,” Psychological Medicine, vol. 10, no. 2, pp. 231–241, 1980.

D. J. Buysse, C. F. Reynolds 3rd, T. H. Monk, S. R. Berman, and D. J. Kupfer, “The Pittsburgh sleep quality index: a new instrument for psychiatric practice and research,” Psychiatry Research, vol. 28, no. 2, pp. 193–213, 1989.

M. Ng, T. Fleming, M. Robinson et al., “Global, regional, and national prevalence of overweight and obesity in children and adults during 1980–2013: a systematic analysis for the global burden of disease study 2013,” The Lancet, vol. 384, no. 9945, pp. 766–781, 2014.

Y. Dessie, J. Ebrahim, and T. Awoke, “Mental distress among university students in Ethiopia: a cross sectional survey,” Pan African Medical Journal, vol. 15, p. 95, 2013.

Samara University, 2018, Students. Retrieved from https://www.su.edu.et/node/23.

M. Tesfaye, C. Hanlon, F. Tessema, M. Prince, and A. Alem, “Common mental disorder symptoms among patients with malaria attending primary care in Ethiopia: a cross-sectional survey,” PLoS One, vol. 9, no. 9, p. e108923, 2014.

WHO, WHO: A Users Guide to Self Reporting Questionnaire, WHO, Geneva, 1994.

B. A. Dachew, T. Azale Bisetegn, and R. Berhe Gebremariam, “Prevalence of mental distress and associated factors among undergraduate students of university of Gondar, Northwest Ethiopia: a cross-sectional institutional based study,” PLoS One, vol. 10, no. 3, p. e0119464, 2015.

A. Tesfaye, “Prevalence and correlates of mental distress among regular undergraduate students of hawassa university: a cross sectional survey,” East African Journal of Public Health, vol. 6, no. 1, pp. 85–94, 2009.

M. Lõhmus, “Possible biological mechanisms linking mental health and heat – a contemplative review,” International Journal of Environmental Research and Public Health, vol. 15, no. 7, p. 1515, 2018.

P. Verger, J. B. Combes, V. Kovess-Masfety et al., “Psychological distress in first year university students: socioeconomic and academic stressors, mastery and social support in young men and women,” Social Psychiatry and Psychiatric Epidemiology, vol. 44, no. 8, pp. 643–650, 2009.

P. Nerdrum, T. Rustøen, and M. H. Rønnestad, “Student psychological distress: a psychometric study of 1750 Norwegian 1st-year undergraduate students,” Scandinavian Journal of Educational Research, vol. 50, no. 1, pp. 95–109, 2006.

J. Bernhardsdottir and R. Vilhjalmsson, “Psychological distress among university female students and their need for mental health services,” Journal of Psychiatric and Mental Health Nursing, vol. 20, no. 8, pp. 672–678, 2013.

H. M. Stallman, “Psychological distress in university students: a comparison with general population data,” Australian Psychologist, vol. 45, no. 4, pp. 249–257, 2010.

C. M. Leahy, R. F. Peterson, I. G. Wilson, J. W. Newbury, A. L. Tonkin, and D. Turnbull, “Distress levels and self-reported treatment rates for medicine, law, psychology and mechanical engineering tertiary students: cross-sectional study,” Australian & New Zealand Journal of Psychiatry, vol. 44, no. 7, pp. 608–615, 2010.

P. Verger, V. Guagliardo, F. Gilbert, F. Rouillon, and V. Kovess-Masfety, “Psychiatric disorders in students in six french universities: 12-month prevalence, comorbidity, impairment and help-seeking,” Social Psychiatry and Psychiatric Epidemiology, vol. 45, no. 2, pp. 189–199, 2010.

N. Bayram and N. Bilgel, “The prevalence and socio-demographic correlations of depression, anxiety and stress among a group of university students,” Social Psychiatry and Psychiatric Epidemiology, vol. 43, no. 8, pp. 667–672, 2008.

M. D. Pagel, W. W. Erdly, and J. Becker, “Social networks: we get by with (and in spite of) a little help from our friends,” Journal of Personality and Social Psychology, vol. 53, no. 4, pp. 793–804, 1987.

P. F. Buckley, “Dual diagnosis of substance abuse and severe mental illness: the scope of the problem,” Journal of Dual Diagnosis, vol. 3, no. 2, pp. 59–62, 2007.

L. L. Smith, F. Yan, M. Charles et al., “Exploring the link between substance use and mental health status: what can we learn from the self-medication theory?” Journal of Health Care for the Poor and Underserved, vol. 28, no. 2S, pp. 113–131, 2017.

T. Damena, A. Mossie, and M. Tesfaye, “Khat chewing and mental distress: a community based study, in Jimma city, Southwestern Ethiopia,” Ethiopian Journal of Health Sciences, vol. 21, no. 1, pp. 37–45, 2011.

N. D. Volkow, “Substance use disorders in Schizophrenia–clinical implications of comorbidity,” Schizophrenia Bulletin, vol. 35, no. 3, pp. 469–472, 2009.

K. Aboalshamat, X. Y. Hou, and E. Strodl, “Psychological well-being status among medical and dental students in Makkah, Saudi Arabia: a cross-sectional study,” Medical Teacher, vol. 37, no. 1, pp. S75–S81, 2015.

M. Rezaei, M. Khormali, S. Akbarpour, K. Sadeghniiat-Hagighi, and M. Shamsipour, “Sleep quality and its association with psychological distress and sleep hygiene: a cross-sectional study among pre-clinical medical students,” Sleep Science, vol. 11, no. 4, pp. 274–280, 2018.

K. Shamsuddin, F. Fadzil, W. S. W. Ismail et al., “Correlates of depression, anxiety and stress among Malaysian university students,” Asian Journal of Psychiatry, vol. 6, no. 4, pp. 318–323, 2013.

A. Theadom and M. Cropley, “Dysfunctional beliefs, stress and sleep disturbance in Fibromyalgia,” Sleep Medicine, vol. 9, no. 4, pp. 376–381, 2008.