Mental health issues

A key finding of our study was that 73.6% of students reported at least mild depressive symptoms (PHQ-9 ≥ 5). Importantly, 35.8% met the threshold for probable major depression (PHQ-9 ≥ 10), representing moderate-to-severe symptoms and reflecting the clinically meaningful burden of depression in this population, with 18.4% reporting major difficulties in functioning. This finding was consistent with a previous study in medical students in the UAEU by Abdel Aziz et al, ^{Reference Abdel Aziz, Okasha, Bhugra, Molodynski, AlKhyeli and AlNeyadi9} which reported rates of 74.5% for depressive symptoms measured with the General Health Questionnaire-12 in a sample of 385 participants.

When focusing on clinically significant symptoms, the prevalence of probable major depression in our sample (35.8%) was comparable to the 2023–2024 HMS Questionnaire estimate of 38% for moderate-to-severe depression, ⁶ which indicates a similar trend in UAE students as USA students. These comparisons should be interpreted with caution, as our data represent a pre-pandemic period (2016–2017), whereas the 2023–2024 HMS Questionnaire findings were collected in a distinctly different global and regional mental health context. Our data was also similar to the trend of Qatari and Lebanese university students who had a combined prevalence of 34.6%, also using the PHQ-9. ^{Reference Kronfol, Khalifa, Khoury, Omar, Daouk and deWitt2} Rates of moderate or severe anxiety symptoms in our study were 23%, which was somewhat lower than both the HMS Questionnaire (2023–2024), which reported a rate of 34%, ⁶ and Kronfol et al ^{Reference Kronfol, Khalifa, Khoury, Omar, Daouk and deWitt2} in Qatari and Lebanese students, which was 36.1%. In our sample, rates of non-suicidal self-injury, suicidal ideation, suicidal plans and suicidal attempts in the past year were 11.5%, 9.2%, 4.6% and 1.2%, respectively, which were lower than the HMS Questionnaire (2023–2024), which was 26%, 13%, 6% and 2%, respectively. ⁶ This difference might be explained by a very large proportion (87.3%) reporting finding comfort in religion to cope with difficulties (which in the case of the UAE is Islam, which considers suicide a major sin), ^{Reference Shoib, Armiya’u, Nahidi, Arif and Saeed16} and where religious affiliation has the potential to counter impulsivity and facilitate greater self-control. ^{Reference McCullough, Carter, Pargament, Exline and Jones17} Interpretation of suicidal ideation in this study must be made with caution, as the survey did not assess whether these thoughts were short-lived or persistent, nor did it evaluate contextual factors such as adjustment to the early years of medical training. Clinically, suicidal ideation without a formulated plan may not necessarily indicate imminent risk; however, our tool allowed only for reporting of prevalence rather than assessment of severity. Consequently, findings should be viewed as indicative of the presence of suicidal thoughts rather than a determination of clinical seriousness.

Rates of students scoring positive for eating disorder symptoms on the SCOFF in our sample was 13.8%, which was similar to the HMS Questionnaire (2023–2024), which was 13%. ⁶ Rates of moderate or severe insomnia on the ISI were 27.6%. Data from the various HMS Questionnaire reports have not commented on rates of insomnia, but a previous study in UAE university students found that almost 22% reported bad quality of sleep, which was somewhat comparable to our study. ^{Reference Ahmed, Shawky and Al Sarraf18}

There may be a number of reasons why university students (including those in our sample) are especially vulnerable to mental health problems. First, these students frequently have high personal standards, which may be an advantage in a highly competitive field, but may also lead to excessive preoccupation with academic performance and maladaptive perfectionism. These are significantly associated with baseline neuroticism and can predict hopelessness and depression. ^{Reference Hays, Cheever and Patel19} Also, most university students around the world are between the ages of 17 and 24 years, which is already a high-risk age for developing mental health problems. ^{Reference El-Gabry, Okasha, Shaker, Elserafy, Yehia and Abdel Aziz20} Furthermore, university students experience high levels of distress because of the quantity of their studies, examination stress, the competitive nature of the university environment and the anxiety that may be associated with new experiences. ^{Reference Dyrbye, Thomas and Shanafelt21} These students are also expected to adapt to new social and academic demands, including changes in the methods of teaching between high school and university, dealing with financial difficulties, having limited leisure time, facing accommodation issues, dealing with personal relationships and having to make career choices. ^{Reference Ishak, Nikravesh, Lederer, Perry, Ogunyemi and Bernstein22}

Knowledge and attitudes about mental health and its services

Our findings reflect students’ awareness and perceptions of available mental health services rather than actual utilisation rates. Despite the high occurrence of mental health issues in our sample, only 33.3% of students identified themselves as suffering from a mental illness. Only 28.7% of students agreed that if they needed professional help for their mental health issue, they would know where to go on campus. This was markedly lower than the HMS Questionnaire (2023–2024), where 76% of participants agreed that if they needed professional help for their mental health issue, they would know where to go on campus. ⁶ In addition, 83.9% of students were not aware of mental health outreach efforts on campus, and only 27.6% agreed that there was a good support system on campus for students going through difficult times. One possible reason for these rates might be underlying beliefs and the level of knowledge about mental health conditions among students. ^{Reference Aluh, Okonta and Odili23} Mental health literacy is intricately linked with factors like age, culture and socioeconomic background, ^{Reference Sampaio, Gonçalves and Sequeira24} and enhancing mental health literacy is one of the most important factors in reducing stigma and improving early recognition of mental health conditions. ^{Reference Javaid, Bennett and Goodall25} Although there have been efforts to improve mental health literacy within the Middle East, ^{Reference Elyamani, Naja, Al-Dahshan, Hamoud, Bougmiza and Alkubaisi26} much more is needed to achieve satisfactory levels of health literacy among the population. ^{Reference Pedersen and Paves27} The importance of this cannot be overstated, especially as mental health problems were identified in our study as the second most likely challenge to prevent students from finishing their degree (31%), with nearly three-quarters of students (73.6%) feeling that the campus environment had a negative impact on their mental and emotional health, and only half of students (51.7%) reporting that they felt that their mental and emotional well-being was a priority at the college, and less than half (44.8%) reporting that they felt that the campus climate encouraged free and open discussion about mental and emotional health.

Perceived and personal stigma toward mental health issues

Perceived mental health stigma is defined as how a person believes others would view and treat those who sought out treatment for mental illness. ^{Reference Knaak, Mantler and Szeto28} In our study, we found that 69% of participants agreed that most people would think less of a person who has received mental health treatment, while for personal stigma, only 8.1% agreed that they would think less of a person who has received mental health treatment. Compared to the HMS Questionnaire (2023–2024), this was much higher than the rate of 41% for perceived stigma, but was comparable to the rate of 7% for personal stigma. ⁶ Both our study and the HMS Questionnaire (2023–2024) highlight the discrepant rates between perceptions of personal and public stigma, with a negative trend toward the perception of public stigma. Furthermore, our study found that 26.4% reported that they sometimes felt ashamed of having a mental illness, with 42.5% reporting that they sometimes kept their mental illness a secret. This reinforces the role of stigma (especially public stigma) as a possible reason for reluctance in seeking help for mental health issues among students. Although efforts have been made to increase the visibility of mental health, mental health stigma remains a major concern. ^{Reference Shalbafan, El Hayek and de Filippis29} The relationship between stigma and reluctance to seek help has been investigated in the general population, ^{Reference Corrigan, Druss and Perlick30} and has also been studied among medical students. ^{Reference Wilkinson31} A study involving medical students in nine medical schools across the UK found that nearly half of the participants experienced significant mental health-related symptoms, and stigma was a major impediment to getting appropriate help. ^{Reference Wilkinson31} Studies from the Middle East also acknowledge stigma as a major factor behind the underreporting of mental health problems and a reluctance to seek professional help. ^{Reference Elyamani, Naja, Al-Dahshan, Hamoud, Bougmiza and Alkubaisi26,Reference Amiri, Voracek, Yousef, Galadari, Yammahi and Sadeghi32}

Coping with stress

Regarding strategies to cope with stress, around half of participants (52.8%) reported coping by getting emotional support from family and friends, 87.3% reported that they coped with stress by finding comfort in religion, 92% reported that they coped with stress by praying or meditating and >95% denied use of alcohol or drugs to cope with stress. Previous literature associated with coping mechanisms used by students has shown that alongside religion, peer and family support are commonly utilised as positive coping mechanisms against stress, ^{Reference Lipson, Zhou, Abelson, Heinze, Jirsa and Morigney33} with informal social support identified as a buffer against mental health conditions among students from Middle Eastern backgrounds. ^{Reference Samari, McNall, Lee, Perlstadt and Nawyn34} Although no participants met screening criteria for a substance use disorder, a small proportion of students (5.8%) reported using alcohol or drugs as a coping strategy, indicating occasional or situational use rather than clinically significant misuse. The finding of low drug and alcohol use in Emirati medical students is consistent with the previous study by Abdel Aziz et al, ^{Reference Abdel Aziz, Okasha, Bhugra, Molodynski, AlKhyeli and AlNeyadi9} which reported that <1% of students screened positive on the Cut down drinking, Annoyed by criticism, Guilty feelings, Eye-opener (CAGE) questionnaire for alcohol misuse and ≤1% reported using illicit substances (cannabis, opiates and amphetamines). Previous studies have reported on the role of religious affiliation as a positive protective factor against the use of drugs and alcohol, where religious affiliation has the potential to counter impulsivity and facilitate greater self-control. ^{Reference McCullough, Carter, Pargament, Exline and Jones17} Although the present study did not directly assess protective strategies among students who experienced suicidal ideation but did not engage in self-harm or suicide attempts, the high prevalence of adaptive coping strategies reported, particularly reliance on family support and religious or spiritual practices, may represent potential protective influences. These strategies may help mitigate distress and reduce the likelihood of acting on suicidal thoughts, although this cannot be confirmed within the scope of the current data.

Overall, our findings provide an important historical benchmark for medical student mental health in the UAE before the COVID-19 pandemic, offering a reference point for future post-pandemic research and for evaluating the impact of evolving mental health initiatives.

Limitations

There were several limitations to our study. First, the sample size was relatively small, with a response rate of 16.3%, which may introduce selection bias, as students experiencing greater mental health concerns may have been more likely to participate. However, the gender distribution of the sample (77.0% female) closely mirrored that of the overall undergraduate medical student population at the time (76.9% female), suggesting reasonable demographic representativeness with respect to gender. Additionally, the length of the survey and the sensitive nature of mental health topics may have further limited participation.

Another limitation is that the assessment of suicidality was restricted by the structure of the HMS Questionnaire, which included only a single screening question on suicidal thoughts and did not capture duration, frequency or severity of ideation. The tool also did not distinguish between ideation with or without a plan, nor did it assess whether suicidal thoughts varied across academic years. This limits the ability to interpret the clinical significance of suicidal ideation or identify developmental or contextual patterns.

A further limitation relates to the self-administered nature of the questionnaire. As the survey was completed independently, there remains the possibility that some students may have misinterpreted individual items (as with all self-administered questionnaires). Although investigator contact details were provided for clarification, misunderstandings may still have occurred and could have contributed to under- or overreporting of symptoms.

Another limitation is that the HMS Questionnaire version used in this study did not include questions assessing personal psychiatric history or family history of mental illness. Although students were asked whether they identified themselves as having a mental illness, the absence of detailed lifetime or family mental health information limited our ability to determine whether university-related stressors may have precipitated symptoms or whether findings may reflect pre-existing vulnerabilities. Future studies would benefit from incorporating these variables to better contextualize mental health outcomes.

In addition, the questionnaire assessed mental health symptoms within the past year, but did not distinguish between current and resolved symptoms, nor did it include items exploring factors that may have contributed to symptom improvement or recovery. As a result, we were unable to examine temporal trajectories of mental health difficulties or identify protective strategies that may have facilitated symptom resolution. Future studies incorporating longitudinal designs or retrospective symptom assessment could help identify preventive factors applicable to newer cohorts of medical students.

Furthermore, there may have been a reluctance on the part of students to participate in a mental health survey given the negative perceived public stigma associated with mental health issues. Another limitation was that participants were from one college (the College of Medicine), where academic stress tends to be high, ^{Reference Farrell, Moir, Molodynski and Bhugra35} which may limit the generalisability of our findings with other colleges. Future studies using the HMS Questionnaire should aim to include a broader range of colleges and universities to reflect the experience of the broader UAE university student population.

In conclusion, our study revealed a high prevalence of mental health difficulties in medical students in the UAEU. We also found a reluctance to report and seek help for mental health difficulties, which may be associated with a negative perceived public stigma. These findings highlight the need for targeted preventive interventions, including structured mental health literacy programmes to improve recognition of symptoms, stigma-reduction initiatives addressing negative perceptions of mental health treatment, and improved visibility and accessibility of on-campus mental health services. Early screening initiatives, particularly during transitional phases of medical training, alongside culturally sensitive support strategies that acknowledge the role of family and religious coping, may serve as protective measures to reduce psychological distress and promote help-seeking among medical students.