RESEARCH ARTICLE: Prevalence and correlates of depression, anxiety and stress among undergraduate pharmacy students in Nigeria
DOI:
https://doi.org/10.46542/pe.2020.201.236248Keywords:
Depression, Anxiety, Stress, Pharmacy students, NigeriaAbstract
Background: Mental health disorders are increasingly becoming a global concern among university students. The prevalence of depression, anxiety and stress among pharmacy students in Nigeria is unknown.
Objective: This study sought to examine the occurrence of depression, anxiety and stress and associated sociodemographic factors among undergraduate pharmacy students in Nigeria. Methods: The study was an online-based cross-sectional descriptive survey conducted among students from seven pharmacy schools in Nigeria. Students were recruited via their class WhatsApp groups and a link to a Google Form was provided for those who agreed to participate in the study. Data were analysed using IBM Statistical Product and Services Solution for Windows version 21.0.
Results: A total of 408 students out of approximately 3,068 students responded to the survey (response rate: 13.32%). The prevalence of depression, anxiety and stress was 44.6%, 63.5%, and 35%, respectively. Depression was found to be strongly correlated with stress (r=0.739, p<0.001) and anxiety (r=0.715, p<0.001). Depression, anxiety and stress scores significantly correlated with perceived academic performance and year of study. There was no significant association between gender, cigarette smoking, type of accommodation, and the levels of depression, anxiety, and stress.
Conclusion: The prevalence of depression, anxiety and stress among pharmacy students responding to a survey in Nigeria was high. Students in lower years of study and those with perceived poor academic performance had higher levels of depression, anxiety and stress. More studies are needed to explore the causes of depression, anxiety and stress among pharmacy students.
References
Adebisi, Y.A., Olaoye, O.C., Ekpenyong, A.M., Alaran, A.J., & Lucero-Prisno III, D.E. (2019). Depression Among Pharmacy Students in Nigeria: Is It a Neglected Issue? Strides in Development of Medical Education, 16(1), e97918. https://doi.org/10.5812/sdme.97918
Adewuya, A.O., Ola, B.A., Aloba, O.O., Mapayi, B.M., & Oginni, O.O. (2006). Depression amongst Nigerian university students: Prevalence and sociodemographic correlates. Social Psychiatry and Psychiatric Epidemiology, 41, 674–678. https://doi.org/10.1007/s00127-006-0068-9
Adewuya, A.O., Atilola, O., Ola, B.A., Coker, O.A., Zachariah, M.P., Olugbile, O., et al. (2018). Current prevalence, comorbidity and associated factors for symptoms of depression and generalised anxiety in the Lagos State Mental Health Survey (LSMHS), Nigeria. Comprehensive Psychiatry, 81, 60-5. https://doi.org/10.1016/j.comppsych.2017.11.010
Ajumobi, O., Uhomoibhi, P., Onyiah, P., Babalola, O., Sharafadeen, S., Ughasoro, M.D., et al. (2018). Setting a Nigeria national malaria operational research agenda: The process. BMC Health Services Research, 18(459). https://doi.org/10.1186/s12913-018-3224-5
Al-qaisy, L.M. (2011). The relation of depression and anxiety in academic achievement among group of university students. International Journal of Psychology and Counselling. 3(5), 96-100
Ani, O.E. (2010). Internet access and use: A study of undergraduate students in three Nigerian universities. The Electronic Library, 28(4), 555-67. https://doi.org/10.1108/02640471011065373
Aniebue, P.N., & Onyema, G.O. (2008). Prevalence of depressive symptoms among Nigerian medical undergraduates. Tropical Doctor, 38(3), 157-8. https://doi.org/10.1258/td.2007.070202
Asa, F.T., & Lasebikan, V.O. (2016). Mental Health of Teachers: Teachers' Stress, Anxiety and Depression among Secondary Schools in Nigeria. International Neuropsychiatric Disease Journal, 7(4), 1-10. https://doi.org/10.9734/INDJ/2016/27039
Basha, E., & Kaya, M. (2016). Depression, Anxiety and Stress Scale (DASS): The Study of Validity and Reliability. Universal Journal of Educational Research, 4(12), 2701-5. https://doi.org/10.13189/ujer.2016.041202
Bayram, N., & Bilgel. N. (2008). The prevalence and socio- demographic correlations of depression, anxiety and stress among a group of university students. Social Psychiatry and Psychiatric Epidemiology, 43, 667–672. https://doi.org/10.1007/s00127-008-0345-x
Beiter, R., Nash, R., McCrady, M., Rhoades, D., Linscomb, M., Clarahan, M., & Sammut, S. (2015). The prevalence and correlates of depression , anxiety , and stress in a sample of college students. Journal of Affective Disorders, 173, 90-6. https://doi.org/10.1016/j.jad.2014.10.054
Callender, J., Fagin, L., Jenkins, G., Lester, J. (2011). Mental health of students in higher education. College report CR 166. Royal College of Psychiatrists. Available at: https://www.rcpsych.ac.uk/docs/default-source/improving-care/better-mh-policy/college- reports/college-report-cr166.pdf?sfvrsn=d5fa2c24_2
Cheung, T., Wong, S.Y., Wong, K.Y., Law, L.Y., Ng, K., Tong, M.T.,Wong, K.U., Ng, M.Y., & Yip, P.S.F. (2016). Depression, anxiety and symptoms of stress among baccalaureate nursing students in Hong Kong: A cross-sectional study. International Journal of Environmental Research and Public Health, 13(8), 779. https://doi.org/10.3390/ijerph13080779
Chinawa, A.T., Chinawa, J.M., Aniwada, E., Amadi, O., Ndukuba, A.C., & Uwaezuoke, S.N. (2018). Spectrum of Anxiety Disorders Among Medical Students in a Nigerian Medical School: A Cross- Sectional Study With Standardized Screening Tools. Journal of Educational and Development Psychology, 8(2), 132. https://doi.org/10.5539/jedp.v8n2p132
Coker, A.O., Coker, O.O., & Sanni, D. (2018). Sociodemographic Correlates and Symptoms of Depression, Anxiety and Stress among a Sample of Nigerian Medical Students. Nigerian Journal of Basic and Clinical Sciences, 15(1), 58-62. https://doi.org/10.4103/njbcs.njbcs_50_16
Collins, B.N., & Lepore, S.J. (2009). Association between anxiety and smoking in a sample of urban black men. Journal of Immigration and Minority Health, 11(1), 29-34. https://doi.org/10.1007/s10903-008-9164-0
Cramer, V.C., Torgersen, S., & Kringlen, E. (2005). Quality of life and anxiety disorders: A population study. The Journal of Nervous and Mental Disease, 193(3), 196-202. https://doi.org/10.1097/01.nmd.0000154836.22687.13
Cruz, S.Y., González, A.M., González, M.J., Rivera-Soto, W.T., Palacios, C. (2013). Academic load, Academic stress, Caffeinated beverages. Puerto Rico Health Sciences Journal, 32(2), 95-100.
Downs, N., Galles, E., Skehan, B., & Lipson, S.K. (2018). Be True to Our Schools-Models of Care in College Mental Health. Current Psychiatry Reports, 20(72). https://doi.org/10.1007/s11920-018-0935-6
Ebert, J.F., Huibers, L., Christensen, B., & Christensen, M.B. (2018). Paper-or web-based questionnaire invitations as a method for data collection: Cross-sectional comparative study of differences in response rate, completeness of data, and financial cost. Journal of Medical Internet Research, 20(1). https://doi.org/10.2196/jmir.8353
Edwards, P.J., Roberts, I., Clarke, M.J., DiGuiseppi, C., Wentz, R., Kwan, I., Cooper, R., Felix, L.M., & Pratap, S. (2009). Methods to increase response to postal and electronic questionnaires. Cochrane Database of Systematic Reviews, 3(MR000008). https://doi.org/10.1002/14651858.MR000008.pub4
Eisenberg, D., Golberstein, E., & Hunt, J.B. (2009). Mental Health and Academic Success in College. B.E Journal of Economic Analysis and Policy, 9(1), 1-40. https://doi.org/10.2202/1935-1682.2191
Esan, O., Esan, A., Folasire, A., & Oluwajulugbe, P. (2019). Mental health and wellbeing of medical students in Nigeria: a systematic review. International Review of Psychiatry, 31(7-8), 661-72. https://doi.org/10.1080/09540261.2019.1677220
Esmaeelzadeh, S., Moraros, J., Thorpe, L., & Bird, Y. (2018). The association between depression, anxiety and substance use among Canadian post-secondary students. Neuropsychiatric Disease and Treatment, 14, 3241-51. https://doi.org/10.2147/NDT.S187419
Fawzy, M., & Hamed, S.A. (2017). Prevalence of psychological stress, depression and anxiety among medical students in Egypt. Psychiatry Research, 255, 186-94. https://doi.org/10.1016/j.psychres.2017.05.027
Frazier, P., Gabriel, A., Merians, A., & Lust, K. (2019). Understanding stress as an impediment to academic performance. Journal of American College Health, 67(6), 562-70. https://doi.org/10.1080/07448481.2018.1499649
Gomez, F. (2002). A Guide to the Depression, Anxiety and Stress Scale (DASS 21)-Consultant Clinical Psychologist. Black Dog Inst. (Dass 21), 3
Gonçalves, R., & Figueiredo-braga, M. (2018). Evaluation of the relationships among happiness, stress, anxiety, and depression in pharmacy students. Currents in Pharmacy Teaching and Learning, 10(7), 903-910. https://doi.org/10.1016/j.cptl.2018.04.002
Gureje, O., & Lasebikan, V.O. (2006). Use of mental health services in a developing country. Results from the Nigerian survey of mental health and well-being. Social Psychiatry and Psychiatric Epidemiology, 41, 44–49.https://doi.org/10.1007/s00127-005-0001-7
Gureje, O., Lasebikan, V.O., Kola, L., & Makanjuola, V.A. (2006). Lifetime and 12-month prevalence of mental disorders in the Nigerian Survey of Mental Health and Well-Being. The British Journal of Psychiatry, 188(5), 465-71. https://doi.org/10.1192/bjp.188.5.465
Gureje, O., Uwakwe, R., Oladeji, B., Makanjuola, V.O., & Esan, O. (2010). Depression in adult Nigerians: Results from the Nigerian Survey of Mental Health and Well-being. Journal of Affective Disorders, 120(1-3), 158-64. https://doi.org/10.1016/j.jad.2009.04.030
Hanna, L.-A., Melissa, W., Maurice, H., & Hanna, A. (2018). Pharmacists by Gender and Year Group. Pharmacy, 6(75). https://doi.org/10.3390/pharmacy6030075
Harrison, S., Henderson, J., Alderdice, F., & Quigley, M.A. (2019). Methods to increase response rates to a population-based maternity survey: A comparison of two pilot studies. BMC Medical Research Methodology, 19(65). https://doi.org/10.1186/s12874-019-0702-3
Haskell, C.F., Kennedy, D.O., Wesnes, K.A., & Scholey, A.B. (2005). Cognitive and mood improvements of caffeine in habitual consumers and habitual non-consumers of caffeine. Psychopharmacology, 179, 813-25. https://doi.org/10.1007/s00213-004-2104-3
Henning, K., Ey, S., & Shaw, D. (2002). Perfectionism, the impostor phenomenon and psychological adjustment in medical, dental, nursing and pharmacy students. Medical Education, 32(5), 456-64. https://doi.org/10.1046/j.1365-2923.1998.00234.x
Herrmann, K., Déchelotte, P., Ladner, J., & Tavolacci, M.P. (2019). Depression, anxiety stress and associated factors among university students in France. European Journal of Public Health, 29(4). https://doi.org/10.1093/eurpub/ckz186.555
Ibrahim, A.K., Kelly, S.J., Adams, C.E., & Glazebrook, C. (2013). A systematic review of studies of depression prevalence in university students. Journal of Psychiatric Research, 47(3), 391-400. https://doi.org/10.1016/j.jpsychires.2012.11.015
Ibrahim, M.B., & Abdelreheem, M.H. (2015). Prevalence of anxiety and depression among medical and pharmaceutical students in Alexandria University Prevalence of anxiety and depression among medical and pharmaceutical students in Alexandria. Alexandria Journal of Medicine, 51(2), 167-73. https://doi.org/10.1016/j.ajme.2014.06.002
Iorga, M., Dondas, C., & Zugun-Eloae, C. (2018). Depressed as freshmen, stressed as seniors: The relationship between depression, perceived stress and academic results among medical students. Behavioral Sciences (Basel), 8(8). https://doi.org/10.3390/bs8080070
Izadinia, N., Amiri, M., Jahromi, R.G., & Hamidi, S. (2010). A study of relationship between suicidal ideas, depression, anxiety, resiliency, daily stresses and mental health among Tehran university students. Procedia - Social Behavioral Sciences, 5, 1615-9. https://doi.org/10.1016/j.sbspro.2010.07.335
Jafari, P., Nozari, F., Ahrari, F., & Bagheri, Z. (2017). Measurement invariance of the Depression Anxiety Stress Scales-21 across medical student genders. International Journal of Medical Education, 8, 116-22. https://doi.org/10.5116/ijme.58ba.7d8b
Jin, M.J., Yoon, C.H., Ko, H.J., Kim, H.M., Kim, A.S., Moon, H.N., & Jung, S.-P. (2016). The relationship of caffeine intake with depression, anxiety, stress, and sleep in Korean adolescents. Korean Journal of Family Medicine, 37(2), 111-6. https://doi.org/10.4082/kjfm.2016.37.2.111
Pedersen, M.J., & Nielsen, C.V. (2016). Improving survey response rates in online panels: effects of low-cost incentives and cost-free text appeal interventions. Social Science Computer Review, 34(2), 229-43. https://doi.org/10.1177/0894439314563916
Kebede, M.A., Anbessie, B., & Ayano, G. (2019). Prevalence and predictors of depression and anxiety among medical students in Addis Ababa, Ethiopia. International Journal of Mental Health Systems, 13(30). https://doi.org/10.1186/s13033-019-0287-6
Khanam, S.J., & Bukhari, S.R. (2015). Depression As a Predictor of Academic Performance in Male and Female University Students. Journal of Pakistan Psychiatric Society, 12(2).
Kötter, T., Wagner, J., Brüheim, L., & Voltmer, E. (2017). Perceived Medical School stress of undergraduate medical students predicts academic performance: An observational study. BMC Medical Education, 17(256). https://doi.org/10.1186/s12909-017-1091-0
Lee, D. (2019). The convergent, discriminant, and nomological validity of the Depression Anxiety Stress Scales-21 (DASS-21). Journal of Affective Disorders, 259, 136-42. https://doi.org/10.1016/j.jad.2019.06.036
Lovibond, P.F., & Lovibond, S.H. (1995). Manual for the Depression Anxiety & Stress Scales. (2nd Ed.). APA PsycTests. https://doi.org/10.1037/t39835-000
Mahoney, C.R., Giles, G.E., Marriott, B.P., Judelson, D.A., Glickman E.L., Geiselman, P.J., Lieberman, H.R. (2018). Intake of caffeine from all sources and reasons for use by college students. Clinical Nutrition, 38(2), 668-75. https://doi.org/10.1016/j.clnu.2018.04.004
Marshall, L., Allison, A., Nykamp, D. (2008). Perceived stress and quality of life among doctor of pharmacy students. American Journal of Pharmaceutical Education, 72(6), 137. https://doi.org/10.5688/aj7206137
McIlvain, G.E., Noland, M.P., & Bickel, R. (2011). Caffeine consumption patterns and beliefs of college freshmen. American Journal of Health Education, 42(4), 235-44. https://doi.org/10.1080/19325037.2011.10599193
Mirón, J., Goldberg, X., López-solà, C., Nadal, R., Armario, A., Andero, R., Giraldo, J., Ortiz, J., Cardoner, N., & Palao, D. (2019). Perceived Stress, Anxiety and Depression Among Undergraduate Students: An Online Survey Study. Journal of Depression and Anxiety, 8(1), 1-5. https://doi.org/10.26226/morressier.5b681765b56e9b005965c249
Moreira de Sousa, J., Moreira, C.A., & Telles-Correia, D. (2018). Anxiety, depression and academic performance: A study amongst Portuguese medical students versus non-medical students. Acta Medica Portuguesa, 31(9), 454-62. https://doi.org/10.20344/amp.9996
Naquin, M.R., & Gilbert, G.G. (1996). College students' smoking behavior, perceived stress, and coping styles. Journal of Drug Education, 26(4), 367-76. https://doi.org/10.2190/MTG0-DCCE-YR29-JLT3
Nichter, M., Nichter, M., & Carkoglu, A. (2007). Reconsidering stress and smoking: A qualitative study among college students. Tobacco Control, 16, 211-4. https://doi.org/10.1136/tc.2007.019869
Nichter, M., Nichter, M., Carkoglu, A., Lloyd-Richardson, E., the Tabacco Etiology Research Netwirk (TERN). (2010). Smoking and drinking among college students: "It's a package deal." Drug and Alcohol Dependence, 106(1), 16-20. https://doi.org/10.1016/j.drugalcdep.2009.07.025
Nuffic. (2017). Education system Nigeria. Available at: https://www.nuffic.nl/en/publications/education-system-nigeria/
Nwachukwu, C., & Onyenankeya, K. (2017). Use of Smartphones among College Students in Nigeria: Revelations and Reflections. Journal of Communication, 8(2), 171-82. https://doi.org/10.1080/0976691X.2017.1396007
Oduaran, C.A., & Akanni, A.A. (2019). Perceived stress effect and socio-demographic factors in substance use: A study of undergraduate students in a South African university. Studies on Ethno-Medicine, 13(2), 17-21.https://doi.org/10.31901/24566772. 2019/13.02.586
Ogaji, J., Ojabo, C. (2014). Pharmacy education in Nigeria: The journey so far. Archives of Pharmacy Practice, 5(2), 47. https://doi.org/10.4103/2045-080X.132644
Oh, C.-M., Kim, H.Y., Na, H.K., Cho, K.H., & Chu, M.K. (2019). The Effect of Anxiety and Depression on Sleep Quality of Individuals With High Risk for Insomnia: A Population-Based Study. Frontiers in Neurology, 10(849). https://doi.org/10.3389/fneur.2019.00849
Olsen, F., Abelsen, B., & Olsen, J.A. (2012). Improving response rate and quality of survey data with a scratch lottery ticket incentive. BMC Medical Research Methodology, 12(52). https://doi.org/10.1186/1471-2288-12-52
Onigbogi, C., & Banerjee, S. (2019). Prevalence of psychosocial stress and its risk factors among health-care workers in Nigeria: A systematic review and meta-analysis. Nigerian Medical Journal, 60(5), 238. https://doi.org/10.4103/nmj.NMJ_67_19
Onyukwu, E., Clark, N., & Ausukuya, C. (2017). Education System Profiles. Education in Nigeria - WENR - World Education News and Reviews. Available at: https://wenr.wes.org/2017/03/education- in-nigeria
Opoku-Acheampong, A., Kretchy, I.A., Acheampong, F., Afrane, B.A., Ashong, S., Tamakloe, B., & Nyarko, A.K. (2017). Perceived stress and quality of life of pharmacy students in University of Ghana. BMC Res Notes. 10(115). https://doi.org/10.1186/s13104-017-2439-6
Othman, N., Ahmad, F., Morr, C.E., & Ritvo, P. (2019). Perceived impact of contextual determinants on depression , anxiety and stress : a survey with university students. International Journal of Mental Health Systems, 13(17). https://doi.org/10.1186/s13033-019-0275-x
Penmetsa, G., & Seethalakshmi, P. (2019). Effect of stress, depression, and anxiety over periodontal health indicators among health professional students. Journal of Indian Association of Public Health Dentistry, 17(1), 36-40. https://doi.org/10.4103/jiaphd.jiaphd_53_18
Pettit, M.L., & DeBarr, K.A. (2011). Perceived Stress, Energy Drink Consumption, and Academic Performance Among College Students. Journal of American College Health, 59(5), 334-41. https://doi.org/10.1080/07448481.2010.510163
Pharmacists Council of Nigeria. (2020). Benchmark and Minimum Academic Standard-Pharmaceutical Sciences. Available at: http://www.pcn.gov.ng/files/BMS.pdf
Plichta, S.B., & Kelvin, E.A. (2013). Munro's Statistical Methods For Health Care Research. 6th Ed. Wolters Kluwer Health, Lippincott Williams & Wilkins
Rasheed, L. (2016). Prevalence and Correlates of Depression , Anxiety and Academic Stress among Science Students in Oduduwa University, Ile-Ife. Texila International Journal Public Health, 4(3), 1-11. https://doi.org/10.21522/TIJPH.2013.04.03.Art001
Richards, G., & Smith, A. (2015). Caffeine consumption and self- assessed stress, anxiety, and depression in secondary school children. Journal of Psychopharmacology, 29(12), 1236-47. https://doi.org/10.1177/0269881115612404
Ryu, E., Couper, M.P., & Marans, R.W. (2006). Survey Incentives: Cash vs. In-Kind; Face-to-Face vs. Mail; Response Rate vs. Nonresponse Error. International Journal of Public Opinion Research, 18(1), 89–106. https://doi.org/10.1093/ijpor/edh089
Sabourin, A.A., Prater, J.C., & Mason NA. (2019). Assessment of mental health in doctor of pharmacy students. Currents in Pharmacy Teaching & Learning, 11(3), 243-250. https://doi.org/10.1016/j.cptl.2018.12.004
Saravanan, C., & Heidhy, I. (2014). Psychological problems and psychosocial predictors of cigarette smoking behavior among undergraduate students in Malaysia. Asian Pacific Organization for Cancer Prevention, 15(18), 7629-34. https://doi.org/10.7314/APJCP.2014.15.18.7629
Saxena, S., Thornicroft, G., Knapp, M., & Whiteford, H. (2007). Resources for mental health: scarcity, inequity, and inefficiency. The Lancet, 370(9590), 878-89. https://doi.org/10.1016/S0140-6736(07)61239-2
Shaikh, B.T., Kahloon, A., Kazmi, M., Khalid, H., Nawaz, K., Khan, N., & Khan, S. (2004). Students, stress and coping strategies: a case of Pakistani medical school. Educational Health (Abingdon), 17(3), 346-53. https://doi.org/10.1080/13576280400002585
Sohail, N. (2013). Stress and Academic Performance Among Medical Students. Journal of College of Physicians and Surgeons Pakistan, 23(1), 67-71.
Stallman, H.M. (2010). Psychological distress in university students: A comparison with general population data. Australian Psychology, 45(4), 249-57. https://doi.org/10.1080/00050067.2010.482109
Suleyiman, M., & Zewdu, A. (2018). Prevalence and associated factors of stress among undergraduate students in Ambo University: Implication for Intervention. International Journal of Psychology and Counselling, 10(4), 29-39. https://doi.org/10.5897/IJPC2018.0532
Sun, S.H., & Zoriah, A. (2015). Assessing Stress among Undergraduate Pharmacy Students in University of Malaya. Indian Journal of Pharmaceutical Education and Research, 49(2), 99-105. https://doi.org/10.5530/ijper.49.2.4
Šabić L., & Mujanović A. (2020). Smoking and Caffeine Consumption as Stress Coping Mechanisms in Medical Students. In A. Badnjevic, R. Škrbić, L. Gurbeta Pokvić (Eds.) IFMBE Proceedings, 73. Springer, Cham. https://doi.org/10.1007/978-3-030-17971-7_102
Talwar, P. (2016). The Goodness-of-Fit of Dass-21 Models Among University Students. Malaysian Journal of Public Health Medicine, 16(3), 219-26
Tanaja, N., Sachdeva, S., & Dwivedi, N. (2018). Assessment of Depression , Anxiety , and Stress among Medical Students Enrolled in a Medical College of New Delhi, India. Indian Journal of Social Psychiatry, 34(2), 157-162
Uwakwe, R. (2019). Mental Health Service and Access in Nigeria: A Short Overview. International Journal of Global Social Work, 2(103). https://doi.org/10.15344/ijgsw/2018/103
Van Mol, C. (2017). Improving web survey efficiency: the impact of an extra reminder and reminder content on web survey response. International Journal of Social Research Methodology, 20(4), 17-27. https://doi.org/10.1080/13645579.2016.1185255
Votta, R.J., & Benau, E.M. (2014). Sources of stress for pharmacy students in a nationwide sample. Currents in Pharmacy Teaching and Learning, 6(5), 675-81. https://doi.org/10.1016/j.cptl.2014.05.002
Vukomanovic, I., Kocic, S., Radovanovic, S., Mihailovic, N., Vasiljevic, D., & Vukomanovic, V. (2017). The prevalence of cigarette smoking and its correlates of depressive and anxiety symptoms among university students in Central Serbia. Tobacco Prevention and Cessation, May(3). https://doi.org/10.18332/tpc/73697
WHO [World Health Organisation]. (2017). Depression and Other Common Mental Disorders Global Health Estimates. Available at: https://apps.who.int/iris/bitstream/handle/10665/254610/WHO-MSD-MER-2017.2-eng.pdf
WHO & Nigeria Ministry of Health. (2006). WHO-AIMS Report on Mental Health System in Nigeria. WHO and Ministry of Health, Ibadan, Nigeria. Available at: https://www.who.int/mental_health/evidence/nigeria_who_aims_report.pdf?ua=1
Wright, K.B. (2006). Researching Internet-Based Populations: Advantages and Disadvantages of Online Survey Research, Online Questionnaire Authoring Software Packages, and Web Survey Services. Journal of Computer-Mediated Communication, 10(3). https://doi.org/10.1111/j.1083-6101.2005.tb00259.x
Yousif, W., Wahed, A., Hassan, S.K., Yousif, W., Wahed, A., Hassan, S.K. (2019). Prevalence and associated factors of stress , anxiety and depression among medical Fayoum University students Prevalence and associated factors of stress , anxiety and depression among medical Fayoum University students. Alexandria Journal of Medicine, 53(1), 77-84. https://doi.org/10.1016/j.ajme.2016.01.005
Zegeye, A., Mossie, A., Gebrie, A., & Markos, Y. (2018). Stress among Postgraduate Students and Its Association with Substance Use. Journal of Psychiatry, 21(3). https://doi.org/10.4172/2378-5756.1000448
