Prevalence of mental health disorders and associated factors among premedical students preparing for medical entrance exams: A cross- sectional study in Pakistan

Prevalence of mental health disorders and associated factors among premedical students preparing for medical entrance exams: A cross- sectional study in Pakistan | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Prevalence of mental health disorders and associated factors among premedical students preparing for medical entrance exams: A cross- sectional study in Pakistan Syed Muhammad Arsalan, Syed Ibrahim, Zayan Noor, Ahsan Ahmad, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8864622/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose In low- and middle-income countries like Pakistan, premedical students preparing for competitive medical entrance examinations experience increasing academic, emotional, and societal pressures that affect their mental health. This study aims to assess the burden of depression, anxiety, and stress and determine associated factors within this population, with our research question being: What is the prevalence of mental health problems (stress, anxiety, and depression), and what are the associated factors contributing to mental health outcomes among premedical students in Pakistan? Methods A cross-sectional study was conducted among premedical students aged 18 and above in Pakistan who appeared for the Medical and Dental College Admission Test. Results A total of 743 premedical students participated in the study (69.4% female; mean age 20.06 ± 1.37 years). Prevalence of mental health symptoms, including depression, anxiety, and stress, was 75.2%, 77.1%, and 65.3% respectively. Extremely severe levels of depression, anxiety, and stress were observed in 25%, 13.6%, and 12.7%. Female gender was significantly associated with increased odds of severe anxiety (OR 2.27, 95% CI 1.56–3.29, p<0.001) but decreased odds of being in higher categories of depression (Normal vs Mild+: OR 0.48, 95% CI 0.35–0.65, p<0.001; Mild vs Moderate+: OR 0.49, 95% CI 0.37–0.66, p<0.001) and stress (Normal vs Mild+: OR 0.47, 95% CI 0.36–0.60, p<0.001; Mild vs Moderate+: OR 0.47, 95% CI 0.36–0.60, p<0.001; Moderate vs Severe+: OR 0.44, 95% CI 0.34–0.57, p<0.001). Conclusions Mental health symptoms were highly prevalent among premedical students, with anxiety, depression, and stress affecting a substantial majority. These findings underscore the urgent need for policy-level interventions to support the mental health of MDCAT aspirants. Mental Health Depression Anxiety Stress Disorders Developing Countries Figures Figure 1 Background Mental health disorders are rapidly increasing among children and adolescents. Globally, depression and anxiety have been estimated at 33.6% and 39.0%, respectively, among college students ( 1 ). Furthermore, a systematic review reported that both of these symptoms are highest among medical students in lower- and middle-income countries (LMICs) ( 1 ). A study in Bangladesh reported that among students applying to undergraduate programs, the proportion of students with mild to extremely severe levels of depression, anxiety, and stress was 57.7%, 61.4% and 44.6%, respectively ( 2 ). This raises the concern of mental health issues among premedical students in LMICs, including Pakistan. Levels of stress tend to be high in premedical students due to the overwhelming demands of their coursework and preparations for competitive exams. They face high pressures to achieve good results in their exams, take part in extracurricular activities such as research and volunteering, and meet the expectations of their parents ( 3 , 4 ). A study reported that such students, with high levels of anxiety, have a higher tendency to change their career plans ( 5 ). Furthermore, unlike the developed countries, the academic system in Pakistan places particular importance on entrance exams, where students’ success is largely determined by a single test, creating significant stress ( 6 ). Additionally, financial constraints, familial expectations, and the societal pressure to secure a medical degree contribute to the mental health burden on premedical students ( 7 , 8 ). Premedical students, particularly those in countries like Pakistan, face unique stressors during the admission process, which often involve exhausting entrance exams, interviews, and an uncertain future. This is further aggravated by the frequent mismanagement in the admission process in Pakistan. Practices such as academic dishonesty, examination paper leaks, and the use of political or social influence to secure admission have become recurring challenges. These unethical practices have become a part of the system and tend to demotivate students from pursuing medicine. Additionally, lack of support, both academically and psychologically, adds to the factors contributing to anxiety and stress among the premedical students ( 9 ). According to the Pakistan Medical and Dental Council (PMDC) website, approximately 187,000 candidates appeared in the Medical and Dental Colleges Admission Test (MDCAT) in 2023, a significant increase from 46,885 candidates in 2015 ( 10 , 11 ). These include candidates appearing for the entrance exam for the first time and those who appeared for the second or subsequent time. This increase, of nearly four times, in just eight years, reflects the growing competition and increasing stress faced by aspiring medical students. Despite these issues, there is a lack of research on the prevalence and causes of mental health issues among premedical students in Pakistan, making it crucial to investigate the psychological burdens they face ( 12 ). This study aims to assess the prevalence of mental health disorders among premedical students in Pakistan, along with the contributing factors, to inform relevant stakeholders about the need to implement interventions that can improve the mental health of these students. This will help plan reforms in the admission processes of the medical universities so that premedical students from all backgrounds have equal opportunities without any advantages to some students. Awareness also needs to be created among parents and family members about the adverse effects of putting too much pressure on their children. Methods Study Design and Participants This study employs a cross-sectional design and includes premedical students who were at least 18 years of age. This study was conducted from January to August 2025. In Pakistan, premedical students are high school students who plan to seek admission in a medical college (a direct-entry undergraduate program) right after high school. These students are required to study Biology, Chemistry, and Physics (or Mathematics) in their high school curriculum. The most widely followed educational boards for high school in Pakistan, offering premedical education, are the National Board of Intermediate and Secondary Education (BISE), Pakistan (comprising of Matriculation 1–2 and FSc/Intermediate 1–2), and the Cambridge Assessment International Education (CAIE) board (comprising of O-Levels and A-Levels). Other less commonly followed boards include the Aga Khan University Examination Board (AKU-EB) and the International Baccalaureate (IB). Premedical students who appeared for the MDCAT in 2023 and 2024 and provided consent to participate in the study were included, as their recent experience was expected to yield more accurate and relevant responses. Including individuals from earlier cohorts could introduce recall bias, thereby affecting the reliability of the findings. No restrictions regarding the participants' geographic location within the country or the academic program they intended to pursue were present. Sample Size Calculation and Sampling Strategy The sample size was calculated using the software Open-Source Epidemiologic Statistics for Public Health (OpenEpi) ( 13 ). The sample size for this study was calculated while keeping an anticipated frequency at 72% based on a study in Karachi among medical students, which reported the frequency of depression, anxiety, and stress as 71%, 72% and 35%, respectively. ( 14 ). Design effect was kept at 1.0 for a random sample. Hence, for a confidence level of 95%, the sample size was 310 students. Given the online nature of MDCAT preparation, a non-probability convenience sampling supplemented by a snowball sampling approach was used to reach participants through online educational platforms and students groups dedicated to MDCAT preparation. The form was also sent to students, and they were encouraged to circulate the survey within their class groups and among colleagues or acquaintances belonging to different cities and provinces of Pakistan, to ensure a representative sample. Data Collection A Google form was disseminated using the online resources outlined above. The survey was preceded by a consent form to be filled out by the participants before taking part in the study. Considering the MDCAT is an exam that involves online registration, all participants had access to the internet and thereby could access this form. Questionnaire and Tool The assessment tools that were used in this questionnaire were divided into five sections. The first section gave an overview of the details of the study and affirmed that filling out the survey was voluntary and consensual. The second section was used to screen the participants for any pre-existing factors for poor mental health. The third section asked for demographic characteristics, including gender, age, monthly family income range, province of residence, board of education, the year the student appeared for the MDCAT, desired university type (public or private sector) at the time of the MDCAT, average daily study hours for the MDCAT preparation, and mode of preparation. The fourth section focused on factors associated with mental health problems, such as pressure from family, study workload, sleep schedule, financial stress, and access to mental health support. The fifth section surveyed participants’ mental health. Although mental health is a very broad term, this study specifically focused on depression, anxiety, and stress to assess them. This was achieved using the Depression, Anxiety, and Stress Scale (DASS-21). This tool had been previously validated in a study, so no pilot testing was needed ( 15 ). The DASS-21 instrument consists of 21 items, with seven items allocated to each subscale: depression, anxiety, and stress. Participants rated each item using a 4-point Likert scale, where a higher score represented greater symptom severity. To ensure comparability with the complete DASS-42 instrument, final subscale scores were doubled and categorized according to the recommended severity thresholds ( 16 ). This was used to calculate the prevalence of depression, anxiety, and stress, which are the parameters being tested for mental health disorders in premedical students. Since all premedical students receive an English-medium education, a translation of the tool was not needed. Statistical Analysis Statistical analyses were carried out using R Statistical Software ( 17 ). Categorical data were reported as frequencies and percentages ( n; % ) and continuous variables as mean and standard deviation. Comparisons were made according to factors such as the board of education, desired university type, city of residence, family income range, and gender. Inferential statistics, including chi-square tests, were applied to assess relationships between variables, such as causes of mental health disorders, outcomes of DASS-42, and demographics. Bivariate and multivariable regression were performed to assess causes associated with mental health disorders. Significant variables in the bivariate analysis were modeled separately in the multivariable regression analysis for depression, anxiety, and stress. It is important to note that ordinal regression was applied since DASS-42 scores were analyzed according to the referenced severity index. In addition, a partial proportional odds model was utilized for depression and stress due to violation of the proportional odds assumption, which was assessed using the Brant test, while a proportional odds model was used for anxiety, as there was no violation observed. Statistical significance was set at p < 0.05. Results Demographics A total of 743 participants (20.1 years ± 1.37) were included in the analysis. Most participants were female, and students were recruited from all over Pakistan, with the largest numbers residing in Sindh (43.9%), Punjab (27.1%), and Khyber Pakhtunkhwa (28.1%). In terms of educational background, FSc was the most common board for premedical studies (65.9%), with most students attending private colleges. The ratio of participants attempting MDCAT in 2023 and 2024 was approximately equal. Most of the students showed a preference for admission to a public medical university (82.8%). (Table 1 ) Table 1 Socio-demographic and academic characteristics of premedical students appearing for the Medical and Dental Colleges Aptitude Test (MDCAT) (n = 743). Variables n (%) * Gender Male 186 ( 25 ) Female 516 (69) Prefer not to say 41 ( 6 ) Monthly family income (PKR) 100,000 495 (67) Province of residence Sindh 326 (44) Punjab 201 ( 27 ) Khyber Pakhtunkhwa 209 ( 28 ) Balochistan 5 ( 1 ) Gilgit Baltistan 2 (0) Board of education (before the MDCAT) A Level 232 (32) FSc/Intermediate 474 (66) Aga Khan Education Board 13 ( 2 ) College for education before the MDCAT Private 484 (65) Public 259 (35) Last appeared for the MDCAT 2023 379 (51) 2024 364 (49) Preferred university for MBBS (at the time of the MDCAT) Private 128 ( 17 ) Public 615 (83) Average daily study hours to prepare for the MDCAT 10 hours 116 ( 16 ) Mode of preparation Coaching academy 117 ( 16 ) Self-study 142 ( 19 ) Online resources (e.g. YouTube, WhatsApp groups, student-led platforms) 78 ( 11 ) Combinations from above † 406 (55) PKR, Pakistani rupee; MDCAT, Medical and Dental Colleges Aptitude Test; MBBS, Bachelor of Medicine, Bachelor of Surgery. * Data are presented as frequency (n) and percentage (%). Percentages may not add up to 100% due to rounding off to the closest integer. † Refers to students who utilize two or more methods. Most participants reported no history of neurological disease (92.6%) and no pre-existing mental health condition (91.1%). Almost half (369, 49.7%) had experienced a major life event in the past 3–4 years, while 84.1% had not sought psychological counseling during this period. During MDCAT preparation, 260 students (35.0%) reported an average daily study time of around 8–10 hours, and the most common mode of preparation was a combination of self-study, coaching academy, and online resources (406, 54.6%). In addition, 239 participants (32.2%) reported financial stress, while excessive workload (568, 76.4%), social isolation (351, 47.2%), and disturbed sleep (400, 53.8%) were all commonly reported. Several other characteristics have been reported in Table 2 . Table 2 Prevalence of psychosocial stressors, academic pressures, lifestyle factors, and mental health history among study participants. Variables n (%) * Did you feel pressure from your family to succeed in the MDCAT exam? Always 118 (15.9) Often 119 ( 16 ) Sometimes 249 (33.5) Rarely 119 ( 16 ) Never 138 (18.6) Did you experience frequent comparisons with siblings/peers regarding academic performance? Yes 304 (40.9) No 439 (59.1) Did you feel your study workload is excessive? Yes 568 (76.4) No 175 (23.6) Did you have difficulty in maintaining a healthy sleep schedule Yes, frequently 400 (53.8) Sometimes 251 (33.8) No 92 (12.4) Did you experience financial stress related to tuition/coaching fees or educational expenses? Yes 239 (32.2) No 504 (67.8) Did you feel socially isolated due to your study commitments? Yes, frequently 351 (47.2) Sometimes 298 (40.1) No 94 (12.7) Did you experience test anxiety before mock exams or practice tests? Always 167 (22.5) Often 175 (23.6) Sometimes 235 (31.6) Rarely 120 (16.2) Never 46 (6.2) Did you feel adequately supported by family and friends during your exam preparation? Yes, completely 470 (63.3) Somewhat 229 (30.8) No 44 (5.9) Did you engage in any physical activity or exercise regularly? Yes (at least 3 times a week) 250 (33.6) No 493 (66.4) Did you use any substances to cope with stress (e.g., caffeine, tobacco , energy drinks, medications)? Yes 273 (36.7) No 470 (63.3) continued on next page Variables n (%) Do you think there should be mental health support services/ opportunities for MDCAT students? Yes 593 (79.8) No 53 (7.1) I don't know 97 (13.1) How would you rate your access to mental health support (e.g. counseling services, peer support)? Easily available 142 (19.1) Limited access 324 (43.6) No access 196 (26.4) Not sure 81 (10.9) Do you have any Neurological Disease History (e.g., epilepsy, migraine, Alzheimer’s)? Yes 55 (7.4) No 688 (92.6) Do you have any pre-existing mental health conditions diagnosed by a professional? Yes 66 (8.9) No 677 (91.1) Have you sought any psychological counseling or psychiatric help in the past four years? Yes 118 (15.9) No 625 (84.1) Have you had any major life events (e.g., family issues, health problems) affecting your mental well-being in the past four years? Yes 369 (49.7) No 374 (50.3) MDCAT, Medical and Dental Colleges Aptitude Test. * Data are presented as frequency (n) and percentage (%). Percentages may not add up to 100% due to rounding off to the nearest decimal. DASS-21 Findings For the DASS-21 subscale, the total DASS-21 score had a mean of 27.5 (SD 15.4; range 0–62).All distributions demonstrated slight positive skewness (stress: 0.04; anxiety: 0.22; depression: 0.25; total: 0.13), with kurtosis values ranging between − 0.74 and − 0.88, indicating moderately platykurtic distributions. Depression The mean depression score was 9.2 (SD 5.8; range 0–21). Prevalence rates of mild, moderate, severe, and extremely severe depression were 11.2%, 25.4%, 13.6%, and 25.0%, respectively (Fig. 1 ). Partial proportion odds (PPO) ordinal regression analysis demonstrated multiple significant predictors of depression severity (Table 3 ). When compared to males, female participants had lower odds of being in higher depression categories (Normal vs Mild+: OR 0.48, 95% CI 0.35–0.65, p < 0.001; Mild vs Moderate+: OR 0.49, 95% CI 0.37–0.66, p < 0.001), while participants who preferred not to disclose their gender showed even further lower odds compared with males (Normal vs Mild+: OR 0.14, 95% CI 0.11–0.20, p < 0.001). Table 3 Ordinal regression analysis identifying predictors associated with the severity of Depression, Anxiety, and Stress among premedical students. Depression – Partial Proportion Ordinal Regression Model * Variable Threshold aOR ‡ 95% CI p-value Gender ( vs Male ) Female Normal vs Mild+ 0.48 0.35–0.65 < 0.001 Mild vs Moderate+ 0.49 0.37–0.66 < 0.001 Prefer not to say Normal vs Mild+ 0.14 0.11–0.20 100k ) 25k–50k Severe vs Extremely Severe 0.69 0.59–0.81 < 0.001 50k–100k Severe vs Extremely Severe 0.89 0.80–0.99 0.032 Province of Residence ( vs Sindh ) Punjab Severe vs Extremely Severe 0.79 0.70–0.87 < 0.001 Board of Education (before the MDCAT) ( vs A-Level ) FSc/Intermediate Severe vs Extremely Severe 1.91 1.70–2.14 < 0.001 Aga Khan Board Severe vs Extremely Severe 1.61 1.50–1.73 < 0.001 Average daily study hours to prepare for the MDCAT ( vs 3–5 hours ) < 3 hours/day Severe vs Extremely Severe 0.47 0.35–0.61 < 0.001 Mode of preparation ( vs Coaching ) Self-study Severe vs Extremely Severe 1.47 1.37–1.57 < 0.001 Test Anxiety ( vs Sometimes ) Always Severe vs Extremely Severe 0.34 0.31–0.37 < 0.001 Anxiety – Proportional Ordinal Regression Model † Variable aOR ‡ 95% CI p-value Gender ( vs Male ) Female 2.27 1.56–3.29 < 0.001 Prefer not to say² 17.94 5.14–62.6 100k ) 50,000-100,000 PKR 1.57 1.06–2.31 0.03 Province of Residence ( vs Sindh ) Punjab 0.64 0.41–1.01 0.05 Khyber Pakhtunkhwa 0.55 0.35–0.88 0.008 Balochistan¹ 0.15 0.03–0.65 0.026 Board of Education (before the MDCAT) ( vs A-Level ) FSc/Intermediate 0.61 0.40–0.94 0.025 Sleep Difficulty (vs Never) Frequently 2.25 1.35–3.75 0.002 Socially Isolated (vs Sometimes) Frequently 1.71 1.22–2.42 0.003 Test Anxiety ( vs Sometimes ) Always 2.71 1.71–4.28 < 0.001 Rarely 0.66 0.42–1.04 0.07 Often 2 1.31–3.06 0.002 continued on next page Support by family (vs Yes) Somewhat 1.4 0.98–2.0 0.06 Mental Health services support (vs Yes) No 2.27 1.08–4.79 0.024 Mental Health access (vs Limited access) Easily available 0.6 0.39–0.93 0.021 Stress – Partial Proportion Ordinal Regression Model * Variable Threshold aOR ‡ 95% CI p-value Gender ( vs Male ) Female Normal vs Mild+ 0.47 0.36–0.60 < 0.001 Female Mild vs Moderate+ 0.47 0.36–0.60 < 0.001 Female Moderate vs Severe+ 0.44 0.34–0.57 < 0.001 Sleep Difficulty (vs Never) Yes, frequently Normal vs Mild+ 3.59 2.52–5.12 < 0.001 Yes, frequently Mild vs Moderate+ 3.04 2.14–4.34 < 0.001 Social isolation (vs Sometimes) Yes, frequently Moderate vs Severe+ 1.68 1.32–2.14 < 0.001 Test Anxiety ( vs Sometimes ) Always Severe vs Extremely Severe 2.22 1.75–2.81 < 0.001 Support by family (vs Yes) Somewhat Severe vs Extremely Severe 0.71 0.58–0.87 0.001 OR, adjusted odds ratio; CI, confidence interval; PKR, Pakistani rupee; MDCAT, Medical and Dental Colleges Aptitude Test. * This model was utilized for depression and stress due to violation of the proportional odds assumption which was assessed using the Brant test. Thresholds indicate the specific transition points where the odds differ. † This model was used for anxiety as the proportional odds assumption was satisfied. ¹ The extremely low odds observed for Balochistan (aOR 0.15) must be interpreted cautiously because the sample from that province was very small (n = 5), limiting statistical power and likely inflating the model effect. ²The magnitude of this association should be interpreted cautiously as the ‘prefer not to say’ subgroup was small (n = 41), which may inflate odds ratios and widen confidence intervals. ‡ Values presented are adjusted odds ratios (aOR). Reference categories are indicated next to the variable name in parentheses. An aOR > 1 indicates increased odds of greater symptom severity compared to the reference category. Only statistically significant variables have been reported (p-value < 0.05). At severe vs extremely severe levels, some other contributing predictors were also identified. Such as compared to A-Level students, FSc students had almost twice the odds of extremely severe depression (OR 1.91, 95% CI 1.70–2.14, p < 0.001). Shorter duration of study (< 3 hours) was associated with reduced odds relative to studying 3–5 hours per day (OR 0.47, 95% CI 0.35–0.61, p < 0.001). Additional patterns were observed across socioeconomic and psychosocial domains: lower income, residing in Punjab compared to Sindh, and always experiencing test anxiety compared to sometimes, had lower odds of extremely severe depression. However, self-study, compared to coaching-based preparation, had higher odds of more severe depression. Anxiety The mean anxiety score was 8.4 (SD 5.4; range 0–21). Prevalence rates of mild, moderate, severe, and extremely severe anxiety were 6.2%, 18.0%, 11.3%, and 41.6%, respectively (Fig. 1 ). Proportional Odds (PO) ordinal regression analyzed several factors of anxiety (Table 3 ). When compared to males, females had higher odds of being in a greater anxiety severity category (OR 2.27, 95% CI 1.56–3.29, p < 0.001), and participants who preferred not to disclose their gender demonstrated markedly higher odds (OR 17.94, 95% CI 5.14–62.60, p < 0.001). At higher anxiety severity, many factors contributed as follows. Compared to A-Level students, those with an FSc/Intermediate background had lower odds of greater anxiety severity (OR 0.61, 95% CI 0.40–0.94, p = 0.025). Similarly, participants with no access to mental health services had higher odds of greater anxiety severity compared with those who had access (OR 2.27, 95% CI 1.08–4.79, p = 0.024), and paradoxically, easy access to mental health services was associated with lower odds compared with limited access (OR 0.60, 95% CI 0.39–0.93, p = 0.021). Financially, compared with a monthly family income of PKR > 100,000, participants with an income of PKR.50,000-100,000 had higher odds of greater anxiety severity (OR 1.57, 95% CI 1.06–2.31, p = 0.03). Students facing social isolation and frequent sleep disturbances had greater odds of anxiety severity. Provincial differences were also noted, with students from Khyber Pakhtunkhwa and Balochistan showing lower odds relative to those from Sindh. A stepwise increase in anxiety severity was also observed with test anxiety. Stress The mean stress score was 10.0 (SD 5.4; range 0–21). Prevalence rates of mild, moderate, severe, and extremely severe stress were 12.2%, 19.9%, 20.5%, and 12.7%, respectively (Fig. 1 ). In the PPO ordinal regression model, several predictors remained significant across various thresholds (Table 3 ). Females had lower odds of being in higher stress level categories compared with males (Normal vs Mild+: OR 0.47, 95% CI 0.36–0.60, p < 0.001; Mild vs Moderate+: OR 0.47, 95% CI 0.36–0.60, p < 0.001; Moderate vs Severe+: OR 0.44, 95% CI 0.34–0.57, p < 0.001). Students reporting frequent sleep difficulties, social isolation, and test anxiety were associated with higher odds of increased stress severity. In addition, reduced family support (compared to adequate family support) was associated with lower odds of being in the highest stress category (Severe vs. Extremely Severe: OR 0.71, 95% CI 0.58–0.87, p = 0.001). Discussion Our findings show that the prevalence of depression, anxiety, and stress among premedical students appearing for the MDCAT exam was 75.2%, 77.1%, and 65.3%, respectively. This is higher than that reported in previous literature on medical students, which range from 19.4% to 64% ( 18 – 20 ).​​ This difference can be attributed to the difference in study population, i.e., premedical students versus medical students. While it must be kept in mind that medicine is one of the most academically demanding degrees, with high achievers typically studying between 6–8 hours per day​ ( 21 )​, the factors that influence stress in premedical students differ. MDCAT aspirants face the additional uncertainty of admission into medical universities, coupled with parental and societal pressure, particularly seen in LMICs ( 9 ).​Furthermore, such discrepancies may also be attributed to differences in methodologies, with some studies using the Patient Health Questionnaire-9 (PHQ-9) or Beck Depression Inventory​to assess levels of depression ( 22 ); meanwhile the DASS-21 questionnaire encompasses other mental health disorders as well. Our findings concluded gender to be a significant predictor, with females having lower odds of experiencing higher levels of depression and stress, but higher odds of undergoing greater levels of anxiety. This is contrary to another study conducted in Bangladesh amongst high school students, which identified that the level of depression was 1.8 times higher in females when compared with males ( 23 ).​​ These findings can again be attributed to differences in societal factors, where males may experience more financial and familial pressure to succeed compared to women, who would experience the push for early marriages, particularly in families with a lower socioeconomic status, exacerbating the feeling of anxiety ( 24 – 26 ).​​ Socioeconomic status also played a critical role, with students from lower-income families being at a notably lower risk of depression but a higher risk of anxiety. This is in contrast with the findings in other studies, where family financial hardship was closely linked with psychological distress ( 23 ).​​ This difference is possibly due to greater performance expectations and parental pressure that overshadow financial security, hence increasing depression risk. To add on, students educated under the FSc system reported higher odds of depression and lower odds of anxiety compared to students from A levels. While the current literature does not have an answer to why this may occur, it is a worthwhile observation to note and warrants further investigation in order to better both educational systems and promote positive mental well-being for the student, irrespective of the board they may be studying. Furthermore, access to mental health services was protective, with students lacking such access showing higher odds of severe anxiety. These findings highlight the urgent need for structured mental health support systems for premedical students. Moreover, sleep disturbance, social isolation, and test-related anxiety were prominent predictors of mental health severity; students who had sleep difficulties reported greater odds of presenting with anxiety and depression. The strong influence of such variables is consistent with current literature that marks poor sleep and isolation as significant predictor of depression, stress, and anxiety ( 27 ).​ Current research suggests that family conflict and strained relationships between the parent and the child are strongly associated with higher rates of depression ( 28 ). ​ However, our findings are not similar, where reduced family support exhibited lower odds of higher depression severity. Despite these findings, our study has several limitations. Aside from the study design being cross-sectional, thereby limiting the ability to ascertain causality, since our results rely on self-reported outcomes of depression, anxiety, and stress, these may carry bias and hence may not extend to all MDCAT students. Another limitation is recall bias, since this study includes students who appeared for their exams in the years 2023 and 2024, so probably there be limitations associated with the recall. A key methodological consideration is the use of the PPO model for analysing DASS-21 outcomes. Although the PO model is the most widely used logistic regression model for assessing ordinal outcomes, and much of the existing literature evaluating the prevalence of depression, anxiety, and stress uses it, its utility assumes that the effect of each predictor is the same for all levels of outcomes ( 29 , 30 ).​ ​ The PPO approach relaxes the PO assumption, allowing the effect of predictors to vary across different thresholds of symptom severity ( 30 ).​​ This flexibility enabled us to identify the effects of various factors such as gender, income, and educational background across mild, moderate, severe, and extremely severe categories. The use of PPO in our study may therefore explain some of the divergences between our findings and the existing literature. While this complicates direct comparisons, it also provides a more nuanced and accurate understanding of risk gradients within the population, which we consider a strength of this study. Conclusion Irrespective of these limitations, this study is the first of its kind to examine the prevalence of mental health disorders specifically amongst premedical students .Our findings highlight the importance of establishing mental health support systems tailored to MDCAT aspirants, such as counselling services. In addition, financial support mechanisms or scholarships should be made easily accessible for low-income students to alleviate socioeconomic stressors, and parental and institutional awareness campaigns should be conducted to destigmatize mental health support, thereby encouraging students to seek help. Abbreviations • AKU Aga Khan University • AKU EB—Aga Khan University Examination Board • AYL / A Levels—Advanced Level (Cambridge Assessment International Education) • BISE Board of Intermediate and Secondary Education • CAIE Cambridge Assessment International Education • CI Confidence interval • DASS 21—Depression, Anxiety and Stress Scale—21 items • DASS 42—Depression, Anxiety and Stress Scale—42 items • ERC Ethics Review Committee • FSc Faculty of Science (Intermediate) • IB International Baccalaureate • LMICs Low—and middle—income countries • MDCAT Medical and Dental College Admission Test • OR Odds ratio • PKR Pakistani Rupee • PMDC Pakistan Medical and Dental Council • PO Proportional odds (model) • PPO Partial proportional odds (model) • PHQ 9—Patient Health Questionnaire—9 Declarations Author Contributions SMA, SI, and ZN planned the study, performed data cleaning and analysis, and served as the guarantor of the overall content. SMA, SI, ZN, and AA contributed to data processing, methodology development, and manuscript preparation. AYS, SAM, HBZ, and UK contributed to manuscript preparation. AS supervised the study, provided conceptual guidance, and critically reviewed the manuscript. Acknowledgements None. Funding No funding was required for this study. Competing interests None declared. Patient consent for publication Not applicable. Ethics approval The study was approved by the Ethics Review Committee of the Aga Khan University (ERC #2025-11430-34826). Data Availability Statement De-identified individual participant data that support the findings of this study will be made available upon reasonable request. Requests should be directed to the corresponding author at [email protected] . Data will be shared after review of the request and subject to applicable ethical and institutional approvals. Trial Registration Clinical trial number: not applicable References Zhang H, Wang D. 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Student anxiety in introductory biology classrooms: Perceptions about active learning and persistence in the major. PLoS ONE. 2017 Aug 3;12(8):e0182506. A Qualitative Exploratory Study of the Factors Causing Academic Stress in Undergraduate Students in Pakistan | Liberal Arts and Social Sciences International Journal (LASSIJ) [Internet]. [cited 2025 Oct 7]. Available from: https://ideapublishers.org/index.php/lassij/article/view/123 Kirkbride JB, Anglin DM, Colman I, Dykxhoorn J, Jones PB, Patalay P, et al. The social determinants of mental health and disorder: evidence, prevention and recommendations. World Psychiatry Off J World Psychiatr Assoc WPA. 2024 Feb;23(1):58–90. Rizwan M, Talha MA, Qi X. Cultural Impact of Perceived Parental Expectations on Students’ Academic Stress. Ann Soc Sci Perspect. 2020 Dec 31;1(2):53–65. Latif A, Ashraf I. Academic Stress among the Medical and Dental College Admission Test Students. PhysioPlus Open. 2024 Dec 22;1(1):37–45. Press release 15-09-2023.pdf [Internet]. [cited 2025 Oct 7]. Available from: https://pmdc.pk/Documents/press/Press%20release%2015-09-2023.pdf Bilal A, Riaz A. Academic stress and suicidal ideation in MDCAT repeating candidates: mediating role of depression and moderating role of age and gender. Pak J Physiol. 2020 Sept 30;16(3):7–10. Martins RS, Fatimi AS, Ladak S, Jehanzeb H, Saleh R, Kumar G, et al. Factors Influencing the Intention to Pursue Surgery among Female Pre-Medical Students: A Cross-Sectional Study in Pakistan. World J Surg. 2022 Sept;46(9):2063–72. OpenEpi: Open Source Epidemiologic Statistics for Public Health. Version 2.3.1. | Semantic Scholar [Internet]. [cited 2025 Oct 7]. Available from: https://www.semanticscholar.org/paper/OpenEpi%3A-Open-Source-Epidemiologic-Statistics-for-Dean-Sullivan/c366cfd51bb4d98a81b103b9ce23ec2a0c5fe034 Azim SR, Baig M. Frequency and perceived causes of depression, anxiety and stress among medical students of a private medical institute in Karachi: a mixed method study. JPMA J Pak Med Assoc. 2019 June;69(6):840–5. Waqar H, Amir G. Translation, adaptation and validation of Depression, Anxiety and Stress Scale in Urdu. Insights Depress Anxiety. 2020 Feb 25;4(1):001–4. The DASS-21 Scoring template and interpretation [Internet]. [cited 2025 Feb 15]. Available from: https://comorbidityguidelines.org.au/appendix-k-depression-anxiety-stress-scale-dass-21/dass21-scoring-template-and-interpretation R: The R Project for Statistical Computing [Internet]. [cited 2025 Oct 8]. Available from: https://www.r-project.org/ Waseem Sajjad, Anwisha Samreen, Syed Asfand Yar Shah, Afifa Batool, Muhammad Umair, Talha Ahmad, et al. Prevalence of depression among medical students: A Cross-Sectional Study. Prof Med J. 2021 Nov 30;28(12):1723–31. Rizwan Zafar, Muhammad Raheel, Muhammad Ahmed Mujtaba, Rabia Mahmood, Muhammad Umair Nawaz, Bhavesh Kumar. Prevalence of anxiety and depression in medical students of a public sector medical college in Islamabad and coping mechanisms adopted. J Pak Med Assoc [Internet]. 2021 Nov 1 [cited 2025 Oct 7]; Available from: https://ojs.jpma.org.pk/index.php/public_html/article/view/2107 Nida Gul, Ayaz Ali, Rizwanullah, Khayam, Manahil Saeed Khan, Faiza Gul, et al. Prioritizing Mental Health: A Cross-Sectional Investigation of Depression Prevalence and Risk Factors among Medical Students in Peshawar, Pakistan. Int J Med Stud. 2024 Apr 12;12(1):22–8. Liles J, Vuk J, Tariq S. Study Habits of Medical Students: An Analysis of Which Study Habits Most Contribute to Success in the Preclinical Years. MedEdPublish. 2018 Mar 12;7:61. Depression Assessment Instruments [Internet]. [cited 2025 Oct 7]. Available from: https://www.apa.org/depression-guideline/assessment Siddik MAB, Hasan MN, Mahmud A, Munmun MS, Milad MH, Ali A, et al. Prevalence of depression and its associated factors among undergraduate admission candidates in Bangladesh: A nation-wide cross-sectional study. Hsan K, editor. PLOS ONE. 2023 Nov 30;18(11):e0295143. Khan MdN, Khanam SJ, Khan MdMA, Billah MA, Akter S. Exploring the impact of perceived early marriage on women’s education and employment in Bangladesh through a mixed-methods study. Sci Rep. 2024 Sept 17;14(1):21683. Abera M, Nega A, Tefera Y, Gelagay AA. Early marriage and women’s empowerment: the case of child-brides in Amhara National Regional State, Ethiopia. BMC Int Health Hum Rights. 2020 Dec 14;20(1):30. Remes O, Brayne C, Van Der Linde R, Lafortune L. A systematic review of reviews on the prevalence of anxiety disorders in adult populations. Brain Behav. 2016 July;6(7):e00497. Seun-Fadipe CT, Mosaku KS. Sleep quality and psychological distress among undergraduate students of a Nigerian university. Sleep Health. 2017 June;3(3):190–4. Consoli A, Peyre H, Speranza M, Hassler C, Falissard B, Touchette E, et al. Suicidal behaviors in depressed adolescents: role of perceived relationships in the family. Child Adolesc Psychiatry Ment Health. 2013 Mar 16;7:8. McCullagh P. Regression Models for Ordinal Data. J R Stat Soc Ser B Stat Methodol. 1980 Jan 1;42(2):109–27. Peterson B, Harrell FE. Partial Proportional Odds Models for Ordinal Response Variables. Appl Stat. 1990;39(2):205. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Hospital","correspondingAuthor":false,"prefix":"","firstName":"Syed","middleName":"","lastName":"Ibrahim","suffix":""},{"id":590686280,"identity":"8f3f17a3-b266-4f94-bd00-082c8f9a8339","order_by":2,"name":"Zayan Noor","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABEUlEQVRIie3RMUvDQBjG8SccRIfXZr0jknyFC4GCmA+TInSK4FTcdDqXVNcWv0RFKI6BDC5HZ0UHpdDJoSVTcDGnIggJ6uZw/yUhvD/e4wLYbP87VsA5xa55bZ5NxY/ETc0o/YWQ/B0Jz3RUHeEx8HxdreubhLzLwtlMFYLeXdpKnDyL/QlWsTg/nIuxHhJfpExcKcSigzBk0ieUg5nemTNHlQQNiGeFwayDuN5L/PpBaFkZEmqwuiEnXYR41v/cQvANkRquOVgqOwjnq9E+yTIWudsXYzWkSDtqb7Lg0VQ/td/YxcH1Ax2XgUdsua5VEgSalff5KAl7t+1bgG0JyG9f3v8K7xg3bbWvt9lsNttXb3v+WlECe5AbAAAAAElFTkSuQmCC","orcid":"","institution":"Aga Khan University Hospital","correspondingAuthor":true,"prefix":"","firstName":"Zayan","middleName":"","lastName":"Noor","suffix":""},{"id":590686281,"identity":"8e29be72-168b-4e90-99f9-f196e7f68da0","order_by":3,"name":"Ahsan Ahmad","email":"","orcid":"","institution":"Aga Khan University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ahsan","middleName":"","lastName":"Ahmad","suffix":""},{"id":590686282,"identity":"954fb7a6-7967-4889-b895-3bbd7adc4378","order_by":4,"name":"Umaima Khan","email":"","orcid":"","institution":"Northwest School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Umaima","middleName":"","lastName":"Khan","suffix":""},{"id":590686283,"identity":"be0bce37-3268-4ec6-91ef-0dc2538c00fe","order_by":5,"name":"Hamnah Binte Zafar","email":"","orcid":"","institution":"Jinnah Sindh Medical University","correspondingAuthor":false,"prefix":"","firstName":"Hamnah","middleName":"Binte","lastName":"Zafar","suffix":""},{"id":590686284,"identity":"057c02b2-21ab-40ef-ad96-45f829b6447e","order_by":6,"name":"Shaheryar Ali Mirza","email":"","orcid":"","institution":"United Medical and Dental College","correspondingAuthor":false,"prefix":"","firstName":"Shaheryar","middleName":"Ali","lastName":"Mirza","suffix":""},{"id":590686285,"identity":"1101e29d-1471-44e8-be87-9277ea36b799","order_by":7,"name":"Ayesha Siddiqa","email":"","orcid":"","institution":"Wah Medical College","correspondingAuthor":false,"prefix":"","firstName":"Ayesha","middleName":"","lastName":"Siddiqa","suffix":""},{"id":590686286,"identity":"a50b6168-d23c-40e7-a9cf-1d4c3c35a5ec","order_by":8,"name":"Afreen Sadia","email":"","orcid":"","institution":"Aga Khan University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Afreen","middleName":"","lastName":"Sadia","suffix":""}],"badges":[],"createdAt":"2026-02-12 17:24:33","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8864622/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8864622/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102893254,"identity":"70056c60-64b1-4316-8ba3-096689cf56dd","added_by":"auto","created_at":"2026-02-18 05:41:58","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":88524,"visible":true,"origin":"","legend":"\u003cp\u003eSeverity distribution of Anxiety, Depression, and Stress symptoms among premedical students based on Depression, Anxiety, and Stress Scale (DASS-21) scores.\u003c/p\u003e","description":"","filename":"Figure1BMC.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8864622/v1/0caa94fb49a69e8b51f8bf4d.jpeg"},{"id":102963946,"identity":"8eb5f9a3-90d0-48f9-adf5-5479fbc32096","added_by":"auto","created_at":"2026-02-19 04:20:57","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2160050,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8864622/v1/d74a5d38-e863-4590-9968-56352dc18d66.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Prevalence of mental health disorders and associated factors among premedical students preparing for medical entrance exams: A cross- sectional study in Pakistan","fulltext":[{"header":"Background","content":"\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eMental health disorders are rapidly increasing among children and adolescents. Globally, depression and anxiety have been estimated at 33.6% and 39.0%, respectively, among college students (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Furthermore, a systematic review reported that both of these symptoms are highest among medical students in lower- and middle-income countries (LMICs) (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). A study in Bangladesh reported that among students applying to undergraduate programs, the proportion of students with mild to extremely severe levels of depression, anxiety, and stress was 57.7%, 61.4% and 44.6%, respectively (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). This raises the concern of mental health issues among premedical students in LMICs, including Pakistan.\u003c/p\u003e \u003cp\u003eLevels of stress tend to be high in premedical students due to the overwhelming demands of their coursework and preparations for competitive exams. They face high pressures to achieve good results in their exams, take part in extracurricular activities such as research and volunteering, and meet the expectations of their parents (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). A study reported that such students, with high levels of anxiety, have a higher tendency to change their career plans (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFurthermore, unlike the developed countries, the academic system in Pakistan places particular importance on entrance exams, where students\u0026rsquo; success is largely determined by a single test, creating significant stress (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Additionally, financial constraints, familial expectations, and the societal pressure to secure a medical degree contribute to the mental health burden on premedical students (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Premedical students, particularly those in countries like Pakistan, face unique stressors during the admission process, which often involve exhausting entrance exams, interviews, and an uncertain future.\u003c/p\u003e \u003cp\u003eThis is further aggravated by the frequent mismanagement in the admission process in Pakistan. Practices such as academic dishonesty, examination paper leaks, and the use of political or social influence to secure admission have become recurring challenges. These unethical practices have become a part of the system and tend to demotivate students from pursuing medicine. Additionally, lack of support, both academically and psychologically, adds to the factors contributing to anxiety and stress among the premedical students (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAccording to the Pakistan Medical and Dental Council (PMDC) website, approximately 187,000 candidates appeared in the Medical and Dental Colleges Admission Test (MDCAT) in 2023, a significant increase from 46,885 candidates in 2015 (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). These include candidates appearing for the entrance exam for the first time and those who appeared for the second or subsequent time. This increase, of nearly four times, in just eight years, reflects the growing competition and increasing stress faced by aspiring medical students.\u003c/p\u003e \u003cp\u003eDespite these issues, there is a lack of research on the prevalence and causes of mental health issues among premedical students in Pakistan, making it crucial to investigate the psychological burdens they face (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis study aims to assess the prevalence of mental health disorders among premedical students in Pakistan, along with the contributing factors, to inform relevant stakeholders about the need to implement interventions that can improve the mental health of these students. This will help plan reforms in the admission processes of the medical universities so that premedical students from all backgrounds have equal opportunities without any advantages to some students. Awareness also needs to be created among parents and family members about the adverse effects of putting too much pressure on their children.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Participants\u003c/h2\u003e \u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThis study employs a cross-sectional design and includes premedical students who were at least 18 years of age. This study was conducted from January to August 2025. In Pakistan, premedical students are high school students who plan to seek admission in a medical college (a direct-entry undergraduate program) right after high school. These students are required to study Biology, Chemistry, and Physics (or Mathematics) in their high school curriculum. The most widely followed educational boards for high school in Pakistan, offering premedical education, are the National Board of Intermediate and Secondary Education (BISE), Pakistan (comprising of Matriculation 1\u0026ndash;2 and FSc/Intermediate 1\u0026ndash;2), and the Cambridge Assessment International Education (CAIE) board (comprising of O-Levels and A-Levels). Other less commonly followed boards include the Aga Khan University Examination Board (AKU-EB) and the International Baccalaureate (IB).\u003c/p\u003e\u003cp\u003ePremedical students who appeared for the MDCAT in 2023 and 2024 and provided consent to participate in the study were included, as their recent experience was expected to yield more accurate and relevant responses. Including individuals from earlier cohorts could introduce recall bias, thereby affecting the reliability of the findings. No restrictions regarding the participants' geographic location within the country or the academic program they intended to pursue were present.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSample Size Calculation and Sampling Strategy\u003c/h3\u003e\n\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe sample size was calculated using the software Open-Source Epidemiologic Statistics for Public Health (OpenEpi) (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). The sample size for this study was calculated while keeping an anticipated frequency at 72% based on a study in Karachi among medical students, which reported the frequency of depression, anxiety, and stress as 71%, 72% and 35%, respectively. (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Design effect was kept at 1.0 for a random sample. Hence, for a confidence level of 95%, the sample size was 310 students.\u003c/p\u003e\u003cp\u003e Given the online nature of MDCAT preparation, a non-probability convenience sampling supplemented by a snowball sampling approach was used to reach participants through online educational platforms and students groups dedicated to MDCAT preparation. The form was also sent to students, and they were encouraged to circulate the survey within their class groups and among colleagues or acquaintances belonging to different cities and provinces of Pakistan, to ensure a representative sample.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eA Google form was disseminated using the online resources outlined above. The survey was preceded by a consent form to be filled out by the participants before taking part in the study. Considering the MDCAT is an exam that involves online registration, all participants had access to the internet and thereby could access this form.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eQuestionnaire and Tool\u003c/h3\u003e\n\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThe assessment tools that were used in this questionnaire were divided into five sections. The first section gave an overview of the details of the study and affirmed that filling out the survey was voluntary and consensual. The second section was used to screen the participants for any pre-existing factors for poor mental health. The third section asked for demographic characteristics, including gender, age, monthly family income range, province of residence, board of education, the year the student appeared for the MDCAT, desired university type (public or private sector) at the time of the MDCAT, average daily study hours for the MDCAT preparation, and mode of preparation. The fourth section focused on factors associated with mental health problems, such as pressure from family, study workload, sleep schedule, financial stress, and access to mental health support.\u003c/p\u003e \u003cp\u003eThe fifth section surveyed participants\u0026rsquo; mental health. Although mental health is a very broad term, this study specifically focused on depression, anxiety, and stress to assess them. This was achieved using the Depression, Anxiety, and Stress Scale (DASS-21). This tool had been previously validated in a study, so no pilot testing was needed (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). The DASS-21 instrument consists of 21 items, with seven items allocated to each subscale: depression, anxiety, and stress. Participants rated each item using a 4-point Likert scale, where a higher score represented greater symptom severity. To ensure comparability with the complete DASS-42 instrument, final subscale scores were doubled and categorized according to the recommended severity thresholds (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). This was used to calculate the prevalence of depression, anxiety, and stress, which are the parameters being tested for mental health disorders in premedical students. Since all premedical students receive an English-medium education, a translation of the tool was not needed.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eStatistical analyses were carried out using R Statistical Software (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Categorical data were reported as frequencies and percentages (\u003cem\u003en; %\u003c/em\u003e) and continuous variables as mean and standard deviation. Comparisons were made according to factors such as the board of education, desired university type, city of residence, family income range, and gender. Inferential statistics, including chi-square tests, were applied to assess relationships between variables, such as causes of mental health disorders, outcomes of DASS-42, and demographics. Bivariate and multivariable regression were performed to assess causes associated with mental health disorders. Significant variables in the bivariate analysis were modeled separately in the multivariable regression analysis for depression, anxiety, and stress. It is important to note that ordinal regression was applied since DASS-42 scores were analyzed according to the referenced severity index. In addition, a partial proportional odds model was utilized for depression and stress due to violation of the proportional odds assumption, which was assessed using the Brant test, while a proportional odds model was used for anxiety, as there was no violation observed. Statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eDemographics\u003c/h2\u003e \u003cp\u003eA total of 743 participants (20.1 years\u0026thinsp;\u0026plusmn;\u0026thinsp;1.37) were included in the analysis. Most participants were female, and students were recruited from all over Pakistan, with the largest numbers residing in Sindh (43.9%), Punjab (27.1%), and Khyber Pakhtunkhwa (28.1%). In terms of educational background, FSc was the most common board for premedical studies (65.9%), with most students attending private colleges. The ratio of participants attempting MDCAT in 2023 and 2024 was approximately equal. Most of the students showed a preference for admission to a public medical university (82.8%). (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSocio-demographic and academic characteristics of premedical students appearing for the Medical and Dental Colleges Aptitude Test (MDCAT) (n\u0026thinsp;=\u0026thinsp;743).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%)\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e186 (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e516 (69)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrefer not to say\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41 (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMonthly family income (PKR)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;25,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e25,000\u0026ndash;50,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53 (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e50,000\u0026ndash;100,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e165 (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;100,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e495 (67)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eProvince of residence\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSindh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e326 (44)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePunjab\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e201 (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKhyber Pakhtunkhwa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e209 (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBalochistan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGilgit Baltistan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBoard of education (before the MDCAT)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA Level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e232 (32)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFSc/Intermediate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e474 (66)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAga Khan Education Board\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCollege for education before the MDCAT\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrivate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e484 (65)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePublic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e259 (35)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLast appeared for the MDCAT\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e379 (51)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e364 (49)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePreferred university for MBBS (at the time of the MDCAT)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrivate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e128 (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePublic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e615 (83)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAverage daily study hours to prepare for the MDCAT\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;3 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47 (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u0026ndash;5 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e119 (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u0026ndash;8 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e201 (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u0026ndash;10 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e260 (35)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;10 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e116 (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMode of preparation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCoaching academy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e117 (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf-study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e142 (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOnline resources (e.g. YouTube, WhatsApp groups, student-led platforms)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e78 (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCombinations from above\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e406 (55)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003ePKR, Pakistani rupee; MDCAT, Medical and Dental Colleges Aptitude Test; MBBS, Bachelor of Medicine, Bachelor of Surgery.\u003c/p\u003e \u003cp\u003e\u003csup\u003e*\u003c/sup\u003eData are presented as frequency (n) and percentage (%). Percentages may not add up to 100% due to rounding off to the closest integer.\u003c/p\u003e \u003cp\u003e\u003csup\u003e\u0026dagger;\u003c/sup\u003eRefers to students who utilize two or more methods.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eMost participants reported no history of neurological disease (92.6%) and no pre-existing mental health condition (91.1%). Almost half (369, 49.7%) had experienced a major life event in the past 3\u0026ndash;4 years, while 84.1% had not sought psychological counseling during this period.\u003c/p\u003e \u003cp\u003eDuring MDCAT preparation, 260 students (35.0%) reported an average daily study time of around 8\u0026ndash;10 hours, and the most common mode of preparation was a combination of self-study, coaching academy, and online resources (406, 54.6%). In addition, 239 participants (32.2%) reported financial stress, while excessive workload (568, 76.4%), social isolation (351, 47.2%), and disturbed sleep (400, 53.8%) were all commonly reported. Several other characteristics have been reported in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePrevalence of psychosocial stressors, academic pressures, lifestyle factors, and mental health history among study participants.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%)\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eDid you feel pressure from your family to succeed in the MDCAT exam?\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlways\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e118 (15.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOften\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e119 (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSometimes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e249 (33.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRarely\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e119 (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e138 (18.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDid you experience frequent comparisons with siblings/peers regarding\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eacademic performance?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e304 (40.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e439 (59.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDid you feel your study workload is excessive?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e568 (76.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e175 (23.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDid you have difficulty in maintaining a healthy sleep schedule\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes, frequently\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e400 (53.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSometimes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e251 (33.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e92 (12.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDid you experience financial stress related to tuition/coaching fees or\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eeducational expenses?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e239 (32.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e504 (67.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDid you feel socially isolated due to your study commitments?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes, frequently\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e351 (47.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSometimes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e298 (40.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e94 (12.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDid you experience test anxiety before mock exams or practice tests?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlways\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e167 (22.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOften\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e175 (23.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSometimes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e235 (31.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRarely\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e120 (16.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46 (6.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDid you feel adequately supported by family and friends during your exam preparation?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes, completely\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e470 (63.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSomewhat\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e229 (30.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44 (5.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDid you engage in any physical activity or exercise regularly?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes (at least 3 times a week)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e250 (33.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e493 (66.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDid you use any substances to cope with stress (e.g., caffeine, tobacco\u003c/b\u003e,\u003c/p\u003e \u003cp\u003e\u003cb\u003eenergy drinks, medications)?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e273 (36.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e470 (63.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003econtinued on next page\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eVariables\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003en (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDo you think there should be mental health support services/\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eopportunities for MDCAT students?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e593 (79.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53 (7.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI don't know\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e97 (13.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHow would you rate your access to mental health support (e.g.\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003ecounseling services, peer support)?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEasily available\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e142 (19.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLimited access\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e324 (43.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo access\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e196 (26.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot sure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e81 (10.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDo you have any Neurological Disease History (e.g., epilepsy, migraine, Alzheimer\u0026rsquo;s)?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55 (7.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e688 (92.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDo you have any pre-existing mental health conditions diagnosed by a professional?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66 (8.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e677 (91.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHave you sought any psychological counseling or psychiatric help in the\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003epast four years?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e118 (15.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e625 (84.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHave you had any major life events (e.g., family issues, health problems)\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eaffecting your mental well-being in the past four years?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e369 (49.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e374 (50.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eMDCAT, Medical and Dental Colleges Aptitude Test.\u003c/p\u003e \u003cp\u003e\u003csup\u003e*\u003c/sup\u003eData are presented as frequency (n) and percentage (%). Percentages may not add up to 100% due to rounding off to the nearest decimal.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eDASS-21 Findings\u003c/h3\u003e\n\u003cp\u003eFor the DASS-21 subscale, the total DASS-21 score had a mean of 27.5 (SD 15.4; range 0\u0026ndash;62).All distributions demonstrated slight positive skewness (stress: 0.04; anxiety: 0.22; depression: 0.25; total: 0.13), with kurtosis values ranging between \u0026minus;\u0026thinsp;0.74 and \u0026minus;\u0026thinsp;0.88, indicating moderately platykurtic distributions.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eDepression\u003c/h2\u003e \u003cp\u003eThe mean depression score was 9.2 (SD 5.8; range 0\u0026ndash;21). Prevalence rates of mild, moderate, severe, and extremely severe depression were 11.2%, 25.4%, 13.6%, and 25.0%, respectively (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003ePartial proportion odds (PPO) ordinal regression analysis demonstrated multiple significant predictors of depression severity (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). When compared to males, female participants had lower odds of being in higher depression categories (Normal vs Mild+: OR 0.48, 95% CI 0.35\u0026ndash;0.65, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; Mild vs Moderate+: OR 0.49, 95% CI 0.37\u0026ndash;0.66, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), while participants who preferred not to disclose their gender showed even further lower odds compared with males (Normal vs Mild+: OR 0.14, 95% CI 0.11\u0026ndash;0.20, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOrdinal regression analysis identifying predictors associated with the severity of Depression, Anxiety, and Stress among premedical students.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eDepression \u0026ndash; Partial Proportion Ordinal Regression Model\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThreshold\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eaOR\u003csup\u003e\u0026Dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eGender (\u003cem\u003evs Male\u003c/em\u003e)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNormal vs Mild+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.35\u0026ndash;0.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMild vs Moderate+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.37\u0026ndash;0.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrefer not to say\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNormal vs Mild+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.11\u0026ndash;0.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMonthly Family Income (PKR) (\u003c/b\u003e\u003cb\u003evs \u0026gt;\u0026thinsp;100k\u003c/b\u003e\u003cb\u003e)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e25k\u0026ndash;50k\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSevere vs Extremely Severe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.59\u0026ndash;0.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e50k\u0026ndash;100k\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSevere vs Extremely Severe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.80\u0026ndash;0.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.032\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eProvince of Residence (\u003c/b\u003e\u003cb\u003evs Sindh\u003c/b\u003e\u003cb\u003e)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePunjab\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSevere vs Extremely Severe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.70\u0026ndash;0.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBoard of Education (before the MDCAT) (\u003c/b\u003e\u003cb\u003evs A-Level\u003c/b\u003e\u003cb\u003e)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFSc/Intermediate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSevere vs Extremely Severe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.70\u0026ndash;2.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAga Khan Board\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSevere vs Extremely Severe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.50\u0026ndash;1.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAverage daily study hours to prepare for the MDCAT (\u003c/b\u003e\u003cb\u003evs 3\u0026ndash;5 hours\u003c/b\u003e\u003cb\u003e)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;3 hours/day\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSevere vs Extremely Severe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.35\u0026ndash;0.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMode of preparation (\u003c/b\u003e\u003cb\u003evs Coaching\u003c/b\u003e\u003cb\u003e)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf-study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSevere vs Extremely Severe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.37\u0026ndash;1.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTest Anxiety (\u003c/b\u003e\u003cb\u003evs Sometimes\u003c/b\u003e\u003cb\u003e)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlways\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSevere vs Extremely Severe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.31\u0026ndash;0.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAnxiety \u0026ndash; Proportional Ordinal Regression Model\u003c/b\u003e\u003csup\u003e\u003cb\u003e\u0026dagger;\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eVariable\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eaOR\u003c/b\u003e\u003csup\u003e\u003cb\u003e\u0026Dagger;\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e95% CI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003ep-value\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender (\u003c/b\u003e\u003cb\u003evs Male\u003c/b\u003e\u003cb\u003e)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.56\u0026ndash;3.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003ePrefer not to say\u0026sup2;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.14\u0026ndash;62.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMonthly Family Income (PKR) (\u003c/b\u003e\u003cb\u003evs \u0026gt;\u0026thinsp;100k\u003c/b\u003e\u003cb\u003e)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e50,000-100,000 PKR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.06\u0026ndash;2.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.03\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eProvince of Residence (\u003c/b\u003e\u003cb\u003evs Sindh\u003c/b\u003e\u003cb\u003e)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003ePunjab\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.41\u0026ndash;1.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eKhyber Pakhtunkhwa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.35\u0026ndash;0.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.008\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eBalochistan\u0026sup1;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.03\u0026ndash;0.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.026\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBoard of Education (before the MDCAT) (\u003c/b\u003e\u003cb\u003evs A-Level\u003c/b\u003e\u003cb\u003e)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eFSc/Intermediate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.40\u0026ndash;0.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.025\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSleep Difficulty (vs Never)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eFrequently\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.35\u0026ndash;3.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSocially Isolated (vs Sometimes)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eFrequently\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.22\u0026ndash;2.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTest Anxiety (\u003c/b\u003e\u003cb\u003evs Sometimes\u003c/b\u003e\u003cb\u003e)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eAlways\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.71\u0026ndash;4.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eRarely\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.42\u0026ndash;1.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.07\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eOften\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.31\u0026ndash;3.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003econtinued on next page\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSupport by family (vs Yes)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eSomewhat\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.98\u0026ndash;2.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMental Health services support (vs Yes)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.08\u0026ndash;4.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.024\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMental Health access (vs Limited access)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eEasily available\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.39\u0026ndash;0.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.021\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStress \u0026ndash; Partial Proportion Ordinal Regression Model\u003c/b\u003e\u003csup\u003e\u003cb\u003e*\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eVariable\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eThreshold\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eaOR\u003c/b\u003e\u003csup\u003e\u003cb\u003e\u0026Dagger;\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e95% CI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003ep-value\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender (\u003c/b\u003e\u003cb\u003evs Male\u003c/b\u003e\u003cb\u003e)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNormal vs Mild+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.36\u0026ndash;0.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMild vs Moderate+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.36\u0026ndash;0.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eModerate vs Severe+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.34\u0026ndash;0.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSleep Difficulty (vs Never)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes, frequently\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNormal vs Mild+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.52\u0026ndash;5.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes, frequently\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMild vs Moderate+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.14\u0026ndash;4.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSocial isolation (vs Sometimes)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes, frequently\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eModerate vs Severe+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.32\u0026ndash;2.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTest Anxiety (\u003c/b\u003e\u003cb\u003evs Sometimes\u003c/b\u003e\u003cb\u003e)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlways\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSevere vs Extremely Severe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.75\u0026ndash;2.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSupport by family (vs Yes)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSomewhat\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSevere vs Extremely Severe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.58\u0026ndash;0.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eOR, adjusted odds ratio; CI, confidence interval; PKR, Pakistani rupee; MDCAT, Medical and Dental Colleges Aptitude Test.\u003c/p\u003e \u003cp\u003e\u003csup\u003e*\u003c/sup\u003eThis model was\u0026nbsp;utilized\u0026nbsp;for depression and stress due to violation of the proportional odds assumption which was assessed using\u0026nbsp;the Brant\u0026nbsp;test. Thresholds indicate the specific transition points where the odds differ.\u003c/p\u003e \u003cp\u003e\u003csup\u003e\u0026dagger;\u003c/sup\u003eThis model was used for anxiety as the proportional odds assumption was satisfied.\u003c/p\u003e \u003cp\u003e\u0026sup1; The extremely low odds observed for Balochistan (aOR 0.15) must be interpreted cautiously because the sample from that province was very small (n\u0026thinsp;=\u0026thinsp;5), limiting statistical power and likely inflating the model effect.\u003c/p\u003e \u003cp\u003e\u0026sup2;The magnitude of this association should be interpreted cautiously as the \u0026lsquo;prefer not to say\u0026rsquo; subgroup was small (n\u0026thinsp;=\u0026thinsp;41), which may inflate odds ratios and widen confidence intervals.\u003c/p\u003e \u003cp\u003e\u003csup\u003e\u0026Dagger;\u003c/sup\u003eValues presented are adjusted odds ratios (aOR). Reference categories are indicated next to the variable name in parentheses. An aOR\u0026thinsp;\u0026gt;\u0026thinsp;1 indicates increased odds of greater symptom severity compared to the reference category.\u003c/p\u003e \u003cp\u003eOnly statistically significant variables have been reported (p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAt severe vs extremely severe levels, some other contributing predictors were also identified. Such as compared to A-Level students, FSc students had almost twice the odds of extremely severe depression (OR 1.91, 95% CI 1.70\u0026ndash;2.14, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Shorter duration of study (\u0026lt;\u0026thinsp;3 hours) was associated with reduced odds relative to studying 3\u0026ndash;5 hours per day (OR 0.47, 95% CI 0.35\u0026ndash;0.61, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Additional patterns were observed across socioeconomic and psychosocial domains: lower income, residing in Punjab compared to Sindh, and always experiencing test anxiety compared to sometimes, had lower odds of extremely severe depression. However, self-study, compared to coaching-based preparation, had higher odds of more severe depression.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eAnxiety\u003c/h2\u003e \u003cp\u003eThe mean anxiety score was 8.4 (SD 5.4; range 0\u0026ndash;21). Prevalence rates of mild, moderate, severe, and extremely severe anxiety were 6.2%, 18.0%, 11.3%, and 41.6%, respectively (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eProportional Odds (PO) ordinal regression analyzed several factors of anxiety (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). When compared to males, females had higher odds of being in a greater anxiety severity category (OR 2.27, 95% CI 1.56\u0026ndash;3.29, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and participants who preferred not to disclose their gender demonstrated markedly higher odds (OR 17.94, 95% CI 5.14\u0026ndash;62.60, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eAt higher anxiety severity, many factors contributed as follows. Compared to A-Level students, those with an FSc/Intermediate background had lower odds of greater anxiety severity (OR 0.61, 95% CI 0.40\u0026ndash;0.94, p\u0026thinsp;=\u0026thinsp;0.025). Similarly, participants with no access to mental health services had higher odds of greater anxiety severity compared with those who had access (OR 2.27, 95% CI 1.08\u0026ndash;4.79, p\u0026thinsp;=\u0026thinsp;0.024), and paradoxically, easy access to mental health services was associated with lower odds compared with limited access (OR 0.60, 95% CI 0.39\u0026ndash;0.93, p\u0026thinsp;=\u0026thinsp;0.021). Financially, compared with a monthly family income of PKR\u0026thinsp;\u0026gt;\u0026thinsp;100,000, participants with an income of PKR.50,000-100,000 had higher odds of greater anxiety severity (OR 1.57, 95% CI 1.06\u0026ndash;2.31, p\u0026thinsp;=\u0026thinsp;0.03). Students facing social isolation and frequent sleep disturbances had greater odds of anxiety severity. Provincial differences were also noted, with students from Khyber Pakhtunkhwa and Balochistan showing lower odds relative to those from Sindh. A stepwise increase in anxiety severity was also observed with test anxiety.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eStress\u003c/h2\u003e \u003cp\u003eThe mean stress score was 10.0 (SD 5.4; range 0\u0026ndash;21). Prevalence rates of mild, moderate, severe, and extremely severe stress were 12.2%, 19.9%, 20.5%, and 12.7%, respectively (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn the PPO ordinal regression model, several predictors remained significant across various thresholds (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Females had lower odds of being in higher stress level categories compared with males (Normal vs Mild+: OR 0.47, 95% CI 0.36\u0026ndash;0.60, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; Mild vs Moderate+: OR 0.47, 95% CI 0.36\u0026ndash;0.60, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; Moderate vs Severe+: OR 0.44, 95% CI 0.34\u0026ndash;0.57, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Students reporting frequent sleep difficulties, social isolation, and test anxiety were associated with higher odds of increased stress severity. In addition, reduced family support (compared to adequate family support) was associated with lower odds of being in the highest stress category (Severe vs. Extremely Severe: OR 0.71, 95% CI 0.58\u0026ndash;0.87, p\u0026thinsp;=\u0026thinsp;0.001).\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eOur findings show that the prevalence of depression, anxiety, and stress among premedical students appearing for the MDCAT exam was 75.2%, 77.1%, and 65.3%, respectively. This is higher than that reported in previous literature on medical students, which range from 19.4% to 64% (\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).​​ This difference can be attributed to the difference in study population, i.e., premedical students versus medical students. While it must be kept in mind that medicine is one of the most academically demanding degrees, with high achievers typically studying between 6\u0026ndash;8 hours per day​ (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e)​, the factors that influence stress in premedical students differ. MDCAT aspirants face the additional uncertainty of admission into medical universities, coupled with parental and societal pressure, particularly seen in LMICs (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).​Furthermore, such discrepancies may also be attributed to differences in methodologies, with some studies using the Patient Health Questionnaire-9 (PHQ-9) or Beck Depression Inventory​to assess levels of depression (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e); meanwhile the DASS-21 questionnaire encompasses other mental health disorders as well.\u003c/p\u003e \u003cp\u003eOur findings concluded gender to be a significant predictor, with females having lower odds of experiencing higher levels of depression and stress, but higher odds of undergoing greater levels of anxiety. This is contrary to another study conducted in Bangladesh amongst high school students, which identified that the level of depression was 1.8 times higher in females when compared with males (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).​​ These findings can again be attributed to differences in societal factors, where males may experience more financial and familial pressure to succeed compared to women, who would experience the push for early marriages, particularly in families with a lower socioeconomic status, exacerbating the feeling of anxiety (\u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).​​\u003c/p\u003e \u003cp\u003eSocioeconomic status also played a critical role, with students from lower-income families being at a notably lower risk of depression but a higher risk of anxiety. This is in contrast with the findings in other studies, where family financial hardship was closely linked with psychological distress (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).​​ This difference is possibly due to greater performance expectations and parental pressure that overshadow financial security, hence increasing depression risk.\u003c/p\u003e \u003cp\u003eTo add on, students educated under the FSc system reported higher odds of depression and lower odds of anxiety compared to students from A levels. While the current literature does not have an answer to why this may occur, it is a worthwhile observation to note and warrants further investigation in order to better both educational systems and promote positive mental well-being for the student, irrespective of the board they may be studying. Furthermore, access to mental health services was protective, with students lacking such access showing higher odds of severe anxiety. These findings highlight the urgent need for structured mental health support systems for premedical students.\u003c/p\u003e \u003cp\u003eMoreover, sleep disturbance, social isolation, and test-related anxiety were prominent predictors of mental health severity; students who had sleep difficulties reported greater odds of presenting with anxiety and depression. The strong influence of such variables is consistent with current literature that marks poor sleep and isolation as significant predictor of depression, stress, and anxiety (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).​\u003c/p\u003e \u003cp\u003eCurrent research suggests that family conflict and strained relationships between the parent and the child are strongly associated with higher rates of depression (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). ​ However, our findings are not similar, where reduced family support exhibited lower odds of higher depression severity.\u003c/p\u003e \u003cp\u003eDespite these findings, our study has several limitations. Aside from the study design being cross-sectional, thereby limiting the ability to ascertain causality, since our results rely on self-reported outcomes of depression, anxiety, and stress, these may carry bias and hence may not extend to all MDCAT students. Another limitation is recall bias, since this study includes students who appeared for their exams in the years 2023 and 2024, so probably there be limitations associated with the recall.\u003c/p\u003e \u003cp\u003eA key methodological consideration is the use of the PPO model for analysing DASS-21 outcomes. Although the PO model is the most widely used logistic regression model for assessing ordinal outcomes, and much of the existing literature evaluating the prevalence of depression, anxiety, and stress uses it, its utility assumes that the effect of each predictor is the same for all levels of outcomes (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).​ ​ The PPO approach relaxes the PO assumption, allowing the effect of predictors to vary across different thresholds of symptom severity (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).​​ This flexibility enabled us to identify the effects of various factors such as gender, income, and educational background across mild, moderate, severe, and extremely severe categories. The use of PPO in our study may therefore explain some of the divergences between our findings and the existing literature. While this complicates direct comparisons, it also provides a more nuanced and accurate understanding of risk gradients within the population, which we consider a strength of this study.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eIrrespective of these limitations, this study is the first of its kind to examine the prevalence of mental health disorders specifically amongst premedical students .Our findings highlight the importance of establishing mental health support systems tailored to MDCAT aspirants, such as counselling services. In addition, financial support mechanisms or scholarships should be made easily accessible for low-income students to alleviate socioeconomic stressors, and parental and institutional awareness campaigns should be conducted to destigmatize mental health support, thereby encouraging students to seek help.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; AKU\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAga Khan University\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; AKU\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEB\u0026mdash;Aga Khan University Examination Board\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; AYL / A\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLevels\u0026mdash;Advanced Level (Cambridge Assessment International Education)\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; BISE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBoard of Intermediate and Secondary Education\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; CAIE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCambridge Assessment International Education\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; CI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eConfidence interval\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; DASS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e21\u0026mdash;Depression, Anxiety and Stress Scale\u0026mdash;21 items\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; DASS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e42\u0026mdash;Depression, Anxiety and Stress Scale\u0026mdash;42 items\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; ERC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEthics Review Committee\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; FSc\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFaculty of Science (Intermediate)\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; IB\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInternational Baccalaureate\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; LMICs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLow\u0026mdash;and middle\u0026mdash;income countries\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; MDCAT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMedical and Dental College Admission Test\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; OR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eOdds ratio\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; PKR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePakistani Rupee\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; PMDC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePakistan Medical and Dental Council\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; PO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eProportional odds (model)\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; PPO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePartial proportional odds (model)\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; PHQ\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e9\u0026mdash;Patient Health Questionnaire\u0026mdash;9\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSMA, SI, and ZN planned the study, performed data cleaning and analysis, and served as the guarantor of the overall content. SMA, SI, ZN, and AA contributed to data processing, methodology development, and manuscript preparation. AYS, SAM, HBZ, and UK contributed to manuscript preparation. AS supervised the study, provided conceptual guidance, and critically reviewed the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was required for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone declared.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient consent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Ethics Review Committee of the Aga Khan University (ERC #2025-11430-34826).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDe-identified individual participant data that support the findings of this study will be made available upon reasonable request. Requests should be directed to the corresponding author at [email protected]. Data will be shared after review of the request and subject to applicable ethical and institutional approvals.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial Registration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eClinical trial number: not applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eZhang H, Wang D. Commentary: The global prevalence of depression and anxiety symptoms among college students and its influencing factors \u0026ndash; a commentary on Li et al. (2022). J Child Psychol Psychiatry. 2022;63(11):1231\u0026ndash;3.\u003c/li\u003e\n \u003cli\u003eRabby MdRA, Islam MdS, Orthy MT, Jami AT, Hasan MT. Depression symptoms, anxiety, and stress among undergraduate entrance admission-seeking students in Bangladesh: a cross-sectional study. Front Public Health. 2023 Apr 26;11:1136557.\u003c/li\u003e\n \u003cli\u003eFang DZ, Young CB, Golshan S, Fellows I, Moutier C, Zisook S. Depression in Premedical Undergraduates:A Cross-Sectional Survey. Prim Care Companion J Clin Psychiatry. 2010;12(6):PCC.10m00958.\u003c/li\u003e\n \u003cli\u003eYoon J, Lau AS. Maladaptive perfectionism and depressive symptoms among Asian American college students: contributions of interdependence and parental relations. Cultur Divers Ethnic Minor Psychol. 2008 Apr;14(2):92\u0026ndash;101.\u003c/li\u003e\n \u003cli\u003eEngland BJ, Brigati JR, Schussler EE. Student anxiety in introductory biology classrooms: Perceptions about active learning and persistence in the major. PLoS ONE. 2017 Aug 3;12(8):e0182506.\u003c/li\u003e\n \u003cli\u003eA Qualitative Exploratory Study of the Factors Causing Academic Stress in Undergraduate Students in Pakistan | Liberal Arts and Social Sciences International Journal (LASSIJ) [Internet]. [cited 2025 Oct 7]. Available from: https://ideapublishers.org/index.php/lassij/article/view/123\u003c/li\u003e\n \u003cli\u003eKirkbride JB, Anglin DM, Colman I, Dykxhoorn J, Jones PB, Patalay P, et al. The social determinants of mental health and disorder: evidence, prevention and recommendations. World Psychiatry Off J World Psychiatr Assoc WPA. 2024 Feb;23(1):58\u0026ndash;90.\u003c/li\u003e\n \u003cli\u003eRizwan M, Talha MA, Qi X. Cultural Impact of Perceived Parental Expectations on Students\u0026rsquo; Academic Stress. Ann Soc Sci Perspect. 2020 Dec 31;1(2):53\u0026ndash;65.\u003c/li\u003e\n \u003cli\u003eLatif A, Ashraf I. Academic Stress among the Medical and Dental College Admission Test Students. PhysioPlus Open. 2024 Dec 22;1(1):37\u0026ndash;45.\u003c/li\u003e\n \u003cli\u003ePress release 15-09-2023.pdf [Internet]. [cited 2025 Oct 7]. Available from: https://pmdc.pk/Documents/press/Press%20release%2015-09-2023.pdf\u003c/li\u003e\n \u003cli\u003eBilal A, Riaz A. Academic stress and suicidal ideation in MDCAT repeating candidates: mediating role of depression and moderating role of age and gender. Pak J Physiol. 2020 Sept 30;16(3):7\u0026ndash;10.\u003c/li\u003e\n \u003cli\u003eMartins RS, Fatimi AS, Ladak S, Jehanzeb H, Saleh R, Kumar G, et al. Factors Influencing the Intention to Pursue Surgery among Female Pre-Medical Students: A Cross-Sectional Study in Pakistan. World J Surg. 2022 Sept;46(9):2063\u0026ndash;72.\u003c/li\u003e\n \u003cli\u003eOpenEpi: Open Source Epidemiologic Statistics for Public Health. Version 2.3.1. | Semantic Scholar [Internet]. [cited 2025 Oct 7]. Available from: https://www.semanticscholar.org/paper/OpenEpi%3A-Open-Source-Epidemiologic-Statistics-for-Dean-Sullivan/c366cfd51bb4d98a81b103b9ce23ec2a0c5fe034\u003c/li\u003e\n \u003cli\u003eAzim SR, Baig M. Frequency and perceived causes of depression, anxiety and stress among medical students of a private medical institute in Karachi: a mixed method study. JPMA J Pak Med Assoc. 2019 June;69(6):840\u0026ndash;5.\u003c/li\u003e\n \u003cli\u003eWaqar H, Amir G. Translation, adaptation and validation of Depression, Anxiety and Stress Scale in Urdu. Insights Depress Anxiety. 2020 Feb 25;4(1):001\u0026ndash;4.\u003c/li\u003e\n \u003cli\u003eThe DASS-21 Scoring template and interpretation [Internet]. [cited 2025 Feb 15]. Available from: https://comorbidityguidelines.org.au/appendix-k-depression-anxiety-stress-scale-dass-21/dass21-scoring-template-and-interpretation\u003c/li\u003e\n \u003cli\u003eR: The R Project for Statistical Computing [Internet]. [cited 2025 Oct 8]. Available from: https://www.r-project.org/\u003c/li\u003e\n \u003cli\u003eWaseem Sajjad, Anwisha Samreen, Syed Asfand Yar Shah, Afifa Batool, Muhammad Umair, Talha Ahmad, et al. Prevalence of depression among medical students: A Cross-Sectional Study. 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BMC Int Health Hum Rights. 2020 Dec 14;20(1):30.\u003c/li\u003e\n \u003cli\u003eRemes O, Brayne C, Van Der Linde R, Lafortune L. A systematic review of reviews on the prevalence of anxiety disorders in adult populations. Brain Behav. 2016 July;6(7):e00497.\u003c/li\u003e\n \u003cli\u003eSeun-Fadipe CT, Mosaku KS. Sleep quality and psychological distress among undergraduate students of a Nigerian university. Sleep Health. 2017 June;3(3):190\u0026ndash;4.\u003c/li\u003e\n \u003cli\u003eConsoli A, Peyre H, Speranza M, Hassler C, Falissard B, Touchette E, et al. Suicidal behaviors in depressed adolescents: role of perceived relationships in the family. Child Adolesc Psychiatry Ment Health. 2013 Mar 16;7:8.\u003c/li\u003e\n \u003cli\u003eMcCullagh P. Regression Models for Ordinal Data. J R Stat Soc Ser B Stat Methodol. 1980 Jan 1;42(2):109\u0026ndash;27.\u003c/li\u003e\n \u003cli\u003ePeterson B, Harrell FE. Partial Proportional Odds Models for Ordinal Response Variables. Appl Stat. 1990;39(2):205.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Mental Health, Depression, Anxiety, Stress Disorders, Developing Countries","lastPublishedDoi":"10.21203/rs.3.rs-8864622/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8864622/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn low- and middle-income countries like Pakistan, premedical students preparing for competitive medical entrance examinations experience increasing academic, emotional, and societal pressures that affect their mental health. This study aims to assess the burden of depression, anxiety, and stress and determine associated factors within this population, with our research question being: What is the prevalence of mental health problems (stress, anxiety, and depression), and what are the associated factors contributing to mental health outcomes among premedical students in Pakistan?\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA cross-sectional study was conducted among premedical students aged 18 and above in Pakistan who appeared for the Medical and Dental College Admission Test.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 743 premedical students participated in the study (69.4% female; mean age 20.06 ± 1.37 years). Prevalence of mental health symptoms, including depression, anxiety, and stress, was 75.2%, 77.1%, and 65.3% respectively. Extremely severe levels of depression, anxiety, and stress were observed in 25%, 13.6%, and 12.7%. Female gender was significantly associated with increased odds of severe anxiety (OR 2.27, 95% CI 1.56–3.29, p\u0026lt;0.001) but decreased odds of being in higher categories of depression (Normal vs Mild+: OR 0.48, 95% CI 0.35–0.65, p\u0026lt;0.001; Mild vs Moderate+: OR 0.49, 95% CI 0.37–0.66, p\u0026lt;0.001) and stress (Normal vs Mild+: OR 0.47, 95% CI 0.36–0.60, p\u0026lt;0.001; Mild vs Moderate+: OR 0.47, 95% CI 0.36–0.60, p\u0026lt;0.001; Moderate vs Severe+: OR 0.44, 95% CI 0.34–0.57, p\u0026lt;0.001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMental health symptoms were highly prevalent among premedical students, with anxiety, depression, and stress affecting a substantial majority. \u0026nbsp;These findings underscore the urgent need for policy-level interventions to support the mental health of MDCAT aspirants.\u003c/p\u003e","manuscriptTitle":"Prevalence of mental health disorders and associated factors among premedical students preparing for medical entrance exams: A cross- sectional study in Pakistan","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-18 05:41:50","doi":"10.21203/rs.3.rs-8864622/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"81e5bfe9-fed6-4a63-b30b-76c30f7e9c32","owner":[],"postedDate":"February 18th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-02-18T05:41:50+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-18 05:41:50","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8864622","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8864622","identity":"rs-8864622","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}