Depression Among Saudi International University Students and Its Associated Risk Factors.

Depression Among Saudi International University Students and Its Associated Risk Factors. | 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 Depression Among Saudi International University Students and Its Associated Risk Factors. MOHAMMED A. ALNAIM, Abdullah H. AlGhamdi, Mohammed R. AlJawair, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4626304/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 11 Nov, 2024 Read the published version in BMC Public Health → Version 1 posted 10 You are reading this latest preprint version Abstract Introduction Depression disorders are one of the most widespread mental disorders among college students. In university students, depression has been associated with lower academic performance, worse work performance, and increased dropout risk. his study aims to assess the prevalence of depression and highlight risk factors among Saudi international university students (IUS) in the United States (US), the United Kingdom (UK), and Australia. Subject and methods This cross-sectional study was conducted among Saudi students who chose to study abroad. A self-administered online questionnaire was sent to the students using an online survey. The questionnaire includes socio-demographic data (e.g., age, gender, specialty, etc.), medical characteristics, social status, and the Patient Health Questionnaire (PHQ-8) to assess the student's depression. Results Of the 401 students, 52.4% were younger (age 18 – 25 years), and more than half were males (53.9%). Most of the participants were studying in the US (46.6%), followed by the UK (40.6%) and Australia (12.7%). The rate of major depression among Saudi students studying abroad was 40.4%. In univariate analysis, major depression was influenced by age, marital status, specialty, personal and family history of mental illness, contact with family and friends, and feeling like a stranger. However, after conducting multivariate regression analysis, previous diagnoses of mental illness and feeling a stranger were identified as the significant independent risk factors for major depression. Conclusion This study provides insights into the prevalence and risk factors associated with depression among Saudi IUS. The prevalence of major depression among Saudi IUS was 40.4%. Previous history of mental illness and feeling like strangers were identified as the most prominent risk factors in this study. Identifying the prevalence and contributing factors of depression can guide academic institutions and governments in the development of effective interventions and support for IUS’s mental well-being. Future research could diversify the sample and employ longitudinal designs. International university students Depression Saudi Arabia prevalence risk factor PHQ-8 Figures Figure 1 Figure 2 Introduction Depression is a mood disorder that causes a continual feeling of sorrow and loss of interest. It is commonly characterized by sadness, emptiness, irritable mood, and cognitive and somatic alterations that impact the individual’s capacity for everyday performance[ 1 ]. Moreover, depression is a multi-faceted disorder that impairs interpersonal, social, and occupational functioning. A lack of self-care, anxiety, poor attention, sleep disturbances, and a loss of interest in everyday experiences are some of the symptoms of depression[ 2 ]. Depression has a multifactorial etiology, with genetic and environmental factors contributing. For example, people with first-degree relatives with depression are three times more likely to develop depression than the general population. Regarding the treatment of depression, medication or brief psychotherapy alone can relieve depressive symptoms. Nevertheless, combination therapy has been linked with markedly higher rates of depressive symptom relief, better treatment adherence, and improved quality of life[ 1 ]. It was found that while psychotherapy tends to increase frontal activity, pharmacotherapy reduces limbic structures' overactivity[ 3 ]. Furthermore, the inclusion of circadian rhythms normalization as a part of treatment for depression has been proposed [ 4 , 5 ]. It was found that dysregulation of the circadian system increases susceptibility to depression [ 5 ]. Around 60% of depressed people do not seek medical help[ 1 ]. Many factors may hinder help-seeking. One is the stigma toward mental disorders and people who have them[ 1 , 6 ]. Another factor is the lack of mental health literacy among the general public[ 6 ]. Several factors have been linked with depression. Having a depressed parent, particularly a depressed mother, is a strong risk factor for depression. A stable relation across countries is that women, beginning from adolescence, have a 2:1 greater probability of getting MDD than men. Moreover, for men, childhood sexual abuse, conduct disorders, substance misuse, and stressful experiences with financial, professional, or legal significance were all strong predictors of depression. However, in women, divorce, low parental warmth, low marital satisfaction, and low social support were all found to be stronger predictors of depression[ 7 ]. Depression is a widespread mental disorder among college students[ 2 , 8 , 9 ]. A systematic review involving twenty-four studies reporting on the depression prevalence rate among university students has found that the average depression prevalence is 30.6%. This is a greater rate than the 9% observed in the United States’s (US) population rates[ 2 ]. Also, many predisposing factors have been linked with university students’ depression. These factors include being a first-year student, living alone, being single rather than married, and having a low or high Grade Point Average (GPA)[ 6 ]. Additionally, sleep and eating disturbances, family relationship alterations, financial stressors, and academic worries are all factors that might increase students’ vulnerability to depression [ 2 ]. In university students, depression has been associated with lower academic performance[ 10 ], worse work performance[ 2 ], and increased dropout risk [ 11 ]. Furthermore, depression can result in a buildup of harmful consequences through adulthood because of its effect on social relationships and career prospects[ 2 ]. Many papers have assessed the prevalence of depression among university students, especially among medical students[ 2 , 6 , 8 , 9 ]. However, to our knowledge, none have measured it among international university students (IUS). Furthermore, none has taken into consideration the factors associated with depression among the said population. We aim to highlight these factors and assess the prevalence of depression among Saudi IUS in the US, United Kingdom(UK), and Australia. Hopefully, this research will draw attention to international students’ mental health and help acknowledge the factors associated with it. Methodology Design and Participants A cross-sectional, questionnaire-based design was adopted in this study, which was conducted in February 2023. All Saudi students studying at a university or a college in the US, UK, or Australia for a bachelor’s, master’s, or doctorate degree were eligible to participate in the study. The three countries included in the study were chosen because they were Saudi students' most prevalent scholarship destinations. Participants who were non-Saudi, not studying in the US, UK, or Australia, studying for a fellowship or a diploma, in their first year of college, or had not properly completed the form were excluded. Participation was voluntary, and informed consent was obtained online before the survey. Additionally, confidentiality was assured, questionnaires were submitted anonymously, and all participants could withdraw from completing the survey at any time. This study was approved by the Deanship of Scientific Research at King Faisal University on February 1, 2023 (KFU-REC-2023-FEB-ETHICS525) Sample size calculation Four hundred and one participants were included in this study. The sample size needed for the study was calculated to be 324 participants. Taking a 5% margin of error, a 95% confidence interval, a 30.6% expected population proportion, and a population size of 35840 international Saudi students. The formula used is: The population size number was obtained in January 2023 from a governmental platform used by all Saudi IUS called “SAFEER2.” Which includes the number of all Saudi IUS in all countries. The expected population proportion was assumed according to a systematic review of depression prevalence among university students, which found that the average depression prevalence is 30.6%. [ 2 ] Data collection Data was collected through an online Google Forms survey from February 2023 to April 2023. Then, the survey was distributed on social media platforms and Saudi IUS WhatsApp groups. The data of all subjects were subsequently stored in a secured Microsoft Excel spreadsheet file on Google Drive. Study variables and instruments: The survey consisted of three sections. The first is for informed consent. The second section is the demographic data and risk factors section. The demographic part was designed to collect the general characteristics of Saudi IUS. Including sex, age, country of study, marital status, housing, academic discipline, sought academic degree, and number of years studying abroad. The risk factors’ part consists of the last GPA, personal and family history of mental illness, frequency of family contact, frequency of going out with friends, the yearly average number of visits to Saudi Arabia, having a financial aid program and feeling like a stranger. All GPAs are converted to a 5-point system and then grouped into five hierarchical categories. Only those who are getting their bachelor’s degree were asked about their GPAs. The last section is for depression screening. To screen for depression, we used the eight-item version of the Patient Health Questionnaire (PHQ-8). PHQ-8 includes all items of the nine-item version of the Patient Health Questionnaire (PHQ-9) except the ninth item that concerns self-harm. Items in the PHQ-9 consist of the nine criteria for depression from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)[ 12 – 14 ]. We used a PHQ-8 score of ≥ 10 as a cut-off point for defining clinically significant depression[ 14 ]. Statistical Analysis The data were analyzed using the software program Statistical Packages for Software Sciences (SPSS) version 26 (Armonk, New York, IBM Corporation, USA). The numbers and percentages (%) were given for categorical variables. Univariate analysis was performed to identify the factors that influence major depression. Significant results were then placed in a multivariate regression model to determine the significant independent risk factors for major depression. Values were considered significant with a p-value of less than 0.05. Results This study enrolled four hundred and one Saudi university students studying abroad. As described in Table 1 , 52.4% were between 18 and 25 years of age. Male students constitute 53.9%, and 46.6% are currently enrolled in the USA. Most students were single (67.8%) and lived alone (30.7%). Engineering and technology disciplines were the most common specialties (48.4%). Over half (54.9%) were bachelor's degree holders. Approximately 20% had 1 year of studying abroad. In addition, 62.3% had excellent GPAs (between 4.5 and 5 out of 5). Table 1 Socio-demographic characteristics of Saudi International University Students (n=401) Study variables N (%) Age group • 18–25 years 210 (52.4%) • > 25 years 191 (47.6%) Gender • Male 216 (53.9%) • Female 185 (46.1%) Country of study • United States of America 187 (46.6%) • United Kingdom 163 (40.6%) • Australia 51 (12.7%) Marital status • Single 272 (67.8%) • Married 120 (29.9%) • Divorced 07 (01.7%) • Widowed 02 (0.50%) Living status • Alone 123 (30.7%) • With parents 18 (04.5%) • With friend(s)/roommate(s) 122 (30.4%) • With Spouse 15 (03.7%) • With spouse and children 76 (19.0%) • With children without a spouse 18 (04.5%) • With other family members 29 (07.2%) Specialty • Medical disciplines 50 (12.5%) • Engineering and technology disciplines 194 (48.4%) • Arts and Humanities 61 (15.2%) • Business and finance disciplines 56 (14.0%) • Natural science 14 (03.5%) • Architecture and design disciplines 05 (01.2%) • Other 21 (05.2%) Academic degree • Bachelor’s degree 220 (54.9%) • Master's degree 86 (21.4%) • Doctorate degree 95 (23.7%) Years studying abroad • 1 year 80 (20.0%) • 2 years 57 (14.2%) • 3 years 53 (13.2%) • 4 years 126 (31.4%) • 5 years 33 (08.2%) • 6 years or more 52 (13.0%) GPA (n=220) • 4.5 to 5 out of 5 137 (62.3%) • 4.0 to 4.5 out of 5 54 (24.5%) • 3.5 to 4.0 out of 5 16 (07.3%) • 3.0 to 3.5 out of 5 12 (05.5%) • Less than 3.0 out of 5 01 (0.50%) Regarding the medical history of the students, 23.2% had a previous diagnosis of mental illness. Of them, only 10.8% received medical treatment. Family history of mental illness constitutes 17.5%. Regarding social status, approximately 37.9% of the students contacted their families almost every day. 39.2% indicated going with friends once a week. Nearly half (49.4%) were visiting Saudi Arabia once a year. Students who felt like being a stranger all the time constitute 10.5%. Additionally, 92.8% received financial aid programs (Table 2 ). Table 2 University students' medical history and social status (n=401) Medical history N (%) Diagnosed with any mental illness • No 308 (76.8%) • Yes 93 (23.2%) Received treatment for mental illness (n=93) • No 83 (89.2%) • Yes 10 (10.8%) Family history of mental illness • No 209 (52.1%) • Yes 70 (17.5%) • I don't know 122 (30.4%) Social status How often do you contact your family? • Every day 70 (17.5%) • Nearly every day 152 (37.9%) • Once weekly 128 (31.9%) • Once every two weeks to once a month 36 (09.0%) • Less than once a month 13 (03.2%) • I don't have a family in Saudi Arabia 02 (0.50%) How often do you go out with friends? • Every day 16 (04.0%) • Nearly every day 93 (23.2%) • Once weekly 153 (38.2%) • Once every two weeks to once a month 67 (16.7%) • Less than once a month 33 (08.2%) • I don't go out with friends 39 (09.7%) How often did you visit Saudi Arabia? (Yearly average) • Less than once a year 58 (14.5%) • Once a year 198 (49.4%) • Twice a year 90 (22.4%) • Three times a year 31 (07.7%) • More than three times a year 24 (06.0%) Do you feel like a stranger? • Never 34 (08.5%) • Rarely 78 (19.5%) • Sometimes 178 (44.4%) • Most of the time 69 (17.2%) • All the time 42 (10.5%) Do you have a financial aid program? • No 29 (07.2%) • Yes 372 (92.8%) In Fig. 1 , among those who were previously diagnosed with mental illness (N = 93), the most common of them was depression (45.2%), followed by anxiety disorders (34.4%) and ADHD/ADD (10.8%). Figure 2 shows that 40.4% were deemed to have a major depression, and the rest were normal (59.6%) When exploring the relationship between major depression according to the socio-demographic and medical characteristics along with social status (Table 3 ), it was observed that students with major depression were more likely to be younger students (p = 0.038), in engineering and technology disciplines (p = 0.030), never been married (p = 0.047), with previous diagnosis of a mental disorder (p < 0.001), with family history of mental illness (p < 0.001), having infrequent contact with family (p = 0.047), having infrequent going out with friends (p = 0.022) and feeling like a stranger most or all the time (p < 0.001). Table 3 Univariate analysis for the predictors of major depression (n=401) Factor Major depression P-value § Yes N (%) (n=162) No N (%) (n=239) Age group • 18–25 years 95 (58.6%) 115 (48.1%) 0.038 ** • > 25 years 67 (41.4%) 124 (51.9%) Gender • Male 78 (48.1%) 138 (57.7%) 0.059 • Female 84 (51.9%) 101 (42.3%) Country of study • United States of America 78 (48.1%) 109 (45.6%) 0.835 • United Kingdom 65 (40.1%) 98 (41.0%) • Australia 19 (11.7%) 32 (13.4%) Marital status • Never been married 119 (73.5%) 153 (64.0%) 0.047 ** • Been married 43 (26.5%) 86 (36.0%) Living status • Living Alone 57 (35.2%) 66 (27.6%) 0.272 • Living with family 59 (36.4%) 97 (40.6%) • Living with friend(s)/roommate(s) 46 (28.4%) 76 (31.8%) Specialty • Engineering and technology disciplines 89 (54.9%) 105 (43.9%) 0.030 ** • Non-engineering and technology disciplines 73 (45.1%) 134 (56.1%) Academic degree • Bachelors's degree 98 (60.5%) 122 (51.0%) 0.062 • Master's or Doctorate degree 64 (39.5%) 117 (49.0%) Years studying abroad • ≤ 3 years 78 (48.1%) 112 (46.9%) 0.800 • > 3 years 84 (51.9%) 127 (53.1%) Diagnosed with any mental illness • No 104 (64.2%) 204 (85.4%) < 0.001 ** • Yes 58 (35.8%) 35 (14.6%) Family history of mental illness • No 56 (60.2%) 153 (82.3%) < 0.001 ** • Yes 37 (39.8%) 33 (17.7%) How often do you contact your family? • Nearly every day to every day 80 (49.4%) 142 (59.4%) 0.047 ** • Every two weeks or more 82 (50.6%) 97 (40.6%) How often do you go out with friends? • Nearly every day to every day 34 (21.0%) 75 (31.4%) 0.022 ** • Every two weeks or more 128 (79.0%) 164 (68.6%) How often did you visit Saudi Arabia? • Once a year or less 101 (62.3%) 155 (64.9%) 0.608 • Two years or more 61 (37.7%) 84 (35.1%) Do you feel like a stranger? • Never or rarely 21 (13.0%) 91 (8.1%) < 0.001 ** • Sometimes 62 (38.3%) 116 (48.5%) • Most or All the time 79 (48.8%) 32 (13.4%) § P-value has been calculated using Chi-square test. ** Significant at p < 0.05 level. When conducting a multivariate regression analysis (Table 4 ), it was found that students who had previous diagnoses of mental illness were 2.89 times more likely to have major depression compared to students who did not have it (AOR = 2.890; 95% CI = 1.440–5.800; p = 0.003). Also, compared to students who never or rarely feel like strangers, students sometimes felt like strangers were at increased risk of having major depression by at least 7.06 times higher (AOR = 7.058; 95% CI = 3.219–15.476; p < 0.001) and increased by 5.07 times higher among those who felt like strangers most or all the time (AOR = 5.069; 95% CI = 2.558–10.044; p < 0.001). No significant effects were observed between major depression in terms of age, marital status, family history of mental illness, frequent contact with family, and going with friends after adjustment to a regression model (p > 0.05). Table 4 Multivariate regression analysis to determine significant independent risk factors of major depression (n=401) Factor AOR 95% CI P-value Age group • 18–25 years Ref • > 25 years 0.671 0.290–1.553 0.351 Marital status • Never been married Ref • Been married 0.787 0.350–1.771 0.562 Specialty • Engineering and technology disciplines Ref • Non-engineering and technology disciplines 0.773 0.409–1.461 0.428 Diagnosed with any mental illness • No Ref • Yes 2.890 1.440–5.800 0.003 ** Family history of mental illness • No Ref • Yes 1.879 0.973–3.631 0.060 How often do you contact your family? • Nearly every day to every day Ref • Every two weeks or more 1.385 0.775–2.475 0.272 How often do you go out with friends? • Nearly every day to every day Ref • Every two weeks or more 1.361 0.665–2.784 0.399 Do you feel like a stranger? • Never or rarely Ref • Sometimes 7.058 3.219–15.476 < 0.001 ** • Most or All the time 5.069 2.558–10.044 < 0.001 ** AOR – Adjusted Odds Ratio; CI – Confidence Interval. ** Significant at p < 0.05 level. Discussion Depression among university students has negative effects on their academic careers, including poorer academic results, reduced productivity at work, and higher dropout rates. Moreover, depression's impact extends into adulthood, impeding social interactions and professional opportunities, and establishing a detrimental cycle of adverse outcomes. [ 2 , 10 , 11 ] There are many screening tools developed from the patient health questionnaire (PHQ). However, we preferred using PHQ-8 rather than PHQ-9 for two reasons. First, the ninth item in the PHQ-9 is “Thoughts that you would be better off dead or of hurting yourself in some way.” The authors of PHQ-9 (and PHQ-8) believe that excluding this item is appropriate if it will be self-administered which, in our study, it was. Second, The PHQ-8 and PHQ-9 have similar sensitivity, specificity, and positive predictive value and have a similar likelihood of predicting any depressive disorder. [ 12 – 14 ] Our study investigated the prevalence and potential predictors of depression among Saudi students studying internationally, which to our knowledge has not been discussed in previous literature. There were limited studies in Saudi Arabia that provided evidence about the issue of mental health among this group of population. Hence, the outcome of this study could be an important contribution to the literature, given the high prevalence of depression among university students in Saudi Arabia and the wide range of illnesses brought by depression if left untreated.[ 2 , 6 ] The results of this study revealed that out of 401 Saudi international university students, 162 (40.4%) were detected to have major depression (PHQ-8 score > 10). This is almost consistent with the study done in Bangladesh, with a prevalence of depressive symptoms in international students at 47.7%.[ 15 ] Consistent with these reports, in the UK[ 16 ], the rate of depression among international postgraduate students was 34.6%. In contrast, American international students recorded the lowest depression rate, as only 4.5% were positive for depression.[ 17 ] The results of our study offer insight into the higher rate of depression while studying abroad. Previous history of mental illness increased the likelihood of major depression by at least 2.89-fold higher. This finding is in accordance with a report documented by Amanvermez et al. (2023)[ 18 ]. They found that after adjustment for confounders such as socio-demographic data, depressive and anxiety symptoms, and other sources of stress, international student status was positively associated with higher perceived stress, particularly in the dimensions of financial situation and health of loved ones. However, in a paper published by Jamilah et al. (2020)[ 15 ], socio-demographic characteristics such as age and marital status, as well as living condition satisfaction, problems with studies, food, homesickness, accommodation, and health were all predicted to increase the risk of developing depression. In our study, major depression did not vary significantly by gender, country of study, living status, specialty, and academic degree (p > 0.05), which did not coincide with previous reports. Feeling like a stranger increased the likelihood of developing depression in both "sometimes" (AOR: 7.058) and "most or all time" (AOR: 5.069). Not opposing this result, several studies documented that language barriers increase the likelihood of depression among international students.[ 18 – 21 ] Language barriers have always been an issue among foreigners, particularly among first timers abroad who are used to speaking the native language. This contributed to the development of depression. Hence, linguistic proficiency is an important contributor to coping strategies against depression.[ 22 ] Kabir et al. (2023) reported that international students who were suffering from financial constraints had a 2-fold higher risk of suffering from depression. Other contributing factors were living alone and living with others.[ 23 ] This corroborates the findings of Jamilah et al.[ 15 ], with approximately one-third of cases complaining of financial difficulties and health problems. Hunley (2010) also observed that having a lower level of functioning was concomitant to an increase in psychological distress and loneliness.[ 24 ] In our study, living status and years studying abroad were not seen to influence the development of depression (p > 0.05). the financial difficulties may have been mitigated for our study group by easier access to financial aid programs from the Saudi government and companies as 92.8% had financial aid programs. Motivating factors are indispensable to coping with mental issues abroad. Supporting this view, Hu et al. (2022) asserted that effective coping strategies could link to better interaction with other cultures.[ 22 ] Supporting these reports, Zhao et al. (2021) noted that taking preventive measures more seriously could reduce the depression rate of the students. Measures such as counseling and education programs are vital to support and enhance the mental health status of students living abroad.[ 25 ] In our study, communication with family and going out with friends more frequently were factors most associated with less depression occurrence. These findings underscore the importance of social support networks in mitigating the impact of stressors and promoting mental well-being. The influence of these factors implies that institutions should emphasize creating supportive environments that encourage meaningful relationships and opportunities for social engagement among international students. While the study contributes valuable insights into depression among Saudi students studying internationally, it is not without limitations. It suffers from sampling bias, focusing only on Saudi international students in specific countries and thus limiting generalizability. Relying on voluntary self-reported data and exclusion criteria might lead to selection bias. The cross-sectional design makes it difficult to draw causal conclusions and comprehend how depression levels change over time. The study's focus on specific risk factors might overlook other vital elements like social support and cultural adjustment. Finally, the study's temporal limitations might have missed seasonal fluctuations or long-term trends in the mental health of students studying abroad. For comprehensive and complex insights into depression among Saudi international students, these constraints must be addressed. The study's findings carry significant implications for academic institutions, mental health professionals, and policymakers. Understanding the prevalence and determinants of depression among Saudi IUS can guide the development of targeted interventions to enhance their mental well-being. Culturally Sensitive mental health resources, awareness campaigns, and peer support programs can address the unique challenges faced by these students. Conclusion and Recommendations There was a high prevalence of major depression among Saudi university students studying abroad. Students who felt like strangers and had a previous diagnosis of mental disorder were more likely to develop major depression than any other university students. However, those with more frequent communication with families and friends were less likely to have depression. The study emphasizes the need for tailored mental health support for Saudi students abroad, focusing on social connections and accessible mental health services. Diplomatic headquarters abroad should take necessary actions to help their citizens who are experiencing mental breakdown. To further enhance our understanding and develop comprehensive intervention strategies, it is important to diversify participant samples, employ mixed methods, conduct longitudinal studies, include clinical assessments for accurate diagnoses, broaden the focus to encompass social and cultural factors, analyze data over different timeframes, promote international collaborations, advocate for supportive policies within institutions, and expand the research focus to include depression among Saudi international students. Implementing these measures will deepen research insights and guide the development of culturally sensitive support systems. Abbreviations International university students (IUS); United States (US); United Kingdom (UK); patient health questionnaire (PHQ); grade point average (GPA); adjusted odds ratios (AOR). Declarations Ethical Approval and Consent to Participate Ethical approval was obtained from the Research Ethics Committee at King Faisal University in Al-Ahsa, Saudi Arabia (KFU-REC-2023-FEB-ETHICS525). All methods were carried out under relevant guidelines and regulations. There was no experimentation on humans, human tissue, or other species. Participants responded anonymously to the online survey, which began with an informed consent form in the first section. In this consent form, participants were informed about the confidentiality of the information. They were provided with information concerning the research purpose and that they had the right to revoke their participation without prior justification. Consent for Publication Not Applicable Availability of data and materials The corresponding author can be contacted to obtain data concerning the survey tool used for this study to gather data on depression among Saudi international university students. The raw survey responses and particular data regarding respondents will not be made accessible to the public due to the sensitive nature of the collected information and the potential for participant identification. Competing Interests The authors declare no competing interests. Funding This research was supported by the Deanship of Scientific Research, King Faisal University, Alahsa, Kingdom of Saudi Arabia (GRANT NO. 5506) Authors Contribution All authors participated in the preparation of the manuscript and approved the final version submitted. Mohammed A. Alnaim, Abdullah M. Al-Omair, Abdullah H. Alghamdi, Mohammed R. Aljuwair, and Faisal A. Alhadi contributed to the original draft's Conceptualization, Methodology, and writing. Ali J. Alsaad reviewed and edited the manuscript and contributed to the supervision and project administration. Acknowledgments The authors would like to express deep appreciation for all those who willingly contributed their time to this research. We also acknowledge the financial support for this research provided by the Deanship of Scientific Research at King Faisal University in Al-Ahsa, Kingdom of Saudi Arabia. References Chand SP, Arif H. Depression. StatPearls. Treasure Island (FL): StatPearls Publishing; 2022. Ibrahim AK, Kelly SJ, Adams CE, Glazebrook C. A systematic review of studies of depression prevalence in university students. Vol. 47, Journal of Psychiatric Research. 2013. Tiller JWG. Depression and anxiety. Med J Aust. 2013;199(6). Monteleone P, Martiadis V, Maj M. Circadian rhythms and treatment implications in depression. Progress in Neuro-Psychopharmacology and Biological Psychiatry. 2011;35(7). Satyanarayanan SK, Su H, Lin YW, Su KP. Circadian Rhythm and Melatonin in the Treatment of Depression. Current Pharmaceutical Design. 2018;24(22). AlJaber M. The prevalence and associated factors of depression among medical students of Saudi Arabia: A systematic review. Journal of Family Medicine and Primary Care. 2020;9(6). Hammen C. Risk Factors for Depression: An Autobiographical Review. Vol. 14, Annual Review of Clinical Psychology. 2018. Auerbach RP, Alonso J, Axinn WG, Cuijpers P, Ebert DD, Green JG, et al. Mental disorders among college students in the World Health Organization World Mental Health Surveys. Vol. 46, Psychological Medicine. 2016. Auerbach RP, Mortier P, Bruffaerts R, Alonso J, Benjet C, Cuijpers P, et al. WHO world mental health surveys international college student project: Prevalence and distribution of mental disorders. Journal of Abnormal Psychology. 2018;127(7). Hysenbegasi A, Hass SL, Rowland CR. The impact of depression on the academic productivity of university students. Journal of Mental Health Policy and Economics. 2005;8(3). Arria AM, Caldeira KM, Vincent KB, Winick ER, Baron RA, O’Grady KE. Discontinuous college enrollment: Associations with substance use and mental health. Psychiatric Services. 2013;64(2). Kroenke K, Spitzer RL, Williams JBW. The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine. 2001;16(9). Kroenke K, Spitzer RL. The PHQ-9: A new depression diagnostic and severity measure. Vol. 32, Psychiatric Annals. 2002. Kroenke K, Strine TW, Spitzer RL, Williams JBW, Berry JT, Mokdad AH. The PHQ-8 as a measure of current depression in the general population. Journal of Affective Disorders. 2009;114(1–3). Jamilah A, Haque MI, Muhammad F, Harun MG, Chowdhury AA, Akramuzzaman M, Arafat SY, Kabir R. Depression and associated factors among international students in a private university of Bangladesh. Global Psychiatry. 2020. Hosseinpur H, Parsa AD, Kabir R. The Prevalence of Depression and its Predictors among International Postgraduate Students Studying Public Health at a UK University. Journal of Psychosexual Health. 2023 Apr;5(2):94-101. Poyrazli S, Mitchell MA. Mental health problems of US students studying abroad. Journal of International Students. 2020 Feb 15;10(1):17-27. Amanvermez Y, Karyotaki E, Cuijpers P, Ciharova M, Bruffaerts R, Kessler RC, Klein AM, Wiers RW, de Wit LM. Sources of stress among domestic and international students: a cross-sectional study of university students in Amsterdam, The Netherlands. Anxiety, Stress, & Coping. 2023 Dec 5:1-8. Xiang G, Ahmad MI, Zhuang W, Rehman RU, Naseem MA. Depressive symptoms faced by non-native international medical students in China during COVID-19. Frontiers in Psychology. 2022 Nov 17;13:1037786. Mahihu C. Prevalence of Depression, Anxiety among International Students in the Health Professions at Southern Medical University, PR China. Open Journal of Social Sciences. 2020 Dec 16;8(12):161. Alshammari MK, Othman MH, Mydin YO, Mohammed BA. The Effect of Social Isolation on the Mental Health of International Students. Inf. Sci. Lett. 2023; 12, No. 4, 1235-1240. Kabir R, Isha SN, Chowdhury MT, Siddika N, Jahan SS, Saha AK, Nath SK, Jahan MS, Sivasubramanian M, Mahmud I, Hoque Apu E. Depression among the non-native international undergraduate students studying Dentistry in Bangladesh. International Journal of Environmental Research and Public Health. 2021 May 28;18(11):5802. Hu YL, Roberts A, Ching GS, Chao PC. Moderating effects of intercultural social efficacy and the role of language in the context of coping strategies in study abroad depression. International Journal of Environmental Research and Public Health. 2022 Feb 19;19(4):2409. Hunley HA. Students' functioning while studying abroad: The impact of psychological distress and loneliness. International Journal of Intercultural Relations. 2010 Jul 1;34(4):386-92. Zhao B, Kong F, Nam EW. Assessing knowledge, preventive practices, and depression among chinese university students in Korea and China during the COVID-19 pandemic: an online cross-sectional study. InHealthcare 2021 Apr 8 (Vol. 9, No. 4, p. 433). MDPI. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 11 Nov, 2024 Read the published version in BMC Public Health → Version 1 posted Editorial decision: Revision requested 27 Sep, 2024 Reviews received at journal 23 Aug, 2024 Reviewers agreed at journal 17 Aug, 2024 Reviews received at journal 15 Aug, 2024 Reviewers agreed at journal 05 Aug, 2024 Reviewers invited by journal 02 Aug, 2024 Editor invited by journal 25 Jun, 2024 Editor assigned by journal 24 Jun, 2024 Submission checks completed at journal 24 Jun, 2024 First submitted to journal 23 Jun, 2024 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. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4626304","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":322840644,"identity":"b2f43095-585a-4fa2-a3cc-4b7eaa86481a","order_by":0,"name":"MOHAMMED A. ALNAIM","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABL0lEQVRIie3RMWvCQBQH8BdeuSyvuF4Qv8OFgDgE/SoegpOUQkG6NRIwS+hcqR/CqfNJhmy62q2SwcUho5t9EbqUs5ROHe4/PHJwv7y7dwAuLv8wLUSzrk8xtvyElwIupebqJVdIkAldBfnYD3LDm5gQCO/lJ6K2FCkSRUvthr8kUFBXSsI2vB8OFU3juwEInRLEnZXx97VFeKmYyvueiLzXSZjSZvzAXdZMxtHKUCQtBBHfuAuNsD3x0tt5oXPws4qg0EzARgRCV5KQT/Og3DM5N2TGXc5M/OpkIYQ3zfUVkoSQiWFyOZhhwn+zEImXIQ9R0iRcLDcjnRdCz5ZqFC14Mj0LGWyL5inPOCjLj/o47essm4fJ8bHfeS6zandt0N8m0hT19eHi4uLi8pd8AtApYYCFoOJJAAAAAElFTkSuQmCC","orcid":"","institution":"King Faisal University","correspondingAuthor":true,"prefix":"","firstName":"MOHAMMED","middleName":"A.","lastName":"ALNAIM","suffix":""},{"id":322840645,"identity":"b9cb8fb7-799f-4bde-87ad-544ff4e504c0","order_by":1,"name":"Abdullah H. AlGhamdi","email":"","orcid":"","institution":"King Faisal University","correspondingAuthor":false,"prefix":"","firstName":"Abdullah","middleName":"H.","lastName":"AlGhamdi","suffix":""},{"id":322840647,"identity":"1924fad5-cf7f-4358-8306-a2100290863c","order_by":2,"name":"Mohammed R. AlJawair","email":"","orcid":"","institution":"King Faisal University","correspondingAuthor":false,"prefix":"","firstName":"Mohammed","middleName":"R.","lastName":"AlJawair","suffix":""},{"id":322840648,"identity":"b52d123e-f521-476b-93eb-7a4e8eec1713","order_by":3,"name":"Faisal A. AlHadi","email":"","orcid":"","institution":"King Faisal University","correspondingAuthor":false,"prefix":"","firstName":"Faisal","middleName":"A.","lastName":"AlHadi","suffix":""},{"id":322840649,"identity":"b1e6d204-7be6-4544-be97-872885822d2e","order_by":4,"name":"Abdullah M. AlOmair","email":"","orcid":"","institution":"King Faisal University","correspondingAuthor":false,"prefix":"","firstName":"Abdullah","middleName":"M.","lastName":"AlOmair","suffix":""},{"id":322840650,"identity":"7e0c0f57-e5ce-48ee-a3f8-0ac4adfa7d27","order_by":5,"name":"Ali Alsaad","email":"","orcid":"","institution":"King Faisal University","correspondingAuthor":false,"prefix":"","firstName":"Ali","middleName":"","lastName":"Alsaad","suffix":""}],"badges":[],"createdAt":"2024-06-23 18:53:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4626304/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4626304/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12889-024-20565-y","type":"published","date":"2024-11-11T15:57:12+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":60624938,"identity":"7a3799a5-1609-40c2-a14b-3aedd2b3092b","added_by":"auto","created_at":"2024-07-18 22:18:57","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":46041,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSpecific type of mental illness\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4626304/v1/19e6e9d2e33f9d8cb98484b1.jpg"},{"id":60625743,"identity":"de5b0d76-116f-483e-9e84-21e208cddd43","added_by":"auto","created_at":"2024-07-18 22:26:58","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":5713,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePrevalence of major depression according to PHQ-8\u003c/strong\u003e(\u003cstrong\u003ePHQ-8 score\u0026gt;10) among international university students\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Placeholderimage.png","url":"https://assets-eu.researchsquare.com/files/rs-4626304/v1/a7f9924088e5d251d4531750.png"},{"id":69274916,"identity":"ddc9caa2-f89d-4af7-8c30-c991945218d1","added_by":"auto","created_at":"2024-11-18 16:38:01","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":830673,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4626304/v1/95c4f1b4-5ba9-40cc-aaec-9e4fdc3cb353.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Depression Among Saudi International University Students and Its Associated Risk Factors.","fulltext":[{"header":"Introduction","content":"\u003cp\u003eDepression is a mood disorder that causes a continual feeling of sorrow and loss of interest. It is commonly characterized by sadness, emptiness, irritable mood, and cognitive and somatic alterations that impact the individual\u0026rsquo;s capacity for everyday performance[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Moreover, depression is a multi-faceted disorder that impairs interpersonal, social, and occupational functioning. A lack of self-care, anxiety, poor attention, sleep disturbances, and a loss of interest in everyday experiences are some of the symptoms of depression[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Depression has a multifactorial etiology, with genetic and environmental factors contributing. For example, people with first-degree relatives with depression are three times more likely to develop depression than the general population.\u003c/p\u003e \u003cp\u003eRegarding the treatment of depression, medication or brief psychotherapy alone can relieve depressive symptoms. Nevertheless, combination therapy has been linked with markedly higher rates of depressive symptom relief, better treatment adherence, and improved quality of life[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. It was found that while psychotherapy tends to increase frontal activity, pharmacotherapy reduces limbic structures' overactivity[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Furthermore, the inclusion of circadian rhythms normalization as a part of treatment for depression has been proposed [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. It was found that dysregulation of the circadian system increases susceptibility to depression [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Around 60% of depressed people do not seek medical help[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Many factors may hinder help-seeking. One is the stigma toward mental disorders and people who have them[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Another factor is the lack of mental health literacy among the general public[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSeveral factors have been linked with depression. Having a depressed parent, particularly a depressed mother, is a strong risk factor for depression. A stable relation across countries is that women, beginning from adolescence, have a 2:1 greater probability of getting MDD than men. Moreover, for men, childhood sexual abuse, conduct disorders, substance misuse, and stressful experiences with financial, professional, or legal significance were all strong predictors of depression. However, in women, divorce, low parental warmth, low marital satisfaction, and low social support were all found to be stronger predictors of depression[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDepression is a widespread mental disorder among college students[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. A systematic review involving twenty-four studies reporting on the depression prevalence rate among university students has found that the average depression prevalence is 30.6%. This is a greater rate than the 9% observed in the United States\u0026rsquo;s (US) population rates[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Also, many predisposing factors have been linked with university students\u0026rsquo; depression. These factors include being a first-year student, living alone, being single rather than married, and having a low or high Grade Point Average (GPA)[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Additionally, sleep and eating disturbances, family relationship alterations, financial stressors, and academic worries are all factors that might increase students\u0026rsquo; vulnerability to depression [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn university students, depression has been associated with lower academic performance[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], worse work performance[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], and increased dropout risk [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Furthermore, depression can result in a buildup of harmful consequences through adulthood because of its effect on social relationships and career prospects[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMany papers have assessed the prevalence of depression among university students, especially among medical students[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. However, to our knowledge, none have measured it among international university students (IUS). Furthermore, none has taken into consideration the factors associated with depression among the said population. We aim to highlight these factors and assess the prevalence of depression among Saudi IUS in the US, United Kingdom(UK), and Australia. Hopefully, this research will draw attention to international students\u0026rsquo; mental health and help acknowledge the factors associated with it.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eDesign and Participants\u003c/h2\u003e \u003cp\u003eA cross-sectional, questionnaire-based design was adopted in this study, which was conducted in February 2023. All Saudi students studying at a university or a college in the US, UK, or Australia for a bachelor\u0026rsquo;s, master\u0026rsquo;s, or doctorate degree were eligible to participate in the study. The three countries included in the study were chosen because they were Saudi students' most prevalent scholarship destinations. Participants who were non-Saudi, not studying in the US, UK, or Australia, studying for a fellowship or a diploma, in their first year of college, or had not properly completed the form were excluded. Participation was voluntary, and informed consent was obtained online before the survey. Additionally, confidentiality was assured, questionnaires were submitted anonymously, and all participants could withdraw from completing the survey at any time. This study was approved by the Deanship of Scientific Research at King Faisal University on February 1, 2023 (KFU-REC-2023-FEB-ETHICS525)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eSample size calculation\u003c/h2\u003e \u003cp\u003eFour hundred and one participants were included in this study. The sample size needed for the study was calculated to be 324 participants. Taking a 5% margin of error, a 95% confidence interval, a 30.6% expected population proportion, and a population size of 35840 international Saudi students. The formula used is:\u003c/p\u003e \u003cp\u003e\u003cimg src=\"data:image/png;base64,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\" style=\"width: 318px; height: 197.354px;\" width=\"318\" height=\"197.354\"\u003e\u003c/p\u003e\u003cp\u003e \u003c/p\u003e \u003cp\u003eThe population size number was obtained in January 2023 from a governmental platform used by all Saudi IUS called \u0026ldquo;SAFEER2.\u0026rdquo; Which includes the number of all Saudi IUS in all countries. The expected population proportion was assumed according to a systematic review of depression prevalence among university students, which found that the average depression prevalence is 30.6%. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003eData was collected through an online Google Forms survey from February 2023 to April 2023. Then, the survey was distributed on social media platforms and Saudi IUS WhatsApp groups. The data of all subjects were subsequently stored in a secured Microsoft Excel spreadsheet file on Google Drive.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStudy variables and instruments:\u003c/h2\u003e \u003cp\u003eThe survey consisted of three sections. The first is for informed consent. The second section is the demographic data and risk factors section. The demographic part was designed to collect the general characteristics of Saudi IUS. Including sex, age, country of study, marital status, housing, academic discipline, sought academic degree, and number of years studying abroad. The risk factors\u0026rsquo; part consists of the last GPA, personal and family history of mental illness, frequency of family contact, frequency of going out with friends, the yearly average number of visits to Saudi Arabia, having a financial aid program and feeling like a stranger. All GPAs are converted to a 5-point system and then grouped into five hierarchical categories. Only those who are getting their bachelor\u0026rsquo;s degree were asked about their GPAs. The last section is for depression screening. To screen for depression, we used the eight-item version of the Patient Health Questionnaire (PHQ-8). PHQ-8 includes all items of the nine-item version of the Patient Health Questionnaire (PHQ-9) except the ninth item that concerns self-harm. Items in the PHQ-9 consist of the nine criteria for depression from the \u003cem\u003eDiagnostic and Statistical Manual of Mental Disorders, Fourth Edition\u003c/em\u003e (DSM-IV)[\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. We used a PHQ-8 score of \u0026ge;\u0026thinsp;10 as a cut-off point for defining clinically significant depression[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eThe data were analyzed using the software program Statistical Packages for Software Sciences (SPSS) version 26 (Armonk, New York, IBM Corporation, USA). The numbers and percentages (%) were given for categorical variables. Univariate analysis was performed to identify the factors that influence major depression. Significant results were then placed in a multivariate regression model to determine the significant independent risk factors for major depression. Values were considered significant with a p-value of less than 0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThis study enrolled four hundred and one Saudi university students studying abroad. As described in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, 52.4% were between 18 and 25 years of age. Male students constitute 53.9%, and 46.6% are currently enrolled in the USA. Most students were single (67.8%) and lived alone (30.7%). Engineering and technology disciplines were the most common specialties (48.4%). Over half (54.9%) were bachelor's degree holders. Approximately 20% had 1 year of studying abroad. In addition, 62.3% had excellent GPAs (between 4.5 and 5 out of 5).\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 characteristics of Saudi International University Students \u003csup\u003e(n=401)\u003c/sup\u003e\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=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudy variables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; 18\u0026ndash;25 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e210 (52.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; \u0026gt;\u0026thinsp;25 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e191 (47.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Male\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e216 (53.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Female\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e185 (46.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCountry of study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; United States of America\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e187 (46.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; United Kingdom\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e163 (40.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Australia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e51 (12.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarital status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Single\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e272 (67.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Married\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e120 (29.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Divorced\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e07 (01.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Widowed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e02 (0.50%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiving status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e123 (30.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; With parents\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18 (04.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; With friend(s)/roommate(s)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e122 (30.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; With Spouse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15 (03.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; With spouse and children\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e76 (19.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; With children without a spouse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18 (04.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; With other family members\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e29 (07.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpecialty\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Medical disciplines\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e50 (12.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Engineering and technology disciplines\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e194 (48.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Arts and Humanities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e61 (15.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Business and finance disciplines\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e56 (14.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Natural science\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14 (03.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Architecture and design disciplines\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e05 (01.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Other\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21 (05.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcademic degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Bachelor\u0026rsquo;s degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e220 (54.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Master's degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e86 (21.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Doctorate degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e95 (23.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYears studying abroad\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; 1 year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e80 (20.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; 2 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e57 (14.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; 3 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e53 (13.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; 4 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e126 (31.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; 5 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e33 (08.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; 6 years or more\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e52 (13.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGPA \u003csup\u003e(n=220)\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; 4.5 to 5 out of 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e137 (62.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; 4.0 to 4.5 out of 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e54 (24.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; 3.5 to 4.0 out of 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16 (07.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; 3.0 to 3.5 out of 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12 (05.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Less than 3.0 out of 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e01 (0.50%)\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\u003eRegarding the medical history of the students, 23.2% had a previous diagnosis of mental illness. Of them, only 10.8% received medical treatment. Family history of mental illness constitutes 17.5%. Regarding social status, approximately 37.9% of the students contacted their families almost every day. 39.2% indicated going with friends once a week. Nearly half (49.4%) were visiting Saudi Arabia once a year. Students who felt like being a stranger all the time constitute 10.5%. Additionally, 92.8% received financial aid programs (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\u003eUniversity students' medical history and social status \u003csup\u003e(n=401)\u003c/sup\u003e\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=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedical history\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiagnosed with any mental illness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; No\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e308 (76.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Yes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e93 (23.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReceived treatment for mental illness \u003csup\u003e(n=93)\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; No\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e83 (89.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Yes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10 (10.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFamily history of mental illness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; No\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e209 (52.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Yes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e70 (17.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; I don't know\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e122 (30.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSocial status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHow often do you contact your family?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Every day\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e70 (17.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Nearly every day\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e152 (37.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Once weekly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e128 (31.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Once every two weeks to once a month\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e36 (09.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Less than once a month\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13 (03.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; I don't have a family in Saudi Arabia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e02 (0.50%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHow often do you go out with friends?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Every day\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16 (04.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Nearly every day\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e93 (23.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Once weekly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e153 (38.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Once every two weeks to once a month\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e67 (16.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Less than once a month\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e33 (08.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; I don't go out with friends\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e39 (09.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHow often did you visit Saudi Arabia? (Yearly average)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Less than once a year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e58 (14.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Once a year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e198 (49.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Twice a year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e90 (22.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Three times a year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31 (07.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; More than three times a year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24 (06.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDo you feel like a stranger?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Never\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e34 (08.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Rarely\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e78 (19.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Sometimes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e178 (44.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Most of the time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e69 (17.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; All the time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e42 (10.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDo you have a financial aid program?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; No\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e29 (07.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Yes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e372 (92.8%)\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\u003eIn Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, among those who were previously diagnosed with mental illness (N\u0026thinsp;=\u0026thinsp;93), the most common of them was depression (45.2%), followed by anxiety disorders (34.4%) and ADHD/ADD (10.8%).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFigure 2 shows that 40.4% were deemed to have a major depression, and the rest were normal (59.6%)\u003c/p\u003e \u003cp\u003eWhen exploring the relationship between major depression according to the socio-demographic and medical characteristics along with social status (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e), it was observed that students with major depression were more likely to be younger students (p\u0026thinsp;=\u0026thinsp;0.038), in engineering and technology disciplines (p\u0026thinsp;=\u0026thinsp;0.030), never been married (p\u0026thinsp;=\u0026thinsp;0.047), with previous diagnosis of a mental disorder (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), with family history of mental illness (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), having infrequent contact with family (p\u0026thinsp;=\u0026thinsp;0.047), having infrequent going out with friends (p\u0026thinsp;=\u0026thinsp;0.022) and feeling like a stranger most or all the time (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\u003eUnivariate analysis for the predictors of major depression \u003csup\u003e(n=401)\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eFactor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eMajor depression\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eP-value \u003csup\u003e\u0026sect;\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003cp\u003e\u003csup\u003e(n=162)\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003cp\u003e\u003csup\u003e(n=239)\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; 18\u0026ndash;25 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e95 (58.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e115 (48.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e0.038 **\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; \u0026gt;\u0026thinsp;25 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e67 (41.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e124 (51.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Male\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e78 (48.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e138 (57.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.059\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Female\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e84 (51.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e101 (42.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCountry of study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; United States of America\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e78 (48.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e109 (45.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.835\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; United Kingdom\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e65 (40.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e98 (41.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Australia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19 (11.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32 (13.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarital status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Never been married\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e119 (73.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e153 (64.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e0.047 **\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Been married\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e43 (26.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e86 (36.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiving status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Living Alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e57 (35.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e66 (27.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.272\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Living with family\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e59 (36.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e97 (40.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Living with friend(s)/roommate(s)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e46 (28.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e76 (31.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpecialty\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Engineering and technology disciplines\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e89 (54.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e105 (43.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e0.030 **\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Non-engineering and technology disciplines\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e73 (45.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e134 (56.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcademic degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Bachelors's degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e98 (60.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e122 (51.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.062\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Master's or Doctorate degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e64 (39.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e117 (49.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYears studying abroad\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; \u0026le;\u0026thinsp;3 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e78 (48.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e112 (46.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.800\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; \u0026gt;\u0026thinsp;3 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e84 (51.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e127 (53.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiagnosed with any mental illness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; No\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e104 (64.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e204 (85.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001 **\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Yes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e58 (35.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e35 (14.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFamily history of mental illness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; No\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e56 (60.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e153 (82.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001 **\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Yes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e37 (39.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e33 (17.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHow often do you contact your family?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Nearly every day to every day\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e80 (49.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e142 (59.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e0.047 **\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Every two weeks or more\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e82 (50.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e97 (40.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHow often do you go out with friends?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Nearly every day to every day\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e34 (21.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e75 (31.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e0.022 **\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Every two weeks or more\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e128 (79.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e164 (68.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHow often did you visit Saudi Arabia?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Once a year or less\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e101 (62.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e155 (64.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.608\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Two years or more\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e61 (37.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e84 (35.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDo you feel like a stranger?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Never or rarely\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21 (13.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e91 (8.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001 **\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Sometimes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e62 (38.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e116 (48.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Most or All the time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e79 (48.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32 (13.4%)\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\u003e \u003csup\u003e\u0026sect;\u003c/sup\u003e P-value has been calculated using Chi-square test.\u003c/p\u003e \u003cp\u003e** Significant at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 level.\u003c/p\u003e \u003cp\u003eWhen conducting a multivariate regression analysis (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e), it was found that students who had previous diagnoses of mental illness were 2.89 times more likely to have major depression compared to students who did not have it (AOR\u0026thinsp;=\u0026thinsp;2.890; 95% CI\u0026thinsp;=\u0026thinsp;1.440\u0026ndash;5.800; p\u0026thinsp;=\u0026thinsp;0.003). Also, compared to students who never or rarely feel like strangers, students sometimes felt like strangers were at increased risk of having major depression by at least 7.06 times higher (AOR\u0026thinsp;=\u0026thinsp;7.058; 95% CI\u0026thinsp;=\u0026thinsp;3.219\u0026ndash;15.476; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and increased by 5.07 times higher among those who felt like strangers most or all the time (AOR\u0026thinsp;=\u0026thinsp;5.069; 95% CI\u0026thinsp;=\u0026thinsp;2.558\u0026ndash;10.044; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). No significant effects were observed between major depression in terms of age, marital status, family history of mental illness, frequent contact with family, and going with friends after adjustment to a regression model (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultivariate regression analysis to determine significant independent risk factors of major depression \u003csup\u003e(n=401)\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\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=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFactor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAOR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; 18\u0026ndash;25 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; \u0026gt;\u0026thinsp;25 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.671\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.290\u0026ndash;1.553\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.351\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarital status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Never been married\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Been married\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.787\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.350\u0026ndash;1.771\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.562\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpecialty\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Engineering and technology disciplines\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Non-engineering and technology disciplines\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.773\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.409\u0026ndash;1.461\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.428\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiagnosed with any mental illness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; No\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Yes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.890\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.440\u0026ndash;5.800\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.003 **\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFamily history of mental illness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; No\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Yes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.879\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.973\u0026ndash;3.631\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.060\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHow often do you contact your family?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Nearly every day to every day\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Every two weeks or more\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.385\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.775\u0026ndash;2.475\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.272\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHow often do you go out with friends?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Nearly every day to every day\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Every two weeks or more\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.361\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.665\u0026ndash;2.784\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.399\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDo you feel like a stranger?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Never or rarely\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Sometimes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.058\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.219\u0026ndash;15.476\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001 **\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Most or All the time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.069\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.558\u0026ndash;10.044\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001 **\u003c/b\u003e\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\u003eAOR \u0026ndash; Adjusted Odds Ratio; CI \u0026ndash; Confidence Interval.\u003c/p\u003e \u003cp\u003e** Significant at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 level.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eDepression among university students has negative effects on their academic careers, including poorer academic results, reduced productivity at work, and higher dropout rates. Moreover, depression's impact extends into adulthood, impeding social interactions and professional opportunities, and establishing a detrimental cycle of adverse outcomes. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] There are many screening tools developed from the patient health questionnaire (PHQ). However, we preferred using PHQ-8 rather than PHQ-9 for two reasons. First, the ninth item in the PHQ-9 is \u0026ldquo;Thoughts that you would be better off dead or of hurting yourself in some way.\u0026rdquo; The authors of PHQ-9 (and PHQ-8) believe that excluding this item is appropriate if it will be self-administered which, in our study, it was. Second, The PHQ-8 and PHQ-9 have similar sensitivity, specificity, and positive predictive value and have a similar likelihood of predicting any depressive disorder. [\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] Our study investigated the prevalence and potential predictors of depression among Saudi students studying internationally, which to our knowledge has not been discussed in previous literature. There were limited studies in Saudi Arabia that provided evidence about the issue of mental health among this group of population. Hence, the outcome of this study could be an important contribution to the literature, given the high prevalence of depression among university students in Saudi Arabia and the wide range of illnesses brought by depression if left untreated.[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThe results of this study revealed that out of 401 Saudi international university students, 162 (40.4%) were detected to have major depression (PHQ-8 score\u0026thinsp;\u0026gt;\u0026thinsp;10). This is almost consistent with the study done in Bangladesh, with a prevalence of depressive symptoms in international students at 47.7%.[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] Consistent with these reports, in the UK[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], the rate of depression among international postgraduate students was 34.6%. In contrast, American international students recorded the lowest depression rate, as only 4.5% were positive for depression.[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] The results of our study offer insight into the higher rate of depression while studying abroad.\u003c/p\u003e \u003cp\u003ePrevious history of mental illness increased the likelihood of major depression by at least 2.89-fold higher. This finding is in accordance with a report documented by Amanvermez et al. (2023)[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. They found that after adjustment for confounders such as socio-demographic data, depressive and anxiety symptoms, and other sources of stress, international student status was positively associated with higher perceived stress, particularly in the dimensions of financial situation and health of loved ones. However, in a paper published by Jamilah et al. (2020)[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], socio-demographic characteristics such as age and marital status, as well as living condition satisfaction, problems with studies, food, homesickness, accommodation, and health were all predicted to increase the risk of developing depression. In our study, major depression did not vary significantly by gender, country of study, living status, specialty, and academic degree (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05), which did not coincide with previous reports.\u003c/p\u003e \u003cp\u003eFeeling like a stranger increased the likelihood of developing depression in both \"sometimes\" (AOR: 7.058) and \"most or all time\" (AOR: 5.069). Not opposing this result, several studies documented that language barriers increase the likelihood of depression among international students.[\u003cspan additionalcitationids=\"CR19 CR20\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] Language barriers have always been an issue among foreigners, particularly among first timers abroad who are used to speaking the native language. This contributed to the development of depression. Hence, linguistic proficiency is an important contributor to coping strategies against depression.[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eKabir et al. (2023) reported that international students who were suffering from financial constraints had a 2-fold higher risk of suffering from depression. Other contributing factors were living alone and living with others.[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] This corroborates the findings of Jamilah et al.[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], with approximately one-third of cases complaining of financial difficulties and health problems. Hunley (2010) also observed that having a lower level of functioning was concomitant to an increase in psychological distress and loneliness.[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] In our study, living status and years studying abroad were not seen to influence the development of depression (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). the financial difficulties may have been mitigated for our study group by easier access to financial aid programs from the Saudi government and companies as 92.8% had financial aid programs.\u003c/p\u003e \u003cp\u003eMotivating factors are indispensable to coping with mental issues abroad. Supporting this view, Hu et al. (2022) asserted that effective coping strategies could link to better interaction with other cultures.[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] Supporting these reports, Zhao et al. (2021) noted that taking preventive measures more seriously could reduce the depression rate of the students. Measures such as counseling and education programs are vital to support and enhance the mental health status of students living abroad.[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] In our study, communication with family and going out with friends more frequently were factors most associated with less depression occurrence. These findings underscore the importance of social support networks in mitigating the impact of stressors and promoting mental well-being. The influence of these factors implies that institutions should emphasize creating supportive environments that encourage meaningful relationships and opportunities for social engagement among international students.\u003c/p\u003e \u003cp\u003eWhile the study contributes valuable insights into depression among Saudi students studying internationally, it is not without limitations. It suffers from sampling bias, focusing only on Saudi international students in specific countries and thus limiting generalizability. Relying on voluntary self-reported data and exclusion criteria might lead to selection bias. The cross-sectional design makes it difficult to draw causal conclusions and comprehend how depression levels change over time. The study's focus on specific risk factors might overlook other vital elements like social support and cultural adjustment. Finally, the study's temporal limitations might have missed seasonal fluctuations or long-term trends in the mental health of students studying abroad. For comprehensive and complex insights into depression among Saudi international students, these constraints must be addressed.\u003c/p\u003e \u003cp\u003eThe study's findings carry significant implications for academic institutions, mental health professionals, and policymakers. Understanding the prevalence and determinants of depression among Saudi IUS can guide the development of targeted interventions to enhance their mental well-being. Culturally Sensitive mental health resources, awareness campaigns, and peer support programs can address the unique challenges faced by these students.\u003c/p\u003e"},{"header":"Conclusion and Recommendations","content":"\u003cp\u003eThere was a high prevalence of major depression among Saudi university students studying abroad. Students who felt like strangers and had a previous diagnosis of mental disorder were more likely to develop major depression than any other university students. However, those with more frequent communication with families and friends were less likely to have depression. The study emphasizes the need for tailored mental health support for Saudi students abroad, focusing on social connections and accessible mental health services. Diplomatic headquarters abroad should take necessary actions to help their citizens who are experiencing mental breakdown. To further enhance our understanding and develop comprehensive intervention strategies, it is important to diversify participant samples, employ mixed methods, conduct longitudinal studies, include clinical assessments for accurate diagnoses, broaden the focus to encompass social and cultural factors, analyze data over different timeframes, promote international collaborations, advocate for supportive policies within institutions, and expand the research focus to include depression among Saudi international students. Implementing these measures will deepen research insights and guide the development of culturally sensitive support systems.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eInternational university students (IUS); United States (US); United Kingdom (UK); patient health questionnaire (PHQ); grade point average (GPA); adjusted odds ratios (AOR).\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical Approval and Consent to Participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the Research Ethics Committee at King Faisal University in Al-Ahsa, Saudi Arabia (KFU-REC-2023-FEB-ETHICS525). All methods were carried out under relevant guidelines and regulations. There was no experimentation on humans, human tissue, or other species. Participants responded anonymously to the online survey, which began with an informed consent form in the first section. In this consent form, participants were informed about the confidentiality of the information. They were provided with information concerning the research purpose and that they had the right to revoke their participation without prior justification.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe corresponding author can be contacted to obtain data concerning the survey tool used for this study to gather data on depression among Saudi international university students. The raw survey responses and particular data regarding respondents will not be made accessible to the public due to the sensitive nature of the collected information and the potential for participant identification.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was supported by the Deanship of Scientific Research, King Faisal University, Alahsa, Kingdom of Saudi Arabia (GRANT NO. 5506)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors Contribution\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors participated in the preparation of the manuscript and approved the final version submitted. Mohammed A. Alnaim, Abdullah M. Al-Omair, Abdullah H. Alghamdi, Mohammed R. Aljuwair, and Faisal A. Alhadi contributed to the original draft\u0026apos;s Conceptualization, Methodology, and writing. Ali J. Alsaad reviewed and edited the manuscript and contributed to the supervision and project administration.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to express deep appreciation for all those who willingly contributed their time to this research. We also acknowledge the financial support for this research provided by the Deanship of Scientific Research at King Faisal University in Al-Ahsa, Kingdom of Saudi Arabia.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eChand SP, Arif H. Depression. StatPearls. Treasure Island (FL): StatPearls Publishing; 2022.\u003c/li\u003e\n\u003cli\u003eIbrahim AK, Kelly SJ, Adams CE, Glazebrook C. A systematic review of studies of depression prevalence in university students. Vol. 47, Journal of Psychiatric Research. 2013. \u003c/li\u003e\n\u003cli\u003eTiller JWG. Depression and anxiety. Med J Aust. 2013;199(6). \u003c/li\u003e\n\u003cli\u003eMonteleone P, Martiadis V, Maj M. Circadian rhythms and treatment implications in depression. Progress in Neuro-Psychopharmacology and Biological Psychiatry. 2011;35(7). \u003c/li\u003e\n\u003cli\u003eSatyanarayanan SK, Su H, Lin YW, Su KP. Circadian Rhythm and Melatonin in the Treatment of Depression. Current Pharmaceutical Design. 2018;24(22). \u003c/li\u003e\n\u003cli\u003eAlJaber M. The prevalence and associated factors of depression among medical students of Saudi Arabia: A systematic review. Journal of Family Medicine and Primary Care. 2020;9(6). \u003c/li\u003e\n\u003cli\u003eHammen C. Risk Factors for Depression: An Autobiographical Review. Vol. 14, Annual Review of Clinical Psychology. 2018. \u003c/li\u003e\n\u003cli\u003eAuerbach RP, Alonso J, Axinn WG, Cuijpers P, Ebert DD, Green JG, et al. Mental disorders among college students in the World Health Organization World Mental Health Surveys. Vol. 46, Psychological Medicine. 2016. \u003c/li\u003e\n\u003cli\u003eAuerbach RP, Mortier P, Bruffaerts R, Alonso J, Benjet C, Cuijpers P, et al. WHO world mental health surveys international college student project: Prevalence and distribution of mental disorders. Journal of Abnormal Psychology. 2018;127(7). \u003c/li\u003e\n\u003cli\u003eHysenbegasi A, Hass SL, Rowland CR. The impact of depression on the academic productivity of university students. Journal of Mental Health Policy and Economics. 2005;8(3). \u003c/li\u003e\n\u003cli\u003eArria AM, Caldeira KM, Vincent KB, Winick ER, Baron RA, O\u0026rsquo;Grady KE. Discontinuous college enrollment: Associations with substance use and mental health. Psychiatric Services. 2013;64(2). \u003c/li\u003e\n\u003cli\u003eKroenke K, Spitzer RL, Williams JBW. The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine. 2001;16(9). \u003c/li\u003e\n\u003cli\u003eKroenke K, Spitzer RL. The PHQ-9: A new depression diagnostic and severity measure. Vol. 32, Psychiatric Annals. 2002. \u003c/li\u003e\n\u003cli\u003eKroenke K, Strine TW, Spitzer RL, Williams JBW, Berry JT, Mokdad AH. The PHQ-8 as a measure of current depression in the general population. Journal of Affective Disorders. 2009;114(1\u0026ndash;3).\u003c/li\u003e\n\u003cli\u003eJamilah A, Haque MI, Muhammad F, Harun MG, Chowdhury AA, Akramuzzaman M, Arafat SY, Kabir R. Depression and associated factors among international students in a private university of Bangladesh. Global Psychiatry. 2020.\u003c/li\u003e\n\u003cli\u003eHosseinpur H, Parsa AD, Kabir R. The Prevalence of Depression and its Predictors among International Postgraduate Students Studying Public Health at a UK University. Journal of Psychosexual Health. 2023 Apr;5(2):94-101.\u003c/li\u003e\n\u003cli\u003ePoyrazli S, Mitchell MA. Mental health problems of US students studying abroad. Journal of International Students. 2020 Feb 15;10(1):17-27.\u003c/li\u003e\n\u003cli\u003eAmanvermez Y, Karyotaki E, Cuijpers P, Ciharova M, Bruffaerts R, Kessler RC, Klein AM, Wiers RW, de Wit LM. Sources of stress among domestic and international students: a cross-sectional study of university students in Amsterdam, The Netherlands. Anxiety, Stress, \u0026amp; Coping. 2023 Dec 5:1-8.\u003c/li\u003e\n\u003cli\u003eXiang G, Ahmad MI, Zhuang W, Rehman RU, Naseem MA. Depressive symptoms faced by non-native international medical students in China during COVID-19. Frontiers in Psychology. 2022 Nov 17;13:1037786.\u003c/li\u003e\n\u003cli\u003eMahihu C. Prevalence of Depression, Anxiety among International Students in the Health Professions at Southern Medical University, PR China. Open Journal of Social Sciences. 2020 Dec 16;8(12):161.\u003c/li\u003e\n\u003cli\u003eAlshammari MK, Othman MH, Mydin YO, Mohammed BA. The Effect of Social Isolation on the Mental Health of International Students. Inf. Sci. Lett. 2023; 12, No. 4, 1235-1240.\u003c/li\u003e\n\u003cli\u003eKabir R, Isha SN, Chowdhury MT, Siddika N, Jahan SS, Saha AK, Nath SK, Jahan MS, Sivasubramanian M, Mahmud I, Hoque Apu E. Depression among the non-native international undergraduate students studying Dentistry in Bangladesh. International Journal of Environmental Research and Public Health. 2021 May 28;18(11):5802.\u003c/li\u003e\n\u003cli\u003eHu YL, Roberts A, Ching GS, Chao PC. Moderating effects of intercultural social efficacy and the role of language in the context of coping strategies in study abroad depression. International Journal of Environmental Research and Public Health. 2022 Feb 19;19(4):2409.\u003c/li\u003e\n\u003cli\u003eHunley HA. Students\u0026apos; functioning while studying abroad: The impact of psychological distress and loneliness. International Journal of Intercultural Relations. 2010 Jul 1;34(4):386-92.\u003c/li\u003e\n\u003cli\u003eZhao B, Kong F, Nam EW. Assessing knowledge, preventive practices, and depression among chinese university students in Korea and China during the COVID-19 pandemic: an online cross-sectional study. InHealthcare 2021 Apr 8 (Vol. 9, No. 4, p. 433). MDPI.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"International university students, Depression, Saudi Arabia, prevalence, risk, factor, PHQ-8","lastPublishedDoi":"10.21203/rs.3.rs-4626304/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4626304/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDepression disorders are one of the most widespread mental disorders among college students. In university students, depression has been associated with lower academic performance, worse work performance, and increased dropout risk. his study aims to assess the prevalence of depression and highlight risk factors among Saudi international university students (IUS) in the United States (US), the United Kingdom (UK), and Australia.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSubject and methods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis cross-sectional study was conducted among Saudi students who chose to study abroad. A self-administered online questionnaire was sent to the students using an online survey. The questionnaire includes socio-demographic data (e.g., age, gender, specialty, etc.), medical characteristics, social status, and the Patient Health Questionnaire (PHQ-8) to assess the student's depression.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOf the 401 students, 52.4% were younger (age 18 – 25 years), and more than half were males (53.9%). \u0026nbsp;Most of the participants were studying in the US (46.6%), followed by the UK (40.6%) and Australia (12.7%). The rate of major depression among Saudi students studying abroad was 40.4%. In univariate analysis, major depression was influenced by age, marital status, specialty, personal and family history of mental illness, contact with family and friends, and feeling like a stranger. However, after conducting multivariate regression analysis, previous diagnoses of mental illness and feeling a stranger were identified as the significant independent risk factors for major depression.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study provides insights into the prevalence and risk factors associated with depression among \u0026nbsp;Saudi IUS. The prevalence of major depression among Saudi IUS was 40.4%. Previous history of mental illness and feeling like strangers were identified as the most prominent risk factors in this study. Identifying the prevalence and contributing factors of depression can guide academic institutions and governments in the development of effective interventions and support for IUS’s mental well-being. Future research could diversify the sample and employ longitudinal designs.\u003c/p\u003e","manuscriptTitle":"Depression Among Saudi International University Students and Its Associated Risk Factors.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-18 22:18:53","doi":"10.21203/rs.3.rs-4626304/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-09-27T10:50:45+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-23T06:05:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"275892154025044622164367260088600407930","date":"2024-08-18T02:41:04+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-15T11:52:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"206165011592024361525344684252853878098","date":"2024-08-05T07:41:43+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-08-02T16:52:04+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-06-25T05:29:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-24T07:00:25+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-06-24T06:59:15+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2024-06-23T18:51:22+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5f9fca46-3431-4917-939f-df91b575e143","owner":[],"postedDate":"July 18th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-11-18T16:00:25+00:00","versionOfRecord":{"articleIdentity":"rs-4626304","link":"https://doi.org/10.1186/s12889-024-20565-y","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2024-11-11 15:57:12","publishedOnDateReadable":"November 11th, 2024"},"versionCreatedAt":"2024-07-18 22:18:53","video":"","vorDoi":"10.1186/s12889-024-20565-y","vorDoiUrl":"https://doi.org/10.1186/s12889-024-20565-y","workflowStages":[]},"version":"v1","identity":"rs-4626304","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4626304","identity":"rs-4626304","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}