Prevalence of Adjustment Disorder and Its Predictors Among First- and Second-Year Medical Students in Madinah, Saudi Arabia

Background The first years of college, notably the first and second, are challenging and time-intensive, frequently characterized by substantial pressure that can lead to dissatisfaction among new students. Such an environment may precipitate adjustment difficulties, potentially resulting in depression, anxiety, and stress. This phenomenon is particularly pronounced among medical students. Despite the widespread nature of these challenges, research focusing on the prevalence of adjustment disorder among medical students in Madinah, Saudi Arabia, is notably scarce in the literature. This study aims to evaluate the prevalence and identify predictors of adjustment disorder among a substantial cohort of first- and second-year medical students in Madinah. Methodology An institution-based, quantitative, cross-sectional study was conducted from April 2022 to August 2022. The study encompassed a total of 273 first- and second-year medical students from the Madinah region. To measure stressor exposure and symptoms of adjustment disorder, the Adjustment Disorder-New Module 20 (ADNM-20) scale was employed. Results Our study, comprising 273 participants from Taibah University and Al-Rayan Colleges, revealed a higher prevalence of adjustment disorder among Al-Rayan students: 54.8% (n = 63) compared to their counterparts at Taibah University 41.8% (n = 66), with a p-value of 0.033. However, no significant association was found with other demographic factors. Utilizing the ADNM-20 questionnaire, the study identified prevalent symptoms of adjustment disorder among participants. Key findings included 47.6% (n = 130) of participants feeling low and sad, 41% (n = 112) experiencing repetitive stressful thoughts, approximately one-third (n = 81) exhibiting avoidance behaviors and intrusive thoughts, 38.1% (n = 104) reducing enjoyable activities, 29.3% (n = 80) encountering increased anxiety, 30% (n = 80) reporting irritability, 31.1% (n = 85) facing concentration issues, 23.4% (n = 64) having sleep disturbances, and 28.2% (n = 77) observing impacts on personal and leisure activities. Conclusions The study concludes that adjustment disorder is prevalent among new university students, particularly at Al-Rayan University, where it manifests in various symptoms including mood disturbances and anxiety.


Introduction
Transitioning from high school to college constitutes a significant, stressful, social, and psychological event for first-year students [1].While entering college is generally regarded as a positive milestone, it can challenge an individual's sense of personal security, physical comfort, and capacity for enjoying gratifying activities [2].The initial years at the university, particularly for medical students compared to other specialties, are notably challenging.These years demand a heightened effort from students to adapt to psychological pressures.Adjustment is a psychological process that aids in managing stress and is crucial for enhancing students' academic performance [3].
In the college environment, students encounter developmental challenges in unfamiliar and often demanding situations.The initial stages of this transition, especially the struggles faced by first-year students, are emphasized in research, as noted by Bruffaerts et al. (2018) [4].How students respond to these stressors can have significant and long-term consequences [5].Adjustment disorder, as defined by the Diagnostic and Statistical Manual of Mental Health 5, is the development of emotional or behavioral symptoms in response to an identifiable stressor occurring within three months of the onset of the stressor [6].Among university students, it can stem from numerous factors impacting mental health, particularly within the first three months of exposure to stress.Key factors, as identified by prior research, include separation from family and friends, changes in the living environment, difficulties in forming new friendships, emotional and financial crises, health concerns, and challenges in time management [7].Studies among young adults indicate that those living with their parents are less prone to emotional issues and tend to have behaviors more influenced by parental guidance [8].Recently, the COVID-19 pandemic has emerged as a factor exacerbating adjustment disorders among medical students [9].These factors can deteriorate students' academic performance and mental health, increasing their susceptibility to anxiety, stress, and depression [3].Despite the prevalence of these issues, there is a notable dearth of research on this topic in Saudi Arabia.Consequently, this study aims to assess the prevalence of adjustment disorder and its associated factors among university students.

Materials And Methods
This study was designed as an observational cross-sectional study conducted among first-and second-year medical students at Taibah University and Al-Rayan University in Madinah, Saudi Arabia.It excluded medical students from other years and first-and second-year medical students not located in Madinah.Data collection occurred from April to August 2022.
Ethical approval was granted by the Scientific Ethical Committee at Taibah University.Participants were informed of the voluntary nature of their involvement, with assurances of confidentiality, and that responses would be used solely for scientific purposes.They were given the option to consent or to decline participation.
The combined student population at both universities for the two years totaled 573.Using the OpenEpi sample size calculator [10], we determined that a sample size of 231 was necessary, accounting for a 5% margin of error and a 95% confidence level.To accommodate potential non-responses, this number was increased by 20%, resulting in a total of 277.
The questionnaire was distributed via the colleges' WhatsApp groups, inviting students to participate in a voluntary web-based survey.Consent was obtained before participation, and we received 273 responses out of 573 students through Google Forms, with a response rate of 48%.
The questionnaire comprised two main sections.The first section included sociodemographic factors (age, gender, academic year, marital status, living situation, and monthly income).The second section utilized the Adjustment Disorder-New Module 20 (ADNM-20) scale, a psychological assessment tool validated by Glaesmer et al. [11].This self-administered instrument consists of two parts, namely, a list of acute and chronic life events from the past two years, and items assessing symptoms related to the most significant of these events.The scale facilitates a comprehensive assessment of stressors and their psychological effects.
Comprising 20 items, it was used in its original English format, as participants are proficient in English due to their English-based educational curriculum.For this study, 10 relevant stressors were selected, i.e., divorce or separation, family conflict, illness in the family, death of a loved one, academic overload, deadline pressures, relocating, financial difficulties, personal illness, and ceasing a key leisure activity.The symptom section of the questionnaire includes 20 questions, categorized into core symptoms (preoccupation with four items, failure to adapt with four items) and accessory symptoms (avoidance with four items, depressive mood with three items, anxiety with two items, and impulse disturbance with three items).Participants rated the frequency of their reactions to the stressors on a scale from 1 (never) to 4 (often) and noted the duration of these reactions, ranging from less than a month to up to two years.Of note, in the questionnaire and results table, the years were referred to as second and third because of a preparatory year before enrolling in medical college.Therefore, the second and third years of university education correspond to the first and second years of medical college.
We performed a pilot study involving 10 students, randomly selected from two universities.The primary aim of this preliminary study was twofold: first, to verify the clarity, specificity, and neutrality of the demographic questions we developed; and second, to ascertain the time participants would typically require to complete the questionnaire.This questionnaire was disseminated to the participants via WhatsApp.Feedback was meticulously gathered from each of the 10 participants individually.It is important to note that the data obtained from this pilot study were not included in the final analysis of our main study, as their primary purpose was to fine-tune our research tools and procedures.During this pilot phase, none of the participants raised significant concerns or offered substantial comments about the questionnaire, suggesting its initial effectiveness and suitability.To enhance the credibility of this pilot phase, a consultant psychiatrist oversaw the process, lending their expertise to ensure both the face validity and accuracy of the pilot study.We did not deem it necessary to conduct further validity tests.This decision was underpinned by our use of a scale that had already been validated, thus providing a strong foundation of reliability for our research instrument.
After data collection, it was checked for accuracy, completeness, and consistency.The data were then coded The data are represented as N with its corresponding %.
The demographic characteristics of the participants revealed that a significant proportion, 34.1% or 93 individuals, were aged 18 to 20, while the majority, 64.1% or 175 respondents, fell within the 21 to 23 age brackets, and a minor segment, 1.8% or five participants, were 24 years or older.Regarding gender distribution, females represented 60.1% with 164 respondents, while males comprised 39.9% with 109 respondents.Regarding academic standing, 59.3% or 162 respondents were third-year students, whereas 40.7% or 111 were in their second year.A predominant majority, 99.3% or 271 participants, were unmarried, contrasting with a mere 0.7% or two respondents who were married.Residential patterns indicated that most, 89.4% or 244 respondents, resided with family, while 8.4% or 23 lived independently, and a small fraction, 2.2% or six, stayed on campus.In terms of monthly income, a vast majority, 90.8% or 248 students, reported earning below 5,000 Saudi Riyals, whereas a smaller proportion, 9.2% or 25 students, earned between 5,000 and 10,000 Saudi Riyals, as detailed in Table 1.The data are represented as N with its corresponding %.

Adjustment disorder results among our sample
Of the participants, 129 (47.3%) were identified with adjustment disorder, while 158 (52.7%) did not exhibit the disorder (Figure 2).

FIGURE 2: Prevalence of adjustment disorder among participants.
The data are represented as n with its corresponding %.
In our study, the personal narratives of the participants painted a vivid picture of the challenges they faced.A substantial 79.1% (216 participants) shared their struggles with the overwhelming demands of their academic workload.For 40.3% (110 participants), the race against time to meet pressing deadlines was a significant source of stress.The complexities of family dynamics were not far behind, affecting 30% (82 participants) who navigated through family conflicts.Financial constraints posed a concern for 24.2% (66 participants), underscoring the often-overlooked economic pressures faced by students.The emotional toll of illness of loved ones was a reality for 20.5% (56 participants), highlighting the intersection of personal life and academic responsibilities.The grief of losing loved ones was an unfortunate reality for 14.3% (39 participants), a poignant reminder of the personal losses that often go unseen in academic settings.The need to sacrifice cherished leisure activities was felt by 12.8% (35 participants), illustrating the trade-offs students make in pursuit of their studies.Life transitions, such as moving to a new home, presented challenges for 11.7% (32 participants), while dealing with personal health issues was a concern for 8.8% (24 participants).Furthermore, navigating the emotional landscape of divorce or separation was a challenge faced by 6.6% (18 participants), highlighting the diverse and complex issues that university students encounter (Figure 3).The data are presented as a percentage above the columns with its number below the column.

Factors related to adjustment disorder
In our exploration of factors related to adjustment disorder, we discovered a notable trend tied to the educational institutions of the participants.At Al-Rayan University, students faced a considerably higher incidence of adjustment disorder, with 54.8% (n = 63) reporting such challenges, in contrast to 41.8% (n = 66) at Taibah University (p = 0.033).This finding points to the unique environments of different colleges influencing student well-being.However, when considering other factors such as age, gender, academic year, marital status, living arrangements, and monthly income, there was no significant link with the likelihood of experiencing adjustment disorder, as detailed in  The data are represented as n with its corresponding %.
P-value is considered significant at <0.05.
Concerning participant responses to the ADNM-20 questionnaire, Table 3 presents a comprehensive list of all identified stressful events, along with the frequency of their occurrence in the sample.

273).
The data are represented as n with its corresponding %.
Regarding the frequency of symptoms, a considerable proportion of participants frequently reported symptoms associated with adjustment disorder.Notably, 47.6% of respondents occasionally experienced feelings of sadness and low mood (Q1), and 41% intermittently dwelled on the stressful situation (Q2).This reflects a moderate level of distress among a significant segment of the participants.
Regarding avoidance and intrusive thoughts, the data revealed a prominent pattern in avoidance behaviors and intrusive thoughts.In response to Q3, 31.1% of participants occasionally tried to avoid discussing the stressful situation, while 34.1% often did so.Similarly, Q4 responses indicated that 37.4% occasionally were plagued by persistent thoughts about the stressor.These findings highlight a widespread struggle with avoidance and intrusive thoughts.
Regarding the impact on enjoyment and anxiety, responses to Q5 and Q6 demonstrated a substantial effect on leisure activities and an increase in anxiety.Specifically, 38.1% of participants engaged less in previously enjoyable activities, and 29.3% frequently felt anxious about the stressful situation.
The duration of symptoms varied among respondents.For most items, the majority reported experiencing symptoms for less than a month.However, a considerable number experienced symptoms for longer periods, underscoring the potential chronic nature of adjustment disorders.
Regarding irritability and concentration issues, there were notable reports of increased irritability (Q12) and difficulties with concentration (Q10), with 30% and 31.1% of participants occasionally encountering these issues, respectively.This suggests that adjustment disorder can markedly impact emotional regulation and cognitive function.
Concerns regarding sleep disturbances (Q19) and the impact on personal relationships and leisure activities (Q20) were also significant.A total of 33.3% experienced sleep-related issues and 28.2% observed a pronounced effect on their personal and leisure lives.

Comparison of participants' experience with stressful events across colleges
A similar pattern of stressful events was observed between the two colleges, corresponding to the general pattern of stressful life events with no significant differences between participants from either institution.The sole exception to this was financial problems, where a notable disparity emerged.Participants from Al-Rayan Colleges reported a significantly higher incidence of financial difficulties compared to those from Taibah University (30.4% vs. 19.6%,p = 0.039), as illustrated in Figure 4.

FIGURE 4: Comparison of participants' experience with stressful events across college.
The data is represented as a percentage above the column with its corresponding number within the same column.

Discussion
As previously established, the path to medical education and health-related professions is incredibly stressful, particularly for recent high school graduates (first-and second-year medical students) [12].The training involves various stressors, such as adapting to a high workload within limited timeframes, learning a new language for non-native speakers, familiarizing with medical terminology, memorizing vast amounts of information, frequent evaluations, peer competitiveness, financial constraints, and limited time for recreation and social relationships [13].Consequently, medical students, especially in their first and second years, face a heightened risk of psychological distress and illness, struggling more to adjust to these stressors compared to non-medical peers [13][14][15][16].Prolonged stress can lead to various mental illnesses, including depression, anxiety, and adjustment disorder [17,18].According to the International Classification of Diseases 11th Revision, adjustment disorder is a maladaptive reaction to identifiable psychosocial stressors, typically occurring within a month of the stressor [19].While outside the scope of our study, research indicates that patients with adjustment disorder are more prone to substance abuse and impulsive behaviors [20], with an increased risk of suicidal acts, particularly among adolescents [21][22][23].
The prevalence of adjustment disorder among first-and second-year medical students in this survey was 47.3%, highlighting significant psychological distress and low resilience against stressors.This rate is consistent with other studies among university students.For example, studies in Ethiopia reported adjustment disorder rates of 42.5% and 48% among first-year undergraduate students at Dilla and Jimma Universities, respectively [7,24].Additionally, a study at Gulf University in Bahrain found a 36.8%prevalence of adjustment disorder among medical students, particularly first-year students [25].Similar trends were seen in North Jordan and Malaysia, with rates of 42.8% and 50%, respectively [26,27].However, a study in Riyadh reported a lower rate of 21.3%, possibly due to early-year assessments before exposure to significant stressors [28].A more comprehensive, nationwide survey across all universities and colleges in Saudi Arabia is necessary for a more accurate assessment of adjustment disorder.
In this study, the most reported stressors were excessive studying (79.1%), pressure and difficulty meeting deadlines (40.3%), financial issues, illness in loved ones, and bereavement (24.2%, 20.5%, and 14.3%, respectively).These findings align with a study from Riyadh, Saudi Arabia, among first-year medical students, but contrast with a study at Duhok University in Iraq, where personal illness or that of a loved one and family conflicts were the main stressors [28,29].The similarities with Riyadh and differences with Iraq may be attributed to shared cultural, social, and environmental values.
In this survey, the only significant factor associated with adjustment disorder was the participant's college.
Students from Al-Rayan University had a higher rate of adjustment disorder compared to Taibah University, potentially linked to greater financial challenges at Al-Rayan.Conversely, a study in Riyadh found gender to be a significant predictor, with female students at higher risk [28].Age did not show a significant association with AD in this study, aligning with findings from King Saud University that indicated an inverse relationship between age and adjustment disorder risk, emphasizing the vulnerability of younger medical students [28].

Strengths and limitations
This contribution of this study is significant, focusing on a crucial issue impacting the mental health of aspiring doctors.It appears to fill a notable gap in the current body of research, as there seems to be a scarcity of studies addressing the prevalence of adjustment disorder among early-year medical students, both in Saudi Arabia and globally.By examining this specific demographic in the Madinah region, our research adds valuable insights to the literature on their psychological health and adjustment disorder prevalence.Nonetheless, it is pertinent to note certain limitations, including the methodology, involving a cross-sectional design, and self-report questionnaires, which might somewhat limit the precision of our findings.

Conclusions
Adjustment disorder was prevalent in our sample, and even more so among students at Al-Rayan University.
Our sample exhibited various symptoms, such as mood disturbances and anxiety.These findings advocate for further research to understand the causes of this prevalence in student groups, as well as to enhance prevention and treatment methods.

Second part
Below is a list of stressful life events.Please indicate those events that happened during the past year and are currently a strong burden to you, or have burdened you in the last six months.You can indicate as many events as applicable.

Third part
In the following, you will find various statements about which reactions these types of events can trigger.In the first step, we ask you to indicate how often the respective statement applies to you ("never" to "often").
In the second step, we would like to ask you to indicate how long you have been having this reaction.It can be less than one month (<1 month), for approximately one month to half a year (<6 months), or longer than 6 months (>6 months).
This will probably not be very easy to estimate, but please try to give a rough classification of the duration of the reaction.

Question
Frequency in the last week Duration of complaint

Questionnaire to assess the
prevalence of adjustment disorder and its predictors among first-and second-year medical students in Madinah,

10 .
Termination of an important leisure activity

Human subjects:
Consent was obtained or waived by all participants in this study.Research Ethics Committee, College of Medicine, Taibah University, Ministry of Education, Kingdom of Saudi Arabia issued approval STU-21-030.Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue.Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: Statistical analysis was assessed by a third party (an authorized Freelancer Data Analyst by the Ministry of Human Resources and Social Development, Saudi Arabia (authorized document ID: c07c9057)).Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work.Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.