Obsessive-compulsive Symptoms Prevalence among Medical Students in Four Major Universities, Saudi Arabia: A Cross-Sectional Study

1. INTRODUCTION

The World Health Organization (WHO) regards Obsessive-compulsive Disorder (OCD) as one of the top 10 most disabling disorders [1]. OCD is characterized by both obsessions and/or compulsions. Compulsions and obsessions can consume significant time, severely disrupting various aspects of life, including daily tasks, education, employment, career development, and social relationships [2].

According to The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), obsessions are recurrent and persistent thoughts, urges, or images that are experienced as intrusive and unwanted. When experienced, such anxious thoughts can be relieved by performing some acts known as compulsions. Compulsions are repetitive behaviors or mental acts that an individual feels driven to perform according to rules that must be applied rigidly [3]. Obsessions are ego-dystonic, meaning that individuals recognize them as irrational thoughts that are inconsistent with their beliefs. They can involve many themes, including fear of contamination, symmetry, or religion. Compulsions, on the other hand, are unenjoyable acts that can be behavioral acts, such as checking whether the door is closed, or a mental act, like counting to a certain number [2]. Merely, the presence of obsessions and/or compulsions is not enough to establish a diagnosis of OCD. They must be time-consuming, causing marked distress, and interfering with one’s routine, functioning, or social life [3]. For example, in a study involving high school students, out of 2,323 participants, approximately 18.3% exhibited Obsessive-compulsive Symptoms (OCS). However, only 3.3% received a diagnosis of OCD [4].

The lifetime prevalence of OCD is estimated to be 2.3%. The mean age of onset of OCD is 19.5 years. Co-morbidities with other psychiatric disorders are highly common, affecting about 90% of individuals. The most common co-morbid conditions are anxiety disorders (75.8%), followed by mood disorders (63.3%) [5]. In Saudi Arabia, the lifetime prevalence of OCD is estimated to be 4.2%, with the mean age of onset being 16.8 years [6].

Medical students have a higher burden of psychological stress, depression, and anxiety compared to the general population in different countries. Many factors, including academic pressure, workload, sleep deprivation, and exposure to patients, have been hypothesized to contribute to poor mental health among medical students [7]. Studies conducted among medical students in Saudi Arabia have shown a higher prevalence of OCD compared to the general population. For instance, a study conducted in 2021 at Taibah University in Madina found that 26% of medical students had probable OCD [8]. Similarly, a research study conducted among medical students at Al Imam Mohammad Ibn Saud Islamic University in Riyadh in 2020 reported a prevalence of probable OCD at 36.2% [9]. Additionally, a study conducted in 2019 at Umm Al-Qura University on female students at the College of Applied Medical Sciences revealed a prevalence of OCS of 20%, with confirmed cases of OCD having a prevalence of 5.06% [10]. Given the heightened prevalence observed within the medical field, particularly among medical students, there is a pressing need for more extensive investigation. Therefore, this study aimed to explore the prevalence of OCS among undergraduate medical students in four major universities in the Kingdom.

2. METHODS

3. RESULTS

Within the complete sample (n=886), gender distribution was nearly equal, with 48.9% male and 51.1% female representation (Table 1). The predominant demographic characteristics included a high proportion of Saudi nationals (98.4%), unmarried individuals (96.4%), and those residing with their families (86.8%). Conversely, 9.3% lived independently, and a mere 4% shared residences with friends or peers. Regarding monthly household income, which was converted from Saudi Riyal to United States Dollar (USD), more than half of the participants reported incomes on the higher spectrum, with 26.1% indicating 2661-5323 USD and 39.2% reporting an income of ≥5323 USD. In terms of university affiliation, a notable percentage of medical students originated from KFU (29.5%) and IAU (27.7%), followed by KAU students (24.5%), and lastly, KSU (18.4%). Lastly, the prevalence of OCD among medical students, as determined by an OCI-R score of ≥21, was 46.4% (411 students), while 53.6% (475 students) scored below this threshold.

Table 2 shows the median OCI-R score and IQR across the subgroups of sociodemographic, academic, and clinical variables. The median OCI-R score for the overall sample was 19, with an Interquartile Range (IQR) of 11 to 32. Notably, the sociodemographic variables of nationality and marital status showed non-significant differences with p-values of 0.35 and 0.53, respectively, whereas living situation approached significance with a p-value of 0.06. On the other hand, there was a significant gender difference in OCI-R median score (p < 0.01) as females exhibited a higher median score (21, IQR: 12-34) compared to males (17, IQR: 10-30). As per household income, there was a significant association with a higher median OCI-R score shown by those belonging to the 1330-2661 USD income level (p = 0.01). Variables related to the university of study and academic life were all found to be significantly associated with the median OCI-R score (p < 0.05). The highest OCI-R scores were found among those studying at KAU and students who found it difficult to adjust to the new academic year with OCI-R scores of 22 (IQR: 13-35) and 24 (IQR: 14-36), respectively. Satisfaction with academic performance was inversely associated with the OCI-R score. Students who were very unsatisfied with their academic performance had the highest score (27.5, IQR: 19-36; p<0.01). Similarly, students with academic setbacks who needed to repeat any academic year had a higher OCI-R (24, IQR: 13-34.5; p=0.04). Lastly, participants with a family history of OCD and those who had a history of psychological illness reported significantly higher OCI-R scores (28, IQR: 15-38 and 24.5, IQR: 15-36), respectively.

In Table 3, fully adjusted estimates of the multivariate analysis are displayed, examining the association between the different variables and the outcome of the OCI-R score. Age was inversely associated with the OCI-R score, decreasing to 1.92 for each additional year (95% CI: -2.42 to -1.41; p < 0.01). Females tended to have 1.86 more OCI-R units compared to male participants (95% CI: 0.13 to 3.59; p < 0.05). Living situation and household income seemed to have no significant influence on OCI-R scores, except for individuals earning 1330-2661 USD, as they showed an increase in OCI-R scores by 3.1 (95% CI: -1.06 to 7.62, p < 0.05) compared to individuals earning less than 1330 USD. Concerning university affiliation, it influenced OCI-R scores. Compared to students attending IAU, students from KSU and KAU showed significantly higher OCI-R scores by 2.8 (95% CI: 0.26 to 5.35; p < 0.05) and 5.54 (95% CI: 3.15 to 7.94; p < 0.01), respectively. Having “somewhat difficulty” in adjusting to the new academic year showed a significant decrease in the OCI-R score by -2.85 (p<0.01). As a gradient effect was observed, satisfaction with academic performance appeared to be a crucial factor. Increasing satisfaction was inversely associated with OCI-R score, where “very satisfied” students appeared to have the most significant decrease in OCI-R score by 8.59 units (95% CI: -12.71 to -4.47; p < 0.01). Lastly, a positive family history of OCD and prior psychological illness seemed to be positive contributors to increasing OCI-R scores by 3.76 (p <0.05) and 3.21 (p <0.01), respectively. Upon assessing the interaction between female gender and living situation, it was found that females living alone (compared to females living with family) had OCI-R scores that were, on average, 10.10 points higher (β = 10.10, 95% CI: 3.93–16.27, p = 0.001) compared to their counterparts.

4. DISCUSSION

This study aimed to assess the prevalence and factors associated with OCS among medical students across four major universities in Saudi Arabia. The findings revealed a considerable prevalence of OCS within this population, underscoring the heightened vulnerability of medical students to mental health challenges. This was also evident in a Canadian cross-sectional study showing that medical students had significantly higher rates of psychiatric disorders and psychological distress compared to the general population of the same age [15]. Out of the 886 medical students who participated in our study, 411 (46.4%) scored above 21, indicating probable OCD according to the OCI-R score. This prevalence has been found to be consistent with other studies performed at different medical colleges in Saudi Arabia [8, 9].

Our findings generally showed a higher prevalence compared to other studies conducted locally and internationally. A study at Taibah University in Saudi Arabia reported that 26% of participants had probable OCD using the OCI-R [8]. Another Saudi study in Riyadh found a prevalence of 36.2% [9]. In comparison, a study by Yoldascan et al. (2009) found a prevalence of OCD of 29.9% among Turkish university students [16]. Interestingly, a Brazilian study that applied a higher cutoff score (>27 points) reported a significantly lower prevalence of 3.8% [17]. Additionally, an earlier study from the United States, using a different scale (LOI-SF) with a cutoff of 28.4, found a prevalence of 5.2% among medical students [18]. The lower prevalence found by the two studies could be explained by the use of different cutpoints or scales; however, they both reported the prevalence to be significantly higher compared to the general population, indicating medical students to be at a high risk of developing OCD globally [17, 18]. The differences between populations could also be influenced by the various cultural factors, academic pressures, or educational environments across these populations.

Our study found a significant gender difference in the mean OCI-R score, as females averaged 1.86 points higher than males after adjusting for other factors (p < 0.05). Specifically, females had a mean score of 21, which reached the clinical threshold for OCD, compared to males, with a mean score of 17. This finding was consistent with a study conducted in Riyadh assessing the prevalence of OCD among medical students in which there was a statistically significant higher prevalence among females [9]. This may be probably due to the fact that female medical students are more prone to anxiety and depression, both closely tied to OCD [19]. It might be also related to hormonal fluctuations and the pressure to achieve perfectionism in medical school, further increasing their vulnerability to OCS. Contrastingly, other studies conducted in various countries have reported no significant gender difference, while some others have found a significant positive association between OCD and males [16, 17, 20, 21]. These findings suggest a large variation in OCD and OCS across different populations and demographics.

Although the mean age of onset of OCD is 16.8 years in Saudi Arabia, our study also revealed an inverse relationship between age and OCI-R score. This indicates that younger medical students may experience more pronounced OCS, possibly due to the stress of starting medical school. This decrease in the level of stress through the years was highlighted in a study assessing the prevalence of stress among medical students in Saudi Arabia [22]. This was supported by Taher et al., who also found OCS to be significantly related to younger age and earlier years of study among Iraqi medical students [23]. However, this contrasted with the results of Khalaf et al., Sultan et al., and Alsubaie et al., who did not find a significant age-related difference [9, 10, 13].

When looking at the relationship among OCD, age, and gender, the literature was found to show interesting patterns. Studies that looked at age of onset showed that OCS often occurs during childhood, with clinical OCD typically appearing in early adulthood [24]. The majority of cases were reported to occur by the age of 20, with few new cases after 30 years [25]. Age also appeared to relate to gender differences. Several childhood OCD studies reported a higher prevalence among males, while adult samples often exhibited equal or higher prevalence among females [25-27]. For example, a study in Switzerland reported a cumulative prevalence of 5.3% for females compared to 1.7% for males, and studies among adolescents found higher rates of OCS among females [27]. Such differences may stem from biological factors, such as hormonal influences, or sociocultural dynamics, including differing expressions of distress and societal expectations across genders. Moreover, males have often been noted to have a younger age of onset, associated with more severe and chronic presentations of OCD [28].

Furthermore, those with a family history of OCD showed a significantly higher mean OCI-R score. This was in line with the literature, suggesting OCD to have familiar aggregation and partially due to genetic factors. Studies on twins and families have been found to be compelling that genetics have a great impact on OCD [29]. For example, family studies have revealed a prevalence of 7%-15% of OCD in first-degree relatives. Also, twin studies have found concordance of 80% and 50% in monozygotic and dizygotic twins, respectively, suggesting OCD to be significantly impacted by genetics [30]. Additionally, this may also be attributed to behavioral modeling, where a child imitates his/her strict parents' behaviors and internalizes the high expectations placed upon him/her [31]. Such environments can reinforce obsessive-compulsive tendencies, as the child learns to adopt rigid patterns of behavior in an attempt to meet these demanding standards. However, two studies found no significant association between family history of OCD or psychiatric illness to OCD, possibly due to demographic or environmental differences, as well as a smaller sample size. In addition, a personal history of other psychiatric diseases was found to have a significant association with higher mean OCI-R scores. This finding was observed to align with numerous studies that have previously seen a significant relationship between OCD and depressive disorders and symptoms [10, 17, 32].

Another statistically significant variable associated with a higher mean OCI-R score was a household income of 1330-2661 USD compared to the reference group of <1330 USD. Interestingly, this was inconsistent with the existing literature, where several studies did not find a significant association between economic situation and OCD [17, 33]. In the Household Income and Expenditure Survey (2018) conducted by the General Authority for Statistics (GASTAT), the average monthly income of Saudi households was reported to be 3,950 USD [34]. This might suggest that the identified income range represents a segment of households earning below the national average, potentially reflecting unique socioeconomic factors specific to this group that could negatively influence OCD, warranting further investigation.

Participants in our study did not show a significant difference in OCS based on their living situation. This aligned with previous literature as Sultan (2021), Torres et al. (2016), and Özdemir (2016), all reported no significant association between OCS and living situation [10, 17, 20]. In contrast, Yoldascan et al. (2009) found significant associations between OCD and living in government dormitories, students’ or parental houses, and having a private room in the parental home [16]. In contrast to these broader patterns, our study highlighted a novel interaction: living situation can amplify the relationship between female gender and risk of OCD. Specifically, the impact of living alone, as opposed to living with family, was more pronounced among females than males, with the difference being 10 points higher for females when considering the interaction term (β = 10.10). This interaction highlighted that the dynamics of living alone may uniquely affect women. Also, this gender-specific interaction added to how living environments can shape mental health and suggested that targeted support strategies may be beneficial for female medical students.

Moreover, it was found that finding it somewhat difficult to adjust to the new academic year was significantly associated with lower OCI-R scores. Different results were found in the studies carried out by Torres et al. and Khalaf AM et al., although the association was not significant [17]. The options for this question in the survey were “easy”, “somewhat difficult”, and “difficult”, differing from the “yes” and “no” approaches used in these studies. This may explain the difference in results. It showed a significant association with lower OCI-R scores regarding satisfaction with academic performance. Similar, although not significant, results were found in the literature [9, 10, 17]. For this question, a scale of 5 options from “very unsatisfied” to “very satisfied” was used. It showed that OCI-R scores followed this scale, with higher scores for unsatisfaction and lower scores for satisfaction, and “very satisfied” showing the lowest score. This also differed from the “yes” and “no” approach used in the literature. Significant associations of higher OCI-R scores were also found with academic year repetition and being from KAU and KSU. However, these factors were not found to be explored in previous literature.

CONCLUSION

In conclusion, this study has highlighted a significant prevalence of OCS among medical students in Saudi Arabia, with nearly half of the participants showing probable OCD based on the OCI-R scale. Several factors have been identified as key predictors of OCS severity, including gender, age, family history of OCD, and psychiatric comorbidities. Female medical students have exhibited higher mean OCI-R scores than males, and younger students have reported more pronounced symptoms, indicating the need for targeted mental health support for these groups. Additionally, a family history of OCD and psychiatric illnesses has been significantly associated with higher OCS scores, reinforcing the genetic and environmental influences on OCD development. Academic satisfaction has also emerged as an important factor, with lower OCI-R scores observed among students being more satisfied with their academic performance. This finding has highlighted the potential link between academic well-being and mental health outcomes, emphasizing the need for interventions that support both academic and emotional health. While living situations have not shown a significant association with OCS in our sample, difficulties adjusting to a new academic year and repeating an academic year have been associated with higher OCI-R scores.

REFERENCES