Correspondence:
Mostafa Amr
Lecturer of Psychiatry,
Departement of Psychiatry,
College of Medicine, Mansoura University,
Mansoura 35516
Egypt
E-mail: mostafapsy@yahoo.com

The topic of stress among college or university students has been the subject of much research for many years. Researchers have found that the perception of high stress levels in students can lead to poor academic performance, depression, attrition and serious health problems^[1-3].

Medical school can be a very stressful environment for students. A variety of sources of stress have been identified. These include, among others, the academic pressures, social pressures and financial problems^[4]. Other studies suggested that high levels of stress and psychiatric morbidity are not limited to medical students but occur also among law students^[5].

Many students experienced stress as they pursue a law degree^[6]. Archer and Peter^[7] suggested that much of this excessive stress may have its origins in law school. The Socratic method of teaching, high expectations, competitive environment, heavy work load, final examinations, social isolation, and family tension have been identified as stressors, though they are not necessarily ranked in that order. The effect of profession on stress in students varies. While some studies suggested that medical students have a higher level of stress than their law counterparts^[5], other studies do not reveal such differences^[8]. There are also suggestions that profession may influence the way medical students perceive stress^[9]. To the best of authors' knowledge no similar comparative studies were done in Egypt, where the situation appears to be different.

The objectives of the study were to:
(1) assess the level of perceived stress of medical and law undergraduates
(2) identify common sources of stress in their lives
(3) assess the psychiatric disorders such as anxiety and depression
(4) observe any association between the high level of stress and sociodemographic profile.

Participants
This is a comparative study between medical and law students in Mansoura University, Egypt, conducted during October and December 2007 G. Filled questionnaires were collected one month before the first term examination period so as to minimise the extra stress symptoms. The undergraduate medical course is six years with the fourth to sixth years consisting of clinical training along with didactic courses, while the law course is didactic courses of four years. Written approval was obtained from the authorities of both colleges to conduct the survey in the setting. There is no research ethical committee at the moment in our university. After obtaining this approval for data collection the researchers introduced themselves to the students in each grade and informed them about the aim of the study and about guarantees of anonymity and confidentiality and the need for verbal consent. The students were allowed to respond in their own time and privacy. The participation was entirely on a voluntary basis. All students who agreed to participate were given questionnaires; all incomplete questionnaires were excluded. A total of 620 (283 medical, 277 law) students who provided complete questionnaires were involved in the study, representing 4.1% and 2.9% of the enrolled students in both colleges, respectively.

Study tools
Participants were given a packet with three Arabic instruments used and validated in previous studies^[10-12]. The first instrument enquires about sociodemographic and sources of stress during the past year. The second is Perceived stress levels, which were measured by Cohen's Perceived Stress Scale. The third instument is the hospital anxiety and depression scale.
Sources of stress include 15 items divided into 4 categories of potential sources of stress:
3 items representing relationship sources of stress,
5 representing personal sources of stress,
5 representing academic sources of stress, and
2 representing environmental sources of stress.

In respect to the research question '' what are the greatest stressors in the last year". The time frame of 12 months was deliberately chosen based on the assumption that a 12-month period is long enough to obtain a reasonable estimate of variation in exposure to recent life events, and short enough to avoid inaccurate recall and perception of the events^[13]. Students were asked to list the four categories of stress viz, relationship, personal, academic, and environmental situations or conditions that they found were most stressful. The four categories and the fifteen items were developed from the responses given by students. Student responses were placed into the categories by a psychatrist and a psychologist working independently. The raters agreed upon 85% of the categorisations.

Relationship sources result from interactions with other people, such as trouble with course mates; personal sources result from internal sources such as personal injury or illness or death of a family member. Academic sources arise from college related activities such as relationship with the instructor. Environmental sources result from problems in the environment outside the academics such as accommodation problems.

Stress was measured by a previously validated 14-item perceived stress scale (PSS). Cronbach coefficient of internal consistency was reported to be 0.85, and test-retest reliability during a short retest interval (several days) was 0.85^[14] and the Arabic version was tested among a sample US Arab immigrants^[11]. The PSS does not tie appraisal to a particular situation; it is sensitive to the non-occurrence of events as well as to ongoing life circumstances. The stress score was stratified into no, mild, moderate (merged as low level) stress or severe (high level) stress according to first, second and third quartiles. The degree of anxiety and depressive symptoms were measured by Hospital Anxiety and Depression Scale (HAD), where a score of 12 or more for either the anxiety or the depression components denotes possible anxiety or depression^[15]. This cut off point had sensitivity of 0.89 and specificity of 0.75^[16]. The Arabic version of the HAD scale was validated by El-Rufaie and Absood^[12]. The overall Cronbach alpha measures of internal consistency were 0.7836 and 0.8760 for anxiety and depression, respectively.

Sampling
Sample size was calculated using Epi info program version 6.02. According to students' affairs administration, the total number of registered medical students in 2007 was 6843 students of both sexes in the six years. A previous study^[10] reported that 20.3% of medical students suffer high level of stress. With the worst acceptable level 25%, the sample needed for the study was estimated to be at least 237 students at a study power of 80% and 95% confidence level. To overcome the attrition due to cluster sampling 15% was added to the sample size with a final number of 273 students. An equal number of law students were targeted.

Students were selected through stratified cluster sampling technique. First students were stratified into the different academic years (first to sixth in medicine and first to fourth in law). From each year a section or group (cluster) was randomly chosen. All students in the chosen clusters were included. A total of 366 and 412 students were registered in chosen clusters in medicine and law colleges, respectively. The response rates were 77.9% (285 of 366) in medicine and 67.2% (277 of 412) in law with an overall response rate of 70.2%. No participation was due to lack of interest in the study, absence during the study period and incomplete questionnaires.

Data analysis
We analyzed data using SPSS (Statistical Package for Social Sciences) version 11. In quantitative data, unpaired student's t-test was used for group comparison. In categorical data, Chi-squared test was used for comparison between groups. Significant factors predicting of high stress level on univariate analysis were entered into multivariate logistic regression analysis to find out the independent predictors of stress. Odds ratio and 95% confidence interval was calculated. P£ 0.05 was considered statistically significant.

Compared to medical students law students are more of female sex (66.1% Vs. 47.7%), of younger age (18.9 vs. 20.7 years), of rural residence (53.4% vs. 40.6%), with unsatisfactory family income (26.0%Vs. 11.3%), with less than secondary educated parents (52 % Vs. 14.8% for fathers and 58.1% Vs. 23% for mothers, respectively) working as non-professionals. Housewives/ mothers accounted for 71.5% in law Vs. 43.7% in medical students. Thus the two groups of students were not matched regarding their basic sociodemographic characteristics (data unshown in tables).
On comparison three main categories of potential stressors distinguish law from medical students (Table 1). Law students were more likely to cite personal, environmental and relationship categories as stressors. Findings revealed that coping with the course of the study and inconsiderate and insensitive instructors (33.9%, each) and troubles with coursemates (27.6%) were the most common among medical students.The most common items in law students were anxiety and depression (62.8%); time limitation for recreational activities (43.3%); problems with opposite gender (38.6%) and congested classrooms (37.9%).

Table (2) shows that high stress level and anxiety are signficantly more reported by law students than medical students.

Univariate analysis revealed that high levels of stress were reported by law students, of female sex, with unsatisfactory income, low educated parents and non-professional fathers, presence of anxiety and depression (Table 3).

However the logistic regression analysis revealed that the significant independent predictor of high levels of stress are, in order; presence of anxiety (OR=4.5), being a law student (OR=2.3), presence of depression (OR=1.4) and number of stressors (OR=1.3) (Table 4).

†Categories are not mutually exclusive
‡e.g. overcrowded accomodation, noisy living environment, transportation problems.

Marked significant difference in the response rate to the questionnaire was noted among the medical and law students (77.9% Vs. 67.2%, respectively, P<0.001). Law students take lectures in several departments for varying lengths of time, making them less accesible when compared to the medical students who are fewer in number and do not have contact with many different departments.

The law compared to medical students had a lower socioeconomic status and belong to the low and middle classes. The study examined the family income, education and occupation of the parents as markers of socioeconomic status. In contrast to our finding, Astin^[17] reported that law students do not mirror the socio-economic makeup of the society from which they come; instead, they come from an elite background of higher socioeconomic status than the general population.

PSS scores generally increased as household income decreased. The number of people living in the respondent's household increased^[18]. This social disadvantage is associated with increased stress. One explanation for this pattern is that individuals lower down the socioeconomic status ladder have fewer psychological resources for meeting the stress of the increasingly more challenging environment that may negatively impact physical and psychological well-being^[19].

We found that environmental, personal and relationship sources of stress were the more common in law students, with the five most frequently stressors being anxiety and depression, limited time spent for recreational activities, problems with opposite gender, congested classrooms and accomodation problems. Most of the law students come from remote villages and towns outside Mansoura and study for four years in that city. Thus for these students, living in a university campus may cause more stress than for those who live in Mansoura. In addition, this data was collected during the first semester, when students are at the beginning of their courses, being away from home, have difficulty in adjustment to a new environment and take responsibilty for themselves. They try to begin more intimate relationships and seek acceptance from their peers. Also they have diffculty in maintaining relationships with the opposite sex as most of them are from rural conservative communities and facing a world of mixed values. They have to cope in crammed campuses and congested classrooms, the heavy demands of the law school, and inadequate recreational facilities. In college students, some stress is motivating, whereas too high a level interferes with learning. Excessive stress can be harmful to a student's academic performance and students who perceive their stress as very high may often lead to depression, anxiety, attrition and serious health problems^[20].

The top five items of stressors in medical students identified in this study were troubles with the instructors, excessive workload, problems with coursemates, close contact with serious illness and personal injury or illness. These findings were in keeping with Dyrbye et al^[1] in their meta-analysis of stresses in medical students in other parts of the world. Coles [3] commented on enormous overload of information that medical students face and workload was the most common source of stress in the study by Guthrie et al^[2].

The problem of poor relationship with teachers appears to be quite widespread in the health professions. Student nurses and medical students regularly mention this stressor^[21] and it has been reported that the culture of abuse of medical students is deeply ingrained in medical education, associated with the false belief by teachers that it helps students to learn^[22].

As reported in previous studies of major stressors for students^[21,23] the importance of perceived financial situation is evident in the study. Egypt, despite its wealth and its natural and human resources, has fared poorly in many aspects of development. Important problems include high inflation, flat wages, lack of job opportunities and slow economic growth because of loss of traditional economy, low productivity and innovation and rapid expansion of population^[24].

The results of this study indicate significant higher prevalence of stress and anxiety in our undergraduate law students than medical students. Depression is more frequent in the law group, although it does not reach a significant statistical difference. This increased level of stress indicates a decrease of psychological health in our students which may impair students' behavior, diminish learning, and play a role in alcohol and substance abuse.

Ko et al^[5] reported that 57% of medical students versus 47.3% of law students scored above cut-off points on the General Health Questionnaire (GHQ). Helmers et al^[9] found that medical students are not greatly stressed relative to other groups and they had subjective feelings of stress that are marginally above population norms, but their total-stress scores related to environmental factors, personality mediators, and emotional responses were below those of the general population, the law students, and the graduate students.

On the other hand, a study of American law and medical students revealed no difference in overall stress levels, but law students showed higher perceived stress on the academic and fear-of-failing subscales than medical students^[25]. Furthermore, Kellner et al^[26] and Benjamin et al^[27] reported that law students had significantly more depression, obsessive compulsive disorders, interpersonal sensitivity, anxiety, and hostility as compared to the general population.

The legal profession in Egypt has a long, illustrious history but the current education policy allows an increasing number of admitted law students depending on the total marks alone, and this does not reflect the student's real desire to choose the field of specialization^[28]. This policy increases pressure on the limited resources of universities, reduces performance of faculty members and lowers the efficiency of the graduates. By then, they are dispossessed of the means to make a success of their careers. The legal education program was of the traditional type and and students lack the skills of the labor market such as multi-language abilities, international law specialists and technological skills^[29].

Misra and McKean^[30] investigated the inter-relationship among independent predictors of stress in undergraduate university students. It was hypothesized that a student's academic stress would show a positive correlation with anxiety. Stress as measured by the PSS would be moderately correlated with the number of live events that respondents indicated they had experienced within the last year^[18].

Due to the major impact that perceived stress levels may have on a student, it is important that the problem be identified and dealt with effectively. Counseling and preventive mental health services should be an integral part of the routine clinical facilities caring for university students to help students to make smooth transitions between different learning environments with changing learning demands and a growing burden. Studies of the effects of stress on practicing members of the legal profession are needed to further explore the possible effects of law school stress in the subsequent career years and to examine the specific effects of excessive stress on practicing attorneys.

Study limitations

1. The findings of this study are based on self reported information provided by students and some potential for reporting bias may have occurred because of respondents' interpretation of the questions or desire to report their emotions in a certain way or simply because of inaccuracies of responses.
   
2. The study takes place at one university which will affect the generalizability to other institutions. Consequently, the results will only be applicable to similar institutions in similar settings.
   
3. The study takes place at one point in time which will limit the ability to generalize the findings to other time periods, this is referred to as a threat to temporal validity.
   
4. The study will be limited to all medical and law students and will not address freshman, sophomores, senior or juniors.
   
5. The study does not take into account faculty characteristics or teaching styles which could have an effect on student's perceived stress levels.
   
   
   

1. Dyrbye LN, Thomas MR, Shanafelt TD. Systematic review of depression, anxiety and other indicators of psychological distress among U.S. and Canadian Medical students. Acad Med 2006;81(4):354-373.
   
2. Guthrie EA, Black D, Shaw CM, Hamilton J, Creed FH, Tomenson B. Embarking upon a medical career: Psychological morbidity in first year medical student. Med Educ1995;35:619-621
   
3. Coles C. Medicine and stress. Med Educ1994;28:3-4.
   
4. Morrison J .More on medical student stress. Med Educ 2001;35:617-618.
   
5. Ko SM, Kua EH, Fones CS. Stress and the undergraduates.Singapore Med J. 1999;40(10):627-30.
   
6. Dammeyer MM, Nunez N. Anxiety and depression among law students: Current knowledge and future directions. Law Hum Bhav 1999;23(1):55-73.
   
7. Archer J, Peters MM. Law student stress. NASPAJ 1986;23:48-54.
   
8. Heins M, Fahey SN, Leiden LI. Perceived stress in medical, law, and graduate students. J Med Educ1984;59(3):169-79.
   
9. Helmers KF, Danoff D, Steinert Y, Leyton M, Young SN. Stress and depressed mood in medical students, law students, and graduate students at McGill University. Acad Med1997;72(8):708-14.
   
10. Amr M, El-Gilany A, El-Sayed M, El-Sheshtawy E. study of stress among medical students at Mansoura University. Banha Medical Journal 2007; 37(5):25-31
    
11. Jaber LA, Brown LA, Hammad A, Zhu Q, Herman WH. Lack of acculturation is a risk factor for diabetes in Arab immigrants in the U.S. Diabetes Care 2003;26:2010-2014
    
12. EL-Rufaie OE, Absood GH. Retesting the validity of the Arabic version of the Hospital Anxiety and Dpression (HAD) scale in primary health care. Soc Psychiatr Psychiatr epidemiol 1995;30:26-31
    
13. Turner RJ, Wheaton B. Checklist measurement of stressful life events. In S. Cohen, RC Kessler, LU Gordon(Ed.) Measuring stress: a guide for health and social scientists. New york:Oxford Univeristy Press. 1995 pp.29-35.
    
14. Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav 1983;24:385-396.
    
15. Zigmond S, Snaith RP. The hospital anxiety and depression scale (HADS). Acta Psychiat Scand 1983;67:361-370.
    
16. Olssøn I, Mykletun A, Dahl AA. The hospital anxiety and depression rating scale: A cross-sectional study of psychometrics and case finding abilities in general practice. BMC Psychiatry 2005; 5:46.
    
17. Astin AW. Pre-law Students-A National Profile. J Legal Educ 1984;34(1):73-85.
    
18. Cohen S, Willamson GM. Perceived stress in a probability sample of the United State. In Spacapan S, Oskamp S (Eds.) The social psychology of health. Newbury Park, CA: Sage1988 pp. 31-67.
    
19. Grant KE, Compas BE, Thurm AE, et al. Stressors and child and adolescent psychopathology: evidence of moderating and mediating effects. Clinical Psychology Review 2006;26(3):257-83.
    
20. Evans W, Kelly B. pre-registration diploma student nurse stress and coping measures. Nurse Educ Today 2004;24(6):473-482.
    
21. Trimmins F, Kaliszer M. Aspects of nurse education programs that frequently cause stress to nursing students -fact finding sample survey. Nurse Educ Today 2002;22:203-211.
    
22. Kassebaum DG, Culter ER. On the culture of student abuse in medical school. Acad Med 1998;37:49-58.
    
23. Omigbodun OO, Odukogbe AA, Omigbodun AO, Yusuf OB, Bella TT, Olayemi B. Stressors and psychological symptoms in students of medicine and health allied health professions in Nigeria. Soc Psychiatry Psychiatr Epidemiol 2006;41:415-421.
    
24. Okasha A. Focus on Psychiatry in Egypt. British Journal of Psychiatry 2004;185:266-272.
    
25. Heins M, Fahey SN. Comparison of perceived stress levels among medical and law students. Annu Conf Res Med Educ 1981;20:201-6.
    
26. Kellner R, Wiggins RJ, Pathak D. Distress in medical and law students. Compr Psychiatry1986;27(3):220-223.
    
27. Benjamin GA, Kazniak A, Sales B, Shanfield SB. The role of legal education in producing psychological distress among law students. Am Bar Found Res J 1986;11(2):225- 252.
    
28. Moustafa AF. The axes of the future dimension of the development of university education in Egypt to face the unemployment of graduates. J Financial Commercial Studies. 2004; 2:213-220.
    
29. Kenawy EM. University Education and its Relation to Development in Egypt. J Applied Sciences Research 2006; 2(12): 1270-1284.
    
30. Misra R, McKean M. College students' academic stress and its relation to their anxiety, time management, and leisure satisfaction. Am J Health Studies 2000;16(1):41-51