357J Contemp Med Sci | Vol. 8, No. 5, September-October 2022: 357–362 Original Executive Function Deficits Associated with Anxiety and Depression and their Impact on Medical Students’ Academic Performance in Saudi Arabia Sulhi A. Alfakeh1* , Alya S. Alharbi2, Mohammed K. Alhebshi2, Abdullah F. Attar2 1Faculty of Medicine, Department of Internal Medicine, King Abdulaziz University, Jeddah, Saudi Arabia. 2Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia. *Correspondence to: Sulhi A. Alfakeh (Email: salfakeh@kau.edu.sa) (Submitted: 10 April 2022 – Revised version received: 22 May 2022 – Accepted: 17 June 2022 – Published Online: 26 October 2022) Abstract Objectives: This study aimed to determine the relationship between EF deficits associated with anxiety and depression and their impact on medical students’ academic achievement in Saudi universities. Methods: A cross-sectional online survey was conducted on 242 medical students. Anxiety and depression were assessed using the Barkley Deficits in Executive Functioning Scale (BDEFS), General Anxiety Disorder-7 scale (GAD-7), and the Patient Health Questionnaire (PHQ-9). Results: Participants’ mean age was 22.57 (2.26) years and the mean GAD-7, PHQ-9, and BDEFS scores were 10.54 (5.83), 12.29 (6.86), and 196.78 (47.78), respectively. Males, Saudi students, those in their fourth academic year, and those who were not satisfied with their academic performance had significantly higher mean GAD-7, PHQ-9, and BDEFS scores. A significant negative association was found between students’ grade point average (GPA) and BDEFS scores, and a significant positive association was found between GPA and GAD-7 scale scores, PHQ-9 scores, and BDEFS scores. Additionally, there was a positive association between the PHQ-9 and BDEFS scores. Conclusion: A real-world application of EF scales to address EF deficits for all university students should be considered. Keywords: Executive function, anxiety, depression, academic performance, Saudi Arabia, students, medical ISSN 2413-0516 Introduction Executive functions (EFs) are a widespread set of neurocogni- tive processes that include flexible and complex goal-directed behaviors, thoughts, and emotions. In addition, they include working memory, sustained attention, inhibition, and plan- ning (Shanmugan & Satterthwaite, 2016)1 allowing for adapta- tion to fluctuating environmental demands.2 EFs are important in many aspects, including mental and physical health, well- being, and educational and career development.3 They are essential in maintaining and measuring improvements in academic performance.4 Memory, self-control and inhibition, flexibility, and plan- ning are skills related to EFs, which are consequential for good academic performance.5 The relationship between EFs and education starts in early childhood and continues to develop over the years, with a clear impact on academic achievement.1 Recently, the importance of EFs and their effect on academic performance and achievement have been observed in the development of studying methods and environments. Therefore, changes in these skills may alter academic achieve- ment.6 Furthermore, new academic environments challenge students’ EFs, and a lack of self-control deteriorates study pro- gress.6 Additionally, failure in self-regulation also causes pro- crastination, which is defined as an intentional delay to initiate or complete a task, leading to severe difficulties for students in obtaining optimal educational outcomes.7 In a study con- ducted in the USA, 30–60% of undergraduate students com- plained about postponing tasks and studying for exams, writing papers, and completing assignments.7 Students with EF deficits achieve lower grade point averages (GPAs) than other students.6 Students with cognitive or emotional disabili- ties are also at risk of academic failure.8 Additionally, students with lower levels of multiple EF skills are more prone to encountering issues when planning and controlling their study progress.6 In 2015, a study was conducted in the Netherlands on 1,332 students who were in their first academic year of Applied Sciences. EFs with regard to behavioral ratings were assessed to measure its influence on academic achievement. Results indicated that students with higher EF scores at the beginning of the first academic year gained higher grades; in contrast, students with lower EF scores attained lower grades.6 Previous studies have found that medical education is a stressful and predisposing factor for anxiety.9,10 In addition, studies have also stated that first-year students are more anx- ious than final-year students and that their level of anxiety decreases over.11,12 However, the prevalence of anxiety symptoms was high even in patients with no cognitive impairment.13 A thorough literature review revealed that no study in the Kingdom of Saudi Arabia (KSA) so far has aimed to assess the associations among EF deficits, anxiety, and depression among medical students. Materials and Methods The Barkley Deficits in Executive Functioning Scale (BDEFS) is used to identify areas of impairment, based on which effec- tive student counseling can be implemented.14 It helps the counselor inform students about their strengths and weak- nesses and provide the ultimate guide to successful academic life. It can also provide an indication of current or future academic performance for college students.15 This cross-sectional study was conducted in 10 Saudi universities. An online survey was conducted using a self- administered questionnaire. The inclusion criteria were med- ical students and interns in Saudi Arabia aged 17–25 years; non-medical students were excluded. Electronic consent was obtained from all participants. Regarding ethical considerations, ethical approval for the study was obtained from the research ethics committee of http://orcid.org/0000-0003-1371-876X mailto:salfakeh@kau.edu.sa 358 J Contemp Med Sci | Vol. 8, No. 5, September-October 2022: 357–362 EF Associated with Anxiety and Depression and their Impact on Medical Students’ Academic Performance Original S.A. Alfakeh et al. King Abdulaziz University (KAU), Jeddah, KSA (Reference number 21–22). Participants were informed about the study idea and its aim at the beginning of the survey to obtain their consent for participation. Students were asked about their age, gender, nationality, academic year, GPA, and satisfaction with academic perfor- mance. EFs were assessed using the BDEFS since it has the salient ability to predict impairments in social relationships, professional work, and everyday life.16 The BDEFS is divided into five major categories: time management, organization and problem solving, self-inhibition, motivation, and emotion reg- ulation. In addition, the scale provides a total score for EFs. Participants with higher scores were believed to have greater EF deficits.17–19 Anxiety was assessed using the General Anxiety Disorder-7 (GAD-7) scale, which is a valuable tool used to screen for anx- iety and assess its severity in different fields.20 This scale com- prises seven questions regarding whether participants have been bothered by the symptoms mentioned in the question- naire (and how often) during the past two weeks. Each symptom has four response options, scored from 0–3, where 0 represents not at all and 3 represents nearly every day. The results are interpreted according to the total score; 0–4 corre- sponds to minimal anxiety, 5–9 to mild anxiety, 10–14 to moderate anxiety, and 15–21 to severe anxiety.20,21 We used the Patient Health Questionnaire (PHQ-9) to assess depression; it comprises 10 questions: the first includes nine items and has four response options from 0 to 3. Conse- quently, a score of ≥10 in this questionnaire is considered a diagnostic cutoff point for depressive symptoms.22,23 Data were analyzed using SPSS version 25 (Armonk, NY: IBM Corp.). Qualitative data were presented as numbers and percentages. Quantitative data were presented as means and standard deviations (Mean [SD]). The Mann–Whitney U, Kruskal–Wallis, independent sample t-test, and ANOVA were applied to assess the relationships between variables according to data normality. Statistical significance was set at P < 0.05. Results Table 1 shows that the mean age of the participants was 22.57 (2.26) years, 57.9% were females, 88.8% had a Saudi nation- ality, and 57% were from the KAU university. Approximately 35% (35.5%) were sixth year students, and 28.9% were satisfied with their academic performance, with a mean GPA of 4.44 (5.89). The mean GAD-7, PHQ-9, and BDEFS scores were 10.54 (5.83), 12.29 (6.86), and 196.78 (47.78), respectively. Table 2 shows that male students, Saudi students, those in the fourth academic year, and those who were not satisfied with their academic performance had significantly higher mean GAD-7 scores (P < .05). Alternatively, a non-significant relationship was found between mean GAD-7 scores and par- ticipants’ university (P > .05). Table 3 shows that male students, those in the fourth academic year, and those who were not satisfied with their academic performance had significantly higher mean PHQ-9 scores (P < .05). Alternatively, a non-significant relationship was found between the mean PHQ-9 scores and participants’ nationality and university (P > .05). Table 4 shows that students of Taif university, those in the fourth academic year, and those who were not satisfied with their academic performance had significantly higher mean BDEFS scores (P < .05). Alternatively, a non-significant rela- tionship was found between the mean BDEFS scores and par- ticipants’ gender or age (P > .05). Table 5 shows that a significant negative correlation was found between students’ GPA and BDEFS scores (r = –.19, P = .003). Figures 1 and 2 illustrate a highly significant positive correlation between GPA and GAD-7 scores and both PHQ-9 (r = .647, P < .001) and BDEFS (r = 0.44, P < .001) scores, Table 1. Participant distribution according to their demographic details, university, academic year, satisfaction with academic performance, and mean scores of GPA, GAD-7, PHQ-9, and BDEFS (N = 242) Variable No. (%) Age (mean ± SD) 22.57 ± 2.26 Gender Female 140 (57.9) Male 102 (42.1) Nationality Non-Saudi 27 (11.2) Saudi 215 (88.8) University BMC 15 (6.2) FCOMS 10 (4.1) ISNC 29 (12) KFU 13 (5.4) KAU 138 (57) KSU 10 (4.1) KSAU 10 (4.1) Taibah U 4 (1.7) TU 1 (0.4) UQU 12 (5) Academic year Second 47 (19.4) Third 29 (12) Fourth 31 (12.8) Fifth 19 (7.9) Sixth 86 (35.5) Intern 30 (12.4) Satisfaction with academic performance No 172 (71.1) Yes 70 (28.9) GPA 4.44 ± 5.89 GAD-7 10.54 ± 5.83 PHQ-9 12.29 ± 6.86 BDEFS 196.78 ± 47.78 BMC, Batarji Medical College; FCOMS, Fakeeh College for Medical Sciences; ISNC, Ibn Sena Medical College; KFU, King Faisal University; KAU, King Abdulaziz University; KSU, King Saud University; KSAU, King Saud Bin Abdulaziz University; Taibah U, Taibah University; TU, Taif University; UQU, Um AlQura University; GPA, Grade Point Average; GAD-7, General Anxiety Disorder-7 scale; PHQ-9, Patient Health Questionnaire; BDEFS, Barkley Deficits in Executive Functioning Scale. 359J Contemp Med Sci | Vol. 8, No. 5, September-October 2022: 357–362 S.A. Alfakeh et al. Original EF Associated with Anxiety and Depression and their Impact on Medical Students’ Academic Performance universities; the participants were 18 to 28 years of age, and two-thirds of the population was female (64.9%). The results found that males encountered significant problems on the self-inhibition and self-motivation scales.15 This study found that students in the fourth academic year had significantly higher mean PHQ-9 scores than those in other academic years. The previously mentioned US study indicated that the younger the participants, the more problems they had with self-restraint and emotion regulation.15 Addi- tionally, another study found that male students and those in higher academic years may need specific attention and interventions.24 We used the PHQ-9 to assess depression in contrast to the Beck Depression Inventory used in other studies.25 We used respectively. Figure 3 illustrates a highly significant positive cor- relation between PHQ-9 and BDEFS scores (r = .61, P < .001). Discussion EF skills are essential in achieving satisfaction in academic life; although it is an important field of study, there is a significant knowledge gap regarding the assessment of EF in a represent- ative college sample.15 Thus, our study aimed to assess the rela- tionship between EF deficits, depression, and anxiety, and the impact of these factors on academic achievement. In the present study, male students had significantly higher mean GAD-7 anxiety scores. A recent study was conducted in 2019, with a sample size of 1,311 college students enrolled in five US Table 2. Relationship between mean GAD-7 scores and participants’ demographic details, university, academic year, and satisfaction with academic performance Variable GAD-7 Anxiety scale scores (Mean ± SD) Test P-value Gender Female 8.4 ± 5.91 4.96* <.001 Male 12.09 ± 5.27 Nationality Non-Saudi 10.24 ± 5.84 2.26* .023 Saudi 12.93 ± 5.25 University BMC 12.27 ± 4.87 8** 0.0688 FCOMS 9.00 ± 4.69 ISNC 11.07 ± 6.27 KFU 11.85 ± 5.58 KAU 10.22 ± 5.92 KSU 11.40 ± 6.41 Taibah U – TU 8.83 ± 5.27 UQU 12.40 ± 6.51 KSAU 9.40 ± 5.68 Academic year Second 11.02 ± 5.19 5** .001 Third 10.97 ± 5.3 Fourth 14.48 ± 5.42 Fifth 9.37 ± 5.27 Sixth 9.19 ± 6.44 Intern 9.90 ± 4.42 Satisfaction with academic performance Yes 8.97 ± 5.59 2.69* .007 No 11.17 ± 5.82 BMC, Batarji Medical College; FCOMS, Fakeeh College for Medical Sciences; ISNC, Ibn Sena Medical College; KFU, King Faisal University; KAU, King Abdulaziz University; KSU, King Saud University; KSAU, King Saud Bin Abdulaziz University; Taibah U, Taibah University; TU, Taif University; UQU, Um AlQura University; GAD-7, General Anxiety Disorder-7 scale. *Mann–Whitney test; ** Kruskal–Wallis test. Table 3. Relationship between mean PHQ-9 scores and participants’ demographic details, university, academic year, and satisfaction with academic performance Variable PHQ-9 Depression scale scores (Mean ± SD) Test P-value Gender Female 9.8 ± 6.83 4.86* <.001 Male 14.11 ± 6.3 Nationality Non-Saudi 12.06 ± 6.95 1.58* .113 Saudi 14.19 ± 5.85 University BMC 12.87± 5.3 8** .636 FCOMS 9.20 ± 4.36 ISNC 12.59 ± 6.25 KFU 13.15 ± 6.76 KAU 12.04 ± 7.28 KSU 13.00 ± 5.53 Taibah U – TU 11.50 ± 6.81 KSAU 16.40 ± 7.6 UQU 112.20 ± 7.75 Academic year Second 12.68 ± 6.3 5** .002 Third 12.24 ± 5.22 Fourth 17.26 ± 7.64 Fifth 9.95 ± 6.22 Sixth 11.21 ± 7 Intern 11.20 ± 6.18 Satisfaction with academic performance Yes 10.06 ± 6.93 3.16* .002 No 13.2 ± 6.63 BMC, Batarji Medical College; FCOMS, Fakeeh College for Medical Sciences; ISNC, Ibn Sena Medical College; KFU, King Faisal University; KAU, King Abdulaziz University; KSU, King Saud University; KSAU, King Saud Bin Abdulaziz University; Taibah U, Taibah University; TU, Taif University; UQU, Um AlQura University; GPHQ-9, Patient Health Questionnaire. *Mann–Whitney test; ** Kruskal–Wallis test. 360 J Contemp Med Sci | Vol. 8, No. 5, September-October 2022: 357–362 EF Associated with Anxiety and Depression and their Impact on Medical Students’ Academic Performance Original S.A. Alfakeh et al. prevalence of depression was found to be higher among female medical students.25 A study conducted in Riyadh, Saudi Arabia, showed that depression was more prevalent among first-year medical stu- dents.25 This corroborates the results of the present study. Additionally, a study conducted in India showed that third year medical students reported significantly increased depres- sive symptoms.29 Table 4. Relationship between mean BDEFS scores and participants’ demographic details, university, academic year, and satisfaction with academic performance Variable BDEFS scores (Mean ± SD) Independent sample t-test P-value Gender Female 190.36 ± 46.02 1.79 .075 Male 201.43 ± 48.64 Nationality Non-Saudi 208.25 ± 52.99 1.32 .186 Saudi 195.35 ± 47.03 University BMC 183.46 ± 42.8 2.24* .016 FCOMS 149.5 ± 20.7 ISNC 203.20 ± 38.54 KFU 200.91 ± 49.19 KAU 206.84 ± 61.81 KSU 178.84 ± 47.3 Taibah U 221.5 ± 48.53 TU 210.54 ± 54.09 KSAU 208 ± 32.58 UQU 199.58 ± 29.8 Academic year Second – 5.24* .001 Third 176.41 ± 32.5 Fourth 228.54 ± 57.91 Fifth 199.26 ± 39.22 Sixth 195.41 ± 44.73 Intern 194.48 ± 47.51 Satisfaction with academic performance Yes 192.07 ± 51.79 3.18 .002 No 198.45 ± 46.13 BMC, Batarji Medical College; FCOMS, Fakeeh College for Medical Sciences; ISNC, Ibn Sena Medical College; KFU, King Faisal University; KAU, King Abdulaziz University; KSU, King Saud University; KSAU, King Saud Bin Abdulaziz University; Taibah U, Taibah University; TU, Taif University; UQU, Um AlQura University; BDEFS, Barkley Deficits in Executive Functioning Scale. *ANOVA. Table 5. Spearman’s correlation analysis among participants’ age and GPA and GAD-7, PHQ-9, and BDEFS scores Variable Age r P-value GAD-7 –.09 .162 PHQ-9 –.04 .457 BDEFS .1 .11 GPA r P-value GAD-7 .002 .97 PHQ-9 .09 .149 BDEFS –.19 .003 GPA, Grade Point Average; GAD-7, General Anxiety Disorder-7 scale; PHQ-9, Patient Health Questionnaire; BDEFS, Barkley Deficits in Executive Functioning Scale. the PHQ-9 because it allows us to measure the severity of the participant’s depression and assign a numerical score that can be then used to assess the relationship between depression and EF. A high prevalence of depression has been observed among medical students.26 Our study supports this result. A score of ≥10 in PHQ-9 is considered significant for the diagnosis of depression; in our study, the mean scale score was found to be 12.29 for PHQ-9. This study showed that male medical students (especially those in their fourth year) were not satisfied with their aca- demic performance and had a significantly higher mean depression score. In contrast, some studies have denied any variation in depression scores depending on sex.27,28 Alterna- tively, the World Health Organization states that women are more prone to depression.25 Similarly, in other studies, the Fig. 1 Spearman’s correlation analysis between GAD-7 Anxiety scores and PHQ-9 Depression scores. N.B.: (r = 0.647, P-value = <0.001). Fig. 2 Spearman’s correlation analysis between GAD-7 Anxiety scores and BDEFS scale scores. N.B.: (r = 0.44, P-value = <0.001). 361J Contemp Med Sci | Vol. 8, No. 5, September-October 2022: 357–362 S.A. Alfakeh et al. Original EF Associated with Anxiety and Depression and their Impact on Medical Students’ Academic Performance This study showed that 71.1% of students were not satis- fied with their academic performance, and students who were not satisfied had higher mean depression scores. Severe depression is a problem, and it is essential to diagnose depres- sion and anxiety early to improve quality of life.30 In the present study, we used the GAD-7, which is a valid questionnaire to measure the prevalence and severity of GAD in medical students in association with EF deficits.21,31,32 The prevalence of anxiety among medical students reported in 69 studies with 40,438 students was found to be 33.8%.27 One study stated that the cognitive skills of people with anxiety are not different from those of the healthy general population.33 Similarly, anxiety is frequently diagnosed in medical students and is found to negatively impact their academic performance.33 This study found that students in their fourth academic year were at the beginning of their clinical years and were found to have higher mean GAD-7 anxiety scale scores. Addi- tionally, they were not satisfied with their academic perfor- mance. A similar result was found in another study that studied the importance of developing coping strategies and finding a balance between medical students’ academic and personal.9 A study conducted in Singapore found that anxiety is more common in females than in males, in comparison with another study, which stated that there is no difference between the sexes.33 Medical students who were not satisfied with their academic performance had a significantly higher mean GAD-7 score, higher mean PHQ-9 depression scores, and higher mean BDEFS scores. The effects of stress, anxiety, and depression on students’ academic performance have also been reported in previous.26,34–36 The present study observed a non-significant relationship between mean BDEFS scores and participants’ gender or age. This result does not complement that of previous studies, as age was significantly correlated with self-inhibition and emotion regulation. Additionally, younger participants reported that they had encountered more problems with inhibition.15,37,38 This variation from our results could be due to the inclusion of only medical students in our study participants. This study found that students in the fourth academic year had significantly higher mean BDEFS scores. Alterna- tively, another study did not find any association between edu- cation level and EF regarding academic progress.6 Our results showed a significant negative correlation between the BDEFS scores and GPA of students. The effect of EF on study process and academic performance was also revealed in a previous study, which revealed the importance of implementing clearly targeted interventions that should be combined with student-counseling facilities and policy within universities.6 Limitations This study has some limitations. First, this study was con- ducted with a relatively small and specific population (n = 242), and all participants were medical students. Second, other pos- sible potentially important covariates that should be assessed in relation to academic performance were not included, for instance, childhood brain damage, learning disability, or any socioeconomic factors. Third, all medical colleges in Saudi Arabia were not involved in this study, which may have affected the generalization of the results. Conclusion Male students, Saudi students, those in the fourth academic year, and those who were not satisfied with their academic performance had significantly higher mean GAD-7, PHQ-9, and BDEFS scores. A significant negative association was found between students’ GPA and BDEFS scores, and a signif- icant positive association was found between the GPA and GAD-7 scores and both PHQ-9 and BDEFS scores. Future studies including a larger sample size of Saudi medical stu- dents are recommended. In addition, a real-life application of such scales should be considered to address the EF of all uni- versity students. Funding None. Disclosure Statement There are no relevant financial or non-financial competing interests to report. Data Availability Statement Data supporting the results and analyses presented in the paper can be provided upon request.  Fig. 3 Spearman’s correlation analysis between PHQ-9 Depression scores and BDEFS scale scores. N.B.: (r = 0.61, P-value = <0.001). References 1. Shanmugan, S., & Satterthwaite, T. D. (2016). Neural markers of the development of executive function: relevance for education. Current Opinion in Behavioral Sciences, 10, 7–13. 2. Ahmed, S. F., Tang, S., Waters, N. E., & Davis-Kean, P. (2019). Executive function and academic achievement: longitudinal relations from early childhood to adolescence. Journal of Educational Psychology, 111(3), 446–458. 3. Diamond, A. (2013). Executive functions. Annual Review of Psychology, 64, 135–168. 4. Visu-Petra, L., Cheie, L., Benga, O., & Miclea, M. (2011). Cognitive control goes to school: The impact of executive functions on academic performance. Procedia Social and Behavioral Sciences, 11, 240–244. 5. Cortés, P. A., Moyano, M. N., & Quílez, R. A. (2019). The relationship between executive functions and academic performance in primary 362 J Contemp Med Sci | Vol. 8, No. 5, September-October 2022: 357–362 EF Associated with Anxiety and Depression and their Impact on Medical Students’ Academic Performance Original S.A. Alfakeh et al. education: Review and meta-analysis. Frontiers in Psychology, 10(10), 1582. 6. Baars, M. A., Nije Bijvank, M., Tonnaer, G. H., & Jolles, J. (2015). Self-report measures of executive functioning are a determinant of academic performance in first-year students at a university of applied sciences. Frontiers in Psychology, 6, 1131. 7. Rabin, L. A., Fogel, J., & Nutter-Upham, K. E. (2011). Academic procrastination in college students: the role of self-reported executive function. Journal of Clinical and Experimental Neuropsychology, 33(3), 344–357. 8. Samuels, W. E., Tournaki, N., Sacks, S., Sacks, J., Blackman, S., Byalin, K., & Zilinski, C. (2019). Predicting GPAs with executive functioning assessed by teachers and by adolescents themselves. European Educational Researcher, 2(3), 173–194. 9. Abdulghani, H. M., AlKanhal, A. A., Mahmoud, E. S., Ponnamperuma, G.G., & Alfaris, E. A. (2011). Stress and its effects on medical students: A cross- sectional study at a college of medicine in Saudi Arabia. Journal of Health, Population, and Nutrition, 29(5), 516–522. 10. Saeed, A. A., Bahnassy, A. A., Al-Hamdan, N. A., Almudhaibery, F. S., & Alyahya, A. Z. (2016). Perceived stress and associated factors among medical students. Journal of Family and Community Medicine, 23(3), 166–171. 11. Bayram, N, & Bilgel, N. (2008). The prevalence and socio-demographic correlations of depression, anxiety and stress among a group of university students. Social Psychiatry and Psychiatric Epidemiology, 43(8), 667–672. 12. Beiter, R., Nash, R., McCrady, M., Rhoades, D., Linscomb, M., Clarahan, M., & Sammut, S. (2015). The prevalence and correlates of depression, anxiety, and stress in a sample of college students. Journal of Affective Disorders, 173, 90–96. 13. Castaneda, A. E., Suvisaari, J., Marttunen, M., Perälä, J., Saarni, S. I., Aalto- Setälä, T., Aro, H., Koskinen, S., Lönnqvist, J., & Tuulio-Henriksson, A. (2011). Cognitive functioning in a population-based sample of young adults with anxiety disorders. European Psychiatry, 26(6), 346–353. 14. Prevatt, F., & Yelland, S. (2015). An empirical evaluation of ADHD coaching in college students. Journal of Attention Disorders, 19(8), 666–677. 15. Kamradt, J. M., Nikolas, M. A., Burns, G. L., Garner, A. A., Jarrett, M. A, Luebbe, A. M., & Becker, S. P. (2021). Barkley Deficits in Executive Functioning Scale (BDEFS): Validation in a large multisite college sample. Assessment, 28(3), 964–976. 16. Kamradt, J. M., Ullsperger, J. M., & Nikolas, M. A. (2014). Executive function assessment and adult attention-deficit/hyperactivity disorder: Tasks versus ratings on the Barkley deficits in executive functioning scale. Psychological Assessment, 26(4), 1095–1105. 17. Barkley, R. A. (2011a). Barkley Adult ADHD Rating Scale–IV (BAARS-IV). Guilford Press. 18. Barkley, R. A. (2011b). Barkley Deficits in Executive Functioning Scale (BDEFS for adults). Guilford Press. 19. Barkley, R. A. (2012). Barkley deficits in executive functioning scale–children and adolescents (BDEFS-CA). Guilford Press. 20. Mousa, O. Y., Dhamoon, M. S., Lander, S., & Dhamoon, A.S. (2016). The MD blues: Under-recognized depression and anxiety in medical trainees. PLOS One, 11(6), e0156554. 21. Spitzer, R. L., Kroenke, K., Williams, J. B., & Löwe, B. (2006). A brief measure for assessing generalized anxiety disorder: The GAD-7. Archives of Internal Medicine, 166(10), 1092–1097. 22. Alhadi, A. N., Alateeq, D. A., Al-Sharif, E., Bawazeer, H. M., Alanazi, H., Alshomrani A. T., Shuqdar, R. M., & AlOwaybil, R. (2017). An Arabic translation, reliability, and validation of Patient Health Questionnaire in a Saudi sample. Annals of General Psychiatry, 16(1), 1–9. This work is licensed under a Creative Commons Attribution-NonCommercial 3.0 Unported License which allows users to read, copy, distribute and make derivative works for non-commercial purposes from the material, as long as the author of the original work is cited properly. https://doi.org/10.22317/jcms.v8i5.1290 23. Inoue, T., Tanaka, T., Nakagawa, S., Nakato, Y., Kameyama, R., Boku, S., Toda, H., Kurita, T., & Koyama, T. (2012). Utility and limitations of PHQ– 9 in a clinic specializing in psychiatric care. BMC Psychiatry, 12(1), 1–6. 24. Dekker, S., Krabbendam, L., Aben, A., de Groot, R., & Jolles, J. (2013). Coding task performance in early adolescence: A large-scale controlled study into boy-girl differences. Frontiers in Psychology, 27(4), 550. 25. Alaqeel, M. K., Alowaimer, N. A., Alonezan, A. F., Almegbel, N.Y., & Alaujan, F. Y. (2017). Prevalence of irritable bowel syndrome and its Association with Anxiety among Medical Students at King Saud Bin Abdulaziz University for Health Sciences in Riyadh. Pakistan Journal of Medical Sciences, 33(1), 33–36. 26. Alzahrani, A. M., Hakami, A., AlHadi, A., Batais, M. A., Alrasheed, A. A., & Almigbal, T. H. (2020). The interplay between mindfulness, depression, stress and academic performance in medical students: A Saudi perspective. PLOS One, 15(4), e0231088. 27. Alharbi, H., Almalki, A., Alabdan, F., & Haddad, B. (2018). Depression among medical students in Saudi medical colleges: A cross-sectional study. Advances in Medical Education and Practice, 9, 887–891. 28. Al-Busaidi, Z., Bhargava, K., Al-Ismaily, A., Al-Lawati, H., Al-Kindi, R., Al-Shafaee, M., & Al-Maniri, A. (2011). Prevalence of depressive symptoms among university students in Oman. Oman Medical Journal, 26(4), 235–239. 29. Iqbal, S., Gupta, S., & Venkatarao, E. (2015). Stress, anxiety and depression among medical undergraduate students and their socio-demographic correlates. The Indian Journal of Medical Research, 141(3), 354–357. 30. American Psychiatric Association. (n.d.). What is depression? https://www. psychiatry.org/patients-families/depression/what-is-depression. 31. Alatawi, A., Alghamdi, A., Albalwi, A., Altayar, M., Jalal, M., & Frah, E. A. M. (2020). Prevalence of generalized anxiety disorder (GAD) among Saudi medical students and associated risk factors. International Journal of Medical Research and Health Sciences, 5(9), 1–9. 32. Rutter, L. A., & Brown, T. A. (2017). Psychometric properties of the generalized anxiety disorder scale-7 (GAD-7) in outpatients with anxiety and mood disorders. Journal of Psychopathology and Behavioral Assessment, 39(1), 140–146. 33. Tian-Chi Quek, T., Tam, W. W., Tran, B. X., Zhang, M., Zhang, Z., Su-Hui Ho, C., & Chun-Man Ho, R. (2019). The global prevalence of anxiety among medical students: A meta-analysis. International Journal of Environmental Research and Public Health, 16(15), 2735–2753. 34. Awadalla, S., Davies, E. B., & Glazebrook, C. A. (2020). Longitudinal cohort study to explore the relationship between depression, anxiety and academic performance among Emirati university students. BMC Psychiatry, 20(1), 448. 35. Bergmann, C., Muth, T., & Loerbroks, A. (2019). Medical students’ perceptions of stress due to academic studies and its interrelationships with other domains of life: A qualitative study. Medical Education Online, 24(1), 1603526. 36. Moir, F., Yielder, J., Sanson, J., & Chen, Y. (2018). Depression in medical students: current insights. Advances in Medical Education and Practice, 9(9), 323–333. 37. Little, T. D., Rhemtulla, M., Gibson, K., & Schoemann, A. M. (2013). Why the items versus parcels controversy needn’t be one. Psychological Methods, 18(3), 285–300. 38. Moreau, M. P. (2011). The societal construction of ‘boys’ underachievement’ in educational policies: A cross-national comparison. Journal of Education Policy, 26(2), 161–180. https://www.psychiatry.org/patients-families/depression/what-is-depression https://www.psychiatry.org/patients-families/depression/what-is-depression