Prevalence of Depression, Anxiety and Stress
as Measured by the Depression, Anxiety, and

Stress Scale (DASS-42) among Secondary
School Girls in Abha, Saudi Arabia

*Khalid S. Al-Gelban,1 Hasan S Al-Amri,2 Ossama A Mostafa1

SQU Med J, August 2009, Vol. 9, Iss. 2, pp. 140-147, Epub 30th June 2009
Submitted - 6th November 08
Revision Req. 22nd April 09, Revision Recd. 11th May 09
Accepted - 12th May 09

Departments of 1Family and Community Medicine, 2Internal Medicine, College of Medicine, King Khalid University, Abha, Saudi
Arabia

*To whom correspondence should be addressed. Email: khalidgelban@hotmail.com

clinical & basic research

Advances in Knowledge
1. Symptoms of negative emotional syndromes (depression, anxiety and stress) are highly prevalent among Saudi female secondary school

students.
2. These symptoms are higher among female than male secondary school students and do not differ significantly according to girls’

sociodemographic characteristics.

Application to Patient Care
1. It is important to screen adolescents for negative emotional syndromes and to refer those with morbid symptoms for psychiatric

consultation.
2. School health unit staff and primary health care physicians can play a major role in the diagnosis and management of mental

disorders.

مدى انتشار االكتئاب والقلق والكرب النفسي )طبقا
ملقياس داس-42( بني طالبات املرحلة الثانوية يف مدينة

أبها باململكة العربية السعودية
خالد سعد آل جلبان، حسن سعيد العمري، أسامة عبد الرحمن مصطفى

امللخص: الهدف: قياس مدى انتشار أعراض االكتئاب والقلق والكرب النفسي بني طالبات املرحلة الثانوية. الطريقة: أجريت دراسة مقطعية على
طالبات املرحلة الثانوية في مدينة أبها، مبنطقة عسير، باململكة العربية السعودية باستخدام النسخة العربية من مقياس داس-42 لقياس االكتئاب
والقلق والكرب النفسي. النتائج :مت إدراج 545 طالبة في هذه الدراسة، التي أظهرت أن %73 من الطالبات لديهن أعراض أحد االعتالالت الثالثة
حتت الدراسة على األقل، بينما %50.1 منهن لديهن أعراض العتاللني أو أكثر. كانت نسبة انتشار أعراض االكتئاب والقلق والكرب 41.5%، 66.2%
والكرب والقلق االكتئاب أن الدراسة الشدة. أظهرت متوسط إلى بسيط من معظمها في االعتالالت هذه درجات التوالي. كانت %52.5 على و
مترابطة مع بعضها إيجابيا بدرجة إحصائية ذات قيمة عالية. لم تظهر الدراسة ارتباطا بني اخلصائص االجتماعية للطالبات ومدى انتشار أعراض
االعتالالت الثالثة التي متت دراستها. اخلالصة: أظهرت هذه الدراسة أن القدرة على تشخيص وعالج األمراض النفسية الشائعة بني طالبات املرحلة

الثانوية يجب أن تكون من أولويات أطباء الرعاية الصحية األولية.

مفتاح الكلمات: داس -42 ، اكتئاب ، قلق ، كرب نفسي، مراهقني ، بنات املدارس الثانوية ، اململكة العربية السعودية.

abstract: Objectives: To determine the prevalence of symptoms of depression, anxiety and stress among secondary
school girls. Methods: A cross- sectional study was carried out on secondary school girls in Abha city, Aseer Region,
Saudi Arabia, using the Arabic version of the Depression, Anxiety, and Stress Scale )DASS-42(. Results: Of 545
female students recruited in this study, 73.4% had the symptoms of at least one of the three studied disorders; 50.1%
had at least two disorders. The prevalence of symptoms of depression, anxiety and stress was 41.5 %, 66.2% and 52.5%
respectively. The majority of symptoms were mild to moderate in severity. The scores for depression, anxiety, and stress
were positively and significantly correlated. No significant association was found between the girls’ sociodemographic
characteristics and the scores of the three studied disorders. Conclusion: One of the most important aspects of a
primary care physician’s care of females is to screen for and treat common mental disorders.

Keywords: DASS-42; Depression; Anxiety; Stress; Adolescent; Secondary school girls; Saudi Arabia.

Khalid S Al-Gelban, Hasan S Al-Amri and Ossama A Mostafa

Clinical and Basic Research | 141

Adolescence (11-21 years old) is a transitional stage from childhood to adulthood.1,2 During this stage, many
psychological changes take place.1-3 Psychiatric
disorders in this period constitute a major
public health concern and can result in serious
consequences.1,2 Research has shown that the
majority of adult sufferers of mental disorders
indicate that their symptoms began in childhood
and adolescence.1-3 The appropriate identification
and treatment of mental disorders in this period
provide teenagers with immediate positive benefits,
and serve to counteract consequences such as
poor academic performance, substance abuse and
suicidal behaviour.3-6

Globally, Roberts et al.7 reported that the
prevalence rates of mental disorders among children
and adolescents range from 1% to 51% with a mean
rate of 15.8% for adolescents. In the USA and
Australia, one in five teenagers suffers from mental
health problems.8, 9 In developing countries, the
prevalence of mental disorders among adolescents
attending primary health care facilities ranges
between 12% and 29%.10 Several studies indicate
that prevalence rates of the individual disorders:
depression, anxiety and stress are growing among
adolescents.8, 9, 11 Harrington and Clark12 reported
that 60% of adolescents experience depressive
symptoms. An earlier study on Saudi secondary
school boys indicated that 38.2% had depression,
while 48.9% experienced anxiety and 35.5% suffered
from stress.13

The Saudi community is undergoing great
economic and social changes. It has a young
population, with 60% under 30 years old, and 47%
under 15 years;14 however, very little is known about
the extent of psychiatric illnesses among Saudi
female adolescents. Therefore, this study aimed to
evaluate the extent of depression, anxiety, and stress
among secondary school girls in Abha City, Saudi
Arabia.

Methods
This cross-sectional study was conducted during
the school year, in October 2007, in Abha, the
capital city of Aseer Region, in the southwest of
Saudi Arabia with a total population of 300,000.

Through the School Health Unit for Girls
(SHU-G), all secondary schools for girls located in
Abha City (n=10) were invited to participate in this
study. Principals and directors of these schools were
provided with the important information about
this study. All of them agreed to cooperate and to
participate.

In Saudi Arabia, general education of children
starts at 7 years old. Girls have separate schools from
boys. Each secondary school has three teaching
levels, which represent the 10th, 11th, and 12th years
of education.

Data were collected using the Arabic version of
the Depression Anxiety Stress Scale (DASS),15 while
demographic and environmental data, as well as the
presence of associated psychological factors, were
collected via a questionnaire devised for the study.
The DASS-42 is used for data collection to assess the
negative emotional symptoms among students. It is
a 42-item self-report inventory designed to measure
the presence and severity of symptoms of depression,
anxiety and stress among people as young as 12
years of age.15 This scale was psychometrically
validated to the Arabic culture by Taouk et al.16

This screening and outcome measure reflects the
experience of the person over the previous 7 days.
Gamma coefficients that represent the loading of
each scale on the overall factor (total score) are 0.71
for depression, 0.86 for anxiety, and 0.88 for stress.
One would expect anxiety and stress to load higher
than depression on the common factors as they are
more highly correlated and, therefore, dominate
the definition of this common factor. The reliability
of the test is considered adequate and test-retest
reliability is likewise considered adequate with 0.71

Table 1: Scoring and grading of the Depression, Anxiety and Stress Scale (DASS)15

Category Depression Anxiety Stress
Normal 0-9 0-7 0-14
Mild 10-13 8-9 15-18
Moderate 14-20 10-14 19-25
Severe 21-27 15-19 26-33
Extremely severe 28+ 20+ 34+

Prevalence of Depression, Anxiety and Stress as Measured by the Depression, Anxiety, and Stress Scale (DASS-42) among
Secondary School Girls in Abha, Saudi Arabia

142 | SQU Medical Journal, August 2009, Volume 9, Issue 2

for depression and 0.79 for anxiety. Exploratory and
confirmatory factor analyses have sustained the
proposition of its factors (p <0.05).15 Table 1 shows
the scoring and grading of the DASS.

At each school, one classroom from each year
level was selected by simple random sampling. Prior
to administration of the questionnaire, the purpose
of the study was briefly and clearly described to
the students. They were informed that they could
choose not to participate and were assured of the
full confidentiality of their data. A total of 545
secondary school girls participated in this study,
their age ranged from 14-20 years with an average
of 17.13 ±1.12 years and a median of 17.0 years.

Data were collected by 4th year trained female
medical students (n=20), under the supervision of
their college professors (n=5). These medical students
were trained on practical research methodology, as
a part of their community medicine course.

Statistical analysis was conducted by the staff
of the Department of Family and Community
Medicine, College of Medicine, King Khalid
University, using the Statistical Package for the
Social Sciences (SPSS, Version 15 for Windows).
The significance of differences was tested using the
χ2 test at the 5% level of probability significance.
Students who obtained high DASS scores (i.e. severe
or extremely severe symptoms) were referred to
the research psychiatrist to confirm the diagnosis
and to provide proper psychiatric consultation and
management.

Results
Table 2 shows the distribution of students’ age
groups and scholastic years. About 60% of the

students were enrolled in the 2nd and 3rd year, while
40.2% were enrolled in the first year.

Table 3 shows that the majority of girls lived
with both their parents (89.0%). The most frequent
level of education among fathers was university
education (39.4%), while only 7.9% were illiterate.
On the other hand, the most frequent mothers’
education level was primary education (29.9%)
followed by illiterates (28.3%). The most frequent
fathers’ occupations of the studied sample were
retired or currently not working (34.5%) followed
by governmental civil employee (29.7%), while most
mothers were housewives (87.9%).

Table 4 shows that 73.4% of the girls had at least
one of the three studied disorders (depression,
anxiety or stress). Moreover, 50.1% of subjects had at
least two disorders, and more than one-third of the

Table 2: Distribution of secondary school girls in Abha,
Saudi Arabia according to their age, scholastic year and
type of study (n=545)

Student characteristics No. %
Age groups (in years)
14-15
16- 17
18- 20

22
333
190

4
61.1
34.9

School year
First year 219 40.2
Second year 163 29.9
Third year 163 29.9
Total 545 100

Table 3: Socio-demographic characteristics of
secondary school girls, Abha, Saudi Arabia (n=545)

Characteristics No. %
Parents’ status
Living within the family 485 89.0
Divorced/separated 24 4.4
Deceased father 28 5.1
Deceased mother 5 0.9
Both parents deceased 3 0.6
Father’s education
Illiterate 43 7.9
Primary 87 16.0
Intermediate 93 17.1
Secondary 107 19.6
University 149 27.3
Postgraduate 66 12.1
Father’s employment
Unemployed 25 4.6
Military 89 16.3
Governmental employee 162 29.7
Private business 106 19.5
Retired 163 29.9
Mother education
Illiterate 154 28.3
Primary 163 29.9
Intermediate 88 16.1
Secondary 69 12.7
University 54 9.90
Post graduate 17 3.10
Mother’s employment
Housewife 479 87.9
Employed 66 12.1

Khalid S Al-Gelban, Hasan S Al-Amri and Ossama A Mostafa

Clinical and Basic Research | 143

students (35.5%) had all the three disorders under
study. Depression, anxiety, and stress were found in
41.5 %, 66.2% and 52.5% of the subjects respectively.
Table 5 reveals that depression, anxiety, and stress
were positively and significantly correlated. Table
6 shows that the prevalence of symptoms of
depression, anxiety and stress among secondary
school girls did not differ significantly according to
their sociodemographic characteristics.

Discussion
DASS-42 was utilised in this research.15,16 It has
the advantage that it can discriminate between the
negative emotional symptoms of depression, anxiety,
and stress; it is suitable for screening adolescents as

young as 12 years of age; it is freely available in the
public domain, and it is a short and easily answered
questionnaire.

The present study indicated high prevalence
rates for symptoms of depression, anxiety and
stress among Saudi secondary school girls. About
10% of students showed severe or extremely severe
symptoms of depression and stress while 25% of
them showed severe or extremely severe symptoms
of anxiety.

Moreover, results revealed that about 75% of the
female Saudi secondary school students reported
the symptoms of at least one of the three studied
disorders. This is higher than those reported
by several national, regional and international
studies7-10,12,13,17,18 A review of the literature reveals
a considerable disparity in figures on the prevalence
of psychiatric disorders in adolescents. This could
be due to the diversity in methods, definitions
used, or geographical locations.7 In 1998, Robert
et al.,7 reviewed 52 studies carried out in over 20
countries over the past four decades, and found that
prevalence estimates of psychopathology ranged
from 1 to 51%, (mean 15.8%), with a median rate of
15% among adolescents. In Taif City, Saudi Arabia,
Abdel-Fattah et al.17 reported that 8.3% of male
pupils in primary and secondary schools (5.6% of the
sample was adolescent) were emotionally disturbed
as measured by the Child Behavior Checklist
“parent form”. Using the “Child Behavior Checklist”,
Eapen et al.18 conducted a study on schoolchildren
aged 6 to 15 years in the United Arab Emirates, a
neighbouring country which has a similar culture to
Saudi Arabia, and found that 23.9% of children had
a mental health problem. The prevalence estimate
for behavioural disorders was 16.5%.

Of the individual disorders, anxiety was the
most prevalent (66.2%), followed by stress (52.5
%), then depression (41.5%). This finding is in
agreement with that of Pelcovitz et al.,19 who found
that anxiety disorders are the main psychiatric

Table 5: Correlation matrix between severities of depression, anxiety, and stress among secondary school girls, Abha,
Saudi Arabia (n =545)

Depression Anxiety Stress
r p-value r p-value r p-value

Depression -- -- 0.693 < 0.001 0.691 < 0.001
Anxiety 0.691 < 0.001 -- -- 0.728 < 0.001
Stress 0.694 < 0.001 0.728 < 0.001 -- --

Table 4: Prevalence and intensity of Depression,
Anxiety, and stress among secondary school girls, Abha,
Saudi Arabia. (n=545)

Psychological traits No. %
Depression 226 41.5
Mild 92 16.9
Moderate 77 14.1
Severe 39 7.20
Extremely severe 18 3.30
Anxiety 361 66.2
Mild 75 13.8
Moderate 144 26.4
Severe 81 14.8
Extremely severe 61 11.2
Stress 286 52.5
Mild 108 19.8
Moderate 114 20.9
Severe 50 9.20
Extremely severe 14 2.60
Morbidity
One symptom or more 400 73.4
More than one symptom 273 50.1
Free of symptoms* 145 26.60
Total 545 100

*Depression, anxiety or stress

Prevalence of Depression, Anxiety and Stress as Measured by the Depression, Anxiety, and Stress Scale (DASS-42) among
Secondary School Girls in Abha, Saudi Arabia

144 | SQU Medical Journal, August 2009, Volume 9, Issue 2

Table 6: Prevalence of depression, anxiety and stress among secondary school girls according to their
sociodemographic characteristics (n=545)

Depression Anxiety Stress
Normal Depression

p Value
Normal Anxiety

p Value
Normal Stress

p Value
No. % No. % No. % No. % No. % No. %

Age groups (in years)

14-15 15 68.2 7 31.8 - 7 33.3 14 66.7 - 12 54.5 10 45.5 -
16-17 195 59.3 134 40.7 - 106 32.2 223 67.8 - 153 46.8 174 53.2 -
18-19 109 58.9 76 41.1 0.697 71 38.6 113 61.4 0.345 94 50.3 93 49.7 0.627
School year

First 126 58.3 90 41.7 - 71 32.9 145 67.1 - 103 48.1 111 51.9 -
Second 93 57.4 69 42.6 - 55 34.6 104 65.4 - 70 42.9 93 57.1 -
Third 100 63.3 58 36.7 0.507 58 36.5 101 63.5 0.767 86 54.1 73 45.9 0.135
Parents’ status

Living within the family 288 60.4 189 39.6 - 163 34.3 312 65.7 - 234 49.1 243 50.9 -
Divorced/separated 10 43.5 13 56.5 - 11 47.8 12 52.2 - 9 39.1 14 60.9 -
Deceased father 15 53.6 13 46.4 - 7 25.0 21 75.0 - 13 46.4 15 53.6 -
Deceased mother 4 80.0 1 20.0 - 1 20.0 4 80.0 - 1 20.0 4 80.0 -
Both parents deceased 2 66.7 1 33.3 0.413 2 66.7 1 33.3 0.311 2 66.7 1 33.3 0.569
Father’s education

Illiterate 26 60.5 17 39.5 - 19 44.2 24 55.8 - 24 57.1 18 42.9 -
Primary 37 43.0 49 57.0 - 22 25.9 63 74.1 - 36 41.4 51 58.6 -
Intermediate 53 58.2 38 41.8 - 19 20.7 73 79.3 - 40 43.5 52 56.5 -
Secondary 68 65.4 36 34.6 - 43 41.7 60 58.3 - 54 52.4 49 47.6 -
University 94 63.9 53 36.1 - 58 39.5 89 60.5 - 73 49.7 74 50.3 -
Postgraduate 41 63.1 24 36.9 0.125 23 35.9 41 64.1 0.106 32 49.2 33 50.8 0.457
Mother’s education

Illiterate 56 36.6 97 63.4 - 76 49.7 77 50.3 - 11 45.8 13 54.2 -
Primary 52 32.5 108 67.5 - 89 55.3 72 44.7 - 49 55.1 40 44.9 -
Intermediate 25 29.1 61 70.9 - 37 42.5 50 57.5 - 88 55.3 71 44.7 -
Secondary 25 36.2 44 63.8 - 26 38.2 42 61.8 - 65 61.9 40 38.1 -
University 20 40.0 30 60.0 - 22 43.1 29 56.9 - 106 66.7 53 33.3 -
Postgraduate 6 37.5 10 62.5 0.772 9 56.3 7 43.8 0.150 319 59.5 217 40.5 0.118
Father’s occupation

Unemployed 11 45.8 13 54.2 - 8 32.0 17 68.0 - 13 52.0 12 48.0 -
Military 49 55.1 40 44.9 - 31 35.2 57 64.8 - 45 51.7 42 48.3 -
Governmental employee 88 55.3 71 44.7 - 52 33.1 105 66.9 - 66 41.5 93 58.5 -
Private business 65 61.9 40 38.1 - 39 37.1 66 62.9 - 54 51.4 51 48.6 -
Retired 106 66.7 53 33.3 0.118 54 34.0 105 66.0 0.967 81 50.6 79 49.4 0.375
Mother’s employment

Housewife 289 61.4 182 38.6 - 165 35.0 306 65.0 - 236 50.1 235 49.9 -
Employed 30 46.2 35 53.8 0.119 19 30.2 44 69.8 0.483 23 35.4 42 64.6 0.126

diagnosis in adolescents. In a previous study on
Saudi male adolescents, symptoms of anxiety were
the most prevalent (48.9%), followed by depression
(38.2%), then symptoms of stress (35.5%).13 These
high prevalence rates of symptoms of depression,
anxiety and stress among Saudi female students
can be attributed to the increasing stresses on
Saudi females related to the social and cultural

transformations in Saudi society. In addition,
choosing a career has grown more difficult as the
job market for women has become more complex.
Furthermore, high psychological distress among
students can be related to their study problems
during the secondary school study period.

In agreement with previous studies, where
comorbidity among adolescents ranged from 25%

Khalid S Al-Gelban, Hasan S Al-Amri and Ossama A Mostafa

Clinical and Basic Research | 145

to 68 %,20,21 the comorbidity in this study was 50.1%.
Psychiatric morbidity and comorbidity among girls
in this study is higher than that reported in a study
of 1,723 Saudi secondary school boys in the same
region using the same methodology where 59.4%
had at least one of the three disorders, (38.2%) had
depression, while 48.9% had anxiety and 35.5% had
stress.13 In a study conducted at four primary care

clinics affiliated to university hospitals throughout
the eastern United States, women were more likely
than men to have at least one mental disorder (43%
versus 33%; p <0.05). Psychiatric comorbidity was
also more common in women (26% of women had
two or more mental disorders versus 15% of men,
p <0.05).22

Unlike previous studies19,23,24 this research

Table 6: Prevalence of depression, anxiety and stress among secondary school girls according to their
sociodemographic characteristics (n=545)

Depression Anxiety Stress
Normal Depression

p Value
Normal Anxiety

p Value
Normal Stress

p Value
No. % No. % No. % No. % No. % No. %

Age groups (in years)

Housewife 289 61.4 182 38.6 - 165 35.0 306 65.0 - 236 50.1 235 49.9 -
Employed 30 46.2 35 53.8 0.119 19 30.2 44 69.8 0.483 23 35.4 42 64.6 0.126

Prevalence of Depression, Anxiety and Stress as Measured by the Depression, Anxiety, and Stress Scale (DASS-42) among
Secondary School Girls in Abha, Saudi Arabia

146 | SQU Medical Journal, August 2009, Volume 9, Issue 2

failed to find any association between
psychiatric morbidity and the socio-demographic
characteristics of the participants. In a study of
8,934 Norwegian adolescents, those with a family
history of divorce and parental distress were more
vulnerable to symptoms of anxiety than those
without such distress.24 Vazsony looked at 6,935
adolescents from Hungary, Switzerland and the
United States and found that increased anxiety
occurred in the presence of extreme maternal and
paternal closeness to the adolescents, possibly
caused by parental over intrusiveness.

The World Health Organization (WHO)25 noted
that there are increasing numbers of people in
the Eastern Mediterranean Region, who are now
entering the age of risk for development of mental
disorders, i.e. adolescence/early adulthood and old
age. Existing conditions of social and physical strife
provide fertile grounds for an upsurge in mental
health problems and their consequences such as
suicide and substance dependence. The school
environment can offer an excellent opportunity
to promote sound principles of mental health and
healthy lifestyles. Consequently, further national
studies are needed to explore the ability of school
health unit staff and primary health care physicians
to diagnose and manage mental disorders.

l i m i tat i o n s

This study has the following limitations: it was
performed exclusively in the City of Abha, hence,
its results exclusively reflect the psychiatric status
of urban adolescents; it was restricted to female
students only, which prevented the determination
of sex-specific prevalence rates; it was a school-
based study, which might therefore miss adolescents
in the community who do not attend school. In
addition, there is no built-in lie scale in DASS, as
it is just a self-reporting data collection tool (with
triangulation). Finally, no information on suicidal
ideation can be picked up in DASS.

Conclusion
The present study confirms the high prevalence of
depression, anxiety, and stress among Saudi female
adolescent students. The challenges ahead include
the need to carry out extensive further research,
and to develop national intervention programmes
to promote mental health.

Acknowledgments
The authors would like to thank 4th year female
medical students for collecting the data and their
professors at the Department of Family and
Community Medicine, College of Medicine, King
Khalid University, Saudi Arabia for their great help
in supervising the data collection and conducting
the statistical analysis.

conflict of Interest
The authors report no conflit of interest.

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