Mental health is an integral component of the individual’s well-being. Many mental health disorders appear at a young age and accessing mental health services is a preliminary and essential step for the treatment. Multiple barriers could delay or hinder help-seeking; untreated mental health problems could leave negative imprints on later stages of life and reduce the involvement in salient cognitive, emotional, and social activities [16]. This study aimed at recognizing the most frequent mental disorders among medical students in Egypt and identifying the major barriers that deter them from seeking professional help.
Our study revealed that depression, anxiety, and OCD were the most diagnosed disorder among our sample with a relative frequency of 14.9%, 12.1%, and 6.3%. Almost a quarter of the participants (23.4%) were previously diagnosed with one or more mental disorders, in contrast to the 16.9% prevalence in the general Egyptian population. The gap between the results could be attributed to the time difference, as this nationwide survey was conducted in 2003 [17]. But previous studies have highlighted that university and medical students experience a higher level of psychological distress compared to the general population [3], [18].
Of the top major barriers, the first three were altitudinal, while the fourth was stigma-related. Although many studies yielded the stigma as the most major barrier [11], our study results come in line with previous studies conducted on the young generation where the most major barriers were attitudinal and the stigma barriers were of less concern to the young population [9], [16]. This could be explained by the awareness among the medical students as they are medically literate. Another possible explaining factors are the ongoing endeavor and the anti-stigma campaigns that might have mitigated the burden of stigma among the younger generations in developed and developing countries [19], [20].
The first major barrier was "I want to solve the problem on my own” with a 41.2% percentage. It reflects a self-reliance tendency that is noticeably observed, with similar frequencies, by my many studies conducted on the young generation from different countries to detect the barriers of help-seeking [9], [11], [19]. The same barrier was commonly reported by a third of the youth with a higher degree of depression and suicidality in one study [21] and the fifth in another [16]. Possible explanations could be provided; young people aspire to hold more responsibility for their health problems, aiming for acquiring more strength and weakness avoidance [22], [23]. Besides, the majority of the Egyptian students in a previous study showed dissatisfaction with the provided mental health care system [24]; this might urge them to search for alternative solutions. Almost 85% of Egyptian medical students showed a preference to use a trusted national internet mental health platform if available, and more than 73% have used the internet to self-educate about mental health [25]. The advent of social media has played a role in changing the patterns of help-seeking; a review showed that social networking websites are highly used internationally among young people for mental health literacy [26].
“Dislike of talking about my feelings, emotions, or thoughts”, was the second major barrier. The lack of trust and confidentiality might be justifying as it carries a risk of breach and stigma [11]. The fear of not being taken seriously and the public image was reported by the fifth of our study participants. Those internal fears may impede communication opportunities with peers and family members and discourage students from seeking professional help [27]. Interestingly in a previous multicentric study, The Egyptian university students scored lower on the scale of interpersonal openness compared to other Arabic counterparts from the middle east, which could be explanatory for more than a third of our sample didn’t like to share their personal distresses with others [28].
The third major barrier was the concern that they thought that the problems would get better by themselves. This finding is consistent with other publications; one study revealed that the most common reasons for not seeking any help were viewing stress as normal, no need is required, and that problems will get better by themselves [29]. The normalization of mental health problems could lead to serious consequences due to undermining severe conditions; in a previous study on students who were at a high risk of suicide, 66% reported viewing their problems as minor or transient as the most concerning barrier [16].
“What my family might think, say, do, or feel” was the fourth major barrier in this study.
In Egypt, like other Arabic countries, the society has a collectivist culture where family plays a central role in individual lives and choices. Stigma against the individual could have negative consequences on the family as a whole. In Egyptian culture, the family is held responsible for giving care to its sick members as an alternative to hospital or institutional confinement [30]. As negative as it seems, this could be utilized for designing family involvement programs for psychoeducation, directed by previous literature [31].
In our study, having a history of previous mental health disease was associated with personal and family factors; the personal factors included age, grade achievement, and order among siblings. Interestingly, the relative frequency of the previous diagnosis was higher among females, but not statistically significant. Similar findings from different countries were reported in other studies where gender didn't have an effect [32]–[34] but other studies demonstrated significant differences between male and female medical students. In Egypt, a previous study from Fayoum University found a significant difference between both male and female medical students in anxiety and no difference in depression [35], an opposite finding was reported in another study from Mansoura University [36]. Globally, A large systematic review including 129123 medical students, highlighted the inconsistent findings regarding sex and depression [7]; another systematic review highlighted similar inconsistency for anxiety [37]. Consequently, no firm conclusion could be drawn regarding sex, which could be traced back to due to the interference of various social, cultural, and biological factors [38].
In addition, the presence of previous mental health diagnoses was associated with a positive family attitude and support. Previous studies showed that families with members having a mental illness are more likely to have higher mental health literacy [2], [39], [40], more positive attitudes towards mental illness, and hold less stigmatizing views. As a result, members benefit more from the treatment [27], [41]. This might be a consequence of familiarity with the mental illness that leads to higher levels of knowledge [42], [43].
This study revealed that positive parents’ attitude toward mental was associated with a higher educational level. This comes in accordance with other studies highlighting a positive relationship between the educational level and the attitude toward mental health[44]. In the Arab world, where the majority has a negative portrayal of mental disease [45], education could play a vital role in changing how people perceive mental health. A higher level of education is proven to ameliorate the attitude toward mental health [46], [47]. Moreover, parental education could impact the mental health integrity of their offspring; some studies demonstrated that medical students of parents with higher educational levels have a lower likelihood of developing depression and anxiety in medical students [48], [49].
Some limitations should be taken into consideration while interpreting the study results: males were underrepresented in the study, and the participants were reached online by snowball and convenience sampling which eliminated those with internet inaccessibility imposing a risk of bias. In addition, the study is below the calculated sample size by 30 responses. However, this study is strengthened by other elements. This is the first cross-sectional study in Egypt investigating the mental health help-seeking barriers among medical students at different Egyptian universities. The study included a large sample size representing different socioeconomic levels from rural and urban areas in upper and Lower Egypt and coming from families with variable educational levels.
This study could have multiple implications to be considered by the stakeholder and researchers working in the field of mental health. The self-reliance tendency in the young generation needs to be investigated through more research to be better understood, but on the other hand, it could be utilized to build self-help programs that endow the young generation with educational and interventional tools from mental health workers and advising them on the degree of disorders where the help-seeking is necessary. The attitude of disliking to talk about one’s emotions is needed to be changed to increase emotional openness and foster communication opportunities. As demonstrated by this study and others, the pivotal role that family plays in the student’s life could be deployed by psychiatrists through family psychoeducation and intervention as adjunctive in the therapeutic process.