Depression, Anxiety and Stress Among International Postgraduate Students in a Uk University: A Cross-Sectional Study

Background: Little is known about the prevalence of DAS among postgraduate international students in the UK. The study aimed to determine in these students the prevalence, associated individual characteristics, life and academic challenges related to DAS and suicidal thoughts, and management strategies used by the affected students. Methods: This cross-sectional study was conducted at a large English university. Self-selected postgraduate international students, aged 20-50 years, participated through online and paper questionnaires. The World Health Organisation’s Self-Reporting Questionnaire (SRQ-20) was used to indicate the presence of DAS. Additional open questions explored social and academic challenges, and coping strategies. Results: Amongst the 289 participants, 43% (n=123) presented with DAS and 12% (n=34) experienced suicidal thoughts. In the multivariate analysis, signicant independent predictors (p ≤ 0.05) were length of stay in the UK (>3 years) and studying in a certain faculty. Signicant challenges associated with DAS included relationship issues, inadequate nances, homesickness, diculty carrying out domestic chores, problem nding a community with shared cultural/religious values, change of climate, and perceived insucient support from university staff. Coping strategies included talking to academic advisors/tutors, friends/family in the UK or their home country. Of all students with DAS and suicidal thoughts, 25% and 21%, respectively sought medical help, and 17% and 32% were on medication. Conclusion: International postgraduates had higher rates of DAS and suicidal thoughts than the UK population. A low percentage sought medical help, which has implications for service planning. A model of inuencing factors is presented, requiring future studies. of stay in the UK and studying certain subjects. Being they experienced additional and environmental challenges during their transition to a university in a foreign country which may have contributed to depression and anxiety symptoms. Additionally, postgraduate international students often represent a high-achieving group of future professionals who have not been accustomed to isolation nor poor outcomes for study or work. Acculturation, feelings of rejection and academic diculties, pre-existing mental health problems, and subsequent symptoms may account for poorer mental health outcomes. Interventions in the home countries and the host universities’ ability to identify effective strategies and implement targeted high quality support measures will help to reduce psychological stress amongst this population and improve their quality of life and academic outcomes. However, existing services were not taken up optimally pointing to the need for more complex mental health strategies that should be culturally informed and tailored around each student’s needs given the diverse background of international and furthermore postgraduate students, as well as effectively advertised and universally accessible. In order to develop targeted resources in UK universities, we need further research to understand and address the issues that affect these students. This study has made a contribution in this area. Further studies across multiple universities need to examine what mechanisms, policies and procedures are in place to respond to international students experiencing a mental health crisis and aim to monitor minimum standard policies and practice in order to intervene early by acknowledging the vulnerabilities of this large group of students. We also suggest a re-evaluation of the way the SRQ-20 questionnaire is used to screen for mental health problems, as some participants who reported suicidal thoughts had lower SRQ-20 scores than those without suicidal thoughts and some did not score for DAS at all, despite suicidal ideation being a sign of more severe depressive disorders.


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Of the participants 149 (51%) were between 20-24 years old, 255 (88%) were enrolled on taught programmes (for example masters) and 152 (52%) had lived in the UK for <1 year -with 47% having worked before commencing study in the UK. A large proportion of the respondents were female (63%), from East/Central Asia (49%), were middle-class (74%) and studied a subject relating to social science (53%).

Predictors of DAS and Suicidal Thoughts
In the univariate analysis, the following variables were associated with having DAS: length of stay in the UK >3 years and studying in a certain faculty ( Suicidal thoughts were also independently associated with staying >3 years in the UK and studying an Arts and Humanities subject. Social Factors Associated with DAS and Suicidal Thoughts Table 2A shows several social factors that were associated with having DAS in this study. On univariate analysis, those who met the criteria for DAS were signi cantly more likely (at least by a factor of 2) to report challenges pertaining to: nances, managing day-to-day chores, personal relationships, missing family and/or a support network, nding people with similar interests and adjusting to the weather. Financial constraints, and nding people with similar interests were independent factors that remained associated with DAS on multivariate analysis.

Academic Factors associated with DAS and Suicidal Thoughts
Challenging factors of an academic nature that were signi cantly associated with having DAS are shown in Table 2B. On univariate analysis, these academic challenges included: being faced with unfamiliar learning styles, con dence on critically appraising the academic literature (an integral part of postgraduate work), and low con dence levels relating to self-study and low levels of perceived staff support. Perceived staff support remained an independent variable in multivariate analysis.
Those reporting suicidal thoughts were three times more likely to report low levels of con dence in using the university library (this nding was statistically signi cant on univariate analysis).
Other Challenges that could lead to DAS The answers retrieved from the free-text sections of the questionnaires were analysed and categorised into two themes: life/social challenges and academic challenges. Three main sub-themes were then identi ed from the answers within each theme, as shown in Table 3.
The qualitative ndings echo the quantitative ndings in that studying in a different language with a large amount of self-directed learning without frequent support from academics may lead to isolation. This, together with missing home, feeling lonely and having to adjust to life in the UK, are major problems facing our international postgraduate students.

Preferred Source(s) of Support for Students with DAS and Suicidal Thoughts
We also gathered data on coping strategies used by respondents with DAS (n=123) and suicidal thoughts (n=34) to alleviate their psychological distress. As shown in Figure 2, overall, patterns were similar with the majority having spoken with close friends or families in the UK, or someone in their home countries and tutor or academic advisor. Although those with DAS were more likely to have spoken with a healthcare professional (doctor or nurse 31(25%) about their psychological distress compared with those who reported suicidal thoughts (doctor or nurse 7(21%), the use of antidepressant medication was more common amongst those who reported suicidal thoughts: 11(32%) of respondents with suicidal thoughts reported taking anti-depressant medication (only 7(21%) of whom had seen a doctor/nurse in the UK) compared with 21(17%) of those with DAS. Weather was unpredictable in the UK compared to their home countries. Struggled with attending lectures during the winter when most courses at the university commenced.
"I live a little far away from school, and it really rains a lot. Sometimes I choose to skip the lessons to stay at home because of the weather" (Female MSc student).
"The unpredictable weather and the winter stress" (Male MSc student). Limited support provided by university staff which affected their decision-making during their course work and that many attributed to very busy staff schedule.
"There are times I need to brain storm or engage in an intellectual discourse, this has not been made extremely available, the process is isolating" (Female MSc student).
"Many tutors have been really helpful, but don't really have the time to work with students one-onone...there should be more time allocated for that" (Female MSc student).
Con dent directing selflearning 24 Studying in a new language was a signi cant barrier to self-directed learning as using the internet to study and to extract useful materials online was problematic. This resulted in having limited con dence and lacking technical skills.
"English is my second language, so sometimes I have some troubles to understand the contents of textbooks and other learning materials" (Female MSc student).
"I don't know the search techniques" (Female MSc student).

Discussion
We present the ndings of a study investigating DAS in international postgraduates studying at a large UK university seeking to generate indicators of risk factors in order to guide intervention development. In this self-selected group of students, we demonstrated a DAS prevalence of 43% who scored ≥ 5 in the SRQ-20 about their situation in 'the recent days or at the current time'. Furthermore, in our study, 12% of students experienced suicidal thoughts, although only three quarters of these had DAS symptoms. This suggests that the interaction of internal and external factors contributes to the development of DAS. Surprisingly, those with a longer in the UK who may have been expected to have adjusted were at higher risk, as were those studying Arts and Humanities that may be considered less demanding compared to STEM subjects. Living in the UK as an international student posed both academic and sociocultural challenges. Sociocultural issues included nancial; coping with the new country setting; poor social support; loneliness; and feeling unwelcome, lead to students seeking support predominantly from friends and family in their home countries. Academically, despite the university providing extensive support services such as library, translation and writing for international students, a signi cant number of students with DAS or suicidal thoughts encountered major challenges such as having to adopt an independent learning style, use of library and a perception of poor staff support, and language. In spite of the ease of access to counselling and medical services at the researched university, only about 25% and 22% respectively sought these services. A number of students on medication for DAS appeared to have received these from their home countries or other sources, rather than seeing a medical doctor in the UK.

Rates of DAS and Suicidal Thoughts
Although different instruments were used for detection of DAS amongst studies of the UK general population, the DAS rate in our study is signi cantly higher than reported DAS levels amongst the UK general population (19.7% DAS prevalence using the GHQ-12 with a cut-off score of ≥ 4) (32).
However, the DAS prevalence in this study is similar to other studies of global international postgraduates. For example, an on-line survey of 551 international postgraduate students in the US, demonstrated a DAS prevalence of 44% (19). Another study of postgraduate medical trainees in Bangladesh using the Hamilton Rating Scale for Depression (HAM-D) showed 40% (33), while the prevalence was still higher among international medical postgraduates in Malaysia (54%) using the General Health Questionnaire (GHQ-28 cut-off score of ≥ 4.5) (34). Although these papers studied different subpopulations, similar DAS prevalence rates across studies can also be attributed to the relation between DAS and the academically challenging environments most international or postgraduate students face (35,36).
In terms of suicidal thoughts, the evidence is con icting and no data exists for international postgraduate students. Two studies in the USA found lower rates in postgraduates (7.3%(37) and 1.6% (20)) though these were not speci cally international students. Our rates are consistent with undergraduate studies thus far published: 12% in a medical residents in the Netherlands (38), 14% in Norwegian medical students (39), and 11.1% in American undergraduates using the PHQ-9 (40). Thus, differences may be explained by the demographics of the subpopulations studied. Moreover, international postgraduate students experiencing higher levels of DAS are likely to show higher levels of suicidal thoughts as well and social isolation, a risk factor for suicidality, may have accounted for the higher rates of suicidal thoughts (41).
In our study, a quarter of those with suicidal thoughts had lower SRQ-20 scores than those who did not report suicidal thoughts (24%). This nding is anti-intuitive, since suicidal ideation often is a symptom of emotional disorders such as DAS (42). However, SRQ-20 was designed to detect DAS and not suicidal ideation (there is only one question about suicidal ideation), and accurate prediction of suicide attempts amongst high-risk and less highrisk patients remains indistinct and relationships such as the above are not fully understood (42).

Predictors of DAS
In our study, certain factors contributed to DAS which can be said to be speci c to being a postgraduate and/or an international student. For example, Arts and Humanities students had the highest risk of DAS. This is consistent with a study of graduate students in California where increased DAS levels amongst arts students was due to factors such as career prospects after graduation (43). However, more relevant to postgraduate international students is that such courses in the UK often involve less directive teaching (leading to the need for more independent study) and less face-to-face time with academic staff compared to science courses (44,45). Quantitative and qualitative data supported students' dislike for the strong emphasis on independent study with signi cantly lower con dence in managing their own self-directed learning and showing a greater preference towards in-person tutor groups. However, respondents generally felt unsupported in their postgraduate studies. Other factors present in our qualitative data, which contributed to academic related stress included language di culties, e.g. di culties understanding a fast-paced British accent and low con dence in articulating the complexity of their academic points in English, rendering them unable to engage in many academic activities. Fear that these challenges would impact their academic success was common. Research suggests that social support and English literacy constitute signi cant protective factors against depression in students (46,47). Social support serves as a coping mechanism for stress and can override negative perceptions in periods of stress (46). Accordingly, uency in English can facilitate social interactions, friendships, cultural integration and ease homesickness.
Furthermore, such challenges (learning style, language and need for greater academic support) can lead to students questioning their own academic potential (reduced con dence) and consequently further stress and depression (48). Similar challenges were reported in an ethnographic study of international postgraduate students in the UK in 2008 (22) which found that students who were often high-achieving in their home countries where they had good communication skills and were familiar with the higher education culture struggled with new unfamiliar challenges faced in their host countries. While it may be assumed that such di culties may be resolved with time, our study demonstrated that students who stayed in the UK for > 3 years had a signi cant 3-fold higher risk of DAS when compared to others who were in the UK for < 3 years. One possible explanation could be that these are nal year PhD students with greater stress while completing their thesis (49). Alternative explanations supported by our data (including free text) may include: long-term distance from family (and social and practical support networks); problems with personal relationships; nancial issues (possibly due to long period of not earning an adequate salary and having to support family at home); racism (22); and di culty adapting to the host culture (50,51). Other studies have cited the concept of "cultural stress" which may impact the psychological wellbeing of international students, especially when the host country shares different cultural values (51,52). Cultural distance may exacerbate feelings of loneliness and isolation which are common features of depressive episodes that may come with living in an unfamiliar environment (51).
Moreover, we had a large proportion of students from South Asia and Africa for whom the cold and rain in the UK may be a challenge. Students reported stress due to the unpredictable British weather (both rainy weather and in winter months), which interrupted their journeys to university and forced some to skip academic sessions. Some may even experience a form of seasonal affective disorder (53).
The published literature has cited additional factors with increased DAS levels amongst postgraduate students, such as being married whilst at university (54) and being on a "taught" lecture-based course (in the UK this equates to masters courses with heavy work load) (55). The direction of association in our results re ected these evidence, but they were not statistically signi cant and could be due to our small sample size. Although more female students had DAS and suicidal thoughts (in line with previous studies (18,(56)(57)(58)(59)) this was also not statistically signi cant.
Therefore, in our study, the challenges speci c to the international student experience (e.g. distance from and missing home, social and practical support networks, di culty communicating in a second language, nancial and academic pressures, navigating in a different academic and sociocultural environment, predisposing mental illness, and weather) may explain the higher DAS levels amongst our international postgraduate students.

DAS and Coping Strategies
The main coping strategy used for those experiencing DAS and suicidal thoughts was speaking to friends and family; a similar proportion talked to people at home as often as in the UK. This has also been demonstrated in other studies (3,60). Recent literature supports our ndings that there is a shift in the support network of international students the longer they live in their host countries, with students relying more on home within their host countries for emotional support as their length of stay in the host country lengthens (61). Other avenues for support include from a religious counsellor, academic advisor or a healthcare professional, all of these were also reported by our population (22). Interventions provided by some universities (including the one we surveyed) include psychological support, such as offering cognitive and psychological behavioural therapies (19,62) which, though important for some of our respondents, seem not to have reached the majority who may have needed it. These ndings indicate a need for creative methods to better promote these services with the vulnerable international postgraduate students.
The question needing further research is: 1) why our respondents have not accessed academic and psychosocial support that was offered by university; and 2) whether this was because support was inadequate, inappropriate, and inaccessible (for a range of possible reasons including timing and scale of service) or that the international postgraduate students were simply unaware of them? Qualitative data on the preferred coping strategies among respondents was not obtained in our study; however, other studies report that students often did not pursue formal counselling or medical services out of fear of stigmatisation, lack of con dence in their foreign language skills, or potential prejudice against their religious and cultural beliefs (3,60). Medication use was twice as common in those with suicidal thoughts compared to those with DAS, possibly because they were more likely to have been previously diagnosed with mental health problems, which may require pharmacological treatment (63). It seems that some may have been on medication from their home country since in the UK only doctors prescribe such medications while they said they had not seen a doctor in the UK.
This points to the need for such students to be better connected with university health services in order to ensure appropriate and prompt prescribing for their mental health conditions. It is important to review the information and availability of specialist health services at the host universities and to ensure that it is appropriately communicated to the students.

A model for Factors in uencing DAS in International Postgraduates
Although further research is needed, we offer a model for predictors of DAS in postgraduate international students in order to inform practice and policy. We used previous research on international postgraduate students, psychosocial and diathesis schemas to understand the role of exogenous and endogenous factors in the development of DAS (64). Based on our own and reviewed evidence, we might reason that international students comprise a high-vulnerability/susceptible group (65) due to different characteristics (compared to under-graduate and non-international students), such as, a higher social and work status pre-enrolment on the postgraduate course, signi cantly higher familiarity with academic and other systems in their home country, a greater likelihood of being mature students with family to support and who cannot support them in the host university. Those who bring family to the host university, have the added di culty of supporting them in an unfamiliar setting in addition to studying. These constitute a combination of student, home and host country factors of exogenous and endogenous origin. These are presented in Fig. 3.
In their home countries, a greater emphasis on self-learning and independent study, management of daily chores, and English pro ciency (written, listening and speaking skills) may help protect students during their study away from home. In the host countries, measures and support that address academic and sociocultural issues in Fig. 3 may provide a supportive and protective environment against DAS.

Figure 3
Strengths and Limitations of the study A self-selecting sampling methodology could lead to response bias that could either reduce or increase the number of DAS affected students responding, as some students affected with DAS may not have wished to remind themselves of their symptoms. Conversely, a higher proportion of DAS students may have participated since they were motivated by their problems and glad to share their views, and lower proportion of those not affected may have participated as it was not a priority for them. Considering that the study was conducted during spring and summer periods, some postgraduate students may not have been available to participate due to exam periods or their studies concluding, though this seems not to introduce an inherent bias. Lastly, although the survey was anonymous, social acceptability bias may have reduced reporting symptoms, since some may have felt the nature of the topic is private.
The strengths of this study were the adoption of the cross-culturally validated SRQ-20 item questionnaire to identify DAS, exploration of possible predictors and challenges, and coping mechanisms that are associated with DAS using mixed methods, among international postgraduates in a large UK university.

Conclusion
The mental health status of university students is of great concern to public and policy makers alike (6,7). International postgraduates are an important group of students in high-income country universities and often go on to achieve positions of in uence in their home countries, particularly if they originate from LMICs. We found that international postgraduates were vulnerable to higher rates of DAS and suicidal thoughts than the general UK population and the UK born student population, which will potentially affect the former's academic performance and future outcomes. This is particularly concerning given the existing pressures on student mental health services (6, 7). This was associated with several factors including length of stay in the UK and studying certain subjects. Being international students, they experienced additional academic and environmental challenges during their transition to a university in a foreign country which may have contributed to depression and anxiety symptoms. Additionally, postgraduate international students often represent a high-achieving group of future professionals who have not been accustomed to isolation nor poor outcomes for study or work. Acculturation, feelings of rejection and academic di culties, pre-existing mental health problems, and subsequent symptoms may account for poorer mental health outcomes. Interventions in the home countries and the host universities' ability to identify effective strategies and implement targeted high quality support measures will help to reduce psychological stress amongst this population and improve their quality of life and academic outcomes. However, existing services were not taken up optimally pointing to the need for more complex mental health strategies that should be culturally informed and tailored around each student's needs given the diverse background of international and furthermore postgraduate students, as well as effectively advertised and universally accessible. In order to develop targeted resources in UK universities, we need further research to understand and address the issues that affect these students. This study has made a contribution in this area. Further studies across multiple universities need to examine what mechanisms, policies and procedures are in place to respond to international students experiencing a mental health crisis and aim to monitor minimum standard policies and practice in order to intervene early by acknowledging the vulnerabilities of this large group of students.
We also suggest a re-evaluation of the way the SRQ-20 questionnaire is used to screen for mental health problems, as some participants who reported suicidal thoughts had lower SRQ-20 scores than those without suicidal thoughts and some did not score for DAS at all, despite suicidal ideation being a sign of more severe depressive disorders. Ethics approval and consent to participate The Ethics Review Committee of the University approved the research on the 6 th of July, 2015 (Ethical Review ERN_15-0369). We con rm that all methods in this study were carried out in accordance with relevant guidelines and regulations. Informed consent was obtained from the respondents.
For students in need of support, information was provided on how to seek help in case of psychological distress. Figure 1 Scatter plot of respondents with Suicidal Thoughts Figure 2 Coping strategies used by respondents with DAS (n=123) and Suicidal Thoughts (n=34) in percentages.