Depression among university students has negative effects on their academic careers, including poorer academic results, reduced productivity at work, and higher dropout rates. Moreover, depression's impact extends into adulthood, impeding social interactions and professional opportunities, and establishing a detrimental cycle of adverse outcomes. [2, 10, 11] There are many screening tools developed from the patient health questionnaire (PHQ). However, we preferred using PHQ-8 rather than PHQ-9 for two reasons. First, the ninth item in the PHQ-9 is “Thoughts that you would be better off dead or of hurting yourself in some way.” The authors of PHQ-9 (and PHQ-8) believe that excluding this item is appropriate if it will be self-administered which, in our study, it was. Second, The PHQ-8 and PHQ-9 have similar sensitivity, specificity, and positive predictive value and have a similar likelihood of predicting any depressive disorder. [12–14] Our study investigated the prevalence and potential predictors of depression among Saudi students studying internationally, which to our knowledge has not been discussed in previous literature. There were limited studies in Saudi Arabia that provided evidence about the issue of mental health among this group of population. Hence, the outcome of this study could be an important contribution to the literature, given the high prevalence of depression among university students in Saudi Arabia and the wide range of illnesses brought by depression if left untreated.[2, 6]
The results of this study revealed that out of 401 Saudi international university students, 162 (40.4%) were detected to have major depression (PHQ-8 score > 10). This is almost consistent with the study done in Bangladesh, with a prevalence of depressive symptoms in international students at 47.7%.[15] Consistent with these reports, in the UK[16], the rate of depression among international postgraduate students was 34.6%. In contrast, American international students recorded the lowest depression rate, as only 4.5% were positive for depression.[17] The results of our study offer insight into the higher rate of depression while studying abroad.
Previous history of mental illness increased the likelihood of major depression by at least 2.89-fold higher. This finding is in accordance with a report documented by Amanvermez et al. (2023)[18]. They found that after adjustment for confounders such as socio-demographic data, depressive and anxiety symptoms, and other sources of stress, international student status was positively associated with higher perceived stress, particularly in the dimensions of financial situation and health of loved ones. However, in a paper published by Jamilah et al. (2020)[15], socio-demographic characteristics such as age and marital status, as well as living condition satisfaction, problems with studies, food, homesickness, accommodation, and health were all predicted to increase the risk of developing depression. In our study, major depression did not vary significantly by gender, country of study, living status, specialty, and academic degree (p > 0.05), which did not coincide with previous reports.
Feeling like a stranger increased the likelihood of developing depression in both "sometimes" (AOR: 7.058) and "most or all time" (AOR: 5.069). Not opposing this result, several studies documented that language barriers increase the likelihood of depression among international students.[18–21] Language barriers have always been an issue among foreigners, particularly among first timers abroad who are used to speaking the native language. This contributed to the development of depression. Hence, linguistic proficiency is an important contributor to coping strategies against depression.[22]
Kabir et al. (2023) reported that international students who were suffering from financial constraints had a 2-fold higher risk of suffering from depression. Other contributing factors were living alone and living with others.[23] This corroborates the findings of Jamilah et al.[15], with approximately one-third of cases complaining of financial difficulties and health problems. Hunley (2010) also observed that having a lower level of functioning was concomitant to an increase in psychological distress and loneliness.[24] In our study, living status and years studying abroad were not seen to influence the development of depression (p > 0.05). the financial difficulties may have been mitigated for our study group by easier access to financial aid programs from the Saudi government and companies as 92.8% had financial aid programs.
Motivating factors are indispensable to coping with mental issues abroad. Supporting this view, Hu et al. (2022) asserted that effective coping strategies could link to better interaction with other cultures.[22] Supporting these reports, Zhao et al. (2021) noted that taking preventive measures more seriously could reduce the depression rate of the students. Measures such as counseling and education programs are vital to support and enhance the mental health status of students living abroad.[25] In our study, communication with family and going out with friends more frequently were factors most associated with less depression occurrence. These findings underscore the importance of social support networks in mitigating the impact of stressors and promoting mental well-being. The influence of these factors implies that institutions should emphasize creating supportive environments that encourage meaningful relationships and opportunities for social engagement among international students.
While the study contributes valuable insights into depression among Saudi students studying internationally, it is not without limitations. It suffers from sampling bias, focusing only on Saudi international students in specific countries and thus limiting generalizability. Relying on voluntary self-reported data and exclusion criteria might lead to selection bias. The cross-sectional design makes it difficult to draw causal conclusions and comprehend how depression levels change over time. The study's focus on specific risk factors might overlook other vital elements like social support and cultural adjustment. Finally, the study's temporal limitations might have missed seasonal fluctuations or long-term trends in the mental health of students studying abroad. For comprehensive and complex insights into depression among Saudi international students, these constraints must be addressed.
The study's findings carry significant implications for academic institutions, mental health professionals, and policymakers. Understanding the prevalence and determinants of depression among Saudi IUS can guide the development of targeted interventions to enhance their mental well-being. Culturally Sensitive mental health resources, awareness campaigns, and peer support programs can address the unique challenges faced by these students.