Depression, Anxiety and Stress Among University Students in Pakistan: New Evidence

Depression, anxiety and stress among university students in Pakistan are not problems confined to medical education. New evidence from a 2026 BMC Psychology study of 602 undergraduate students in Lahore found that non-medical students reported higher depressive and anxiety symptoms than medical students after adjustment for measured characteristics, while stress scores did not differ significantly by academic discipline. The findings suggest that university mental health strategies should focus on the entire student population rather than assuming that one academic group carries most of the burden.

By Taimoor Asghar

Why student mental health in Pakistan deserves closer attention

University life coincides with a demanding developmental period. Students may be managing academic workloads, examinations, changing social networks, financial pressures, uncertainty about employment, family expectations and decisions about their future. Some also experience disrupted sleep, relocation away from family, relationship difficulties or previous mental health problems.

Depression, anxiety and stress are related but not interchangeable experiences. Depressive symptoms may include persistent low mood, loss of interest, problems with concentration, feelings of worthlessness, changes in sleep or appetite and reduced energy. Anxiety may involve excessive fear, physiological arousal or persistent apprehension. Stress can present as difficulty relaxing, irritability, tension and feeling overwhelmed.

These experiences also occur on a continuum. A questionnaire score can identify elevated symptoms, but it does not automatically establish a psychiatric diagnosis. That distinction is particularly important when discussing research conducted with self-report screening instruments.

Pakistan has a large and diverse university population, yet much of the student mental health literature has historically concentrated on medical students. Medical education is undoubtedly demanding, but focusing almost exclusively on medical trainees can create a misleading impression that students in other disciplines are comparatively protected.

The new evidence from Lahore provides a useful challenge to that assumption.

What the new Pakistani study examined

The study, published in BMC Psychology in August 2026, was titled Psychometric properties and symptom profiles of the PHQ-9 and DASS-21 among medical and non-medical university students: a cross-sectional study in Pakistan. The research included 602 undergraduate students from universities in Lahore: 424 medical students and 178 non-medical students.

Readers can access the published BMC Psychology study on PHQ-9 and DASS-21 symptom profiles among Pakistani university students.

The research had two related aims. First, it examined whether depressive, anxiety and stress symptoms differed between medical and non-medical students. Second, it evaluated how two widely used psychological instruments—the Patient Health Questionnaire-9 (PHQ-9) and Depression Anxiety Stress Scales-21 (DASS-21)—performed within this student population.

The analysis went beyond simply comparing average questionnaire scores. It included multivariable regression, confirmatory factor analysis, item response theory, measurement invariance testing and symptom network analysis. This allowed the researchers to examine not only which groups reported more symptoms but also how well individual questionnaire items and psychological constructs behaved statistically.

Medical students did not have the highest depressive symptoms

One of the clearest findings challenges a common assumption about university mental health.

Non-medical students had a median PHQ-9 score of 10 compared with 9 among medical students. The difference remained statistically significant in the adjusted analysis. Non-medical students also had higher adjusted scores on the DASS-21 depression and anxiety domains.

The direction of these results matters. Medical students are frequently portrayed as the university population most vulnerable to psychological distress because of long training periods, demanding examinations and exposure to illness and clinical responsibility. Those pressures are real, but the Pakistani study indicates that they should not lead universities to overlook students studying other subjects.

Non-medical students can face their own substantial pressures. Career uncertainty, financial concerns, academic competition and questions about employment after graduation may contribute to psychological distress. The present study was not designed to determine precisely why the differences occurred, so these possible explanations should be treated as hypotheses rather than established causes.

More importantly, the statistical models explained only a small proportion of the variation in symptom scores. The reported R-squared values were approximately 0.029 to 0.041. In practical terms, academic discipline and the other variables included in these models captured only a limited part of the complexity underlying student mental health.

This is an important caution against turning the finding into a simplistic claim that non-medical students are inherently more depressed or anxious. The study showed a group-level association in this sample, not a universal rule about individual students.

Stress showed a different pattern

The DASS-21 stress results provide another useful reminder that depression, anxiety and stress should not automatically be treated as identical outcomes.

Although non-medical students had significantly higher adjusted depression and anxiety scores, the difference in DASS-21 stress scores between academic groups was not statistically significant. The adjusted discipline coefficient for stress was reported with a p-value of 0.089.

This means the evidence did not support a clear discipline-based difference in stress at the conventional statistical threshold used in the analysis.

The finding also illustrates why researchers benefit from measuring several dimensions of psychological distress rather than using one general mental health label. Two student groups can differ in depressive or anxiety symptoms without showing the same pattern for stress.

Female students reported higher symptoms across all domains

Gender was one of the more consistent associations identified in the study. Female students had higher scores across the PHQ-9 and all three DASS-21 domains—depression, anxiety and stress—with the reported associations reaching statistical significance.

This finding can help identify populations that may require particular attention, but it should be interpreted carefully. A cross-sectional survey cannot establish the mechanisms responsible for a gender difference. Biological, psychological, socioeconomic and cultural influences may all contribute, and the relative importance of those influences was not determined by this study.

The practical implication is therefore not that every female student is at greater individual risk than every male student. Instead, universities evaluating mental health services should consider whether their screening, counselling, outreach and prevention programmes adequately reach groups that report higher symptom burdens at the population level.

Sleep was associated with depressive symptoms

Sleep also emerged as a relevant factor. In the adjusted PHQ-9 model, each additional reported hour of sleep was associated with a 0.37-point lower PHQ-9 score.

This is an association rather than proof that increasing sleep by a particular amount will produce a predictable reduction in depressive symptoms. The relationship between sleep and mental health can operate in both directions. Poor sleep may contribute to emotional difficulties, while depression and anxiety can themselves disrupt sleep.

Nevertheless, the finding reinforces the value of treating sleep as part of student wellbeing rather than merely a lifestyle issue. Academic scheduling, late-night study, commuting, digital habits and irregular routines may all influence sleep opportunities.

Universities considering mental health prevention strategies could therefore look beyond counselling alone. Education about sleep, realistic scheduling, awareness campaigns and access to appropriate professional support may form part of a broader campus wellbeing approach.

Previous depression treatment was an important marker

Among the factors examined, a history of previous depression treatment showed the strongest association with PHQ-9 scores in the reported model. Students reporting prior treatment had substantially higher current depressive symptom scores.

This result should not be interpreted as evidence that treatment causes higher symptoms. A far more plausible interpretation is that students who have previously required treatment may represent a group with a history of greater or recurrent mental health difficulties.

For university support systems, previous mental health history can therefore be an important contextual factor when assessing student needs. Continuity of care may be particularly relevant for students moving between cities, transitioning from family care to university life or losing contact with previous healthcare providers.

What PHQ-9 and DASS-21 actually measure

Two self-report instruments were central to the research, and understanding their roles helps prevent overinterpretation of the findings.

PHQ-9

The PHQ-9 is a nine-item questionnaire developed to assess depressive symptom severity. Each item corresponds to a major depressive symptom area, including mood, interest, sleep, energy, appetite, self-worth, concentration, psychomotor changes and thoughts related to death or self-harm.

The PHQ-9 is widely used in clinical and research settings because it is brief and has established evidence supporting its reliability and validity. However, it remains a screening and severity instrument. A PHQ-9 score alone should not be treated as equivalent to a clinical diagnosis of major depressive disorder.

DASS-21

The DASS-21 is a shortened version of the Depression Anxiety Stress Scales. It includes 21 items divided into three seven-item domains designed to assess depression, anxiety and tension or stress-related experiences.

Because the instrument separates these related emotional states, it can provide a broader description of psychological distress than a depression-only questionnaire. At the same time, the Pakistani study found an interesting psychometric issue: the underlying DASS-21 depression, anxiety and stress factors were very strongly correlated.

The questionnaires were reliable, but the DASS-21 domains overlapped strongly

The study reported Cronbach’s alpha values between 0.82 and 0.88 across the evaluated scales, indicating good internal consistency in this sample.

Confirmatory factor analysis also showed adequate overall fit for the conventional three-factor DASS-21 model. Reported indices included a comparative fit index of 0.954, Tucker-Lewis index of 0.948 and root mean square error of approximation of 0.052.

However, there was an important qualification. Correlations between the latent DASS-21 factors were extremely high. The depression-stress correlation was 0.939, while anxiety and stress correlated at 0.949.

These values suggest that although the questionnaire’s theoretical three-domain structure could be statistically represented, the domains were very closely related in this sample. In practical terms, depression, anxiety and stress scores may capture considerable shared psychological distress rather than three completely independent experiences.

This does not make the DASS-21 unusable. Instead, it is a reminder that subscale scores should be interpreted within the cultural and population context in which the instrument is used.

Some symptoms provided more information than others

The item response theory analysis examined how informative individual PHQ-9 items were across different levels of underlying depressive symptom severity.

Items concerning self-worth, concentration, feeling down and appetite were among those showing the strongest discrimination. The interest or anhedonia item showed the lowest discrimination parameter in the reported model.

This does not mean that loss of interest is clinically unimportant. Anhedonia remains a core feature considered in depression assessment. Instead, the result means that within this particular statistical model and student sample, some other PHQ-9 items differentiated levels of the underlying depression trait more strongly.

The distinction illustrates why psychometric research matters. Two questionnaires can have satisfactory total reliability while individual questions contribute different amounts of measurement information.

The symptom network highlighted self-worth and concentration

The study also used symptom network analysis, which treats individual symptoms as interconnected elements rather than assuming that all symptoms simply reflect a single hidden disease process.

Self-worth, concentration and downheartedness emerged among the most central nodes in the combined symptom network. Sleep, appetite and energy-related symptoms also contributed connections between domains.

Network centrality should not automatically be interpreted as proof that targeting a central symptom will improve every other symptom. The analysis was cross-sectional, so it cannot establish temporal or causal pathways.

Still, it offers an informative perspective. Students may experience mental health problems as interconnected difficulties: poor concentration can interfere with academic performance, reduced performance can affect self-worth, sleep disruption may worsen energy, and emotional distress can further impair concentration. Longitudinal research would be needed to determine how these relationships unfold over time.

Why measurement invariance matters

The researchers also tested measurement invariance across academic discipline and found support for it. This is an important technical result.

When researchers compare questionnaire scores between groups, they need confidence that the instrument is measuring approximately the same underlying construct in each group. Without that evidence, an apparent difference between medical and non-medical students could partly result from questionnaire items functioning differently across disciplines.

Support for measurement invariance strengthens the interpretation of the group comparisons by indicating that the scales operated sufficiently similarly across the medical and non-medical groups for those comparisons to be meaningful.

What the study does not prove

The findings are useful, but several limitations should shape how they are communicated.

• The design was cross-sectional. Exposure and outcome information was collected at one point in time, so causal relationships cannot be established.
• The measures were self-reported. PHQ-9 and DASS-21 responses describe reported symptoms rather than clinician-confirmed psychiatric diagnoses.
• The sample came from universities in Lahore. Results should not automatically be generalized to every university student in Pakistan, especially students in rural areas or different educational systems.
• Group sizes differed. The study included 424 medical students and 178 non-medical students.
• The regression models explained limited variance. Many relevant determinants of psychological health were therefore likely not captured by the measured variables.
• Psychometric findings are population-dependent. Item discrimination and network centrality observed in one sample may not reproduce identically elsewhere.

These limitations do not erase the findings. They define the questions the study can answer responsibly.

What universities in Pakistan can learn from the findings

The strongest practical message is that campus mental health should not be organised around the assumption that psychological distress belongs primarily to medical students.

Medical colleges certainly require appropriate mental health resources, but universities serving engineering, business, social sciences, humanities, computing and other disciplines should not be considered lower-priority settings without evidence.

A broader university mental health strategy could include several components:

• confidential and accessible counselling services;
• clear referral pathways for students requiring professional assessment or treatment;
• mental health literacy programmes that explain common symptoms without encouraging self-diagnosis;
• training for relevant staff to recognise concerning changes in student functioning;
• support for sleep health and sustainable academic routines;
• attention to students with previous mental health treatment or continuing care needs;
• periodic, ethically conducted assessment of student wellbeing across different faculties rather than concentrating surveillance on one discipline.

Screening programmes also need appropriate safeguards. Identifying elevated symptoms is only useful when institutions have clear procedures for confidentiality, follow-up, referral and management of urgent safety concerns.

Why Pakistan needs more cross-disciplinary mental health research

The present study provides evidence from 602 students, but it should be viewed as part of a larger research agenda rather than a final national estimate.

Future research could recruit students from multiple provinces, public and private universities, urban and rural settings and a wider range of disciplines. Longitudinal designs would help determine whether symptoms change across academic years, examination periods, clinical transitions or graduation.

Researchers could also investigate potentially modifiable contributors such as financial strain, loneliness, physical activity, commuting, family expectations, digital media use, academic workload, employment uncertainty and sleep patterns.

Another priority is culturally sensitive measurement. A questionnaire developed and validated internationally can still behave differently in a particular language, culture or educational population. The very high correlations between the DASS-21 latent factors in this study demonstrate why local psychometric evaluation should accompany prevalence research.

The broader message from the new evidence

The study changes the emphasis of the discussion more than it changes the fundamental concern.

Psychological distress among university students remains important, but the evidence argues against assuming in advance where that distress will be greatest. In this Lahore sample, non-medical students had higher adjusted depressive and anxiety symptoms than medical students. Stress did not significantly differ by academic discipline. Female students reported higher symptoms across measured domains, sleep was associated with PHQ-9 scores, and previous depression treatment identified a group with substantially greater current depressive symptoms.

At the same time, academic discipline explained only a small amount of the overall variation. Student mental health is more complicated than a medical-versus-non-medical comparison.

The most defensible conclusion is therefore a broad one: universities should make mental health support accessible across faculties, evaluate needs with reliable tools, interpret screening scores carefully and avoid overlooking students simply because their academic discipline is not traditionally viewed as psychologically demanding.

Frequently asked questions

Are Pakistani medical students more depressed than non-medical students?

Not in this 2026 Lahore study. Non-medical students had a higher median PHQ-9 score and higher adjusted depressive symptom scores. However, the study was cross-sectional and conducted in a specific university sample, so it should not be interpreted as proving that non-medical students are always more depressed throughout Pakistan.

Did non-medical students also report more anxiety?

Yes. The adjusted DASS-21 anxiety score was higher among non-medical students in the study. The academic-group difference in DASS-21 stress, however, was not statistically significant.

Can the PHQ-9 diagnose depression?

The PHQ-9 is a validated questionnaire used to measure depressive symptoms and assist with screening and severity assessment. A score alone should not replace a full clinical evaluation when a diagnosis is required.

What does the DASS-21 measure?

The DASS-21 contains three seven-item scales intended to measure symptoms related to depression, anxiety and stress. In the Pakistani study, these domains showed high internal consistency but also very strong correlations with one another.

What was the most important implication of the study?

The results support providing mental health services across the university population rather than concentrating attention only on medical students. They also highlight female students, sleep health and previous mental health history as relevant considerations for further assessment and support.

Does poor sleep cause depression in university students?

The study found an association between more sleep and lower PHQ-9 scores, but its cross-sectional design cannot establish cause and effect. Sleep and depression can influence each other, and other variables may contribute to both.

Medical disclaimer: This article is intended for educational and research communication purposes only. PHQ-9, DASS-21 and other screening measures do not by themselves establish an individual psychiatric diagnosis. Anyone experiencing persistent or worsening depression, anxiety, significant distress, impaired daily functioning or thoughts of self-harm should seek assessment from an appropriately qualified healthcare professional or urgent local medical services when immediate safety is a concern.