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OPEN Insights into self-evaluated stress,

anxiety, and depression among
dental students
Doina Iulia Rotaru1,5, Radu Marcel Chisnoiu1,5, Sorana D. Bolboacă2, Edith Ana Gileru3,
Andrea Maria Chisnoiu4 & Ada Gabriela Delean1
Stress, anxiety, and depression have a negative impact on students’ learning and academic
performances. In our longitudinal study conducted on dental students from Cluj-Napoca and Oradea,
the most representative university centers in north-west of Romania, we evaluated the prevalence
and effect of exams on stress, anxiety, and depression, in association with socio-demographic factors.
The students self-administered the DASS-21R questionnaire at the beginning of the academic year
2022–2023, before the Christmas holiday, during the winter session, and after the winter session.
Students from Cluj-Napoca had higher stress scores at the beginning of the academic year compared
to those from Oradea (6.8% vs. 3.7%, P-value < 0.05), especially the females and students with no
previous university graduations. Anxiety and depression were significantly more frequently reported
by students who study in Cluj-Napoca compared to those who study in Oradea (anxiety 37% vs. 28.2%,
P-value < 0.05; depression 17% vs. 11%, P-value < 0.05). We did not observe any significant differences
in DASS-21R scores regarding summer jobs, foreign language knowledge, or monthly income. Our
results support the needs for interventions regarding stress, anxiety, and depression implemented
from the very beginning of university studies and, along with strategies for stress prevention and
management of these conditions.

Keywords Dental medicine, Depression, Anxiety, Stress, DASS-21

The Richard S. Lazarus Theory of Stress (1966), developed by Cohen (1977) and Folkman (1984) states that
the approach we take in a stressful situation is a process that depends on the context and two variables, the
evaluations that the person does on the stress factor (how difficult is the task to be performed) and the personal,
social, or cultural resources available to the person when faced with such an agent (is he/she able to perform the
respective task?)1.
In the case of doctors, including medical students, stress is associated with multiple and major responsibilities
towards the patient, time pressure, the constantly requested professional component, role conflicts, and financial
problems2. Healthcare workers face rising pressures from increasing patient demands, complex health conditions,
workforce shortages, administrative burdens, and emotional stress, intensified by evolving technologies3.
Additionally, the recent pandemic experience influenced the medical students and made them concerned about
the risk of viral infection and exposed them to mental stress as future members of the patient care teams4.
Medical students represent a human mass vulnerable to stress, anxiety, and depression. Students can be more
emotionally vulnerable because of exam stress. Anxiety negatively affects performance and disrupts the learning
process5. According to Carneiro6, 15–25% of students in medical fields face different psychiatric problems
during their undergraduate training. Academic stress, caused by various factors in university and socio-familial
contexts, can negatively impact students’ educational performance. Thus, the identification of risk factors, the
reduction of stress, anxiety, and depression, can lead to the improvement of educational performances. Academic
stress is due to the pressures from the family, teachers, as well as personal expectations. The higher the stress
level, the lower the power of concentration, working memory, and consequently, school performances7.
The reported data in the scientific literature show different levels of stress, anxiety, and depression among
dental students in different countries. More than half of U.K. dental students (56%) investigated by Collin et

1Department of Odontology, Endodontics and Oral Pathology, ″Iuliu Hațieganu″ University of Medicine and
Pharmacy, 33 Moților Street, Cluj-Napoca 400001, Romania. 2Department of Medical Informatics and Biostatistics,
″Iuliu Hațieganu″ University of Medicine and Pharmacy, 6 Pasteur Street, Cluj-Napoca 400349, Romania. 3Individual
psychology office, 423A Avram Iancu Street, Florești 407280, Romania. 4Department of Prosthodontics, ″Iuliu
Hațieganu″ University of Medicine and Pharmacy, 32 Clinicilor Street, Cluj-Napoca 400006, Romania. 5Doina Iulia
Rotaru and Radu Marcel Chisnoiu contributed equally to this work. email: [email protected]

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al.8 reported a high level of stress, with higher scores but without a significant statistical difference on fifth-year
students compared to first-years students. Garcia et al.9 reported on a sample of 244 dental students in Brazil
a frequency of 42.6% for stress (moderate or severe), 44.6% for anxiety (moderate or severe), and 40.2% for
depression symptoms (moderate or severe), with higher self-reported levels of severe depression among students
with a history of academic failure (P-value = 0.008). The frequency of moderately severe or severe anxiety (56%
vs. 34.78%) and depression (49.06% vs. 37.68%) proved different between two locations in Southeastern United
States (community college setting vs. university setting)10.
The prevalence pattern changed during COVID-19 pandemic, with a higher frequency of anxiety (moderate,
severe, or severely extreme anxiety) of 56% among dental students in Malaysia11 and 52.2% among undergraduate
dental students at the Medical University of Sofia, Bulgaria12. Similar prevalences of major depression (42.7%)
and anxiety (44.0%) were reported in China during in COVID-19 wave two, with higher prevalence among
students currently in Australia than in China and other countries (difference of 11.4% for depression and
5.6% for anxiety)13. Students from the different faculties of dentistry in Turkey self-reported in the first year of
COVID-19 pandemic similar percentages of anxiety (~ 48%) and depression (~ 44%), and a v of stress around
37%14. Senior dental students (fifth and sixth year) in Lima, Peru reported during COVID-19 waves moderate,
severe, or extremely severe depression in 33%, anxiety in 31%, and stress in 29%, percentages significantly higher
compared to dental professional (P-value < 0.03)15.
Evidence concerning the frequency of stress, anxiety, and depression, among dental students in Romania
remains limited. A prospective study on 2nd years dental students conducted in 2014–2015 academic year
reported a decline of the WHO-5 (WHO-Five Well-Being Index) score over semester, with higher well-being
levels at the beginning of the semester and pronounced decline after three consecutive mandatory examinations16.
Our aim was to assess the occurrence of stress, anxiety, and depression among dental medicine students in Cluj-
Napoca and Oradea, two prominent university centers in Transylvania, Romania. Considering that the most
common forms of mental illness in the European Union are anxiety and depression disorders, it should be noted
that Bihor County, where the town of Oradea is located, ranks first in the prevalence of mental illnesses, while
Cluj County, where Cluj-Napoca is located, ranks 14th, according to the National Institute of Public Health17.

Methods
The eligible students were informed about the study and the participants gave their consent to take part in the
study. Participation in the study was voluntary, based on informed consent, with the possibility of withdrawal
at any time or the possibility of choosing not to answer specific questions, with no consequences. The Ethics
Committee of the “Iuliu Hațieganu” University of Medicine and Pharmacy Cluj-Napoca approved the study (no.
277/01.11.2022). Participants in the study were required to give GDPR-type written consent for their inclusion
and data processing. The researchers conducted the study following the principles outlined in the Declaration
of Helsinki.

Study design and participants

A prospective longitudinal study was conducted between 1 October 2022 and 28 February 2023 targeting the
students from Faculty of Dental Medicine, "Iuliu Hațieganu" University of Medicine and Pharmacy Cluj-Napoca
(IHUMP), Dental Medicine specialization, Romanian section and the Dental Medicine specialization of the
Faculty of Medicine and Pharmacy, University of Oradea (UO), Romania. The number of eligible students
enrolled at the time of the study was 585 at IHUMP and 513 students at UO.
Without any constraints or coercions all eligible students were invited to participate. Non participation did
not reflect anyhow on students’ evaluations or on teaching process.

Research instruments and data collection

The DASS-21 (Depression, Anxiety, and Stress Scale)18 was used in our study, which is a tool commonly used
in research and clinical settings. DASS-21 contains a set of three self-assessment scales, built to assess negative
emotional states in the sphere of depression, anxiety, and stress. The Romanian version of the questionnaire,
DASS-21R, has 21 items divided equally into three scales (Anxiety, Depression, Stress) and has been previously
adapted and standardized for Romanian population15. The DASS-21R has assessed states rather than features
19-22,

The researchers asked the participants to fill out a paper-based survey that contained socio-demographic data
and the DASS-21 survey. The collected socio-demographic data were: sex at birth, age, level of education (high
school graduate with a humanities/sciences profile, other higher education graduated), where they live (Cluj-
Napoca, Oradea), place of residence (urban/rural), monthly budget (monthly income), marital status (married/
single/divorced—separated/widowed, in a relationship, other situations), religion, nationality, (number of)
foreign languages known, and whether they work during the holidays. In the first section of DASS-21, the
students were guided to respond relative to how well the statement suited thinking about their last week. The
possible answers were: (0) It did not suit me; (1) It suited me to some extent or from time to time; (2) It suited
me quite a lot or quite often; (3) It suited me a lot or almost all the time. The researchers informed the students
that they would need about 10 min to complete the survey.
The students’ representatives distributed paper-based questionnaires to all colleagues who joined the study.
The students filled out the questionnaire and returned it to their representative, who gave the filled questionnaire
to the researchers. The questionnaires were distributed on Monday and collected on Friday in the same week.
Data collection took place at four points in time: (1) at the beginning of the academic year, (2) before the
Christmas holiday, (3) during the winter session, and (4) after the winter session. The two-page survey included
on the first page a brief presentation of the study objectives and who to contact in case of questions. Students
were required to create an identification code that had nothing in common with any personal data and then

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use that code during the four data collection periods. Demographic data were collected only in the first data
collection period.
A home-made Microsoft Excel database was designed, and one researcher translated the students’ responses
to electronic form. The incomplete data was identified using the Excel features and filled in when provided
in the questionnaires. A second researcher double-checked the raw data and implemented correction prior to
statistical analysis.

Statistical analysis
Statistical analysis was conducted whenever all four-points data were available. The analysis was stratified on
different subgroups, such as university center (Cluj-Napoca vs. Oradea), year of study (three classes: freshmen
that included first year students, sophomore that included intermediate years of study, and senior that included
the students in the final year of training), sex, rural vs. urban living place, previous university degree, and
bachelor’s degree in humanities vs. sciences. Quantitative raw data (age, stress, anxiety, and depression scores)
were tested to determine whether they followed the normal distribution within each group. The results were
reported as mean (standard deviation) in case of normal distribution, respectively median and [Q1 to Q3],
where Q is the quartile, when the raw data did not follow the normal distribution. Comparisons between groups
(tests for independent groups) and within groups (tests for dependent groups) were performed with parametric
tests for normally distributed data or non-parametric otherwise. Qualitative data were reported as absolute
and relative frequencies and comparisons between groups were made using tests from the Chi-square family
(Chi-square, corrected Chi-square, Fischer’s exact test), the Z test for proportions (for comparisons between
two independent groups) or McNemar (for dependent groups, e.g. the presence/absence of stress, anxiety or
depression between two examinations). No interim analysis was performed.
The sample size was not calculated before the study because no data is available on the Romanian population
regarding stress, anxiety, and depression among the dental students. A posteriori, the power of the study was
calculated, considering a level of significance equal with 5%.
The statistical analysis was done using Statistica (v.13.5, TIBCO Software, CA, USA). The significance level of
5% was applied for comparisons of the two groups. The level of significance was adjusted using the Bonferroni
correction whenever over two groups were compared.

Results
Characteristics of the participants
The overall participation, defined as filling all four-point assessments, was 81.4%, 514/585 (87.9%) in Cluj-
Napoca and 380/513 (74.1%) in Oradea. Participants from the two universities were similar in terms of year of
study class, monthly budget, frequency of students in a relationship, and bachelor’s degree (Table 1).

Depression, anxiety, and stress by university center

No differences were observed in depression, anxiety, and stress scores between the university centers at the
beginning of the university year and before the Christmas holiday. Anxiety was significantly higher during the
winter session in Cluj-Napoca university center and the level of stress proved significantly higher in Cluj-Napoca
dental medicine students as compared to Oradea dental medicine students (Fig. 1 and Table 2).
Data are summarized as median [Q1 to Q3] where Q1 is the value of the 25th percentile and Q3 is the
value of 75th percentile; Mann–Whitney test P-value gave the significance of comparison between Cluj-Napoca
and Oradea for each score. Friedman’s post-hoc analysis (adjusted α, p-values less than 0.0083 were considered
statistically significant): aP-value < 0.001 for comparison with 1; bP-value < 0.001 for comparison with 2; cP-
value < 0.001 for comparison with 3; a1P-value = 0.030; b1P-value = 0.030; a2 P-value = 0.0004; b1 P-value = 0.0088.

Characteristic All (n = 894) Cluj-Napoca (n = 514) Oradea (n = 380) Stat. (p-value)

Agea 22 [21 to 24] 22 [20 to 23] 22 [21 to 24] -4.3 (< 0.0001)
Femaleb 701 (78.4) 416 (80.9) 285 (75.0) 4.5 (0.033)
Ruralb 157 (17.6) 77 (15.0) 80 (21.1) 5.6 (0.0183)
Bachelor’s degree-humanitiesb 95 (10.6) 46 (8.9) 49 (12.9) 3.6 (0.0585)
Romanian nationalityb 858 (96.0) 507 (98.6) 351 (92.4) 22.2 (< 0.0001)
Orthodox religionb 700 (78.3) 415 (80.7) 285 (75.0) 4.2 (0.0396)
In a relationb 375 (41.9) 203 (39.5) 172 (45.3) 3.1 (0.0804)
Year of study classb
164 (18.3) 97 (18.9) 67 (17.6)
freshman
567 (63.4) 317 (61.7) 250 (65.8) 1.8 (0.4152)
sophomore
163 (18.2) 100 (19.5) 63 (16.6)
senior
1859 1859 1917
Monthly budgeta -0.9 (0.3471)
[1213 to 2500] [1200 to 2500] [1300 to 2500]

Table 1. Demographic characteristics of participants by university center. amedian [Q1 to Q3], where Q is the
quartile; comparisons made with Mann–Whitney test; bnumber (%); comparisons made with Chi-squared test;
Stat statistics of the test; p-value = test significance

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Fig. 1. Distributions of DASS-21 scores by university center. The point within line represents the values of
median, the lower whisker is given by the value of the first quartile and the upper whisker by the value of the
third quartile.

Depression scores ranged from absence (normal scores) to moderate (after the winter session) or severe
(Table 3), with significantly more students with abnormal scores studying in Cluj-Napoca (17%) than in Oradea
(11%) after the winter session (Chi-squared test: P-value = 0.0146).
Anxiety was significantly more present in students who studied in Cluj-Napoca during the winter session
(50.2% vs. 43.4%, P-value = 0.0449) and after the winter session (37.0% vs. 28.2%, P-value = 0.0057) (Table 3).
At the beginning of the academic year, significantly more students who study in Cluj-Napoca had a class of
stress mild or moderate as compared to those who studied in Oradea (6.8% vs. 3.7%; P-value = 0.0424, Table 3).

Depression, anxiety, and stress of freshmen, sophomore, and senior

Stress and anxiety are higher among students in the first year of the study, but the scores follow a similar trend
regardless of the academic year class, with higher scores during the winter session (Fig. 2). The P-values resulted
from post-hoc analysis for identified statistical significant differences are reported in Table 4.
na not applicable (no significant differences between all groups); ns  not statistically significant.

Depression, anxiety, and stress scores by other subgroups

The scores of stress (Fig. 3) were significantly different between female and male only at the beginning of the
academic year (median = 6 [3 to 9] for female and 5 [2 to 8], P-value = 0.0113) and after the winter session

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P-Value
Beginning of the Before Christmas During the winter Friedman
Group Score academic year (1) holiday (2) session (3) After winter session (4) test
Depression 3 [1 to 5] 3 [1 to 6] 5 [2 to 9] 3 [1 to 7] < 0.0001
All Anxiety 3 [1 to 6.8] 3 [1 to 6.8] 7 [3 to 12] 5 [2 to 9] < 0.0001
Stress 5 [3 to 9] 6 [3 to 9] 10 [6 to 13] 7 [3 to 11.8] < 0.0001
Depression 3 [1 to 5] 3 [1 to 6] 5 [2.3 to 9]a,b 3 [1 to 8]a, b, c < 0.0001
Cluj-Napoca Anxiety 3 [1 to 7] 3 [1 to 7] 8 [4 to 12]a,b 5 [2 to 10]a, b, c < 0.0001
Stress 6 [3 to 9] 6 [3 to 10] 10 [6 to 13]a,b 7 [3.3 to 13]a, b, c < 0.0001
Depression 3 [1 to 5] 3 [1 to 5] 5 [2 to 9]a,b 3 [2 to 6]a1, c < 0.0001
Oradea Anxiety 3 [1 to 6] 4 [1.5 to 6] 6 [3 to 12]a,b 5 [2 to 8]a, b, c < 0.0001
Stress 5 [3 to 8] 6 [3 to 9] 9 [6 to 12]a,b 6 [3 to 10]a2, b1, c < 0.0001
Depression 0.6366 0.8597 0.3184 0.1628
Mann–Whitney test
Anxiety 0.1456 0.5825 0.0316 0.0307
P-value
Stress 0.2490 0.6267 0.1935 0.0180

Table 2. Summary of scores by university center.

Cluj-Napoca Oradea
Before Beginning of Before After the
Beginning of the Christmas During the After the the academic Christmas During the winter
academic year holiday winter session winter session year holiday winter session session
normal 473 (92) 455 (88.5) 389 (75.7) 429 (83.5) 348 (91.6) 331 (87.1) 303 (79.7) 339 (89.2)
mild 24 (4.7) 44 (8.6) 93 (18.1) 48 (9.3) 19 (5) 43 (11.3) 49 (12.9) 26 (6.8)
Depression
moderate 16 (3.1) 14 (2.7) 31 (6) 37 (7.2) 8 (2.1) 6 (1.6) 28 (7.4) 15 (3.9)
severe 1 (0.2) 1 (0.2) 1 (0.2) 0 (0) 5 (1.3) 0 (0) 0 (0) 0 (0)
normal 414 (80.5) 414 (80.5) 256 (49.8) 324 (63) 308 (81.1) 315 (82.9) 215 (56.6) 273 (71.8)
mild 40 (7.8) 36 (7) 60 (11.7) 46 (8.9) 28 (7.4) 21 (5.5) 42 (11.1) 39 (10.3)
moderate 49 (9.5) 50 (9.7) 134 (26.1) 95 (18.5) 32 (8.4) 38 (10) 72 (18.9) 53 (13.9)
Anxiety
severe 8 (1.6) 13 (2.5) 62 (12.1) 41 (8) 7 (1.8) 6 (1.6) 46 (12.1) 15 (3.9)
extremely
3 (0.6) 1 (0.2) 2 (0.4) 8 (1.6) 5 (1.3) 0 (0) 5 (1.3) 0 (0)
severe
normal 479 (93.2) 484 (94.2) 431 (83.9) 440 (85.6) 366 (96.3) 367 (96.6) 318 (83.7) 336 (88.4)
Stress mild 28 (5.4) 25 (4.9) 63 (12.3) 58 (11.3) 12 (3.2) 10 (2.6) 54 (14.2) 39 (10.3)
moderate 7 (1.4) 5 (1) 20 (3.9) 16 (3.1) 2 (0.5) 3 (0.8) 8 (2.1) 5 (1.3)
Data are summarized per university center as number (percentage)

Table 3. Depression, anxiety, and stress classes by university center.

(median = 7 [4 to 12] for female and 6 [3 to 9], P-value = 0.0113), without statistically significant differences on
depression and anxiety scores between female and male (P-values > 0.07).
Students who grew up in rural environments had statistically significant different scores for depression and
anxiety after the winter session (rural vs. urban): 4 [2 to 8], n = 157 vs. 3 [1 to 7], n = 737, P-value = 0.0219 for
depression and 6 [3 to 9], n = 157 vs. 5 [2 to 9], n = 737, P-value = 0.0075 for anxiety (Fig. 4).
The stress score at the beginning of the academic year was statistically significant different (P-value = 0.0313)
among students with no previous university graduations (6 [3 to 9], n = 853) compared to students who already
graduated from a university (4 [2.25 to 6], n = 42).
Students with a bachelor’s degree in humanities showed statistically significantly different anxiety (3 [2 to
7], n = 95) and stress (5 [3 to 9], n = 95) after the winter session compared to those with a bachelor’s degree in
sciences (5 [2 to 9], n = 798 for anxiety and 7 [4 to 12], n = 798 for stress) (P-value = 0.0009 for anxiety and 0.0136
for stress).
No significant differences were observed in scores of depression, anxiety, or stress at any evaluated point
when the students who work during summer holiday were compared to those who did not (P-values > 0.17),
between those who know one foreign language compared to those who know more than one foreign language
(P-values > 0.15), or between those with low monthly income as than those with more than the minimum
income per month in Romania (P-values > 0.25).

Discussion
Our results show that dental students in north-west Romanian universities experience high levels of psychological
distress. Female dental students and students with no previous university graduations experience even higher

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Fig. 2. Distributions of DASS-21 median scores by academic year class (Friedman’s

test p-values: senior 0.2387-depression, 0.00001-anxiety, < 0.0001-stress;
sophomores: < 0.0001-depression, < 0.0001-anxiety, < 0.0001-stress;
freshman: < 0.0001-depression, < 0.0001-anxiety, < 0.0001-stress).

When? All Freshman vs. Sophomore Freshman vs. Senior Sophomore vs. Senior
beginning of the academic year 0.1475 na na na
before Christmas holiday 0.7582 na na na
Depression
during the winter session 0.0001 ns 0.0019 0.0002
after the winter session 0.0048 0.0054 ns ns
beginning of the academic year 0.0537 na na na
before Christmas holiday 0.0882 na na na
Anxiety
during the winter session < 0.0001 ns 0.00004 0.00002
after the winter session 0.0050 0.0040 ns ns
beginning of the academic year 0.0107 ns ns 0.0244
before Christmas holiday 0.7385 na na na
Stress
during the winter session < 0.0001 ns 0.00006 0.00002
after the winter session 0.0083 0.0198 0.0134 ns

Table 4. Kruskal–Wallis’s test and post-hoc analysis of students in different classes according to the year of
study.

levels of distress, at least in specific moments of the academic year. As far as we know, this is the first research
endeavor to employ the DASS-21R questionnaire on dental students in Romania.
Dental education in Romania is a six-years program. The tuition fees are supported by the government or by
the student or students’ family. To benefit from the education paid by the government, the student results must
be remarkable. So, competition among students is in place, as higher the grades are, the smaller the possibility to
need to pay for the education. Additionally, performances are rewarded with different scholarships. The Faculty
of Dental Medicine of the "Iuliu Hațieganu" University of Medicine and Pharmacy offers six types of scholarships:
scientific scholarships (180 Euro/month), four categories of merit scholarships (150, 140, 130, and 120 Euro/
month), and social scholarships (116 Euro/month). At the time of the study, 151 dental students benefited from
a scholarship. The Faculty of Medicine and Pharmacy in Oradea, Dental Medicine specialty, offers students four

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Fig. 3. Distributions of DASS-21 stress scores by sex. The points represent the values of medians, the lower
line the value of the first quartile and the upper line the value of the third quartile.

Fig. 4. Distribution of depression and anxiety scores after the winter session for students who grew up in rural
areas compared to those who grew up in urban settings.

types of scholarships: merit (140 Euro/month), performance (200 Euro/month), special (200 Euro/month), and
social (116 Euro/month). At the time of the study, 167 dental students benefited from the scholarship.
According to Schmitter et al., dental education is more stressful than medical education23. Also, according
to literature, the students enrolled in dental schools in different parts of the world reported higher levels of
depression, anxiety, and interpersonal sensitivity than the same age students in other fields of study 24,25–28,29.
Our study found no significant differences between students in Cluj-Napoca and Oradea during the beginning
of the academic year, before the Christmas holiday, and during the winter session. However, after the winter

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session, a larger number of students in Cluj-Napoca compared with students in Oradea experienced mild to
moderate levels of depression (17% vs. 11%, Table 3). The students who studied in Cluj-Napoca reported similar
levels of anxiety during the beginning of the academic year and before the Christmas holiday compared to the
students who studied in Oradea, most students reporting normal levels (Table 3). Our findings revealed that
students in Cluj-Napoca had higher levels of anxiety compared to students in Oradea during the winter session
(50.2% vs. 43.4%, P-value = 0.0449) and after the winter session, with levels of anxiety ranging from mild to
extremely severe (37.0% vs. 28.2%, P-value = 0.0057). Stress levels did not differ significantly between universities
after the Christmas holiday, and during the winter session and following the winter session. Nevertheless, at the
beginning of the academic year, a significantly higher proportion of students in Cluj-Napoca (6.8%) reported
mild to moderate stress levels compared to students in Oradea (3.7%) (Table 4).
The prevalence of anxiety and stress was higher during the winter session among dental students in Cluj-
Napoca university center, compared with those in Oradea (Table 3). Whenever we talk about performance-
related anxiety, it should be noted that the level of expectancies (both personal and interpersonal – teachers,
relatives, peers) and academic standards play an important role in how we manage pressure – deadlines, the
workload and how people perceive themselves managing these tasks30. High psychological vulnerability in
anxious students is often associated with risk and failure, leading to heightened frustration. Anxious students
often struggle with decision making, managing assignments, and adapting to changes.
The stress, anxiety, and depression scores showed similar patterns when we compared students according
to the year of study, with significant differences during the winter session when freshman and sophomores
(high scores) were compared to seniors (low scores), and after the winter session when freshman group (lower
scores) was compared to sophomore group (higher scores). An explanation could be the extensive volume
and complexity of subjects that must be studied, requiring young students to navigate a far more challenging
adaptation process that was already passed by the seniors. Additionally, the stress score proved significantly
different after the winter session in the freshman group (lower scores) compared to the senior group (higher
scores). The reason behind the higher DASS-21R scores observed in our study could be attributed to the senior
group’s prioritization of the specialty exam over the curriculum exams. Another possible explanation could
be hypochondria, which appears when medical students imagine they have the illnesses they are studying,
affecting their mental health 31. Anxiety can arise in students who perceive a higher chance of failure and are
held to high achievement standards32,33. Our findings may suggest that the levels of anxiety and stress tend to
rise whenever the students face experiences with little prediction. The relevant number of exam exposures they
faced during the whole academic program can explain the observed differences of anxiety and stress in favor
of senior students. Moreover, evidence in scientific literature exists to support the idea that repeated exposure
to stressful situations creates a context of predictability and can reduce the levels of anxiety associated with
the same inducing situation. Over time, it becomes more manageable to anticipate specific results and make
necessary adjustments34. It is worth mentioning that student anxiety tends to develop when they face situations
that have a direct impact on their self-esteem. Female participants in our study exhibited significantly higher
stress scores at the beginning of the academic year and after the winter session, while depression and anxiety
scores showed no significant differences. The explanation for this observation lies in the psychological disparities
between men and women, with women having a higher tendency to express their emotions. Men tend to avoid
or deny problems and, as a result, are less likely to describe themselves as stressed. Women, on the other hand,
are more inclined to share how they feel, even if it does not resolve their issues. Additionally, unlike men, women
display a greater vulnerability to psychologically stressful and frustrating situations. This vulnerability may stem
from differences in personal resources. Moreover, in certain socio-cultural contexts, women’s lives are more
stressful than men’s, as family responsibilities are added to their professional duties35. It is well known that
women are more prone than men to express their symptoms, there also may be a commonly shared opinion that
men have to endure and resist differently to life stressful situations. Social and psychological influences may also
mediate this effect36.
Students who grew up in rural environments had higher scores associated with depression and anxiety
compared to those who grew up in urban environment. Depression is mainly characterized by a sad and hopeless
mindset, loss of interest in previously enjoyable activities, self-deprecating thoughts, feelings of worthlessness,
low self-esteem, and reduced motivation to engage in activities. One in three young people from rural areas fears
that their family will not have the financial resources needed to support them through university, and 14% are
afraid they would not find accommodation in the university campus, as apartment rent are too high relative to
their family incomes, according to a survey conducted by the World Vision Romania foundation37. Additionally,
according to the same survey, 78% of young people are concerned about the rising prices37. In this context, losing
the paid educational place in the university could contribute to the stress level. It is important to acknowledge
that being in an urban academic setting exposes individuals to various situations, such as public performance
evaluations and the opportunity to compare academic achievements with high achievers. This environment can
foster a drive for excellence and set the standard for individuals. Additionally, the urban academic setting can
serve as a place to manage emotions after failure, offering a range of resources that may lack, limited, or inexistent
in rural settings38. Due to limited resources, students who come from rural settings may be less equipped with
effective learning strategies, but also with less experience in competitive academic settings, which can predispose
to frustration, sadness, and devaluation39.
The same mediating role of predictably may also be responsible for the levels of stress which were significantly
higher among students with no previous university graduations (6 [3 to 9], n = 853) compared to students who
already graduated a university (4 [2.25 to 6], n = 42). However, it should be noted that the government funds
only one cycle of university studies, which increases the stress level for those who are graduates. In many cases,
the difficulties encountered in finding a job drive individuals to choose a faculty that offers more opportunities
or financial advantages, rather than selecting a field of interest or passion.

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Our findings show that stress, anxiety, and depression are high among dental students, pointing out that
interventions or preventive strategies are needed. One strategy may relate to the curriculum itself. Evidence
reported by Jowkar et al. suggests that the academic factors and clinical education contribute significantly
to student stress40. Potential modifications of the curriculum, such as adjustment of assessment methods, or
integration of wellness modules into the curriculum, can create a more supportive learning environment41.
Promoting a healthy lifestyle among dental students, such as regular physical activity, proper nutrition, and
adequate sleep, can enhance students’ resilience to stress42. Universities can facilitate a healthy lifestyle by providing
resources such as fitness programs, nutritional counseling, and workshops on time management and self-care
practices. Another effective strategy for managing stress among dental students could be the implementation
of structured stress management programs, such as relaxation techniques, mindfulness training, and coping
mechanisms tailored to the specific challenges faced by dental students43,44. Another potential intervention is the
existence of a peer support system within dental schools, a safe environment with individuals who understand
their experiences45. Mental health awareness, such as regular mental health screenings, workshops on stress
management, and creating accessible mental health resources, could also be a valid strategy46,47. Considering
the findings of the present study and taking into consideration that the stress in dental education cannot be
totally avoided, stress management strategies should be recommended as an integral part of the curriculum.
Interaction between dental faculties and trained educational psychologists is essential for teachers to learn the
latest educational methods, reducing stress and helping students cope.
Although the present study is based on a simple and concise test tool, it still has some limitations that
need to be highlighted. A significant drawback is that the assessment tool relies on self-reported information,
potentially leading to bias. In self-reporting, students might under-report symptoms because of recall bias
(not remembering accurately), social desirability bias (answers they believe are more socially acceptable or
desirable), self-perception bias (inaccurate perception of themselves), misinterpretation of questions, mood and
emotional state (negative emotions could induce pessimistic responses), survey fatigue (as the same questions
were asked four times the participants could rushed responses) etc. To better capture the reality, ideally, self-
reporting can be duplicated by with objective measures (e.g., medical records, observational data, interviews,
teaching staff assessment, etc.), anonymizing the surveys but assuring the matching for the same participant,
pretesting, reducing the number of surveys per academic year, inclusion of question to evaluate the mood or
similar. Furthermore, the self-reported nature of our study does not allow the assessment of psychological
changes over time. The absence of more objective measures of performance, like test scores, grades, or teachers’
ratings of performance, is another limitation of our study. Study grades and other objective measurements of
student performance should be used to correctly reflect the targeted relationships. Not considering factors that
can influence individuals’ mental health, like sleep deprivation, lack of proper nutrition, family issues, financial
problems, etc., also represents limitations. The relationship between the scholarship amount and mental health
outcomes was not evaluated in our cohort, because the participants’ confidentiality could not be respected if
we would ask the participants to declare personal scholarship, if any. The scholarship amount was indirectly
included in the total monthly income declared by the participants, but the information regarding the scholarship
could not be extracted from this data since different incomes were declared at different points of data collection.
The aim of our study limited the evaluation of only two universities and only the students from one specialty,
so the results reflect the participants’ experience. Thus, the reported frequencies might not reflect all dental
students in Romania but could be representative for the north-west of Romania. To enhance the outcomes,
future research should incorporate all dental schools in Romania and extend the time-frame to capture the
association between clinical training and stress, anxiety, and depression. It also would be of interest to compare
self-evaluated depression, anxiety, and stress of the targeted group with students from other disciplines and to
the general population to show if the observed frequency can or cannot be attributed to the specialty.
Some students participating in our study also received medical training during COVID pandemic. School
and university closures due to the COVID-19 pandemic disrupted daily routines, teaching approaches, and other
aspects of everyday life. These changes deeply affected university students and young adults, with significant
consequences for their mental health48.
High rates of emotional disturbances, including depression, anxiety, and stress, are present among
undergraduate science students, indicating a need for early intervention. To promote a healthy lifestyle, students
should be encouraged to dedicate sufficient time to their social and personal lives and adopt health-promoting
coping strategies that can help manage stress throughout their medical studies. Academically, a well-equipped
student counseling center with qualified staff should be established on campus to provide a resource for mental
health support. Additionally, preventive programs should start early in medical education, addressing a range of
issues from academic pressures to interpersonal and financial concerns. Identifying and addressing early signs
of depressive symptoms is essential, as timely intervention can support students in managing stress, facilitating a
smooth transition through their medical education and adaptation to varied learning environments. Nowadays,
universities should take into consideration methods and actions, including artificial intelligence, to improve the
mental health status of the students. This marks an evolution and a revolution in mental well-being49. Besides
this, the government can play a significant role in reducing depression, anxiety, and stress among dental students
by implementing policies and providing resources that promote mental health and support students’ overall
well-being, supporting regular screening programs, offering more scholarships, grants, and low-interest student
loans, organizing mental health awareness campaigns and providing grants for research into mental health
challenges specific to dental students.

Conclusions
The levels of depression, anxiety, and stress in evaluated undergraduate dental students are relatively high. The
freshmen reported higher levels of anxiety and stress than the rest of the students, which means that, by time,

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they get used and accommodate with the academic environment and requirements. Moreover, the students in
Cluj-Napoca reported an increase in the frequency of anxiety and stress compared with the students in Oradea all
over the academic year. Students with abnormal depression and anxiety scores should receive special attention,
as they require a clinical diagnosis and specialized treatment. Female students should be given more attention.
For an early identification and, if needed, specialized intervention for psychological conditions, education
regarding depression, anxiety, and stress should be implemented from the very beginning of studies. Moreover,
strategies for stress prevention and management of these conditions should be implemented in dental schools,
under the coordination of the universities and the government.

Data availability
The raw data used and analyzed during the current study are available from the corresponding author upon
reasonable request.

Received: 20 February 2024; Accepted: 8 November 2024

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Author contributions
Conceptualization: D.I.R.; methodology: S.D.B., A.G.D., and E.A.G.; investigation: D.I.R.; data curation: S.D.B.;
formal analysis: S.D.B., R.M.C., E.A.G. and A.M.C.; visualization: S.D.B.; writing – original draft: S.D.B., R.M.C.
and E.A.G.; writing – review & editing: A.M.C. and A.G.D.; resources: D.I.R.; project administration: D.I.R. All
authors read and approved the final version of the manuscript.

Declarations

Competing interests
The authors declare no competing interests.

Ethics approval and consent to participate

The study was approved by the Ethics Committee of the "Iuliu Hațieganu" University of Medicine and
Pharmacy Cluj-Napoca (approval no. 277/01.11.2022). Our study was conducted, adhering to the principles
outlined in the Declaration of Helsinki. Eligible participants who signed a written consent for participation and
data processing, resembling GDPR were included in the study.

Additional information
Correspondence and requests for materials should be addressed to S.D.B.
Reprints and permissions information is available at www.nature.com/reprints.

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