SOCIAL BEHAVIOR AND PERSONALITY, 2013, 41(9), 1457-1468

Society for Personality Research

http://dx.doi.org/10.2224/sbp.2013.41.9.1457

PERCEIVED STRESS, STRESSORS, AND MENTAL DISTRESS

AMONG DOCTOR OF PHARMACY STUDENTS
GEMMA P. GESLANI AND CLAUDE J. GAEBELEIN
St. Louis College of Pharmacy
We conducted an online survey to assess stress levels, stressors, coping strategies, and mental
distress among first year professional Doctor of Pharmacy students at St. Louis College
of Pharmacy. We used the Perceived Stress Scale (PSS10) to measure perceived stress
and the Health-related Quality of Life Scale (HRQOL-14) to assess physical and mental
health. Self-reported stress levels among our respondents were elevated, significantly higher
than among other populations as reported in previous studies, and exceeded the threshold
benchmarked as being unhealthy. Mental health scores were negatively correlated with stress
levels, exceeded the threshold for frequent mental distress, and were significantly higher than
in comparison groups as reported in previous studies. Examinations were ranked the most
stressful events and spending time with family ranked as the most effective stress reliever.
Further specific investigation is needed to identify probable contributors to distress and to
solicit recommendations to help students alleviate their stress and strengthen their mental
health.
Keywords: perceived stress, stressors, mental distress, Doctor of Pharmacy students, coping
strategies, mental health.

Stress is described as the experience resulting from a physiological and/or

emotional reaction to an environmental event, or stressor, which causes distress
(Aldwin, 2007). Physiological response refers to effects on ones physical health
brought about by a disturbance in the cells or molecules structures and functions
(McEwen, 2008). Emotional or psychological response is usually associated
with negative feelings such as anger, anxiety, and tension (Lazarus & Folkman,
1984). However, stress can have positive results, such as the release of certain

Gemma P. Geslani and Claude J. Gaebelein, St. Louis College of Pharmacy.

Correspondence concerning this article should be addressed to: Gemma P. Geslani, Division of Basic
and Pharmaceutical Sciences, Jones 1461, St. Louis College of Pharmacy, 4588 Parkview Place,
St. Louis, Missouri 63110-1088, USA. Email: Gemma.Geslani@stlcop.edu

1457

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STRESS AMONG DOCTOR OF PHARMACY STUDENTS

hormones that confer protective effects on the organism or the development of

mental or emotional resilience (McEwen, 2008). Whatever may be the response
to a particular stressor, the process involves cognitive appraisal of the event,
that is, evaluation of the threat of the situation and coping capability (Lazarus &
Folkman, 1984). Both this perception and the reaction it elicits vary from person
to person and can be influenced by previous life experiences and the individuals
developmental stage (Aldwin, 2011). The way an individual responds to stressors
also depends on the duration of exposure thereto, which could be transient
or chronic, with the latter generally resulting in more deleterious physical or
emotional consequences (McEwen, 2008). Chronic stress has been associated
with mental distress such as anxiety and depression (Hammen, 2005).
Although anyone at any time can be exposed to stressful events, students
may be especially vulnerable to stress effects. College students, in particular,
may undergo significant developmental changes that affect decision making,
interpersonal skills, competence, reasoning, identity, independence, and other
aspects of their personality and character (Vye, Scholljegerdes, & Welch, 2007).
Furthermore, moving away from home to a school could cause an individual to
have feelings of uncertainty, fear, helplessness, and loss of control (Vye et al.,
2007). Additionally, the transition from high school to college and from college
to an institution for training health professionals involves considerable changes
in volume and level of difficulty of academic requirements, which could prove
more challenging to students and which, thus, necessitates their adapting to a
new situation. This could significantly contribute to the level of stress of the
students due to mismatched expectations of institutions and students (Miller,
Bender, & Schuh, 2005). For example, at college and health professional schools,
instead of receiving specific guidance from instructors for homework completion
and preparation for examinations, as is customary in high school, students are
expected by the institution to work independently using syllabi distributed at the
start of the semester as a guide. They are also expected to be able to prioritize
their course work in relation to their participation in extracurricular activities. In
terms of behavior, the expectations at college and health professional school are
different from the expectations at high school, both in and outside the classroom.
For students, the expectation may be that their lecturers at college or health
professional school will be like their teachers at high school and will show a
caring attitude towards each of them, and this expectation may also not be met.
The stress that results from all these factors may be either detrimental to students
well-being or, if their anxiety is associated with academic demands, such as
examinations or deadlines, and becomes a motivation, it may be beneficial
(Martin, Cayanus, Weber, & Goodboy, 2006) as the anxious student may then
work hard, which could, ultimately, affect their performance and successful
completion of the program.

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Indeed, high stress levels among college and health profession students are
well documented (Beck, Hackett, Srivastava, McKim, & Rockwell, 1997;
Hamaideh, 2011). However, the stress levels of students in Doctor of Pharmacy
(Pharm D) courses have been described in only a few studies (Gupchup,
Borrego, & Konduri, 2004; Marshall, Allison, Nykamp, & Lanke, 2008). The
most common stressors identified by various student groups are academic issues,
separation from family, peer pressure, financial issues, and time constraints
(Beck et al., 1997; Dutta, Pyles, & Miederhoff, 2005; Murphy & Archer, 1996).
Students in a Bachelor of Pharmacy course also reported additional stress arising
from self-doubt and perfectionism, and these students were found to be at risk of
psychological distress (Henning, Ey, & Shaw, 1998).
Researchers have established that there is an inverse relationship among
students between stress levels and health-related quality of life (HRQOL),
particularly in relation to mental health (Gupchup et al., 2004; Marshall et
al., 2008). Additionally, it has been found that even transient stress during
examinations impeded the healing of wounds among students (Marucha, KiecoltGlaser, & Favagehi, 1998), brought about changes in immune response markers
such as neutrophils (Ellard, Barlow, & Mian, 2005), and slowed down regulation
of expression of the proto-oncogenes (Glaser, Lafuse, Bonneau, Atkinson, &
Kiecolt-Glaser, 1993). Moreover, stress has been correlated with psychological
distress among nursing students and depression among medical students (Dahlin,
Joneborg, & Runeson; 2005; Watson et al., 2009). However, we were not aware
of any researchers who had examined stress and frequent mental distress (FMD),
which is an important indicator of mental health (Centers for Disease Control and
Prevention, 2011), among Pharm D students.
The institution at which we conducted our study is the St. Louis College of
Pharmacy, an independent school that offers a 6-year program leading to the
Pharm D academic qualification. The first two years entail preprofessional
studies, followed by four years of professional studies. Students who join the
program in the first year come straight out of high school; thus, students in the
preprofessional and first two professional years are of college age. The results
obtained in our pilot study, specifically, showed that the students had high levels
of perceived stress (PS) and poor mental health, and these findings could have
implications in the creation and implementation of programs to help pharmacy
students cope with stressors that could affect their academic performance and
health. We believe that this is important because in the Accreditation Council for
Pharmacy Education Standard No. 15, Guideline 15.5, it is stated that that the
college or schools assessments should include measurement of perceived stress
in faculty, staff, and students, and evaluate the potential for a negative impact
on programmatic outcomes and morale (Accreditation Council for Pharmacy
Education, 2011, p. 25).

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STRESS AMONG DOCTOR OF PHARMACY STUDENTS

Our objectives in this research were to: (a) assess PS levels of students in
the first professional year (Pro 1) at the St. Louis College of Pharmacy, and to
compare this to the PS levels among the general population, undergraduates, and
other health professional students; (b) determine the quality of life of the students
and examine its relationship with PS; (c) explore differences in the PS levels of
the students as a function of amount of exercise, grade point average (GPA),
and gender; (d) characterize the relative importance of stressors and stress relief
strategies.
Method
Participants

Participants were Pro 1 students, entering their third year at St. Louis College
of Pharmacy. They had completed the preprofessional years of study and, having
met the requirements for admission into the professional program, were starting
on this course. With a few exceptions, the students were living in apartments
away from home during the academic year; none of them were living in the
school dormitories, which are solely for the accommodation of students in the
preprofessional years.
Of the 207 students who received the recruitment email, 139 (67% response
rate) completed the survey. The study population was composed of 61% women,
two thirds were White and almost one third were Asian. Most of the participants
were under 20 years of age (60%) and 36% were between 21-24 years old. A
little over one third (37.4%) indicated that they exercised three times per week
and 69% had a GPA >3.0.
Procedure

We recruited study participants via email. This email also contained the survey
instrument and was sent to Pro 1 students during a period in November 2012
when no examinations were scheduled for these students during either that week
or the following week. Participation in the study was anonymous and voluntary,
and survey completion indicated informed consent. All surveys were available
for two weeks and completed online. The study was declared exempt by St.
Louis College of Pharmacys Institutional Review Board.
Measures

We collected demographic information of gender, race, age, GPA, and exercise

habits; the students indicated their responses with a checkmark beside one of the
choices provided.
We used the Perceived Stress Scale (PSS10; Cohen, Kamarck, & Mermelstein,
1983) to determine students PS. A 10-item, 5-point Likert scale, with alternative

STRESS AMONG DOCTOR OF PHARMACY STUDENTS

1461

responses ranging from never (0) to very often (4) was used to measure the
extent to which participants perceived as stressful certain situations they had
experienced in the past month. Positively framed questions were reverse scored.
The highest possible score was 40 and the higher the total score, the higher the
level of PS. The PSS10 was chosen for its brevity and greater internal reliability
(Cronbachs alpha coefficient = .78) compared to the original longer PSS14.
The HRQOL-14 (Centers for Disease Control and Prevention, 2011) is
composed of 14 questions, and we used this to assess quality of life as
indicated by physical and mental health; higher scores (number of unhealthy
days) correspond to poorer health. Fourteen or more mentally unhealthy days
characterize FMD based on the 14-day period used by physicians and researchers
to define clinical depression and anxiety disorder (Zahran et al., 2004). The
performance of the four core measures (HRQOL-4) of HRQOL-14, the main
items used in our analysis, has been tested and found to be suitable for various
populations including college students (Zullig, 2005). For our questionnaire,
in their responses the students indicated the number of days that the situation
described applied to them. For example, one of the core HRQOL questions also
used for FMD determination is: Now thinking about your mental health, which
includes stress, depression, and problems with emotions, for how many days
during the past 30 days was your mental health not good? Another question that
relates to mental health is: During the past 30 days, for about how many days
have you felt WORRIED, TENSE, or ANXIOUS?
We culled a list of stressors from the literature, which were examinations,
outside class assignments, finances, and relationships with family and friends,
with the stressor Monday morning examinations specifically obtained from the
paper written by Marshall et al. (2008). We wanted to compare our students to
the population in the study by Marshall et al. because the Pharm D program at
the institution where Marshall and colleagues conducted their study resembles
the program at St. Louis College of Pharmacy in that it runs from years 0 to
6, and entrants to the course are not required to have completed a Bachelor of
Pharmacy before enrolling. The respondents in the study conducted by Marshall
et al. were also in the same year of their course as those in our study. The list
of coping strategies that we selected that is, spending time with family and
friends, sleeping, watching television, drinking alcohol, and exercising were
the most common responses that we had obtained from a preliminary survey.
The respondents were asked to rank items on the list of stressors ranging from
1 = least significant to 5 = most significant, and coping mechanisms ranging from
1 = least effective to 5 = most effective.
Data Analysis

For the primary statistical analyses we used Microsoft Excel to calculate

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STRESS AMONG DOCTOR OF PHARMACY STUDENTS

independent and repeated measurement t test statistics and 95% confidence

intervals of overall effects and subgroup analyses. We used SPSS version 17
to analyze more than two means using analysis of variance (ANOVA) with
Bonferroni post hoc tests. All analyses were carried out with an level of .05.
Results
The omnibus average PSS10 score was 23.2 (s = 3.3) and was significantly
higher than the PSS10 scores of the general population in the same age bracket
(Cohen, 1988), undergraduates (Olpin, 1996), and other health profession
students consisting of first-year dental, medical, nursing, and mental-health
graduate school students (Birks, McKendree, & Watt, 2009). The dental students
in the study by Birks et al. (2009) served as comparison for analysis (t = 14.0,
df = 137, p < .05) as their scores were higher than those of other groups. Thus,
by inference, the PSS10 scores of our participants exceeded these other values as
well. The PS scores of the students in our study could not be directly compared
to the scores of two similar Pharm D populations in previous studies because
different stress scales were employed in those studies, but, as in our study, high
stress levels were reported in both (Gupchup et al., 2004; Marshall et al., 2008).
The PSS10 subscores of our students did not differ significantly between men
and women (22.3 vs. 23.8, t = 1.28, df = 186) or between those who did and did
not exercise three times per week (24.3 vs. 23.6, t = 0.7, df = 186), but those with
a GPA of 3.0 or lower had higher scores than those with a higher GPA (23.2 vs.
25.3, t = 2.10, df = 186, p < .04).
Overall, for the PSS10 68% of our students scored more than the threshold
(score of 21) determined to be unhealthy (Kelly & Percival, 2012). In addition,
this same level of mental health was reflected in the HRQOL scores. Specifically,
the group of students with PSS10 scores above 21 reported an average of 15.7
mentally unhealthy days, which was a significantly longer period than was
reported by those with PSS10 scores below 21 (M = 9.1 days; t =3.99, df =136,
p < .05). In this regard, what we believe was more important is that this figure
exceeded the threshold for FMD and is significantly higher than the total number
of days reported in previous studies by undergraduates (4.4 days, t = 15.2, df =
187, p < .001), younger graduate students (2.8 days, t = 17.6, df = 187, p < .001),
and a nationally representative sample of medical students (1 day or less, t = 20.3,
df = 187, p < .001; Zahran, Vernon-Smiley, & Hertz, 2007; Zullig, Teoli, & Ward,
2011). In contrast, scores reflecting better health were reported for physical
health and were similar regardless of PSS (score higher than 21 vs. score lower
than 21 = 3.7 vs. 5.6 days, t = 1.85, df = 138).
Differences in mental health status were not detected with respect to GPA and
exercise status, but women self-reported poorer mental health than men did. Men

STRESS AMONG DOCTOR OF PHARMACY STUDENTS

1463

reported fewer mentally unhealthy days (t = 2.18, df = 137, p < .05) and fewer
physically and mentally unhealthy days (t = 2.04, df = 137, p < .05) than women
did. Finally, men reported fewer days of feeling worried, tense, or anxious than
women did (t = 2.37, df = 137, p < .05). In Table 1 the responses to the HRQOL
mental-health questions are shown.
Table 1. HRQOL Health Measures as a Function of Gender
Men

Women

11.4
14.4
14.6

15.0
18.0
18.5

Mental health measure, number of days

Mentally unhealthy
Physically and mentally
Worried, tense, anxious
Note. p < .05.

Ranking of stressors and coping strategies are presented in Table 2. No

significant differences were observed in the ranking of stressors by men and
women (2 = 1.01, df = 4). Preparing for and sitting an examination was ranked
the most significant stressor, and family and relationship issues were reported
as the least stressful. Family was reported as the most effective stress reliever,
and drinking alcohol, although deemed the least effective way to relieve stress,
was still used for this purpose by 3 in 10 pharmacy students. There were no
statistically significant differences in the ranking of coping strategies by gender
(2 = 7.67, df = 4).
Table 2. Percentages of Reported Stressors and Coping Mechanisms by Gender

Stressors
Examinations
Monday morning examinations
Outside class assignments
Finances
Family and relationships
Coping mechanisms
Spending time with family/friends
Nap/sleep
Television
Exercise
Alcohol

Men
%

Women
%

95
66
38
24
17

82
67
41
31
23

73
48
42
50
31

83
77
58
40
29

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STRESS AMONG DOCTOR OF PHARMACY STUDENTS

Discussion
In previous research it has been found that stress is an inevitable part of academic
training in health sciences, including Pharm D, due not only to the academic rigor
of the program and the responsibilities assumed by student pharmacists, but
also to demands placed on individuals to work efficiently, effectively, and in a
timely manner. The hard work, long hours of study, competence required, and
self-discipline necessary for degree completion can be daunting and stressful for
many, although the severity of stress perceived by students may vary from week
to week, depending on current workload such as tests, presentations, reports, and
other assignments. We expected stress levels to be higher during periods when
there were a number of examinations pending, so we scheduled the survey when
the students had no such extra cause for stress or anxiety.
Our students PS scores were high and exceeded those reported for other
groups in previous studies (Birks et al., 2009; Cohen, 1988; Olpin, 1996).
Moreover, our results supported previous findings of high levels of PS among
Pharm D students (Gupchup et al., 2004; Marshall et al., 2008). However, what
we found more troubling was that two-thirds of the students in our study group
had scores for the PSS10 that were higher than the unhealthy threshold of 21
(Kelly & Percival, 2012). Furthermore, this unhealthy stress level seemed to us
to be quite pervasive and, according to our results, there was no relationship with
gender and exercise status and, regardless of whether the GPA of the students was
higher or lower than 3.0, all had PS scores exceeding the threshold. These results
suggest a common stressor, most likely academic-related, contributed the most to
the students stress. Both male and female students recorded a similar ranking of
the top three stressors, all of which were academic matters, and this supposition
is also supported by the fact that the group of students with a lower GPA reported
greater stress. Although we are concerned by these findings, the elevated stress
levels of the students in our study did not surprise us as they were completing the
survey during their transition period into the professional program, with courses
that were new to them, more rigorous, and directly related to the pharmacy
profession. The stringency of the program could have been greater than they
had anticipated and they may have felt overwhelmed, which was affecting their
response to academic challenges.
The unhealthy PS scores of our students were negatively correlated with
mental health scores. Moreover, the women reported poorer mental health scores
than the men, concurring with the observations of Gupchup et al. (2004) and
Marshall et al. (2008). We found it of greater concern that our students average
mental health score exceeded the Centers for Disease Control and Preventions
(CDC) cut-off point for FMD. The score for the students in our study was also
significantly higher and, thus, unhealthier than that for students in previous

STRESS AMONG DOCTOR OF PHARMACY STUDENTS

1465

studies (Zahran et al., 2007; Zullig et al., 2011). In addition to stress, the
questions about mental health explored the topics of anxiety, worry, depression,
and emotional problems. Therefore, these results could not be a reflection solely
of students struggling to cope with the demands of the course work. Lack of
experience, maturity, and support in coping with, and managing, trying situations,
and personal and emotional issues common in this age group (Vye et al., 2007)
could have negatively skewed their evaluation of problems and, consequently,
their assessment of their mental health.
That gender differences in mental health scores were not observed in PS
scores could be attributed to mens and womens differences in their assessment
of vulnerability, and response to nonacademic-related situations. Women have
been reported to be more susceptible to depression than men are under stressful
conditions, particularly those involving personal interactions and life events, and
this susceptibility has been found to increase if the stressors are chronic (Hammen,
2005; Helgeson, 2011). The school setting provides numerous opportunities
for interactions, some of which may be undesirable and unavoidable, such as
problems with roommates, classmates, and professors. The small campus and
low population of the St. Louis College of Pharmacy could exacerbate the stress
of students facing this predicament.
We were, therefore, not surprised that the students ranked examinations the
most stressful on the list of stressors in the survey, followed by Monday morning
examinations. However, the students ranked relationships with family and
friends as the least stressful, which is in direct contrast to the students in the
study conducted by Marshall et al. (2008), who ranked these relationships as
the most stressful although academic stressors were also ranked as significant
in that study. To handle stress, our students primarily preferred spending time
with families and friends. We found it logical that their least significant stressor
would be their most important stress reliever. Unfortunately, students at St. Louis
College of Pharmacy are living away from home most of the time and this could
partly explain their elevated stress levels; the unsettling effect of departure from
family and the safety of home has been reported by previous researchers (Vye et
al., 2007). Furthermore, sleep was ranked as the second most favored method of
stress release by the students, but they were deprived of sufficient sleep by their
tight schedule. At the other end, only 30% of our students ranked alcohol as an
effective stress reliever, but this rate is still comparable to national figures among
adults 21 years and older in the US (Guenther, Ding, & Rimm, 2013). However,
60% of our respondents were younger than the legal drinking age, which could
mean that the proportion of our students of legal age who drank to relieve stress
was actually higher than the national average.
That exercise was not ranked a top coping mechanism among our students runs
counter to their Pharm D counterparts in previous studies who cited it as their

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STRESS AMONG DOCTOR OF PHARMACY STUDENTS

first choice (Marshall et al., 2008). However, our findings that both exercisers
and nonexercisers reported similar PS and mental health scores were consistent
with the findings in the study by Marshall and colleagues. Although these results
need to be confirmed by testing with a different sample, our findings suggest
that the interplay of stressors and coping mechanisms may be rather complex. As
our respondents were in the first year of the professional program, the pressure
to succeed may have been particularly strong, and the response of the students
to stress may have been to reduce it directly by earning good grades rather
than indirectly through exercise. Their decisions could have been prompted
primarily by pressing demands requiring immediate action, even at the expense
of their health, and paying less regard to long-term and healthier consequences.
Moreover, our students positive evaluation of their physical health could have
influenced the way they prioritized the list of coping measures.
In conclusion, in our view, first professional year Pharm D students self-reported
unhealthy perceived stress and HRQOL scores cannot be disregarded. Although
our findings cannot be directly extrapolated to the whole college population, our
results provide a portrait of the stress levels and quality of life of Pro 1 Pharm D
students and highlight the necessity of providing these students with programs
and activities to alleviate their stress and boost their mental health. Creating a
supportive and nurturing environment on campus and providing time and stress
management workshops could be options to consider seriously. Additionally, the
hiring of another professional counselor by the College, which was in progress at
the time of writing, could lend further support to the students at St. Louis College
of Pharmacy. As these students would be matriculating for a further two years
beyond the year in which we conducted the survey, we believe it is imperative
that they handle difficulties effectively in order to avoid the unhealthy effects of
excessive chronic stress (Hammen, 2005). A follow-up study to solicit students
recommendations to address their concerns was the next step in this project.
Furthermore, a more specific inquiry into circumstances that contributed to
their mental distress could shed light on the discrepancy in mental health scores
between the St. Louis students in our study and student populations in other
studies who did not exhibit FMD, and this could steer the College in the right
direction as it explores alternatives to help students.
Two limitations in our study were nonrandom sampling and the self-reporting
nature of the survey. Self-selection could have introduced sampling bias, that is,
the group of students who participated in our study could have been those with
higher stress levels. The use of self-reporting surveys could have encouraged
the respondents to overstate actual conditions or experiences. Another limitation
could have been the collection of data at only one time-point in our study, but
the timing of our survey could probably justify our judgment of the results
approximating or representing the stress levels experienced by the students

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1467

during the school year. An additional limitation was the selection criterion of our
PS and FMD comparison groups, which was dictated by the survey instruments
used and the absence of similar data for more comparable populations in the
literature. Finally, the unique setup of the educational process at the St. Louis
College of Pharmacy limited the generalizability of our findings.
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