Introduction

According to WHO, quality of life (QoL) is defined as “The perception of their position in life within the context of the culture and the value systems during which they live and in reference to their goals, expectations, standards, and concerns”1. A novel array to study QoL in numerous populations is health-related quality of life (HRQoL), which could be a multidimensional concept directly associated with an individual’s or group’s physical and psychological state over time2,3,4,5. It has been reported that drastic changes in the QoL of individuals result in significant interference in many areas of daily human life6. In evaluating QoL, age may seem an influential variable; the reason can be attributed to the fact that among older people, physical health is a crucial factor and psychological and behavioral factors are more noticeable among youth7,8.

Studies have shown that factors such as depression and anxiety, which are the most commonly known psychiatric disorders in the world, may impact the quality and satisfaction of life by affecting both personal and professional individuals’ lives6,9,10,11. It has been demonstrated that adolescents and young adults are three times more likely to develop symptoms of depression and anxiety than children and adults7. Finding an academic trace, research has shown that transition from adolescence to adulthood and the experience of entering college for some students are associated with positive feelings of increased personal control12. On the contrary, it can be associated with different adverse outcomes affecting general health and HRQoL, such as homesickness, emotional separation, academic pressures, social issues, and financial and economic status13,14. Therefore, they are prone to mental health issues affecting their academic achievements and QoL, particularly among medical students whose education is highly stressful and challenging15,16.

Recent research shows that positive and negative experiences, especially the feeling of stress in long periods, particularly during childhood, among students of different disciplines lead to depression and anxiety17,18,19. Due to professional ethics or material gain, individuals who have chosen the clinical and non-clinical medical professions to serve the public are more prone to experience anxiety20. From this respect, medical students are more susceptible to endure depression and anxiety due to being exposed to study-related stress due to curriculum load, ongoing assessments, short time, or variable hours for the clinical rotation. In line with this justification, experiencing stress of occupation over time and its influence on their health and life may lead them to depression and anxiety and consequently affect their HRQoL21. Subsequently, it will impact their academic performance due to poor cognitive function arising from memory disorders and inability to perform22. Looking at this issue from a deeper perspective, researchers maintained that experiencing depression and anxiety may result in adverse consequences for themselves, the population they are serving, and their QoL23; perchance, evaluating the QoL of this population should be given priority15.

To the best of our knowledge, a few studies have investigated depressive and anxiety disorders and their association with HRQoL among medical students15,24,25,26. For further plans for future intervention, the current research has been carried out to examine the association between depression and anxiety with HRQoL among freshmen students of Neyshabur University of Medical Science (NUMS).

Materials and methods

Study design

The present cross-sectional study was performed as a part of a cohort at NUMS among 471 students who entered in 2019 and 2020. The data relating to the HRQoL, depression, and anxiety were collected during the academic year’s enrolment period (late September to early October 2019 and 2020). The baseline data were taken from the mentioned cohort study for this cross-sectional study. The cohort study has been approved by the Ethics Committee of NUMS (Ethic code: IR.NUMS.REC.1398.018). Taking ethical issues into account, the informed consent forms were collected from all participants. Besides, all methods in our study were performed in accordance with the relevant guidelines and regulations.

Data collection tools

Health-related quality of Life questionnaire (HRQoL)

HRQoL of students was measured using the second version of the Medical Outcome Study 12-Item Short-Form Health Survey (SF12-V2), conducted from SF36 27. The Iranian version of the SF12-V2 questionnaire has been validated for the Persian population27. Based on 12 questions inquiring about overall health states, pain, social functioning, moderate physical activity, physical and mentally limited, secure energetic, and depressed feelings, eight subscales have been defined: physical functioning (PF), role limitations due to physical problems (RP), bodily pain (BP), general health (GH), vitality (VT), social functioning (SF), role limitations due to emotional problems (RE), and mental health (MH). Eventually, two components will be calculated, Physical Component Summary (PCS), which is obtained by the summation of PF, RP, BP, and GH, and Mental Component Summary (MCS), which is acquired by the addition of VT, SF, RE, and MH28. Converted to the score from 0 to 100, where 0 represents the worth score, and 100 demonstrates the best score28.

Depression and anxiety questionnaires

The Beck Depression Inventory-II (BDI-II) has been used to evaluate the depression of the participants29. The BDI-II has been translated into Persian and validated for the Iranian population30. It has 21 items, each of which scores from 0 to 3. The total point is calculated by adding up each item’s score, ranging from 0 to 63. The total score demonstrates the level of depression, in which the interpretations are as follows: (i) minimal range (normal) = 0–13, (ii) mild depression = 14–19, (iii) moderate depression = 20–28, and (iv) 29–63 represent severe depression29.

Likewise, the Beck Anxiety Inventory (BAI) is utilized for assessing anxiety31,and it has been validated for Persian individuals32. Similarly, this questionnaire has 21 items with scores ranging from 0 to 3 for each item, in which 0 means “Not at all”, one means “Mildly, but it did not bother me much”, two means “Moderately, it was not pleasant at times”, and three means “Severely, it bothered me a lot” for all the items. In the same way, the total point varies from 0 to 63, which indicates levels of anxiety. A score of 0 to 7 represents a minimal range (normal). Subsequently, a score of 8 to 15 indicates mild, 16 to 25 represents moderate, and a score of 26 and above designates severe31.

Covariates

Several variables were used as covariates in this study, including gender (male vs. female), age (≤ 20 vs. >20 years old), marital status (single vs. married), Body Mass Index (BMI) (< 25 vs. ≥25), family residency (urban vs. rural), family size (\(\:\le\:\)4 vs. >4 persons), ethnicity (Fars vs. other), tobacco use (no vs. yes), wealth index (WI) (poorest, poor, moderate, rich and richest), and physical activity (low, moderate and high).

Statistical analysis

Descriptive analysis was performed using frequency (number and percentage), mean, and standard deviation (SD) of the studied variables. The Pearson correlation coefficient (Pearson’s r) was used to assess the correlation between depression, anxiety, and HRQoL. An Independent t-test was used to evaluate the association of different variables with HRQoL at the univariate analysis level. A multiple linear regression model was used to assess the adjusted association of depression and anxiety with HRQoL. Data analysis was conducted in STATA, version 14, and the statistical significance was considered at p < 0.05.

Results

The mean ± SD of participants’ age was 21.9 ± 6.1, with a male-to-female ratio of almost 2:3. Based on the characteristics of the studied population, presented in Table 1, less than a quarter had BMI ≥ 25, and according to physical activity, more than half of them (53.7%) had moderate to high activity levels. Less than a quarter of them (21.4%) had mild to severe depressive symptoms, and less than a third of college students (31.9%) had mild to severe anxiety symptoms. Other participants’ characteristics are presented in Table 1. The mean ± SD of the total score of HRQoL among the studied population equals 81.6 ± 14.9. The reliability of the questionnaires was calculated with Cronbach’s alpha (Cronbach’s alpha for HRQoL, depression, and anxiety were 0.87, 0.90, and 0.90, respectively). Table 2 presents the correlation of depression and anxiety with HRQoL and its subscales. According to our correlation analysis (Pearson’s r), the correlations between depression, anxiety, and total HRQoL were relatively strong negative (Table 2; Figs. 1 and 2). Table 3 illustrates the mean scores of the SF12 subscales and components based on different characteristics of the population. As presented in Table 3, there are significant associations between gender, tobacco use, physical activity, depression, anxiety, and total HRQoL score at the univariate level (P < 0.05). But no statistically significant association has been found between age, marital status, BMI, family residency, family size, ethnicity, WI, and total HRQoL score (P > 0.05). The results demonstrate a significant association between gender, marital status, BMI, tobacco use, physical activity, depression, anxiety, and PCS (p < 0.05). Although there are significant association between tobacco use, depression, anxiety, and MCS (p < 0.05). Other evaluated associations between studied variables and different subscales of HRQoL are presented in Table 3. The multiple linear regression model was used to control the confounding effect of covariates. The results of Table 4 demonstrate the adjusted association of depression with HRQoL. Different levels of depression have a strong significant association with all subscales and components (MCS and PCS) of HRQoL (p < 0.05) (except the association between mild and moderate depression with PF subscale). Moreover, different levels of depression are negatively associated with the total score of HRQoL (p < 0.05). Table 5 illustrates the adjusted association of anxiety with HRQoL. A statistically significant association was obtained between anxiety and all subscales (PF, RP, RE, VT, MH, SF, BP, and GH) and components (MCS and PCS) of HRQoL (p < 0.001, except for mild anxiety level and PF which was p = 0.002). Moreover, different anxiety levels are negatively associated with the total score of HRQoL (p < 0.05).

Table 1 Descriptive analysis of the variables
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Table 2 The correlation of depression and anxiety with total HRQoL, PCS, and MCS components
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Fig. 1
figure 1

Correlation plots comparing depression with total HRQoL, PCS, and MCS components.

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Fig. 2
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Correlation plots comparing anxiety with total HRQoL, PCS, and MCS components.

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Table 3 Unadjusted association of studied variables with HRQoL.
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Table 4 Adjusted association of depression with HRQoL (using multiple linear regression model).
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Table 5 Adjusted association of anxiety with HRQoL (using multiple linear regression model).
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Discussion

Medical students are prepared to ensure the well-being of patients and the general public health, regardless of gender. It turns out that such preparation brings many problems and challenges physiologically and intellectually demanding and has a negative impact on the medical students’ health. Studies indicate that medical and paramedical students are exposed to more stress factors that negatively affect their mental health due to their occupation nature, particularly nurses and healthcare assistants associates are more contrarily influenced by this subject33. Therefore, the present study has attempted to investigate the HRQoL and its relationship with depression and anxiety among medical freshmen. HRQoL has a notable impact on students’ achievement performance and enhanced productivity, hence to fulfill the goal of this study, the participants completed three questionnaires (SF-12, Beck anxiety, and depression) to report their characteristics.

The results obtained from the descriptive analysis show that the majority of the surveyed population suffers from mild depression, while 21.4% suffer from mild to severe depression (Table 1), rates lowered compared to the results of other meta-analyses showing a prevalence of 24.4 to 34.0% depressive symptoms for the same population. University students have a high prevalence of depressive symptoms compared to large samples from different communities, ranging from 7.3% in countries such as Australia to 20.6% in South American countries34.

An overall prevalence of mild to severe anxiety was found 31.9% which is not much different from the previous studies conducted in Iran. Similar findings noted anxiety was less prevalent among Chinese medical students (21%) and more prevalent among Malaysian and Saudi Arabian medical students (63% and 46% respectively) compared to Iranian students35,36.

An exploration into the relationship between depressive symptoms and various subscales, alongside the overall mean of HRQoL, has been undertaken. The results demonstrated that the total score of HRQoL has been correlated negatively with depression and anxiety (ρ: -0.70 and − 0.71, respectively). The higher absolute value of the Pearson coefficient of MCS with both depression and anxiety illustrates a more substantial relation. Besides, among all the eight subscales, MH has the highest absolute value of the Pearson coefficient, and its negativity can be interpreted that higher levels of depression and anxiety as psychological disorders may reduce mental health, and subsequently, the total score of HRQoL of individuals, which has been indicated in the previous studies26,37. As shown in Table 2, the statistical analysis demonstrates a significant negative association between depressive symptoms and each subscale, as well as the total mean of HRQoL (P-value < 0.05, for each domain). This correlation aligns with the Pearson correlation and corroborates findings from prior studies7,15,23,38. The collective evidence indicates that an escalation in depression levels corresponds to a subsequent decline in HRQoL.

Arsalan et al. have specifically articulated that individuals exhibiting depressive symptoms are prone to lower satisfaction levels with HRQoL in comparison to their non-depressive counterparts38. Furthermore, Gan et al., despite utilizing a distinct methodological approach to assess QoL, have underscored the substantial repercussions of depression on various facets of students’ lives, encompassing academic performance and behavioral patterns15. Notwithstanding variations in measurement scales, the consistent narrative emerging from diverse studies supports the overarching hypothesis that depression bears a negative correlation with HRQoL7,23,24,25.

Similar to depression, lower scores of individuals with higher anxiety levels in all domains of QoL indicate a significant reduction of HRQoL. Materializing this finding, Kelemenc-Ketis et al. found an association between anxiety and QoL, regardless of the method they used to measure the two mentioned variables, which differs from the current study7. Furthermore, another study by Racic et al. obtained a similar result, higher levels of stress resulted in higher levels of anxiety and would weaken the HRQoL23. Additionally, several studies suggested results following the hypothesis that among clinical and non-clinical medical students, several factors, including study pressure, extreme study load, an inordinate amount of new information, and long working hours during internship and residency will increase the anxiety level, and explain the negative association between anxiety and HRQoL6,10,15,25,39.

According to the findings of this study, the overall mean score of HRQoL in students was 81.6, which is supported by previous studies38,40. For instance, in a large-scale study in Belgrade on college students, the total score of HRQoL was reported as 76.7, which is relatively consistent with our finding41. However, there are studies in which the HRQoL score was lower than our findings37,42,43. These discrepancies for HRQoL can be due to the differences in the economic situation, work capacity, education major, grade of degree, and physical and mental health37,44.

Also, higher levels of depression and anxiety were reported by female students compared to male students45,46. Similarly, the lower HRQoL scores in our study might be in relation to higher levels of depression and anxiety measured by BDI and BAI in clinical and non-clinical medical students. It is well known that academic and personal stressors could impact the QoL of college students. Inefficiency, lack of self-confidence, uselessness, fear, and anger can lead to mental and physical complications and ultimately reduce the HRQoL in this population41,47.

Limitations & strengths

Although the present study noticeably contributed and added rich and novel values to the body of literature, the findings should be construed in light of limitations, especially in the data-gathering stage. Due to the nature of the participant’s mental state, which can differ from time to time, the results may be affected and become less accurate; thus, generalizing findings should be done carefully. Considering the cross-sectional essence of the study design, it is evident that it might not represent cause and effect association between variables and hence conducting further follow-up research is highly suggested. Although the selected population included a specific academic location (Neyshabur University of Medical Science) which can be considered a limitation, the students may come from different geographical parts and ethnicities. One way to ameliorate the generalizability of the study is the inclusion of medical freshmen students from different provinces in Iran.

Notwithstanding these limitations, the first and foremost strength of this study is that we performed comprehensive analyses including different variables, such as gender, tobacco use, physical activity, and so on, to investigate the adjusted association of depression and anxiety with HRQoL. Second, the selected population demonstrates a sample with particular characteristics (clinical and non-clinical medical students).

Conclusion

In conclusion, our study has supported that the depression and anxiety of freshman medical students are negatively associated with HRQoL, meaning that increasing the level of depression and anxiety decreases the HRQoL among the studied population. Accordingly, controlling lifestyle and work-related factors such as assigning less time to exercise, lack of attention to healthy nutrition, clinical specialty, study pressure, long working hours during internship and residency, and lack of time for leisure could influence individuals’ level of depression and anxiety and subsequently may result in higher HRQoL scores.