**1. Introduction**

Medical education is considered one of the most difficult professions of specialized training in terms of program duration, competition, and emotional demands [1]. Students transitioning from high school to medical college may suffer from a variety of challenges, including depression, alexithymia, burnout, and anxiety [2,3]. Alexithymia was identified to be one of the most common mental disorders among students [4]. The Greek term alexithymia means "lack of words for emotions" or "inability to discover words that identify and express feelings". It is described as a subclinical lack of emotional awareness, or more specifically, difficulties recognizing and defining feelings, as well as differentiating feelings from body sensations associated with emotional arousal [5,6]. As alexithymia is a symptom rather than a condition, it does not have any diagnostic criteria in the DSM-5 [7]. However, this symptom can worsen and lead to other mental illnesses such as depression, subjective

**Citation:** Aleisa, M.A.; Abdullah, N.S.; Alqahtani, A.A.A.; Aleisa, J.A.J.; Algethami, M.R.; Alshahrani, N.Z. Association between Alexithymia and Depression among King Khalid University Medical Students: An Analytical Cross-Sectional Study. *Healthcare* **2022**, *10*, 1703. https:// doi.org/10.3390/healthcare10091703

Academic Editors: Tselebis Athanassios, Argyro Pachi and Daniele Giansanti

Received: 6 July 2022 Accepted: 2 September 2022 Published: 6 September 2022

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**Copyright:** © 2022 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

distress, and burnout [7–9]. The prevalence of alexithymia varied between medical and nonmedical students [10]. For example, a study carried out among Egyptian medical students showed the prevalence of alexithymia was 24.4% [11]. In addition, a study conducted by Velea et al. [12] showed the prevalence of alexithymia among Romanian medical students was 36.02%. In Arab countries, the prevalence of alexithymia was higher than in non-Arab countries, studies in Jordan and Saudi Arabia showed the prevalence among university students was 24.6% and 49%, respectively [4,13]. Medical students were found to be more prone to alexithymia due to their difficult curriculum and training [13]. According to studies, first- and fifth-year medical students had higher alexithymia scores than second-, third-, and fourth-year students [14,15]. In contrast, Morice-Ramat et al. [16] reported that there was no significant difference in alexithymia across medical students of different years of study. Nevertheless, students with alexithymia are more likely to participate in maladaptive behaviors such as suicide, substance misuse, poor academic performance, low self-efficacy, and poor self-care [7,17–19]. Although poor academic achievement, a lack of physical exercise, chronic illnesses, and cigarette smoking all seem to be related in some way to alexithymia, lack of family support among medical students is a crucial factor that needs to be investigated, especially its association with alexithymia [14,20]. In addition, several sociodemographic factors are associated with alexithymia among different sub-groups of the population (such as medical students, university students, or adults) including gender, advanced age, low educational level, marital status, and low socioeconomic status (see Figure 1) [4,14,21–23].

**Figure 1.** Framework indicating the social and other (such as psychological factors) determinants of alexithymia. (Note: The framework is prepared by the authors based on the literature.)

Additionally, medical students are susceptible to certain types of psychological distress, such as depression, anxiety, and stress, which can alter their emotional states and make it difficult or impossible for them to express and recognize their emotions [4,24,25]. According to a recent review study, depression is quite prevalent among Saudi Arabian medical students, showing the prevalence of depression varied from 30.9% to 77.6% with a mean prevalence of 51.5% [26]. Depression is a common form of mental suffering that can have a variety of clinical forms, is linked to numerous diseases, and can even lead to mortality [27]. Moreover, depression was found to be associated with alexithymia in several studies from non-Arabian countries [28,29]. Therefore, the relationship between alexithymia and depression among Saudi medical students needs to be investigated immediately because it has not been conducted yet given the extreme importance of these two issues. According to research evidence, Saudi people, similar to other Arab nations, have trouble identifying and explaining their emotions, particularly among men. Customs and cultural beliefs play a vital role in this fact, emotions are a private matter that should not be probed [13]. In Saudi Arabia, few studies have been conducted on alexithymia among medical students or university students, all of which evaluated the relationship with sociodemographic factors, students' academic factors, and internet addiction [13,20,30]. These studies acknowledged that depression was underreported in the studies and offered recommendations for further research. Moreover, since these studies were conducted at a single institution using data from various Saudi Arabian regions, their generalization to the entire country had limitations. The southern Saudi Arabian city of Abha has cultural and sociodemographic differences (such as capital city, tourist point, climatically vulnerable, and considerably high level of mental distress among different sub-groups [31,32]) than other Saudi Arabian cities (such as Jeddah), where studies on alexithymia have been undertaken. As a result, there may be variations in the prevalence and determinants of alexithymia among medical students from Abha. In order to fill the gap in the literature and consider the regional variability, the current study sought to determine the prevalence of alexithymia and its relationships with socio-demographics and depression among medical students at King Khalid University, Abha, Saudi Arabia. The outcomes of this study will be helpful to university authorities in proposing and establishing intervention programs to diagnose and treat alexithymia.
