*3.3. Relationship between Alexithymia and Depression*

A total of 94.3% of students with alexithymia showed depression symptoms compared to 86.7% of students with possible alexithymia and 75% of students with no alexithymia (*p* = 0.001) (Table 2).

**Table 2.** Relationship between alexithymia and depression among medical students at King Khalid University, Saudi Arabia, 2022.


*p*: Pearson X<sup>2</sup> test, \* *p* < 0.05 (significant).

#### *3.4. Factors Associated with Alexithymia*

A total of 52.6% of female students had alexithymia compared to 42% of male students with a recorded statistical significance (*p* = 0.048). Additionally, 56.3% of students with a family monthly income of SAR 6000–10,000 had alexithymia versus 51.9% of students with an income of more than SAR 15,000, and 35% of those with a family income of less than SAR 3000 (*p* = 0.011). Other factors were insignificantly associated with students' alexithymia status (Table 3).


**Table 3.** Factors associated with Alexithymia among medical students at King Khalid University, Saudi Arabia, 2022.

*p*: Pearson X<sup>2</sup> test, \$: Exact probability test, \* *p* < 0.05 (significant).

A binary multivariate logistic regression to examine the factors related to alexithymia is shown in Table 4. Among included factors, female students showed an almost doubled risk for alexithymia compared to males (OR = 2.09; 95% CI: 1.18–4.78), students of families with a high income showed less probability for alexithymia (OR = 0.39; 95% CI: 0.17–0.97), and students with chronic health problems showed doubled risk for alexithymia (OR = 2.04; 95% CI: 1.23–7.11). In addition, depression was found to be associated with alexithymia (OR = 1.91; 95% CI: 1.11–3.34).

**Table 4.** Binary multivariate logistic regression of factors associated with alexithymia among medical students at King Khalid University, Saudi Arabia, 2022.


OR: Odds ratio, CI: Confidence interval, \* *p* < 0.05 (significant).

#### **4. Discussion**

The current study assessed the prevalence of alexithymia among medical students in Saudi Arabia and evidenced that alexithymia was associated with sociodemographic factors (such as female, having a chronic disease, and income) and depression. As per the TAS-20 scale, the sample of this study showed a lower prevalence of alexithymia (47.3%) than other studies among medical students in other Saudi cities such as Jeddah (49%) [14], and Makkah (56.5%) [30]. However, we found a higher prevalence of alexithymia than a previous study conducted in the Kingdom of Saudi Arabia, which reported that 30.2% of university students had alexithymia and 33.8% had possible alexithymia [39]. Using the same scale, Al-Eithan et al. [35] showed that Saudi mothers of disabled children had a significantly higher degree of alexithymia. Moreover, the prevalence of alexithymia differs from Arab regions to other countries [13]. In Chinese medical students, the prevalence was found to be 34% [14], and only 6.02% [12] among Romanian medical students. The high proportion of alexithymia among these participants, especially in Saudi Arabia, might be related to a number of variables that have been linked to an increased risk of mental problems in the literature [7]. These characteristics include beliefs and prior experiences with mental health concerns, a lack of information regarding official services, social stigma, uncertainties regarding the validity of mental diseases, and the utilization of indigenous informal resources [13,40]. However, the prevalence among non-medical students such as nursing students [41], university students [4], and high school students [29] was less when we compared it with medical students. Due to the higher proportions, medical students should be aware of alexithymia's prevalence and its consequences in their own lives as it might reflect on their performance which could influence their future as physicians [18].

Our study found significant gender differences in susceptibility to alexithymia. The current study reported female medical students had a higher risk of developing alexithymia compared to male students. This finding is consistent with the findings of several studies, including Hamaideh et al. [4] and Alharthi et al. [30], which state that females are more likely to develop emotional problems, which explains why they are more likely to develop alexithymia. In contrast, a study carried out by Zhu et al. [14] revealed that male medical students were at higher risk for alexithymia. Previous studies among young adults/general population reported that prevalence of alexithymia was higher in men than in women [21,22]. Our findings also demonstrated that students whose families have a high income were less likely to experience alexithymia. This finding is consistent with a study conducted among the Lebanese population by Obeid et al. [23], which showed that the prevalence of alexithymia decreased as income increased. Moreover, Kokkonean et al. found that alexithymia was associated with poor education and low-income status, and was common among unmarried people [21]. A previous study also found a strong association

of alexithymia with increasing age among the general population [22]. However, in this study, we did not find any significant association between alexithymia and age.

In this study, we found medical students with chronic diseases were more likely to have alexithymia. Several studies revealed that chronic diseases have a high occurrence worldwide and psychological illnesses may impact patients' capacity to manage them, as a chronic disease is an age-related problem that will be with them to the end of their lives [42,43]. Generally, alexithymia is found to be associated with mortality and morbidity, for instance, a study reported the risk of cardiovascular disease death among middle-aged Finnish men was increased by 1.2% for each 1-point increase in TAS [44].

In our study, we found the prevalence of depression among medical students was 88.9%; nearly a third of them (31.8%) had moderate to severe depression, which is relatively high when compared to several studies carried out in Saudi Arabia [26,45]. A study conducted by Alamri et al. (2020) [46] reported that 28.9% of the general population in Saudi Arabia had depressive symptoms. As per a recent study, the rate of depression among the general population of the Jazan region in Saudi Arabia was nearly 26% during the COVID-19 pandemic [47]. However, Al Rashed and his colleagues [48] found a lower prevalence of depression (8.6%) among the general population in the Al-hasa region than in other parts of Saudi Arabia. Worldwide, mental health and psychological problems of university/medical students are recognized as serious public health issues [49,50]. Medical students are more likely to develop depressive symptoms since stress level is higher in medical students compared to the general population [3,51].

This study found a statistically significant difference among medical students with severe depression as they had the highest score of alexithymia in our sample. A meta-analysis of studies using both clinical and general population samples found that alexithymia scores were moderately correlated to scores for depression severity [51]. Our regression model showed that depression is a potential risk factor for alexithymia (OR = 1.91, 95% CI: 1.11–3.34). These findings were consistent with those of previous research that showed comparatively similar results [4,28,29]. A previous study undertaken among Jordanian university students reported that alexithymia was significantly correlated with depression, anxiety, and stress [4]. Another study conducted among Lebanese adolescents found higher levels of alexithymia were significantly associated with higher depression scores [52]. These results suggested that university officials would place the mental health and well-being of medical students at the top of their priority lists. Additionally, it is strongly recommended that future research examines the relationship between alexithymia and other psychological states such as stress, anxiety, and life satisfaction of medical students in Saudi Arabia.

Literature suggests that the higher the alexithymia scores, the higher the depression scores (i.e., positive association between the presentation of alexithymia and depression) [53]. A follow-up study also revealed that following the remission of depression, alexithymia persisted to some extent [54]. This implies that alexithymia has both statedependent (e.g., mood but also general psychopathology) and trait-dependent characteristics [53]. If strong alexithymia hinders a consistent expression of emotional changes, for example, for patients who admit to a sad mood only erratically, a phenomenological form of depression may manifest without sadness [53,55].

Alexithymia and depression are often described as similar constructs; however, according to some researchers, the subscales of alexithymia only serve to measure the pre-defined concept of depression [56]. The evidence to date indicates that depression and alexithymia are distinct but closely linked entities [56–59]. One issue is still debatable whether alexithymia is a predisposing factor (vulnerability hypothesis) or the consequence of depression (reactivity hypothesis), or whether they coexist [56,58]. However, to date, most studies have provided support for the predisposition role of alexithymia (i.e., vulnerability hypothesis). For instance, Gilanifar and Delavar [59] found that women with alexithymia had a 2.6-fold higher risk of developing depressive symptoms.

Alexithymia is defined as a condition of poor emotional regulation that can lead to significant unpleasant feelings such as depression, anxiety, separation anxiety, and

avoidance behaviors [11]. Medical students who scored highly for both alexithymia and depression in this study had more trouble with their experiences and feelings than those who did not. As a result, these students might practice harmful coping mechanisms such as smoking or risky actions such as suicidal behavior or social disengagement, leading a sedentary lifestyle, or even dropping out of college [60].

In this study, almost 40.5% of the participants had possible alexithymia, so it is necessary to keep reassessing these students to check if their scores are improving or declining over time, as some of them may be able to recover by using self-help coping methods such as spiritual coping mechanisms [13,61]. Further research should be conducted on the impact of customs and cultural beliefs on depressive symptoms and alexithymia among at-risk populations such as students, children, mothers, and the elderly.
