1. Background
Medical schools are tasked with cultivating competent and compassionate physicians to serve patients and advance public health (1). However, the educational pathway is exceptionally demanding, requiring substantial academic and emotional commitment from students (2). This sustained pressure can adversely affect psychological well-being, potentially triggering or exacerbating mental health conditions such as depression and anxiety (3). The risk of psychological disorders is significantly higher among medical students and professionals than in the general population (4, 5).
A substantial body of literature has shown that medical students experience psychological distress at higher rates than the general population (5). Meta-analytic evidence has reported a considerable prevalence of depressive symptoms among medical students worldwide (6). Anxiety is also frequently reported in this population, although prevalence estimates vary across studies and settings, partly because of differences in instruments, cutoff points, and sociocultural context (7, 8). In Iran, available studies have likewise documented notable levels of depression, anxiety, and stress among students of medical sciences. Nevertheless, evidence regarding the role of personality-related factors that may contribute to these outcomes among Iranian medical students remains limited (9).
Among the personality traits implicated in student mental health, perfectionism has received considerable attention. Defined as a multidimensional construct characterized by exceedingly high personal standards and overly critical self-evaluation (10, 11), perfectionism has a dual nature. Although striving for excellence can be adaptive, maladaptive forms are consistently associated with adverse psychological consequences, including increased depression, anxiety, and stress (12). Studies have identified perfectionism as a strong predictor of psychological distress in medical students (13). However, the existing literature presents a complex picture, and the precise nature of this relationship, particularly within the Iranian context, remains underexplored.
2. Objectives
This study was conducted to address this research gap by examining the associations between perfectionism and levels of depression, anxiety, and quality of life among medical students at a major university in Iran. It aimed to provide evidence-based insights to inform mental health support in Iranian medical education, where cultural and academic pressures may uniquely influence these associations. A total of 437 students were invited to participate, and 306 completed the survey, yielding a response rate of approximately 70%.
3. Methods
3.1. Study Design and Participants
Eligible participants were medical students who 1) were enrolled at the School of Medicine during the study period, 2) were Iranian citizens, and 3) were willing and able to complete an online questionnaire. Students who had taken a major examination during the month preceding participation were excluded because recent major examinations could act as an acute situational stressor and confound the assessment of general levels of perfectionism, depression, anxiety, and quality of life. Questionnaires with substantial missing data were excluded from the final analysis.
3.2. Sampling Procedure
A stratified random sampling technique was used to ensure representation across academic years. First, the student population was stratified into four academic levels: basic sciences, physiopathology, externship, and internship. The number of students required from each stratum was calculated based on its proportional size within the entire medical student body. Subsequently, the required number of participants was selected from the official list of students in each stratum using a simple random sampling method with a random number generator.
3.3. Instruments
The online survey comprised a demographic questionnaire and four standardized instruments.
The demographic questionnaire collected information on age, sex, marital status, parity, place of residence, monthly family income, academic stage, native/non-native student status, tuition payment status, history of failure in final examinations, grade point average, substance use, history of psychiatric disorders, and use of psychiatric medication.
Perfectionism was assessed using the Persian-validated version of the Frost Multidimensional Perfectionism Scale (FMPS), a 35-item self-report instrument comprising six subscales: personal standards, concern over mistakes, parental expectations, parental criticism, doubts about actions, and organization. Items were rated on a 5-point Likert scale, and selected items were reverse-scored before summation according to the standard scoring protocol (14). A total perfectionism score was calculated by summing all item scores, with higher scores indicating greater overall perfectionistic tendencies. The Persian version of the FMPS used in this study has demonstrated acceptable internal consistency and validity in previous Iranian research (15).
Depressive symptoms were assessed using the Persian-validated version of the Beck Depression Inventory-II (BDI-II), a 21-item self-report instrument in which each item was rated on a 4-point scale (0 - 3), yielding a total score ranging from 0 to 63. Higher total scores indicate greater severity of depressive symptoms (16). The Persian version of the BDI-II has shown good reliability and validity in Iranian samples.
Anxiety symptoms were assessed using the Persian-validated version of the Beck Anxiety Inventory (BAI), a 21-item self-report instrument assessing the severity of somatic and cognitive symptoms of anxiety over the preceding week, with each item rated on a 4-point scale (0 - 3). Total scores range from 0 to 63, with higher scores indicating greater anxiety severity (17). The Persian version of the BAI has demonstrated acceptable psychometric properties in previous studies conducted in Iran.
Quality of life was assessed using the Persian-validated version of the World Health Organization Quality of Life-BREF (WHOQOL-BREF), a 26-item self-report instrument comprising four domains: physical health (7 items), psychological health (6 items), social relationships (3 items), and environmental health (8 items), in addition to two general items on overall quality of life and general health that were not included in domain scoring. Raw domain scores were calculated by summing the relevant items and then transformed to a standardized 0 - 100 scale using the following formula: (raw domain score × 100) divided by the maximum possible raw score for that domain. The overall quality-of-life score was calculated as the mean of the four transformed domain scores, with higher scores indicating better perceived quality of life (18). The Persian version of the WHOQOL-BREF has been validated and widely used in Iranian populations (19).
3.4. Statistical Analysis
Data were analyzed using SPSS version 22.0. Descriptive statistics, including means, standard deviations, frequencies, percentages, minimum values, and maximum values, were used to summarize participant characteristics and study variables. The normality of the main study variables was assessed using the Kolmogorov-Smirnov test and visual inspection of histograms. Pearson correlation coefficients were used to examine the relationships between total perfectionism scores and depression, anxiety, and quality-of-life scores. Scatterplots were also generated to visually assess the direction and strength of the observed associations. A 2-tailed P value < 0.05 was considered statistically significant.
3.5. Ethical Considerations
The study protocol was approved by the Ethics Committee of Mashhad University of Medical Sciences (Code: IR.MUMS.MEDICAL.REC.1401.597). An information sheet outlining the study purpose and ensuring anonymity was provided on the first page of the online survey. Participants provided digital informed consent before proceeding. The study was funded by Mashhad University of Medical Sciences (Grant code: 4011520).
4. Results
4.1. Participant Characteristics
A total of 306 medical students completed the survey. The mean age of the participants was 24.30 ± 1.94 years. Demographic characteristics are presented in Table 1. The sample comprised 52.9% males; most students were single (80.4%) and in their internship year (57.8%).
Table 1.
Demographic Characteristics of the Participants
| Variables | No. (%) |
|---|---|
| Gender | |
| Male | 162 (52.9) |
| Female | 144 (47.1) |
| Marital status | |
| Single | 246 (80.4) |
| Married | 60 (19.6) |
| Having children | 16 (5.2) |
| Place of residence | |
| Dormitory | 125 (40.8) |
| With parents | 181 (59.2) |
| Family income/month (RLS) a | |
| 30 - 50 | 13 (4.2) |
| 50 - 100 | 73 (23.9) |
| > 100 | 220 (71.9) |
| Education period | |
| Basic sciences | 25 (8.2) |
| Physiopathology | 36 (11.8) |
| Extern | 68 (22.2) |
| Intern | 177 (57.8) |
| Local student | 138 (45.1) |
| Paid enrollment | 79 (25.8) |
| History of failure in final examination | 41 (13.4) |
| Grade point average (maximum, 20 points) | |
| < 14 | 27 (8.8) |
| 14 - 17 | 178 (58.2) |
| 17 - 20 | 101 (33.0) |
a RLS: Iranian rials (values reflect the local currency scale; equivalent to approximately 0.00002 USD per rial at the time of the study).
The mean scores of the FMPS, BDI-II, BAI, and WHOQOL-BREF were 115.13 ± 14.85, 46.19 ± 10.94, 39.51 ± 8.28, and 65.49 ± 10.51, respectively.
4.2. Correlation Analysis
The results of the Pearson correlation analysis are presented in Table 2. A statistically significant, although weak, negative correlation was observed between the total FMPS score and BDI-II scores (r = -0.162, P = 0.005), as well as BAI scores (r = -0.196, P = 0.001). Accordingly, as total perfectionism scores increased, self-reported levels of depression and anxiety tended to decrease. A significant negative correlation was also found between the total FMPS score and WHOQOL-BREF scores (r = -0.118, P = 0.039), suggesting that higher perfectionism was associated with lower quality of life (Figure 1).
Table 2.
Pearson Correlation Between Perfectionism (FMPS) and Other Study Variables
| Variable Correlated with FMPS | Pearson r | P-Value |
|---|---|---|
| BDI-II score (depression) | -0.162 | 0.005 |
| BAI score (anxiety) | -0.196 | 0.001 |
| WHOQOL-BREF score (quality of life) | -0.118 | 0.039 |
Figure 1.
Correlation between FMPS scores and the scores of the BDI-II, BAI, and WHOQOL-BREF questionnaires. Abbreviations: FMPS, Frost Multidimensional Perfectionism Scale; BDI-II, Beck Depression Inventory-II; BAI, Beck Anxiety Inventory; WHOQOL-BREF, World Health Organization Quality of Life-BREF.
The dispersion of the data points suggests that the observed associations are weak.
5. Discussion
This study explored the relationship between perfectionism and mental health outcomes in a sample of Iranian medical students. The principal finding was nuanced: higher overall perfectionism was associated with lower self-reported symptoms of depression and anxiety, while also being associated with lower quality of life.
At first glance, the inverse associations between perfectionism and depression or anxiety may appear inconsistent with studies linking perfectionism to psychological distress (9, 12). However, this apparent discrepancy may be explained by the multidimensional nature of perfectionism. Perfectionism includes dimensions that may reflect relatively adaptive striving, such as high personal standards and orderliness, as well as dimensions that are more clearly maladaptive, such as excessive concern over mistakes and chronic self-criticism (20). In a high-achieving academic environment such as medical school, adaptive aspects of perfectionism may be more prominent in some students and may be associated with fewer self-reported emotional symptoms. At the same time, perfectionistic tendencies may still undermine broader well-being, which may help explain the negative association observed with quality of life (6, 18).
These findings should therefore be interpreted cautiously. Because only the total perfectionism score was analyzed in the present study, it was not possible to distinguish the effects of adaptive and maladaptive dimensions of perfectionism. This limitation may partly explain why our findings differ from studies reporting positive associations between maladaptive perfectionism and depression, anxiety, or stress. Differences in the study setting, culture, student population, and measurement strategies may also contribute to variability across findings.
Another important finding was the high mean scores for depression and anxiety in this sample. Based on commonly used interpretations of the BDI-II and BAI, the mean scores observed in this study fall within the severe range of symptomatology. This finding indicates a substantial burden of psychological distress among the surveyed students and is broadly consistent with prior reports highlighting the mental health vulnerability of medical students (17, 9, 5).
5.1. Strengths and Limitations
A primary strength of this study is the use of a stratified random sampling method, which enhances the representativeness of the sample compared with convenience sampling. The use of well-validated instruments is another strength.
However, several limitations must be acknowledged. First, the cross-sectional design precludes any inference of causality. Second, reliance on self-report questionnaires may introduce reporting bias. Third, because we did not perform a subscale analysis of the FMPS, we were unable to differentiate adaptive and maladaptive perfectionism. Finally, because this was a single-center study, the findings may not be generalizable to all medical students in Iran, and the single-center design may also have affected the representativeness of the sample.
5.2. Future Directions
5.3. Conclusions
In this sample of Iranian medical students, overall perfectionism demonstrated a paradoxical relationship with mental health, being associated with fewer symptoms of depression and anxiety but also with lower quality of life. This finding underscores the nuanced and multidimensional nature of perfectionism. Regardless of this complexity, the severe levels of psychological distress reported by students indicate an urgent need for universities to implement comprehensive mental health and stress management programs. Such initiatives are vital to support students' well-being throughout their demanding educational journey.
