|Year : 2019 | Volume
| Issue : 2 | Page : 126-131
Short-term changes in the mental health of recently enrolled university students
Rubi Abigail Cruz-Sanchez1, Luis Enrique Ferrer-Juárez1, Martha Edith Reyes-Garduño1, María José Gil-Trejo1, Sergio Manuel Sánchez-Moguel2, Sofía González-Salinas2
1 Academic Area of Medicine, Superior School of Tepeji del Río, Autonomous University of the State of Hidalgo, Tepeji del Río, Hidalgo, México
2 Academic Area of Medicine, Superior School of Tepeji del Río, Autonomous University of the State of Hidalgo, Tepeji del Río, Hidalgo; Department of Behavioral and Cognitive Neurobiology, Institute of Neurobiology, National Autonomous University of Mexico, Querétaro, México
|Date of Web Publication||22-Jul-2020|
Department of Behavioral and Cognitive Neurobiology, Institute of Neurobiology, National Autonomous University of Mexico, Campus Juriquilla, Boulevard Juriquilla 3001, Querétaro 76230
Source of Support: None, Conflict of Interest: None
Background: There are no studies that evaluate whether briefly after beginning of university studies, emotional changes, sleeping alterations, or disordered eating habits take place. Aim: To evaluate whether depression, anxiety, stress, sleep quality, and eating behaviors change 1 month after the beginning of medical school. Methods: We applied an online version of the scales Depression, Anxiety, and Stress Scale-21, Pittsburgh Quality Index, and Eating Attitudes Test-26 to recently enrolled medical students in their 1st week of classes and 1 month after. A total of 17 students completed both tests; their mean age was 18.4 years. Results: Sleep quality decreased 1 month after starting undergraduate studies, while no significant changes occurred in the level of depression, anxiety, stress, or eating behaviors. Importantly, waist circumference increased 1 month after starting classes. A correlation analysis showed that poor sleep quality in Test 2 was positively related to depression, anxiety, and stress also in Test 2. By multivariate linear regression, we found that sleep quality was only statistically related to depression scores. We found no statistical relationship between eating behaviors and the emotional state of the students. Conclusion: We provide evidence in favor of a relationship of emotional alterations and sleep quality while did not find an association of these variables with eating behaviors. We conclude that briefly after enrollment at medical school, sleep quality is mainly affected and this may later lead to emotional alterations.
Keywords: Anxiety, depression, eating habits, emotions, medicine, sleep, stress, students
|How to cite this article:|
Cruz-Sanchez RA, Ferrer-Juárez LE, Reyes-Garduño ME, Gil-Trejo MJ, Sánchez-Moguel SM, González-Salinas S. Short-term changes in the mental health of recently enrolled university students. J Mental Health Hum Behav 2019;24:126-31
|How to cite this URL:|
Cruz-Sanchez RA, Ferrer-Juárez LE, Reyes-Garduño ME, Gil-Trejo MJ, Sánchez-Moguel SM, González-Salinas S. Short-term changes in the mental health of recently enrolled university students. J Mental Health Hum Behav [serial online] 2019 [cited 2020 Aug 9];24:126-31. Available from: http://www.jmhhb.org/text.asp?2019/24/2/126/290517
| Introduction|| |
Strong stressful events such as childhood maltreatment, illness,,,,, natural disasters, or being in combat in a war, increment the probability to develop major depressive disorder and anxiety. Less intense experiences also predispose to develop these mood disorders; for example, intense work stress or low control at home or work. The enrollment at undergraduate school might also trigger the appearance of depression and anxiety symptoms. University students are subject not only to new demands regarding academic achievements but also to social and emotional changes. The incidence of depression in the student community is reported to lay between 12% and 60.8%, the incidence of stress is around 20%, and anxiety presents in >50% of students.,,,,,, Depression and anxiety disorders can be accompanied with sleep disturbances, and with poor eating habits., Due to the curricular design, the activities in health institutions, and the duration of the studies, medical students present important emotional and health problems;,,,,, however, it has not been tested whether the emotional affections occur briefly after enrollment at university. We wanted to explore whether enrollment at medical school can trigger changes in depression, anxiety, stress, sleep quality, and eating habits 1 month after the beginning of classes.
| Methods|| |
Design of the study
Sixty-eight students recently enrolled at medical school from a public university from Hidalgo, Mexico, were asked to participate in the study; their weight, height, and perimeter of their waist were measured. The students were asked to answer an electronic questionnaire elaborated using Google Forms. This electronic questionnaire included the Spanish version of the Depression, Anxiety, and Stress Scale-21 (DASS-21), the Pittsburgh Sleep Quality Index (PSQI), and the Eating Attitudes Test-26 (EAT-26). The students were informed that their answers were going to be used only for research purposes and that their identity would not be revealed at any stage of the investigation. The participants that agreed to participate gave informed consent by providing their name and e-mail; after that, the electronic questionnaire was sent to them. The same questionnaire was applied in the 1st week of classes (Test 1) and approximately 1 month later (Test 2). The application of the questionnaire was performed following the ethical standards stated in the Helsinki Declaration of 1964, as revised in 2013.
Only 17 students completed the questionnaire in the two applications (retention of 25%, 17/68). Thus, our sample was composed of 6 male and 11 female students whose mean age at Test 1 was 18.4 years. The socioeconomic status of the participants located between medium–low and medium. All the participants declared not being under any medical treatment and to not have any important clinical condition. The admission to the medical school described in this study is a highly selective process that relies on a written examination. Each semester, 30 students from an average of 300 applications are accepted. The number of students on each semester lays also around 30 considering the students who abandon their studies and students who failed to approve courses; however, the number of students who progress without any delay is low, around 10 on each semester.
The DASS-21 is composed by 21 items and evaluates depression, anxiety, and stress symptoms over the previous week.,, The range of values for normal symptomatology for depression, anxiety, and stress is 0–4, 0–3, and 0–7, respectively. The PSQI, previously validated in Spanish speakers,,, evaluates sleeping disturbances in the previous month. The PSQI consists of seven components and the sum of all the components constituted the global PSQI; a global PSQI of 5 or above indicates poor sleep quality. The EAT-26 scale is conformed by 26 items; scores of 20 or higher indicate concerns regarding body weight, body shape, and eating.,
Due to the lack of normality of all the compared groups, nonparametric statistics were used to compare between Test 1 and Test 2; the Wilcoxon paired-ranked test was applied. To compare the number of students with normal scores between Test 1 and Test 2, we used the Chi-square test (the categories were “normal” and “abnormal” scores based on the cutoffs mentioned previously). For correlation analysis, the Spearman test was used. Multivariate linear regression analysis for sleep quality as the dependent variable was tested including the scores of depression, anxiety, stress, and number of test. The R software version 3.5.1 (2018) R Foundation for Statistical Computing, Vienna, Austria https://www.R-project.org/ was used for statistical analysis and for graph design.
| Results|| |
Depression, anxiety, and stress
We found that there were no significant changes in the level of depression (Z = 32, P = 0.60), anxiety (Z = 20, P = 0.24), or stress (Z = 23, P = 0.68) between the first and the second test [Figure 1]. Total DASS-21 score neither showed differences between the two points of study (Z = 42.5, P = 0.55). In Test 1, 100% of students had normal levels of depression, 84.4% had normal levels of anxiety, and 88.2% had normal levels of stress. In Test 2, the prevalence of normal levels of depression, anxiety, and stress was 94.2%, 84.4%, and 82.4%, respectively. The Chi-square test did not show significant differences for the proportion of students with normal scores between Test 1 and Test 2 (χ2 = 0.0, P = 1.0; the same result for depression, anxiety, and stress proportions).
|Figure 1: Boxplots of the scores obtained in the Depression, Anxiety, and Stress Scale-21 to assess depression, anxiety, and stress in the 1st week of classes (Test 1) and 1 month after (Test 2). Outliers are shown with circles|
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We found that sleep quality of students was better in Test 1 (median = 3) compared to Test 2 (median = 4; Z = 10.5, P = 0.04). While 88.2% of students had a good quality in Test 1 and only 59% had a good quality in Test 2, the Chi-square did not reach statistical significance (χ2 = 2.42, P = 0.12). Furthermore, the number of hours of real sleep (total time in bed − time to fall asleep) decreased between Test 1 (median = 8.75 h) and Test 2 (median = 5.95 h; Z = 119, P = 0.009) [Figure 2].
|Figure 2: Boxplots of the scores obtained in the Pittsburgh Sleep Quality Index, number of hours of real sleep, the scores of the Eating Attitudes Test-26, and waist circumference in the 1st week of classes (Test 1) and 1 month after (Test 2). *P < 0.05, **P < 0.01, outliers are shown with circles|
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Eating attitudes and anthropometric measurements
The data obtained with the EAT-26 scale showed that there were no changes in the eating attitudes between Test 1 and Test 2 (Z = 21, P = 0.54) [Figure 2], and 100% of students showed normal levels of eating habits in both Test 1 and Test 2. The analysis of the circumference of the waist showed that there was a significant increase between Test 1 (median = 82 cm) and Test 2 (median = 87 cm; Z = 18.5, P = 0.006) [Figure 1]. Taking values lower to 80 cm for female and 90 cm for male students as normal, 53% of the students had normal levels of waist circumference in Test 1; the same percentage was observed in Test 2. Body mass index (BMI) did not differ between Test 1 and Test 2 (Z = 77, P = 1.0). Taking values lower than 25 kg/m2 as normal, in Test 1, 71% of the students had normal BMI, while in Test 2, 65% of students had normal BMI; no statistical differences between the proportions were found (χ2 = 0.0, P = 1.0).
Correlation between scores of depression, anxiety, stress, sleep quality, and eating behavior
As can be observed in [Table 1], just few correlations were observed within measures of Test 1 in which sleep quality and depression were correlated, stress with anxiety, and BMI with waist circumference. When visualizing the correlations within Test 2 [Table 1], we found that depression, anxiety, stress, and sleep quality were all interrelated; the correlation between BMI and waist circumference maintained. Scores of sleep quality, anxiety, and stress obtained in Test 1 were further correlated with measures of sleep quality, depression, anxiety, and stress in Test 2 [Table 1]; interestingly, depression observed in Test 1 was not related to any variable measured in Test 2.
|Table 1: Statistical correlations among the measures of sleep quality, depression, anxiety, stress, eating behaviors, and anthropometric measurements obtained in Test 1 and Test 2|
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The eating habits' behaviors measured in Test 1 were only correlated with values of eating habits in Test 2.
Multivariate linear regression analysis of sleep quality
Based on the statistical difference between sleep quality in Test 1 and Test 2, and due to the multiple correlations found with depression, anxiety, and stress, we next tested the participation of scores of depression, anxiety, stress, and time of the test to explain the values of the sleep quality in a multivariate linear regression analysis. We found that only depression scores were significantly associated with sleep quality [Table 2].
| Discussion|| |
We wanted to test whether the entrance to medical school represents a stressful experience enough to cause destabilization in the mental health of students. Despite it is known that medical students show disturbances in depression and anxiety whose symptoms exacerbate as they advance in their studies,,, the studies have not stated whether the emotional affections present early after they begin their studies. In the present work, we show that 1 month after the beginning of medical school, students do not present an increase in the scores of depression, anxiety, or stress; however, their sleep quality decreases significantly as well as the duration of sleeping. Our finding that sleep quality in Test 1 was related to depression in Test 2, and the multivariate analysis showed that only depression was related to sleep quality leading us to suggest that sleeping disturbances might precede future depressive symptoms in the student community.
Sleep disturbances deserve important attention due to the functions of sleeping: To restore brain metabolism; to eliminate metabolites accumulated during the day, for the correct development of the brain and release of growth hormone to allow body growth and regeneration; and to consolidate memories.,,,, This last function is essential in the student community as poor sleep quality might be related with scholar achievements as a work previously showed.
It was unexpected that eating habits did not change between Test 1 and Test 2 beside an increment in waist circumference was observed. It is possible that students are not fully aware of their eating habits. The increment in waist circumference is an important predictor of diabetes type 2. A follow-up of students' weight and waist circumference will provide an objective measurement of their general health.
It is worth to mention that in our particular sample, we found lower scores in all the studied variables as compared with reports from other countries,,, showing that Mexican students seem to present less emotional affections. A recent systematic review focused on Indian students also supports this finding; the prevalence of abnormal levels of depression, anxiety, and stress in Indian students was 39.2%, 34.5%, and 51.3%, respectively, while the values in the present study (Test 2) were 5.8%, 15.6%, and 17.6%. Overall, the studies focused on students' mental health show that stress is the most problematic area. Despite the small sample used in the present study, strong correlations were found; a higher sample including different states of Mexico will strengthen the findings. This methodological consideration is of particular interest as depression incidence is known to differ among regions in Mexico, being Hidalgo one with the highest rates of depression among woman.
Interventions to reduce mood disorders in the student community have been tested being those approaches that use face-to-face sessions coupled to electronic applications the most effective to reduce symptoms of depression and anxiety.,, The reductions of the aforementioned symptoms were also accompanied by improvements in sleep quality. Music therapy has also shown effective results in improving sleep quality in students.
Beside different therapies are available to improve mental health of students, the reality is that only around 50% of the students with depressive or anxiety symptomatology receive psychological treatment., Some of the reasons of this low attendance rate are a lack of perceived necessity to attend the problem, misinformation about how to access to mental health programs, and ignorance about the treatments., Altogether, the findings emphasize the necessity to implement and diffuse programs for university students to improve their sleeping habits and to control the related emotional affections.
Finally, we want to mention some limitations of our study that need further investigation. First, the small sample size might have lowered the power of our statistical analysis and gender differences cannot be ruled out. Second, our sample focused on only one public medical school from one state of Mexico; the studied variables could depend on the region of the country and whether the school was private or public. Finally, we did not address sleeping problems during students' infancy. The lack of this information limits our interpretation that the entrance to medical school was the only associated factor that reduced sleeping quality; it is possible that previous, even minor, sleeping problems just clearly emerged when starting the undergraduate studies.
| Conclusion|| |
In this work, we studied the short-term changes in the mental health of medical students after they initiate the university. We found that sleep quality was affected 1 month after the beginning of classes while depression, anxiety, stress, and eating habits were not altered. Importantly, we showed that sleep quality was statistically related to depression. We hope that our findings will promote the creation and effective implementation of mental health programs into the universities.
We want to thank the Collaboration of Magnolia Benítez, Jenny Vianey Pérez, Verónica Cristhela Trujillo, Arlette Fabiola Nieto, Dulce Chávez, Arnold Flores, Luisa Jasubi Apaez, and Dalia Elizabeth García in obtaining the anthropometric measurements of the students and processing the data.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2]