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ISSN 1678-4464

37 nº.10

Rio de Janeiro, Outubro 2021


ARTIGO

Comportamentos relacionados ao estilo de vida e sintomas depressivos em estudantes universitários

Flávia da Silva Taques Vieira, Ana Paula Muraro, Paulo Rogério Melo Rodrigues, Rosely Sichieri, Rosangela Alves Pereira, Márcia Gonçalves Ferreira

http://dx.doi.org/10.1590/0102-311X00202920


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RESUMO
O estudo buscou examinar a associação entre comportamentos relacionados ao estilo de vida e sintomas depressivos em estudantes universitários. O estudo transversal analisou os dados da linha de base de um estudo em estilo coorte dinâmica de uma universidade pública da Região Centro-oeste do Brasil, recrutados em 21 cursos de graduação de tempo integral. Foram incluídos no estudo, universitários de até 25 anos de idade matriculados pela primeira vez na universidade, exceto mulheres gestantes e lactantes. Todos os universitários que atenderam os critérios de elegibilidade foram convidados a participar do estudo. Entre o total de 1.212 elegíveis, 1.038 foram estudados (85,6%). Todos os participantes responderam a um questionário auto-aplicado sobre tabagismo, consumo de álcool, tempo de uso de computador, Internet e TV, duração do sono e padrões alimentares. Os sintomas depressivos foram avaliados com o Patient Health Questionnaire-9 (PHQ-9). Modelos de regressão Poisson multivariada, estratificados por sexo, foram usados para estimar as associações. Sintomas depressivos foram observados em 31,6% da amostra (homens, 23,6%; mulheres, 39,9%; valor de p do teste de qui-quadrado = 0,01). Tabagismo, consumo de bebidas destiladas e hábitos alimentares irregulares mostraram associação direta com sintomas depressivos em homens e mulheres. A ocorrência simultânea de dois comportamentos de risco (homens: RPa = 2,23, IC95%: 1,25; 3,99; mulheres: RPa = 1,54, IC95%: 1,03; 2,30) e três ou mais comportamentos de risco (homens: RPa = 3,42, IC95%: 1,90; 6,16; mulheres: RPa = 2,09, IC95%: 1,39; 3,15) aumentaram a ocorrência de sintomas depressivos entre os universitários. Comportamentos não saudáveis relacionados ao estilo de vida mostraram uma associação com o aumento de sintomas depressivos entre os universitários. Os achados sugerem a necessidade de intervenções para incentivar mudanças de estilo de vida, no sentido de promover a saúde mental e melhorar a qualidade de vida desse grupo.

Transtorno Depressivo; Estudantes; Universidades; Estilo de Vida; Epidemiologia


 

Introduction

Depression is a mental disorder characterized by a loss of interest or pleasure in activities or depressed mood, accompanied by fluctuations in feelings of guilt and low self-esteem, suicidal thoughts, and other manifestations 1,2. It currently occupies the top position among the 20 most disabling diseases and affects approximately 322 million individuals, with prevalence of 4.4% worldwide 2. Prevalence rates vary according to cultural differences, genetic vulnerability, environmental factors, and diagnostic tools.

Depression is common among college students with an overall estimated prevalence rate of 30.6%, which varies among countries, ranging from 10 to 85% 3, with a higher probability of depression in first-year students compared to later levels of undergraduate or graduate students 4. Depression has been related to poor quality of life, unsatisfactory academic performance, university abandonment, and self-destructive behaviors 5,6.

Many conditions increase the vulnerability of college students to depression, particularly the conflicts that accompany the transition from adolescence to adulthood, pressure in academic performance, job competition, and a routine with excessive time devoted to studies 7. Moreover, in many cases, students move away from home, and as such there is a consequent increase in independence and autonomy that requires social and affective adaptations in the face of new situations 8.

The transition into adult life coupled with university admission may favor unhealthy changes in lifestyle, such as changes in diet quality and physical activity levels, experimentation or frequent use of cigarettes and alcoholic drinks, decreased sleep duration, decreased sun exposure, and reduced practice of outdoor activities 9,10. These changes undermine the physiology of the brain and increase vulnerability to depression 11.

Lifestyle-related behaviors are mostly modifiable and socially determined, and play an important role in the etiology, progression, and treatment of depression 12,13. However, a bidirectional association between lifestyle and depression is expected 13. Previous cross-sectional studies with university students have shown an association between depression and unhealthy behaviors such as smoking, alcohol consumption, physical inactivity, sleep disturbances 6,7, and consumption of unhealthy foods 14.

The literature consistently shows differences in prevalence rates of depression between men and women, with greater susceptibility among the latter 1,2. This includes the first Brazilian National Health Survey, conducted in 2013 15; the same pattern is observed among college students 7,16,17. Similarly, the association between depression and lifestyle-related behaviors also occurs differently for men and women 6,18,19.

Studies on depression conducted with Brazilian college students are scarce and were conducted mainly among students of health-related courses. Because the theme is relevant as a public health problem and college students are rather vulnerable to the disease, the objective of this study was to estimate the prevalence of depressive symptoms in college students and its association with lifestyle-related behaviors.

Methods

Study population and data collection

Cross-sectional study, carried out in the first academic semester of 2015 and 2016, at a public university in Central-Western Brazil. This study is part of the Longitudinal Study on the Lifestyle and Health of University Students (ELESEU). The eligibility criteria were to be enrolled in a full-time course at the studied university and to be ≤ 25 years old. The ELESEU did not include students who had formerly attended an undergraduate course because this dynamic cohort was designed to investigate possible changes in lifestyle and health conditions related to the transition between high school and university 20. All students who met the eligibility criteria were invited to participate in the study.

In 2015, 599 students were eligible for the study, from whom 46 (7.7%) declined to participate and 58 (9.7%) did not answer the questionnaire; hence, 495 college students were evaluated (82.6% of the eligible ones). In 2016, among the eligible students (n = 613), 28 (4.6%) refused to participate in the study and 42 (6.9%) did not answer the questionnaire; thus, 543 students were evaluated. Therefore, a total of 1,038 participants were included in this analysis, representing 85.6% of the eligible students in both years.

Data were collected by trained interviewers who followed standardized procedures and used a structured, self-administered questionnaire containing demographic, socioeconomic and lifestyle-related information, as well as questions about depressive symptoms. Further details on the methodology of the ELESEU study are available elsewhere 20.

Outcome

The presence of depressive symptoms was evaluated using the Patient Health Questionnaire-9 (PHQ-9) validated for the Brazilian population with high sensitivity and specificity 21. The nine-question scores were assessed on a Likert scale, ranging from 0 to 3, corresponding to the options “not at all (0)”, “several days (1)”, “more than half the days (2)”, and “nearly every day (3)”. The scores of the questions were summed and the cut-off point ≥ 9 was used as a criterion to identify the presence of depressive symptoms.

Measurements

Lifestyle-related behaviors were defined as follows: elevated screen time 22, including television, computers, and video games, was defined with the cut-off point based on the 75th percentile of the participants' screen time distribution (≤ 4 hours or > 4 hours); smoking (current smoker, non-smoker, mild smoker: 1 to 10 cigarettes daily, or moderate to heavy smoker: 11 to 20 cigarettes daily) 23,24; type of alcoholic beverage consumed (none, beer, wine, or spirits); sleep duration (≥ 6 hours or < 6 hours daily) 18; meal patterns (satisfactory: at least breakfast, lunch and dinner daily; or irregular: one or two main meals daily) 25. Additionally, students were classified according to the co-occurrence of lifestyle-related behaviors (none, 1 behavior, 2 behaviors or ≥ 3 behaviors).

Age group (16-17; 18-19; ≥ 20 years old), economic level, field of study, and body mass index (BMI) were the variables used in the adjustment of the final model. The economic level of the families was evaluated using the criteria established by the Brazilian Association of Research Companies (http://www.abep.org/criterio-brasil, accessed on 22/Nov/2017), in 2015, which employs a scoring system from A (highest) to E (lowest) based on household appliances, owned cars, having domestic servants at home, and schooling level of the head of the family. BMI (kg/m2) was calculated with a basis on measured weight and height according to standardized techniques 26. Weight status was categorized using the BMI according to criteria recommended by the World Health Organization (WHO) for adults 27 and adolescents 28.

The knowledge area of the undergraduate courses was categorized according to Brazilian Ministry of Education classification into five main fields (http://www.capes.gov.br/avaliacao/instrumentos-de-apoio/tabela-de-areas-do-conhecimento-avaliacao, accessed on 30/Nov/2017): (1) Agricultural Sciences: agronomy, forestry, animal husbandry, veterinary medicine; (2) Engineering: civil, electrical, sanitary; (3) Exact and Earth Sciences: mathematics, computer science, physics, chemistry, geology; (4) Life and Health Sciences: biology, medicine, nutrition, nursing; (5) Social and Human Sciences: architecture, urbanism, philosophy, psychology.

Statistical analysis

Statistical analyses were performed using SPSS software, version 17.0 (https://www.ibm.com/). All the analyses were stratified according to sex. The chi-square test was applied to evaluate the association between the independent variables and the presence of depressive symptoms. Poisson regression models with robust variance were used to estimate the crude (PR) and adjusted (aPR) prevalence ratio and their respective 95% confidence intervals (95%CI). The covariates that presented a p-value ≤ 0.20 in the bivariate analysis were selected for adjustments in the final multiple models. Separate models were constructed for each lifestyle-related behavior, adjusted for age, economic level, undergraduate course field of knowledge, and BMI. In addition, alcohol consumption and smoking were mutually adjusted. Each model's fit was evaluated using deviance statistic.

Ethical issues

The research project was approved by the Research Ethics Committee of the Júlio Muller University Hospital of the Federal University of Mato Grosso (n. 1.006.048, March 31, 2015). The participants were informed about the purposes of the study and data was collected only after they had signed the Free and Informed Consent Form.

Results

A total of 1,038 college students were evaluated: 51% were men, 47.4% belonged to economic level B, 59.4% were between 17 and 19 years old and 31.6% reported depression symptoms, being 39.9% among women and 23.6% in men (p = 0.01). Due to the differences between men and women in the prevalence of depressive symptoms, the statistical analyses were stratified by sex.

Demographic and socioeconomic variables did not present significant association with depressive symptoms in either sex. There was a statistically significant difference in the prevalence of the outcome according to the field of knowledge of the undergraduate course (p < 0.01). Among men, the highest prevalence of depressive symptoms was found among students of the Social and Human Sciences field (48.6%) while among women, the highest depressive symptoms prevalence was observed among students of Exact and Earth Sciences courses (52.3%) and among students of the Social and Human Sciences (48.8%), with no difference in the prevalence of depressive symptoms among women in these two fields of knowledge Table 1.

 

 

Tab.: 1
Table 1 Distribution of the participants (%) and prevalence (P) of depressive symptoms by sex according to sociodemographic and economic variables, field of study, and weight status of college students evaluated in the baseline of the Longitudinal Study on the Lifestyle and Health of University Students (ELESEU). Cuiabá, Mato Grosso State, Brazil, 2015-2016.

 

For men, in the adjusted model, the prevalence of depressive symptoms was higher among those reporting more than 4 hours per day of screen time (aPR = 1.61, 95%CI: 1.18; 2.20), smokers (mild: aPR = 1.73, 95%CI: 1.08; 2.77; moderate to heavy: aPR = 2.51, 95%CI: 1.47, 4.29), who consumed beverages with a higher alcohol content (spirits: aPR = 1.45, 95%CI: 1.01; 2.08), and those reporting irregular meal patterns (aPR = 1.77, 95%CI: 1.26; 2.48), compared to those who did not present any of the mentioned behaviors. Sleep duration was not associated with depressive symptoms among men Table 2. It was observed among men an association between the co-occurrence of two lifestyle-related behaviors (aPR = 2.23, 95%CI: 1.25, 3.99) and three or more lifestyle-related behaviors (aPR = 3.42, 95%CI: 1.90; 6.16) with depressive symptoms Table 3.

 

 

Tab.: 2
Table 2 Distribution of the participants (%), prevalence (P) of depressive symptoms, crude (PR) and adjusted (aPR) prevalence ratio and respective 95% confidence intervals (95%CI) according to sex and lifestyle-related behaviors variables among college students evaluated in the baseline of the Longitudinal Study on the Lifestyle and Health of University Students (ELESEU). Cuiabá, Mato Grosso State, Brazil, 2015-2016.

 

 

 

Tab.: 3
Table 3 Distribution of the participants (%), prevalence (P) of depressive symptoms, crude (PR) and adjusted (aPR) prevalence ratio and respective 95% confidence intervals (95%CI) by sex according to the co-occurrence of risk behaviors among college students evaluated in the baseline of the Longitudinal Study on the Lifestyle and Health of University Students (ELESEU). Cuiabá, Mato Grosso State, Brazil, 2015-2016.

 

Regarding the women, after adjusting for confounding factors, there was higher prevalence of depressive symptoms among moderate to heavy smokers (aPR = 2.44, 95%CI: 1.56; 3.82) compared to nonsmokers and those that consumed spirits (aPR = 1.42, 95%CI: 1.12; 1.81) compared to non-drinkers. There was also higher prevalence of the outcome among students who presented irregular meal patterns (aPR = 1.35, 95%CI: 1.04; 1.73) compared to those with satisfactory meal patterns and those who reported sleeping less than 6 hours per day (aPR = 1.40, 95%CI: 1.11; 1.77) compared to those reporting to sleep ≥ 6 hours per day. Sedentary behaviors were not associated with depressive symptoms among women Table 2. The prevalence of depressive symptoms was higher among female college students who presented co-occurrence of two lifestyle-related behaviors (aPR = 1.54, 95%CI: 1.03; 2.30) and three or more lifestyle-related behaviors (aPR = 2.09, 95%CI: 1.39; 3.15) Table 3.

Discussion

A census study with Brazilian college students enrolled in full-time courses showed that almost one third of them presented depressive symptoms, with higher prevalence in females; moreover, the association between unhealthy behaviors and depressive symptoms presented differences according to sex. Sleep duration was only associated with depressive symptoms among females while screen time, only among males. In addition, smoking, type of alcoholic beverage consumed, irregular meal patterns, and the co-occurrence of unhealthy lifestyle-related behaviors were associated with depressive symptoms in both sexes.

The prevalence of depressive symptoms among college students observed in this study was similar to the figures found in a systematic review 3 and also in cross-sectional studies conducted with college students from several countries, using different detection methods 6,7,19. However, a cross-sectional study conducted in the United States, between 2007 and 2013, using the PHQ-9 instrument and including 61,561 college students, estimated a prevalence of depressive symptoms of 24.1% 29, hence, below to the 31.6% estimated in our study. The high figures estimated for prevalence of depressive symptoms in our study is partially due to the cut-off of 9 points, a cutoff acceptable to associate depressive symptoms with other factors 21.

In our study, in both sexes, compared to other fields of study, high prevalence of depressive symptoms was observed among students of Social and Human Sciences. Similar studies carried out in Brazil found that students from Life and Health Sciences 30, especially in medical schools 31,32, presented higher prevalence of depressive symptoms compared to students from other fields of knowledge. According to Brandtner & Bardagi 33, students of human sciences are more concerned with the interpersonal relationships, which may favor greater sensitivity to emotional issues and would justify the higher prevalence of depressive symptoms in this group. In this study, a high prevalence of depressive symptoms was also observed among women of the Exact and Earth Sciences courses. This particularity may be related to discriminatory attitudes towards women in this field of knowledge, which creates perspectives of unequal opportunities in the labor market, due to the stigmas of these fields of knowledge seen as typically masculine 34.

Longitudinal studies 35,36,37 and a systematic review 13 have shown a bidirectional relationship between lifestyle-related behaviors and depression, suggesting that unhealthy behaviors may favor the occurrence of depressive disorders, and the presence of these disorders may have an impact on these behaviors. This relationship is also justified by a series of neurobiological processes that are influenced by lifestyle as well as by the physiological pathways of major depression, thus forming a cycle 38.

In this study, college students with lifestyle-related risk behaviors had higher prevalence of depressive symptoms compared to those with healthier behaviors. Studies with college students have related depression to alcohol abuse or dependence 5,6,39. The results found in our study showed an association of depressive symptoms with the consumption of beverages with higher alcohol content in both sexes, even though alcohol consumption had not been characterized as abusive or had been found to be addictive. There are studies showing that disorders relative to alcohol consumption increase the risk of major depression in young adults 40 while for college students major depression increases the risk of alcohol abuse or dependence 39. Different theories have suggested that excessive or abusive consumption of alcohol can cause depression in a short period of time as a result of the pharmacological effects of alcohol in adult men 41.

Only among the studied male students there was a direct association between sedentary behaviors with depressive symptoms. In our study, evaluation of sedentary behaviors was based on screen time, including television, computers, and video games. The time using electronic devices has been associated with depression in college students, which was directly associated with problematic cell phone use 42, and with screen time above two hours per day 22,43. However, a study with Chinese college students has shown an inverse association between screen time of up to two hours daily and depression 44. In addition, a prospective study showed that the chance of depression at the baseline was 55% higher for college students exposed to the longer screen time (> 2 hours/day), compared to those with shorter screen time (≤ 2 hours/day), and after one year of follow-up, the chance of depression among participants with the longest exposure time was 92% higher 37. Similarly, a longitudinal study carried out in Bangladesh found higher risk of depression among college students exposed to ≥ 4 hours per day of screen time when compared to those with < 2 hours per day of screen time 22. Comparable results were found in a systematic review confirming the association between sedentary behaviors such as watching television or using the computer and a higher risk of depression in adults 45.

In this study, smoking was directly associated with depressive symptoms in both male and female college students, and the prevalence of depressive symptoms among those who smoked more than ten cigarettes per day was over twice than that observed for individuals who reported that they did not smoke. Similar results were observed in cross-sectional studies with college students 46,47. In a cohort study conducted in Denmark with participants aged over 20 years, followed for 26 years, smoking was associated with an increased risk of developing depression 36.

Some hypotheses are considered in the literature for the association between depression and smoking, either as a mechanism to alleviate negative feelings or because it provides pleasure and socialization 47. However, in the reverse direction, the effect of nicotine on neurotransmitter activity in the brain can cause changes that increase the risk of depression 48. Tobacco use is more common among women as a strategy to reduce negative feelings, relieve symptoms of bad moods, and loss of pleasure 19.

This study showed higher prevalence of depressive symptoms among students of both sexes with irregular meal patterns, compared to those having satisfactory meal patterns. Cross-sectional studies have shown consistency in the association between depression among college students and irregular meals and meal skipping 7,8,14,49. The benefits of regularly having breakfast, for example, have been discussed in recent research and the findings have shown that having breakfast is associated with lower scores of depression among university students 7 and that skipping breakfast significantly increases the risks of stress and depressive mood in adolescents older than 16 years 49.

In this study, sleep duration under six hours daily showed a significant association with depressive symptoms among females. Even after further adjustments, sleep time fewer than six hours daily represented a 40% increase in the prevalence of depressive symptoms. These findings are comparable to cross-sectional population-based studies which have suggested that the reduction of only one hour of sleep over the recommended amount can cause significant damage, and it is associated with depression 18,50. Among college students, sleep time fewer than six hours daily increases the likelihood of depression by 79% compared to students who sleep for more than six hours 7. In adolescents, sleep deprivation may lead to an increase in negative mood and a decrease in the ability to regulate emotions 51. In students aged over 18 years, sleep disturbances may lead to cognitive and mood changes 52.

The co-occurrence of lifestyle-related risk behaviors among college students and their association with depressive symptoms were evaluated in this study. The prevalence of depressive symptoms increased with the number of aggregated unhealthy behaviors among males as well as among females. Similarly, a study carried out with 2,422 Chinese university students found that participants with two or more risk behaviors (physical inactivity, sleep disturbances, poor eating behavior, Internet addiction disorder, frequent alcohol use, smoking) presented higher prevalence of depressive symptoms when compared to those with less than two risk behaviors 53.

The identification of depressive symptoms based on self-reports may be considered a limitation of the study, because of the possibility of information bias. Nevertheless, the instrument used in this study, the PHQ-9, was validated for the Brazilian population and was applied in the most important nationwide health survey conducted in Brazil 54. In addition, the prevalence of depressive symptoms found among college students is consistent with findings from other studies in this population group in several countries 3,6,7,19.

Another limitation of this study was the lack of information on physical activity. The practice of physical activity may be a protective factor against depression. A four-year follow-up study in Germany showed that regular physical activity practitioners between 14-24 years old had lower incidence of depressive disorders, including major depressive disorder, compared with those who did not practice physical activity 55. On the other hand, physical inactivity may be related to some symptoms of depression such as lack of energy or apathy 56. A systematic review of controlled trials has shown that exercise reduces depressive symptoms in people aged over 18 years with a diagnosis of depression 57. Previous studies with college students have shown that the practice of physical activity promotes greater personal fulfillment, reduces exhaustion and, consequently, improves emotional well-being, thus relieving the depressive mood 58,59.

This study also has strengths. First of all, the group examined was selected from a census and involved students from various fields of knowledge; since in similar studies conducted in Brazil the prevalence of depression and associated factors was evaluated in students from specific areas, particularly from medical schools 31,32. Furthermore, in this study, the association between various lifestyle-related behaviors and depressive symptoms was analyzed, which was an advantage if compared to analogous studies that usually focused on specific risk factors 14,19,29,39,46,47,50. It is noteworthy that this study's findings on the association of lifestyle-related behaviors with depressive symptoms among college students are consistent with longitudinal studies 22,37,48,49,60, as well as systematic reviews 3,13,61 and a meta-analysis 62.

In addition, the study analyzed 85.6% of the eligible population, using procedures widely tested in epidemiological studies and robust statistical analysis with control of potential confounding factors, characteristics that support the consistency of the results found and the internal validity of the study. There were also no differences between students who participated in the study and those that did not participate according to sex and course (p > 0.05, data not shown).

In face of the high prevalence of depressive symptoms among college students, universities, as environments aimed at developing citizenship, should be committed to implementing initiatives and policies that favor students' health. The promotion of mental health among college students should be prioritized by the development of activities that stimulate positive changes in lifestyle, by early detection of mental disorders, especially depressive symptoms, and by putting into service programs to support students with psychological problems, which is provided by the university where this study was carried out. Such proposals may reduce the burden of mental disorders, help to ensure a successful academic performance, and to improve the quality of life of this population group.

In conclusion, there was a high prevalence of depressive symptoms among the university students evaluated in this study, especially among women. Lifestyle-related behaviors were associated with depressive symptoms differently for men and women. Participants with unfavorable behaviors had higher prevalence of depression-related symptoms and the co-occurrence of unhealthy lifestyle-related increased the prevalence of the depressive symptoms in this population.

Acknowledgments

The authors appreciate the collaboration from the students who kindly agreed to participate in the study.

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