Mood Disorders and Sleep Quality among Undergraduate Students during Covid-19

1. Introduction

Students encounters different activities which could affect their health effectiveness to function subsequently. Considering the challenges from the sudden skyrocket of Covid19 pandemic in the educational system, students tend to cope with the stress which could be challenging [1,2]. Psychological distress could affect the sleep quality of the students [3,4]. There are different life stressors which students usually encounter such as the level of social support [5], diet [6], internet and smartphone addiction [7,8] which can have an impact in the required sleep quality and cause mood changes.

Sleep is crucial for the body biological process which helps to promote health [9,10]. Undergraduate students have been identified to be prone to sleep disturbances [11] which could be because of the high demand of time in achieving academic task. Students are subjected to high academic stress as the prevalence which could cause anxiety and depression surges [12]. This study aimed to examine the psychiatry mood disorders and sleep quality among undergraduate students at the University of Georgia (UG) and comparison between students’ nationality.

2. Methodology

2.1. Study Design and Sampling

This cross-sectional study which was web based self-reported questionnaire comprised of demographic including age, gender, year of study, current location, lifestyle data (Exercise and smoking), the Depression, Anxiety and Stress Scale (DASS21) and the Pittsburgh Sleep Quality Index (PSQI). 535 students responded to the anonymous questionnaires shared among the UG students through the University intranet after its ethical approval. There was no reward to the participants as the study was voluntary. The data were collected between September and October 2022.

2.2. Assessment

Demographic variables: included gender, age group (<20, 21-25 >26), year of study, current location, nationality, and lifestyle data (Exercise and smoking).

Psychological Problems: We used the Depression, Anxiety and Stress Scale (DASS21) as designed to assess the students’ depression, anxiety, and stress symptoms. Each comprised of seven self-assessed questions as respondents were required to rate their psychological symptoms for the past one week on a Likert scale from 0- 3 (0: did not apply at all over the last week, 1: applied to some degree, or some of the time; 2: applied a considerable degree, or a good part of time; 3: applied very much or most of the time). The DASS21 cut off were as follows, ≥ 10 in depression, ≥ 8 in anxiety, and ≥ 15 in stress according to the DASS21 manual [14]

PSQI: Sleep quality was assessed using the Pittsburgh Sleep Quality Index scale (PSQI) which contained 19 self-rated questions. It comprised of seven subscales including subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep alterations, sleep pills, daytime sleep dysfunction. The seven subscales were comprised to get global score which ranged from 0 – 21 points.

PSQI grading: subjective sleep quality- Poor (Very poor and poor), Good (Very good and pretty good), sleep latency- High (31–60 minutes and > 60 minutes), Low (<15 minutes and 16–30 minutes), sleep pills- <1 time/week (Not during the last month and less than once a week) and > 1 time/week (once or twice a week and three or more times a week). The cut-off point of the global score was > 5 which can show more than 80% of both poor sleep quality sensitivity and specificity [13].

2.3. Statistical Analysis

Statistical Package for the Social Sciences (SPSS) version 23.0 software (SPSS Inc., Chicago, IL, USA) was used to assess all data analysis. The descriptive analysis and Chi-square were performed to determine the risk of psychological problems on sleep quality, statistically significant at p<0.05. Though the DASS21 were categorized into dichotomous responses (yes/no) before performing the multivariate analysis. Multivariate analysis examined the multicollinearity, homogeneity of variance and Variance Inflation Factors (VIF <4). The prevalence was at 95% confidence interval (95% CI).

3. Results

3.1. Demographic Characteristics of the Students

The female students (65.4%) were most of the respondents, majority were below the age of 20years (67.5%), and the mean age was 20.20 (SD± 3.0). 53.1% of the students were in First year, currently in Georgia (96.3%), 50.8% reported self-perceived poor mental health, 39.4% do not exercise and 37.6% smokes cigarette (Table 1). In DASS report (Table 2) 72.7% of students reported depressive symptoms, 77.8% had anxiety symptoms and 62.2% had stress as 89.2% reported had poor sleep quality.

3.2. Students Nationality and Gender Differences

Table 3 showed that Georgian students were more at risk of having depressive complaints (83.2%, OR 2.437; χ2 (16.208a), p= 0.000, 95% Cl[1.567-3.788]), anxiety (87.4%, OR 2.628; χ2 (15.737a), p= 0.000, 95% Cl[1.612-4.285]), and stress symptoms (75.8%, OR 2.584; χ2 (23.007a), p= 0.000, 95% Cl[1.743-3.831]). However, in Table 4 female students had increased risk for depression (76.6%, OR 0.578; χ2 (7.605a), p= 0.006, 95% Cl[0.391-0.855]), anxiety (83.7%, OR 0.386; χ2 (20.769a), p= 0.000, 95% Cl[0.254-0.585]), and stress (68.3%, OR 0.480; χ2 (15.726a), p= 0.000, 95% Cl[0.333-0.692]).

3.3. Comparison of Psychological Symptoms and Sleep Quality

In Table 5, 62.70% of students that had poor subjective sleep had an increased risk for depressive symptoms (OR 4.62; χ2 (55.256), p <0.05, 95% Cl[3.033-7.029]). 81.20% of students that slept less than 7hours were at increased risk of depression (OR 0.61; χ2 (4.747), p <0.05, 95% Cl[0.393-0.954]) including students that had high sleep alterations (53.7%; OR 6.91; χ2 (67.048), p <0.05, 95% Cl[4.178-11.433]), daytime dysfunction (94.3%; OR 12.984; χ2 (114.365), p <0.05, 95% Cl[7.564-22.289]), and the students that used sleep pills (18.8%; OR 0.15; χ2 (20.062), p <0.05, 95% Cl[0.061-0.388]).

Table 6 presented that the students who reported poor subjective sleep quality (61.1%; OR 4.87; χ2 (49.987), p <0.05, 95% Cl[3.064-7.728]), less than 7hours sleep (81.3%; OR 0.55; χ2 (6.313), p <0.05, 95% Cl[0.348-0.882]), sleep alterations (51.2%; OR 6.30; χ2 (51.452), p <0.05, 95% Cl[3.639-10.893]) and daytime sleep dysfunction (92.8%; OR 11.41; χ2 (108.587), p <0.05, 95% Cl[6.8-19.136]) were at increased risk of anxiety.

Table 7 showed that students that complained of poor subjective sleep quality (65.5%; OR 3.995; χ2 (55.914), p <0.05, 95% Cl[2.755-5.794]), high sleep alterations (58.6%; OR 6.74; χ2 (87.214), p <0.05, 95% Cl[4.41-10.309]), used sleep pills (19.5%; OR 0.28; χ2 (17.283), p <0.05, 95% Cl[0.152-0.529]) and high daytime sleep dysfunction (95.2%; OR 10.473; χ2 (82.734), p <0.05, 95% Cl[5.865-18.703]) had increased risk of stress symptoms.

3.4. Multivariate Analysis

The multicollinearity like the variance inflation factor (VIF) in depression, anxiety and stress were assessed. The VIF suggested that all the independent variables were not strongly correlated with the dependent factors. In the final model, three variables which are exercise, smoking status, and sleep quality were significant correlate of depressive symptoms (Table 8). Among these variables, the students that do not exercise had adjusted odds ratio (aOR) of 1.61 than students that smoked cigarette (aOR 0.41). There was a strong relationship between the students who experienced poor sleeping patterns and depressive complaints (aOR 0.10).

For anxiety, (Table 8) the female students, students who do not exercise, smokers, and poor sleep quality were the significant predictors. The students who had poor sleep quality (aOR 0.15) had the strongest correlate as the female students were at risk of anxiety (aOR 2.43). Students who are smokers (aOR 0.39) more likely to report anxiety symptoms than the students that do not exercise (aOR 1.68).

In Table 8 for stress, the female students, exercise, smoking status, and sleep quality, significantly correlated. The students that experienced poor sleep habits had the strongest correlate (aOR 0.17), followed by cigarette smokers (aOR 0.50). As the students who do not exercise (aOR 1.79) were more at risk than the female students (1.80).

4. Discussion

We found that Georgian students were more at risk of having depressive symptoms than the international students as this was consistent with our previous study [15] though Covid-19 restrictions from social events was suggested as a major factor. International students have been compelled to have high sleep and psychological disturbances considering the struggles to adapt to a new environment, food, culture, friends, and society [16,17]. As studies have shown that most international students requested for counseling because of depressive complaints, anxiety symptoms and stress in which they sought for a comprehensive means in managing such symptoms as it becomes intolerable [18,19]. Considering the large extent in which foreign students can be prone to mental health complaints [20],which can manifest in feeling of loneliness and sadness, Georgian students were more prone to psychological complaints considering the recovery from Covid-19 crisis and socio-economic issues.

Meanwhile the female students involved in our study were more at risk of experiencing depression, anxiety, and stress. As most of the participants were female students from first year of study and less than the age of 20years. Gender differences as related to psychological problems have an effect among the male and female students [21]. Studies have shown that the young females, go to bed earlier than male but were more likely to be disturbed by nightmares or awaken by little noise [22,23] which could result to manifestation of psychological symptoms over a prolonged period. These differences can be influenced by certain life factors such as age differences as observed in a wide cohort study [24], seasonal changes [25], family and next day activities [26].

Our study evaluated the prevalence of poor sleep habits in association with psychological problems such as depression, anxiety, and stress symptoms. Overall, was consistent, with the results from the previous studies regarding the sleep patterns among undergraduate students from University of Georgia (UG) [15]. In this study, it was observed that students with depressive symptoms had significant high risk of poor sleep quality. As it has been reported that undergraduate students are more vulnerable to experiencing both psychological symptoms and poor sleep habits [3]considering the required course load [27,28].

Students with anxiety symptoms had poor subjective sleep quality, slept less than 7hours, had sleep alterations and daytime sleep dysfunction. The students with depressives and stress symptoms had poor subjective sleep quality, high sleep alterations, used sleep pills and had high daytime sleep dysfunction. Though poor sleep quality, sleep alterations, sleeping pills and disturbances have remained prevalent among students because of different academic challenges and non-academic activities [29]

Despite the required sleep duration (7-9hours) for proper body function [30], our study reported less than 7 hours of sleep as reported in Gaultney studies, 2010 [31]. Moreover, the level of sleep duration and night sleep alterations can affect student’s daytime dysfunction [32]. Studies performed among undergraduate students from northeastern United States reported the use of sleep medication which could increase the symptoms of insomnia [33] as we recorded a slight increase in use sleep pills among the students which was consistent with the previous studies [15].

Students tend to adopt different coping mechanism such as smoking and drinking lifestyle to adapt to the stress [34] which could cause deteriorating sleep quality [35]. The students from this study who are smokers had poor sleep quality. Previous studies conducted among UG students have presented the prevalence of stress and sleep deprivation because of poor academic performance [36] which corresponds with the level of psychological problems observed in this study.

5. Conclusions

Our study presented the associations of self-reported students sleep quality with depression, stress, and anxiety symptoms. Poor sleep quality associated with the high prevalence of the psychological symptoms as female students and Georgian students were prone to more complaints. Students should always put their health in consideration as negligence of these can lead to deteriorating events.