Correlation between anxiety, depression and excessive daytime sleepiness and selected lifestyle elements of medical students in Poland

Introduction

Medical studies are designed to prepare and train qualified physicians who are empathetic, help and treat patients, develop their medical knowledge and strive to promote a healthy lifestyle. They are considered among the most academically demanding, are also emotionally and mentally taxing, and consume a lot of time and energy (Tian-Ci Quek et al. 2019). Studies have shown that medical students face a lot of pressure to succeed academically and competition among students (Miller et al. 2018; Tavolacci et al. 2018). According to the study, 68.5% of participants said that the primary cause of stress in college is the academic curriculum, and 39.9% of respondents highlighted high levels of tension related to expectations from the academic environment (Satpathy et al. 2021). Factors contributing to the development of depression and anxiety among medical students include exposure to patient suffering or death, nicotine and alcohol addiction, clinical training, financial struggles in the family, and lack of social support (Azim and Baig 2019; Mao et al. 2019). Studies show that excessive alcohol use affects 17-34% of medical students (Ayala et al. 2017b; Dahlin et al. 2011; Shah et al. 2009), and about a third of medical students have used illicit substances (Shah et al. 2009). About 15% of students who experienced bullying, humiliation or harassment during medical school considered dropping out (Wilkinson et al. 2006). A common problem among medical students, more common than in other majors, is a higher prevalence of sleep disorders (Azad et al. 2015). High scores on the Epworth Sleepiness Scale (ESS) were observed in 46.5% of medical students (Perotta et al. 2021). In addition, it is worrying that sleep deprivation or poor sleep hygiene was a strong factor in the development of high levels of anxiety and mood disorders (Azad et al. 2015).
Studies show that the prevalence of anxiety among medical students is estimated at around 33.8% (Tian-Ci Quek et al. 2019). High levels of anxiety in this group can have negative effects on academic achievement and professional development. Both students and physicians with high levels of anxiety were characterized by less engagement and empathy in caring for patients with chronic conditions (Dyrbye et al. 2006). Researchers suggest that relative to their peers, medical students experience significantly more stressors and have lower mental health quality during their studies (Dyrbye et al. 2006; Eisenberg et al. 2012). According to studies, the prevalence of depressive symptoms in non-medical students ranges from 13.8% to 21.0% (Eisenberg et al. 2007; Steptoe et al. 2007) while the results of a meta-analysis conducted in 2018 indicate that the prevalence of depression among medical students was 27.2% (global population) (Rotenstein et al. 2016).
Unfortunately, people who struggle with symptoms of depression or anxiety disorders tend to avoid specialized help. Students choose not to seek professional help due to fear of lack of confidentiality from physicians or perceiving their symptoms as signs of failure or weakness (Moir et al. 2018). Among medical students diagnosed with depression, only 15.7% chose to seek appropriate treatment.
The aim of this study was to examine the relationship between selected lifestyle elements of medical students in Poland and their mental health.

Material and methods

The study used an original questionnaire, which was posted on the LimeSurvey portal. The survey was conducted from February 13 to 23, 2022 among medical students of 20 medical universities in Poland. The questionnaire consisted of 4 parts: course of studies, the Beck Depression Inventory, the Generalized Anxiety Disorder-7 (GAD-7) questionnaire and the Epworth Sleepiness Scale (ESS). Among the author’s questions related to the course of study were questions about: satisfaction with life in university, satisfaction with learning outcomes, amount of time spent studying, and participation in extracurricular activities. The author’s section was validated by conducting a test and retest after two weeks, which was answered by 38 students and consisted of 5 questions. Cohen’s kappa coefficient was calculated, yielding fairly good to very good repeatability.
The Beck Depression Inventory is used to screen for depression and consists of 21 questions scored on a scale of 0-3. A total score of 0 to 10 is considered normal, 11 to 27 indicates moderate severity, and above 27 indicates significant severity of depression (Beck et al. 1961; Zawadzki et al. 2009).
The Generalized Anxiety Disorder-7 (GAD-7) questionnaire is a screening tool for assessing anxiety severity and consists of 7 questions (Spitzer et al. 2006). They cover the DSM-IV core diagnostic criteria for generalized anxiety disorder (Guze 1995). Each question has 4 response options scored on a scale from 0 to 3 points. A total score of 5-9 indicates the presence of mild anxiety, a score of 10-14 indicates moderate anxiety, and scoring 15 or more points suggests the presence of severe anxiety. A score of 10 or more indicates a high likelihood of generalized anxiety disorder (GAD).
The Epworth Sleepiness Scale (ESS) is used to measure the severity of sleepiness. Respondents rate on a 4-point scale the likelihood of falling asleep under 8 everyday circumstances (e.g., reading, watching TV, sitting in a public place) (Johns 1991). A total score above 10 indicates excessive daytime sleepiness.
Approval of the bioethics committee was not required due to the anonymous nature of the questionnaire. Also the applied scales are standardized and were used for their intended purpose.
Results were compiled using Statistica v. 13.3 PL software by StatSoft, USA. Statistical significance was calculated using the chi-square test. A p-value < 0.05, < 0.01 or < 0.001 was considered statistically significant. Cramér’s V and the phi coefficient were calculated to measure the association between variables. It is worth noting that according to Akoglu, both phi and Cramér’s V > 0.25 can be interpreted as a very strong association and > 0.15 as a strong association (Akoglu 2018).

Results

The survey included 3649 students, and 2339 questionnaires completed by medical students of 20 medical universities in Poland were included in the final analysis. Most of the respondents were women, urban residents, studying in the second and third years. The average age was 21.48 years (SD = 2.05).
Of the 2339 respondents, 320 (13.7%) on the Beck Depression Inventory had scores indicative of severe depression, while 49.0% of the subjects showed moderate depression (Table 1). The GAD-7 questionnaire showed symptoms of severe anxiety in 533 (22.8%) subjects, and moderate anxiety in 23.2% of subjects (Table 2). On the ESS sleepiness scale, severe daytime sleepiness was observed in 107 (4.6%) subjects (Table 3). The ESS scale score indicating normal sleepiness was obtained by 1707 (73.0%) respondents.
Generalized anxiety appears to be a disorder that is related to students’ lifestyles, as correlations were noted between scores and answers to each question (Fig. 1, Table 4) with Cramér’s V ranging from 0.063 to 0.257. Similarly, the Beck Depression Inventory showed correlations between BDI scores and answers to all questions (Fig. 2, Table 3) and Cramér’s V as high as 0.367, and in terms of the ESS scale, correlations were noted between the degree of excessive daytime sleepiness and answers to 4 questions, with Cramér’s V being lower than 0.080 (Fig. 3, Table 4).
Lack of sufficient free time for non-academic activities was significantly associated with worse scores on the Beck, GAD-7 and ESS scales (p < 0.001) (Figs. 1-3). As many as 66% of those showing symptoms of severe anxiety and major depression were not active outside the university. Lack of satisfaction with studies in the group showing severe anxiety was reported by 62% of people, and in the group showing severe depression 67% of people. Among students with a low or average score on the ESS scale, satisfaction with their studies was reported by 50% of the subjects. Studying more than 4 hours a day was associated with a higher incidence of depression and anxiety (Tables 2, 3). The average exam grade obtained during this academic year was significant, with those with lower mean scores (≤ 4.00) scoring higher in each of the 3 tools for assessing students’ mental health. In all 3 tools, worse scores were observed in those reporting a definite lack of satisfaction with their academic performance (Tables 4-6). Among academically fulfilled students, severe anxiety and severe daytime sleepiness were found in only 6% of subjects, and depression was observed in 2% of subjects.
Furthermore, we summarized results in 2 × 2 tables and calculated the phi coefficient to better understand which groups are more susceptible to certain disorders (Tables 5-7). In terms of BDI and GAD-7 scores, we found that in 5 out of 6 questions, the results were significantly different with the phi coefficient ranging up to 0.246 for GAD-7 and 0.363 for BDI. Results considering ESS were significantly different in 5 out of 7 questions with the phi coefficient from 0.021 to 0.094.

Discussion

The mental health of medical students is undoubtedly a topic worthy of attention. Many factors contribute to the deterioration of the mental health of medical students. Among other things, loneliness and the quality of meals consumed had an impact on increased stress levels among students at the Medical University of Mumbai (Satpathy et al. 2021). Students living with their parents were more likely to experience suicidal thoughts, while those with financial problems were more likely to experience depression and anxiety (Eisenberg et al. 2007). Among the respondents, 27.0% had an ESS score greater than 10, which is slightly higher than that of students in other majors (Lund et al. 2010). Significantly more respondents in the study population had scores corresponding to depressive or anxiety disorders than in studies involving students from other majors. Li et al. (2022) in a meta-analysis obtained results that suggest the prevalence of depression and anxiety at 32.5% and 36.8%, respectively, among non-medical students, which are significantly lower than those obtained in our study. In addition, the mentioned study noted a higher prevalence of these disorders among medical students, which was explained by more responsibilities and pressure. Similarly, in the results we presented, in the case of generalized anxiety, depression and excessive daytime sleepiness, those who lacked free time for non-academic activities scored significantly higher on each test. This may indicate the importance of free time and related recreation in the lives of future doctors. Excessive responsibilities and the large amount of information that must be assimilated in a short period of time can cause the occurrence of these disorders, which draws attention to the need for better time management by students. Our results are consistent with other studies. Kiziela et al. (2019) presented results demonstrating the relationship between a burden of responsibilities and anxiety among medical students. In one study conducted in Saudi Arabia, risk of having poor sleep quality was 3.83 times higher among students whose cumulative grade point average was less than 4.25 (Almojali et al. 2017). The way of spending leisure time is also important. The results obtained in this study present a significant relationship between mental disorders and non-academic activities. Medical students take care of their mental health through relaxation, exercise or hobbies, among other activities (Ayala et al. 2017a). Being able to relax appropriately and temporarily escape with your thoughts from university-related issues can be one way to improve your mood. Similarly, physical exertion can have a positive impact on the issues mentioned. Ghrouz et al. (2019) observed a reduced incidence of anxiety and depression among students who engaged in physical exercise. Therefore, it is important to pay attention to the ways they spend their leisure time. Another aspect related to the decrease of mental health of the study group is their general dissatisfaction with life. This may be related to professional burnout, among other things. One study conducted in England on a group of 84 medical students showed that most of them have poor mental health and exhibit symptoms of burnout (Kumpikaitė-Valiūnienė et al. 2021). In addition, a factor such as satisfaction with their chosen field of study had an impact on the incidence of depression (Mao et al. 2019; Piumatti 2018). These elements can add up to overall life satisfaction, which was reflected in the results of this study, where in each test, lower levels of life satisfaction significantly increased the risk of mental disorders. General dissatisfaction with life may also be related to academic performance. In the present study, those with lower grades showed more severe anxiety and higher levels of sleepiness. This may indicate an increased risk of psychiatric disorders in this group of individuals due to difficulties in coping with university responsibilities, negative peer evaluation and associated stress. The relationship may go both ways – anxiety and sleepiness may impair the ability to study effectively. Confirmation of our observations comes from a nationwide cross-sectional study done in South Korea in which it was found that students with symptoms of severe depression achieved significantly lower grades in comparison to those without symptoms (Roh et al. 2010). A major source of stress for medical students may be the excessive workload (Hill et al. 2018). The results presented in our study demonstrate the complexity of the problem and suggest a much larger number of factors affecting mental health. Reconstructing curricula and grading students by using a credit system as a substitute for traditional grade awarding would likely reduce medical students’ stress levels and increase satisfaction with the quality of education (Dahlin et al. 2011; Rotenstein et al. 2016; Slavin et al. 2014). Our survey was conducted in 2022, after the lockdown and the worst wave of the COVID-19 pandemic. A study on a group of medical students in Turkey published in 2021 found that 44.4% of the group stated that they experienced moderate/severe anxiety in the GAD-7 test (Çimen et al. 2022). This result is very close to ours (46%). However, a study of medical students in Greece found higher levels of moderate or severe anxiety in the earlier stages of the pandemic, at 67.6% (Eleftheriou et al. 2021). According to a study conducted in 2020, which used the GAD-7 to survey 1139 students at 16 medical schools located in the US, 58% of respondents reported anxiety (38% mild, 13% moderate, 7% severe) (Christophers et al. 2021). In our study, the percentage was 55.4% (30.4% mild, 2.2% moderate, and 22.8% severe). The percentage of medical students from France who scored equivalent to severe depressive symptoms on the BDI was 13.6% (Leroy et al. 2021). It is almost identical to our result. Interesting results were obtained in a study conducted in 2022 in South Korea. Investigators using the BDI scale reported results that fell within the normal range of depressive symptoms. Only 19 of 400 students showed moderate or major depression (Yeo et al. 2023). A 2021 study in Morocco assessing the severity of depressive symptoms using the BDI scale found that 26.4% of respondents had moderate depression (22.6% less than in our study), and 35.8% reported severe depression (22.1% more than in our study) (Rammouz et al. 2023). A survey was conducted among Polish medical students during the COVID-19 pandemic to assess, among other things, daytime sleepiness. Sleepiness was diagnosed in 3872 (26.1%) students, of whom 892 (6.1%) stated that they suffered from pathological sleepiness (Babicki et al. 2022). These results indicate a higher level of sleepiness than that found in our study. However, it is necessary to remember the limitations of the study. The collected results of the study are inconclusive and do not allow us to conclusively confirm the presence or absence of a relationship between the earlier stages of the pandemic and the deterioration or improvement of the mental health of medical students over time. A closer look at the topic and a thorough analysis of the collected data are required.

Conclusions

This study proves that the prevalence of depression, anxiety and excessive daytime sleepiness in medical students in Poland is distressingly high. The most significant factors contributing to the poor mental state of medical students were primarily lack of time for extracurricular activities, general dissatisfaction with life, and poorer academic performance. It is recommended to promote extracurricular activities such as participation in sports or arts clubs, professional development events, or volunteer work and reorganize classes to allow for these activities. Learning time management skills and effective study habits could help reduce the time required to fulfill the demands of the study program. The findings suggest the need for action on the part of medical schools. These should consist of providing students with specialized assistance and promoting mental health awareness, which would aim to reduce both the self-stigmatization of mental disorders and stigmatization by those around them.

Disclosures

This research received no external funding.
Institutional review board statement: Not applicable.
The authors declare no conflict of interest.

References