Viaţa de student la Medicină – de la stres la depresie şi consum de alcool

Introduction

Depression represents one of the most common psychiatric disorders, manifested with changes in thinking and modified mental tone, limited psychosocial relationships, as well as somatic symptoms (fibromyalgia, chronic fatigue syndrome or irritable bowel syndrome), all affecting the individual’s quality of life⁽¹⁾. Currently, more than 3.8% of the population, the equivalent of more than 280 million people, suffer from depression⁽²⁾. Depression increases the risk of suicide, so that approximately 800,000 cases of suicide have been recorded annually, becoming the second cause of death among young people aged 15 to 29 years old, according to the World Health Organization (WHO) document Depression and Other Common Mental Disorders: Global Health Estimates (2017)⁽³⁾.

This pathology is also common among adolescents and is manifested by various symptoms (sadness, frustration, hopelessness, low self-esteem, loss of interest)⁽⁴⁾. At the same time, this particular population, characterized by vulnerability and perhaps naivety, is more likely to adopt methods/solutions to improve their feelings and moods, for example by using illicit substances (cocaine, cannabis, opioids) or alcohol^(5-8). Thus, the consumption of alcoholic beverages among young adults is a real public health problem, with multiple negative consequences (injuries, violence, sexual abuse)⁽⁸⁾. Although alcohol consumption occurs in all age groups, young adults aged 18 to 25 years old represent the age group with the highest rates of alcohol consumption and the highest percentage of the population who consume alcohol in a pathological and abusive way^(9-10). A particular category of this group is represented by students, who, in order to limit the stress generated by factors such as academic pressures (exams, workload, competition), lack of free time, moving to a city and a new group, the difficulty in creating interpersonal relationships, financial problemss, accommodation and adaptation to a new lifestyle, as well as responsibilities in terms of adaptation to adult life, begin to consume alcohol^(11-12).

In addition, a new factor that was considered responsible for amplifying anxiety appeared in 2020, in the context of the pandemic caused by the SARS-CoV-2. In this perspective, human relations have been affected, which has led to an increase in the number of patients diagnosed with psychiatric disorders, especially anxiety and depression^(13-14). For this reason, it is expected that alcohol consumption be increased in these crisis situations, because alcohol, through its inhibitory effect on the central nervous system (CNS), has the property of creating the impression that the person in question can cope with stress, negative emotions, anxiety and/or depression⁽¹⁵⁾. This is presented in a study conducted by Chodkiewicz et al., who observed an increase in alcohol consumption with the onset of the pandemic⁽¹⁶⁾, which has been as well reported in other situations throughout history⁽¹⁷⁾. In this regard, in the USA, in March 2020, there was a 240% increase in online alcohol sales⁽¹⁸⁾.

Given that both depression and alcoholism are two pathologies on the rise worldwide, with a significant contribution in terms of decreased functioning capacity in different areas, an association between these medical conditions would represent a situation with a negative impact on the quality of life. Regarding the prevalence of heavy episodic drinking, according to Eurostat 2019 report, Romania ranks second in Europe. Even more interesting is that, according to the same study, in Romania there is a major difference in alcohol consumption between men and women (32.2% versus 6.6%)⁽¹⁸⁾. Referring to students, they are quite reluctant to seek psychological help for mental health issues, alcohol drinking being an alternative for coping with stress and depression⁽¹⁹⁾. For example, students who are enrolled in professional health programs (medicine, pharmacy) are exposed to the aforementioned factors (academic overload, pressure, competition), hence the major risk and prevalence of alcohol consumption. A study conducted by Eisenberg et al. shows that, in the USA, 50% of students in these fields experience feelings, stress and burnout, which affect their mental health more, compared to individuals of the same age from the general population⁽²⁰⁾, but certainly these things are also valid in other countries. Another important topic directly related to depressive symptoms is the suicide rate among medical students. Thus, over 25% of medical students considered suicide attempt^(21,22).

Considering that depressive symptoms are risk factors for the development of pathological ethanol use disorders, in the present study we attempted to identify the existence of a possible relationship between the occurrence of depressive symptoms and the risk of pathological or abusive ethanol use in a population at high risk for such behavior. The characteristics of students at high risk of developing these disorders were also tracked.

Methodology

Participants

We conducted a cross-sectional descriptive study on a group of 301 Romanian students through an online questionnaire consisting of 32 questions. The questionnaire was distributed online to students attending the Faculty of Medicine of the “George Emil Palade” University of Medicine, Pharmacy, Sciences and Technology of Târgu-Mureş, Romania, aged 18 to 30 years old. We chose to study this behavior among medical students, starting from the premise that, of all specializations, they are best aware of the risks related to alcohol consumption, namely they can most correctly assess the symptoms that could be correlated with the depressive state. The sample size was calculated in such a way that the obtained results were representative for the students of the Faculty of Medicine of the aforementioned university. In the academic year 2020-2021, according to statistical data, 2533 students were enrolled. Following the application of the exclusion criteria (age), the sub-sample obtained included a number of 296 students.

Given the number of the remained respondents (n=296) after the application of exclusion criteria, the sample is representative with a 95% confidence interval and a 5.35% margin of error. People who did not meet the age criterion were excluded from the study (n=5).

Procedure

During a period of two months, from May to July 2021, the subjects were asked to anonymously complete the questionnaire. The study was approved by the Ethics Committee of Scientific Research of the “George Emil Palade” University of Medicine, Pharmacy, Sciences and Technology of Târgu-Mureş, Romania (approval no. 1362, 10/05/2021). All participants were informed about the objectives of the study.

The questionnaire was disseminated online through social media platforms and was conducted using the Google Forms. In the description of the form, there were mentioned the purpose of the study and the preservation of data confidentiality. The collected data were analyzed under the protection of anonymity.

Questionnaire

The questionnaire was divided into four sections. In the first section (questions 1 to 6) we addressed general questions (year of study, age category, gender, permanent residence – urban or rural, and living arrangements – rent, student hostel or with their parents). The second section of questions (7 to 14) investigated the existence of depressive symptoms (feelings of devaluation, social isolation, sleep quality, existence of overwork, sexual appetite, existence of somatic symptoms). The third section of questions (15 to 26) aimed to assess the attitude of the students regarding the use of alcohol: whether students usually drink alcohol, how often they drink alcohol, the type of alcohol they prefer, whether they have tried to give up drinking alcohol, the circumstances in which it is consumed, the time of alcohol consumption, namely the consequences of alcohol use. The last section (questions 27 to 32) aimed to establish the existence of a correlation between alcohol consumption and depressive symptoms.

Statistical analysis

The obtained data from the survey were analyzed using the statistical software GraphPad Prism (San Diego, California USA, ver. 9). Descriptive analyses (Kolmogorov-Smirnov normality test) were conducted in order to characterize the study sample. The correlational test used was the Spearman test, and the results were interpreted considering the Spearman R correlation index. The relation between variables was calculated using Fisher statistical test. Results with a p<0.05 were considered statistically significant.

Results

First section results

Of the total of 296 surveyed students, 75.68% were female students and 24.32% were male students, the majority (59.12%) being aged 21 to 24. The least receptive were those aged 18 to 20 years old (13.51%), and the rest of the respondents (27.36%) were 25-30 years old. It was also observed that the students’ responsiveness to the questionnaire increased with the year of study, the distribution being presented in Table 1.

It seems that the senior students were more receptive to the questionnaire, one possible explanation being that they are more aware of the link between depressive symptoms and alcohol consumption. Moreover, they can recognize better the depressive symptoms than younger students.

In terms of origin, most came from urban areas (68.92%) and lived on rent (57.43%), in a student dormitory (31.08%) or with their parents (11.49%).

Second section results

Questions 7 to 14 aimed to determine the presence of depressive symptoms; the students could answer with “Yes” or “No”, in each case. We focused on the following aspects: the presence of the feeling of devaluation, disinterest in everyday habits, disinterest in social activity, sleep quality, sexual appetite, the existence of overwork or somatic symptoms (slow and monotonous time passing over a longer period, headache, shortness of breath, palpitations, constipation, dry mouth, muscle pain).

Approximately 62% of students tended to devalue or blame themselves during their student years, but 62.84% had periods when they lost interest in everyday habits. An interesting aspect observed is the tendency to isolation, the presence of insomnia, overwork and time perception disorders. Thus, 66.55% said that they felt the desire to isolate themselves, 69.93% said that they suffered from insomnia and/or nightmares, 86.10% said that they suffered from physical and/or intellectual overwork, and 60.81% said that they had the feeling of a slower passing of time for a longer period.

All these did not affect the sexual life of the students, with more than half of them (58.45%) stating that they did not suffer from sexual dysfunction during their student years, regardless of age or gender. The results are presented in Table 2.

Moreover, half of the students (53.38%) presented somatic and vegetative symptoms such as headache, tachycardia, constipation, dry mouth or muscle pain over a longer period regardless of age or gender.

Correlations between the year of study and the number of depressive symptoms were also calculated using Spearman’s coefficient, but the negative correlation found between the two variables was not statistically significant (p>0.05).

After completing the questionnaires, it was observed that 93.58% of the respondents presented at least one symptom similar to those found in depression, especially female respondents and those from urban areas.

With the aid of Fisher exact test, we aimed to determine if the female gender is a risk factor for the development of depressive symptomatology, respectively if students who came from urban areas are at risk for developing depressive symptomatology. Neither of the two variables could be identified as risk factors (p>0.05).

Third section results

With the aid of questions 15-26, we wanted to assess the students’ attitude regarding alcohol consumption. Around 50.68% (n=150) of students consume alcohol occasionally, 27.36% (n=71) once a week, 8.45% (n=25) no more than once a month, 2.03% (n=6) daily, and 11.49% (n=34) of the surveyed students stated that they did not consume alcohol at all. The results, reported according to the year of study, are presented in Table 3.
 

Most students (63.05%) admitted they did not consume alcohol for an extended period. Students were questioned about the existence of attempts to give up alcohol. Most of the students did not experience difficulties in terms of giving up alcohol, only 11 students admitted failure in terms of abstinence. Fortunately, the purchase and consumption of alcohol were not important concerns for 83.11% of respondents. Moreover, 77.7% of them didn’t feel an irresistible urge to consume alcohol during their years of study. Of those who answered “Yes” to the question, 70.15% were female and more than half were in their final years.

At the same time, for 86.82% of students, school obligations and social life were not influenced by alcohol consumption, and there were no noticeable differences regardless of gender or year of study. Most of the students admitted they did not put their lives in danger after alcohol consumption, only 2.36% requiring hospitalization following consumption.

Fourth section results

The last six questions were intended to help establish a correlation between alcohol consumption and depressive symptoms.

First of all, the respondents were asked if they consume alcohol, with no significant differences observed between genders, respectively the origin (p>0.1)

By correlating the positive answers to the question “Do you consume alcohol?” and the symptoms that could suggest a psychosocial impairment, comparable to that of the depressive syndrome (presented in Table 2), it could be observed that only in the case of symptoms such as loss of sexual appetite and slower passing of time feeling, there were no statistically significant correlations (p>0.1). In the case of other symptoms, such as feeling of devaluation, disinterest in everyday habits, insomnia and/or nightmares, physical and/or intellectual overwork and alcohol consumption, statistically significant correlations (p<0.01) have been observed. The respondents were then asked if they drank alcohol in order to join easily in a student’s group, to hide restlessness, because of a failure, to overcome a stressful period, a sad event, or insomnia. The main reasons were to join easily in a student’s group (43%) or because of a failure (41.7%). Interestingly, those who admitted to drinking alcohol to facilitate inclusion in a group of students were in their final years (especially in the sixth year), although first-year students usually feel this pressure. The difference could be explained by the fact that the question was not formulated in such a way as to show exactly in which year of study they felt this pressure. When asked what type of alcohol they consume most frequently, most female students (54.46%) said they prefer medium-alcoholic beverages (e.g., wine). On the second place as frequency in the preferences of the students are the soft-alcoholic drinks (23.66%), and the strong alcoholic being preferred by the lowest percentage of the female students (9.37%).

In the case of the male gender, it was observed that the majority prefer soft-alcoholic drinks (36.11%), on the second place in preferences are the medium-alcoholic drinks (30.55%), and the last place is occupied, just as in the case of female gender, by strong drinks (26.38%).

Based on the symptoms of alcohol-related disorder, the subjects included in the study were classified as follows: without alcohol-related disorders (maximum one symptom), with mild intensity disorder (minimum two, maximum three symptoms), with medium intensity disorder (minimum four, maximum five symptoms), or with severe disorder (minimum six symptoms). The majority (71.96%; n=213) of the total number of respondents did not present symptoms or presented a single symptom. Mild intensity disorder was identified in 19.26% (n=57), medium intensity disorder was identified in 6.42% (n=19), and severe disorder was identified in 2.36% (n=7) of the total number of respondents.

The study also attempted to establish a correlation between the year of the study and the degree of alcohol-related disorder according to the number of symptoms met, using the Spearman nonparametric correlation test. Between the two variables, there is an inverse correlation, so that the degree of alcohol consumption disorder is higher in the case of students in the primary years, and is reduced in the case of students in the terminal year.

In order to determine if the severity of depressive symptoms (quantified by the number of the present symptoms) is correlated with the degree of impairment of alcohol-related disorders, we applied a nonparametric Spearman correlation coefficient determination test. The results showed that the two variables influence each other and are dependent on each other, the differences being statistically significant (p<0.01). Therefore, the number of depressive symptoms influences the degree of alcohol-related disorder.

Discussion

The etiology of alcoholism is complex and multifactorial, involving both genetic, socioeconomic and sociocultural environment, and psychosocial factors⁽²³⁾. Among the psychosocial factors, we can mention the psychoaffective lability of young people and the history of psychological and sexual abuse in childhood⁽²⁴⁾.

The sociocultural factors are involved in increasing the predisposition to excessive and abusive alcohol consumption. They are represented by cultural traditions that promote alcohol consumption, religious customs, and increased tolerance of public opinion about alcohol consumption. The socioeconomic status, which includes the level of education, the employment and the financial status, is an accurate indicator in terms of exposure to alcohol, so that the studies that have compared the groups in the population with high and low socioeconomic status have linked the frequent use of alcohol, but in small quantities, with a high socioeconomic status, and the frequent use of alcohol in large quantities with a low level of socioeconomic conditions⁽²⁵⁾.

Globally, there is a growing concern about the mental health of students, especially those enrolled in health science programs. It is well known that medical school is one of the most stressful programs, and this statement has several reasons. Among them is the volume of work, which involves both internships during the year in the hospital, but also study hours, to which is added the competition with other colleagues to obtain a financed place and/or a scholarship. In addition, it should be noted that this category of students must endure and manage the emotional burden resulting from exposure to patient suffering. All these can affect the mental health of students, and perhaps especially of young people admitted to this program, who may show symptoms of anxiety, acute stress disorder, post-traumatic stress disorder and/or depression. These problems are known, with previous studies reporting a variation between 21% and 56%⁽²⁶⁾. It should be noted and emphasized that these problems are not linked to the onset of the pandemic caused by SARS-CoV-2, as they are present before this event⁽²⁷⁾.

In terms of alcohol consumption, data published in recent years are controversial, with some articles reporting a decrease in consumption, while others, on the contrary, an increase^(28,29). This decrease in alcohol consumption during the pandemic may also be due to the fact that students go back home, where in the presence of parents and under their control, they limit alcohol consumption⁽³⁰⁾. When it comes to alcohol consumption, the students prefer to consume it especially in a social setting, and not necessarily in large quantities, but necessary for the installation of the anxiolytic effect⁽³¹⁾. Alcohol consumption among students is not a problem that is strictly observed in Romania, but also in other European countries^(32,33). It is also important to note the impact generated by the COVID-19 pandemic, which led to changes in the university, from an organizational point of view. Thus, face-to-face education was abandoned for a while, and e-learning platforms were used, which created a mental and emotional discomfort, both for teachers and especially for students. Migration to online education also has a setback, perhaps the most important being that of inequality and educational uncertainty, contributing to the impairment of students’ mental health⁽³⁴⁾. Social isolation is also a stressful factor that contributes to depression⁽³⁵⁾.

Since this target group – namely, medical students – is a vulnerable group to stress, alcohol is a cheap option, available to anyone to cope with stress and to limit the symptoms of anxiety.

Indeed, as stated in this article, medical students point out the lack of free time, but as much as possible, they find other ways to cope with stress, one of them being physical activity. The study led by Bland et al. reveals a positive correlation between the protective effect of exercise and the ability to cope with stress^(36,37). Instead, pandemic conditions have also limited the access to exercise, hence the possible contribution to increasing alcohol consumption, as an alternative to coping with stress^(38,39).

Regarding alcohol consumption among the students included in the study, we can note that more than 80% of them confirmed the consumption. Referring to the literature, in Botswana, a study conducted by Riva et al. mentions a prevalence of alcohol consumption among students of 41.2%⁽⁴⁰⁾. In contrast, a study from Brazil, conducted by Freire et al., that evaluated alcohol consumption among students in medical universities, reported a prevalence of ethanol consumption of 85%, having similar results to those in our study⁽⁴¹⁾. These differences only confirm the importance of socioeconomic factors in alcohol consumption. In 2008, the Botswana government increased at 30% the alcohol tax levy, reduced the hours of operation for bars, outlawed residential sales of alcohol, and increased penalties for alcohol trafficking to control alcohol consumption^(42,43).

In a study which focused on the consumption of alcohol among the students from Poland, Slovakia, Ukraine and Romania, it has been observed that, in the case of the Romanian students, most of them usually consume low alcoholic drinks, followed by the moderate alcoholic drinks, while the strong alcoholic drinks are on the last place in the preferences of the students⁽⁴⁴⁾.

Our results are in accordance with those presented in the study mentioned before; however, we noticed gender differences, female students preferring moderate alcoholic beverages, while male students usually consuming low alcoholic beverages.

Although the number of respondents belonging to urban areas was almost double compared to those from rural areas, following the statistical analysis of the results, no significant differences were identified. Similar studies conducted in the USA have shown an increased prevalence of alcohol consumption among urban students compared to rural students⁽⁴⁵⁾.

In the present study, we also investigated the relationship between alcohol consumption and living conditions. Thus, students who live on rent consume more alcohol than those who live in the student campus, and students who live with their parents consume the least. Referring to the literature, we can emphasize the fact that similar results were obtained in a study that followed alcohol consumption in students from the Carpathian Euroregion in terms of the relationship between living conditions and ethanol consumption⁽⁴⁴⁾.

Based on the obtained results, an increased incidence of depressive symptomatology was observed in the case of urban students, compared to rural students, probably due to higher social pressures. Similar results were also reported in a study conducted by Lew et al. in China which concluded that students in urban areas show more depressive symptoms compared to those in rural areas⁽⁴⁶⁾.

Studies have shown that men are 2-3 times more likely to develop addictions or the habit of consuming toxic substances than the female gender, but the differences are determined by opportunities and situations, and not by the degree of vulnerability⁽⁴⁷⁾.

Moreover, the sociodemographic impact of the subjects should not be neglected either, two variables being of major interest – namely, sex and the year of study, respectively. Women and men respond differently to stress and, at the same time, create different ways to protect themselves from stressful situations. Thus, the literature suggests that females are more prone to stress, anxiety and depression compared to males. The same studies reveal that this is due to the fact that women are more concerned about pleasing others (teachers or parents). As mentioned earlier, the two groups have different strategies for dealing with stress, with women relying on social support, establishing friendships, and tending to discuss their problems to find a solution. On the other hand, men tend to act directly in order to solve the problem, by talking less about them, being more reluctant to discuss, which is why the number of respondents in this subgroup is lower^(48,49). In our study, even though the majority of respondents were females (almost 80%), no significant differences were identified following the statistical analysis of the results, which means that gender cannot be considered a risk factor for alcohol consumption.

The second variable related to the year of study is very important, because it is expected that, in the first years of study, subjects experience overwhelm and anxiety, due to inability to manage study time, and high expectations from teachers and/or parents. Instead, it is expected that, with the advancement in the academic years, they will have less of these feelings, hence the reduction of the need for alcohol consumption for anxiolytic purposes⁽⁵⁰⁾.

At the same time, we observed an inverse correlation between the number of depressive symptoms and the year of study, so that junior students have a higher number of depressive symptoms as compared to senior students, for whom the number of depressive symptoms is lower⁽⁵¹⁾.

Our results showed that female students are more prone to depression. These results can be explained by the monthly hormonal fluctuations, more precisely by the decrease of the estradiol level before menstruation, knowing that estrogen plays a protective role in depression. In contrast, in men, testosterone produces a constant level of estrogen through aromatase, which makes them less predisposed to develop mood disorders⁽⁵²⁾. Previous studies ascribe this protective effect to the direct action of testosterone on androgen receptors located in the dentate gyrus⁽⁵³⁾. Regarding the involvement of demographic factors such as rural/urban permanent residence in the pathogenesis of depression, we cannot compare the situation from Romania with that observed in other countries, because the social conditions are different. Young people from rural areas are very attached to their community, and they have the support of their family to overcome their social condition. Although there are no studies to support this statement, they can cope more easily with everyday difficulties and stress compared to young people in urban areas who are accustomed to a certain lifestyle, and where any change in daily routine can significantly change their mood.

In this paper, the presence of depressive symptoms in Romanian students was also observed, so, based on these results, we can observe that a worrying percentage of students presented at least one depressive symptom during the university years, representing 93.58% of the total number of interviewed students.

We can point out that students with more depressive symptoms also show a higher degree of disorders related to ethanol consumption. Assessing the reasons why students turned to ethanol in various situations, we can point out that most of the interviewed subjects consumed alcohol as a result of a failure or to overcome a period marked by the feeling of sadness.

Limitations. The data collected come from a single medical school and, thus, cannot be generalized. As questionnaire completion was voluntarily, there may be a selection bias, which can be observed by a larger number of female respondents. Students’ responsiveness to the study was low, the questionnaire being completed by only 301 people. Our data were collected during the COVID-19 pandemic and, due to lack of data, observations cannot be compared with those before the pandemic; such a comparison can help us to better understand how the pandemic affected depressive symptoms, namely alcohol consumption. Although, based on the data published in the last year in literature which showed an increase in the prevalence of depressive symptomatology among students during the COVID-19 pandemic^(54,55), we tend to believe that the results would have been slightly different if the questionnaire had been completed prior to its onset.

Conclusions

Of the total subjects included in the study, an alarming proportion have depressive symptoms, with 93.58% of the interviewed students reporting having at least one depressive symptom. Although of the total respondents with at least one depressive symptom, 75.81% were females, the gender was not identified as a risk factor for the development of depressive symptoms. Regarding the permanent place of residence, most of the students with at least one depressive symptom came from urban areas, but the background could not be identified as a risk factor for depressive symptoms, nonetheless it represents a risk factor for alcohol consumption. The number of depressive symptoms and the year of study are inversely correlated with junior students showing more depressive symptoms compared to senior students (years 5 and 6), although with the increase of the year of study, alcohol-related disorders are more present.

Finally, it is important to point out the importance of these types of studies that highlight the connection between medical students and alcohol consumption, because during their careers, they will also treat patients with problems related to alcohol consumption, and their own beliefs about this issue may influence the attitude towards the patient.