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

Studies have established the crucial role of sleep among the students which plays a significant role in their mood. This study aimed to examine the mood disorders and sleep quality among undergraduate students at the University of Georgia (UG) and comparison between students’ nationality.This cross-sectional study was a self-reported questionnaire comprised of demographics including age, gender, year of study, current location, lifestyle data (Exercise and smoking), the Depression, Anxiety, and Stress Scale (DAS21) and the Pittsburgh Sleep Quality Index (PSQI). We performed a descriptive analysis, and the Chi-square was statistically significant at p<0.05. The prevalence was at a 95% confidence interval (95% CI) as multivariate analysis examined the multicollinearity. The female students were most of the respondents, below the age of 20 years. The student's mean age was 20.20 (SD± 3.0). DAS report presented 72.7% of students with depressive symptoms, 77.8% with anxiety symptoms, and 62.2% had stress. Georgian students were more at risk of having depressive complaints (95% Cl[1.567-3.788]), anxiety (95% Cl[1.612-4.285]), and stress symptoms (95% Cl[1.743-3.831]). There was a strong relationship between the students who experienced poor sleeping patterns and depressive complaints (aOR 0.10). The students who were smokers (aOR 0.39) were more likely to report anxiety symptoms than the students that do not exercise (aOR 1.68). It was observed that students with depressive symptoms, anxiety, and complaints of stress had a significantly high risk of poor sleep quality. Further studies are recommended to curb psychological symptoms of mood changes in association with sleep disorders among students.

Keywords:

Subject: Medicine and Pharmacology - Psychiatry and Mental Health

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.

Supplementary Materials

Table S1- Sociodemographic characteristics between Georgian students and international students. Table S2- Distribution on Psychological Report of Georgian students and international students. Table S3- Distribution on Sleep Report of Georgian students and international students.

Funding

This study received no external funding.

Recommendations

Initiating a counseling department for the students would help in managing the prevalence of psychological symptoms as it is not popular in Georgia. This have been proven helpful by Yahushko et al. (2008) [37] in which the awareness spread from friends to friends. Most times, during these psychological events, the student might not have the mood to appear for lectures or stick around with friends but can book an appoint for counseling regarding the issues. Students mostly feel that sleeping medication (which is used without physician’s prescriptions) could help them whenever such moody or depressive feeling overwhelms. There should be educational programs and events in the university environment which can be organized by the students’ club to help promote healthy sleep habits. Considering the increased rate of sleep disturbances, students should be encouraged to create a conducive environment, discourage cigarette smoking, and encourage exercise which would promote good sleep quality.

Data Availability

This article contained all collected and analyzed data. Additional inquiries can be directed to any of the corresponding author.

Ethical Approval

This research study is approved by the Institutional Review Board (IRB) of the School of Health Sciences, the University of Georgia (Approval number- UGREC-01-22) in accordance with the Declaration of Helsinki.

Informed Consent Statement

There was no consent required because of the IRB institutional approval.

Acknowledgments

The authors wish to thank the participants who dedicated their time in completing the surveys and the University of Georgia for supporting this study.

Conflicts of Interest

The authors declare no conflict of interest.

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Table 1. Demographic Characteristics of UG Undergraduate students.

Variables	N	%
Gender
Female	350	65.4
Male	185	34.6
Age
< 20	361	67.5
21-25	156	29.2
>26	18	3.4
Year of Study
First year	284	53.1
Second year	110	20.6
Third year	68	12.7
Fourth year	48	9
Fifth year	22	4.1
Sixth year	3	0.6
Students in Tbilisi
Yes	515	96.3
No	20	3.7
Nationality
Georgian students	190	35.5
International students	345	64.5
Nationality
Good	263	49.2
Poor	272	50.8
Exercise
Yes	324	60.6
No	211	39.4
Smoking Status
Yes	201	37.6
No	334	62.4

Table 2. Distribution of the Students Responses to DASS and PSQI questionnaires.

	DASS 21 Report
Depression	N	%
Yes	389	72.7
No	146	27.3
Anxiety
Yes	416	77.8
No	119	22.2
Stress
Yes	333	62.2
No	202	37.8
	PSQI Report
Subjective Sleep	N	%
Poor	283	52.9
Good	252	47.1
Sleep Latency
High	534	99.8
Low	1	0.2
Sleep Duration
> 7hours	113	21.1
< 7hours	422	78.9
Sleep Efficiency
< 75%	178	33.3
> 75%	357	66.7
Sleep alterations
High	230	43
Low	305	57
Sleep pills
< 1 time/week	457	85.4
> 1 time/Week	78	14.6
Day time Sleep Dysfunction
High	448	83.7
Low	86	16.1
Global Score
Poor	477	89.2
Good	58	10.8

Table 3. Comparison of Nationality among Psychological Symptoms, and Sleep Quality.

		Nationality
	Georgian students	International students	Total	Chi-square	P-value	OR	95% Confidence Interval
							Lower	Upper
Depression
Yes	158 (83.20%)	231 (67.00%)	389	16.208a	0.000	2.437	1.567	3.788
No	32 (16.80%)	114 (33.00%)	146
Anxiety
Yes	166 (87.40%)	250 (72.50%)	416	15.737a	0.000	2.628	1.612	4.285
No	24 (12.60%)	95 (27.50%)	119
Stress
Yes	144 (75.80%)	189 (54.80%)	333	23.007a	0.000	2.584	1.743	3.831
No	46 (24.20%)	156 (45.20%)	202
Sleep quality
Poor	175 (92.10%)	302 (87.50%)	477	2.646a	0.104	1.661	0.897	3.077
Good	15 (7.90%)	43 (12.50%)	58

Table 4. Comparison between gender differences, psychological symptoms, and sleep quality.

		Gender
	Male students	Female students	Total	Chi-square	P-value	OR	95% Confidence Interval
							Lower	Upper
Depression
Yes	121 (65.40%)	268 (76.60%)	389	7.605a	0.006	0.578	0.391	0.855
No	64 (34.60%)	82 (23.40%)	146
Anxiety
Yes	123 (66.50%)	293 (83.70%)	416	20.769a	0.000	0.386	0.254	0.585
No	62 (33.50%)	57 (16.30%)	119
Stress
Yes	94 (50.80%)	239 (68.30%)	333	15.726a	0.000	0.480	0.333	0.692
No	91 (49.20%)	111 (31.70%)	202
Sleep quality
Poor	160 (86.50%)	317 (90.60%)	477	2.089a	0.148	0.666	0.383	1.159
Good	25 (13.50%)	33 (9.40%)	58

Table 5. Comparison between depressive symptom and PSQI subcomponent.

	Depression Symptoms		Total	χ2	p-value	OR	95% Confidence Interval (Cl)
	Yes	No					Lower	Upper
Subjective Sleep
Poor	244 (62.7%)	39 (26.7%)	283	55.256a	0.000	4.617	3.033	7.029
Good	145 (37.3%)	107 (73.3%)	252
Sleep Latency
High	388 (99.7%)	146 (100%)	534	.376a	0.540	0.727	0.69	0.765
Low	1 (0.3%)	0	1
Sleep Duration
> 7hours	73 (18.8%%)	40 (27.4%)	113	4.747a	0.029	0.612	0.393	0.954
< 7hours	316 (81.2%)	106 (72.6%)	422
Sleep Efficiency
< 75%	130 (33.4%)	48 (32.9%)	178	.014a	0.906	1.025	0.684	1.536
> 75%	259 (66.6%)	98 (67.1%)	357
Sleep alterations
High	209 (53.7%)	21 (14.4%)	230	67.048a	0.000	6.911	4.178	11.433
Low	180 (46.3%)	125 (85.6%)	305
Sleep pills
< 1 time/week	316 (81.2%)	141 (96.6%)	457	20.062a	0.000	0.154	0.061	0.388
> 1 time/week	73 (18.8%)	5 (3.4%)	78
Day time Sleep Dysfunction
High	366 (94.3%)	82 (56.2%)	448	114.365a	0.000	12.984	7.564	22.289
Low	22 (5.7%)	64 (43.8%)	86

Table 6. Comparison between anxiety symptoms and PSQI subcomponent.

	Anxiety Symptoms		Total	Chi-Square Tests	p-value	OR	95% Confidence Interval
	Yes	No					Lower	Upper
Subjective Sleep
Poor	254 (61.1%)	29 (24.4%)	283	49.987a	0.000	4.866	3.064	7.728
Good	162 (38.9%)	90 (75.6%)	252
Sleep Latency
High	415 (99.8%)	119 (100%)	534	.287a	0.592	0.777	0.743	0.813
Low	1 (0.2%)	0	1
Sleep Duration
> 7hours	78 (18.8%)	35 (29.4%)	113	6.313a	0.012	0.554	0.348	0.882
< 7hours	338 (81.3%)	84 (70.6%)	535
Sleep Efficiency
< 75%	144 (34.6%)	34 (28.6%)	178	1.522a	0.217	1.324	0.847	2.068
> 75%	272 (65.4%)	85 (71.4%)	357
Sleep alterations
High	213 (51.2%)	17 (14.3%)	230	51.452a	0.000	6.296	3.639	10.893
Low	203 (48.8%)	102 (85.7%)	305
Sleep pills
< 1 time/week	344 (82.7%)	113 (95.0%)	457	11.178a	0.001	0.254	0.107	0.599
> 1 time/Week	72 (17.3%)	6 (5.0%)	78
Day time Sleep Dysfunction
High	385 (92.8%)	63 (52.9%)	448	108.587a	0.000	11.407	6.8	19.136
Low	30 (7.2%)	56 (47.1%)	86

Table 7. Comparison between stress complaints and PSQI subcomponent.

	Stress Symptoms		Total	Chi-Square Tests	p-value	OR	95% Confidence Interval
	Yes	No					Lower	Upper
Subjective Sleep
Poor	218 (65.5%)	65 (32.2%)	283	55.914a	0.000	3.995	2.755	5.794
Good	115 (34.5%)	137 (67.8%)	252
Sleep Latency
High	332 (97.7%)	202 (100%)	534	.608a	0.436	0.622	0.582	0.664
Low	1 (0.3%)	0	1
Sleep Duration
> 7hours	62 (18.6%)	51 (25.2%)	113	3.316a	0.069	0.677	0.445	1.032
< 7hours	271 ( 81.4%)	151 (74.8%)	422
Sleep Efficiency
< 75%	112 (33.6%)	66 (32.7%)	178	.052a	0.819	1.044	0.72	1.514
> 75%	221 (66.4%)	136 (67.3%)	357
Sleep alterations
High	195 (58.6%)	35 (17.3%)	230	87.214a	0.000	6.742	4.41	10.309
Low	138 (41.4%)	167 (82.7%)	305
Sleep pills
< 1 time/week	268 (80.5%)	189 (93.6%)	457	17.283a	0.000	0.284	0.152	0.529
> 1 time/Week	65 (19.5%)	13 (6.4%)	78
Day time Sleep Dysfunction
High	316 (95.2%)	132 (65.3%)	448	82.734a	0.000	10.473	5.865	18.703
Low	16 (4.8%)	70 (34.7%)	86

Table 8. Multiple logistic regression model predicting depression, anxiety, and stress symptoms among UG students.

Variable		B	Wald	Sig.	aOR	95% Confidence Interval
						Lower Bound	Upper Bound
			Depression
	Constant	-0.261	0.135	0.713
Gender	Female	-0.356	2.264	0.132	0.7	0.44	1.114
	Male⁺	-	-	-	-	-	-
Age	<20	1.002	3.134	0.077	2.723	0.898	8.257
	21-25	0.727	1.548	0.213	2.069	0.658	6.503
	>26⁺	-	-	-	-	-	-
Exercise	Yes	-0.421	2.93	0.087	0.656	0.405	1.063
	No⁺	-	-	-	-	-	-
Smoking status	Yes	0.819	9.834	0.002	2.268	1.359	3.783
	No⁺	-	-	-	-	-	-
Sleep quality	Poor	1.79	26.586	0.000	5.988	3.033	11.824
	Good⁺	-	-	-	-	-	-
			Anxiety
Yes	Constant	1.211	2.63	0.105
Gender	Female	-0.872	12.659	0.000	0.418	0.258	0.676
	Male⁺	-	-	-	-	-	-
Age	<20	0.498	0.699	0.403	1.646	0.512	5.297
	21-25	-0.15	0.061	0.806	0.86	0.26	2.85
	>26⁺	-	-	-	-	-	-
Exercise	Yes	-0.492	3.467	0.063	0.612	0.364	1.026
	No⁺	-	-	-	-	-	-
Smoking status	Yes	0.896	10.288	0.001	2.451	1.417	4.238
	No+	-	-	-	-	-	-
Sleep quality	Poor	1.38	17.578	0.000	3.973	2.085	7.573
	Good⁺	-	-	-	-	-	-
			Stress
Yes	Constant	0.901	1.65	0.199
Gender	Female	-0.595	7.518	0.006	0.551	0.36	0.844
	Male⁺	-	-	-	-	-	-
Age	<20	-0.006	0	0.991	0.994	0.33	2.99
	21-25	-0.418	0.521	0.47	0.658	0.212	2.048
	>26⁺	-	-	-	-	-	-
Exercise	Yes	-0.58	6.934	0.008	0.56	0.363	0.862
	No⁺	-	-	-	-	-	-
Smoking status	Yes	0.657	8.358	0.004	1.929	1.236	3.01
	No⁺	-	-	-	-	-	-
Sleep quality	Poor	1.152	10.612	0.001	3.163	1.582	6.324
	Good⁺	-	-	-	-	-	-

aOR= adjusted odd ratio; Reference category is +; Bolded values are the significant predictors.

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