chapter one: depression and anxiety

overview of the chapter

During the podcast episode, I talked with Dr. Iarovici about depression and anxiety. This chapter contains various sections that build on the information from the podcast episode. In the first section, I explain what depression and anxiety are and the extent to which they impact university students, extending the information that you heard in the podcast. The second section details some of the factors that can contribute to or cause depression and anxiety among college students. The third section then explains what current interventions and strategies exist to help students. In contrast, the final section explains significant gaps in the literature that remain researched and explored.

understanding depression and anxiety among college students

Depression and anxiety are among the most common mental health disorders globally. Researchers often group them due to their high comorbidity rates, which indicate the presence of conditions that happen simultaneously (ADAA, 2020). They are often diagnosed simultaneously and influence one another.

Depression and anxiety are highly prevalent among undergraduate students, and leaving them untreated can often lead to poor academic performance and failure (Iarovici, 2014). It is vital to understand precisely how depression and anxiety are diagnosed among undergraduate students, what underlying factors contribute to high depression and anxiety rates, and what college students can do to mitigate their effects. As the podcast episode mentioned, according to a report by the American College Health Association (ACHA) in 2018, 63% of college students in the US felt overwhelming anxiety (American College Health Association, 2018). Due to the initial transition readjustment period when students begin college, anxiety rates tend to have a sharp increase during that period (Conley et al., 2020). Moreover, a report published in 2020 found that about one-third of undergraduate, graduate, and professional school students had depression and anxiety or both (Anderson, 2020). It indicated that due to the coronavirus pandemic, the rate of major depressive disorder (MDD) in graduate and professional students is two times higher than it was in 2019 (Anderson, 2020).

To complicate things further, depressed or suicidal students can have a higher risk of self-medicating non-prescribed and non-medical drugs like painkillers, stimulants, and antidepressants (Iarovici, 2014). A multivariate analysis of suicide ideation in undergraduate students found that about 40% of students with suicide ideation had depressive symptoms (Arria et al., 2009).

These grim statistics are drastic and alarming, and they indicate that depression and anxiety severely affect college students’ lives. However, what exactly are depression and anxiety?

Colloquially, depression describes various experiences ranging from subtle decreases in the everyday mood to mild feelings of sadness to Major Depressive Disorder, a potentially life-threatening disorder (Hammen & Watkins, 2018). Depression captures various conditions that range in intensity from mild disruptions to high-intensity episodes (Hollon et al., 2002). It is an affective disorder, as it affects one’s moods, often causing sadness, feeling low or down, feeling worthless, or leaving one feeling empty (American Psychiatric Association, 2020). Various symptoms of depression include irritability, change in appetite, trouble sleeping, loss of interest or pleasure, apathy, listlessness, and when previously enjoyable activities were fun but are no longer appealing and are even viewed negatively (Hammen & Watkins, 2018).

There are different types of depression, each with different nuances. The most known type of depression is MDD. MDD is categorized by its long-lasting symptoms of at least two weeks, such as fatigue, lack of interest in activities, changes in weight or sleep patterns, and feelings of guilt or worthlessness (Schimelpfening, 2021). Atypical depression is similar to MDD in the expression of symptoms. However, the crucial difference is that people experiencing atypical depression can improve with positive events (Schimelpfening, 2021). Other types of depression include persistent depressive disorder, postpartum depression, and seasonal affective disorder (Schimelpfening, 2021).

 

Anxiety has evolutionary roots that evolved to help us survive by staying aware of dangerous threats in our environments. If humans encountered a potentially hazardous situation, such as being in proximity to a wild animal, our anxious response would trigger stress that would help us run away and then return to homeostasis, where we no longer feel anxious. However, in the modern world, we live with many challenges that trigger stress and make us anxious are no longer life-threatening. Moreover, they persist even when we take action to face them. For example, unanswered emails could trigger our stress response. Although we take action to clear our inbox during the day, we will go through the same process that begins the stressful or anxious response the following morning. Thus, the anxiety we experience is no longer as beneficial as compared to facing a wild animal. When this emotion is problematic and becomes overwhelming, it can cause significant chronic problems in a person’s life.

But how does one distinguish between regular worry and stress vs. an anxiety disorder? When those feelings of anxiety are prolonged, debilitating, and interfere with one’s daily life, it could indicate an anxiety disorder. In general anxiety disorder (GAD), one feels excessive, uncontrollable, and often unrealistic worry for little or no reason (Tull et al., 2009). Another common anxiety disorder is panic disorder. Panic disorder often brings on panic attacks, during which a person can break out in a heavy sweat, have chest pain and heart palpitations that may feel like a heart attack (Bhargava, 2020). Panic attacks are often also a symptom of GAD (Tull et al., 2009). About 11% of people in the United States experience a panic attack (Cleveland Clinic, 2020).

As we can see, the implications of having depression or anxiety disorders as a college student are vast and detrimental. Depression and anxiety can severely influence academic performance, impair social connections, weaken physical health, and even lead to suicide in worst-case scenarios. However, what causes these disorders, and why are they so prevalent among undergraduate students? The following section attempts to distill some of the most critical factors involved in causing depression and anxiety.

contributing factors and causes of depression and anxiety among undergraduate students

Firstly, to fully understand the contributing factors that lead to depression and anxiety among undergraduate students, it is essential to note that depression and anxiety both have high comorbidities rates, which means that they often co-occur. Therefore, they likely contribute to the onset of the other and are often researched concurrently.

Depression and anxiety disorders are highly complex, and there are multiple factors associated with higher levels of them in students. One factor that seems to be prevalent in exacerbating depression and anxiety is the excessive use of technology. Technology encompasses various types of usage such as playing video games, utilizing social media, watching tv, and more. One study found that a mobile device’s mere presence could have adverse effects on closeness, empathy, connection, and conversation quality (Przybylski & Weinstein, 2012). This lack of connection can lead individuals to feel lonely, which can then predispose them to depression. Another study surveyed young adults and calculated their social media usage based on self-reports (Lin et al., 2016). They found that participants in the highest quartile of total time spent per day on social media had a significantly higher chance of having depression (Lin et al., 2016).

Contrastingly, another study focused on understanding the effects of passive social media use from a network perspective, such as scrolling through news feeds or browsing photographs on Instagram, found that previous fatigue and loneliness predicted passive social media use (Aalber et al., 2019). However, passive social media use did not directly indicate depressive symptoms (Aalbers et al., 2019). This finding suggests that the scientific community needs a better understanding of the temporal precedence of social media, depression, and other interrelated factors like loneliness and fatigue. The cause and effect may not be as linear as one makes them out to be, as social media usage could lead to depression or vice versa.

Another factor that when analyzing depression and anxiety rates among college students is culture. Many researchers have explored the correlations and associations between cultural and ethnic differences in depression and anxiety levels among students. One study compared the severity of depression among Asian-American and Caucasian students at UC San Diego and found that Asian-Americans had significantly elevated levels of depression than Caucasian students.

Moreover, Korean-American students were the most depressed than other Asian minorities (e.g., Chinese-American) (Young et al., 2010). One study based in India found that 51.3% percent of its respondents, undergraduate medical students, were affected by depression, 66.9% by anxiety, and 53% by depression (Iqbal et al., 2015).

South Korea, a country that suffers from one of the highest suicide rates per capita (Ryall, 2020), also faces significant problems regarding their college students’ mental well-being. One study from South Korea found that there was a stark correlation between depression and anxiety (p < .001) that indicated that students with higher levels of depression were more likely to have more significant anxiety as well (Yeun & Jeon, 2015). Moreover, due to the coronavirus pandemic in 2020, suicide rates among young women in South Korea rose to 17.9% in April (Ryall, 2020).

Although these statistics reflect that cultural components play a role in worsening depression and anxiety, the exact causal mechanisms are not yet fully understood.

One study found that prejudice towards depression was more pronounced in Eastern countries than in Western ones (Krendl & Pescosolido, 2020). This finding could indicate that because depression is highly stigmatized, students may not feel comfortable disclosing their struggles with depression or that the prejudice exacerbates their depression. Moreover, South Koreans value hard work, professionalism, and academic excellence. These societal pressures could induce anxiety or feelings of depression as students are pressured to succeed.

Contrastingly, another study argued that Asian cultures approach emotion differently than Western cultures in a way that benefits individuals and does not exacerbate negative affect disorders at the same rate as Western cultures (DeVaus et al., 2018). DeVaus et al. explained that Asian cultures are more likely to experience positive and negative emotions as covarying. They also explained that experiences of failure are more likely to be associated with thoughts of self-improvement. Thus Asian cultures develop better skills for combating negative emotions (DeVaus et al., 2018).

As you can see from the examples presented above, determining the causal relationship between technology and culture and depression and anxiety is incredibly complex. The field of mental health still fails to understand what gives rise to these disorders fully. However, dear reader, do not despair. Although we may not fully understand the cause of depression and anxiety, many interventions exist to help students and everyone cope with them.

interventions and coping strategies for undergraduate students

So what interventions exist to help students cope with these disorders? At what stages should the interventions be implemented? And what strategies can undergraduates do to mitigate their levels of depression and anxiety?

The most commonly accepted treatments in the field include biological and psychological therapies, and Dr. Iarovici particularly recommends taking a holistic approach when treating university students (Iarovici, 2014). The biological approach regards pharmacotherapy. Many antidepressants are currently on the market, such as selective serotonin reuptake inhibitors (SSRIs) like fluoxetine (Prozac) and citalopram (Cipramil). However, these drugs can often have severe side effects like nausea, diarrhea, insomnia, drowsiness, and headaches (Hollon et al., 2002). The psychological approach concerns psychotherapy. Cognitive-behavioral, interpersonal, and psychodynamic therapies are all under the umbrella of psychotherapy, although there is debate regarding which treatment works best for undergraduate students (Iarovici, 2014).

Additionally, various intervention phases can help indicate which intervention is most appropriate for the individual student. Hollon et al., 2002, describes the intervention phases as 1. Prevention of Onset, 2. Acute Treatment, 3. Continuation Treatment, and 4. Maintenance Treatment (see Figure 1).

Moreover, there are various strategies for undergraduate students that do not require additional help from a therapist or psychiatrist and could potentially help mitigate or prevent these disorders’ onslaught. Practicing daily self-care acts, like eating well, getting enough sleep, and exercising for 30 a few times per week, have clear benefits for overall health (Iarovici, 2014).

Figure 1. Phases of treatment of depression: prevention, treatment, relapse, and recovery.

The x-axis indicates time, while the y axis indicates the severity of the depression. The solid line in this figure describes the course of a typical episode of depression. The first dotted line with arrow prevention indicates what the depressive episode would look like if preventative measures were implemented. The dotted lines with arrow relapse indicate the depressive episode if the patient were to relapse.  Adapted from Hollon et al., 2002.

Current gaps in research

One significant research gap is that the research community needs to analyze the causes and effects of depression and anxiety from a network perspective to obtain a holistic understanding of the problem. Although a few papers have already attempted to do this (Aalbers et al., 2019), most of the literature does not consider this perspective. Many of these factors leading to depression and anxiety could be creating reinforcing network loops that exacerbate the symptoms of depression and anxiety and vice versa.

Likewise, the proposed interventions can act as reinforcing network loops that change the negative patterns in individuals. Still, not much focus is placed on understanding how interventions could create positive reinforcing loops.

Moreover, there is currently not much research on the degree to which mental health information is accessible to students and whether students view it despite accessibility. Although a wealth of valuable information exists online, many students may not be aware of it or may have to do a deep search before they find what they are looking for. To my knowledge, not many studies have attempted to understand why students are accessing mental health information or what forms of access have the highest engagement among college students.

references

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