Assessment of depression and anxiety among pre-university students in an urban area: A cross-sectional study

INTRODUCTION

The World Health Organization (WHO), defines mental health as “a state of well-being in which the individual realizes their abilities, can cope with normal stresses of life, works productively, and contributes to their community.”^[1] When untreated, mental health issues can persist for months or years; however, with appropriate interventions, recovery is possible.

A rapid epidemiological transition is underway in India, which is marked by a steady rise in the proportion of noncommunicable diseases, with mental and neurological disorders contributing significantly to the public health burden. These conditions can affect individuals across all age groups, including adolescents, who constitute 16% of the global population^[2] and about 20% of India’s population.^[3]

In recent years, mental health disorders such as depression and anxiety have increasingly contributed to the global burden of disease, leading to disability and premature mortality. By 2020, neuropsychiatric disorders accounted for 14.7% of the global disease burden.^[4] Depression is particularly prevalent, affecting both the general population and clinical patients.^[5] The WHO estimated that, as of 2012, about 350 million people are affected by depression worldwide and it is projected to become the second leading cause of disability after heart disease by 2020, which is turning out to be a reality.^[6] Depression is the second leading cause of death among 15–29-year-old individuals, which is a matter of most concern.^[7] To address this growing concern, the 2017 campaign on World Health Day focused on increasing awareness about depression and reducing associated stigma.^[7]

The prevalence of depression varies across age groups, with studies reporting rates of 25–39% among the higher aged in Gujarat^[8] and a lifetime prevalence of 20% among teenagers.^[9] Adolescents are particularly vulnerable, with nearly 19% affected by depression.^[10] Anxiety disorders are also significant, ranking as the sixth leading cause of disability globally and contributing to nearly 7% of suicidal deaths as of 2010.^[11] The highest number of years lived with disability due to anxiety is observed in individuals aged 16–35 years.^[11]

Adolescence is a critical developmental stage marked by increased vulnerability to conditions of mental health, especially depression and anxiety.^[9] These disorders can negatively impact academic performance, social relationships, and family dynamics. Long-term consequences include psychosocial impairment, substance abuse, antisocial behavior, and heightened suicidal risk.^[10] Common risk factors include academic stress, peer issues, poor sleep, genetic predisposition, and psychosocial stressors.^[12] Depression onset during adolescence significantly raises the likelihood of recurrence and chronicity in adulthood.^[13]

Pre-university (PU) students often face significant academic demands, social pressures, and various other stressors that make them vulnerable to depression and anxiety. Although these mental health issues are becoming increasingly common, limited awareness and hesitancy to seek help continue to worsen the problem. This study seeks to assess the prevalence of depression and anxiety among PU students in Belagavi and to identify related socioeconomic and other contributing risk factors. The insights gained will inform targeted interventions and offer support to both the students and their families.

MATERIALS AND METHODS

This cross-sectional study was conducted among PU college students in Belagavi city, Karnataka, from December 2021 to November 2022. The study population included students aged 14–19 years enrolled in PU colleges under various streams of science, commerce, and arts. The sample size was calculated using the formula n = 4pq/d², where the prevalence of depression (p) was assumed to be 25% based on a previously conducted study,^[14] q = 100 −p = 75, and the relative error (d) was 20% of p (5%). The calculated sample size was 300, with an additional 10% (30 students) included to account for non-responses, ensuing an enrolment of 330 participants.

A sampling frame was created using attendance records of students aged 14–19 years from selected colleges. Participants were chosen through simple random sampling with the help of a random number table. Before data collection, necessary permissions were obtained from the heads of the respective institutions. During the college visits, students were informed about the purpose of the study and educated on the risk factors and potential impacts of depression and anxiety during adolescence. Written informed consent was obtained from students above 18 years of age, while assent was taken from those below 18 years.

Validated self-administered questionnaires were used to gather data. A pre-structured questionnaire was utilized to record risk variables and sociodemographic information. The generalized anxiety disorder-7 (GAD-7) scale^[15] and the patient health questionnaire-9 (PHQ-9)^[16] were used to measure anxiety and depression, respectively. 0–4 (no or minimum depression), 5–9 (mild depression), 10–14 (moderate depression), 15–19 (moderately severe depression), and 20–27 (severe depression) were the categories used to interpret PHQ-9 results. GAD-7 scores were divided into four categories: Mild anxiety (scores 0–4), moderate anxiety (10–14), severe anxiety (15–21), and minimal anxiety (scores 5–9).

Descriptive statistics were used to analyze the data, and the Chi-square and Fisher’s exact tests were used for bivariate analysis. To ascertain correlations with risk factors, multiple logistic regression analysis was employed. Statistical significance was defined as a P < 0.05.

RESULTS

A total of 330 students participated in the study, with a mean age of 17.3 ± 2.4 years. Of the participants, 155 (47%) were male, and 175 (53%) were females [Table 1]. Regarding parental education, 121 (36.7%) of mothers had completed primary education, while 103 (31.2%) of fathers had attained secondary education. Most mothers (271; 82.1%) were homemakers, and the majority of fathers (172; 52.1%) were self-employed.

Concerning the living situation, 172 (52.1%) of participants lived with their grandparents, and 261 (79.1%) lived in a group setting rather than alone. Financial difficulties were reported by 137 (41.5%) participants, 184 (55.8%) experienced family quarrels, and 83 (25.2%) encountered violence. Academic pressures were common, with 140 (42.4%) reporting parental pressure, 149 (45.2%) struggling to cope with their studies, and 201 (61%) experiencing academic stress [Table 2].

Depression analysis

Among the risk factors, living alone (P = 0.01), family conflicts (P < 0.001), financial issues (P = 0.041), and exposure to violence (P < 0.001) were all substantially associated with the degree of depression among students. Academic stressors also had a significant impact; students who were struggling to manage their studies or who were under stress from their studies had greater levels of depression (both P < 0.001). These results show that academic pressure, financial stress, and family conflict are the main causes of depression in PU students [Figure 1].

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Figure 1:

Association of risk factors with severity of depression among pre-university students (n = 330). Y-axis: Percentage, X-axis: Association of demographic, family, financial, and academic stress factors with depression severity.

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Table 3 presents the unadjusted and adjusted odds ratios (AORs) with 95% confidence intervals (CIs) for various risk factors associated with depression among PU students. Among PU students, depression was significantly associated with staying alone (AOR = 3.89, P = 0.032), experiencing family quarrels (AOR = 2.65, P = 0.007), and stress related to studies (AOR = 2.15, P = 0.034). These students had notably higher odds of depression compared to their counterparts. Other factors such as gender, financial crisis, violence, parental pressure, and coping difficulties were not statistically significant.

Table 3: Association of various risk factors with depression among pre-university students (n=330).

Risk factors	Category	Unadjusted odds ratio (95% CI)	P-value	Adjusted odds ratio (95% CI)	P-value
Gender	Female	0.78 (0.41–1.48)	0.45	0.75 (0.36–1.52)	0.43
	Male	1 (Ref)		1 (Ref)
Staying alone	Yes	4.10 (1.23–13.67)	0.022	3.89 (1.12–13.46)	0.032
	No	1 (Ref)		1 (Ref)
Family quarrel	Yes	3.140 (1.59–6.12)	0.001	2.65 (1.29–5.42)	0.007
	No	1 (Ref)		1 (Ref)
Financial crisis	Yes	1.44 (0.74–2.79)	0.285	1.19 (0.57–2.47	0.642
	No	1 (Ref)		1 (Ref)
Violence	Yes	1.01 (0.48–2.10)	0.980	0.73 (0.32–1.66)	0.459
	No	1 (Ref)		1 (Ref)
Sibling	Yes	1.63 (0.82–3.21)	0.161	1.64 (0.77–3.47)	0.200
	No	1 (Ref)		1 (Ref)
Parent pressure	Yes	1.50 (0.77–2.92)	0.232	1.30 (0.60–2.79)	0.501
	No	1 (Ref)		1 (Ref)
Living with grandparents	Yes	1.10 (0.58–2.08)	0.762	1.04 (0.52–2.09)	0.906
	No	1 (Ref)		1 (Ref)
Living with parent	Yes	0.45 (0.10–1.99)	0.297	0.58 (0.12–2.77)	0.494
	No	1 (Ref)		1 (Ref)
Punishment	Yes	1.24 (0.49–3.11)	0.639	1.03 (0.39–2.9)	0.950
	No	1 (Ref)		1 (Ref)
Cannot cope with studies	Yes	1.52 (0.79–2.93)	0.211	1.28 (0.60–2.74)	0.514
	No	1 (Ref)		1 (Ref)
Stress with studies	Yes	2.86 (1.49–5.50)	0.002	2.15 (1.06–4.34)	0.034
	No	1 (Ref)		1 (Ref)

CI: Confidence interval, Ref: Reference. Bold P-values indicate P<0.05.

Anxiety analysis

Anxiety severity among participants was significantly influenced by several factors. Those experiencing financial difficulties reported higher levels of severe anxiety (P = 0.021), while exposure to domestic violence was strongly associated with moderate to severe anxiety (P < 0.001). Parental pressure also contributed to increased anxiety levels (P = 0.03). Living arrangements mattered, with students living with grandparents showing lower anxiety compared to others (P = 0.001). In addition, academic-related factors, such as study-related stress and difficulty coping with academic demands, were significantly linked to higher anxiety levels (P = 0.007). These results highlight the impact of financial, family, and academic stressors on student anxiety [Figure 2].

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Figure 2:

Association of risk factors with severity of anxiety among pre-university students (n = 330). Y-axis: Percentage, X-axis: Association of demographic, family, financial, and academic stress factors with depression severity.

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Table 4 shows the association between various risk factors and anxiety among PU students. After adjusting for confounders, significant associations were found for financial crisis (AOR = 1.89; 95% CI: 1.04–3.43; P = 0.036), exposure to violence (AOR = 2.74; 95% CI: 1.21–6.21; P = 0.016), and inability to cope with studies (AOR = 2.35; 95% CI: 1.26– 4.36; P = 0.007). These students had nearly 2–3 times higher odds of anxiety. Other variables, including gender, staying alone, family quarrel, parental pressure, and academic stress, did not show significant associations in the adjusted model (P > 0.05).

Table 4: Association of various risk factors with anxiety status among pre-university Students (n=330).

Risk factors	Category	Unadjusted odds ratio (95% CI)	P-value	Adjusted odds ratio (95% CI)	P-value
Gender	Female	0.85 (0.51–1.42)	0.546	0.84 (0.46–1.54)	0.581
	Male	1 (Ref)		1 (Ref)
Staying alone	Yes	1.75 (0.86–3.53)	0.119	1.38 (0.65–2.93)	0.403
	No	1 (Ref)		1 (Ref)
Family quarrel	Yes	1.55 (0.92–2.59)	0.094	1.17 (0.66–2.05)	0.586
	No	1 (Ref)		1 (Ref)
Financial crisis	Yes	2.20 (1.25–3.85)	0.006	1.89 (1.04–3.43)	0.036
	No	1 (Ref)		1 (Ref)
Violence	Yes	3.56 (1.63–7.77)	0.001	2.74 (1.21–6.21)	0.016
	No	1 (Ref)		1 (Ref)
Sibling	Yes	0.73 (0.39–1.35)	0.317	0.75 (0.38–0.47)	0.404
	No	1 (Ref)		1 (Ref)
Parent pressure	Yes	1.82 (1.06–3.13)	0.030	1.63 (0.87–3.03)	0.123
	No	1 (Ref)		1 (Ref)
Living with grandparents	Yes	1.12 (0.67–1.86)	0.673	1.11 (0.63–1.95)	0.716
	No	1 (Ref)		1 (Ref)
Living with parent	Yes	0.36 (0.10–1.22)	0.102	0.36 (0.10–1.30)	0.121
	No	1 (Ref)		1 (Ref)
Punishment	Yes	0.80 (0.41–1.57)	0.524	0.58 (0.25–1.33)	0.197
	No	1 (Ref)		1 (Ref)
Cannot cope with studies	Yes	2.66 (1.52–4.65)	0.001	2.35 (1.26–4.36)	0.007
	No	1 (Ref)		1 (Ref)
Stress with studies	Yes	1.56 (0.93–2.61)	0.093	1.28 (0.72–2.26)	0.394
	No	1 (Ref)		1 (Ref)

CI: Confidence interval, Bold P-values indicate P<0.05.

DISCUSSION

This study investigated the prevalence of anxiety and depression among PU students in Belagavi, Karnataka, as well as the factors that may be linked to these mental health conditions. With 41.5% reporting mild depression, 26% reporting moderate depression, and 19% reporting moderately severe or severe depression, our results indicate that anxiety and depression are common among college students. Likewise, mild anxiety was reported by 41.8% of students, moderate anxiety by 26.6%, and severe anxiety by 8.4%. The results showed a strong correlation between the mental health outcomes of anxiety and depression and sociodemographic characteristics, family dynamics, financial difficulties, and academic stress. These figures are consistent with previous studies conducted in various regions.

As per a study by Kumar and Akoijam, among Indian students in higher secondary schools, the incidence of anxiety was 21.4% and that of depression was 19.5%.^[17] In contrast, our study discovered that anxiety and depression, especially moderate versions of both, were more common. The age differences and the academic demands placed on students during their PU education may be the cause of this discrepancy. Similar to our results, a study by Alharbi et al. found that 34% of participants had mild depression, 24.6% had moderate depression, and 34.1% had mild anxiety.^[18]

In our study, anxiety was more common in women; however, the difference was not statistically significant. According to research from Bangalore, women were more likely than men to suffer from anxiety.^[19] This finding is in line with those findings. On the other hand, a Saudi Arabian study discovered that anxiety and sadness were substantially correlated with gender, with higher levels among females.^[20] These disparities might be a reflection of regional cultural variations in the way mental health concerns are viewed and handled.

In our study, a number of familial and socioeconomic characteristics were revealed to be strongly linked to anxiety and depression. Financial troubles and family conflicts were strongly linked to depression. These results are comparable to those published by Bansal et al., who emphasized the importance of family disputes, financial difficulties, and bullying at school in causing student depression.^[10] In addition, academic-related stress, including parental pressure, was strongly associated with both depression and anxiety. Students who felt overwhelmed by academic pressure or were dissatisfied with their academic performance had higher levels of depression and anxiety, in line with findings from Sandal et al. and Kumar et al.^[21,22]

Our study also revealed that students who lived alone had higher prevalence rates of depression, while students who lived with their grandparents had lower levels of anxiety. These findings underscore the status of familial and community support in mitigating mental health issues. In particular, the protective role of grandparents in students’ mental well-being is an area that warrants further exploration. This was found consistent with a review by Zgambo et al., which indicated that living arrangements, particularly living with parents, can influence the mental health of young individuals.^[23]

Exposure to violence was also found to be a major risk factor for anxiety and depression. According to studies by Slopen et al., who discovered that exposure to violence raises the likelihood of major depressive disorder and general anxiety disorder^[24] students who had witnessed violence reported noticeably higher levels of both disorders. Overall, our research added to the expanding corpus of research on mental health concerns among college-bound kids.

CONCLUSION

PU students are more likely to suffer from mild forms of anxiety and depression than moderate or severe ones. Socioeconomic factors, academic pressure, and family dynamics play key roles in these mental health issues. In addition, students who prefer to stay alone exhibit a higher prevalence of depression, while those living with their grandparents show lower levels of anxiety. Our findings underscore the need for early identification and intervention through validated screening tools, which are crucial to address these mental health concerns, ensuring the well-being and academic success of this vulnerable population.