The prevalence and socioeconomic correlates of depressive and anxiety symptoms in a group of 1,940 Serbian university students

Background/Aim. Mental health of university students is under increasing concern worldwide, because they face challenges which predisposes them to depression and anxiety. The aim of this study was to identify demographic and socioeconomic variables associated with depressive and anxiety symptoms among university students. Methods. This cross-sectional study on 1,940 university students was performed using a questionnaire including demographic and socioeconomic variables, Beck Depression Inventory and Beck Anxiety Inventory. Results. The prevalence of depressive symptoms in students was 23.6%, while the prevalence of anxiety symptoms was 33.5%. The depressive symptoms were significantly related to the study year (p = 0.002), type of faculty (p = 0.014), satisfaction with college major choice (p < 0.001), satisfaction with grade point average (p < 0.001). Female students (odds ratio – OR = 1.791, 95% confidence interval – CI = 1.351–2.374), older students (OR = 1.110, 95% CI = 1.051-1.172), students who reported low family economic situation (OR = 2.091, 95% CI = 1.383–3.162), not owning the room (OR = 1.512, 95% CI = 1.103–2.074), dissatisfaction with graduate education (OR = 1.537, 95% CI = 1.165–2.027) were more likely to show depressive symptoms. The anxiety symptoms were significantly related to study year (p = 0.034), type of faculty (p < 0.001), family economic situation (p = 0.011), college residence (p = 0.001) satisfaction with the college major choice (p = 0.001), and satisfaction with graduate education (p < 0.001). Female students (OR = 1.901, 95% CI = 1.490–2.425), and students who reported parents high expectations of academic success (OR = 1.290, 95% CI = 1.022–1.630) were more likely to show anxiety symptoms. Conclusion. This is one of the largest study examining mental disorders in a sample of university students in Serbia. These findings underscore the importance of early detections of mental problems and prevention interventions in university students.


Introduction
Mental health problems are a major public health concern due to their high prevalence rates, difficult treatment, and often chronic course 1 .In addition, the unrecognized burden of depression and anxiety became undeniably evident in developed and developing countries until the year 2000 2 .In the European region, mental disorders, including anxiety and depression, are the second largest contributor to the burden of disease (measured using disability-adjusted life years − DALYs) and the most important cause of disability 3 .By the year 2020, if current trends for demographic and epidemiological transition continue, burden of depression will become the second leading cause of DALYs lost 4 .Anxiety disorders also rank among the twenty conditions contributing the largest global share of years lived with disability (YLDs) 5 .Furthermore, most lifetime mental disorders have their first onset during the typical university age 6,7 , making depression a particularly salient problem area for student population 8 .Worldwide estimation of current depression prevalence range upwards from 8% 9 to as high as 85% among university students 10 .Regarding anxiety symptoms, the prevalence will range from 8% 9 to 47.7% 10 .Generally, the prevalence seems to be increasing.In the United States of America, the National College Health Assessment reported that 1 in 3 undergraduates had at least one episode in the previous year of "feeling so depressed it was difficult to function" 7 .With symptoms of nearly three-fourths of all lifetime diagnosable mental health disorders it is critical to identify these disorders as early in life as possible 11 .
Studies show that female students had almost two times higher level of depression compared to their male counterparts 12 .Socioeconomic parameters that are connected with the prevalence of depression are low incomes and financial problems (lower socioeconomical status), lower education level, bad living conditions and urban life style 13 .Higher anxiety level in female (aged 20-30 years) shows no differences regarding religion and socioeconomical status 14 .Other potential stressors for depression and anxiety can be: transition to university life, acclimating to a new environment, establishing new social networks, meeting their personal goals 15 , academic factors (year of study, area of study) 16 , academic overload and demands, financial pressures, pressure to succeed 17 , separation from their usual support network 15,18 .On the other hand, sometimes there is a high level of stigmatization associated with mental illness 19 .Previously obtained data in Serbia showed that about 1/3 of high school and university students population manifested signs of psychological distress and has mental problems 20 .Moreover, mild depression was reported to be six times more prevalent than severe depression and it was more prevalent in the 20-24 age groups.This could be considered as a kind of maladaptive behavior 21 .
From the public health perspectives, early detection of mental health problems is essential, especially in young adults, in order to conduct appropriate screening and intervention programs 22,23 and to improve the longer-term prognosis related to future risk of depression 24 .
The general applicability of published results concerning student's mental health is limited.Most studies are based on samples that are not representative of the general student population, due to confinedment to a single faculty, to the specified years of study to one academic field or are selected using non-probabilistic methods 16 .After considering all these factors, we planed to estimate the prevalence of depressive and anxiety symptoms and to examine the specific demographic, socioeconomic correlates of depressive and anxiety symptoms.

Study design and participants
The study was a cross-sectional survey of students attending University of Kragujevac, Serbia, in the year 2013/2014.University of Kragujevac, with its twelve faculties, is a state-owned university in Central Serbia.Six of its faculties are located in Kragujevac, while the other six faculties are located in five towns of Central Serbia, thus covering the area with more than 2,500,000 inhabitants.All the twelve faculties were selected for the survey: Faculty of Agronomy, Faculty of Economics, Faculty of Engineering, Faculty of Mechanical and Civil Engineering, Faculty of Medical Sciences, Faculty of Education, Faculty of Law, Faculty of Natural Sciences and Mathematics, Faculty of Technical Sciences, Teachers Training Faculty, Faculty of Philology and Arts, Faculty of Hotel Management and Tourism.The students were randomly sampled from every study year of each faculty, in proportion to the size of the faculty in relation to the total number of students in University.We randomly selected 1,940 students from the total of 18,123 students at the University of Kragujevac.The students were sorted out from the university students data base according to previously generated random order (random computer function).

Procedure
A self administered anonymous questionnaire which comprised of demographic and socioeconomic variables, Beck Depression Inventory (BDI-IA) and Beck Anxiety Inventory (BAI) were used.Ethical approval was obtained from the Faculty of Medical Sciences Ethical Committee.Participation was completely voluntary, with no economic or other motivation.Informed consent was obtained, and confidentiality of the responses was assured.The study was conducted in the participants own classrooms by the leading researcher.Those who were absent during the distribution of questionnaires were excluded.The research was completed within 35 weeks.

Instruments
A self-assessment questionnaire with detailed subdomain questions was used to determine variables.Symptoms of depression were evaluated through the scale BDI-IA.This scale was developed in the 1960's and is one of the most widely used instruments for measuring the severity of depression, with the focus on behavioral and cognitive aspects of these disorders 25 .It was designed to document a variety of depressive symptoms the individual experienced over the preceding week.It consists of 21 items, each answer being scored on a scale ranging from 0 to 3. The total score has a minimum of 0 and a maximum of 63.The rating scale was as follows: 0 to 9 -no symptoms, 10 to 15 -mild mood change or mild depression state; 16 to19 -mild to moderate depression, 20 to 29moderate depression and 30 to 63 -severe or clinical depression The internal consistency for the BDI-IA was good, with average alpha coefficient of 0.81 for non psychiatric samples and with highly intercorrelated items 26 .
Symptoms of anxiety were evaluated through the BAI scale, a short list describing 21 anxiety symptoms which bothered them in the past week.The scale consists of 21 items, each answer being scored on a scale ranging from 0 to 3. The total score has a minimum of 0 and a maximum of 63.A total score of 0 to 7 is interpreted as a "minimal" level of anxiety, 8 to 15 as a "mild" level of anxiety, 16 to 25 as a "moderate" level of anxiety, and 26 to 63 as a "severe" level of anxiety 27 .

Statistical analysis and assessment
Data analysis was carried out using IBM Statistical Package for the Social Sciences (SPSS) software version 19.0.Data cleaning was done to detect any missing values, coding error or any illogical data values.The qualitative variables (demographic and socioeconomic) were presented with the numbers and as a percentage.The continuous variables (depression, anxiety and symptoms scores), were presented as means and standard deviation (SD).Descriptive statistics for all sociodemographic characteristics, depressive and anxiety symptoms of the participants were calculated, expressed as appropriately in frequencies, mean values and standard deviation.Student's t-test, Fisher's exact test  2 Pearson and Spearman correlations were all used to look for any existing association between demographic and socioeconomic cha-racteristics, and anxiety and depression.All tests were 2tailed, and the level of significance was set at p < 0.05.We conducted univariate and multivariate logistic regression analysis to study associations between depressive, anxiety symptoms and potential risk factors.The results are reported as odds ratios (OR) with 95% confidence intervals (CI).

Results
From 1,968 distributed questionnaires, a total of 1,940 students completed questionnaire during the survey with the response rate of 98.6%.The mean age of the participating students was 21.04 (SD = ± 2.23) years with the range of 18-57 years.The demographic and socioeconomic characteristics of the sample are summarized in Table 1.
Regarding depressive symptoms, the mean BDI-IA score was 6.12 (SD = ± 6.4), with the range between 0 and 63.Further analysis indicated that 15.4% of the students had the score between 10 and 15 (mild depression state), 4.2% the score between 16 and 19 mild to moderate depression), 2.9% the score between 20 and 29 (moderate depression), 1.1% the score between 30 and 63 (severe depression).The mean BAI score for anxiety symptoms was 6.88 (SD = ±7.3),with the range between 0 and 63.About 22.7% of the respondents had a score between 8 and 15 (mild anxiety), 7.4% the score between 16 and 25 (moderate anxiety), 3.4% the score between 26 and 63 (severe anxiety).
The depressive symptoms were significantly related to the study year (p = 0.002), the type of faculty (p = 0.014), satisfaction with the college major choice (p < 0.001), and satisfaction with grade point average (p < 0.001).
The anxiety symptoms were significantly related to study year (p = 0.034), type of faculty (p < 0.001), family economic situation (p = 0.011), college residence (p = 0.001), satisfaction with the college major choice (p = 0.001), and satisfaction with graduate education (p < 0.001).
The possibility of having anxiety symptoms was significantly higher in students who were female (OR = 1.901; 95% CI, 1.490-2.425);and had parents with high expectations about academic success (OR = 1.290; 95% CI, 1.022-1.630).Logistic regression model on anxiety symptoms is shown in Table 5.

Discussion
The present study is one of the largest epidemiological studies, regarding mental health status among university students, in this region.
The primary objective of this study was to investigate the prevalence of depressive and anxiety symptoms in university students.We found that the prevalence of depressive symptoms was 23.6%, while the prevalence of anxiety symptoms was 33.5%.A significantly increased rate of depression in college students, previously reported from the U.S. and Western Europe studies, confirmed previous concerns about global growth 28 , especially which includes deficits in cognitive, emotional and physical development 29  our findings for the prevalence of depressive and anxiety symptoms are higher than the results of a large American study (17.3% and 9.8%, respectively) 30 , and Australian study (8% and 13% respectively) 9 , they are similar with some European studies, especially about the prevalence of depressive symptoms (23% in Germany, 27.1% in Turkey) 18,31 .Interestingly, other European studies reported higher occurrence of depressive symptoms (34% in Poland, 39% in Bulgaria, 52.4% in Greece) 15, while the lowest prevalence has been reported in the students in Switzerland (10.2%) 32 .All these variations could be explained by cultural differences, demographic and socioeconomic situation.One of the few studies from the former republics of Yugoslavia showed lower prevalence of depressive symptoms than our study (Croatia 9.4% 33 , FYR Macedonia 10.4% 34) but higher for anxiety symptoms (FYR Macedonia 65.5% 34 ).It should, however, be noted that these discrepancies may be due to the small sample sizes.No closely related research studies, on the prevalence of depressive and anxiety symptoms, have been previously conducted among university students in Serbia, thus there are no data available for comparison.
The second objective of this study was to examine the demographic, socioeconomic correlates of depressive and anxiety symptoms, and the results are summarized in Tables 2 and 4. The present study reported statistically significant differences in depressive symptoms by gender, with a higher prevalence among female student.Using regression analysis we found that female students were 79.1% likely to get dep- ressive symptoms, while 90.1% were more likely to suffer from anxiety symptoms, compared to male students.This is consistent with the majority of the studies regarding depressive symptoms 15,18,30 , while a number of studies have found either no differences 6,7,31 or the opposite pattern 17 .In addition, our results are consistent with higher rates of anxiety symptoms among females found by other researchers, although no significant association existed for depressive symptoms 35 , 36 .One of the explanations may be because females are more likely to report concern, stress and feeling of lack of competence, different sociodemographic background or even including factors related to gender role and potentially stressful transforming events.
In our study depressive symptoms increased with increasing age, about 11% for every year of life.Tendencies showed significant increases from early adolescence, peaks in late adolescence (16-18 years) and decreases towards older ages 18,37 .Potentially stressful events are presumed to elicit mental health problems, such as employment, economic situation, graduation and marriage pressures 6,30,38 .On the contrary, some other studies have failed to find this association 39 .
This study shows that students with lower socioeconomic background had a statistically significantly higher risk of depressive and anxiety symptoms.Using regression analysis, we also observed that students which reported low socioeconomic situation substantially have 109.1% the likelihood to develop depressive symptoms compared with those in the highest socioeconomic group.The inverse relationship between socioeconomic status and mental health problems is well established in general population samples 6,30,35 .Additionally, a meta-analysis in different European countries found unambiguous evidence that financial struggles had higher odds for depression 18 and anxiety, as well 22 .
Furthermore, our study concludes that there is a significant difference between the mean depression scores and not having own room, with a higher likelihood of depressive symptoms up to 51.2%.There were almost significant interactions regarding the student's anxiety symptoms.More than three persons per room are related to psychiatric illness 40 although some studies findings are contrary 39 .These findings might be correlated with sociological and culturological differences.
Another important aspect of our study, regarding subclinical depressive symptoms (usually corresponds to mild depressive episodes according to ICD-10 classification), revealed that it is high in such populations (15.4%).Studies from other countries show a wide variety of rates ranging between 10% and 44% 6,[41][42][43][44] .In our culture there is still no awareness that depression and anxiety are disorders of youth.Because of that, mild depression and anxiety sometimes are not diagnosed and treated by health professionals.This underlines the importance for establishing proper screening tools for early identification and treatment of subclinical forms of depression.Some stressful life events like dissatisfaction with the college major choice and dissatisfaction with graduate education was significant associated with depressive and anxiety symptoms.Our study indicates that students who are dissatisfied with graduate education were 53.7% more likely to have depressive symptoms.Students exposed to heavy acade-mic workloads, strong examination criteria and being overburdened with test schedule, contributed to many of unhealthy behaviors 44,45 and were significantly associated with anxiety 30 and depressive symptoms 6,31 .
Consequently, the present study also revealed association between low overall success in grade point average and depressive symptoms, but no significant association with anxiety symptoms.These coincidence have been reported by other authors 46 , while others failed to find this correlation 37 .
Another important aspect of our study is statistically significant correlations of pressure for success and depressive and anxiety symptoms especially when they are not able to meet the expectations of their parents.The observed association signifies that students were 29.0% more likely to have anxiety symptoms.Pressure to perform well academically, parental expectations and criticism is a strong predisposing factor for depression 47 .These findings suggest that relationship with parents have a substantial causal relation with the depressive and anxiety symptoms, especially during this delicate period in their life.
Consistent with findings from similar studies 22,31 we also found a significant correlation between the study year and higher level of depressive and anxiety symptoms.In addition, we found that the sixth year students had the highest average BDI-IA scores, compared with the first year students.Next, the highest average BAI scores had the third year students, in regard to senior students.Senior students had higher depression scores compared with freshmen because postgraduate students worry about employment and future perspective and these stresses could be risk factors for depressive and anxiety symptoms 6,22,37 .The severity of the employment situation in Serbia, aggravates the employment pressure of college graduate.The Statistical Office of the Republic of Serbia published that the unemployment rate for youth aged 15-24 is reaching nearly 50% 48 and that situation might be potential risk factor for mental disorders.The prevalence of anxiety and depressive symptoms were significantly related to the type of faculty.We also found that the students who were studying Faculty of Mechanical and Civil Engineering had the highest depression score (38.4%).Regarding anxiety, Faculty of Education (54.8%),Faculty of Hotel Management and Tourism (54.8%),Teachers Training Faculty (48.6%), had higher anxiety scores.Students who were studying Faculty of Engineering had the lowest depression and anxiety scores (12% and 24.1% respectively).Several studies have been conducted with various and controversial results [49][50][51] due to methodological issues that limit interpretation, different measure instruments and different settings and cultures.
The primary limitation of the study is its cross-sectional design, which does not permit inferences about possible causal relations between the explanatory variables and disorders of interest.It was not possible to assess the test-retest reliability of BDI/BAI in this sample as the survey was anonymous.Another limitation was the self-reported nature of this study.Finally, our sample comprised a group of students in just one university of Serbia, which may limit generalization of the results through the other universities.Health Organization 52 strengthening mental health promotion programmes is highly relevant.

Conclusion
These results demonstrate that the high rates of depressive and anxiety symptoms among university students are related to academic, nonacademic and cultural backgrounds.The last several years have provided data that highlight a neglected public health problem in institutes of higher education.The importance of early identification, especially the minor signs of depression, could prevent or reduce its severity and chronicity.From a public health perspective, onset and development of mental illness in students is a potentially critical area for intervention programs.A particular challenge is to promote the early diagnosis of depression by initiating community-based intervention programmes and to reduce the stigma of mood disorders.Such efforts hold substantial promise for the development of interventions that may have a positive impact on the health and well-being of college students.