Depression,Suicidal Ideation and Perceived Stress in Italian Humanities Students: A Cross-Sectional Study

Abstract

Mental health issues are common among university students. Nevertheless, few studies focused on Italian students. This study aimed to assess prevalence and associated factors of perceived stress (PS), depressive symptoms (DS) and suicidal ideation (SI) in an Italian sample. A cross-sectional study was conducted amongst a convenience sample of students in humanities field (2018). Questionnaires were self-administered. Outcomes were assessed through Beck Depression Inventory-II (DS, SI) and Perceived Stress Scale (PS). Multivariable regressions were performed (p-value < 0.05 significant; sample size = 203). DS and SI prevalence was 30.6% and 8.8%. PS median score was 20 (IQR = 11), 87.7% reported moderate/severe PS. DS likelihood was increased by psychiatric disorders family history and not attending first year of course and decreased by not thinking that university hinders personal activities. Chronic disease and higher stress score increased SI probability; good/excellent family cohesion reduced it. Being female, thinking that university hinders resting/relaxing, seeing a psychologist/psychiatrist were positively associated with PS; having no worries about future was negatively associated. A high prevalence of mental health issues was reported, with miscellaneous associated factors that were linked to both private and social aspects. Universities must be aware of this to provide efficient preventive measures.

Keywords

Depression humanities mental health stress suicidal ideation university students

Introduction

Depressive disorders represent a major public health issue, since 4% of the world population suffers from these conditions. These disorders are also the single largest contributor to non-fatal health loss worldwide, causing 5% - and the trend is going upwards – of all Years Lived with Disability (YLDs) (Global Burden of Disease Collaborative Network, 2018). Despite depressive disorders are not directly linked to Years of Life Lost (YLLs), these conditions are a major contributor to suicide, which, in 2015, accounted to 1.5% of all deaths and were the second cause of death among 15–29-year-olds globally (World Health Organization, 2017).

It is estimated that, globally, at any given time, 20% to 25% of students, from both university and college, are stressed (Kumaraswamy, 2013), and more than 50% of students may experience anxiety and depression in some forms (Regehr et al., 2013). In particular, students deal with stress differently and it is not simple to estimate a prevalence of perceived stress. For instance, a French study reported that up to 79% of students were stressed (Saleh et al., 2017). Moreover, also the suicidal ideation prevalence in college students varies between different studies. Mortier et al reported a twelve-month prevalence of suicidal ideation of 1.8% within this age group (Mortier, Auerbach et al., 2018) while a meta-analysis described a 12-month prevalence of 10.6% (Mortier, Cuijpers, et al. 2018). As a matter of fact, psychological distress is frequent in the average university student for various academic fields. Furthermore, it must be noted that psychological distress is common between university students worldwide (Sharp & Theiler, 2018). Hence, students worldwide experience a wide range of stressors, which impact their mental health. In the past, little attention was paid to identifying mental disorders among college students other than in the United States or in the UK (Sharp & Theiler, 2018). One study estimated that 1/3 of first-year students in 19 colleges - in countries like Australia, Belgium, Germany, Mexico, Northern Ireland, South Africa, Spain, and the United States - screened positive for at least one between anxiety, mood, or substance disorder (Auerbach et al., 2018). An overview assumed that there is also evidence of elevated psychological distress among students attending universities across Africa, the Middle East and Asia and similar results were shown among European university students (Sharp & Theiler, 2018). Among first year university students from four European countries, many were identified as experiencing clinically relevant depression according to a modified BDI (Mikolajczyk et al., 2008): Germany (24.8%), Denmark (18.5%), Poland (36.4%) and Bulgaria (38.4%) (Sharp & Theiler, 2018). In Italy, a multicenter survey estimated that the prevalence of depressive symptoms was at 29.5% (Bert et al., 2020). However, this study was focused on medical students - 5% of the general student population in Italy - who attended a single cycle University program that lasts six years. It is worth noting that the majority of non-medical students might face different challenges and difficulties during their academic path while attending shorter degree courses. As a matter of fact, the Italian university system is organized in three cycles whose main academic degrees are: the bachelor’s degree (1st cycle, which has the highest number of students per year compared to other cycles (MIUR, n.d.)), the master’s degree (2nd cycle) and the PhD (3rd cycle). Depressive symptoms, perceived stress and suicidal ideation have been extensively studied in medical university students worldwide, whereas little information on non-medical students exists. However, factors accountable for this risk are diverse among different countries and fields of study. Indeed, education models, socioeconomic factors and cultural influences vary across countries. For instance, Italy is among the European countries with the lowest employment rates for humanities graduates, compared to other degree courses (Organisation for Economic Co-operation Development., 2019). Uncertainty for the future might pose a serious threat to mental health. Moreover, humanities students could face a number of difficulties during their academic path. Particularly, during their training, students of social sciences and education might be exposed to social disadvantage, emotional pain, mental suffering and juvenile distress, to name a few. These special conditions can lead to psychological suffering.

In the literature it is known which factors can be associated with mental health in college students. Mainly, these factors can be at individual, interpersonal and institutional levels. Specifically, the interpersonal level considers a student's adaptation in a social environment (family, social and academic fields) and the institutional level is, for instance, the educational setting and academic climate (Byrd & McKinney, 2012). However, there is no data about the impact of these factors on humanities college students.

Therefore, this study aimed to estimate depressive symptoms, suicidal ideation and perceived stress on a sample of Italian humanities students. Another purpose was to explore factors associated with mental health issues, considering certain variables at individual-, interpersonal- and institutional-level.

Methods

Between November and December 2018, a cross-sectional study was carried out amongst a convenience sample of students attending a university located in the Lazio region (Central Italy). All procedures performed were in accordance with the 1964 Helsinki declaration and its later amendments. The Internal Review Board of the Department of Public Health Sciences of the University of Torino (Italy) approved the protocol. Participants were chosen by convenience in two courses of the first cycle: indeed, participants were recruited in the Social Sciences Bachelor’s Degree and in the Education Bachelor’s Degree. The duration of these degrees is of three years. Students were enrolled by opportunity sampling during the lessons. Participation was voluntary, anonymous and without compensation. Informed consent was obtained from all participants.

The questionnaire

The self-administered questionnaire consisted of a socio-demographic section, the Beck Depression Inventory-II (BDI) (Beck, 1996) and the Perceived Stress Scale (PSS) (Cohen, 1988).

The present study used the socio-demographic section developed in the Psychosocial Report in Italian MEdical Students (PRIMES) (Bert et al., 2020). This part gathered data about socio-demographic characteristics (e.g. gender, age, economic status, living condition), and further data about other potential factors that could influence mental health of students (family cohesion, relationship status, exercise, hobbies, relationships with classmates, sexual orientation, use of psychiatric medications, psychologist/psychiatrist follow-up, family history of psychiatric disorders and suicide, personal chronic disease, distance from home, necessity of working, career motivations, worries about the future career). A detailed description of this section is available in the PRIMES paper about depressive symptoms in medical students (Bert et al., 2020).

The BDI-II is a 21-item self-report tool that assesses the severity of depressive symptoms over the last two weeks (Beck, 1996). In the present study, the Italian version was used (Ghisi et al., 2006). The total score is calculated by summing each item score (from 0 to 3). Scores from 0 to 13 represent no/minimal depression, from 14 to 19 represent mild depression, from 20 to 28 represent moderate depression, and from 29 to 63 represent severe depression (Beck, 1996). A comprehensive review reported that the BDI-II internal consistency has been described as around 0.9 and the retest reliability ranged from 0.73 to 0.96 (Wang & Gorenstein, 2013). In our sample, Cronbach's Alpha was 0.873.

In this study, the binary outcome “presence of depressive symptoms” was defined around the cut-off of 14, which has already been used in several studies as reported in systematic reviews (Tam et al., 2019). The BDI-II was also used to define the binary outcome “presence of suicidal thoughts”. Indeed, the item 9 investigated suicidal thoughts/wishes, with the following options: (a) “I don't have any thoughts of killing myself”, (b) “I have thoughts of killing myself, but I would not carry them out”, (c) “I would like to kill myself”, (d) “I would kill myself if I had the chance” (Beck, 1996). Therefore, the last three options were grouped.

The PSS is a self-reported instrument to measure psychological distress over the last month (Cohen et al., 1983). It was firstly created as a 14-item scale (Cohen et al., 1983) and then shortened to 10 items (Cohen, 1988). In the present work, the 10-item version was used (Italian version; Fossati, 2010). The total score is the sum of the 6 positive stress predictors scored with a 5-point Likert scale (points from 0 to 4) and the 4 negative predictors scored with a reversed 5-point Likert scale (Cohen, 1988). Higher probability of perceived stress is represented by higher score. The PSS Cronbach’s alpha reliability coefficient has been reported to be 0.89 among college students (Roberti et al., 2006). In our sample, Cronbach's Alpha was 0.807.

The PSS score was considered as a continuous outcome since no cut-offs have been reported (Cohen, 1988). Scores ranging from 0-13 would be considered low stress, scores ranging from 14–26 would be considered moderate stress, and scores ranging from 27–40 would be considered high perceived stress (State of New Hampshire Employee Assistance Program, 1983).

Statistical analysis

Descriptive analyses were carried out for all the variables. The continuous variables were expressed as medians and interquartile range (IQR) since the Shapiro-Wilk test reported non-normal distributions. To evaluate differences between groups defined by the presence of depressive symptoms and by the presence of suicidal thoughts, chi-squared tests and adjusted residuals were calculated (Kruskal-Wallis and Mann-Whitney U test where appropriate). To assess differences in the PSS scores, Mann-Whitney U test was used (Kruskal-Wallis where appropriate). Missing values were excluded by pairwise deletion.

Multivariable regression models, adjusted for age and gender, were computed to explore the effect of the independent variables (coded from the items of the socio-demographic section) on the outcomes. Multivariable logistic regressions were run for the outcomes about the presence of depressive symptoms and suicidal thoughts, and the final models were achieved through backward stepwise selection. The suicidal ideation model was performed both without and with the BDI-II score (without the suicidal ideation item) as independent variable. A multivariable linear regression was executed for the continuous outcome PSS score, and the covariates to be included into the model were selected using a stepwise forward selection process, with a univariate p < 0.25 as the main criterion (Hosmer, 1989). Missing values were excluded by listwise deletion.

The overwhelming majority of variables had less than 2 missing values (1.0%). The only exceptions were: relationship status (3 missing values, 1.5%), taking psychiatric drugs (3 missing values, 1.5%), suicidal ideation item (4 missing values, 2.0%), climate among classmates (12 missing values, 5.9%), PSS total score (16 missing values 7.9%), year of course (21 missing values 10.3%), and BDI-II total score (23 missing values, 11.3%). The Little’s MCAR (Missing Completely At Random) test was not significant (p = 0.110).

All analyses were performed with the SPSS software (version 25), and a two-tailed p-value < 0.05 was considered to be statistically significant.

Results

Characteristics of the sample

Collected questionnaires were 203. Descriptive analyses were performed on all questionnaires, DS analyses on 180 (23 BDI-II were incomplete). PSS missing participants were 16.

Females were 81.8% and median age was 20 (IQR = 3). Participants studying far from home were 70.4%. Relatives with psychiatric disorders were 16.3% and students followed by a psychologist/psychiatrist were 5.1%. The 61.5% of students attended first year of course. Students who considered not satisfying (poor, very poor or excessive) their family cohesion were 9.9%. Participants with chronic disease were 5.0%. The 11.4% did not have valuable friendships with a circle of classmates and 16.2% did not have an opinion on classroom climate. Other data are presented in Table 1.

Table 1.

Associations between depressive symptoms presence, suicidal thoughts presence and characteristics of the sample: descriptive and chi-squared analysis.

Characteristics	Overall (n = 203)	Depressive symptoms			Suicidal thoughts
Characteristics	Overall (n = 203)	No n = 125	Yes n = 55	P-value	No n = 176	Yes n = 23	P-value
	N (%)	N (%)	N (%)		N (%)	N (%)
Age*	20 [3]	20 [3]	20 [3]	0.758	20 [3]	20 [1]	0.076
Gender
Male	37 (18.2)	27 (21.6)	6 (10.9)	0.098	35 (19.9)	2 (8.7)	0.261
Female	166 (81.8)	98 (78.4)	49 (89.1)		141 (80.1)	21 (91.3)
Nationality
Italian	197 (98.0)	121 (96.7)	53 (98.2)	1.000	171 (98.3)	22 (95.7)	0.394
Other	4 (2.0)	3 (2.4)	1 (2.8)		3 (1.7)	1 (4.3)
Living away from home
No	58 (28.9)	35 (28.2)	14 (25.5)	0,896	51 (29.3)	4 (17.4)	0.405
Yes, same region	77 (38.3)	50 (40.3)	22 (40)		67 (38.5)	9 (39.1)
Yes, different region	66 (32.8)	39 (31.5)	19 (10.6)		56 (32.2)	10 (43.5)
Relationship status
Single	96 (48.0)	56 (45.2)	27 (50.9)	0.480	83 (47.4)	11 (52.4)	0.668
Involved	104 (52.0)	68 (54.8)	26 (49.1)		92 (52.6)	10 (47.6)
Sexual orientation
Heterosexual	186 (92.1)	116 (92.8)	50 (90.9)	0.764	161 (92.0)	22 (95.7)	1.000
Homosexual/bisexual	16 (7.9)	9 (7.2)	5 (9.1)		14 (8.0)	1 (4.3)
Living condition
With parents/relatives	169 (83.7)	100 (80.6)	48 (87.3)	0.280	146 (83.4)	19 (82.6)	1.000
Other	33 (16.3)	24 (19.4)	7 (12.7)		29 (16.6)	4 (17.4)
Family cohesion
Poor/very poor/excessive	20 (9.9)	6 (4.8^b)	12 (21.8^a)	<0.001	11 (6.3^b)	9 (39.1^a)	<0.001
Good/very good	182 (91.1)	119 (95.2^a)	43 (78.2^b)		165 (93.8^a)	14 (60.9^b)
Working because of income need
Yes	28 (86.1)	16 (12.8)	10 (18.2)	0.344	23 (13.1)	5 (21.7)	0.266
No job/job not for income need	174 (13.9)	109 (87.2)	45 (81.8)		152 (86.9)	18 (78.3)
Family economic status
Good	39 (19.3)	103 (82.4)	41 (74.5)	0.225	142 (81.1)	17 (73.9)	0.412
Poor	163 (80.7)	22 (17.6)	14 (25.5)		33 (18.9)	6 (26.1)
Year of course attended
1^st year	112 ( 61.5)	72 (63.7)	25 (51.0)	0.130	98 (62.4)	11 (50.0)	0.264
other	70 (38.5)	41 (36.3)	24 (49.0)		59 (37.6)	11 (50.0)
Having at least one hobby^#	133 (66.2)	83 (66.9)	38 (69.1)	0.776	113 (64.9)	17 (74.9)	0.393
Practicing sport less than 90’ weekly^#	138 (68.7)	84 (32.3)	36 (34.5)	0.764	54 (31.0)	9 (39.1)	0.434
1^st/2^nd degree relatives with psychiatric disorders^#	33 (16.3)	5 (4.0^b)	22 (40.0^a)	< 0.001	23 (13.1^b)	9 (39.1^a)	0.001
Suicides/suicide attempts ^#in 1^st/2^nd degree relatives^#	15 (7.4)	6 (4.8)	7 (12.7)	0.058	12 (6.8)	3 (13.0)	0.390
Having a chronic disease^#	10 (5.0)	2 (1.6^b)	6 (11.1^a)	0.010	6 (3.4^b)	4 (17.4^a)	0.019
Taking stimulants to improve academic performance^#	6 (3.0)	2 (1.6)	3 (5.5)	0.170	4 (2.3)	2 (8.7)	0.093
Taking psychiatric drugs	3 (1.5)	2 (1.6)	1 (1.9)	1.000	3 (1.7)	0 (0.0)	1.000
Under psychiatric/psychological care	10 (5.1)	6 (5.0)	3 (5.5)	1.000	9 (5.3)	1 (4.3)	1.000
Judging the choice of University
Positively	167 (83.1)	107 (85.6)	43 (79.6)	0.320	144 (82.8)	20 (87.0)	0.612
Negatively/no opinion	34 (16.9)	18 (14.4)	11 (20.4)		30 (17.2)	3 (13.0)
Satisfying friendships with a circle of classmates
No	23 (11.4)	7 (5.6^b)	13 (23.6^a)	< 0.001	19 (10.9)	4 (17.4)	0.317
Yes/not yet	179 (88.6)	118 (94.4^a)	42 (76.4^b)		156 (89.1)	19 (82.6)
Climate among classmates
No opinion	31 (16.2)	13 (11.0^b)	15 (28.8^a)	0.004	24 (14.5)	6 (28.6)	0.097
Friendly/competitive but stimulating	160 (83.8)	105 (89.0^a)	37 (71.2^b)		142 (85.5)	15 (71.4)
Thinking that university hinders:°
Practicing sport^#	37 (18.4)	19 (15.3^a)	16 (29.1^b)	0.032	29 (16.7)	7 (30.4)	0.104
Having hobbies^#	47 (23.4)	25 (20.2^b)	20 (36.4^a)	0.021	41 (23.6)	6 (26.1)	0.790
Sleeping properly^#	38 (18.9)	16 (12.9^b)	16 (29.1^a)	0.009	31(17.8)	7 (30.4)	0.149
Resting and relaxing^#	48 (23.9)	22 (17.7^b)	22 (40.0^a)	0.001	35 (20.1^b)	11 (47.8^a)	0.003
Having chosen university for:°
Helping people who suffer^#	85 (42.3)	49 (39.5)	25 (45.5)	0.554	68 (39.1^b)	14 (60.9^a)	0.046
Intellectual curiosity^#	31 (15.4)	13 (10.5^b)	14 (25.5^a)	0.010	28 (16.1)	3 (13.0)	0.706
Worries about the future:°
No, future is stimulating^#	54 (27.0)	42 (34.1^a)	7 (12.7^b)	0.003	52 (30.1^a)	2 (8.7^b)	0.044
Yes, not measured up to the profession^#	46 (23.0)	21 (17.1^b)	18 (32.7^a)	0.020	38 (22.0)	6 (26.1)	0.656
Yes, about specialty/job limited chances^#	78 (39.0)	39 (31.7^b)	27 (40.9^a)	0.027	61 (35.3^b)	14 (60.9^a)	0.018

Note: n = sample size.

Figures are expressed as number (N) and column percentages (%).

*Figures are expressed as median and interquartile range in brackets.

^aAdjusted residual >1.96.

^bAdjusted residual < −1.96.

^#Possible options: “No” and “Yes”. “Yes” reported in table.

°Possibility to selected more options.A two-tailed p-value <0.05 was considered to be statistically significant.

Depressive symptoms

Median BDI-II score was 9 (IQR = 11). Among students with DS the median was 19 (IQR = 9), while it was 7 (IQR = 6) among students without DS. DS prevalence was 30.6% (55 students). Specifically, 16.7% (30) had mild depression, 10.0% (18) moderate and 3.9% (7) severe. Students who considered poor, very poor or excessive their family cohesion were 21.8% of people with DS showing a significant association (p < 0.001) confirmed by chi-squared analyses. Students with 1^st/2^nd degree relatives with psychiatric disorders were 40.0% of people with DS with a significant association (p < 0.001). Among participants without DS, 63,7% were freshman (attending first year of course), 34,1% think that future is stimulating, and 1,6% have a chronic disease. No significant DS association was found with female gender. Other data are shown in Table 1.

The overall multivariable logistic regression model Table 2 showed some risk factors for DS presence. Relatives with psychiatric disorders (OR 18.2, CI: 2.8–111.7 p = 0.002), high perceived stress (OR 1.23, CI: 1.11–1.35; p < 0.001) and not attending the first year of course (not being a freshman) (OR 4.87, CI: 1.53–15.5; p = 0.007) were associated to DS presence among students. Not thinking that University hinders carrying out personal activities (OR 0.16, CI: 0.04 - 0.60; p = 0.007) was protective instead.

Table 2.

Predictors for depressive symptoms presence: overall multivariable logistic regression model.

Predictors for depressive symptoms presence	Overall	P-value
	adjOR (95% CI)
Age	1.02 (0.85–1.22)	0.818
Gender
Male	Ref.
Female	0.50 (0.11–2.26)	0.365
1^st/2^nd degree relatives with psychiatric disorders#	18.2 (2.8–117.7)	0.002
Satisfying friendships with a circle of classmates
No	Ref.
Yes/not yet	0.18 (0.03–1.26)	0.084
Working because of income need
Yes	Ref.
No job/job not for income need	0.26 (0.05–1.34)	0.107
Having hobbies^#	2.72 (0.81–9.11)	0.104
PSS score	1.23 (1.11–1.35)	<0.001
Year of course attended
1st year	Ref.
Other	4.87 (1.53–15.5)	0.007
Not thinking that University hinders carrying out personal activities^#	0.16 (0.04–0.6)	0.007

Note: Figures are expressed as adjusted Odds Ratios (adjOR) and 95% Confidence Interval (CI).

^#possible options: “No” and “Yes”. “No” considered the reference level.A two-tailed p-value <0.05 was considered to be statistically significant.°Possibility to selected more options.

Suicidal ideation

Correlations between characteristics of the sample and suicidal ideation are reported in Table 1. Students with suicidal thoughts were 8.8% (23) of the sample and their median age was of 20 (IQR = 1). The 9.9% of the sample reported to have a very poor/poor/excessive family cohesion, with a higher percentage among students with suicidal ideation (p < 0.001). Significance was found also among students with a chronic disease (17.4%, p = 0.019) and those with a family history of mental illness (39.1%, p = 0.001). In addition, high percentages of students with suicidal ideation were found among those who considered University as a barrier for resting and relaxing (47.8%, p = 0.003) and those worried about job limited chances in the future (60.9%, p = 0.018). Nonetheless, in our logistic regression model, only having a chronic disease (OR 12.6, CI: 1.09-144.9, p = 0.042) or higher PSS scores (OR 1.12, CI: 1.05-1.26, p = 0.003) were predictors of suicidal ideation, while considering its family cohesion as “good” or “very good” appears as protective factor (OR 0.18, CI: 0.05-0.71, p = 0.014). Other data are presented in Table 3.

Table 3.

Predictors for suicidal ideation: overall multivariable logistic regression model.

Predictors for suicidal ideation	Overall	P-value
	adjOR (95% CI)
Age	0.65 (0.42–1.02)	0.061
Gender
Male	Ref.
Female	1.12 (0.19–6.69)	0.904
Family cohesion
Poor/very poor/excessive	Ref.
Good/very good	0.18 (0.05–0.71)	0.014
Having a chronic disease^#	12.6 (1.09–144.9)	0.042
PSS score	1.12 (1.05–1.26)	0.003

Note: Figures are expressed as adjusted Odds Ratios (adjOR) and 95% Confidence Interval (CI).

^#possible options: “No” and “Yes”. “No” considered the reference level.A two-tailed p-value <0.05 was considered to be statistically significant.

Considering the suicidal ideation model adjusted for the BDI-II score (without the suicidal ideation item), less variables resulted to be included in the final model. The BDI-II score showed a significant relationship with the suicidal ideation outcome (OR 1.18; CI: 1.09-1.18, p < 0.001). Gender was confirmed to have a non-significant relationship with suicidal ideation (OR 1.15; CI: 0.16-8.22, p = 0.889), while increasing age significantly reduced suicidal ideation risk (OR 0.65; CI: 0.42-0.99, p = 0.045). Regarding the other variables, only family cohesion was included, thus confirming a good/very good family cohesion may lead to a lower likelihood of reporting suicidal ideation (OR 0.13; CI: 0.03-0.63, p = 0.011).

Perceived stress

Table 4 shows the association between each variable and perceived stress scale (PSS) score in median and interquartile range (IQR). In the sample PSS median was 20 (IQR = 11). Prevalence of stress (moderate and severe) in this sample was 87.7% (164) and students who perceived high stress were 20 (10.7%). Mann-Whitney test showed a significant difference across gender (p < 0.001) for perceived stress, with females having a median score of 21 (IQR = 10) compared to males who had a median score of 14.5 (IQR = 7). A median score of 26 (IQR = 10) was found among those students who considered poor, very poor or excessive their family cohesion. It was significantly higher (p = 0.007) than the median score of 19 (IQR = 10) found in those who considered good or very good their family cohesion. Also, having a family history of psychiatric disorders was significantly associated (p < 0.001) with a higher PSS score (27.5, IQR = 12) compared to students with no psychiatric illness in their first and second relatives (19, IQR = 9). However, no inter-group significant differences in perceived stress were observed based on being or not under psychological/psychiatric treatment or taking or not psychiatric drugs. Furthermore, those who thought University hinders sleeping properly (23.5, IQR = 13) or resting and relaxing (24, IQR = 9) had a significantly higher median score then those who did not, 19 (IQR = 10) and 18 (IQR = 10) respectively.

Table 4.

Associations between PSS score and characteristics of the sample: Mann-Whitney U test.

	PSS score
Characteristics	Median [IQR]	P-value
Age*	−0.29 (−0.63–0.05)	0.091
Gender
Male	14.5 [7]	<0.001
Female	21 [10]
1st/2nd degree relatives with psychiatric disorders
Yes	27.5 [12]	<0.001
No	19 [9]
Under psychiatric/psychological care
Yes	24 [15]	0.062
No	19 [11]
Thinking that university hinders:°
Not thinking that university hinders carrying out personal activities
Yes	16 [7]	<0.001
No	22 [10]
Resting and relaxing
Yes	24 [9]	<0.001
No	18 [10]
Having chosen university for:°
Intellectual curiosity
Yes	23 [14]	0.068
No	19 [10]
Worries about the future:°
No, future is stimulating
Yes	15 [9]	<0.001
No	21 [10]
Yes, not measured up to the profession
Yes	23 [10]	0.002
No	19 [10]
Yes, about specialty/job limited chances
Yes	21 [10]	0.029
No	19 [11]

Note: Figures are expressed as median and interquartile range [IQR] in brackets, except for age.

*Figure are expressed as unstandardized coefficient B and 95% CI.

°possibility to selected more options.

p-value obtained via Mann-Whitney U test between each variable and PSS score (except for age: linear regression model performed).A two-tailed p-value <0.05 was considered to be statistically significant.

Stress predictors, evaluated performing a multivariable linear regression model, are displayed in Table 5. Analyses showed that female gender is significantly associated (p = 0.022) with perceived stress (adjB = 3.23, 95% CI: 0.48-5.98). Other stress predictors were thinking that University hinders resting and relaxing (adjB = 3.21, 95% CI: 0.78-5.63, p = 0.010); family history of psychiatric disorders (adjB = 5.94, 95% CI: 3.16-8.72, p < 0.001); being under psychiatric or psychological care (adjB = 6.67, 95% CI 1.74-11.79, p = 0.009) and, surprisingly, having chosen University for intellectual curiosity (adjB = 2.80, 95% CI: 0.13-5.47, p = 0.040). Instead, having no worries about the future (thinking that future is stimulating) (adjB = -3.63, 95% CI: -6.36; -0.90, p = 0.010) seemed to act as a protective factor.

Table 5.

Predictors for stress presence: overall multivariable linear regression model.

Predictors for stress presence	Overall	P-value
	adjB (95% CI)
Age	−0.49 (−0.37; 0.27)	0.763
Gender
Male	Ref.
Female	3.23 (0.48–5.98)	0.022
1st/2nd degree relatives with psychiatric disorders#	5.94 (3.16–8.72)	<0.001
Thinking that university hinders resting and relaxing
Yes	3.21 (0.78–5.63)	0.010
No	Ref.
Having chosen university for intellectual curiosity
Yes	2,80 (0.13–5.47)	0.040
No	Ref.
Thinking that future is stimulating
Yes	−3.63 (−6.36; −0.90)	0.010
No	Ref.
Under psychiatric/psychological care
Yes	6.67 (1.74–11.79)	0.009
No	Ref.

Note: Figures are expressed as adjusted unstandardized coefficient B (adjB) and 95% Confidence Interval (CI).

^#possible options: “No” and “Yes”. “No” considered the reference level.A two-tailed p-value <0.05 was considered to be statistically significant.

Discussion

The results from the present study aimed to increase knowledge about prevalence and correlates of mental health issues among humanities university students

Depressive symptoms

Our findings showed that the prevalence of depressive symptoms was found to be 30.6%, dramatically higher than the proportion of global population with depression, estimated to be 4.4% in 2015 (World Health Organization, 2017). However, it was in line with 29.5% found by Bert et al. in their multicenter study on Italian medical students (Bert et al., 2020). Using a comparative group design study, Naseem and Munaf found that social sciences students scored significantly higher in depression levels, assessed with the Depression Anxiety Stress Scale- 21 (DASS-21), compared to medical students (Naseem & Munaf, 2017).A similar finding was already reported by Al-Qaisy (2011). On the other hand, using DASS-21, Shriyan et al. (2011) found higher levels of depression in medical students compared to engineering and other non-medical students. Based on available literature, Bacchi and Licinio conclude that there is not sufficient evidence to argue that medical students have higher rates of depression compared to their peers attending non-medical university faculties (Bacchi & Licinio, 2015).

Although it is well known that females are more commonly affected by depressive disorder than males (Kuehner, 2003), we found no significant difference across gender for depressive symptoms presence. A possible explanation for this finding has to be sought in the different distribution of gender in participants. Indeed, in our sample females were 81.8% while males 19.2%.

In our study, family history of psychiatric illness emerged as a very strong predictor of depressive symptoms. As a matter of fact, several studies have implied that familiarity for psychiatric disorders can be considered a risk factor for depression (Rasic et al., 2014; Weissman et al., 2016). Our multivariable logistic regression also found higher scores at Perceived Stress Scale and not being a freshman as predictive of depressive symptoms. The former has already been demonstrated by a work showing that PSS correlated significantly with depression symptomatology, evaluated by Beck Depression Inventory (BDI) (Hewitt et al., 1992). The latter, regarding the presence of depressive symptomatology according to the year of course, is a conflicting topic in literature studies. Some of these reported that freshman students had higher risk of depression than their upper classes colleagues (Bewick et al., 2010; Liu et al., 2019), others have found the opposite, with depression, anxiety and stress rising over time during the course of the academic path (Beiter et al., 2015; Rosal et al., 1997). Univariate analysis showed a higher percentage of depressive symptoms in those worried about limited job chances in the future. Indeed, this is true especially in Italy, where students coming from the humanities field often face more obstacles finding a job relevant to their academic education compared to colleagues who graduated in scientific disciplines. Therefore, a possible explanation for our finding is that, as students approach the end of their academic career, they experience a wide range of stressors, such as fear and worries for their future opportunities, which might increase their risk of developing depressive symptomatology.

Moreover, we found that those students who did not feel University as a hinder to carry out their personal activities were less likely to have depressive symptoms. Besides, this is not surprising, being University a complex environment and requiring students to achieve an adequate balance between academic work and social life.

Suicidal ideation

Suicidal ideation was present in 8.8% of the sample. Unfortunately, scientific literature lacks of studies investigating prevalence and factors associated with suicidal ideation, plans and behavior in humanities and social sciences students. While Naseem & Munaf found no significant differences for levels of suicidal behavior among social sciences and medical students, our prevalence is slightly lower than reports from various studies (Bert et al., 2020; Rotenstein et al., 2016). Findings of our multivariable logistic regression show that having a chronic disease is highly predictive of suicidal ideation. This is in line with the study from Ferro et al, in which young people between the ages of 15 and 30 living with a chronic illness were three times more likely to attempt suicide than their healthy peers (Ferro et al., 2017). In addition, as already extensively clarified by literature on suicidality (Miller et al., 2017; Polanco-Roman et al., 2016), higher levels of perceived stress were likely to be found on students who reported suicidal ideation. Moreover, having reported a good or very good family cohesion appears as a protective factor for suicidal thoughts, also adjusting for BDI-II score. This finding is consistent with Eshun’s study, in which negative correlations were found between family cohesion and suicidal ideation (Eshun, 2003). Undoubtedly, this finding strongly points out the importance of family emotional support and closeness as determinants of university student’s psychological well-being.

Perceived stress

Stress impacts the quality of life worldwide and increases risk of many mental illnesses, other diseases (cardiovascular events and metabolic syndrome) and overall mortality. So, stress may also cause serious productivity losses with societal implications. Although a stress condition carries a substantial burden, it is merely considered a ‘risk factor’. College students are in a phase of transition from adolescence to adulthood. Stress affects health in college students for many reasons (students are away from home, trying to adjust in the new environment and anxious enough for their future) (Singh et al., 2016). In our study, prevalence of stress (moderate and high stress) was 87.7% and we found that severe stress level among students was 10.7%. These prevelances are in agreement with an Egyptian study (Seedhom et al., 2019), lower than a Pakistan study (Sohail, 2013), but higher than three studies on medical students (Abdel Wahed & Hassan, 2017; Mahmoud et al., 2016; Sani et al., 2012). However, some studies report a lower prevalence of stress among college non-medical students in Poland and USA (Beiter et al., 2015; Leppink et al., 2016; Średniawa et al., 2019). Prevalence of stress in our study is similar to medical students than other university students. A possible explanation could be the strong emotional impact of Social and Educational Sciences faculties. Indeed, secondary traumatic stress (STS) has been described in social services workers, as a result of their exposure to traumatized populations through their work (Bride, 2007). Similarly, during faculty training Social Science students deal with troublesome families, observing events of violence, mistreatment and abuses, while Education students are involved in juvenile distress, facing children exposed to traumatic events or suffering from developmental disabilities. Therefore, we hypothesize that, likewise their older colleagues, students coming into contact and empathizing with people who experience social deprivation and trauma may have an increased risk of emotional disruption.

University-related factors such as thinking that University hinders rest and relaxation and surprisingly intellectual curiosity are associated with greater PS. Previous studies found that academic-related problems were the most common source of stress among medical students (El-Gilany et al., 2009; Mahmoud et al., 2016; Shah et al., 2010). A Korean study (An et al., 2012) found that novelty-seeking individuals in medical college tend to be more stressed. Studying at university can be considered time-consuming and difficult. Probably novelty-seeking students or students with high intellectual curiosity may tend to lose interest in their studies out of boredom. Further studies are needed to investigate associations between personality traits and perceived stress in college students. In addition, we also found that having no worries about the future seems to be a protective factor for stress development. This is probably a consequence of lower perceived stress.

Moreover, our findings reported that females perceived higher stress compared to males, as already reported in literature (Seedhom et al., 2019). Lastly, we found that family history of psychiatric disorders and being under psychiatric or psychological care were associated with higher perceived stress. This association may be probably due to a close link between high stress and anxious or depressive syndromes.

Strengths and limitations

At the best of our knowledge, this is the first study to investigate prevalence and predictors of depressive symptoms, suicidal ideation and perceived stress in a sample of humanities students in Italy. The empirical results reported herein should be considered in the light of some limitations. First, the cross-sectional nature of the data prevents claims about cause-effect associations between the studied demographic and psychosocial variables and psychological distress. Secondly, sample-size and, mostly, sampling from a single University may have affected external validity of our results. Finally, our study may suffer from sampling bias, in that participants were chosen among those who were available and willing to join the study.

Given the lack of knowledge, the results from this study provide evidence for significant psychological distress also in humanities students, such as those attending Social Sciences and Education faculties. Indeed, the high prevalence of depressive symptoms, suicidal ideation and perceived stress we found, indicate that these students must be considered a population at high risk of developing mental and psychiatric issues and raises questions about appropriate preventive measures. Hence, there is an urgent need of mental health awareness campaigns and prevention programs, organized by both local and national institutions. Within the University context, this can be done by promoting dedicated classes specifically addressing the issue of mental health. Moreover, it becomes necessary to promptly adopt a periodical evaluation of students’ psychological well-being. This may be achieved by performing anonymous surveys repeatedly during academic years. Such monitoring would be extremely useful for universities, in that they may perform a more effective assessment of their counseling programs.

Psychological distress has been widely studied in medical students and our study shows that it may also be a severe issue in Italian humanities students. The factors undermining psychological well-being of the students are miscellaneous, linked to both private and social facets of their life. Universities must be aware of these issues in order to provide efficient preventive measures. Indeed, the present study highlighted some factors associated with mental issues that could be addressed in university campaigns or services. For instance, counselling or other specific interventions should take into account the low family support that high-risk students can experience and, in addition, such interventions should be tailored to students that are attending years of course higher than the first as they probably find different difficulties. Moreover, interventions targeted to reduce stress could be useful to decrease the burden of depressive symptoms and universities should think how to reorganize the schedules to give more time to students to do other activities. Finally, further longitudinal studies are needed to better define risk factors for psychological distress in university students, especially those involved in the humanities.

Footnotes

Author Biographies

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Giuseppina Lo Moro

Elisabetta De Vito

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