Factors Related to Depressive Symptoms in University Students

Objective: To identify and discuss the frequency of depressive symptoms and their associated factors in university students. Materials and method: This is a cross-sectional and descriptive study with a quantitative approach, conducted in a Higher Education Institution. The study was developed with a convenience sample consisting of 571 undergraduate students from different areas. A questionnaire was used to collect sociodemographic/academic data, as well as depressive symptoms and their associations, life habits, emotional aspects, and possible eating disorders. For data analysis, descriptive statistics and Pearson’s chi-square test were used for associations, with a significance level of 5 % (p-value ≤ 0.05). Results: The university students presented depressive symptoms such as sleep disorders (61.1 % ) and reduced self-confidence (50.9 % ). There was an association of depressive symptoms with the course, satisfaction with academic performance, obesity, consumption of sugars and sweets, and practice and frequency of physical activity. Conclusions: It is expected that the results of this research contribute to the population’s critical and reflective thinking to expand visibility and scientific studies referring to the theme, as well as to increase resources for the management of mental health and reduce the stigmas generated. Contribution to the subject: This study contributes to the Nursing and Health areas by enabling a reflection about depressive symptoms and their associated factors in university students. Consequently, it provides more grounds for Nursing care assistance regarding the development of strategies for health promotion and prevention. Objetivo: y superior. El estudio se desarrolló a partir de un muestreo de conveniencia con 571 estudiantes de diferentes facultades. Se utilizó cues-tionario para recolectar los datos sociodemográficos/académicos, de la sintomatología depresiva y sus asociaciones, los hábitos de vida, los aspectos emocionales y los posibles disturbios alimenticios. Para el análisis de los datos, se emplearon la estadística descriptiva y la prueba de Qui-Cuadrado de Pearson para asociaciones, con nivel de significancia del 5 % (valor p ≤ 0,05). Resultados: los universitarios presentaron sintomatología depresiva como sueño perturbado (61,1 % ) y autoconfianza reducida (50,9 % ). Hubo asociación de la sintomatología depresiva con el grado, con la satisfacción del desempeño académico, con el sobrepeso, con el consumo de azúcares y dulces, con la práctica y la frecuencia de actividad física. Conclusiones: se espera que los resultados de la investigación puedan aportar al pensamiento crítico


Introduction
Depression is a public health problem and one of the causes of disabilities in social life (1), where it affects approximately 322 million people worldwide (2). In Brazil, this figure is over 11.5 million individuals, and diverse evidence points out an increase in the prevalence of this pathological process in university students (3,4).
Depression is understood as a multi-factorial pathological process, which encompasses biopsychosocial and spiritual aspects. This disease is characterized by losses in mood balance, a complete absence of interest, sleep alterations, anxiety, decreased concentration, excessive guilt, feelings of worthlessness and periodic thoughts of death and suicide, among other signs, and symptoms, which result in negative consequences in the process of professional training during undergraduate (1,3,5).
As a result of the significant academic overload and the increasingly competitive environment, these signs and symptoms are common in the university environment, which predisposes students to various stressors that can configure triggering factors for depression (6). After entering academic life, the following are emphasized as stressful elements that predispose this population: significant emotional instability, heavy study load, academic requirements, fears about future instability and change in the individual's daily routine, bad habits and unruly lifestyle, as well as carelessness in performing basic care with their own health (7)(8)(9)(10)(11).
Considering that depression is a public health problem on the rise, whose high prevalence in university students results in harm during undergraduate and life, such as social withdrawal, disinterest in curricular activities, and even dropping out of the course, it is relevant to explore the factors associated with this mental disorder in this population to expand scientific knowledge on the theme and to reflect on the importance of thinking about strategies to promote the students' mental health in the academic environment (1,3,12,13). Given the above, this study has the following guiding question: "Which factors are related to depressive symptoms in university students of a Higher Education Institution (HEI) in the Federal District?". In addition to that, the objective is to identify and discuss the frequency of depressive symptoms and their associated factors in university students.

Study type or design
This is a descriptive and cross-sectional study with a quantitative approach.

Locus and period
The study was conducted in three units of an HEI in Brasília, Brazil. Data collection took place between April and May 2019.

Selection criteria
As participants, students with a regular enrollment in the HEI and aged between 18 and 60 years old were included. University students diagnosed with depression and/or using an antidepressant, anxiolytic and psychotropic medications, in general, were excluded since the objective of the study was to identify the depressive symptoms and not the established disease, in which these medications could alter the signs and symptoms presented by the students, which could lead to biases in the study.

Study variables
Gender, occupation, affective relationship, course, semester, individual and family income, life habits, emotional factors and possible eating disorders were the variables studied to verify the association between them and depressive symptoms in the students.

Instruments used to collect the information
A questionnaire was used consisting of 22 questions corresponding to sociodemographic characteristics (age, gender, emotional relationship, occupation, individual and family income); life habits (eating habits, practice of physical activity, use of illicit and licit substances, water intake); emotional factors (level of satisfaction with affective relationships); possible eating disorders (bulimia, obesity, anorexia, underweight); academic factors (school, course, semester, level of satisfaction with academic performance) and depressive symptoms, as well as their associations (depressed mood, reduced concentration/attention, feeling of guilt, suicidal ideation, ideation of self-mutilation, loss of interest, feeling of worthlessness, reduced self-esteem, reduced self-confidence, pessimistic view of the future, sleep disorders, fatigue, and decreased appetite), according to the Diagnostic and Statistical Manual of Mental Disorders (1).
It is noteworthy that this questionnaire was developed by the researchers based on the Diagnostic and Statistical Manual of Mental Disorders (1) and on the Patient Health Questionnaire-9 (PHQ9), an instrument validated and adapted in Brazil (14)(15)(16) and used in one of the stages of the larger research project to which the current study belongs.

Data collection
The questionnaires were applied by duly trained undergraduate female students, from the research team, linked to a scientific initiation project of the HEI. Data collection took place at the institution's premises, in places with the greatest circulation of students, such as food court, library, corridors, parking lot and classrooms, through an active search and in agreement with the professor, when performed in a classroom. The questionnaire was self-administered, and the meantime for its completion was 20 minutes.

Data treatment and analysis
The descriptive data analysis was performed in the Statistical Package for the Social Sciences (SPSS) software, version 21.0, to identify the frequency, median and interquartile range, as well as the valid percentage of the variables. To associate the sociodemographic, emotional, academic and life habits variables with the presence of depressive symptoms, the Pearson's Chi-Square test was used, with a statistical significance level of p < 0.05.

Ethical aspects
Data collection took place upon approval by the Research Ethics Committee, under Certificate of Presentation for Ethical Appreciation protocol number 08598819.4.0000.505, following with the ethical precepts stipulated in Resolution 466/2012 (17) and the necessary institutional authorizations. The Free and Informed Consent Form (FICF) was handed into all the study participants for them to read: such document informed them about the study topic, objective and justification, the responsible researchers, the benefits of the project (contributing to knowledge about depressive symptoms and their associated factors in the population of students and thus stimulate awarenessraising in society about the prevention, promotion and restoration of mental health in this population), as well as the risks of this research (feeling of possible discomfort, embarrassment or fatigue in the participant when answering the questionnaire), as well as how such risks could be minimized. The participants could answer the questionnaire in their own time, sitting comfortably and, if they presented any discomfort, they could stop participating, and the researchers would be available to talk to and, if necessary, guide the participants to seek professional help, according to their possibilities. This document was elaborated in two copies: one to be kept by the researcher in charge and the other, by the research volunteer.
The FICF requested permission to use the data provided by the participant and ensured confidentiality of the information, in addition to the freedom to refuse to answer any question in the questionnaire and/or instrument that would cause them embarrassment or to withdraw at any time during the study. Data collection was initiated immediately after signature by the participants, when accepting to participate in the study.
Concerning satisfaction in interpersonal relationships, 51.2 % (n = 274; p* = 0.79) of the students indicated satisfaction with their friends; 41.8 % (n = 225; p* = 0.36), with their family members, and 38.1 % (n = 199; p* = 0.64), with their affective re-lationships. In relation to the academic setting, 47 % (n = 255) reported little satisfaction. Of the university students who stated having some professional/employment contract, 33.9 % (n = 133; p* = 0.97) reported satisfaction with the work environment. Table 1 presents the frequency of depressive symptoms among university students. Regarding the depressive symptoms, 59.7 % (n = 323; p* = 0.41) and 55.0 % (n = 295) of the university students stated the influence of the semester and the course, respectively, on the negative feelings. With the analysis of Pearson's Chi-square test, it was possible to notice an association between depressive symptoms and some of the variables under study, which are presented in Table 2. As for the interest in participating in activities aimed at mental health, 84.3 % (n = 451; p* = 0.67) of the students showed interest if such activities were offered by the institution and 81.4 % (n = 438; p* = 0.91) of the participants agreed that promoting mental health in the university environment would be beneficial for their quality of life.

Discussion
In agreement with the results presented in the current study about the predominance of females in terms of depressive symptoms, Flesch et al. (18) carried out a cross-sectional study with 1,825 students, aiming to assess the prevalence of major depressive episodes in students, and reported that 55.1 % (n = 1005) of the participants were women. Other studies also point out such similarity (3,5,19,20).
In the Brazilian context, the insertion of women in the academic setting, concerning men, is a recent episode in history and, in the 2000s, a reversal was evidenced as to the number of students, in which 60 % of the university graduates were women (21,22). Such situation can elucidate the frequency of the female gender in the study.
Although this study does not show any significance between the gender variable and depressive symptoms, it is noted that, generally, the number of women affected by the depressive process is higher than in men. Such phenomenon can be explained due to women's vulnerability, by their own physiologicals issue (mood swings due to hormonal interference) and by their role in countless social roles (maternal, professional, marital), which can often be stressful and contributing factors to the depressive process (12,23).
About depressive symptoms, sleep disorders and reduced self-confidence were the symptoms most frequently mentioned by the participants, resulting in complications in their lives. Such result is similar to other scientific evidence (3,5,24,25).
A cross-sectional study carried out in an HEI from Ceará with 649 students attending health courses and to evaluate the prevalence and factors associated with depression and anxiety identified, among the results, the participants' dissatisfaction with sleep quality and a high tendency for the onset of the depressive process among them (5). Galvão et al. (26) indicate that sleep dis-orders can result in impaired concentration and attention, fatigue and other pathologies.
As for reduced self-confidence, understood as an individual's limited perception of their ability to believe in the success of their actions (27), there are similarities with results presented by other studies (28,29). A descriptive study carried out in an HEI from the Federal District with a sample of 91 Nursing students related to fear of dealing with patients with the practical teaching-learning process experienced by the university students, as well as situations of insecurity in their professional activity (29).
In addition, the quantitative study by Nogueira (28), carried out in an HEI from Belo Horizonte with 70 university students attending courses in the areas of Humanities and Social Sciences, associated the students' feelings of vulnerability and insecurity with the uncertainties about the professional market and with social ascension. According to Menezes et al. (30), the development of critical and reflective thinking in the academic environment allows influencing the improvement of the transition from theoretical to practical knowledge, to ensure self-confidence in the professional performance.
It is understood that a way to minimize these feelings of vulnerability and insecurity in the university students would be the use of active methodologies in undergraduate courses, as proposed in the National Curriculum Guidelines for the Nursing course (31). The active methodology allows the students to act as protagonists in the development of their training since, by getting involved in the teaching-learning process, instead of being mere receivers of knowledge, they acquire cognitive, procedural and attitudinal skills for the development of critical and reflective thinking (32,33).
This study indicated the course as a significant factor for the development of depressive symptoms in university students. In a quantitative and analytical study carried out in a public institution from Brasília with 203 Nursing students and to measure the levels of depressive symptoms among the students, in addition to evaluating their association with academic life factors, Facioli et al. (34) evidenced certain depressive predisposition with the course, due to the significant dedication to the workload by the students, in addition to being associated with a limitation of the time available to perform physical and leisure activities.
Another descriptive study by Victoria et al. (35), conducted in a public university from Rio de Janeiro with a sample of 637 students and referring to courses in the areas of Biomedical Sciences, Social Sciences, Education and Humanities, Technologies and Science, identified depressive rates in the students attending the courses in the aforementioned areas, with high levels in students from the Language and Linguistics course. Diverse scientific evidence also point to depressive predisposition associated with the course, with an emphasis on academic overload, mainly in the health area courses; for example, during the internships, when the students are faced with the health-disease process and address the life and death duality (20,24,35).
Regarding satisfaction with academic performance, this study presents significant values similar to the study by Flesch et al. (18), which evidenced an association between academic performance (p* = < 0.001) and depressive symptoms. According to Victoria (35), academic performance can be impaired due to the demands, along with the strong emotional strain and the intense academic routines.
The results of the study by Bresolin et al. (20) corroborate those of the present study, regarding the association between academic performance and the prevalence of depressive symptoms, which can compromise daily and personal issues. In addition to that, these researchers indicate that the possibility of developing a pessimistic and negative outlook in university students can cause them distress and contribute to the onset of depression.
The practice and frequency of physical activity were also factors that presented significance concerning depression, according to what is pointed out in diverse scientific evidence (5,20,36). A quantitative and observational study, carried out through an online questionnaire and applied in a social network with students from the Physical Education course, with a sample of 155 participants, revealed an association of depressive symptoms with low frequency of physical activity and showed that students who exercise for more than 150 minutes per week were less likely to develop depressive symptoms (37).
It is revealed that the practice of physical activity has a direct effect on the individuals' life cycle because, due to the production of endorphin and serotonin, neurotransmitters responsible for the feeling of pleasure and well-being, it interferes with sleep quality, promotes physical and psychological well-being, guarantees an increase in self-esteem, and helps maintain homeostasis and prevent complications. In addition to that, the practice of physical activity is understood as an opportunity for social mingling and works as a therapeutic agent against depression (5).
In relation to the consumption of sugars and sweets by university students, diverse scientific evidence has pointed, as in this study, to an association between depression and high-energy foods, classified as emotional eating, as they are probably eaten compulsively during the manifestation of depressive symptoms. An observational cohort study (Nutri-Net-Santé), carried out in France and which monitored 30,240 participants, revealed a strong relationship between emotional eating and depressive symptoms in women, for foods such as cakes, cookies, sweets and artificially sweetened chocolates, among others (38).
It is noteworthy that excessive consumption of these foods judged as comforting can lead to serious health problems, such as the development of chronic diseases like systemic arterial hypertension, diabetes mellitus and obesity (1,39,40). This study revealed an association between obesity and depressive symptoms, following others found in the literature. In a cross-sectional research study carried out in the Netherlands with 2,809 participants to examine the association between depressive disorders, anxiety, obesity, physical activity and social activity, Wit et al. (41) highlighted bilaterality between obesity and depression, that is, obesity contributes to the development of the depressive process and vice versa.
Santos et al. (42) suggest that body weight and compulsive eating in unfavorable situations can be associated, in addition to generating negative feelings. Obesity leads to complications in brain structures such as the hypothalamus, responsible for satiety, the hippocampus, related to memory and learning, and the prefrontal cortex, associated with the reward system. Such disorders in these structures can favor the emergence of cognitive and mental problems, such as depression (43).
It is understood that health promotion strategies are fundamental to prevent cognitive and mental problems such as depression (19). In this study, for example, the university students stated their interest in participating in activities aimed at mental health, offered by the school, in addition to asserting the importance of health promotion in the university environment.
Such results disclosed in this study can contribute for students and other members of the academic population to reflect on the importance of the existence of health promotion and prevention actions in the academic environment, as well as to encourage them to participate in existing programs and/or even create health strategies within the educational institutions to which they are linked.
The literature emphasized that the use of strategies for health promotion and prevention in the university setting exerts a positive influence on the students' mental health. After applying these strategies, improvements are noticed in social relationships, balance in the daily activities, and reduction in the risk behavior among the students (44,45).
In synthesis, it is observed that this study attained the objective proposed. As described, the results can contribute to advances in scientific knowledge in the Health and Nursing areas, considering that data generation and their interpretation by researchers is the basis for the creation of strategies for the promotion, prevention, treatment and recovery of the population's health.
Although there are references in the literature about depressive symptoms, such as reduced self-confidence and the association found between the consumption of sugars and sweets and depression, they are outdated. Consequently, it is recommended to intensify studies on the theme addressed.
It is emphasized that the limitations of this research were as follows: the non-probabilistic sampling field, by convenience, and the difficulty accessing university students attending the last semester who were in the internship periods of their courses and, therefore, were not in the places where data collection was conducted.

Conclusions
Characterized as a multi-factorial pathological process, it is considered that depression can trigger negative interferences in the academic training process. According to what has been described, the university students presented a high frequency of depressive symptoms, such as sleep disorders (61.1 %) and reduced self-confidence (50.9 %).
It was verified that the depressive symptoms presented by the students are associated with academic factors due to academic overload and to the tensions experienced at the university, as well as to the life habits regarding binge/emotional eating and the reduction of the time available for physical activities. Variables such as the course, satisfaction with academic performance, obesity, consumption of sugars and sweets, and the practice and frequency of physical activity influenced the emergence and exacerbation of depressive symptoms in students in the current study.
It is expected that the results of this research may contribute to the critical and reflective thinking of the population in general, specifically, the studied population (health professionals and researchers), to increase visibility and promote scientific research studies about this disease, as well as to increase resources for the management of mental health and reduce the stigma generated.
Conflict of interests: None declared.