Sleep Quality, Anxiety, and Depression in Medical Students: A Mediation Model
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Abstract
Introduction. The association between sleep and mental health has been observed in the clinical context since individuals with a sleep disorder are more likely to suffer from a mental disorder. Medical students are at high risk in this respect due to the lack of sleep time because of their high workload.
Objective. To evaluate a structural equation model predicting the presence of depression through the mediation of anxiety, based on sleep quality in medical students.
Method. A quantitative, descriptive, cross-sectional study was conducted with the medical students of the Autonomous University of the State of Quintana Roo from Chetumal, Quintana Roo, Mexico from February to November 2023. Participants completed a questionnaire assessing sociodemographic factors, sleep quality, anxiety, and depression symptoms.
Results. Two hundred medical students with an average age of 19.9 years were surveyed to propose a Structural Equation Model, showing that poor sleep quality positively and significantly influences depression, with anxiety serving as a mediator. No direct association was found between poor sleep quality and depression.
Discussion and conclusion. A high prevalence of poor sleep quality was observed (75%), surpassing the rates reported in Brazil (68.8%), China (19%), and Lithuania (40%). Moreover, the study showed that women students exhibited higher rates of anxiety and depression. This study underscores the association between sleep quality and mental health, demonstrating that poor sleep quality contributes to increased anxiety and depression among medical students.
References
Altena, E., Baglioni, C., Espie, C. A., Ellis, J., Gavriloff, D., Holzinger, B., Schlarb, A., Frase, L., Jernelöv, S., & Riemann, D. (2020). Dealing with sleep problems during home confinement due to the COVID‐19 outbreak: Practical recommendations from a task force of the European CBT‐I Academy. Journal of Sleep Research, 29(4). https://doi.org/10.1111/jsr.13052
Arcand, M., Juster, R., Lupien, S. J., & Marin, M. (2020). Gender roles in relation to symptoms of anxiety and depression among students and workers. Anxiety, Stress, & Coping, 33(6), 661–674. https://doi.org/10.1080/10615806.2020.1774560
Bentler, P. M. (2007). On tests and indices for evaluating structural models. Personality and Individual Differences, 42(5), 825–829. https://doi.org/10.1016/j.paid.2006.09.024
Buysse, D. J., Monk, T. H., Berman, S. R., & Kupfer, D. J. (1989). The Pittsburgh Sleep Quality Index: A New Instrument for Psychiatric Practice and Research. Psychiatry Research, 28(2), 193–213. https://doi.org/10.1016/0165-1781(89)90047-4
Chen, J., Tuersun, Y., Yang, J., Xiong, M., Wang, Y., Rao, X., & Jiang, S. (2022). Association of depression symptoms and sleep quality with state-trait anxiety in medical university students in Anhui Province, China: a mediation analysis. BMC Medical Education, 22(1). https://doi.org/10.1186/s12909-022-03683-2
Clement-Carbonell, V., Portilla-Tamarit, I., Rubio-Aparicio, M., & Madrid-Valero, J. J. (2021). Sleep Quality, Mental and Physical Health: A Differential Relationship. International Journal of Environmental Research and Public Health, 18(2), 1–8. https://doi.org/10.3390/ijerph18020460
Corral, V., & Figueredo, A. (1999). Convergent and Divergent Validity of Three Measures of Conservation Behavior. Environment and Behavior, 31(6), 805–820. https://doi.org/10.1177/00139169921972353
Corrêa, C. D. C., Oliveira, F. K. D., Pizzamiglio, D. S., Ortolan, E. V. P., & Weber, S. A. T. (2017). Sleep quality in medical students: a comparison across the various phases of the medical course. Jornal Brasileiro de Pneumologia, 43(4), 285–289. https://doi.org/10.1590/s1806-37562016000000178
De la Vega, R., Tomé-Pires, C., Solé, E., Racine, M., Castarlenas, E., Jensen, M. P., & Miró, J. (2015). The Pittsburgh Sleep Quality Index: Validity and factor structure in young people. Psychological Assessment, 27(4), e22–e27. https://doi.org/10.1037/pas0000128
Elguera, A., Talavera, J., Cárdenas, M., & Vargas, J. (2021). Trastornos del sueño y ansiedad de estudiantes de Medicina del primer y último año en Lima, Perú. Revista de la Fundación Educación Médica, 24(3), 133–138. https://doi.org/10.33588/fem.243.1125
Eysenck, M. W., & Fajkowska, M. (2018). Anxiety and depression: toward overlapping and distinctive features. Cognition and Emotion, 32(7), 1391–1400. https://doi.org/10.1080/02699931.2017.1330255
Fabbri, M., Beracci, A., Martoni, M., Meneo, D., Tonetti, L., & Natale, V. (2021). Measuring Subjective Sleep Quality: A Review. International Journal of Environmental Research and Public Health, 18(3), 1082. https://doi.org/10.3390/ijerph18031082
Feng, G., Chen, J., & Yang, X.-Z. (2005). Study on the status and quality of sleep-related influencing factors in medical college students. Zhongua Liu Xing Bing Xue Za Zhi, 26(5), 328–331. https://pubmed.ncbi.nlm.nih.gov/16053754/
Field, A. (2024). Discovering statistics using IBM SPSS statistics (6th ed.). Sage.
Gaona-Pineda, E. B., Martinez-Tapia, B., Rodríguez-Ramírez, S., Guerrero-Zúñiga, S., Perez-Padilla, R., & Shamah-Levy, T. (2021). Dietary patterns and sleep disorders in Mexican adults from a National Health and Nutrition Survey. Journal of Nutritional Science. https://doi.org/10.1017/jns.2021.24
Garbarino, S. (2020). Sleep Disorders across the Lifespan: A Different Perspective. International Journal of Environmental Research and Public Health, 17(23), 9025. https://doi.org/10.3390/ijerph17239025
Gaus, V., Kiep, H., Holtkamp, M., Burkert, S., & Kendel, F. (2015). Gender differences in depression, but not in anxiety in people with epilepsy. Seizure, 32, 37–42. https://doi.org/10.1016/j.seizure.2015.07.012
Gregory, A. M., Buysse, D. J., Willis, T. A., Rijsdijk, F. V., Maughan, B., Rowe, R., Cartwright, S., Barclay, N. L., & Eley, T. C. (2011). Associations between sleep quality and anxiety and depression symptoms in a sample of young adult twins and siblings. Journal of Psychosomatic Research, 71(4), 250–255. https://doi.org/10.1016/j.jpsychores.2011.03.011
Huang, L. T., & Sullivan, K. L. (2021). Sleep, anxiety, and depression. In C. Martin, L. Hunter (Eds.), In The Neuroscience of Depression: Genetics, Cell Biology, Neurology, Behavior, and Diet (pp. 405–414). Elsevier. https://doi.org/10.1016/b978-0-12-817935-2.00014-3
Instituto Nacional de Estadística Geografía e Informática. (2018). Encuesta nacional sobre salud y envejecimiento en México (ENASEM) 2018. https://www.inegi.org.mx/contenidos/programas/enasem/2018/doc/enasem_2018_nota_tecnica.pdf
Instituto Nacional de Estadística Geografía e Informática. (2021). Encuesta nacional sobre salud y envejecimiento en México (ENASEM) y encuesta de evaluación cognitiva 2021. https://www.inegi.org.mx/contenidos/programas/enasem/2021/doc/enasem_2021_nota_tecnica.pdf
Instituto Mexicano del Seguro Social. (2010). Guía de Referencia Rápida. Diagnóstico y Tratamiento de los Trastornos de Ansiedad en el Adulto. https://imss.gob.mx/sites/all/statics/guiasclinicas/392GRR.pdf
Jackson-Koku, G. (2016). Beck Depression Inventory. Occupational Medicine, 66(2), 174–175. https://doi.org/10.1093/occmed/kqv087
Jalali, R., Khazaie, H., Khaledi Paveh, B., Hayrani, Z., & Menati, L. (2020). The Effect of Sleep Quality on Students’ Academic Achievement. Advances in Medical Education and Practice, 11, 497–502. https://doi.org/10.2147/amep.s261525
Joo, H. J., Kwon, K. A., Shin, J., Park, S., & Jang, S. (2022). Association between sleep quality and depressive symptoms. Journal of Affective Disorders, 310, 258–265. https://doi.org/10.1016/j.jad.2022.05.004
Kaiser, H. F. (1974). An Index of Factorial Simplicity. Psychometrika, 39(1), 31–36. https://doi.org/10.1007/bf02291575
Kirch, W. (2008). Pearson’s Correlation Coefficient. In Encyclopedia of Public Health, 1090–1091. Springer Netherlands. https://doi.org/10.1007/978-1-4020-5614-7_2569
Landeros, O., Valadés, A., Cosme, J. A., & Arenas, F. E. (2019). Cambios en la calidad de sueño, somnolencia diurna, ansiedad y depresión durante el internado médico de pregrado. Investigación en Educación Médica, 8(31), 48–54. https://doi.org/10.22201/facmed.20075057e.2019.31.18118
McKinley, B., Daines, B., Allen, M., Pulsipher, K., Zapata, I., & Wilde, B. (2022). Mental health and sleep habits during preclinical years of medical school. Sleep Medicine, 100, 291–297. https://doi.org/10.1016/j.sleep.2022.09.001
McLean, C. P., Asnaani, A., Litz, B. T., & Hofmann, S. G. (2011). Gender differences in anxiety disorders: Prevalence, course of illness, comorbidity and burden of illness. Journal of Psychiatric Research, 45(8), 1027–1035. https://doi.org/10.1016/j.jpsychires.2011.03.006
Miletínová, E., & Bušková, J. (2021). Functions of Sleep. Physiological Research, 70(2), 177-182. https://doi.org/10.33549/physiolres.934470
Mirza, A. A., Baig, M., Beyari, G. M., Halawani, M. A., & Mirza, A. A. (2021). Depression and Anxiety Among Medical Students: A Brief Overview. Advances in Medical Education and Practice, 12, 393–398. https://doi.org/10.2147/amep.s302897
Moalla, M., Maalej, M., Nada, C., Sellami, R., Ben Thabet, J., Zouari, L., & Maalej, M. (2020). Sleep disorders, depression and anxiety among medicine university students in Sfax. European Psychiatry, 33(S1), s268–s269. https://doi.org/10.1016/j.eurpsy.2016.01.704
Moreira de Sousa, J., Moreira, C. A., & Telles-Correia, D. (2018). Anxiety, Depression and Academic Performance: A Study Amongst Portuguese Medical Students Versus Non-Medical Students. Acta Médica Portuguesa, 31(9), 454–462. https://doi.org/10.20344/amp.9996
Nima, A. A., Rosenberg, P., Archer, T., & Garcia, D. (2013). Anxiety, Affect, Self-Esteem, and Stress: Mediation and Moderation Effects on Depression. PLoS ONE, 8(9), e73265 . https://doi.org/10.1371/journal.pone.0073265
Oh, C., Kim, H. Y., Na, H. K., Cho, K. H., & Chu, M. K. (2019). The Effect of Anxiety and Depression on Sleep Quality of Individuals With High Risk for Insomnia: A Population-Based Study. Frontiers in Neurology, 10. https://doi.org/10.3389/fneur.2019.00849
O’Leary, K., Bylsma, L. M., & Rottenberg, J. (2017). Why might poor sleep quality lead to depression? A role for emotion regulation. Cognition and Emotion, 31(8), 1698–1706. https://doi.org/10.1080/02699931.2016.1247035
Paniagua, D., Salvador, J., Ayala, K., Rodríguez, L., Elizarraraz, L., García, P., Moya, M., & Morales, O. (2023). Impacto en la calidad del sueño y trastornos psicológicos en estudiantes universitarios. Jóvenes En La Ciencia, 21, 1–15. https://www.jovenesenlaciencia.ugto.mx/index.php/jovenesenlaciencia/article/view/4107
Perotta, B., Arantes-Costa, F. M., Enns, S. C., Figueiro-Filho, E. A., Paro, H., Santos, I. S., Lorenzi-Filho, G., Martins, M. A., & Tempski, P. Z. (2021). Sleepiness, sleep deprivation, quality of life, mental symptoms and perception of academic environment in medical students. BMC Medical Education, 21(1). https://doi.org/10.1186/s12909-021-02544-8
Preišegolavičiūtė, E., Leskauskas, D., & Adomaitienė, V. (2010). Associations of quality of sleep with lifestyle factors and profile of studies among Lithuanian students. Medicina (Kaunas), 46(7), 482–489. https://pubmed.ncbi.nlm.nih.gov/20966622/
Richter, P., Werner, J., Heerlein, A., Kraus, A., & Sauer, H. (1998). On the Validity of the Beck Depression Inventory. Psychopathology, 31(3), 160–168. https://doi.org/10.1159/000066239
Suardiaz Muro, M., Morante Ruiz, M., Ortega Moreno, M., Ruiz, M. A., Martín Plasencia, P., & Vela Bueno, A. (2020). Sueño y rendimiento académico en estudiantes universitarios: revisión sistemática. Revista de Neurología, 71(2), 43. https://doi.org/10.33588/rn.7102.2020015
Toscano-Hermoso, M. D., Arbinaga, F., Fernández-Ozcorta, E. J., Gómez-Salgado, J., & Ruiz-Frutos, C. (2020). Influence of Sleeping Patterns in Health and Academic Performance Among University Students. International Journal of Environmental Research and Public Health, 17(8), 2760. https://doi.org/10.3390/ijerph17082760
Yassin, A., Al-Mistarehi, A., Beni Yonis, O., Aleshawi, A. J., Momany, S. M., & Khassawneh, B. Y. (2020). Prevalence of sleep disorders among medical students and their association with poor academic performance: A cross-sectional study. Annals of Medicine and Surgery, 58, 124–129. https://doi.org/10.1016/j.amsu.2020.08.046
Zhang, M., Qin, L., Zhang, D., Tao, M., Han, K., Chi, C., Zhang, Z., Tao, X., & Liu, H. (2023). Prevalence and factors associated with insomnia among medical students in China during the COVID-19 pandemic: characterization and associated factors. BMC Psychiatry, 23(1). https://doi.org/10.1186/s12888-023-04556-8
Zhu, Y., Jiang, C., Yang, Y., Dzierzewski, J. M., Spruyt, K., Zhang, B., Huang, M., Ge, H., Rong, Y., Ola, B. A., Liu, T., Ma, H., & Meng, R. (2023). Depression and Anxiety Mediate the Association between Sleep Quality and Self-Rated Health in Healthcare Students. Behavioral Sciences, 13(2), 82. https://doi.org/10.3390/bs13020082
