Anxiety and depression: prevalence and correlates among undergraduate students of a government nursing college of Murshidabad District, West Bengal

INTRODUCTION

Mental and physical health is equally essential to a person’s overall well-being. Mental disorders are among the leading causes of the global health-related burden; depression and anxiety both ranked among the top 25 leading causes of burden worldwide.^1,2 Both the conditions are found in varying proportions governed by a complex interplay of individual, social and structural stresses and vulnerabilities.^1,2 Globally about 1 in every 8 people suffer from mental illness; the most prevalent diseases being anxiety and depressive disorders.¹ Adolescent mental health disorders are becoming increasingly prevalent globally.³ In India, around 253 million teenagers between 10 to 19 years are vulnerable to such mental health conditions.⁴ Global concern surrounds the poor mental health of young adults of college-university students; passing through a transitional phase of mental development.⁵ Evidence shows higher occurrence of depressive symptoms among college-university students than among non-college students or the general population.⁶

Transition from adolescence into young adulthood is one of considerable physical, cognitive, and psychological developments and also a period of chaotic emotional reactions in an individual’s life. Additionally depressive and anxiety symptoms are often attributed to the stress of “growing up,” and hence unrecognized or neglected; and a public health concern both globally and natioanlly.⁷

Nursing students passing through the similar transitional contexts are also facing the problems of mental health conditions; particularly depression, anxiety and stress.^8,9 Evidence rather shows extent and severity of depression and anxiety are more among nursing students compared to college-university students and general workforce.^9,10 Evidence also suggests higher progression of mental health problems among the future practicing nurses negatively affecting their quality of work including individual lifestyle behaviours.^11,12

For nursing students, transition from middle childhood to adolescence and adulthood, staying away from home, academic pressure, strenuous professional training etc. represents a confluence on their social, academic, cognitive, physiological and physical state. Such psychological distress may lead to less productivity, reduced quality of life, learning difficulties and negatively affect patient care.^9,11

Both academic stressors (exams, research projects, class assignments, poor grades, strained relationships with faculty members etc.) and clinical stressors (adjustments to new clinical environments, inadequate nursing knowledge and skills, fears of making mistakes, conflicts with peers and senior nurses, concerns about patient care, excessive workload, witnessing traumatic events such as death etc) may contribute to stress and impact the mental health of nursing students.¹³

Various studies on mental health status of nursing students, particularly depression, anxiety and stress were conducted in different countries in different time frames.^{6,8,10,12,14-17} reporting widely varied prevalence and correlates. In India also, there are various published studies on mental health status among nursing students in different states.^9,18-22 However, studies in the post COVID period is yet limited. The studies also used different measuring tools for assessment of depression, anxiety and stress.

In diverse geographic and socio-cultural context, both the magnitude and stressors of depression and anxiety are always likely to vary and needs to be quantified and understood. For assessing the common mental health conditions at the community level, many easy to apply and valid tools are widely available. PHQ-9 and GAD-7 are two such easy to apply and validated tools for assessing depression and anxiety respectively.^23-25

Further evidence on magnitude and factors associated with depression and anxiety among nursing students is required to be generated, which might help in formulating effective preventive and coping strategies.

In this perspective, the present study was conducted to estimate the prevalence and severity of depression and anxiety as well the correlates of both among nursing students in an urban nursing college of West Bengal.

METHODS

Study design, place and duration

We conducted a descriptive cross-sectional study in the Government nursing college within the premises of a medical college in a municipality of Murshidabad district, West Bengal; which is the only government nursing college in the area. The study was undertaken during August-November 2024.

Study population, sample size and sampling technique

Undergraduate B.Sc. nursing students enrolled/studying in all the four academic years (2021-22, 2022-23, 2023-24, 2024-25) from the Government College of Nursing comprised the study population.

A recent multi-centric study involving Murshidabad, West Bengal and Guwahati, Assam reported mild depression and anxiety as 57.7% and 60.2% respectively.²² Considering 57.7% prevalence of depression, 95% confidence interval and an absolute precision of 5%; the minimum required sample size for this study was calculated to be 375; adding for an anticipated drop out of 10%, the sample size was 375+38=413. However, in the study setting expected total study population was 263, less than the calculated sample size. Thus, using the formulae for finite population correction: n=n₀/ (1+ (n₀-1)/N) where n = corrected sample size; n₀ = sample size calculated by applying standard formulae, N = population size (finite). The final sample size obtained was 161.

Stratified random sampling was adopted to select the study participants representing four academic years of the students, applying the principle of population proportion to population size. The required sample of participants form each academic year was selected by simple random sampling. Finally, we could study 160 participants with one non-respondent.

Tools and techniques- data collection

A pre-designed and pre-tested schedule and two validated questionnaires (PHQ-9 for assessing depression and GAD-7 for assessing anxiety) were used for data collection.

Prior to data collection necessary approval from the concerned authorities was taken. Data were collected from individual participants through self-administered schedule comprising three sections: Background and socio-demographic characteristics which also included variables regarding nursing education, personal and family attributes; followed by specific scales of PHQ-9 and GAD-7.

PHQ-9 consists of nine questions regarding the participant’s feelings in the preceding two weeks. Response to each item gets a score in a four point Likert-scale from 0 to 3; as follows: not at all =0; several days =1; more than half the days =2; nearly every day =3. The overall score ranges from 0 to a maximum of 27. The severity of depression based on the score is categorized as follows: 1-4: minimal depression; 5-9: mild depression: 10-14: moderate depression; 15-19: moderately severe depression and 20- 27: severe depression.

An overall score of ≥10 was considered as having depression.²⁴

GAD-7 is a self-reported 7-item questionnaire for screening generalized anxiety disorder. Participants are asked how often during the last two weeks they have encountered anxiety symptoms. Response options for each item range from 0 to 3 on a 4-point Likert-scale (0 = not at all, 1 = several days, 2 = more than half the days and 3 = nearly every day). Adding the scores of all seven items provide the GAD-7 total score ranging from 0 to 21.

The severity of anxiety level based on the scores is categorized as follows: no/low anxiety (score 0-4); mild anxiety (score 5-9); moderate (score10-14) and severe (score 15-21). An overall score of ≥10 was considered as having anxiety.²⁵

Data analysis

After checking the completeness and consistency, data was entered in the computer on excel data sheets. Descriptive statistics (frequencies, percentages, means, standard deviation etc.) were performed. Primary outcome variable (prevalence of depression and anxiety) was presented as proportion. Finally, we applied both bi-variate and multivariable logistic regression to identify the correlates/predictors of depression and anxiety among the nursing students. SPSS (version 20) was used in analysis.

Ethical considerations

Ethics approval was obtained from the appropriate institutional ethics committee (24-Sep/2024/IEC/MSDMCH), participants were briefed about the purpose and process of the study and other ethical concerns (confidentiality and anonymity of the information). Prior to data collection informed written consent was obtained from each participant.

RESULTS

Socio-demographic, personal attributes and nursing education related characteristics

A total of 160 undergraduate nursing students participated in the study, with mean±SD age of 20.82±1.41 years; majority (75.6%) being Hindu; 48.1% belonging to the general caste; most participants (82.5%) living in a nuclear family; majority (70.6%) residing in rural area; more than half (56.9%) currently being hostel-residents and one fourth (25.6%) belonging to upper socio-economic class.

Of 160 participants, only 60 (37.5%) joined nursing course by own choice; 46 (28.7%) participants reported dissatisfaction with the course; 98 (61.3%) perceived their academic workload as high; and majority (71.3%) had fear of failure in examination. Interpersonal challenges were evident, with 21.3% reporting conflicts with friends or roommates; though 71.9% of students were not yet committed to in any relationship, 17 (10.6%) had experienced a break-up. Lifestyle factors further highlighted the vulnerability of students, with 71.3% perceiving their sleep as inadequate; 44 (27.5%) engaging in extra physical activities and only 6 (3.8%) reported habit of substance use. Financial vulnerability at the family level and family history of chronic/psychiatric illness both were reported by 50 (31.3%) participants. Most students (92.5%) having parents who lived together with normal relationship, while 16 (10%) students reported parental separation or conflicts.

Prevalence of depression, anxiety and their correlates

Overall prevalence of depression was found to be 48.8% (78/160; 95% CI:41.1-56.5) based on PHQ-9 score ≥10; 4.4%, 13.1% and 31.3% had severe, moderately severe and moderate depression respectively (Table 1).

Overall prevalence of anxiety (based on GAD-7 score ≥10) was 40.6% (65/160; 95% CI:33-48.2); 17.5% and 23.1% had severe and moderate anxiety respectively (Table 1).

Note: SES = socio-economic status; *Modified according to CPI (IW)- March 2023; CPI (IW) = Consumer price index (industrial workers).

None of the background and socio-demographic characteristics of the study participants were significantly associated with anxiety and depression (Table 2). However, our study revealed association of depression and anxiety with some of the nursing education and personal attributes (Table 3).

Students perceiving a high academic workload had significantly higher depression (56.1%, p=0.019) and anxiety (46.9%, p=0.041) than those with medium or low workload. Those with conflict involving friends/ roommates had higher prevalence of depression (70.6%, p=0.004) and anxiety (55.9%, p=0.041) (Table 3).

Participants reporting inadequate sleep were more likely to be depressed (54.4%, p=0.025) and anxious (46.5%, p=0.017) compared to those with adequate sleep. Financial vulnerability in the family was also significantly associated with both depression (68.0%, p=0.001) and anxiety (52.0%, p=0.048). However, family history of chronic/psychiatric illness was significantly linked to anxiety (54.0%, p=0.020) but not with depression (54.0%, p=0.370); dissatisfaction with nursing course was associated with depression (p=0.022) but not with anxiety (p= 0.059) (Table 3).

Note: cOR= crude odds ratio; CI = confidence interval

Note: cOR= crude odds ratio, aOR=adjusted odds ratio; CI = confidence interval. Model Statistics: Hosmer and Leme-show test =3.902, p=0.866; omnibus test of model coefficient =26.519, p=0.000; Cox and Snell R²=0.153; Nagelkerke R²=0.204 (For depression). Hosmer and Leme-show test =5.097, p=0.747; omnibus test of model coefficient =26.551, p=0.000; Cox and Snell R²=0.153; Nagelkerke R²=0.204 (For anxiety).

Finally, we also performed multivariable logistic regression for predictors of depression and anxiety. The model for depression included satisfaction with nursing course, perceived academic workload, conflict with friends/roommates, perceived adequacy of sleep, financial vulnerability, and parental relationship; besides these variables the model for anxiety also included family history of chronic/psychiatric illness (Table 4).

Finally, both for depression (aOR 2.652; CI: 1.252-5.618) and anxiety (aOR 2.657; CI: 1.254-5.631), only financial crisis/vulnerability at the family level remained significant predictors (Table 4).

DISCUSSION

The present study is one of the few recent studies in West Bengal assessing depression and anxiety among undergraduate nursing students of a government nursing college using the two simple validated tools- PHQ-9 and GAD-7 respectively. The study revealed alarming insights- nearly half (48.8%) of the nursing students had depression and two-fifths (40.6%) had anxiety; along with existence of severe grades of both depression and anxiety. These findings reflect the global recognition of mental disorders as major contributors to morbidity among young adults.^1,2 The prevalence observed is consistent with both international and Indian studies, indicating that nursing students are particularly vulnerable to psychological distress due to the unique demands of their academic and clinical training.^{5,9,15,16,18-22}

Mean±SD age 20.8±1.41 and other basic socio-demographics of the participants in our study were almost similar to some other studies in different parts of the country.^20-22,26 However, contrary to some prior reports, socio-demographic variables such as age, gender, residence, family type were not significantly associated with depression or anxiety in this study. Similar findings have been reported by Chatterjee et al and Helenpuii and Choudhury, suggesting that mental health outcomes may be more strongly influenced by educational and personal factors than by baseline demographics.^18,22 However, other Indian studies also included factors like age, gender and rural/urban residence but significant associations have not been reported.^9,19,20

A significant association was observed between perceived high academic workload and both depression and anxiety in our study. This is consistent with global evidence that academic stress is a primary risk factor for psychological morbidity among nursing students.^{6,8,10,13,26-28} Intensive curricula, frequent examinations, and clinical responsibilities create chronic stress, affecting both mental health and academic performance.¹⁴ The association with course dissatisfaction and depression further underscores the importance of intrinsic motivation and career choice in mitigating psychological distress.^6,17

Conflict with peers or roommates emerged as another significant correlate, affected students showing higher prevalence of depression (70.6%) and anxiety (55.9%) as compared to their counterparts. This aligns with Onieva-Zafra et al, who emphasized the buffering effect of social support against stress.¹³ Nursing students often face limited time for social integration due to rigorous academic schedules, increasing vulnerability to interpersonal stress.¹⁴ Additionally, relationship disruptions (10.6% experienced a breakup) may contribute to emotional distress, consistent with findings from Mi et al highlighting links between loneliness, anxiety, and depression.²⁹

Inadequate sleep was quite high (seven in ten students) and was significantly associated with both depression and anxiety. This finding mirrors prior studies among nurses and nursing students, where disrupted sleep and irregular schedules exacerbated mood disturbances.^11,12 Sleep inadequacy not only contributes to mental health problems but may also compromise cognitive performance, clinical judgment, and patient safety.¹²

Financial vulnerability at the family level emerged as predictor for both depression (aOR 2.652; CI: 1.252-5.618) and anxiety (aOR 2.657; CI: 1.254-5.631), Students from economically stressed families were nearly three times more likely to experience psychological morbidity. This finding is consistent with studies in Cameroon and India emphasizing that socioeconomic adversity compounds academic and personal stressors.^8,21,22 Economic strain is a recognized social determinant of mental health globally, and interventions targeting financial support or counselling may substantially reduce distress.^2,7

Family history of chronic/psychiatric illness was significantly associated with anxiety but not depression in this study. This may reflect genetic predisposition and the influence of environmental stressors, in line with path analyses of depression-related factors among nursing students ¹⁷ and network analyses of anxiety-depression interconnections.^17,29

The present study in a single government nursing college limits the generalizability of the findings. Data generation through self-reported questionnaires might introduce recall bias or social desirability bias.

CONCLUSION

This study highlights a concerning prevalence of anxiety and depression among undergraduate nursing students in a government institution in Murshidabad, West Bengal. The findings suggest that academic stress, financial vulnerability, interpersonal conflicts, family-related factors significantly contribute to the mental health burden among nursing students.

Given the critical role of nursing students in future healthcare delivery, it is imperative to implement targeted mental health interventions, including stress management, peer support initiatives, academic counselling. Institutional policies should also consider integrating mental well-being awareness and resilience-building programs into nursing curriculum. Future studies with larger sample size and multi-institutional approach may help in better understanding the long-term impact of mental health challenges among nursing students.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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