1.
Article 1.
Depression. By: Oyama, Oliver, PhD, Piotrowski, Nancy A., PhD, Magill’s Medical
Guide (Online Edition), 2013
Depression
Last reviewed: January 2017
Anatomy or system affected: Brain, heart, musculoskeletal system, psychic-emotional
system
Definition: One of the most common psychiatric disorders to occur in most lifetimes,
caused by biological, psychological, social, and/or environmental factors
Causes and Symptoms
The word “depression” is often used to describe many different things. For some, it
defines a fleeting mood, for others an outward physical appearance of sadness, and for
others a diagnosable clinical disorder. In any year, millions of adults suffer from a
clinically diagnosed depression, a mood disorder that often affects personal,
vocational, social, and health functioning. The fifth edition of the Diagnostic and
Statistical Manual of Mental Disorders (DSM-5, 2013) of the American Psychiatric
Association delineates a number of mood disorders that include clinical depression,
known as major depressive disorder.
Neuroimaging can be a valuable tool in the
diagnostic work-up of various psychiatric disorders including depression. By Helmut
Januschka (Helmut Januschka) [GFDL (http://www.gnu.org/copyleft/fdl.html) or CC-BYSA-3.0 (http://creativecommons.org/licenses/by-sa/3.0/)], via Wikimedia Commons
Major depressive disorder is characterized by a syndrome of symptoms, present during
a two-week period and representing a clinically significant change from previous
functioning. The symptoms include at least five of the following: depressed or irritable
mood for most of the day, diminished interest in previously pleasurable activities,
significant unintentional weight loss or weight gain, insomnia or hypersomnia, physical
agitation or slowness, loss of energy or fatigue, feelings of worthlessness or excessive
guilt, indecisiveness or a diminished ability to concentrate, and recurrent thoughts of
death. The clinical depression cannot be initiated or maintained by another illness or
condition.
Major depressive disorder is often first recognized in the patient’s twenties, while a
major depressive episode can occur at any age. Women are twice as likely to suffer
from the disorder than are men.
There are several potential causes of major depressive disorder. Genetic factors may
determine a person's susceptibility to developing depression following stressful life
events. Genetic studies suggest a familial link with higher rates of clinical depression in
first-degree relatives. There also appears to be a relationship between clinical
depression and levels of the brain’s neurochemicals, specifically decreased
monoamines—the neurotransmitters dopamine, norepinephrine, and serotonin. It is
important to keep in mind, however, that anywhere from 15 to 20 percent of adults will
experience major depression at some point in their lifetimes. Furthermore, not
everyone has a biological cause for this depression. Common causes of clinical
depression also include psychosocial stressors such as the death of a loved one,
financial stress, loss of a job and unemployment, interpersonal problems, or traumatic
world events such as natural disasters and war. It is unclear, however, why some
people respond to a specific psychosocial stressor with a clinical depression and others
do not. Finally, certain prescription medications have been noted to cause or be related
to clinical depression. These drugs include muscle relaxants, heart medications,
hypertensive medications, ulcer medications, oral contraceptives, painkillers, narcotics,
and steroids. Thus there are many causes of clinical depression, and no single cause
is sufficient to explain all clinical depressions.
Other likely risk factors for depression include past alcohol dependence, insecure
attachment to parents in early adolescence, and the experience of childhood abuse or
neglect. Possible risk factors for depression that have been explored include cannabis
use, low birth weight, high levels of television viewing and media exposure in
adolescence, and head injury.
In the DSM-5, the existence of at least three manic symptoms (which is insufficient to
satisfy the diagnostic criteria for a manic episode) within a major depressive episode is
acknowledged by the specifier "major depressive disorder with mixed features." The
presence of mixed features in an episode of major depressive disorder increases the
likelihood that the illness exists in the bipolar spectrum, although separate criteria exist
for the diagnosis of bipolar disorder, which can share some symptoms with major
depression.
Dysthymic disorder is another persistent depressive disorder characterized by chronic
low-level depression. In the United States, the twelve-month prevalence of dysthymic
disorder is estimated to be approximately 1.5 percent of the adult population. Dysthymic
disorder is characterized by at least a two-year history of depressed mood and at least
two of the following symptoms that cause clinically significant impairment in social, work,
or other important areas of functioning: poor appetite or overeating, insomnia or
hypersomnia, low energy or fatigue, low self-esteem, poor concentration or decision
making, or feelings of hopelessness. The individual cannot be without the symptoms for
more than two months at a time, the disorder cannot be superimposed on another
psychotic disorder, and it cannot be initiated or maintained by another illness or
condition. Dysthymic disorder is more common in adult women, equally common in both
sexes of children, and with a greater prevalence in families. The causes of dysthymic
disorder are believed to be similar to those listed for major depressive disorder, but the
disorder is less well understood than is depression.
In order to prevent the overdiagnosis of bipolar disorder in children, the DSM-5 added a
new depressive disorder called disruptive mood dysregulation disorder (DMDD). This
diagnosis is given to children up to the age of eighteen years who exhibit persistent
irritability and frequent episodes of extreme emotional outbursts and behavioral
dyscontrol. DMDD is characterized by severe and recurrent temper outbursts that are
grossly out of proportion in intensity or duration to the situation at hand, occurring on
average three or more times per week for one year or more. Diagnosis of DMDD
requires the symptoms to be present in at least two settings (at school, at home, and/or
in social settings), and the child cannot have gone three or more consecutive months
without symptoms to be diagnosed with DMDD. Onset of DMDD must occur before the
age of ten years, and diagnosis cannot be made for the first time before the age of six
years or after eighteen years.
Also in the category of depressive disorders, the DSM-5 includes premenstrual
dysphoric disorder (PMDD), which was previously categorized under Appendix B
"Criteria Sets and Axes Provided for Further Study" in the DSM-IV, due to a strong body
of evidence supporting its existence and the validity of the diagnostic criteria. PMDD is
an extreme version of premenstrual syndrome that affects approximately 2 to 5 percent
of women of reproductive age. PMDD is characterized by the presence of symptoms for
most of the time during the last week of the luteal phase of the menstrual cycle; these
symptoms begin to remit within a few days of the onset of the follicular phase and are
not present in weeks following menstruation. For the diagnosis of PMDD, a woman must
have five or more of the following symptoms for most menstrual cycles during the past
one year: markedly depressed mood or feelings of hopelessness, marked anxiety or
tension, persistent anger or irritability or increased interpersonal conflicts, sense of
difficulty in concentrating, lethargy or fatigue, marked changes in appetite, hypersomnia
or insomnia, feelings of being overwhelmed or out of control, and/or physical symptoms
such as headache, joint or muscle pain, and breast tenderness. These symptoms must
also cause a clinically significant impact on functioning at work, school, and social
settings or within personal relationships.
A final variant of clinical depression is known as seasonal affective disorder (SAD).
Patients with this illness demonstrate a pattern of clinical depression during the winter,
when there is a reduction in the amount of daylight hours. For these patients, the
reduction in available light is thought to be the cause of the depression. In the DSM-5,
SAD is categorized as a mood disorder with a specifier called "with seasonal pattern."
Treatment and Therapy
Crucial to the choice of treatment for clinical depression is determining the variant of
depression being experienced. Each of the diagnostic categories has associated
treatment approaches that are more effective for a particular diagnosis. Multiple
assessment techniques are available to the health care professional to determine the
type of clinical depression. The most valid and reliable is the clinical interview. The
health care provider may conduct either an informal interview or a structured, formal
clinical interview assessing the symptoms that would confirm the diagnosis of clinical
depression. If the patient meets the diagnostic criteria set forth in the DSM-5, then the
patient is considered for depression treatments. Patients who meet many but not all
diagnostic criteria are sometimes diagnosed with a “subclinical” depression. These
patients might also be considered appropriate for the treatment of depression, at the
discretion of their health care providers.
Another assessment technique is the “paper-and-pencil” measure, or depression
questionnaire. A variety of questionnaires have proven useful in confirming the
diagnosis of clinical depression. Questionnaires such as the Beck Depression
Inventory, Hamilton Depression Rating Scale, Zung Self-Rating Depression Scale, and
the Center for Epidemiologic Studies Depression Scale are used to identify persons
with clinical depression and to document changes with treatment. This technique is
often used as an adjunct to the clinical interview and rarely stands alone as the definitive
assessment approach to diagnosing clinical depression.
Once a clinical depression (or a subclinical depression) is identified, several types of
treatment options are available. These options are dependent on the subtype and
severity of the depression. They include individual and group psychotherapy, light
therapy, family therapy, psychopharmacology (drug therapy), electroconvulsive therapy
(ECT), and other less traditional treatments. These treatment options can be provided to
the patient as part of an outpatient program or, in certain severe cases of clinical
depression in which the person is a danger to the self or others, as part of a
hospitalization.
Clinical depression often affects the patient physically, emotionally, and socially.
Therefore, prior to beginning any treatment with a clinically depressed individual, the
health care provider will attempt to develop an open and communicative relationship
with the patient. This relationship will allow the health care provider to provide patient
education on the illness and to solicit the collaboration of the patient in treatment.
Supportiveness, understanding, and collaboration are all necessary components of any
treatment approach.
For the treatment of mild to moderate depression in adults, the American Psychiatric
Association (APA) recommends psychotherapy as the initial treatment choice. The APA
also recommends antidepressant medications as an initial treatment choice, whereas
the National Institute for Clinical Excellence (NICE) recommends antidepressants only if
the patient is unresponsive to initial psychosocial interventions. For moderate to severe
depression in adults, the APA and the NICE recommend a combination of
psychotherapy and antidepressants. The APA also recommends electroconvulsive
therapy (ECT) for the treatment of severe unresponsive major depression in adults.
For the treatment of depression in children and adolescents, the recommended initial
treatment choices include education, supportive treatment, and case management. If
depression is complicated or chronic, psychotherapy may then be recommended.
Interpersonal therapy and cognitive-behavioral therapy have been shown to be among
the best psychotherapeutic options for the treatment of depression. If the child or
adolescent with depression is unresponsive to psychotherapy, he or she may benefit
from some types of antidepressant medications; however, in most children with
depression, antidepressants do not appear to be an effective treatment.
Psychotherapy refers to a number of different treatment techniques used to deal with
the psychosocial contributors and consequences of clinical depression. In
psychotherapy, the patients develop knowledge and insight into the causes of and
treatment for their clinical depression. In cognitive psychotherapy, symptom relief
comes from assisting patients in modifying maladaptive, irrational, or automatic beliefs
that can lead to clinical depression. In behavioral psychotherapy, patients modify their
environment such that social or personal rewards are more forthcoming. This process
might involve being more assertive, reducing isolation by becoming more socially active,
increasing physical activities or exercise, or learning relaxation techniques or other
coping skills. Research upholds the effectiveness of these and other psychotherapy
techniques for the treatment of depression and other mood disorders.
The primary types of medications used in the treatment of clinical depression in adults
include selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine
reuptake inhibitors (SNRIs), mirtazapine (Remeron), and bupropion (Wellbutrin).
Monoamine oxidase inhibitors (MAOIs) should be restricted to patients who do not
respond to other treatments. The health care professional will select an antidepressant
based on side effects, dosing convenience (once daily versus three times a day), and
cost.
Cyclic antidepressants represent one class of antidepressant medications. As the name
implies, the chemical makeup of the medication contains chemical rings, or “cycles.”
There are unicyclic (buproprion and fluoxetine, or Prozac), bicyclic (sertraline and
trazodone), tricyclic (amitriptyline, desipramine, and nortriptyline), and tetracyclic
(maprotiline) antidepressants. These antidepressants function to either block the
reuptake of neurotransmitters by the neurons, allowing more of the neurotransmitter to
be available at a receptor site, or increase the amount of neurotransmitter produced.
The side effects associated with the cyclic antidepressants—dry mouth, blurred vision,
constipation, urinary difficulties, palpitations, and sleep disturbance—vary and can be
quite problematic. Some of these antidepressants have deadly toxic effects at high
levels, so they are not prescribed to patients who are at risk of suicide. Furthermore, in
some patients, antidepressants such as SSRIs are associated with increased suicidal
ideation, so patients should be carefully monitored as they begin an antidepressant
treatment regimen.
Newer drugs are more specific in terms of the drug action. For instance, fluoxetine is a
selective serotonin reuptake inhibitor (SSRI) and works specifically on the
neurotransmitter serotonin. Similarly, buproprion is a norepinephrine and dopamine
reuptake inhibitor (NDRI) and works specifically on the neurotransmitters norepinephrine
and dopamine. More specific drugs generally create fewer side effects. Fewer side
effects can be associated with greater medication compliance, making these drugs a
more effective treatment for many individuals.
Monoamine oxidase inhibitors (isocarboxazid, phenelzine, and tranylcypromine) are
another class of antidepressants. They function by slowing the production of the enzyme
monoamine oxidase. This enzyme is responsible for breaking down the
neurotransmitters norepinephrine and serotonin, which are believed to be responsible
for depression. By slowing the decomposition of these transmitters, more of them are
available to the receptors for a longer period of time. Restlessness, dizziness, weight
gain, insomnia, and sexual dysfunction are common side effects of the MAOIs. MAOIs
are most notable because of the dangerous adverse reaction (severely high blood
pressure) that can occur if the patient consumes large quantities of foods high in
tyramine (such as aged cheeses, fermented sausages, red wine, foods with a heavy
yeast content, and pickled fish). Because of this potentially dangerous reaction, MAOIs
are not usually the first choice of medication and are more commonly reserved for
depressed patients who do not respond to other treatment options.
Electroconvulsive or shock therapy is the single most effective treatment for severe and
persistent depression that does not respond to other treatments. If the clinically
depressed patient fails to respond to medications or psychotherapy and the depression
is life-threatening, electroconvulsive therapy is considered. It is also considered if the
patient cannot physically tolerate antidepressants, as with elderly patients who have
other medical conditions. This therapy involves inducing a seizure in the patient by
administering an electrical current to specific parts of the brain. The therapy has become
quite sophisticated and much safer than when it was introduced in the mid-twentieth
century, and it involves fewer risks to the patient. Patients undergo several treatments
over a period of time. Some temporary memory impairment is a common side effect of
this treatment.
A special treatment used for individuals with seasonal affective disorder is light therapy,
or phototherapy. Light therapy involves exposing patients to bright light for a period of
time each day during seasons of the year when there is decreased light. This may be
done as a preventive measure and also during depressive episodes. The manner in
which this treatment approach modifies the depression is unclear and awaits further
research, but some believe it affects the internal clock of the body, or circadian rhythm.
Studies of the effectiveness of light therapy have been mixed, but interest in this
promising treatment is strong, as it may prove useful for working with nonseasonal
mood disorders as well. It should be noted, however, that light therapy does have some
risks associated with it. Caution must be used to protect the eyes and to use the light as
directed. Additionally, the intensity of light must be correct so as to achieve therapeutic
effects and not cause other problems. Finally, some individuals can experience manic
episodes if they are exposed to too much light, so caution must be exercised in terms of
the length of time for light exposure treatment sessions.
Surgery, the final treatment option for severe depression, is quite rare. Psychosurgery
is used only after all treatment options have failed and the clinical depression is lifethreatening. Vagus nerve stimulation (VNS) is a form of surgery that implants a stimulus
generator on the vagus nerve; it is approved by the FDA for the treatment of severe
unresponsive depression. Nonsurgical methods of creating similar stimuli have been
explored as well.
Perspective and Prospects
Depression, or the more historical term “melancholy,” has had a history predating
modern medicine. Writings from the time of the ancient Greek physician Hippocrates
refer to patients with a symptom complex similar to the present-day definition of clinical
depression.
The rates of clinical depression have increased since the early twentieth century, while
the age of onset of clinical depression has decreased. Women appear to be at least
twice as likely as men to suffer from clinical depression.
While most psychiatric disorders are nonfatal, clinical depression can lead to death.
About 60 percent of individuals who commit suicide have a mood disorder such as
depression at the time. In a lifetime, however, only about 7 percent of men and 1
percent of women with lifetime histories of depression will commit suicide. Though
these numbers are high, what this means is that not everyone who is depressed will
commit suicide. In fact, many receive help and recover from depression. There are,
however, other costs of clinical depression. Billions of dollars are spent on clinical
depression, divided among the following areas: treatment, suicide, and absenteeism
(the largest). Clinical depression obviously has a significant economic impact on
society, and major personal impacts on the lives of individuals suffering from
depression.
Studies have shown a marked increase in depression among those in their twenties
and thirties in the early twenty-first century. The American College Counseling
Association reported in 2012 that there had been a 16 percent increase in visits to
mental health counselors on college campuses since 2000. A reported 44 percent of
college students experience depression symptoms. In a 2011 study, the CDC found
overall that from the period between 1988–1994 to the period between 2005–2008,
antidepressant use had increased by 400 percent.
The future of clinical depression lies in early identification and treatment. Identification
will involve two areas. The first is improving the social awareness of mental health
issues to include clinical depression. By eliminating the negative social stigma
associated with mental health treatment, there will be an increased level of the reporting
of depression symptoms and thereby an improved opportunity for early intervention,
preventing the progression of the disorder. The second approach to identification
involves the development of reliable assessment strategies for clinical depression.
Data suggests that the majority of those who commit suicide see a physician within thirty
days of the suicide. The field of psychology will continue to strive to identify biological
markers and other methods to predict and identify clinical depression more accurately.
Treatment advances will focus on the further development of nonpharmacological and
pharmacological strategies to increase effectiveness.
2.
Article 2.
Depression, anxiety, and tobacco use: Overlapping impediments to sleep in a national
sample of college students.
By: Boehm, Matthew A.; Lei, Quinmill M.; Lloyd, Robin M.; Prichard, J. Roxanne. Journal of American
College Health , Oct2016, Vol. 64 Issue 7, p565-574, 10p, 3 Charts, 4 Graphs; DOI:
10.1080/07448481.2016.1205073, Database: Education Source
ABSTRACT Objectives: To examine how tobacco use and depression/anxiety disorders are related to disturbed sleep
in college students. Participants: 85,138 undergraduate respondents (66.3% female, 74.5% white, non-Hispanic, ages
18–25) from the Spring 2011 American College Health Association–National College Health Assessment II database.
Methods: Multivariate analyses of tobacco use (none, intermediate, daily) and mental health (diagnosed and/or
symptomatic depression or anxiety) were used to predict sleep disturbance. Results: Daily tobacco use was associated
with more sleep problems than binge drinking, illegal drug use, obesity, gender, and working >20 hours/week.
Students with depression or anxiety reported more sleep disturbances than individuals without either disorder, and
tobacco use in this population was associated with the most sleep problems. Conclusions: Tobacco use and
depression/anxiety disorders are both independently associated with more sleep problems in college students.
Students with depression and/or anxiety are more likely to be daily tobacco users, which likely exacerbates their sleep
problems.
Emerging adulthood is a formative time for overall health, a sensitive period for forming lifestyle patterns, and an age
when mental illnesses often first emerge.1 Colleges and universities in the United States are working to cope with
record high levels of psychological distress among students, a trend that has been attributed to multiple factors,
including increased financial stress, the changing demographics of college students, increasing technology
dependence, and the lifestyle changes young adults experience as they abruptly gain independence in decision
making.2,3 Accordingly, colleges and universities are searching for ways to improve students’ health through early
identification and treatment of mental illness, identifying modifiable risk factors, and promoting healthier lifestyle
choices. In April 2012, the American College Health Association (ACHA) introduced the Healthy Campus 2020
initiatives, which include goals to reduce the incidence of specific negative health behaviors, including nicotine use
and sleep disturbance, by 10% by 2020.4 Data from the Spring 2015 ACHA–National College Health Assessment
(NCHA) II show that within the last year, 15.8% of undergraduates have been diagnosed with or treated for an anxiety
disorder, 13.1% have been diagnosed with or treated for depression, 20% have reported
that their academic performance has been adversely impacted by sleep problems, and that within the last month at
least 10% have used tobacco.5 Recently, Ridner et al identified sleep quality and tobacco use as 2 of the most
important predictors in students’ subjective sense of well-being.6 Depression, anxiety, and frequent tobacco use have
all been independently linked to sleep problems, and those with depression and/or anxiety are more likely than
others to use tobacco.7–9 To gain a better understanding of the relationships among these variables in college
students, we used multivariate analysis on data from the Spring 2011 ACHA-NCHA II database to evaluate the relative
impacts of anxiety, depression, and tobacco use on rates of sleep disturbance.
Depression, anxiety, and sleep disturbance The relationships between depression, anxiety, and sleep have been a
topic of research for over 40 years. Among individuals with depression, sleep disturbances often include difficulty
with sleep initiation, frequent early awakenings, and insomnia or hypersomnia.10 Depression is also associated with
electrophysiological disturbances in sleep, including disinhibition of rapid eye movement (REM) sleep, REM sleep
fragmentation, a reduction of slow-wave sleep, and circadian rhythm dysregulation.11 Sleep disturbances in anxiety
disorders include difficulty in initiating and/or maintaining sleep, restless or unsatisfying sleep, nightmares, insomnia,
and alterations in sleep architecture similar to those with depression.12 Depression and anxiety are often comorbid
with insomnia, sleep problems exacerbate depressive and anxious symptoms, and insomnia is a risk factor in the
development of depression and anxiety disorders.7,12–14 There is growing evidence from prospective population
studies that disturbed sleep is in itself a predictor and modifiable risk factor for anxiety and depression. Data from a
national survey of adults showed that frequent insufficient sleep is associated with depressive and anxiety disorders,
and the odds of having a sleep disorder are increased when both classes of psychiatric disorders are diagnosed.15 A
population study of approximately 15,000 participants found that in those with depressive disorders, more than 40%
experienced insomnia before the onset of the mood disorder symptoms and more than 20% experienced the
symptoms concurrently.16 However, in individuals diagnosed with anxiety disorders, insomnia appeared concurrently
(>38%) or after (>34%) the anxiety disorder.16 An adolescent population study (N > 1,000) found that among those
with comorbid anxiety and depression, anxiety disorders preceded 73% of insomnia diagnoses, whereas insomnia
preceded 69% of comorbid insomnia and depression cases. 17 Prospective studies have also shown that persistent
sleep problems in childhood predict adult anxiety disorders.18 In adults, both anxiety and depression at baseline
predict new cases of insomnia, and insomnia at baseline predicts new diagnoses of anxiety and depression 1 year
later.19 Understanding the nature of these relationships should be of importance to college health professionals
because sleep disturbances are clinically relevant for both evaluation and treatment of mental health. Individuals with
anxiety disorders and poor sleep experience significantly worse mental health related quality of life and increased
disability, compared with those with anxiety disorders alone.20 Furthermore, insomnia severity is a predictor of
suicidal ideation in individuals with depression, even after controlling for cofactors such as level of depressed mood
and anhedonia.21 Treating insomnia improves depression and anxiety symptoms, and treating anxiety/depression
improves insomnia.22–24 tobacco use, depression/anxiety, and sleep Tobacco use is more common among
individuals with depression and/or anxiety than in the general population.9 In national surveys, people with a lifetime
history of depression, anxiety, or comorbid anxiety and depression were more likely to be current smokers, smoke
with higher intensity and dependence, and have lower success at quitting than those without a history of anxiety or
depression.25 A 26-year longitudinal study demonstrated that smoking is associated with an increased risk of
developing depression later in life; individuals who smoked more than 10 g of tobacco per day had significantly higher
depression rates than did nonsmokers.26 A 10-year longitudinal study of adolescents showed that both occasional
and daily smokers with high levels of depression and anxiety symptoms had an approximately 2-fold increase in
nicotine dependence in young adulthood, compared with those with low levels of adolescent depression and anxiety
symptoms.27 Similarly, an earlier age of smoking onset predicts an earlier development of anxiety disorders, even
after controlling for the effects of gender, education, and childhood trauma.28 Many people who are vulnerable to
depression or anxiety use tobacco because they expect smoking to relieve negative affect.29 However, tobacco use
might actually exacerbate symptoms of depression and anxiety through impairments to sleep. Polysomnography
studies reveal that smokers have longer sleep latencies, less slow wave sleep, and less total sleep time compared with
nonsmokers.8,30 Smokers tend to have higher REM densities, more leg movements throughout the night, and more
breathing difficulties during sleep and report feeling less refreshed in the morning compared with nonsmokers.31 In a
sample of US adults, those who were tobacco users had twice the odds of insufficient sleep compared with nontobacco users and secondhand smoke exposure was associated with insufficient rest among nonsmokers.32 In
addition, a 25-year prospective study showed that women who were chronic heavy smokers had a 2.76 times
increased chance for reporting insomnia in late adulthood.33 In smokers, sleep deprivation increases the frequency of
cigarette smoking, which can in turn negatively impact sleep.34 In contrast, a reduction in smoking is associated with
improvements in sleep, and better sleep can help with successful reduction and cessation of smoking.9,35
Hypotheses We sought to examine how tobacco use and depression/ anxiety disorders are related to disturbed sleep
in a national sample of college students. Specifically, we hypothesized that those with depression and anxiety, or
probable undiagnosed anxiety and depression, will be more likely to have impaired sleep (H1) and more likely to use
tobacco (H2) than those without these disorders. Furthermore, we hypothesized that tobacco use will be associated
with increased reports of sleep disturbance (H3), particularly among those with anxiety/mood disorders (H4). This
study is the first to explore the interaction of these factors in a large national sample of college students.
Methods Survey We used data from the Spring 2011 American College Health Association–National College Health
Assessment II (ACHA-NCHA II).36 The ACHA-NCHA II is a nationally recognized research survey that is used to collect
precise data about students’ health habits, behaviors, and perceptions. It is systematically evaluated for reliability and
validity by comparing common survey items with national studies such as the National College Health Risk Behavior
Survey (Centers for Disease Control and Prevention [CDC]) and College Alcohol Study (Harvard School of Public
Health). The survey consists of 294 questions regarding physical and mental health, health education, and alcohol,
tobacco, and drug use, as well as questions about impediments to academic performance. The Spring 2011 survey
was administered to a total of 105,781 students at 129 postsecondary institutions, including associate’s,
baccalaureate, master’s, and research institutions. We limited our analysis to participants aged 18–25 (ND85,218) in
order to eliminate age as a possible confounding variable. In addition, respondents whose data seemed purposely
falsified (eg, students who indicated daily use of every type of drug [nD44] or a diagnosis of all 15 mental disorders [n
D 36]) were excluded from the data analyses, reducing the number of student respondents in the sample to 85,138.
The sample used for this analysis was 66.3% female, 73.7% white, 11.1% Asian/Pacific Islander, 7.8% Hispanic/Latino,
5.7% black non-Hispanic, and 1.7% American Indian/ Alaskan Native/Hawaiian Native.
Classification of tobacco use To quantify tobacco use, we coded responses to ACHANCHA Question 8, “Within the last
30 days, on how many days did you use: cigarettes, tobacco from a water pipe (hookah), cigars, little cigars, clove
cigarettes, and smokeless tobacco,” into 3 categories. Participants in the None category reported “Never used” or
“Have used, but not in last 30 days” (n D 64,369). Participants in the Intermediate category reported tobacco use “1–2
days, 3–5 days, 6–9 days, 10–19 days, or 20–29 days” in the last 30 days (n D 15,535), and Daily tobacco users
responded “Used daily” (n D 3,890). We opted for this categorical grouping because the ACHA-NCHA II
does not include quantitative data regarding the number of times a day a person uses tobacco products.
Classification of depression To get closer to capturing the true population, we included individuals who were
undiagnosed but symptomatic for depression/anxiety in our analysis. Research indicates that at least 25% of
individuals with depression are undiagnosed and less than half receive treatment.37,38 We combined individuals who
responded that they had been formally diagnosed with depression (a positive response to ACHA-NCHA II Question 31,
“Within the last 12 months have you been diagnosed or treated by a professional for depression (n D 7,924) and/or
bipolar disorder (n D 955)”) with respondents who appeared to be symptomatic for depression. Participants who
endorsed at least 3 of the following 4 statements were classified as having probable undiagnosed depression (n D
9,389): In the last 12 months, have you felt things were hopeless (Question 30A); felt very sad (30E); felt so depressed
that it was difficult to function (30F), and seriously considered suicide (30J). This estimation likely underestimates
participants with undiagnosed depression because students who were formally diagnosed with depression reported
an average of 2.7 of the 4 symptoms, whereas we set the cutoff for probable undiagnosed depression at 3 of 4
symptoms. The ACHA-NCHA II survey questions used for this classification are similar to other criteria used for
depression diagnosis (eg, DSM-V [Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition] diagnostic
criteria for Depression, the Hamilton Rating Scale for Depression, and the Center for Epidemiologic Studies
Depression Scale). Of the 17,205 individuals who were either diagnosed with or symptomatic for depression, 9,198
(53%) were also either diagnosed with or symptomatic for an anxiety disorder.
Classification of anxiety It is estimated 20% of adults meet criteria for at least 1 anxiety disorder, but are not formally
diagnosed.39 In order to get closer to capturing the true population, we combined individuals who responded that
they had been formally diagnosed with an anxiety disorder (nD9,721), defined as a positive response to Question 31,
“Within the last 12 months have you been diagnosed or treated by a professional for panic attacks (nD4,231),
obsessive compulsive disorder (n D 1,777), and/or anxiety (n D 8,898),” with respondents who appeared to by
symptomatic for an anxiety disorder (n D 6,559). Of the 9,721 individuals diagnosed with an anxiety disorder, 5,185
had a comorbid anxiety disorder (eg, panic disorder and obsessive compulsive disorder). Individuals who endorsed at
least 2 of the following 3 statements: experienced “tremendous stress” within the past 12 months (Question 37); “felt
overwhelming anxiety within the last 2 weeks” (30G); and reported that anxiety has negatively affected academic
performance within the last 12 months (45C) were classified as having probable undiagnosed anxiety. This estimation
likely underestimates participants with undiagnosed anxiety because students who were formally diagnosed with
anxiety reported an average of 1.2 of the 3 symptoms, whereas we set the cutoff for probable undiagnosed anxiety at
2 of 3 symptoms. The ACHA-NCHA II survey questions used for this classification are similar to other criteria used for
anxiety diagnosis (eg, DSM-V diagnostic criteria for Generalized Anxiety Disorder, Generalized Anxiety Disorder 7-item
scale, Hamilton Anxiety Rating Scale).
Comorbid depression and anxiety In the sample population, 5,279 individuals were formally diagnosed with comorbid
anxiety and depression. Within the sample, 498 individuals were formally diagnosed with depression and also
reported symptoms of probable anxiety, 795 received a formal diagnosis of an anxiety disorder and reported
symptoms of probable depression, and 2,626 individuals reported concurrent symptoms from both probable
undiagnosed anxiety and undiagnosed depression groups as defined above, yielding a total of 9,198 groupedin the
comorbid classification.
Reported sleep problems Self-reported sleep problems were defined as the average score of responses to questions
about sleep in the past 7 days: In the last week, how many days did you “get enoughsleep to feelwell rested in the
morning” (Question 42,reverse scored); “awoketoo early and couldn’t get back asleep” (44A); “felt tired or sleepy
during the day” (44B); “gone to bed because they could not stay awake any longer” (44C); and “had an extremely
hard time falling asleep” (44D). The impact of poor sleep on daily life and academic performance was also assessed
with the following questions: “Within last 12 months have sleep difficulties been traumatic or very difficult to
handle?” (33K) and “Within the last 12 months have sleep difficulties affected academicperformance?” (45CC).
Statistical analyses All statistical analyses were performed with IBM SPSS version 22 (Armonk, NY). We performed a 2
(depression: yes/no) £ 2 (anxiety: yes/no) £ 3 (tobacco:
none, intermediate, daily) multivariate analysis of variance (MANOVA) with least significant difference (LSD) post hoc
tests to calculate the various impacts of depression, anxiety, and tobacco on sleep. The alpha level was set at p < .01.
Additionally, chisquare and odds ratio analyses were used to assess the impact of daily tobacco use, as compared with
other factors, on responses to categorical questions regarding the impact of poor sleep on daily life and academic
performance (questions 33K and 45CC).
Results Depression/anxiety Within the population sample, 9.9% were diagnosed with or symptomatic of depression (n
D 8,007), 8.3% were diagnosed with or symptomatic of an anxiety disorder (n D 6,683), and 11.1% were diagnosed
with and/or symptomatic of both anxiety and depression (n D 9,198). Of the 23,888 individuals diagnosed with or
identified as having probable anxiety and/or depression, 45.4% received a formal diagnosis (n D 10,854) and 34.0%
received some form of treatment (n D 8,124). Those with co-occurring anxiety and depression had the highest
occurrence of a number of problematic factors, including traumatic sleep difficulties, insomnia diagnosis, suicide
ideation/attempt, daily tobacco use, and marijuana use in the last month (Table 1). In support of hypothesis 1, there
was a significant association between depression/anxiety status (anxiety, depression, comorbid anxiety/depression,
or no anxiety/depression symptoms or diagnoses) and the number of self-reported sleep problems (Figure 1). Those
with diagnosed and/or symptomatic anxiety (F1,78908 D 793.29, p < .001) or depression (F1,78908 D 696.22, p <
.001) had significantly higher number of self-reported sleep problems in the last week than those without either
disorder, but there was no significant difference in the average number of sleep problems among those with anxiety
compared with those with depression. There was a significant interaction between depression and anxiety status;
individuals with co-occurring depression and anxiety reported the highest average number of sleep problems per
week (F1,78908 D 39.78, p < .001). Depression/anxiety status also significantly predicted the proportion of students
who reported that sleep problems negatively impacted their academic performance (x2(3, N D 80,597) D 7084.31, p <
.001). Among those without anxiety or depression, 13.3% reported that sleep problems negatively impacted academic
performance. In contrast, 31.2% of those with depression, 32.8% of those with anxiety, 47.6% of those with cooccurring depression and anxiety reported this occurrence.
Tobacco use Within the sample population, 76.8% reported not using tobacco in the last month (n D 64,369), 18.5%
reported intermediate tobacco use (nD15,535) and 4.6% reported daily tobacco use (nD3,890). In support of
hypothesis 2, those with depression and/or anxiety, or probable undiagnosed anxiety and/or depression, were more
likely to use tobacco (x2(4, ND79,706)D1073.31, p < .001). In support of hypothesis 3, the frequency of tobacco use
was associated with an increase in the number of selfreported sleep problems in the last week, regardless of
depression/anxiety status (F2,78897 D 81.87, p < .001; Figure 2). Daily tobacco users reported a higher number of
sleep complaints in the last week than both nonusers and intermediate users (p < .01). Tobacco use frequency also
significantly predicted the proportion of students who reported that sleep problems negatively impacted their
academic performance (x2(2, N D 83,039) D 741.90, p < .001. Of students with no tobacco use in the last month,
18.7% reported that sleep problems negatively affected academic performance, whereas 25.7% of students with
intermediate tobacco use and 32.8% of students with daily tobacco use reported this occurrence. Daily tobacco use
increased the odds of sleep negatively affecting academic performance by 2.13 (95% confidence interval [CI]: 1.99–
2.28). Tobacco use and depression/anxiety Depression and anxiety status was significantly associated with tobacco
use frequency in support of hypothesis 1( x2(6, N D 79,706) D 1127.98, p < .001; Figure 3). Among nonusers, 27.1%
were either diagnosed with or symptomatic for depression or anxiety, as compared with 36% of intermediate users
and 44.9% of daily tobacco users. Anxiety categorization increased the odds of daily tobacco use by 2.15 (95% CI:
2.01–2.31) and depression categorization increased the odds of daily tobacco use by 2.31 (95% CI: 2.15–2.48). Fifty-six
percent of daily tobacco users with cooccurring depression and anxiety reported that sleep problems negatively
impacted their academic performance, whereas 50.5% of intermediate users and 45.3% of nonusers comorbid for
these disorders reported negative academic impacts due to sleep problems. Regardless of disorder type, daily
tobacco use was associated with both an increased reporting of academic problems caused by sleep difficulties, and
of sleep being experienced as traumatic or difficult to handle (Table 2).
To compare the impacts of tobacco on sleep problems relative to other risk factors, we provided a table of odds ratio
comparisons for relevant factors as they relate to the likelihood of experiencing traumatic sleep difficulties in the last
12 months and reporting that sleep problems negatively impacted academic performance (Table 3).
Depression/anxiety status was the strongest indicator for these sleep problems. Depression increased the odds of
traumatic sleep difficulties by 4.11 (95% CI: 3.91–4.32), anxiety increased the odds by 3.23 (95% CI: 3.09–3.45), and
comorbid depression/anxiety by 7.55 (95% CI: 7.20– 7.92). Tobacco use was the second strongest indicator for these
sleep problems, as daily tobacco use increased the odds of traumatic sleep difficulties by 2.25 (95% CI: 2.11–2.41).
Both depression/anxiety status and daily tobacco use had larger impacts on sleep than obesity, illegal drug use, binge
drinking, gender, and working/volunteering 20 hours a week or more. Figure 4 compares the mean number of sleep
problems across the 12 groups in the multivariate analysis. In support of hypothesis 4, the lowest number of sleep
problems was observed in nonusers without depression or anxiety (2.18 § 0.01) and the highest number was
observed in daily tobacco users with co-occurring depression and anxiety (3.63 § 0.04). Multivariate analysis revealed
no significant interactions between tobacco use and depression/anxiety status in relation to the average number of
reported sleep problems (F2,78909 D .60, p > .05). Comment Our results provide strong evidence for the
interconnected relationships between depression and anxiety, tobacco use, and sleep problems in young adults. Odds
ratio analyses revealed that depression/anxiety status was the strongest predictor of sleep difficulties, and those
diagnosed with or symptomatic for both disorders experienced the greatest frequency of self-reported sleep
problems. Diagnosed/symptomatic individuals also showed a nearly 2-fold increase in the probability of daily tobacco
use. In addition, daily tobacco use increased the risk for sleep problems more so than did obesity, illegal substance
use, binge drinking, gender, and working/volunteering more than 20 hours a week.
Limitations As with any study of data from a large national sample, we are limited by a number of factors inherent in
the survey design. First, all measures are self-reported. We do not have independent confirmation of substance use,
medical diagnoses, or sleep problems. Second, we are limited to the survey questions, so we do not have access to
questions that are typically included in studies of sleep (eg, total sleep time, daily sleep diaries, circadian preference,
and sleep schedule regularity), which limits direct comparisons with other studies of sleep and nicotine use. The
ACHA-NCHA II also does not include questions about socioeconomic status (SES). A lower SES has been shown to
increase the likelihood of insomnia, as well as smoking initiation and progression to regular use.40,41 Third, the
survey respondents were disproportionately white and female and therefore not representative of the current
demographics of US college students. Fourth, we constructed a proxy measure to identify students with probable
depression and/or anxiety. We are not the first to use this approach; Wickens et al established cutoff values in the 12Item General Health Questionnaire (GHQ-12) to detect probable anxiety and mood disorders in a large national
sample.42 We cannot conclude causality using the relationships identified in this study. Depressed smokers are more
likely than nondepressed smokers to report tobacco use as a self-medicating tool to reduce negative affect and
increase alertness.43 This selfmedicating behavior seems to be mediated by the dopamine D4 receptor.44 A large,
population-based twin study (N 28,000) also demonstrated that the associations between regular tobacco use and
major depression are partially mediated by genetics.45 The weight and direction of causality in the association
between smoking and mood disturbance remain
unclear. However, evidence suggests a bidirectional relationship, wherein those with depression and/or anxiety use
tobacco to reduce mood disturbance during wakefulness, but that tobacco use also impairs sleep, which in turn
exacerbates depression and anxiety symptoms.
Conclusions This study is the first to explore the interaction of tobacco use, sleep disturbances, and anxiety and
depression in a large national sample of college students. Here, we demonstrated that tobacco use and
depression/anxiety disorders are both independently associated with more sleep problems in college students, and
those students with depression/anxiety are more likely to use tobacco, a behavior that likely exacerbates their sleep
problems. These data suggest that treatment of depression and/or anxiety should emphasize tobacco cessation as a
way to improve sleep problems associated with these disorders, along with other more established lifestyle
modifications such as implementing stress reduction and improving sleep hygiene. Furthermore, colleges and
universities might find that focusing on tobacco cessation programs and transitioning to tobacco-free campuses might
have secondary positive impacts on mental health and sleep, both of which are initiatives in the Healthy Campus 2020
campaign.
Table 1. Population sample by depression/anxiety status and problematic health factors.
Nondiagnosed and nonsymptomatic 70.5% (nD56,962)
Anxiety (diagnosed or symptomatic) 8.3% (nD6,683)
Depression (diagnosed or symptomatic) 9.9% (nD8,007)
Comorbid anxiety and depression (diagnosed or symptomatic) 11.4% (nD9,198) Sample total (ND80,850) % n % n % n % n %
With formal diagnosis 0 0 50.7% 3,390 27.3% 2,185 57.4% 5,279 % Receiving psychological treatment last year 0 0 35.0% 2,341
22.1% 1,770 43.6% 4,013 % Reported tremendous stress in the last year 2.5% 1,417 29.4% 1,962 6.8% 541 38.9% 3,575 %
Seriously considered suicide in the last year 0.5% 273 0.7% 45 28.1% 2,253 30.8% 2,836 % Attempted suicide in the last year
0.1% 65 0.2% 13 3.9% 309 4.7% 435 % Diagnosed with insomnia 0.7% 375 4.6% 308 3.7% 299 17.3% 1,588 % Extreme difficulty
falling asleep >3 days/week 8.3% 4,720 17.5% 1,166 18.3% 1,463 25.8% 2,368 % Reporting sleep as difficult to handle 15.9%
9,010 38.1% 2,541 43.6% 3,484 58.7% 5,385 % Daily tobacco use 3.6% 2,030 5.5% 363 5.9% 468 9.1% 823 % Some tobacco last
month (1–29 days) 16.7% 9,399 19.0% 1,250 23.6% 1,865 24.1% 2,182 % Reporting binge drinking in last 2 weeks 35.4% 20,108
36.7% 2,443 37.4% 2,981 38.0% 3,482 % Reporting marijuana use in last month 15% 8,496 18.3% 1,216 23.1% 1,842 26.2%
2,395
3.
Article 3.
DEPRESSION AND ANXIETY STIGMA, SHAME, AND COMMUNICATION ABOUT
MENTAL HEALTH AMONG COLLEGE STUDENTS: IMPLICATIONS FOR COMMUNICATION WITH
STUDENTS.
By: Carmack, Heather J.; Nelson, C. Leigh; Hocke-Mirzashvili, Tatjana M.; Fife, Eric M.. College Student
Affairs Journal , Spring2018, Vol. 36 Issue 1, p68-79, 12p, 1 Chart, Database: Education Source
Colleges and universities report an increase in the number of students who seek out counseling for
mental health issues, such as depression and anxiety. Although more college students are seeking
treatment, there continues to be stigma related to mental health issues. The purpose of this exploratory
study was to examine college students’ attitudes about mental health, stigma related to depression and
anxiety, and communication about mental health. Two hundred ninety-two college students enrolled in
a basic communication course at a large southern university completed a survey about their mental
health beliefs, stigmas, and communication about mental health. Students reported more stigma for
depression than anxiety. There were also significant differences in perceived personal and perceived
public stigma about these issues, with students believing the general public is more likely to stigmatize
mental health. Students also reported that as communication about mental health issues increased,
their personal stigmas about the health issues decreased. Implications of these findings and
recommendations for communication are also discussed. College life is fraught with uncertainty and
stress as students negotiate new social and educational experiences. These experiences, ranging from
dealing with roommates to adapting their learning styles to succeed in their college courses, may
contribute to the increases in reports of depression and anxiety among college students. According to
the 2015 National College Health Assessment, approximately 35 % of all college students reported
depression or depression-like experiences, 58% reported overwhelming anxiety, and 10% seriously
considered suicide (ACHA, 2016). Approximately 14.5% of students reported being diagnosed or treated
for depression, 17% reported being diagnosed or treated for anxiety, and 11% reported being diagnosed
and treated for both (ACHA, 2016). Depression and anxiety disorders can have a severe impact on
students’ ability to complete their undergraduate education; 62 % of college students who dropped out
attributed it to mental health issues (Gruttadaro & Crudo, 2012). Linked to the adolescent period during
which many students begin college (Eisenberg, Gollust, Golberstein, & Hefner, 2007), these increased of
college student mental health distress have become a serious concern for university staff and health
providers. Interestingly, a paradox seems to exist: college counseling centers are reporting a rapid
increase in students seeking treatment, with many centers reporting being booked in the first few weeks
of school (Rector, 2013), but at the same time, there continues to be a stigma associated with
depression and anxiety (Gruttadaro & Crudo, 2012). This study focuses on college students’ personal
and perceived stigma associated with depression and anxiety and their communication about these
issues. Specifically, this study examines the differences between depression stigmas, anxiety stigmas,
and the shame associated with those stigmas, and the impact communication about depression and
anxiety has on these stigmas. The article begins with a discussion of
stigma, attitudes about mental health, depression, and anxiety. After explaining the methodological
approach, the results of the study are presented. Finally, the article concludes with a discussion of the
implications and practical application of the findings, focusing on how student affairs professionals and
faculty can use these findings to help reduce depression and anxiety stigma with communication.
Literature Review Communication about mental health, especially depression and anxiety, often focuses
on the impact of stigma on how individuals talk about the issues (McNair, Highet, Hickie, & Davenport,
2002). Although there continues to be a concerted effort to reduce stigma associated with mental
health issues, including working mental health issues into television shows (Fruth & Padderud, 1985;
Hoffner & Cohen, 2012; Pirkis, Blood, Francis, & McCallum, 2006), TedTalks about depression and
anxiety, and multiple university counseling center workshops (Eustis et al., 2016), stigma is still a primary
concern. Stigma remains a major concern because of general attitudes about mental health issues
(Kosyluk et al., 2016). An inconsistency exists between perceptions of mental health issues and
communication about mental health. Part of this inconsistency stems from a lack of knowledge about
mental health issues, including causes, symptoms, and treatment options (Busby Grant, Bruce, &
Batterham, 2016; Jorm, 2000). For college students, the lack of knowledge is important because they
may have difficultly differentiating between depression and just being “blue” and generalized anxiety
disorders and typical anxiety associated with tests and homework. Although the general public is
supportive of the use of mental health services for those that have a mental health issue (Leaf, Bruce,
Tischler, & Holzer, 1987), whether those services actually get used can depend on the stigma individuals
associated with mental health issues (Tucker et al., 2013). For these individuals, embarrassment and
perceived negative reactions to seeking treatment continue to be barriers to help-seeking (Barney et al.,
2006).
Stigma In his seminal work, Stigma: Notes on the Management of Spoiled Identity, Goffman (1963)
discussed the social role of stigma in categorizing and discrediting certain individuals from being
considered an unacceptable part of society. Stigma, or the “socialized, simplified, standardized image of
the disgrace of a particular social group” (Smith, 2011, p. 455), is a socially constructed phenomenon
which socialized societal members into recognizing traits, characteristics, or physical attributes which
identify someone as different. As a communicative phenomenon, stigma relies primarily on identifying
difference and using communication to devalue and segregate others, which reinforces what is
considered (un)acceptable in society (Smith, 2007). Stigma is a multifaceted experience. There are three
levels of stigma (or taint) individuals might experience: physical, social, and moral (Ashforth & Kreiner,
1999). Physical stigma is categorized by difference that can be readily identified, such as the loss of a
limb or a physical deformity. Social stigma, also known as courtesy stigma (Page, 1984), is separation as
a result of association with someone who is stigmatized. Finally, moral stigma occurs when the
difference is regarded as sinful or is associated with dubious virtue, such as alcohol and drug. Mental
health issues are unique in that they can involve all three types of stigma (Thoits, 2011). There are
physical impacts of mental health (physical pain, panic attacks), poor mental health can be seen as a
deficiency in character or lack of self-control, and some many find it difficult to associate or have
relationships with people with mental health issues. There are three elements of stigma to consider
when attempting to understand stigma perceptions: personal stigma, perceived stigma, and shame
(Gilbert et al.,
2007; Griffiths, Batterham, Barney, & Parsons, 2011; Griffiths, Christensen, & Jorm, 2008). Personal
stigma is concerned with an individual’s personal attitudes toward the stigmatized person (Griffiths et
al., 2008). Personal stigma about mental health issues may include not considering the mental health
issue a “real” medical disorder, individuals having control over their mental health issues, and associated
negative personality or behavioral traits with the individuals. Interestingly, increased knowledge of
mental health issues does not seem to impact or lower personal stigma. Wang and Lai (2008) found that
individuals stigmatized people with depression as unpredictable and dangerous regardless of whether
they had high levels of depression literacy; having family members with depression also did not
influence people’s personal stigma of depression. Other factors which have an impact on personal
stigma and depression include sex (men report higher levels) and education (those with less education
report higher levels; Giffiths et al., 2008). Individuals who disclosed their depression to others reported
lower levels of personal stigma (Griffiths et al., 2008). Individuals do report lower levels of personal
stigma for anxiety disorders (Griffiths et al., 2011) than for depression. Women reported lower levels of
personal stigma toward anxiety, as did individuals who had more exposure to or who had been
diagnosed with an anxiety disorder (Batterham et al., 2013). Importantly, personal stigma is negatively
related to help seeking; those with higher levels of personal stigma reported seeking out and using
therapeutic support than those with lower levels of personal stigma (Eisenberg et al., 2009). Perceived
stigma, also known as public stigma, focuses on the perceived beliefs about others’ negative attitudes
(Griffiths et al., 2008). Perceived stigma about others’ negative attitudes can include a variety of
different groups, including family, friends, the general community, and health providers. The important
emphasis here, however, is on the fact that “most people”, or a “majority of society” believes a certain
way about an issue. Age is a factor influencing perceived stigma, with younger populations reporting
higher levels of perceived stigma (Vaughn-Sandler, Sherman, Aronsohn, & Volk, 2014); this is consistent
with Griffiths and colleague (2008) who found that perceived stigma is lower in older populations.
Individuals with higher levels of perceived stigma also reported higher levels of depression, lower levels
of quality of life, had less social support, and were less likely to seek medical care (Momen, Strychacz, &
Viirre, 2012; Vaughn-Sandler et al., 2014). Additionally, family members’ experiences with depression
may also impact perceived stigma (Griffiths et al., 2008). Individuals who self-disclosed their depression
also reported lower levels of perceived stigma (Griffiths et al., 2008). For anxiety, individuals who had
higher exposure to anxiety disorders reported higher levels of perceived stigma (Batterham et al., 2013).
H1: There is a difference in depression stigma between personal depression stigma and perceived
depression stigma. H2: There is a difference in anxiety stigma between personal anxiety stigma and
perceived anxiety stigma. The emotional response to stigma communication is crucial to understanding
the entire stigma experience, especially how individuals respond to stigma (Meisenbach, 2010). For
stigmatized individuals, a key emotional response is shame. Shame is a reaction to criticism by other
people (Shultz, 2000). Shame focuses on others’ perceptions of the individual. Shame is unequivocally
tied to embarrassment because attention is focused on the individual (Andersen & Guerrero, 1998) and
is the product of being exposed, judged, and deemed different. Shame is a primary emotion associated
with stigma because we often view criticism as reflection of self (Luoma & Platt, 2015). The focus is on
the individual who has been shamed, in this case stigma
tized, and his or her emotional response is because he or she believes this is how the world sees them.
Individuals may experience different types of shame, including external shame, internal shame, and
reflected shame. External shame is shame focused on “the negative feelings associated with experiences
that others are looking down on the self with desires to reject or harm the self” (Gilbert et al., 2007, p.
128). In other words, external shame focuses on the minds of others. Importantly, external shame is also
associated with stigma awareness, especially in relation to attitudes about mental health (Gilbert, 1998;
Gilbert et al., 2007). Internal shame focuses on the personal shame an individual experiences. Whereas
external shame is concerned with stigma awareness, internal shame is concerned with stigma
consciousness, a fear of being stigmatized because of certain traits (Gilbert, 1998). Shame occurs even at
the thought of being stigmatized. Finally, a stigmatized individual can experience reflected shame.
Reflected shame focuses on the reciprocal nature of stigma and shame. Reflected shame is concerned
with the shame an individual can bring to others, especially family, close friends, and the community.
Reflected shame assumes a level of stigma will be associated with those close to the stigmatized
individual because of the stigma, so the individual feels shameful. For individuals with mental health
conditions, there is an assumption that family members may be seen as weak or also having mental
health issues and that members of the community may not want to associated with the individual
(Gilbert et al., 2007). H3: There is a difference in external shame and internal shame for attitudes
toward mental health. H4: There is a difference in reflected shame if a person suffers from mental
illness versus reflected shame if a close relative suffers from a mental illness. One way to reduce the
stigma and shame associated with mental health issues to focus on increasing positive communication
about those mental health issues. Over the past decade, communication scholarship has seen a
resurgence in research dedicated to the study of depression and anxiety among college students,
especially in how these mental health issues impact disclosure (Scott, Caughlin, Donovan-Kicken, &
Mikucki-Enyart, 2013), how they seek out, receive, and perceive social support (Pauley & Hess, 2009;
Wright, King, & Rosenberg, 2014; Wright et al., 2013), the role of communication competence and
negative messages (Lienemann, Siegel, & Crano, 2013; Wright et al., 2013) and the impact of technology
in seeking treatment and social support (Joyce & Weibelzahl, 2011; Wright et al., 2013). What is missing
from these examinations is the role of mental health stigma on how students communicate about these
mental health issues. Communication about mental health issues can involve a number of different
conversations, from openly speaking about a diagnosis in order to dispel myths to the communication
between patients and counselors. In this study, communication is conceptualized as general talk about
mental health issues with family, friends, and other important people in students’ lives. H5: Talking
about anxiety and mental health issues is related to stigmas and attitudes towards mental health
problems.
Method Participants and Procedure The participants were 292 students (61 males, 231 females, and 3
missing) enrolled in a basic communication course at a large southern university. The participants’
average age was 18.48; 272 freshmen, 13 sophomores, six juniors, and one senior participated in the
study. Thirty-two participants reported being diagnosed with depression by a health provider (11%) and
43 students reported a generalized anxiety disorder diagnosis (15%). At the time of this study, 15
students were currently receiving psychological or counseling treatment (5%) and 28
were taking medication for anxiety or depression (9.5%). Ninety-four students had a close relative who
had been diagnosed with depression (32%), 84 students had a family member who had been diagnosed
with an anxiety disorder (29%), 124 students had a close friend with depression (42%), and 116 students
had a close friend who had been diagnosed with an anxiety disorder (40%). After the researchers
obtained university Institutional Review Board approval, the study was listed on the communication
department’s research participation system. The research participation system is an online system that
helps facilitate research studies and tracks student participation without tying students’ names to the
actual study. Students see the study description listed on the site and voluntarily choose to participate
in a study. The online survey was administered through Qualtrics web surveying software.
Measures Depression stigma was measured by Griffiths, Christensen, and Jorm’s (2008) Depression
Stigma Scale. This 18-item scale has two subscales and responses were measured on a 5-point Likert
scale with strongly disagree coded as a 1 to strongly agree coded as a 5. Responses were coded so that
a high score represented more stigma. Respondents’ personal attitude towards depression was
measured with the 9-item subscale of personal stigma with items such as “Depression is a sign of
personal weakness.” Cronbach’s alpha for this subscale was .77. The other 9 items on this scale
composed the perceived depression stigma subscale which assesses the respondent’s beliefs about the
attitudes of others toward depression. Items such as “Most people believe that depression is not a real
medical illness” composed this subscale. Cronbach’s alpha for this subscale was .83. General anxiety
stigma was measured with Griffiths, Batterham, Barney, and Parson’s (2011) Generalised Anxiety Stigma
Scale (GASS). This 20-item scale has two subscales and responses were measured on a 5-point Likert
scale with strongly disagree coded as a 1 to strongly agree coded as a 5. Higher numbers represented
more anxiety. The 10-item subscale of personal anxiety had items such as “People with an anxiety
disorder should be ashamed of themselves.” Cronbach’s alpha for this subscale was .90. The perceived
anxiety subscale had 10 items and had statements such as “Most people think that people with an
anxiety disorder are to blame for their problem.” Cronbach’s alpha for this subscale was .91. Attitudes
towards mental health were measured with Gilbert, Bhundia, Mitra, McEwan, Irons, and Sanghera’s
(2007) Attitudes towards Mental Health Problems scale. This 35-item scale is divided into five subscales.
Responses were adapted to a 5-point Likert scale with strongly disagree coded as a 1 to strongly agree
coded as a 5 to maintain consistency throughout the questionnaire. General attitudes towards mental
health was measured with an 8-item subscale with the word “community” changed to “friends” to
better examine the student population perceptions. The subscale was comprised of items such as “My
family see mental health problems as something to keep secret.” The subscale had a Cronbach’s alpha
of .87. The external shame subscale was measured with 10 items with “community” again changed to
“friends” in these items. Items such as “I think my friends (formerly community) would look down on
me” were on this subscale which had a Cronbach’s alpha of .94. Internal shame was a 5-item subscale
with Cronbach’s alpha of .90. Items such as “I would see myself as inferior” were on this subscale.
Items such as “My family would be seen as inferior” were on the 7-item reflected shame 1 subscale,
which had a Cronbach’s alpha of .90. Reflected shame 2 was the last subscale of the attitudes towards
mental health scale which had a Cronbach’s alpha of .97 and was composed of five items with items
such as “I would worry that others will look down on me” if a close relative had a mental health
problems. Talking about anxiety and depression was measured by six items developed for this study and
included the following: How often do you talk with your friends about anxiety issues (in general)? How
often do you talk with your family about anxiety issues (in general)? How often do you talk with health
providers about anxiety issues (in general)? How often do you talk with your friends about depression
issues (in general)? How often do you talk with your family about depression issues (in general)? How
often do you talk with health providers about depression issues (in general)? Responses were never
(coded as a 1), yearly (coded as a 2), monthly (coded as a 3), weekly (coded as a 4), 2-3 times a week
(coded as a 5), and daily (coded as a 6). Responses were then summed so that a higher number
represented more talking about anxiety and depression issues in general. Sex, age, and year in school
were also assessed for demographic information. See Table 1 for means and standard deviations of all
of the scales.
Results Hypothesis one examined whether there were significant differences among personal stigmas of
depression (M = 2.13, SD = .54) and perceived stigmas of depression (M = 3.41, SD = .61). To test this
hypothesis, a paired-sample t-test was conducted and was significant t(291) = -26.43, p
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