Abstract:

The COVID-19 pandemic may have had an impact on the mental health of university students and, consequently, led to the initiation on psychotropic medications or an increase on its use. This study aimed to assess the prevalence of the use of psychotropic medications among university students and evaluate the association of the use of such medicine with students who belong to minority groups. This is a cross-sectional study, in which all students enrolled in undergraduate courses at eight Brazilian public universities were invited to answer an online self-administered questionnaire. The data collection was conducted from October 2021 to February 2022. The outcome was the use of psychotropic medications and the explanatory variables were students who belong to minority groups, such as female, black, mixed-race, and other skin colors, and LGBTQIAPN+ individuals. The variables were descriptively analyzed and Pearson’s chi-squared test and multinomial logistic regression were performed. A total of 8,650 students participated in the study, of which 25.7% reported using psychotropic medications in the 30 days prior to completing the questionnaire. It was observed that among students, female (OR = 1.8; 95%CI: 1.41-2.20) and non-heterosexual (OR = 1.5; 95%CI: 1.23-1.80) had higher chances of using psychotropic medications during the COVID-19 pandemic. It was found that university students began using psychotropic medications and the association of its use with minority groups was observed.

Keywords:
COVID-19; Minority Groups; Psychotropic Drugs; Mental Health; Universities

Resumo:

A pandemia de COVID-19 pode ter impactado a saúde mental de estudantes universitários e, consequentemente, levado ao início ou ao aumento do uso de medicamentos psicotrópicos. Este estudo avaliou a prevalência do uso de medicamentos psicotrópicos entre estudantes universitários e avaliar a associação do uso dessa classe de medicamentos com estudantes de grupos minoritários. Trata-se de um estudo transversal, no qual todos os estudantes matriculados em cursos de graduação em oito universidades públicas brasileiras foram convidados. Dados foram coletados de outubro de 2021 a fevereiro de 2022, por meio de um questionário online autoaplicável. A variável de interesse foi o uso de medicamentos psicotrópicos e as variáveis explicativas foram estudantes pertencentes a grupos minoritários, como mulheres; negros, pardos e de outras cores de pele; e orientação sexual LGBTQIAPN+. As variáveis foram analisadas de forma descritiva, sendo realizados o teste qui-quadrado de Pearson e a regressão logística multinomial. Um total de 8.650 estudantes participaram do estudo, dos quais 25,7% relataram o uso de medicamentos psicotrópicos nos 30 dias anteriores ao preenchimento do questionário. Observou-se que, entre os estudantes, ser do sexo feminino (OR = 1,8; IC95%: 1,41-2,20) e não ser heterossexual (OR = 1,5; IC95%: 1,23-1,80) aumentaram as chances de usar medicamentos psicotrópicos durante a pandemia de COVID-19. Constatou-se que estudantes universitários iniciaram o uso de medicamentos psicotrópicos e encontrou-se associação entre esse uso e estudantes de grupos minoritários.

Palavras-chave:
COVID-19; Grupos Minoritários; Psicotrópicos; Saúde Mental; Universidades

Resumen:

La pandemia del COVID-19 puede haber afectado a la salud mental de los estudiantes universitarios y, en consecuencia, haber llevado al inicio o aumento del uso de los psicofármacos. Este estudio evaluó la prevalencia del uso de los psicofármacos entre estudiantes universitarios y examinó la asociación de este uso con estudiantes de grupos minoritarios. Se trata de un estudio transversal, en el que se invitó a todos los estudiantes matriculados en cursos de grado en ocho universidades públicas brasileñas. Los datos se recopilaron desde octubre de 2021 hasta febrero de 2022 mediante un cuestionario en línea autoadministrado. La variable de interés fue el uso de psicofármacos; y las variables explicativas fueron estudiantes pertenecientes a grupos minoritarios, como mujeres; negros, pardos u otros colores de piel; y orientación sexual LGBTQIAPN+. Las variables se analizaron de manera descriptiva y se realizaron la prueba de chi-cuadrado de Pearson y la regresión logística multinomial. Un total de 8.650 estudiantes participaron en el estudio, de los cuales el 25,7% informó haber usado los psicofármacos a los 30 días previos a completar el cuestionario. Se observó que, entre los estudiantes, ser mujer (OR = 1,8; IC95%: 1,41-2,20) y no ser heterosexual (OR = 1,5; IC95%: 1,23-1,80) aumentaron las posibilidades de uso de psicofármacos durante la pandemia del COVID-19. Se encontró que los estudiantes universitarios empezaron a usar los psicofármacos y se encontró una asociación entre este uso y los estudiantes de grupos minoritarios.

Palabras-clave:
COVID-19; Grupos Minoritarios; Psicotrópicos; Salud Mental; Universidades

Introduction

The World Health Organization (WHO) emphasizes that mental health is an integral component of general health, encompassing a state of physical, emotional, psychological, and social balance ¹1. World Health Organization. Mental health. https://www.who.int/en/news-room/fact-sheets/detail/mental-health-strengthening-our-response (accessed on 15/Oct/2023).
https://www.who.int/en/news-room/fact-sh... . Social, economic, and environmental determinants can influence mental health ²2. Gary F, Lotas M. A population health approach to health disparities for nurses: care of vulnerable populations. New York: Springer; 2023.^,33. World Health Organization. World Mental Health Report: transforming mental health for all. Geneva: World Health Organization; 2012.. During crisis, such as those experienced in outbreaks, endemics, and pandemics, there is an increased fear of contracting a disease, which becomes a major stressor ⁴4. Brooks SK, Webster RK, Smith LE, Woodland L, Wessely S, Greenberg N, et al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Lancet 2020; 395:912-20.^,55. Filgueiras A, Stults-Kolehmainen M. The relationship between behavioural and psychosocial factors among Brazilians in quarantine due to COVID-19. SSRN 2020; 14 apr. https://ssrn.com/abstract=3566245.
https://ssrn.com/abstract=3566245... ^,66. Qiu J, Shen B, Zhao M, Wang Z, Xie B, Xu Y. A nationwide survey of psychological distress among Chinese people in the COVID-19 epidemic: implications and policy recommendations. Gen Psychiatr 2020; 33:e100213..

In 2019, before the COVID-19 pandemic, the worldwide prevalence of depression in women and men aged 20 to 24 years was 4.7% and 3.2%, respectively, while anxiety had a prevalence of 5.7% in women and 3.6% in men ⁷7. Institute of Health Metrics and Evaluation. Global health data exchange (GHDx). https://vizhub.healthdata.org/gbd-results/ (accessed on 09/Aug/2024).
https://vizhub.healthdata.org/gbd-result... . Despite the lack of data on the prevalence of these mental disorders among university students, a systematic review involving 56,816 participants from several countries revealed a concerning situation, with prevalence rates of 26.1% for depression symptoms and 24.5% for anxiety symptoms ⁸8. Paula W, Breguez GS, Machado EL, Meireles AL. Prevalence of anxiety, depression, and suicidal ideation symptoms among university students: a systematic review. Braz J Health Rev 2020; 3:8739-56.. This scenario may have been modified by the pandemic, which led to a significant increase in stress, anxiety, and concerns regarding health, employment, finances, and uncertainties in general ⁹9. Nelson BW, Pettitt A, Flannery JE, Allen NB. Rapid assessment of psychological and epidemiological correlates of COVID-19 concern, financial strain, and health-related behavior change in a large online sample. PLoS One 2020; 15:e0241990.^,1010. Wilson JM, Lee J, Fitzgerald HN, Oosterhoff B, Sevi B, Shook NJ. Job insecurity and financial concern during the COVID-19 pandemic are associated with worse mental health. J Occup Environ Med 2020; 62:686-91.. Consequently, sales of prescription medications rose in 2020, reflecting the burden of mental health impairments related to the pandemic ¹¹11. Afonso P, Figueira L. Pandemia COVID-19: quais são os riscos para a saúde mental? Revista Portuguesa de Psiquiatria e Saúde Mental 2020; 6:2-3.^,1212. Rodrigues PS, Francisco P, Fontanella AT, Borges RB, Costa KS. Use and sources of psychotropic medicines by Brazilian adults and seniors. Ciênc Saúde Colet 2020; 25:4601-14.^,1313. Escalante Saavedra PA, Galato D, Silva CMS, Silva ICR, Silva EV. Dispensing of psychotropic medicines in the Brazilian capital city before and during the COVID-19 pandemic (2018-2020). Front Pharmacol 2022; 13:1028233.. Psychotropic medication use can differ between university students and the general population, influenced by factors like age, academic environment, workload, stress levels, and mental health prevalence. Studies show the rates of use of psychotropic medications among university students increased from 12.7% to 30.4% and may even surpass those observed in the general population ¹⁴14. Fasanella NA, Custodio CG, Cabo JSD, Andrade GS, Almeida FA, Pavan MV. Use of prescribed psychotropic medicines among medical students and associated factors: a cross-sectional study. Sao Paulo Med J 2022; 140:697-704.^,1515. Balayssac D, Pereira B, Darfeuille M, Cuq P, Vernhet L, Collin A, et al. Use of psychotropic medications and illegal drugs, and related consequences among French pharmacy students - SCEP Study: a nationwide cross-sectional study. Front Pharmacol 2018; 9:725.^,1616. Tovani JBE, Santi LJ, Trindade EV. Use of psychotropic drugs by students from the health area: a comparative and qualitative analysis. Rev Bras Educ Méd 2021; 45:e175..

University students face academic pressure, expectations, transitions, and emotional demands during their studies ¹⁷17. Aspelmeier JE, Love MM, McGill LA, Elliott AN, Pierce TW. Self-esteem, locus of control, college adjustment, and GPA among first-and continuing-generation students: a moderator model of generational status. Research in Higher Education 2012; 53:755-81.. For minority groups, including women, black and mixed-race people, and LGBTQIAPN+ individuals, the COVID-19 pandemic may have intensified these challenges ¹⁸18. Shachar A. Multicultural jurisdictions: cultural differences and women's rights. Cambridge: Cambridge University Press; 2001.^,1919. Copeland WE, McGinnis E, Bai Y, Adams Z, Nardone H, Devadanam V, et al. Impact of COVID-19 pandemic on college student mental health and wellness. J Am Acad Child Adolesc Psychiatry 2021; 60:134-41.^,2020. Fruehwirth JC, Biswas S, Perreira KM. The COVID-19 pandemic and mental health of first-year college students: examining the effect of COVID-19 stressors using longitudinal data. PLoS One 2021; 16:e0247999.^,2121. Seehuus M, Moeller RW, Peisch V. Gender effects on mental health symptoms and treatment in college students. J Am Coll Health 2021; 69:95-102.^,2222. Wilson LC, Liss M. Safety and belonging as explanations for mental health disparities among sexual minority college students. Psychol Sex Orientat Gend Divers 2022; 9:110-9.^,2323. Bermúdez Figueroa E, Dabetic V, Yuste RP, Saeidzadeh Z. Gender and structural inequalities from a socio-legal perspective. In: Vujadinovic D, Fröhlich M, Giegerich T, editors. Gender-competent legal education. Cham: Springer; 2023. p. 95-142.. These groups often face barriers to mental health services, such as a shortage of professionals and discrimination ²⁴24. Hall WJ, Chapman MV, Lee KM, Merino YM, Thomas TW, Payne BK, et al. Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: a systematic review. Am J Public Health 2015; 105:e60-76.^,2525. Conner CK, Lamb KM, Dermody SS. Access and barriers to health services among sexual and gender minority college students. Psychol Sex Orientat Gend Divers 2023; 10:498.. The pandemic worsened these issues by straining health systems and limiting in-person services, which may have increased reliance on medication ²⁶26. Brown P, Watts V, Hanna M, Rizk M, Tucker E, Saddlemire A, et al. Two epidemics and a pandemic: the collision of prescription drug misuse and racism during COVID-19. J Psychoactive Drugs 2021; 53:413-21.^,2727. Diaz A, Baweja R, Bonatakis JK, Baweja R. Global health disparities in vulnerable populations of psychiatric patients during the COVID-19 pandemic. World J Psychiatry 2021; 11:94-108.. Because psychological support and on-site therapy were often interrupted, some countries temporarily eased restrictions on psychotropic medications ²⁸28. Agência Nacional de Vigilância Sanitária. RDC nº 357, de 24 de março de 2020. Estende, temporariamente, as quantidades máximas de medicamentos sujeitos a controle especial permitidas em Notificações de Receita e Receitas de Controle Especial e permite, temporariamente, a entrega remota definida por programa público específico e a entrega em domicílio de medicamentos sujeitos a controle especial, em virtude da Emergência de Saúde Pública de Importância Internacional (ESPII) relacionada ao novo Coronavírus (SARS-CoV-2). Diário Oficial da União 2020; 24 mar.^,2929. Sousa EJS, Gonçalves NJP, Dias AAS, Brito MCA, Serejo AP, Fernandes MA. Changes in pharmaceutical legislation during COVID-19 pandemic. Res Soc Dev 2021; 10:e89101220124.. Inadequate social and family support may further hinder treatment effectiveness and increase negative mental health outcomes for these minorities ³⁰30. Moore SE, Wierenga KL, Prince DM, Gillani B, Mintz LJ. Disproportionate impact of the COVID-19 pandemic on perceived social support, mental health and somatic symptoms in sexual and gender minority populations. J Homosex 2021; 68:577-91.^,3131. Acoba EF. Social support and mental health: the mediating role of perceived stress. Front Psychol 2024; 15:1330720..

Studies on pharmacoepidemiology are of paramount importance in collecting data on the effectiveness and safety of medications use and prescription profile, as well as factors associated with use, among others ³²32. Montastruc JL, Benevent J, Montastruc F, Bagheri H, Despas F, Lapeyre-Mestre M, et al. What is pharmacoepidemiology? Definition, methods, interest and clinical applications. Therapie 2019; 74:169-74.. Although studies on psychotropic medication use during the pandemic exist ³³33. Benistand P, Vorilhon P, Laporte C, Bouillon-Minois JB, Brousse G, Bagheri R, et al. Effect of the COVID-19 pandemic on the psychotropic drug consumption. Front Psychiatry 2022; 13:1020023.^,3434. Leong C, Kowalec K, Eltonsy S, Bolton JM, Enns MW, Tan Q, et al. Psychotropic medication use before and during COVID-19: a population-wide study. Front Pharmacol 2022; 13:886652.^,3535. Villanueva-Blasco VJ, Villanueva-Silvestre V, Vazquez-Martinez A, Vicente LP, Perez-Galvez B. Depression, suicidal ideation, and consumption of psychotropic drugs during lockdown by COVID-19 according to gender and age. Int J Ment Health Addict 2022; 22:1-17., data on university students, especially minority groups, are lacking. This study hypothesizes the COVID-19 pandemic may have increased the use of psychotropic medication among university students, potentially via self-medication, despite the Brazilian regulation under Federal Ordinance n. 344³⁶36. Secretaria de Vigilância em Saúde, Ministério da Saúde. Portaria nº 344, de 12 de maio de 1998. Aprova o Regulamento Técnico sobre substâncias e medicamentos sujeitos a controle especial. Diário Oficial da União 1998; 15 may., 1998. Additionally, minority students - such as women, black, mixed-race, and LGBTQIAPN+ individuals - may have used these medications more than other students during the pandemic.

Therefore, this study aimed to assess the prevalence of the use of psychotropic medications and self-medication, as well as associations with minority groups, comparing pre-pandemic and pandemic periods among students at Federal Higher Education Institutions (IFES) in Brazil.

Methods

Study design and population

This cross-sectional study is part of the survey Symptoms of Anxiety and Depression Disorders among University Students in Minas Gerais: Multicenter Study (Project on Anxiety and Depression in University Students - PADu-multicenter), whose population are undergraduate students of eight public universities: Federal University of Ouro Preto (UFOP, acronym in Portuguese), Federal University of Minas Gerais (UFMG, acronym in Portuguese), Federal University of Juiz de Fora (UFJF, acronym in Portuguese), Federal University of São João del-Rei (UFSJ, acronym in Portuguese), Federal University of Lavras (UFLA, acronym in Portuguese), Federal University of Alfenas (UNIFAL, acronym in Portuguese), Federal University of Jequitinhonha and Mucuri Valleys (UFVJM, acronym in Portuguese), and Federal University of Uberlândia (UFU, acronym in Portuguese).

All students aged over 18 years, enrolled in undergraduate courses during the second semester of 2021, were invited to participate in the PADu-multicenter, totaling 118,828 students. A list of students’ email addresses was provided by the university itself so that researchers could send out invitations to participate in the survey. In other cases, the invitation was automatically sent via the university’s own communication system. The PADu-multicenter dataset included valid responses from 8,650 students. All students were invited to complete the survey, so no initial sample size calculation was performed. Posthoc power analysis showed satisfactory results (normal approximation > 98%). With a 7.3% response rate, the sample size was sufficient to detect significant associations, ensuring robust and reliable findings. For more details, see Barbosa et al. ³⁷37. Barbosa BCR, Paula W, Ferreira AD, Freitas ED, Chagas CMS, Oliveira HN, et al. Anxiety and depression symptoms in university students from public institutions of higher education in Brazil during the covid-19 pandemic: a multicenter study. Scielo Preprints 2023; 25 may. https://doi.org/10.1590/SciELOPreprints.6080.
https://doi.org/10.1590/SciELOPreprints.... .

Data collection

The research was publicized on the official websites and social networks of the participating institutions, as well as in research groups, centers, and academic departments. Data collection was conducted from October 2021 to February 2022 via an online and self-administered questionnaire, available on Google Forms (https://docs.google.com/forms/u/0/), with questions regarding sociodemographic and academic characteristics, lifestyle habits, and health conditions.

All procedures were performed according to the Brazilian guidelines and standards for research involving human beings of the Declaration of Helsinki and approved by the Research Ethics Committee of the participating universities (CAAE from the coordinating center - UFOP: 43027421.3.1001.5150).

Study variables

The outcome variable was the use of psychotropic medications (anxiolytics and sedatives, antidepressants, antipsychotics, psychomotor stimulants, psychomimetics, and those with cognitive enhancing activity). Such use was determined by self-report, based on the answers to the questions: (1) In the last 30 days, did you use any medication?; (2) Mention the name of the medication you are taking or have used in the last 30 days; and (3) Did you start using the medication after the onset of the pandemic? For questions one and three the answer options were no/yes. The second was an open-ended question. The reported medications were grouped into classes according to the third (pharmacological class) and fifth (chemical substance) levels of the Anatomical Therapeutic Chemical (ATC classification) ³⁸38. WHO Collaborating Centre for Drug Statistics Methodology. Guidelines for ATC classification and DDD assignment 2024 (last updated: 2024-03-01). Oslo: WHO Collaborating Centre for Drug Statistics Methodology; 2023..

Subsequently, the participants were classified into four groups: those who do not use psychotropic medication; those who reported using some psychotropic medication before the COVID-19 pandemic; those who started using psychotropic medications during the pandemic; and participants who were already using them previous to the pandemic and started using new psychotropic medications during the pandemic.

The explanatory variables were students who belong to minority groups: female; non-white skin color, such as black, mixed-race and others (Asians, Indigenous people); and non-heterosexual, (LGBTQIAPN+).

Sociodemographic, lifestyle habits, and health conditions variables were used to characterize the sample, such as age (18-22 years old or > 22 years old), marital status (single, married, stable union, widowed, or divorced), type of housing (alone, with family or with friends or colleagues in an apartment, house, or dormitory), family income (up to 4 minimum wages or more than 4 minimum wages in Brazil), knowledge area (Life Sciences, Exact Sciences, Human and Social Sciences, or Applied Sciences), routine of academic activities (fully remote, hybrid, or on-site), alcohol consumption (no/yes), smoking (no/yes), practice of physical activity (no/yes), overweight (no/yes), COVID-19 infection (no, I think so (not confirmed by test), yes), diagnosis of chronic illness (no/yes), suicidal ideation (no/yes), anxiety (normal/mild, moderate, or severe/extremely severe), depression (normal/mild, moderate, severe, or extremely severe), and stress (normal/mild, moderate, or severe/extremely severe).

The variables were obtained from questions adapted from national surveys, such as the Brazilian Household Budget Survey³⁹39. Instituto Brasileiro de Geografia e Estatística. Pesquisa de Orçamentos Familiares 2008-2009: antropometria e estado nutricional de crianças, adolescentes e adultos no Brasil. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2010. and Brazilian National Survey of Health⁴⁰40. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde 2013. Percepção do estado de saúde, estilos de vida e doenças crônicas: Brasil, Grandes Regiões e Unidades da Federação. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2014.. The variable overweight (no/yes) was self-reported by the students, based on the body mass index, and subsequently categorized regarding age group, according to the reference values recommended by WHO for adolescents and adults ⁴¹41. World Health Organization. Obesity: preventing and managing the global epidemic. Geneva: World Health Organization; 2000. (WHO Technical Report Series, 894).. The assessment of anxiety, depression, and stress symptoms was performed using the Depression Anxiety Stress Scale-21 (DASS-21), adapted and validated for the Brazilian Portuguese by Vignola & Tucci ⁴²42. Vignola RC, Tucci AM. Adaptation and validation of the depression, anxiety and stress scale (DASS) to Brazilian Portuguese. J Affect Disord 2014; 155:104-9.. The DASS-21 enables a summation, which is later multiplied by two, generating scores that allow for classifying symptoms into five levels: “normal”, “mild”, “moderate”, “severe” and “extremely severe”. In this study, symptoms were reclassified into three categories: “normal/mild”, “moderate” and “severe/extremely severe”.

Statistical analysis

The consistency of the collected data and the database coding was performed using Microsoft Excel 2013 (https://products.office.com/). Statistical analyses were performed using Stata software, version 13.0 (https://www.stata.com). Firstly, descriptive analysis was conducted using frequency distribution and bivariate analysis using Pearson’s chi-squares test. The covariates related to the use of psychotropic medications at p < 0.050 in the bivariate analysis were included as adjustments in the multivariate analysis.

For the multivariate analysis, three explanatory variables were considered: sex, skin color, and sexual orientation. A multinomial logistic regression was performed, which enabled odds ratios (OR) calculation considering an outcome with more than two categories and each category was compared to the reference category in a single processing. The reference category was non-use of psychotropic medications, which was compared to three categories: use of psychotropic medications in the period before the pandemic; use of psychotropic medications during the pandemic; previous use of psychotropic medications and the use of new ones during the pandemic. Notably, 95% confidence intervals (95%CI) were used.

Results

The sample population was composed of 8,650 students. It was observed that most were female (65.7%), self-declared white (55.4%), heterosexual (66.1%), aged from 18 to 22 years (54.2%), and had a mean age of 23.9 years (standard deviation - SD ±6.3). Severe or extremely severe symptoms of anxiety and depression affected 43.5% and 44.8% of students, respectively (Table 1).

The use of at least one medication in the 30 days prior to completing the questionnaire, regardless of the pharmacological class, was reported by 4,629 participants (53.5%), with a mean of 1.9 medications (SD ±1.3). The prevalence of psychotropic medications use was 25.7% (95%CI: 24.8-26.6) regarding the total sample.

Among students using psychotropic medications, most started using them during the COVID-19 pandemic (44.9%), followed by those who were already using them and added new medications from the same pharmacological class during the pandemic (29.8%) and, finally, those who were already using them before the pandemic and maintained this use (25.3%). Moreover, 137 (6.2%) cases of self-medication were identified (Figure 1).

Regarding the number of medications used, 3,741 psychotropic medications were reported by the students, who could use more than one medication or class at the same time. Antidepressants (N06A) were the most used, being cited by 38.5% (n = 1,782) of the students who reported using some medication (n = 4,629). In addition, 11.3% (n = 524) reported the use of antiepileptics (N03A); 6.4% (n = 297) of antipsychotics (N05A); 5.4% (n = 251) of hypnotics and sedatives (N05C); 4.6% (n = 215) of anxiolytics (N05B), and 3.9% (n = 179) psychostimulants, agents used for attention deficit hyperactivity disorder (ADHD) and nootropics (N06B). Table 2 shows the number of medications citations by category and ranking of the most cited medications by the students, respectively.

Table 3 shows the results of the multinomial logistic regression between minority groups and the use of psychotropics. Compared to male students, female students had a greater chance of starting and increasing the use of psychotropic medications during the pandemic (OR = 1.8; 95%CI: 1.41-2.20). Those who declared themselves mixed-race, black and others had lower chances of starting (OR = 0.8; 95%CI: 0.68-0.92) or increasing (OR = 0.7; 95%CI: 0.56-0.81) the use of psychotropic medications when compared to those who declared themselves white. And, finally, LGBTQIAPN+ students were more likely to have started (OR = 1.3; 95%CI: 1.09-1.48) or increased (OR = 1.5; 95%CI: 1.23-1.80) the use of psychotropic medications during the pandemic compared to heterosexual students.

Discussion

This study found a high prevalence of the use of psychotropic medication among Brazilian university students, with over a quarter reporting usage. Many students started or increased the use of these medications during the pandemic, reflecting the impact of this period. Instances of self-medication with prescription-only medications were noted. Female and LGBTQIAPN+ students were more likely to start or increase the use of psychotropic medication during the pandemic.

Prevalence studies are crucial for understanding students’ mental health, guiding policies, facilitating interventions, reducing stigma, and directing future research ⁴³43. Mamat CF, Jamshed SQ, El Syed T, Khan TM, Othman N, Al-Shami AK, et al. The use of psychotropic substances among students: the prevalence, factor association, and abuse. J Pharm Bioallied Sci 2015; 7:181.^,4444. Maidana MS, Fernandes CLF, Dumith SC, Silva Júnior FMR. Prevalence and factors associated to the use of illicit drugs and psychotropic medicines among Brazilian undergraduates. Acta Sci Health Sci 2020; 42:e46774-e.. This research is essential for providing the support students need for academic and personal success.

A 2019 study on Brazilian medical students reported lower use of psychotropic before the pandemic ¹⁴14. Fasanella NA, Custodio CG, Cabo JSD, Andrade GS, Almeida FA, Pavan MV. Use of prescribed psychotropic medicines among medical students and associated factors: a cross-sectional study. Sao Paulo Med J 2022; 140:697-704.. Another study indicated an increased use of psychotropic among younger people (18-25 years), which includes most university students ¹³13. Escalante Saavedra PA, Galato D, Silva CMS, Silva ICR, Silva EV. Dispensing of psychotropic medicines in the Brazilian capital city before and during the COVID-19 pandemic (2018-2020). Front Pharmacol 2022; 13:1028233.. Therefore, a rise in psychotropic use during the pandemic was anticipated, driven by fear and uncertainty. Studies from other Brazilian states reported the use of psychotropic medications rates ranging from 10.1% to 37.3% ⁴⁵45. Santos WC, Santos EMSD, Cavalcante KMH. Utilização de psicofármacos e sintomas de ansiedade e depressão em estudantes universitários de Lagarto/SE durante a pandemia da COVID-19. Revista Multidisciplinar em Saúde 2021; 2:ID2391.^,4646. Fontes BA, Jacinto PMS, Rocha RVS. Consumo de ansiolíticos benzodiazepínicos durante a pandemia de COVID-19: um estudo remoto com estudantes universitários. Int J Interdiscip Stud Commun 2022; 3:34-44.^,4747. Kantorski LP, Brum AN, Menezes ES, Silva PS, Santos CG, Almeida MD, et al. Psicotrópicos: uso por estudantes universitários antes e durante a pandemia de doença por coronavírus 2019. J Nurs Health 2022; 12:2212322932..

Pre-pandemic studies showed lower rates of mental disorders than our study for both the general population and university students ⁴⁸48. Stallman HM. Psychological distress in university students: a comparison with general population data. Aust Psychol 2010; 45:249-57.^,4949. Cvetkovski S, Reavley NJ, Jorm AF. The prevalence and correlates of psychological distress in Australian tertiary students compared to their community peers. Aust N Z J Psychiatry 2012; 46:457-67.^,5050. Prado M, Francisco P, Barros MBA. Use of psychotropic medicines in adults and elderly living in Campinas, Sao Paulo, Brazil: cross-sectional population-based study. Epidemiol Serv Saúde 2017; 26:747-58.^,5151. Kim H, Rackoff GN, Fitzsimmons-Craft EE, Shin KE, Zainal NH, Schwob JT, et al. College mental health before and during the COVID-19 pandemic: results from a nationwide survey. Cognit Ther Res 2022; 46:1-10.. Students are particularly vulnerable due to academic pressures and various demands ⁵²52. Padovani RC, Neufeld CB, Maltoni J, Barbosa LNF, Souza WF, Cavalcanti HAF, et al. Vulnerability and psychological well-being of college student. Revista Brasileira de Terapias Cognitivas 2014; 10:2-10.. Sabião et al. ⁵³53. Sabião TS, Mendonca RD, Meireles AL, Machado-Coelho GLL, Carraro JCC. Food insecurity and symptoms of anxiety and depression disorder during the COVID-19 pandemic: COVID-Inconfidentes, a population-based survey. SSM Popul Health 2022; 19:101156. found lower rates of symptoms of mental disorders in adults and older adults during the pandemic than this study, highlighting the significant emotional and mental challenges students faced, including social isolation, routine changes, and health concerns ⁵⁴54. Salimi N, Gere B, Talley W, Irioogbe B. College students mental health challenges: Concerns and considerations in the COVID-19 pandemic. J College Stud Psychother 2023; 37:39-51.. The high use of psychotropic medications among students reflects this increased mental load.

The increased use of psychotropic medications during the pandemic is not inherently negative. These medications are prescribed for conditions such as depression, anxiety, bipolar disorder, and sleep disorders ⁵⁵55. Rang R, Ritter JM, Flower RJ, Henderson G. Rang & Dale farmacologia. 8th Ed. Rio de Janeiro: Elsevier; 2016., and can be necessary and beneficial for managing mental health. The most cited types include antidepressants, antiepileptics, antipsychotics, and hypnotics, of which escitalopram, sertraline, clonazepam, and zolpidem being frequently used, consistent with other studies on Brazilian students ⁴⁷47. Kantorski LP, Brum AN, Menezes ES, Silva PS, Santos CG, Almeida MD, et al. Psicotrópicos: uso por estudantes universitários antes e durante a pandemia de doença por coronavírus 2019. J Nurs Health 2022; 12:2212322932.^,5656. Bauchrowitz C, Paz LEC, Müller EV, Possagno GCH, Minozzo BR. Prevalência de uso de psicofármacos por acadêmicos: efeitos do processo de graduação. Braz J Dev 2019; 5:24815-933.. A study in Spain also noted a significant rise in antidepressant use among younger people after the onset of the pandemic ⁵⁷57. García MLN, Martínez PF, Bretón EF, Martínez Alfonso MM, Gil PS. Psychotropic consumption before and during COVID-19 in Asturias, Spain. BMC Public Health 2023; 23:494..

Some psychotropic medications, like clonazepam, initially developed as anticonvulsants, are now widely used as anxiolytics, particularly in Brazil ⁵⁸58. Dokkedal-Silva V, Berro LF, Galduroz JCF, Tufik S, Andersen ML. Clonazepam: indications, side effects, and potential for nonmedical use. Harv Rev Psychiatry 2019; 27:279-89.. Anticonvulsants like valproic acid, carbamazepine, and lithium are also commonly used as mood stabilizers for bipolar disorders ⁵⁹59. Rybakowski JK. Mood stabilizers of first and second generation. Brain Sci 2023; 13:741.. Understanding these distinctions is crucial for interpreting psychotropic use data, highlighting their psychiatric rather than neurological application among university students.

Cases of self-medication were identified in this study, and this medication category is regulated by Federal Ordinance n. 344 ³⁶36. Secretaria de Vigilância em Saúde, Ministério da Saúde. Portaria nº 344, de 12 de maio de 1998. Aprova o Regulamento Técnico sobre substâncias e medicamentos sujeitos a controle especial. Diário Oficial da União 1998; 15 may. of 1998 that approves the technical regulation on substances and medications subject to special control. Among the total participants, 14.3% reported self-medication. When considering only students who reported using psychotropic medications, the percentage is 1.6%, and clonazepam, alprazolam and zolpidem were the most cited. A study ⁶⁰60. Berrouet MC, Lince M, Restrepo D. Actitudes, conocimientos y prácticas frente a la automedicación con productos herbales y psicofármacos en estudiantes de medicina de Medellín-Colombia. Med UPB 2018; 37:17-24. with Colombian medical students found a 39.5% rate of psychotropic medication use, including self-medication with herbal products. The most cited medications were fluoxetine, zolpidem, and trazodone ⁶⁰60. Berrouet MC, Lince M, Restrepo D. Actitudes, conocimientos y prácticas frente a la automedicación con productos herbales y psicofármacos en estudiantes de medicina de Medellín-Colombia. Med UPB 2018; 37:17-24..

The discrepancy between the high prevalence of severe anxiety and depression symptoms and the lower use of psychotropic medications among university students may be due to factors like limited access to mental health care and stigma. During the COVID-19 pandemic, barriers such as virtual care and limited availability of healthcare providers worsened this issue ⁵⁴54. Salimi N, Gere B, Talley W, Irioogbe B. College students mental health challenges: Concerns and considerations in the COVID-19 pandemic. J College Stud Psychother 2023; 37:39-51.^,6161. Chen T, Lucock M. The mental health of university students during the COVID-19 pandemic: an online survey in the UK. PLoS One 2022; 17:e0262562.. Students may underdiagnose or underestimate their symptoms, affected by pandemic-related stressors like isolation and academic uncertainty ¹⁹19. Copeland WE, McGinnis E, Bai Y, Adams Z, Nardone H, Devadanam V, et al. Impact of COVID-19 pandemic on college student mental health and wellness. J Am Acad Child Adolesc Psychiatry 2021; 60:134-41.^,6262. Hamza CA, Ewing L, Heath NL, Goldstein AL. When social isolation is nothing new: a longitudinal study on psychological distress during COVID-19 among university students with and without preexisting mental health concerns. Can Psychol 2021; 62:20.. Social and cultural stigma around mental health and the use of medication also discourage students from seeking treatment, leading them to rely on alternatives or self-manage of symptoms ⁶³63. Vogel DL, Strass HA, Heath PJ, Al-Darmaki FR, Armstrong PI, Baptista MN, et al. Stigma of seeking psychological services: examining college students across ten countries/regions. Couns Psychol 2017; 45:170-92.. These factors explain why many students with severe symptoms avoid psychotropic medications, highlighting the complexities of mental health treatment during a global crisis.

Self-medication can be dangerous and lead to undesirable consequences such as addiction, compulsion, and adverse events ⁵⁵55. Rang R, Ritter JM, Flower RJ, Henderson G. Rang & Dale farmacologia. 8th Ed. Rio de Janeiro: Elsevier; 2016.. The use of psychotropic medications needs to be monitored by health professionals, who can assess the need, make appropriate prescriptions, and provide continuous monitoring and support ⁶⁴64. Rivera JGB, Duarte FCM, Silva RRC, Monteiro SB, Guimarães MCM, Vale VV. Impacto da automedicação de fármacos benzodiazepínicos. Brazilian Applied Science Review 2021; 5:1767-80..

In our findings, most students who belong to minority groups were more likely to use psychotropic medications during the COVID-19 pandemic compared to their peers, except those identifying as black, mixed-race and others.

The designation of a group as a minority is based not only on numbers but also on power dynamics, inequalities, and discrimination. Minority groups often have diminished access to resources and representation, leading to social and economic disadvantages ⁶⁵65. Paula CEA, Silva AP, Bittar CML. Vulnerabilidade legislativa de grupos minoritários. Ciênc Saúde Colet 2017; 22:3841-8.^,6666. Nascimento AR, Alves FB. Vulnerabilidade de grupos minoritários entre cenários de crise e proteção de direitos. Revista da Faculdade de Direito do Sul de Minas 2020; 36:363-88.. The pandemic added stress, anxiety, depression, and adaptation challenges may have prompted seeking professional help and considering medication as part of treatment ⁶⁷67. Amill-Rosario A, Lee H, Zhang C, Reis S. Psychotropic prescriptions during the COVID-19 pandemic among U.S. children and adolescents receiving mental health services. J Child Adolesc Psychopharmacol 2022; 32:408-14..

Women tend to report higher levels of anxiety and depression, which is often worsened by social and academic pressures, leading to increased use of psychotropic medications for symptom management ⁵⁷57. García MLN, Martínez PF, Bretón EF, Martínez Alfonso MM, Gil PS. Psychotropic consumption before and during COVID-19 in Asturias, Spain. BMC Public Health 2023; 23:494.^,6868. Browning M, Larson LR, Sharaievska I, Rigolon A, McAnirlin O, Mullenbach L, et al. Psychological impacts from COVID-19 among university students: risk factors across seven states in the United States. PLoS One 2021; 16:e0245327. Female students deal daily with different stressors, such as gender discrimination, social inequalities, and social and family pressures, in addition to specific challenges related to female health. These experiences, added to the stressors of the pandemic, may have contributed to a greater chance of developing mental health disorders and the need for psychotropic treatment during the pandemic ⁵⁷57. García MLN, Martínez PF, Bretón EF, Martínez Alfonso MM, Gil PS. Psychotropic consumption before and during COVID-19 in Asturias, Spain. BMC Public Health 2023; 23:494.^,6868. Browning M, Larson LR, Sharaievska I, Rigolon A, McAnirlin O, Mullenbach L, et al. Psychological impacts from COVID-19 among university students: risk factors across seven states in the United States. PLoS One 2021; 16:e0245327^,6969. Boclin KLS, Cecilio FFC, Fae G, Fanti G, Centenaro G, Pellizzari T, et al. Academic performance and use of psychoactive drugs among healthcare students at a university in southern Brazil: cross-sectional study. Sao Paulo Med J 2020; 138:27-32.. In addition, women may be more likely to seek health services and express their emotions compared to men ⁷⁰70. Gao W, Ping S, Liu X. Gender differences in depression, anxiety, and stress among college students: a longitudinal study from China. J Affect Disord 2020; 263:292-300..

Previous studies show LGBTQIAPN+ individuals are more likely to experience depression, anxiety, suicide attempts, and substance abuse compared to heterosexuals. Factors like discrimination, stigma, lack of support, marginalization, and violence contribute to these challenges ²¹21. Seehuus M, Moeller RW, Peisch V. Gender effects on mental health symptoms and treatment in college students. J Am Coll Health 2021; 69:95-102.^,2222. Wilson LC, Liss M. Safety and belonging as explanations for mental health disparities among sexual minority college students. Psychol Sex Orientat Gend Divers 2022; 9:110-9.^,7171. Corliss HL, Rosario M, Wypij D, Wylie SA, Frazier AL, Austin SB. Sexual orientation and drug use in a longitudinal cohort study of U.S. adolescents. Addict Behav 2010; 35:517-21.^,7272. Hoyt LT, Cohen AK, Dull B, Maker Castro E, Yazdani N. "Constant stress has become the new normal": stress and anxiety inequalities among U.S. college students in the time of COVID-19. J Adolesc Health 2021; 68:270-6.. Social distancing has reduced social circles and support, possibly leading to increased use of psychotropic medications.

The increased use of psychotropic medications among university students, particularly women and LGBTQIAPN+ individuals, may stem from factors like mental disorder prevalence, access to care, family support, and discrimination. Research indicates that women and LGBTQIAPN+ individuals report higher anxiety and depression, leading to greater medication use ⁷³73. Borgogna NC, McDermott RC, Aita SL, Kridel MM. Anxiety and depression across gender and sexual minorities: implications for transgender, gender nonconforming, pansexual, demisexual, asexual, queer, and questioning individuals. Psychol Sex Orientat Gend Divers 2019; 6:54.^,7474. Maestre-Miquel C, Lopez-de-Andres A, Ji Z, de Miguel-Diez J, Brocate A, Sanz-Rojo S, et al. Gender differences in the prevalence of mental health, psychological distress and psychotropic medication consumption in Spain: a nationwide population-based study. Int J Environ Res Public Health 2021; 18:6350.. LGBTQIAPN+ students without family support face higher mental health risks and rely more on medication, probably driven because of social isolation and lower family acceptance ⁷⁵75. Meyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychol Bull 2003; 129:674-97.^,7676. Ryan C, Russell ST, Huebner D, Diaz R, Sanchez J. Family acceptance in adolescence and the health of LGBT young adults. J Child Adolesc Psychiatr Nurs 2010; 23:205-13.. The pandemic has exacerbated these issues, increasing the use of psychotropic medication as a coping mechanism ⁷⁷77. Salerno JP, Williams ND, Gattamorta KA. LGBTQ populations: psychologically vulnerable communities in the COVID-19 pandemic. Psychol Trauma 2020; 12(S1):S239-42..

Although the literature lacks studies showing differences in mental health between white students and racial minorities regarding the use of psychotropic medication during the pandemic, some studies found that white students reported more symptoms of mental disorders potentially leading to medication use ²⁰20. Fruehwirth JC, Biswas S, Perreira KM. The COVID-19 pandemic and mental health of first-year college students: examining the effect of COVID-19 stressors using longitudinal data. PLoS One 2021; 16:e0247999.^,7878. Charles NE, Strong SJ, Burns LC, Bullerjahn MR, Serafine KM. Increased mood disorder symptoms, perceived stress, and alcohol use among college students during the COVID-19 pandemic. Psychiatry Res 2021; 296:113706.. Previous research indicates that white skin color is a remarkable sociodemographic factor that contributes to unprescribed use of sedatives/hypnotics among young adults ⁷⁹79. McCabe SE. Correlates of nonmedical use of prescription benzodiazepine anxiolytics: results from a national survey of U.S. college students. Drug Alcohol Depend 2005; 79:53-62.^,8080. Peter L, Paksi B, Magi A, Eisinger A, Kotyuk E, Czako A, et al. Severity of behavioral addiction symptoms among young adults using non-prescribed sedatives/hypnotics. Addict Behav Rep 2023; 17:100485.. Black university students may use less psychotropic medications due to barriers to access mental health services, historical distrust of healthcare, and cultural stigma, resulting in treatment disparities ⁸¹81. Han E, Liu GG. Racial disparities in prescription drug use for mental illness among population in US. J Ment Health Policy Econ 2005; 8:131-43.^,8282. Fernandes CSE, Lima MG, Barros MBA. Emotional problems and the use of psychotropic drugs: investigating racial inequality. Ciênc Saúde Colet 2020; 25:1677-88.. Our findings suggest social, economic, and health factors - such as income, education, and access to housing and health service - may contribute to disparities in medication use among white students.

This study must be considered in light of its limitations and strengths. Although this study uses a convenience sample of university students, the considerable number of participants offers advantages such as increased statistical power and better representation of demographic subgroups ⁸³83. Button KS, Ioannidis JP, Mokrysz C, Nosek BA, Flint J, Robinson ES, et al. Power failure: why small sample size undermines the reliability of neuroscience. Nat Rev Neurosci 2013; 14:365-76.. Online data collection faces challenges such as limited internet access, high non-response rates, selection bias, and platform familiarity. Despite these issues, online studies have been proved to be crucial, and often the only option, for research during the COVID-19 pandemic ⁸⁴84. Salvador P, Alves KYA, Rodrigues C, Oliveira LVE. Online data collection strategies used in qualitative research of the health field: a scoping review. Rev Gaúcha Enferm 2020; 41:e20190297.. Self-reported information was used, with potential memory and information bias. Although the study design does not enable inferring causality, the objective of knowing the prevalence of the use of psychotropic medication initiated during the pandemic was met. Another limitation of our study is the measurement of the use of psychotropic medication, which relied on a dichotomous question (no/yes) about use in the 30 days before the survey and whether it began after the pandemic. Since data collection started in October 2021, changes in medication patterns due to immediate pandemic stressors might not be fully captured. However, the 30-day window offers insight into the ongoing impact of the pandemic on the use of psychotropic medication. The influence of the use of psychotropic medication could not be clearly attributed solely to the COVID-19 pandemic or the transition to university life. This is especially relevant for students who began university during the pandemic. Future studies should separate these factors for a more accurate analysis.

As strengths, the information was obtained in a critical period in which remote teaching at universities was taking place due to the COVID-19 pandemic, which allowed progress in elucidating how the pandemic may have affected the mental health of the university population in minority groups and a survey of the use of psychotropic medications by students.

Studies on the use of medications are very scarce in the literature and our findings reinforce how important and necessary it is to worry about the university population, mostly youth, and who will be professionals in the future.

Most students used psychotropic medications and those who were female and LGBTQIAPN+ had an increased chance of starting or increasing the use of psychotropic medications during the pandemic, which reflects a mentally ill population that sought relief for symptoms - mainly anxiety, depression, and insomnia - in pharmacotherapy.

As the promotion of mental health is essential for the general improvement of people’s health and quality of life, students must have access to psychological support. Universities and educational institutions should offer student counseling services and other forms of support to help students who are experiencing emotional and mental difficulties. Such actions can help to reduce the cases of evasion and suspension.

Acknowledgments

The authors thank Research and Study Group on Nutrition and Public Health (Grupo de Pesquisa e Estudo em Nutrição e Saúde Coletiva - GPENSC), Toxicogenetic, Epidemiological and Clinical Study and Research Group (Grupo de Estudos e Pesquisas Toxicogenéticas, Epidemiológicas e Clínicas - G-TEC) and the Project on Anxiety and Depression in University Students (Projeto de Ansiedade e Depressão em Universitários - PADu) and Brazilian Coordination for the Improvement of Higher Education Personnel (CAPES) for all their support. To Minas Gerais State Research Foundation (FAPEMIG/DOF; n. 8288757/2019) for the financial support.

References

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