ABSTRACT

To explore the associations between current mental health symptoms and social disparities in university students.

We recruited participants from nine public universities in Brazil, from August to November 2022, using online advertisements and in-person lectures. All participants completed an online survey containing social (sex, race/color, gender identity, sexual orientation, and income) and mental health assessments. The Jeopardy index was composed of social variables. The index considered zero points for subjects with less oppressive experienced characteristics (men, White, cisgender, heterosexual, higher income) and one point for the opposite characteristics. We defined six clusters according to Jeopardy Index results: 0, 1, 2, 3, 4, and 5 points, with the greatest number of points representing the most disadvantaged group. The mental health symptoms were assessed on two levels. First by the “DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure – Adult,” and second by the “Patient Health Questionnaire-9,” and the “Generalized Anxiety Disorder Questionnaire-7.” Adjusted Odds Ratio (OR) analyses was performed for age and educational level.

748 participants were allocated into the six Jeopardy clusters: 0 (n = 46; 6.1%), 1 (n = 112; 15.0%), 2 (n = 163; 21.8%), 3 (n = 218; 29.1%), 4 (n = 171; 22.9%), and 5 (n = 38; 5.1%). It was observed a high prevalence of anxiety (42.5%) and depression (51.0%), however, the less privileged group (5) had a higher risk of having severe symptoms of anxiety (OR = 6.21; 1.51–25.58; p < 0.01) and depression (OR = 8.60; 2.15–34.43; p < 0.01), compared against the most privileged group.

Although anxiety and depressive symptoms were highly prevalent for all participants, these disorders are not equally distributed in this population and the intersectionality between social factors plays an important role in contributing to these differences.

DESCRIPTORS:
Mental Health; Mental Disorders; Ethnic and Racial Minorities; Sexual and Gender Minorities; Health Status Disparities

INTRODUCTION

Among mental disorders, anxiety and depression emerged as the two most widespread conditions, impacting around 580 million individuals worldwide¹1. GBD 2019 Mental Disorders Collaborators. Global, regional, and national burden of 12 mental disorders in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet Psychiatry. 2022 Feb;9(2):137-50. https://doi.org/10.1016/s2215-0366(21)00395-3
https://doi.org/10.1016/s2215-0366(21)00... . In addition to their high prevalence, mental disorders pose a public health challenge globally, ranking among the top ten causes of global burden¹1. GBD 2019 Mental Disorders Collaborators. Global, regional, and national burden of 12 mental disorders in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet Psychiatry. 2022 Feb;9(2):137-50. https://doi.org/10.1016/s2215-0366(21)00395-3
https://doi.org/10.1016/s2215-0366(21)00... . Thus, suicide stands out as the fourth leading cause of death among young people aged 15 to 29 years old²2. World Health Organization – WHO. Suicide worldwide in 2019. Global Health Estimates. Geneva: WHO; 2021..

In late adolescence and emerging adulthood, there is a peak onset of several common mental and substance use disorders³3. Solmi M, Radua J, Olivola M, Croce E, Soardo L, Pablo GS, et al. Age at onset of mental disorders worldwide: large-scale meta-analysis of 192 epidemiological studies. Mol Psychiatry. 2022 Jan; 27(1):281-95. https://doi.org/10.1038/s41380-021-01161-7
https://doi.org/10.1038/s41380-021-01161... . Coinciding with this stage of life, many young adults enroll in college, leading to an anticipated high prevalence of mental disorders among the university student population⁴4. Auerbach RP, Mortier P, Bruffearts R, Alonso J, Benjet C, Cujipers P, et al. WHO World Mental Health Surveys International College Student Project: Prevalence and distribution of mental disorders. 2018 Oct;127(7):623-38. https://doi.org/10.1037/abn0000362
https://doi.org/10.1037/abn0000362... . Moreover, the transition to university is marked by numerous changes and newfound responsibilities, and financial and/or academic demands, potentially contributing to social instability and heightened distress⁵5. Tett L, Cree VE, Christie H. From further to higher education: transition as an on-going process. Higher Educ. 2017 Mar;73:389-406. https://doi.org/10.1007/s10734-016-0101-1
https://doi.org/10.1007/s10734-016-0101-... . Further, the changes in lifestyle behaviors can be important risk factors to mental disorders during this period⁵5. Tett L, Cree VE, Christie H. From further to higher education: transition as an on-going process. Higher Educ. 2017 Mar;73:389-406. https://doi.org/10.1007/s10734-016-0101-1
https://doi.org/10.1007/s10734-016-0101-... , ⁶6. Sussman S, Arnett JJ. Emerging Adulthood: Developmental Period Facilitative of the Addictions. Eval Health Prof. 2014 Jun;37(2):147-55. https://doi.org/10.1177/0163278714521812
https://doi.org/10.1177/0163278714521812...

Evidence suggests that approximately one-third of first-year university students (30%) experience a mental health or substance use problem within their initial year at the institution⁴4. Auerbach RP, Mortier P, Bruffearts R, Alonso J, Benjet C, Cujipers P, et al. WHO World Mental Health Surveys International College Student Project: Prevalence and distribution of mental disorders. 2018 Oct;127(7):623-38. https://doi.org/10.1037/abn0000362
https://doi.org/10.1037/abn0000362... . Even though most research on university students’ mental health focuses on high-income countries⁷7. Mojtabai R, Stuart EA, Hwang I, Eaton WW, Sampson N, Kessler RC. Long-term effects of mental disorders on educational attainment in the National Comorbidity Survey ten-year follow-up. Soc Psychiatry Psychiatr Epidemiol. 2015 Oct;50(10):1577-91. https://doi.org/10.1007/s00127-015-1083-5
https://doi.org/10.1007/s00127-015-1083-... , a comprehensive survey conducted by the World Health Organization across six high-income countries and two upper-middle-income countries⁴4. Auerbach RP, Mortier P, Bruffearts R, Alonso J, Benjet C, Cujipers P, et al. WHO World Mental Health Surveys International College Student Project: Prevalence and distribution of mental disorders. 2018 Oct;127(7):623-38. https://doi.org/10.1037/abn0000362
https://doi.org/10.1037/abn0000362... revealed a widespread distribution of mental health problems among the student population. However, social inequalities and poor mental health are known to be inseparable, and that social disparities negatively affects a person’s access to treatment globally⁸8. Lund C, Brooke-Sumner C, Baingana F, Baron EC, Breuer E, Chandra P, et al. Social determinants of mental disorders and the Sustainable Development Goals: a systematic review of reviews. Lancet Psychiatry. 2018 Apr;5(4):357-69. https://doi.org/10.1016/s2215-0366(18)30060-9
https://doi.org/10.1016/s2215-0366(18)30... .

Access to mental health care is influenced by various micro and macro-level factors⁹9. Frankish H, Boyce N, Horton R. Mental health for all: a global goal. Lancet. 2018 Oct;392(10157):1493-4. https://doi.org/10.1016/s0140-6736(18)32271-2
https://doi.org/10.1016/s0140-6736(18)32... . At the macro-level perspective, there is an pervasive impact of economic and political forces of the country, such as the healthcare policies, the income level, and cultural barriers, including social stigma⁹9. Frankish H, Boyce N, Horton R. Mental health for all: a global goal. Lancet. 2018 Oct;392(10157):1493-4. https://doi.org/10.1016/s0140-6736(18)32271-2
https://doi.org/10.1016/s0140-6736(18)32... . A recent Lancet Commission on global mental health underscored that sustainable efforts in mental health constitute a global public good¹⁰10. Patel V, Saxena S, Lund C, Thornicroft G, Baingana F, Bolton P, et al. The Lancet Commission on global mental health and sustainable development. Lancet. 2018 Oct;392(10157):1553-98. https://doi.org/10.1016/s0140-6736(18)31612-x
https://doi.org/10.1016/s0140-6736(18)31... .

Furthermore, the Commission emphasized that mental health problems exist on a continuum of progressively severe conditions, in which individuals with mental disorders have complex needs, resultant from a unique interplay of social and biological influences throughout one’s lifetime¹⁰10. Patel V, Saxena S, Lund C, Thornicroft G, Baingana F, Bolton P, et al. The Lancet Commission on global mental health and sustainable development. Lancet. 2018 Oct;392(10157):1553-98. https://doi.org/10.1016/s0140-6736(18)31612-x
https://doi.org/10.1016/s0140-6736(18)31... . These influences could be observed as micro-level factors associated with subjective mental health. Accordingly, the commission underscored the need to prioritize vulnerable populations subjected to discrimination based on social factors such as sex, race, ethnicity, and sexual orientation⁹9. Frankish H, Boyce N, Horton R. Mental health for all: a global goal. Lancet. 2018 Oct;392(10157):1493-4. https://doi.org/10.1016/s0140-6736(18)32271-2
https://doi.org/10.1016/s0140-6736(18)32... , ¹⁰10. Patel V, Saxena S, Lund C, Thornicroft G, Baingana F, Bolton P, et al. The Lancet Commission on global mental health and sustainable development. Lancet. 2018 Oct;392(10157):1553-98. https://doi.org/10.1016/s0140-6736(18)31612-x
https://doi.org/10.1016/s0140-6736(18)31... . Consequently, the Commission advocates for a focus on intersectional social factors to identify specific risk protection actions in mental health.

Intersectionality is a term coined by Kimberly Crenshaw in the 1990s to elucidate the exclusion of Black women from discussions within White Feminism¹¹11. Crenshaw K. Mapping the Margins: Intersectionality, Identity Politics, and Violence against Women of Color. Stanford Law Rev. 1991 Jul;43(6):1241-99. https://doi.org/10.2307/1229039
https://doi.org/10.2307/1229039... . This perspective posits that various social factors, including race, sex, gender identity, sexual orientation, and socioeconomic status, intersect at the individual (micro) and at society (macro) level, which encompass systems of privileges and oppression, and issues such as sexism, racism, and heterosexism¹¹11. Crenshaw K. Mapping the Margins: Intersectionality, Identity Politics, and Violence against Women of Color. Stanford Law Rev. 1991 Jul;43(6):1241-99. https://doi.org/10.2307/1229039
https://doi.org/10.2307/1229039... . Fundamental to the concept of intersectionality is the recognition that these social factors are not unidimensional and independent, instead, they are multiple, interrelated, and mutually constitutive¹²12. Collins PH. Intersectionality’s Definitional Dilemmas. Annual Rev Sociol 2015 Aug;41:1-20. https://doi.org/10.1146/annurev-soc-073014-112142
https://doi.org/10.1146/annurev-soc-0730... .

The US Department of Health and Human Services report on health disparities suggests that while one single social or sociodemographic factor can be employed to understand or address health disparities, this approach overlooks the nuanced interactions among multiple social factors¹³13. Geller AB, Polsky DE, Burke SP, editors. Federal Policy to Advance Racial, Ethnic, and Tribal Health Equity. Washington, DC: National Academies Press; 2023.. Furthermore, it neglects the social discrimination that arises from the interplay of these intersecting categories, resulting in disparities and social inequalities in health¹²12. Collins PH. Intersectionality’s Definitional Dilemmas. Annual Rev Sociol 2015 Aug;41:1-20. https://doi.org/10.1146/annurev-soc-073014-112142
https://doi.org/10.1146/annurev-soc-0730... , ¹³13. Geller AB, Polsky DE, Burke SP, editors. Federal Policy to Advance Racial, Ethnic, and Tribal Health Equity. Washington, DC: National Academies Press; 2023..

Among university students, it is known that the new challenges and responsibilities of the academic lifespan pose risks for elevated stress and mental health problems¹⁴14. Bruffaerts R, Mortier P, Kiekens G, Auerbach RP, Cujipers P, Demyttenaere K, et al. Mental health problems in college freshmen: Prevalence and academic functioning. J Affect Disord. 2018 Jan;225:97-103. https://doi.org/10.1016/j.jad.2017.07.044
https://doi.org/10.1016/j.jad.2017.07.04... . Regarding financial problems, the educational debt system seems to be a stressor associated with decreased mental health, especially for Black and Latino students when compared with their White counterparts¹⁵15. Deckard FM, Goosby BJ, Cheadle JE. Debt Stress, College Stress: Implications for Black and Latinx Students’ Mental Health. Race Soc Probl. 2022 Sep;14(3):238-53. https://doi.org/10.1007/s12552-021-09346-z
https://doi.org/10.1007/s12552-021-09346... . Besides socioeconomic problems, interpersonal factors for racism-related stress, perceived stigma, and discrimination are also associated with poor mental health in Black and Latino students¹⁶16. Goodwill JR, Zhou S. Association between perceived public stigma and suicidal behaviors among college students of color in the U.S. J Affect Disord. 2020 Feb;262:1-7. https://doi.org/10.1016/j.jad.2019.10.019
https://doi.org/10.1016/j.jad.2019.10.01... . Sexual minority students also deal with perceived stigma, as well as fear of violence and lack of a sense of belonging. They had higher risks for mental distress and depression, self-injuries, and suicidal thoughts and behaviors¹⁷17. Rentería R, Benjet C, Gutierrez-Garcia RA, Ramírez AA, Albor Y, Borges G, et al. Suicide thought and behaviors, non-suicidal self-injury, and perceived life stress among sexual minority Mexican college students. J Affect Disord. 2021 Feb;281:891-8. https://doi.org/10.1016/j.jad.2020.11.038
https://doi.org/10.1016/j.jad.2020.11.03... .

Despite several studies investigating the mental health of social minorities in universities, there is a gap in understanding the interplay of multiple social factors in mental health, particularly in Brazil, which is a country with approximately 203 million people, most of whom are Non-White (56.5%)¹⁸18. Instituto Brasileiro de Geografia e Estatística – IBGE. Censo Demográfico 2022: identificação étnico-racial da população, por sexo e idade: resultados do universo. Rio de Janeiro: IBGE; 2023.. Among these vulnerable population, Black and Mixed-race people face lower income, reduced educational opportunities, poorer living conditions, and higher rates of death by homicide¹⁹19. Instituto Brasileiro de Geografia e Estatística – IBGE. Desigualdades Sociais por Cor ou Raça no Brasil.2. ed. Rio de Janeiro: IBGE; 2022.. Given the shortage of studies concerning mental health and intersectionality in Brazilian university students, this paper aims to explore the associations between current mental health symptoms and social disparities in university students.

METHODS

Study Design, Setting, and Participants

In this multicenter cross-sectional study, university students enrolled in both undergraduate and postgraduate programs were recruited from nine Brazilian public universities representing the country’s diverse regions, from South, Southeast, North, Northeast, and Midwest. The institutions enrolled in this study were: Universidade Federal de Santa Maria (UFSM), Universidade Federal de Santa Catarina (UFSC), Universidade Federal do Rio de Janeiro (UFRJ), Universidade Estadual de Montes Claros (UNIMONTES), Universidade Federal do Pará (UFPA), Universidade Federal do Rio Grande do Norte (UFRN), Universidade Federal do Ceará (UFC), Universidade Federal de Sergipe (UFS), and Universidade de Brasília (UNB). It was a convenience sample conducted from August to November 2022. The students were recruited online and in in-person lectures, in accordance with relevant local ethics and data privacy laws and policies. Inclusion criteria were those aged > 18 years old and enrolled in the university. The participants agreed to be part of this research by virtually signing the informed consent form and answering the online questionnaire in the REDCap platform. The Research Ethics Committee of the IPUB-UFRJ approved this study under registration permit CAAE:55481422.5.1001.5346.

The questionnaire comprised assessments of sociodemographic data and mental health problems, of which the latter was conducted at two levels. Initially, the participants completed the “DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure (CCSM-1),” a self-reported questionnaire assessing crucial domains across various psychiatric diagnoses. The instrument screens for symptoms of anxiety, depression, suicidal ideation, anger, mania, somatic symptoms, psychosis, dissociation, personality functioning, memory and sleep problems, repetitive thoughts and behaviors, and substance use. It employs a 5-point scale (scoring from 0 to 4) to gauge the frequency with which an individual has been troubled by any of the aforementioned symptoms over the past two weeks. Respondents who received a positive screening at the level one instrument (rating ≥ 2) for depression and anxiety were directed to a level two instrument for a more in-depth investigation of these symptoms.

Depressive symptoms were assessed using the “Patient Health Questionnaire-9 (PHQ-9),”which comprises nine items to evaluate the presence of symptoms over the last two weeks. The scoring ranges from 0 to 27, with higher scores indicating greater symptom severity (5–9 = mild; 10–14 = moderate; 15–19 = moderate to severe; 20–27 = severe). To assess anxiety symptoms, the “Generalized Anxiety Disorder Questionnaire-7 (GAD-7)” was employed, consisting of seven items with the score ranging from 0 to 21. Similar to the PHQ-9, the GAD-7 evaluates symptoms over the two preceding weeks, and higher scores indicate greater symptom severity (5–9 = mild; 10–14 = moderate; ≥ 15 = severe). For both questionnaires, participants with scores ≥ 10 points were classified as cases of depression or anxiety. These instruments have been translated and validated for the Brazilian population²⁰20. Doss RA, Lowmaster SE. Validation of the DSM-5 Level 1 Cross-Cutting Symptom Measure in a Community Sample. Psychiatry Res. 2022;318:114935. https://doi.org/10.1016/j.psychres.2022.114935
https://doi.org/10.1016/j.psychres.2022....

21. Santos IS, Tavares BF, Munhoz TN, Almeida LSP, Silva NTB, Tams BD, et al. Sensibilidade e especificidade do Patient Health Questionnaire-9 (PHQ-9) entre adultos da população geral. Cad Saude Publica. 2013 Aug;29(8):1533-43. https://doi.org/10.1590/0102-311X00144612
https://doi.org/10.1590/0102-311X0014461... - ²²22. Moreno AL, DeSousa DA, Souza AMFLP, Manfro GG, Salum GA, Koller SH, et al. Factor structure, reliability, and item parameters of the brazilian-portuguese version of the GAD-7 questionnaire. Temas Psicol. 2016 Mar;24(1):367-76. https://doi.org/10.9788/TP2016.1-25
https://doi.org/10.9788/TP2016.1-25... .

Procedures and Statistical Analysis

To categorize our data into clusters, we based the sociodemographic classification on the multiple jeopardy, which is a concept rooted in the principle of intersectionality. The multiple jeopardy theory posits that disadvantaged identities, regarding gender or race/color for example, contribute to a complex risk of oppression and social discrimination in an individual’s experience. This effect is exacerbated by the interdependent combination of identities, resulting in a multiplicative compound rather than a simple cumulative idea²³23. Veenstra G. Race, gender, class, and sexual orientation: intersecting axes of inequality and self-rated health in Canada. Int J Equity Health. 2011 Jan;10:3. https://doi.org/10.1186/1475-9276-10-3
https://doi.org/10.1186/1475-9276-10-3... . Consequently, we classified the sample using the Jeopardy Index composite score (Figure 1). The index assigns zero points to subjects with less oppressed characteristics (men, White, cisgender, heterosexual, higher income) and one point to those with the opposite characteristics (woman, non-White, non-heterosexual, lower income)²⁴24. Mielke GI, Malta DC, Nunes BP, Cairney J. All are equal, but some are more equal than others: social determinants of leisure time physical activity through the lens of intersectionality. BMC Public Health. 2022 Jan;22(1):36. https://doi.org/10.1186/s12889-021-12428-7
https://doi.org/10.1186/s12889-021-12428... . Income was categorized into three brackets, based on the 2022 Brazilian minimum wage BRL (R$ 1.287,00). Income was classified into: < 2 minimum salaries, from 2 to 6 salaries, and > 6 minimum salaries. For the index calculation, it was assigned zero points to the higher income category and two points the lower income category. The Jeopardy Index score ranged from zero to six points, which were classified into the six clusters (0, 1, 2, 3, 4, and 5 points) for statistical analysis.

A descriptive analysis of the sociodemographic data was undertaken. The Chi-square test was employed to evaluate differences between groups, including sociodemographic and mental health problems. A sub-analysis of symptom severity distributed by each Jeopardy Index cluster was undertaken, only with those respondents who screened positive in the Level 1 assessment. Binary and multinomial logistic regression models were used to estimate the odds ratio (OR) with 95% confidence intervals (95%CI) for depression and anxiety within each Jeopardy Index group category. An independent model for each outcome was performed: binary analyses were performed to assess the presence of depression and anxiety cases; and multinomial analyses were conducted to verify symptoms severity. The reference group used in logistic regression analyses was the most privileged one, according to the Jeopardy Index classification (group 0). Adjusted odds ratio (Adj. OR) were conducted for age and educational level, since the prevalence of anxiety and depression are apparently higher in postgraduate students²⁵25. Charles ST, Karnaze MM, Leslie FM. Positive factors related to graduate student mental health. J Am Coll Health. 2022 Aug-Sep;70(6):1858-66. https://doi.org/10.1080/07448481.2020.1841207
https://doi.org/10.1080/07448481.2020.18... . All statistical analyses were carried out using SPSS® version 26.0, with a significance level set at p ≤ 0.05.

RESULTS

In this study, 868 university students were screened at first, of which120 were excluded, since they interrupted the survey after answering only the sociodemographic section. Thus, the analytical sample consists of 748 participants, mostly female (n = 416; 61.6%), identifying as Black and Mixed-race (n = 414; 55.3%), cisgender (n = 727; 97.1%), and heterosexual (n = 556; 74.3%), with a mean age of 23.2 years (SD = 6.1). Most participants reported a lower family income (R$), receiving less than two Brazilian minimum wages (n = 350; 46.7%), followed by two to six wages (n = 236; 31.5%), and more than six wages (n = 151; 20.1%). The distribution of participants by region was as follows: South (n = 119; 15.5%), Southeast (n = 173; 23.1%), North (n = 133; 17.8%), Northeast (n = 247; 33.0%), and Midwest (n = 60; 8.0%); in addition to other16 participants who did not respond to the university site question (2.1%).

The process of mental health data collection occurred as follows: all participants answered the first part of the screening section regarding mental health problems using the CCSM-1 scale. Of them (n = 748), n = 636 participants reached the cutoff point (≥ 2) in the level one assessment for anxiety, and n = 606 reached the cutoff point for depression. Consequently, these participants were further investigated for these symptoms, answering the specific assessment for anxiety (GAD-7 scale) and depression (PHQ-9 scale). A flowchart of the survey process of data collection is presented in Figure 2.

The prevalence of anxiety and depression cases in the study sample was 42.5% (n = 318) and 51.0% (n = 382), respectively. According to the GAD-7 scale, the prevalence of anxiety, categorized by symptom severity, was as follows: mild (n = 230; 30.8%), moderate (n = 166, 22.2%), and severe (n = 152; 20.3%). Meanwhile, 26.7% (n = 200) of the students reported no current symptoms of anxiety. Regarding the severity categories of depressive symptoms as per the PHQ-9, prevalence was observed across the following four classifications: mild (n = 183; 24.5%), moderate (n = 167; 22.3%), moderate to severe (n = 119; 15.9%), and severe (n = 96; 12.8%). Additionally, 24.5% (n = 183) of the students did not report any depressive symptoms.

To elucidate socio-characteristics of the sample, Table 1 presents the prevalence and association between sociodemographic data, mental health, and each Jeopardy Index cluster group. Additionally, Figure 3 illustrates the prevalence of each dichotomy Jeopardy Index variable. The Jeopardy Index classification ranked the sample (n = 748) into six cluster groups, resulting in: 46 students classified in group 0 (6.1%), 112 in group 1 (15.0%), 163 in group 2 (21.8%), 218 in group 3 (29.1%), 171 in group 4 (22.9%), and 38 students in group 5 (5.1%).

Regarding the prevalence of anxiety cases, Chi-square analyses revealed significant differences between the first four cluster groups (0, 1, 2, and 3) and the last two groups (4 and 5) of the Jeopardy Index classification (Table 1). Additionally, odds ratio analyses showed that these last two groups (4 and 5) also had significantly higher risks of experiencing anxiety when compared with the other cluster groups (Table 2). The Chi-square analyses for the prevalence of depression cases showed very similar results to those for anxiety, with significant differences observed between the first cluster groups (0, 1, and 2) and the last ones (3, 4, and 5) (Table 1). Furthermore, the odds ratio analyses revealed significantly higher chances of experiencing depression from the third group of the Jeopardy Index on. This suggests that accumulating just three points of intersectionality already elevates the odds of depressive cases (Table 2). The prevalence of mild and severe symptoms in each Jeopardy group is highlighted in Figure 4.

Chi-square analyses showed no differences between groups 4 and 5 regarding the prevalence of clinical cases of anxiety and depression (≥ 10 points on the clinical scales). However, those final cluster groups (4 and 5) exhibit substantial similarity in the sociodemographic characteristics allied with the Jeopardy Index approach. Both groups predominantly comprised women (81.3%; 99.4%), people of color (87.2%; 94.7%), and lower-income individuals (100%), with a smaller proportion identifying as non-cisgender (4.1%; 13.2%). The sole distinguishing factor observed in group 5 was sexuality, since all participants (100%) identified as non-heterosexual (refer to Figure 3).

Figure 4 demonstrates the changes in the distribution of symptom severity based on intersectionality factors, revealing a crescent pattern of severe mental health problems symptoms with the cumulative effect of social oppressive characteristics. To comprehend the risks associated with mental health problems according to the Jeopardy classification, a sub analysis with adjusted logistic regression models was conducted only with the participants who answered the GAD-7 (n = 636) and PHQ-9 scale (n = 606) (Table 2). Non-adjusted odds ratio is presented in Table 3.

In terms of anxiety symptom severity, our observations indicate that university students who accumulate more than four or five points of intersectionality (groups 4 and 5) show a significant increase in odds of experiencing severe anxiety symptoms by almost five and six times, respectively. Conversely, for depressive symptoms, accumulating three points in the Jeopardy Index already poses a significant risk for moderate to severe symptoms, with the odds gradually increasing with the addition of one or two social factors. Individuals who accumulate five points in the Jeopardy Index (group 5) present alarming odds ratio, being nearly nine times more likely to have severe depressive symptoms, suggesting a substantially higher likelihood of struggling with depression.

DISCUSSION

The prevalence of self-reported anxiety and depression symptoms was notably high in this study, 43.5% and 51%, respectively. Studies with university students show high prevalence of mental health problems²⁶26. Evans TM, Bira L, Gastelum JB, Weiss LT, Vanderford NL. Evidence for a mental health crisis in graduate education. Nat Biotechnol. 2018 Mar;36(3): 282-4. https://doi.org/10.1038/nbt.4089
https://doi.org/10.1038/nbt.4089... , with a heightened average level of depressive symptoms merely two months after entering college²⁷27. Guassi Moreira JF, Telzer EH. Changes in family cohesion and links to depression during the college transition. J Adolesc. 2015 Jun;43(1):72-82. https://doi.org/10.1016/j.adolescence.2015.05.012
https://doi.org/10.1016/j.adolescence.20... , and a trend of worsening perception of mental health throughout the academic lifespan²⁶26. Evans TM, Bira L, Gastelum JB, Weiss LT, Vanderford NL. Evidence for a mental health crisis in graduate education. Nat Biotechnol. 2018 Mar;36(3): 282-4. https://doi.org/10.1038/nbt.4089
https://doi.org/10.1038/nbt.4089... . Given the potential negative impact of the academic journey on mental health, this study conducted adjusted odds ratio analyses for age and the enrollment in postgraduate programs, but no significant differences were observed with the non-adjusted analyses (Table 3).

Despite the already elevated prevalence of mental health problems in college students, it is crucial to underscore the additional negative impact of COVID-19 pandemic for the increase in symptoms of depression, anxiety, stress, and sleep problems in the young population²⁸28. Jones EAK, Mitra AK, Bhuiyan AR. Impact of COVID-19 on Mental Health in Adolescents: A Systematic Review. Int J Environ Res Public Health. 2021 Mar;18(5):2470. https://doi.org/10.3390/ijerph18052470
https://doi.org/10.3390/ijerph18052470... . In Brazil, the public universities have maintained stringent safety restrictions due to COVID-19 pandemic, with most classes remaining online until the first semester of 2022²⁹29. Polonia ADC, Miotto AI, Coelho ADSC, Almeida ALD, Ribeiro DCS. Transição do ensino presencial remoto à ‘volta às aulas’: relato de experiência. In: Anais VIII Congresso Nacional de Educação [Internet]; 2023 Oct 12-14; João Pessoa, PB: Conedu; 2023 [cited 2024 Oct 10]. Available from: https://editorarealize.com.br/editora/anais/conedu/2022/TRABALHO_COMPLETO_EV174_MD1_ID14286_TB4051_01122022103738.pdf .
https://editorarealize.com.br/editora/an... .

Due to socioeconomic disparities and lack of technological infrastructure to promptly address the new demands imposed by the COVID-19 pandemic, several universities went through a prolonged period without even online classes. Considering the Brazilian social context, we highlight that this study was conducted during the initial year of transitioning back to normality with in-person classes, and this particular juncture could itself contribute to heightened anxiety levels among participants³⁰30. Masha’al D, Shahrour G, Aldalaykeh M. Anxiety and coping strategies among nursing students returning to university during the COVID-19 pandemic. Heliyon. 2022 Jan;8(1):e08734. https://doi.org/10.1016/j.heliyon.2022.e08734
https://doi.org/10.1016/j.heliyon.2022.e... .

Beyond the overarching socio-political context and the heightened prevalence rates in the general population, the Jeopardy Index approach showed that the less privileged cluster groups accumulate higher prevalence for anxiety and depressive symptoms. Concerning anxiety, 54.3% of individuals in group four and 63.1% in group five surpassed the anxiety scale cutoff point. Regarding depression, 59.6% of group four and 76.3% of group five scored above the cutoff point. The severity of symptoms showed a clear trend of escalation for these groups, illustrated in Figure 4, from mild to severe symptoms, corresponding to the group classification. Specifically, for severe anxiety symptoms, groups four and five exhibited similar higher prevalence rates (32.1% and 36.8%, respectively), with no statistical difference between them, but notably different from all other groups. Similarly, for depression, group five had the highest prevalence (39.4%), followed by group four (19.2%), with no significant statistical difference between these two groups.

Groups four and five, characterized by an accumulative oppressive characteristics, probably face a higher risk of enduring social stigma, injustice, or oppression throughout their lives³¹31. Friedman RC. Homosexuality, Psychopathology, and Suicidality. Arch Gen Psychiatry. 1999 Oct;56(10):887-8. https://doi.org/10.1001/archpsyc.56.10.887
https://doi.org/10.1001/archpsyc.56.10.8... . These groups primarily consisted of women (81.3% and 99.4%), Black or Mixed-race individuals (87.2% and 94.7%), and those with lower incomes (87.1% and 97.9%). These shared characteristics delineate a social group historically subjected to various forms of structured oppression, including sexism and racism²³23. Veenstra G. Race, gender, class, and sexual orientation: intersecting axes of inequality and self-rated health in Canada. Int J Equity Health. 2011 Jan;10:3. https://doi.org/10.1186/1475-9276-10-3
https://doi.org/10.1186/1475-9276-10-3... , ³¹31. Friedman RC. Homosexuality, Psychopathology, and Suicidality. Arch Gen Psychiatry. 1999 Oct;56(10):887-8. https://doi.org/10.1001/archpsyc.56.10.887
https://doi.org/10.1001/archpsyc.56.10.8... . A meta-analysis, encompassing 37 studies and a total of 76,608 undergraduate and graduate students from 20 Low-and Middle-Income Countries (LMCs), revealed an overall prevalence of 24.4% for depressive symptoms, with a highlighted gender disparity regarding suicidal ideation (women = 20.7%; men=15.5) and significant risk ratio; RR = 1.9; p < 0.01)³²32. Akhtar P, Ma L, Waqas A, Naveed S, Li Y, Rahman A, et al. Prevalence of depression among university students in low and middle income countries (LMICs): a systematic review and meta-analysis. J Affect Disord. 2020 Sep;274:911-9. https://doi.org/10.1016/j.jad.2020.03.183
https://doi.org/10.1016/j.jad.2020.03.18... .

The theory of intersectionality posits that systems of inequality, such as racism and sexism, interact in intricate ways, mutually reinforcing each other and giving rise to unique social contexts where privilege and oppression can coexist¹²12. Collins PH. Intersectionality’s Definitional Dilemmas. Annual Rev Sociol 2015 Aug;41:1-20. https://doi.org/10.1146/annurev-soc-073014-112142
https://doi.org/10.1146/annurev-soc-0730... . It suggests that a complex social landscape, comprising multiple disadvantaged identities in combination, results in what is termed multiplicative disadvantage. This concept implies that the effects of various identity combinations exacerbate one another, surpassing a mere cumulative or moderating impact³³33. King DK. Multiple jeopardy, multiple consciousness: The context of a Black feminist ideology. Signs [Internet]. 1988 [cited 2024 Oct 10];14(1):42-72. Avaiable from: https://www.journals.uchicago.edu/doi/abs/10.1086/494491
https://www.journals.uchicago.edu/doi/ab... . Conversely, certain complex contexts, such as those inhabited by affluent, heterosexual, White men, are theorized to experience multiplicative advantage owing to the interconnected nature of intersectional theories²³23. Veenstra G. Race, gender, class, and sexual orientation: intersecting axes of inequality and self-rated health in Canada. Int J Equity Health. 2011 Jan;10:3. https://doi.org/10.1186/1475-9276-10-3
https://doi.org/10.1186/1475-9276-10-3... .

Thus, the emergence of mental health risks and the observed disparities in depressive symptom trajectories within and across various social groups are notably influenced by the diverse social realities experienced by individuals at different intersections of racial/ethnic and gender hierarchies. As depressive symptoms hinder access to social, economic, and political resources, disparities in mental health may perpetuate broader social inequality patterns³⁴34. Lépine JP, Briley M. The increasing burden of depression. Neuropsychiatr Dis Treat. 2011;7(Suppl 1):3-7. https://doi.org/10.2147/ndt.s19617
https://doi.org/10.2147/ndt.s19617... .

Despite the similarities, an exclusive characteristic of group five is that it comprises entirely non-heterosexual individuals. This demographic encompasses another historically marginalized social group that experiences various forms of violence, endured suffering, and engages in struggles for equal rights³⁵35. Meyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psycholl Bull. 2003 Sep;129(5):674-97. https://doi.org/10.1037/0033-2909.129.5.674
https://doi.org/10.1037/0033-2909.129.5.... . According to the Associação Nacional de Travestis e Transexuais (ANTRA – National Association of Travestis and Transexuals), Brazil has held the unfortunate distinction of being the country with the highest number of murders of trans individuals worldwide, for fifteen consecutive years³⁶36. Benevides BG. Dossiê: assassinatos e violências contra travestis e transexuais brasileiras em 2023. Brasília, DF: Distrito Drag; Associação Nacional de Travestis e Transsexuais; 2024.. Most of these victims (80%) were young, Black or Mixed-race trans individuals, openly embracing feminine gender identities, specifically as trans women³⁶36. Benevides BG. Dossiê: assassinatos e violências contra travestis e transexuais brasileiras em 2023. Brasília, DF: Distrito Drag; Associação Nacional de Travestis e Transsexuais; 2024..

This alarming figure underscores the substantial violence that the LGBTQIA+ community faces daily in this country. It further supports studies indicating that non-heterosexual individuals are at a 1.5 times higher risk of encountering mental disorders, experiencing suicidal thoughts, and engaging in intentional self-harm compared to their heterosexual counterparts³⁷37. Wittgens C, Fischer MM, Buspavanich P, Theobald S, Schweizer K, Trautmann S. Mental health in people with minority sexual orientations: A meta-analysis of population-based studies. Acta Psychiatr Scand. 2022 Jan;145(4):357-72. https://doi.org/10.1111/acps.13405
https://doi.org/10.1111/acps.13405... . Increasing evidence gathered over the past few decades demonstrates that sexual minority youth and adults exhibit notably poorer mental health outcomes than their heterosexual peers³⁵35. Meyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psycholl Bull. 2003 Sep;129(5):674-97. https://doi.org/10.1037/0033-2909.129.5.674
https://doi.org/10.1037/0033-2909.129.5.... , ³⁷37. Wittgens C, Fischer MM, Buspavanich P, Theobald S, Schweizer K, Trautmann S. Mental health in people with minority sexual orientations: A meta-analysis of population-based studies. Acta Psychiatr Scand. 2022 Jan;145(4):357-72. https://doi.org/10.1111/acps.13405
https://doi.org/10.1111/acps.13405... .

The minority stress theory highlights that stigma, discrimination, and victimization stemming from a homophobic and violent culture contribute to distinct stressors experienced by non-heterosexual individuals³⁵35. Meyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psycholl Bull. 2003 Sep;129(5):674-97. https://doi.org/10.1037/0033-2909.129.5.674
https://doi.org/10.1037/0033-2909.129.5.... . These stressors encompass regular discriminatory experiences, such as micro aggressions, along with the fear of rejection, self-devaluation due to internalized homophobia, hiding one’s identity, and other stigmatizing factors³⁷37. Wittgens C, Fischer MM, Buspavanich P, Theobald S, Schweizer K, Trautmann S. Mental health in people with minority sexual orientations: A meta-analysis of population-based studies. Acta Psychiatr Scand. 2022 Jan;145(4):357-72. https://doi.org/10.1111/acps.13405
https://doi.org/10.1111/acps.13405... . These pressures may intensify feelings of hopelessness and helplessness, ultimately contributing to the development of depression and suicidal thoughts³⁸38. Marshal MP, Dietz LJ, Friedman MS, Satll R, Smith HA, McGinley, et al. Suicidality and depression disparities between sexual minority and heterosexual youth: a meta-analytic review. Journal Adolesc Health. 2011 Aug;49(2): 115-23. https://doi.org/10.1016/j.jadohealth.2011.02.005
https://doi.org/10.1016/j.jadohealth.201... .

Despite the already elevated levels of depression and anxiety symptoms among university students, the Jeopardy Index approach revealed a specific subset of students at a significantly higher risk of experiencing severe symptoms. This group primarily consists of individuals from the LGBTQIA+ community, demonstrating nearly nine times higher odds for severe depressive symptoms and six times higher odds for severe anxiety. Additionally, the groups exhibiting higher prevalence and elevated risk rates predominantly comprised women of color and individuals with lower income levels.

A comprehensive study conducted in Brazil, using data from the National Survey of Health (PNS), highlighted the public health issue of under treatment in mental health, with more than 70% of depressed adults not receiving any care³⁹39. Mrejen M, Hone T, Rocha R. Socioeconomic and racial/ethnic inequalities in depression prevalence and the treatment gap in Brazil: A decomposition analysis. SSM Popul Health. 2022 Dec;20:101266. https://doi.org/10.1016/j.ssmph.2022.101266
https://doi.org/10.1016/j.ssmph.2022.101... . The study revealed that individuals with lower incomes were more likely to experience depression, while Black or Mixed-race individuals were more prone to untreated depression³⁹39. Mrejen M, Hone T, Rocha R. Socioeconomic and racial/ethnic inequalities in depression prevalence and the treatment gap in Brazil: A decomposition analysis. SSM Popul Health. 2022 Dec;20:101266. https://doi.org/10.1016/j.ssmph.2022.101266
https://doi.org/10.1016/j.ssmph.2022.101... . Another alarming statistic in Brazil is that suicide is the fourth leading cause of death among adolescents and young people, with higher rates observed among Black and Mixed-race individuals, who have a 45% higher risk of committing suicide⁴⁰40. Ministério da Saúde (BR). Secretaria de Gestão Estratégica e Participativa. Departamento de Apoio à Gestão Participativa e ao Controle Social. Óbitos por suicídio entre adolescentes e jovens negros 2012 a 2016. Brasília, DF: Ministério da Saúde; 2018..

To identify the symptom severity of college students’ mental health problems is crucial, given the positive association with risk for suicidal thoughts and self-injurious behavior⁴¹41. Mortier P, Cuijpers P, Kiekens G, Auerbach RP, Bemyttenaere K, Green JG, et al. The prevalence of suicidal thoughts and behaviours among college students: a meta-analysis. Psychol Med. 2018 Mar;48(4):554-65. https://doi.org/10.1017/s0033291717002215
https://doi.org/10.1017/s003329171700221... . The Jeopardy Index approach used in this study represents an effort to integrate the perspectives of social sciences into quantitative research on mental health, bringing up relevant social factors that are known as risk factors for mental health issues. However, the study has some limitations that need to be emphasized.

First, the self-reported instruments to assess depression and anxiety symptoms could be misinterpreted by the students, and we could have a self-selection bias that inflates the prevalence of symptoms in the recruited sample. Second, it is crucial to underscore that the findings from a cross-sectional study offer valuable indications deserving attention, however, their interpretation should be approached with caution due to their inherent limitation of not testing cause and effect. Moreover, the multiple jeopardy theory of intersectionality is a complex phenomenon that cannot be reduced to an additive concept²³23. Veenstra G. Race, gender, class, and sexual orientation: intersecting axes of inequality and self-rated health in Canada. Int J Equity Health. 2011 Jan;10:3. https://doi.org/10.1186/1475-9276-10-3
https://doi.org/10.1186/1475-9276-10-3... , ²⁴24. Mielke GI, Malta DC, Nunes BP, Cairney J. All are equal, but some are more equal than others: social determinants of leisure time physical activity through the lens of intersectionality. BMC Public Health. 2022 Jan;22(1):36. https://doi.org/10.1186/s12889-021-12428-7
https://doi.org/10.1186/s12889-021-12428... . Nevertheless, identifying students in urgent need for mental health support is the initial step to provide necessary attention, prevention, or interventions to mitigate mental health challenges in the university settings.

The Jeopardy Index approach showed that severe symptoms of anxiety and depression appear concentrated within a specific social group. It was revealed that women of color, with lower income, and those identifying as non-heterosexual exhibited nearly nine times higher odds for severe depressive symptoms and six times higher odds for severe anxiety symptoms. Despite the high overall prevalence of mental health issues, individuals with those social oppressive characteristics are experiencing significantly greater distress. This underscores the urgent need to incorporate social determinants of mental health into the screening processes for mental health problems within university settings.

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