Depressive symptoms, anxiety, stress, and the use of medicinal plants by nursing studentsABSTRACT
Objective: to verify the presence of symptoms of depression, anxiety and stress among nursing students related to the use of medicinal plants.
Method: cross-sectional study carried out virtually in January and November 2023, with undergraduate nursing students from a public university in Minas Gerais, Brazil. Descriptive statistical analysis, calculation of mean and standard deviation, and independent T-test were used for comparison between groups.
Results: 73 students participated, reporting severe or extremely severe symptoms of depression (35.6%), anxiety (42.4%), and stress (36.9%). The majority (56.2%) used medicinal plants, the most common being: chamomile, lemon grass, mint, boldo, aloe, and fennel, mainly for calming/relaxing effects, anxiety, flu/cold, and stress. Consumer students reported improvement in the symptoms for which they sought to use the plants, planting them in their own backyard, however they used them empirically.
Conclusion: the study showed a wide use of medicinal plants among nursing students. Symptoms of depression, anxiety, and stress were more present among students who used medicinal plants and among those enrolled in the initial periods (1st to 5th). The difference between groups was statistically significant for stress, considering the period studied.
Descriptors:
Medicinal plants; Nursing Students; Depression; Anxiety; Psychological Stress
RESUMO
Objetivo: verificar a presença de sintomas de depressão, ansiedade e estresse por acadêmicos de enfermagem relacionados ao uso de plantas medicinais.
Método: estudo transversal realizado em janeiro e novembro de 2023, de forma virtual com alunos de graduação em enfermagem de uma universidade pública de Minas Gerais, Brasil. Foi realizada análise estatística descritiva, cálculo de média e desvio padrão e Teste t independente para comparação entre os grupos.
Resultados: participaram 73 estudantes, que relataram sintomas graves ou extremamente graves de depressão (35,6%), ansiedade (42,4%) e estresse (36,9%). A maioria (56,2%) utilizava plantas medicinais, sendo as mais frequentes: camomila, capim-cidreira, hortelã, boldo, babosa e erva-doce, principalmente para efeito calmante/relaxante, ansiedade, gripe/resfriado e estresse. Os discentes consumidores relataram melhora nos sintomas para os quais buscaram o uso e obtinham as plantas no próprio quintal, contudo utilizaram de forma empírica.
Conclusão: o estudo evidenciou um amplo uso de plantas medicinais entre os acadêmicos de enfermagem. Os sintomas de depressão, ansiedade e estresse foram mais presentes entre os alunos que usavam plantas medicinais e entre aqueles matriculados nos períodos iniciais (1º ao 5º). A diferença entre os grupos foi estatisticamente significativa apenas para estresse, considerando o período cursado.
Descritores:
Plantas Medicinais; Estudantes de Enfermagem; Depressão; Ansiedade; Estresse Psicológico
RESUMEN
Objetivo: verificar la presencia de síntomas de depresión, ansiedad y estrés en estudiantes de enfermería relacionados con el uso de plantas medicinales.
Método: estudio transversal realizado em enero y noviembre de 2023, de forma virtual, con estudiantes de graduación en enfermería de una universidad pública de Minas Gerais, Brasil. Se realizaron análisis estadísticos descriptivos, cálculo de media y desviación estándar y prueba t independiente para comparación entre grupos.
Resultados: participaron 73 estudiantes, que refirieron síntomas graves o extremadamente graves de depresión (35,6%), ansiedad (42,4%) y estrés (36,9%). La mayoría (56,2%) utiliza plantas medicinales, siendo las más comunes: manzanilla, limoncillo, menta, boldo, aloe vera e hinojo, principalmente por sus efectos calmante/relajante, ansiedad, gripe/resfriado y estrés. Los estudiantes consumidores informaron mejoría en los síntomas por los que buscaron su utilización y obtuvieron las plantas en su propio patio casero y, sin embargo, las usaron empíricamente.
Conclusión: el estudio demostró un amplio uso de plantas medicinales entre los estudiantes de enfermería. Los síntomas de depresión, ansiedad y estrés fueron más presentes entre los alumnos que utilizaron plantas medicinales y entre los matriculados em los períodos iniciales (1º a 5º año). La diferencia entre los grupos fue estadísticamente significativa sólo para el estrés, considerando el período estudiado.
Descriptores:
Plantas Medicinales; Estudiantes de Enfermería; Depresión; Ansiedad; Estrés Psicológico
INTRODUCTION
Integrative and Complementary Health Practices (ICPS) are therapeutic approaches in the field of health that play a comprehensive role in the Unified Health System (SUS), as they aim to prevent diseases and promote and recover health1-2. Thus, ICPS stand out as they do not follow a biomedical care model, offering care with a view to the individuality of each person, considered holistically, emphasizing reception, listening, the construction of therapeutic ties, and the connection between human beings, the environment and society2.
The ICPS were instituted by SUS through the National Policy on Integrative and Complementary Practices (PNPIC), in 2006. First, they included acupuncture, homeopathy, medicinal plants, and herbal medicine, social thermalism/crenotherapy and anthroposophic medicine. Later, others were incorporated, and currently, 29 therapies are offered, including herbal medicine1-2.
Phytotherapy is the study of medicinal plants (plant species used for therapy in their fresh form) in their various forms of application, to prevent, promote, and preserve health. The herbal medicine is a product that originates from the medicinal plant and is presented in the form of medicine 1,3. Its holistic approach ensures that cultural, emotional, and physical particularities of each one involved are considered; therefore, it is not limited to treating diseases3-4.
Medicinal plants and herbal medicine are widely searched as routes for complementary therapeutic treatments, specifically for cases of depression, since, compared to allopathic treatment, they have a reduced propensity to adverse effects and, thus, ensures that the client complies better with the therapeutic regime5.
In the academic environment, there are stressors such as changes in family and social relationships, changes in housing, excessive academic activities and work, exams and internships, which can trigger mental suffering, since students are in a moment of transition involving changes in their environment and social life. Students in the field of health, especially nursing students, strive to have harmonious personal relationships as they associate the demands of health services and academic goals, transforming such situations into stressful moments and leading to different levels of stress and even depressive symptoms. These issues not only affect academic performance, but also their personal life, causing social and occupational harm6.
In order to mitigate anxiety symptoms, reduce insomnia, and increase their readiness for activities, nursing students have used medicinal plants with calming or anxiolytic effect, such as chamomile, lemon balm, fennel, mint, rosemary, lemongrass, and others7.
Nevertheless, phytotherapy and other ICPS are not a part of their mandatory curriculum, only being offered in some universities as an optional subject or in scientific events. Therefore, if it is to be understood by health academics and become a part of future nurses’ professional practice and passed on to users, there is a complex discussion to be held on the subject and how necessary it is to debate it in graduation, to provide integral care, considering the aspects of Brazilian biodiversity 3.
Considering the challenges faced by nursing students and the therapeutic properties of medicinal plants on mental health, this study aimed to verify the presence of symptoms of depression, anxiety and stress affecting nursing students and related to the use of medicinal plants.
METHOD
Cross-sectional study with a quantitative approach, developed in a public university in the Triângulo Mineiro region of Minas Gerais, Brazil, and guided by the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) (8.
The research was disseminated via invitations sent to the institutional email of the students and to existing WhatsApp® groups of students from the first to the tenth semester. It included a link to access the Informed Consent Form and, after their consent, the students were directed to an online form in Google Forms® for data collection.
To calculate the sample size, we considered the population of 284 regularly enrolled students, with a margin of error of 10% and a confidence level of 95%, resulting in a sample size of 72 participants. The study used non-probabilistic convenience sampling, that is, students who accessed the form and agreed to participate were included. Inclusion criteria were: students from the 1st to the 10th semester, regularly enrolled in the undergraduate nursing course of the institution, of both genders, aged 18 or older.
Students were first invited in January 2023, and 40 of them responded, leading to a partial analysis of data. In order to reach the minimum sample size, the invitation was repeated weekly in November 2023. There were three attempts to invite each group, from the first to the tenth semester. To avoid bias, all enrolled students received the invitations individually, via institutional email, in addition to the messages sent via the WhatsApp® groups of the classes of all semesters of the course.
Of 284 enrolled undergraduates, 75 accessed the invitation link, which contained detailed information about the research and how to fill in the consent form. Two refused to participate after accessing the term. Access to the online form was granted to the 73 (25.7%) students who agreed to participate in the study.
The form contained a survey to collect sociodemographic and clinical data on age, gender, self-reported color, number of people with whom they lived (including themselves), marital status, employment status, monthly family income, religion, semester in the course, diagnosed diseases and/or comorbidities, and treatments performed. It included questions about the use of medicinal plants before the pandemic (before March/2020), whether they started using them drugs during the pandemic (March/2020 to March/2022), if they used them after they returned to in-person activities at the university (from March/2022), and which medicinal plants they used, considering only weekly use for at least one month, in addition to which part of the plant they used, for what purpose, where they obtained them, if it led to improvements or unwanted effects, and if they would indicate them to others.
We also made available to them the Depression, Anxiety and Stress Scale (DASS-21), validated for the adult Brazilian population. This scale comprises 21 questions, seven for each of its three constructs. The participants had to agree to indicate the degree to which they experienced each of the symptoms of depression, anxiety and stress during the previous week on a 4-point Likert scale, where: 0 - did not apply to me at all; 1 - Applied to me to some degree, or some of the time; 2 - Applied to me a considerable degree, or a good part of the time; and 3 - Applied to me very much, or most of the time9.
The calculation for each symptom refers to the sum of seven specific questions, multiplied by two. Symptoms of stress were classified as such: 0-10 = normal, 11-18 = mild, 19-26 = moderate, 27-34 = severe, and 35-42 = extremely severe; those of anxiety: 0-6 = normal, 7-9 = mild, 10-14 = moderate, 15-19 = severe, and 20-42 extremely severe; and those of depression: 0-9 = normal, 10-12 = mild, 13-20 = moderate, 21-17 = severe, and 28-42 = extremely severe10.
The data was directly transferred from the form to an Excel spreadsheet and validated by double checking. The Statistical Package for the Social Sciences (SPSS) for Windows, version 23.0, was used for data analysis. Descriptive statistics were carried out and variables were analyzed using measures of absolute and relative frequency. Normality was verified using the Shapiro-Wilk test, with a significance level established at 5%. Homogeneity was verified using the Levene Test for Equality of Variances. WE calculated the means and standard deviation of the three constructs, and the independent t-test was used to verify the difference in the means of depression, anxiety and stress between the groups of students who used or did not use medicinal plants. The students were divided as belonging to the initial (1st to 5th) or final (6th to 10th) semesters of the course.
The project was approved by the Research Ethics Committee (REC) of the proposing institution, under CAE 62432522.5.0000.5154 and opinion No. 5.824.186/2022.
RESULTS
73 nursing students participated in this study. Their mean age was 24.36 (SD= 6.37), with a minimum of 18 and maximum of 53 years. Most were female, self-declared white, single, living with up to five people in their residence. They were mostly non-practitioning Catholics, as shown in Table 1.
Regarding the semester of the course, 23 (31.6%) students reported being enrolled in basic cycle subjects (between the 1st and 4th semesters), while 33 (45.2%) were from the 5th to the 8th semesters. 17 (23.2%) students were in the last year (supervised internship, between the 9th and 10th semesters). Most students (63-86.3%) reported that they do not work while doing the course, and the majority have a monthly family income of up to three minimum wages (31 - 42.5%).
As for the clinical variables, 27 (37.0%) students have some diagnosed physical or mental illness, the most common being: anxiety (16), depression (8), and hypothyroidism (3). 23 (31.5%) students undergo pharmacological treatments and 11 (15.1%) undergo non-pharmacological treatments.
According to DASS-21, a significant number of students reported depression (26-35.6%), anxiety (31-42.4%), and stress (27-36.9%) between the severe and extremely severe levels, as shown in Table 2.
Regarding medicinal plant use, 36 (49.3%) students reported having used them before the pandemic. During the pandemic and after returning to in-person activities in the university in question, 12 (16.4%) started using new plants, seven (9.6%) reported having started using them for the first time, and 30 (41.1%) reported never having used them. Of the 43 (58.9%) students who used medicinal plants, 37 reported that they noticed improvement in the symptoms they were trying to address. No one reported side effects or unwanted effects, and all of them recommend their use to other students.
The students used more than one medicinal plant, and Table 3 shows the plants used. Chamomile, lemongrass, mint, boldo, aloe vera, and fennel stand out as the most common.
The parts of the plants used by the students were: leaf (32-43.8%), root (16-21.9%), whole plant (12-16.4%), flower (12-16.4%), fruit (12-16.4%), stalk (11-15.1%), seed (7-9.6%), pulp (7-9.6%), and shaped as a capsule (9-12.3%).
Students reported the empirical use of the plants for the following reasons: calming/relaxing effect (33-45.2%), anxiety (25-34.2%), flu/cold (19-26.0%), stress (18-24.7%), detoxification (15-20.5%), pain (15-20.5%), indigestion/gastritis (14-19.2%), insomnia (14-19.2%), immunity (13-17.8%), hair loss (11-15.1%), heartburn (10-13.7%), depression (9-12.3%), diuretic (9-12.3%), skin (7-9.6%), intestinal problems/gas/constipation (6-8.2%), nausea (5-6.8%), infection (4- 5.5%), respiratory problems (4-5.5%), anemia (3-4.1%), liver problems (3-4.1%), hematoma (3-4.1%), kidney stones (2-2.7%), adverse effects of some treatment (1-1.4%), circulatory problems (1-1.4%), and other reasons (6-8.2%).
Regarding where these plants or part of them were found, the students reported: own cultivation in a yard (30-41.1%), natural product store (21-28.8%), market (18-24.7%), friends (9-12.3%), pharmacy (7-9.6%), and others (2-2.7%).
Table 4 shows the means and standard deviation of the variables depression, anxiety, and stress for the two groups of students, who were divided into a group of students who used medicinal plants at the time of data collection (n=43) and a group who did not (n=30). Students who used medicinal plants had higher means for the three variables; however, there was no statistically significant difference between the groups.
Table 5 shows the means and standard deviation of the variables depression, anxiety, and stress for two groups of students according to the semester attended. One group included students from the 1st to the 5th semesters (n=30), while the other included those from the 6th to the 10th (n=43). The students from the earlier semesters were more affected by depression, anxiety, and stress than those in the final semesters. The difference was statistically significant for stress.
DISCUSSION
There were much more female than male participants in this study, owing to the fact that, historically, nursing professionals have predominantly been female7,11-13.
Our results also corroborate studies carried out in higher education institutions in Bahia (Brazil)11-12 and Spain13, which found a predominance of single 11-12, young-adult 11-13, and unemployed students 11,13.
Regarding depression symptoms, anxiety, and stress, more than half the students reported having them at some level, and more than one third showed severe to extremely severe cases, as measured by DASS-21. Reports of lower mental health have been found in other universities, such as in Bahia. There, of 172 nursing students, 40.1% declared to have mental health considered “good” before entering the undergraduate course and during the course, with 47.1% characterizing their health as “regular”12. This decline in mental health was also reported by 98.9% of medical and nursing students from the countryside of São Paulo, who stated that the course contributed to increase stress, distress, excessive preoccupation, mood swings, sleep disturbances, and excessive self-imposed demands14.
Spanish nursing students had a prevalence of 3.8% for depression and 24.5% for anxiety, related to factors such as alcohol and tobacco use, low levels of physical activity, and unhealthy diets 13.
The growing presence of mental illness among nursing students is closely associated with elements of the environment, such as coping with high pressure situations and the challenges inherent in the health field, which require emotional skills to deal with the suffering of patients. Furthermore, as one advances in studies and the course advance, signs of depression tend to increase15, as opposed to the results found in this study, in which the students of the last five semesters showed lower mean levels of depression, anxiety, and stress.
A study with nursing students from Saudi Arabia showed that these and other challenges faced by the student in their routine were associated with higher levels of depression, such as being female, experiencing academic pressure, and having weak or unstable relationships with parents 16. In Italy17, on the other hand, women and students with low perceived socioeconomic status were the most predisposed.
Factors such as previous diagnoses of mental disorders, romantic relationships, perceived academic performance, use of tobacco, cannabis, and alcoholic beverages showed an association with depressive and/or anxiety symptoms. The high consumption of these substances to mitigate the impact academic and personal difficulties can aggravate mental health problems 17. Studies point out the need for universities and health services to develop mental health promotion programs aimed at this population, in order to prevent their cases from getting worse16-17.
A study evaluated the impact of anxiety over the academic life of 30 university students who attended the last year of nursing, finding a predominance of moderate (33.2%) and severe (23.4%) levels. It highlighted that, in 93% of cases, the university routine, the demands from professors, the tests, the mandatory end-of-course paper, and the concern for the future caused insomnia and discomfort, making them tense and worried, in addition to the lack of self-care for health, which generated anxiety18.
A meta-analysis, which included 121 systematic reviews, showed that most nursing students had moderate levels of stress (42.1%) and anxiety (19.4%-25.1). Students in the 3rd and 4th years experienced more severe stress levels compared to those in the 1st and 2nd years of the course (29.0% vs, 15.1%)19.
Measures to mitigate these symptoms must also be investigated. Some sociodemographic variables, such as sex, current semester, year of admission, hours at university, and practice of physical exercises were effective in managing stress among nursing students in Bahia. Women, those who entered the university a longer time ago and, therefore, were in a more advanced semester, as well as those who practiced some physical activity and those who spent less time at university managed stress better than the others20.
Another alternative to relieve symptoms of depression, anxiety and stress is the use of medicinal plants, as in the present investigation, in which students reported use to calm down/relax, and for anxiety, colds/flu, stress, among others. A review study recommended the use of lavender, hops, maypop, lemon balm, and valerian to alleviate mild forms of depression, anxiety and stress, but recommends further studies to prove the mechanism of action of these plants, so they can be used safely and successfully in the relief of these and other mental disorders 21.
Concerning the use of medicinal plants, it became clear that half the students interviewed use many of these plants in their day to day. As a result, it is important for students to be aware of the benefits of these medicinal and herbal plants, since ICPS have been assuming, throughout history, a position as a new model of community health care 22.
Chamomile, lemongrass, and melissa have a positive effect on relieving anxiety, depression, and other neurological problems. These plants helped reduce these disorders, probably due to their components affecting the nervous system. They were highlighted as a potential complementary and supporting resource in the treatment of psychopathologies23.
Lemon balm was evaluated in a meta-analysis that showed significant improvements for anxiety and depression compared to a placebo group (SMD: -0.98; 95% CI: -1.63 to -0.33; p = 0.003), (SMD: -0.47; 95% CI: -0.73 to -0.21; p = 0.0005) respectively, without detecting serious side effects; it is recommended, mainly, in acute situations 24.
The use of medicinal plants has been effective in controlling anxiety and relieving depressive symptoms, while their low toxicity makes them suitable for the formulation of herbal medicines 25. However, it should be mentioned that these studies 21,23-24 that analyzed the plants most used for mental disorders such as depression, anxiety, and stress in different populations - not specifically for undergraduate nursing students, therefore, not considering the specificities of this population.
Students who used medicinal plants had higher means of depression, anxiety, and stress than those who did not use them. This could be due to the fact they already felt these symptoms, having searched the medicine to soften and/or control these issues, seen as in the reports, they state to have sought the medication for its calming/relaxing effect over anxiety, stress, and others.
Since the results suggest that students use medicinal plants in their routine, they must have scientific knowledge about their use. This is essential so they can apply this knowledge safely and effectively and, later, transmit these care practices to future users.
Therefore, future health workers must be adequately prepared to provide care from an integral perspective, that embraces the user while showing awareness of their reality, in order to adopt practices such as this, which are less intrusive, automated, low-cost, and easier for the population to access22.
Limitations that stand out in this research were the convenience sample and the low adherence of students, as despite being informed about the goals of the research more than once, few actually participated. It should also be noted that the instruments used are self-reported, both in regard to medicinal plant used and the psychological symptoms used by the students. Therefore, they should be evaluated carefully and not generalized. Additionally, few articles address the use of medicinal plants in nursing students and investigate their use and benefits for the mental health of these students, who deal with the impact of symptoms of depression, anxiety, and stress.
The results show the need to address the topic during graduation, in order to spread scientific knowledge about medicinal plants and train professionals that can indicate which plant is adequate for each symptom or problem, thus avoiding the empirical use, be it personal or in future clinical practice. The benefits of medicinal plants in the mental health of students must be highlighted; however, new research is necessary to investigate the specific use of these plants and phytotherapic drugs with this target audience.
CONCLUSION
This study showed an expressive number of students with depression, anxiety, and stress in severe or extremely severe levels. These symptoms were more common among those who used medicinal plants and those enrolled in the first semesters of the course. A significant difference was found in stress levels, when comparing students from the first to the fifth semesters with those from the sixth to the tenth.
This study showed that the use of medicinal plants by nursing students was widespread and increased after the COVID-19 pandemic. The most used plants were: chamomile, lemon grass, mint, boldo, aloe, and fennel, mainly for calming/relaxing effects, anxiety, flu/colds, and stress.
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The dataset may be accessed upon request to the corresponding author.
