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Ann Clin Psychiatry. Author manuscript; available in PMC 2015 August 18. Published in final edited form as: Ann Clin Psychiatry. 2015 May ; 27(2): 100–108.
College students with depressive symptoms with and without fatigue: Differences in functioning, suicidality, anxiety, and depressive severity
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Maren Nyer, PhD, David Mischoulon, MD, PhD, Jonathan E. Alpert, MD, PhD, Daphne J. Holt, MD, PhD, Charlotte D. Brill, BA, Albert Yeung, MD, Paola Pedrelli, PhD, Lee Baer, PhD, Christina Dording, MD, Ilana Huz, BA, Lauren Fisher, PhD, Maurizio Fava, MD, and Amy Farabaugh, PhD Depression Clinical and Research Program, Massachusetts General Hospital, Boston, Massachusetts, USA
Abstract BACKGROUND—We examined whether fatigue was associated with greater symptomatic burden and functional impairment in college students with depressive symptoms.
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METHODS—Using data from the self-report Beck Depression Inventory (BDI), we stratified a group of 287 students endorsing significant symptoms of depression (BDI score ≥13) into 3 levels: no fatigue, mild fatigue, or moderate/severe fatigue. We then compared the 3 levels of fatigue across a battery of psychiatric and functional outcome measures. RESULTS—Approximately 87% of students endorsed at least mild fatigue. Students with moderate/severe fatigue had significantly greater depressive symptom severity compared with those with mild or no fatigue and scored higher on a suicide risk measure than those with mild fatigue. Students with severe fatigue evidenced greater frequency and intensity of anxiety than those with mild or no fatigue. Reported cognitive and functional impairment increased significantly as fatigue worsened. CONCLUSIONS—Depressed college students with symptoms of fatigue demonstrated functional impairment and symptomatic burden that worsened with increasing levels of fatigue. Assessing and treating symptoms of fatigue appears warranted within this population.
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INTRODUCTION Fatigue appears to be a common problem in the general population. According to the Diagnostic Interview Schedule, fatigue unexplained by a medical etiology has lifetime prevalence of 20% to 25%.1-4 In individuals with depression, fatigue is even more common. The relationship between fatigue and depression is complex. Fatigue is a common symptom of depression5; a frequent prodromal depressive symptom,6 especially with first onset of depression1; and a common residual depressive symptom.7 Fatigue and depression may share pathophysiologic mechanisms,5 and are associated with functional impairment.8-10
CORRESPONDENCE Maren Nyer, PhD, Depression Clinical and Research Program, 1 Bowdoin Square, 6th Floor, Boston MA 02114 USA, [email protected].
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Fatigue may persist after depressive symptoms respond to treatment or, in some cases, as a side effect of antidepressants.11 The prevalence of asthenia (ie, loss of energy and strength) or fatigue depends on the specific antidepressant agent used.12 Fatigue as a side effect of anti-depressant medication may result in poorer treatment outcomes.11 Fatigue was the second most common residual symptom after 215 outpatients with major depressive disorder received a selective serotonin reuptake inhibitor (SSRI) for 8 weeks; despite remission of depressive symptoms (17-item Hamilton Rating Scale for Depression [HRSD-17] score ≥7), many individuals continued to show subthreshold (40%) or threshold (5%) fatigue.13 A previous study from our group14 found that 40% to 45% of antidepressant remitters experienced residual fatigue or decreased wakefulness after ≥3 months of treatment. Fatigue may be less responsive to antidepressant medications and to psychotherapy compared with other depression symptoms.13,15
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Fatigue is highly prevalent among undergraduate collegestudents;itnegativelyimpactsacademicperformance,16 cognitive functioning,17 and psychological well-being.17,18 Fatigue in college students may be related to many factors, such as a heavy course load,19 extracurricular activities, work obligations, social activities, or drug use.18 In a sample of 189 undergraduate nursing students, 83.5% reported feeling moderately to extremely tired; 59.8% said fatigue caused moderate to severe impairment in functioning.20 Interestingly, social support has been found to negatively correlate with perceptions of fatigue.21
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Our study aims to explore whether varying levels of fatigue in college students with significant depressive symptoms are associated with psychiatric symptoms and impaired functioning. We hypothesized that individuals with greater levels of fatigue would have a greater symptomatic burden of these outcomes.
METHODS The 287 students in this study represented a subsample of a larger study conducted by the Depression Clinical and Research Program at Massachusetts General Hospital (MGH), Department of Psychiatry.22 Students were under-graduates who volunteered to participate in a mental health screening at their university. They signed consent forms approved by the MGH institutional review board, filled out self-report measures, and were given a $10 voucher to the university bookstore. Graduate students were excluded. This study includes only students reporting significant symptoms of depression, as measured by a score of ≥13 on the Beck Depression Inventory (BDI).23 Because different scales were used over the course of the study, total sample sizes for the scales are not the same.
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Self-report measures Demographics questionnaire—This 4-page questionnaire (unpublished; available upon request) measured demographic domains: age, grade point average (GPA), marital status, living situation, ethnicity, family socioeconomic status, and school year. Other than age and GPA, the demographic information was collected categorically (TABLE 1).
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BDI.23—On this 21-item measure, students self-reported the extent to which they had experienced depressive symptoms over the past week. Each item was scored 0 to 3, with higher scores indicating greater depressive severity. For purposes of this study, the BDI fatigue item 17 was excluded from BDI total score, as this item was used as the grouping variable (independent variable). BDI fatigue item 17—This item was used to assess level of fatigue within the past week. The 4 possible responses are: 0 = “I don’t get more tired than usual,” 1 = “I get tired more easily than I used to,” 2 = “I get tired from doing almost anything,” and 3 = “I am too tired to do anything.” For data analysis, students were placed into 3 categories based on their responses: Group 1 (no fatigue, response of 0), Group 2 (mild fatigue, response of 1), and Group 3 (moderate/severe fatigue, response of 2 or 3).
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Beck Hopelessness Scale (BHS).24—The BHS was used to assess an individual’s degree of hopelessness. The BHS contains 20 true-false statements that reflect attitudes toward the future. A higher total score represents a greater level of hopelessness over the past week. Quality of Life Enjoyment and Satisfaction Questionnaire–Short Form (QLES–Q-SF).25—This measure asks about physical health, general feelings of well-being, work satisfaction, leisure activities, social relationships, and life satisfaction over the past week. Students were asked to respond on a scale of 1 (poor) to 5 (very good). Items were totaled, and higher scores indicated better quality of life.
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Anxiety Symptom Questionnaire (ASQ)–Intensity and Frequency.26—The ASQ is a 17-item instrument that assesses anxiety symptoms during the previous week. Symptom intensity was rated from 0 = “none” to 10 = “extreme distress.” Symptom frequency was rated 0 = “never” to 10 = “all the time.” Items were totaled independently for these subscales, with higher scores indicating greater intensity or frequency of anxiety symptoms, respectively. Beck Anxiety Inventory (BAI).27—This 21-item instrument measures the severity of self-reported anxiety symptoms. Students rated statements on a 4-point scale: 0 = “not at all,” 1 = “mildly, but it didn’t bother me much,” 2 = moderately—it wasn’t pleasant at all, and 3 = “severely—it bothered me a lot”. A higher total score indicates greater severity of anxiety.
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MGH Cognitive and Physical Functioning Questionnaire (CPFQ).28—This 7-item questionnaire assesses cognitive and physical functioning during the past month on a scale of 1 = “greater than normal” to 6 = “totally diminished.” Higher total scores indicate worse functioning. The Suicidal Behaviors Questionnaire–Revised (SBQ–R).29—This 4-item selfreport questionnaire assesses suicidal ideation and behavior. Higher scores indicate greater risk of future suicidality.
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Data analysis
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For all measures, descriptive statistics were calculated for the total sample and then separately for each of the 3 fatigue groups (no fatigue, mild fatigue, and moderate/severe fatigue). Analyses of variance (ANOVA) were conducted, using the fatigue levels as the independent variables. The dependent variables were the BDI total (minus fatigue item 17), BHS total, ASQ intensity total, ASQ frequency total, QLES-Q total, CPFQ total, and BAI total. A P value of .05), except for sex; female students were significantly more likely to have mild (67.3%) to moderate/severe fatigue (74.4%) compared with male students (Pearson chi-square test = 8.60; P < .05). Of note, the GPA increased marginally across the 3 fatigue groups. Students who are working harder to perform academically may be more fatigued as a result; however, this difference is very modest, statistically nonsignificant (P = .63), and does not permit us to draw any firm conclusions. Mean BDI score for the entire sample was 18.25 ± 6.44, and 86.4% of all students endorsed at least mild fatigue on BDI fatigue item 17 (TABLE 2).
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In this sample of students with depressive symptoms (BDI ≥13), those with moderate/severe fatigue had significantly greater depressive symptom severity compared with those with mild (P < .001) or no fatigue (P < .01) (BDI total minus BDI fatigue item 17: Welch statistic [2,98.30]= 11.50; P < .001). Students with moderate/severe fatigue had higher levels of suicidality (SBQ–R total: F2,154 = 5.24; P < .01), compared with those with mild fatigue (P < .01). Students with more severe fatigue evidenced significantly greater levels of anxiety across the ASQ intensity subscale (F2,142 = 12.67; P < .001), as well as across the ASQ frequency subscale (F2,140 = 14.01; P < .001) compared with students with no or mild fatigue. On the BAI, students with no fatigue had significantly lower anxiety scores than those with moderate/severe fatigue (P < .001) or mild fatigue (P < .01) (Welch statistic [2,34] = 16.13; P < .001). Students reported significantly greater cognitive and physical functional impairment (CPFQ total: Welch statistic [2,70.82] = 17.98; P < .001), as their level of fatigue worsened (P < .01 for all). No significant associations with fatigue were observed with regard to quality of life (QLES–Q-SF total: F2,129 = 1.92; P = .15) and hopelessness (BHS total: F2,92 = 2.15; P = .12). TABLE 3 summarizes results from the independent ANOVA.
DISCUSSION Our study examined the relationship between varying levels of fatigue and clinical and functional domains in a sample of college students with depressive symptoms. We found that fatigue was common in college students with depressive symptoms: 86.4% of students Ann Clin Psychiatry. Author manuscript; available in PMC 2015 August 18.
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endorsed at least mild fatigue. Study hypotheses were primarily supported, in that higher levels of fatigue were generally associated with a greater burden of psychiatric symptoms and poorer cognitive and physical functioning.
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Although our sample had a limited range of depressive symptom severity (BDI ≥13), levels of fatigue were still associated with depressive symptoms. College students with depressive symptoms and moderate/severe fatigue had significantly greater depressive symptom severity compared with those with mild or no fatigue. We have found mixed results for other BDI items and depressive severity in previous investigations with this population.30-32 The current findings therefore suggest that this association is not simply a function of symptom severity per se but rather the nature of fatigue. In another sample of undergraduates who completed the BDI and the Fatigue Severity Questionnaire, depression correlated with fatigue.33 In a more recent study of adults with major depressive disorder (MDD), those with fatigue had higher HRSD scores compared with those without fatigue.34 Our findings appear to be consistent with the literature on the association between depressive severity and fatigue. The complex relationship between these symptoms warrants further investigation, especially in the college population. Higher levels of fatigue also were significantly related to higher levels of anxiety on both anxiety scales used in this study. In a longitudinal study of girls from adolescence to young adulthood, an increase in fatigue was associated with increased anxiety and depressive symptoms.35 Another study of patients with MDD found a positive correlation among somatic anxiety, fatigue, and depression.36 Fatigue is considered a symptom of anxiety and may share some common pathways.
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In our study, moderate/severe fatigue was associated with greater suicidality in college students with depressive symptoms. Another study showed a trend toward higher mortality rates for chronic fatigue patients stratified by lifetime history of MDD compared with those without a history of MDD.37 Some research suggests that the opposite may be true: higher levels of energy may predict suicide attempts in patients with MDD.38 This is a complicated relationship, as an increase in energy could reflect bipolarity or hypomania, also associated with increased suicidality.39
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We found that as fatigue worsened, so did cognitive and physical functioning. This is consistent with a report by Pedrelli et al40 of greater cognitive deficits (in alertness and focused attention) in adults with remitted MDD and residual fatigue. Similarly, Constant et al41 found in a group of depressed patients a significant association between fatigue and impairment in memory, visual episodic memory, and alertness. Despite what might seem an obvious relationship between fatigue and cognitive functioning, the literature in this area is sparse, and more research is needed. On a related note, Cassano and Fava42 suggested that fatigue can be a common side effect of chronic SSRI treatment, impairing function in social, familial, and work domains. Contrary to our expectations, quality of life and degree of hopelessness did not vary across levels of fatigue. We were unable to find other literature examining the relationship between
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fatigue and hopelessness. Further investigation of other correlates of fatigue, such as hopelessness and quality of life, is warranted in college students. Given that fatigue may be common among college students with depressive symptoms and that fatigue is associated with other psychological symptoms and impaired functioning, monitoring and treatment of fatigue in this population may be important. Successful treatment of depression sometimes improves mood and somatic symptoms including fatigue.43 On the other hand, fatigue could be an adverse effect of pharmacologic treatment, particularly with SSRIs.42 When fatigue emerges as a side effect, antidepressant treatment that is dopaminergic and noradrenergic may be preferable to SSRIs.44 Non-pharmacologic treatments of fatigue, including cognitive-behavioral therapy, exercise, diet, and good sleep hygiene, also have been proposed43,45-47 and may be effective for college students with depression.
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Our findings must be interpreted with some caution, given the study’s limitations. For example, the ANOVA investigating quality of life scores (Q-LES–Q-SF) across fatigue groups included only 16 students in the “no fatigue” group and may have lacked sufficient power to detect a true difference (P = .15). Our non-clinical sample included only college undergraduates and may not reflect the general population. The sample was largely female (approximately 67%) and also may not have adequately represented non-white and lower socioeconomic groups. We used the BDI–I, rather than the more recent BDI–II, and relied solely on BDI fatigue item 17 to measure fatigue. Using a nonintrusive, easily administered question to measure fatigue in a non-clinical population can be beneficial. For example, endorsing the symptom of fatigue on a self-report questionnaire carries less stigma than disclosing depressive symptoms and could help identify individuals with unrecognized depression. Even so, future studies are needed with more comprehensive fatigue measures. For patients with depression, few standardized tools exist to measure fatigue. Further measurement development could help to elucidate the complex relationship between MDD and fatigue. Finally, we did not assess for medical conditions or other non-psychiatric contributors to fatigue, such as medication side effects and other comorbid conditions. We also did not account for whether a participant was taking an antidepressant, and thus we could not determine whether fatigue was a symptom of depression and/or a side effect of medication. Any of these factors, and especially treatment status, could have influenced our findings, and unfortunately, we did not assess for them in our screenings. Future longitudinal research could help elucidate the causal relationship between depression and fatigue in this population and whether this relationship is tractable to anti-depressant treatment.
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As our group previously has found with sleep disturbance, suicidality, and irritability in students with depressive symptoms,30-32 the presence of fatigue appears to be associated with greater symptom burden. Fatigue in students with depressive symptoms may characterize a worse clinical presentation. Assessing and treating symptoms of fatigue appears to be warranted in this population made vulnerable to psychiatric symptoms by their stress level, developmental challenges, and lifestyle. The potential cause or effect
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relationship between fatigue and depression is not fully understood. Fatigue could be both cause and/or effect of depression.
CONCLUSIONS
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Depressed college students with symptoms of fatigue demonstrated functional impairment and symptomatic burden that worsened with increasing levels of fatigue. Specifically, students categorized as having moderate/severe fatigue (Group 3) reported the greatest burden of depressive symptoms and the greatest frequency and intensity of anxiety compared with those with mild fatigue (Group 2) or no fatigue (Group 1). Group 3 also evidenced higher scores on the suicide risk instrument, compared with Group 2. Levels of cognitive and physical functioning also worsened as the level of fatigue increased. We conclude, therefore, that assessing fatigue—especially in college populations prone to fatigue and depression—may be important in mental illness prevention and treatment efforts.
ACKNOWLEDGEMENTS This work was supported by a grant from The Jed Foundation, a nonprofit organization whose mission is to promote emotional health and prevent suicide among college students.
DISCLOSURES
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Drs. Nyer, Holt, Yeung, Baer, Dording, Fisher, and Farabaugh, and Ms. Brill, and Ms. Huz report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products. Dr. Nyer has received grant/research support from National Institute of Complimentary and Alternative Medicine (1K23AT008043-01A1). Dr. Mischoulon receives grant/research support from Bowman Family Foundation, FisherWallace, Nordic Naturals, Methylation Sciences, Inc., and PharmoRx Therapeutics; is a consultant to Pamlab; is a speaker for Pamlab and the Massachusetts General Hospital Psychiatry Academy; and receives royalties from Lippincott Williams & Wilkins for published book Natural Medications for Psychiatric Disorders: Considering the Alternatives. Dr. Pedrelli receives grant/research report from National Institute of Alcohol Abuse and Alcoholism.
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Dr. Alpert reports financial relationships with Abbot Laboratories, Alkermes, American Psychiatric Association, Aspect Medical Systems, Astra-Zeneca< Belvoir Publishing, Bristol-Myers Squibb Company, Cephalon, Cyberonics, Eli Lily & Company, Forest Pharmaceuticals Inc., GlaxoSmithKline, J & J Pharmaceuticals, Lichtwer Pharma GmbH, Lorex Pharmaceuticals, MGH Academy, Novartis, Organon Inc., PamLab, LLC, Pfizer Inc, Pharmavite, Primedia, Reed Medical Education, Roche, Sanofi/Synthelabo, Solvay Pharmaceuticals, Inc., Wyeth-Ayerst Laboratories, and Xian-Janssen. Dr. Fava receives research support from Abbott Laboratories, Alkermes, Inc., American Cyanamid, Aspect Medical Systems, AstraZeneca, Avanir Pharmceuticals, BioResearch, BrainCells Inc., Bristol-Myers Squibb, CeNeRx Bio Pharma, Cephalon, Clintara, LLC, Covance, Covidien, Eli Lilly and Company, EnVivo Pharmaceuticals, Inc., Euthymics
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Bioscience, Inc., Forest Pharmaceuticals, Inc., Ganeden Biotech, Inc., GlaxoSmithKline, Harvard Clinical Research Institute, Hoffman-LaRoche, i3 Innovus/Ingenix, Icon Clinical Research, Janssen R&D, LLC, Jed Foundation, Johnson & Johnson Pharmaceutical Research & Development, Lichtwer Pharma GmbH, Lorex Pharmaceuticals, Lundbeck Inc, MedAvante, Methylation SciencesInc.,NARSAD,NationalCenterforComplementary and Alternative Medicine, National Institute of Mental Health, National Institute on Drug Abuse, Neuralstem, Inc., Novartis AG, Organon Pharmaceuticals, PamLab, LLC, Pfizer, Inc., Pharmacia-Upjohn, Pharmaceutical Research Associates, Inc.; Pharmavite LLC, PharmoRx Therapeutics, Photothera, Reckitt Benchkiser, Roche Pharmaceuticals, RCT Logic, LLC, Roche Pharmaceuticals, Sanofi-Aventis US LLC, Shire, Solvay Pharmaceuticals, Inc., Stanley Medical Research Institute, Synthelabo, and Wyeth-Ayerst Laboratories; is an advisor or consultant to Abbott Laboratories, Affectis Pharmaceuticals AG, Alkermes, Inc., AmarinPharma,Inc.,AspectMedicalSystems,AstraZeneca, Auspex Pharmaceuticals, Bayer AG, Best Practice Project Management, Inc., BioMarin Pharmaceuticals, Inc., Biovail Corporation, BrainCells Inc., Bristol-Myers Squibb, CeNeRx Bio Pharma, Cephalon, Carecor, CNS Response, Inc., Compellis Pharmaceutics, Cypress Pharmaceutical, Inc., DiagnoSearch Life Sciences (P) Ltd., Dainippon Sumitomo Pharma Co. Inc., Dov Pharmaceuticals, Inc., Edgemont Pharmaceuticals, Inc., Eisai, Inc., Eli Lilly and Company, EnVivo Pharmaceuticals, Inc., ePharmaSolutions, EPIX Pharmaceuticals, Euthymics Bioscience, Inc., Fabre-Kramer Pharmaceuticals, Forest Pharmaceuticals, Inc., GenOmind, LLC, GlaxoSmithKline, Grunenthal GmbH, i3 Innovus/Ingenis, Janssen Pharmaceutica, Jazz Pharmaceuticals, Inc., Johnson & Johnson Pharmaceutical Research & Development, LLC, Knoll Pharmaceuticals Corp., Labopharm Inc., Lorex Pharmaceuticals, Lundbeck Inc., MedAvante, Inc., Merck, MSI Methylation Sciences, Inc., Naurex, Inc., Neuralstem, Inc., Neuronetics, Inc., NextWave Pharmaceuticals, Novartis AG, Nutrition 21, Orexigen Therapeutics, Inc., Organon Pharmaceuticals, Otsuka Pharmaceuticals, PamLab, LLC, Pfizer, Inc., PharmaStar, Pharmavite LLC, PharmoRx Therapeutics, Precision Human Biolaboratory, Prexa Pharmaceuticals, Inc., PsychoGenics, Psylin Neurosciences, Inc., Puretech Ventures, RCT Logic, LLC, Rexahn Pharmaceuticals, Inc., Ridge Diagnostics, Inc., Roche Pharmaceuticals, Sanofi-Aventis, Schering-Plough Corporation, Sepracor, Inc., ServierLaboratories,SolvayPharmaceuticals,Inc.,Somaxon Pharmaceuticals, Inc., Somerset Pharmaceuticals, Inc., Sunovion Pharmaceuticals, Supernus Pharmaceuticals, Inc., Synthelabo, Takeda Pharmaceutical Company Limited, Tal Medical, Inc., Tetragenex Pharmaceuticals, Inc., TransForm Pharmaceuticals, Inc., and Vanda Pharmaceuticals, Inc.; is a speaker for or has been published by: Adamed, Co., Advanced Meeting Partners, American Psychiatric Association, American Society of Clinical Psychopharmacology, AstraZeneca, Belvoir Media Group, Boehringer Ingelheim GmbH, Bristol-Myers Squibb, Cephalon, Inc., CME Institute/Physicians Postgraduate Press, Inc., Eli Lilly and Company, Forest Pharmaceuticals, Inc., GlaxoSmithKline, Imedex, LLC, MGH Psychiatry Academy/ Primedia, MGH Psychiatry Academy/Reed Elsevier, Novartis AG, Organon Pharmaceuticals, Pfizer, PharmaStar, United BioSource Corp., and Wyeth-Ayerst Laboratories; has equity holdings with Compellis and PsyBrain, Inc.; has a patent for Sequential Parallel Comparison Design (SPCD) and a patent application for a combination of ketamine and scopolamine in major depressive disorder, for research and licensing of SPCD, licensed by MGH to Pharmaceutical Product Development, LLC (PPD); and has a
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copyright for the MGH Cognitive & Physical Functioning Questionnaire (CPFQ), Sexual Functioning Inventory (SFI), Antidepressant Treatment Response Questionnaire (ATRQ), Discontinuation-Emergent Signs & Symptoms (DESS), and SAFER; Lippincott, Williams & Wilkins; Wolkers Kluwer; World Scientific Publishing Co. Pte.
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42. Cassano P, Fava M. Tolerability issues during long-term treatment with antidepressants. Ann Clin Psychiatry. 2004; 16:15–25. [PubMed: 15147109] 43. Rosenthal TC, Majeroni BA, Pretorius R, et al. Fatigue: an overview. Am Fam Physician. 2008; 78:1173–1179. [PubMed: 19035066] 44. Stenman E, Lilja A. Increased monoaminergic neurotransmission improves compliance with physical activity recommendations in depressed patients with fatigue. Med Hypotheses. 2013; 80:47–49. [PubMed: 23127500] 45. Rooks DS, Gautam S, Romeling M, et al. Group exercise, education, and combination selfmanagement in women with fibromyalgia: a randomized trial. Arch Intern Med. 2007; 167:2192– 2200. [PubMed: 17998491] 46. Stevinson C, Steed H, Faught W, et al. Physical activity in ovarian cancer survivors: associations with fatigue, sleep, and psychosocial functioning. Int J Gynecol Cancer. 2009; 19:73–78. [PubMed: 19258945] 47. Wick JY, LaFleur J. Fatigue: implications for the elderly. Consult Pharm. 2007; 22:566–570. 573-574,576-578. [PubMed: 17714001]
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TABLE 1
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College students with depressive symptoms with and without fatigue: Demographic data Total sample (N = 287)
No fatigue (n = 39)
Mild fatigue (n = 161)
Moderate/severe fatigue (n = 87)
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Mean
SD
Mean
SD
Mean
SD
Mean
SD
Age (n = 269)
a
19.81
1.87
19.78
1.97
19.81
1.95
19.82
1.68
Grade point average (n = 242)
3.24
0.50
3.21
0.59
3.23
0.48
3.29
0.48
n
%
n
%
n
%
n
%
Female
184
66.7
18
6.5
105
38
61
22.1
Male
92
33.3
20
7.2
51
18.5
21
7.6
School year (n = 275)
n
%
n
%
n
%
n
%
Freshman
74
26.9
11
4
45
16.4
18
6.5
Sophomore
73
26.5
10
3.6
37
13.5
26
9.5
Junior
70
25.5
11
4
38
13.8
21
7.6
Senior
49
17.8
5
1.8
29
10.5
15
5.5
Other
9
3.3
1
0.4
6
2.2
2
0.7
Marital status (n = 276)
n
%
n
%
n
%
n
%
Sex (n = 276)
Never married
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273
98.9
38
13.8
155
56.2
80
Other
3
1.2
0
0
1
0.4
2
Living situation (n = 112)
n
%
n
%
n
%
n
%
On campus alone
33
29.5
3
2.7
21
18.8
9
8
On campus with roommates
34
30.4
5
4.5
17
15.2
12
10.7
Off campus alone
8
7.1
2
1.8
4
3.6
2
1.8
Off campus with relatives
8
7.1
0
0
5
4.5
3
2.7
Off campus with roommates
29
25.9
2
1.8
24
21.4
3
2.7
Ethnicity (n = 249)
n
%
n
%
n
%
n
%
Black, not of Hispanic origin
22
8.8
1
0.4
15
6
6
2.4
Hispanic
19
7.6
3
1.2
11
4.4
5
2
White, not of Hispanic origin
157
63.1
24
9.6
84
33.7
49
19.7
American Indian or Alaskan native
1
0.4
0
0
0
0
1
0.4
Asian or Pacific Islander
36
14.5
3
1.2
23
9.2
10
4
Other
14
5.6
2
0.8
8
3.2
4
1.6
Family socioeconomic status (n = 101)
n
%
n
%
n
%
n
%
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Low income (
Ann Clin Psychiatry. Author manuscript; available in PMC 2015 August 18. Published in final edited form as: Ann Clin Psychiatry. 2015 May ; 27(2): 100–108.
College students with depressive symptoms with and without fatigue: Differences in functioning, suicidality, anxiety, and depressive severity
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Maren Nyer, PhD, David Mischoulon, MD, PhD, Jonathan E. Alpert, MD, PhD, Daphne J. Holt, MD, PhD, Charlotte D. Brill, BA, Albert Yeung, MD, Paola Pedrelli, PhD, Lee Baer, PhD, Christina Dording, MD, Ilana Huz, BA, Lauren Fisher, PhD, Maurizio Fava, MD, and Amy Farabaugh, PhD Depression Clinical and Research Program, Massachusetts General Hospital, Boston, Massachusetts, USA
Abstract BACKGROUND—We examined whether fatigue was associated with greater symptomatic burden and functional impairment in college students with depressive symptoms.
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METHODS—Using data from the self-report Beck Depression Inventory (BDI), we stratified a group of 287 students endorsing significant symptoms of depression (BDI score ≥13) into 3 levels: no fatigue, mild fatigue, or moderate/severe fatigue. We then compared the 3 levels of fatigue across a battery of psychiatric and functional outcome measures. RESULTS—Approximately 87% of students endorsed at least mild fatigue. Students with moderate/severe fatigue had significantly greater depressive symptom severity compared with those with mild or no fatigue and scored higher on a suicide risk measure than those with mild fatigue. Students with severe fatigue evidenced greater frequency and intensity of anxiety than those with mild or no fatigue. Reported cognitive and functional impairment increased significantly as fatigue worsened. CONCLUSIONS—Depressed college students with symptoms of fatigue demonstrated functional impairment and symptomatic burden that worsened with increasing levels of fatigue. Assessing and treating symptoms of fatigue appears warranted within this population.
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INTRODUCTION Fatigue appears to be a common problem in the general population. According to the Diagnostic Interview Schedule, fatigue unexplained by a medical etiology has lifetime prevalence of 20% to 25%.1-4 In individuals with depression, fatigue is even more common. The relationship between fatigue and depression is complex. Fatigue is a common symptom of depression5; a frequent prodromal depressive symptom,6 especially with first onset of depression1; and a common residual depressive symptom.7 Fatigue and depression may share pathophysiologic mechanisms,5 and are associated with functional impairment.8-10
CORRESPONDENCE Maren Nyer, PhD, Depression Clinical and Research Program, 1 Bowdoin Square, 6th Floor, Boston MA 02114 USA, [email protected].
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Fatigue may persist after depressive symptoms respond to treatment or, in some cases, as a side effect of antidepressants.11 The prevalence of asthenia (ie, loss of energy and strength) or fatigue depends on the specific antidepressant agent used.12 Fatigue as a side effect of anti-depressant medication may result in poorer treatment outcomes.11 Fatigue was the second most common residual symptom after 215 outpatients with major depressive disorder received a selective serotonin reuptake inhibitor (SSRI) for 8 weeks; despite remission of depressive symptoms (17-item Hamilton Rating Scale for Depression [HRSD-17] score ≥7), many individuals continued to show subthreshold (40%) or threshold (5%) fatigue.13 A previous study from our group14 found that 40% to 45% of antidepressant remitters experienced residual fatigue or decreased wakefulness after ≥3 months of treatment. Fatigue may be less responsive to antidepressant medications and to psychotherapy compared with other depression symptoms.13,15
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Fatigue is highly prevalent among undergraduate collegestudents;itnegativelyimpactsacademicperformance,16 cognitive functioning,17 and psychological well-being.17,18 Fatigue in college students may be related to many factors, such as a heavy course load,19 extracurricular activities, work obligations, social activities, or drug use.18 In a sample of 189 undergraduate nursing students, 83.5% reported feeling moderately to extremely tired; 59.8% said fatigue caused moderate to severe impairment in functioning.20 Interestingly, social support has been found to negatively correlate with perceptions of fatigue.21
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Our study aims to explore whether varying levels of fatigue in college students with significant depressive symptoms are associated with psychiatric symptoms and impaired functioning. We hypothesized that individuals with greater levels of fatigue would have a greater symptomatic burden of these outcomes.
METHODS The 287 students in this study represented a subsample of a larger study conducted by the Depression Clinical and Research Program at Massachusetts General Hospital (MGH), Department of Psychiatry.22 Students were under-graduates who volunteered to participate in a mental health screening at their university. They signed consent forms approved by the MGH institutional review board, filled out self-report measures, and were given a $10 voucher to the university bookstore. Graduate students were excluded. This study includes only students reporting significant symptoms of depression, as measured by a score of ≥13 on the Beck Depression Inventory (BDI).23 Because different scales were used over the course of the study, total sample sizes for the scales are not the same.
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Self-report measures Demographics questionnaire—This 4-page questionnaire (unpublished; available upon request) measured demographic domains: age, grade point average (GPA), marital status, living situation, ethnicity, family socioeconomic status, and school year. Other than age and GPA, the demographic information was collected categorically (TABLE 1).
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BDI.23—On this 21-item measure, students self-reported the extent to which they had experienced depressive symptoms over the past week. Each item was scored 0 to 3, with higher scores indicating greater depressive severity. For purposes of this study, the BDI fatigue item 17 was excluded from BDI total score, as this item was used as the grouping variable (independent variable). BDI fatigue item 17—This item was used to assess level of fatigue within the past week. The 4 possible responses are: 0 = “I don’t get more tired than usual,” 1 = “I get tired more easily than I used to,” 2 = “I get tired from doing almost anything,” and 3 = “I am too tired to do anything.” For data analysis, students were placed into 3 categories based on their responses: Group 1 (no fatigue, response of 0), Group 2 (mild fatigue, response of 1), and Group 3 (moderate/severe fatigue, response of 2 or 3).
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Beck Hopelessness Scale (BHS).24—The BHS was used to assess an individual’s degree of hopelessness. The BHS contains 20 true-false statements that reflect attitudes toward the future. A higher total score represents a greater level of hopelessness over the past week. Quality of Life Enjoyment and Satisfaction Questionnaire–Short Form (QLES–Q-SF).25—This measure asks about physical health, general feelings of well-being, work satisfaction, leisure activities, social relationships, and life satisfaction over the past week. Students were asked to respond on a scale of 1 (poor) to 5 (very good). Items were totaled, and higher scores indicated better quality of life.
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Anxiety Symptom Questionnaire (ASQ)–Intensity and Frequency.26—The ASQ is a 17-item instrument that assesses anxiety symptoms during the previous week. Symptom intensity was rated from 0 = “none” to 10 = “extreme distress.” Symptom frequency was rated 0 = “never” to 10 = “all the time.” Items were totaled independently for these subscales, with higher scores indicating greater intensity or frequency of anxiety symptoms, respectively. Beck Anxiety Inventory (BAI).27—This 21-item instrument measures the severity of self-reported anxiety symptoms. Students rated statements on a 4-point scale: 0 = “not at all,” 1 = “mildly, but it didn’t bother me much,” 2 = moderately—it wasn’t pleasant at all, and 3 = “severely—it bothered me a lot”. A higher total score indicates greater severity of anxiety.
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MGH Cognitive and Physical Functioning Questionnaire (CPFQ).28—This 7-item questionnaire assesses cognitive and physical functioning during the past month on a scale of 1 = “greater than normal” to 6 = “totally diminished.” Higher total scores indicate worse functioning. The Suicidal Behaviors Questionnaire–Revised (SBQ–R).29—This 4-item selfreport questionnaire assesses suicidal ideation and behavior. Higher scores indicate greater risk of future suicidality.
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Data analysis
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For all measures, descriptive statistics were calculated for the total sample and then separately for each of the 3 fatigue groups (no fatigue, mild fatigue, and moderate/severe fatigue). Analyses of variance (ANOVA) were conducted, using the fatigue levels as the independent variables. The dependent variables were the BDI total (minus fatigue item 17), BHS total, ASQ intensity total, ASQ frequency total, QLES-Q total, CPFQ total, and BAI total. A P value of .05), except for sex; female students were significantly more likely to have mild (67.3%) to moderate/severe fatigue (74.4%) compared with male students (Pearson chi-square test = 8.60; P < .05). Of note, the GPA increased marginally across the 3 fatigue groups. Students who are working harder to perform academically may be more fatigued as a result; however, this difference is very modest, statistically nonsignificant (P = .63), and does not permit us to draw any firm conclusions. Mean BDI score for the entire sample was 18.25 ± 6.44, and 86.4% of all students endorsed at least mild fatigue on BDI fatigue item 17 (TABLE 2).
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In this sample of students with depressive symptoms (BDI ≥13), those with moderate/severe fatigue had significantly greater depressive symptom severity compared with those with mild (P < .001) or no fatigue (P < .01) (BDI total minus BDI fatigue item 17: Welch statistic [2,98.30]= 11.50; P < .001). Students with moderate/severe fatigue had higher levels of suicidality (SBQ–R total: F2,154 = 5.24; P < .01), compared with those with mild fatigue (P < .01). Students with more severe fatigue evidenced significantly greater levels of anxiety across the ASQ intensity subscale (F2,142 = 12.67; P < .001), as well as across the ASQ frequency subscale (F2,140 = 14.01; P < .001) compared with students with no or mild fatigue. On the BAI, students with no fatigue had significantly lower anxiety scores than those with moderate/severe fatigue (P < .001) or mild fatigue (P < .01) (Welch statistic [2,34] = 16.13; P < .001). Students reported significantly greater cognitive and physical functional impairment (CPFQ total: Welch statistic [2,70.82] = 17.98; P < .001), as their level of fatigue worsened (P < .01 for all). No significant associations with fatigue were observed with regard to quality of life (QLES–Q-SF total: F2,129 = 1.92; P = .15) and hopelessness (BHS total: F2,92 = 2.15; P = .12). TABLE 3 summarizes results from the independent ANOVA.
DISCUSSION Our study examined the relationship between varying levels of fatigue and clinical and functional domains in a sample of college students with depressive symptoms. We found that fatigue was common in college students with depressive symptoms: 86.4% of students Ann Clin Psychiatry. Author manuscript; available in PMC 2015 August 18.
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endorsed at least mild fatigue. Study hypotheses were primarily supported, in that higher levels of fatigue were generally associated with a greater burden of psychiatric symptoms and poorer cognitive and physical functioning.
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Although our sample had a limited range of depressive symptom severity (BDI ≥13), levels of fatigue were still associated with depressive symptoms. College students with depressive symptoms and moderate/severe fatigue had significantly greater depressive symptom severity compared with those with mild or no fatigue. We have found mixed results for other BDI items and depressive severity in previous investigations with this population.30-32 The current findings therefore suggest that this association is not simply a function of symptom severity per se but rather the nature of fatigue. In another sample of undergraduates who completed the BDI and the Fatigue Severity Questionnaire, depression correlated with fatigue.33 In a more recent study of adults with major depressive disorder (MDD), those with fatigue had higher HRSD scores compared with those without fatigue.34 Our findings appear to be consistent with the literature on the association between depressive severity and fatigue. The complex relationship between these symptoms warrants further investigation, especially in the college population. Higher levels of fatigue also were significantly related to higher levels of anxiety on both anxiety scales used in this study. In a longitudinal study of girls from adolescence to young adulthood, an increase in fatigue was associated with increased anxiety and depressive symptoms.35 Another study of patients with MDD found a positive correlation among somatic anxiety, fatigue, and depression.36 Fatigue is considered a symptom of anxiety and may share some common pathways.
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In our study, moderate/severe fatigue was associated with greater suicidality in college students with depressive symptoms. Another study showed a trend toward higher mortality rates for chronic fatigue patients stratified by lifetime history of MDD compared with those without a history of MDD.37 Some research suggests that the opposite may be true: higher levels of energy may predict suicide attempts in patients with MDD.38 This is a complicated relationship, as an increase in energy could reflect bipolarity or hypomania, also associated with increased suicidality.39
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We found that as fatigue worsened, so did cognitive and physical functioning. This is consistent with a report by Pedrelli et al40 of greater cognitive deficits (in alertness and focused attention) in adults with remitted MDD and residual fatigue. Similarly, Constant et al41 found in a group of depressed patients a significant association between fatigue and impairment in memory, visual episodic memory, and alertness. Despite what might seem an obvious relationship between fatigue and cognitive functioning, the literature in this area is sparse, and more research is needed. On a related note, Cassano and Fava42 suggested that fatigue can be a common side effect of chronic SSRI treatment, impairing function in social, familial, and work domains. Contrary to our expectations, quality of life and degree of hopelessness did not vary across levels of fatigue. We were unable to find other literature examining the relationship between
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fatigue and hopelessness. Further investigation of other correlates of fatigue, such as hopelessness and quality of life, is warranted in college students. Given that fatigue may be common among college students with depressive symptoms and that fatigue is associated with other psychological symptoms and impaired functioning, monitoring and treatment of fatigue in this population may be important. Successful treatment of depression sometimes improves mood and somatic symptoms including fatigue.43 On the other hand, fatigue could be an adverse effect of pharmacologic treatment, particularly with SSRIs.42 When fatigue emerges as a side effect, antidepressant treatment that is dopaminergic and noradrenergic may be preferable to SSRIs.44 Non-pharmacologic treatments of fatigue, including cognitive-behavioral therapy, exercise, diet, and good sleep hygiene, also have been proposed43,45-47 and may be effective for college students with depression.
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Our findings must be interpreted with some caution, given the study’s limitations. For example, the ANOVA investigating quality of life scores (Q-LES–Q-SF) across fatigue groups included only 16 students in the “no fatigue” group and may have lacked sufficient power to detect a true difference (P = .15). Our non-clinical sample included only college undergraduates and may not reflect the general population. The sample was largely female (approximately 67%) and also may not have adequately represented non-white and lower socioeconomic groups. We used the BDI–I, rather than the more recent BDI–II, and relied solely on BDI fatigue item 17 to measure fatigue. Using a nonintrusive, easily administered question to measure fatigue in a non-clinical population can be beneficial. For example, endorsing the symptom of fatigue on a self-report questionnaire carries less stigma than disclosing depressive symptoms and could help identify individuals with unrecognized depression. Even so, future studies are needed with more comprehensive fatigue measures. For patients with depression, few standardized tools exist to measure fatigue. Further measurement development could help to elucidate the complex relationship between MDD and fatigue. Finally, we did not assess for medical conditions or other non-psychiatric contributors to fatigue, such as medication side effects and other comorbid conditions. We also did not account for whether a participant was taking an antidepressant, and thus we could not determine whether fatigue was a symptom of depression and/or a side effect of medication. Any of these factors, and especially treatment status, could have influenced our findings, and unfortunately, we did not assess for them in our screenings. Future longitudinal research could help elucidate the causal relationship between depression and fatigue in this population and whether this relationship is tractable to anti-depressant treatment.
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As our group previously has found with sleep disturbance, suicidality, and irritability in students with depressive symptoms,30-32 the presence of fatigue appears to be associated with greater symptom burden. Fatigue in students with depressive symptoms may characterize a worse clinical presentation. Assessing and treating symptoms of fatigue appears to be warranted in this population made vulnerable to psychiatric symptoms by their stress level, developmental challenges, and lifestyle. The potential cause or effect
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relationship between fatigue and depression is not fully understood. Fatigue could be both cause and/or effect of depression.
CONCLUSIONS
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Depressed college students with symptoms of fatigue demonstrated functional impairment and symptomatic burden that worsened with increasing levels of fatigue. Specifically, students categorized as having moderate/severe fatigue (Group 3) reported the greatest burden of depressive symptoms and the greatest frequency and intensity of anxiety compared with those with mild fatigue (Group 2) or no fatigue (Group 1). Group 3 also evidenced higher scores on the suicide risk instrument, compared with Group 2. Levels of cognitive and physical functioning also worsened as the level of fatigue increased. We conclude, therefore, that assessing fatigue—especially in college populations prone to fatigue and depression—may be important in mental illness prevention and treatment efforts.
ACKNOWLEDGEMENTS This work was supported by a grant from The Jed Foundation, a nonprofit organization whose mission is to promote emotional health and prevent suicide among college students.
DISCLOSURES
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Drs. Nyer, Holt, Yeung, Baer, Dording, Fisher, and Farabaugh, and Ms. Brill, and Ms. Huz report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products. Dr. Nyer has received grant/research support from National Institute of Complimentary and Alternative Medicine (1K23AT008043-01A1). Dr. Mischoulon receives grant/research support from Bowman Family Foundation, FisherWallace, Nordic Naturals, Methylation Sciences, Inc., and PharmoRx Therapeutics; is a consultant to Pamlab; is a speaker for Pamlab and the Massachusetts General Hospital Psychiatry Academy; and receives royalties from Lippincott Williams & Wilkins for published book Natural Medications for Psychiatric Disorders: Considering the Alternatives. Dr. Pedrelli receives grant/research report from National Institute of Alcohol Abuse and Alcoholism.
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Dr. Alpert reports financial relationships with Abbot Laboratories, Alkermes, American Psychiatric Association, Aspect Medical Systems, Astra-Zeneca< Belvoir Publishing, Bristol-Myers Squibb Company, Cephalon, Cyberonics, Eli Lily & Company, Forest Pharmaceuticals Inc., GlaxoSmithKline, J & J Pharmaceuticals, Lichtwer Pharma GmbH, Lorex Pharmaceuticals, MGH Academy, Novartis, Organon Inc., PamLab, LLC, Pfizer Inc, Pharmavite, Primedia, Reed Medical Education, Roche, Sanofi/Synthelabo, Solvay Pharmaceuticals, Inc., Wyeth-Ayerst Laboratories, and Xian-Janssen. Dr. Fava receives research support from Abbott Laboratories, Alkermes, Inc., American Cyanamid, Aspect Medical Systems, AstraZeneca, Avanir Pharmceuticals, BioResearch, BrainCells Inc., Bristol-Myers Squibb, CeNeRx Bio Pharma, Cephalon, Clintara, LLC, Covance, Covidien, Eli Lilly and Company, EnVivo Pharmaceuticals, Inc., Euthymics
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Bioscience, Inc., Forest Pharmaceuticals, Inc., Ganeden Biotech, Inc., GlaxoSmithKline, Harvard Clinical Research Institute, Hoffman-LaRoche, i3 Innovus/Ingenix, Icon Clinical Research, Janssen R&D, LLC, Jed Foundation, Johnson & Johnson Pharmaceutical Research & Development, Lichtwer Pharma GmbH, Lorex Pharmaceuticals, Lundbeck Inc, MedAvante, Methylation SciencesInc.,NARSAD,NationalCenterforComplementary and Alternative Medicine, National Institute of Mental Health, National Institute on Drug Abuse, Neuralstem, Inc., Novartis AG, Organon Pharmaceuticals, PamLab, LLC, Pfizer, Inc., Pharmacia-Upjohn, Pharmaceutical Research Associates, Inc.; Pharmavite LLC, PharmoRx Therapeutics, Photothera, Reckitt Benchkiser, Roche Pharmaceuticals, RCT Logic, LLC, Roche Pharmaceuticals, Sanofi-Aventis US LLC, Shire, Solvay Pharmaceuticals, Inc., Stanley Medical Research Institute, Synthelabo, and Wyeth-Ayerst Laboratories; is an advisor or consultant to Abbott Laboratories, Affectis Pharmaceuticals AG, Alkermes, Inc., AmarinPharma,Inc.,AspectMedicalSystems,AstraZeneca, Auspex Pharmaceuticals, Bayer AG, Best Practice Project Management, Inc., BioMarin Pharmaceuticals, Inc., Biovail Corporation, BrainCells Inc., Bristol-Myers Squibb, CeNeRx Bio Pharma, Cephalon, Carecor, CNS Response, Inc., Compellis Pharmaceutics, Cypress Pharmaceutical, Inc., DiagnoSearch Life Sciences (P) Ltd., Dainippon Sumitomo Pharma Co. Inc., Dov Pharmaceuticals, Inc., Edgemont Pharmaceuticals, Inc., Eisai, Inc., Eli Lilly and Company, EnVivo Pharmaceuticals, Inc., ePharmaSolutions, EPIX Pharmaceuticals, Euthymics Bioscience, Inc., Fabre-Kramer Pharmaceuticals, Forest Pharmaceuticals, Inc., GenOmind, LLC, GlaxoSmithKline, Grunenthal GmbH, i3 Innovus/Ingenis, Janssen Pharmaceutica, Jazz Pharmaceuticals, Inc., Johnson & Johnson Pharmaceutical Research & Development, LLC, Knoll Pharmaceuticals Corp., Labopharm Inc., Lorex Pharmaceuticals, Lundbeck Inc., MedAvante, Inc., Merck, MSI Methylation Sciences, Inc., Naurex, Inc., Neuralstem, Inc., Neuronetics, Inc., NextWave Pharmaceuticals, Novartis AG, Nutrition 21, Orexigen Therapeutics, Inc., Organon Pharmaceuticals, Otsuka Pharmaceuticals, PamLab, LLC, Pfizer, Inc., PharmaStar, Pharmavite LLC, PharmoRx Therapeutics, Precision Human Biolaboratory, Prexa Pharmaceuticals, Inc., PsychoGenics, Psylin Neurosciences, Inc., Puretech Ventures, RCT Logic, LLC, Rexahn Pharmaceuticals, Inc., Ridge Diagnostics, Inc., Roche Pharmaceuticals, Sanofi-Aventis, Schering-Plough Corporation, Sepracor, Inc., ServierLaboratories,SolvayPharmaceuticals,Inc.,Somaxon Pharmaceuticals, Inc., Somerset Pharmaceuticals, Inc., Sunovion Pharmaceuticals, Supernus Pharmaceuticals, Inc., Synthelabo, Takeda Pharmaceutical Company Limited, Tal Medical, Inc., Tetragenex Pharmaceuticals, Inc., TransForm Pharmaceuticals, Inc., and Vanda Pharmaceuticals, Inc.; is a speaker for or has been published by: Adamed, Co., Advanced Meeting Partners, American Psychiatric Association, American Society of Clinical Psychopharmacology, AstraZeneca, Belvoir Media Group, Boehringer Ingelheim GmbH, Bristol-Myers Squibb, Cephalon, Inc., CME Institute/Physicians Postgraduate Press, Inc., Eli Lilly and Company, Forest Pharmaceuticals, Inc., GlaxoSmithKline, Imedex, LLC, MGH Psychiatry Academy/ Primedia, MGH Psychiatry Academy/Reed Elsevier, Novartis AG, Organon Pharmaceuticals, Pfizer, PharmaStar, United BioSource Corp., and Wyeth-Ayerst Laboratories; has equity holdings with Compellis and PsyBrain, Inc.; has a patent for Sequential Parallel Comparison Design (SPCD) and a patent application for a combination of ketamine and scopolamine in major depressive disorder, for research and licensing of SPCD, licensed by MGH to Pharmaceutical Product Development, LLC (PPD); and has a
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copyright for the MGH Cognitive & Physical Functioning Questionnaire (CPFQ), Sexual Functioning Inventory (SFI), Antidepressant Treatment Response Questionnaire (ATRQ), Discontinuation-Emergent Signs & Symptoms (DESS), and SAFER; Lippincott, Williams & Wilkins; Wolkers Kluwer; World Scientific Publishing Co. Pte.
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TABLE 1
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College students with depressive symptoms with and without fatigue: Demographic data Total sample (N = 287)
No fatigue (n = 39)
Mild fatigue (n = 161)
Moderate/severe fatigue (n = 87)
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Mean
SD
Mean
SD
Mean
SD
Mean
SD
Age (n = 269)
a
19.81
1.87
19.78
1.97
19.81
1.95
19.82
1.68
Grade point average (n = 242)
3.24
0.50
3.21
0.59
3.23
0.48
3.29
0.48
n
%
n
%
n
%
n
%
Female
184
66.7
18
6.5
105
38
61
22.1
Male
92
33.3
20
7.2
51
18.5
21
7.6
School year (n = 275)
n
%
n
%
n
%
n
%
Freshman
74
26.9
11
4
45
16.4
18
6.5
Sophomore
73
26.5
10
3.6
37
13.5
26
9.5
Junior
70
25.5
11
4
38
13.8
21
7.6
Senior
49
17.8
5
1.8
29
10.5
15
5.5
Other
9
3.3
1
0.4
6
2.2
2
0.7
Marital status (n = 276)
n
%
n
%
n
%
n
%
Sex (n = 276)
Never married
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273
98.9
38
13.8
155
56.2
80
Other
3
1.2
0
0
1
0.4
2
Living situation (n = 112)
n
%
n
%
n
%
n
%
On campus alone
33
29.5
3
2.7
21
18.8
9
8
On campus with roommates
34
30.4
5
4.5
17
15.2
12
10.7
Off campus alone
8
7.1
2
1.8
4
3.6
2
1.8
Off campus with relatives
8
7.1
0
0
5
4.5
3
2.7
Off campus with roommates
29
25.9
2
1.8
24
21.4
3
2.7
Ethnicity (n = 249)
n
%
n
%
n
%
n
%
Black, not of Hispanic origin
22
8.8
1
0.4
15
6
6
2.4
Hispanic
19
7.6
3
1.2
11
4.4
5
2
White, not of Hispanic origin
157
63.1
24
9.6
84
33.7
49
19.7
American Indian or Alaskan native
1
0.4
0
0
0
0
1
0.4
Asian or Pacific Islander
36
14.5
3
1.2
23
9.2
10
4
Other
14
5.6
2
0.8
8
3.2
4
1.6
Family socioeconomic status (n = 101)
n
%
n
%
n
%
n
%
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Low income (
