University students experience a great level of psychological distress. With psychotropics being the mainstay treatment in addition to psychological interventions, it would be expected to have an increase in psychotropic medication use among students especially medical students, given the demands of medical school [19, 20]. We hypothesized that a difference exists in the use of psychotropics among non-medical students as compared to medical students in Lebanon. We anticipated that medical students would have higher rates of psychotropic medication use because of the added stressors. Our results showed that the prevalence of psychotropic use among Lebanese medical students was 13.1% which was less than the reported rates in the literature [27]. However, although non-significant, the rate was higher than that reported among non-medical students (9.9%). The percentage of psychotropic medication use among the students in our study (10.8%) was higher than that of the general world population reported in the literature in different countries [28, 29]. This value was found to be 6.4% in a study examining the general population of France, Germany, Italy, and the United Kingdom [29]. In a study conducted in several Asian countries, the values ranged from 0.7% in Vietnam to 5.5% in Laos [15]. Other places like Ethiopia, southern Brazil, and urban universities in the United States have a higher prevalence of psychotropic substance use among their undergraduate student population, reaching up to 45% [18, 30, 31]
The most prevalent psychotropics used were antidepressants and sedatives/anxiolytics, with a use rate of 5.9% and 5.6% respectively. This aligns with the findings of Morris et al. which looked at university students primarily in North America, and showed antidepressants to be the most commonly used class of psychotropic medication followed by anxiolytics with a prevalence of 15.3% and 7.6% respectively [32]. This is also supported by our data that shows MDD, GAD and SAD to be among the most commonly diagnosed psychiatric disorders in our sample: 9.0%, 9.7% and 9.0% respectively.
Among those using psychotropics in our study, only 6.6% were prescribed by a psychiatrist. This does not come as a surprise, as rates of self-medication in a cross-sectional study in Saudi Arabia among health professional students was found to be 55.9% (p = 0.0001) [33]. However, this is not usually expected among the non-medical students and raises the important issue of self-medication and its harms.
In our study, the prevalence of potential psychiatric disorders was found to be 74%; this exceeds the level reported in 2008 regarding the Lebanese national prevalence rate of psychiatric disorders (25.8%) [34]. This difference could be attributed to the fact that our study targeted only students, whereas the national data is representative of the whole Lebanese community. This is consistent with the student population being subject to a more stressful lifestyle with the need to balance academic performance and other psychosocial stressors. This increase could also be interpreted in the context of the events Lebanon has faced in the more recent years, most prominently the socio-economic hardships and political instability.
One specific incident was the catastrophic Beirut Port explosion in 2020, which affected most of the Lebanese, emotionally and/or physically. Our results show that affected students were 1.77 times more likely to use psychotropic drugs than those who were not affected. Similar studies in the literature also show that trauma exposure is associated with higher rates of psychotropic drug use [35]. In a study exploring the prevalence of PTSD in Lebanon, 26% of the sample was found to have PTSD from the Beirut blast [36]. The blast caused the economic situation in Lebanon to further deteriorate as well, leading to further instability.
Unsurprisingly, PHQ-4 scores were also found to predict the use of psychotropic medications; this scale is a standardized screening tool for anxiety and depression. The PHQ-4 scores are divided into groups according to severity; in our study, all the subcategories were significant predictors towards the use of psychotropic drugs, a finding that was also reported by Abi-Ackel et al. in a cross-sectional study in Brazil [37]. Although the difference in mean PHQ-4 scores between medical and non-medical students was not significant, both groups had mean values belonging to the moderate depression category. Those who belonged to this category are 3.34 times more likely to use psychotropics.
When exploring temporal patterns of psychotropic drug use over different academic years, we found that medical students in their 6th year have the highest odds of psychotropic use. In medical school, this year coincides with the start of clinical rotations which can be a stressful phase as it entails a major shift in their academic careers. Similar results were also reported in a meta-analysis by Eslami et al. This study looked at the prevalence of psychotropic drug use among the youth and the factors affecting it, where the authors found that older age is associated with increased use of psychotropics [28].
With regards to cigarette smoking, there is a statistically significant difference between the two groups, with the non-medical students reporting higher rates, which is supported by the existing literature [38]. They also reported higher rates of using other tobacco products, such as water pipes, cigars, and electronic cigarettes. This difference can be attributed to the knowledge that medical students have about the grave side effects of all forms of smoking which acts as a beneficial impediment.
The literature sheds light on the use of cannabis in medical students, Papazisis et al. showed in their study that 1 in 3 has ever used cannabis [39]. In our study, cannabis use was significantly higher among medical students with a rate of 16.8% compared to that of non-medical students with a rate of 10.6%. Cannabis use in our study was still lower than the rate that was reported in the meta-analysis by Papazisis et al. which examined the incidence of cannabis consumption among medical students and found the lifetime usage rate to be 31.4% [39]. Cannabis is known for its euphoric and sedating effects; thus, it can be suggested that medical students, with their added understanding of these effects and their exposure to increased levels of stress, resort to using cannabis as a form of relaxation more often than their non-medical counterparts. Similarly, recreational drug use was more common in medical students in terms of lifetime use as well as current use. This reflects the overall evolving perspective on the use of recreational drugs, gearing towards less discriminatory and more tolerant societal norms.
Limitations
Our study acknowledges certain limitations. The potential for a higher response rate from students with a pre-existing interest in mental health may introduce selection bias, as these individuals may be more inclined to participate in a study focused on psychiatric issues. This could impact the generalizability of our findings to the entire student population. To mitigate this limitation, future research could employ random sampling techniques and targeted outreach strategies to ensure a more representative sample.
Secondly, the high proportion of students who self-diagnosed psychiatric illnesses may introduce inaccuracies in the reported prevalence rates. Self-diagnosis is subject to individual perceptions and may not align with a formal clinical assessment. To address this limitation, future studies could incorporate diagnostic interviews conducted by qualified mental health professionals.
No causality can be established from our data, as this is a cross-sectional study. We advocate more work to be invested into this matter, over a timeframe to establish cause-effect relationships between predicting factors for psychotropic medication and recreational drug use among medical and non-medical students.
Our study did not investigate the use of formal psychotherapy or psychological interventions. The reduced availability and high cost of psychotherapy would be prohibitive to most university student in Lebanon, however this can be considered a limitation in our study.