International Journal of

Environmental Research
and Public Health

Brief Report
Mental Health Problems and Related Factors in
Ecuadorian College Students
Claudia Torres 1, *, Patricia Otero 2 , Byron Bustamante 1 , Vanessa Blanco 3 , Olga Díaz 4 and
Fernando L. Vázquez 4
1 Deparment of Psychology, Universidad Técnica Particular de Loja, Loja 11-01-608, Ecuador;
[email protected]
2 Deparment of Psychology, University of A Coruña, 15071 A Coruña, Spain; [email protected]
3 Deparment of Evolutive and Educational Psychology, University of Santiago de Compostela,
15782 Santiago de Compostela, Spain; [email protected]
4 Deparment of Clinical Psychology and Psychobiology, University of Santiago de Compostela,
15782 Santiago de Compostela, Spain; [email protected] (O.D.);
[email protected] (F.L.V.)
* Correspondence: [email protected]; Tel.: +593-07-370-1444

Academic Editor: Paul B. Tchounwou

Received: 26 February 2017; Accepted: 11 May 2017; Published: 15 May 2017

Abstract: Although the mental health problems of college students have been the subject of increasing
research, there are no studies about its prevalence in Ecuadorian college students. The aim of this study
was to determine the mental health problems and their associated factors in Ecuadorian freshmen
university students. A sample of 1092 students (53.7% women; mean age = 18.3 years) were recruited
from the Technical Particular University of Loja (Ecuador). Socio-demographic, academic, and clinical
characteristics were gathered, as well as information on the participants’ mental health through
a number of mental health screens. Prevalence of positive screens was 6.2% for prevalence of major
depressive episodes, 0.02% for generalized anxiety disorders, 2.2% for panic disorders, 32.0% for
eating disorders, 13.1% for suicidal risk. Mental health problems were significantly associated with
sex, area of study, self-esteem, social support, personality and histories of mental health problems.
The findings offer a starting point for identifying useful factors to target prevention and intervention
strategies aimed at university students.

Keywords: mental health; prevalence; correlates; college students

1. Introduction
The onset of most lifetime mental disorders occurs during young adulthood (late teens through
early 20s) [1], and in many countries, the majority of young adults of this age are college students.
In the U.S., for example, approximately 66% of the high school graduates enrolled in college in
the subsequent school year and half of young adults attend college [2]. In developing countries,
such as Ecuador, the number of young adults attending college is increasing [3]. More specifically,
the Ecuadorian college population is growing annually by over 4%, with 39.6% of young adults
attending college in 2012, and it is expected that this figure will exceed 50% by 2017 [4].
Previous research has demonstrated that the transition from high school to college can be stressful
for students [5]. The college years represent a developmentally challenging transition to adulthood.
University students, especially during the first year, are exposed to a variety of stressors that may
trigger or exacerbate mental health problems, including not only academic burden but also those
deriving from the change of environment, such as leaving the parental home, affective isolation,
financial hardship, adaptation to methods of instruction very different from the high school or worries

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about the future [6,7]. These stressful experiences are related to an increased risk of psychopathology,
which can have a negative impact for many aspects of well-being, including academic success [8] and
future relationships [9].
Therefore, the mental health problems and overall well-being of college students have been
the subject of increasing research. An elevated level of psychological distress and symptoms among
college students has been found [10,11]. In fact, a prevalence of various mental disorders has been
estimated as the following: between 5.3% and 17.3% for depression [12,13], between 1.6% and 7.0% for
generalized anxiety disorder [12,14,15], between 0.6% and 4.1% for panic disorder [12,14,15], between
0.9% and 9.4% for eating disorders [15,16] and between 0.6% and 9.5% for suicidal ideation [12,13,17].
However, these studies on the prevalence of mental disorders did not focus on freshmen and most
focused on anxiety disorders and depression [12,14]. There are few studies examining eating disorders,
even though these usually appear in adolescence and early adulthood [18]. Furthermore, the majority
of studies have a response rate of about 44–56.2% [12,16], which could introduce response bias.
The factors that influence the appearance of these mental health problems are as varied and
numerous as they are complex. They are located at different levels (individual and environmental),
can exert their influence directly or indirectly, and can maintain interconnections among themselves.
Certain factors can influence the predisposition to suffer from a mental disorder, increasing the
probability of onset or modifying a person’s response to some environmental hazard [19,20]. Therefore,
psychological development must be understood as a complex process that responds to the influence
of a multiplicity of factors closely linked to the environment or ecological context in which such
development takes place. Specifically, in this study, we adopted as a theoretical framework the
bioecological theory of Bronfenbrenner [21], later revised by Bronfenbrenner and Ceci [22] to analyze
the mental health of the Ecuadorian university students from an integral, systemic and naturalistic
perspective. This theory considers the development of the human being as a process that derives
from the characteristics of individuals (including genetic and psychological) and of the context, both
immediate and remote, as well as the relationships between them. These contexts are organized
in systems called microsystems (immediate context of the individual that includes the individual
conditions and the individuals or groups with which the individual has direct relationships), mesosystem
(interconnections between microsystems), exosystem (connection between the immediate context of the
individual and an environment in which the individual does not have an active role), and macrosystem
(the culture in which the individual and his immediate contexts are immersed). This theoretical model
is referred to as a Process–Person–Context–Time model. The critical element of this model is experience,
which includes not only the objective properties, but also those that are subjectively experienced by
the people living in that environment. Until now, it has been found that certain factors of microsystem
and macrosystem such as gender and socioeconomic background influence the emergence of mental
health problems in university students [23]. However, other psychological individual factors have
been poorly investigated in students, even though they may also influence the predisposition to mental
health problems. Among all of these, we selected self-esteem, social support, stressful life events
and personality traits because they have been shown to be the main risk or protective factors for the
development of depressive, anxiety and eating disorders as well as for suicidal behaviors in the general
population [19,20,24].
Self-esteem can protect against mental health problems by reducing the stress [25] and the impact
of negative thoughts [26] and has been related to depression, anxiety [27], eating disorders [28] and
suicidal risk [29]. Social support provides instrumental, informational and emotional assistance that
provide resources and can modulate the impact of negative life events [30] acting as a buffer for
mental problems [31] and it has been related to depression [32], anxiety [33] and risk of suicide [34].
Stressful life events can increase the risk of suffering mental health problems because they pose
a threat to the status of the individual and impose high adaptative demands [35]; they have been
related to depression [36], eating disorders [37] and risk of suicide [38]. Personality traits condition
the student’s way of acting, thinking and feeling, acting as triggers or moderators of mental health
Int. J. Environ. Res. Public Health 2017, 14, 530 3 of 14

problems [39]; they have also been correlated to depression [40], anxiety [41], eating disorders [28] and
suicidality [42]. In addition, there is little research on the specific factors of the academic context, such as
the area of study. This factor determines the method of study, the demands of study, the academic
climate, the projection of the future. Furthermore, it is known that different areas of study have
different percentages of academic success and dropouts [43], all of which can influence the student
emotional state, and if this is not handled properly, students could be predisposed to mental health
problems [44,45]. Furthermore, no previous studies have analyzed the effect of associated factors
simultaneously, which provides a more clinical, realistic and holistic perspective and considers the
interconnections between the different contexts.
Finally, most of the studies were conducted in the United States [12,14,16,17]. To date, there are
no studies about mental health problems in Ecuadorian college students, despite the fact that the
students of this country have some peculiarities that distinguish them from those of other countries
such as their Hispanic culture and the variety of ethnicities represented (including indigenous and
montubios with little representation in the United States and Europe) and the predominance of mixed
races [46]. Furthermore, it is known that the definitions of mental health problems, the forms of
expression of such problems and the coping mechanisms employed can be significantly influenced
by sociocultural factors [47,48]. It is therefore important to include aspects of Hispanic culture in
the study of mental health problems, such as low income level, the importance of social and family
support or ethnic diversity and mixed races, which can influence the prevalence of mental health
problems [49,50]. In the general population, it was found that Hispanics have a significantly higher
prevalence of affective disorders and comorbidity than non-Hispanic whites [51]. More specifically,
among youngsters, Hispanic students were found to be more likely to suffer from depression than
whites and multi-racial/ethnic students had more depression, suicidal ideation and self-harm than
whites [12]. In addition, Ecuador is an emerging country that, with an increasing number of young
adults attending college, represents the eighth largest economy of Latin America by GDP [52].
The purpose of this study was to determine the prevalence of major depressive episodes, generalized
anxiety disorder, panic disorder, eating disorders and suicide risk, as well as associated risk factors,
in freshmen at the Technical Particular University of Loja (Ecuador).

2. Materials and Methods

2.1. Sample
Participants were recruited from October 2012 to February 2013 from the student body of the
Technical Particular University of Loja (Ecuador). Loja is a province in the south of Ecuador that
covers an area of 11,027 km2 and has a population of 495,464 inhabitants, and has the second-highest
percentage of college students, with a university attendance rate of 28.7% [53].
To participate in the study, students had to be enrolled in their freshman year and entering the
university for the first time. Students who did not give their informed consent and upper-class students
who had previously failed, and were thus repeating freshmen level courses, were excluded. The reason
for this is that this study focused on freshman students entering the university for the first time,
since there is evidence that they are exposed to a variety of new stressors related to the change of
environment from secondary education to higher education that may trigger the development of
mental disorders [7]. Students who have more than one year in college may have become familiar with
and adapted to the new conditions of university life (acting as a confounding variable), so they were
excluded from the study to avoid biasing the results. A total of 1113 registered students were invited
to participate in the study during the 2012/2013 academic year.
To standardize the data collection process, a previously prepared assessment protocol was
followed. Subsequently, we conducted a pilot test to refine the measuring instruments and improve
the evaluation procedure. Five psychologists with more than five years of experience in teaching
and research, who were previously trained, were involved in the data collection process. Training
Int. J. Environ. Res. Public Health 2017, 14, 530 4 of 14

was given by two experts in psychological evaluation with more than nine years of experience and
consisted of about eight hours of theoretical and practical workshops on the following: evaluation
strategies, the evaluation protocol, instructions and correct completion of each instrument, frequent
doubts that the students could have and how to address them, and role-playing of the application of
assessment tools. The assessment was conducted in a classroom, in a collective and face-to-face format
during non-examination periods for approximately one hour. During the evaluation, we first requested
permission from the teacher who had been previously informed of the study and whose collaboration
had been requested. Secondly, we made a presentation where we explained the nature of the study
to the students, we gave out paper copies of the instruments, we provided instructions for their
completion and addressed any questions raised by the students. Students self-administered the
instruments and once all the instruments were completed by the students, they were collected. We then
thanked the students for their participation in the study.
The participants read and signed their written consent prior to participation and their anonymity
was guaranteed. Participation was voluntary and did not result in any academic, monetary, or other
compensation. To minimize the loss of participants, we followed the strategies recommended by
Hulley et al. for sample collection [54]; for example, made an appealing presentation of the study to
the participants, emphasized the personal, social and scientific importance of their participation in the
study, treated the patients with kindness, affection and respect, and avoided collecting information in an
invasive and unpleasant manner. The study was carried out in accordance with the latest revision of the
Declaration of Helsinki of 1975 revised in 2008, and was approved by the university Ethics Committee
(Project identification code PY250-191-CEP-2011). The response rate was 99.7%. Three students (0.3%)
declined to participate, stating that they did not feel comfortable answering that type of questions.
Of the students who participated (n = 1110), 18 were excluded because they were upper-class
students that were re-taking freshmen courses. The final study sample was comprised of 1092 students
(53.7% women, mean age 18.3 years) and characterized with respect to other variables in Table 1.

2.2. Instruments
Using an ad hoc questionnaire, data were collected on the participants’ sex, age, marital status,
ethnicity, family monthly income, employment, area of study (assessing all study areas) and history of
mental health problems, with the latter being defined as self-reported information on whether or not
the student had suffered any mental health problems throughout their life.
Outcome measures were assessed using screening instruments. Depression was assessed using
the Patient Health Questionnaire-9 (PHQ-9 [55]; Spanish version of Díez-Quevedo et al. [56] validated
in Spain), a self-administered nine-item questionnaire based on the DSM-IV criteria for major depressive
disorder, the sensitivity and specificity of which was 84% and 92%, respectively. Generalized anxiety
and panic disorder were assessed with the Patient Health Questionnaire (PHQ-A [55]; Spanish version
of Díez-Quevedo et al. [56] validated in Spain), which is comprised of 15 basic questions based on the
DSM-IV criteria with a sensitivity and specificity of 83% and 98%, respectively. Eating disorders were
evaluated using the Sick Control On Fast Food (SCOFF [57]; Spanish version of García-Campayo et al. [58]
validated in Spain), a self-administered five-item eating disorder screening questionnaire based on the
DSM-IV. It has a 100% sensitivity and an 87.5% specificity for anorexia and bulimia. Suicide risk was
evaluated with the Suicidality Scale (SC [59]; Spanish version of Salvo et al. [60]), a self-administered
four-question scale with a scoring range of 0 to 12, in which the higher the score the greater the risk of
suicide, and a cut-off point of 5, which has a sensitivity of 90% and a specificity of 79%.
Regarding possible associated factors, self-esteem was assessed using the Rosenberg Self-Esteem
Scale (RSES [61]; Spanish version of Atienza et al. [62] validated in Spain). This scale is composed
of 10 items; scores range from 10 to 40, with higher scores indicating higher self-esteem, with
a Cronbach’s alpha of 0.92. Perceived social support was assessed with the Multidimensional Scale of
Perceived Social Support (MSPSS [63]; Spanish version of Landeta and Calvete [64] validated in Spain),
which includes 12 items with a scoring range of 1 to 7, in which a higher score indicates greater
Int. J. Environ. Res. Public Health 2017, 14, 530 5 of 14

perceived social support, and has a Cronbach’s alpha of 0.88. Stressful life events were assessed with
the Social Readjustment Rating Scale (SRRS [65]; Spanish version of Bruner et al. [66]), which includes
43 events for which the participant can indicate their occurrence (or not) and each event has a stress
score from 11 to 100. The higher the score, the higher the stress level that the person has gone
through in the last year. The test–retest reliability is 0.85 [67]. Personality characteristics were
assessed with the Eysenck Personality Questionnaire Revised-Abbreviated (EPQR-A [68]; Spanish version
of Sandín et al. [69] validated in Spain), which contains 24 items and four subscales (Neuroticism,
Extraversion, Psychoticism and Sincerity). The neuroticism subscale refers to how easily and frequently
a person becomes upset and anguished and it is related to emotional instability. The extraversion
subscale refers to tendencies toward sociability, vivacity, activity and dominance. The psychoticism
subscale implies a tendency towards psychological detachment from and a lack of concern for
others. Lastly, the sincerity dimension evaluates the tendency to provide socially desired responses.
Each subscale has a score range for each subscale between 0 and 6, with a higher score indicating
greater presence of the characteristics (except for the sincerity subscale, where a higher score indicates
lower sincerity). The Cronbach’s alpha for each subscale is the following: Neuroticism = 0.78,
Extraversion = 0.74, Psychoticism = 0.63 and Sincerity = 0.54.

2.3. Data Analysis

Statistical analyses were performed using the SPSS version 20.0 (IBM Corp., Armonk, NY, USA).
The socio-demographic and academic characteristics of the participants were described with means and
percentages, as appropriate. About 3.7% of the screening results for major depressive episode, about
2.0% for eating disorder and about 3.4% for suicide risk were eliminated from the analysis because the
questionnaires were not filled out correctly. The chi-square test for qualitative variables or the Student
t-test for quantitative variables were used to analyze whether there were significant differences between
the excluded students and those included in the study for the sociodemographic, academic or clinical
variables and for the prevalence of the mental health problems evaluated. To analyze whether there were
differences between those who present mental health problems and those who did not present them
according to sociodemographic, academic and clinical variables, bivariate analyses were carried out
for qualitative variables through the Pearson’s chi-square test or the Fisher’s exact test (with expected
values less than 5) and for quantitative variables using the Student’s t-test for two independent samples
with Bonferroni correction. Subsequently, logistic multivariate regressions analyses were performed to
evaluate the association between current mental health problems and sociodemographic, academic and
clinical variables that were previously significant in the bivariate analyses, in order to determine adjusted
differences in associations between independent variables and mental health problems. The results are
reported providing the adjusted odds ratio (OR) with 95% confidence interval (CI). Sociodemographic
variables included sex, age, marital status, ethnicity, monthly family income, employment. Academic
variable included area of study. Clinical variables included self-esteem, social support, stressful life
events, personality traits and history of mental health problems.

3. Results

3.1. Participant Characteristics

Participants averaged 18.3 years of age (SD = 1.1), 53.7% were women, 98.5% were single,
95.1% were mestizos (i.e., persons with a mixed racial background), 44.0% had a monthly family
income between $571 and $1040, 91.2% were not working, about 24.0% were taking courses in the life
sciences area. Concerning clinical characteristics, the mean score for self-esteem was 31.7 (SD = 5.3),
for social support was 53.0 (SD = 14.7) and for stressful life events was 190.1 (SD = 117.4). The mean
score for the neuroticism subscale was 2.7 (SD = 1.8), 4.1 for extraversion (SD = 1.8), 1.0 for psychoticism
(SD = 1.9), and 3.5 for sincerity (SD = 1.6). Finally, 91.5% had never experienced any mental health
problems in the past (Table 1).
Int. J. Environ. Res. Public Health 2017, 14, 530 6 of 14

We found no significant differences between the students excluded from the study and the final
study sample regarding sociodemographic, academic and clinical variables.

Table 1. Socio-demographic, academic and clinical characteristics.

Variables n %
Sex
Male 506 46.3
Female 586 53.7
Age
M 18.3
SD 1.1
Range 17–24
Marital status
Single 1076 98.5
Married 7 0.6
Widow/Widower 1 0.1
Divorced 1 0.1
Domestic partnership 7 0.7
Ethnicity
Mestizo 1039 95.1
White 35 3.2
Afro-Ecuadorian 10 0.9
Montubio 2 0.2
Indigenous 5 0.5
Others 1 0.1
Monthly income ($)
0 to 570 229 21.0
571 to 1040 481 44.0
1041 to 1610 218 20.0
1611 to 2180 119 10.9
>2181 45 4.1
Works
No 996 91.2
Yes 96 8.8
Area of study
Legal and social sciences 123 11.3
Economic sciences 212 19.4
Arts and humanities 92 8.4
Life sciences 262 24.0
Technological sciences 241 22.1
Health sciences 162 14.8
Self-esteem
M (SD) 31.7 (5.3)
Social support
M (SD) 4.4 (1.2)
Stressful life events
M (SD) 190.1 (117.4)
Personality
Neuroticism, M (SD) 2.7 (1.8)
Extraversion, M (SD) 4.1 (1.8)
Psychoticism, M (SD) 1.0 (1.9)
Sincerity, M (SD) 3.5 (1.6)
History of mental health problems
No 999 91.5
Yes 93 8.5
Int. J. Environ. Res. Public Health 2017, 14, 530 7 of 14

3.2. Prevalence of Mental Health Problems

It was found that 6.2% (n = 65) of students met the criteria for diagnosis of a major depressive
episode, 0.02% (n = 2) met criteria for generalized anxiety disorder, 2.2% (n = 24) for panic disorder,
32.0% (n = 343) were at risk of an eating disorder and 13.1% (n = 138) were at risk for suicide.
We found no significant differences between the students excluded from the study and the final
study sample in the prevalence of mental health problems.

3.3. Correlates of Mental Health Problems

The factors related to meeting criteria for depression were having lower self-esteem, t(1011) = 7.41,
p < 0.001, less social support, t(1030) = 4.02, p < 0.001, greater neuroticism, t(73) = −9.00, p < 0.001,
less extraversion, t(64) = 3.85, p < 0.001, and having a history of mental health problems,
χ2 (1, N = 1052) = 14.9, p < 0.001. The other sociodemographic, academic and clinical variables were not
significant. When analyzed simultaneously (i.e., self-esteem, social support, neuroticism, extraversion,
and history of mental health problems), it was found that students with higher self-esteem (adjusted
OR = 0.91, 95% CI [0.87, 0.96]) are much less likely to have depression, and those with greater
neuroticism (adjusted OR = 1.49, 95% CI [1.23, 1.80]) and a history of mental health problems (adjusted
OR = 2.31; 95% CI [1.11, 4.82]) are more likely to have depression (Table 2).

Table 2. Correlates of mental health problems.

95% CI
Mental Health Problem Adjusted OR
Lower Limit Upper Limit
Major depressive episode
Self-esteem 0.91 0.87 0.96
Social support 0.98 0.97 1.00
Neuroticism 1.49 1.23 1.80
Extraversion 0.91 0.78 1.06
History of mental health problems
No 1.0
Yes 2.31 1.11 4.82
Panic disorder
Self-esteem 0.91 0.84 0.99
Stressful life events 1.01 1.00 1.01
Neuroticism 1.89 1.33 2.69
History of mental health problems
No 1.0
Yes 2.79 0.94 8.29
Eating disorders
Sex
Male 1.0
Female 1.55 1.13 2.11
Area of study
Legal and social sciences 1.0
Economic sciences 0.86 0.50 1.46
Arts and humanities 0.56 0.28 1.11
Life sciences 0.67 0.39 1.14
Technological sciences 0.69 0.40 1.18
Health sciences 0.45 0.25 0.81
Self-esteem 0.97 0.94 1.00
Stressful life events 1.04 1.00 1.08
Neuroticism 1.49 1.36 1.64
Extraversion 0.97 0.89 1.06
Int. J. Environ. Res. Public Health 2017, 14, 530 8 of 14

Table 2. Cont.

95% CI
Mental Health Problem Adjusted OR
Lower Limit Upper Limit
Suicide risk
Self-esteem 0.95 0.91 0.99
Social support 0.98 0.97 0.99
Neuroticism 1.51 1.33 1.73
Extraversion 1.02 0.91 1.14
History of mental health problems
No 1.0
Yes 1.64 0.89 3.03
Note: OR = Odds Ratio; CI = Confidence interval.

Lower self-esteem, t(1046) = 4.25, p < 0.001, more stressful life events, t(1090) = 3.40, p = 0.001,
lower neuroticism, t(969) = −4.65, p < 0.001 and having history of mental health problems,
χ2 (1, N = 1092) = 8.56, p = 0.003 were associated with meeting the criteria for panic disorder. The other
socio-demographic, academic and clinical variables were not significant. When introducing all of
these variables into the analysis, it was found that greater self-esteem (adjusted OR = 0.91, 95% CI
[0.84, 0.99]) was associated with a lower risk of developing a panic disorder and greater neuroticism
(adjusted OR = 1.89, 95% CI [1.33, 2.69]) was associated with a greater risk of developing it (Table 2).
Being female, χ2 (1, N = 1065) = 22.94, p < 0.001, enrolling in health sciences studies among all
study areas, χ2 (5, N = 1043) = 13.38, p = 0.02, lower self-esteem, t(1029) = 5.99, p < 0.001, more stressful
life events, t(1068) = −3.93, p < 0.001, greater neuroticism, t(956) = −11.60, p < 0.001, and less
extraversion, t(546) = 3.95, p < 0.001 were associated with risk of meeting criteria for an eating
disorder. The other sociodemographic and clinical variables were not significant. When analyzing
all variables simultaneously, it was found that having enrolled in health science majors and not in
any other area of study (adjusted OR = 0.45, 95% CI [0.25, 0.81]) decreased the likelihood of having
an eating disorder, while being female (adjusted OR = 1.55, 95% CI [1.13, 2.11]) and having greater
neuroticism (adjusted OR = 1.49, 95% CI [1.36, 1.64]) increased the likelihood (Table 2).
Having lower self-esteem, t(1016) = 6.83, p < 0.001, lower social support, t(163) = 4.44, p < 0.001,
greater neuroticism, t(182) = −9.93, p < 0.001, less extraversion, t(942) = 3.73, p < 0.001, and having
a history of mental health problems, χ2 (1, N = 1055) = 10.59, p = 0.001 were associated with a greater
risk of suicide. The other sociodemographic and academic variables were not significant. When all
variables were entered into the analysis, it was found that greater self-esteem (adjusted OR = 0.95,
95% CI [0.91, 0.99]) and greater perceived social support (adjusted OR = 0.98, 95% CI [0.97, 0.99])
decreased the likelihoods of suicide risk; however, greater neuroticism (adjusted OR = 1.51, 95% CI
[1.33, 1.73]) increased it (Table 2).

4. Discussion
The purpose of this study was to examine mental health problems and associated factors in
freshmen at the Technical Particular University of Loja (Ecuador). It was found that 6.2% of students
met the criteria for diagnosis of a major depressive episode, which is consistent with the 5.3% in
female students and 8.7% in students of both sexes identified as having a major depressive episode
by Vázquez et al. [15] and Vázquez and Blanco [13], although it was less than the 17.3% found by
Eisenberg et al. [12]. However, these differences are reduced if we consider that this study, unlike
the previous ones, focused only on freshmen. Self-esteem was a protective factor against meeting
the criteria for major depressive episode; however, neuroticism and having a history of mental
health problems were risk factors. This result is consistent with the findings in the scientific literature.
Specifically, at universities, Song et al. [70] found that low self-esteem, concern over mistakes and
high neuroticism were associated with depressive symptoms. One possible explanation is that the
Int. J. Environ. Res. Public Health 2017, 14, 530 9 of 14

characteristics of neuroticism such as emotional instability, insecurity, tendency toward guilt and
somatization are usually present in depressive disorders. Likewise, having a personal history of mental
health problems (especially depressive symptoms, anxiety and substance abuse) has been considered
a factor that increases the risk of developing depression [71,72].
It was also found that 0.02% met the criteria for generalized anxiety disorder. This prevalence is
much lower than found in other studies [12,14,15]. Given the low prevalence, we have been unable
to analyze what variables may be associated with this mental disorder. One hypothesis for this low
percentage could be that the majority of students who attend this university come from the city of
Loja and, therefore, they have no concerns related to new situations that generate uncertainty due to
leaving the family home and going to live in other parts of the country, such as looking for housing or
economic problems.
Furthermore, it was found that about 2.2% of students met the criteria for panic disorder. This data
is between the 0.6% prevalence found by Vázquez et al. [15] for panic disorder with and without
agoraphobia and the 4.1% found by Eisenberg et al. [12]. Having high self-esteem is a protective factor
against panic disorder, in line with the evidence that highly frequent attacks were predicted by low
self-esteem [73]. Furthermore, high neuroticism was a risk factor for development of the disorder.
This result is consistent with the previous findings in clinical samples, where significantly higher
neuroticism scores were found in panic disorder patients compared to the control group [41].
On the other hand, it was found that 32.0% of students had a risk of suffering from an eating
disorder, which is higher than the 0.9% to 9.4% prevalence found in prior studies with college
students [15,16]. Given that the age of highest risk of onset of anorexia and bulimia is 15 to 19 years
old [23], our greater prevalence rate may be due to the age of our students (only freshmen 17 to
24 years old), compared to the 21.9% of students from various years of college over 31 years of age in
the study of Eisenberg et al. [16]. Among all areas of study analyzed, belonging to the health sciences
was a protective factor against these disorders. Although research in relation to the variable area of
study is limited, one possible explanation for this relationship is that health science (medicine and
psychology) students have knowledge about the risks and consequences of these disorders, which may
be a protective factor against them. Conversely, female gender and neuroticism act as risk factors for
these disorders. The gender gap might be influenced by maintaining the standards of beauty associated
with thinness for females and the vulnerability of the stage of development of the participants in this
study, and is consistent with numerous studies worldwide that have found that these disorders occur
most frequently in the young female population [23]. Furthermore, the relationship found between
high neuroticism and risk for eating disorders is consistent with the findings that female college
students with eating disorder symptoms differed from those who were asymptomatic in neuroticism,
extraversion and agreeableness [74].
Finally, about 13.1% of the college students were identified as being at risk for suicide.
These findings have a high clinical and social relevance, because suicide is the second-leading cause
of death in those 15 to 29 years of age worldwide [75]. This prevalence is greater than the 0.6% and
9.5% for suicidal ideation found in previous studies [12,13,17], which may be due to the different
assessment tools used, as only this study had a validated tool. It was found that self-esteem and social
support were protective factors against suicide risk, in line with previous findings. Self-esteem is
negatively associated with suicidal ideation even after controlling for depression and hopelessness in
psychiatric patients [29]. In addition, it has been seen that feelings of loneliness and not belonging and
not having support from people around them, especially at this stage of development, may predispose
young adult college students to experience emotional destabilization and lead to extreme situations
such as suicide [34]. Moreover, neuroticism as a personality trait acted as a risk factor for suicide risk.
This personality trait, frequently associated with negative affectivity and maladaptive coping strategies,
has consistently been found to be associated with increased suicidality [42].
The present prevalence of mental disorders among our university students was higher than those
observed in community studies, such as the prevalence of 4.4% for major depression and 0.6% for panic
Int. J. Environ. Res. Public Health 2017, 14, 530 10 of 14

disorder found in Latin America [76] or the 12-month prevalence of 3.6% for major depression, 2.7% for
panic disorder and 1.5% for any eating disorder observed among 14- to 24-year-old people [77], which
is consistent with the greater risk of psychopathology of which college students are exposed.
However, this study should be interpreted within the scope of their limitations. This is
a cross-sectional study and, therefore, the relationships analyzed cannot demonstrate causality.
Moreover, Spanish versions of the questionnaires were not validated in Ecuador. As it is a study
with self-reported questionnaires, there is the possibility of response bias. Future research with
hetero-administered tools and structured clinical interviews could help to contrast the information
obtained. Given that our sample is limited to students from a single university, the results may not be
generalizable to students located at other universities or countries; however, this is unlikely to be the
case, because the distribution by age, sex or areas of study is similar to the universities in the rest of
the country.

5. Conclusions
This is the first mental health problems study of Ecuadorian college students where associated risk
and protective factors were also identified. It provides clear indicators about the mental health needs
of the university population and its results will allow research priorities to be organized. Since the
majority of these disorders can be treated effectively through evidence-based psychological and/or
psychopharmacological methods, it is recommended that treatment and prevention interventions be
applied [78,79]. Specifically, promoting self-esteem, social support and extraversion (e.g., training social
skills), as well as strategies for management of neuroticism by clinicians and teachers. Universities
are in fact in an excellent position to promote those among young people, providing them not only
with academic services but also with residences, social environment, extracurricular activities and
health services.

Acknowledgments: This study was funded by grant PY250 from the Universidad Técnica Particular
de Loja (Ecuador).
Author Contributions: Claudia Torres designed the study, participated in the research and wrote the paper.
Patricia Otero conducted the analyses and participated in writing the paper. Byron Bustamante participated in the
research and helped in writing the paper. Vanessa Blanco conducted the analyses and participated in writing
the paper. Olga Díaz and Fernando L. Vázquez designed the study, supervised the research and reviewed the
text critically.
Conflicts of Interest: The authors declare no conflict of interest.

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