Journal of American College Health
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Depressive and anxiety symptoms in first
generation college students
Jonathan K. Noel, Haleigh A. Lakhan, Cara J. Sammartino & Samantha R.
Rosenthal
To cite this article: Jonathan K. Noel, Haleigh A. Lakhan, Cara J. Sammartino & Samantha R.
Rosenthal (2021): Depressive and anxiety symptoms in first generation college students, Journal of
American College Health, DOI: 10.1080/07448481.2021.1950727
To link to this article: https://doi.org/10.1080/07448481.2021.1950727
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JOURNAL OF AMERICAN COLLEGE HEALTH
https://doi.org/10.1080/07448481.2021.1950727
MAJOR ARTICLE
Depressive and anxiety symptoms in first generation college students
Jonathan K. Noel, PhD, MPHa, Haleigh A. Lakhan, BSa, Cara J. Sammartino, PhD, MSPHa
and Samantha R. Rosenthal, PhD, MPHa,b
a
Department of Health Science, College of Health & Wellness, Johnson & Wales University, Providence, Rhode Island, USA;
Department of Epidemiology, Brown School of Public Health, Providence, Rhode Island, USA
b
ARTICLE HISTORY
ABSTRACT
Objectives: Depression and anxiety contribute to the burden of disease among college
students. The current study determined if depressive and anxiety symptoms were more
prevalent in first generation students and if social and emotional support moderated this
relationship. Methods: Depressive and anxiety symptoms were measured in 432 U.S. college
students via an online survey. Single items determined student generation status and
available social support. The CES-D10 and GAD-7 measured depression and anxiety,
respectively. Structural equation modeling was used to identify significant effects. Results: First
generation status was associated with increased cognitive-emotional (p = 0.036) and somatic
(p = 0.013) anxiety symptoms, but not depression. High social and emotional support appeared
to suppress somatic anxiety symptoms experienced by first generation students (p = 0.004).
Conclusions: Greater anxiety symptoms in first generation students may be due to increased
general and acculturative stress, although more research is needed. Large national surveys
of college students should consider adding a question about first generation status.
Introduction
There were 258 million cases of depression worldwide
in 2017, a 50% increase since 1990.1 Currently, depression is a leading cause of disability, as measured by years
lived with disability, and is the fourth leading contributor
to the global burden of disease.2 Characterized as having
low energy, loss of interest, sadness, poor concentration,
and low self-worth, depression affects 16 million
American adults each year and is more likely to affect
women than men.3–5 Worldwide, the lifetime prevalence
of depression ranges from ten to fifteen percent. 1
Co-morbid depression and anxiety have been well documented,3 and past-year anxiety prevalence among U.S.
adults has been estimated at approximately 21%.6
Undergraduate and graduate students often report
symptoms of a mental illness. Results from the American
College Health Association (ACHA)-National College
Health Assessment (American College Health Association
(ACHA)-NCHA) suggest that approximately 20% and
28% of college students report that depression and anxiety, respectively, has interfered in their academic performance over the past 12 months. 7 Over 85%
self-reported that they felt overwhelmed by all they had
to do over the past year; nearly two-thirds felt very
lonely or overwhelming anxiety; and 45% felt so
depressed that it was difficult for them to function. A
recent systematic review, compiling data across 24
CONTACT Jonathan K. Noel
Rhode Island 02903, USA
© 2021 Taylor & Francis Group, LLC
jknoel@hotmail.com
Received 13 November 2019
Revised 10 March 2021
Accepted 25 June 2021
KEYWORDS
Depression; anxiety; first
generation; students; college
articles, suggests that the prevalence of depression in
undergraduate students is approximately 31%.8 A study
using the Counseling Center Assessment for Psychological
Symptoms (CCAPS) survey and a sample of n = 1,056
students from the Midwest United States (U.S.) reported
similar results.9
Evidence suggests that there may be disparities in the
prevalence of depression and anxiety symptoms between
population sub-groups. Disproportionately underrepresented groups are more likely to be exposed to psychological, environmental, systematic, and interpersonal risk
factors that may lead to anxiety, and generalized anxiety
disorder (GAD) may be more prevalent among lower
socioeconomic groups.10 For example, Hispanic patients
seeking primary care services may have higher rates of
mental illness, which may be moderated by social status
or social standing within the community.11
Importantly, first generation college students, defined
as the first persons in their immediate family to attend
college, may be at increased risk for symptoms of mental
illness, although research is limited. For many first generation (first gen) students, post-secondary education
comes with added stressors that those whose parents
received a college degree are less likely to endure.12 In
a survey of 58,000 students, first gen students were more
likely to have competing job responsibilities, competing
familial responsibilities, weaker math and English skills,
and worse study skills.12
Department of Health Science, Johnson & Wales University, 8 Abbott Park Place, Providence,
2
J. K. NOEL ET AL.
Lacking these advantages, first gen students may be
negatively impacted. First gen students were more likely
to feel depressed, stressed, or upset,12 and academic performance may suffer.13 Using data from approximately
36,000 students who participated in the Community
College Survey of Student Engagement, grade-point averages (GPA) were significantly lower among first gen
students, compared to non-first gen students, regardless
of gender, ethnicity, or race,13 and in a sample of 1,864
undergraduates from a large, public research university
in the U.S., first gen students were less academically
engaged and less likely to graduate. 14 Moreover, the
results from 948 freshman and sophomores enrolled in
science, technology, engineering, and math (STEM)
courses suggest that first gen students are more likely
to experience imposter feelings, which occur when an
individual feels like they will be exposed as incompetent
or unfit.15
Receiving social support, whether emotional, informational or companionate, may moderate the development
and severity of depression and anxiety symptoms.16 Positive
effects of social support on psychological well-being have
been documented,17 and in a systematic review of 34 studies, poor perceived social support was associated with
worse depression and anxiety symptoms, lower probability
of recovery, and poorer social functioning.18 Among those
from ethnic and racial minority groups, low social support
has been documented as a predictive factor for the diagnosis of depression.16 In a review of 797 longitudinal
studies, poorer perceived social support was associated
with worse depressive symptoms and poorer physical functioning.18 A systematic review of 63 articles also documented an association between social support and mental
health symptoms.19 Among 45 cross-sectional studies, 33
(73%) found a significant positive association between
social support and mental health. The remaining cross-sectional studies either found no significant associations or
did not test for the association in the study. Among seven
longitudinal studies that assessed the association between
social support and depression, two concluded that less
social support at earlier time points was associated with
depression symptoms later in life.
Although health disparities in depressive and anxiety
symptoms have been documented across several population groups, the existing literature is sparse regarding
symptoms of mental illness in first generation college
students. To address this gap, the current study sought
to determine if there was an association between first
gen student status and depressive and anxiety symptoms
in a sample of U.S. college students. Additionally, the
study tested whether the relationship between student
generation status and depression and anxiety symptoms
was moderated by perceived social support. It was
hypothesized that depressive and anxiety symptoms
would be greater among first gen students but the effect
would be limited to those with lower perceived social
support.
Methods
Data
The data for the present analysis originates from the
Mobile Screen Time Project, which was a cross-sectional
Web-based survey that was conducted to determine if
mobile screen time was associated with mental health
outcomes. Data collection occurred from March to
May 2019.
Sample and sample recruitment
Individuals were eligible to participate if they were
18 years old or older, spoke English and were enrolled
in a U.S.-based institution of higher education at the
time of survey administration. There were no exclusion
criteria. A convenience sample was recruited through
several different digital and traditional modalities, including: craigslist.org, Amazon’s Mechanical Turk, Facebook,
and Twitter. An invitation to participate was also distributed via email listservs from two colleges and universities located in the northeast U.S. As an incentive,
six participants were randomly selected to receive a $25
electronic gift card. A total of 565 individuals initiated
the survey by clicking on the link in the study advertisement. Of those, 432 (76.5%) met study eligibility
requirements and are included in the current analysis.
The remaining 133 individuals were either less than
18 years old or not currently enrolled in a 2-year or
4-year higher education program. Sample recruitment
and study protocols were approved by two university
Institutional Review Boards.
Measures
The independent variable was first generation student
status, which was measured using the following question:
“Are you a first generation college student?” The response
options were “Yes” and “No,” which were contrast coded
with “No” as the reference group.
There were two dependent variables: depressive symptoms and anxiety symptoms. Depressive symptoms were
measured using the Center for Epidemiological Study
Short Depression Scale (CES-D10).20 The CES-D10 contains 10 items regarding past week experiences of symptoms related to the development of depression (α = 0.83).
For example, items include “I felt hopeful about the
future” and “I felt lonely.” The response options ranged
from “rarely or none of the time,” which was coded as
0, to “all of the time,” coded as 3. Reverse scoring was
implemented for two of the items. The CES-D10 has
shown strong test/re-test reliability and convergent validity in youth and adult populations.21–23 Anxiety symptoms
were measured using the Generalized Anxiety Disorder
7-item scale (GAD-7).24 The GAD-7 measures the experience of nervousness, anxiousness, worrying, difficulty
JOURNAL OF AMERICAN COLLEGE HEALTH
relaxing, restlessness, annoyance, irritability, and fear over
the past two weeks on a 4-point Likert scale that ranges
from “not at all” to “nearly every day.” Responses were
scored from 0 to 3 for all items. GAD-7 validity and
reliability has been demonstrated in adolescents and the
general adult population.25,26
Perceived social and emotional support was used as
a moderating variable. It was measured using the following question: “How often do you get the social and emotional support you need?” Responses were measured on
a 5-point Likert scale ranging from “Never” to “Always,”
and responses were coded from 0 to 4.
Several covariates were measured. Age was measured
as an ordinal variable, and participants were able to
indicate if they were ≤ 18, 19, 20, 21, 22, 23, or ≥
24 years old. Gender was categorized as male, female, or
transgender, although persons who were transgender
were excluded from the analysis due to low counts
(n = 5). Race was measured as Asian, Black/African
American, Caucasian, Multiple or Other, and ethnicity
was categorized as Hispanic or non-Hispanic. Relative
socioeconomic status (SES) was measured using the
Macarthur Scale of Subjective Social Status (Macarthur
SSS),27 which assesses a person’s perceived rank relative
to others in their community, where 1 indicates being
the “worst off ” and 10 indicates being the “best off.”
Statistical analysis
Prior to analysis, the distribution of continuous variables
were examined for significant skewness and kurtosis. All
were considered normally distributed. Because prior literature suggests that the factor structure of the CESD1028–30 and GAD-731,32 may vary between populations,
an exploratory factor analysis (EFA) was conducted.
Given the low number of items in each scale, possible
solutions were limited to one and two factors because it
was determined that a greater number of factors would
not be substantively meaningful. Model fit was assessed
using the Root Mean Square Error of Approximation
(RMSEA, < 0.08), Comparative Fit Index (CFI, > 0.90),
Tucker Lewis Index (TLI, > 0.90), and Standardized Root
Mean Square Residual (SRMR, < 0.08). Significant differences in model fit between the one and two factor
solutions were determined using the chi-square difference
test. The factor structure identified by the EFA was used
in the remaining analyses.
Structural equation modeling (SEM) was used to
determine if first gen status was associated with depressive and anxiety symptoms. The CES-D10 and GAD-7
factor structure, as determined by the EFA, were specified as latent constructs and regressed on first gen status, which was specified as a manifest independent
variable. To determine if social and emotional support
moderated the relationship between first gen status and
depressive and anxiety symptoms, the social and emotional support variable was centered prior to the first
3
gen by social emotional support interaction term being
specified. Additionally, the models were adjusted for age,
gender, race, ethnicity, and relative SES. Model fit was
assessed using the RMSEA, CFI, TLI, and SRMR. Plots
and simple slope tests were used to further investigate
significant interaction terms.
Descriptive statistics were generated using SPSS for
Windows Version 25.0 (Armonk, NY: IBM Corp.). EFA
and SEM models were generated using Mplus version
8.3 (Los Angeles, CA: Muthén & Muthén). Models were
estimated using maximum likelihood, and statistical significance was set at α = 0.05.
Results
Sample
Approximately 43% of the sample were first generation
students (Table 1). A majority of participants (50.7%)
were 19 to 21 years old while 26.4% indicated they were
24 years old or older. Nearly two-thirds of the sample
were female (65.3%) and a majority (54.5%) identified
as Caucasian. The sample was predominantly non-Hispanic (83.8%), and the mean SES score was greater than
5, suggesting that participants thought, on average, that
they were better off than others in the community. The
majority (53.3%) of participants reported usually or
always receiving the social and emotional support they
needed. No participants indicated they never receive
social and emotional support.
CES-D10
One and two factor solutions of the CES-D10 were
explored. Based on the chi-square difference test, model
fit for the two factor solution was significantly greater
than the one factor solution (χ2(1) = 144.32, p < 0.001),
and the fit indices suggested good model fit (RMSEA
[90%CI] = 0.07 [0.05, 0.08]; CFI = 0.95; TLI = 0.94; SRMR
= 0.05). Therefore, the two factor solution for the CESD10 was accepted and used in subsequent analyses.
Factor 1 consisted of the positive affect items: hopeful
about the future and happy (Table 2). Factor 2 consisted
of the negative affect items: bothered, trouble concentrating, depressed, everything was an effort, fearful, restless sleep, lonely, and could not get going.
GAD-7
One and two factor solutions to the GAD-7 were
explored. Based on the chi-square difference test, model
fit for the two factor solution was significantly greater
than the one factor solution (χ2(1) = 61.71, p < 0.001),
and the fit indices suggested good model fit (RMSEA
[90%CI] = 0.06 [0.04, 0.09]; CFI = 0.99; TLI = 0.98;
SRMR = 0.02). Therefore, the two factor solution for
the GAD-7 was accepted and used in subsequent analyses. Factor 1 consisted of cognitive-emotional symptoms
4
J. K. NOEL ET AL.
Table 1. Descriptive statistics (n = 432).
Variable
Relative SES
Depression scale 1
Depression scale 2
Anxiety scale 1
Anxiety scale 2
Age (yrs)
≤18
19
20
21
22
23
≥24
First generation student
Yes
No
Receive social/emotional support
Always
Usually
Sometimes
Rarely
Never
Gender
Female
Male
Race
Asian
Black/African American
Caucasian
Multiple
Other
Ethnicity
Hispanic
Non-Hispanic
Mean (SD)
6.3 (1.8)
2.5 (1.7)
8.7 (5.0)
4.8 (3.8)
2.7 (2.5)
Count (%)
38 (8.8)
67 (15.5)
85 (19.7)
67 (15.5)
39 (9.0)
22 (5.1)
114 (26.4)
185 (42.8)
247 (57.2)
73 (16.9)
170 (39.4)
131 (30.3)
58 (13.4)
0 (0)
Figure 1. Final structural equation model for the effect of first generation
student status on depressive and anxiety symptoms, moderated by emotional/social support. Standardized values. Bold indicates statistical significance (p < .05). Model fit: RMSEA (90%CI) =.04 (.03, .05); CFI = .96; TLI
= .95; SRMR = .04.
282 (65.3)
150 (34.7)
63 (14.6)
61 (14.1)
235 (54.5)
26 (6.0)
47 (10.9)
70 (16.2)
362 (83.8)
Table 2. Exploratory factor analysis – factor loadings.
Variable
CES-D10*
Hopeful about the future
Happy
Bothered
Trouble concentrating
Depressed
Everything was an effort
Fearful
Restless sleep
Lonely
Could not get going
GAD-7**
Nervous
Worry
Worrying about different things
Trouble relaxing
Annoyed
Afraid
Restless
*
Factor 1
.692
.826
.860
.901
.880
.835
Factor 2
.502
.672
.811
.642
.604
.562
.597
.582
.678
.769
.731
Model fit: RMSEA (90%CI) = .07 (.05, .08); CFI = .95; TLI = .94; SRMR = .05.
Model fit: RMSEA (90%CI) = .06 (.04, .09); CFI = .99; TLI = .98; SRMR = .02.
**
of anxiety: nervous, worry, worrying about difference
things, and trouble relaxing (Table 2). Factor 2 consisted
of the somatic symptoms of anxiety: annoyed, afraid,
and restless.
Structural equation modeling
The proposed SEM model demonstrated good model fit
(RMSEA [90%CI] = 0.04 [0.03, 0.05]; CFI = 0.96; TLI =
0.95; SRMR = 0.04), and no model modifications were
pursued. First gen status was not a significant predictor
of either CES-D10 factor (p > 0.05) (Figure 1; Table 3).
However, first gen status was significantly associated with
both GAD-7 factors. There was a positive association
with the cognitive-emotional factor (b = 0.22, p = 0.036)
and the somatic factor (b = 0.30, p = 0.013). Further, social
and emotional support was a statistically significant
moderator of the relationship between first gen status
and the somatic factor (b = −0.27, p = 0.028). A simple
slopes analysis suggests that first gen students who rarely
receive social and emotional support have greater somatic
anxiety symptoms compared to non-first gen students
(p = 0.004), while there was no significant difference in
somatic anxiety symptoms in students reporting sometimes (p = 0.602), usually (p = 0.182), or always (p = 0.853)
receiving social and emotional support (Figure 2).
There were several other interesting findings. There
was a negative association between relative SES and
depressive and anxiety symptoms (p’s < 0.001) (Table
3). Age was positively associated with the positive
affect factor of the CES-D10 (p = 0.007), and males
reported fewer cognitive-emotional anxiety symptoms
(p < 0.001). Additionally, relative to Caucasians, participants who identified as Asian reported higher negative
affect depressive symptoms (p = 0.006) and somatic
anxiety symptoms (p = 0.023), while Black/African
Americans reported fewer cognitive-emotional anxiety
symptoms (p = 0.048).
Discussion
The findings suggest that first generation college students are at an increased risk for experiencing cognitive-emotional and somatic symptoms of anxiety.
However, moderate to high levels of social and
JOURNAL OF AMERICAN COLLEGE HEALTH
5
Table 3. Structural equation model standardized coefficients.
Variable
First generation
Yes
No
Emotional/social support
First generation* emotional/social support
Age
Relative SES
Gender
Male
Female
Race
Asian
Black/African American
Multiple
Other
Caucasian
Ethnicity
Hispanic
Non-Hispanic
*
CESD-10: Factor 1
Estimate
p
CESD-10: Factor 2
Estimate
p
GAD-7: Factor 1
Estimate
p
GAD-7: Factor 2
Estimate
p
−.03
.
−.38
−.03
.14
−.25
.610
.
<.001
.496
.007
<.001
.15
.
−.25
−.13
.02
−.21
.185
.
<.001
.269
.414
<.001
.22
.
−.14
−.16
−.02
−.17
.036
.
.012
.156
.464
<.001
.30
.
−.16
−.27
.03
−.17
.013
.
.014
.028
.267
<.001
.20
.
.120
.
−.11
.
.364
.
−.45
.
<.001
.
−.16
.
.181
.
.01
.10
.04
.06
.
.943
.562
.864
.841
.
.44
.20
.27
−.30
.
.006
.231
.259
.248
.
.14
−.30
−.20
−.11
.
.356
.048
.375
.650
.
.38
−.05
.23
−.21
.
.023
.757
.357
.455
.
.30
.
.218
.
.35
.
.113
.
.16
.
.439
.
.23
.
.324
.
Statistically significant effects (p < 0.05).
Figure 2. GAD-2: Factor 2 symptoms by first generation status and
emotional/social support.
emotional support appear to act as a protective factor
against somatic anxiety symptoms among this population. Interestingly, there were no signification relationships between student generation status and depressive
symptoms, although there were several other significant
relationships that may merit further investigation.
Specifically, higher relative SES was associated with
lower depressive and anxiety symptoms; females
reported experiencing greater cognitive-emotional anxiety symptoms; and Asian Americans reported experiencing greater negative affect depressive symptoms and
somatic anxiety symptoms.
Anxiety in first generation students
Anxiety symptoms in first generation students may be
pronounced due to increased stress. The Cognitive
Activation Theory of Stress (CATS) posits that a stress
response occurs whenever there is a discrepancy between
the expectations of an experience and what occurs in
reality.33 When expectancies are not met, the stress
response manifests as a general increase in arousal that
can affect numerous body systems. Short-term experiences of stress in response to expectancy discrepancies
often have positive benefits that serve to protect the
individuals from a threatening or negative experience,
but sustained stress may produce negative psychological
and physiological consequences due to allostatic load.
Within the context of the present study, we propose that
first generation students may be experiencing chronic
increased stress, which manifests in some as anxiety
symptoms, due to a discrepancy between what the college experience was expected to be and the reality of
college life.
Using CATS as a model, the findings are consistent
with previous research. For example, psychological distress (ie, anxiety, stress, and depression) rose steadily
through the first semester of college and remains elevated through the second semester in a sample of undergraduates.34 Anxiety symptoms were previously strongly
correlated with perceived stress,35 and additional findings
from the American College Health Association (ACHA)NCHA survey suggest that stress increases the likelihood
of being diagnosed with a mental illness, including anxiety.36 Here, the effects were seen after experiencing as
few as one stressful event. Moreover, perceived stress
mediated the relationship between sleep quality and anxiety symptoms in a sample of undergraduate nurses.37
First generation students may experience high levels
of acculturative stress, which reflects the stress experienced
during the cultural adaptation process and has been previously identified as a significant risk factor for anxiety.38
Among Latinx college students, acculturative stress mediated the relationship between acculturation and depression, with the effects stronger among men, 39 and
acculturative stress may increase symptoms of anxiety and
depression due to a lack of access to emotional regulation
strategies.40 Moreover, in a three-year longitudinal study
6
J. K. NOEL ET AL.
of immigrant-origin adolescents, exposure to acculturative
stress was predictive of greater experiences of anxiety-related symptoms.41
Consequently, interventions that target stress have
been shown to decrease anxiety symptoms. A meta-analysis of 24 intervention studies that included over 1,400
university students concluded that mindfulness programs
on college campuses significantly decrease symptoms of
stress and anxiety.42 Mindfulness programs that are
designed to reduce stress in order to decrease anxiety
may be more effective at reducing anxiety symptoms
than those that focus on physical activity levels,43 and
in a pilot study of 33 pre-healthcare undergraduate students, positive benefits were seen in as little as 5 minutes
of meditation daily.44
Social support and anxiety
The findings suggest that the experience of somatic anxiety symptoms, such as being annoyed, afraid or restless,
may be moderated by increased social and emotional
support, whereby decreased social support resulted in
greater levels of somatic anxiety symptoms. Research
conducted on other populations is supportive. Among
student veterans, social support moderated the relationship between coping mechanisms and anxiety symptoms 45 and predicted academic adjustment among
returning veterans.46 Peer social support moderated the
relationship between distress and self-stigma among college students with a previous mental health diagnoses47
and may predict later anxiety symptoms.48 Importantly,
the relationship between social support and anxiety
symptoms in students may be universal, with consistent
effects found in numerous countries.49
SES and mental illness
Higher relative SES was associated with lower depressive
and anxiety symptoms, which is consistent with existing
research. For example, individuals from lower SES classes
are more likely to suffer depressive symptoms,50 and
college students with greater financial burdens are more
likely to suffer from depressive and anxiety symptoms.51
Moreover, the relationship between objective measures
of social class and depressive symptoms may be mediated by subjective measures of SES,52 which were used
in the current study, while others have demonstrated
that the effect is stronger among women relative to
men.53 Additionally, a systematic review concluded that
the relationship between economic stress and symptoms
of mental illness in adolescents is mediated via parental
conflict, parental depression, parenting practices, and
resiliency.54 Moreover, the relationship between SES and
mental illness has been tentatively extended to treatment
outcomes, with evidence suggesting that SES deprivation
is associated with poorer psychological therapy
outcomes.55
Females and anxiety
The findings suggest that female college students experience more cognitive-emotional symptoms of anxiety,
which is consistent with previous research. Anxiety disorders are the most common psychological condition
among female adolescents and young adults,56 and in
the present context, greater anxiety symptoms may be
due to greater anxiety sensitivity, which is a fear of
anxiety-related situations or the consequences of anxiety.
Other studies have reported that female college students
had significantly greater anxiety sensitivity scores than
their male counterparts,35 and such gender disparities
likely begin in childhood and continue through adolescence and into adulthood.57,58 Moreover, anxiety sensitivity mediated the relationship between gender and
cognitive symptoms of anxiety in a sample of adults,59
and anxiety mediated the relationship between anxiety
sensitivity and functional impairment.60
Asian americans and mental illness
Relative to Caucasians, self-identified Asian Americans
reported greater negative affect depressive symptoms and
somatic symptoms of anxiety, which adds to a mixed
body of literature. Greater depressive symptoms, using
the CES-D, among Korean American adolescents compared to Caucasians have been previously reported,61
and elevated depression symptoms were identified in
Asian American undergraduate students compared to
Caucasian students.62 However, others have reported that
the prevalence of mental illness is lower in Asian
Americans, although differences in rates may be due to
cultural perceptions of the disease, access to linguistically
appropriate care, and disease presentation.63 Moreover,
a study of non-institutionalized Asian and European
Americans reported that Asian Americans were less likely
to express specific somatic and psychological symptoms
of depression, even if the overall symptomology is equivalent across groups.64
Implications and next steps
There are research and programmatic implication to the
findings. First, additional research studies are needed on
the relationship between first generation student status
and symptoms and diagnoses of mental illness. As noted
previously, the literature is relatively sparse on this topic.
Initially, cross-sectional research using representative
samples are needed to confirm the present findings and
expand upon them. Interestingly, there are several existing, high quality studies that could add a question to
classify students based on generation status. For example,
the Behavioral Risk Factor Surveillance System (BRFSS)
currently collects employment data that allows participants to identify themselves as students and questions
about poor mental health and previous diagnosis of
JOURNAL OF AMERICAN COLLEGE HEALTH
depressive disorder are included in recent years of data
collection.65 Although students are a minority of BRFSS
respondents, the number of respondents is likely to be
greater than 10,000 due to the large sample recruited
for each year’s survey. In 2018, approximately 2.7%
(n = 11,688) of respondents were students. Additionally,
the American College Health Association (ACHA)’s
National College Health Assessment (NCHA) should
include a question to determine first generation status.
The NCHA currently contains several items assessing
the mental health of respondents, and its large sample
size (n = 54,497 in Spring 2019) makes it ideal for further
investigating the relationships identified here.66
If the current findings are confirmed in larger
cross-sectional surveys, prospective longitudinal research
may be warranted to determine if symptoms of mental
illness among first generation students develop during or
prior to the college experience; if first generation students
are more or less likely to access institutional healthcare
resources; the effectiveness of available healthcare
resources; and protective and risk factors for the development of symptoms of mental illness. A representative
sample of the U.S. college student population would be
ideal, but given the logistical difficulties, well designed
cohorts of students recruited from a representative sample
of colleges and universities may be an effective and pragmatic alternative.
Programmatically, the findings extend previous
research suggesting that first generation students may
be at risk for experiencing symptoms of mental illness,
and while some of those symptoms may be moderated
by student social networks, such a focus is not a cureall. If the current findings are confirmed, colleges and
universities should consider developing and implementing programs that can specifically address the mental
health concerns of first generation students. Such programs may include resources to assist these students in
acclimating to the college and university environment;
developing a healthy work-life-family balance; and providing early intervention treatment programs. Moreover,
while the use of university resources is an individual
choice, developed programs should proactively identify
first generation students upon enrollment and routinely
provide relevant information via email or other appropriate media.
Limitations
There are several limitations to the study. It was a
cross-sectional survey that recruited a convenience sample. It is unlikely that the sample was representative of
all college students, particularly since the prevalence of
first generation students was greater than 40%, and the
results may not be generalizable to other populations.
According to the U.S. Department of Education, 23.9%
7
of college students in the 2015–2016 academic year were
first generation.67 The study is also limited be the restrictive nature of the response options for age, which ended
at ≥ 24 years old. Further research using representative
samples are required to confirm the results. Due to the
anonymous nature of the survey, it was not possible to
confirm student generation status, and it is possible that
misclassification occurred. Moreover, a definition of “first
generation student” was not provided to participants,
and different interpretations between participants may
lead to skewed results. The study relied on self-report,
which is subject to recall bias, and since self-reporting
depressive and anxiety symptoms may be a sensitive
topic for participants, social desirability bias may have
occurred, which could have led to participants indicating
that they experience fewer symptoms than what occurs
in reality. Social support may have been under or
over-estimated since it was measured with a single item,
and unique sources of social support may be better captured using a multi-item scale. Finally, the study was
not powered by first generation student status, and while
the sample size was moderately large, it is possible that
the study was underpowered to detect differences in
depressive symptoms by student generation status and
the potential interactive effects of social and emotional
support.
Conclusions
First generation undergraduate students may be at an
increased risk of experience cognitive-emotional and
somatic symptoms of anxiety, although the somatic
symptoms of anxiety may be moderated by receiving
adequate social and emotional support. The relationship
may be due to increased stress felt by first generation
students, although more research is needed. Existing
surveillance studies that include college students should
consider asking a question about generation status, and
universities and colleges should consider developing programs that can specifically address college-related stress
in this population.
Conflict of interest disclosure
The authors have no conflicts of interest to report. The
authors confirm that the research presented in this article
met the ethical guidelines, including adherence to the
legal requirements, of the United States and received
approval from the Johnson & Wales University
Institutional Review Board.
Funding
No funding was used to support this research and/or
the preparation of the manuscript.
8
J. K. NOEL ET AL.
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