Association between depression, examination-related stressors, and sense of coherence: The ronin-sei study
In the Japanese education system, students who fail university entrance exam often go to special preparatory schools to prepare for the following year's exam. These students are called ronin-sei. The purpose of this study was to clarify: (i) depression and somatic complaints in ronin-sei; and (ii) the association between depression, examination-related stressors, and sense of coherence (SOC).
A total of 914 ronin-sei from two preparatory schools were asked to answer a self-rating questionnaire. Depression was measured using the Center for Epidemiologic Studies Depression Scale (CES-D) and SOC was measured using the SOC-13 Scale.
Overall, 57.9% of subjects were considered to have depression (CES-D ≥ 16) and 19.8% had severe depression (CES-D ≥ 26). Higher CES-D scores were associated with a higher rate of somatic complaints. In hierarchical logistic regression analysis, having no one to talk to about his/her worries and having parents who disagree about the first-choice of university and faculty were independent risk factors for depression and severe depression, respectively, even after controlling for SOC.
Preparatory school students have various somatic complaints, and their depression is in part related to examination-related stressors. To maintain mental health, it is important to enhance SOC, to understand their examination-related stressors and to provide adequate support for these students.
In Japan, more than half of high school graduates enter university. In general, a university entrance exam is conducted, and competition to pass the exam is high. Most students who fail the entrance exam attend a special preparatory school to prepare for the following year's exam, and some of them study for many years until they pass. Such students are called ronin-sei (ronin students). Ronin, the original meaning of which is ‘masterless samurai’, is a culture-specific phenomenon based on the Japanese university admission system. Although the number of ronin-sei has been gradually decreasing because of the falling birthrate and increase in the number of universities, about 100 000 ronin-sei still exist.
We speculate that ronin-sei are in stressful situations because they have to cope with both psychological and psychosocial development tasks attributed to defining their own identity, a feeling of failure related to the exam, and anxiety, irritation, and impatience regarding the next exam.
A previous study pointed out that Japanese preparatory school students had many types of physical complaints and that their lifestyles were very restricted and strained. Some preparatory schools have professional staff to provide mental health services, including counseling, for ronin-sei. In Korea, the competition for the university entrance exam is also high, and a relation between entrance examination-related stressors and mental health in adolescents has been identified.[4-6] Similarly, in China, the educational system is highly competitive. A few studies about examination-related stressors have been published regarding countries other than those in East Asia.[8, 9] However, there are few quantitative studies targeted for ronin-sei regarding the relation between their mental health and specific stressors.
There is a widely accepted concept of sense of coherence (SOC) advocated by Antonovsky, which reflects the capability to cope with stressful situations. He defined SOC as ‘a global orientation that expresses the extent to which one has a pervasive, enduring though dynamic feeling of confidence that one's internal and external environments are predictable and that there is a high probability that things will work out as well as can reasonably be expected’. SOC is central to the salutogenic perspective that focuses on identifying people's resources and capacity to create health (salutogenesis) rather than the classic focus on risk, ill health, and disease (pathogenesis). Eriksson and Lindström concluded that SOC was a health-promoting resource that strengthens resilience and develops a positive subjective state of health. They also reported that SOC had a moderating effect on health. We hypothesized that SOC would be associated with the depression of ronin-sei. Our study aims to clarify: (i) depression and somatic complaints in ronin-sei; and (ii) the association between depression, examination-related stressors, and SOC.
Our survey was conducted in July 2011, which was just before summer vacation. The study was approved by the Human Subjects Committee of Kumamoto University, Japan. The staff of two preparatory schools handed out questionnaires to students. Return of the completed questionnaire was considered informed consent, and the research was conducted anonymously.
Subjects in our study were ronin-sei enrolled in two preparatory schools, most of whom had failed the university exam the previous year and planned to take it again. Some of them had graduated from university before and would apply to another university or faculty. In one school, all of the students were asked to participate in our research, and in another one, subjects included only students who lived in the school dormitory. Of 1075 students who were asked to participate in our study, 914 (85.0%) answered all the questions.
The Japanese version of the Center for Epidemiologic Studies Depression Scale (CES-D) was used in this study to measure depressive feelings and behaviors. This scale consists of 20 items answered on a 4-point Likert scale from 0 (rarely or none of the time) to 3 (most or all of the time); it has been shown to have good reliability and validity. A score ≥ 16 was regarded as representing depression and a score ≥ 26 represented severe depression.
Antonovsky's SOC was measured by the Japanese version of the SOC-13 Scale, scored on a 7-point Likert scale, with higher scores representing healthier conditions. Although the original SOC-13 was shown to have good reliability and validity, the Japanese version has only been examined for validity. In our study, we defined subjects with scores ≤ 50 as having low SOC and others as having high SOC.
For somatic complaints, we developed a symptom list consisting of 14 items; headache, stomachache/abdominal pain, stiff shoulder/backache, constantly tired, constipation/diarrhea, easily fatigued, listlessness, irritation, apathy, dizziness, nausea, excessive sweating, palpitations, and binge eating. Subjects were asked to select symptoms experienced during the past month. This original list was developed based on previous studies and scales, such as the University Personality Inventory (UPI) and the Self-rating Depression Scale (SDS). The UPI is a questionnaire developed in Japan to measure the mental health of university students and has been used in Japanese universities for more than 40 years. The SDS is a widely used questionnaire measuring depression severity.
Other variables examined included sex, years of ronin (categorized as first year, second year, and more than second year), whether he/she has someone to talk to about his/her worries (with, without), academic achievement (percentage of questions answered correctly on last year's National Center Test for University Admissions, categorized as ‘poor’, ‘average’, or ‘good’), and whether his/her parents agree with his/her first-choice university and faculty for the next exam (agree, disagree, neither agree nor disagree). We defined ‘without anyone to talk to about his/her worries’, ‘poor academic achievement’, and ‘parents do not agree with first-choice university and faculty for the next exam’ as examination-related stressors.
The two-proportion z-test was used to compare the percentage of the subjects who had each somatic complaint among the non-depressed group, the mildly depressed group (CES-D score 16–25), and the severely depressed group (CES-D score ≥26). Two hierarchical logistic regressions were conducted to assess whether examination-related stressors were associated with depression after controlling for SOC. In each analysis, depression (CES-D score ≥16) and severe depression (CES-D score ≥26) were entered as dependent variables. In Step 1, sociodemographic variables and examination-related stressors were entered as independent valuables. In Step 2, we added SOC score as independent valuables. All significance tests were two-sided and values of 0.05 level represented significant differences. Analyses were performed using pasw statistics 21.0 (ibm spss, Tokyo, Japan).
Table 1 shows subjects' demographics. Of all subjects, 20.7% of ronin-sei answered that their parents did not agree strongly with the first-choice university and faculty. A total of 14.1% of the ronin-sei had nobody to talk to about their worries. The mean CES-D score was 18.5 (SD = 9.5). A total of 529 (57.9%) were assessed as depressed (CES-D ≥ 16) and 181 of them (19.8%) were severely depressed (CES-D ≥ 26).
Table 1. Sociodemographics of respondents (n = 914)
|Sex|| || |
|Years of ronin-sei|| || |
|More than second year||41||4.5|
|Opinion of parents about their first-choice university and faculty|| || |
|Person to whom respondent talks about his/her worriesa|| || |
|Academic achievementb|| || |
As shown in Table 2, more than 40% of students experienced headache, stomachache/abdominal pain, stiff shoulder/backache, constantly tired, constipation/diarrhea, and listlessness within the past month. Tiredness, irritation, and apathy were felt by about 30% of respondents. The rate of students who experienced each symptom was significantly different among the non-depressed group (n = 385), the mildly depressed group (CES-D score of 16–25; n = 348), and the severely depressed group (CES-D ≥ 26; n = 181) except for stiff shoulder/backache. The group with severe depression had the highest proportion of almost all symptoms.
Table 2. Somatic complaints of ronin-sei (multiple answers permitted), %
The first hierarchical logistic regression analysis (Step 1) revealed that students who were female, whose parents did not agree strongly (‘neither agreed nor disagreed’, and ‘disagreed’) about the first-choice university and faculty, who did not have anyone to talk to about his/her worries, and whose academic achievement was poor had a higher risk of depression. In Step 2, only students who did not have anyone to talk to about his/her worries had higher risk of depression after controlling for SOC (Table 3). In the second hierarchical logistic regression analysis, students whose parents did not agree strongly about the first-choice university and faculty had a higher risk of severe depression after controlling for SOC (Table 4).
Table 3. Hierarchical logistic regression analysis predicting depression (CES-D ≥ 16)
|Sex (reference = male)||0.31||1.37||1.02–1.83||0.036||0.25||1.29||0.91–1.83||0.152|
|Years of ronin-sei (reference = first year)|| || || ||0.436|| || || ||0.570|
|More than second year||0.45||1.57||0.72–3.40||0.256||0.20||1.22||0.49–3.04||0.671|
|Parents do not agree strongly with first-choice university and faculty (reference = agree)||0.54||1.72||1.21–2.45||0.003||0.19||1.21||0.79–1.85||0.381|
|Not having anyone to talk to about his/her worries (reference = having)||1.07||2.93||1.87–4.60||<0.001||0.66||1.93||1.14–3.28||0.015|
|Academic achievement (reference = Average)|| || || ||0.073|| || || ||0.264|
|SOC score|| || || || ||−0.14||0.87||0.85–0.88||<0.001|
|Model χ2||48.76|| || || ||340.08|| || || |
|Model Δ χ2|| || || || ||291.32|| || || |
Table 4. Hierarchical logistic regression analysis predicting severe depression (CES-D ≥ 26)
|Sex (reference = male)||0.38||1.46||1.02–2.09||0.036||0.33||1.39||0.93–2.08||0.108|
|Years of ronin-sei (reference = first year)|| || || ||0.794|| || || ||0.892|
|More than third year||0.36||1.44||0.50–4.12||0.501||−0.04||0.96||0.31–2.99||0.944|
|Parents do not agree strongly with first-choice university and faculty (reference = agree)||0.80||2.23||1.53–3.24||<0.001||0.52||1.68||1.10–2.57||0.016|
|Not having anyone to talk to about his/her worries (reference = yes)||0.92||2.52||1.65–3.86||<0.001||0.46||1.58||0.97–2.57||0.067|
|Academic achievement (reference = Average)|| || || ||0.158|| || || ||0.747|
|SOC score|| || || || ||−0.13||0.88||0.86–0.90||<0.001|
|Model χ2||46.75|| || || ||217.87|| || || |
|ModelΔ χ2|| || || || ||171.12|| || || |
We clarified the presence of depression and somatic complaints among ronin-sei in Japan. In our study, the mean CES-D score was 18.5 and 57.9% of subjects scored higher than the cut-off point representing depression (≥16). In addition, 19.8% of respondents met the definition of severe depression based on CES-D score. Compared with other countries, such as those in East Asia and Europe,[8, 16, 17] the CES-D score of Japanese youths is generally higher. In previous studies, the mean score of Japanese college and university students was around 17.[18, 19] Kawada et al. reported that 36.9% of students who attended a clinical practice course exceeded the cut-off point for depression. The CES-D score of ronin-sei was higher than these studies, suggesting that they were not necessarily mentally healthy. They also had various somatic complaints, with more than 40% of them complaining of headache, stomachache/abdominal pain, stiff shoulder/backache, constantly tired, constipation/diarrhea, or listlessness in the past month. These symptoms were the most frequently observed in the severely depressed group, but also occurred in the mildly depressed group. Some studies have pointed out the relation between examination-related stressors and somatic complaints, such as irritable bowel syndrome or physical pain.[4-9, 21] These symptoms, which are common in many generations, are reported to be associated with poorer social and emotional outcomes.[22-24] Although these symptoms may be common and largely transient, we should be careful not to overlook mental problems and to prevent ronin-sei from transitioning to depression or other mental illnesses.
In general, female sex and having no one to talk to about his/her worries are risk factors for depression.[25-27] In our study, in addition to these factors, examination-related stressors were also risk factors for depression. However, when we input SOC scores as an independent variable in hierarchical logistic regressions analysis, some of these factors were not significantly related to depression or the relations were weakened. This means that low SOC correlates with depression more strongly than examination-related stressors and that SOC weakens the relation between examination-related stressors and depression. Namely, ronin-sei with high SOC could avoid becoming depressed and maintain mental health even if they were subjected to some examination-related stressors.
As some previous studies showed the effect of SOC as a mediator of stressors,[28-30] our result also indicates that high SOC is an important factor for ronin-sei to prevent depression. However, SOC may be related with not only depression but also examination-related stressors. Further studies are needed as to the interaction of these factors. Similarly, our result indicates that although female ronin-sei had a higher risk for depression, they could maintain mental health by high SOC.
There are many arguments regarding the stability of the SOC. Several studies show the test–retest correlations of the SOC measure to be high,[11, 30] which suggests that SOC is stable. However, some studies suggest that, from a long-term standpoint, SOC changes with various life events.[31, 32] Although failing the entrance exam would be an adverse event for ronin-sei, they might be able to enhance their SOC by continuous efforts and the subsequent success in the next exam.
Even after controlling for SOC, having no one to talk to about his/her worries and having parents who do not agree strongly with their first-choice of university and faculty were independently related to depression and severe depression, respectively. Because of inconsistency of related factors between depression and severe depression in our study, we have to interpret our result cautiously. However, it can be assumed that these examination-related stressors would affect negatively for ronin-sei. These students have a tendency to be isolated because many of their friends have already passed the exam and are enjoying university life. In preparatory school, which is attended with the specific aim of studying to pass the university examination, making new friends may be difficult. Moreover, ronin-sei have to reconcile their desire and their parents' opinion about which university to attend. We should not overlook this conflict between ronin-sei and their parents because this stressor is related with their severe depression. Our results suggest the importance of appropriate support for ronin-sei subjected to these two examination-related stressors.
There are several limitations to this study. First, because there was no control group in our study, we could not conclude that ronin-sei were really a high-risk group for depression and clarify the extent to which examination-related stressors were specific to ronin-sei. A comparison with high school students preparing for exam or university students would clear up these questions. Second, subjects might not be representative of the whole ronin-sei because our research was limited to two preparatory schools in provincial cities, although these two schools are located in separate regions. Third, the health status of ronin-sei might differ based on the time of year that the research is conducted. In Japan, the entrance exam is often conducted around January or February, as the new school term begins in April. Motonaga pointed out from his experiences that the risk of suicide for ronin-sei was high during summer vacation and just before the entrance exam. Conversely, a survey conducted by Sakurada et al. found no difference in the health status of ronin-sei between September and December. More research is needed about seasonal variation of mental health of ronin-sei.
Most ronin-sei are studying hard for the next exam and experience examination-related stressors; others might experience worsening mental conditions, resulting in a mental illness, such as depression. Adequate support is important, especially for ronin-sei who are isolated and who are in conflict with their parents about which university or faculty to choose.
Japanese ronin-sei were relatively depressed and had various somatic complaints. Adequate support is needed for ronin-sei who have low SOC, are isolated, and in conflict with their parents about which university or faculty to choose.
This study was supported by a Grant-in-Aid for the Japan Society for the Promotion of Science (JSPS) Fellows. None of the authors has any conflicts of interest associated with this study.