Test anxiety as a risk factor for use of psychoactive compounds in medical students


 <p><strong>Introduction. </strong>Test anxiety implies an intense pathological fear in situations of preparing and taking exams which is a significant problem for 15&ndash;70% of medical students. The frequent use of psychoactive substances is recognized as a problem for young people. The aim was to determine the frequency and degree of test anxiety and the association with misuse of psychoactive substances in medical students of the Faculty of Medicine in Foča.<br /><strong>Methods.</strong> The research was conducted according to the principle of a cross-sectional study at the Faculty of Medicine in Foča. Students were offered a custom-made questionnaire containing general and specific questions for test anxiety and use and dependence of psychoactive compounds and social networks. Test anxiety was evaluated by Westside anxiety scale.&nbsp;<br /><strong>Results.</strong> The sample included 145 respondents, 69.7% females and 30.3% males. The results indicate that the degree of test anxiety does not differ in male and female students, but test anxiety is less pronounced in younger students and students with medium academic success. The level of test anxiety was correlated with the rate of psychoactive compound use. Psychoactive substances were used by 50.3% of students, primary for anti-anxiety, than for psychostimulation and for hypnotic effects. The most commonly used classes of psychoactive substances were plant anxiolytics, followed by benzodiazepines, marijuana, alcohol and narcotics/cocaine (18.6%, 12.4%, 12.4%, 8.3%, and 4.8%, respectively).<br /><strong>Conclusion.</strong> A significant number of students reach for anxiolytics and other drugs that can create addiction. Elevated levels of test anxiety are positively correlated with increased consumption of psychoactive compounds. However, the frequency of use of psychoactive compounds surpasses the frequency of altogether moderate, high and extreme test anxiety.</p>



Introduction
Medical professionals are frequently subjected to high levels of stress throughout their careers and they must be capable of maintaining their psychological well-being amid demanding work environments.Anxiety stands out as the most prevalent psychological issue worldwide [1].While an optimal level of anxiety can enhance an individual's performance, excessive anxiety can lead to negative consequences for both physical and psychological health.The rigorous nature of medical studies can be viewed as part of the preparatory process for future professional endeavors, inevitably involving stress and anxiety [2].
One specific form of anxiety, exam anxiety, is particularly prevalent in academic environments, especially in demanding fields such as medicine.Exam or test anxiety refers to a psychological condition characterized by intense feelings of apprehension, fear, or nervousness experienced before, during, or after an examination or assessment [3,4].The rate and intensity of exam anxiety vary significantly across different faculties, influenced by various factors such as education systems, the quality and alignment of pre-academic education, the coherence of teaching methods and examination formats, student demographics including age and study type.Medical education is often regarded as one of the most stressful faculties, typically associated with the highest levels of exam anxiety.While some degree of anxiety is inevitable and can even be beneficial, high levels of anxiety are detrimental to students' academic success, health, and quality of life.Moreover, elevated levels of exam anxiety may be associated with the use of legal and illegal substances with anxiolytic or other psychoactive effects, potentially leading to dependence and causing long-term consequences for personal and public health.
Psychoactive substances act on the central nervous system, altering mood, behavior, and even consciousness [5].In addition to prescribed drugs such as anxiolytics, sedatives, antidepressants, and opioid analgesics, psychoactive effects have legal compounds like alcohol and nicotine, as well as illegal substances such as marijuana, cocaine, and amphetamines.Additionally, certain foods, beverages, and dietary supplements are believed to enhance mental functions, such as energy drinks, coffee, herbal teas, vitamins, and minerals, and are sometimes consumed by students for this purpose [6].All of these substances can induce detrimental effects.Overuse of psychoactive substances can be linked to exam anxiety.It is crucial to determine the levels of exam anxiety and psychoactive substance use among medical students in Bosnia and Herzegovina, as well as the potential association between these two factors.This is necessary as a foundation for future intervention strategies

Methods
The cross-sectional study was conducted at the Faculty of Medicine in Foča, involving students in the second, fourth, and sixth year of study.A questionnaire was distributed to all students present at the Faculty during the survey period (April 1-15, 2023) who had consented to participate in the study.The participants were briefed on the purpose of the study and provided verbal informed consent.Participation was voluntary and anonymous, with no requirement for names or identification data on the questionnaire.To ensure no undue influence, students, rather than teachers, distributed the questionnaire.Out of the 186 medical students enrolled in the second, fourth, and sixth year of the Faculty of Medicine in Foča in 2023, 145 participated in this study (53, 46, and 46 from each year, respectively), representing assessment rates of 62.3%, 90.2%, and 92% of the total population.
The questionnaire was custom-designed for this study and tailored to suit the student population.It was focused on assessing exam anxiety among medical students using the Westside Test Anxiety (WTA) Scale, which consisted of 10 Likert scale questions with five possible responses ranging from 'not at all' or 'never true' to 'extremely' or 'always true.' Anxiety levels were determined by calculat-ing the Westside score (WTAS), ranging from 1 to 5 for each question and totaling 10 to 50 overall.The level of anxiety was categorized based on the total score divided by 10, with a final WTAS of 1.0-2.5 indicating low anxiety, 2.5-3.5 indicating medium anxiety, and WTAS greater than 3.5 indicating high anxiety.In terms of descriptive variables, students were surveyed about their use of psychoactive compounds, encompassing synthetic compounds such as benzodiazepines and antidepressants, herbal drugs, sleep supplements, coffee, tea, nicotine, marijuana, and alcohol as well as social network use and dependence.The considered covariables included sex (female or male), age (17 to 20 years old or over 20 years old), year of study (second, fourth and sixth), socioeconomic status (low, middle, and high), and academic success, measured by average marks and number of renewed years.The survey questions were divided into four parts: demographic data (3 questions), academic success (3 questions), test anxiety (11 questions), deprivation of night sleeping (2 questions), psychoactive compound use and dependence (12 questions), and social network use and dependence (2 questions).Respondents were presented closed-ended statements, offering a range of answers or a choice between true/false responses.

Data analysis
Descriptive and analytical statistics methods were employed for data description and analysis.To assess statistical differences among categorical variables, Pearson's chi-square test was utilized, with results yielding p-values lower than 5% (p-value < 0.05) considered statistically significant.All statistical analyses were conducted using IBM SPSS Statistics Software version 20.0 for Windows.(IBM Corp., Armonk, NY, USA).

Results
The study population consisted of 44 male and 101 female medical students.Concerning socioeconomic status, the majority of students reported being in the low category, followed by middle and high statuses (74, 52, and 12, respectively).Anxiety levels were self-reported by students and assessed in two ways.The first method involved the WTAS, while the second method involved scoring responses to the question 'How stressful does taking exams influence you?' The scores obtained from both methods were significantly associated (Table 1), suggesting that approximately one-quarter of students were experiencing high or extreme levels of test anxiety.Learning itself was reported as highly or extremely stressful by 20.6% of students according to their self-reports, but our results suggested that it was not the single factor associated with test anxiety (Table 2).Sex did not appear to have a significant impact on the level of test anxiety, but test anxiety may increase with the progression of years of study.Additionally, we observed marginal significance in the association between socioeconomic level and average marks with test anxiety level (Table 2).
Students with low and high average marks exhibited a higher likelihood of experiencing high and extreme anxiety compared to students with medium average marks.Increased anxiety levels were also associated with disturbed sleep, dependence on social networks, and the use of psychoactive substances for anti-anxiety and hypnotic purposes (Table 2).Furthermore, the level of test anxiety was correlated with the rate of psychoactive compound use, both for anti-anxiety (p<0.05) and hypnotic effects (p<0.001).
Among the examined students, 50.3% reported using psychoactive substances for various reasons.Among them, 35.2% cited anti-anxiety effects as the primary motivation for their usage.Even though 30.3% of students reported frequent problems with sleeping at night, only 6.2% of them exclusively used these substances for their hypnotic effects.Additionally, 33.1% of students reported using psychoactive substances for psychostimulation purposes.When the consumption of coffee and tea, the rate of psychostimulant use increased to 62.8%.Specifically, coffee was reported by 60.0% of students, while green tea was used by 50.3% of students for psychostimulation purposes.In addition to caffeine-containing beverages, other psychoactive substances were also common.Plant anxiolytics were the most frequently used, followed by benzodiazepines and marijuana (Figure 1).Sex, socioeconomic status, and study year were not found to be correlated with the use of psychoactive substances.However, a significant association was observed between psychoactive substance use and academic performance, as measured by the number of years renewed (Table 3).Additionally, the use of psychoactive substances was significantly associated with disrupted sleep patterns, social network usage, and the level of test anxiety.

Discussion
The objective of this study was twofold: to assess the degree of test anxiety among medical students enrolled at the Faculty of Medical in Foča, and to explore potential associations with the frequency of psychoactive substance use.According to the results, approximately one-quarter of students reported experiencing high or extreme test anxiety, while nearly twice that number used psychoactive substances to alleviate anxiety, insomnia, or for psychostimulation.Moreover, students experiencing high or extreme test anxiety were more inclined to use psychoactive substances.
The results confirmed the assumption that the level of test anxiety was associated with academic success, consistent with the findings of the majority of studies on this issue.However, the methods used to measure test anxiety and academic success varied among studies.Test anxiety was assessed by cortisol levels [7,8], visual analog scales [9], or different test anxiety scales [10].Measures of academic success included average marks, retention rates, personal satisfaction [11], or various other psychological factors.Due to the absence of a standardized scale for measuring academic success in Bosnia and Herzegovina, average marks and the duration taken to complete the program were employed as objective indicators of academic achievement.The discovered negative association between test anxiety level and academic success was anticipated and aligned with findings from other studies [12][13][14].
In comparison with a previous study in Bosnia and Herzegovina, where high and extreme levels of test anxiety were found in 38.2% of students, the level found in our study was significantly lower.This difference may be partially explained by the examination method employed.In our study, students were assessed by peers during lectures, rather than immediately before exams when test anxiety was typically heightened.Addition-ally, while moderate anxiety is often deemed beneficial, it is conceivable that some students experiencing moderate levels of anxiety still find it somewhat disruptive during exams.
In this study, no difference was found between male and female students regarding test anxiety levels.This contrasts with some other studies where higher levels of test anxiety were observed in females than in males, including studies conducted in Bosnia and Herzegovina [9,10,15,16], while some authors reported higher levels in males [17].It is evident that sex differences depend on the country, culture, and organizational structure of the institution.The higher test anxiety observed in female students in the Bosnian and Herzegovinian study was attributed to the emotional vulnerability of women and the more significant social roles of men [10].The similar levels of exam anxiety observed in our study suggest sex equality within our society, particularly at the Faculty of Medicine in Foča, where significantly more women than men are enrolled.Despite historical disparities in educational opportunities, more women than men are currently pursuing higher education in Bosnia and Herzegovina.
The percentage of students using psychoactive substances exceeds the rate of high and extreme test anxiety by almost twice.Additionally, the percentage of students who reported using psychoactive substances for anxiolytic purposes surpasses the rate of test anxiety, suggesting that anxiety in the student population is not solely connected to exams, learning, and studying.The poor socioeconomic situation reported in this study could be one of the reasons for this phenomenon.Comparing the use of psychostimulants among students in Foča with their peers in Sarajevo, it was found to be at the same level, approximately 30% in both locations.However, students from Sarajevo more commonly reported using nicotine and energy drinks, whereas students from Foča, in contrast, reported using narcotics (opioids) and cocain.Specifically, 4.8% of students reported the use of narcotics and/or cocain, while there were no such reports in Sarajevo.This is a cause for concern and requires urgent action, even though we are aware of significantly higher levels of illicit substance use among students in European countries.In a study conducted in France during the COVID-19 pandemic, opioid use was reported in 14.7% of students and cocaine in 7.5% of students [6].
In addition to the use of narcotics and cocaine, French students reported more frequent use of alcohol, marijuana, and benzodiazepines compared to their counterparts in Bosnia and Herzegovina.The results of this study indicate a strong association between the level of test anxiety and the overall use of psychoactive substances, as well as their separate use for treating anxiety and insomnia.The use of psychoactive compounds frequency among medical students in Foča overpasses overall frequency of moderate and high/ extreme test anxiety.The use of psychostimulants for neuroenhancement was not associated with the level of test anxiety.It implies that medical students in Foča used psychostimulants more probably for recreational purposes than for neuroenhancement associated with learning and exams.It is in contrast with findings from the previous study in Bosnia and Herzegovina [10].The difference in findings could be attributed to the different faculties involved in these two studies.It is possible that the better medical knowledge of medical students led to less interest in using psychostimulants as cognitive enhancers.Conversely, it is expected that students of economics would have less knowledge and more misconceptions about the effects of psychostimulants on learning abilities.

Conclusion
High to extreme test anxiety was present in approximately one quarter of students.Associations were observed between test anxiety levels and the use of psychoactive substances for treating anxiety and insomnia.Students with high or extreme test anxiety showed a greater inclination towards using psychoactive substances.The obtained results indicate an increase in test anxiety with the progression of study years.The use of legal and illegal psychoactive substances among medical students in Foča is evident, with the most concerning finding being that 4.8% of students reported using narcotics and cocaine.This is a cause for concern and necessitates urgent action.

Figure 1 .
Figure 1.Frequency of psychoactive substance use among medical students

Funding source .
The authors received no specific funding for this work.Ethical approval.The EthicsCommittee of the Faculty of Medicine Foča, University of East Sarajevo, Republic of Srpska, Bosnia and Herzegovina, approved the study (No: 01-2-27, 15.03.2023) and informed consent was obtained from all individual respondents.The research was conducted according to the Declaration of Helsinki Conflicts of interest.The authors declare no conflict of interest.

Table 1 .
Frequency of test anxiety according to WTAS score and students self-evaluation

Table 2 .
Characteristics of medical students population regarding level of exam anxiety

Table 3 .
The use of psychoactive substances among students