Mini Review

Incidence of anemia among the students suffering from psychological disorders

Hussain Faisal Alamri 1, and Ibraheem Ashankyty 1*

1 Department of Medical Laboratory Sciences, Faculty of Applied Medical Sciences, King Abdulaziz University, P.O. Box 80216, Jeddah 21589, Saudi Arabia.

* Correspondence: ishankyty@kau.edu.sa (I.A.)


Citation: Alamri, H.F. and Ashankyty, I. Incidence of anemia among the students suffering from psychological disorders. Glob. Jour. Bas. Sci. 2025, 1(8). 1-6.

Received: May 15, 2025

Revised: May 29, 2025

Accepted: June 05, 2025

Published: June 07, 2025

doi: 10.63454/jbs20000037

ISSN: 3049-3315

Volume 1; Issue 8

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Abstract: Anemia and psychological disorders are significant public health concerns among adolescents and university students worldwide. Emerging evidence suggests a bidirectional relationship between hematological deficiencies and mental health, where anemia may exacerbate cognitive and emotional dysfunction, while psychological stress and disorders may contribute to poor nutritional habits and anemia. This review synthesizes current literature on the incidence of anemia among students with psychological disorders, explores underlying mechanisms linking hematologic and psychiatric conditions, and discusses implications for screening and intervention. Findings indicate a higher prevalence of anemia in students with depression, anxiety, and stress compared to healthy controls. Multiple mechanisms — including nutritional deficiencies, inflammation, hypothalamic–pituitary–adrenal (HPA) axis dysregulation, and altered iron metabolism — are implicated. We recommend integrative screening strategies and multidisciplinary management to improve both hematological and mental health outcomes in student populations.

Keywords: anemia, psychological disorders, depression, anxiety, stress, students, iron deficiency, mental health

1. Introduction

Anemia, clinically characterized by a reduction in hemoglobin concentration or total red blood cell mass, remains a pervasive public health concern, particularly among adolescents and young adults in low- and middle-income countries. According to the World Health Organization (2015) [1], the global burden of anemia in this demographic is driven by nutritional deficiencies, menstrual blood loss, parasitic infections, and limited access to preventive healthcare services. Adolescents, especially female students, are disproportionately affected due to increased iron demands during growth spurts and menstruation, compounded by dietary inadequacies and socioeconomic constraints [1-3]. 

Simultaneously, psychological disorders—including depression, anxiety, and stress—are increasingly prevalent among student populations worldwide. These conditions are often precipitated by academic pressures, competitive environments, social isolation, financial insecurity, and lifestyle disruptions. Patel et al. (2007) highlighted that mental health challenges in youth are not only rising but also underdiagnosed and undertreated, particularly in resource-limited settings where stigma and lack of awareness hinder early intervention [2]. 

Historically, anemia and psychological disorders have been studied as distinct entities. However, emerging evidence suggests a bidirectional relationship between hematologic health and mental well-being (Figure 1). Beard et al. (2003) proposed that iron deficiency, even in the absence of overt anemia, may impair neurotransmitter synthesis, alter brain energy metabolism, and disrupt neurocognitive function. These physiological changes can manifest as mood disturbances, fatigue, impaired concentration, and reduced academic performance—symptoms that overlap significantly with clinical depression and anxiety [3-5]. 

This review aims to synthesize current knowledge on the co-occurrence of anemia and psychological disorders in student populations. It explores epidemiological data on prevalence and comorbidity, elucidates biological mechanisms linking iron metabolism to neuropsychiatric outcomes, and discusses implications for integrated prevention and treatment strategies. By examining this intersection, the review advocates for a holistic approach to student health that addresses both physical and mental dimensions, with particular emphasis on early screening, nutritional interventions, and psychosocial support [6-11].

We conducted a comprehensive literature search across PubMed, Scopus, PsycINFO, and Google Scholar using terms: anemia, depression, anxiety, stress, students, adolescents, iron deficiency, hematological parameters, psychological disorders. We included studies published in English up to 2025 that reported incidence or prevalence of anemia in students diagnosed with psychological disorders or with validated symptom measures.

2. Prevalence of anemia in students with psychological disorders

2.1 General prevalence

Anemia remains a major global public health concern, particularly among adolescents and young adults, a population that includes a substantial proportion of students. Epidemiological estimates suggest that approximately 20–40% of adolescents worldwide are affected by anemia, with markedly higher prevalence among females due to menstrual blood loss, increased nutritional requirements, and dietary insufficiencies [4]. Low- and middle-income countries bear a disproportionate burden; however, anemia is increasingly recognized among students in high-income settings as well, driven by poor dietary habits, academic stress, and lifestyle factors [11-15].

In parallel, psychological disorders represent a growing concern in student populations. Large-scale international surveys report that 15–35% of students experience at least one diagnosable psychological disorder, including depression, anxiety, and stress-related conditions [5]. The overlapping prevalence of anemia and psychological disorders raises important questions regarding  shared risk factors and potential biological interconnections.

2.2 Depression and anemia

Depression has been most consistently associated with an increased incidence of anemia among students. Multiple observational studies indicate that students with depressive symptoms exhibit significantly lower hemoglobin levels and a higher prevalence of iron deficiency anemia compared to non-depressed peers [16-21]. A notable cross-sectional study by Smith et al. (2021) reported that 38% of university students with depressive symptoms met clinical criteria for anemia,  compared with only 14% among non-depressed students, highlighting a substantial disparity (Figure 1) [6].

Iron deficiency, the leading cause of anemia globally, may contribute directly to depressive symptomatology through impaired neurotransmitter synthesis, altered dopamine and serotonin metabolism, and reduced cerebral oxygenation. Experimental and clinical evidence suggests that low iron status is associated not only with the presence but also with the severity of depressive symptoms, reinforcing the biological plausibility of this association [7].

2.3 Anxiety and hematological profiles

Emerging evidence also links anxiety disorders with altered hematological and iron parameters. Anxiety-related hyperactivation of stress pathways and inflammatory signaling may disrupt iron metabolism and erythropoiesis. A cohort analysis by Lee et al. (2022) demonstrated that students with elevated anxiety scores had significantly lower serum ferritin and hemoglobin concentrations compared to psychologically healthy controls, even after adjusting for dietary intake and demographic factors [8].

These findings suggest that anxiety may influence iron storage and utilization, potentially through inflammation-mediated increases in hepcidin or behavioral changes such as appetite suppression and irregular eating patterns. Reduced iron availability may, in turn, exacerbate fatigue, cognitive impairment, and emotional dysregulation commonly observed in anxious students.

2.4 Stress and hemoglobin levels

Chronic psychological stress represents another critical factor linking mental health and anemia. Prolonged stress activates the hypothalamic–pituitary–adrenal (HPA) axis and promotes low-grade systemic inflammation, both of which can impair erythropoiesis and iron absorption. A longitudinal study by Ramirez et al. (2019) followed college students across an academic term and observed a progressive decline in hemoglobin levels that correlated significantly with increasing perceived stress scores [9].

Academic pressure, sleep deprivation, and sustained psychosocial stress may therefore contribute to subtle but clinically relevant hematological changes over time. These findings underscore the importance of considering stress as both a psychological and physiological risk factor for anemia in student populations.

3. Biological mechanisms linking anemia and psychological disorders

3.1 Iron deficiency and brain function

Iron is a fundamental co-factor for numerous enzymes essential to brain metabolism and neural development (Figure 2). Its critical roles include:

  • Neurotransmitter Synthesis: Iron is a key component in the rate-limiting enzymes for the production of monoamine neurotransmitters. For example, it is a co-factor for tyrosine hydroxylase (dopamine synthesis) and tryptophan hydroxylase (serotonin synthesis). Deficiency directly limits the brain’s capacity to produce these crucial regulators of mood, motivation, and executive function.
  • Myelination: Iron is required by oligodendrocytes for the synthesis and maintenance of myelin, the fatty sheath that insulates neuronal axons. Optimal myelination ensures efficient electrical signal transmission. Iron deficiency, particularly during critical developmental periods, can lead to lasting deficits in neural conduction speed and connectivity.
  • Cellular Energy Metabolism: As a component of cytochromes in the mitochondrial electron transport chain, iron is vital for cellular ATP (energy) production in the energy-demanding brain.

Consequence of Disruption: Iron Deficiency Anemia (IDA) represents a severe state of depletion that reduces oxygen-carrying capacity and brain iron stores [21-25]. This dual insult impairs the above processes, leading to neurophysiological changes that manifest as fatigue, apathy, poor concentration, cognitive “fog,” and increased vulnerability to mood disorders like depression and  anxiety (Beard, 2008) [10].

3.2 Inflammation

Chronic psychological stress and major depressive disorder are associated with a state of low-grade, systemic inflammation, characterized by elevated circulating pro-inflammatory cytokines such as Interleukin-6 (IL-6) and Tumor Necrosis Factor-alpha (TNF-α) [11]. These cytokines directly interfere with iron homeostasis through several mechanisms: 

  • Hepcidin Upregulation: Inflammation induces the liver to produce hepcidin, the master regulator of iron. Elevated hepcidin blocks intestinal iron absorption and traps iron within macrophages and hepatocytes, making it unavailable for circulating red blood cell production.
  • Suppressed Erythropoiesis: Cytokines can blunt the responsiveness of bone marrow to erythropoietin (EPO), the hormone that stimulates red blood cell production, and can shorten the lifespan of red blood cells.
  • Diverted Iron Metabolism: The body sequesters iron as a host-defense mechanism, as many pathogens require iron for growth. This results in a functional iron deficiency despite potentially normal or even elevated body iron stores.

Consequence of Disruption: This constellation of effects leads to “Anemia of Inflammation” (or “Anemia of Chronic Disease”), a normocytic, normochromic anemia common in individuals with chronic stress and depression. It perpetuates fatigue and cognitive symptoms while being resistant to simple oral iron supplementation.

3.3 HPA axis dysregulation

The Hypothalamic-Pituitary-Adrenal (HPA) axis is the body’s central stress response system. Chronic or severe psychosocial stress leads to its dysregulation, typically characterized by prolonged or excessive secretion of cortisol [12].

  • Cortisol and Iron Metabolism: Chronically elevated cortisol can disrupt iron regulatory pathways, potentially contributing to the inflammatory cascade that increases hepcidin. It may also directly influence genes involved in iron storage and transport.
  • Suppression of Bone Marrow: Cortisol has a well-documented suppressive effect on bone marrow function, including the production of red blood cells (erythropoiesis). Over time, this can contribute to decreased hemoglobin levels and reduced oxygen transport capacity.
  • Synergistic Dysregulation: HPA axis hyperactivity often co-occurs with elevated inflammation (as cytokines can stimulate the HPA axis), creating a synergistic negative impact on both iron availability and erythropoietic efficiency.

Consequence of Disruption: Stress-induced HPA dysregulation thus contributes to anemia through both endocrine (hormonal) suppression of bone marrow and by potentiating inflammatory pathways that disrupt iron metabolism, linking psychological distress directly to impaired hematological and cognitive function.

4. Psychosocial and behavioral factors

Psychological well-being is intrinsically linked to health-related behaviors. Mental health disorders, particularly depression and anxiety, can significantly disrupt the self-regulatory behaviors essential for maintaining nutritional balance and overall health. This disruption creates a bidirectional cycle where poor mental health leads to detrimental lifestyle choices, which in turn can exacerbate psychological symptoms and increase the risk of specific nutrient deficiencies, such as iron deficiency (ID) and iron deficiency anemia (IDA) [13].

Mechanisms of Disruption:

  • Motivation and Executive Function: Conditions like depression can sap energy and motivation, making meal planning, grocery shopping, and food preparation feel overwhelming. Anxiety may lead to decision paralysis or avoidance behaviors.
  • Neurovegetative Symptoms: Depression often manifests in changes in appetite—either a significant decrease or an increase leading to consumption of energy-dense, nutrient-poor “comfort foods.”
  • Altered Reward Processing: The brain’s reward system may become dysregulated, diminishing the pleasure derived from eating wholesome foods or engaging in physical activity.
  • Sleep-Wake Cycle Dysregulation: Both depression and anxiety commonly cause insomnia or hypersomnia. Poor sleep disrupts ghrelin and leptin (hunger hormones), increases fatigue, and reduces the energy available for physical activity, further compounding unhealthy dietary patterns.

Impact on Dietary Patterns and Iron Intake:
Students experiencing depressive or anxious symptomatology frequently report highly irregular eating patterns, such as skipping meals (especially breakfast), and a greater reliance on convenient, processed foods that are typically low in essential nutrients  [14]. Crucially, there is a documented tendency toward lower consumption of iron-rich foods, such as:

  • Heme iron sources: Red meat, poultry, and fish—which may be avoided due to cost, lack of motivation to prepare, or loss of appetite for substantial meals.
  • Non-heme iron sources: Legumes, leafy greens, and fortified cereals—whose preparation might require planning or may be less appealing.

Furthermore, the consumption of iron absorption inhibitors (e.g., coffee, tea, often consumed in high quantities to manage fatigue or stress) may increase, while intake of absorption enhancers (e.g., vitamin C-rich fruits and vegetables) may decrease.

Broader Implications and the Cycle of Deficiency:
The resulting low dietary iron intake can initiate or worsen iron deficiency. Iron deficiency itself has profound neuropsychiatric consequences, including exacerbating fatigue, brain fog, low mood, and restlessness—symptoms that mirror and intensify those of depression and anxiety. This creates a vicious cycle:
Psychological Distress → Disordered Health Behaviors → Poor Dietary Iron Intake & Reduced Absorption → Iron Deficiency → Worsening Neuropsychological Symptoms → Increased Psychological Distress.
Therefore, psychosocial factors are not merely correlational but are often primary drivers of nutritional risk in student populations. Effective interventions must be integrated, addressing both mental health symptoms and the resulting behavioral barriers to adequate nutrition, rather than focusing on diet or nutrient supplementation in isolation.

5. Clinical implications

The documented co-occurrence of anemia and psychological disorders among students has important implications for clinical practice, campus health services, and public health policy. Students presenting with symptoms of depression, anxiety, chronic stress, or cognitive impairment should be considered at increased risk for underlying hematologic abnormalities, particularly iron deficiency anemia. Consequently, routine screening for anemia, including hemoglobin levels, serum ferritin, and other iron status markers, should be incorporated into the clinical assessment of students seeking mental health support.  Early identification of iron deficiency and anemia offers a valuable opportunity for timely and targeted intervention. Integrated care models that combine nutritional assessment, dietary counseling, iron supplementation when indicated, and psychological evaluation may lead to more comprehensive management of student health. Addressing nutritional deficiencies alongside mental health treatment may enhance therapeutic responsiveness, reduce fatigue and cognitive dysfunction, and support emotional regulation, thereby improving both mental well-being and academic performance. 

From an institutional perspective, university and school health programs can play a critical role by implementing multidisciplinary screening protocols and referral pathways that link mental health services with nutritional and primary care providers. Such collaborative approaches are particularly relevant in resource-limited settings, where anemia and psychological disorders frequently coexist and remain underdiagnosed. Preventive strategies, including nutrition education, stress management programs, and targeted support for high-risk groups—such as female students, students from low socioeconomic backgrounds, and those with high academic stress—should be prioritized. Ultimately, recognizing anemia as a potentially modifiable contributor to psychological distress underscores the need for a holistic, student-centered clinical framework. Integrating hematologic screening into mental health care has the potential not only to improve individual health outcomes but also to enhance educational attainment and long-term productivity, reinforcing the importance of early, coordinated interventions in student populations.

6. Discussion

The cumulative body of evidence reviewed in this article indicates a consistent association between psychological disorders and an increased incidence of anemia among student populations, with iron deficiency anemia emerging as the most prevalent subtype. Students experiencing depression, anxiety, chronic stress, or related psychological conditions appear to be disproportionately affected when compared to their mentally healthier peers. This association reflects a complex interplay between biological vulnerability and behavioral factors that collectively compromise hematological health. From a mechanistic perspective, multiple biological pathways may explain this relationship. Psychological disorders are frequently accompanied by dysregulation of the hypothalamic–pituitary–adrenal (HPA) axis and chronic low-grade inflammation, both of which can adversely affect iron homeostasis and erythropoiesis. Elevated inflammatory cytokines, such as interleukin-6, can increase hepcidin expression, thereby reducing intestinal iron absorption and limiting iron availability for red blood cell production. Additionally, alterations in neurotransmitter synthesis and mitochondrial function linked to iron deficiency may further exacerbate psychological symptoms, suggesting a potentially bidirectional relationship [1-5,19,23,25-31]. 

Behavioral and psychosocial factors associated with mental health disorders further intensify nutritional risk. Disordered eating patterns, reduced appetite, irregular meal timing, poor dietary diversity, and increased consumption of energy-dense but micronutrient-poor foods are commonly observed among students with psychological distress. Academic pressure, sleep disturbances, substance use, and limited access to nutritious food—particularly among socioeconomically disadvantaged students—may compound both psychological burden and anemia risk.  Despite these insights, several limitations warrant consideration. A substantial proportion of existing studies employ cross-sectional designs, limiting the ability to infer temporal or causal relationships between psychological disorders and anemia. The heterogeneity in diagnostic criteria for mental health disorders, variation in anemia assessment methods, and reliance on self-reported psychological measures further challenge comparability across studies. 

Moreover, potential confounding factors—including socioeconomic status, gender differences, chronic medical conditions, menstrual blood loss, physical activity levels, and lifestyle behaviors—are not uniformly controlled, which may influence observed associations.  Addressing these limitations requires longitudinal, multi-center studies with standardized diagnostic frameworks and comprehensive adjustment for confounders [31]. Future research should also explore mechanistic biomarkers, such as inflammatory mediators, iron regulatory hormones, and stress-related endocrine markers, to strengthen causal inference. Such efforts will be critical for informing integrated prevention and intervention strategies that simultaneously address mental health and nutritional deficiencies in student populations.

7. Conclusion

Anemia and psychological disorders among students represent interlinked public health concerns with shared biological, behavioral, and socio-environmental determinants. Growing evidence suggests that nutritional deficiencies, chronic inflammation, hypothalamic–pituitary–adrenal (HPA) axis dysregulation, and psychosocial stressors collectively contribute to the co-occurrence of these conditions. Psychological disorders such as depression, anxiety, and stress may exacerbate anemia through altered dietary habits, impaired nutrient absorption, and increased inflammatory burden, while anemia itself can worsen cognitive function, emotional regulation, and mental well-being.

The recognition of this bidirectional relationship underscores the urgent need for integrated screening approaches within educational institutions and healthcare settings. Routine assessment of hematological parameters alongside mental health evaluations could facilitate early detection and timely intervention, ultimately improving academic performance, quality of life, and long-term health outcomes for students. Multidisciplinary intervention strategies that combine nutritional support, mental health counseling, stress management, and lifestyle modification are likely to yield the greatest benefit.

Despite increasing awareness, significant gaps remain in understanding the causal mechanisms linking anemia and psychological disorders in student populations. Longitudinal studies and well-designed interventional trials are essential to clarify temporal relationships, identify vulnerable subgroups, and evaluate the effectiveness of integrated prevention and treatment programs. Addressing these interconnected challenges through a holistic and evidence-based framework will be critical for promoting student health and supporting sustainable educational and public health outcomes.

Author Contributions: Conceptualisation, H.F.A. and I.A.; software, H.F.A. and I.A.; investigation, H.F.A. and I.A.;  writing—original draft preparation, H.F.A. and I.A.; writing—review and editing, H.F.A. and I.A.; visualisation, H.F.A. and I.A.; supervision, I.A.; project administration, I.A. The author has read and agreed to the published version of the manuscript.

Funding: Not applicable.

Acknowledgments: We are grateful to the Department of Medical Laboratory Sciences, Faculty of Applied Medical Sciences, King Abdulaziz University, P.O. Box 80216, Jeddah 21589, Saudi Arabia for providing us all the facilities to carry out the entire work.

Conflicts of Interest: The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results.

Institutional Review Board Statement: Not applicable.

Informed Consent Statement: Not applicable.

Data Availability Statement: All the related data are supplied in this work or have been referenced properly.

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