research questions about mental health of students during pandemic

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Open Access

Peer-reviewed

Research Article

The mental health of university students during the COVID-19 pandemic: An online survey in the UK

Roles Conceptualization, Data curation, Formal analysis, Methodology, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Department of Computer Science, School of Computing and Engineering, University of Huddersfield, Huddersfield, West Yorkshire, United Kingdom

Roles Methodology, Writing – review & editing

Affiliation Centre for Applied Research in Health, School of Human and Health Sciences, University of Huddersfield, Huddersfield, West Yorkshire, United Kingdom

• Tianhua Chen, 
• Mike Lucock

• Published: January 12, 2022
• https://doi.org/10.1371/journal.pone.0262562
• Reader Comments

Higher education students’ mental health has been a growing concern in recent years even before the COVID-19 pandemic. The stresses and restrictions associated with the pandemic have put university students at greater risk of developing mental health issues, which may significantly impair their academic success, social interactions and their future career and personal opportunities. This paper aimed to understand the mental health status of University students at an early stage in the pandemic and to investigate factors associated with higher levels of distress. An online survey including demographics, lifestyle/living situations, brief mental well-being history, questions relating to COVID-19 and standardised measures of depression, anxiety, resilience and quality of life was completed by 1173 students at one University in the North of England. We found high levels of anxiety and depression, with more than 50% experiencing levels above the clinical cut offs, and females scoring significantly higher than males. The survey also suggested relatively low levels of resilience which we attribute to restrictions and isolation which reduced the opportunities to engage in helpful coping strategies and activities rather than enduring personality characteristics. Higher levels of distress were associated with lower levels of exercising, higher levels of tobacco use, and a number of life events associated with the pandemic and lockdown, such as cancelled events, worsening in personal relationships and financial concerns. We discuss the importance of longer-term monitoring and mental health support for university students.

Citation: Chen T, Lucock M (2022) The mental health of university students during the COVID-19 pandemic: An online survey in the UK. PLoS ONE 17(1): e0262562. https://doi.org/10.1371/journal.pone.0262562

Editor: Prabhat Mittal, Satyawati College (Eve.), University of Delhi, INDIA

Received: October 15, 2021; Accepted: December 30, 2021; Published: January 12, 2022

Copyright: © 2022 Chen, Lucock. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: Data cannot be shared publicly because of confidential nature of university student information. Data are available from the University of Huddersfield, School of Computing and Engineering Institutional Data Access / Ethics Committee (contact via [email protected] ) for researchers who meet the criteria for access to confidential data.

Funding: The authors received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Introduction

The mental well-being of higher education students was a growing concern even before the COVID-19 pandemic, with increasing numbers of students experiencing mental health problems as reported by UK Parliament Briefing Paper [ 1 ]. Community surveys suggest that common mental health problems, anxiety and depression, generally affect one in six people in a given week in England [ 2 ], and concerns were expressed early in the pandemic about the mental health impact of the pandemic on the general population [ 3 ], at least in the short term. For higher education students, the pandemic presented a number of specific challenges, such as the transfer of more learning and support services online, which many students found difficult to engage effectively [ 4 ], leading to increased anxiety and concerns about their academic performances and long-term employment [ 5 , 6 ]. Other impacts include the closure of student halls, cancellation of exchange studies and graduation ceremonies, loss of part-time jobs, and increased uncertainties regarding career options. The lockdown and social distancing measures also led to limited opportunities for socialising and establishing relationships, with greater reliance on social media, and possible chronic loneliness brought by social isolation [ 7 ].

A number of studies have explored the impact of the pandemic on the mental health of university students and factors associated with higher levels of distress. For example, a US interview survey of 195 undergraduate students from one university [ 8 ] reported negative impacts of the COVID-19 pandemic and the urgent need to develop interventions and preventive strategies. Another US survey of 162 undergraduates [ 9 ] found high levels of mental health distress, with depression being associated with difficulties focusing on academic work and loss of employment and higher levels of anxiety more likely in students who spent more than an hour per day looking for information on COVID-19. An online survey of 255 students at a university in Hong Kong in July 2020 also found high levels of depression with perceived available peer support being negatively associated with depressive symptoms [ 10 ]. Another cross-sectional web-based study of 324 college students in India between November and December 2020 [ 11 ] suggested that 68.8% had high fear of COVID-19, 28.7% had moderate to severe depression, and 51.5% had mild to severe anxiety, with having a family member who was infected with COVID-19 being significantly associated with anxiety and depression. Studies have also provided evidence of a worsening of common mental health problems and wellbeing during the pandemic. For example, a survey of undergraduate students by the Higher Education Policy Institute in the UK found that 58% reported a worsening in their mental health because of the pandemic, 14% said it was better and the remaining 28% said it was the same [ 12 ]. Also in the UK, a survey of students in higher and further education conducted by the National Union of Students, found that 52% described their current mental health and well-being as worse, 35% described it as the same and 8% as better, compared with their life before the pandemic [ 13 ]. The Student Covid Insight Survey (SCIS), conducted in November 2020, found 57% of students reported that their well-being and mental health had become slightly or much worse since the start of the autumn term [ 14 ], with lower levels of life satisfaction and happiness, and higher levels of anxiety, compared with the general population.

Longitudinal studies comparing mental health before and during the pandemic are rare but a study of 254 undergraduates at one UK university [ 15 ], found a significant increase in depression and reduction in wellbeing during the first lockdown (April/May 2020) compared with before the pandemic (autumn 2019) and that over a third of the sample could be classed as clinically depressed at lockdown, an increase from 15% before the pandemic. The increase in depression was highly correlated with a worse sleep quality. A longitudinal survey of 66 students in a Chinese college also concluded that sleep quality was a key factor in the emotional impact on students, and that daily physical activity and good sleep may mitigate mental health problems [ 16 ]. Interestingly, they also found reductions in people’s aggressiveness, which they suggested was due to people realizing the fragility and preciousness of life.

These studies have contributed to our understanding of the impact of the pandemic and lock-down on students’ mental health, but they have tended to involve relatively small sample sizes of undergraduates and have not looked at positive factors associated with better mental health, such as resilience. This paper describes a relatively large survey of undergraduate and postgraduate students which investigates different aspects of mental health and coping, including anxiety, depression, the resilience to cope with difficulties, quality of life and general health, and a range of questions on demographics, lifestyle/ living situation and COVID-19 related factors. Conducted at a university in the UK, this study aimed to identify: 1) The impact of the COVID-19 pandemic on University students; 2) Levels of mental health and quality of life in University students during the COVID-19 pandemic; 3) Predictors of mental health and quality of life.

Materials and methods

Design and setting.

This was a cross-sectional on-line survey at a large university in the North of England, UK. Almost 20,000 students attend the University each year. The study was approved by a University ethics committee. The data collection was conducted in the period between 26.06.2020 and 30.07.2020. To put this in context with the lockdown in England, it entered the first national lockdown on 23.03.20 and lockdown measures were eased on 01.06.20.

Participants

Students, including both undergraduates and postgraduates across all seven schools at the university were eligible and sent an invitation by local school administrators through their mailing-list.

A link to the survey that was deployed in Google Forms was delivered to students via e-mail. The anonymous survey questionnaire took up to 10 minutes to complete, once participants agree to take part. Students completing the survey were entered into a prize draw for £650 worth of gift vouchers, distributed in varying amounts to 36 prize winners.

The following set of demographic information and measures are used to identify the students’ mental health, wellbeing and resilience.

Demographics.

The first part of survey included demographic information including age, gender, ethnicity, current educational level, and relationship status.

Patient health questionnaire (PHQ-9) [ 17 ].

The PHQ-9 is a self-administered screening questionnaire, validated for use in primary care and community settings, to measure the severity of depression. Nine questions cover different aspects of depression on a four-point scale—“0” (not at all), “1” (several days), “2” (more than half the days), “3” (nearly every day). Scores can be categorised as 0-4 none, 5-9 mild, 10-14 moderate, 15-19 moderately severe, 20-27 severe. The total score was used as the dependent variable with the aim to conduct statistical significance test for alternative independent variables.

Generalised anxiety disorder questionnaire (GAD-7) [ 18 ].

The GAD-7 is also a self-administered screening questionnaire, which measures the severity of generalised anxiety disorder (GAD). Seven questions are rated on the same four-point scale as the PHQ-9. Scores of 5, 10, and 15 are taken as the cut-off points for mild, moderate and severe anxiety, respectively. In this study the total score was be used as the dependent variable to conduct statistical significance test.

Lifestyle / Living situation under COVID-19.

This set of questions explored the lifestyle, living situation, behaviours and experiences of individuals. These included experiences of adversities (e.g., worsen personal relations/financial situation/live conditions, loss of employment/families etc.), and the frequency of conducting exercise/ communicating with friends/relatives and the 122 consumption of alcohol/tobaccos during the lockdown period. The values of these variables were dichotomised to 0 (Never, Rarely, Sometimes) and 1 (Often, Always) for 124 analysis [ 9 ].

Brief resilience scale (BRS) [ 19 ].

The BRS aims to measure the ability to bounce back or recover from stress. It has a 5-point Likert response scale, for six items, ranging from 1 = strongly disagree to 5 = strongly agree, with three items positively phrased and three negatively phrased. The BRS is scored by reverse coding items 2, 4, and 6, and then calculating the mean of the six items. An averaged score of 1.00 to 2.99 suggests low resilience, 3.00 to 4.30 normal resilience and 4.31 to 5.00 high resilience. Similar to PHQ-9 and GAD-7, the overall averaged score was used as the dependent variable to conduct statistical significance test.

Brief mental wellbeing history.

Three questions asked about the students’ history of treatment and support for a mental health issue, including therapy and medication.

The EQ-5D-5L instrument [ 20 ] is a self-assessed, health related, quality of life questionnaire. The descriptive system comprises five dimensions: mobility, self-care, usual activities, pain/discomfort and anxiety/depression. Each dimension has 5 levels: no problems, slight problems, moderate problems, severe problems and extreme problems. Responses are coded as single-digit numbers expressing the severity level selected in each dimension. The overall score will be used as a dependent variable, with the best health state (11111) being a score of 5 and the worst health state (55555) being a score of 25. Additionally, the EQ-VAS was also used for students to provide a broad self assessment of their health, on a visual analogue scale ranging between 100 (best imaginable health) and 0 (worst imaginable health).

COVID-19 related questions.

A set of five questions were asked in relation to COVID-19 pandemic. These included: how often the person practised the recommended social distancing on a 5-point scale (‘1’ is never and ‘5’ is always); the severity of the risk group the subject assumes they belong to; whether the subject is cohabiting with anyone falling with the risk groups; how likely the subject feels at the risk of contracting COVID-19 (on a 5-point scale where ‘1’ is definitely not and ‘5’ is certain); the extent to which the subject had felt needing extra support during lockdown (where ‘0’ was no need for extra support and ‘100’ indicated immediate support required).

Data analysis

All analysis below used the SciPy (Scientific Python) [ 21 ], which is a free and open-source Python library extensively used for scientific and technical computations for data science. Descriptive analyses examined the distribution of all variables/questions of interest, with the summarised information presented in Tables 1 – 5 . A bivariate analysis was then conducted to examine the associations between each of the independent variables against each of the six decision variables that had been previously introduced, including PHQ9 depression, GAD 7 Anxiety, BRS6 Resilience, EQ-5D-5L life quality, self-rated health score and support needs. Specifically, paired two tail t-tests were used to examine the significance of the associations. The findings are presented in Tables 6 – 9 , where the significance levels are represented as ns ( p > 0.05), *( p ≤ 0.05);**( p ≤ 0.01);***( p ≤ 0.001) on the basis of the associated p values. Furthermore, a multivariate linear regression was utilised to evaluate the predictive capabilities of the independent variables that have achieved statistical significance (i.e., p < 0.05) with respect to the corresponding decision variable.

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A total of 1173 valid responses were collected without any missing values (each of the 48 asked questions was required to fill in before the survey could be submitted).

Descriptive analysis

Table 1 presents the descriptive analysis for demographic related variables. The mean of age was 25.65 (standard deviation = 8.89), with a median value of 22 and 70% of participates were females. Approximately one third of the students were living in the University town, with 23% living in nearby cities and 43% living in various other places. Nearly one third of the students were from non-white ethnic backgrounds and there were slightly more (53%) post graduates than undergraduates. 45% were single and 54% in a relationship.

Table 2 summarises the descriptive statistics regarding the life style/living situation, including the experience of an adverse life event during the pandemic. Regarding adversity, 979 out of the 1173 (86.6%) participants reported at least one adverse effect of the pandemic, with an average of 2.3 adverse effects per student. The three most prevalent adverse effects were the cancellation of an important event (56.1%), worse personal relations (40.2%) and worse financial situation (39.6%). Over 13% of students also reported the death of a partner, close relative or friend. Approximately 30% of students were exercising frequently despite lockdown, 18% reported often or always using alcohol and 12% often or always using tobacco. 72% reported that their relationships with friends or families had been impacted and 60% had often or always been communicating with friends and family remotely.

Table 3 shows high levels of use of mental health and talking therapies, with approximately 40% of students having been referred to or participated in talking therapies for a mental health issue in the past (not just at the current time), 27.7% reported currently or previously taking medications for a mental health issue and about a third had accessed or attempted to access healthcare services personally or for a family member during the pandemic period. Table 4 shows that over 90% of the students reported practicing the recommended social distancing often/always, 15% believed they were in high or increased risk groups for pre-existing health conditions or needing special medical care, with 30% living with another person in the high risk groups, while 16.5% of students felt they were likely or extremely likely to contract COVID-19 virus.

Table 5 shows the descriptive analysis on decision variables. The mean value of PHQ9 (depression) was in the moderate range and the mean GAD7 score (anxiety) was in the mild range; the BRS6 measure of resilience was very slightly above the lower boundary of the range [3.00 to 4.30], just within the average level of normal resilience. The EQ-5D-5L mean of 7.9 is relatively close to the best possible value of 5, suggesting good quality of life for the sample as a whole. The mean self-rated health score, which is part of the EQ-5D-5L instrument, was 69.51, but with a large standard deviation suggesting a wide variation across the sample. The perceived support needs value of 29.9 suggests relatively low levels of urgent support was required during lockdown across the sample.

Table 10 shows distribution of PHQ9, GAD7 and BRS6 scores across the severity levels and table VII shows the numbers and percentages of students who scored above and below the clinical cut-offs on the PHQ9 and GAD7, as a whole sample and by gender. Table 11 shows 53.4% of students scored in the clinical range for depression on the PHQ9 (suggestive of clinically significant depression), with females being more likely (56.8%) than males (43.3%) to be above the cut-off. 51.5% of the students scored above the anxiety cut off (suggestive of clinically significant anxiety) on the GAD7 and again the percentage was higher for females (54.8%) than for males (43.2%). The BRS6 scores suggest 26% were in the low resilience category, with no significant gender difference. No students were in the high resilience category.

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Bivariate associations analysis with decision variables

Bivariate associations between demographic characteristics and mental health variables are presented in Table 6 . With respect to gender, female students had significantly higher levels of anxiety and depression and poorer overall self-rated health. Comparing scores for undergraduates and post-graduates, a statistically significant difference was found for the PHQ-9 (depression) only, with undergraduates showing a higher level of depression. This is also reflected in a higher percentage of undergraduates scoring above the clinical cut off on the PHQ9 (56.4%) compared to post-graduates (51%), shown in Table 12 . No significant differences were found in relation to any decision variable when comparing those who were single or in a relationship.

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Bivariate associations between lifestyle/living situations and mental health burden variables are presented in Table 7 . Regarding adverse life experiences during the pandemic, there were no statistically significant differences in depression, anxiety or quality of life between those reporting a negative impact of the pandemic on their life compared to those without any. Interestingly, students reporting at least one impact showed higher level of resilience and self-rated health scores but lower support needs. Regarding exercising, those who always or very often exercised showed lower levels of depression and anxiety, better quality of life, higher self-rated health score and lower support needs, compared to those who occasionally or never exercised.

Regarding the consumption of alcohol and tobacco, most students reported using either substance less often during the pandemic. Alcohol use was not related to any of the decision variables but tobacco use was significantly related to five decision variables, with those using tobacco showing higher anxiety and depression, lower life quality of life and self-reported health, and higher support needs.

Those students reporting an impact of the pandemic on their relationships tended to report higher scores of depression and anxiety, significant enough to put the affected cohort in one level up in terms of severity for both depression and anxiety. This also applied to students reporting scarce communication with friends and family. Those whose relationships had not been impacted or who had maintained good communication with family and friends tended to have better quality of life and self-reported health and lower support needs.

The bivariate analysis of the students’ mental wellbeing history against the set of decision variables are presented in Table 8 . Students who had been referred to or participated in talking therapies for a mental health issue in the past (not just at the current time), tended to report higher scores of depression and anxiety, significant enough to put the affected cohort in one level up in terms of severity for both depression and anxiety. Students who reported currently or previously taking medications for a mental health issue, or had accessed or attempted to access healthcare services personally or for a family member during the pandemic period, also tended to experience higher levels of depression and anxiety with lower life quality and self-rated health score and more support needs.

The bivariate analysis on COVID-19 related questions against the set of decision variables are presented in Table 9 . A large majority of participants, 93.4%, reported always or very often practising social distancing and this factor was not related to any of the decision variables (possibly due to the highly skewed distribution on this factor). About 15% of the students were in high or increased risk due to pre-existing medical conditions or needing special care and the higher risk group showed higher scores of depression and lower health scores, yet they had lower support needs and better index for quality of life. Furthermore, approximately 30% of the students reported living with someone in a high or increased risk group and these tended to showed higher levels of depression and anxiety, poorer quality of life and lower self-rated health scores, while having more support needs. Finally, 16.5% of the participants reported feeling likely or extremely likely to contract the virus, and these showed an increased level of anxiety, worse health score and higher support needs.

Multivariate linear regression analysis

A multivariate linear regression was conducted for each of the dependent variables, with results presented in Tables 13 and 14 , with each regression analysis using a different subset of independent variables, those which were found to be statistically significantly related from the bivariate analysis as shown in Tables 6 – 9 .

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Apart from the regression model for the BRS6 Resilience variable, which achieves the statistical significance at the level of p < 0.01 (with R 2 only being 0.014), the remaining regression models all achieve statistical significance with p < 0.001, indicating the selection of underlying variables are meaningful in associating with the level of the corresponding decision variable.

Ten out of eleven variables included for the analysis of the PHQ9 show statistical significance. Exercise was the predictor with biggest coefficient, closely followed by communication, and then the history of accessing a talking therapy and impact on relationships. The values of these coefficients within 95% of the data, (the confidence interval, CI), or within two standard deviations, are also listed accordingly. For the regression analysis for the GAD7, ten variables were included with only the contract risk not showing a statistical significance contribution. The level of communication with families/friends was the most significant predictor for anxiety, followed by accessing a talking therapy and impact on relationships. There were also significant gender differences, with female students showing higher levels of anxiety and depression, and lower self-rated health scores. For BRS6, only three independent variables were included, with ethnicity and the adversity question (which asked whether the student had experienced any adverse events) showing statistical significance.

Nine predictors were included for the analysis of EQ5D5L quality of life measure, with the three most significant predictors being a history of talking therapy, taking medication for a mental health issue and access or attempt to access healthcare service personally or for a family member during the pandemic.

Twelve predictors were included for the analysis of self-rated health score, with seven showing a statistically significant correlation. Exercise, accessing talking therapy and communication were the top three predictors.

Eight out of twelve variables were significant predictors for the support needs dependent variable, with healthcare service, medication and communication being top three predictors.

This survey set out to investigate the mental health and wellbeing of higher education students during the COVID19 pandemic and predictive factors. Perhaps the most striking finding was the high levels of depression and anxiety, with scores above the clinical cut off for over half the students. This suggests they are likely to have been experiencing clinically significant levels of depression and/or anxiety at the time of the survey. Measures such as the PHQ9 and GAD7 are screening instruments which highlight individuals likely to have significant problems and requiring further assessment and support. Although these measures are not diagnostic, they have been favourably compared to diagnostic interviews [ 22 ]. Previous community surveys suggest about one in six people report experiencing a common mental health problem (anxiety or depression) in a given week in England [ 2 ] so our survey suggests the incidence of common mental health problems was much higher than usual in this student group during the pandemic. The survey took place over one month, about three to four months after the first lockdown in the UK began (and after exam time for undergraduates), so it is likely to be due to the pandemic rather than other factors but we do not know how the levels of anxiety and depression changed over time. A recent study [ 23 ] identified different trajectories of depression and anxiety symptoms over time for subgroups in a large community sample in England during the pandemic. For example, they found young, female and more sociable people, and essential workers, experienced severe anxiety at the start of the lockdown which quickly decreased whilst younger people with lower incomes and previous mental health problems experienced increasing levels of symptoms over time. Other surveys have also showed increases in common mental health problems during the pandemic. For example, an Office for National Statistics (ONS) survey in early 2021 reported about 1 in 5 (21%) adults experienced depression in early 2021, more than double that found before the COVID-19 pandemic (10%). This ONS survey also reported that younger adults and women were more likely to experience some form of depression, with 43% of women and 26% of men in the 16 to 29 year age range found to be experiencing depressive symptoms. This higher level of depressive symptoms in women and younger adults is consistent with our survey and we also found higher levels of anxiety symptoms. Other studies have also reported higher levels psychological distress in younger people, with higher levels in females compared to males, during the pandemic [ 24 ]. The high percentages of students reporting current or past referral to or receiving talking therapy (40%) and/or medication for mental health problems (28%) suggest this may have been a sample with relatively high levels of pre-existing mental health difficulties but this is speculative. The high levels of anxiety and depression contrast to some extent with the quality of life scores, which might suggest that the experience of low mood and anxiety were due to the current circumstances of the pandemic (and therefore transient for many people), rather than longer term mental health difficulties that had impacted on quality of life. However, we do not how, as the pandemic and restrictions persisted, quality of life was affected in the longer term. It was interesting that the 15% of the students who were in high or increased risk due to pre-existing medical conditions or needing special care showed higher scores of depression and lower health scores, yet they had lower support needs and better index for quality of life. It is possible that this was due to them having better support systems in place before the pandemic, which they continued to access.

The study also set out to investigate levels and predictors of resilience and most students scored in the normal range with 26% in low resilience category and none in the high category. This is reflected in the overall mean of 3.1 which is lower than that reported in the original validation study [ 19 ] which reported on four samples (including two student samples), with means ranging from 3.53 to 3.98 and lower scores in the younger age groups. An interpretation of the resilience scores is that the pandemic not only led to increases in anxiety and depression but also undermined personal resilience. For example, the restrictions of lockdown were likely to have deprived students of outlets and activities important to their wellbeing. Also, low mood may have contributed to a negative appraisal of personal resilience at the time. It is therefore possible that the low resilience is due to the adverse circumstances of the pandemic and lockdown, not stable characteristics of the individuals. We suggest our findings should be interpreted in terms of attributing the distress and coping as consequence of the situation the students found themselves in, ‘what happened to them’ during the pandemic, rather than ‘what is wrong with’ them [ 25 , 26 ].

The survey also suggested a number of factors that may have contributed to the high levels of common mental health problems (in addition to gender), such as cancellation of an important event (56%), worse personal relations (40%) and worse financial situation (40%). Students with higher levels of depression tended to exercise less, communicated less with friends/family, and experienced greater impacts on their relationships, as well as (not surprisingly) having more history of accessing a talking therapy. Those with higher anxiety levels also tended to communicate less with friends/family, experience greater impacts on their relationships, and had more history of accessing a talking therapy. We cannot attribute causal effects and in some cases the relationships between these variables are likely to work both ways. For example, low mood may lead to worse personal relationships which would adversely affect mood.

The relationship between exercise and mental health in our survey is consistent with evidence that physical activity has a role in preventing depression [ 27 ] and a physical activity programme is recommended for people with mild to moderate depression [ 28 ]. The finding that tobacco use was significantly related to higher anxiety and depression, lower life quality of life and self-reported health, and higher support needs is consistent with reports that as the severity of mental health problems increase, the prevalence of smoking is higher [ 29 ]. For example, Public Health England reports that whilst the prevalence of smoking for all adults in England was 16.4% in 2014 to 2015, the prevalence was 28% for people with anxiety or depression, and 40.5% for those with serious mental illness. There is also good evidence that smoking cessation is associated with reductions in anxiety and depression, and with improvements in mood and quality of life, and that this applies to those with mental health problems [ 30 ].

There are a number of limitations of this study. Firstly, this was a one off, cross sectional survey over one month, four months into the pandemic so we are not able to report on changes over time, and crucially, whether the high levels of anxiety and depression were transitory or longer term. Secondly, the survey was carried out at only one University in England so it is possible findings will differ in other localities. Having said that, there was diversity in our sample, which included students from all over the UK with a higher proportion of non-white students (32%) than in the general population in England, enabling comparisons to be made between white and non-white students. Thirdly, it is possible that there was a bias in our sample, in that those experiencing mental health difficulties at the time of the survey were more likely to be attracted by the advert for the survey and to complete it. It may not therefore be representative of the larger population of students but the high levels of anxiety and depression and gender difference are nevertheless significant findings. Finally, although the study identifies levels and predictors of mental health distress, it does not identify how the pandemic impacted on individuals, and how they coped with the challenges. This would require more in depth, qualitative research and we recommend this to complement surveys.

Despite these limitations, this study identifies high levels of anxiety and depression in undergraduate and postgraduate students early in Covid-19 pandemic in England and relatively low levels of resilience which are likely to reflect the impact of restrictions and isolation which reduced the opportunities to engage in helpful coping strategies and activities. These high levels of psycho logical distress are therefore likely to be a combination of pandemic-related stresses and limited access to positive coping behaviours, such as socialising. Mental health distress was associated with lower levels of exercising, higher levels of tobacco use, and a number of life events likely to be associated with the pandemic and lockdown, such as cancelled events, worsening in personal relationships and financial concerns. We can assume that some of the students would have been experiencing high levels of depression and anxiety for the first time, whilst others would have experienced a worsening of pre-existing difficulties. This study highlights how these mainly younger adult students may be particularly prone to experiencing high levels of anxiety and low mood during a pandemic, and the importance of providing support to reduce the likelihood of longer-term problems. Given the global context for these increased levels of psychological distress, it is important to see this as an understandable reaction to an adverse situation which may be transitory, rather than necessarily the start of continued and long-term problems but this will only be achieved with support. Some will find adequate support within their social networks, coping strategies and activities, but it is likely a significant number would be at risk of longer term and more severe difficulties and might therefore benefit from professional support including psychological therapy and counselling.

Acknowledgments

The authors highly appreciate Altif Ali’s general technical support in this research.

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• Published: 20 September 2021

Mental health prevalence and predictors among university students in nine countries during the COVID-19 pandemic: a cross-national study

• Dominika Ochnik   ORCID: orcid.org/0000-0002-9019-7091 1 ,
• Aleksandra M. Rogowska 2 ,
• Cezary Kuśnierz 3 ,
• Monika Jakubiak 4 ,
• Astrid Schütz 5 ,
• Marco J. Held 5 ,
• Ana Arzenšek 6 ,
• Joy Benatov 7 ,
• Rony Berger 8 , 9 ,
• Elena V. Korchagina 10 ,
• Iuliia Pavlova   ORCID: orcid.org/0000-0002-8111-4469 11 ,
• Ivana Blažková 12 ,
• Imran Aslan 13 ,
• Orhan Çınar 14 , 15 &
• Yonni Angel Cuero-Acosta 16  

Scientific Reports volume  11 , Article number:  18644 ( 2021 ) Cite this article

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The student population has been highly vulnerable to the risk of mental health deterioration during the coronavirus disease (COVID-19) pandemic. This study aimed to reveal the prevalence and predictors of mental health among students in Poland, Slovenia, Czechia, Ukraine, Russia, Germany, Turkey, Israel, and Colombia in a socioeconomic context during the COVID-19 pandemic. The study was conducted among 2349 students (69% women) from May–July 2020. Data were collected by means of the Generalized Anxiety Disorder (GAD-7), Patient Health Questionnaire (PHQ-8), Perceived Stress Scale (PSS-10), Gender Inequality Index (GII), Standard & Poor's Global Ratings, the Oxford COVID-19 Government Response Tracker (OxCGRT), and a sociodemographic survey. Descriptive statistics and Bayesian multilevel skew-normal regression analyses were conducted. The prevalence of high stress, depression, and generalized anxiety symptoms in the total sample was 61.30%, 40.3%, and 30%, respectively. The multilevel Bayesian model showed that female sex was a credible predictor of PSS-10, GAD-7, and PHQ-8 scores. In addition, place of residence (town) and educational level (first-cycle studies) were risk factors for the PHQ-8. This study showed that mental health issues are alarming in the student population. Regular psychological support should be provided to students by universities.

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Introduction.

The coronavirus disease (COVID-19) pandemic is an unexpected, global phenomenon that has affected people worldwide in various aspects of life. Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is the virus responsible for the COVID-19 pandemic 1 which affects the respiratory and central nervous systems system 2 . Apart from physical health, the ongoing pandemic has substantially affected mental health in a negative manner 3 , 4 . Due to preventive restrictions, the global population has led to social isolation on an unprecedented scale, which is strongly related to psychological distress, high anxiety, and acute stress 5 , 6 , 7 , 8 , 9 .

Even though young adults are the least susceptible to COVID-19 infection 10 , this group is the most vulnerable to mental health deterioration 11 , 12 , 13 . Young adults with a student status often deal with mental health issues. Even in the prepandemic period, more than one-third of students experienced mental health problems 14 .

Additionally, high stress and anxiety risk prevalence were observed in students prior to the pandemic 15 . Students are also at greater risk of depression than the general population 16 or other types of occupational status, e.g., employed or retired 17 , including academic staff 18 . The coronavirus pandemic has affected students' lives in many aspects, i.e., distance learning, labor market, career opportunities or hygiene-related behavior, and daily routines 19 . Considering that mental health issues at a young age can lead to low employment rates, poor academic outcomes, and substantial loss of total earnings over the lifetime 20 , there should be a strong focus on research concerning students' mental health during the ongoing pandemic.

Even though the number of research papers referring to the COVID-19 pandemic has already exceeded the number of studies dedicated to Ebola and H1N1, few studies have emerged as the product of international collaboration 21 . Therefore, the pursuit of international studies is crucial to determine implications of the sociocultural context of mental health issues during the global pandemic.

Cross-national research on mental health during the COVID-19 pandemic more frequently pertains to the general population 22 , 23 , 24 , 25 , 26 rather than the student population 27 , 28 , 29 . Evidence from 78 countries revealed that the prevalence of depressive symptoms was 25% in the general population and that of high stress was 11% 26 . A cross-national study showed that the prevalence of the depressive disorder was 30.7% for the general sample, with Czech students presenting lower levels of depression than Emirati students, but similar to the American and Taiwanese samples 28 . Israeli and Russian students presented a similar prevalence level concerning the feeling of being depressed: 45.3% and 46.4%, respectively 29 . The prevalence of moderate and severe anxiety symptoms among Polish students was 21% and 14%, respectively, and high perceived stress was manifested by 56% at the beginning of the pandemic 30 . In the student sample from Bavarian universities, nearly 40% reported an increased psychological burden, while 17.3% of the students claimed to experience less mental stress during the COVID-19 pandemic 31 .

Mental health prevalence varies in between-country comparisons as well as within a country. In China, the prevalence of anxiety symptoms in the adult population ranges from 6.33 to 35.1%, and depression symptoms range from 14.6 to 48.6% 32 . The differences might be due to the stage of the pandemic or measurements applied in the study. Another issue is the variety of sample sizes in cross-national research. In one study, it ranged from 33 (Chinese sample) to 869 respondents (USA sample) 22 or from 1285 students in Latvia to 100 in the UK 26 . Additionally, it should be be noted that little attention has been devoted to understanding cross-national differences.

Several risk factors have contributed to declining mental health during the COVID-19 pandemic, including (female) gender, (younger) age, and (lower) income 24 , 33 , 34 . Even in research regarding the global population, student status appears to be a risk factor of mental health issues. This is especially valid for students of the first-cycle studies 19 , 23 , 26 , 34 . However, when analyzing the student population, the evidence behind risk factors found in the general population has been inconsistent. Age as a risk factor is noticeable among students. It was noted that being under 24 was linked to higher anxiety and depression 35 and higher COVID-19-related psychological impact 36 . However, research among German students has shown that younger students (17–25) reported lower mental stress than older groups 31 . Female gender is considered a risk factor for students' mental health 30 , 31 , 35 , 36 , 37 . Nevertheless, male students reported a higher prevalence of depression and anxiety compared to female students in Bangladesh 38 . In Turkish students, gender was a weaker predictor of high perceived stress levels than the level of physical inactivity, and the role of gender was diminished by satisfaction with life and anxiety 39 . The role of the place of residence is unclear and depends on the country of origin. Living in an urban area was linked to lower anxiety in China 40 but to higher anxiety and depression in Bangladesh 38 .

The nine countries in our study represent the cultural diversity portrayed by traditional vs. secular and survival vs. self-expression values. The Inglehart-Welzel World Cultural Map 41 aggregates all countries into eight clusters based on those values. Six of the value clusters are exemplified in our study. Catholic Europe is represented by Poland, Slovenia, and Czechia; Orthodox Europe by Ukraine and Russia; Protestant Europe by Germany; African-Islamic region by Turkey; West and South Asia by Israel; and Latin America by Colombia. Therefore, these countries represent a great diversity of global cultural values.

In addition to cross-cultural differences, one possible explanation for the prevalence of mental health problemsin cross-national samples may be socioeconomic development indices, such as the Gender Inequality Index (GII) 42 , or the credit risk of the country as measured by Standard and Poor's Global Ratings (S&P) 43 . The COVID-19 pandemic has negatively affected the global economy on an unprecedented scale. It is perceived as the deepest global recession in eight decades 44 . Previous financial crises exposed increased levels of anxiety, depression 45 , and psychological stress 46 . Recession leads to higher mortality and suicide rates 47 . In addition, considering that lower social status is related to mental health deterioration 48 , 49 , it seems crucial to include the financial index in the mental health model. The S&P rating refers to the evaluation of credit risk at the national level. The index is more comprehensive compared to the gross domestic product (GDP) per capita, as it refers to the social situation 43 .

Additionally, during the pandemic, labor markets have fallen into a recession. Moreover, the existing gender gap has widened 50 . In light of the this, we propose applying the GII in this context. The GII is a comprehensive indicator referring to the dimensions of reproductive health (maternal mortality and adolescent birth ratio), empowerment (education, parliamentary seats), and labor market. The index relates to the Human Development Index (HDI). The greater the GII value, the more gaps between women and men exist, and the greater loss to human development. Both the GII and S&P credit ratings are well established and considered to be objective and reliable measurements.

To monitor the effect of national governmental restrictions on mental health, the Oxford COVID-19 Government Response Tracker (OxCGRT) was introduced. It enables the measurement of the stringency level of restrictions 51 , whichis based on three groups of indicators: community mobility, economic aspects and public health. This is rescaled to a value ranging from 0 to 100, where 100 denotes the strictest restrictions. During data collection, the stringency level varied across Poland, Slovenia, Czechia, Ukraine, Russia, Germany, Turkey, Israel, and Colombia, from the lowest in Czechia (41.67) to the highest in Colombia (87.04) (detailed analysis in Supplementary Table S1 ). The stringency of restrictions affects mental health as a study in six countries shows, although its role is rather limited 22 . The aforementioned macrolevel indices pertaining to the nine countries selected for the present study (Poland, Slovenia, Czechia, Ukraine, Russia, Germany, Turkey, Israel, and Colombia) are outlined in detail in Table S1 . All countries differ regarding their socioeconomic situation as measured by the GII and S&P credit rating as well as the course of the pandemic indicated by means of the stringency level. The indexes are presented on geographical maps (Fig.  1 ) and reflect the situation at the moment of the study (May–July 2020). The aforementioned socioeconomic indices (GII and S&P Global Rating), together with the stringency level, have rarely been analyzed regarding mental health during the COVID-19 pandemic.

Maps present the following data in nine countries (Poland, Slovenia, Czechia, Ukraine, Russia, Germany, Turkey, Israel, and Colombia): ( a ) credit rating (indicated by the size of the dot) and the stringency level of restrictions (highlighted in color); ( b ) gender Inequality Index (GII) (size) and the stringency level (color). The map was developed in Tableau 2021.1.

Our aim in this study was to reveal the prevalence and predictors of mental health among students in Poland, Slovenia, Czechia, Ukraine, Russia, Germany, Turkey, Israel, and Colombia in a socioeconomic context marked by the COVID-19 pandemic.

We will introduce a Bayesian multilevel prediction model combining macrolevel and individual-level variables. We will examine whether the individual-level (gender, place of residence, level of study) and macrolevel variables (stringency, GII, and S&P Rating) constitute predictors of anxiety, depression, and perceived stress at the subnational level among students in the nine countries during the COVID-19 pandemic.

We hypothesize that female gender, residence in a city, higher education level, higher stringency, and greater GII and S&P credit risk rating will constitute risk factors for all the measured mental health dimensions.

Participants

The initial total sample was 2453 individuals. However, 104 persons (4.24% of the total sample) declined to participate (responded No to the informed consent). Therefore, the final total sample of university students participating in the study was 2349. All the respondents were eligible for the study and confirmed their student status. Additionally, respondents who did not want to reveal their gender were excluded from statistical analyses concerning gender (n = 6). A sample size was computed by G*Power software 52 with regard to χ 2 contingency tables, with p  < 0.05, two-tailed, and 95% CI , and a sample size of 159 for each country was established.

Descriptive statistics

The research sample consisted of 2349 students from Poland (n = 301), Slovenia (n = 209), Czechia (n = 310), Ukraine (n = 310), Russia (n = 285), Germany (n = 270), Turkey (n = 310), Israel (n = 199) and Colombia (n = 155). Women comprised 69.30% of the total sample, ranging from 55.80% in Turkey to 85.20% in Slovenia. Polish, Slovenian, and Czech students mostly lived in rural areas, Ukrainian and German in towns, Russian and Israeli in cities, whereas Turkish and Colombian students in large urban agglomerations. Most of the students attended first cycle studies (Bachelor, 78.50%) and studied full-time (85.40%). Detailed sociodemographic descriptive statistics are presented in Table 1 . Comprehensive description of the recruitment (universities in each of nine countries) are presented in the Supplementary Note .

The distribution of the generalized anxiety disorder (GAD-7), perceived stress (PSS-10), and depression (PHQ-8) scores in the nine countries is outlined in Fig.  2 . There were no missing data in the statistical analyses. A comprehensive description is given in Table 2 .

Distribution of anxiety (GAD-7), perceived stress (PSS-10), and depression (PHQ-8) parameters within each surveyed country presented by violin and box plots. COL = Colombia, CZ = Czechia, GER = Germany, ISR = Israel, PL = Poland, RU = Russia, SL = Slovenia, TR = Turkey, UKR = Ukraine.

Prevalence of anxiety, depression, and perceived stress

The prevalence of mental health indicators in students from the nine countries is presented in Table 3 . More than half of the respondents (61.30%) reported high PSS-10. Polish (71.10%) and Turkish (70.30%) students reported the greatest prevalence of high PSS-10, whereas Czech students (30%) reported the lowest prevalence.

The GAD-7 and PHQ-8 risks were reported in 30% and 40.30% of the total student sample, respectively. The highest prevalence of the GAD-7 and PHQ-8 risks occurred in Turkey, at 51.30% and 62.30%, respectively. However, the GAD-7 risk was also high in Poland (46.80%). The lowest occurrence of the GAD-7 risk emerged in Germany (5.20%) and the PHQ-8 emerged in Czechia (21%). Almost every fourth student (24.50%) in the nine countries experienced the GAD-7 and PHQ-8 risks, with the highest prevalence in Turkey (44.80%) and the lowest in Germany (4.80%).

Bayesian multilevel regression analyses

Bayesian multilevel skew-normal regression analyses with a country as a grouping variable (i.e., 'random effect') were employed to reveal predictors of dependent variables: generalized anxiety disorder (GAD-7), perceived stress (PSS-10), and depression (PHQ-8). This allowed us to combine macrolevel variables with individuallevel variables, with a country as a grouping variable. Gender, place of residence, and education constituted individual-level predictors and were estimated at the population and country levels (i.e., these effects could vary between countries), and were entered into the model with sum-to-zero contrasts. The country-level predictors, GII, stringency, and S&P rating were recoded to provide an informal grouping of countries surveyed in the study. The GII and stringency were coded with sum-to-zero contrast, whereas linear (L) and quadratic trends (Q) were estimated for the S&P rating due to the ordinal character of the variable. Dependent variables were z-scaled before modeling; thus, the regression weights were on a standardized scale. Additionally, Bayesian R 2 was provided for each model 53 . A summary of the models parameters are presented in Table 4 .

Only gender had a credible effect on the GAD-7 values, with average values being credibly lower among men than among women (Fig.  3 ). Similarly, the average PSS-10 score was credibly lower among men than women (Fig.  4 ). Gender also had a credible effect on PHQ-8 scores, again with an average value credibly lower among men than among women (Fig.  5 ). Additionally, the average PHQ-8 was credibly lower among participants with master's degrees and higher among participants with bachelor's degrees. The effect of the place of residence was also credible. To investigate the factor further (since the regression weights represent differences from the grand mean), a post hoc analysis was conducted. The only credible difference between the averages was observed for the comparison of towns and villages, d  = 0.14, [0.02, 0.27], with a higher average for towns (Fig.  5 ).

Posterior means of predicted marginal means (points) with 95% credible intervals (vertical lines) from the Bayesian skew-normal multilevel model for generalized anxiety (GAD-7) scores. Boxplots and violin plots show the distribution of the data.

Posterior means of predicted marginal means (points) with 95% credible intervals (vertical lines) from the Bayesian skew-normal multilevel model for perceived stress (PSS-10) scores. Boxplots and violin plots show the distribution of the data.

Posterior means of predicted marginal means (points) with 95% credible intervals (vertical lines) from the Bayesian skew-normal multilevel model for depression (PHQ-8) scores. Boxplots and violin plots show the distribution of the data.

The present study investigated the prevalence and predictors of mental health indicators among students in nine countries during the early stage of the COVID-19 pandemic. The prevalence of high stress, depression, and generalized anxiety disorder risk among students was 61.30%, 40.3%, and 30% in the total sample, respectively. Female gender was a predictor of perceived stress, anxiety, and depression. Additionally, students living in towns (compared to those from rural areas) and those attending first cycle studies (bachelor’s students) presented a higher depression risk. However, macrolevel variables (GII, S&P rating, stringency) were irrelevant predictors of mental health.

The results of the study suggest that students in the nine countries suffered from high perceived stress and mild anxiety and depression symptoms. The international university student population experienced higher stress than the general population, which reported perceived stress at a medium level at the onset of the COVID-19 pandemic 23 , 26 . High stress (11.1%) and depression (6.6%) risk prevalence in the general population 26 was substantially lower compared to the student sample in this study, at 61.30%, and 40.3%,respectively. However, a different measurement (the Multidimensional State Boredom Scale) was used in the general population study 26 . An international sample of the general population (USA and Israel) reported a similarly lower prevalence of anxiety (22.2%) (with the same cutoff point of GAD7 > 10) 54 . The prevalence of anxiety and depression risk in our study was higher than in the general Chinese population 55 , 56 and a large Chinese student sample, which was 11% and 21.10%, respectively 57 . Considering that the cutoff point was lower in Chinese analyses (7) than in our research (10), the differences in depression and anxiety prevalence were even more pronounced. Our results are congruent with research showing higher anxiety rates than the general population 33 , 40 , 58 . Additionally, a recent systematic review of global prevalence of mental health issues in the general population showed prevalences of stress, depression, and anxiety, at 36.50%, 28.00%, and 26.90%, respectively 59 . In our study, students reported almost twice as high stress and depression levels.

Over half of the students in the nine countries (54.1%) did not meet any diagnostic criteria for anxiety or depression. On the other hand, 24.5% reported high depression and anxiety risk concurrently. This means that almost every fourth student in the international sample experienced the comorbidity of depression. Additionally, the prevalence of severe depression risk (12%) was almost twice as high when compared to severe anxiety prevalence risk (6.7%), which seems to be the case for the student sample 58 but not the general population 54 .

The prevalence of anxiety (51.3%) and depression (62.3%) risk was the largest in Turkish students, whereas the lowest anxiety risk (5.2%) was in German students and the lowest depression risk (21%) in Czech students. Comparing mild anxiety symptoms among German and Russian students to the general population in those countries 25 , a similar intensity was observed in the German general population but higher (moderate levels) in the general Russian sample. However, discussion concerning the average anxiety and depression levels has been hindered by a variety of measurements used in research. On the other hand, previous evaluations of anxiety prevalence with the same measurement (GAD7) in Polish (35%) 30 and Israeli students (56%) 58 showed different prevalences, 46.80%, and 32.70%, respectively, compared to our results. However, those differences might have been due to the type of university or the field of study. The prevalence of moderate and high stress (84.90%) in Czech students was higher than that in the general Czech population before (35.40%) and during (51.10%) the COVID-19 pandemic 60 . Ukrainian students reported similar prevalence of anxiety and depression risk (19%) compared to a large sample of Ukrainian students in other studies during the COVID-19 pandemic (18.85%) 39 . Additionally, Polish students suffered from substantially higher depression risk prevalence (49.20%) than Polish students examined before the COVID-19 pandemic (21.98%) 61 .

The analysis of the Bayesian multilevel regression model showed that, consistent with other works 30 , 31 , 36 , 37 , female gender in students was a predictor of high perceived stress, anxiety, and depression. The additional predictors for depression were the place of residence and the level of study. In contrast to the results of Chinese research 40 , students from rural areas presented lower depression levels. Furthermore, students at the bachelor’s level reported higher depression than those with master's degrees or higher, which is similar to research concerning the general population 19 , 26 However, being a first-cycle student was not a credible predictor of anxiety or perceived stress in the student sample. The stringency of restrictions was of trivial importance in the multilevel model. It seems that more psychological importance is laid upon the perception of restrictions' efficacy 22 , usefulness 24 , self-protective values 62 , or motives for compliance with restrictions 63 . The role of the Gender Inequality Index (GII) and global credit rating was found to be irrelevant in the surveyed models of mental health predictors. This might be due to several issues, such as the number of investigated countries. On the other hand, such a result may be explained by the specificity of the student population, which varies from the general population. For example, in our study, the number of female students exceeded that of male students in countries with high GII. Therefore, the global indices could explain mental health to a higher degree in the general population because the global student population is frequently more homogeneous.

Limitations

There are several limitations to the present study. First, the study is of a cross-sectional nature. Second, the results pertaining to the participant level were obtained via self-reported questionnaires. Therefore, they can be subject to retrospective response bias. Finally, the lack of random sampling and the representation of the student population limited to specific regions in each country make it difficult to generalize the results. The irrelevance of macrolevel indices might be due to the small number of countries and a narrow range of indices within the nine surveyed countries. Therefore, the prospective verification of the proposed model based on a larger number of countries seems valid.

Conclusions

The study showed that students across the nine countries seem to be a relatively homogeneous group in regard to susceptibility to mental health issues. In particular, female students are at high risk of perceived stress, anxiety and depression across Poland, Slovenia, Czechia, Ukraine, Russia, Germany, Turkey, and Colombia. As far as high perceived stress and anxiety levels are concerned, they may be interpreted as an adaptive response to the extremely volatile and unpredictable nature of the COVID-19 pandemic. Depression risk prevalence seems to be the most alarming factor, as it is even higher than the anxiety prevalence. Considering the recurring reports on severe mental health issues among students globally, the issue should be recognized at public health levels by governments or other international bodies. Our results underline the universities' need to provide dedicated programs and regular psychological support to students.

Study design

A cross-national study was conducted online between May and July in the following nine countries—Ukraine: 14 May–02 June, Slovenia: 14 May–26 June; Turkey: 16–29 May; Czechia: 17 June–24 July; Poland: 19 May–25 June; Israel: 21 May–03 June; Russia: 01–22 June; Germany: 02–25 June; and Colombia: 05 June.

The survey was created via Google Forms in eight countries. The German data were collected via SoSci Survey. Sampling was purposive, with the selection criterion being a university student. The invitation to the online questionnaire was sent to students by researchers via email, social media and the Moodle e-learning platform. The average time of data collection was 23.26 min ( SD  = 44.03). No form of compensation was offered as an incentive to participate. To minimize sources of bias, the student sample was highly diverse due to its key characteristics: the type of university, field of study and cycle of study.

Ethics statement

The study protocol was approved by the University Research Committee at the University of Opole, Poland, decision no. 1/2020. The study followed the ethical requirements of the anonymity and voluntariness of participation. Each person answered the informed consent question. Following the Helsinki Declaration, written informed consent was obtained from each student before inclusion. This study is a part of an international research project: Well-being of undergraduates during the COVID-19 pandemic: International study, registered at the Center for Open Science (OSF) 64 https://doi.org/10.17605/OSF.IO/BRKGD . The authors received no specific funding for this work.

To measure whether the respondents appraised the situation in their life as stressful, the Perceived Stress Scale (PSS-10) 65 was employed. Perceived stress is related to the subjective assessment of events occurring in one's life 66 . It evaluates how unpredictable, uncontrollable, and overloaded individuals find their lives 65 . The PPS-10 consists of 10 items referring to the frequency of stressful events that occurred in the month preceding the study, which is assessed on a 5-point scale (0 = never to 4 = very often). The Cronbach's α for this sample was 0.82.

The 7-item generalized anxiety disorder (GAD-7) scale 67 is a self-reported measure designed to screen for symptoms following Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-V) criteria 68 . Based on those criteria, the generalized anxiety disorder (GAD) is characterized by persistent and excessive worry about various issues. It relates to anxiety as a state 67 . People rated how often they experienced anxiety symptoms in the 2 weeks preceding the study on a 4-point Likert scale (0 = not at all, 1 = several days, 2 = more than half the days, and 3 = nearly every day). The GAD-7 ranges from 0 to 21. Scores above 10 points indicate an anxiety disorder risk 67 . The Cronbach's α for the GAD-7 in this study equals 0.92.

The Patient Health Questionnaire (PHQ-8) was used to measure depression symptoms. The PHQ-8 consists of eight items, conforming to the DSM-V diagnostic criteria 68 . Depression is one of the most common yet treatable mental health disorders 69 . The symptoms include depressed mood, loss of interest in most or all activities, loss of energy, or feeling of worthlessness 70 . Participants use a Likert-type response scale ranging from 0 = not at all to 3 = nearly every day. The range of PHQ-8 scores is 0–24. A cutoff score of 10 or above is recommended to screen for major depressive disorder risk 70 . The individual language versions were derived from the Multicultural Mental Health Resource Centre. The internal consistency reliability of the original version measured by Cronbach's α was 0.86, and 0.88 in this study.

Demographics included four questions on gender, place of residence, level of study, and type of study (full-time vs part-time). The questionnaire was primarily designed in Polish and English, and further translated from English into Slovenia, Czech, Ukrainian, Russian, German, Turkish, Hebrew and Spanish, using backward translations by a team consisting of native speakers and psychology experts, according to the guidelines 71 . Details regarding each country and the total sample are shown in Table 1 .

Gender Inequality Index

The Gender Inequality Index (GII) measures gender inequalities in three dimensions (and five indicators) of reproductive health (maternal mortality and adolescent birth ratio), empowerment (education, parliamentary seats), and labor market (labor force participation). The GII value ranges from 0 to 1, where 0 indicates equality between women and men, while 1 indicates inequality in the aforementioned dimensions (women fare as poorly as possible). Detailed values of the GII were derived from the United Nations Human Development Programme 42 and were recoded with respect to the median to provide an informal grouping of countries included in the study. Detailed values are presented in Table S1 .

Standard and Poor's Global Ratings

Standard and Poor's Global Ratings refers to the assessment of credit risk for investments in a particular country. It is based on a variety of factors, such as economic diversity and volatility, effectiveness, stability, and predictability of policy-making, political institutions, and civil society. Therefore, the values range from low credit risk AAA to extremely high risk at the D level. Countries in this study were divided into three groups based on the S&P rating 43 . Group A was characterized by low credit risk (Germany, Israel, Slovenia, Czechia, Poland), Group B with medium credit risk but still valid investment level (Russia and Colombia), and finally Group C at the speculative level with high credit risk (Turkey, Ukraine)—operationalized respectively as O, 1, 2. A detailed description of the S&P Global rating can be found in Table S1 .

The Oxford COVID-19 Government Response Tracker (OxCGRT)

The Oxford COVID-19 Government Response Tracker (OxCGRT) enables tracking of the stringency of government responses to the COVID-19 pandemic across countries and time 51 . The stringency level is composed of multiple indicators. It refers to community mobility: school closings, workplace closings, cancelation of public events, restrictions on gathering, public transport closings, stay at home requirements, restrictions on internal movement, international travel restrictions; and economic measures: income support, debt/contract relief, fiscal measures, and international support. The final set of indices relates to public health issues: public information campaigns, testing policy, contact tracking, emergency investment in health care, investments in vaccines, facial coverings, and vaccination. However, not all indexes were available in all countries. Those detailed measurements are rescaled to a value ranging from 0 to 100, where 100 denotes the strictest restrictions.

The timing was crucial for the stringency level evaluation. The stringency value in this study was evaluated based on the mean of the given stringency value on the first and the last days of data collection in each country 51 . Subsequently, those values for each country were dichotomized to the median to be incorporated into the statistical model. The results are shown in Table S1 .

Statistical analysis

The study used SPSS.25 (IBM, Armonk, NY, USA) and R 4.0.2 statistical software 72 . The analysis encompassed descriptive statistics: mean (M), standard deviation (SD), 95% confidence interval (CI) with lower limit (LL) and upper limit (UL). Hot-deck imputation was introduced to address a low number of missing data (n = 5, 0.02%) and they were included in the statistical analysis.

To verify the prediction model, Bayesian multilevel skew-normal regression analyses, with a country as a grouping variable (i.e., 'random effect'), were carried out using R 4.0.2 statistical software 72 . In Bayesian statistics, the inference is based on analyzing the posterior probability distributions of model parameters, obtained by integrating likelihood (data) with prior probability distributions. The parameter (e.g. regression weight) is said to be statistically credible when 95% credibility intervals (CI) of the posterior distribution exclude zero 73 . As a point estimate of the effect, the means of posterior distributions are presented. A standard normal distribution (M = 0, SD = 1) was used as a prior for the regression weights.

The approximated posterior distributions of the models were accompanied by a Markov chain Monte Carlo (MCMC) sampling procedure using the brms package 74 . For each reported model, six parallel MCMC chains were used. Each chain consisted of 8000 samples, with 4000 samples used as a warmup period and every 10th sample recorded, resulting in 2400 recorded samples in total. The sampling procedure was efficient and resulted in well-mixed and not autocorrelated chains and unimodal posteriors.

Data availability

The materials and methods are accessible at the Center for Open Science (OSF) 64 , titled: Well-being of undergraduates during the COVID-19 pandemic: International study, at https://doi.org/10.17605/OSF.IO/BRKGD . The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

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Conceptualization, D.O. and A.M.R.; data curation, D.O.; formal analysis, D.O.; investigation, D.O., A.M.R., C.K., M.J., A.S., M.J.H., A.A., J.B., R.B., E.V.K., I.P., I.B., I.A., O.C., Y.A.C.-A.; methodology, D.O.; project administration, D.O.; resources, D.O., A.M.R., C.K., M.J., A.S., M.J.H., A.A., J.B., R.B., E.V.K., I.P., I.B., I.A., O.C., Y.A.C.-A.; supervision, D.O., A.M.R., A.S.; visualization, D.O; writing—original draft preparation, D.O.; writing—review and editing, D.O., A.M.R., C.K., M.J., A.S., M.J.H., A.A., J.B., R.B., E.V.K., I.P., I.B., I.A., O.C., Y.A.C.-A. All authors have read and approved the manuscript.

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Published on 3.9.2020 in Vol 22 , No 9 (2020) : September

Effects of COVID-19 on College Students’ Mental Health in the United States: Interview Survey Study

Authors of this article:

Original Paper

• Changwon Son 1 , BS, MS   ; 
• Sudeep Hegde 1 , BEng, MS, PhD   ; 
• Alec Smith 1 , BS   ; 
• Xiaomei Wang 1 , BS, PhD   ; 
• Farzan Sasangohar 1, 2 , BA, BCS, MASc, SM, PhD  

1 Department of Industrial and Systems Engineering, Texas A&M University, College Station, TX, United States

2 Center for Outcomes Research, Houston Methodist Hospital, Houston, TX, United States

Corresponding Author:

Farzan Sasangohar, BA, BCS, MASc, SM, PhD

Department of Industrial and Systems Engineering

Texas A&M University

College Station, TX, 77843

United States

Phone: 1 979 458 2337

Email: [email protected]

Background: Student mental health in higher education has been an increasing concern. The COVID-19 pandemic situation has brought this vulnerable population into renewed focus.

Objective: Our study aims to conduct a timely assessment of the effects of the COVID-19 pandemic on the mental health of college students.

Methods: We conducted interview surveys with 195 students at a large public university in the United States to understand the effects of the pandemic on their mental health and well-being. The data were analyzed through quantitative and qualitative methods.

Results: Of the 195 students, 138 (71%) indicated increased stress and anxiety due to the COVID-19 outbreak. Multiple stressors were identified that contributed to the increased levels of stress, anxiety, and depressive thoughts among students. These included fear and worry about their own health and of their loved ones (177/195, 91% reported negative impacts of the pandemic), difficulty in concentrating (173/195, 89%), disruptions to sleeping patterns (168/195, 86%), decreased social interactions due to physical distancing (167/195, 86%), and increased concerns on academic performance (159/195, 82%). To cope with stress and anxiety, participants have sought support from others and helped themselves by adopting either negative or positive coping mechanisms.

Conclusions: Due to the long-lasting pandemic situation and onerous measures such as lockdown and stay-at-home orders, the COVID-19 pandemic brings negative impacts on higher education. The findings of our study highlight the urgent need to develop interventions and preventive strategies to address the mental health of college students.

Introduction

Mental health issues are the leading impediment to academic success. Mental illness can affect students’ motivation, concentration, and social interactions—crucial factors for students to succeed in higher education [ 1 ]. The 2019 Annual Report of the Center for Collegiate Mental Health [ 2 ] reported that anxiety continues to be the most common problem (62.7% of 82,685 respondents) among students who completed the Counseling Center Assessment of Psychological Symptoms, with clinicians also reporting that anxiety continues to be the most common diagnosis of the students that seek services at university counseling centers. Consistent with the national trend, Texas A&M University has seen a rise in the number of students seeking services for anxiety disorders over the past 8 years. In 2018, slightly over 50% of students reported anxiety as the main reason for seeking services. Despite the increasing need for mental health care services at postsecondary institutions, alarmingly, only a small portion of students committing suicide contact their institution counseling centers [ 3 ], perhaps due to the stigma associated with mental health. Such negative stigma surrounding mental health diagnosis and care has been found to correlate with a reduction in adherence to treatment and even early termination of treatment [ 4 ].

The COVID-19 pandemic has brought into focus the mental health of various affected populations. It is known that the prevalence of epidemics accentuates or creates new stressors including fear and worry for oneself or loved ones, constraints on physical movement and social activities due to quarantine, and sudden and radical lifestyle changes. A recent review of virus outbreaks and pandemics documented stressors such as infection fears, frustration, boredom, inadequate supplies, inadequate information, financial loss, and stigma [ 5 ]. Much of the current literature on psychological impacts of COVID-19 has emerged from the earliest hot spots in China. Although several studies have assessed mental health issues during epidemics, most have focused on health workers, patients, children, and the general population [ 6 , 7 ]. For example, a recent poll by The Kaiser Family Foundation showed that 47% of those sheltering in place reported negative mental health effects resulting from worry or stress related to COVID-19 [ 8 ]. Nelson et al [ 9 ] have found elevated levels of anxiety and depressive symptoms among general population samples in North America and Europe. However, with the exception of a few studies, notably from China [ 10 - 12 ], there is sparse evidence of the psychological or mental health effects of the current pandemic on college students, who are known to be a vulnerable population [ 13 ]. Although the findings from these studies thus far converge on the uptick of mental health issues among college students, the contributing factors may not necessarily be generalizable to populations in other countries. As highlighted in multiple recent correspondences, there is an urgent need to assess effects of the current pandemic on the mental health and well-being of college students [ 14 - 17 ].

The aim of this study is to identify major stressors associated with the COVID-19 pandemic and to understand their effects on college students’ mental health. This paper documents the findings from online interview surveys conducted in a large university system in Texas.

Study Design

A semistructured interview survey guide was designed with the purpose of assessing the mental health status of college students both quantitatively and qualitatively. In addition, the interview aimed to capture the ways that students have been coping with the stress associated with the pandemic situation. First, our study assesses participants’ general stress levels using the Perceived Stress Scale-10 (PSS) [ 18 ]. PSS is a widely used instrument to measure overall stress in the past month [ 19 ]. Second, participants were asked if their own and peers’ (two separate questions) stress and anxiety increased, decreased, or remained the same because of the COVID-19 pandemic. For those who indicated increased stress and anxiety during the pandemic, we questioned their stress coping strategies and use of available mental health counseling services. We then elicited pandemic-specific stressors and their manifestations across 12 academic-, health-, and lifestyle-related categories of outcomes such as effects on own or loved ones’ health, sleeping habits, eating habits, financial situation, changes to their living environment, academic workload, and social relations. Students were also asked about the impact of COVID-19 on depressive and suicidal thoughts. These constructs were derived from existing literature identifying prominent factors affecting college students’ mental health [ 20 , 21 ]. Feedback on the severity of COVID-19’s impact on these aspects were elicited using a 4-point scale: 0 (none), 1 (mild), 2 (moderate), and 3 (severe). Participants were asked to elaborate on each response. Third, participants were guided to describe stressors, coping strategies, and barriers to mental health treatment during a typical semester without associating with the COVID-19 pandemic. Although multiple analyses of the collected data are currently under progress, PSS results and the COVID-19–related findings are presented in this paper.

Participants

Participants were recruited from the student population of a large university system in Texas, United States. This particular university closed all their campuses on March 23, 2020, and held all its classes virtually in response to the COVID-19 pandemic. In addition, the state of Texas issued a stay-at-home order on April 2, 2020. Most interviews were conducted about 1 month after the stay-at-home order in April 2020. Figure 1 illustrates the trend of cumulative confirmed cases and a timeline of major events that took place in the university and the state of Texas. Participants were recruited by undergraduate student researchers through email, text messaging, and snowball sampling. The only inclusion criteria for participation was that participants should have been enrolled as undergraduate students in the university at the time of the interviews.

The interviews were conducted by 20 undergraduate researchers trained in qualitative methods and the use of the interview survey guide described above. None of the authors conducted the interviews. All interviews were conducted via Zoom [ 22 ] and were audio recorded. The recordings were later transcribed using Otter.ai [ 23 ], an artificial intelligence–based transcription service, and verified for accuracy manually. Prior to the interview, participants were provided an information document about the study approved by the university’s Institutional Review Board (No 2019-1341D). Upon verbal consent, participants were asked to respond to a questionnaire about their demographic information such as age, gender, year of college, and program of study before completing the interview. Participation was voluntary and participants were not compensated.

Data Analysis

First, descriptive statistics were compiled to describe participants’ demographics (eg, age, gender, academic year, and major) and the distribution of the ratings on PSS-10 survey items. A total PSS score per participant was calculated by first reversing the scores of the positive items (4-7, 9, and 10) and then adding all the ten scores. A mean (SD) PSS score was computed to evaluate the overall level of stress and anxiety among the participants during the COVID-19 pandemic. Second, participants’ answers to 12 academic-, health-, and lifestyle-related questions were analyzed to understand relative impacts of the pandemic on various aspects of college students’ mental health. Percentages of participants who indicated negative ratings (ie, mild, moderate, or severe influence) on these questions were calculated and ranked in a descending order. Qualitative answers to the 12 stressors and coping strategies were analyzed using thematic analysis [ 24 , 25 ] similar to the deductive coding step in the grounded theory method [ 26 ]. A single coder (CS), trained in qualitative analysis methods, analyzed the transcripts and identified themes using an open coding process, which does not use a priori codes or codes created prior to the analysis and places an emphasis on information that can be extracted directly from the data. Following the identification of themes, the coder discussed the codes with two other coders (XW and AS) trained in qualitative analysis and mental health research to resolve discrepancies among related themes and discuss saturation. The coders consisted of two Ph.D. students and one postdoctoral fellow at the same university. MAXQDA (VERBI GmbH) [ 27 ] was used as a computer software program to carry out the qualitative analysis.

Of the 266 university students initially recruited by the undergraduate researchers, 17 retreated and 249 participated in this study. There were 3 graduate students and 51 participants who had missing data points and were excluded, and data from 195 participants were used in the analysis. The average age was 20.7 (SD 1.7) years, and there were more female students (111/195, 57%) than male students (84/195, 43%). Approximately 70% of the participants were junior and senior students. About 60% of the participants were majoring in the college of engineering, which was the largest college in the university population ( Table 1 ). The mean PSS score for the 195 participants was 18.8 (SD 4.9), indicating moderate perceived stress in the month prior to the interview ( Table 2 ).

a PSS: Perceived Stress Scale-10.

Challenges to College Students’ Mental Health During COVID-19

Out of 195 participants, 138 (71%) indicated that their stress and anxiety had increased due to the COVID-19 pandemic, whereas 39 (20%) indicated it remained the same and 18 (9%) mentioned that the stress and anxiety had actually decreased. Among those who perceived increased stress and anxiety, only 10 (5%) used mental health counseling services. A vast majority of the participants (n=189, 97%) presumed that other students were experiencing similar stress and anxiety because of COVID-19. As shown in Figure 2 , at least 54% (up to 91% for some categories) of participants indicated negative impacts (either mild, moderate, or severe) of COVID-19 on academic-, health-, and lifestyle-related outcomes. The qualitative analysis yielded two to five themes for each category of outcomes. The chronic health conditions category was excluded from the qualitative analysis due to insufficient qualitative response. Table 3 presents the description and frequency of the themes and select participant quotes.

a Not every participant provided sufficient elaboration to allow for identification of themes, so the frequency of individual themes does not add up to the total number of participants who indicated negative impacts of the COVID-19 outbreak.

b The five-digit alphanumeric value indicates the participant ID.

c TA: teaching assistant.

Concerns for One’s Own Health and the Health of Loved Ones

A vast majority of the participants (177/195, 91%) indicated that COVID-19 increased the level of fear and worry about their own health and the health of their loved ones. Over one-third of those who showed concern (76/177, 43%) were worried about their families and relatives who were more vulnerable, such as older adults, those with existing health problems, and those who are pregnant or gave birth to a child recently. Some of the participants (26/177, 15%) expressed their worry about their family members whose occupation increased their risk of exposure to COVID-19 such as essential and health care workers. Some participants (19/177, 11%) specifically mentioned that they were worried about contracting the virus.

Difficulty With Concentration

A vast majority of participants (173/195, 89%) indicated difficulty in concentrating on academic work due to various sources of distraction. Nearly half of them (79/173, 46%) mentioned that their home is a distractive environment and a more suitable place to relax rather than to study. Participants mentioned that they were more prone to be interrupted by their family members and household chores at home. Other factors affecting students’ concentration were lack of accountability (21/173, 12%) and social media, internet, and video games (19/173, 11%). Some (18/173, 10%) stated that online classes were subject to distraction due to lack of interactions and prolonged attention to a computer screen. Additionally, monotonous life patterns were mentioned by some to negatively affect concentration on academic work (5/173, 3%).

Disruption to Sleep Patterns

A majority of participants (168/195, 86%) reported disruptions to their sleep patterns caused by the COVID-19 pandemic, with over one-third (38%) reporting such disruptions as severe. Half of students who reported some disruption (84/168, 50%) stated that they tended to stay up later or wake up later than they did before the COVID-19 outbreak. Another disruptive impact brought by the pandemic was irregular sleep patterns such as inconsistent time to go to bed and to wake up from day to day (28/168, 17%). Some (12/168, 7%) reported increased hours of sleep, while others (10/168, 6%) had poor sleep quality.

Increased Social Isolation

A majority of participants answered that the pandemic has increased the level of social isolation (167/195, 86%). Over half of these students (91/167, 54%) indicated that their overall interactions with other people such as friends had decreased significantly. In particular, about one-third (52/167, 31%) shared their worries about a lack of in-person interactions such as face-to-face meetings. Others (9/167, 5%) stated that disruptions to their outdoor activities (eg, jogging, hiking) have affected their mental health.

Concerns About Academic Performance

A majority of participants (159/195, 82%) showed concerns about their academic performance being impacted by the pandemic. The biggest perceived challenge was the transition to online classes (61/159, 38%). In particular, participants stated their concerns about sudden changes in the syllabus, the quality of the classes, technical issues with online applications, and the difficulty of learning online. Many participants (36/159, 23%) were worried about progress in research and class projects because of restrictions put in place to keep social distancing and the lack of physical interactions with other students. Some participants (23/159, 14%) mentioned the uncertainty about their grades under the online learning environment to be a major stressor. Others (12/159, 8%) indicated their reduced motivation to learn and tendency to procrastinate.

Disruptions to Eating Patterns

COVID-19 has also negatively impacted a large portion of participants’ dietary patterns (137/195, 70%). Many (35/137, 26%) stated that the amount of eating has increased, including having more snacks since healthy dietary options were reduced, and others (27/137, 20%) addressed that their eating patterns have become inconsistent because of COVID-19, for example, irregular times of eating and skipping meals. Some students (16/137, 12%) reported decreased appetite, whereas others (7/137, 5%) were experiencing emotional eating or a tendency to eat when bored. On the other hand, some students (28/195, 14%) reported that they were having healthier diets, as they were cooking at home and not eating out as much as they used to.

Changes in the Living Environment

A large portion of the participants (130/195, 67%) described that the pandemic has resulted in significant changes in their living conditions. A majority of these students (89/130, 68%) referred to living with family members as being less independent and the environment to be more distractive. For those who stayed in their residence either on- or off-campus (18/130, 14%), a main change in their living environment was reduced personal interactions with roommates. Some (9/130, 7%) mentioned that staying inside longer due to self-quarantine or shelter-in-place orders was a primary change in their living circumstances.

Financial Difficulties

More than half of the participants (115/195, 59%) expressed their concerns about their financial situations being impacted by COVID-19. Many (44/115, 38%) noted that COVID-19 has impacted or is likely to impact their own current and future employment opportunities such as part-time jobs and internships. Some (21/115, 18%) revealed the financial difficulties of their family members, mostly parents, getting laid off or receiving pay cuts in the wake of COVID-19.

Increased Class Workload

The effect of COVID-19 on class workload among the college students was not conclusive. Although slightly over half of participants (106/195, 54%) indicated their academic workload has increased due to COVID-19, the rest stated the workload has remained the same (70/195, 36%) or rather decreased (19/195, 10%). For those who were experiencing increased workloads, nearly half (51/106, 48%) thought they needed to increase their own efforts to catch up with online classes and class projects given the lack of in-person support from instructors or teaching assistants. About one-third of the participants (33/106, 31%) perceived that assignments had increased or became harder to do. Some (6/106, 6%) found that covering the remainder of coursework as the classes resumed after the 2-week break to be challenging.

Depressive Thoughts

When asked about the impact of the COVID-19 pandemic on depressive thoughts, 44% (86/195) mentioned that they were experiencing some depressive thoughts during the COVID-19 pandemic. Major contributors to such depressive thoughts were loneliness (28/86, 33%), insecurity or uncertainty (10/86, 12%), powerlessness or hopelessness (9/86, 10%), concerns about academic performance (7/86, 8%), and overthinking (4/86, 5%).

Suicidal Thoughts

Out of 195 participants, 16 (8%) stated that the pandemic has led to some suicidal thoughts with 5% (10/16) reporting these thoughts as mild and 3% (6/16) as moderate. There were 6 participants (38%) that attributed their suicidal thoughts to the presence of depressive thoughts. Other reasons were related to academic performance (1/16, 6%), problems with family as they returned home (1/16, 6%), and fear from insecurity and uncertainty (1/16, 6%).

Coping Mechanism During COVID-19

To cope with stress and anxiety imposed by COVID-19, college students reported seeking support from others but were mainly using various self-management methods.

Self-Management

The majority of the participants (105/138, 76%) with increased stress due to the outbreak of COVID-19 explained that they were using various means to help themselves cope with stress and anxiety during the pandemic. Some (24/105, 23%) relied on negative coping methods such as ignoring the news about COVID-19 (10/105), sleeping longer (7/105), distracting themselves by doing other tasks (5/105), and drinking or smoking (2/105). Approximately one-third (30/105, 29%) used positive coping methods such as meditation and breathing exercises (18/105), spiritual measures (7/105), keeping routines (4/105), and positive reframing (2/105). A majority of the participants (73/105, 70%) who used self-management mentioned doing relaxing hobbies including physical exercise (31/105), enjoying streaming services and social media (22/105), playing with pets (7/105), journaling (5/105), listening to music (4/105), reading (2/105), and drawing (2/105). Finally, some participants (15/105, 14%) stated that they were planning activities (eg, drafting to-do lists) for academic work and personal matters as a self-distraction method.

Seeking Support From Others

Approximately one-third of the participants (47/138, 34%) mentioned that communicating with their families and friends was a primary way to deal with stress and anxiety during COVID-19. Some explicitly stated that they were using a virtual meeting application such as Zoom frequently to connect to friends and family. Only 1 participant claimed to be receiving support from a professional therapist, and another participant was using Sanvello, a mobile mental health service app provided by the university.

Barriers to Seeking Professional Support During COVID-19

Despite the availability of tele-counseling and widespread promotion of such services by the university, a vast majority of participants who indicated an increase in stress and anxiety (128/138, 93%) claimed that they had not used school counseling services during the pandemic. Reasons for such low use included the condition not being perceived as severe enough to seek the services (4/128, 3%), not comfortable interacting with unfamiliar people (1/128, 0.8%), not comfortable talking about mental health issues over the phone (1/128, 0.8%), and lack of trust in the counseling services (1/128, 0.8%).

Principal Findings

College students comprise a population that is considered particularly vulnerable to mental health concerns. The findings of this study bring into focus the effects of pandemic-related transitions on the mental health and well-being of this specific population. Our findings suggest a considerable negative impact of the COVID-19 pandemic on a variety of academic-, health-, and lifestyle-related outcomes. By conducting online survey interviews in the midst of the pandemic, we found that a majority of the participants were experiencing increased stress and anxiety due to COVID-19. In addition, results of the PSS showed moderate levels of stress among our participants. This is in line with a recent pre–COVID-19 survey conducted in the United Kingdom (mean PSS score 19.79, SD 6.37) [ 28 ]; however, the administration of PSS as interview questions (compared to allowing participants to read and respond to the 10 questions) might have introduced bias and resulted in underreporting.

Among the effects of the pandemic identified, the most prominent was worries about one’s own health and the health of loved ones, followed by difficulty concentrating. These findings are in line with recent studies in China that also found concerns relating to health of oneself and of family members being highly prevalent among the general population during the pandemic. Difficulty in concentrating, frequently expressed by our participants, has previously been shown to adversely affect students’ confidence in themselves [ 29 ], which has known correlations to increased stress and mental health [ 30 ]. In comparison with stress and anxiety in college students’ general life, it appears that countermeasures put in place against COVID-19, such as shelter-in-place orders and social distancing practices, may have underpinned significant changes in students’ lives. For example, a vast majority of the participants noted changes in social relationships, largely due to limited physical interactions with their families and friends. This is similar to recent findings of deteriorated mental health status among Chinese students [ 10 ] and increased internet search queries on negative thoughts in the United States [ 31 ]. The findings on the impact of the pandemic on sleeping and eating habits are also a cause for concern, as these variables have known correlations with depressive symptoms and anxiety [ 20 ].

Although a majority of participants expressed concerns regarding academic performance, interestingly, almost half of the participants reported lower stress levels related to academic pressure and class workload since the pandemic began. This may be due, in part, to decisions taken by professors and the university to ease the students’ sudden transition to distance learning. For instance, this university allowed students to choose a pass/fail option for each course instead of a regular letter grade. Additionally, actions taken by professors, such as reduced course loads, open book examinations, and other allowances on grading requirements, could also have contributed to alleviating or reducing stress. Although participants who returned to their parental home reported concerns about distractions and independence, students might have benefited from family support and reduced social responsibilities. Therefore, the increased stress due to the pandemic may have been offset, at least to some extent.

Alarmingly, 44% (86/195) of the participants reported experiencing an increased level of depressive thoughts, and 8% (16/195) reported having suicidal thoughts associated with the COVID-19 pandemic. Previous research [ 32 ] reported about 3%-7% of the college student population to have suicidal thoughts outside of the pandemic situation. Furthermore, with the exception of high-burnout categories, depression levels among students, reported in several recent studies [ 33 - 35 ], have varied between 29% and 38%, which may suggest an uptick in pandemic-related depressive symptoms among college students similar to recent studies in China [ 10 , 11 ]. Although our participants specifically mentioned several factors such as feelings of loneliness, powerlessness, as well as financial and academic uncertainties, other outcomes that were perceived to be impacted by the COVID-19 pandemic may also act as contributors to depressive thoughts and suicidal ideation. In particular, both difficulty concentrating and changes in sleeping habits are associated with depression [ 20 , 29 , 36 ].

Our study also identifies several coping mechanisms varying between adaptive and maladaptive behaviors. The maladaptive coping behaviors such as denial and disengagement have been shown to be significant predictors of depression among young adults [ 37 ]. In contrast, adaptive coping such as acceptance and proactive behaviors are known to positively impact mental health. Our findings suggest that the majority of our participants exhibited maladaptive coping behaviors. Identifying students’ coping behavior is important to inform the planning and design of support systems. In this regard, participatory models of intervention development can be used, in which researchers’ and psychologists’ engagement with the target population to adapt interventional programs to their specific context has shown promise [ 37 , 38 ]. For instance, Nastasi et al [ 37 ] used a participatory model to develop culture-specific mental health services for high school students in Sri Lanka. Similar approaches can be adopted to engage college students as well to develop a mental health program that leverages their natural positive coping behaviors and addresses their specific challenges.

Participants described several barriers to seeking help, such as lack of trust in counseling services and low comfort levels in sharing mental health issues with others, which may be indicative of stigma. Perceiving social stigma as a barrier to seeking help and availing counseling services and other support is common among students [ 29 ]. One study showed that only a minor fraction of students who screened positive for a mental health problem actually sought help [ 39 ]. Although overcoming the stigma associated with mental health has been discussed at length, practical ways of mitigating this societal challenge remains a gap [ 40 , 41 ]. Our findings suggest that self-management is preferred by students and should be supported in future work. Digital technologies and telehealth applications have shown some promise to enable self-management of mental health issues [ 42 ]. For instance, Youn et al [ 43 ] successfully used social media networks as a means to reach out to college students and screen for depression by administering a standardized scale, the Patient Health Questionnaire-9. Digital web-based platforms have also been proposed to enhance awareness and communication with care providers to reduce stigma related to mental health among children in underserved communities [ 44 ]. For instance, one of the online modules suggested by the authors involves providing information on community-identified barriers to communicating with care providers. Technologies such as mobile apps and smart wearable sensors can also be leveraged to enable self-management and communication with caregivers.

In light of the aforementioned projections of continued COVID-19 cases at the time of this writing [ 45 ] and our findings, there is a need for immediate attention to and support for students and other vulnerable groups who have mental health issues [ 17 ]. As suggested by a recent study [ 46 ] based on the Italian experience of this pandemic, it is essential to assess the population’s stress levels and psychosocial adjustment to plan for necessary support mechanisms, especially during the recovery phase, as well as for similar events in the future. Although the COVID-19 pandemic seems to have resulted in a widespread forced adoption of telehealth services to deliver psychiatric and mental health support, more research is needed to investigate use beyond COVID-19 as well as to improve preparedness for rapid virtualization of psychiatric counseling or tele-psychiatry [ 47 - 49 ].

Limitations and Future Work

To our knowledge, this is the first effort in documenting the psychological impacts of the COVID-19 pandemic on a representative sample of college students in the United States via a virtual interview survey method in the middle of the pandemic. However, several limitations should be noted. First, the sample size for our interview survey was relatively small compared to typical survey-only studies; however, the survey interview approach affords the capture of elaboration and additional clarifying details, and therefore complements the survey-based approaches of prior studies focusing on student mental health during this pandemic [ 10 , 11 , 50 ]. Second, the sample used is from one large university, and findings may not generalize to all college students. However, given the nationwide similarities in universities transitioning to virtual classes and similar stay-at-home orders, we expect reasonable generalizability of these findings. Additionally, a majority of our participants were from engineering majors. Therefore, future work is needed to use a stratified nationwide sample across wider disciplines to verify and amend these findings. Third, although a vast majority of participants answered that they have not used the university counseling service during the pandemic, only a few of them provided reasons. Since finding specific reasons behind the low use is a key to increasing college students’ uptake of available counseling support, future research is warranted to unveil underlying factors that hinder college students’ access to mental health support. Finally, we did not analyze how student mental health problems differ by demographic characteristics (eg, age, gender, academic year, major) or other personal and social contexts (eg, income, religion, use of substances).

Future work could focus on more deeply probing the relationships between various coping mechanisms and stressors. Additionally, further study is needed to determine the effects of the pandemic on students’ mental health and well-being in its later phases beyond the peak period. As seen in the case of health care workers in the aftermath of the severe acute respiratory syndrome outbreak, there is a possibility that the effects of the pandemic on students may linger for a period beyond the peak of the COVID-19 pandemic itself [ 51 ].

Acknowledgments

This research was partly funded by a Texas A&M University President’s Excellence (X-Grant) award.

Conflicts of Interest

None declared.

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Abbreviations

Edited by G Eysenbach, G Fagherazzi, J Torous; submitted 10.06.20; peer-reviewed by T Liu, V Hagger; comments to author 28.07.20; revised version received 01.08.20; accepted 15.08.20; published 03.09.20

©Changwon Son, Sudeep Hegde, Alec Smith, Xiaomei Wang, Farzan Sasangohar. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 03.09.2020.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information must be included.

Students’ Mental Well-Being During the COVID-19 Pandemic: Exploring Ways Institutions Can Foster Undergraduate Students’ Mental Well-Being

• Gudrun Nyunt, Ph.D. Northern Illinois University
• Jeanine McMillen, Ed.D Waubonsee Community College
• Kaley Oplt University of Northern Colorado
• Vanessa Beckham Beloit College

College student mental health has been a concern on U.S. college campuses for decades. The COVID-19 pandemic, which started to impact operations on U.S. college campuses in March 2020, created new stressors and challenges that negatively impacted college student mental health. The purpose of this mixed-methods study was to explore the mental well-being of undergraduate students at one large, public institution in the midwestern United States during the Fall 2020 semester. We collected data via two surveys, one at the beginning and one at the end of the Fall 2020 semester, as well as interviews at the beginning of the Spring 2021 semester. Overall, participants reported significantly lower social-psychological well-being during the COVID-19 pandemic than pre-pandemic. Participants struggled with social isolation, academic challenges, and a lack of motivation. Participants appreciated opportunities to engage with others, flexible and supportive faculty, and efforts of institutional leadership to keep them safe. However, participants had mixed feelings about the way institutional safety regulations and information on resources was communicated. While some found support through on-campus counseling services, others encountered barriers when trying to seek help. By early spring 2021, many participants had developed their own strategies to proactively foster their well-being. Findings indicate a need for institutions to more proactively foster students’ well-being during and beyond the COVID-19 pandemic. Implications for practice are discussed.

Funding: This work was supported by a NASPA Region IV-East Research and Assessment Grant.

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Journal of Student Affairs Inquiry, Improvement, and Impact eISSN: 2381-5396

Data: What We Know About Student Mental Health and the Pandemic

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It’s been a rough year.

Since the pandemic began, children and adolescents have higher rates of anxiety, depression, and stress, and even more specific issues such as addictive internet behaviors.

“I’ve never had so many referrals than in the last six months. … Normally it’s two or three a month and now it’s maybe two a week,” said Celeste Birkhofer, a licensed clinical psychologist at Stanford Medical School who works with children’s mental health issues. “I’m booked. I try to help send them to other colleagues and they’re booked, too. It’s challenging, especially challenging for a family that’s feeling like they’re in a bit of a crisis.”

The U.S. Centers for Disease Control and Prevention reported that from April through October of last year, the proportion of children between the ages of 5 and 11 visiting an emergency department because of a mental health crisis climbed 24 percent compared to that same time period in 2019. Among 12- to 17-year-olds, the number increased by 31 percent.

And that increase took place in a virus-laden year during which many people were hesitant to seek medical attention.

The effects of the pandemic on students are likely to be felt for years to come, experts say.

“The issue is that there can be a very long delay. It can be someone reacts to an event that happened a year or two or 10 years ago with a kind of trauma-related response or depression or suicide,” said Sara Gorman, the research and knowledge director for the JED Foundation, a national nonprofit that works with high schools and colleges on student mental health issues. “We obviously won’t know what the full impact of this is for many years, which is one of the reasons why it’s important for schools to be prepared to deal with this in a very comprehensive and long-term way.”

In a nationally representative survey of more than 2,000 parents and nearly 900 teenagers this fall, the JED Foundation found that fundamental fears about the pandemic—how long it will last, whether the student or their family will get ill—cause more anxiety for teenagers than keeping up on their academics or getting ready for college. That suggests helping students learn to cope with the pandemic will be critical to keeping them focused on school.

EdWeek survey highlights disparities

In a separate new nationally representative survey, the EdWeek Research Center asked both educators and students in grades 9 through 12 to talk about the mental health challenges they’ve faced and supports they’ve received during the pandemic.

The survey also highlights disparities in how the pandemic has affected high school students. A wide majority of all students reported they are experiencing more problems now than they did in January 2020, before the pandemic began, but 77 percent of Black and Latinx students reported more struggles, at least 9 percentage points higher than the percentage of white or Asian students who said the same. Low-income and LGBTQ students were also significantly more likely to report experiencing more problems in the wake of the pandemic.

While nearly 1 in 4 white students are back to full-time in-person classes, it’s closer to 1 in 10 Black, Latinx, and Asian American students who are attending in person full time. By contrast, 64 percent or more of students of color are still learning entirely in remote classes, compared to only 41 percent of white students.

That can make a big difference in how easily students feel they can get support when they are struggling mentally and emotionally. Only 64 percent of high school students who were in full-time remote classes reported there was “at least one adult at school to talk to” if they are “feeling upset, stressed, or having problems”—9 percentage points lower than students attending hybrid schooling, and 20 percentage points lower than students back in regular in-person classes. Students, particularly low-income students, were also significantly less likely to report that their school offered mental health programs like counseling than their principals did, and they were more likely to think mental health services were no longer available after the pandemic.

The question of resources remains huge and uncertain, however.

The federal COVID-19 relief package signed into law March 11 includes grants to support youth suicide prevention and child trauma interventions, but it does not provide direct funding for schools for student mental health. There has been some effort by Democrats in the U.S. House of Representatives to authorize grants to school districts through the federal Substance Abuse and Mental Health Services Administration, but no similar bill yet in the Senate, and it’s uncertain how successful the effort will be now that the stimulus package has been completed.

Coverage of whole-child approaches to learning is supported in part by a grant from the Chan Zuckerberg Initiative, at www.chanzuckerberg.com . Education Week retains sole editorial control over the content of this coverage. A version of this article appeared in the March 31, 2021 edition of Education Week as What We Know About Student Mental Health and the Pandemic

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Educators are key in protecting student mental health during the COVID-19 pandemic

Subscribe to the brown center on education policy newsletter, marty swanbrow becker marty swanbrow becker associate professor of psychological and counseling services, educational psychology and learning systems department - florida state university.

February 24, 2021

American students were experiencing widespread mental-health distress long before the COVID-19 pandemic took hold. A tragic expression of this distress, youth suicide has been on the rise for the past decade and is now the second leading cause of death for 15- to 24-year-olds . Now, the pandemic is making matters worse. In a recent survey , over 80% of college students reported that COVID-19 has impacted their lives through increased isolation, loneliness, stress, and sadness. Although it’s too soon to conclusively link national youth suicide data to the pandemic, school districts across the nation have been reporting alarming spikes in both suicides and attempts at self-harm.

These connections are entirely unsurprising given what we know about the impact of social isolation on mental and emotional well-being. While stay-at-home orders, quarantines, and social-distancing precautions are essential public-health tools for curbing the spread of infectious disease, these measures may well have the opposite effect on the prevalence of psychological anguish and distress. Students in kindergarten through college faced a sudden transition to online learning in the spring of 2020, finding themselves abruptly disconnected from their established daily routines, support systems, and sources of security. This disruption occurred at the precipice of a year of extended isolation in the context of a devastating global pandemic and social, political, and economic unrest. Millions of students have still not returned to the classroom and new research identifies young adults as the most vulnerable group for anxiety and depression during the pandemic. Indeed, we find ourselves amid a student mental-health crisis.

As we continue to weather the impacts of the pandemic and work toward recovery and an eventual full return the classroom, here are three things educators, school counselors, administrators, and parents can do.

1. Know the warning signs of distress in students.

Given the scale of disruption that students have experienced over the course of the pandemic, parents and educators should know that some increased stress, anxiety, and apathy among students is expected. Students who were thriving in an active educational community before the pandemic may resist or find it difficult to fully participate in a virtual environment. As a college professor, I’ve noticed students who were confident and enthusiastic participants in the classroom struggle in finding their voice during a Zoom class riddled with technological glitches and new cultural norms related to communication. As a parent, I’ve navigated myriad meltdowns trying to convince my six-year-old to log on to yet another day of virtual school. While not necessarily normal, this type of low-grade distress has become the norm in these strange times.

Parents and educators should expect challenges but keep a careful lookout for sudden or extreme changes in student behavior, moods, and activities. If a student abruptly begins refusing to participate in their normal activities or begins lashing out in ways that cause harm to themselves or others, it is important to connect them with resources to help. As students begin returning to the classroom, educators should watch for new signs of social phobia or discomfort, understanding that students may struggle to transition seamlessly back into the social setting they successfully navigated in pre-COVID-19 times.

With so much going on, it may be hard for adults to spot signs of distress in a timely manner. Harnessing increasingly sophisticated technological risk-assessment tools , creating smaller group settings for students, maintaining connection touch points, and championing a culture that empowers peers to look out for each other (such as the Sources of Strength model ) are all ways to help ensure that someone spots and acts on a warning sign in time.

2. Connect students with resources to help.

For students who are struggling, resources for help are out there. The trick is connecting students to the best form of available support, whether in their homes, schools, or communities. Communication is key to this challenge. At my children’s elementary school, a “parents as partners” model establishes and encourages pathways for communication between parents and teachers. This is a great place for educators and parents to start. Parents should know whom to talk to at their child’s school or university about mental health concerns and should be aware of the school’s resources for helping. Educators and administrators should be proactive in sharing information about mental well-being programs available on their campus and in the community as well as school policies with parents, so that adults are working together to identify and address problems before they become more serious.

Parents can provide resources at home, including dedicating physical space for virtual learning and creating structure for students to focus on school at home, while offering plenty of breaks to step away from screens and get outside. Distressed students might benefit from at least some in-person connection with peers—another important resource—if (and only if) parents can find safe ways for such interactions to occur. Considering the high levels of stress that students, parents, and teachers have been exposed to over a long time, we all should actively seek pleasant activities and practice self-compassion to increase our ability to cope.

Educators and administrators can help by making available dedicated resources for mental well-being, resilience, addressing challenges with online learning, and assisting with the transition back to in-person learning. This may take the form of counseling staff or services, or a comprehensive online program such as the Student Resilience Project Toolkit , a trauma-informed, student mental-health and wellness toolkit recently launched at my university to help students build coping skills and connect them to university resources. Parents, educators, and administrators should always have available community resources at the ready to share with students, such as the National Suicide Prevention Lifeline or the Trevor Project to support LGBTQ youth.

3. Build social connection.

Just as we can intuit that social isolation is likely to exacerbate psychological distress and even suicide risk, we can expect social connection to be a strong protective factor for young people. In fact, research tells us that students at risk of suicide are more likely to turn to a peer than an adult or authority figure for help, and that social connection may reduce the risk of suicide by fostering a sense of belonging. Indeed, tapping into existing peer networks appears to be a promising means of supporting students and intervening with those who are struggling. The challenge, though, is how do schools and universities nurture social connection in the virtual, inherently disconnected environment of the pandemic?

I hope to address this question directly in upcoming research, but for now I can share some best practices already at educators’ fingertips. For example, when it comes to social connection in an educational setting, class size matters. Especially in a virtual setting, reducing class sizes or offering ample opportunity for dedicated small-group interaction for the same kids to interact over time can help students feel more connected to their peers. One-on-one connection points are critical, too. If it is not feasible to offer students extended one-on-one time with a teacher, pairing students with a peer or an older student mentor can encourage students to support each other and connect over what they are learning. Educators should also take care to prioritize opportunities for active connection (direct, back-and-forth interactions) over passive connection (scrolling a chat or social-media feed), as passive connection can have the opposite effect on the goal of increasing social connection. Educators should also be explicit with students that they are a source of support for mental-health issues.

The bottom line in these challenging times is that focused, meaningful interactions matter greatly. Encourage students to take breaks from screens when they can and take care to cultivate connections wherever possible. Schools and parents may find the benefits to mental well-being extend far beyond the end of the pandemic.

Thanks to Lily Swanbrow Becker for writing support on this post.

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Sleep Duration, Mental Health, and Increased Difficulty Doing Schoolwork Among High School Students During the COVID-19 Pandemic

RESEARCH BRIEF — Volume 20 — March 16, 2023

Sarah A. Sliwa, PhD 1 ; Anne G. Wheaton, PhD 1 ; Jingjing Li, MD, PhD, MPH 2 ; Shannon L. Michael, PhD, MPH 1 ( View author affiliations )

Suggested citation for this article: Sliwa SA, Wheaton AG, Li J, Michael SL. Sleep Duration, Mental Health, and Increased Difficulty Doing Schoolwork Among High School Students During the COVID-19 Pandemic. Prev Chronic Dis 2023;20:220344. DOI: http://dx.doi.org/10.5888/pcd20.220344 .

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Acknowledgments

Author information.

What is already known on this topic?

Insufficient sleep among adolescents has been associated with lower academic grades, increased health risk behaviors, and poorer physical and mental health.

What is added by this report?

Most high school students were not sleeping enough during the COVID-19 pandemic, which was correlated with poor mental health. Students who experienced short sleep duration were more likely to report greater difficulty doing schoolwork during the pandemic than before the pandemic.

What are the implications for public health practice?

Schools can consider including policies and practices known to improve sleep duration within a broader strategy to bolster adolescent mental health and learning.

We estimated the prevalence of short sleep duration (<8 h/average school night) among high school students (grades 9–12) during the COVID-19 pandemic by using data from the Adolescent Behaviors and Experiences Survey (January–June 2021; N = 7,705). An adjusted logistic regression model predicted prevalence ratios for more difficulty doing schoolwork during the pandemic compared with before the pandemic. Most (76.5%) students experienced short sleep duration, and two-thirds perceived more difficulty doing schoolwork. Students who slept less than 7 hours per school night or experienced poor mental health were more likely to report increased difficulty doing schoolwork. Addressing students’ sleep duration could complement efforts to bolster their mental health and learning.

The COVID-19 pandemic has disrupted daily life in many ways, including changes that could either improve or impede sleep duration among adolescents. Periods of remote learning may have provided opportunities for adolescents to sleep late; findings from some small studies suggest adolescents may have shifted to later bedtimes and wake times and slept longer (1–3). Short sleep duration among adolescents is linked to higher risk of injury, worse metabolic and mental health, and difficulty focusing (4). The prevalence of short sleep duration and its association with difficulty doing schoolwork and poor mental health during the COVID-19 pandemic have yet to be explored in a nationally representative sample. Examining this association and estimating the co-occurrence of short sleep duration with poor mental health might provide schools with an additional rationale to adopt policies that lead to improvements in sleep duration within a comprehensive approach to support student academic achievement and mental health.

We used data from the Adolescent Behaviors and Experiences Survey (ABES) — a one-time, nationally representative, cross-sectional survey of high school students (grades 9–12) — fielded from January through June 2021 (N = 7,705). The overall ABES response rate during the study period was 18% (school response rate [38%] × student response rate [48%]) (5). Details on ABES are available elsewhere (www.cdc.gov/healthyyouth/data/abes.htm). ABES was reviewed and approved by institutional review boards at the Centers for Disease Control and Prevention and ICF International (5).

Data on sleep duration were derived from the question “On an average school night, how many hours of sleep do you get?” ( Table 1 ). To align with American Academy of Sleep Medicine recommendations (8–10 h for ages 13–18 y) (4), we restricted analyses to participants who reported their age as 13 years or older. We combined the response options for 8, 9, and 10 or more hours into a single category (≥8 h), which resulted in 5 categories (≤4, 5, 6, 7, or ≥8 h). We defined short sleep duration as sleeping ≤4, 5, 6, or 7 hours and ≥8 hours as meeting sleep recommendations. Data on the primary outcome was derived from the question “Do you agree or disagree that doing your schoolwork was more difficult during the COVID-19 pandemic than before the pandemic started?” with “strongly agree” and “agree” coded as experiencing “more difficulty doing schoolwork” vs “not sure,” “disagree,” or “strongly disagree.”

Bivariate analyses (χ 2 tests, Pearson correlation) and univariate logistic regression models (Wald F test) assessed the associations between difficulty doing schoolwork, short sleep duration, and selected covariates (poor mental health, high level of screen time [≥5 h/d], and self-reported sex, race and ethnicity, grade, and hunger). An adjusted logistic regression model predicted prevalence ratios (PRs) for experiencing more difficulty doing schoolwork, including the covariates. We tested whether poor mental health modified the association between sleep duration and more difficulty doing schoolwork (interaction term: sleep duration × poor mental health). Analyses were conducted in SAS-callable SUDAAN version 11.0.3 (RTI International) and used sample weights to account for complex sampling and nonresponse. Statistical significance was set at P < .05.

The sample was evenly distributed across sex and grade and racially and ethnically diverse; no racial or ethnic group comprised a majority ( Table 2 ). Most high school students (76.5%) experienced short sleep duration, and 66.6% reported more difficulty doing schoolwork during the COVID-19 pandemic than before the pandemic.

Overall, 37.1% reported poor mental health during the pandemic, which correlated with short sleep duration (Pearson correlation r = 0.22, P < .001; χ 2 4 = 347.48, P < .001). Among students who met sleep recommendations, 25.2% reported poor mental health. About half of students who slept 5 (49.1%) or 4 hours or less (55.9%) reported poor mental health ( P < .001).

The unadjusted models confirmed the hypothesized association between short sleep duration and greater difficulty doing schoolwork, which remained robust after adjusting for covariates ( Table 3 ). Students who slept less than 7 hours during an average school night had a significantly greater prevalence of experiencing more difficulty doing schoolwork during the COVID-19 pandemic compared with students who met sleep duration recommendations (6 h sleep: PR = 1.17 [95% CI, 1.08–1.27]; 5 h sleep: PR = 1.18 [95% CI, 1.09–1.28]; ≤4 h sleep: PR = 1.20 [95% CI, 1.08–1.33] vs ≥8 h sleep).

Students who experienced poor mental health had 17% higher prevalence of more difficulty doing schoolwork compared with students who did not report poor mental health (PR = 1.17; 95% CI, 1.10–1.25). Poor mental health did not moderate the association between short sleep duration and more difficulty doing schoolwork. Students with 5 or more hours of screen time were slightly less likely to report more difficulty doing schoolwork than students who spent less than 5 hours per day using screens (PR = 0.95; 95% CI, 0.91–0.997). Self-reported sex, grade, and hunger were not associated with more difficulty doing schoolwork in the adjusted model. Hispanic or Latino students were more likely to report more difficulty doing schoolwork than White students.

Before the COVID-19 pandemic, short sleep duration was becoming more prevalent among US high school students (74.6% [73.1%–76.0%] in 2017 and 77.9% [76.3%–79.4%] in 2019, P < .001) (6). We found that short sleep duration remained widespread during the COVID-19 pandemic, affecting roughly three-quarters of students. Students who slept less than 7 hours during an average school night were more likely to report greater difficulty doing schoolwork during the pandemic compared with before the pandemic, as were those who experienced poor mental health. This study contributes to the literature by highlighting the co-occurrence of short sleep duration and poor mental health during the COVID-19 pandemic. Teachers have identified behavioral and mental health challenges among the leading barriers to addressing learning gaps during the 2022–2023 school year (7). Policies known to improve sleep duration among students, including later school start times and family practices, such as good sleep habits and parent-set bedtimes, might help support both learning and mental health (8,9).

Previously noted limitations to ABES include the low response rate and the inability to draw causal inferences about the impact of the COVID-19 pandemic (5). We note additional limitations. The recall period differed across some of the items: the sleep and screen time questions reference the average school day or night, whereas items about mental health and greater difficulty doing schoolwork reference “during the COVID-19 pandemic.” We do not know how students interpretated “average school day.” Rapid survey development during the COVID-19 pandemic precluded item validation and testing. Previous univariate models confirmed small significant associations in the expected direction between short sleep duration, self-reported hunger (10), and poor mental health (4), which suggests concurrent validity. We cannot account for some potential confounders, such as socioeconomic status and school instruction modality (eg, remote, hybrid, in-person). The latter may have influenced wake times and sleep duration, even if school start times were unchanged. Instruction modality may also have influenced self-reported screen time; the question excludes time doing schoolwork but does not specify whether to count time using screens to attend school. This may help explain the counterintuitive finding that a high level of screen time was inversely associated with greater difficulty doing schoolwork. ABES addressed a single dimension of sleep; we could not assess sleep quality, sleep schedules, or sleep disorders.

Nevertheless, our findings show that most students were not sleeping enough and that many students concurrently experienced poor mental health and insufficient sleep. Schools can consider addressing sleep duration within a broader strategy to bolster adolescent mental health and learning, including addressing protective factors (11,12).

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. No copyrighted materials were used in this article.

Corresponding Author: Sarah Sliwa, PhD, Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Hwy NE, Atlanta, Georgia 30341 ( [email protected] ).

Author Affiliations: 1 Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. 2 Division of Adolescent and School Health, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia.

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a Rather than setting a time limit, the American Academy of Pediatrics recommends placing consistent limits on the time spent using media and the types of media for adolescents and ensuring that media does not take the place of adequate sleep, physical activity, and other behaviors essential to health. From previous studies, we defined high level of screen time by using the largest response category: ≥5 hours per day.

Abbreviations: AIAN, American Indian or Alaska Native; NHPI, Native Hawaiian or Other Pacific Islander. a Ns are unweighted, percentages are weighted. b Respondents answered “agree” or “strongly agree.” c Respondents answered “always,” “most of the time,” or “sometimes.” d Respondents answered “always” or “most of the time.” e Hours of screen time encompass time spent “in front of a TV, computer, smart phone, or other electronic device watching shows or videos, playing games, accessing the Internet, or using social media (also called screen time ),” not including time spent doing schoolwork.

Abbreviations: AIAN, American Indian or Alaska Native; NHPI, Native Hawaiian or Other Pacific Islander. a Models present prevalence ratios calculated from predicted marginals from univariate logistic regressions. Each row presents the value from a regression model specific to that variable. b Sample size fluctuates for univariate models and is smaller for the fully adjusted model (N = 6,903) because of missing values. c Single model adjusted for self-reported hunger, poor mental health, screen time, sex, race or ethnicity, and grade. d P < .05 as indicated by Wald F test in logistic regression models. e Nonrounded value is 0.997, P = .03.

The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions.

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• Open access
• Published: 16 December 2022

Impact of COVID-19 pandemic on the mental health of university students in the United Arab Emirates: a cross-sectional study

• Anamika Vajpeyi Misra 1 ,
• Heba M. Mamdouh 3 , 4 ,
• Anita Dani 2 ,
• Vivienne Mitchell 1 ,
• Hamid Y. Hussain 3 ,
• Gamal M. Ibrahim 3 &
• Wafa K. Alnakhi 3 , 5  

BMC Psychology volume  10 , Article number:  312 ( 2022 ) Cite this article

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The COVID-19 pandemic had a significant impact on the mental well-being of students worldwide. There is a scarcity of information on the mental health impact of the COVID-19 pandemic on university students in the United Arab Emirates (UAE). This study aimed to investigate the mental health impact of the COVID-19, including depression, anxiety and resilience among a sample of university students in the UAE.

A cross-sectional study using an online survey was conducted from September to November 2021. The patient health questionnaire (PHQ-9), generalized anxiety disorder-7 (GAD-7) and Connor–Davidson Resilience Scale (CD-RISC-10) were used to assess depression, anxiety, and resilience. The COVID-19 impact was assessed using a list of questions.

Only, 798 students completed the survey and were analyzed for this study. Overall, 74.8% of the students were females, 91.2% were never married, and 66.3% were UAE-nationals. Based on PHQ-9 and GAD-7 cut-off scores (≥ 10), four out of ten of the students self-reported moderate to severe depression (40.9%) and anxiety (39.1%). Significantly higher mean PHQ-9 and GAD-7 scores were found among students who were impacted by COVID-19 than those non-impacted (mean PHQ-9 = 9.51 ± 6.39 and 6.80 ± 6.34; p  = 0.001, respectively) and (mean GAD-7 = 9.03 ± 6.00 and 8.54 ± 6.02; respectively, p  < 0.001). Female students who were impacted by COVID-19 had statistically significant higher depression and anxiety scores (mean PHQ-9 of 9.14 ± 5.86 vs. 6.83 ± 6.25, respectively; p  < 0.001) than the non-impacted females (mean GAD-7 of 9.57 ± 6.32 vs. 5.15 ± 3.88, respectively; p  = 0.005). Never married students had significantly higher PHQ-9 and GAD-7 scores than ever-married (9.31 ± 6.37 vs. 6.93 ± 5.47, P  = 0.003) and (8.89 ± 6.11 vs. 7.13 ± 5.49, respectively; p  = 0.017).

Conclusions

The results of this study demonstrate that the COVID-19 pandemic has negatively impacted the mental health of this sample of university students in terms of depression and anxiety. The results highlight the need to adopt culturally appropriate interventions for university students and focus on vulnerable groups.

Peer Review reports

Introduction

In March 2020, the World Health Organization declared the coronavirus disease 2019 (COVID-19) a world pandemic status [ 1 ]. The pattern of the virus has affected many aspects including physical wellbeing, psychosocial life, and the local and global economy [ 2 ]. The high morbidity and mortality rates and the ambiguity around the ongoing pandemic have brought up many mental sufferings for a large proportion of people worldwide [ 3 ]. In addition, the unprecedented public health interventions that were implemented across the globe, including the United Arab Emirates (UAE) caused a wide range of psychosocial impacts [ 4 ]. The societal effects of the COVID-19 pandemic are so pervasive—and yet vary so tremendously according to individual and contextual factors—that global characterization regarding its psychological impact is likely impossible [ 2 , 5 , 6 ].

Several studies have looked at the impact of epidemics on population mental health over the last few decades, and they have reported a wide range of psychological impacts [ 7 , 8 , 9 , 10 ]. Around the world, published research on the impact of the COVID-19 pandemic on mental health revealed that the pandemic is linked to an increase in the rates of depression, anxiety, stress and sleep disturbance among various population groups [ 11 , 12 , 13 , 14 , 15 , 16 , 17 ]. Research endorsed that universal pandemics can endanger one’s mental well-being since only some people are resilient to change in their environment and able to seek out psychological assistance when needed. Whilst others may emphasize on the physical aspect of themselves during the pandemic time rather than their mental well-being [ 18 ]. Psychologists define resilience as the process of adapting well in the face of adversity, trauma, tragedy, threats, or significant sources of stress—such as family and relationship problems [ 19 ]. People's reactions to crises vary, yet coping strategies to manage such situations require more investigation.

It is clear that the burden of mental health adverse outcomes of the pandemic is not equally shared. Indeed, a substantially greater risk accrues to those facing ongoing stressors, such as job loss, economic distress, occupational stress, responsibilities, social isolation, interpersonal loss, and virus exposure. Moreover, specific dispositional vulnerabilities or diatheses (such as internalizing tendencies or fears of contamination) could interact with the stress and may substantially increase the risk [ 20 ].

University students’ mental health issues are not well recognized and infrequently addressed. Students at universities are often at a vulnerable age (between adolescence and early adulthood), making them sensitive to mental illnesses [ 21 ]. Research revealed that student status was associated with a higher frequency of depressive and anxiety symptoms, perceived stress, and suicidal thoughts [ 21 ]. Blanco et al. estimated in their early research that half of the college-age people they surveyed had a mental health issue [ 22 ]. Literature showed that although the physical implications of COVID-19 were milder on young adults, their mental health was negatively impacted by the pandemic [ 23 ]. Reduced socialization along with the quarantine protocols due to COVID-19 resulted in worsened mood status and increased anxiety during the pandemic [ 23 ]. Patwary et al. 2022 found in their study that more than three in four students experienced clinically significant anxiety levels during the early stages of the COVID-19 pandemic. [ 24 ]. The mental health of young people has been a concern in the UAE, where a published study of the mental health of university students in the UAE (as screened by PHQ-9) found that the prevalence of depression among university students was estimated to be 22.2% [ 25 ]. In addition, a previous pre-pandemic study from the UAE revealed significant levels of anxiety among young adults, making this group especially prone to mental health issues [ 26 ].

Higher colleges of Technology (HCT), founded in 1988, is one of the largest applied higher education institutions, with 16 campuses across the UAE. Currently, there are 21,572 students enrolled in the HCT under 72 programs [ 27 ]. During the COVID-19 pandemic, HCT remained agile and swiftly moved to the online classes and assessments, then continued the hybrid learning model of education.

Despite excellent precautionary, preventative and therapeutic healthcare measures, being put in place by the UAE government, and the lower COVID-19 infection rates than the global average (8.12%), the psychological impact of COVID-19 on the UAE population should not be overlooked [ 25 , 26 ]. Information about the influence of COVID-19 on the mental health of the different sectors of the UAE population is limited [ 28 ]. Few published research pointed to a high prevalence of anxiety, depression, and stress among the general public [ 29 ], healthcare workers [ 30 , 31 ], and the elder population [ 32 ]. However, the mental health effects on university students within the UAE are inadequately addressed. Given these situations, it is important to investigate the university students’ mental health during the COVID- pandemic to inform the possible interventions. Therefore, the current study aimed to address a number of existing gaps including the COVID-19 impact on mental health, in particular depressive and anxiety symptoms, as well as to assess the resilience of a sample of HCT university students in the UAE during the COVID-19 pandemic. It also investigated the effect of some socio-demographic characteristics and the COVID- 19 impact on the mental health of the sampled students.

Materials and methods

Study population, design and setting.

A cross-sectional study was conducted among a sample of students who were enrolled in the undergraduate and postgraduate programs of the HCT university across the UAE. A structured self-administered questionnaire was used for data collection in the current study. Participants were recruited via announcements through the email network of the HTC University. The data collection took place online from September to November 2021. The responses were extracted using an electronic survey via the google survey tool (Google Forms). Participants were asked for consent approval before participation. The median completion time for the survey was 9 min. Based on the Raosoft calculator for sample size estimation, the minimum required sample for this study was 378 with a confidence interval of 95.0 and 0.5 margin of error [ 33 ]. Out of the total survey sent, 819 students voluntarily responded with a response rate of 43%. Only, 798 students fully completed the survey and were analyzed for this study.

Variables and measures

The questionnaire included socio-demographic demographics, COVID-19 -related Items, 9-item patient health questionnaire (PHQ-9), 7-item generalized anxiety disorder (GAD-7) scale and the 10-items Connor–Davidson Resilience Scale (CD-RISC-10). The socio-demographics included gender, age groups, nationality, marital status, working status (Currently employed or not employed) and Emirate of residence within the UAE. Nationality was dichotomized to UAE nationals and non-UAE nationals. Marital status was grouped into ever-married that included married and divorced/widowed or single/ never married participants.

The impact of Covid-19 on the participants was assessed using an outcome variable (the COVID-19 impact). The variable was dichotomized into those who were impacted by COVID-19 or not impacted by COVID-19. Seven questions in the survey assessed if the respondents were impacted by COVID-19 in some way or another. “Impacted by COVID-19” was defined if the participants answered “yes”, they were diagnosed with COVID-19 themselves or a close family/ friend, witnessed a COVID-19 related death or had high exposure to COVID-19 at the workplace in the past year preceding the survey. The respondents who answered no to all of the seven questions were grouped in the category of “not impacted by COVID-19”.

Mental health assessment scales

The patient health questionnaire-9 (phq-9).

The PHQ-9 is a 9-item depression assessment module adopted from the full PHQ. The PHQ-9 has been previously recognized as a valid and reliable instrument for screening of depression in the general population and in university context [ 34 , 35 , 36 ]. It consists of nine questions probing the frequency of depressive symptoms over the past 2 weeks. Responses ranged from 0 to 3 (0 = not at all, 1 = several days, 2 = more than half the days, 3 = nearly every day). Total scores, obtained by summing the responses to each item, range from 0 to 27. Cut-off scores adopted in the present study included scores of ≤ 9 and ≥ 10 that suggest minimal to mild depression and moderate to severe depression on the PHQ-9, respectively [ 35 ]. The reliability of the scale among the current sample was excellent (α = 0.876).

The generalized anxiety disorder-7 (GAD-7)

The Gad-7 is widely used as a self-reporting scale to assess the symptoms of anxiety. It consists of 7-Items that measures anxiety over the past 2 weeks. Items are rated on a 4-point Likert-type scale (0 = not at all, 1 = several days, 2 = more than half the days, 3 = nearly every day). The GAD-7 score is calculated by assigning scores of 0, 1, 2, and 3, then adding together the scores for the seven questions. GAD-7 total score for the seven items ranges from 0 to 21. Cut-off scores of ≤ 9 and ≥ 10 are considered minimal to mild and moderate to severe levels of anxiety on the GAD-7, respectively [ 37 , 38 ]. The reliability of the scale among the current sample was excellent (α = 0.906).

Connor–Davidson Resilience Scale (CD-RISC-10)

CD-RISC-10 is a widely used self-reported questionnaire [ 39 , 40 ]. It consists of 10-items to assess the population’s resilience levels or their ability to tolerate and overcome adverse situations such as illness, pressure, and failure. Each item is rated on a 5-point Likert scale (0 = not true at all, 1 = rarely true, 2 = sometimes true, 3 = often true, and 4 = true nearly all of the time), with a higher total score indicates greater resilience. Due to the lack of a recognized cut-off point, resilience scores were categorized into high resilience (score ≥ 33) and normal or low resilience (score ≤ 32) [ 39 , 40 ]. The reliability of the scale among the current sample was excellent (α = 0.893).

Estimating the prevalence and the levels of depression and anxiety

Prevalence rates of depression and anxiety were determined using cut-off points based on PHQ-9 and GAD-7 scales validation [ 34 , 37 ]. In the current study, depression was defined as a total score of (≥ 10) in the PHQ-9 instrument, indicating a case of moderate to severe depression. Anxiety was defined using the GAD-7 instrument with a total score of (≥ 10), indicating a case of moderate to severe anxiety. The prevalence of depression or anxiety was estimated by dividing the number of students who exceeded the cut-off score by the total number of students who responded.

Statistical analysis

Data coding, data cleaning, and analysis have been carried out by using IBM SPSS (Version 22.0, IBM SPSS, IBM Corp, USA). Cronbach’s alpha coefficients were calculated to indicate scale reliability. Outliers were observed on the PHQ-9 scale, indicating that only four male and two female respondents had severe depression. Descriptive statistics, including means, standard deviations (+ SD) and percentages were used to illustrate participants’ demographics. The normal distribution of data was verified using box plots and histograms. Complete case analysis was considered in this study, then 12 missing cases with responses were excluded from the statistical analysis. The equality of variances was checked using Levene’s test. Independent sample T-test was used to compare the mean scores between the participant COVID-19 impact category and mean scores of the three scales (depression, anxiety and resilience). Participants’ anxiety, depression and resilience mean scores were compared with demographics characteristics using independent-samples t-test, one-way analysis of variance (ANOVA). An independent samples t-test was used to compare the mean scores of the three psychometric scales (anxiety, depression, and resilience scales) between different socio-demographic groups and between the COVID-19 impact categories, separately.

Univariate analysis of variance (ANNOVA) was used to examine if the mean score of the three psychometric scales (anxiety, depression and resilience scales) were different between the impacted by COVID-19 and non-impacted and participants’ gender. Analysis of between-subject effects was run to examine the effect of those categorized as impacted by COVID-19 and those not-impacted students revealed insignificant differences for the mean scores of GAD-7, PHQ 9 and CD-RISC 10 scales. The statistical significance of ≤ 0.05 was considered in the study, with 95% confidence intervals.

Ethical approval and consent

The study was approved by the Higher College of Technology research ethics review board. Participants gave online written consent to participate in the study prior to starting the survey.

Table 1 shows the socio-demographic characteristics of the participants. It reveals that 74.8% of the students were females, and the majority (91.2%) were single/ never married. Most of the participants (66.3%) were UAE-nationals. As for the Emirate of residence, 38.1% reported living in Abu Dhabi city. The students’ age ranged from 16 to 41 years, with the highest proportion in the age group of 19 to 25 years (63.5%). Overall, 65.5% of the students stated they were currently not employed.

The distribution of the participants by COVID-19 related questions is clarified in Fig.  1 . It was revealed that the majority of the participants (88.7%) were classified as impacted by COVID-19 (as per the COVID-19 impact questions). The vast majority of students reported they were diagnosed with COVID-19 themselves or a significant relatives/ friends (86.8%). Additionally, 27.2% of students stated they knew some close relatives/ friends who died from COVID-19 or its complications.

Distribution of the participants by COVID-19 related questions

Prevalence estimates of depression, anxiety and resilience (as measured by PHQ- 9, GAD-7 9, and CD-RISC-10 cut-off scores) by gender among the participants were summarized in Fig.  2 . Overall, four out of ten of the participants had moderate and severe depression and anxiety (40.9% and 39.1%, respectively). A slightly higher proportion of females had moderate to severe depression and anxiety than males. It can be seen that males had higher resilience (12%) than females (9%). Prevalence estimates of depression, anxiety, and resilience by COVID-19 impact among the participants are shown in Table 2 . Based on PHQ-9 cut-off scores (≥ 10), the self-reported prevalence of moderate to severe depression symptoms was 40.9%, and it was higher in students who were categorized as impacted by COVID-19 (43.8%) than those who were not impacted (17.8%). Based on GAD-7 cut-off scores (≥ 10), the self-reported prevalence of moderate to severe anxiety was 39.1%. Students with moderate to severe anxiety symptoms categorized as impacted by COVID-19 had higher scores (40.1%) than those who were not impacted (31.8%). Few students (11.5%) self-reported high levels of resilience (based on CD-RISC-10 score ≥ 33).

Prevalence of depression, anxiety and resilience by gender among the participants

Independent sample t-test for the comparison between the mean scores (± SD) of the psychometric scales by COVID-19 impact is presented in Table 3 . Notably, the total mean scores (± SD) of all the three psychometric scales used were below the assumed cut-off threshold of moderate to severe depression (9.10 ± 6.33) or moderate to severe anxiety (8.78 ± 6.07), and high resilience level (21.46 ± 8.80) for the participating students. Significantly higher mean PHQ-9 and GAD-7 scores were found among students who were impacted by COVID-19 than those non-impacted. No statistically significant difference was detected in the mean CD-RISC-10 scores for those who were impacted by COVID-19 and those who were non-impacted.

Independent sample t-test was used to compare the mean scores (± SD) for the three psychometric scales by socio-demographic characteristics (as shown in Table 4 ). The mean scores of the three psychometric scales (PHQ-9, GAD-7, and CD-RISC-10) were insignificantly different between male and female participants ( p  > 0.05). Participants of UAE-nationality had significantly higher mean scores ± SD for PHQ-9 than their non-national counterparts (9.63 ± 6.51 vs. 7.92 ± 5.81, respectively, p  = 0.001*). As for the employment status, currently non-employed participants had significantly higher CD-RISC-10 scores than the currently employed ones (22.01 ± 8.60 and 20.44 ± 9.10, respectively; p  = 0.018*). For the marital status single/never married participants had significantly higher PHQ-9 and GAD-7 scores than ever-married (9.31 ± 6.37 and 6.93 ± 5.47, p  = 0.003) and (8.89 ± 6.11 and 7.13 ± 5.49, respectively; p  = 0.017*).

The interaction between the effects of COVID-19 impact and gender on the mean scores (± SD) of PHQ 9, GAD-7, and CD-RISC 10 psychometric scales were examined using a two-way ANNOVA test are shown in Table 5 . There was a statistically significant interaction between the effects of gender and COVID-19 impact on both depression and anxiety scores. In particular, females who were categorized as impacted by COVID-19 (interaction term) had a significantly higher mean PHQ-9 score ± SD than those who were not impacted (9.14 ± 5.86 vs. 6.83 ± 6.25, respectively; p  < 0.001). Similarly, females who were impacted by COVID-19 had a significantly higher GAD-7 score than the ones who were non-impacted impacted (9.57 ± 6.32 vs. 5.15 ± 3.88, respectively; p  = 0.005). Resilience mean scores were almost similar in females who were impacted by COVID and those who were not. No significant differences were detected in the mean scores of any of the mental health scales studied for male participants by COVID-19 impact. The interaction between the effects of COVID-19 impact and marital status and nationality group on mean scores of PHQ 9, GAD-7, and CD-RISC 10 psychometric scales were non-significant (Additional file 1 : Appendix 1).

Prevalence of depressive and anxiety symptoms and COVID-19 impact

The current study suggested that the COVID-19 pandemic has had a significant impact on the mental health and well-being of this sample of university students, with four out of ten of the students self-reported moderate to severe depression (taking PHQ-9 cut-off scores of ≥ 10) and anxiety (GAD-7 cut-off scores of ≥ 10) symptoms. These levels were most prevalent among females and never-married students. The prevalence of depression in our study was higher than in what was reported in other studies [ 12 , 13 , 14 , 16 , 18 ]. In particular, among university students, several studies across the globe showed that the prevalence of depression varied, as low as 4% [ 41 ], and as high as 79.2% [ 42 ] depending on the severity and the instruments used [ 43 , 44 , 45 , 46 ]. In addition, according to a systemic review of published research on the mental health of young adults in the UAE between 2007 and 2017, prevalence scores ranged widely from 12.5 to 28.6% due to wide-ranging sample sizes [ 47 ].

The present study was implemented in the context of the COVID-19 pandemic. For that, our study observed higher mean PHQ-9 and GAD-7 scores among those participants who were impacted by COVID-19 than those who were categorized as not impacted. These results imply that the COVID-19 pandemic might have intensified the negative mental health impact on this sample of university students. Our findings were further supported by the results of a recent study that used PHQ-9 and the GAD-7 scales to evaluate a sample of university students during the COVID-19 pandemic and found that depressive and anxiety symptoms were prevalent in 45.2% and 38.3% of the students [ 48 ]. During stressful situations, like this pandemic, fear and anxiety about the disease can be overwhelming and it may negatively impact the mental health of all the sectors of the population [ 49 , 50 ], and students in particular [ 51 ]. Fears of infection, social distancing, vaccination drives, prolonged university closure, challenges with online learning and uncertainty over examinations all cause stress and anxiety to students worldwide [ 6 , 36 , 43 ].

The effect of socio-demographic characteristics and the COVID-19 impact on the students’ mental health

The current findings revealed that depression symptoms were more reported by females than males. As previously observed, being a female was linked to a higher risk of having elevated depressive symptoms. Gender differences in depressive symptoms are typically explained in terms of gender-role socialization processes that lead to females being more likely to adopt passive cogitative responses to negative moods [ 52 , 53 ]. Besides, women are more likely to be emotionally, socially and financially disadvantaged during crisis times like COVID-19 pandemic [ 54 , 55 ]. This finding is consistent with a large-scale, UAE population-based survey that found females had a greater risk for depression compared to males [ 56 ]. Moreover, the present findings agree with the results of similar studies that have investigated depression among population of neighboring Gulf countries [ 57 , 58 , 59 ].

This study revealed that never-married university students had significantly higher depression and anxiety symptoms than their ever-married counterparts. Research speculated that marriage has been found to be associated with better mental well-being compared to other relationship statuses [ 60 , 61 , 62 ]. Moreover, a study confirmed that positive family-level factors (e.g. positive parenting, healthy family functions and environment) were associated with decreased depression and anxiety [ 62 ]. The married respondents enjoyed more positive family-level factors than the respondents who were not married. The unique nature of COVID-19 which offered the reduced opportunity for social interaction in single respondents while the home-bound married respondents had a robust companionship could be one of the reasons behind such findings [ 63 ]. This finding is consistent with other research [ 2 , 30 , 47 , 50 , 64 ], however, some claimed that the strength of association between single status and depression was modified by age and gender [ 50 , 65 , 66 ]

Although the research on the association between depression and ethnicity is inconclusive [ 67 , 68 , 69 , 70 ], our findings indicate that PHQ-9 is sensitive to ethnicity/ nationality, whereas UAE-national students had higher PHQ-9 scores than non-UAE national ones. The differences in the prevalence of depression outcomes may depend on whether the studies were adjusted for other factors that might be associated with depression or not [ 71 , 72 ]. Factors like sociodemographic and economic profiles should be adjusted carefully. Early research provided evidence of measurement invariance of the PHQ-9 scale regarding ethnicity, implying that the observed inequalities in depressive symptoms may not be attributed to the ethnicity factor alone [ 73 ]. Some considerations can be made based on descriptions of social and cultural norms at large. Contrary to the present findings, no significant difference was observed between Emirati and non-Emirati patients in the frequency of depressive disorders using PHQ-9 [ 2 , 74 ]. Our results could reflect the need to investigate the association between nationality/ ethnicity and reporting of depression symptoms among the UAE population at large.

Resilience scores and COVID-19

The majority of the students surveyed in the present study demonstrated low to normal levels of resilience (CD-RISC 10 cut-off score of ≥ 32). It has been observed that the levels of resilience vary widely according to the sample size and the assessment tool used [ 75 , 76 ]. However, considering the current total sample mean resilience score of 21.46 (± 8.80) indicates that our sample had a lower mean score than the reported mean score of 31.8 in the general population [ 77 ] and 30.97 (± 5.46) in a specific sample during COVID-19 [ 76 ]. Furthermore, the present findings highlighted that students who were categorized as impacted by COVID-19 had significantly lower resilience levels than those who were not impacted by COVID-19. Similarly, research reported that the COVID-19 stress and fear had a significant inverse correlation with resilience and that students' academic stress is negatively related to social support and resilience [ 78 ].

The present findings also showed that the resilience mean score was higher in non-employed students than in currently employed ones. This could be directly related to the increased stress levels caused by COVID-19 at the workplace. Working students might be exposed to different stressors at the workplace, including COVID-19, particularly in settings that require close human contact [ 20 ]. COVID-19 pandemic implied increased demand at the workplace in regards to the online work, travel restrictions, testing, sanitization, and vaccination drives. The UAE government applied strict work safety guidelines during the pandemic [ 79 ]. As a result, extended online working hours, added to the college's academic expectations, higher risk exposure to COVID-19 infection, changing work culture and balancing study and work could have contributed to reduced resilience in currently employed students in this study [ 80 , 81 ].

Strengths and limitations

The current study has many strengths. The novelty of the data that were collected primarily during the pandemic for this study cannot be argued, as this study added evidence to the pool of research on the mental health impact of the pandemic among a sample of university students in the UAE. The use of validated psychometric scales allows us to presume that the levels of depression and anxiety reported in this sample significantly exceeded the previously reported numbers for similar samples and could be related to COVID-19 pandemic. In addition, assessment of the demographic variables allows us to report on groups which appear to be at greatest mental health burden, and suggest a role for future interventions.

However, this study has similar limitations to other cross-sectional self-reported surveys that investigate sensitive mental health issues. First, the results represent the views of a single university student population in the UAE, that may limit the generalizability of the results. As potential participants were selected by a convenience sampling, non-random selection of the sample may limit the generalizability of this study. Another limitation may arise as there may have been a relevant difference between the students who chose to participate in the study and those who did not. It was also possible that the social desirability bias might have led some students to respond to survey items in ways that they believed were the most socially desirable [ 82 ]. Some responses also might have been influenced by confidentiality concerns as study was conducted by faculty members. Hence the above reasons might lead to some students answering in ways that they believed were the most socially desirable. Instead, it is possible that students with depression and anxiety symptoms were more willing to answer as a result of their fears about their studies.

Moreover, as the study experienced relatively high non-response rate and missing data, bias may have been introduced. However, neither of these factors should affect the attitude of those students who responded for the survey. In addition, the data was adequality managed at statistical handling to address the true values and impacts of the measured variables. Females were overrepresented in this study as in many other university settings in the UAE, which may affect the observed prevalence of depressive and anxiety in this sample. Lastly, the cross-sectional design makes it difficult to have causal relationships.

The results of this study revealed that the COVID-19 pandemic has negatively impacted the mental health of this sample of university students in terms of depression and anxiety. Based on PHQ-9 and GAD-7 cut-off scores, prevalence estimates highlight that moderate to severe depression as well as anxiety symptoms were self-identified by four out of ten of the sampled students. The COVID-19 pandemic was remarkably linked to significantly higher depression and anxiety symptoms among this sample. The assessment of demographic variables revealed that differences based on gender, marital status and nationality affected the mental health of this sample and suggest a role for future interventions. This study also showed that only one in ten of the students revealed high resilience levels, however, differences in the mean CD-RISC-10 scores by COVID-19 impact were not statistically significant. In contrast, the students who were not affected by COVID-19 had a lower level of resilience. The results also revealed no significant differences in anxiety, depression, and resilience levels by gender, except when COVID-19 impact was taken as an interaction term, which further emphasize the negative impact of COVID-19 on students’ mental health.

As for the policy implications, the application of the validated PHQ-9 and GAD-7 scales are recommended as initial screening tools, however, detected cases should be later assessed using more comprehensive instruments. Besides, mental healthcare providers should offer continuous monitoring of the psychological status of university students, in particular for the vulnerable groups, and provide the required mental health support at the university setting. Strategies for could focus on increasing the availability of mental health support interventions. The results of this study highlight the importance of developing a university culture in which students could have an opportunity to communicate their mental health concerns in confidential and comfortable ways. Hotline and virtual consultations could be introduced to ensure the students confidentially and privacy. Though a huge information on students' mental health has been gathered since March 2020, research on the psychological and behavioral effects of lockdowns should still be done when the epidemic ends. Further research can include follow-ups of this sample and similar samples from various colleges and university students to allow accurate detection of the true impact of the COVID-19 pandemic on this targeted population.

Availability of data and materials

The datasets generated and analyzed during the current study are not publicly available because the data analysis is ongoing to study variables other than covered in this study. The data that supports the findings of this study are available upon request, but restrictions apply to the availability of these data. Data are however available from the authors upon reasonable request and with permission of the Higher Colleges of Technology.

Abbreviations

One-way analysis of variance

Connor–Davidson Resilience Scale

Coronavirus disease 2019

Higher Colleges of Technology

Generalized anxiety disorder

Patient health questionnaire

• United Arab Emirates

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Acknowledgements

The authors would like to thank all the students who voluntarily shared their time and took part. The team also express gratitude to Professor Dr Gregory Blatch, the Executive Dean of Health Science Department and Dr Heyam Dalky for supporting this research as the Chair for Sharjah Women College’s Research Committee.

The current research was launched in late 2021 under the seed Grant Number [103802] from HCT. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of HCT.”

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AM designed and initiated the study. WA critically reviewed and edited the research proposal AD and GI performed the analysis. HM and AD interpreted the results. AM, WA, HH, and VM drafted the introduction and conclusion. HM wrote the paper with input from all authors. All authors read and approved the final manuscript.

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The interaction between the effects of COVID-19 impact, marital status and nationality groups on mean scores of PHQ 9, GAD-7, and CD-RISC 10 psychometric scales.

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Vajpeyi Misra, A., Mamdouh, H.M., Dani, A. et al. Impact of COVID-19 pandemic on the mental health of university students in the United Arab Emirates: a cross-sectional study. BMC Psychol 10 , 312 (2022). https://doi.org/10.1186/s40359-022-00986-3

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• COVID–19 pandemic
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BMC Psychology

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Changes in College Students Mental Health and Lifestyle During the COVID-19 Pandemic: A Systematic Review of Longitudinal Studies

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• 1 Department of Clinical and Experimental Sciences, University of Brescia, Viale Europa 11, 25123 Brescia, Italy.
• PMID: 35966832
• PMCID: PMC9362152
• DOI: 10.1007/s40894-022-00192-7

College students have poorer mental health than their peers. Their poorer health conditions seem to be caused by the greater number of stressors to which they are exposed, which can increase the risk of the onset of mental disorders. The pandemic has been an additional stressor that may have further compromised the mental health of college students and changed their lifestyles with important consequences for their well-being. Although research has recognized the impact of COVID-19 on college students, only longitudinal studies can improve knowledge on this topic. This review summarizes the data from 17 longitudinal studies examining changes in mental health and lifestyle among college students during the COVID-19 pandemic, in order to improve understanding of the effects of the outbreak on this population. Following PRISMA statements, the following databases were searched PubMed, EBSCO, SCOPUS and Web of Science. The overall sample included 20,108 students. The results show an increase in anxiety, mood disorders, alcohol use, sedentary behavior, and Internet use and a decrease in physical activity. Female students and sexual and gender minority youth reported poorer mental health conditions. Further research is needed to clarify the impact of the COVID-19 pandemic on vulnerable subgroups of college students.

Supplementary information: The online version contains supplementary material available at 10.1007/s40894-022-00192-7.

Keywords: COVID-19 pandemic; College students; Lifestyle; Mental health; Well-being.

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Exposure to Violence in Children and Youth During COVID-19 and Mental Health Outcomes

Bullying Victimization and Mental Health Before and During the COVID-19 Pandemic Provisionally Accepted

• 1 Brock University, Canada
• 2 University of Ottawa, Canada

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Bullying victimization is associated with numerous mental health difficulties yet studies from early in the COVID-19 pandemic revealed significant decreases in bullying victimization but significant increases in mental health difficulties for many children and adolescents. It is unclear whether the decrease in bullying victimization early in the pandemic translated to weaker associations between bullying victimization and mental health difficulties. Using a population-based design, we examined whether the correlations between bullying victimization and mental health difficulties were significantly weaker in magnitude during the COVID-19 pandemic compared to before the pandemic in a sample of 6578 Canadian students in grades 4-12. Students were randomly assigned to report on their bullying and mental health experiences either during the school year before the pandemic or the school year during the pandemic. Only students who reported experiences of victimization were included in the present study as questions on mental health were specifically on difficulties experienced due to victimization. As expected, overall bullying victimization and mental health difficulties were significantly correlated before and during the pandemic, but correlations were significantly weaker in magnitude during the pandemic for girls and secondary students. Significant decreases in correlation magnitude were also found predominately for general, verbal, and social forms of bullying victimization, but not for physical and cyber victimization. Among students who reported victimization, we also found significantly lower means for mental health difficulties and most forms of bullying victimization during the pandemic compared to pre-pandemic. Findings indicate a strong coupling of bullying victimization and mental health difficulties, particularly before the pandemic, and the need to reduce these associations to improve the well-being of children and adolescents.

Keywords: bullying victimization, Mental Health, COVID-19, Students, population-based

Received: 02 Apr 2024; Accepted: 07 May 2024.

Copyright: © 2024 Farrell, Brittain, Krygsman and Vaillancourt. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

* Correspondence: Dr. Tracy Vaillancourt, University of Ottawa, Ottawa, K1N 6N5, Ontario, Canada

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Standardized prevalence rates for participants, excluding nonbinary students, were calculated, creating a sample size of 68 106 students for T1; 22 205, T2; and 44 157, T3. Stress decreased 10.3% between T1 and T2 and increased 2.5% between T2 and T3. Anxiety decreased 18.4% between T1 and T2 and increased 13.9% between T2 and T3. Depression decreased 11.9% between T1 and T2 and increased 22.2% between T2 and T3. Suicidal thoughts increased 16.0% between T1 and T2 and 12.2% between T2 and T3. Posttraumatic stress disorder (PTSD) increased 61.9% between T2 and T3.

a Comparisons between T3 and T1 and between T2 and T1 were not conducted because acute distress was measured at T1 (using the Impact of Events Scale–Revised) rather than PTSD.

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Wathelet M , Horn M , Creupelandt C, et al. Mental Health Symptoms of University Students 15 Months After the Onset of the COVID-19 Pandemic in France. JAMA Netw Open. 2022;5(12):e2249342. doi:10.1001/jamanetworkopen.2022.49342

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Mental Health Symptoms of University Students 15 Months After the Onset of the COVID-19 Pandemic in France

• 1 Department of Psychiatry, Centre Hospitalo-Universitaire de Lille, Lille, France
• 2 Fédération de Recherche en Psychiatrie et Santé Mentale des Hauts-de-France, Lille, France
• 3 Centre National de Ressources et de Résilience Lille-Paris, Lille, France
• 4 University Lille, Inserm, Centre Hospitalo-Universitaire de Lille, U1172–Lille Neuroscience & Cognition, Lille, France
• 5 Assistance Publique–Hôpitaux de Paris, Avicenne Hospital, Department of Infant, Child and Adolescent Psychiatry, Sorbonne Paris Nord University, Centre de recherche en Epidémiologie et Santé des Populations, Bobigny, France
• 6 Fonds Fédération Hospitalière de France Recherche et Innovation, Paris, France

Question   Has the mental health of university students in France changed 15 months after the start of the COVID-19 pandemic?

Findings   In this cross-sectional study of 44 898 university students who participated in the third measurement time of the Conséquences de la pandémie de COVID-19 sur la santé mentale des étudiants (COSAMe) survey, high prevalence rates for stress (20.6%), anxiety (23.7%), depression (15.4%), suicidal thoughts (13.8%), and posttraumatic stress disorder (29.8%) were observed.

Meaning   These results suggest that the pandemic may have had long-lasting consequences on the mental health of students.

Importance   The Conséquences de la pandémie de COVID-19 sur la santé mentale des étudiants (COSAMe) survey was conducted among university students in France during the COVID-19 pandemic and found that although there was a slight decrease in anxiety, depression, and stress between the first lockdown (T1) and 1 month after it ended (T2), the prevalence of suicidal ideation had increased between these periods and 1 in 5 students had probable posttraumatic stress disorder (PTSD) at T2. These results emphasize the need to explore the long-term consequences of the COVID-19 pandemic.

Objectives   To measure the prevalence of mental health symptoms among university students in France 15 months after the first lockdown (T3) and to identify factors associated with outcomes.

Design, Setting, and Participants   This cross-sectional study reports data from the third measurement time of the repeated COSAMe survey, which took place from July 21 to August 31, 2021, through an online questionnaire sent to all French university students.

Main Outcomes and Measures   The prevalence of suicidal thoughts, PTSD (PTSD Checklist for the Diagnostic and Statistical Manual of Mental Disorders [Fifth Edition] [PCL-5]), stress (Perceived Stress Scale), anxiety (State-Trait Anxiety Inventory), and depression (Beck Depression Inventory) at T3 were gender- and degree-standardized and compared with prevalence rates at T1 and T2. Multivariable logistic regression analyses identified risk factors.

Results   A total of 44 898 students completed the questionnaires. They were mainly women (31 728 [70.7%]), and the median (IQR) age was 19 (18-21) years. Standardized prevalence rates of stress, anxiety, depression, suicidal thoughts, and PTSD were 20.6% (95% CI, 20.2%-21.0%), 23.7% (95% CI, 23.3%-24.1%), 15.4% (95% CI, 15.1%-15.8%), 13.8% (95% CI, 13.5%-14.2%), and 29.8% (95% CI, 29.4%-30.2%), respectively. Compared with the decreased prevalence rates at T2, there was an increase at T3 for stress (2.5% increase), anxiety (13.9% increase), and depression (22.2% increase). The prevalence of suicidal ideation continued to increase from T1 (10.6%) to T3 (13.8%), and the prevalence of probable PTSD increased from 1 in 5 students to 1 in 3 students between T2 and T3. Female and nonbinary participants; participants without children and living in an urban area; and those with financial difficulties, a chronic condition, psychiatric history, COVID-19 history, social isolation, and low perceived quality of information received were at risk of all poor outcomes at T3 (eg, stress among women: adjusted OR, 2.18; 95% CI, 2.05-2.31; suicidal thoughts among nonbinary respondents: adjusted OR, 5.09; 95% CI, 4.32-5.99; anxiety among students with children: adjusted OR, 0.68; 95% CI, 0.56-0.81; depression among students living in a rural area: adjusted OR, 0.80; 95% CI, 0.75-0.85).

Conclusions and Relevance   These results suggest severe long-lasting consequences associated with the pandemic on the mental health of students. Prevention and care access should be a priority.

The COVID-19 pandemic had a major impact on mental health. Numerous studies conducted during the first months of the pandemic found high rates of mental health symptoms (stress, distress, anxiety, depression, posttraumatic stress) in the general population. 1 The student population, whose vulnerability to mental health disorders was already well known, 2 was quickly identified as particularly at risk of negative psychological repercussions from the pandemic and associated health measures. 1 , 3 , 4

In France, the repeated cross-sectional survey Conséquences de la pandémie de COVID-19 sur la santé mentale des étudiants (COSAMe), whose first measurement time (T1) took place during the first lockdown (March 17 to May 11, 2020), reported high prevalence rates of severe self-reported stress (24.7%; 95% CI, 24.4%-25.1%), anxiety (27.5%; 95% CI, 27.1%-27.8%), depression (16.1%; 95% CI, 15.8%-16.4%), and suicidal thoughts (11.4%; 95% CI, 11.2%-11.7%) among the 69 054 participants. Overall, nearly half of students were affected by at least 1 severe mental health issue. 4 During the second measurement period (T2), 1 month after the lifting of the lockdown, the prevalence of anxiety, depression, and stress had decreased without reaching prepandemic levels. In contrast, suicidal ideation increased from 11.4% to 13.2% (95% CI, 12.8%-13.6%), and symptoms of posttraumatic stress disorder (PTSD) were reported by nearly 1 in 5 students. 5

The COVID-19 pandemic has been characterized by the occurrence of multiple waves of outbreaks and multiple measures deployed to limit the consequences of these waves. 6 While there is still a growing body of research on the consequences of the pandemic on students’ mental health, studies assessing the long-term impacts are rarer. However, the direct (infections, hospitalizations, deaths) and indirect (economic crisis, difficulties in accessing care, isolation) consequences of the pandemic are likely to induce a very long-lasting mental health crisis, 7 , 8 and recommendations invite monitoring the mental health of populations over the next few years. 9 The present study used data from the third measurement time (T3) of the COSAMe survey, conducted 15 months after the beginning of the COVID-19 pandemic to (1) measure the prevalence rates of self-reported mental health symptoms (stress, anxiety, depression, PTSD, and suicidal thoughts) and (2) identify factors associated with mental health outcomes.

The study used data from the repeated cross-sectional university-based survey COSAMe, which consisted of 3 measurement times: T1, during the first lockdown (April 17 to May 4, 2020); T2, 1 month after the lift of the first lockdown (June 15 to July 15, 2020); and T3, 15 months after the start of the pandemic (July 21 to August 31, 2021). At each time, the French Ministry of Higher Education, Research, and Innovation requested the 82 universities to send an email to their students (target population, approximately 1 600 000 students) asking them to participate in the survey by completing online self-administered questionnaires. Due to the heterogeneity of sanitary measures from 1 country to another, the study only included students residing in France during the first lockdown.

The 2 first measurement times have already been analyzed, and the results have been published elsewhere. 4 , 5 , 10 For this study, they are recalled to facilitate the interpretation of the third measurement time.

This survey was reviewed by a French research ethics committee, the Comité de Protection des Personnes Ile de France VIII, before its initiation. For T3, financial compensation was offered: €100 was awarded to 100 students randomly selected from those who completed the questionnaire entirely. To maintain anonymity, at the end of the questionnaire, students were directed to a page disconnected from the questionnaire, allowing them to enter their contact details to participate. Consent is not required for this type of observational study. An information note presented before the questionnaire informed the students about the study and the possibility of refusing to participate. Completion of the questionnaire was considered consent to participate. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guideline.

The following outcomes were screened: (1) suicidal thoughts, by asking participants whether they had experienced suicidal thoughts during the preceding month (yes or no); (2) PTSD, using the French version of the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (PCL-5), a 20-item scale that explores PTSD symptom severity over the past month 11 , 12 ; (3) stress, using the 10-item Perceived Stress Scale (PSS-10) to evaluate stress experiences during the preceding month 13 - 15 ; (4) depression, using the 13-item Beck Depression Inventory (BDI-13) to assess current depression symptoms 16 , 17 ; and (5) anxiety, using the 20-item State-Trait Anxiety Inventory, State subscale (STAI Y-2), to measure the intensity of current anxiety symptoms. 18 , 19 The Cronbach α of the 4 scales in the sample were all greater than 0.89.

Outcomes were the presence of severe symptoms, ie, the presence of suicidal thoughts or a score above the threshold identified in the literature on 1 of the scales (PCL-5, >32 of 80; PSS-10, >26 of 40; BDI-13, >15 of 39; STAI Y-2, >55 of 80). 13 - 21 We considered the following covariates to evaluate their association with the outcomes: (1) sociodemographic characteristics, age (in years), gender (male, female, other), academic degree (bachelor, master, doctorate), being a foreign student (yes, no), living area (urban, semiurban, rural), and having children (yes, no); (2) precariousness, financial difficulties (important for students reporting that it is difficult to make ends meet every month, moderate for participants for whom it is a bit difficult, low or no financial difficulties for others); (3) health-related data, history of psychiatric follow-up (benefiting from follow-up by a health professional for mental health reasons before the pandemic: yes, no), chronic condition (physical infirmity, handicap, or chronic disease: yes, no), COVID-19 (positive test for SARS-CoV-2 infection or suspected but without confirmatory test: yes, no); (4) social isolation, students who never physically meet or who only have very episodic contacts (sometimes in the year or less) with the members of all of their social networks (family, friends, neighbors, classmates, or members of their associative activities) were considered isolated; and (5) information data, perceived quality of information received about COVID-19 (on a scale of 10).

First, we described the sample using medians with IQRs for the scores of the measurement tools and quantitative covariates, since they were mostly not normally distributed. We used numbers and percentages for scores ranked by level and other qualitative variables.

To compare the results of T3 with those of T1 and T2, we calculated gender- and degree-standardized prevalence rates, using the university student population 2019 to 2020 published by the French Ministry of National Education 22 and excluding nonbinary students given that their proportion among students was not available. We conducted χ 2 tests to compare prevalence rates 2 by 2 (ie, T1 vs T2, T2 vs T3, T1 vs T3). PTSD was measured at T2 and T3 because according to the DSM-5, symptoms of PTSD must last for at least 1 month. 23 At T1, we measured acute distress using the Impact of Events Scale–Revised.

Bivariate analyses were conducted to test the association between outcomes and covariates using χ 2 tests, and multivariate logistic regression models identified risk factors of reporting at least 1 poor outcome (suicidal thoughts, PTSD, stress, depression, or anxiety) at T3. Then, similar models were conducted for each outcome. All explanatory variables were included except age due to collinearity with the year of study. Associations between risk factors and outcomes were presented as odds ratios (ORs) and 95% CIs.

Data analysis was performed using R version 3.6.1 (R Project for Statistical Computing). The level of significance was set at .05, and all tests were 2-sided.

A total of 55 457 students opened the online questionnaire. Among them, 44 898 completed (81.0%) it entirely and were analyzed.

The sample was mainly composed of women (31 728 [70.7%]), with 12 429 (27.7%) men and 741 students (1.6%) identifying as nonbinary. The median (IQR) age was 19 (18-21) years. Half of the respondents (22 716 [50.6%]) were in their first academic year, and 36 772 (81.9%) were bachelor students, whereas only 880 (2.0%) were in the sixth year or more. Among the participants, 3276 (7.3%) declared being foreign students, and 698 (1.5%) had children. Finally, 19 909 (44.3%) lived in an urban area, 11 808 (26.3%) in a semiurban area, and 13 181 (29.4%) in a rural area.

Nearly 1 in 8 students reported important financial difficulties (5830 [13.0%]). This proportion increased to 1 in 3 (15 844 [35.3%]) when we considered important and moderate financial difficulties together.

Regarding health information, 4002 respondents (8.9%) declared having a history of psychiatric follow-up, and 4713 (10.5%) reported having a chronic condition. More than one-quarter of the participants (12 105 [27.0%]) reported having had COVID-19 (positive test or suspicion without confirmatory test). Concerning social ties, 2013 (4.5%) were socially isolated. Finally, participants rated the quality of the information related to COVID-19 and quarantine, giving a median (IQR) score of 5 (3-7) of 10.

Crude and standardized prevalence rates are described in Table 1 . Among the 44 898 respondents, the crude prevalence rates of anxiety, depression, stress, PTSD, and suicidal thoughts were 25.0% (95% CI, 24.6%-25.4%), 16.9% (95% CI, 16.6%-17.3%), 22.5% (95% CI, 22.1%-22.9%), 31.0% (95% CI, 30.6%-31.4%), and 15.0% (14.7%-15.3%), respectively. After gender- and degree-standardization, prevalence rates were slightly lower (23.7% [95% CI, 23.3%-24.1%], 15.4% [95% CI, 15.1%-15.8%], 20.6% [95% CI, 20.2%-21.0%], 29.8% [95% CI, 29.4%-30.2%], and 13.8% [95% CI, 13.5%-14.2%], respectively). The medians (IQRs) of the scores were 45 (34-56) for the STAI Y-2 (anxiety), 8 (4-13) for the BDI-13 (depression), 20 (15-26) for the PSS-10 (stress), and 22 (10-37) for the PCL-5 (PTSD).

The Figure presents the standardized prevalence rates measured at T3 as well as those measured previously at T2 and T1. For stress, depression, and anxiety, a V-shaped pattern was identified, with a decrease in prevalence at T2 and an increase at T3. Prevalence rates at T3 were lower than those at T1 for stress (20.6% vs 22.4%) and anxiety (23.7% vs 25.5%), but higher for depression (15.4% vs 14.3%); however, these results represented a 2.5% increase for stress, a 13.8% for anxiety, and a 22.2% increase for depression compared with T2. The prevalence of PTSD was particularly high at T3, with 29.8% of students affected, compared with 18.4% at T2. Finally, the prevalence of suicidal ideation increased since the beginning of the survey, reaching 13.8% at T3, against 12.3% at T2 and 10.6% at T1. All tests performed were significant ( P  < .001), except for the comparison of stress prevalence between T2 and T3 ( P  = .13).

Bivariate analyses are presented in Table 2 . Multivariate analyses are presented in Table 3 .

After adjustment, women and nonbinary students had increased risks of poor mental health symptoms compared with men (eg, stress among women: adjusted OR, 2.18; 95% CI, 2.05-2.31; suicidal thoughts among nonbinary respondents: adjusted OR, 5.09; 95% CI, 4.32-5.99). On the contrary, having children and living in a rural area (vs urban area) were associated with less risk (eg, anxiety among students with children: adjusted OR, 0.68; 95% CI, 0.56-0.81; depression among students living in a rural area: adjusted OR, 0.80; 95% CI, 0.75-0.85). Academic degree program was associated with all outcomes, except stress, but with less clear patterns. Compared with bachelor students, PhD students had lower risk of depression (OR, 0.63; 95% CI, 0.51-0.78; P  < .001), PTSD (OR, 0.74; 95% CI, 0.63-0.87; P  < .001), and suicidal thoughts (OR, 0.64; 95% CI, 0.51-0.80; P  < .001). Master students were less at risk for depression (OR, 0.82; 95% CI, 0.76-0.88; P  < .001) and suicidal thoughts (OR, 0.91; 95% CI, 0.84-0.98; P  = .02) but at higher risk for anxiety (OR, 1.12; 95% CI, 1.05-1.19; P  < .001). Being a foreign student was associated with a higher risk of depression (OR, 1.14; 95% CI, 1.04-1.24; P  = .003), PTSD (OR, 1.18; 95% CI, 1.07-1.31; P  = .001), and suicidal thoughts (OR, 1.87; 95% CI, 1.72-2.02; P  < .001).

For all mental health outcomes, the greater the financial difficulties reported by the students, the higher the risk of a poor outcome. Compared with students with no or few difficulties, those reporting moderate difficulties had ORs ranging from 1.36 (95% CI, 1.27-1.45) for suicidal thoughts to 1.75 (95% CI, 1.67-1.84) for PTSD, and those declaring significant difficulties had ORs ranging from 2.19 (95% CI, 2.03-2.35) for suicidal thoughts to 3.44 (95% CI, 3.21-3.68) for depression.

Prevalence rates of mental health disorders were significantly higher among students with a history of COVID-19 (confirmed or suspected), with a chronic condition, and with a history of psychiatry follow-up. ORs ranged from 1.12 (95% CI, 1.05-1.19) for suicidal thoughts to 1.42 (95% CI, 1.36-1.49) for PTSD among those with a history of COVID-19, from 1.49 (95% CI, 1.39-1.59) for PTSD to 1.62 (95% CI, 1.50-1.75) for suicidal thoughts among those with a chronic condition, and from 2.06 (95% CI, 1.92-2.21) for PTSD to 2.81 (95% CI, 2.60-3.03) for suicidal thoughts among those with psychiatry history.

Socially isolated students were consistently at higher risk for mental health issues. ORs ranged from 1.28 (95% CI, 1.16-1.41; P  < .001) for PTSD to 2.07 (95% CI, 1.86-2.30; P  < .001) for depression.

The lower the quality of the information received, the more the students were at risk for severe mental health issues. ORs ranged from 1.25 (95% CI, 1.19-1.32) for PTSD to 1.36 (95% CI, 1.30-1.42) for suicidal thoughts if they rated the quality with a score between 4 and 5 compared with a score greater than 6, and from 1.57 (95% CI, 1.48-1.66) for suicidal thoughts to 1.80 (95% CI, 1.70-1.91) for PTSD if they rated the quality with a score less than 4.

This large nationwide study found high rates of stress, anxiety, depression, suicidal thoughts, and PTSD among university students in France 15 months after the start of the pandemic. By comparing these results with the 2 previous measurement times of the COSAMe survey (during the first lockdown and 1 month after it ended), a V-shaped pattern was observed for anxiety and depression, ie, an increase following a drop in the prevalence rates observed after the lifting of the first lockdown. Only the prevalence of suicidal thoughts has been steadily increasing since the first lockdown. The prevalence of PTSD has reached important levels 15 months after the beginning of the pandemic, with nearly 1 in 3 students concerned. Women and nonbinary students, those without children and living in an urban area, and those with financial difficulties, social isolation, history of psychiatric follow-up, history of COVID-19 (suspected or confirmed), a chronic condition, and low assessment of the quality of the information received had increased risk of mental health issues.

Comparisons with other studies are complex insofar as the prevalence of disorders is influenced by health restrictions (which differed from one country to another), study period (given variations in restrictions over time and seasonality of certain mental disorders), the type of population concerned (as vulnerabilities may vary), and the measuring tools (whose psychometric properties may differ). 24 However, our results are consistent with the study by Charbonnier et al, 24 who measured levels of anxiety and depression among French university students. Using the Hospital Anxiety and Depression Scale, the authors found a higher prevalence of probable depression (between 12.1% and 26.4%) and anxiety (between 26.6% and 45.0%) in 2021 compared with 2020. 24 Results are also consistent with the study by Schmits et al, 28 including 23 307 French university students 1 year after the beginning of the pandemic. The authors reported that 50.6% of participants described anxiety symptoms, 55.1% described depressive symptoms, and 20.8% described suicidal ideation. 28 However, this study was cross-sectional without a prior point of comparison. A few longitudinal studies have been conducted in the general population over a period like that of our study. A study of 1838 Belgian adults, conducted from April 2020 to June 2021, 25 showed that the prevalence of symptoms of anxiety and depression was higher in times of stricter policy measures. This study did not include student status. However, although time trends were similar for all population subgroups, higher levels of both anxiety and depression were generally found in young people. 25 Conversely, a longitudinal study conducted among 988 adults in Argentina showed a gradual increase in anxiety and depression between August 2020 and April 2021. 26 Again, young adults had higher prevalence rates of symptoms than other age groups. 26 Finally, in the study by Lu et al, 27 including 613 French adults, a continuing increase in the mean scores of anxiety and depression symptoms was observed throughout the 2 lockdown periods in France, with younger participants being more vulnerable to anxiety symptoms.

The risk factors identified in our study are similar to those identified in the previous measurement times of the COSAMe survey and consistent with those described in the literature on pandemics or lockdowns. The review by Brooks et al 3 pointed out that gender, psychiatric history, physical symptoms, social isolation, lack of information, and financial loss were all associated with mental health conditions. Schmits et al 28 also identified women and nonbinary individuals as having increased risk for poor mental health as well as a deterioration of the financial situation and reduced contact with family and friends. Of note, for most students, the academic year at T3 differed from the academic year at the time of exposure. Except for students repeating a year or returning to university after a break, they all had been confined while they were in the lower academic year, including the last high school year for first-year students at T3. Consequently, standardization on the current academic degree does not correspond to standardization on the academic degree at the time of exposure, and this may slightly bias the comparisons of the results at T3 with those at T1 and T2. Nevertheless, whatever the measurement time, we found that the prevalence of mental health disorders tended to decrease among those pursuing a higher degree, and in particular, that the risk appeared to be lower among doctoral students. This association is consistent with the literature that has established a strong link between mental health and the level of education. 29

Even if the situation were still unstable in the summer of 2021, restrictions had been reduced compared with the strict lockdown periods. This improvement in the COVID-19 health crisis was instead accompanied by a worsening of the mental health of students. Several hypotheses can explain this situation. The first explanation is that the health crisis has led to a social and economic crisis, with well-known consequences. 30 It has already been shown that, during periods of crisis (natural disasters, war, or epidemics), suicide rates may momentarily decrease before increasing thereafter, particularly under the influence of economic repercussions and social of the crisis. 8 , 31 The occurrence or increase of unemployment, poverty, or even loneliness is likely to contribute to the increase in mental health disorders, such as depression, anxiety, and PTSD, and the suicide rate. 8 However, the specific evolution in the prevalence of PTSD, which reached a particularly high level at T3, raises questions. The recent network approach to psychopathology explains the persistence of disorders over time, even after the disappearance of the initial triggering event (eg, the first lockdown). 32 It posits that mental disorders can be conceptualized and studied as causal systems of mutually reinforcing symptoms 33 : according to this theory, there are causal associations between mental health symptoms, and if these associations are strong enough, the symptoms can be self-perpetuating, regardless of the event that initially triggered them. 34 The COVID-19 pandemic is an unprecedented and particularly complex event, which may be better understood as a collection of several events that are direct or indirect consequences of COVID-19. We hypothesize that the COVID-19 pandemic and its related consequences are underestimated and that prolonged and cumulative exposure to stressors and/or potentially traumatic events during this period could have led to the occurrence or decompensation of mental health disorders, self-sustaining even after the health situation has improved. Although recent and still unstable, exploring the network approach to mental disorders could help to better understand mental health symptoms interact with each other, contributing to a better understanding of how mental disorders persist over time.

This study has limitations. First, although the number of respondents is large, it represents a minority of students (2.8%). The overrepresentation of women and bachelor students was considered by standardizing on gender and academic degree, the only 2 variables common to our sample and those available at the national level via the Ministry of Education. Association measures are only marginally affected by a low response rate. Second, self-administrated tools used in this study cannot be considered diagnostic tools. Third, the present study cannot establish the direct link between the high rates of mental health disorders and the COVID-19 pandemic and its associated restriction measures, even though high rates were also observed in other studies related to the COVID-19 pandemic or previous pandemics. 3 , 35 Fourth, this survey did not include any measures prior to the pandemic. However, as discussed by Wathelet et al 4 regarding estimates obtained at T1, the prevalence rates measured were higher than the prepandemic measurements identified in the literature. Fifth, the seasonality of certain mental disorders might be a subject of concern. Indeed, in our study, T3, unlike T2 and T1, was conducted exclusively during the summer holidays. Although the phenomenon is complex and poorly understood and contrary to most mental health disorders, 36 an increased risk of suicide during late spring and early summer has been observed. 37 Among students, the differences in suicidal ideation between summer and winter were shown to be, in large part, accounted for by belongingness. 38 That being said, although seasonality cannot be strictly controlled here, all of the measurement times took place during spring or summer periods, which limits the bias in the comparisons. Additionally, some other factors could be associated with mental health disorders but have not been considered here, such as relationship, residence, or institution type.

This large nationwide study found high prevalence rates of anxiety, depression, perceived stress, PTSD, and suicidal ideation 15 months after the beginning of the COVID-19 pandemic among university students in France. If a slight decrease had been observed just after the first lockdown for anxiety and depression, evidence shows that suicidal ideation has increased throughout the survey and that PTSD has jumped from 1 in 5 to 1 in 3 students concerned. These results suggest long-lasting consequences associated with the pandemic on the mental health of students. Prevention and care access should be a priority.

Accepted for Publication: November 13, 2022.

Published: December 29, 2022. doi:10.1001/jamanetworkopen.2022.49342

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2022 Wathelet M et al. JAMA Network Open .

Corresponding Author: Marielle Wathelet, MD, Department of Psychiatry, Centre Hospitalo-Universitaire de Lille, CS 70001, 59037 Lille Cedex, France ( [email protected] ).

Author Contributions: Drs D’Hondt and Wathelet had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Wathelet, Fovet, Habran, Vaiva, D’Hondt.

Acquisition, analysis, or interpretation of data: Wathelet, Horn, Creupelandt, Fovet, Baubet, Habran, Martignène, D’Hondt.

Drafting of the manuscript: Wathelet, D’Hondt.

Critical revision of the manuscript for important intellectual content: Horn, Creupelandt, Fovet, Baubet, Habran, Martignène, Vaiva, D’Hondt.

Statistical analysis: Wathelet, Habran, D’Hondt.

Obtained funding: Wathelet, Vaiva, D’Hondt.

Administrative, technical, or material support: Creupelandt, Habran, Vaiva, D’Hondt.

Supervision: Horn, Fovet, Baubet, Vaiva, D’Hondt.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was supported by the French National Research Agency and the Hauts-de-France region (ANR-21-HDF1-0013), the Fondation de Lille, and the Fondation de France.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See the Supplement .

Additional Contributions: We thank the French Ministry of Higher Education, Research and Innovation and the French National Center for School and University Affairs (CNOUS) for disseminating the survey. We are also grateful to university students for their participation.

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A Study on Students' Mental Health During the COVID-19 Pandemic Through the Perspective of Mental Health Professionals

• Masters Thesis
• Hightower, Shelby
• Navarro, Richard
• Olson, Peter
• Lim, Andrew
• Education & Integrative Studies
• California State Polytechnic University, Pomona
• pandemic lockdown 2020
• mental health
• http://hdl.handle.net/20.500.12680/9306t488f

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