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• Springer Nature - PMC COVID-19 Collection

Stress, Anxiety, and Depression Among Undergraduate Students during the COVID-19 Pandemic and their Use of Mental Health Services

Jungmin lee.

1 Department of Educational Policy Studies and Evaluation, University of Kentucky, 597 S. Upper Street, 131 Taylor Education Building, Lexington, KY 40506-0001 USA

Hyun Ju Jeong

2 Department of Integrated Strategic Communication, University of Kentucky, Lexington, KY USA

3 Division of Biomedical Informatics, University of Kentucky, Lexington, KY USA

Associated Data

Not applicable.

The coronavirus 2019 (COVID-19) has brought significant changes to college students, but there is a lack of empirical studies regarding how the pandemic has affected student mental health among college students in the U.S. To fill the gap in the literature, this study describes stress, anxiety, and depression symptoms for students in a public research university in Kentucky during an early phase of COVID-19 and their usage of mental health services. Results show that about 88% of students experienced moderate to severe stress, with 44% of students showing moderate to severe anxiety and 36% of students having moderate to severe depression. In particular, female, rural, low-income, and academically underperforming students were more vulnerable to these mental health issues. However, a majority of students with moderate or severe mental health symptoms never used mental health services. Our results call for proactively reaching out to students, identifying students at risk of mental health issues, and providing accessible care.

The coronavirus 2019 (COVID-19) has brought significant and sudden changes to college students. To protect and prevent students, faculty, and staff members from the disease, higher education institutions closed their campus in the spring of 2020 and made a quick transition to online classes. Students were asked to evacuate on a short notice, adjust to new online learning environments, and lose their paid jobs in the middle of the semester. The pandemic has also raised concerns among college students about the health of their family and friends (Brown & Kafka, 2020 ). Because all these changes were unprecedented and intensive, they caused psychological distress among students, especially during the first few months of the pandemic. There is abundant anecdotal evidence describing students’ stress and emotional difficulties as impacted by COVID-19, but there are only a few empirical studies available that directly measure college student mental health since the outbreak (e.g., Huckins et al., 2020 ; Kecojevic et al., 2020 ; Son et al., 2020 ). Most existing studies focus on mental health for general populations (e.g., Gao et al., 2020 ) or health care workers (e.g., Chen et al., 2020 ), whose results may not be applicable to college students. Given that college students are particularly vulnerable to mental health issues (e.g., Kitzrow, 2003 ), it is important to explore their mental health during this unprecedented crisis.

In this study, we describe the prevalence of stress, anxiety, and depression for undergraduate students in a public research university during the six weeks after the COVID-19 outbreak alongside their usage of mental health services. Using a self-administered online survey, we measured stress, anxiety, and depression levels with well-established clinical tools and asked the extent to which college students used on-campus and off-campus mental health services for the academic year. Our results revealed that more than eight out of ten students surveyed experienced modest or severe stress, and approximately 36–44% of respondents showed moderate or severe anxiety and depression. However, more than 60% of students with moderate or severe stress, anxiety, or depression had never utilized mental health services on- or off-campus. Although focusing on a single institution, this paper is one of the few studies that empirically examine mental health of college students in the U.S. during the early phase of the pandemic. Findings from this paper reassure the seriousness of student mental health during the pandemic and call for a proactive mental health assessment and increased support for college students.

Literature Review

Covid-19 and student mental health.

Empirical studies reported a high prevalence of college mental health issues during the early phase of COVID-19 around the world (Cao et al., 2020 ; Chang et al., 2020 ; Liu et al., 2020 , Rajkumar, 2020 ; Saddik et al., 2020 ). In the U.S. a few, but a growing number of empirical surveys and studies were conducted to assess college students’ mental health during the pandemic. Three nationwide surveys conducted across the U.S. conclude that college student mental health became worse during the pandemic. According to an online survey administered by Active Minds in mid-April of 2020, 80% of college students across the country reported that COVID-19 negatively affected their mental health, with 20% reporting that their mental health had significantly worsened (Horn, 2020 ). It is also concerning that 56% of students did not know where to go if they had immediate needs for professional mental health services (Horn, 2020 ). Another nationwide survey conducted from late-May to early-June also revealed that 85% of college students felt increased anxiety and stress during the pandemic, but only 21% of respondents sought a licensed counselor or a professional (Timely MD, n.d. ) According to the Healthy Minds Network’s survey (2020), which collected data from 14 college campuses across the country between March and May of 2020, the percentage of students with depression increased by 5.2% compared to the year before. However, 58.2% of respondents never tried mental health care and about 60% of students felt that it became more difficult to access to mental health care since the pandemic. These survey results clearly illustrate that an overwhelming majority of college students in the U.S. have experienced mental health problems during the early phase of COVID-19, but far fewer students utilized professional help. Despite the timely and valuable information, only Healthy Minds Network ( 2020 ) used clinical tools to measure student mental health, and none of them explored whether student characteristics were associated with mental health symptoms.

To date, only a few scholarly research studies focus on college student mental health in the U.S. since the COVID-19 outbreak. Huckins et al. ( 2020 ) have longitudinally tracked 178 undergraduate students at Dartmouth University for the 2020 winter term (from early-January to late-March of 2020) and found elevated anxiety and depression scores during mid-March when students were asked to leave the campus due to the pandemic. The evacuation decision coincided with the final week, which could have intensified student anxiety and depression. The anxiety and depression scores gradually decreased once the academic term was over, but they were still significantly higher than those measured during academic breaks in previous years. Conducting semi-structured interviews with 195 students at a large public university in Texas, Son et al. ( 2020 ) found that 71% of students surveyed reported increased stress and anxiety due to the pandemic, but only 5% of them used counseling services. The rest of the students explained that they did not use counseling services because they assumed that others would have similar levels of stress and anxiety, they did not feel comfortable talking with unfamiliar people or over the phone, or they did not trust counseling services in general. Common stressors included concerns about their own health or their loved ones’, sleep disruption, reduced social interactions, and difficulty in concentration. Based on a survey from 162 undergraduate students in New Jersey, Kecojevic et al. ( 2020 ) found that female students had a significantly higher level of stress than male students and that upper-class undergraduate students showed a higher level of anxiety than first-year students. Having difficulties in focusing on academic work led to increased levels of stress, anxiety, and depression (Kecojevic et al., 2020 ).

College Student Mental Health and Usage of Mental Health Services Before COVID-19

College student mental health has long been studied in education, psychology, and medicine even before the pandemic. The general consensus of the literature is that college student mental health is in crisis, worsening in number and severity over time. Before the pandemic in the academic year of 2020, more than one-third of college students across the country were diagnosed by mental health professionals for having at least one mental health symptom (American College Health Association, 2020 ). Anxiety (27.7%) and depression (22.5%) were most frequently diagnosed. The proportion of students with mental health problems is on the rise as well. Between 2009 and 2015, the proportion of students with anxiety or depression increased by 5.9% and 3.2%, respectively (Oswalt et al., 2020 ). Similarly, between 2012 and 2020, scores for depression, general anxiety, and social anxiety have constantly increased among those who visited counseling centers on college campuses (Center for College Mental Health [CCMH], 2021 ).

Some groups are more vulnerable to mental health problems than others. For example, female and LGBTQ students tend to report a higher prevalence of mental health issues than male students (Eisenberg et al., 2007b ; Evans et al., 2018 ; Wyatt et al., 2017 ). However, there is less conclusive evidence on the difference across race or ethnicity. It is well-supported that Asian students and international students report fewer mental health problems than White students and domestic students, but there are mixed results regarding the difference between underrepresented racial minority students (i.e., African-American, Hispanic, and other races) and White students (Hyun et al., 2006 ; Hyun et al., 2007 ). Many researchers find either insignificant differences (e.g., Eisenberg et al., 2007b ) or fewer mental health issues reported for underrepresented minority students compared to White students (e.g., Wyatt et al., 2017 ). This may not necessarily mean that racial minority students tend to have fewer mental health problems, but it may reflect their cultural tendency against disclosing one’s mental health issues to others (Hyun et al., 2007 ; Wyatt & Oswalt, 2013 ). In terms of age, some studies (e.g., Eisenberg et al., 2007b ) reveal that students who are 25 years or older tend to have fewer mental health issues than younger students, while others find it getting worse throughout college (Wyatt et al., 2017 ). Lastly, financial stress significantly increases depression, anxiety, and suicidal thoughts among college students (Eisenberg et al., 2007b ).

Despite the high prevalence of mental health issues, college students tend to underutilize mental health services (Cage et al., 2018 ; Hunt & Eisenberg, 2010 ; Lipson et al., 2019 ; Oswalt et al., 2020 ). The Healthy Minds Study 2018–2019, which collected data from 62,171 college students across the country, reports that 57% of students with positive anxiety or depression screens have not used counseling or therapy, and 64% of them have not taken any psychotropic medications within the past 12 months (Healthy Minds, 2019 ). Even when students had visited a counseling center, about one-fourth of them did not return for a scheduled appointment, and another 14.1% of students declined further services (CCMH, 2021 ). When asked the barriers that prevented them from seeking mental health services, students reported a lack of perceived needs for help (41%), preference to deal with mental health issues on their own or with families and friends (27%), a lack of time (23%), financial difficulty (15%), and a lack of information about where to go (10%). Students who never used mental health services were not sure if their insurance covered mental health treatment or were more skeptical about the effectiveness of treatment (Eisenberg et al., 2007a ). Stigma, students’ view about getting psychological help for themselves, is another significant barrier in seeking help and utilizing mental health services (Cage et al., 2018 ).

Current Study

While previous studies have advanced our understanding of student mental health and their usage of mental health services, we find a lack of empirical studies on these matters, particularly in the context of COVID-19. The goal of this study is to fill the gap with specific investigations into the prevalence and pattern of U.S. college student mental health with regard to counseling service use during the early phase of COVID-19. First, very few studies focus on college students and their mental health during the pandemic, and most nationwide surveys conducted in the U.S. did not use clinically validated tools to measure student mental health. In this study, we have employed the three clinical measures to assess stress, anxiety, and depression, which are the most prevalent mental health problems among college student populations (Leviness et al., 2017 ). Secondly, it should be noted that while empirical research conducted in U.S. institutions clearly demonstrate that college students were under serious mental distress during the pandemic (Huckins et al., 2020 ; Son et al., 2020 ; Kecojevic et al., 2020 ), such studies have relatively small sample sizes and rarely examined whether particular groups were more vulnerable than others during the pandemic. To overcome such limitations, the present study has recruited a relatively large number of students from all degree-seeking students enrolled at the study institution. Further, given the high prevalence of mental health issues, we have identified vulnerable student groups and provided suggestions regarding necessary support for these students in an effort to reduce mental health disparity. Lastly, previous studies (e.g., Healthy Minds, 2019 ) show that college students, even those with mental health issues, tended to underutilize counseling services before the pandemic. Yet, there is limited evidence regarding whether this continued to be the case during COVID-19. Our study provides empirical evidence regarding the utilization of mental health services during the early phase of the pandemic and identifies its predictors. Based on the preceding discussions, we address the following research questions in this study:

First, how prevalent were stress, anxiety, and depression among college students during the early phase of the pandemic? Second, to what extent have students utilized mental health services on- and off-campus? Third, what are the predictors of mental health symptoms and the usage of mental health services?

We collected data via a self-administered online survey. This survey was designed to measure student mental health, the usage of mental health services, and demographics. The survey was sent to all degree-seeking students enrolled in a public research university in Kentucky for the spring of 2020. An invitation email was first sent on March 23, which was two days after the university announced campus closure, and two more reminder emails were sent in mid-April and late-April. The survey was available until May 8th, which was the last day of the semester.

A total of 2691 students (out of 24,146 qualified undergraduate and graduate degree-seeking students enrolled for the semester) responded to the survey. The response rate was 11.14%, but this is acceptable as it is within the range of Internet survey response rates, which is anywhere from 1 to 30% (Wimmer & Dominick, 2006 ). We deleted responses from 632 students who did not answer any mental health questions, which left 2059 valid students for the analysis. In this study, we focused on undergraduate students because they are significantly different from graduate students in terms of demographics (e.g., racial composition, age, and income) and major stressors (Wyatt & Oswalt, 2013 ). As a result, 1412 undergraduate students are included in our sample. 90% of these students had complete data. The rest of students skipped a couple of questions (usually related to their residency) but answered most of the question. Thus, we conducted multiple imputation, created ten imputed data sets, and ran regression models using these imputed data (Allison, 2002 ). Our regression results using imputed data are qualitatively similar to the estimates using original data; however, for comparison, we also provided the regression estimates using original data in Appendix Tables  6 and ​ and7. 7 . Please note that we still used original data for descriptive research questions (presented in Tables  1 , ​ ,2, 2 , and ​ and4) 4 ) to accurately describe the prevalence of mental health symptoms and use of counseling services.

Descriptive statistics of sample characteristics

Descriptive statistics for stress, anxiety, and depression prevalence

Usage of mental health services among students with moderate or severe symptoms

Ordinal logistic regression models for severity of mental health symptoms (original data)

Odds ratio are reported, and numbers in parentheses are standard error

+ p  < 0.1, * p  < 0.05, ** p  < 0.01, *** p  < 0.001

Logistic regression models predicting the usage of mental health services (original data)

+ p < 0.1, * p < 0.05, ** p < 0.01, *** p < 0.001

Table  1 provides descriptive statistics for students in our data. Female (73%), White (86%), and students who are below 25 years old (95%) are the vast majority of our sample. About one in four students are rural students and/or students from Appalachian areas (27%) and first-generation students (23%). Wealthier students (whose family income was $100,000 or more) make up about 44% of the sample (44%). Compared to the undergraduate student population at the study site, female students (56.3% at the study site) are overrepresented in our study. The proportion of White students is slightly higher in our sample (86%) than the study population (84%), and that of first-generation students is slightly lower in our sample (23%) than that in the study population (26%).

There are five key outcome variables for this study. The first three outcome variables are stress, anxiety, and depression, and the other two variables are the extent to which students used on-campus and off-campus mental health services for the academic year, respectively. Our mental health measures are well-established and widely used in a clinical setting. For stress, we used the Perceived Stress Scale (PSS) that includes ten items asking students’ feelings and perceived stress measured on a 5-point Likert scale from 0 (strongly disagree) to 4 (strongly agree) (Cohen et al., 1983 ). Using the sum of scores from the ten items, the cut-off score for low, moderate, and high stress is 13, 26, and 40, respectively. PSS scale was used in hundreds of studies and validated in many languages (Samaha & Hawi, 2016 ). PSS also has a high internal consistency reliability. Of the recent studies that used the instrument to measure mental health of U.S. college students, Cronbach’s alpha was around 0.83 to 0.87, which exceeded the commonly used cut-off of 0.70 (Adams et al., 2016 ; Burke et al., 2016 ; Samaha & Hawi, 2016 ).

We used the General Anxiety Disorder 7-item (GAD-7) scale to measure anxiety. This is a brief self-report scale to identify probable cases of anxiety disorders (Spitzer et al., 2006 ). The GAD scores of 5, 10, and 15 are taken as the cut-off points for mild, moderate, and severe anxiety, respectively. In a clinical setting, anyone with a score of 10 or above are recommended for further evaluation. GAD is moderately good at screening three other common anxiety disorders - panic disorder (sensitivity 74%, specificity 81%), social anxiety disorder (sensitivity 72%, specificity 80%), and post-traumatic stress disorder (sensitivity 66%, specificity 81%) (Spitzer et al., 2006 ) In their recent study, Johnson, et al. ( 2019 ) validated that “the GAD-7 has excellent internal consistency, and the one-factor structure in a heterogeneous clinical population was supported” (p. 1).

Lastly, depression was assessed with the eight-item Patient-Reported Outcomes Measurement Information System (PROMIS) Depression Short Form (Pilkonis et al., 2014 ). A score less than 17 is considered as none to slight depression, a score between 17 and 21 is considered as mild depression, a score between 22 and 32 is considered as moderate depression, and a score of 33 or above is considered as severe depression. PROMIS depression scale is a universal, rather than a disease-specific, measure that was developed using item response theory to promote greater precision and reduce respondent burden (Shensa et al., 2018 ). The scale has been correlated and validated with other commonly used depression instruments, including the Center for Epidemiological Studies Depression Scale (CES-D), the Beck Depression Inventory (BDI-II), and the Patient Health Questionnaire (PHQ-9) (Lin et al., 2016 ).

When it comes to the usage of psychological and counseling services, we asked students to indicate the extent to which they used free on-campus resources (e.g., counseling center) and off-campus paid health professional services (e.g., psychiatrists) anytime during the academic year on a scale of 1 (never) to 5 (very often), respectively. These questions do not specifically ask if students utilized these services after the COVID-19 outbreak, but responses for these questions indicate whether and how often students had used any of these services for the academic year until they responded to our survey.

We also collected data about student demographics and characteristics including student gender, race or ethnicity, age, class levels (freshman, sophomore, junior, and senior), first generation student status (1 = neither parent has a bachelor’s degree, 0 = at least one parent with a bachelor’s degree), family income, residency (rural and/or Appalachian students, international students), GPAs, and perceived stigma about seeking counseling or therapy (i.e., “I am afraid of what my family and friends will say or think of me if I seek counseling/therapy”) measured on a 5-point Likert scale. We used these variables to see if they were associated with a high level of stress, anxiety, and depression and the usage of mental health services.

We used descriptive statistics, ordinal logistic regression, and logistic regression models in this study. To address the first and second research questions, we used descriptive statistics and presented the prevalence of stress, anxiety, and depression as well as the frequency of using mental health services. For the third research question, we adopted ordinal logistic regression and logistic regression models depending on outcome variables. We used ordinal logistic regression models to identify correlates of different levels of stress, anxiety, and depression, which were measured in ordinal variables (e.g., mild, moderate, and severe). For the usage of mental health service outcomes, we employed logistic regression models. Because more than two-thirds of students in the sample never utilized either type of mental health services, we re-coded the usage variables into binary variables (1 = used services, 0 = never used services) and ran logistic regression models.

Limitations

Our study is not without limitations. First, we do not claim a causal relationship in this study, but we describe the state of mental health for students soon after the COVID-19 outbreak. We acknowledge that many students may have suffered from mental health problems before the pandemic, with some experiencing escalation after the outbreak (e.g., Horn, 2020 ). Even if our study does not provide a causal relationship, we believe that it is important to measure and document student mental health during the pandemic so that practitioners can be aware of the seriousness of this issue and consider ways to better serve students. Secondly, our study results may not be applicable to students in other institutions or states. We collected data from a public research university in Kentucky where the number of confirmed cases and deaths were relatively lower than other states such as New York. The study site mainly serves traditional college students who attend college right after high school, who live on campus, and who do not have dependents. Therefore, mental health for students at other types of institutions or in other states could be different from what is presented in our study.

Prevalence of Stress, Anxiety, and Depression

Table  2 shows the prevalence of stress, anxiety, and depression. Overall, a majority of students experienced psychological distress during the early phase of the pandemic. When it comes to stress, about 63% of students had a moderate level of stress, and another 24.61% of students fell into a severe stress category. Only 12% of students had a low level of stress. In other words, more than eight in ten students in the survey experienced moderate to severe stress during the pandemic. This result is comparable to the Active Minds’ survey results that report 91% of college students reported experiencing feelings of stress and anxiety since the pandemic (Horn, 2020 ).

In terms of anxiety, approximately 24% and 21% of students in our study had moderate and severe anxiety disorders, respectively. Given that those who scored 10 or above on the GAD-7 scale (moderate to severe category) are recommended to meet with professionals (Spitzer et al., 2006 ), this finding implies that nearly half of students in this study needed to get professional help. This proportion of students with moderate to severe anxiety is almost double that for university students in China (e.g., Chang et al., 2020 ) or the United Arab Emirates soon after the COVID-19 outbreak (Saddik et al., 2020 ). Lastly, approximately 30% and 6% of students suffered from moderate and severe depression, respectively. These proportions are far higher than college students in China measured during the pandemic (Chang et al., 2020 ) but slightly higher than a nationwide sample of U.S. college students assessed before the pandemic (Healthy Minds, 2019 ). Given that our study measured these mental health symptoms for the first six weeks of the pandemic, we speculate that the proportion of students with moderate or severe depression would increase over time.

In order to explore predictors of a higher level of stress, anxiety, and depression, we ran ordinal logistic regression models as presented in Table  3 . Overall, it is clear and consistent that the odds of experiencing a higher level of stress, anxiety, and depression (e.g., severe than moderate, moderate than mild, etc.) were significantly greater for female students by a factor of 1.489, 1.723, and 1.246 than the odds for male students when other things were held constant. This gender difference in mental health symptoms is quite consistent with other studies before and during the pandemic (Eisenberg et al., 2007a ; Kecojevic et al., 2020 ). When it comes to race or ethnicity, the odds of experiencing a higher level of stress, anxiety, and depression for African-American students were almost as half as the odds for White students. However, there was no significant difference in the odds for Hispanic and Asian students compared to White students. Student class level was significantly related to stress and anxiety levels: The odds were greater for upper-class students than lower class students. This result is consistent with Kecojevic et al. ( 2020 ), which reported significantly higher levels of anxiety among upper-class students compared to freshman students. It may reflect that one of major stressors for college students during the pandemic is the uncertain future of their education and job prospects, which would be a bigger concern for upper-class students (Timely MD, n.d.).

Ordinal logistic regression models for severity of mental health symptoms (imputed data)

One’s rurality, family income, and GPA were significantly associated with the severity of mental health symptoms. The odds of experiencing a severe level of anxiety and depression were 1.325 and 1.270 times higher among rural students than urban and suburban students. With every one unit increase in family income or students’ GPAs, the odds of experiencing a more severe stress, anxiety, and depression significantly decreased. This result suggests that students from disadvantaged backgrounds were even more vulnerable to psychological distress during the early phase of the pandemic. The negative association between GPAs and mental distress levels was consistent with previous studies that showed that college students were very concerned about their academic performances and had difficulty in concentration during the early phase of the pandemic (Kecojevic et al., 2020 ; Son et al., 2020 ).

Usage of Mental Health Services

In Table  4 , we first describe the extent to which students with moderate to severe symptoms of stress, anxiety, or depression used mental health services on- and off-campus during the academic year. The university in this study has provided free counseling services for students, and the counseling services have continued to be available for students in the state via phone or Internet even after the university was closed after the outbreak. Table ​ Table4 4 presents the frequency of students using on-campus mental health services (Panel A) and off-campus paid mental health services (Panel B) on a five-point scale. For this table, we limited the sample to students with moderate to severe symptoms of stress, anxiety, or depression to focus on students who were in need of these services. Surprisingly, a majority of these students never used mental health services on- and off-campus even when their stress, anxiety, or depression scores indicated that they needed professional help. More than 60% of students with moderate to severe symptoms never used on-campus services, and more than two-thirds of students never used off-campus mental health services. This underutilization of mental health resources is concerning but not surprising given that college students tended not to use counseling services before and during the pandemic as presented in previous studies (e.g., CCMH, 2021 ; Healthy minds, 2019 ; Son et al., 2020 ).

In order to explore predictors of the usage of mental health services, we ran logistic regression models as shown in Table  5 . We included all students in these regression models to see whether a severity of mental health symptoms was related to the usage of mental health services. Table ​ Table5 5 presents the results for the usage of any mental health services, on-campus mental health services, and off-campus mental health services, respectively. Overall, stress, anxiety, and depression levels were positively associated with using mental health services on- and off-campus: With every one unit increase in each of these mental health symptoms, the odds of using on- and off-campus mental health services significantly increased. This result is relieving as it suggests that students who were in great need of these services actually used them. Other than mental health symptoms, there were different predictors for utilizing on-campus and off-campus services. African-American and Hispanic students were significantly more likely to use on-campus services than White students. The odds of using on-campus mental health services were 3.916 times higher for African-American students and 2.032 times higher for Hispanic students than White students. This result is interesting given that the odds of having severe mental distress were significantly lower for African-American students than White students, according to Table ​ Table3. 3 . It may suggest that African-American students reported relatively lower levels of mental health symptoms as they had been using on-campus mental health services at higher rates. The odds of using on-campus mental health services were 2.269 times higher for international students than domestic students, but there was no significant difference in the odds of using off-campus services between the two groups. Students’ age was significantly associated with the usage of on-campus and off-campus mental health services: The odds of using on-campus services were significantly lower for older students, while the odds of utilizing off-campus services were significantly higher for older students compared to younger students. When it comes to using off-campus mental health services, the odds were significantly higher for female students, older students, and upper-class students than male students, younger students, and lower classman students. Students who were concerned with stigma associated with getting counseling and therapy were less likely to utilize off-campus mental health services.

Logistic regression models predicting the usage of mental health services (imputed data)

Discussions

Our paper describes the prevalence of stress, anxiety, and depression among a sample of undergraduate students in a public research university during an early phase of the COVID-19 outbreak. Using well-established clinical tools, we find that stress, anxiety, and depression were the pervasive problems for college student population during the pandemic. In particular, female, rural, low-income, and academically low-performing students were more vulnerable to psychological distress. Despite its prevalence, about two-thirds of students with moderate to severe symptoms had not utilized mental health services on- and off-campus. These key findings are very concerning considering that mental health is strongly associated with student well-being, academic outcomes, and retention (Bruffaerts et al., 2018 ; Wyatt et al., 2017 ).

Above all, we reiterate that college student mental health is in crisis during the pandemic and call for increased attention and interventions on this issue. More than eight in ten students in our study had moderate to severe stress, and more than one thirds of students experienced moderate to severe anxiety and/or depression. This is much worse than American college students before the COVID-19 (e.g., American College Health Association, 2020 ) and postsecondary students in other countries during the pandemic (e.g., Chang et al., 2020 ; Saddik et al., 2020 ). In particular, rural students, low-income students, and students with low GPAs were more vulnerable to psychological distress. These students have already faced multiple barriers in pursuing higher education (e.g., Adelman, 2006 ; Byun et al., 2012 ), and additional mental health issues would put them at a high risk of dropping out of college. Lastly, although they were dropped from the main analysis due to the small sample size ( n  = 17), it is still noteworthy that a significantly higher proportion of LGBTQ students in our sample experienced severe stress, anxiety, and depression, which calls for significant attention and care for these students.

Despite the high prevalence of mental health problems, a majority of students with moderate to severe symptoms never used mental health services during the academic year, even though the university provided free counseling services. This result could be partially explained by the fact that the university’s counseling center switched to virtual counseling since the COVID-19 outbreak, which was available only for students who stayed within the state due to the license restriction across state boarders. This transition could limit access to necessary care for out-of-state students, international students, or students in remote areas where telecommunications or the internet connection is not very stable. Even worse, these students may also have limited access to off-campus health professionals due to the geographic restrictions (rural students), limited insurance coverage (international students), or a lack of financial means. Our results support that international students relied significantly more on on-campus resources than domestic students. We urge practitioners and policy makers to provide additional mental health resources that are accessible, affordable, and available for students regardless of their locations, insurance, and financial means, such as informal peer conversation groups or regular check-ins via phone calls or texts.

It is also important to point out that the overall usage of both on-campus and off-campus mental health services was generally low even before the COVID-19 outbreak. Previous studies consistently report that college students underutilize mental health services not only because of a lack of information, financial means, or available seats but also because of a paucity of perceived needs or stigma related to revealing one’s mental health issues to others (Cage et al., 2018 ; Eisenberg et al., 2007a ; Son et al., 2020 ). Our results support this finding by demonstrating that stigma one associated with getting counseling or therapy negatively influenced their utilization of off-campus mental health services. Considering these barriers, practitioners should deliver a clear message publicly that mental health problems are very common among college students and that it is natural and desirable to seek professional help if students feel stressed out, anxious, or depressed. In order to identify students with mental health needs and raise awareness among students, it can be also considered to administer a short and validated assessment in classes that enroll a large number of students (e.g., in a freshman seminar course), inform the entire class of how to interpret their scores on their own, and provide a list of available resources for those who may be interested. This would give students a chance to self-check their mental health without revealing their identities and seek help, if necessary.

We recommend that future researchers longitudinally track students and see whether the prevalence of mental health problems changes over time. Longitudinal studies are generally scarce in student mental health literature, but the timing of assessment can influence mental health symptoms reported (Huckins et al., 2020 ). The survey for our study was sent out right after the university of this study was closed due to the pandemic. It is possible that students may adjust to the outbreak over time and feel better, or that their stress may add up as the disease progresses. Tracking students over time can illustrate whether and how their mental health changes, especially depending on the way the pandemic unfolds combined with the cycle of an academic year. Secondly, there should be more studies that evaluate the effect of an intervention program on student mental health. Hunt and Eisenberg ( 2010 ) point out that little has been known about the efficacy of intervention programs while almost every higher education institution offers multiple mental health resources and counseling programs. During this pandemic, it can be a unique opportunity to implement virtual mental health interventions and evaluate their efficacy. Future research on virtual counseling and mental health interventions would guide practices to accommodate mental health needs for students who exclusively take online courses or part-time students who spend most of their time off campus. Lastly, we recommend future research investigate the extent of mental health service utilization among students with mental health needs. Existing surveys and studies on this topic usually rely on responses from those who visit a counseling center or students who respond to their surveys. Neither of these groups accurately represents those who are in need of professional help because there may be a number of students who are not aware of their mental health issues or do not want to reveal it. An effective treatment should first start with identifying those in need.

Our study highlights that college students are stressed, anxious, and depressed in the wake of COVID-19. Although college students have constantly reported mental health issues (e.g., American College Health Association, 2020 ), it is remarkable to note that the broad spectrum of COVID-19-related challenges may mitigate the overall quality of their psychological wellbeing. This is particularly the case for at-risk students (rural, international, low-income, and low-achieving students) who have already faced multiple challenges. We also present that a majority of students with mental health needs have never utilized on- and off-campus services possibly due to the limited access or potential stigma associated with mental health care. Systematic efforts with policy makers and practitioners are requested in this research to overcome the potential barriers. All these findings, based on the clinical assessment of student mental health during the early phase of the pandemic, will benefit scholars and practitioners alike. As many colleges and universities across the country have re-opened their campus for the 2020–2021 academic year, students, especially those who take in-person classes, would be concerned about the disease and continuing their study in this unprecedented time. On top of protecting students from the disease by promoting wearing masks and social distancing, it is imperative to pay attention to their mental health and make sure that they feel safe and healthy. To this end, higher education institutions should proactively reach out to all student populations, identify students at risk of mental health issues, and provide accessible and affordable care.

Biographies

is Assistant Professor of Higher Education at the University of Kentucky. She studies higher education policy, program, and practice and their effects on student success.

is an Assistant Professor of Integrated Strategic Communication at the University of Kentucky. She earned her Ph.D. in Media and Information Studies at Michigan State University. Her research interests include prosocial campaigns, consumer wellbeing, and civic engagement.

is an associate professor in the Division of Biomedical Informatics in the College of Medicine at the University of Kentucky. Dr. Kim’s current research includes: consumer health informatics, personal health information management, and health information seeking behaviors. She uses clinical natural language professing techniques and survey methodologies to better understand patients’ health knowledge and their health information uses and behaviors.

Author’s Contribution

The order of the authors in the title page reflects the share of each author’s contribution to the manuscript.

Data Availability

Code availability, declarations.

The authors declare that they have no conflicts of interest.

All authors agree to publish this paper.

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Contributor Information

Jungmin Lee, Email: [email protected] .

Hyun Ju Jeong, Email: [email protected] .

Sujin Kim, Email: ude.yku@miknijus .

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Open Access

Peer-reviewed

Research Article

Depression, anxiety and stress among high school students: A cross-sectional study in an urban municipality of Kathmandu, Nepal

Contributed equally to this work with: Anita Karki, Bipin Thapa

Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Software, Writing – original draft, Writing – review & editing

* E-mail: [email protected] (PB); [email protected] (AK)

Affiliation Central Department of Public Health, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal

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

Affiliation Department of Child, Adolescent Health and Maternal Care, School of Public Health, Capital Medical University, Beijing, China

Roles Writing – review & editing

Affiliation Department of Community Medicine, Maharajgunj Medical Campus, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal

Roles Conceptualization, Methodology, Supervision, Writing – review & editing

• Anita Karki, 
• Bipin Thapa, 
• Pranil Man Singh Pradhan, 

• Published: May 31, 2022
• https://doi.org/10.1371/journal.pgph.0000516
• Peer Review
• Reader Comments

Depression and anxiety are the most widely recognized mental issues affecting youths. It is extremely important to investigate the burden and associated risk factors of these common mental disorders to combat them. Therefore, this study was undertaken with the aim to estimate the prevalence and identify factors associated with depression, anxiety, and stress among high school students in an urban municipality of Kathmandu, Nepal. A cross-sectional study was conducted among 453 students of five randomly selected high schools in Tokha Municipality of Kathmandu. Previously validated Nepali version of depression, anxiety, and stress scale (DASS-21) was used to assess the level of symptoms of depression, anxiety and stress (DAS). Multivariable logistic regression was carried out to decide statistically significant variables of symptoms of DAS at p-value<0.05. The overall prevalence of DAS was found to be 56.5% (95% CI: 51.8%, 61.1%), 55.6% (95%CI: 50.9%, 60.2%) and 32.9% (95%CI: 28.6%, 37.4%) respectively. In the multivariable model, nuclear family type, students from science or humanities faculty, presence of perceived academic stress, and being electronically bullied were found to be significantly associated with depression. Female sex, having mother with no formal education, students from science or humanities faculty and presence of perceived academic stress were significantly associated with anxiety. Likewise, female sex, currently living without parents, and presence of perceived academic stress were significantly associated with stress. Prevention and control activities such as school-based counseling services focusing to reduce and manage academic stress and electronic bullying are recommended in considering the findings of this research.

Citation: Karki A, Thapa B, Pradhan PMS, Basel P (2022) Depression, anxiety and stress among high school students: A cross-sectional study in an urban municipality of Kathmandu, Nepal. PLOS Glob Public Health 2(5): e0000516. https://doi.org/10.1371/journal.pgph.0000516

Editor: Khameer Kidia, Brigham and Women’s Hospital, UNITED STATES

Received: February 22, 2022; Accepted: May 2, 2022; Published: May 31, 2022

Copyright: © 2022 Karki et al. 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: The data that support the findings of descriptive analysis of this study are available in Figshare with the identifier given below: https://doi.org/10.6084/m9.figshare.19203512 The data that support the findings of inferential analysis of this study are available in Figshare with the identifier given below: https://doi.org/10.6084/m9.figshare.19203491 .

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

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

Introduction

Mental disorders contribute to a huge proportion of disease burden across all societies [ 1 ]. Among them, depression, anxiety and stress are the leading causes of illness and disability among adolescents [ 2 ]. The physical, psychological, and behavioral changes that occur throughout adolescence predispose them to a variety of mental health issues [ 3 ]. Despite this, mental health and mental disorders are largely ignored and not given the same importance as physical health [ 4 ].

The existing community-based studies conducted among high school students of various parts of Nepal have reported a wide range of prevalence of symptoms of depression and anxiety. The prevalence of depressive symptoms has been reported to range from 27% to 76% [ 5 – 7 ]. Likewise, the limited studies conducted in Nepal have estimated the proportion of symptoms of anxiety to range from 10% to 57% [ 7 – 9 ]. A nationwide survey conducted in Nepal revealed the prevalence of mental distress among adolescents (13-17years) to be 5.2% [ 10 ]. The Global School Health Survey which was a nationwide survey conducted in 2015 reported anxiety among 4.6% of the students [ 11 ].

Previous studies have revealed that sex [ 12 – 16 ], staying away from home [ 17 ], grade [ 12 , 14 , 16 ], stream of study [ 18 ], academic performance and examination related issues [ 7 , 19 ], cyber bullying [ 20 ] were linked with depression. Likewise, sex [ 8 , 21 ], grade of students and type of school i.e., public or private [ 8 ], family type [ 17 ], not living with parents, educational level of parents [ 21 ] and high educational stress [ 22 ] had been the determinants of anxiety as per previous studies.

High school education is an important turning point in the life of academic students in Nepal [ 23 ]. As the educational system becomes more specialized and tough in high school, the students become more likely to experience stress at this level. This might put them at risk of developing common mental disorders such as depression, anxiety and stress (DAS). However, there is a paucity of research studies that have assessed DAS among high school students in Nepal.

Exploring the magnitude and risk factors of symptoms of DAS are very crucial to combat the burden of adolescent mental health issues [ 24 ]. However, due to limited access to psychological and psychiatric services as well as the significant social stigma associated with mental health issues, anxiety and depression in early adolescence frequently go undiagnosed and untreated, particularly in developing countries such as Nepal. Therefore, this study aimed to estimate the prevalence and identify factors associated with the symptoms of DAS among high school students in an urban municipality of Kathmandu, Nepal.

Materials and methods

Study setting, design, and population.

This was a cross-sectional survey conducted in randomly selected high schools of Tokha Municipality, Kathmandu District in province no. 3 of Nepal. The data collection period was from 27 th August to 11 th September 2019. This municipality was formed on 7 December 2014 by merging five previous villages. It has an area of 16.2 sq.km. and comprises 11 wards [ 25 , 26 ]. The municipality is rich in cultural and ethnic diversity [ 25 ]. According to Nepal government records as of 2017, there were total 218,554 students in Tokha municipality in 82 schools. High school students were the study population for this study [ 26 ]. In Nepal, high school students comprise of grade 11 and grade 12 students. The high school differs from lower schooling level since the students have the opportunity to enroll in specialized areas such as science, management, humanities and education. High school are also popularly known as 10+2 [ 27 ].

Sample size calculation and sampling technique

Sample size was estimated using the formula for cross-sectional survey [ 28 ], n = Z 2 p(1-p)/ e 2 considering the following assumptions; proportion (p) = 0.24 [ 12 ], 95% confidence level, the margin of error of 5%. The estimated proportion used for sample size calculation was based on proportion of symptoms of anxiety i.e., 24%, as reported by a similar study conducted in Manipur, India [ 12 ].

After calculation, the minimum sample size required was 280. After adjusting for design effect of 1.5 to adjust variance from cluster design and assuming non-response rate of 10%, final sample of 467 was calculated. Two-stage cluster sampling was used. A list of all high schools of Tokha municipality was obtained from the education division of the municipality. Out of twelve high schools (8 private schools and 4 public schools), five schools were randomly selected. Within each selected high school further two sections each of grades 11 and 12 were randomly selected. A total of 20 sections were selected, 4 from each selected school, and all the students from the selected sections were included in the study.

Data collection tools

A structured questionnaire was prepared based on our study objectives which was divided into three sections. The first section included information about socio-demographic, familial and academic characteristics of the students. The second section included two item question to assess socializing among the students which was based on a previous study by Vankim and Nelson [ 29 ], two questions to assess bullying among the students based on 2019 Youth Risk Behavior Survey [ 30 ] and one item question to assess perceived academic stress. The third section consisted of Depression, Anxiety and Stress Scale (DASS-21) used to assess level of symptoms of depression, anxiety and stress among the students.

DASS-21 is a psychological screening instrument capable of differentiating symptoms of DAS. Depression, anxiety, and stress are three subscales and there are 7 items in each subscale. Each item is scored on a 4-point Likert scale which ranges from 0 i.e., did not apply to me at all to 3 i.e., applied to me very much. Scores for DAS were calculated by summing the scores for the relevant items. and multiplying by two [ 31 ]. A previously validated Nepali version of DASS-21 was obtained and used for data collection. Nepali version of the DASS-21 has demonstrated adequate internal consistency and validity. However, in the validation paper, the construct validity of the tool was evaluated against life satisfaction scale and not a systematic diagnostic tool [ 32 ]. Reliability for the symptoms of DAS was tested by Cronbach alpha. Cronbach alpha values for DAS were 0.74, 0.77, and 0.74 respectively.

Data collection procedure and technique

Data was collected after obtaining permission from the municipality’s education division as well as individual high schools. The questionnaire was in both English and Nepali language and had been pre-tested among 45 high school students of neighboring municipality. Self-administered anonymous questionnaires were distributed to students in their respective classrooms and requested for participation. An orientation session was conducted for the filling the questionnaire before distribution. Written informed consent was taken from all students prior to data collection whereas additional written parental consent was obtained from students below 18 years of age. One of the investigators herself collected the data from students. After data collection, a session on depression, anxiety, and stress along with the importance of discussing it with the guardians/ teachers and asking for help was conducted.

Study variables

The study variables are described in Table 1 .

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https://doi.org/10.1371/journal.pgph.0000516.t001

Data analysis

Compilation of data was done in EpiData 3.1 and then exported to IBM SPSS Statistics version 20 (IBM Corp., Armonk, NY) for cleaning and analysis. Descriptive analysis was performed. Frequency tables with percentages were generated for categorical variables, while mean and standard deviation (SD) were calculated for continuous variables.

Binary logistic regression was performed to identify associated factors of symptoms of DAS. Firstly, we performed univariate analysis in which each co-variate was modeled separately to determine the odds of DAS. Those variables with p-value <0.15 in univariate analysis were identified as candidate variables for multivariable logistic regression. In multivariable logistic regression, a p-value of < .05 was considered to be statistically significant and strength of association was measured using adjusted odds ratio (AOR) at 95% confidence interval.

Multicollinearity of variables was tested before entering them in the regression analysis. No problem of multicollinearity was seen among the variables (the highest observed VIF was 1.25,1.10 and 1.13 for symptoms of DAS respectively. The goodness of fit of the regression model was tested by the application of the Hosmer and Lemeshow test; the model was found to be a good fit (P >.05).

The regression model was explained by the equation:

Log [Y/ (1-Y)] = b 0 + b 1 X 1 + b 2 X 2 + b 3 X 3 … ..b n X n + e

Where Y is the expected probability for the outcome variable to occur, b 0 is the constant/intercept, b 1 through b n are the regression coefficients and the X 1 through X n are distinct independent variables and e is the error term.

Ethical approval and consent

The study protocol was approved by the Institutional Review Committee (IRC) of the Institute of Medicine, Tribhuvan University (Reference no. 23/ (6–11) 76/077). Approval to conduct this study was also obtained from the education division of Tokha Municipality (Ref: 076/077-23) and respective school authorities. A written informed consent (in the Nepali language) was obtained from the students before the data collection to assure their willingness to participate and no identifiers were listed in the questionnaire to make it anonymous and confidential. Parental consent was obtained for students who were under the age of 18. No incentives were provided.

Sociodemographic, academic and contextual characteristics of the students

The research questionnaire was distributed to a sample of 468 high school students, one of whom refused to participate in this study, with a response rate of 99.78%. Responses from 14 students were excluded due to incompleteness. This study presents the analysis on a total of 453 students.

The mean age of the students was 16.99 years (SD = ±1.12), ranging from 14 to 22 years. The proportion of female students (54.1%) was higher than male students (45.9%). Majority of the students were found to be currently living with their parents i.e., 65.8%. Around 70% of the students were from nuclear family. Regarding parent’s educational level, majority of the students responded that their father as well as mother had attained secondary level of education i.e., 31.6% and 33.3% respectively.

With regards to academic characteristics, more than two- third of students i.e., 69.5% were from private high schools while the remaining 30.5% were studying in a government or public high school. More than half i.e. (53.4%) of the students studied in grade eleven. About half of the students i.e., 50.6% were from management faculty. Only 3.8% students reported to have failed in the previous examination.

It was noted that about 60% of students perceived themselves to be stressed due to their studies. Most students were low socializing i.e., 60.9%. Around one-tenth students reported being bullied electronically in the past 12 months (10.2%). Similar proportion of students i.e., 10.4% also reported being bullied on school property in the past 12 months ( Table 2 ).

https://doi.org/10.1371/journal.pgph.0000516.t002

Level of symptoms of DAS among the students

The prevalence of symptoms of DAS was found to be 56.5% (51.8%, 61.1%), 55.6% (50.9%, 60.2%) and 32.9% (28.6%, 37.4%) respectively. About a quarter of students showed moderate level of symptoms of depression and anxiety i.e., 25.8% and 24.5% respectively. On the other hand, symptoms of mild stress were most prevalent among the students. i.e., 14.8% ( Table 3 ).

https://doi.org/10.1371/journal.pgph.0000516.t003

Factors associated with symptoms of depression

The results from multivariable logistic regression analyses for correlates of symptoms of depression are shown in Table 4 . The variables that remain in the final model were age, type of family, father’s education, mother’s education, type of school, grade, faculty, perceived academic stress, and bullied electronically as these variables had p-value less than 0.15 in the univariate model. In the final model, nuclear family type (AOR: 1.64, 95% CI: 1.06–2.52), students from science/humanities faculty (AOR: 1.58, 95% CI: 1.05–2.40), presence of perceived academic stress (AOR: 1.62, 95% CI: 1.08–2.44) and bullied electronically in past 12 months (AOR: 2.84, 95% CI: 1.34–5.99) were significantly associated with symptoms of depression.

https://doi.org/10.1371/journal.pgph.0000516.t004

Factors associated with symptoms of anxiety

The results from multivariable logistic regression analyses for correlates of symptoms of anxiety are shown in Table 5 . The variables that remained in the final model were age, sex, mother’s education, stream/ faculty, perceived academic stress, bullied electronically, and bullied on school property (p<0.15). Female sex (AOR: 1.82, 95% CI: 1.23–2.71), no formal education attained by the mother (AOR: 1.63, 95% CI: 1.08–2.47), students from science or humanities faculties (AOR: 1.50, 95% CI: 1.01–2.21), and presence of perceived academic stress (AOR: 1.93, 95% CI: 1.30–2.87), and were significantly associated with symptoms of anxiety.

https://doi.org/10.1371/journal.pgph.0000516.t005

Factors associated with symptoms of stress

The results from multivariable logistic regression analyses for main correlates of symptoms of stress are shown in Table 6 . The variables that remained in the final model were sex, current living status, grade, stream / faculty, perceived academic stress, bullied electronically and bullied on school property. In the final model, female sex (AOR: 1.54, 95% CI: 1.01–2.34), currently living without parents, (AOR: 1.70, 95% CI: 1.11–2.61), and presence of perceived academic stress (AOR: 2.11, 95% CI: 1.36–3.26) were significantly associated with stress symptoms.

https://doi.org/10.1371/journal.pgph.0000516.t006

In our study, the prevalence of depressive symptoms among high school students was found to be 56.5%. The existing community-based studies conducted among high school students of various parts of Nepal have reported a wide range of prevalence of depressive symptoms. A study by Gautam et al. reported that more than one quarter i.e., 27% of high school students in a rural setting of Nepal showed depressive symptoms [ 6 ]. Similarly, in a study conducted by Bhattarai et. al. in four schools of a metropolitan city in Nepal, it was found that more than 2/5 th i.e., 44.2% students exhibited depressive symptoms [ 5 ]. Similar proportion of depressive symptoms i.e., 41.6% was also reported by Sharma et. al in a study conducted among adolescent students of public schools of Kathmandu [ 9 ]. The prevalence estimated by these studies are lower than the findings of our study [ 5 , 6 , 9 ]. On contrary, a single high school study by Bhandari et al reported depressive symptoms among 76% students [ 7 ]. In our study, the proportion of students showing symptoms of anxiety were 55.6%. A study by Sharma et al. revealed that more than half i.e. 56.9% of public high school students showed symptoms of anxiety [ 9 ]. Another study by Bhandari et. al, also found out that nearly one out of two students i.e., 46.5% suffered from anxiety [ 8 ].These findings are in line with the findings of our study. On contrary, a study by Bhandari reported that only 10% students had mild anxiety [ 7 ]. In our study, the prevalence of stress symptoms among students was 32.9%. A study by Sharma et. al reported that more than 1/4 th students i.e., 27.5% showed symptoms of stress which corroborates with the findings of our study.

While the prevalence of symptoms of DAS reported by our study corroborates with the existing literatures in Nepal, it is exceptionally high. One possible explanation for this could be that the data was collected at the beginning of academic session. The students in the eleventh grade were undergoing sudden transition from secondary school life to high school life with regards to new friends, teachers, school environment, and change in daily schedules whereas the students in 12 th grade were awaiting results of previous board exam. This anticipation and the tremendous pressure faced by 12 th grade students for tertiary education might have contributed to the high prevalence of symptoms of DAS among 12 th grade students whereas the higher prevalence of symptoms of DAS among 11 th grade students could be possibly explained by the inability to cope with the adjustment of sudden transition from secondary to high school life. Moreover, the wide range in prevalence of DAS symptoms among these community-based studies could be attributed to the difference in the setting (rural or urban) and difference in methodology used.

Among South Asian countries, the prevalence of depression reported by our study is in line with the studies conducted in India, and Bangladesh, but slightly higher than one conducted in China and [ 13 , 17 , 33 , 34 ]. On contrary, our study has shown higher prevalence of anxiety among students as compared to study conducted in India, Sri Lanka, Vietnam and China [ 12 , 19 , 22 , 34 ].The prevalence of symptoms of stress in this study is comparable to the study from Chandigarh but higher than similar study from Manipur, India [ 12 , 17 ]. Hence, it can be suggested that there is a huge burden of DAS among high school students in South Asia. In context of Nepal, there is no standalone mental health policy. Further, there is inadequate funding allocated for mental health services along with shortage of qualified mental health professionals. In addition, there is much stigma that surrounds mental illness which acts as a barrier to seek and utilize mental health care services [ 35 ]. Due to these reasons, mental health illnesses are likely to remain untreated and continue to persist in the society. This may explain the high prevalence of DAS in our setting.

Socio-demographic characteristics and association with symptoms of DAS (depression, anxiety and stress)

In current study, it was found that females were more likely to suffer from symptoms of anxiety and stress than their male counterparts. This finding corroborates with the findings from previous studies [ 19 , 21 , 36 – 39 ]. On the contrary, a study conducted in Dang, Nepal reported that males were 1.5 times more likely to become anxious [ 8 ].One possible explanation for this is adolescent stage in girls is marked by hormonal changes as a result of various reproductive events which may have a role in the etiology of anxiety disorders [ 40 ]. Furthermore, when compared to boys, girls are more likely to be subjected to stressful situations such as sexual and domestic violence, which may make them more prone to anxiety and stress problems [ 41 ].

This study revealed that the students who live in nuclear families were more likely to exhibit depressive symptoms compared to students from joint or extended families. There are more members in a joint family system, which may provide better opportunities for adolescents to share their emotions and issues, hence providing a strong support system that may serve as a protective factor against depression which may be lacking in nuclear families [ 42 ]. Moreover, this study also found out that risks of stress symptoms was higher among students who were staying far from their parents. A similar finding was reported by Arif et al., 2019 in Uttar Pradesh, India [ 43 ]. One of the possible explanations might be that students who live without their parents may spend a substantial amount of time alone after school, which does not encourage familial intimacy [ 44 ]. As a result, they may feel alone and disconnected from their parents [ 45 ]. These adolescents may miss out on the opportunity to internalize the support they would otherwise get, leading to increased stress.

In our study, the students who reported no formal mother’s education were at greater risk of showing symptoms of anxiety. This was in accordance with other similar studies [ 38 , 46 ]. The attachment theory provides a robust foundation for understanding how parental behavior affects a child’s ability to recognize and manage stressful events throughout their lives [ 47 ]. The theory supports that the educated mother plays a stronger parenting role in the development of emotional skills and mental health outcomes in teenagers which might be protective for anxiety.

Academic characteristics and association with symptoms of DAS

In our study, the students from science or humanities faculties were more likely to have depression and anxiety as compared to management students. This was in line with other studies which showed higher proportion of depressive symptoms among science students. [ 48 ]. Generally, science students have to compete more, study longer hours and have a higher level of curriculum difficulty than management students which explains the finding. Likewise, it is believed that the humanities students have a poorer past academic performance in the secondary school, and may have chosen this stream / faculty as a secondary choice [ 49 ]. This combined with the uncertainty regarding future work prospects among humanities students may likely explain the higher prevalence of depression among humanities students.

In our study, the students who reported to be stressed due to their studies were more likely to suffer from symptoms of DAS. Several studies have documented similar findings [ 7 , 22 ]. A possible explanation might be that high school is an important stage in an individual’s academic life. However, the inability to meet the expectation of parents, teachers, and oneself in terms of academic performance can lead to overburden of stress [ 50 ]. This persistent academic related stress might accelerate the development of mood disorders such as depression, anxiety and stress among the adolescents [ 51 ].

Contextual factors and association with symptoms of DAS

In our study, the risk of depressive symptoms was higher among those students who were bullied via electronic means. Literature suggests that higher the level of cyberbullying/electronic bullying leads to higher the level of depressive symptoms among adolescents [ 52 ]. A similar study by Perren et. al demonstrated that depression was significantly associated with cyberbullying even after controlling for traditional forms of bullying [ 20 ]. The victims of cyberbullying may experience anonymous verbal or visual threats via electronic means. These repeated incidents can cause the victims to feel powerless which exacerbates the feeling of fear. This can cause significant emotional distress among victims and contribute to development of depressive symptoms [ 53 ].

Even though widely utilized in both clinical as well as research setting, DASS scales are screening tools for symptoms of depression, anxiety, and stress. Hence, they cannot be used as a modality for diagnosis. This limitation should be considered when interpreting the findings of this study. Due to its cross-sectional design, this study was unable to establish causal relationship of depression, anxiety, and stress with associated factors. Since the study tools used in this study investigate the habits and activities of the high school students in the past, recall and reporting bias are likely; however, the effect due to potential confounders have been controlled. As Nepal is a culturally diverse country, the findings of only one municipality may not be generalized to the whole country. Therefore, future studies covering a larger population of high school students employing more robust study designs such as interventional studies are recommended to get the real scenario of common mental disorders.

In conclusion, more than half of the students had depression and anxiety symptoms and nearly one third of the students had stress symptoms. Nuclear family type, students from humanities/science faculty, presence of perceived academic stress, and being bullied electronically were found to be significantly associated with symptoms of depression. Female sex, no formal mother education, students from humanities/science faculty, and presence of perceived academic stress were significantly associated with symptoms of anxiety. Likewise, symptoms of stress were significantly associated with female sex, currently living without parents, and presence of perceived academic stress.

Therefore, prevention and control activities such as school-based counseling services focusing to reduce and manage academic stress and electronic bullying faced by the students are recommended considering findings of this research.

Supporting information

S1 file. questionnaire form used in data collection..

https://doi.org/10.1371/journal.pgph.0000516.s001

Acknowledgments

We are grateful to Tokha municipality for granting permission to conduct the study. Special thank goes to the school management and teachers for their co-ordination during data collection. Lastly, we would like to thank all the study participants for their co-operation and support during the study.

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• Published: 11 November 2022

The relationship between depression symptoms and academic performance among first-year undergraduate students at a South African university: a cross-sectional study

• F Wagner 1 ,
• RG Wagner 2 ,
• U Kolanisi 3 ,
• LP Makuapane 1 ,
• M Masango 4 &
• FX Gómez-Olivé 2  

BMC Public Health volume  22 , Article number:  2067 ( 2022 ) Cite this article

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Background:

South African universities face a challenge of low throughput rates, with most students failing to complete their studies within the minimum regulatory time. Literature has begun to investigate the contribution of well-being, including mental health, with depression among students being one of the most common mental disorders explored. However, locally relevant research exploring associations between depression and academic performance has been limited. This research hypothesizes that the presence of depression symptoms, when controlling for key socio-demographic factors, has an adverse impact on student academic outcomes and contributes to the delay in the academic progression of students.

The study used a cross-sectional design. Data were collected in 2019 from first-time, first-year undergraduate students using a self-administered online questionnaire. In total, 1,642 students completed the survey. The Patient Health Questionnaire-9 (PHQ-9) was used to screen for depression symptoms. Data on students’ academic performance were obtained from institutional records. Bivariate and multivariate regression analyses were used to examine associations between depression symptoms and academic performance.

Most participants (76%) successfully progressed (meeting the requirements to proceed to the second year of university study). Of the participants, 10% displayed symptoms of severe depression. The likelihood of progression delay (not meeting the academic requirements to proceed to the second year of university study) increased with the severity of depression symptoms. Moderate depression symptoms nearly doubled the adjusted odds of progression delay (aOR = 1.98, 95% CI: 1.30-3.00, p  = 0.001). The likelihood of progression delay was nearly tripled by moderate severe depression symptoms (aOR = 2.70, 95% CI:1.70–4.36, p  < 0.001) and severe depression symptoms (aOR = 2.59, 95% CI:1.54–4.36, p  < 0.001). The model controlled for field of study, financial aid support as well as sex and race.

Conclusion:

Higher levels of depression symptoms among first-year university students are associated with a greater likelihood of progression delay and may contribute to the low throughput rates currently seen in South African universities. It is important for students, universities and government departments to recognize student mental wellness needs and how these can be met.

Peer Review reports

Mental illness is a public health priority, affecting as much as 47% of the population at some point in their lifetime [ 1 ]. Literature has identified university students as a group that is particularly vulnerable to mental illness [ 2 , 3 , 4 , 5 , 6 ]. A review on depression among university students reported that depression prevalence ranged between 6 and 54% among university students [ 6 ]. Depression is a disorder that can affect one’s overall functioning. Symptoms of depression can often include a lack of a positive outlook, high levels of anxiety, irregular sleeping patterns and reduced concentration [ 4 , 7 ]. The high prevalence of depression among university students is concerning and justifies a need to understand how depression and academic success in this population may be associated.

There is no agreed-upon definition for academic success or failure, but there is consensus that, traditionally, student academic success is represented by student retention, progression and improved throughput; while academic failure can be described as the lack of retention, progression or throughput [ 8 , 9 , 10 ]. In the South African context, universities are faced with low throughput rates, meaning that only a small percentage of students obtain their qualifications within the minimum stipulated times. This is largely due to progression delay, a consequence of students not meeting the academic requirements to progress from one academic year to the next [ 9 ]. These delays in progression are particularly significant in the South African context, where more than half of the population lives in poverty and most young people are unemployed [ 11 , 12 ]. In this context, unemployment is lowest among those with tertiary qualifications [ 12 ] and thus delays in acquiring qualifications can be devasting for students coming from poor homes, who are often expected to support their families financially upon graduation. It is therefore imperative that university student success is prioritised.

Several studies have explored factors and determinants of throughput and student success [ 13 , 14 , 15 , 16 ]. These studies found that the determinants of student success are complex, identifying high school academic achievement [ 13 , 17 ], family background [ 15 ] and the students’ ability to integrate into the different aspects of university life, including social communities and teaching and learning [ 14 ] as key determinants of academic success.

In addition to these traditional determinants, research has begun to explore the contribution of well-being, including mental health, as a potential contributor to student academic performance. This emerging research suggests that university students suffering from common mental disorders, especially anxiety and depression, are likely to perform poorly when compared to students without mental disorders [ 2 , 3 , 18 ]. A study among university students in the United States of America (USA), found that depression was not only linked to a lower grade point average (GPA), but also an increased likelihood of attrition [ 2 ]. Findings from a longitudinal cohort study in the United Arab Emirates (UAE) found that higher levels of depression predicted lower GPA scores both at baseline and follow-up [ 19 ]. Work carried out in South Africa found that students with major depressive disorder as well as those with attention deficit hyperactivity disorder (ADHD) had a higher probability of academic failure [ 3 ]. Research conducted in Australian universities found students often attributed their academic failure to poor mental health, including conditions such as anxiety and depression [ 20 ]. Evidence from students in Nigeria found depression to be inversely linked to perceived poor academic performance [ 21 ].

South African literature on depression and associations between depression and academic failure among university students has started to emerge [ 3 , 22 , 23 ]. However, findings from these studies have been based predominantly on White study participants, making it difficult to generalize these findings to more heterogenous student populations since White students are in minority in the South African higher education sector. Given this, the current research aims to close this knowledge gap while considering other important factors, such as financial aid and field of study, which may impact on progression delay. We hypothesize that the presence of depression symptoms has adverse effects on student academic outcomes and contributes to progression delay in a diverse South African university student population. The main aim of the current study was therefore to investigate the extent to which depression symptoms, when controlling for key demographic and socio-economic factors, predicted student progression delay.

The current study took place in a large research-intensive South African university. In 2019, the headcount student enrolment was around 41,000, with international students making up 9% of the student population. Female students made up 55% of the student population, and the majority of South African students attending the university were Black African (61%). The student population is culturally diverse, with the university having three official languages, English, IsiZulu and Sesotho.

The current research targeted the entire cohort of 2019 first-time, first-year undergraduate students (n = 5,912). The inclusion criteria to participate in this research, which was used to extract the sample, was as follows: being 18 years of age or older; being a first-time, first-year undergraduate student; studying full-time; completion of the Biographic Questionnaire [ 16 ], which is a baseline survey at intake; pursuing either a professional bachelor’s degree (a programme that is generally four years or longer) or a general bachelor’s degree (generally a three-year programme); and being assigned progress codes at the end of the 2019 academic year. All students provided informed consent prior to participating in the study. Students not meeting the inclusion criteria were excluded.

All students meeting the inclusion criteria were invited to participate in the study (n = 5,195). Students could only complete the survey once they had given informed consent. A total of 1,648 participants (32%) completed the survey. Six participants were not assigned progress codes at the end of the 2019 academic year, the possible reasons for this include students deregistering or awaiting the outcome of appeals. The six records were removed from the analysis, leaving a total analysis sample of 1,642 participants.

A comparison between study participants and those who did not participate in the study (non-participants) (Table  1 ) shows that non-participants were significantly older (X 2 (2, N = 5 195) = 14.95, p  = 0.001), more likely to be male ((45% vs. 37%); X 2 (1, N = 5 195) = 32.31, p  < 0.001), less likely to be Black African ((64% vs. 72%); X 2 (5, N = 5 195) = 28.87, p  < 0.001), and were significantly more likely not to be receiving financial aid ((59% vs. 51%); X 2 (1, N = 5 195) = 27.17, p  < 0.001). The participant group was significantly more likely to be from high school quintiles 1–4, and significantly more likely to be first-generation students ((47% vs. 53%); X 2 (1, N = 5 195) = 15.91, p  < 0.001). There were no differences in disability status or field of study.

In the analysis sample (Table  1 ) most study participants were female (63%), Black African (72%), between the ages of 18 and 39 (median 19 years), non-first-generation students (53%), attended high school quintile 5 (33%) and reported having no special needs (98%).

Instruments

the Patient Health Questionnaire-9 (PHQ-9) was used to screen for depression symptoms using a two-week recall period [ 24 ]. The PHQ-9 has been validated and determined to give accurate accounts of the prevalence of depression symptoms [ 25 ]. Responses to each of the questionnaire items were rated on a four-point Likert scale, ranging from 0 (not at all) to 3 (nearly every day) [ 25 ]. Participants’ responses were summed and designated to one of five categories for the PHQ-9 (that is a PHQ-9 score of 0–4 denoting minimal depression symptoms; 5–9 denoting mild depression symptoms, 10–14 denoting moderate depression symptoms, 15–19 denoting moderate-severe depression symptoms, and 20–27 denoting severe depression symptoms), these categories have been used in other studies [ 26 ].

Covariates potentially influencing academic performance associations were identified in literature and included in the models. These covariates included: race (coded as Black African, Chinese, Coloured, Indian, White or Unknown), sex (coded as male or female), first-generation status (coded as 1st generation student for those first in their family to go to university), and 2nd generation or more (coded for those with family members who had attended university). A self-reported account of disability status was also included (coded as ‘yes’ for participants with self-reported disabilities and/or special needs, or ‘no’ for participants with no disabilities and/or special needs). Other covariates included field of study (coded as Commerce, Law and Management, Engineering, Health Sciences, Humanities, or Science), and financial aid from the National Student Financial Aid Scheme (NSFAS) (coded as ‘yes’, for those who were funded, or ‘no’ for those who did not receive funding).

Anxiety symptoms were measured using the GAD-7 questionnaire [ 27 ] which is a seven-item tool used to screen for anxiety symptoms. Like the PHQ-9, the GAD-7 uses a two-week recall period. Responses to each of the questionnaire items were rated on a four-point Likert scale, ranging from 0 (not at all) to 3 (nearly every day). Participants’ responses were summed and designated to one of four categories for the GAD-7 (with severity scores as follows: a score of 0–4 denoting minimal anxiety, 5–9 denoting mild anxiety, 10–14 denoting moderate anxiety and 15–21 denoting severe anxiety), these categories have been used in other studies [ 26 , 27 ].

Students’ main source of general support was also included as a variable from the question: While you are at university, who will be providing you with general support? Participants had the following response options: Both parents, Single parents, Grandparent(s) or, Guardian(s), Other family and/or friends(s), Spouse/ partner, No support. General support, in this instance, means the support given to students in general, without any particular sub-divisions.

High school socio-economic quintile was also included. South African public schools are allocated quintile categories to reflect the socio-economic status of communities surrounding the schools. Quintile 1 represents the poorest communities and quintile 5 the wealthiest [ 17 ]. In addition to the high school quintiles 1–5, was the category ‘other’. The ‘other’ category included participants from non-public high schools (private and international high schools).

Academic performance

progress codes assigned to each student at the end of the academic year were dichotomized as (i) those meeting the requirements to proceed to the second academic year of study (successful progression) and (ii) those who did not meet the academic requirements to proceed to the second year of study (progression delay). This definition has been previously used to define academic success (here defined as ‘successful progression’) and academic failure (here defined as ‘progression delay’) in similar work in South Africa [ 3 , 28 ].

Following ethics approval, as well as written permission from the university registrar, all first-time, first-year undergraduate student email addresses were extracted from the university database using the inclusion criteria stated above. Students were then invited to participate in the study via an email with a unique link to the survey. Students could only complete the survey after consenting (by clicking that they consented to take part in the study). Data collection, which took place over six weeks between July and August 2019, was in the form of a self-administered online questionnaire, which was hosted on the Research Electronic Data Capture (REDCap) web application [ 29 ]. Academic performance data (for the 2019 academic year) were requested from the university for students who completed the survey, this performance data was then linked to survey data.

Data analysis

Data were cleaned and analyzed using STATA (version 14; College Station, Texas, USA). Frequency and descriptive analyses were performed for demographic and mental health variables. Categorical variables were reported using percentages and continuous variables were reported using the median and interquartile ranges (IQR). The Mann-Whitney U test was used to compare continuous variables, while the chi-square test was used to compare categorical variables with student progression. Variables included in the logistic regression model, which used adjusted odds ratios (aOR) as a test statistic, were selected using a forwards and backwards stepwise regression, with a cut-off of p \(\le\) 0.20 used for inclusion in the model. Significance was defined at an p-value \(<\) 0.05 level in all analyses.

As shown in Table  2 , a total of 76% of students progressed successfully, while 24% experienced progression delay. A higher proportion of male students (31%) experienced progression delay, compared to female students (21%). Black African students and students from quintile 1 high schools had the highest proportion of progression delay at 27% and 33% in their respective groupings. In terms of field of study, students registered for programmes in the humanities had the lowest proportion of progression delay at 11%. There were significant differences between progression delay in the distribution by sex (X 2 (1, N = 1 642) = 20.07, p  < 0.001), race (X 2 (5, N = 1 642) = 23.06, p  < 0.001), high school quintile (X 2 (5, N = 1 642) = 34.89, p  < 0.001) and field of study (X 2 (4, N = 1 642) = 228.20, p  < 0.001).

In terms of mental health, the prevalence of severe anxiety symptoms was found to be 18% and severe depression symptoms was 10%. As shown in (Table  3 ) 29% of participants with severe anxiety symptoms experienced progression delay and 30% of participants with severe depression symptoms experienced progression delay. Finally, 27% of participants who listed having no general support experienced progression delay. The bivariate analysis indicated a high correlation between depression (X 2 (4, N = 1 642) = 22.79, p  < 0.001), anxiety symptoms (X 2 (3, N = 1 642) = 12.25, p  = 0.007) and progression.

The multivariate logistic regression (Table  4 ) showed that being enrolled in the Engineering field of study increased the likelihood of progression delay more than nine-fold (adjusted odds ratio (aOR) = 9.33, 95% CI: 6.35–13.72, p  < 0.001) and of Science more than four-fold (aOR = 4.23, 95% CI: 2.88–6.22, p  < 0.001). Furthermore, experiencing moderate depression symptoms increased the adjusted odds of progression delay almost two-fold (aOR = 1.98, 95% CI: 1.30-3.00, p  = 0.001), while moderate severe symptoms of depression increased the likelihood of progression delay almost three-fold (aOR = 2.70, 95% CI:1.70–4.30, p  < 0.001). Severe depression symptoms also increased the odds of progression delay almost three-fold (aOR = 2.59, 95% CI:1.54–4.35, p  < 0.001). An increase in the severity of depression symptoms was also found to lead to a higher likelihood of progression delay. Anxiety symptoms did not meet the threshold to be included in the final model.

Two variables, high school quintile (quintile 5 and other) and receiving financial aid from the National Student Financial Aid Scheme (NSFAS), decreased the odds of progression delay. Participants who completed Grade 12 in well-resourced high schools (high school quintile 5), and those whose high school was classified as ‘Other’ (private and international high schools) were also significantly less likely to experience progression delay (aOR = 0.50, 95% CI:0.30–0.85, p = 0.01) and (aOR = 0.47, 95% CI:0.26–0.83, p = 0.009), respectively. Participants who received financial aid support from the NSFAS were also significantly less likely to experience progression delay (aOR = 0.67, 95% CI:0.26–0.83, p = 0.007).

The prevalence of severe anxiety symptoms was 18% and severe depression symptoms was 10%, when using standardized tools. These findings on anxiety and depression corroborate a recent South African study that found a 21% prevalence of generalized anxiety disorder and 14% prevalence of major depressive disorder among first-year university students when using a 12-month recall [ 3 ]. Findings from international literature vary with studies reporting depression and anxiety levels as high as 54% and 66%, respectively [ 6 ]. It is important to stress that the current study presents findings for anxiety and depression symptoms and not major depressive disorder or generalised anxiety disorder.

Findings from our study suggest that depression symptoms are predictive of progression delay, confirming the hypothesis underpinning this study. In fact, results indicate that moderate depression symptoms increased the odds of progression delay almost two-fold and that moderate severe and severe depression symptoms increased the adjusted odds of progression delay by three-fold. These findings align with both South African literature, which found that students experiencing major depressive disorder were almost four times more likely to perform poorly [ 3 ] and international literature from the USA and the UAE which associated low GPA scores with depression [ 18 , 19 ]. Anxiety symptoms were not significant in their association with progression delay in the logistic regression, also a common finding [ 19 , 30 , 31 ].

Common mental disorders may affect academic performance in a number of ways. One way is class attendance, which is an important contributor to academic success [ 30 ]. Evidence from universities in Australia and Jordan found that students experiencing common mental disorders, including depression, on average had higher levels of class absenteeism compared to students not experiencing mental disorders [ 20 , 32 ]. In their work, Eisenberg et al., (2009) conceptualize the impact of poor mental health on academic performance. In it they emphasize the potential impact of mental illness, including depression, in the acquisition of cognitive skills [ 2 ]. Depression symptoms, such as having low energy and difficulty concentrating [ 2 , 7 , 30 ], impact on non-cognitive skills that include persistence and motivation, which have a direct effect on cognitive function and thus the acquirement of knowledge. The presence of depression impacts on these non-cognitive skills resulting in low academic productivity, leading to potentially lower skill acquisition as reflected by lower scores [ 2 ].

It is also important to note the potential bi-directionality of the above trend. It is plausible that academic failure, including progression delay, may increase the risk of depression symptoms [ 2 ]. Other literature investigating depression, academic achievement and absenteeism, has acknowledged this [ 32 ]. Furthermore, findings from Nigeria, for instance, report that students experiencing academic failure often report feelings of anger, shame, disappointment and hopelessness [ 33 , 34 ]. Research has also highlighted the compounding effects of academic failure, including the additional financial stress of having to re-register and also the time commitment due to increased workloads, all which can have significant implications on mental health [ 34 ].

The current research also found that 24% of the first-time, first-year undergraduate university students experienced progression delay during a single year at a large South African tertiary institution. These levels are consistent with findings from a similar study which found academic failure to be 26% among first-year South African university students in the Western Cape province [ 3 ]. These findings are difficult to compare with international literature that typically measures academic performance using GPA. In terms of student success, variables such as sex, race, high school quintile and field of study have been well documented as predictors of academic success [ 13 , 17 , 35 ] and in the current research, these were also found to significantly impact academic performance. The results of our study on sex and race are supported by other research findings, both in South Africa and internationally, which indicate that female students often outperform their male counterparts [ 3 , 30 ], and that White students often attain the highest academic scores [ 13 , 30 ].

The results indicated that financial aid (NSFAS) as well as attending well-resourced high schools (quintile 5 and other) protected against progression delay. These findings are in line with literature that has demonstrated that students from well-resourced schools perform better academically than students from poorer schools [ 17 ]. Furthermore, studies have found that students with a financial need who receive financial aid were more likely to be academically successful when compared to their counterparts without any state funding [ 15 , 36 ].

Students registered in the field of study of Engineering had a probability of progression delay nine times higher than Humanities where 89% of students successfully progressed, while students registered in the Science field had an increased likelihood of progression delay by a factor of four. These findings correspond with previous research that suggests that students enrolled in science, technology, engineering and mathematics (STEM) fields, across institutions, grapple with the curriculum [ 37 ]. In fact, although enrolment in the STEM field have increased over time in South Africa, they account for the lowest university success and graduation rates [ 38 ].

Our findings highlight the important relationship between student mental health and academic progression, suggesting that student mental health should be recognized as a critical component of academic performance at universities. As such, universities should consider making provisions for mental wellness resources on campus, and build institutional cultures that promote mental wellness. However, mental health is a public health issue, and it is unreasonable to expect universities to be the sole drivers of change. We believe that the student voice is essential to reconciling the roles of both universities and the health care system in improving student academic performance.

We present original findings from a study involving first-time, first-year undergraduate students at a large South African university. Although the generalizability of the findings may be limited, our data builds on a growing body of literature demonstrating the negative impact that depression symptoms have on student academic performance, through delayed student progression and ultimately potentially low student throughput rates. It is important for students, universities as well as government departments to recognize the impact of mental health on student performance and work together to identify student’s mental health needs and how these can be met. Holistic student support programmes offered by universities should work towards fully incorporating student mental wellness activities. The current study has a number of strengths, including: a large study population; being carried out at an institution with a diverse student population; and experiencing a high response rate (32%) when compared to similar studies. To our knowledge, this is one of the largest studies, in terms of the sample size and response rate, on the African continent to explore the relationship between depression symptoms and academic performance. Studies using similar methodological approaches typically achieve response rates between 8 and 13% [ 3 , 22 , 23 ].

However, a number of limitations should also be considered when interpretating the results. The PHQ-9 is used as a screening tool for depression symptoms and is not a diagnostic clinical tool. The PHQ-9 has, however, been validated and determined to give accurate accounts of the prevalence of depression [ 25 ]. The current study was carried out at a single university, with differences delineated between study participants and non-participants, which limits the generalizability of the current findings. Furthermore, bias could have been introduced due to self-selected sampling. Finally, the cross-sectional nature of the study limits establishment of causality.

The students who participated in the current study have subsequently been invited to participate in similar research during the initial COVID-19 pandemic years (2020–2021) and the first “post-COVID-19 year” (2022). This follow-up study will help us understand the impact of the COVID-19 pandemic on the mental health of these South African students.

Data availability

The data that support the findings of this study are available from the University Registrar of the University of the Witwatersrand, Johannesburg, but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the corresponding author upon reasonable request and with permission of the University Registrar of the University of the Witwatersrand, Johannesburg.

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Acknowledgements

The authors would like to thank the students who participated in this study.

This research project received funding from the Kresge Foundation, Grant G-1912-287858. RGW gratefully acknowledges funding from the South African National Research Foundation (119234).

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FW, RGW and MM conceptualized the research and UK, FXG-O and FW determined the scope of the manuscript. FW, LM and MM collected the data and FW and LM analysed the data. FW drafted the first version of the manuscript, which was critically reviewed by all other authors, who then approved the final version for submission.

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Wagner, F., Wagner, R., Kolanisi, U. et al. The relationship between depression symptoms and academic performance among first-year undergraduate students at a South African university: a cross-sectional study. BMC Public Health 22 , 2067 (2022). https://doi.org/10.1186/s12889-022-14517-7

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Depression, Anxiety, Loneliness Are Peaking in College Students

Photo by Cydney Scott 

Nationwide study, co-led by BU researcher Sarah Ketchen Lipson, reveals a majority of students say mental health has impacted their academic performance

Kat j. mcalpine.

A survey by a Boston University researcher of nearly 33,000 college students across the country reveals the prevalence of depression and anxiety in young people continues to increase, now reaching its highest levels, a sign of the mounting stress factors due to the coronavirus pandemic, political unrest, and systemic racism and inequality. 

“Half of students in fall 2020 screened positive for depression and/or anxiety,” says Sarah Ketchen Lipson , a Boston University mental health researcher and a co–principal investigator of the nationwide survey , which was administered online during the fall 2020 semester through the Healthy Minds Network. The survey further reveals that 83 percent of students said their mental health had negatively impacted their academic performance within the past month, and that two-thirds of college students are struggling with loneliness and feeling isolated—an all-time high prevalence that reflects the toll of the pandemic and the social distancing necessary to control it.

Lipson, a BU School of Public Health assistant professor of health law, policy, and management, says the survey’s findings underscore the need for university teaching staff and faculty to put mechanisms in place that can accommodate students’ mental health needs.

“Faculty need to be flexible with deadlines and remind students that their talent is not solely demonstrated by their ability to get a top grade during one challenging semester,” Lipson says.

She adds that instructors can protect students’ mental health by having class assignments due at 5 pm, rather than midnight or 9 am, times that Lipson says can encourage students to go to bed later and lose valuable sleep to meet those deadlines.

Especially in smaller classroom settings, where a student’s absence may be more noticeable than in larger lectures, instructors who notice someone missing classes should reach out to that student directly to ask how they are doing. 

“Even in larger classes, where 1:1 outreach is more difficult, instructors can send classwide emails reinforcing the idea that they care about their students not just as learners but as people, and circulating information about campus resources for mental health and wellness,” Lipson says. 

And, crucially, she says, instructors must bear in mind that the burden of mental health is not the same across all student demographics. “Students of color and low-income students are more likely to be grieving the loss of a loved one due to COVID,” Lipson says. They are also “more likely to be facing financial stress.” All of these factors can negatively impact mental health and academic performance in “profound ways,” she says.

At a higher level within colleges and universities, Lipson says, administrators should focus on providing students with mental health services that emphasize prevention, coping, and resilience. The fall 2020 survey data revealed a significant “treatment gap,” meaning that many students who screen positive for depression or anxiety are not receiving mental health services.

“Often students will only seek help when they find themselves in a mental health crisis, requiring more urgent resources,” Lipson says. “But how can we create systems to foster wellness before they reach that point?” She has a suggestion: “All students should receive mental health education, ideally as part of the required curriculum.”

It’s also important to note, she says, that rising mental health challenges are not unique to the college setting—instead, the survey findings are consistent with a broader trend of declining mental health in adolescents and young adults. “I think mental health is getting worse [across the US population], and on top of that we are now gathering more data on these trends than ever before,” Lipson says. “We know mental health stigma is going down, and that’s one of the biggest reasons we are able to collect better data. People are being more open, having more dialogue about it, and we’re able to better identify that people are struggling.”

The worsening mental health of Americans, more broadly, Lipson says, could be due to a confluence of factors: the pandemic, the impact of social media, and shifting societal values that are becoming more extrinsically motivated (a successful career, making more money, getting more followers and likes), rather than intrinsically motivated (being a good member of the community). 

The crushing weight of historic financial pressures is an added burden. “Student debt is so stressful,” Lipson says. “You’re more predisposed to experiencing anxiety the more debt you have. And research indicates that suicidality is directly connected to financial well-being.” 

With more than 22 million young people enrolled in US colleges and universities, “and with the traditional college years of life coinciding with the age of onset for lifetime mental illnesses,” Lipson stresses that higher education is a crucial setting where prevention and treatment can make a difference.

One potential bright spot from the survey was that the stigma around mental health continues to fade. The results reveal that 94 percent of students say that they wouldn’t judge someone for seeking out help for mental health, which Lipson says is an indicator that also correlates with those students being likely to seek out help themselves during a personal crisis (although, paradoxically, almost half of students say they perceive that others may think more poorly of them if they did seek help).

“We’re harsher on ourselves and more critical of ourselves than we are with other people—we call that perceived versus personal stigma,” Lipson says. “Students need to realize, your peers are not judging you.”

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Boston University moderates comments to facilitate an informed, substantive, civil conversation. Abusive, profane, self-promotional, misleading, incoherent or off-topic comments will be rejected. Moderators are staffed during regular business hours (EST) and can only accept comments written in English. Statistics or facts must include a citation or a link to the citation.

There are 25 comments on Depression, Anxiety, Loneliness Are Peaking in College Students

first of all, excellent writing! This report is extremely triggering for a few reasons. Obviously students are NOT okay at the moment, now confirmed by the student. But what does the university do about it? They micro-manage EVERY aspect of students’ life to mitigate Covid risk. Here, tell me why the university took away household table seating in the dining hall? That was one of the ONLY places on campus where students can eat with each other and actually see their friends’ faces. What type of modeling was used to make this decision and its impact on covid spread on campus. Same thing for the green badge, was there a statistical difference in case before and after students have to walk around showing that? The university’s policies are simply incentivizing off-campus, more dangerous gatherings because the university won’t facilitate anything like that on campus. Oh, and the university response? ‘you’re doing great sweetie’ type of deal – absolutely ridiculous. I know BU can’t keep this up much longer, they are losing far too much money because of Covid and less students on campus – there will be a reckoning. Students, stand up.

BU will acknowledge this but then still won’t do anything to actually help.

Great, but this school is doing absolutely nothing to help it

I appreciate this article because I feel that the issue of mental health isn’t talked about enough amongst students and just college culture in general. I don’t see any concerns coming from college faculty, at least clearly. It’s so important to talk about mental health, especially during a pandemic.

This article is definitely going in the right direction. That being said, as the other comments have also mentioned, BU needs to do MUCH more than just publishing an article telling students, “well, at least you aren’t alone.” If 83% of your student body reports their mental health affects their school work, then if not for them, at least change something for the benefit of the school’s name. To put it bluntly, this does not look good. Also referencing BU’s response to sexual harassment, BU now has a track record of acknowledging issues that significantly impact its students in an article or maybe a speech to only do NOTHING about it. Please, I implore the school to act. Act or we will.

We know mental health stigma is going down

Actually, we know support for those taught and teaching that prejudice is diminishing, though that does not mean by any stretch of the imagination it is not still being taught. It continues to be taught (often resolutely) at Boston University. The above sentence is one manner in which it continues to be taught, Passive Reference. It is also actively taught.  “Perceived stigma” is another interesting Passive Reference, directed prejudices are intended by their directors to be perceived. “perceived” stigma is an obfuscation of the process whereby it is perceived.  It surprises me, that so many women, eschewing “the stigma” of rape, continue to declare “the stigma” of mental illnesses. Sometimes history does not inform us. A few years ago 5 students died by suicide at a Canadian college, blamed was “the stigma” of mental illnesses, not those conveying it. When a young man at U Penn died by suicide it prompted his sister to set up a now national organization protesting “the stigma” of mental illnesses, not those conveying it. National organizations abound conveying “the stigma” of mental illnesses to eagerly awaiting audiences. Publications abound, but to my knowledge not one single publication directly addresses how it is taught or who teaches it.  Nor, to my knowledge is there a campus in the US, or any English speaking country, where someone is given guidance on how to address those directing it. Whom to approach. How to resolve it. [email protected] offers no such guidance. I invite each of you to return to 1972, when a small group of personally empowered women said, “Stop directing the term stigma at rape, you have done enough harm” and take that lesson to heart: We stopped.

And I invite [email protected] to take a role in bringing about that change. 

Harold A Maio, retired mental health editor

Wow – so what is BU doing about this when we have pleaded with admin and offered so many ideas and solutions to helping here since September 2020?

The silence is deafening BU.

The Well Being Project is stagnate.

The Dean is silent.

The provost says students are happy based on some survey they did just before holidays when students knew they were going home.

The Director of Mental Health says appts for mental health are down – that’s the sign everything is fine?

We are hearing the opposite and many students have just lost their faith in support from BU as well as just returning home for LFA where they have a support system.

Where are the social in person safe activities outside and inside?

Where are the RAs and their weekly activities and support of their residents or are they just there to write students up?

Where are the self-care tips and resources offered daily to students?

Where in the daily MANDATORY self-check survey of their health – are any questions about their emotional well being including their mood, stress levels, sleep and appetite?

Where is the support for faculty who are seeing these issues and trying to reach out?

Where are the therapy dogs from pre-pandemic we asked for weekly or biweekly to come outside and offer unconditional emotional support during this tough time?

Where are some campus wide concerts or comedy relief concert paid for by BU – virtually or outside so students have anything to look forward to? If it’s down to money / the $70,000 Tuition or should cover some of it or funds from housing since many were not reimbursed when they returned home for support.

Where is any work with this amazing wise resource Dr. Lipson to take any of her guidance since last summer instead of just posting it here?

Is anyone listening to the isolation and pain of so many terriers? I have heard troubling stories for months since we began our BU Parent group that is NOT monitored by the Deans office unlike others. I have helped refer and counsel families worried if they speak up there might be some retaliation. There is no retaliation just a deaf ear to making any changes to improve morale and well being of our terriers during a pandemic. And then posting this article is the ultimate hutzpah when no one has listened to Dr.Lipson / your own shining star about these issues.

Why not shine as you have with COVID testing? What if this were your family member feeling isolated and disillusioned with their dreams at BU with no outreach from BU except an occasional ZOOM message.

BU can do so much better and be the example for the rest of the nation. Why test so stringently if you will not allow any safe activities except for favorites like sports teams and band members?

Terriers are ZOOMED OUT. Don’t wait for a suicide or more depression to appear in students. It’s almost too late to be proactive / but you can try and we ask that you try hard. Be an example for other colleges.

We are not giving up on being heard. We are parents who care and love BU and know it can do better.

A lot of good points made – I wanted to touch upon when you mentioned that appointments for mental health are apparently down. As a student actively seeking mental health resources, my experience is that it has been extremely difficult to even schedule any sort of mental health appointments or counseling; we are unable to make an appointment online or in-person anymore, and the only information we are given is a phone number to call (the Behavioral Medicine number). I find this frustrating as many of us need more than just a phone conversation to help – even a zoom meeting would be helpful, but why aren’t there zoom appointments for SHS like there are for almost every other service on campus (e.g., pre-professional advising, financial aid, etc.)? I’ve noticed that the loneliness and isolation is affecting not only me but my roommates as well, who have stronger support systems and more friends on campus than I do – we’ve all been lacking motivation to do any of our work and they’ve mentioned that they feel like they need a break (spring break canceled due to pandemic concerns). Even some of my professors seem burnt out – forgetting class, getting behind on their syllabus, etc. In my opinion, BU should be more proactive in giving students resources instead of making it difficult to find said resources. Lastly, I wanted to add that I understand a lot of services are probably very different now due to the pandemic, but a single “wellness week” and emails about it do not do much to actually help students – I find it comparable to “self care” where the self care is just drinking wine and putting on a skincare mask and pushing all your real problems aside.

I agree with those who are asking for BU to do more to support students. I’m a faculty member who is trying to do my best to support my students. I’m more than willing to give extensions, modify assignments, and lower my expectations this semester. I’m checking in on students who miss class to make sure they’re okay. I’m trying to cut as much material as I can while still meeting my course learning objectives. At the same time, I don’t think it’s fair to expect faculty to do everything when it comes to students’ wellbeing. I’ve been in meetings where faculty were asked (both implicitly and explicitly) to help students make friends and socialize during class. I know faculty who are doing this in their courses (and I applaud them for their efforts), but shouldn’t Res Life and other staff at BU be providing opportunities for students to safely socialize? Sure, it’s cold, but certainly BU can be creative and think of ways to encourage students to get out of their dorms and make friends. Faculty are struggling too, and BU’s administration can help us by helping our students.

This is an excellent article, and though not surprising, it is shocking that the BU administration has not done anything to remedy this mental health crises. This is a mental health pandemic happening and it should be as high of a priority for BU as the trying to control the virus. If BU doesn’t step up and come up with a plan to address this then our students will suffer for years to come. This should have happened months ago. You can’t have a healthy individual/society if you are only concerned with physical health. It has to be a holistic approach.

Nice article I hope all instructors read this article I am one of the students sometimes fell a depression and live in the anxiety that is effectives on my life and do not have the energy to do anything particularly during what we live now

First, I would like to focus on the positive and thank BU mental health staff for being there for my son when he was in urgent need of mental health support back in the Fall semester. My call was answered right away and my son was able to speak with a professional with in 15 minutes. I was very impressed and relieved. They were there when we needed them.

On the other hand, I’m hearing from my son and all of his friends that the academic culture of rigor for the sake of rigor, grade deflation and the purposeful weeding out of students from core classes rather than supporting and helping each student succeed, not only continues but has been increased during COVID. These students have a sense that professors are concerned about online cheating so have ramped the rigor to address this. Not sure if this is real or perceived and I’m sure this is not going on in all classes as I also heard examples of supportive professors, but this is definitely a theme I am hearing from students. This style of academics is known to be outdated and ineffective, yet it continues, even at a higher level, during a pandemic.

I’m hoping this feedback can serve helpful to administration.

THANK YOU!!!! As a college student, who has survived the past year with a 4.0, attending full-time to obtain my degree in IT. I am struggling for the first time. After technology issues that set me behind four days, I really thought my instructors would understand. One of my instructors couldn’t care less. The workload is beyond overwhelming, her curriculum seems almost cruel. I graduate next month and I feel like I am losing my mind. I already suffer from severe anxiety, so the level I’m at now is almost debilitating. I have been obtaining degrees since 1998, and familiar with online learning. I’ve never had issues. This morning I received an email from her reminding me of the due date, in all bold caps, followed by some !!!! … She made it clear she is not available on the weekend, but expects us to be flexible. So my dilemma is this, I am failing my coding class now, but I don’t feel that I should be financially responsible to pay for having to retake it, as well as have it impact my financial aid and scholarships I receive for my academic performance.

Hi. I’m a BU alumna, a college professor, and mom to 4 college-aged sons. WONDERING… Do students feel there is explicit and implicit prejudice against college students as “purveyors of COVID?” I think this adds to the discomfort or enjoyment of being a college student and part of a university community. Thoughts? Thanks!

I notice that the students like to complain on here. One thing that university researchers on mental health have a difficult time assessing is knowing the familial support system (or lack thereof) students come into university life with. Psychologists will affirm that this plays a huge role in the mental health of students, at any age. Just as elementary through high schools today are expected to be the emotional, parental, physical, educational, and social supporter of each student, so too are universities being given this sort of expectation. Don’t get me wrong…I believe in striving for mental health and making resources available on campuses. However, within the communities of students – whether their friends or family – we have to realize that the internal conversation around mental health for many cultures is either non-existent or looked down upon. We can sing mental health from the rooftops all day long and hope that students are listening…..and I hope they do.

ECT/Electroshock use has been on the rise last 5 years or so and not just used for depression nor as a last resort. No FDA testing ever done of devices used or the procedure itself. Increase risk for suicide following as many cannot find help for their repeated brain injuries after consenting to this. Lawsuits taking place in the US and England around these damages covered up. See site ectjustice to learn more. Please speak out on social media so others are made aware of the truth of this practice.

People shouldn’t hesitate to ask for psychological help. I think it’s one of the main problems why people struggle mentally. Maybe, it’s a matter of self-critique, and society says sometimes that we should be strong… But when someone gets in an emotional crisis, only a professional can help. And I also never see when students/educators judge their peers/colleagues if someone contacted mental health support. I looked through the list of different affordable mental health services across English-speaking countries – https://ivypanda.com/blog/mental-health-resources – I was shocked how many problems we can have, and how many professionals exist to help with them. Maybe, it may be helpful to others too. Let’s take care of ourselves.

I tried to find the source for “83 %” of college students say their performance was negatively affected by mental health. Did you just pull that number out of thin air? I tried to go through everything I could and could not find this number anywhere in any actual published writing.

Please see page six of the report, the pie chart listed under Academic Impairment.

I think you just made up certain elements of this article and they actually have 0 foundation whatsoever. It has led me down a rabbit hole of attempting to try to find the published support for some of the claims you make. Including the 83 % figure. If you’re going to write articles that will be heavily referenced (which this is, because other idiots went on to quote this article), you should at least get the facts straight.

Please see page 6 of the report, the pie chart listed under Academic Impairment: https://healthymindsnetwork.org/wp-content/uploads/2021/02/HMS-Fall-2020-National-Data-Report.pdf

That is a misrepresentation of the data, in my opinion. Including students who reported mental health impacting their academic performance 1-2 days out of the week is insufficient to be grouped in with 83% of students. The way it is presented in this article makes it seem much more drastic than that. It should say, “28% of students felt 1-2 days out of the week had been negatively impacted by their mental health in the past month..” and report the other percentages. Not combined into one group and twisted in a sensationalistic way. I was attempting to use this information for a research paper of my own and was sent down a rabbit hole trying to find a source. Other people have cited this article, and that is your responsibility as a researcher.

Reading it because to help a friend with his assignment. He studies in FAST, Islamabad, Pakistan. If anyone of his class fellows are here, good luck to you

It is 3:12 in the morning and I just got off the phone with son. He called because he was riddled with anxiety and suffering with loneliness and a seeming inability to form meaningful connections. This is his first year at BU. He loves the University; However, in addition to the rigorous academic challenges, he is crushed by the seeming inability to form connections with others. This, on so many levels, surprises me. He is intelligent, interesting, friendly, handsome and well rounded. Upon my introduction to the University’s logistical layout, I was immediately aware that it not appear easily conducive to meeting people… As opposed to a smaller private college if you will. Clearly, BU had an obligation to address the many challenges brought about as a result of Covid. Understandable, but perhaps a bit extreme, ie: The students not being allowed to eat or congregate. Regardless, what I also observed is that there are few, if any, common rooms.. areas for students to hang out, play board games, ping pong, darts, tell jokes, b.s. and share common concerns. Or My point being, there should be multiple places (Besides sneaking into local clubs, or drinking Alone in your dorm) where kids can go..day or night. Organized events as well, aside from sports. As aforementioned, my son also found it very challenging and frustrating to contact a counselor through your service. When you do, the schedules are booked…… I have been heartbroken. Nonetheless, the consistent voice if encouragement. I want more from the school. I, like all others noted before me. More social emotional support. More access to social opportunities. More professors understanding and working with the challenges our children are struggling to navigate. In closing, it’s not just a BU crisis. I listen to very similar difficulties from many other University families…. PLEASE be more proactive. PLEASE care PLEASE help It is imperative and essential to a successful college experience and outcome. Thank you. And thank you all aforementioned

very very nice

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Combining joyful activities with ‘savoring’ therapy shows positive mental health results among young people

Amidst rising depression rates on college campuses, SMU researchers discovered combining behavioral activation therapy with savoring enhanced students' mental health. This approach improved both positive and negative moods significantly.

Southern Methodist University

Alicia Meuret, Director of the Anxiety and Depression Research Center at SMU.

Credit: SMU

DALLAS ( SMU ) – With rates of depression rising among young people on university campuses, a team of SMU researchers found that combining two different therapeutic approaches demonstrated effectiveness in improving students’ overall mental health. Their findings show that students receiving behavioral activation (BA) therapy augmented with savoring (S) experienced improvements in positive and negative mood. Behavioral activation is a therapeutic approach that alleviates depression by increasing engagement in meaningful activities, while savoring focuses on increasing one’s capacity to savor enjoyable experiences. The research team found favorable results in their participants who used the combination of approaches when compared to another group using emotional awareness (EA), which requires the participants to observe, monitor and reflect upon their positive and negative moods. The study, published in the journal  Behavior Research and Therapy , involved 60 students who were experiencing a lack of joy or enthusiasm (known as low positive affect or anhedonia). Researchers sought to see if using combined BA + S therapy compared to EA aided participants in achieving positive emotions (or high positive affect). Students participated in two online therapy sessions and completed daily mood surveys on their cell phones. Those receiving BA + S were asked to choose enjoyable activities from a list and plan to do them daily. They were also given guidance on how to savor those activities and remember what they enjoyed about them. After carrying out the activities, participants discussed how doing the activities and savoring made them feel and were encouraged to focus on the positive aspects. Students reported feeling happier each day of the study and were also given ways to use BA + S methods in the future, to possibly continue experiencing positive effect. Those receiving EA were encouraged to notice their feelings and to think about them, both good and bad. The students reported no positive affect improvements. “Behavioral activation has been around for decades and used to treat depression,” said  Alicia E Meuret , director of the  Anxiety and Depression Research Center  at SMU and the senior author. “What’s new is the focus on improving positivity instead of reducing negative feedings. Adding savoring, further pushes people to pay attention to what is in these enjoyable activities that make them feel better. The activity then becomes more salient in their memory and makes it easier for them to feel anticipatory reward or excitement.” Depression in university students is associated with decreased academic performance, a greater likelihood of dropping out and a decrease in quality of life. Additionally, accessing mental health treatments on many college campuses can be challenging due to limited resources, growing waitlists, session limits and the need for outside referrals. One of the benefits of using online BA + S therapy is its ease of accessibility compared to in-person therapy. “BA + S could help students feel better as a stand-alone strategy or while they wait for traditional treatment,” said lead author Divya Kumar, who earned her doctorate in clinical psychology under Meuret at SMU and is now a postdoctoral fellow at Harvard/McLean Hospital. “Because there are challenges in accessibility to mental health care, finding ways to provide brief and online therapy interventions continues to gain momentum, especially if those methods are targeting positive emotions as well as negative ones.” Additional research team members include SMU doctoral student Sarah Corner and data scientist Richard Kim.  

The Anxiety and Depression Research Center at SMU specializes in basic and applied research of anxiety, mood and affect dysregulation disorders. Other research includes investigations of novel treatment approaches for anxiety and depression, biomarkers in anxiety disorders and chronic disease (asthma), fear extinction mechanisms of exposure therapy, and mediators and moderators in individuals with affective dysregulations, including suicidal behaviors and non-suicidal self-injury.

About SMU SMU is the nationally ranked global research university in the dynamic city of Dallas. SMU’s alumni, faculty and more than 12,000 students in eight degree-granting schools demonstrate an entrepreneurial spirit as they lead change in their professions, communities and the world.

Behaviour Research and Therapy

10.1016/j.brat.2024.104525

Method of Research

Observational study

Subject of Research

Article title.

A randomized controlled trial of brief behavioral activation plus savoring for positive affect dysregulation in university students

Article Publication Date

24-Mar-2024

Disclaimer: AAAS and EurekAlert! are not responsible for the accuracy of news releases posted to EurekAlert! by contributing institutions or for the use of any information through the EurekAlert system.

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Threat Appraisal and Pediatric Anxiety: Proof of Concept of a Latent-Variable Approach Rachel Bernstein, Ashley Smith, Elizabeth Kitt, Elise Cardinale, Anita Harrewijn, Rany Abend, Kalina Michalska, Daniel Pine, and Katharina Kircanski  

Elevated threat appraisal is a postulated neurodevelopmental mechanism of anxiety disorders. However, laboratory-assessed threat appraisals are task-specific and subject to measurement error. We used latent-variable analysis to integrate youths’ self-reported threat appraisals across different experimental tasks; we next examined associations with pediatric anxiety and behavioral- and psychophysiological-task indices. Ninety-two youths ages 8 to 17 (M = 13.07 years, 65% female), including 51 with a primary anxiety disorder and 41 with no Axis I diagnosis, completed up to eight threat-exposure tasks. Anxiety symptoms were assessed using questionnaires and ecological momentary assessment. Appraisals both before and following threat exposures evidenced shared variance across tasks. Derived factor scores for threat appraisal were associated significantly with anxiety symptoms and variably with task indices; findings were comparable with task-specific measures and had several advantages. Results support an overarching construct of threat appraisal linked with pediatric anxiety, providing groundwork for more robust laboratory-based measurement. 

Investigating a Common Structure of Personality Pathology and Attachment Madison Smith and Susan South

Critical theoretical intersections between adult insecure attachment and personality disorders (PDs) suggest that they may overlap, but a lack of empirical analysis to date has limited further interpretation. The current study used a large sample (N = 812) of undergraduates (N = 355) and adults receiving psychological treatment (N = 457) to test whether a joint hierarchical factor structure of personality pathology and insecure attachment is tenable. Results suggested that attachment and PD indicators load together on latent domains of emotional lability, detachment, and vulnerability, but antagonistic, impulsigenic, and psychosis-spectrum factors do not subsume attachment indicators. This solution was relatively consistent across treatment status but varied across gender, potentially suggesting divergent socialization of interpersonal problems. Although further tests are needed, if attachment and PDs prove to be unitary, combining them has exciting potential for providing an etiologic-developmental substrate to the classification of interpersonal dysfunction. 

Does Major Depression Differentially Affect Daily Affect in Adults From Six Middle-Income Countries: China, Ghana, India, Mexico, Russian Federation, and South Africa? Vanessa Panaite and Nathan Cohen

Much of the research on how depression affects daily emotional functioning comes from Western, Educated, Industrialized, Rich, and Democratic (WEIRD) countries. In the current study, we investigated daily positive affect (PA) and negative affect (NA) and PA and NA variability in a cross-cultural sample of adults with a depression diagnosis (N = 2,487) and without a depression diagnosis (N = 31,764) from six middle-income non-WEIRD countries: China, Ghana, India, Mexico, Russian Federation, and South Africa. Across countries, adults with depression relative to adults without depression reported higher average NA and NA variability and lower average PA but higher PA variability. Findings varied between countries. Observations are discussed within the context of new theories and evidence. Implications for current knowledge and for future efforts to grow cross-cultural and non-WEIRD affective science are discussed.

Depressive Symptoms and Their Mechanisms: An Investigation of Long-Term Patterns of Interaction Through a Panel-Network Approach Asle Hoffart, Nora Skjerdingstad, René Freichel, Alessandra Mansueto, Sverre Johnson, Sacha Epskamp, and Omid V. Ebrahimi  

The dynamic interaction between depressive symptoms, mechanisms proposed in the metacognitive-therapy model, and loneliness across a 9-month period was investigated. Four data waves 2 months apart were delivered by a representative population sample of 4,361 participants during the COVID-19 pandemic in Norway. Networks were estimated using the newly developed panel graphical vector-autoregression method. In the temporal network, use of substance to cope with negative feelings or thoughts positively predicted threat monitoring and depressed mood. In turn, threat monitoring positively predicted suicidal ideation. Metacognitive beliefs that thoughts and feelings are dangerous positively predicted anhedonia. Suicidal ideation positively predicted sleep problems and worthlessness. Loneliness was positively predicted by depressed mood. In turn, more loneliness predicted more control of emotions. The findings point at the theory-derived variables, threat monitoring, beliefs that thoughts and feelings are dangerous, and use of substance to cope, as potential targets for intervention to alleviate long-term depressive symptoms. 

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Student Notebook: Learning Through Exposure

Ellen Finch on what therapists in training can learn from exposure therapy during a pandemic.

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Researchers share how their work is advancing the understanding and treatment of conditions like postpartum depression, OCD, and bipolar disorder.

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• CAREER BRIEF
• 26 March 2018

More than one-third of graduate students report being depressed

You have full access to this article via your institution.

PhD and master’s students worldwide report rates of depression and anxiety that are six times higher than those in the general public ( T. M. Evans et al. Nature Biotech. 36, 282–284; 2018 ). The report, based on the responses of 2,279 students in 26 nations, found that more than 40% of respondents had anxiety scores in the moderate to severe range, and that nearly 40% showed signs of moderate to severe depression. The high rates suggested by this study are alarming, says Teresa Evans, a neuroscientist at the University of Texas Health Science Center at San Antonio and the study’s lead author. She notes that students suffering from anxiety or depression might have been especially motivated to take the survey, which could have skewed the results. But she believes that the findings underscore the severity of the problem and the need for a response. Evans adds that universities should provide students with training to help them manage their time and cope with stress.

Nature 555 , 691 (2018)

doi: https://doi.org/10.1038/d41586-018-03803-3

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The Relationship Between Temporal Sense and Psychopathologies of College Students with Sensory Impairments: Mediation of Religions

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• Published: 13 May 2024

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• Yan Dai   ORCID: orcid.org/0000-0001-8938-2794 1   na1 &
• You Yu   ORCID: orcid.org/0000-0002-1168-2575 1   na1  

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Previous studies on the relationship between temporal sense and negative mental health symptoms have focused primarily on healthy college students, overlooking the role of religion. This study sought to examine the impact of religion on college students with sensory impairment and fill a gap in the research on the relationship between temporal sense and negative mental health symptoms in this population. The results were obtained from a cross sectional survey of 540 participants, including 370 hearing-impaired students and 140 visually impaired students. The survey investigated the mediating effect of religion on the relationship between temporal sense and negative mental health symptoms in impaired students. The rates of negative mental health symptoms (depression, anxiety, and stress) detected were 18.9%, 31.1%, and 2.9%, respectively. Students with different types of sensory impairments showed significant differences in their perception of time. The percentages of students with sensory impairments who attended church and practiced religion were 2.0%, 6.0%, and 1.0%, respectively. The results revealed a significant positive correlation between temporal sense and negative mental health symptoms, with religion serving as a mediating factor.

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Acknowledgements

The authors wish to thank all the students who participated in this project and the research associates and teachers who were involved in organizing the data collation.

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Yan Dai and You Yu shared first authorship.

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Dai, Y., Yu, Y. The Relationship Between Temporal Sense and Psychopathologies of College Students with Sensory Impairments: Mediation of Religions. J Relig Health (2024). https://doi.org/10.1007/s10943-024-02053-0

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DOI : https://doi.org/10.1007/s10943-024-02053-0

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