Impact of COVID-19 Pandemic on Mental Health of General Population and University Students Across the World: A Review

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OJHAS Vol. 20, Issue 2: (April-June 2021)

Original Article
Impact of COVID-19 Pandemic on Mental Health of General Population and University Students Across the World: A Review

Authors:
Shweta Singh, Ph.D Scholar, Department of Anthropology, University of Delhi, Delhi-110007,
Neelam Singh, Ph.D Scholar, Department of Anthropology, University of Delhi, Delhi-110007,
Rajeev Ahirwar, Ph.D Scholar, Department of Anthropology, University of Delhi, Delhi-110007,
Surendra Kumar Sagar, Associate Professor, Swami Shraddhanand College, University of Delhi, Delhi-110086,
Prakash Ranjan Mondal, Professor, Department of Anthropology, University of Delhi, Delhi-110007.

Address for Correspondence
Prakash Ranjan Mondal,
Professor
Department of Anthropology,
University of Delhi,
Delhi-110007
E-mail: prmondal1@rediffmail.com.

Citation
Singh S, Singh N, Ahirwar R, Sagar SK, Mondal PR. Impact of COVID-19 Pandemic on Mental Health of General Population and University Students Across the World: A Review. Online J Health Allied Scs. 2021;20(2):2. Available at URL: https://www.ojhas.org/issue78/2021-2-2.html

Submitted: May 19, 2021; Accepted: Aug 2, 2021; Published: Aug 25, 2021

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This work is licensed under a Creative Commons Attribution-No Derivative Works 2.5 India License

Abstract: Background: With the outbreak of COVID-19 pandemic across the world, people have suffered an unexpected setback to their mental health. As psychological support is being provided to patients and healthcare workers, the general population and university students go unnoticed. This review aims to present existing literature that reports the effects of COVID-19 on psychological outcomes of the general population and university students in different countries. Methods: A manual search was conducted on PubMed, Google Scholar and Mendeley from inception to 31st January 2021. Articles were selected based on the predetermined eligibility criteria. Results: During COVID-19 pandemic, relatively high rates of depression (4.5% to 72.3%), anxiety (12.7% to 85.7%) and stress (5% to 90.1%) were reported in the general population as well as in university students, depression (3% to 70.5%), anxiety (9% to 63.3%) and stress (61.5% to 25%) in India, Nepal, Pakistan, China, Spain, US, UK, France, Egypt, Ethiopia, Bangladesh, Nigeria and Saudi Arabia. Risk factors associated include female gender, younger age group (≤40 years), unemployment, student status, and frequent exposure to social media/news concerning COVID-19. Conclusions: The COVID-19 pandemic is associated with highly significant levels of psychological disorders such as depression, anxiety and stress. Alleviating the hazardous effects of COVID-19 on mental health should be given due attention internationally.
Key Words: COVID-19, General population, University students, Anxiety, Depression, Stress

Introduction:

The World Health Organization officially designated novel coronavirus disease as COVID-19 as it has reached the level of a pandemic, affecting countries across the world. By 1st February 2021, over 10.5 million confirmed cases attributable to this disease have been reported. (1) In the wake of this global health crisis, stringent public health measures essential to halt transmission of the virus have been implemented to curtail the spread of COVID-19. This has led to physical isolation, closure of schools, colleges and offices limiting the necessary human interaction.

Any pandemic brings with itself a major setback in the mental health front. The resulting uncertainties and fears associated with the COVID-19 virus outbreak, along with mass lockdowns and economic recession can lead to increases in suicide as well as associated mental disorders. (2) As was seen in the case of the Ebola outbreak in 2014, symptoms of Post-Traumatic Stress Disorder (PTSD) and anxiety-depression were more prevalent even after 1 year of Ebola response. (3) The risk of PTSD in the aftermath of the pandemic can, therefore, be a huge challenge to the mental health system of the country. (4) Similarly, the widespread outbreak of COVID-19 is associated with mental health issues focusing on health workers, patients, children, students and the general population (5-6).

A recent review of the virus outbreak documented certain stressors such as infection fears, frustration, boredom, inadequate supplies, financial loss, job loss, insecurities, and disruption of work progress in the general population. (7) Elevated levels of stress, anxiety and depressive symptoms among general population samples in North America and Europe were found. (8) A similar trend was also reported in the USA, India, France, Germany, and Italy. (9)

While in university students, additional stressors were reported such as hindering studies, halting research, disruptions in starting classes and taking exams online, feelings of hopelessness and others. (10) High level of psychological distress (51%) was reported among university students of the United Arab Emirates (UAE). (11) Similar trends were reported in Asia, Africa, United Kingdom (UK) and North America in terms of depression, anxiety and stress. (12-15)

Existing literature mostly talks about the impact of COVID-19 on mental health among the general population and university students separately. Keeping this in view, the objective was to provide a comparative review among these groups from countries across the world for better understanding of how different levels of depression, anxiety, stress, and psychological distress can arise in different environmental settings.

Materials and Methods

The literature review was performed during the months of January and February, 2021 using electronic search engines such as: PubMed, Mendeley and Google Scholar. Selection of articles was only related to the current COVID-19 pandemic and how it has affected the mental health of University students and the general population, all around the world. The following keywords were used: “COVID-19”,“Mental health”, “Depression”, “Anxiety”, “Stress”, “Psychological distress”, “University/College students” and “general population”. After this first search, taking into account the works published in both 2020 and 2021, a more thorough search was then carried out, leaving a final sample of 31 scientific papers as shown in Figure 1.

Inclusion and Exclusion criteria: The criteria that were established for the selection of research papers are discussed in Table 1.

Table 1: Inclusion and Exclusion criteria
PICOS acronym	Inclusion criteria	Exclusion criteria
P- Population	Adults, University/college going students, Both sexes, Age > 18 years old, any country.	Children, adolescents, pregnant women, mental health patients
I-Intervention/ Exposure	Covid-19 outbreak	Other previous pandemics as well as studies that analyzed mental and behavioral disorders due to the use of alcohol, drugs and other causes.
C- Comparison	Studies on university students as well as general population of the same country	Other studies defying inclusion criteria
O-Outcome	Prevalence of mental health problems (Depression, anxiety, stress, distress)	Studies that report prevalence and severity of symptoms of young people and adults who have had mental problems by other causes.
S-Study design	Cross-sectional	RCT, NRCT, qualitative studies.
RCT (Randomized control trials), NRCT (Non-random control trials)

Search strategy

The search process was completed following a flow chart given in Figure 1.

Figure 1: Study selection flow diagram

Results

Study characteristics
Study characteristics and primary study findings are summarized in Table 2. In all, 31 studies met the inclusion criteria out of which, 17 were university students and the remaining 14 in the general population. The studies were conducted in 14 different countries (Bangladesh, China, Egypt, Ethiopia, France, India, Nepal, Nigeria, Pakistan, Saudi Arabia, Spain, UAE, United States (US) and UK), including one or more studies on general population and university students from each country. The sample size of the studies on university students ranged from 121 to 7,46,217 participants while that of the general population was 112 to 5470. Only 2 studies followed longitudinal study design, whereas others were cross sectional studies. The primary outcomes chosen for this review varied across studies.

Measurement tools
A variety of scales were used in the included studies for assessing depression, anxiety and stress/distress. The Patient Health Questionnaire-9/4/8/1 (PHQ-9/4/8/1) was used to measure depressive symptoms. (16) General Anxiety Disorder-7 (GAD-7) and Corona-virus anxiety Scale (CAS) was used for evaluation of anxiety. (17-18) Perceived Stress Scale (PSS) and Perceived Stress Questionnaire (PSQ) were used to evaluate symptoms of stress. (19-20) Depression Anxiety and Stress Scale-21 (DASS-21) was used for the evaluation of depression, anxiety, and stress symptoms (DAS). (21) Symptoms of PTSD were assessed by The Impact of Event Scale-(Revised) (IES(-R)) and International Classification of Disease-11 Post-traumatic Stress Disorder (ICD-11 PTSD). (22-23) The General Health Questionnaire (GHQ-12) and Hospital Anxiety and Depression Scale (HADS) were used for assessing anxiety and depressive symptoms. (24-25) Psychological distress was measured by the Kessler Psychological Distress Scale (K6/10). (26)

Table 2: Prevalence of mental health status among general population and university students of different countries
Country	Authors	Study Design	Study tools	Population	Sample size	Results
Bangladesh	Islam et al., 2020. (12)	Cross sectional online survey	DASS-21	University students	3122	76.1% -35.2% mild to severe depression, 71.5%-40.3% mild to severe anxiety, 70.1%-37.7% mild to severe stress
Bangladesh	Al Banna et al., 2020. (30)	Cross sectional online survey	DASS-21	General Population	1427	59.7% stress, 57.9% depression, 33.7% anxiety.
China	Ma et al., 2020. (45)	Cross sectional online survey	GAD-7, PHQ-9,IES-6	University students	746217	21.1% depression, 11% anxiety, stress 34.9%
China	Wang et al., 2020. (34)	Cross sectional online survey	DASS-21, IES-R	General Population	1120	24.5% minimal distress, 21.7% mild distress, 53.8% moderate or severe distress. 13.8% -4.3% mild to extremely severe depression, 7.5%-8.4% mild to extremely severe anxiety, 24.1%-2.6% mild to extremely severe stress.
Egypt	Ghazawy et al., 2020. (13)	Cross sectional online survey	DASS-21	University students	1335	70.5% depression, 53.6% anxiety, 47.8% stress
Egypt	Arafa et al., 2020. (28)	Cross sectional online survey	DASS-21	General Population	1629	67.1%-22.5 % mild to very severe depression, 53.5%-22.9% mild to very severe stress, 48.8%-15% mild to very severe anxiety.
Ethiopia	Aylie et al., 2020. (46)	Cross sectional interview	DASS-21	University students	322	21.3% depression, 27.1% anxiety, 32.5% stress
Ethiopia	Kassaw C, 2020. (33)	Cross sectional online survey	DASS-21	General Population	420	36% anxiety, 12.4% depression, 18% stress.
France	Essadek & Rabeyron, 2020. (42)	Cross sectional online survey	PHQ-9, GAD-7, IES-R	University students	8004	43% depression, 39.19 anxiety, 42.94% distress
France	Hummel et al., 2020. (29)	Cross sectional online survey	DASS-21	General Population	609	57.69% depression, 48.08% anxiety, 51.92% stress
India	Verma K, 2020. (43)	Cross sectional online survey	GAD-7, PHQ-9	University students	131	68.7%- 9% mild to severe anxiety, 61%-3% mild to severe depression
	Chhetri et al., 2020. (51)	Cross sectional online survey	PSS	University students	411	45%-6% mild to severe stress
	Gopal et al., 2020. (38)	Longitudinal online survey	PHQ-4, GAD-7	General Population	159	70.8%-10.4% mild to severe anxiety, 27%-24% intermediate to high stress, 26.1% depression.
Nigeria	Ojewale, 2020. (47)	Cross sectional online survey	HAD	University students	386	31.9% depression, 41.5% anxiety
	Idowu et al., 2020. (50)	Cross sectional online survey	GHQ-12	University students	1010	31.38% psychological distress
	Olaseni et al., 2020. (31)	Cross sectional online survey	GAD-7, PHQ-9	General Population	502	51% -49% moderate to severe anxiety,13.1%-4.5% moderate to severe depression, 25% stress
Nepal	Karmacharya et al., 2020. (48)	Cross sectional online survey	DASS-21	University students	517	30.36% depression, 28.62% anxiety and 20.69% stress
Nepal	Devkota et al., 2020. (32)	Cross sectional Interview	DASS-21	General Population	618	14% anxiety, 7% depression, 5% stress.
Pakistan	Salman et al., 2020. (44)	Cross sectional online survey	GAD-7, PHQ-9	University students	983	21%-10.4% moderate to severe depression, 19.8%-13.7% moderate to severe anxiety
	Raja et al., 2020. (49)	Cross sectional online survey	PSS	University students	706	High stress 53.5%, moderate stress 43.4%, low stress
	Sandesh et al., 2020. (27)	Cross sectional online survey	DASS-21	General Population	112	72.3% moderate to extremely severe depression, 85.7% moderate to extremely severe anxiety, 90.1% moderate to extremely severe stress
Saudi Arabia	Al Omari et al., 2020. (41)	Cross sectional online survey	DASS-21	University students	121	48% depression, 33.1% anxiety, 30.6% stress
Saudi Arabia	Alamri et al., 2020. (39)	Cross sectional online survey	DASS-21	General Population	1597	28.9% depression, 16.4% anxiety, 17.7% stress
Spain	Odriozola-Gonzalez et al., 2020. (40)	Cross sectional online survey	DASS-21, IES	University students	2530	48.1% depression, 35.18% anxiety, 40.32% stress, 50.43% psychological impact
Spain	Ozamiz-Etxebarria et al., 2020. (35)	Longitudinal online survey	DASS-21	General Population	976	18.85% depression, 26.02% anxiety, 23.66% stress
United Arab Emirates (UAE)	Saravanan et al., 2020. (11)	Cross sectional online survey	CAS, K-6	University students	377	15.9% anxiety, 51% psychological distress
United Arab Emirates (UAE)	Thomas et al., 2020. (74)	Cross sectional online survey	GAD-7, PHQ-8	General Population	1039	58.4% depression, 55.7% anxiety.
United States of America (US)	Aiyer et al., 2020. (15)	Cross sectional online survey	PHQ-4, PSS-4	University students	369	34.2% depression, 31.7% anxiety, 48.4% stress
United States of America (US)	Czeisler et al., 2020. (37)	Cross sectional online survey	PHQ-4, IES-6	General Population	5470	24.3% depression, 25.5% anxiety and 26.3% stress
United Kingdom (UK)	Van Der Felitz-Corneliset al., 2020. (14)	Cross sectional online survey	GAD-7, PSQ, PHQ-9	University students	927	46.5% depression, 37.2% anxiety and 61.5% stress
United Kingdom (UK)	Shevlin et al., 2020. (36)	Online questionnaire	PHQ-9, GAD-7, ICD-11, PTSD	General Population	2019	22.1% depression, 21.6% anxiety and 16.79% stress

Prevalence of depression during COVID-19 pandemic
Among general population, the prevalence of depression was high in Pakistan (72.3%), succeeded by Egypt (67.1%), France (57.69%) and Bangladesh (57.9%), while it was low in Nigeria (4.5%), Nepal (7%), Ethiopia (12.4%), China (16.5%) and Spain (18.85%). (27-35) Moderate prevalence was reported in the UK (22.1%), US (24.3%), India (26.1%) and Saudi Arabia (28.9%). (36-39)

Among university students, the prevalence of depression was high in Egypt (70.5%), followed by Bangladesh (62.9%), Spain (48.1%), Saudi Arabia (48%), UK (46.5%) and France (43%) while it was low in India (3%) and Pakistan (10.4%). (12-14,40-44) Moderate prevalence was reported in China (21.1%), Ethiopia (21.3%), Nigeria (31.8%), Nepal (30.36%) and the US (34.2%). (15,45-48)

The prevalence of depression was reported to be similar between both the general population and university students in Bangladesh and Egypt but in India, Nigeria, Nepal, Pakistan, US and UK significant differences were found as shown in figure 2.

Figure 2: Prevalence of depression during COVID-19 pandemic in general population and university students in different countries.

Prevalence of anxiety during COVID-19 pandemic
Among general population, prevalence of anxiety was highest in Pakistan (85.7%), succeeded by Egypt (53.5%), Nigeria (49%) and France (48.08%) while it was low in India (12.7%) and Saudi Arabia (16.4%). (49,13,29,38,39) Moderate prevalence was reported in Ethiopia (36%), Bangladesh (33.7%), China (28.8%), Spain (26.02%), US (25.5%) and UK (21.6%). (30,33-37)

Among university students, prevalence of anxiety was highest in Bangladesh (63.6%), followed by Egypt (53.6%) and Nigeria (41.5%) while it was low in India (9%), China (11%) and Pakistan (13.7%). (12,13,43-45,47) Moderate prevalence was reported in France (39.19%), UK (37.2%), Spain (35.18%), Saudi Arabia (33.1%), US (31.7%), Nepal (28.6%) and Ethiopia (27%). (14,15,40-42,46.48)

Figure 3 illustrates the prevalence of anxiety which was reported to be similar among the general population as well as university students in Egypt, Ethiopia, France, India, Nigeria, Spain and US but in Pakistan, Bangladesh and China, significant differences were found.

Figure 3: Prevalence of anxiety during COVID-19 pandemic in general population and university students in different countries.

Prevalence of stress during COVID-19 pandemic
Among general population, prevalence of stress was high in Pakistan (90.1%), succeeded by Bangladesh (59.7%), France (51.92%), Egypt (48.8%) while it was low in Nepal (5%), China (8.1%), Saudi Arabia (17.7%), UK (16.79%) and Ethiopia (18%). (27-30,32-34,36,39) Moderate prevalence was reported in the US (26.3%), Nigeria (25%), India (24%) and Spain (23.66%). (31,35,37,38)

Among university students, prevalence of stress was high in UK (61.5%), followed by Bangladesh (58.6%), Pakistan (53.5%), US (48.4%), Egypt (47.8%), France (42.94%) and Spain (40.32%). (12-15,40,42,49) Moderate prevalence was reported in China (34.9%), Ethiopia (33%), Nigeria (31.38%), Saudi Arabia (30.6%), Nepal (28.62%) and India (25%). (41,45,46,48,50,51)

The prevalence of stress was reported to be similar among general population and university students in Bangladesh, Egypt, France, India and Nigeria, but in Pakistan, China, Nepal, US and UK significant differences were found as shown in figure 4.

Figure 4: Prevalence of stress during COVID-19 pandemic in the general population and university students in different countries.

Discussion

Globally, Impact of the COVID-19 pandemic on mental health among general population
The spread of COVID-19 has affected all the population groups across the globe on multiple levels. A hidden impact of COVID-19 pandemic on the psychological well-being of the general population has now widely come to light. Our findings indicate that COVID-19 pandemic was associated with increased mental health issues, though the prevalence of depression varied widely from being highest in Pakistan (72.3%) to lowest in Nigeria (4.5%). (27,31) Several factors were found to be associated with the reported symptoms of depression. Higher levels of depressive symptoms were observed in females, which was found to be consistent with other findings. (52-54) A pooled result of five recent studies showed a depression prevalence of 20.3% among men and 26.9% among women. (55) Also, those with the lowest level of education have the highest rates of increased depression symptoms during the pandemic, which is similar to results from a study in China. (30,54) Other studies have found no significant differences in the mental health of participants with different educational backgrounds. (56,57) Reports also suggested that poor economic status, lower education level, and unemployment are significant risk factors for developing symptoms of mental disorders, especially depressive symptoms during the pandemic period. (53,58-60)

Different mental health conditions are disproportionately affecting specific populations. The prevalence of anxiety during COVID-19 pandemic varies among different countries. In the presented literature, the prevalence of anxiety was reported to be highest in Pakistan (85.7%) and lowest in India (12.7%). (27,38) Several factors can be attributed to varying prevalence of anxiety in the general population. There exists extensive previous epidemiological research placing women at a higher risk for experiencing anxiety symptoms. (2) However, few studies reported the opposite relationship between stress and gender. (36,61) Also, pooled results of six studies showed an anxiety prevalence of 20.9% among men and 29.1% among women. (55) The rate of anxiety symptoms among widows is higher than that of married or single individuals. (62) Those in the older age group (40 years and older) reported a high rate of anxiety symptoms. (30) This finding may be attributed to anxieties regarding the higher COVID-19 death rate among older individuals. (62) Several studies identified frequent exposure to social media/news relating to COVID-19 as a cause of anxiety and stress symptoms. (58,63)

Stress and distress symptoms were assessed in all the studies, with a noticeable variation in the prevalence of stress symptoms ranging from 90.1% in Pakistan to 5% in Nepal. (27,32) Another study states that younger age groups and females are more likely to develop psychological distress. (34) Other predictive factors included being migrant workers, profound regional severity of the outbreak and unmarried status. (34,64) In terms of education, graduate students experienced high levels of stress more so than those in undergraduate or higher secondary. (30) The participants with formal education had higher prevalence of stress symptoms compared to those with no school education. (32)

From the literature reviewed for the present study, it was reported that the symptoms of DAS vary across the world. The discrepancies may be attributable to developed socioeconomic and healthcare systems. DAS symptoms were reportedly high in Pakistan, Egypt, France and Bangladesh in the general population.

Globally, Impact of the COVID-19 pandemic on mental health among university students-
Many studies have reported that university students are at elevated risk for mental health concerns with consistently higher levels of depression, stress and anxiety than the general population. (65,66) Measures such as university closure adopted to fight against COVID-19 to restrict it have caused unique stressors leading to disruption of daily life of students globally, which hampered the academic progress of students further with notable impact on their psychological state. (13) Studies have reported prevalence of depression ranging from as high as 70.85% in Egypt students to as low as 3% in Indian students. (13,43) It has been reported in a lot of studies that the mental health of females was more affected in comparison to male students. (12,43,48,)

Factors that are relevant to the student population which impact mental well-being include economic difficulties, debt, familial factors, job losses and unemployment, social disintegration, and poor quality of life. (67,68)

Public health emergencies can affect the psycho-social well-being of the students, and it reflects in the form of mental health problems. Since the start of the COVID-19 pandemic, several studies have already examined the impact of COVID-19 on mental health in different student populations reporting moderate to severe anxiety levels pertaining to low social support, any acquaintances infected with COVID-19, perceived family relationships, place of residence, source of parental income, whether living with parents. (10,13,45,48)

In Bangladesh, a study also found significant relationships in DAS with lack of physical activity, excessive internet usage and smoking. (12) Beside these, other factors that may contribute to mental health problems in students during the COVID-19 epidemic can be social isolation and loneliness, fear and helplessness related to the disease as well as lack of sleep, as this pandemic prompted all the countries to opt for social and physical distancing. (69-71) Also, the media headlines, travel restrictions, inability to meet loved ones, fear of career progression, or academics may have added to anxiety, depression, and high stress among the students. Similar results have also been seen in earlier pandemics such as the severe acute respiratory syndrome (SARS) epidemic.

College student’s stress regarding COVID-19 may be related to the effect of the virus on their studies and not being able to handle the consequences of the infection. (72) On the other hand, their stress may have been caused by gradually losing attention in their online classes during the confinement period. It is known that stress and anger may lead to other negative psychological behavior and mental illness. (73) Literature studies have reported wide variation in stress/distress levels ranging from 61.5% in the UK to 25% in India. (14,51) On the other hand, a study among university students in Bangladesh has found no significant association in monthly family income, relationship or marital status to mental health problems. (12)

The review of existing literature showed the wide variation in prevalence of DAS among university/college students of different countries around the globe. High prevalence owing to varying factors were reported in Egypt, Bangladesh and Spain. Early researches exploring the mental health consequences of COVID-19 across populations in other nations support this view. (74)

Conclusion

This review examined the psychological status of the general public as well as university students during the COVID-19 pandemic in different countries and associated factors. A high to moderate prevalence of DAS symptoms were reported in most studies. Overall, the COVID-19 pandemic represents an inevitable threat to mental health regardless of age, gender and socio-economic status. Therefore, mental health is needed to be taken into consideration at multiple levels – in the general population, among university students, healthcare workers, and in other vulnerable populations. In addition to efforts to curb viral transmission, priority needs to be given to the prevention of mental disorders. As the number of cases increase, psychiatric professionals need to identify and address the situation and produce efforts to stabilize the situation. Further research to assess the impact of this pandemic on mental health in other countries, specially other vulnerable populations, such as children and adolescents, those in remote or rural areas, and those belonging to lower socio-economic class can unearth the hidden severity of pandemic. Government policies and actions are needed to investigate and alleviate the menace of mental health.

Strengths

Our paper is the first review that examines and summarizes existing literature with relevance to the psychological health of the general population and university students across the world during the COVID-19 outbreak. The study examines the prevalence of each psychological outcome (DAS) across studies. The study also makes an effort to highlight the important associated risk factors and provide suggestions for addressing the issue at hand.

Limitations
Certain limitations apply to this review. Firstly, the description of the study findings was qualitative and narrative. All studies were conducted via online questionnaires independently by the study participants, which can cause variability in terms of self-assessment of a symptom. Also, poor internet accessibility was likely not included in the studies, creating a selection bias in the population studied. Another concern is different assessment tools used in all the studies, which can generate the outcomes that are difficult to compare.

Funding: Faculty Research Programme Grant IoE- Institute of Eminence, Ref no.: IoE/FRP/PCMS/2020/27

Acknowledgments

We acknowledge the other authors who have already published the studies on the concerned topic. We thank University of Delhi through Institute of Eminence, for the funding.

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