I.

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

Such negative stigma surrounding mental health diagnosis and care has been
found to correlate with a reduction in adherence to treatment and even early
termination of treatment.

The COVID-19 pandemic has brought into focus the mental health of various
affected populations. It is known that the prevalence of epidemics accentuates or
creates new stressors including fear and worry for oneself or loved ones, constraints
on physical movement and social activities due to quarantine, and sudden and
radical lifestyle changes. A recent review of virus outbreaks and pandemics
documented stressors such as infection fears, frustration, boredom, inadequate
supplies, inadequate information, financial loss, and stigma. Much of the current
literature on psychological impacts of COVID-19 has emerged from the earliest hot
spots in China. Although several studies have assessed mental health issues during
epidemics, most have focused on health workers, patients, children, and the general
population. For example, a recent poll by The Kaiser Family Foundation showed that
47% of those sheltering in place reported negative mental health effects resulting
from worry or stress related to COVID-19. Nelson et. al. have found elevated levels
of anxiety and depressive symptoms among general population samples in North
America and Europe.

However, with the exception of a few studies, notably from China, there is
sparse evidence of the psychological or mental health effects of the current
pandemic on college students, who are known to be a vulnerable population.
Although the findings from these studies thus far converge on the uptick of mental
health issues among college students, the contributing factors may not necessarily
be generalizable to populations in other countries. As highlighted in multiple recent
correspondences, there is an urgent need to assess effects of the current pandemic
on the mental health and well-being of college students.

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

II. Literature Review

Many risk factors were identified to be associated with symptoms of
depression amongst the COVID-19 pandemic. Females were reported as are
generally more likely to develop depressive symptoms when compared to their
male counterparts (Lei et al., 2020; Mazza et al., 2020; Sønderskov et al., 2020; Wang et al., 2020a). Participants
from the younger age group (≤40 years) presented with more depressive
symptoms (Ahmed et al., 2020; Gao et al., 2020; Huang and Zhao, 2020; Lei et al., 2020; Olagoke et al., 2020; Ozamiz-
Etxebarria et al., 2020
;). Student status was also found to be a significant risk factor for
developing more depressive symptoms as compared to other occupational
statuses (i.e. employment or retirement) ( González et al., 2020; Lei et al., 2020; Olagoke et al., 2020).
Four studies also identified lower education levels as an associated factor with
greater depressive symptoms (Gao et al., 2020; Mazza et al., 2020; Olagoke et al., 2020; Wang et al., 2020a). A
single study by Wang et al., 2020b reported that people with higher education and
professional jobs exhibited more depressive symptoms in comparison to less
educated individuals and those in service or enterprise industries.
Two of these papers examined the likely impact of the COVID-19 pandemic in
specific countries. One of these, from Iran ( Zandifar and Badrfam, 2020) highlighted the role
of unpredictability, uncertainty, seriousness of the disease, misinformation and
social isolation in contributing to stress and mental morbidity. The authors
highlighted the need for both mental health services, particularly for vulnerable
populations, and the strengthening of social capital to reduce the adverse
psychological impact of the outbreak. Another, from Japan ( Shigemura et al., 2020),
emphasized the economic impact of COVID-19 and its effects on well-being, as
well as the likely high levels of fear and panic behavior, such as hoarding and
stockpiling of resources, in the general population. This paper also identified
populations at higher risk of adverse mental health outcomes, including patients
with COVID-19 and their families, individuals with existing physical or psychiatric
morbidity, and healthcare workers.
Of the remaining papers, one pointed out that the wide scope and spread
of COVID-19 could lead to a true mental health crisis, especially in countries with
high case loads (Dong and Bouey, 2020) which would require both large-scale
psychosocial crisis interventions and the incorporation of mental health care in
disaster management plans in the future. In a related report ( Duan and Zhu, 2020) it was
 pointed out that while Western countries have incorporated psychological
interventions into their protocols for disease outbreaks, this has not yet happened
in countries such as China, leading to the emergence and persistence of stress-
related disorders in affected persons.

III. Methodology

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

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

First, descriptive statistics were compiled to describe participants’ demographics (eg,

age, gender, academic year, and major) and the distribution of the ratings on PSS-
10 survey items. A total PSS score per participant was calculated by first reversing
the scores of the positive items (4-7, 9, and 10) and then adding all the ten scores. A
mean (SD) PSS score was computed to evaluate the overall level of stress and
anxiety among the participants during the COVID-19 pandemic. Second,
participants’ answers to 12 academic-, health-, and lifestyle-related questions were
analyzed to understand relative impacts of the pandemic on various aspects of
college students’ mental health. Percentages of participants who indicated negative
ratings (ie, mild, moderate, or severe influence) on these questions were calculated
and ranked in a descending order. Qualitative answers to the 12 stressors and
coping strategies were analyzed using thematic analysis similar to the deductive
coding step in the grounded theory method.

V. Discussion

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

VI. Conclusion

Due to the long-lasting pandemic situation and onerous measures such as

lockdown and stay-at-home orders, the COVID-19 pandemic brings negative
impacts on higher education. The findings of our study highlight the urgent need to
develop interventions and preventive strategies to address the mental health of
college students.

VII. References

Unger K. Handbook on Supported Education: Providing Services for Students With

Psychiatric Disabilities. Charleston, SC: BookSurge Publishing; 2007.

2019 annual report. Center for Collegiate Mental Health. University Park, PA: Penn
State University; 2020.   URL: https://ccmh.memberclicks.net/assets/docs/2019-
CCMH-Annual-Report_3.17.20.pdf [accessed 2020-05-11]

Shuchman M. Falling through the cracks — Virginia Tech and the restructuring of
college mental health services. N Engl J Med 2007 Jul 12;357(2):105-110.
[CrossRef]

Eisenberg D, Downs MF, Golberstein E, Zivin K. Stigma and help seeking for mental
health among college students. Med Care Res Rev 2009 Oct;66(5):522-541.
[CrossRef] [Medline]

Brooks SK, Webster RK, Smith LE, Woodland L, Wessely S, Greenberg N, et al.
The psychological impact of quarantine and how to reduce it: rapid review of the
evidence. Lancet 2020 Mar 14;395(10227):912-920 [FREE Full text] [CrossRef]
[Medline]

Lai J, Ma S, Wang Y, Cai Z, Hu J, Wei N, et al. Factors associated with mental

health outcomes among health care workers exposed to coronavirus disease 2019.
JAMA Netw Open 2020 Mar 02;3(3):e203976 [FREE Full text] [CrossRef] [Medline]

Xie X, Xue Q, Zhou Y, Zhu K, Liu Q, Zhang J, et al. Mental health status among
children in home confinement during the coronavirus disease 2019 outbreak in
Hubei Province, China. JAMA Pediatr 2020 Apr 24:e201619 [FREE Full text]
[CrossRef] [Medline]

Kirzinger A, Kearney A, Hamel L, Brodie M. KFF health tracking poll - early April
2020: the impact Of coronavirus on life In America. Kaiser Family Foundation. 2020
Apr 02.   URL: https://www.kff.org/health-reform/report/kff-health-tracking-poll-early-
april-2020/ [accessed 2020-05-10]

Nelson B, Pettitt A, Flannery J, Allen N. Rapid assessment of psychological and

epidemiological correlates of COVID-19 concern, financial strain, and health-related
behavior change in a large online sample. Int J Methods in Psychiatr Res 2020 Apr
13;21(3):169-184. [CrossRef]
Cao W, Fang Z, Hou G, Han M, Xu X, Dong J, et al. The psychological impact of the
COVID-19 epidemic on college students in China. Psychiatry Res 2020
May;287:112934 [FREE Full text] [CrossRef] [Medline]

Liu X, Liu J, Zhong X. Psychological state of college students during COVID-19

epidemic. SSRN J 2020 Mar 24:A. [CrossRef]

Wang C, Zhao H. The impact of COVID-19 on anxiety in Chinese university

students. Front Psychol 2020;11:1168. [CrossRef] [Medline]
Bruffaerts R, Mortier P, Kiekens G, Auerbach RP, Cuijpers P, Demyttenaere K, et al.
Mental health problems in college freshmen: prevalence and academic functioning. J
Affect Disord 2018 Jan 01;225:97-103 [FREE Full text] [CrossRef] [Medline]

Zhai Y, Du X. Addressing collegiate mental health amid COVID-19 pandemic.

Psychiatry Res 2020 Jun;288:113003 [FREE Full text] [CrossRef] [Medline]

Zhai Y, Du X. Mental health care for international Chinese students affected by the
COVID-19 outbreak. Lancet Psychiatry 2020 Apr;7(4):e22 [FREE Full text]
[CrossRef] [Medline]

de Oliveira Araújo FJ, de Lima LSA, Cidade PIM, Nobre CB, Neto MLR. Impact of
Sars-Cov-2 and its reverberation in global higher education and mental health.
Psychiatry Res 2020 Jun;288:112977 [FREE Full text] [CrossRef] [Medline]

Holmes EA, O'Connor RC, Perry VH, Tracey I, Wessely S, Arseneault L, et al.
Multidisciplinary research priorities for the COVID-19 pandemic: a call for action for
mental health science. Lancet Psychiatry 2020 Jun;7(6):547-560 [FREE Full text]
[CrossRef] [Medline]

Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J

Health Soc Behav 1983 Dec;24(4):385-396. [Medline]

Cohen S, Kessler R, Gordon L. Measuring stress: A Guide for Health and Social
Scientists. New York, NY: Oxford University Press; 1997.

Acharya L, Jin L, Collins W. College life is stressful today - emerging stressors and
depressive symptoms in college students. J Am Coll Health 2018 Oct;66(7):655-664.
[CrossRef] [Medline]

Baghurst T, Kelley BC. An examination of stress in college students over the course
of a semester. Health Promot Pract 2014 May;15(3):438-447. [CrossRef] [Medline]

Zoom. Zoom Video Communications.   URL: https://zoom.us/

Otter.ai.   URL: https://otter.ai/login
Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Res Psychol
2006 Jan;3(2):77-101. [CrossRef]

Guest G, MacQueen K, Namey E. Applied Thematic Analysis. Thousand Oaks, CA:

Sage Publications; 2011.

Corbin J, Strauss A. Basics of Qualitative Research (3rd ed.): Techniques and

Procedures for Developing Grounded Theory. Thousand Oaks, CA: Sage
Publications; 2014.

MAXQDA. VERBI Software.   URL: https://www.maxqda.com/

Denovan A, Dagnall N, Dhingra K, Grogan S. Evaluating the perceived stress scale

among UK university students: implications for stress measurement and
management. Stud Higher Education 2017 Jun 22;44(1):120-133. [CrossRef]

Martin JM. Stigma and student mental health in higher education. Higher Education
Res Dev 2010 Jun;29(3):259-274. [CrossRef]

Zuckerman DM. Stress, self-esteem, and mental health: how does gender make a
difference? Sex Roles 1989 Apr;20(7-8):429-444. [CrossRef]

Jacobson NC, Lekkas D, Price G, Heinz MV, Song M, O'Malley AJ, et al. Flattening
the mental health curve: COVID-19 stay-at-home orders are associated with
alterations in mental health search behavior in the United States. JMIR Ment Health
2020 Jun 01;7(6):e19347 [FREE Full text] [CrossRef] [Medline]

Zivin K, Eisenberg D, Gollust SE, Golberstein E. Persistence of mental health

problems and needs in a college student population. J Affect Disord 2009
Oct;117(3):180-185. [CrossRef] [Medline]

Zeng Y, Wang G, Xie C, Hu X, Reinhardt JD. Prevalence and correlates of

depression, anxiety and symptoms of stress in vocational college nursing students
from Sichuan, China: a cross-sectional study. Psychol Health Med 2019
Aug;24(7):798-811. [CrossRef] [Medline]

Nahas ARMF, Elkalmi R, Al-Shami A, Elsayed T. Prevalence of depression among

health sciences students: findings from a public university in Malaysia. J Pharm
Bioallied Sci 2019;11(2):170-175 [FREE Full text] [CrossRef] [Medline]

Fitzpatrick O, Biesma R, Conroy RM, McGarvey A. Prevalence and relationship

between burnout and depression in our future doctors: a cross-sectional study in a
cohort of preclinical and clinical medical students in Ireland. BMJ Open 2019 May
01;9(4):e023297 [FREE Full text] [CrossRef] [Medline]
Heiligenstein E, Guenther G, Hsu K, Herman K. Depression and academic
impairment in college students. J Am Coll Health 1996 Sep;45(2):59-64. [CrossRef]
[Medline]

Nastasi BK, Sarkar S, Varjas K, Jayasena A. Participatory model of mental health

programming: lessons learned from work in a developing country. Sch Psychol Rev
1998;27(2):260-276.

Cappella E, Jackson DR, Bilal C, Hamre BK, Soulé C. Bridging mental health and
education in urban elementary schools: participatory research to inform intervention
development. Sch Psychol Rev 2011;40(4):486-508.

Eisenberg D, Hunt J, Speer N, Zivin K. Mental health service utilization among

college students in the United States. J Nerv Ment Dis 2011 May;199(5):301-308.
[CrossRef] [Medline]

Husain W. Barriers in seeking psychological help: public perception in Pakistan.

Community Ment Health J 2020 Jan;56(1):75-78. [CrossRef] [Medline]

Fischer EP, McSweeney JC, Wright P, Cheney A, Curran GM, Henderson K, et al.
Overcoming barriers to sustained engagement in mental health care: perspectives of
rural veterans and providers. J Rural Health 2016 Sep;32(4):429-438. [CrossRef]
[Medline]

Torous J, Jän Myrick K, Rauseo-Ricupero N, Firth J. Digital mental health and

COVID-19: using technology today to accelerate the curve on access and quality
tomorrow. JMIR Ment Health 2020 Mar 26;7(3):e18848 [FREE Full text] [CrossRef]
[Medline]

Youn SJ, Trinh N, Shyu I, Chang T, Fava M, Kvedar J, et al. Using online social
media, Facebook, in screening for major depressive disorder among college
students. Int J Clin Health Psychol 2013 Jan;13(1):74-80. [CrossRef]

Ginossar T, Nelson S. Reducing the health and digital divides: a model for using
community-based participatory research approach to e-health interventions in low-
income Hispanic communities. J Computer-Mediated Commun 2010;15(4):530-551.
[CrossRef]

COVID-19 projections. Institute for Health Metrics and Evaluation. Seattle, WA:
University of Washington   URL: https://covid19.healthdata.org/united-states-of-
america [accessed 2020-05-20]

de Girolamo G, Cerveri G, Clerici M, Monzani E, Spinogatti F, Starace F, et al.

Mental health in the coronavirus disease 2019 emergency-the Italian response.
JAMA Psychiatry 2020 Apr 30:A. [CrossRef] [Medline]
Zhou J, Liu L, Xue P, Yang X, Tang X. Mental health response to the COVID-19
outbreak in China. Am J Psychiatry 2020 Jul 01;177(7):574-575. [CrossRef]
[Medline]

Zhou X, Snoswell CL, Harding LE, Bambling M, Edirippulige S, Bai X, et al. The role
of telehealth in reducing the mental health burden from COVID-19. Telemed J E
Health 2020 Apr;26(4):377-379. [CrossRef] [Medline]

Shore JH, Waugh M, Calderone J, Donahue A, Rodriguez J, Peters D, et al.

Evaluation of telepsychiatry-enabled perinatal integrated care. Psychiatr Serv 2020
May 01;71(5):427-432. [CrossRef] [Medline]

Huckins JF, daSilva AW, Wang W, Hedlund E, Rogers C, Nepal SK, et al. Mental
health and behavior of college students during the early phases of the COVID-19
pandemic: longitudinal smartphone and ecological momentary assessment study. J
Med Internet Res 2020 Jun 17;22(6):e20185 [FREE Full text] [CrossRef] [Medline]

McAlonan GM, Lee AM, Cheung V, Cheung C, Tsang KW, Sham PC, et al.
Immediate and sustained psychological impact of an emerging infectious disease
outbreak on health care workers. Can J Psychiatry 2007 Apr;52(4):241-247.
[CrossRef] [Medline]