Depression, anxiety, and suicidal ideation in college students in the aftermath of COVID-19 pandemic

Abstract

Background:

The COVID-19 pandemic was not merely limited to physical health concerns, and after the pandemic, the mental health consequences of the pandemic are still reverberating within our societies, especially in India. The college students in India were left to grapple with unforeseen circumstances, facing abrupt uncertainties with respect to their education and careers. Although their physical health was relatively more robust, their mental health status was left unexplored.

Aim:

To assess depression, anxiety, and suicidal ideation in college students in the aftermath of COVID-19 pandemic.

Materials and Methods:

An observational cross-sectional survey was conducted on 323 undergraduate students from June 2021 to August 2021, who were required to fill a survey form which comprised basic sociodemographic details, student’s concerns about COVID-19 and the following scales: Hospital Anxiety and Depression Scale (HADS) and Positive and Negative Suicide Ideation Scale (PANSI) after obtaining written and informed consent from them. The data collected was analyzed using descriptive and inferential statistics.

Results:

The study revealed that 23.52% of the participants suffered from depressive disorders, and 34.98% from anxiety disorders. Although a statistically higher number of males were depressed as compared to females (33.87% versus 17.08%), it was the opposite for anxiety disorders (47.73% females versus 14.51% males). HADS anxiety score was positively correlated with worrying about family members, COVID-19 infection in family members, fear of contracting the infection, presence of psychiatric illness in family, and history of attempted suicide. HADS depression score was positively correlated with worrying about family, COVID-19 infection in family members, a prior consultation with a mental health professional, and history of attempted suicide. Suicidal ideations as predicted by PANSI Positive score was predicted by rural place of residence, number of family members, and presence of psychiatry patient in the family.

Conclusion:

In the following era of the COVID-19 pandemic, anxiety and depression were high amongst college students. Various COVID-19-related and personal correlates for anxiety and depression as well as predictors for suicidal ideations could also be delineated. Institutions need to find out at-risk students and plan active measures for them.

The COVID-19 pandemic was not just a public health crisis; it was a seismic shift in the way we live, work, and interact. Although the virus’s physical effects were devastating, its impact on mental health remains a significant concern, particularly for young adults.[1] India, with over 247 million infected individuals and a staggering 2.7 lakh fatalities, emerged as one of the worst-hit nations in the world. The World Health Organization (WHO) painted a grim picture, estimating that one in seven Indians grappled with poor mental health, even labeling the country as the most depressed globally.[2]

The pandemic’s psychological toll was not uniform. College students, a demographic often characterized by vibrant social lives and academic pursuits, found themselves thrust into an unfamiliar reality. Universities and libraries shut their doors, severing access to essential learning spaces and the social connections that underpin academic success and well-being.[3] This forced transition to a homebound, isolated learning environment proved fertile ground for psychiatric morbidity.[4]

Adding fuel to the fire was the already prevalent stigma surrounding mental health in Indian society.[5] Public awareness remains low, with misconceptions and a culture of shame often preventing individuals from seeking help. This creates a crucial barrier to accessing the very services that could alleviate their suffering. In the face of such challenges, ensuring proper planning and delivery of mental healthcare becomes even more critical.[6]

Beyond the immediate disruption to education, the pandemic’s socioeconomic fallout began to unfold. Financial anxieties, uncertainties about the future, and the fear of losing loved ones were constant companions. This cocktail of stressors manifested in a range of psychological issues. Students reported feeling overwhelmed with a sense of anxiety, boredom, and emptiness.[7] Panic attacks, fears of contracting COVID-19 or spreading it to others, and general health anxiety became commonplace. The future, once brimming with possibilities, now felt shrouded in uncertainty. In addition, the fear of dying alone, isolated from family and friends, added a layer of existential dread to the mix. Sleepless nights filled with nightmares became a regular occurrence.[8]

For some, the prolonged stress and a sense of powerlessness translated into more severe mental health conditions such as depression and other psychiatric disorders. These students found themselves grappling with a seemingly insurmountable struggle. The very factors known to increase suicide risk isolation, hopelessness, and a sense of worthlessness were amplified by the pandemic, raising serious concerns about a potential rise in self-harm.[9]

This study aimed to assess depression, anxiety, suicidal ideation, and associated factors among a sample of college students during the COVID-19 outbreak.

MATERIALS AND METHODS

It was an observational cross-sectional study conducted by the Psychiatry Department of a medical college in Western Maharashtra, India. The study was started after getting permission from the institutional ethical committee (DYPV/EC/840/22 dated 26 April 2020). The study was conducted during June 01, 2020, and December 31, 2021. Data were collected by snowball technique.

Sample size calculation: Using the following formula sample size was calculated:

Where- n = sample size; z = confidence level at 95% (standard value of 1.96); P = expected prevalence (25%); d = margin of error at 5% (standard value of 0.05).

According to the prevalence, by using the above formula calculated sample size was 288.

Sample collection

An online survey of college students was conducted after obtaining approval of the Institutional Ethics Committee. A Google Form containing the study questionnaire was distributed by means of email and social media to college students in India. The questionnaire covers participants’ basic demographic data such as their age, sex, religion, and background, as well as general questions about their financial status, family members, type of family, history of health problems, and psychiatric illness, if present. Questionnaire did not contain any identifying data of the participants to ensure confidentiality. Questions regarding participant’s concerns about COVID-19 pandemic including confidence in pandemic control, risk perception of susceptibility to infection, perceived support, and sources of information in the context of the COVID-19 pandemic were also asked.

The survey also includes an assessment of mental health concerns such as depression, anxiety, and suicidal ideation. Depressive and anxiety symptoms were assessed using the Hospital Anxiety and Depression Scale (HADS).[10] The HADS is a fourteen-item scale. Seven of the items relate to anxiety and seven relate to depression. Each item on the questionnaire is scored from 0-3 and it means that a person can score between 0 and 21 for either anxiety or depression. A score of 0-7 indicates that an individual is normal. A score of 8-10 indicates an individual is a case of borderline abnormality and a score between 11 and 21 the individual is depressed. For suicide ideation, suicide risk assessment tool of 14-item Positive and Negative Suicide Ideation Scale (PANSI) was used.[11] It also comprises 14 items. 6 items of 14 (2, 6, 8, 12, 13, and 14) constitute a positive scale and 8 items (1,3,4,5,7,9,10, and 11) a negative scale. Sensitivity of the scale is 0.8 whereas the specificity is 0.9.

Statistical analyses

Analysis of descriptive data was on the parameters of mean ± standard deviation (SD), range, and frequencies. Continuous variables were analyzed using t-test, and ordinal data were analyzed using the Mann–Whitney U-test. Categorical data were analyzed by the Chi-square test or Fisher’s exact test as applicable. Multiple regression analysis was performed for predictors of suicidal ideation. The statistical software Statistical Package for the Social Sciences (SPSS) version 23.0 was used.

RESULTS

Total of 324 college students responded to the survey; of which 124 were male and 199 were female. Mean age of the study population was 21.88 ± 1.96 years (range: minimum 18 to maximum 28 years). 164 females and 84 males lived in a nuclear family. The difference was statistically significant (P = 0.002). 181 females belonged to urban areas as against 90 males. The difference was statistically significant (P = 0.00). 177 females missed their family members as against 90 male participants. The difference was statistically significant (P = 0.00). 118 female students had a family member with COVID-19 infection. The difference was statistically significant (P = 0.013) [Table 1].

Table 1.

Demographic characteristics of the college students

Characteristics	Total (n=323)	Male (n=124)	Female (n=199)	Chi-square	P
Type of family
Nuclear	248	84	164	9.22	0.002
Joint	75	40	35
Residence
Urban	271	90	181	19.09	0.000
Rural	52	34	18
Worrying about friends and family
Yes	267	90	177	14.27	0.000
No	56	34	22
Family members Had COVID-19
Yes	174	56	118	6.14	0.013
No	149	68	81
Afraid of being infected
Yes	212	74	138	3.167	0.075
No	111	50	61
Psychiatric pt. In family
Yes	43	18	25	0.25	0.613
No	280	106	174
Consulted a psychiatrist
Yes	42	18	24	0.40	0.523
No	281	106	175
Attempted suicide
Yes	28	14	14	1.74	0.186
No	295	110	185

The mean HADS score for anxiety was 10.01 ± 0.24, and for depression, it was 7.22 ± 0.22. The mean HADS score for anxiety in male students was 9.17 ± 4.46, whereas in female students, it was 10.54 ± 4.18. The difference was statistically significant (P = 0.005). There was no difference in the HADS depression score and PANSI score when compared genderwise [Table 2].

Table 2.

Scores obtained by the students on the hospital anxiety and depression scale and the positive and negative suicidal ideation scale

Scales	Total n=323			Male n=124			Female n=199			Mann- Whitney U	P
	Mean (SD)	Median	Min- Max	Mean (SD)	Median	Min- Max	Mean (SD)	Median	Min- Max
HADS anxiety score	10.01 (0.24)	10.00	2-20	9.17 (4.46)	8.50	2-18	10.54 (4.18)	10.00	2-20	10030.00	0.005
HADS depression score	7.22 (0.22)	7.00	0-21	7.24 (4.00)	7.00	1-21	7.21 (4.10)	7.00	0-20	12081.00	0.752
PANSI positive	20.79 (0.26)	21.00	9-30	21.03 (4.63)	22.50	11-29	20.65 (4.95)	20.00	9-30	11707.00	0.439
PANSI negative	13.49 (0.41)	10.00	8-40	13.87 (7.94)	10.00	8-40	13.26 (7.12)	10.00	8-38	11793.00	0.494

As shown in Table 3, 23.52% of the study participants suffered from depression. 17.08% of females and 33.87% of males had depression. The difference was statistically significant (P = 0.001). 34.98% of college students had anxiety. 47.73% of females had anxiety, whereas 14.51% of males had anxiety. The difference was statistically significant (P = <0.00001).

Table 3.

Distribution of sample population on the basis of HADS depression and HADS anxiety scores

Rating scales	Interpretation	Total (n=323)	Female (n=199)	Male (n=124)	Chi-square (P)
Total HADS depression score	Abnormal	76 (23.52)	34 (17.08%)	42 (33.87)	13.01 (0.001)
	Borderline	91 (28.17)	57 (28.64%)	34 (27.41)
	Normal	156 (48.29%)	108 (54.27%)	48 (38.70)
Total HADS anxiety score	Abnormal	113 (34.98%)	95 (47.73%)	18 (14.51)	43.69 (<0.00001)
	Borderline	85 (26.31%)	51 (25.62%)	34 (27.41)
	Normal	125 (38.69%)	53 (26.63%)	72 (58.06)

Correlational analysis of psychological variables with COVID-19–related variables is shown in Table 4. HADS anxiety score was positively correlated with worrying about family members, COVID-19 in family members, fear of contracting COVID-19, psychiatric illness in family, and history of attempted suicide. HADS depression score was positively correlated with worrying about family members, COVID-19 in family members, history of consultation with psychiatrist, and history of attempted suicide.

Table 4.

Correlation of HADS anxiety, HADS depression, PANSI scores with other variables

	Age	Sex	Family type	Residence	Number of family members	Worrying about family member	Covid In family member	Fear of covid infection	Psychiatry illness in family	Consulted psychiatrist	Attempted suicide	HADS anxiety	HADS depression	PANSI positive
Sex
CC	0.162**
Sig.	0.003	.
Family Type
CC	0.004	0.169**
Sig.	0.947	0.002	.
Residence
CC	-0.163**	-0.243**	-0.198**
Sig.	0.003	0.000	0.000	.
Number of family members
CC	0.068	0.075	0.618**	-0.206**
Sig.	0.223	0.177	0.000	0.000	.
Worrying about family members
CC	-0.120*	-0.210**	-0.039	0.044	0.029
Sig.	0.031	0.000	0.489	0.429	0.608	.
COVID-19 in Family members
CC	-0.108	-0.138*	0.097	0.034	0.128*	0.134*
Sig.	0.052	0.013	0.082	0.543	0.021	0.016	.
Fear of COVID-19 infection
CC	0.090	-0.099	-0.019	0.038	0.116*	0.151**	0.050
Sig.	0.106	0.076	0.735	0.499	0.036	0.007	0.374	.
Psych Ptinfly
CC	-0.055	0.028	-0.043	0.023	-0.145**	0.011	0.107	-0.023
Sig.	0.327	0.617	0.443	0.682	0.009	0.844	0.055	0.674	.
Consulted psychiatrist
CC	-0.079	0.036	-0.016	0.119*	0.061	0.055	0.099	0.028	0.255**
Sig.	0.159	0.525	0.769	0.032	0.274	0.320	0.075	0.619	0.000	.
Attempted suicide
CC	0.002	0.074	-0.013	0.075	-0.071	0.025	-0.068	-0.055	0.203**	0.208**
Sig.	0.966	0.187	0.815	0.178	0.204	0.657	0.223	0.324	0.000	0.000	.
HADS anxiety
CC	-0.181**	-0.158**	-0.032	0.115*	-0.030	0.226**	0.141*	0.147**	0.130*	0.104	0.278**
Sig.	0.001	0.004	0.565	0.038	0.591	0.000	0.011	0.008	0.020	0.062	0.000	.
HADS depression
CC	-0.160**	-0.018	-0.099	0.115*	-0.129*	0.148**	0.138*	0.090	0.107	0.165**	0.295**	0.694**
Sig.	0.004	0.752	0.075	0.038	0.021	0.008	0.013	0.105	0.054	0.003	0.000	0.000	.
PANSI positive
CC	0.106	0.043	0.140*	-0.149**	0.146**	-0.018	-0.071	-0.030	0.066	0.051	-0.053	-0.045	-0.045
Sig.	0.056	0.439	0.012	0.007	0.009	0.741	0.204	0.590	0.236	0.359	0.345	0.422	0.422	.
PANSI negative
CC	-0.004	0.038	-0.078	0.050	-0.023	-0.047	0.037	0.018	0.050	0.009	0.073	-0.013	0.031	-0.473**
Sig.	0.936	0.495	0.163	0.367	0.675	0.404	0.504	0.746	0.367	0.875	0.192	0.817	0.580	0.000

**Correlation is significant at the 0.01 level (2-tailed). *Correlation is significant at the 0.05 level (2-tailed). CC - Correlation Coefficient, Sig-Sig. (2-tailed)

A multiple regression was run to predict positive suicidal ideation from PANSI negative, residence, psychiatry patient in family, and number of family members. These variables statistically significantly predicted positive suicidal ideation, [F (4, 318) = 31.171, P <.0001, R2 = 0.282, Durbin Watson = 1.844]. All four variables added statistically significantly to the prediction, P <.05 [Table 5].

Table 5.

Multiple linear regression analysis for the predictors of positive suicidal ideation:Coefficients^a

Model	Unstandardized coefficients		Standardized coefficients	t	Sig.	95.0% Confidence interval for B		Collinearity statistics
	B	Std. Error	Beta			Lower bound	Upper bound	Tolerance	Variance inflation factor
4
(Constant)	25.056	0.919		27.265	0.000	23.247	26.864
PANSI negative	-0.319	0.031	-0.492	-10.246	0.000	-0.381	-0.258	0.978	1.023
Residence	-1.543	0.632	-0.118	-2.440	0.015	-2.787	-0.299	0.971	1.030
Psychiatry patient in family	1.881	0.685	0.133	2.747	0.006	0.534	3.228	0.969	1.032
Number of family members	0.205	0.087	0.115	2.353	0.019	0.034	0.377	0.952	1.051

^aDependent variable: PANSI positive

DISCUSSION

The COVID-19 pandemic has brought unprecedented challenges to college students worldwide, profoundly impacting their mental health. As campuses transitioned to remote learning, implemented social distancing measures, and faced uncertainty about the future, students experienced heightened levels of anxiety. We conducted a cross-sectional study of 324 college students to study anxiety, depression, and suicidal ideation among them. The majority (61.4%) of the participants were female belonging to a nuclear family and hailing from urban areas. Significantly higher number of females missed their family members and had COVID-19 infection in family members.

In this study highlighted the significant proportion of psychological problems among college students. 34.9% of students were suffering from anxiety. Numerous studies conducted during the pandemic have highlighted a significant increase in anxiety levels among college students corroborating with our findings. In a meta-analysis of 69 studies (n = 1,094,240) by Deng et al.,[12] the pooled prevalence of anxiety symptoms was 32% (95% CI 26-38%). Many academic and nonacademic factors were shown to be associated with this increased level of anxiety. Research by Son et al.[13] found that college students reported elevated levels of anxiety because of concerns about academic disruptions, financial insecurity, social isolation, and fears of contracting the virus. COVID-19 pandemic-related stressors have added to the anxiety levels of students. Yang et al.[14] concluded that fear of contracting the virus, worries about the health and safety of oneself and loved ones, and the constant barrage of pandemic-related news have contributed to heightened health-related anxiety among college students. Concerns about access to healthcare, the availability of vaccines, and the potential long-term effects of the virus have added to the overall sense of unease and anxiety.

The anxiety levels were higher in females as compared to male students as well as more female students were found to be suffering from anxiety as compared to their male counterparts. Previous researchers have shown this vulnerability of female students to anxiety.[15,16] Females have been shown to perceive the corona virus as a greater threat to health and hence have greater COVID-19–related fear and anxiety.[17,18]

Depressive symptoms were shown to be present in 23.52% of the students which was comparable with previous research.[16] The prevalence of depressive symptoms was more in male students as compared to females. The results could be because of various potential moderators and causative factors which affect specifically particular gender more as compared to othergenders.

We also found some correlates associated with anxiety and depression in students. Anxiety in students was associated with worrying about family members, COVID-19 in family members, fear of contracting COVID-19, psychiatric illness in family, and history of attempted suicide while depression was associated with worrying about family members, COVID-19 in family members, history of consultation with psychiatrist and history of attempted suicide. It is obvious that presence of psychiatric issues in the family and self would make these students vulnerable for psychological problems. Along with this COVID-19-related fears and health concerns would add on these problems.[14]

During the COVID-19 pandemic, there has been a heightened concern about the mental health of college students, including the prevalence of suicidal ideation. Several studies have investigated this issue, highlighting various factors contributing to suicidal ideation among college students during the pandemic. Research by Kecojevic et al.[19] examined suicidal ideation among college students in the United States during the COVID-19 pandemic. The study found that students who reported higher levels of psychological distress, loneliness, and financial stress were more likely to experience suicidal ideation. The disruption to academic and social routines, as well as concerns about the future, also contributed to increased suicidal ideation among college students. In a systematic review by Farooq et al,[20] it was noted that the -COVID-19-related factors such as loneliness, and physical distancing measures appeared to be important contributory factors to suicidal ideation but evidence was not consistent across studies. In our study, suicidal ideations in students were predicted by certain factors such as rural residence, number of family members, and presence of psychiatry patient in the family. After the COVID-19 pandemic, the education system was moved to online platform and most of the students were studying from their homeplace. Students residing in rural places might have faced practical difficulties in technological issues, while students residing with a greater number of family members might have faced space and privacy issues, adding to their psychological burden. Presence of psychiatry patient in the family particularly in the COVID-19 situation could have a great psychological impact in terms of caregiver burden as well as continuous disturbance in the family environment apart from producing genetic vulnerability.

Limitations

The data in this study were collected using Google Forms. This can produce bias in findings as particular students might be more interested in filling up forms as compared to other students. Another limitation was being a cross-sectional study making interpretation of cause-effect relationship difficult.

CONCLUSION

A student’s life is full of stress, particularly at the undergraduate level because of various personal, interpersonal, and study-related stressors. the COVID-19 pandemic made this more complicated and the same thing has been highlighted in our study. Anxiety and depression were significantly high among the college students. Female students were vulnerable for anxiety, whereas male students were more prone to depression. Various COVID-19–related as well as personal psychiatric correlates were found. Predictors for suicidal ideation could be identified. The study may be valuable for institutions to find out at-risk students and plan active measures to improve their mental health, especially in the period of community health crisis.

Data availability

Data will be made available on reasonable request.

Authors contribution

Concept, design, definition of intellectual content, literature search, data acquisition: PK, TA, DS, JP Data acquisition: TS, SS, PK, JP Data analysis: SC Manuscript preparation: PK, TA, SS Manuscript editing and manuscript review. SC, DS, JP Guarantor: DS.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.