1. Introduction
A scientific briefing released by World Health Organization (1) highlights the massive increase in the global prevalence of anxiety and depression during COVID-19 on the world’s mental health. Many professionals expected a “tsunami of psychiatric illnesses because of the COVID-19 pandemic (2) with a long-lasting impact (3). Rogers et al. (4) reported increased neurocognitive and psychiatric impairments involving significant anxiety levels, depression, and post-traumatic stress disorder. The information collected till now serves as the tip of an iceberg. There has been a significant rise in concern for the psychological distress caused by the pandemic across the globe. Experts have argued for timely action on mental health (5), (6) issuing guidelines in the public interest. A similar pattern of distress levels was observed during SARS where individuals reported increased stress levels with anxiety and depression (7, 8). A rapid assessment conducted by UNICEF (9) in nine countries found that 27% of the participants reported anxiety and at least 15% with depression. During the pandemic, people develop insecurity and are always in the fear of contracting the virus, which results in anxiety, stress, and depression (10).
Existing evidence indicates that women and young adults are disproportionately at risk of developing mental disorders. The worst affected stratum of the global population is the 15–24-year-old young adults (11–13). Before the pandemic, studies had confirmed that young adults are at high risk of developing poor mental health and substance abuse (14, 15). During the pandemic, various reasons such as the closure of universities, unemployment, and lack of social life contributed toward deteriorating mental health. A large portion of the young adult population (56%) exhibited severe symptoms of anxiety and depression with stress. It was found that when compared to adults, young adults were at high risk of poor mental health and substance disorders (16).
India reported one of the highest COVID-19 infection rates with 2.5 million confirmed cases in the whole world (17). Since, the first case was registered on January 30, 2020, the cases saw an upsurge with the government imposing a nationwide lockdown. During the lockdown, there were restrictions, which led to the closure of public spaces like gyms, parks etc., and institutions such as colleges and schools etc. The sudden imposition of restrictions affected people in different ways. A study reported that students and healthcare professionals were severely affected by the pandemic and experienced significant anxiety and depression over others (18). A systematic review by (19) reported that among five studies at least 41.90% of participants reported depression and 42.87% with significant anxiety.
This study was conducted to understand how young adults are dealing with the sudden changes introduced due to the pandemic. We wanted to explore how COVID and its restrictions brought changes in the affective and behavioral states of the students. In this paper, we discuss how the ongoing pandemic has affected the psychological distress and the extent of vulnerability.
2. Method
In this section, we make a brief mention of the situation in India in accordance with the chronology of events in India during the COVID-19 pandemic. The first recorded infection of India with the novel coronavirus was found in Thrissur, Kerala on 27th January, 2020. The first nationwide lockdown was imposed on 25th March, 2020 followed by strict restrictions. The cases saw a constant rise and reached 90,000 cases per day mid-September marking the peak of first wave. Towards the end of the year India lifts several restrictions. In March 2021, sudden spiralling cases had devastating implication on the country as it has to battle with the rising number of daily cases, mortality rate, supply shortage of vaccines, oxygen and unavailability of hospital beds. The first wave was thought of as a successful mitigation of crisis but the second wave shook Indian healthcare system. The onset of second wave was delayed but the cases rose exponentially which again led to imposition of strict lockdown nationwide. During the second wave, India witnessed the highest surge of 4.14 lakh cases per day. The second wave recorded highest mortality taking the numbers to 2.5 lakhs (20).
2.1. Study design and participants
The study was conducted in India during the second and the third wave, i.e., from July 2021. We continued the collection of data until the end of January 2022.
The online form was developed on Google forms. It was officially launched on 15th June 2021 until the end of January 2022. The form was administered to a large sample (N = 1,211) of Indian undergraduates who are pursuing bachelor’s degree from prestigious Indian universities and technical Institutes. Multiple steps were followed for the distribution of forms: (A) email invites were sent out to students with institute ids, (B) snowball sampling was used through social media platforms such as LinkedIn to recruit students from universities without official mail ids, and (C) mailing lists of universities. The whole questionnaire took 10 minutes to complete. Ethical approval for the current study was taken from the Local Ethics committee of the Indian Institute of Technology, Roorkee. The study followed the declaration of Helsinki (21) safeguarding the ethical treatment involving Human subjects. Data were recorded after obtaining informed consent from the participants.
A total of 1,249 responses were recorded. Responses were eliminated if the answers were incomplete or left unattended. Hence, 1,038 responses were retained and included in the final analysis. The median age of all participants were 19 years belonging to age range of (18–23 years), where 55.4% of the participants were female (N = 576) and 44.4% were male (N = 461).
2.2. Sociodemographic variables and assessment tools
Sociodemographic variables included in the study were age, gender, and information on the course and present year of enrolment. The variables related to risks due to COVID-19 were assessed by the administration of three questions asking (A) COVID-19 positivity of any close relative or family member, (B) Virtual Interaction with friends, and (C) following an active lifestyle. All three variables were assessed by using a “YES or NO” response. All the above variables were used individually as there are no know scales for them.
For this study we used the Generalized Anxiety Disorder Questionnaire; Edition 7 (22), a seven-item scale that assesses the clinical markers of GAD. The items are rated on a four-point Likert scale with the score ranging from zero to twenty-one. The reliability of GAD-7 is 0.89 (Cronbach’s Alpha). Intercorrelation with Rosenberg Self-Esteem Scale and PHQ-2 were r = −0.43 and r = 0.64, respectively (23). The Centre for Epidemiological Studies-Depression (CES-D) by (24), a twenty-item scale asking the respondents to rate questions on the defining symptoms of depression. The Cronbach’s alpha coefficient was 0.865.
In this study, we examine using two-way analysis of variance (ANOVA) to determine the statistical difference in anxiety levels and depression based on academic year and the field of study. We also predict the levels of anxiety and depression using regression analysis to examine the variables related to COVID risk.
3. Result
3.1. Gender difference
In order to examine the symptoms of Anxiety and Depression among the undergraduate student population in India, we studied a total of 1,037 participants, where clinical symptoms of Anxiety and Depression were observed in 18.2% (n = 189) and 25.3% (n = 263), respectively.
The descriptive data for anxiety have been shared in Table 1. The results indicated a significant main effect for gender F(1, 1029) = 14.24, p = < 0.001, partial η2 = 0.14; a significant main effect was found for college years F(3, 1029) = 36.81, p = < 0.001, partial η2 = 0.97 and no significant difference was found in the interaction effect of gender and college years F(3, 1029) = 2.716, p = 0.044, partial η2 = 0.08.
Table 1. Descriptive statistics for gender and college year for anxiety.
In Depression, (refer to Table 2 for descriptive details) the results indicated a significant main effect for college year F(3,1029) = 4.6, p = 0.003, partial η2 = 0.13; a significant interaction effect of gender and college year was observed F(3, 1029) = 5.7, p = < 0.001, partial η2 = 0.016; and no significant main effect was found for gender F(1, 1029) = 3.86, p = < 0.05, partial η2 = 0.004.
Table 2. Descriptive statistics for gender and college year for depression.
3.2. Course difference
A two-way ANOVA was performed to evaluate the effects of Course (STEM and Non-STEM) and College year (Freshmen, Sophomore, Junior and Senior) on Anxiety. The Means and Standard Deviations for Courses and College years are presented in Table 3.
Table 3. Descriptive statistics for anxiety in academic year.
The results indicated a significant main effect for Course, F(1, 1030) = 16.87, p = (< 0.001), partial ?2 = 0.016; a significant main effect for college year, F(3, 1030) = 45.67, p = (0.001), partial η2 = 0.117; and a significant interaction effect between course and college years, F(2, 1030) = 10.93, p = (< 0.001), partial η2 = 0.021. Post hoc testing using Tukey’s HSD indicated that the anxiety scores of senior year students were significantly different from those of freshmen (p = < 0.001) and sophomore (p = < 0.001) but not for junior year students (p = 0.346) across the courses.
For depression, two-way ANOVA was used to examine the effects of Course (STEM and Non-STEM) and College year (Freshman, Sophomore, Junior and Senior). The Means and Standard Deviations for Courses and College years are below (Table 4).
Table 4. Descriptive statistics for depression academic year.
The results indicated a significant main effect for Course, F(1, 1030) = 16.7, p = (< 0.001), partial ?2 = 0.016; a significant main effect for college year, F(3, 1030) = 6.95, p = (0.001), partial η2 = 0.02; and a significant interaction effect between course and college years, F(2, 1030) = 0.647, p = (< 0.001), partial η2 = 0.001. Post hoc testing using Tukey’s HSD indicated that the depression scores of senior year students were significantly different from those of freshmen (p = 0.042) whereas no significant difference was observed for sophomore (p = 0.261) and junior year students (p = 0.813) across the courses.
3.3. Multiple regression analysis for COVID peaks
In order to test the independent contribution of (a) COVID-19 positivity of close friends or relatives, (b) Virtual Interaction with friends, and (c) Active lifestyle to clinical symptoms in the first and second COVID waves (see Table 5).
Table 5. Multiple regression models for three variables studied during COVID.
3.3.1. Anxiety
The overall model was significant F(3, 1033) = 3.01, p < 0.005, explaining 48% of the variation. COVID Positivity of close friends or relatives significantly predicted anxiety (B = −0.229, t = −2.87, p < 0.005). Thus, Virtual Interaction with friends and active lifestyle in the model, thus COVID Positivity of close friends or relatives was only significant predictor.
3.3.2. Depression
The overall model was significant F(3, 1033) = 59.1, p < 0.001, explaining 51% of the variation. Virtual interaction with friends (B = 1.73, t = −11.1, p = < 0.001) and active lifestyle (B = 1.64, t = −3.42, p = < 0.001) were significant predictors. Thus, Virtual interaction with friends was the strongest predictor, followed by Active lifestyle, whereas COVID positivity was not a significant predictor.
4. Discussions
The data collected from the undergraduate population of India show that the effects of COVID-19 and restrictions such as lockdowns imposed a profound threat with long-lasting aftereffects on psychological health. The findings of this study show a high risk of anxiety and depression among undergraduate students. In general, we observed that 70.5% students show symptoms of Anxiety, whereas students on the borderline or exhibiting clinical symptoms were 42.7%. For depression, we observed clinical symptoms in 25.5% of the students. These findings are supported by other findings where a study by (25) found that anxiety was prevalent in 50% of cases. In depression, a study in Karnataka (India) observed 14.2% of clinical depressive symptoms among undergraduates whereas (26) reported 22.8% for severe depression and 7.2% for clinical depression for students in Bangladesh. A meta-analysis, conducted by (27) reported an increase in prevalence post-COVID outbreak at 40.7% for anxiety and 35.9% for depression. However, we see studies reporting a wide range of variations in the rate of anxiety and depression found in undergraduate students (27).
Gender differences prevailed as we observed significant main effects of gender on anxiety levels, main effects of college year and also their interaction. However, in depression we found that the main effect of gender does not exist, rather a significant main effect of the academic year and the interaction between gender and academic year. These results are supported by studies with similar findings: a study conducted in India (Kashmir valley) found that anxiety was majorly associated with the female gender (28); with higher states of anxiety in females than males during COVID (29) and another study conducted in Chinese population found an increased prevalence of anxiety symptoms among females and depression for males (30). Other studies have reported an increased risk of females for anxiety and depression due to increased isolation and previously present symptoms. Various variables play roles in their relationship with the clinical symptoms found in gender. A study conducted by Tang and He (31) revealed that during the pandemic, the academic engagement of students suffered highly due to depression. Another study reported that COVID-19 protocols restricting normal day activities affected the mental health of men and women differently, suggesting a sudden increase in the vulnerability of men toward depression (32).
Our Data highlighted the main effect of course, academic year, and their interaction effect of on the risk of developing anxiety and depression. Many studies have stressed the role of course in affected mental health during COVID. A study on medical students reported that half of the sample reported symptoms of mental disorder and only 13.2% demonstrated normal values (33). In this paper, we emphasize the two courses Indian students are largely enrolled in, i.e., STEM and non-STEM courses. Considering that different students were in different academic years, differences in the range of mental health risks were observed. In both the STEM and non-STEM courses, we found that students enrolled in the senior, junior, and sophomore years had an elevated range of anxiety symptoms when compared to freshmen. For Depression, we see that the junior and senior year students are more at risk than students in the first and second year of their academic setting, putting them at higher risk. We see that students are at an all-time high risk of developing mental disorders due to various reasons, such as Genetic and Psychosocial Vulnerability (34), poor performance in exams, high workload, and coping strategies used (35), which is further intensified due to restrictions imposed during COVID-19 (36). COVID restrictions resulted in sudden changes in daily lifestyle that were dealt with major adaptations.. Junior and senior year students regardless of the course were at high risk due to never-ending restrictions. For the freshmen, we could say that the impossibility of not being able to attend university, and the sudden switch to online classes and meeting with friends and partners could be some projected reasons. Students in their final years might be apprehensive about their future, especially students whose job profiles suit on-site work and maintaining study and home boundaries while at home. A study in Italy (37) and Germany (36) reported that students were suffering from the inability to meet friends, being distant from colleagues and attending university.
We also found that increased anxiety is significantly predicted by close friends or family members testing COVID positive. A study found that families of people testing COVID positive exhibited symptoms of anxiety and depression after a 12-month follow-up (38). Two studies reported that the relatives of people diagnosed with COVID-19 had heightened anxiety symptoms and mental health issues over those not diagnosed with COVID (39) and pandemic-related worries with lesser depressive symptoms (40). Another study conducted on adolescents reported frequent usage of electronic communication with friends to ameliorate the stress of isolation and depression (41) especially face-to-face contact or phone/video contact (42). During the pandemic, it was found that people who engaged in active lifestyles maintained healthy mental health. Ai et al. (43) found that physical exercise during the pandemic enhanced happiness and decreased the symptoms of depression and other symptoms related to isolation or quarantine (44). A systematic review (45) of thirty-one studies suggested that people who followed an active routine of exercise during the first year of COVID alleviated the symptoms of negative mental health such as lowering symptoms of depression by increasing well-being with quality of life. It was further concluded that governments of respective states must advise their citizens to engage in exercise during stay-at-home orders.
We found significantly high depressive symptoms in individuals with less virtual contact with friends and a sedentary lifestyle. A study found alleviation of depressive symptoms among people who had online social support (46). Increased social media connectedness during COVID-19 had increased screen time among users which served as boon if used as a healthy digital habit (47)
Finally, we can say that the study demonstrated a relationship between gender (male and female), academic field, and academic course on mental health confirming previous studies where gender differences were observed for developing clinical symptoms of Anxiety. However, we also found that the field of study has an impact on mental health, especially interacting with the academic year. The increased levels of anxiety and depression in the senior and junior years should be a concern and immediate mitigation strategies should be imposed for better mental health of students.
4.1. Limitations and future directions
To our knowledge, this is the first study that identifies the risk of anxiety and depression in the undergraduate population of India emphasizing the vulnerability due to the year of the college course. The study was undertaken during the time India was dealing with extreme health emergencies related to COVID-19. The sample was representative of Indian undergraduates from Indian Technical Institutes or Central Universities. Limitations of the study are related to online snowball sampling and survey design preventing casual interpretations of data. Other limitations were that the study did not rely on the clinical diagnosis of the respondents but on the measures (GAD-7 and CES-D) that have been standardized and commonly used.
5. Results
In this study, we found elevated levels of anxiety and depression among seniors, junior, and sophomore when compared to freshmen, which depended on the gender and the field of study chosen.
6. Conclusion
This study found an increased risk of anxiety and depression among undergraduate students. Gender differences prevailed in the levels of anxiety and depression. In general, students enrolled in different fields of study and their academic year also affected their mental health. We also found that symptoms of anxiety increase in individuals whose families or friends are diagnosed with COVID-19 and severe depression can be managed if virtual contact with friends is maintained and an active lifestyle is followed.
Author contributions
TP and MA conceived and designed the study. SS conducted research and collected and organized data. TP and MA wrote the draft of the manuscript. All authors approved the final draft of the article.
Funding
The corresponding author MA is supported by the F.I.G. grant (IITR/SRIC/2741). The funding agency had no role in the preparation of the manuscript.
Acknowledgments
We appreciate and acknowledge the participants of the study for filling out the questionnaires and giving us their valuable time. We would also extend their gratitude to the Memory and Anxiety Research Group (MARG), Indian Institute of Technology Roorkee, for its constant support and involvement.
Abbreviations
COVID-19, Corona Virus Disease 2019; WHO, World Health Organization; UNICEF, United Nation’s Children Fund; STEM, Science, Technology, Engineering and Mathematics; Non-STEM, Not in Science, Technology, Engineering, and Mathematics.
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