Mental Health Impacts for International Students During the COVID-19 Pandemic in China

The outbreak of Coronavirus disease 2019 (COVID-19), has led to the quarantine of many residents in their homes worldwide. Some of these people might develop mental health problems, and many solutions have been put in place to address the mental health issues of patients and health professionals affected by the disease. However, not much attention has been given to international students studying in China. The present study aims to conduct an online survey to investigate the mental health status of international students from Changsha city, China. Materials and Methods: A WeChat-based survey program comprised of questions on demographic information gender, grade year, duration and status of quarantine, duration of sleep, worries about graduation, being able to go to school and presence or absence of a sense of security; as well as questions from the Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7) scale and State-Trait Anxiety Inventory(STAI). Results: The prevalence of depression was 59.4% and the prevalence of anxiety was 37.8%. The STAI-Y1 STATE scores had a mean value (mean) of 41.42, standard deviation (S.D) of 10.89 and STAI-Y2 TRAIT scores had a mean value (mean) of 41.85, standard deviation (S.D) of 11.13. The risk factors of anxiety or depression were Sleep duration, worrying about graduation in varying degrees, School time, and feeling secure in varying degrees. Higher the Patient Health Questionnaire-9 score and higher Generalized Anxiety Disorder-7 score and higher STAI-Y1 STATE scores were associated with higher STAI-Y2 TRAIT scores. Conclusion: The present study implies that the university needs to consider planning for acute and long-term psychological help services for international students.


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The main aim of this study was to observe the effects of quarantine policy on the psychological health of international students.So that they can be screened, diagnosed, and treated effectively for the same.These students are the future of the health workforce who will contribute to the development of a healthy population in a country.Therefore, it was important to analyze whether mental health issues were affecting foreign international students during the COVID-19 outbreak.It was also imperative to study any discrepancies in these issues based on the parameters of gender, grade year, duration and status of quarantine, duration of sleep, worries about graduation, being able to go to school, and the presence or absence of a sense of security.

Study procedure
The target population comprised of international students from Central South University including undergraduates, Master's degree/postgraduate students, and Ph.D./doctoral students.The questionnaire was comprised of questions on demographic information, gender, grade year, duration and status of quarantine, duration of sleep, worries about graduation, being able to go to school, and the presence or absence of a sense of security.
The data was collected from students who have been unable to go to school since the COVID-19 outbreak, from January 25, 2020, to June 26, 2020.The survey was completed on the Chinese Star Survey website between 19th to 26th June, with the relevant smartphone link sent to the Xiangya WeChat international students group.These students were informed about the motive of the survey i.e to comprehend the effects of the COVID-19 epidemic on the mental health of international students.Depression Depression was assessed using the 9-item Patient Health Questionnaire-9 (PHQ-9), which is sensitive and speci c, su cient to screen adolescents with suspected depression.[10] Furthermore, the PHQ-9 is the most regularly used device designed for screening depression in primary care [11][12], [13], and is a 9item depression module from the full PHQ.The participants were requested to respond to the questions to consider the frequency of the speci c symptoms that they felt during the quarantine period.The solutions were scored as follows: zero(0) point for not at all, one(1) point for several days, two(2) points for more than half of the days, and three(3) points for nearly every day.The score was scaled from 0-27 (0-4: without depressive symptoms, 5-9: with mild depression symptoms, 10-14: with moderate depression symptoms, 15-19: with moderate to severe depression symptoms, and 20-27: with severe depression symptoms) [11].This scale has additionally been broadly used with Chinese populations and has validated brilliant psychometric properties [14].

Anxiety
Anxiety was assessed by the usage of the 7-item Generalized Anxiety Disorder-7 (GAD-7) scale, which has been used to consider the mental health status of people after the MERS outbreak [15].The GAD-7 scale contains seven noticeably applicable questions chosen from 13 items (nine questions from the Diagnostic and Statistical Manual of Mental Disorder, 4th Edition, and four questions from the Anxiety Symptom Scale).For every item, the participants were asked about their frequency of experiencing each one of the emotions at some stage during their quarantine period for COVID-19.The answers were scored as follows: zero (0) point for not at all, one (1) point for several days, two(2) points for more than half of the days, and three(3) points for nearly every day.The score was scaled from 0-21 (0-4: without anxiety symptoms, 5-9: with mild anxiety symptoms, 10-14: with moderate anxiety symptoms, and 15-21: with severe anxiety symptoms) [15].
To gure out if STAI-Y2 TRAIT scores can be a predictive factor of depression or anxiety, all participants have been assessed with the State-Trait Anxiety Inventory (STAI).The STAI-Y consists of 40 self-report items, for both state and trait components.STAI-Y items are rated on a 4-point Likert scale.(STAI-Y1STATE) report the extent of their anxiety at particular moments, while (STAI-Y2TRAIT) indicate the intensity of their anxiety in general: both scores were computed in this study.Scores of each state-and trait-anxiety range from 20 to 80, a higher score indicating greater anxiety.[16] Quarantine Students who lived in the dormitory have been in quarantine since January 25 which is still ongoing as of July 7 until further notice.Hence, they have been in quarantine for about 6 months now.Quarantine period was determined by the question: "How much time on average have you spent in quarantine from the outside since the COVID-19 outbreak and are you still in quarantine now?"According to the duration, participants were categorized into 5 groups: None, 1 month, 2 months, 3 months, 4 months, 5 months, and 6 months.According to the current situation, participants were categorized into two groups: still in quarantine and not in quarantine.

Sleep duration
Sleep length was determined by the question: "How much sleep you had on average every night over the past four weeks?"The participants were categorized into six groups based on their reported average sleep duration: <6 hours/night, ≥ 6 to < 7 hours/night, ≥ 7 to < 8 hours/night, ≥ 8 to < 9 hours/night, ≥ 9 to < 10 and ≥ 10 hours/night [17] with < 6 hours/night being seen as short sleep duration.[18] Degree of worrying about graduation The degree of worrying about graduation was determined from the question: "how much do you worry about graduation?" Participants were categorized into 4 groups: Not at all, a little, somewhat, and very much.

School Time
To be able to go to school was determined by the question: "Can you go back to school/hospital to study now?"If you can, how long?Participants were categorized into 2 groups: Not at all, sometimes.

Sense of security
The presence or absence of a sense of security was determined by the question: "do u feel secure?"Participants were categorized into 4 groups: Not at all, a little, somewhat, and very.

Ethical approval and consent
The participants were informed that the motive of the survey was to comprehend the psychological effects of the COVID-19 epidemic on students and was conducted via an online WeChat noti cation before the investigation.Students who were willing to participate in the survey lled out the questionnaires.Online informed written consent was obtained from all participants at the beginning of the questionnaire.The present study was approved by the Medical Ethics Committee of Second Xiangya Hospital of Central South University (2020) of the National Examination Bureau Number (001)

Statistical Analysis
All statistical analyses were performed using the IBM SPSS Statistical Software (version 22).Counting data was presented in counts (the percentage of the total).The chi-square test was used to determine whether there were signi cant differences between the number of asymptomatic and symptomatic students, in terms of different genders, grade year, duration and status of quarantine, duration of sleep, worries about graduation, being able to go to school and presence or absence of a sense of security.The Kruskal-Wallis test was used to determine whether there were signi cant differences among the number of symptomatic (in varying degrees) students, in terms of different gender, grade year, duration and status of quarantine, duration of sleep, worries about graduation, being able to go to school and presence or absence of a sense of security.One-way ANOVA and t-test calculations were used to assess the differences in the State-Trait Anxiety between the subgroups which were strati ed by different gender, grade year, duration and status of quarantine, duration of sleep, worries about graduation, being able to go to school and presence or absence of a sense of security.A P-value of < 0.05 was considered statistically signi cant.

Results
285 students received the questionnaire and the response rate was 53.7%.A total of 153 students enrolled in the survey, which consisted of 143 students who were not diagnosed with any mental disorders previously and 10 students who were previously diagnosed with one or the other kind of mental disorders.The present survey excluded the students who have previously suffered from mental disorders.Detailed information is presented in Table 1.A large proportion of respondents was found in the Master student group (63.6%)Male students group (67.8%) and quarantine group (59.4%).Based on the results of the questionnaire, it was found that the prevalence of depression (de ned as a total score of ≥ 5 in the PHQ-9) was 59.4% and the prevalence of anxiety (de ned as a total score of ≥ 5 in the GAD-7) was 37.8%.The majority of students who were in a depressed or anxious state were mild or moderate, 13.3% were in moderate to severe and severely depressed state and 9.1% were in a severe anxiety state.

Comparisons of neuropsychological features
As shown in Fig. 1 and Table 2

Figures Figure 1
Figures

Table 1
Demographic characteristics of the participants in the survey.

Table 4 ,
and Table3, regarding the worrying about graduation in varying degrees, the PHQ-9 results revealed that there were 17(38.6%) of the 44 students who did not worry about graduation at all, 23(60.5%) of the 38 students who worried about graduation a little, 14(66.7%) of the 21 students who worried about graduation somewhat, 31(77.5%) of the 40 students who worried about graduation very much were in a state of depression.Besides, the GAD-7 results revealed that 7(15.9%) of the 44 students who did not worry about graduation at all, 19 50.0% of the 38 students who worried about graduation a little, 9 42.9% of the 21 students who worried about graduation somewhat,19 47.5% of the 40 students who worried about graduation very much were in a state of anxiety.About feeling secure in varying degrees, the PHQ-9 results revealed that there were 11(64.7%) of the 17 students who did not feel secure at all, 26(81.3%) of the 32 students who felt a little secure, 27(64.3%) of the 42 students who felt somewhat secure, 21(40.4%) of the 52 students who felt very much secure were in a state of depression.Also, the GAD-7 results revealed that 7(41.2%) of the 17 students who did not feel secure at all, 22(68.8%) of the 32 students who felt a little secure, 17(40.5%) of the 42 students who felt somewhat secure, 8(15.4%) of the 52 students who felt very much the scores of the State-Trait Anxiety Inventory scale were both signi cantly enhanced as compared to the students who sleep more than 6 hours/night group (p = 0.008 and 0.007).Similarly, the scores of the State-Trait Anxiety Inventory scale were both increased when compared with the students who worried less about the graduation group and the students who fell more secure group (p < 0.001 and P < 0.001, p < 0.001 and P < 0.001, secure were in a state of anxiety.Several factors contributed to the prevalence of depression including Sleep duration (p = 0.007), worrying about graduation in varying degrees (p = 0.003) and feeling secure in varying degrees (p = 0.002).Several factors contributed to the severity of depression including Sleep duration (p = 0.016), worrying about graduation in varying degrees (p < 0.001), School time (p = 0.039), and feeling secure in varying degrees (< 0.001).Several factors contributed to the prevalence of anxiety including worrying about graduation in varying degrees (p = 0.004) and feeling secure in varying degrees (p < 0.001).Several factors contributed to the severity of anxiety including Sleep duration (p = 0.011), worrying about graduation in varying degrees (p = 0.001), and feeling secure in varying degrees (p < 0.001).

Table 5 ,
Higher the Patient Health Questionnaire-9 score and higher Generalized Anxiety Disorder-7 score and higher STAI-Y1 STATE scores were associated with higher STAI-Y2 TRAIT scores, all p values were smaller than 0.001.