Mental Health Problems and Related Factors in Chinese University Students During the COVID-19 Pandemic

Background: The coronavirus disease-2019 (COVID-19) pandemic is a serious threat to global public health, including a wide range of metal health problems. Current research focuses mainly on mental health status and related factors among Chinese university students during the COVID-19 pandemic. Methods: Data from 11133 participants was obtained through an online survey of university students in mainland China. Depressive and anxiety symptoms were assessed by the Patient Health Questionnaire-9 (PHQ-9), and the 7-item Generalized Anxiety Disorder Scale (GAD-7), respectively. Results: In total, 37.0% of the subjects were experiencing depressive symptoms, 24.9% anxiety symptoms, 20.9% comorbid depressive and anxiety symptoms, and 7.3% suicidal ideation. Multivariable logistic regression analysis revealed an increased presence of mental health problems in female students, graduate students, and those with personal COVID-19 exposure. Living with family and awareness of COVID-19 were protective factors against depressive and anxiety symptoms. In addition, male, depressive and anxiety symptoms were risk factors for suicidal ideation. Living with family, graduate students, prevention and control measures and projections of COVID-19 trends were protective factors against suicidal ideation. Conclusions: The �ndings underlined that the mental health of university students should be monitored, and provided important information for healthcare planning during the COVID-19 pandemic.


Background
Coronavirus disease-2019 (COVID- 19) is an acute respiratory infectious disease, similar to severe acute respiratory syndrome (SARS) [1], which was rst reported in Wuhan, the capital city of Hubei province, in December 2019.COVID-19 is characterized by rapid, widespread, and strong infectivity, and lack of speci c treatment [2], and was declared an international public health emergency by the World Health Organization (WHO) [3].This highly contagious infectious disease has caused public panic and mental health stress [4].Currently, since the outbreak of COVID-19, a substantial proportion of children, adolescents, and adults report psychological problems, such as depression, anxiety, suicidality, disrupt sleep and behavioral problems [5][6][7][8][9][10].Some experts especially highlighted the urgency and importance of evaluating and managing mental health problems during the COVID-19 pandemic [11][12][13].
University students undergo a critical transition as they become independent and responsible for their own health during university years [14], and experience higher psychological stress levels (e.g., exams, living away from family and nancial hardships ) than their peers in the general population [15,16].University years are a peak period for the rst onset of common mental disorders, while the majority of lifetime cases begin before 24 years of age [16].Many studies in recent years have indicated that the burdensome symptoms of depression and anxiety are highly prevalent among university students and have a signi cant impact on university students' functioning [17][18][19].In addition, suicidal ideation are also common among university students [20].University students' mental health problems have increased signi cantly during the outbreak of infectious diseases such as severe acute respiratory syndrome (SARS) or in uenza H1N1 [21,22].
During the outbreak of COVID-19, university students' education, including university studies and internship, was completed halted, which implies long hours at home and can lead to disordered rhythms of life and irregular sleep patterns.Moreover, the pandemic has brought the risk of infection and death.These may be traumatic experiences and have a psychological impact on this population.Metal health problems in university attracted attention in a recent study, which indicated that the prevalence of mild, moderate and severe anxiety was 21.3%, 2.7%, and 0.9% respectively [23].In this study, only anxiety symptoms were evaluated using the 7-item Generalized Anxiety Disorder Scale (GAD-7).Moreover, it was conducted in a medical university and sampled by cluster sampling, so it was postulated that the 7143 respondents were all medical university students.However, some previous ndings suggested that medical students were more likely to have mental health problems than non-medical students when facing large-scale pandemic outbreaks [24][25][26].Therefore, the type of mental disorders that are prevalent and how they are distributed among the population is unclear in university students during the COVID-19 pandemic.
Since Chinese university students have been exposed to a persistent source of distress during the public health emergency, it is imperative to evaluate and respond to their mental health issues.For this purpose, the prevalence and potential factors contributing to depressive and anxiety symptoms, suicidal ideation were detected.

Subjects and sampling
This cross-sectional study was conducted from March 1 to March 15, 2020, using an online survey to assess mental health problems.Inclusion criteria were full-time university students, including undergraduate and graduate students, living in mainland China, equal to or greater than 18 years of age.All participants were invited to complete a battery of online questionnaires through the Wenjuanxing platform.
This study was approved by the Institutional Review Board of Beijing HuiLongGuan Hospital.All the participants provided online informed consent to participate in the study.

Assessment tools and procedure
Personal COVID-19 exposure was de ned as a person in compulsory isolation or under medical observation, after having been diagnosed with COVID-19 or having a history of close contact with COVID-19 patients.Students' awareness of COVID-19 (COVID-19 knowledge, prevention and control measures, projections of COVID-19 trends, and negative impacts on life) were collected through a questionnaire constructed by the authors of this study.In the rst question, respondents were asked about their familiarity with information about prevention and control of COVID-19, ranging from 1 ("very unfamiliar") to 5 ("very familiar").In the second question, respondents were asked if they had taken all the prevention and control measures against COVID-19 to avoid infection, ranging from 1 ("very consistent") to 5 ("very inconsistent").The last question in the survey prompted respondents to describe their attitudes towards the projections of COVID-19 trends, ranging from 1 ("very pessimistic") to 10 ("very optimistic").
Depressive symptoms was screened using the Chinese version of the 9-item Patient Health Questionnaire (PHQ-9) [27].The PHQ-9 is a self-assessment tool for depressive symptoms based on the American Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), with responses for each item ranging from 0 (not at all) to 3 (nearly every day).The symptom severity is determined by the total score, with 5-9 being mild, 10-14 being moderate, 15-19 being moderately severe, and 20-27 being severe.
Anxiety symptoms were screened using the Chinese version of the 7-item Generalized Anxiety Disorder Scale (GAD-7) [28], with symptom prevalence on a scale from 0 (not at all) to 3 (nearly every day).The symptom severity is determined by the total score, with 5-9 being mild, 10-14 being moderate, and 15-21 being severe.
Suicidal ideation among college students were screened by single item (item 9) of PHQ-9, which has participants response how often they have thoughts that they would be better off dead.Suicidal ideation is divided into four grades: from 0 (not at all) to 3 (nearly every day).The higher the level, the more serious the suicidal ideation.

Statistical analysis
The dataset was established using EpiData software version 3.1 (Odense, Denmark) and analyzed with SPSS version 24.0 (IBM SPSS, IBM Corp., Armonk, NY, USA).Categorical variables, expressed as percentages, were analyzed using a Chi-squared test.The same method was used to compare the difference between the groups with and without anxiety symptoms, with and without suicidal ideation.Logistic regression was used to explore the predictors of depressive or anxiety symptoms, and suicidal ideation.The level of signi cance was set at p < 0.05 (two-sided).

Results
A total of 11372 participants, representing all 31 provincial-level regions of mainland China, completed the online questionnaires.After removing those answering less than three minutes or living abroad, 11133 participants (18-35 years old, median = 21) from 31 provincial-level regions, except Macau and Hong Kong, were involved in the current study, giving a response prevalence of 97.9%.Table 1 shows that 62.3% of the participants were female, 56.4% were urban residents, 90.3% were graduate students, 95.5% were living with their families, and 7.2% had exposure to COVID-19.
A total of 37.0% participants experienced mild to severe depressive symptoms, 24.9% experienced mild to severe anxiety symptoms, and the comorbidity prevalence of depressive and anxiety symptoms was 20.9%.In addition, 7.3% of the students had suicidal ideation.The nonparametric Mann-Whitney test was applied to determine statistically signi cant differences in age between students with and without anxiety symptoms (P < 0.001), but not between those with and without depressive symptoms (P = 0.07).And there was also no signi cant differences in age between students with and without suicidal ideation (P = 0.35).As shown in Table 1, there were no differences in depressive and anxiety symptoms, suicidal ideation among students between regions.The proportion of depressive symptoms among female students was higher than male students (38.9% versus 33.9%; 26.1% versus 22.8%).But the proportion of suicidal ideation for male students was higher than female students (8.1% versus 6.8%).Depressive and anxiety symptoms were more likely to occur in graduate students than in undergraduates (41.2% versus 36.5%;29.6% versus 24.3%), but there was no difference between undergraduate and graduate students for suicidal ideation.The differences in depressive and anxiety symptoms, suicidal ideation between students living with and without their families were statistically signi cant ( trends, and lower scores of negative impacts on life.This differences were also observed between the students with and without anxiety symptoms, with and without anxiety symptom.

Discussion
Emotional problems are the most common psychological symptoms in university students [29], which may further increase during public health emergencies [23].This large-scale, cross-sectional, epidemiological, online study focused on evaluating depressive and anxiety symptoms of university students during the COVID-19 pandemic and explored possible related factors in uencing them.This survey indicated three main ndings.
Firstly, among university students in mainland China, 37.0% experienced depressive symptoms, 24.9% experienced anxiety symptoms, and 20.9% experienced comorbidity depressive and anxiety symptoms.Secondly, the female gender, being a graduate, and personal COVID-19 exposure were independent risk factors and living with family was an independent protective factor for developing depressive and anxiety symptoms.Thirdly, depressive and anxiety symptoms are negatively associated with the level of awareness of COVID-19.
Currently, there is no data on the prevalence of depressive symptoms in university students during the COVID-19 pandemic.Available data on the prevalence of anxiety symptoms was from a study conducted at a single medical university, which showed similar results to this study [23].In general, the prevalence of depressive and anxiety symptoms demonstrated in this study is clearly much higher than in most previous studies during nonpandemic periods.For example, a meta-analysis, involving 39 studies with 32694 Chinese university students, indicated that the prevalence of depressive symptoms was 23.8% (95% CI: 19.9-28.5%)[30].In the case of anxiety symptoms, 10% of university and graduate students reported signi cant anxiety symptoms at some time during their school years [29,31].However, a relatively high prevalence of depressive and anxiety symptoms has also been observed in individual studies [32].On further analysis of the severity of mental health problems, it was found that mild depressive and anxiety symptoms were most common.In addition to anxiety and depression symptoms, college students' suicidal ideation during the COVID-19 epidemic should also be concerned.Studies have shown that during the COVID-19 epidemic, the public has a high rate of suicidal ideation due to factors such as unemployment, home isolation, anxiety, depression, and insomnia symptoms [10,33,34].But there have been no studies of college students.So it is worth mentioning that, even though only 7.3% students had suicide ideation, more attention should be paid to students with these characteristics.
There is now su cient evidence to state that the female gender is a reliable risk factor for depressive and anxiety symptoms [5,17,32,35].The gender difference was veri ed in our study.But our study found female students is a protect factor for suicidal ideation, This is consistent with previous research on factors in uencing suicide ideation among Chinese college students, it may be related to the great pressure placed on male college students by Chinese society [36].Graduate students, in contrast to undergraduate ones, have more negative emotions.This might be explained by more profound stresses regarding economic, marital, academic, interpersonal, and employment concerns as a result of the pandemic.Although graduate students had more negative emotions, they had less suicidal ideation than undergraduates, this is not consistent with previous studies.Studies have shown that in the student population, for those older than 25 years old students, the suicide rate of students is signi cantly higher than that of students younger than 25 years old in college students.In the group of students aged 20 to 24, suicide rate of graduate students is higher than that of undergraduate students [37,38].In the present study, students living with family are related to lower risk of mental health problems, lower percentage of suicidal ideation.Some authors have demonstrated that family support, especially parental support, is very important and could effectively buffer the effects of high stress on anxiety symptoms and depressive symptoms, it also reduces suicidal ideation [39][40][41][42].Conversely, the emotional loneliness resulting from being cut off from one's family is the strongest variable related to issues in mental health [43].As predicted, COVID-19 exposure is closely related to bad moods.Individuals who were quarantined, irrespective of their wishes, suffered from isolation and directly faced the problems of infection, medical treatment, and even death [44,45].
Good knowledge regarding infectious diseases may assist in the prevention of psychological problems [46].More accurate COVID-19 knowledge signi cantly produced a lower likelihood of negative attitudes and potentially dangerous practices towards the pandemic [47], and reduced fear and panic [48].Our ndings supported this view and revealed COVID-19 knowledge as an independent protective factor for mental health among university students.Of course, it is important to provide speci c up-to-date and accurate health information (e.g., treatment, local outbreak situation) about the outbreak [49].Since the early stage of the COVID-19 pandemic, the Chinese government has provided essential COVID-19 knowledge to the public, every day, through media campaigns via television, radio, WeChat, Tik Tok and newspapers.However, it was found that only 42.1% students were familiar and 15.5% were unfamiliar with COVID-19 knowledge.Therefore, public health policy makers and health workers should recognize this target population for COVID-19 prevention training and health education.
Based on the pandemic characteristics of COVID-19, the Chinese government and public authorities made efforts to facilitate the implementation of pandemic prevention measures.The practices were very cautious in the Chinese population: decreased unnecessary outings, avoiding crowded places, wearing masks when going outside, and washing hands frequently [47].Consistent with this, 87.0% students had taken all the prevention and control measures against COVID-19 to avoid infection in the current study.Moreover, our study results were in agreement with a previous study, which suggested that precautionary measures could reduce the psychological impact of the outbreak and levels of anxiety and depression [49][50][51].According to this data, it is necessary to carry out targeted prevention and control measures and allocate health resources effectively.
During this survey period, the number of reported infection cases nationwide began to decline slightly, but the pandemic was spreading rapidly around the world and some imported cases occurred.Therefore, the public was urged to take more stringent preventive and control measures.Almost all students continued to stop their university studies and practice, and their range of activities was greatly restricted, which caused great inconvenience in their lives.Psychologically, when the living environment changes, people feel unsafe, uneasy, and anxious [52].Long-term self-isolation can make people bored and prone to focus too much on negative pandemic information, which also increases the risk of mental health problems [53].However, our nding that the majority of students had an optimistic attitude about overcoming this crisis was unexpected.The most likely explanation for this situation is due to the openness and transparency of data and the effective and standardized implementation of prevention and control work in China [54].The optimistic attitude towards the prospects of COVID-19 could reduce depressive and anxiety symptoms because risk perception has a greater correlation with mental health [55].Recently, the government actively promoted the resumption of work, production and education [56], which will further positively impact on mental health.
The key strengths of this study included the wide-ranging demographics and having the largest sample studied to date.In addition, it was the rst study to investigate the prevalence of mental health among university students and its in uence.However, there are also some limitations to this study.First, the study adopted the method of convenience sampling to recruit subjects, which may lead to a lack of sample representativeness and an imbalance of the sample distribution.Second, reporting bias may exist due to the nature of self-reported data, which may not always be consistent with the evaluation of mental health professionals.Third, all the data were collected in a cross-sectional survey, and therefore, causal relationships could not be established.Finally, the item 9 of PHQ-9 was mainly used for the evaluation of suicide ideation.No professional questionnaire is used for the evaluation of suicide ideation, which may not be systematic and detailed enough.
In conclusion, the mental health status of university students has been affected during the COVID-19 pandemic, with a high prevalence of depressive and anxiety symptoms, suicidal ideation.The female gender, graduates, living with family, personal COVID-19 exposure and awareness of COVID-19 were related factors for depressive and anxiety symptoms.Although various psychological health services have been provided by the Chinese government through various channels, such as hotlines, online consultation and outpatient consultation [57], it is necessary to pay more attention to mental health among university students while combating COVID-19, and to early intervention regarding their psychological problems.In addition, our study showed that anxiety and depression symptoms are important risk factors for suicidal ideation.While paying attention to the anxiety and depression symptoms of university students, we should also pay attention to the students' suicidal ideation, and focus on the intervention of students with suicidal ideation.

Declarations
The design of the questionnaire was completed by Shuang-Jiang Zhou, and Xing-Jie Yang; Meng Qi was responsible for the examination of the contents of the questionnaire; Lan Gao, Suo-Yuan Zhang and Li-Gang Zhang were responsible for the distribution and recovery of the questionnaire; statistical analyses were completed by Lei-Lei Wang and Jing-Xu Chen; Rui Yang and Jing-Xu Chen received funding support for the research.
Shuang-Jiang Zhou and Meng Qi completed the rst draft of this manuscript; Jing-Xu Chen designed the whole study, provided guidance and reviewed and submitted the article.All authors have read and agreed with the published version of the manuscript.

Table 1
Socio-demographic characteristics and association with depressive and anxiety symptoms (N = 11,133)As shown in Table2, compared to students with depressive symptoms, students without depressive symptoms had higher scores of COVID-19 knowledge, prevention and control measures, and projections of the COVID-19