The results of our study revealed a high prevalence of PTS among Chinese college students during the outbreak of COVID-19 virus. More than one-third of participants met the cut-off for PTSD. In comparison, the prevalence of PTS symptoms in the general population during the 2014–2016 Ebola epidemic ranged from10-27% [5]. Compared to PTS symptoms, the prevalence of depression, anxiety and stress as measured by the DASS-21 was lower with 15.70%, 13.31% and 7.10% of respondents reported mild to extremely severe depressive, anxiety, and stress symptoms. Several factors may have contributed to the difference between the level of PTS and DASS among college students. First, the morbidity rate of Covid-19 infection is relatively low among this age group based on the information publicized on various mass medias [25–27]. Second, the college students were on winter vacation at the early stage of the epidemic during which they may reduce the risk of infection due to their family isolation. Furthermore, compared with other working-age populations college students experience less economic pressure caused by the epidemic.
Compared to similar domestic and overseas studies, the prevalence of PTS and DASS symptoms in this study were lower [28–31]. This might be partly due to the timing of the study, which occurred when the COVID-19 outbreak showed a downward trend of new cases in China and an upward trend overseas. As the epidemic was gradually controlled in China, the psychological reaction among the general population and students was relief. In addition, the different psychological scales used in these studies may lead to different measurement outcomes. Furthermore, the present study explored the psychological response to the COVID-19 epidemic among college students, while the target population of other studies was the general population or medical care workers.
The prevalence of psychological symptoms in this study differ from other similar epidemiological studies in China that found that older students have a lower risk of depression and anxiety [31]. Our findings showed the opposite trend. Compared with Chang’s research, the proportion of medical and non-medical students in our study population similar [31]. During our research period, the majority of universities had clearly notified students that the 2020 spring semester was extended, which may increase the pressure of graduation, internships, and employment for older non-medical students. As a result, we found older college students (i.e., over 23 years old) were more likely to report higher levels of depression and stress. Moreover, a previous study revealed gender differences in the psychological impact of the COVID-19 outbreak, which was not found in our study among college students [28]. In addition, older age, heavy loads of study, and certain economic pressures make the postgraduate group more prone to PTS symptoms than undergraduate students. Consistent with the results of a domestic study [31], medical students are more prone to depression during public health emergencies such as outbreaks. Two reasons may have contributed to the more severe psychological status seen in medical students. First, out of professional needs, medical students may pay more attention to the epidemic. Second, medical students may be called upon to join local epidemic prevention teams where medical personnel are lacking, which would undoubtedly increase the risk of infection for medical students and their families, thereby increasing their likelihood of suffering from depression.
The study results are in line with the previous study that showed a marked increase in PTS, depression, anxiety, and stress among those who perceived themselves as not very healthy during the COVID-19 outbreak, including those who ever had chronic disease(s) [28]. People with chronic underlying diseases are not only susceptible to infection (especially with the lack of proper protection) but also have a poor prognosis once diagnosed. During the closed-off period, unhealthy participants might have the need to seek medical treatment for their chronic disease(s) or other health issues, however, these individuals may choose to stay at home until their life is endangered by their disease. With the absence of medical care during the epidemic, these unhealthy populations were at an increased risk of depression, anxiety and stress.
With easy access to the internet, the majority of respondents can get instant updates on news related to the COVID-19 outbreak, which was not as possible during SARS in 2003. In this study, we found that access to instant information has positive and negative consequences. On the one hand, the information related to COVID-19 outbreak can help keep students informed on the epidemic development, including source of infection, route of transmission and preventive measures, etc. The more knowledge students have, the more confidently they can respond to the outbreak. On the other hand, in today's world of instant information, students may suffer from PTSD due to high concern about the outbreak. After WHO declared COVID-19 a PHEIC on January 30, more than half of students worried about poor economics and trade as well as the lack of goods and rising prices due to the declaration. In addition, about a third of the respondents believed that COVID-19 would cause a global outbreak. Under the circumstances at that time, students with such concerns were prone to adverse psychological effects, including PTSD, anxiety, depression and stress.
Moreover, when the epidemic is closely related to one’s own life, it undoubtedly causes people to panic. Our results revealed that those who had confirmed cases among relatives and friends reported perceived risk of infection and those that believed that lives were affected by the outbreak and closed-off management response experienced PTS and higher levels of depression, anxiety, and stress. In addition, most of the participants worried that the epidemic would affect their studies, tests, work, and social activities. Staying motivated at home can be tough for students, since home is often regarded as a place kept away from study and work. Therefore, college students are undoubtedly a distinct psychologically vulnerable population during the home isolation period, due to their unique developmental stage in life and the need to meet academic expectations.
In addition, the results in this study indicate the important influence of perceived social support and coping styles on psychological health. Close and confiding social networks can reinforce individual abilities to manage stressful situations and increase individual resilience levels [32, 33]. Persons who lack social support are prone to various mental health issues. On the contrary, strong social support seems to be a protective factor for psychological impact, which was further verified in this study. Coping strategy is an individual’s cognitive evaluation toward stress and the measures adopted to balance one’s mental state. A positive coping style can optimize an individual’s subjective cognition, improve the ability of handling problems individually, and improve emotion. Those who adopted active coping styles may explain why they were less likely to suffer from adverse psychological outcomes than those who responded negatively during the COVID-19 outbreak.
Due to the overwhelming international situation regarding COVID-19, it is important to provide target guidance for preventing and relieving adverse psychological impacts among college students. First, target vulnerable populations, including those who are unhealthy, major in medicine, graduate students, hold an pessimistic attitude towards the COVID-19 epidemic, lack social support, and adopt passive coping styles since these populations are at risk for mental disorders. In addition, students should be reminded to identify the reliability of information and to get relevant knowledge/news from authoritative agencies. Schools and teachers should recommend official website to students to reduce panic caused by false news. At the same time, up-to-date and evidence- based information should be promoted to ease the nervousness of students during the home isolation period. Furthermore, fully equipped online facilities to minimize the impact of closed-off management on students' routine learning and work tasks. Finally, create a socially supported environment, whether it is an online or in-person surrounding community. Smartphone applications are widely accepted among college students and schools, health authorities, and public welfare psychological counseling organizations could consider providing online or hotline psychological interventions to prevent or reduce possible psychological problems among students. At the same time, reminding students to maintain a daily routine at home, dressing up like they were attending school, attending on-line classes on time, and regularly arranging self-study to create the illusion of studying on campus during the home isolation period [34].
In summary, the findings from this study provide a basis for implementing measures to improve the mental health among college students during the outbreak of COVID-19 and have a reference value for identifying students who may have a high risk of adverse psychological problems. Our study has a number of strengths, including a large sample size and robust statistical analysis. However, there are limitations that need to be considered when interpreting our findings. First, the generalizability of our findings is impacted given the results were possibly due in part to nonrandom selection of the sample. In addition, the uncontrolled observational study of college students and the cross-sectional nature of the data warrant further longitudinal studies to determine the predictors of adverse psychological effects during the outbreak. Finally, due to anonymous network response and self-reported levels of psychological impact, anxiety, depression and stress, our results may not be comparable to clinical psychological diagnosis.