Anxiety, Depression, and PTSD among College Students in the Post-COVID-19 Era: A Cross-Sectional Study

In the post-COVID-19 era, significant changes have taken place regarding the epidemic, the economy, family and social life. However, it remains unclear how these changes encompass the psychological symptoms of college students. We carried out a cross-sectional study to investigate anxiety, depression, and post-traumatic stress disorder (PTSD) symptoms among college students from 10 November 2020, to 16 November 2020. The questionnaire included a self-designed canvas, Generalized Anxiety Disorder 7 (GAD-7), Patient Health Questionnaire 9 (PHQ-9), and Impact of Event Scale (IES-R). Factors associated with psychological symptoms were estimated by ordered and non-conditional logistic regression analysis. Of 4754 participants, 25.0%, 29.7%, 3.4%, 15.3%, 17.1%, and 2.9% reported anxiety, depression, PTSD symptoms, one, any two, and all three, respectively. In cases with anxiety or depression symptoms, there was a 9.11% comorbidity with PTSD. Factors associated with fears of being infected, social, family, and economic changes increased the risk of psychological symptoms in college students caused by COVID-19. Female college students, identified with anxiety or depression symptoms, were at a lower risk of developing PTSD symptoms (OR, 0.61, 95% CI: 0.43–0.86). Non-medical majors at university, rural residence, higher educational background, fear of taking public transport, and deterioration of family relationships increased the risk for PTSD symptoms among male respondents with anxiety or depression symptoms due to COVID-19. Factors correlated with psychological symptoms had expanded from the fear of being infected to extensive social, family, and economic changes caused by COVID-19. Therefore, screening and interventions for psychological symptoms should be consistently strengthened and more targeted to college students in the post-COVID-19 era.


Introduction
Coronavirus disease 2019 (COVID-19) was declared a pandemic by the World Health Organization (WHO) on 11 March 2020 [1][2][3]. As of 13 February 2022, more than 404.9 million people have been infected with COVID-19, and 5.7 million deaths have been reported globally [4]. It is reported that public health emergencies like COVID-19 may lead to psychological and physical damage to the public, and that the psychological impact caused by such events will last for a long time [5]. Relative to other social groups, college students are more gullible regarding the COVID-19 epidemic, experiencing uncertainty and sudden semester interruptions. This cross-sectional study was conducted by using non-probability sampling from 10 to 16 November 2020, when the pandemic of COVID-19 had been brought under control and most college students had returned to regular school life. The participants in this study were college students from Jiangxi Province, China. The online questionnaire with a quick response code (QR code), which was administered through a web-based platform, was sent to colleges located in Jiangxi. A total of 4754 pieces of poll data were collected and further analyzed. Electronic informed written consent was obtained from all respondents before data collection. Moreover, the Research Ethics Board approved the scrutiny at the First Affiliated Hospital of Nanchang University (approval number: 2020-050).

Measurements
The measurements consisted of four sections: sociodemographic data, self-reported COVID-19-related data, Generalized Anxiety Disorder 7-item Scale, Patient Health Questionnaire-9, and Impact of Event Scale.

Sociodemographic Data and COVID-19-Related Data
The sociodemographic data embodied gender, age, education (whether they are medical students or not), census registration, and household income level (low/middle/high). COVID-19-related data included personal protective behaviors during the post-pandemic period as "Whether catching a cold within one week of the survey", "Whether relatives and friends are infected with COVID-19", "Worried about whether COVID-19 is widely spread again in China", "Worried about taking public transportation", "Worried about being infected by COVID-19 for yourself and your family", "Whether to wear a mask", "The impact of the epidemic on household income" (No effect/Increase/Decrease), and "The impact of the pandemic on family relations" (No effect/Positively/Negatively) being surveyed.

Generalized Anxiety Disorder 7-Item (GAD-7) Scale
The Generalized Anxiety Disorder Scale was compiled by Spitzer [17] and is used to screen for generalized anxiety and assess symptom severity. It consists of seven items and is widely used to discern how long respondents are troubled by seven questions, including "difficult to relax" and "excessively worried about various problems" in the past two weeks. GAD-7 has proven to be a reliable tool for measuring anxiety [18]. The GAD-7 scale is a 4-level self-rating scale for seven items, with a total score of 21 points. In this study, the GAD-7 scale is a 7-item self-rating scale with four grades, with a total score of 21 points, <5 points indicate no anxiety symptoms, ≥5 points indicate anxiety symptoms, of which 5-9 points have mild anxiety tendency, 10-13 is divided into moderate anxiety tendency, ≥14 is allotted into severe anxiety tendency.

Patient Health Questionnaire-9 (PHQ-9)
The Patient Health Questionnaire-9 (PHQ-9) is a questionnaire wielded to diagnose and determine the severity of depression. PHQ-9 is a patient self-report measurement that combines simplicity with "structure and standard validity" [19]. The Patient Health Questionnaire-9 (PHQ-9) uses a 4-level score (0-3), with a total score of 27 points. A total score of <5 points for the absence of depressive symptoms, ≥5 points for the presence of depressive symptoms, of which 5-9 points are mild depressive tendency, 10-14 points are moderate depressive tendency, 15-19 points are moderately severe depressive tendency, and 20-27 points were delimited as severe depression.

Impact of Event Scale (IES-R)
The IES-R is a self-administered questionnaire that has been well-validated in the Chinese population for deducing the extent of psychological impact after exposure to a public health crisis within one week of exposure [20]. The total IES-R score was divided into 0-23 (normal), 24-32 (mild psychological impact), 33-36 (moderate psychological impact), and >37 (severe psychological impact).

Statistical Analysis
A chi-square test and a Wilcoxon Rank Sum Test were utilized to compare the characteristics of the distribution for self-reported anxiety, depression, and PTSD symptoms. Order logistic regression analysis was conducted to screen the factors associated with self-reported anxiety, depression, and PTSD symptoms, and calculate the ORs (odds ratios) and a 95% CI (confidence interval). Non-conditional logistic regression was utilized to explore factors associated with PTSD symptoms among cases with anxiety or depression symptoms. Statistical tests were two-tailed with p < 0.05. The database was constructed with EpiDate 3.1 and analyzed with SPSS 25.0. Table 1 demonstrates the prevalence rates of anxiety, depression, and PTSD symptoms among college students. A total of 4754 canvasses completed the survey, 54.0% of respondents were female and the median age was 20 years. The self-reported rates of anxiety, depression, PTSD symptoms, any one, any two, and all three were 25.0%, 29.7%, 3.4%, 15.3%, 17.1%, and 2.9%, respectively. Most of the subjects with symptoms were mild and moderate. There were significant gender differences in the prevalence of anxiety symptoms, depression symptoms, and psychological symptom comorbidities (p < 0.05).

Correlators Associated with Anxiety, Depression, and PTSD among College Students Stratified by Gender
Ordered logistic regression stratified by gender shows that fearing another pandemic, fearing contracting COVID-19, not wearing a mask in public, and deterioration of family relationships by COVID-19 were associated with anxiety and depression for both male and female college students (Table 3). In addition, having caught a cold recently and being affected by decreased household income due to COVID-19 were especially associated with anxiety symptoms for male college students; fear of taking public and self-reported low household income were especially associated with anxiety symptoms for female college students. Having caught a cold recently, fear of another pandemic, fear of taking public transport, fear of contracting COVID-19, not wearing a mask in public, self-reported low household income, and degeneration of family relationships due to COVID-19 were associated with depression symptoms for both male and female college students. In addition, higher educational background and deterioration of family relationships due to COVID-19 were particularly associated with depression symptoms for male college students. Fear of taking public transport and deterioration of family relationships were associated with PTSD symptoms for both male and female college students. In addition, rural household register, higher educational background, fear of another pandemic, and not wearing a mask in public were especially associated with PTSD symptoms for male college students; other majors in university and fear of contracting COVID-19 were especially associated with PTSD symptoms for female college students. Having caught a cold recently, fear of another pandemic, fear of taking public transport, fear of contracting COVID-19, not wearing a mask in public, and deterioration of family relationships due to COVID-19 were found to be linked with a higher risk for more psychological comorbidities in both male and female college students. In addition, high educational background and decreased household income due to COVID-19 were associated with a higher risk of more psychological symptoms for male college students; self-reported low level household income was associated with a higher risk of psychological comorbidities for female college students. Table 4 displays the factors associated with PTSD among college students with anxiety or depression symptoms. The detection rate of PTSD in cases with anxiety or depression symptoms was 9.11% (7.90-10.49%), including 11.03% (9.00-13.46%) in male students and 7.70% (6.10-9.67%) in female students. Logistic regression showed that female (OR, 0.61, 95% CI: 0.43-0.86), rural household register (OR, 1.58, 95% CI: 1.08-2.32), higher educational level (OR, 1.90, 95% CI: 1.08-3.36), fear of taking public transport (OR, 2.84, 95% CI: 1.81-4.47), and deterioration of family relationship due to COVID-19 (OR, 2.30, 95% CI: 1.44-3.67) were found to be equated with a higher risk of comorbidity with PTSD symptoms among cases with anxiety and depression symptoms.

Discussion
This study investigated the common psychological status of college students in the post-COVID-19 era and explored relevant factors. Our findings in the pre-and post-COVID-19 era revealed that levels of anxiety, depression, and PTSD symptoms among college students remained relatively high in the post-pandemic era [16]. It is evident that the epidemic itself continues to affect the mental health status of college students, especially out of concern for the development of the epidemic and the possibility of infection. The deterioration of family relationships and reduced family economic level due to COVID-19 were significantly associated with the three symptoms. Furthermore, there were gender differences in the mental health status among college students, with females more likely to experience anxiety and depression symptoms, and males from rural areas and higher educational backgrounds showing a fear of public transport contributing to a higher risk of PTSD symptoms.
The prevalence of anxiety, depression, and PTSD symptoms reported in this study was 25.0%, 29.7%, and 3.4%, respectively. Compared to the outbreak period, all three still show a higher level. The prevalence rates in our study were lower than in a previous cross-sectional study of young adults in the United States, whose respondents reported symptoms of anxiety, depression, and PTSD in 45.4%, 43.3%, and 31.8%, respectively [21]. This may be due to that study having been conducted one month after the declaration of a state of emergency in the United States for COVID-19, when the epidemic was still progressing at a high level, whereas our study was conducted when the epidemic was largely under control. We observed that the prevalence of PTSD symptoms in college students was lower than the yields of studies performed during the COVID-19 outbreak, while anxiety and depressive symptoms were in line with or higher than them [22][23][24][25]. Prior research identified a higher prevalence of mental health symptoms reported by students than the overall population due to multiple concerns about academic delays, financial support, reduced social relationships, etc. [26]. A worldwide meta-analysis revealed that mental health symptoms were highly prevalent during the COVID-19 pandemic and varied among populations, with medical students suffering the most severe mental health symptoms, followed by general students [27]. It was implied that despite being in the post-pandemic period, college students were still more likely to withstand psychological symptoms due to the persistent impact of sporadic cases in addition to pressure from study and future employment. Moreover, we also compared the prevalence of common psychological conditions of other high-risk groups during this period including medical staff and COVID-19 patients, which suggested that these studies reported considerably higher rates than our study [28,29]. This may be explained by the fact that they were directly affected by the COVID-19 infection or were at greater risk of exposure resulting in a poorer psychological status than other groups.
Family relationships were significantly associated with anxiety, depression, and PTSD due to COVID-19. Factors associated with the three psychological symptoms were both overlapping and different. Among those factors, deteriorated family relationships due to COVID-19 were linked with all three psychological symptoms. Several studies had revealed that family functioning showed a direct influence on the mental health of college students [30]. During the pandemic, students spent a long time with their family members and suffered from the same passive stress. The relatively closed and singlefamily space provided conditions for the mutual venting of negative emotions and further led to the deterioration of family relationships [31]. It's reported that the divorce rate and deterioration of parent-child relationships during the pandemic were higher than those in other periods [32]. The deterioration of family relationships has a strong and lasting impact on the psychological status of college students. Although college students had returned to school, this correlation still existed, suggesting that more attention should be paid to enhance the maintenance of family relationships during and post the epidemic.
Previous studies had found family economic level was significantly associated with college students' mental health [33,34]. In this study, dwindling family income caused by COVID-19 increased the risk of anxiety symptoms and depression symptoms in male students. This might be related to the social role of and pressure on males. Self-reported low household income contributed to a higher risk of depression symptoms for both male and female students. Students with poor family income levels experienced the long-term pressure of family economic burdens, which was prone to inducing negative emotions such as low self-esteem and depression [35].
Consistent with some previous findings [36], this study found that factors associated with anxiety symptoms, depression symptoms, and PTSD symptoms also included concerns or worries about the development of the epidemic and being infected. Although in the post-epidemic era, the impact of the epidemic itself on psychological problems continued. The post-epidemic era was not an epidemic-free era; along with the rise of asymptomatic infections and unexpected regional sporadic cases, coupled with the increase in population mobility in the post-epidemic era, people could still suffer from the tremendous pressure of the epidemic, including college students.
However, there were also gender differences, which were similar to the results of previous studies [37,38]. Identifying gender differences in risk factors was essential for accurate intervention. Our study suggested that females were more likely to develop anxiety and depression symptoms than males consistent with prior research [39][40][41][42]. In addition, we found that a higher proportion of PTSD comorbidity was observed in male cases than in female cases with anxiety or depression symptoms. Previous studies in the general population had shown that females were about twice as likely to develop PTSD as males [43][44][45]. This may pertain to the fact that the subjects of this analysis were college students who had been identified as suffering from anxiety or depression symptoms. In addition, it can be indicated from the results of factor analysis stratified by gender that rural college students, higher educational backgrounds, and fear of taking public transport contributed to a higher risk of PTSD symptoms among male college students. Male college students were relatively active in social activities, may have more opportunities to take public transport, and would then be more likely to panic or fear of being infected when local sporadic cases were reported. However, it is indispensable to know that this research still has some limitations: Firstly, in this research, we used a non-probability sampling survey instead of a random sampling survey; additionally, there were extensive variables equated with psychological symptoms in college students and only information closely related to COVID-19 was collected in this study. Additionally, the results may be varied in different COVID-19 settings, so the extrapolation and comparison of the results need to be performed cautiously.

Conclusions
In contrast to severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS), the COVID-19 epidemic lasted longer. In the pre-and post-COVID-19 era, within our study, the three symptoms involved, anxiety, depression, and PTSD symptoms, have been at high levels from the period of the epidemic outbreak. This result is informative for public health emergencies. Our research also demonstrated the considerable impact of low household economic levels, deteriorating family relationships, and gender on the three symptoms. As subjects of social development, college students have social attributes such as working and reproducing offspring, so targeted strategies should be developed for them. Therefore, colleges are obliged to strengthen daily mental health education for students, screening and providing targeted psychological counseling.