Anxiety, Depression, and Satisfaction With Life Among College Students in China: Nine Months After Initiation of the Outbreak of COVID-19

Background/Objective Mental health problems are common among college students. This study sought to assess the prevalence and risk factors of depressive and anxiety symptoms and well-being among Chinese college students 9 months after initiation of the outbreak of COVID-19. Method A cross-sectional study (N = 3,951, mean age = 19.58) was conducted from October to December 2020. An online survey was used to collect socio-demographic data, and the symptoms of depression and anxiety and satisfaction with life using Disorder 7-Item Scale (GAD-7), the Patient Health Questionnaire 9-Item Scale (PHQ-9), and the 5-items Satisfaction with Life Scale (SWLS). Results The prevalence of depressive and anxiety symptoms was 59.35 and 54.34%, respectively, and the score of satisfaction with life was 20.51 ± 6.42 among Chinese college students during the pandemic. After controlling for covariates, students in urban areas (AOR = 0.73, 95% CI = 0.61–0.87), with good family economic levels (AOR = 0.77, 95% CI = 0.66–0.91), and having psychological counseling (AOR = 0.55, 95% CI = 0.42–0.73) were positively associated with depression symptoms; meanwhile, higher anxiety symptoms were observed among medical students (AOR = 0.81, 95% CI = 0.69–0.95). Besides, healthy lifestyle such as regular physical activity and diet was associated with depression and anxiety symptoms. Multiple linear models revealed that medical students (β = 0.479, P = 0.031), those with good family economic level by self-evaluation (β = 1.283, P < 0.001 for good; β = 3.013, P < 0.001 for general), good academic performance by self-evaluation (β = 1.786, P < 0.001 for good; β = 3.386, P < 0.001 for general), learning burden (β = 1.607, P < 0.001 for general; β = 2.117, P < 0.001 for light), regular physical activity (β = 0.859, P < 0.001), daily routine (β = 1.289, P < 0.001), diet (β = 1.714, P < 0.001), and sufficient sleep (β = 1.408, P < 0.001) had more score of SWLS (all β > 0, P < 0.05), while senior students (β = −1.053, P=0.009), students having psychological counseling (β = −1.753, P < 0.001), and drinking (β = −0.743, P = 0.012) had lower satisfaction with life. Conclusions These findings suggest that more attention should be paid to psychological health among college students, especially during and after the COVID-19 outbreak. Policy makers and educators should help college students develop a healthy lifestyle with regular diet and exercise to promote the psychological health of college students.


INTRODUCTION
The Coronavirus Disease 2019 (COVID-19) caused by SARS-CoV-2, was first reported in December 2019, and rapidly spread around the world (1). To control the pandemic, the stringent COVID-19 control measures were imposed including strict stayat-home policy for all residents and postpone the start of school in China. The COVID-19 epidemic disrupted residents' normal life, sleep and eating patterns, and increased social isolation and disappointment in life, which threatened their psychological health. Psychological problems were caused by all kinds of negative news such as increasing number of patients and deaths, lack of medical resources, etc. (2). Studies reported that psychiatric symptoms including anxiety and depression among the public have remained even more serious during the SARS epidemic and after 1, 30 months, and longer (3). In China, students are required to study online at home and cannot return to school until September or October 2020, and previous studies indicated that the effects of the pandemic on students may linger for a period beyond the peak of the COVID-19 pandemic itself (4) and, thus, it is necessary to assess psychological situations.
Mental health among college students has been an increasing concern, and many studies have been conducted to assess the mental health among college students. There is no doubt that mental disorders among college students is widespread and common in China and other countries (5, 6), and demographic variables such as gender and lifestyles have been explored to be associated with metal health among college students (7)(8)(9). For instance, among female students, smoking and drinking were reported to be associated with higher rates of anxiety and depression among college students. The COVID-19 pandemic situation has brought them into renewed focus, a recent study conducted in Sichuan Province from April 2020 to May 2020 with 521 university students showed 19.0% of respondents reported distress, and 31.5, 8.1, and 5.8% of them reported mild, moderate, and severe anxiety, respectively, by using 20item Self Reporting Questionnaire and Self-Rating Anxiety Scale (10). Online classes and class projects given the lack of in-person support from instructors or teaching assistants may increase class workload, which may further increase their mental pressure (11). To understand and evaluate the psychological features among college students back to school after the epidemic, we conducted a national cross-sectional study to comprehensively describe college students' psychological situations and satisfaction with life.

Study Design and Participants
A national cross-sectional study with multistage cluster random sampling method was conducted among college students from October to December 2020. We first divided China into three regions: eastern (11 provinces), central (8 provinces), and western (12 provinces) based on the geographical area (according to the China health and family planning statistical yearbook), and two provinces were selected from each region randomly by drawing lots. Second, within each province, two colleges were randomly selected in the provincial capital. If there were too few colleges in the capital city then another city would be added. Finally, 12 college schools were selected in the present study. The questionnaires were completed through an online survey platform ("SurveyStar, " Changsha Ranxing Science and Technology, Shanghai, China). Students from the 12 colleges were randomly invited to complete the questionnaire. The study was approved by the Research Ethics Committee in Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China (2020) S164. All agreed participants provided informed consent electronically prior to registration. If they agreed and registered, then they could see the questionnaire, or else they could not see the questionnaire and end up in the survey. Each mobile phone or computer could only be used once, all valid questionnaires identified by a background system were automatically entered into a data file and checked by two independent researchers. Questionnaires that took <3 min to fill out were excluded, 4,102 college students were selected randomly and filled out the questionnaires, and 3,951 students completed the valid surveys with no missing information. Questionnaires included demographic information, the 7-item Generalized Anxiety Disorder Scale (GAD-7), the Patient Health Questionnaire-9 (PHQ-9), and the Satisfaction with Life Scale (SWLS). Demographic information including gender, ethnicity, school type, major, grade, place of origin, only child or not, family income, self-rated family economic conditions, smoking, drinking, study burden, etc.

Measurements
The GAD-7, a practical self-report anxiety questionnaire, has been bothered by each of the 7 core symptoms of generalized anxiety disorder. Response options are "not at all, " "several days, " "more than half the days, " and "nearly every day, " scored as 0, 1, 2, and 3, respectively. Therefore, GAD-7 scores range from 0 to 21, with scores of ≥5, ≥10, and ≥15 representing mild, moderate, and severe anxiety symptom levels, respectively (12). In addition, those with a total score ≤4 were considered as presenting no anxiety symptoms in the present analysis. The GAD-7 scale had good factorial validity and reliability with Cronbach's alpha coefficients of 0.82-0.89 and the validity of scale in assessing anxiety in Chinese has been confirmed (12,13).
The SWLS is designed around the idea that one must ask subjects for an overall judgment of their life to measure the concept of life satisfaction, and is one of the most frequently used tools to measure the global cognitive judgment of satisfaction with one's life, which is comprised of 5 items rated on a 7-point Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree), with higher values representing greater satisfaction (16). The reliability coefficient (Cronbach's alpha) of the scale in different studies ranged from 0.80 to 0.92 (16)(17)(18).

Statistical Methods
The data were tested for normal distribution. Descriptive analysis was compiled to describe the general data, and frequencies and percentages were used for count data. The chi-square test was used to compare the data for differences between basic situation and mental health statuses among various demographics. Only multivariate logistic regression models were used to evaluate the association between different factors and anxiety, depression and satisfaction with life. The dependent variables were anxiety, depression, and satisfaction with life; covariates including age, gender, residence area, specialized subject, family monthly income, father's education background, mother's education background, average monthly living cost, family economic level by self-evaluation, academic year, academic performance, learning burden, psychological counseling, smoking status, alcohol consumption, regular physical activity, regular daily routine, regular diet, sufficient sleep, BMI, and lost weight in the past month. P values < 0.05 (two-tailed) indicated that a difference was statistically significant. All data analysis was performed using IBM SPSS Statistics for Windows (Version 23.0).

RESULTS
The demographic characteristics of participants and the differences in their anxiety and depression statuses 9 months after the epidemic are shown in Table 1. Among 3,951 college students, the average age was 19.58 (SD 1.67), 2,277 (57.63%) were female students, 2,367 (59.91%) came from rural areas, and 1,360 (34.42%) were only children in their families. Of them, 59.35% had depression and 54.34% had anxiety. Significant differences in the students' depression levels were found based on residence area, family economic level by self-evaluation, academic performance by self-evaluation, learning burden, whether they do psychological counseling and lost weight in the past month, regular physical activity, daily routine, diet, and sufficient sleep. Students who came from rural areas were more likely to suffer from depression than those from urban areas (61.30 vs. 56.44%). In addition, significant differences in the anxiety level of students were found based on specialized subjects, family economic level by self-evaluation, academic performance by self-evaluation, learning burden, whether they do psychological counseling and lost weight in the past month, regular physical activity, daily routine, diet, sufficient sleep, and if they smoke. Non-medical students were more likely to have anxiety than others (55.79 vs. 51.14%). Table 2 displays the satisfaction with life within each of the sociodemographic groups. In addition, the average score of satisfaction with life was 20.51 (SD 6.42) and significant differences were observed in residence areas, specialized subject, family monthly income, father's and mother's education background, family economic level by self-evaluation, academic year, academic performance by self-evaluation, learning burden, smoking, drinking, whether they do psychological counseling, regular physical activity, daily routine, diet, and sufficient sleep. Specifically, urban students were more likely to have higher satisfaction with life than rural students (20.98 Table 3 reveals the factors associated with anxiety and depression among college students. Multivariate logistic regression models showed that college students who were from urban areas (adjusted odds ratio, AOR = 0.73, 95% CI, 0.61-0.87), good family economic level by self-evaluation (AOR = 0.77, 95% CI, 0.66-0.91), good academic performance by self-evaluation (AOR = 0.76, 95% CI, 0.61-0.94), light learning burden (AOR = 0.56, 95% CI, 0.39-0.79), psychological counseling (AOR = 0.55, 95% CI, 0.42-0.73), regular physical activity (AOR = 0.85, 95% CI, 0.72-0.99), regular daily routine (AOR = 0.77, 95% CI, 0.66-0.90), regular diet (AOR = 0.56, 95% CI, 0.48-0.65), and sufficient sleep (AOR = 0.62, 95% CI, 0.53-0.72) were less likely to have depression. However, those who were Juniors or Seniors and lost weight in the past month showed higher risk of depression. Factors significantly associated with anxiety among college students included light learning burden (AOR = 0.29, 95% CI, 0.20-0.41), psychological   Table 4) presented that medical students and those with good family economic levels by self-evaluation, good academic performance by self-evaluation, learning burden, regular physical activity, daily routine, diet, and sufficient sleep had more score of SWLS (all of β > 0, P < 0.05), while senior students and students with psychological counseling and drinking had lower satisfaction with life (all of β < 0, P < 0.05).

DISCUSSION
College students considered vulnerable to psychological health are facing unprecedented levels of distress, especially during the COVID-19 pandemic. Due to the COVID-19 outbreak, schools in China have been locked down at all levels, and educational authorities have developed online portals and applications to deliver lectures and teaching activities, the uncertainty of academic development would have adverse impact on students' psychological health. Besides, students were required to report their daily health conditions and comply with prevention promotion of the COVID-19 and daily updates about surveillance and active cases (19), which may result in psychological distress. The high prevalence of mental problems is a warning that we should not ignore, particularly among college students although the COVID-19 situation has been better.
The findings of this study bring into focus the mental health and well-being of this specific population. Thus, far, most studies have been conducted within 1 or 2 months of the COVID-19 outbreak and focused on its immediate impact, and our study conducting online survey found that a majority of college students were experiencing depression and anxiety back to school after about 9 months of home isolation and study online. A nationwide cross-sectional survey was conducted among Chinese college students from February 4 to February 12, 2020 showed  Our study showed a higher prevalence of anxiety (54.34%) and depressive (59.35%) symptoms simultaneously, the higher prevalence of anxiety and depression may be a reflection of overestimation by the tools, as the tools were different in these studies, such as the 21-item Depression, Anxiety, and Stress Scale (DASS-21). However, we still hold it may be more resulting from the residents being forced to quarantine at home and entertainment activities have been restricted for more than 9 months, and a study conducted among 1,242 Wuhan residents showed 27.5% had anxiety, 29.3% had depression (24), who were forced to isolate themselves in their homes, and all forms of gathering have been strictly prohibited. Besides, all kinds of news about the epidemic and deaths told through the Internet also aggravates their psychological burden. Furthermore, all college students had to study online by themselves, a learning burden made them more likely to be depressed and anxious. Moreover, our study suggested that the epidemic may have lasting effects on college students' psychological health, and the risk of psychological disorders may increase over time, which supported two recent studies which found negative impact of the pandemic on mental health may be continuous and long-term (25,26). Therefore, effective interventions from policy makers, educators, and psychologists should be conducted among college students to provide timely and effective interventions for mental health benefits. The present study showed regular and health lifestyle changes such as regular physical activity, daily routine, diet, and sufficient sleep were positively associated with mental health and satisfaction with life. As we all know, healthy lifestyle contributes to protect the population's mental health, and our study was consistent with previous studies, which showed a healthy lifestyle with a balanced diet and regular exercise were associated with lower levels of depression and anxiety symptoms among adolescents during COVID-19 (27). An unhealthy pattern has been found to worsen the mental state and cognitive functioning (28,29), and numerous studies have reported that sustained adherence to healthy eating patterns can reduce markers of inflammation in humans (30), and heightened inflammation was linked to various mental health conditions, including mood disorders (31). In addition, regular physical activity is associated with lower levels of depression and anxiety symptoms, and the psychosocial mechanism hypothesis and behavioral mechanism hypothesis provided some explanation, and physical activity helps students for social interaction, self-efficacy, and perceived competence and improvements (32) as well as may improve self-regulation and coping skills which, in turn, helps students effectively stay positive mentally (33). Given the positive impact of healthy diet and lifestyle, it is expected that the combination of regular and good diet and regular physical activity would lead to greater benefits in the mental health and satisfaction with life than promoting one healthy lifestyle behavior alone during the COVID pandemic. Sleep problems could induce a poorer mental health status, and our study indicated that sufficient sleep was a protective factor for depression and anxiety, the possible mechanism was described in detail in a previous publication with individuals' sleep and mental health status interacting with each other (34). Juniors and seniors were more likely to have depression symptom, perhaps because they may experience greater pressure of study and employment than firstyear students. Additionally, residence of family of origin was associated with depression, urban residents had fewer symptoms of depression, which may be related to their richer and more convenient learning resources, which may contribute to buffer their pressure.
The 5-item SWLS was used to measure subjective well-being. Our study showed the scores of the SWLS among college students during the COVID-19 pandemic was higher than it was during the severe acute respiratory syndrome (SARS) epidemic in 2003, which showed an average score with 19.45 among 381 college students (35). Faster and wider publicity including improvement in health literacy, the touching stories about the fight against the epidemic, and the spirit of unity and more social support may have improved the overall satisfaction of life among current college students compared with those in 2003. Besides, a wide variety of virtual meeting applications, video software, and apps such as WeChat, QQ, Tencent Conference, and Zoom were used frequently to connect to friends and family in COVID-19, which may be helpful for their well-being (11). Besides, the same as depression and anxiety symptoms, a healthy lifestyle and regular physical activity were advantages for improving satisfaction with life.

Strengths and Limitations
Our findings have clinical and policy implications. First, psychology counselors in college should pay attention to the assessment of students' mental problems, communicating with their parents in a timely manner so as to implement effective intervention. In addition, health authorities and educators need to identify high-risk groups to conduct early psychological intervention. Moreover, healthy lifestyle behaviors (regular diet, physical activity, and sufficient sleep) should be promoted as an important preventive strategy to maintain their mental health. Some limitations in our study should be mentioned. First, the cross-sectional design precludes making causal inferences and no comparable pre-COVID-19 data were available within this study. Thus, longitudinal and retrospective studies are encouraged. Second, self-reported information may cause bias due to the social desirability effect and memory error. Thus, there is a need for better-designed studies with larger sample size and objective measure to provide more valuable information. Third, although the presence of mental problems was assessed by standardized questionnaires, these measures are not equivalent to clinical diagnoses, thus future studies with diagnostic interviews should be used. Fourth, we did not measure our participants about their degree of trauma in the outbreak, such as whether any their family members lost their jobs or even lives due to COVID-19, which might influence mental status. Fifth, although several confounders were adjusted in our study, there were still some other factors which were not included, such as a history of COIV-19 infection, admission to the hospital, vaccination, taking medication, and the number of online courses, which were related to COVID-19. Finally, the family's economic level was self-reported, and the assessment was biased and subjective.

CONCLUSION
In conclusion, a higher prevalence of psychological symptom is found among college students especially for medical students after 9 months of COVID-19 outbreak. The findings of our study highlight the urgent need to develop interventions and preventive strategies to address the mental health of college students.

DATA AVAILABILITY STATEMENT
The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.

ETHICS STATEMENT
The study was approved by the Research Ethics Committee in Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China. The patients/participants provided their written informed consent to participate in this study.

AUTHOR CONTRIBUTIONS
WL, PX, LC, XD, and JY conceived and designed the study. ZZ, DW, JY, and WL participated in the acquisition of data. ZZ and WL analyzed the data. PX, LC, and XD drafted the manuscript. JY and DW revised the manuscript. All authors contributed to the article and approved the submitted version.

FUNDING
The Fundamental Research Funds for the Central Universities (2019kfyXJJS032). The funder did not play any role in study design; in the collection, analysis, and interpretation of data; in the writing of the report; nor in the preparation, review, or approval of the manuscript.