Introduction

The covid-19 pandemic triggered mental disorders that altered individual’s cognitive function, especially since a general mental health deterioration had been reported before the pandemic (1,2); this deterioration has been more significant in certain groups (3,4,5). Furthermore, this was enhanced by the psychological impact of the lockdown which is why the pandemic should be regarded as a possible public health concern (6,7). This issue needs to be assessed in students, especially among those with higher frustration levels caused by an inability to focus on their education, those living in populations with high risk of covid-19 transmission, and those experiencing stress or other symptoms of depression (8). Together, these factors may have increased the prevalence of stress, anxiety, and depression, among others, affecting academic performance, professional development, and interpersonal relationships (9,10).

Furthermore, stress is known to highly affect university students because of the lack of adequate coping mechanisms, so they are prone to suffering emotional dysregulation issues, such as depression and anxiety, among others (8). Educational institutions should consider this in order to develop detection and aid programs for students, and to assess whether social distancing resulted in social stress, as well as in terms of depression and feelings of loneliness (11,12,13). Therefore, performing a situational analysis at the beginning of the crisis is essential. The purpose of this study was to determine the prevalence of and associations between anxiety, depression, and stress among Peruvian university students during the covid-19 pandemic.

Materials and methods

Design and population

This was an analytical, multicenter, cross-sectional study with data collection, whose target population was students of different higher education degrees in the most important and largest cities of Peru, including Arequipa, Ayacucho, Cajamarca, Chimbote, Chiclayo, Huancayo, Lima, Cerro de Pasco, Piura, Tacna, Trujillo, Ica, Cusco, Puno, Iquitos, and Huánuco.

University students pursuing a higher education degree during the pandemic and authorizing their participation were included. A total of 44 surveys were excluded since they were answered by technical education students, students that were not living in Peru, or students whose answers were incoherent; 29 surveys were excluded because the students did not agree to participate in the study; and 55 surveys were excluded because the participants did not have at least one of the mental health conditions. Snowball sampling was used by contacting the participants, who would then contact other groups of students and so on, until a minimum sampling size was achieved, consisting of 2,178 subjects (to obtain a minimum difference of 3% [48% vs. 51%], a 95% confidence interval, 80% potency, and a single sample size).

Procedures and ethics

This project was initiated in the middle of the health emergency declared by the Peruvian government, which is why all information was collected during June and July of 2020 using a free-access virtual survey (Google forms). For this reason, and owing to the fact that data had to be reported, the ethical recommendations for research in these contexts were followed. The study was described to the participants, and they were free to participate in the surveys (in all cases, the survey ended immediately if participants refused to participate), which were completely anonymous (so that participants could answer safely). The project was approved by the Ethics Committee of Universidad Privada Antenor Orrego (no. 0207-2020-upao). Once the surveys were conducted, the data were transferred to the general database (Microsoft Excel, 2016), and then filtered, cleared, and analyzed using Stata 11.1 software (StataCorp lp, College Station, tx, usa).

Variables and statistical analysis

The main (dependent) variables were stress, anxiety, and depression. They were estimated using the dass-21 questionnaire, consisting of 21 questions (7 questions for each screening diagnosis). For each participant, a Cronbach’s alpha estimation yielded adequate scores (stress alpha: 0.85; anxiety alpha: 0.84; and depression alpha: 0.87; considering scores of 0.70–0.90 as adequate). Each condition was categorized into normal, low, moderate, severe, and extremely severe. For statistical analysis, each category was classified dichotomously (category of interest: moderate + severe + extremely severe and comparison category: normal + low).

Moreover, other variables were recorded, with the main variables being subject area of the academic degree (health, engineering, management, basic sciences, law, human sciences, and others [the latter was considered a comparator for the statistical analysis]), sex (male or female), age (years), academic year (quantitatively, taking the first year as a comparator for statistical analysis), and university of origin (according to each participating university).

A table was developed to describe the population, as well as a figure to show the percentages for each category of the three dependent variables. Then, statistical association values for the crossing of each independent variable versus the three dependent variables were obtained. Generalized linear models were used for that purpose, with the Poisson family, the log link function, and models for robust variances adjusted according to the university of origin. Based on this information, prevalence ratios (apr), 95% confidence intervals (95% ci), and p values were obtained (values lower than 0.05 were considered statistically significant).

Results

Of the 2,572 participants surveyed during the covid-19 lockdown, 56.4% (1,438) pursued a degree associated with the health sciences, 54.8% (1,407) were women, the median age was 21 years (interquartile range, 20–23 years), and 23.9% (529) were in their third academic year (Table 1).

Anxiety was the most frequent condition (extremely severe in 4%, severe in 3%, and moderate in 10%), followed by depression (extremely severe in 3%, severe in 2%, and moderate in 8%) and stress (extremely severe in 1%, severe in 2%, and moderate in 4%) (Figure 1).

In the multivariate model, stress was not associated with the course of studies (p < 0.330 in all cases) or study years (p > 0.160 in all cases). However, women showed higher stress levels (apr: 1.43; 95% ci: 1.02–2.00; p = 0.040) and being older was associated with lower stress levels (apr: 0.89; 95% ci: 0.83–0.96; p = 0.002) (Table 2).

In the multivariate model, depression was not associated with the course of studies (p > 0.440 in all cases) or sex (p = 0.069). However, being older was associated with lower depression levels (apr: 0.92; 95% ci: 0.87–0.98; p = 0.006) and third-year students had higher depression levels than first-year students (apr: 2.11; 95% ci: 1.19–3.75; p value = 0.011) (Table 3).

In the multivariate model, anxiety was not associated with study years (p ≥ 0.050 in all cases). However, women showed higher anxiety levels (apr: 1.43; 95% ci: 1.07–1.92; p = 0.017) and being older was associated with lower anxiety levels (apr: 0.94; 95 % ci: 0.89–0.99; p = 0.044), as well as studying medicine (apr: 0.72; 95% ci: 0.56–0.93; p = 0.011) (Table 4).

Discussion

In this study, we noted that anxiety (one in every six participants) and depression (one in every seven participants) were more frequently observed among students during the lockdown. Similarly, Porter et al. found that, in Peru, at least 41% of subjects had mild anxiety or depression (14). A study conducted in a neighboring country determined the presence of psychological disorders among university students before the pandemic, and showed that 47% had anxiety, 28% had depression, and 44% had stress (15). Moreover, Arabic countries such as Jordan have also reported a 23.8% prevalence of depression and 13.1% prevalence of anxiety among university students during the covid-19 pandemic, which is a triggering factor for prior manifestations (16). Finally, in Saragossa, levels of anxiety and depression of 23.5% and 18.6%, respectively, were measured with dass-21, which may interfere with the lifestyles of students because of, for example, unhealthy alterations of their feeding patterns (17).

Unfortunately, our study instruments were only applied at one point, so it is unclear whether these conditions may have changed or worsened because of the pandemic (and its consequences). For this reason, we could not determine whether the normal values were increased or decreased, which is why educational institutions should measure these values and compare our results against subsequent findings.

This study evidenced that being older is associated with lower levels of depression, anxiety, and stress, which could be explained by the fact that older students have better emotional control. Wang conducted a study in China during the covid-19 pandemic and showed that 54% of participants classified the psychological impact as moderate or severe, regardless their age, which could be due to their satisfaction with the measures taken by their government (18). Prior epidemics—such as the one that took place in 2003 due to severe acute respiratory syndrome (sars)—have also changed student populations. In countries such as Malaysia, students in their first semesters showed higher anxiety levels than those in their last semesters, since the latter reported having a wider realistic perspective and increased maturity when facing their context (19). This situation was similar to the one described in our study.

Cao conducted a similar study with Chinese medicine students and showed that 25% had some level of anxiety. This was not associated with age, but with living in urban areas, living with their parents, and having a stable family income (all these were protective factors during the lockdown) (20). For this reason, a situational analysis should be conducted for each population according to the current context, since there could be considerable variations due to social, economic, and even cultural factors.

Moreover, Puthran et al. conducted a meta-analysis to determine the prevalence of depression among medical students in 2015, and found that first-year students showed the highest depression rates (34%), which decreased gradually and significantly until reaching 21% in fifth-year students (21). This was because of the difficulties with adaptation experienced by new students, which decrease as academic years go by and students learn to cope with any challenges they may face.

Our study showed that women were more likely to suffer from stress and depression. A study conducted in Pakistan reported that 27% of female medical students had moderate stress and 32% had extremely severe depression (22). In Germany, a study reported statistically significant and higher depression levels among female students (23). In closer countries, such as Cuba, the female sex has also been associated with moderate and high stress levels (90%) (24).This may be attributable to cultural differences associated with social prejudice and gender inequality and, many times, coexistence with other conditions such as major depression, the consumption of harmful substances, and personality disorders (25,26). For this reason, further studies should focus on the relationship between social support, wellbeing, personality, social roles, and even sexism, as well as other aspects found in our population, in order to identify the factors that mostly determine the likelihood of suffering from depression, anxiety, and stress.

Our study shows that health sciences students had lower anxiety levels than other students. A study conducted in Australia found that graduate and undergraduate first-year students had normal values, within the dass-21 limit, in the depression, anxiety, and stress subscales. However, being a woman and having financial problems increased the stress levels of graduate students (27).

Another study associated higher psychological impact with covid-19 outbreak, and with dissatisfaction toward available information about the disease. Thus, access to updated and accurate data on this virus and the application of specific preventive measures were associated with lower levels of the three conditions studied (18). For this reason, educational methods should be available to students in order to avoid a negative academic impact and ensure the availability of adequate data about covid-19.

In our study, students in their middle years showed higher depression levels than first-year students. This varies from study to study, given that some stated that depression was more frequent during the first academic years and others stated that it was more frequent during the last ones (28,29,30,31). Our findings may be explained by the fact that middle-year students feel more uncertainty and fear toward failing their academic semester, since they had already invested in their first study years as opposed to first-year students. They also showed more concern toward their graduation. Another factor is the changing rhythm of university life, which favors physical inactivity and bad sleep quality, affecting students’ academic performance, and is associated with depression, anxiety, and stress (32).

The main limitation was that our results cannot be extrapolated to the entire Peruvian population, mainly due to the sampling method and the fact that the virtual survey had. However, these results can be considered as a baseline study, since it includes thousands of subjects from the most important cities of Peru. This way, each educational institution should follow-up their students (during the pandemic and after it), measure more variables, and even find a bigger sample size (which allows for higher statistical power to estimate smaller percentage differences).

Due to all of the above, we conclude that anxiety and depression were more frequently observed among university students during the pandemic. Older students had lower anxiety and stress levels, women had lower likelihood of suffering from stress and depression, health students had lower anxiety levels than other students, and middle-year students had higher depression levels than first-year students.

Authors’ contributions

All authors participated in the development of the research and project idea, as well as in data collection and interpretation of the results. The final report was written and approved by all authors. Author Christian R. Mejia conducted the statistical analysis.

Conflict of interests

None stated.

References

1. Broche Y, Fernandez E, Reyes D. Consecuencias psicológicas de la cuarentena y el aislamiento social durante la pandemia de covid-19. Rev Cuba Salud Publ. 2020;46(suppl esp):(e2488):1-14.

2. Brooks SK, Webster RK, Smith LE, Woodland L, Wessely S, Greenberg N, et al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Lancet. 2020;395(10227):912-20. https://doi.org/10.1016/S0140-6736(20)30460-8

3. Vargas M, Talledo-Ulfe L, Heredia P, Quispe-Colquepisco S, Mejia CR. Influencia de los hábitos en la depresión del estudiante de medicina peruano: estudio en siete departamentos. Rev Colomb Psiquiatr. 2018;47(1):32-6. https://doi.org/10.1016/j.rcp.2017.01.008

4. Mejia CR, Valladares-Garrido MJ, Talledo-Ulfe L, Sánchez-Arteaga K, Rojas C, RuizArimuya JJ, et al. Burnout syndrome and associated factors in medical students: multicenter study in seven schools Peruvian medicine. Rev Chil Neuropsiquiatr. 2016;54(3):207-14.

5. Amor EM, Baños JE, Sentí M, Amor EM, Baños JE, Sentí M. Prevalencia del síndrome de burnout entre los estudiantes de medicina y su relación con variables demográficas, personales y académicas. fem. 2020;23(1):25-33. https://doi.org/10.33588/fem.231.1036

6. Gasteiger N, Vedhara K, Massey A, Jia R, Ayling K, Chalder T, et al. Depression, anxiety and stress during the covid-19 pandemic: results from a New Zealand cohort study on mental well-being. bmj Open. 2021;11(5):e045325. https://doi.org/10.1136/bmjopen-2020-045325

7. Pfefferbaum B, Schonfeld D, Flynn BW, Norwood AE, Dodgen D, Kaul RE, et al. The H1N1 crisis: A case study of the integration of mental and behavioral health in public health crises. Disaster Med Public Health Prep. 2012;6(1):67-71. https://doi.org/10.1001/dmp.2012.2

8. Leong Bin Abdullah MFI, Mansor NS, Mohamad MA, Teoh SH. Quality of life and associated factors among university students during the covid-19 pandemic: a cross-sectional study. bmj Open. 2021;11(10):e048446. https://doi.org/10.1136/bmjopen-2020-048446

9. Ortega ME, Ortiz GR, Martínez AJ. Burnout en estudiantes de pregrado de medicina y su relación con variables de personalidad. Ter Psicol. 2014;32(3):235-42. https://doi.org/10.4067/S0718-48082014000300006

10. Sepúlveda JDM, Araujo LAD, Katrandzhiev AI, de Los Santos P GP, Toloza CA, et al. Bienestar y afrontamiento psicológico de estudiantes universitarios en estado de confinamiento por covid-19. Rev Inclus. 2020;7(esp):377-98

11. Galante J, Dufour G, Benton A, Howarth E, Vainre M, Croudace TJ, et al. Protocol for the Mindful Student Study: a randomised controlled trial of the provision of a mindfulness intervention to support university students’ well-being and resilience to stress. bmj Open. 2016;6(11):e012300. https://doi.org/10.1136/bmjopen-2016-012300

12. Lemos M, Henao Pérez M, López Medina DC. Estrés y salud mental en estudiantes de medicina: relación con afrontamiento y actividades extracurriculares. Arch Med. 2018;14(2: 3):1-8. https://doi.org/10.3823/1385

13. Astocondor Altamirano JV, Ruiz Solsol LE, Mejia CR. Influencia de la depresión en la ideación suicida de los estudiantes de la selva peruana [English: Influence of depression on suicidal ideation in students from the Peruvian jungle]. Horiz Med. 2019;19(1):53-8. https://doi.org/10.24265/horizmed.2019.v19n1.09.

14. Porter C, Favara M, Hittmeyer A, Scott D, Sánchez Jiménez A, Ellanki R, et al. Impact of the covid-19 pandemic on anxiety and depression symptoms of young people in the global south: evidence from a four-country cohort study. bmj Open. 2021;11(4):e049653. https://doi.org/10.1136/bmjopen-2021-049653

15. Barraza RL, Muñoz Nadia N, Alfaro Marco G, Álvarez Álvaro M, Araya Valeria T, Villagra Johan C, et al. Ansiedad, depresión, estrés y organización de la personalidad en estudiantes novatos de medicina y enfermería. Rev Chil Neuropsiquiatr. 2015;53(4):251-60. https://doi.org/10.4067/S0717-92272015000400005

16. Naser AY, Dahmash EZ, Al-Rousan R, Alwafi H, Alrawashdeh HM, Ghoul I, et al. Mental health status of the general population, healthcare professionals, and university students during 2019 coronavirus disease outbreak in Jordan: a cross-sectional study. Brain Behav. 2020;10(8):e01730. https://doi.org/10.1002/brb3.1730

17. Ramón-Arbués E, Martínez Abadía B, Granada López JM, Echániz Serrano E, Pellicer García B, Juárez Vela R et al. Eating behavior and relationships with stress, anxiety, depression and insomnia in university students. Nutr Hosp. 2019;36(6):1339-45. https://doi.org/10.20960/nh.02641

18. Wang C, Pan R, Wan X, Tan Y, Xu L, Ho CS, et al. Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (covid-19) epidemic among the general population in China. Int J Environ Res Public Health. 2020;17(5):1729. https://doi.org/10.3390/ijerph17051729

19. Loh LC, Ali AM, Ang TH, Chelliah A. Impact of a spreading epidemic on medical students. Malays J Med Sci. 2006;13(2):30-6.

20. Cao W, Fang Z, Hou G, Han M, Xu X, Dong J, et al. The psychological impact of the covid-19 epidemic on college students in China. Psychiatry Res. 2020;287:112934. https://doi.org/10.1016/j.psychres.2020.112934

21. Puthran R, Zhang MWB, Tam WW, Ho RC. Prevalence of depression amongst medical students: a meta-analysis. Med Educ. 2016;50(4):456-68. https://doi.org/10.1111/medu.12962

22. Kumar B, Shah MAA, Kumari R, Kumar A, Kumar J, Tahir A. Depression, anxiety, and stress among final-year medical students. Cureus. 2019;11(3):e4257. https://doi.org/10.7759/cureus.4257

23. Burger PHM, Scholz M. Gender as an underestimated factor in mental health of medical students. Ann Anat. 2018;218:1-6. https://doi.org/10.1016/j.aanat.2018.02.005

24. Román Collazo CA, Ortiz Rodríguez F, Hernández Rodríguez Y. El estrés académico en estudiantes latinoamericanos de la carrera de Medicina.

25. Brenneisen Mayer F, Souza Santos I, Silveira PSP, Itaqui Lopes MH, De Souza ARND, Campos EP, et al. Factors associated to depression and anxiety in medical students: a multicenter study. bmc Med Educ. 2016;16(1):282. https://doi.org/10.1186/s12909-016-0791-1

26. Craske MG, Stein MB. Anxiety. Lancet. 2016;388(10063):3048-59. https://doi.org/10.1016/S0140-6736(16)30381-6

27. Atkinson SR. Elevated psychological distress in undergraduate and graduate entry students entering first year medical school. PloS One. 2020;15(8):e0237008. https://doi.org/10.1371/journal.pone.0237008

28. Teshome Hambisa M, Derese A, Abdeta T. Depressive symptoms among Haramaya University students in Ethiopia: a cross-sectional study. Depress Res Treat. 2020;2020:5027918. https://doi.org/10.1155/2020/5027918

29. Basnet B, Jaiswal M, Adhikari B, Shyangwa PM. Depression among undergraduate medical students. Kathmandu Univ Med J (kumj). 2012;10(39):56-9. https://doi.org/10.3126/kumj.v10i3.8021

30. Jowkar Z, Masoumi M, Mahmoodian H. Psychological stress and stressors among clinical dental students at Shiraz School of Dentistry, Iran. Adv Med Educ Pract. 2020;11:113-20. https://doi.org/10.2147/AMEP.S236758

31. Zafar U, Daud S, Khalid A. Determinants of depression among undergraduate medical students of a private medical college in Lahore. J Pak Med Assoc. 2020;70(3):467-71. https://doi.org/10.5455/JPMA.13896

32. Al-Khani AM, Sarhandi MI, Zaghloul MS, Ewid M, Saquib N. A cross-sectional survey on sleep quality, mental health, and academic performance among medical students in Saudi Arabia. bmc Res Notes. 2019;12(1):665. https://doi.org/10.1186/s13104-019-4713-2

Author notes

* Correspondence author: christian.mejia.md@gmail.com