Effects of COVID-19 on College Students’ Mental Health in the

United States: Interview Survey Study

Effects of COVID-19 on College Students’ Mental Health in the United States:
Interview Survey Study

Authors of this article:

Changwon Son 1  ;  Sudeep Hegde 1  ;  Alec Smith 1  ;  Xiaomei Wang 1  ;  Farzan Sasangohar 1, 2 

Introduction

Mental health issues are the leading impediment to academic success. Mental illness can affect
students’ motivation, concentration, and social interactions—crucial factors for students to
succeed in higher education [1]. The 2019 Annual Report of the Center for Collegiate Mental
Health [2] reported that anxiety continues to be the most common problem (62.7% of 82,685
respondents) among students who completed the Counseling Center Assessment of
Psychological Symptoms, with clinicians also reporting that anxiety continues to be the most
common diagnosis of the students that seek services at university counseling centers. Consistent
with the national trend, Texas A&M University has seen a rise in the number of students seeking
services for anxiety disorders over the past 8 years. In 2018, slightly over 50% of students
reported anxiety as the main reason for seeking services. Despite the increasing need for mental
health care services at postsecondary institutions, alarmingly, only a small portion of students
committing suicide contact their institution counseling centers [3], perhaps due to the stigma
associated with mental health. Such negative stigma surrounding mental health diagnosis and
care has been found to correlate with a reduction in adherence to treatment and even early
termination of treatment [4].

The COVID-19 pandemic has brought into focus the mental health of various affected
populations. It is known that the prevalence of epidemics accentuates or creates new stressors
including fear and worry for oneself or loved ones, constraints on physical movement and social
activities due to quarantine, and sudden and radical lifestyle changes. A recent review of virus
outbreaks and pandemics documented stressors such as infection fears, frustration, boredom,
inadequate supplies, inadequate information, financial loss, and stigma [5]. Much of the current
literature on psychological impacts of COVID-19 has emerged from the earliest hot spots in
China. Although several studies have assessed mental health issues during epidemics, most have
focused on health workers, patients, children, and the general population [6,7]. For example, a
recent poll by The Kaiser Family Foundation showed that 47% of those sheltering in place
reported negative mental health effects resulting from worry or stress related to COVID-19 [8].
Nelson et al [9] have found elevated levels of anxiety and depressive symptoms among general
population samples in North America and Europe. However, with the exception of a few studies,
notably from China [10-12], there is sparse evidence of the psychological or mental health
effects of the current pandemic on college students, who are known to be a vulnerable population
[13]. Although the findings from these studies thus far converge on the uptick of mental health
issues among college students, the contributing factors may not necessarily be generalizable to
populations in other countries. As highlighted in multiple recent correspondences, there is an
urgent need to assess effects of the current pandemic on the mental health and well-being of
college students [14-17].

The aim of this study is to identify major stressors associated with the COVID-19 pandemic and
to understand their effects on college students’ mental health. This paper documents the findings
from online interview surveys conducted in a large university system in Texas.

Methods

Study Design

A semistructured interview survey guide was designed with the purpose of assessing the mental
health status of college students both quantitatively and qualitatively. In addition, the interview
aimed to capture the ways that students have been coping with the stress associated with the
pandemic situation. First, our study assesses participants’ general stress levels using the
Perceived Stress Scale-10 (PSS) [18]. PSS is a widely used instrument to measure overall stress
in the past month [19]. Second, participants were asked if their own and peers’ (two separate
questions) stress and anxiety increased, decreased, or remained the same because of the COVID-
19 pandemic. For those who indicated increased stress and anxiety during the pandemic, we
questioned their stress coping strategies and use of available mental health counseling services.
We then elicited pandemic-specific stressors and their manifestations across 12 academic-,
health-, and lifestyle-related categories of outcomes such as effects on own or loved ones’ health,
sleeping habits, eating habits, financial situation, changes to their living environment, academic
workload, and social relations. Students were also asked about the impact of COVID-19 on
depressive and suicidal thoughts. These constructs were derived from existing literature
identifying prominent factors affecting college students’ mental health [20,21]. Feedback on the
severity of COVID-19’s impact on these aspects were elicited using a 4-point scale: 0 (none), 1
(mild), 2 (moderate), and 3 (severe). Participants were asked to elaborate on each response.
Third, participants were guided to describe stressors, coping strategies, and barriers to mental
health treatment during a typical semester without associating with the COVID-19 pandemic.
Although multiple analyses of the collected data are currently under progress, PSS results and
the COVID-19–related findings are presented in this paper.

Participants

Participants were recruited from the student population of a large university system in Texas,
United States. This particular university closed all their campuses on March 23, 2020, and held
all its classes virtually in response to the COVID-19 pandemic. In addition, the state of Texas
issued a stay-at-home order on April 2, 2020. Most interviews were conducted about 1 month
after the stay-at-home order in April
2020. 
Figure 1 illustrates the trend of cumulative confirmed cases and a timeline of major events that
took place in the university and the state of Texas. Participants were recruited by undergraduate
student researchers through email, text messaging, and snowball sampling. The only inclusion
criteria for participation was that participants should have been enrolled as undergraduate
students in the university at the time of the interviews.
Figure 1. A timeline of major events related to COVID-19 in the university and the state of
Texas (source: Texas Department of State Health Services).View this figure

Procedures

The interviews were conducted by 20 undergraduate researchers trained in qualitative methods

and the use of the interview survey guide described above. None of the authors conducted the
interviews. All interviews were conducted via Zoom [22] and were audio recorded. The
recordings were later transcribed using Otter.ai [23], an artificial intelligence–based transcription
service, and verified for accuracy manually. Prior to the interview, participants were provided an
information document about the study approved by the university’s Institutional Review Board
(No 2019-1341D). Upon verbal consent, participants were asked to respond to a questionnaire
about their demographic information such as age, gender, year of college, and program of study
before completing the interview. Participation was voluntary and participants were not
compensated.

Data Analysis
First, descriptive statistics were compiled to describe participants’ demographics (eg, age,
gender, academic year, and major) and the distribution of the ratings on PSS-10 survey items. A
total PSS score per participant was calculated by first reversing the scores of the positive items
(4-7, 9, and 10) and then adding all the ten scores. A mean (SD) PSS score was computed to
evaluate the overall level of stress and anxiety among the participants during the COVID-19
pandemic. Second, participants’ answers to 12 academic-, health-, and lifestyle-related questions
were analyzed to understand relative impacts of the pandemic on various aspects of college
students’ mental health. Percentages of participants who indicated negative ratings (ie, mild,
moderate, or severe influence) on these questions were calculated and ranked in a descending
order. Qualitative answers to the 12 stressors and coping strategies were analyzed using thematic
analysis [24,25] similar to the deductive coding step in the grounded theory method [26]. A
single coder (CS), trained in qualitative analysis methods, analyzed the transcripts and identified
themes using an open coding process, which does not use a priori codes or codes created prior to
the analysis and places an emphasis on information that can be extracted directly from the data.
Following the identification of themes, the coder discussed the codes with two other coders (XW
and AS) trained in qualitative analysis and mental health research to resolve discrepancies
among related themes and discuss saturation. The coders consisted of two Ph.D. students and one
postdoctoral fellow at the same university. MAXQDA (VERBI GmbH) [27] was used as a
computer software program to carry out the qualitative analysis.

Results

Participants

Of the 266 university students initially recruited by the undergraduate researchers, 17 retreated
and 249 participated in this study. There were 3 graduate students and 51 participants who had
missing data points and were excluded, and data from 195 participants were used in the analysis.
The average age was 20.7 (SD 1.7) years, and there were more female students (111/195, 57%)
than male students (84/195, 43%). Approximately 70% of the participants were junior and senior
students. About 60% of the participants were majoring in the college of engineering, which was

the largest college in the university population ( Table 1). The mean PSS score
for the 195 participants was 18.8 (SD 4.9), indicating moderate perceived stress in the month

prior to the interview ( Table 2).

Table 1. Participants’ demographic characteristics.

Variables Partic
Age (years), mean (SD) 20.7 (
Gender, n (%)
Male 84 (4
Female 111 (
Academic year, n (%)
Freshmen 24 (1
Sophomore 33 (1
Junior 70 (3
Senior 68 (3
Major (college), n (%)
Agriculture & life science 10 (5
Engineering 117 (
Liberal arts 20 (1
Architecture 1 (0.5
Business management 11 (5
Education and human development 12 (6
School of public health 5 (2.5
Science 5 (2.5
Veterinary medicine and biomedical sciences 10 (5
Not specified 4 (2.1
Table 2. Mean score for each of PSS items.

PSSa items
1. In the past month, how often have you felt upset because of something that happened unexpectedly?
2. In the past month, how often have you felt that you were unable to control the important things in your life?
3. In the past month, how often have you felt nervous and “stressed”?
4. In the past month, how often have you dealt successfully with irritating life hassles?
5. In the past month, how often have you felt that you were effectively coping with important changes that were
 PSSa items
6. In the past month, how often have you felt confident about your ability to handle your personal problems?
7. In the past month, how often have you felt that things were going your way?
8. In the past month, how often have you found that you could not cope with all the things that you needed to do
9. In the past month, how often have you been able to control irritations in your life?
10. In the past month, how often have you felt that you were on top of things?
Overall PSS scores

a
PSS: Perceived Stress Scale-10.

Challenges to College Students’ Mental Health During COVID-19

Out of 195 participants, 138 (71%) indicated that their stress and anxiety had increased due to
the COVID-19 pandemic, whereas 39 (20%) indicated it remained the same and 18 (9%)
mentioned that the stress and anxiety had actually decreased. Among those who perceived
increased stress and anxiety, only 10 (5%) used mental health counseling services. A vast
majority of the participants (n=189, 97%) presumed that other students were experiencing
similar stress and anxiety because of COVID-19. As shown
in 
Figure 2, at least 54% (up to 91% for some categories) of participants indicated negative impacts
(either mild, moderate, or severe) of COVID-19 on academic-, health-, and lifestyle-related
outcomes. The qualitative analysis yielded two to five themes for each category of outcomes.
The chronic health conditions category was excluded from the qualitative analysis due to

insufficient qualitative response.  Table 3 presents the description and

frequency of the themes and select participant quotes.
Figure 2. Participants’ ratings on mental health aspects in an order of negative impacts (mild,
moderate, and severe).View this figure
Table 3. Categories and themes of college students’ mental health issues and selected participant
quotes.

Theme Participantsa, n Example quotesb

(%)
Own health and the health of loved ones (n=177)
Worry about families and 76 (43)  JPP17: “I have a grandma who is affected more by [the
relatives with higher something could happen to her.”
vulnerabilities

 SAP16: “My sister just had a baby on Friday and so I\'v

wouldn\'t get anything.”

Worry about families with 26 (15)  JJP06: “My brother just graduated from a med school a
more interpersonal contact patient he sees right now is most likely related to COV
Theme Participantsa, n Example quotesb
(%)

 DDP01: “My mom is actually an essential worker. She

city in Texas]. So, she\'s coming into contact with peop

Worry about themselves 19 (11)  ACP05: “I always end up having runny nose or just ast
being infected symptoms are very similar to corona so I feel like I wo
highly affected by it.”

Difficulty in concentration (n=173)

Home as a source of 79 (46)  EGP03: “I\'m having difficulty concentrating since I\'m
distraction it\'s really hard to focus on what I need to do.”

Lack of accountability and 21 (12)  SAP16: “I just want to lay in my bed. Now no one is ke
motivation phone, I\'m not paying attention to any of these lectures

Distracted by social media, 19 (11)  DDP01: “My desk is right next to my bed so I could ju
internet, and video games could just be on Twitter the whole time and read all the
or how bad this is going to get.”

Lack of interactive learning 18 (10)  SAP17: “I cannot focus on class when it’s online. Thro
environment of interactiveness to make people engaged.”

Monotony of life 5 (3)  DDP07: “Now I\'m stuck only doing everything on a co
computer all day.”

Sleeping habits (n=168)

Stay up later or waking up 84 (50)  DDP03: “I\'ll be up until probably four or five in the m
later Now that most of my classes are online and the lecture
I\'ll watch the lectures later.”

Irregular sleep patterns 28 (17)  SAP03: “I had a really weird sleep schedule now. I stay
Theme Participantsa, n Example quotesb
(%)
early or sometimes I go to sleep early. I wake up really

Increased hours of sleep 12 (7)  ACP06: “I’m sleeping a lot more now. I’m living at ho
have more time to sleep.”

Difficulty of going/staying 10 (6)  DDP07: “Now I wake up constantly. I wake up and go

asleep staying asleep and going asleep.”

Social relation/social isolation (n=167)

Reduced interactions with 91 (54)  MBP01: “We\'re in quarantine so there is significant so
people that I want to hang out with.”

Lack of in-person 52 (31)  JJP02: “I don’t see my friends that much and no face to
interactions

Restricted outdoor activities 9 (5)  SNK10: “I also like meeting new people so sometimes
has impacted me a lot. I\'m not able to do that anymore

Academic performance (n=159)

Challenges of online classes 61 (38)  RMP10: “It\'s so hard to focus on the lecture because e
appointments with a professor or a TAc. Then they help
think it\'s hard to have some understanding compared t

Impacts on academic 36 (23)  ACP07: “The class I wanted to take over the summer h
progress and future career push me back a semester.”

 RMP17: “I think my internship is going to be shortened

experience before graduation.”

Worry about grades 23 (14)  ACP12: “Shortly after COVID-19 was declared a pand
a week of class. So, I had four exams back to back but
Theme Participantsa, n Example quotesb
(%)
failed three out of four exams pretty badly. That also go
major.”

Reduced motivation or 12 (8)  RMP12: “I feel like I started slacking. I was trying to a
procrastination of the work. So, it is stressful academically.”

Eating patterns (n=137)

Increased eating/snacking 35 (26)  SNK08: “I\'ve been munching a lot on snacks recently

Inconsistent eating 27 (20)  SAP02: “I\'m home all the time. Sometimes I eat twice
Sometimes it\'s once a day. It\'s not something I haven\

Decreased appetite 16 (12)  SAP15: “I\'m having trouble eating. I just don\'t eat wh

Emotional eating 7 (5)  SAP04: “I eat so much now just out of boredom becaus

Changes in living environment (n=130)

Changes while staying back 89 (68)  YJP05: “I moved back home. So, things are different h
home bedroom rather than in the library or on campus.”

 JJP07: “By living with family, you don’t have any priv
you are distracted.”

Reduced personal 18 (14)  ACP02: “I live in the dorm and everybody is moving o
interactions anymore.”

Staying longer indoor 9 (7)  RMP19: “Now I\'m at home. I\'m literally sitting in the

Financial difficulties (n=115)

Theme Participantsa, n Example quotesb
(%)
Impacts on current or future 44 (38)  SAP13: “I have rent to pay in [a local town] and I am n
employment So, I\'m going to be basically even in more debt and no

Impacts on financial 21 (18)  ERP03: “My mom has so much that she needs to pay o
situations of families payment, but she still need to pay the same thing. She n
and my brothers, which is a lot.”

Class workload (n=106)

Catching up with online 51 (48)  ERP04: “[Professors] still want me to go to a Zoom cla
courses and class projects meetings and then you can watch it on your own time.
dedicate each week for that class.”

Increased or more difficult 33 (31)  ERP02: “Four or five out of my six professors have giv
assignments was there in person. Some of them have to do with part
watch the lecture or take notes for the class.”

Difficulty of covering the 6 (6)  NEP04: “A two-week break because of the pandemic m
same coursework in shorter last time we had scheduled.”
time

Depressive thoughts (n=86)

Loneliness 28 (33)  MBP02: “I actually suffer from chronic depression. [CO
worse, just being in isolation and being home 24/7. It fe
nowhere to go.”

Insecurity or uncertainty 10 (12)  RMP18: “The first couple of days, it was very scary an
is ending.”

Powerlessness or 9 (10)  SNK01: “Maybe [COVID-19] made me really down. S

hopelessness

 SAP20: “It\'s very easy to fall into a routine of nothingn

It\'s just hopelessness about going back to normal.”
 Theme Participantsa, n Example quotesb
(%)

Concerns about academic 7 (8)  ACP07: “A lot of hackathons I wanted to go to and a lo

performance to have all been shut down. And now it feels like all the
months has been thrown away into the garbage.”

Overthinking 4 (5)  SAP08: “There\'s just a lot and also you start going cra

Suicidal thoughts (n=16)

Linking to depressive 6 (38)  JJP03: “[Suicidal thoughts] go hand in hand with depre
thoughts because I am just too hard on myself.”

 ECP02: “It just has to do with the depressive thoughts a

time to think about things that happened in the past like
Now, I\'m stuck.”

Academic issues 1 (6)  ACP12: “I hate to say it but it comes up on a daily basi
it\'s something that I know I have no intention to ever a
become incorporated in my life purposely or unconscio
related to academics.”

Problems with parents 1 (6)  SNK09: “I have some problems with my family. And n
it\'s more often than normal.”

Fear from insecurity 1 (6)  JPP18: “The biggest thing has been fear of what\'s next
what is to come and what will be the outcome.”

a
Not every participant provided sufficient elaboration to allow for identification of themes, so the
frequency of individual themes does not add up to the total number of participants who indicated
negative impacts of the COVID-19 outbreak.
b
The five-digit alphanumeric value indicates the participant ID.
c
TA: teaching assistant.

Concerns for One’s Own Health and the Health of Loved Ones

A vast majority of the participants (177/195, 91%) indicated that COVID-19 increased the level
of fear and worry about their own health and the health of their loved ones. Over one-third of
those who showed concern (76/177, 43%) were worried about their families and relatives who
were more vulnerable, such as older adults, those with existing health problems, and those who
are pregnant or gave birth to a child recently. Some of the participants (26/177, 15%) expressed
their worry about their family members whose occupation increased their risk of exposure to
COVID-19 such as essential and health care workers. Some participants (19/177, 11%)
specifically mentioned that they were worried about contracting the virus.

Difficulty With Concentration

A vast majority of participants (173/195, 89%) indicated difficulty in concentrating on academic

work due to various sources of distraction. Nearly half of them (79/173, 46%) mentioned that
their home is a distractive environment and a more suitable place to relax rather than to study.
Participants mentioned that they were more prone to be interrupted by their family members and
household chores at home. Other factors affecting students’ concentration were lack of
accountability (21/173, 12%) and social media, internet, and video games (19/173, 11%). Some
(18/173, 10%) stated that online classes were subject to distraction due to lack of interactions and
prolonged attention to a computer screen. Additionally, monotonous life patterns were
mentioned by some to negatively affect concentration on academic work (5/173, 3%).

Disruption to Sleep Patterns

A majority of participants (168/195, 86%) reported disruptions to their sleep patterns caused by
the COVID-19 pandemic, with over one-third (38%) reporting such disruptions as severe. Half
of students who reported some disruption (84/168, 50%) stated that they tended to stay up later
or wake up later than they did before the COVID-19 outbreak. Another disruptive impact
brought by the pandemic was irregular sleep patterns such as inconsistent time to go to bed and
to wake up from day to day (28/168, 17%). Some (12/168, 7%) reported increased hours of
sleep, while others (10/168, 6%) had poor sleep quality.

Increased Social Isolation

A majority of participants answered that the pandemic has increased the level of social isolation
(167/195, 86%). Over half of these students (91/167, 54%) indicated that their overall
interactions with other people such as friends had decreased significantly. In particular, about
one-third (52/167, 31%) shared their worries about a lack of in-person interactions such as face-
to-face meetings. Others (9/167, 5%) stated that disruptions to their outdoor activities (eg,
jogging, hiking) have affected their mental health.

Concerns About Academic Performance

A majority of participants (159/195, 82%) showed concerns about their academic performance
being impacted by the pandemic. The biggest perceived challenge was the transition to online
classes (61/159, 38%). In particular, participants stated their concerns about sudden changes in
the syllabus, the quality of the classes, technical issues with online applications, and the
difficulty of learning online. Many participants (36/159, 23%) were worried about progress in
research and class projects because of restrictions put in place to keep social distancing and the
lack of physical interactions with other students. Some participants (23/159, 14%) mentioned the
uncertainty about their grades under the online learning environment to be a major stressor.
Others (12/159, 8%) indicated their reduced motivation to learn and tendency to procrastinate.

Disruptions to Eating Patterns

COVID-19 has also negatively impacted a large portion of participants’ dietary patterns
(137/195, 70%). Many (35/137, 26%) stated that the amount of eating has increased, including
having more snacks since healthy dietary options were reduced, and others (27/137, 20%)
addressed that their eating patterns have become inconsistent because of COVID-19, for
example, irregular times of eating and skipping meals. Some students (16/137, 12%) reported
decreased appetite, whereas others (7/137, 5%) were experiencing emotional eating or a
tendency to eat when bored. On the other hand, some students (28/195, 14%) reported that they
were having healthier diets, as they were cooking at home and not eating out as much as they
used to.

Changes in the Living Environment

A large portion of the participants (130/195, 67%) described that the pandemic has resulted in
significant changes in their living conditions. A majority of these students (89/130, 68%)
referred to living with family members as being less independent and the environment to be
more distractive. For those who stayed in their residence either on- or off-campus (18/130, 14%),
a main change in their living environment was reduced personal interactions with roommates.
Some (9/130, 7%) mentioned that staying inside longer due to self-quarantine or shelter-in-place
orders was a primary change in their living circumstances.

Financial Difficulties

More than half of the participants (115/195, 59%) expressed their concerns about their financial
situations being impacted by COVID-19. Many (44/115, 38%) noted that COVID-19 has
impacted or is likely to impact their own current and future employment opportunities such as
part-time jobs and internships. Some (21/115, 18%) revealed the financial difficulties of their
family members, mostly parents, getting laid off or receiving pay cuts in the wake of COVID-19.

Increased Class Workload

The effect of COVID-19 on class workload among the college students was not conclusive.
Although slightly over half of participants (106/195, 54%) indicated their academic workload
has increased due to COVID-19, the rest stated the workload has remained the same (70/195,
36%) or rather decreased (19/195, 10%). For those who were experiencing increased workloads,
nearly half (51/106, 48%) thought they needed to increase their own efforts to catch up with
online classes and class projects given the lack of in-person support from instructors or teaching
assistants. About one-third of the participants (33/106, 31%) perceived that assignments had
increased or became harder to do. Some (6/106, 6%) found that covering the remainder of
coursework as the classes resumed after the 2-week break to be challenging.

Depressive Thoughts

When asked about the impact of the COVID-19 pandemic on depressive thoughts, 44% (86/195)
mentioned that they were experiencing some depressive thoughts during the COVID-19
pandemic. Major contributors to such depressive thoughts were loneliness (28/86, 33%),
insecurity or uncertainty (10/86, 12%), powerlessness or hopelessness (9/86, 10%), concerns
about academic performance (7/86, 8%), and overthinking (4/86, 5%).

Suicidal Thoughts

Out of 195 participants, 16 (8%) stated that the pandemic has led to some suicidal thoughts with
5% (10/16) reporting these thoughts as mild and 3% (6/16) as moderate. There were 6
participants (38%) that attributed their suicidal thoughts to the presence of depressive thoughts.
Other reasons were related to academic performance (1/16, 6%), problems with family as they
returned home (1/16, 6%), and fear from insecurity and uncertainty (1/16, 6%).

Coping Mechanism During COVID-19

To cope with stress and anxiety imposed by COVID-19, college students reported seeking
support from others but were mainly using various self-management methods.

Self-Management

The majority of the participants (105/138, 76%) with increased stress due to the outbreak of
COVID-19 explained that they were using various means to help themselves cope with stress and
anxiety during the pandemic. Some (24/105, 23%) relied on negative coping methods such as
ignoring the news about COVID-19 (10/105), sleeping longer (7/105), distracting themselves by
doing other tasks (5/105), and drinking or smoking (2/105). Approximately one-third (30/105,
29%) used positive coping methods such as meditation and breathing exercises (18/105),
spiritual measures (7/105), keeping routines (4/105), and positive reframing (2/105). A majority
of the participants (73/105, 70%) who used self-management mentioned doing relaxing hobbies
including physical exercise (31/105), enjoying streaming services and social media (22/105),
playing with pets (7/105), journaling (5/105), listening to music (4/105), reading (2/105), and
drawing (2/105). Finally, some participants (15/105, 14%) stated that they were planning
activities (eg, drafting to-do lists) for academic work and personal matters as a self-distraction
method.

Seeking Support From Others

Approximately one-third of the participants (47/138, 34%) mentioned that communicating with
their families and friends was a primary way to deal with stress and anxiety during COVID-19.
Some explicitly stated that they were using a virtual meeting application such as Zoom
frequently to connect to friends and family. Only 1 participant claimed to be receiving support
from a professional therapist, and another participant was using Sanvello, a mobile mental health
service app provided by the university.

Barriers to Seeking Professional Support During COVID-19

Despite the availability of tele-counseling and widespread promotion of such services by the
university, a vast majority of participants who indicated an increase in stress and anxiety
(128/138, 93%) claimed that they had not used school counseling services during the pandemic.
Reasons for such low use included the condition not being perceived as severe enough to seek
the services (4/128, 3%), not comfortable interacting with unfamiliar people (1/128, 0.8%), not
comfortable talking about mental health issues over the phone (1/128, 0.8%), and lack of trust in
the counseling services (1/128, 0.8%).

Discussion

Principal Findings

College students comprise a population that is considered particularly vulnerable to mental

health concerns. The findings of this study bring into focus the effects of pandemic-related
transitions on the mental health and well-being of this specific population. Our findings suggest a
considerable negative impact of the COVID-19 pandemic on a variety of academic-, health-, and
lifestyle-related outcomes. By conducting online survey interviews in the midst of the pandemic,
we found that a majority of the participants were experiencing increased stress and anxiety due
to COVID-19. In addition, results of the PSS showed moderate levels of stress among our
participants. This is in line with a recent pre–COVID-19 survey conducted in the United
Kingdom (mean PSS score 19.79, SD 6.37) [28]; however, the administration of PSS as
interview questions (compared to allowing participants to read and respond to the 10 questions)
might have introduced bias and resulted in underreporting.

Among the effects of the pandemic identified, the most prominent was worries about one’s own
health and the health of loved ones, followed by difficulty concentrating. These findings are in
line with recent studies in China that also found concerns relating to health of oneself and of
family members being highly prevalent among the general population during the pandemic.
Difficulty in concentrating, frequently expressed by our participants, has previously been shown
to adversely affect students’ confidence in themselves [29], which has known correlations to
increased stress and mental health [30]. In comparison with stress and anxiety in college
students’ general life, it appears that countermeasures put in place against COVID-19, such as
shelter-in-place orders and social distancing practices, may have underpinned significant changes
in students’ lives. For example, a vast majority of the participants noted changes in social
relationships, largely due to limited physical interactions with their families and friends. This is
similar to recent findings of deteriorated mental health status among Chinese students [10] and
increased internet search queries on negative thoughts in the United States [31]. The findings on
the impact of the pandemic on sleeping and eating habits are also a cause for concern, as these
variables have known correlations with depressive symptoms and anxiety [20].

Although a majority of participants expressed concerns regarding academic performance,

interestingly, almost half of the participants reported lower stress levels related to academic
pressure and class workload since the pandemic began. This may be due, in part, to decisions
taken by professors and the university to ease the students’ sudden transition to distance learning.
For instance, this university allowed students to choose a pass/fail option for each course instead
of a regular letter grade. Additionally, actions taken by professors, such as reduced course loads,
open book examinations, and other allowances on grading requirements, could also have
contributed to alleviating or reducing stress. Although participants who returned to their parental
home reported concerns about distractions and independence, students might have benefited
from family support and reduced social responsibilities. Therefore, the increased stress due to the
pandemic may have been offset, at least to some extent.

Alarmingly, 44% (86/195) of the participants reported experiencing an increased level of

depressive thoughts, and 8% (16/195) reported having suicidal thoughts associated with the
COVID-19 pandemic. Previous research [32] reported about 3%-7% of the college student
population to have suicidal thoughts outside of the pandemic situation. Furthermore, with the
exception of high-burnout categories, depression levels among students, reported in several
recent studies [33-35], have varied between 29% and 38%, which may suggest an uptick in
pandemic-related depressive symptoms among college students similar to recent studies in China
[10,11]. Although our participants specifically mentioned several factors such as feelings of
loneliness, powerlessness, as well as financial and academic uncertainties, other outcomes that
were perceived to be impacted by the COVID-19 pandemic may also act as contributors to
depressive thoughts and suicidal ideation. In particular, both difficulty concentrating and changes
in sleeping habits are associated with depression [20,29,36].

Our study also identifies several coping mechanisms varying between adaptive and maladaptive
behaviors. The maladaptive coping behaviors such as denial and disengagement have been
shown to be significant predictors of depression among young adults [37]. In contrast, adaptive
coping such as acceptance and proactive behaviors are known to positively impact mental health.
Our findings suggest that the majority of our participants exhibited maladaptive coping
behaviors. Identifying students’ coping behavior is important to inform the planning and design
of support systems. In this regard, participatory models of intervention development can be used,
in which researchers’ and psychologists’ engagement with the target population to adapt
interventional programs to their specific context has shown promise [37,38]. For instance,
Nastasi et al [37] used a participatory model to develop culture-specific mental health services
for high school students in Sri Lanka. Similar approaches can be adopted to engage college
students as well to develop a mental health program that leverages their natural positive coping
behaviors and addresses their specific challenges.

Participants described several barriers to seeking help, such as lack of trust in counseling
services and low comfort levels in sharing mental health issues with others, which may be
indicative of stigma. Perceiving social stigma as a barrier to seeking help and availing counseling
services and other support is common among students [29]. One study showed that only a minor
fraction of students who screened positive for a mental health problem actually sought help [39].
Although overcoming the stigma associated with mental health has been discussed at length,
practical ways of mitigating this societal challenge remains a gap [40,41]. Our findings suggest
that self-management is preferred by students and should be supported in future work. Digital
technologies and telehealth applications have shown some promise to enable self-management of
mental health issues [42]. For instance, Youn et al [43] successfully used social media networks
as a means to reach out to college students and screen for depression by administering a
standardized scale, the Patient Health Questionnaire-9. Digital web-based platforms have also
been proposed to enhance awareness and communication with care providers to reduce stigma
related to mental health among children in underserved communities [44]. For instance, one of
the online modules suggested by the authors involves providing information on community-
identified barriers to communicating with care providers. Technologies such as mobile apps and
smart wearable sensors can also be leveraged to enable self-management and communication
with caregivers.

In light of the aforementioned projections of continued COVID-19 cases at the time of this
writing [45] and our findings, there is a need for immediate attention to and support for students
and other vulnerable groups who have mental health issues [17]. As suggested by a recent study
[46] based on the Italian experience of this pandemic, it is essential to assess the population’s
stress levels and psychosocial adjustment to plan for necessary support mechanisms, especially
during the recovery phase, as well as for similar events in the future. Although the COVID-19
pandemic seems to have resulted in a widespread forced adoption of telehealth services to deliver
psychiatric and mental health support, more research is needed to investigate use beyond
COVID-19 as well as to improve preparedness for rapid virtualization of psychiatric counseling
or tele-psychiatry [47-49].

Limitations and Future Work

To our knowledge, this is the first effort in documenting the psychological impacts of the
COVID-19 pandemic on a representative sample of college students in the United States via a
virtual interview survey method in the middle of the pandemic. However, several limitations
should be noted. First, the sample size for our interview survey was relatively small compared to
typical survey-only studies; however, the survey interview approach affords the capture of
elaboration and additional clarifying details, and therefore complements the survey-based
approaches of prior studies focusing on student mental health during this pandemic [10,11,50].
Second, the sample used is from one large university, and findings may not generalize to all
college students. However, given the nationwide similarities in universities transitioning to
virtual classes and similar stay-at-home orders, we expect reasonable generalizability of these
findings. Additionally, a majority of our participants were from engineering majors. Therefore,
future work is needed to use a stratified nationwide sample across wider disciplines to verify and
amend these findings. Third, although a vast majority of participants answered that they have not
used the university counseling service during the pandemic, only a few of them provided
reasons. Since finding specific reasons behind the low use is a key to increasing college students’
uptake of available counseling support, future research is warranted to unveil underlying factors
that hinder college students’ access to mental health support. Finally, we did not analyze how
student mental health problems differ by demographic characteristics (eg, age, gender, academic
year, major) or other personal and social contexts (eg, income, religion, use of substances).

Future work could focus on more deeply probing the relationships between various coping
mechanisms and stressors. Additionally, further study is needed to determine the effects of the
pandemic on students’ mental health and well-being in its later phases beyond the peak period.
As seen in the case of health care workers in the aftermath of the severe acute respiratory
syndrome outbreak, there is a possibility that the effects of the pandemic on students may linger
for a period beyond the peak of the COVID-19 pandemic itself [51].

Acknowledgments

This research was partly funded by a Texas A&M University President’s Excellence (X-Grant) award.

Conflicts of Interest

None declared.

References

1. Unger K. Handbook on Supported Education: Providing Services for Students With

Psychiatric Disabilities. Charleston, SC: BookSurge Publishing; 2007.
2. 2019 annual report. Center for Collegiate Mental Health. University Park, PA: Penn State
University; 2020.   URL: https://ccmh.memberclicks.net/assets/docs/2019-CCMH-Annual-
Report_3.17.20.pdf [accessed 2020-05-11]
3. Shuchman M. Falling through the cracks — Virginia Tech and the restructuring of college
mental health services. N Engl J Med 2007 Jul 12;357(2):105-110. [CrossRef]
4. Eisenberg D, Downs MF, Golberstein E, Zivin K. Stigma and help seeking for mental health
among college students. Med Care Res Rev 2009 Oct;66(5):522-541. [CrossRef] [Medline]
5. 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 Mar 14;395(10227):912-920 [FREE Full text] [CrossRef] [Medline]
6. Lai J, Ma S, Wang Y, Cai Z, Hu J, Wei N, et al. Factors associated with mental health
outcomes among health care workers exposed to coronavirus disease 2019. JAMA Netw
Open 2020 Mar 02;3(3):e203976 [FREE Full text] [CrossRef] [Medline]
7. Xie X, Xue Q, Zhou Y, Zhu K, Liu Q, Zhang J, et al. Mental health status among children in
home confinement during the coronavirus disease 2019 outbreak in Hubei Province, China.
JAMA Pediatr 2020 Apr 24:e201619 [FREE Full text] [CrossRef] [Medline]
8. Kirzinger A, Kearney A, Hamel L, Brodie M. KFF health tracking poll - early April 2020: the
impact Of coronavirus on life In America. Kaiser Family Foundation. 2020 Apr 02.  
URL: https://www.kff.org/health-reform/report/kff-health-tracking-poll-early-april-2020/ [acces
sed 2020-05-10]
9. Nelson B, Pettitt A, Flannery J, Allen N. Rapid assessment of psychological and
epidemiological correlates of COVID-19 concern, financial strain, and health-related behavior
 change in a large online sample. Int J Methods in Psychiatr Res 2020 Apr 13;21(3):169-184.
[CrossRef]
10. 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 May;287:112934 [FREE Full
text] [CrossRef] [Medline]
11. Liu X, Liu J, Zhong X. Psychological state of college students during COVID-19 epidemic.
SSRN J 2020 Mar 24:A. [CrossRef]
12. Wang C, Zhao H. The impact of COVID-19 on anxiety in Chinese university students. Front
Psychol 2020;11:1168. [CrossRef] [Medline]
13. Bruffaerts R, Mortier P, Kiekens G, Auerbach RP, Cuijpers P, Demyttenaere K, et al. Mental
health problems in college freshmen: prevalence and academic functioning. J Affect Disord
2018 Jan 01;225:97-103 [FREE Full text] [CrossRef] [Medline]
14. Zhai Y, Du X. Addressing collegiate mental health amid COVID-19 pandemic. Psychiatry
Res 2020 Jun;288:113003 [FREE Full text] [CrossRef] [Medline]
15. Zhai Y, Du X. Mental health care for international Chinese students affected by the COVID-
19 outbreak. Lancet Psychiatry 2020 Apr;7(4):e22 [FREE Full text] [CrossRef] [Medline]
16. de Oliveira Araújo FJ, de Lima LSA, Cidade PIM, Nobre CB, Neto MLR. Impact of Sars-Cov-
2 and its reverberation in global higher education and mental health. Psychiatry Res 2020
Jun;288:112977 [FREE Full text] [CrossRef] [Medline]
17. Holmes EA, O'Connor RC, Perry VH, Tracey I, Wessely S, Arseneault L, et al.
Multidisciplinary research priorities for the COVID-19 pandemic: a call for action for mental
health science. Lancet Psychiatry 2020 Jun;7(6):547-560 [FREE Full text] [CrossRef]
[Medline]
18. Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc
Behav 1983 Dec;24(4):385-396. [Medline]
19. Cohen S, Kessler R, Gordon L. Measuring stress: A Guide for Health and Social Scientists.
New York, NY: Oxford University Press; 1997.
20. Acharya L, Jin L, Collins W. College life is stressful today - emerging stressors and
depressive symptoms in college students. J Am Coll Health 2018 Oct;66(7):655-664.
[CrossRef] [Medline]
21. Baghurst T, Kelley BC. An examination of stress in college students over the course of a
semester. Health Promot Pract 2014 May;15(3):438-447. [CrossRef] [Medline]
22. Zoom. Zoom Video Communications.   URL: https://zoom.us/
23. Otter.ai.   URL: https://otter.ai/login
24. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Res Psychol 2006
Jan;3(2):77-101. [CrossRef]
25. Guest G, MacQueen K, Namey E. Applied Thematic Analysis. Thousand Oaks, CA: Sage
Publications; 2011.
26. Corbin J, Strauss A. Basics of Qualitative Research (3rd ed.): Techniques and Procedures
for Developing Grounded Theory. Thousand Oaks, CA: Sage Publications; 2014.
27. MAXQDA. VERBI Software.   URL: https://www.maxqda.com/
28. Denovan A, Dagnall N, Dhingra K, Grogan S. Evaluating the perceived stress scale among
UK university students: implications for stress measurement and management. Stud Higher
Education 2017 Jun 22;44(1):120-133. [CrossRef]
29. Martin JM. Stigma and student mental health in higher education. Higher Education Res Dev
2010 Jun;29(3):259-274. [CrossRef]
30. Zuckerman DM. Stress, self-esteem, and mental health: how does gender make a
difference? Sex Roles 1989 Apr;20(7-8):429-444. [CrossRef]
31. Jacobson NC, Lekkas D, Price G, Heinz MV, Song M, O'Malley AJ, et al. Flattening the
mental health curve: COVID-19 stay-at-home orders are associated with alterations in
mental health search behavior in the United States. JMIR Ment Health 2020 Jun
01;7(6):e19347 [FREE Full text] [CrossRef] [Medline]
32. Zivin K, Eisenberg D, Gollust SE, Golberstein E. Persistence of mental health problems and
needs in a college student population. J Affect Disord 2009 Oct;117(3):180-185. [CrossRef]
[Medline]
33. Zeng Y, Wang G, Xie C, Hu X, Reinhardt JD. Prevalence and correlates of depression,
anxiety and symptoms of stress in vocational college nursing students from Sichuan, China:
a cross-sectional study. Psychol Health Med 2019 Aug;24(7):798-811. [CrossRef] [Medline]
34. Nahas ARMF, Elkalmi R, Al-Shami A, Elsayed T. Prevalence of depression among health
sciences students: findings from a public university in Malaysia. J Pharm Bioallied Sci
2019;11(2):170-175 [FREE Full text] [CrossRef] [Medline]
35. Fitzpatrick O, Biesma R, Conroy RM, McGarvey A. Prevalence and relationship between
burnout and depression in our future doctors: a cross-sectional study in a cohort of
preclinical and clinical medical students in Ireland. BMJ Open 2019 May 01;9(4):e023297
[FREE Full text] [CrossRef] [Medline]
36. Heiligenstein E, Guenther G, Hsu K, Herman K. Depression and academic impairment in
college students. J Am Coll Health 1996 Sep;45(2):59-64. [CrossRef] [Medline]
37. Nastasi BK, Sarkar S, Varjas K, Jayasena A. Participatory model of mental health
programming: lessons learned from work in a developing country. Sch Psychol Rev
1998;27(2):260-276.
38. Cappella E, Jackson DR, Bilal C, Hamre BK, Soulé C. Bridging mental health and education
in urban elementary schools: participatory research to inform intervention development. Sch
Psychol Rev 2011;40(4):486-508.
39. Eisenberg D, Hunt J, Speer N, Zivin K. Mental health service utilization among college
students in the United States. J Nerv Ment Dis 2011 May;199(5):301-308. [CrossRef]
[Medline]
40. Husain W. Barriers in seeking psychological help: public perception in Pakistan. Community
Ment Health J 2020 Jan;56(1):75-78. [CrossRef] [Medline]
41. Fischer EP, McSweeney JC, Wright P, Cheney A, Curran GM, Henderson K, et al.
Overcoming barriers to sustained engagement in mental health care: perspectives of rural
veterans and providers. J Rural Health 2016 Sep;32(4):429-438. [CrossRef] [Medline]
42. Torous J, Jän Myrick K, Rauseo-Ricupero N, Firth J. Digital mental health and COVID-19:
using technology today to accelerate the curve on access and quality tomorrow. JMIR Ment
Health 2020 Mar 26;7(3):e18848 [FREE Full text] [CrossRef] [Medline]
43. Youn SJ, Trinh N, Shyu I, Chang T, Fava M, Kvedar J, et al. Using online social media,
Facebook, in screening for major depressive disorder among college students. Int J Clin
Health Psychol 2013 Jan;13(1):74-80. [CrossRef]
44. Ginossar T, Nelson S. Reducing the health and digital divides: a model for using community-
based participatory research approach to e-health interventions in low-income Hispanic
communities. J Computer-Mediated Commun 2010;15(4):530-551. [CrossRef]
45. COVID-19 projections. Institute for Health Metrics and Evaluation. Seattle, WA: University of
Washington   URL: https://covid19.healthdata.org/united-states-of-america [accessed 2020-
05-20]
46. de Girolamo G, Cerveri G, Clerici M, Monzani E, Spinogatti F, Starace F, et al. Mental health
in the coronavirus disease 2019 emergency-the Italian response. JAMA Psychiatry 2020 Apr
30:A. [CrossRef] [Medline]
47. Zhou J, Liu L, Xue P, Yang X, Tang X. Mental health response to the COVID-19 outbreak in
China. Am J Psychiatry 2020 Jul 01;177(7):574-575. [CrossRef] [Medline]
48. Zhou X, Snoswell CL, Harding LE, Bambling M, Edirippulige S, Bai X, et al. The role of
telehealth in reducing the mental health burden from COVID-19. Telemed J E Health 2020
Apr;26(4):377-379. [CrossRef] [Medline]
49. Shore JH, Waugh M, Calderone J, Donahue A, Rodriguez J, Peters D, et al. Evaluation of
telepsychiatry-enabled perinatal integrated care. Psychiatr Serv 2020 May 01;71(5):427-432.
[CrossRef] [Medline]
50. Huckins JF, daSilva AW, Wang W, Hedlund E, Rogers C, Nepal SK, et al. Mental health and
behavior of college students during the early phases of the COVID-19 pandemic: longitudinal
smartphone and ecological momentary assessment study. J Med Internet Res 2020 Jun
17;22(6):e20185 [FREE Full text] [CrossRef] [Medline]
51. McAlonan GM, Lee AM, Cheung V, Cheung C, Tsang KW, Sham PC, et al. Immediate and
sustained psychological impact of an emerging infectious disease outbreak on health care
workers. Can J Psychiatry 2007 Apr;52(4):241-247. [CrossRef] [Medline]