MENTAL HEALTH CHALLENGES AND PREVENTION IN COLLEGE STUDENTS FOLLOWING THE COVID-19

PANDEMIC AND LOCKDOWNS

VINCENZO DE LILLO

Major: Psychology

Class of 2023 INTRODUCTION

The COVID-19 pandemic has exacerbated the incidence of mental disorders amongst individuals worldwide. Throughout the pandemic, the incidence of anxiety and depressive disorders increased fourfold, now affecting about 4 in 10 adults in the United States; a higher incidence of substance-related and abuse disorders, sleep- and food-related disorders was also reported through a number of surveys (Adibi et al., 2021). Several studies have connected the increased incidence of these disorders to an increase in maladaptive behaviors, cognitive distortions, and stress factors – including but not limited to food insecurity – as a direct result of the pandemic and its lockdowns (Coakley et al., 2021, Copeland et al. 2021).

The COVID-19 virus was initially identified in December 2019, in the Chinese province of Wuhan. The virus was initially named “severe acute respiratory syndrome coronavirus 2” and later referred to as Coronavirus or COVID-19 by the general population. Despite China’s efforts to contain the virus, the virus spread to the rest of the world and, at the end of January 2020, the World Health Organization (WHO) declared it a Public Health Emergency of International Concern (WHO, 2021). By March 2020, the WHO declared the novel Coronavirus a pandemic (WHO, 2021). As of today, the virus has claimed the lives of five million people worldwide (WorldoMeter, 2021). The number of American casualties accounts to 15.23% of the grand total - over 750,000 (WorldoMeter, 2021). Since its arrival to the United States, the Coronavirus has become one of the leading causes of death in the country (Ahmad & Anderson, 2021).

While COVID-19 is being thoroughly researched across disciplines, the majority of psychiatric research remains focused on the rates of incidence of mental disorders originated by COVID-19 and the subsequent lockdowns. As the United States government, companies, and schools push for a return to in-person activities, it is of vital importance to create a healthy, productive environment for all citizens — whether employers, employees, teachers, parents, social workers, mental health professionals, students, children — that will not exacerbate the existing stress factors and will facilitate the transition instead. In light of the shortages of mental health professionals, the inadequate mental care system, and the sheer number of individuals affected (Thomas et. al, 2009, Radfar et al., 2021, Sharma et al., 2021) it is of paramount importance to give a prevention-based approach particular consideration so that the current healthcare system will not be flooded from requests, and the incidence of these mental disorders will be decreased to more manageable levels.

Amongst the most at-risk demographics, college students rank highest. Before the pandemic, extensive research has shown how students, especially undergraduates, are prone to developing mental disorders given the number of stressors they face – including but not limited to the separation from their families, increased workload, a severe financial burden, and so forth (Eisenberg et al., 2007, Oswalt et al., 2020). Before the lockdowns, students had been shown to cope with their stress and disorders through drugs — various recreational drugs — and prescription stimulants — such as illicitly obtained Modafinil, Adderall, Ritalin, or some other amphetamine-based compounds (Mochrie et al., 2020, Teter et al., 2006, Vo et al., 2015). With the stay-at-home orders and the disruption of in-person education, it should be assumed that such maladaptive behaviors have been exacerbated. Such a hypothesis can be reinforced by the findings of Firkey et al. (2020), which show an increase of circa 15% in the consumption of cannabis.

More recently, several studies have found a correlation between wellness practices and a reduction of the incidence of mood and anxiety disorders (Bai et al., 2019, Copeland et al., 2021, Kris-Etherton et al., 2021, Ye et al., 2021). Similarly, a positive correlation was found between wellness practices and symptoms of anxiety and depression (Copeland et al., 2021, Kris-Etherton et al., 2021). Given the ongoing nature of the pandemic and the shortage of mental health professionals, these findings should constitute the base to create a prevention plan that focuses on reinforcing and developing mental resilience in college students.

Literature Review

Context

College students have been a demographic at risk for decades. On one hand, heavy workloads, financial pressure, and academic pressure on top of several other stressors make the situation ripe for the onset of common mental disorders such as Anxiety and Mood disorders. On the other hand, poor dietary habits, alcohol consumption, and drug use are some of the maladaptive coping strategies students resort to in their college years. According to a survey published on the American Psychology Association (APA) journal in 2013, over 41% of students struggled with anxiety, while over 36% struggled with depression. In their survey, Oswalt et al. (2020) identified a major increase in Mental Health disorders between 2009 and 2015, which makes it fair to assume that, pre-Coronavirus, almost half of — if not more — students were struggling with their mental health while in college. Despite the availability of free mental health services, there is a consistent trend of avoidance in students when it comes to seeking mental support; 50%-80% of students battling anxiety and depression do not seek services (Eisenberg et al., 2007, Oswalt et al., 2020). In light of the findings of their 2007 webbased survey of 2,495 undergraduates and 2,526 graduate and professional students, Eisenberg et al. (2007) identified common predictors of the students’ avoidant behavior, listing among them “a lack of perceived need, being unaware of services and insurance coverage, skepticism about treatment effectiveness, low socioeconomic background, and being Asian or Pacific Islander” (Eisenberg et al., 2007, pp. 596,597).

Amid the various causes of the increased incidence of disorders amongst college students, sub-par nutrition stands out in light of the findings of a 2004 study from Cosineau et al.: in the study, by conducting a systematic analysis of qualitative information generated from their focus group participants using concept-mapping techniques, scholars found that most students follow poor dietary practices that involve copious quantities of processed foods. In addition, participants showed having littleto-no knowledge about the short- and long-term consequences of their diet. In their 2021 systemic review and meta-analysis, Kris-Etherton et al. thoroughly explored the positive correlation between poor dietary habits and the incidence of mental disorders that has been noticed over the years and identified low-cholesterol diets to be effective in both prevention and improvement of depression symptoms; their review centered around the review of 131 scholarly publications, 16 randomized clinical trials, and the data gathered from 45,826 non-clinically depressed participants. In light of the food shortages and the inability to access grocery stores that have characterized the Coronavirus pandemic, it can be assumed that consumption of cheap, highly processed foods has increased amongst the student population, given several factors, including but not limited to their limited financial availability.

Overall, the Coronavirus pandemic has turned the students’ lives upside down. Several studies have attempted to assess the level of disruptiveness of the pandemic: for example, a quantitative study by Copeland et al. (2021) found that, on a 10-point scale

— in which 0 meant not disruptive whatsoever and 10 meant extremely disruptive –, students reported an average level of disruptiveness of 7.8; over 87% of the participants reported a score of 6 or more. The researchers’ study was based on the results of an online survey of 675 first-year students enrolled at the University of Vermont during the Spring of 2020 semester. The study’s results were consistent with several other quantitative studies, which, in addition, identified how the overall disruption caused by COVID-19 led to an increase in anxiety and depression symptoms and food-, sleep-, alcohol-, drugs-related maladaptive behaviors (Coakley et al., 2021, Copeland et al., 2021, Marelli et al., 2020, Tasso et al., 2021).

Increased Incidence Of Mental Disorders

Several studies have found an increased incidence of mental disorders amongst the general and student population associated with the intolerance of uncertainty caused by the pandemic (Coughenor et al., 2021, Lederer et al. 2021). Similar results were found in the mixed method study conducted by Browning et al. (2021) and the quantitative study conducted by Scharmer et al. (2020). For their 2021 study, Browning et al. recruited cross-sectionally a targeted sample of 14,174 participants across seven large universities in the United States; through the 2,534 responses gathered from the online questionnaires, Browning et al. (2021) concluded that the pandemic had a moderate to high psychological impact in 85% of the respondents, characterized by an increase in frustration, difficulties falling asleep, and anxiety and depression symptoms. Scharmer’s et al. quantitative study from 2020 relied on the responses to an online questionnaire gathered in a sample of 295 undergraduate students (65.1% females) recruited from a single large northeastern university in the United States instead; in their study, the scholars found that the increase in anxiety from COVID-19 and the increased intolerance of the uncertainty were correlated with an increased risk of eating disorder and compulsive exercise.

Considering the already elevated percentage of students that faced mental struggles before the pandemic, an increase in mental health disorders can be threatening to the entire system. Due to the nature of the pandemic, the mental healthcare system — which has been historically proved inadequate to meet its demands (Thomas et. al, 2009, Radfar et al., 2021, Sharma et al., 2021) — has been overburdened and unable to address the necessities of such a vast percentage of individuals. In their 2007 web-based survey, Eisenberg et al. indicated a shortage in personnel in on-campus counseling centers, following the results of their web-based survey. In light of Eisenberg et al. (2007)’s findings, it can be inferred that, following the disruption of services and increased demands, even student-exclusive infrastructures do not have the means to accommodate the request. Amongst the biggest concerns that emerge from the lack of an adequate mental workforce is the “increased” risk of suicide. Despite how in their literature review Sinyor et al. (2021) did not identify an increase in suicide rates in middle and upper-middle-class families during the pandemic, the long-term complications of certain mental disorders — such as depression, post-traumatic stress disorder (PTSD), and complex post-traumatic stress disorder (C-PTSD) — and newfound stressors — such as housing, food, and employment insecurities — constitute a threat to the lives of many and can lead to suicide rates spiking.

Further research — like the 44-studies literature review conducted by Lee et al. (2021) and the quantitative studies based on the replies to online questionnaires conducted by Perz et al. (2020) and Tasso et al. (2021) — has shown how certain demographics — especially lower-income families, academically underperforming students, females, and students of color — have been more at risk of a multitude of mental disorders. This data is particularly relevant as it shows how the most at-risk categories are also the least likely to seek and engage in treatment. Because of this and because of the shortage of personnel, there is a clear need for an alternative to therapy on such a large scale. In order to reduce the incidence of mental health disorders and reduce the burden on mental health professionals, several researchers have suggested that prevention might be the most accessible and implementable option (Copeland et al., 2021, Parimala & Kanchibhotla, 2021, Oswalt et al., 2020,)

Prevention

General well being has been associated with increased physical and mental resilience for years. As seen so far, students tend to have an incredibly stressful life with no healthy coping mechanisms. According to the 2021 systemic review by Kris-Etherton et al., there seems to be a significant connection between the increased incidence of depressive disorders of the past decades and the decline in healthy lifestyle behaviors. To face the exorbitant costs of college and to balance their work-study life, students often scale back on fundamental needs such as sleep, proper diet, exercise, and sun exposure; to address the increased stress and cognitive impairment these produce, students often resort to substances, whether it’s recreational drugs, alcohol, or illobtained prescription stimulants.

Extensive research has been conducted on the correlation between dietary habits and the incidence of mental disorders. According to a study from Pilato et al. (2020), which included extensive computerized cognitive testing and an online questionnaire on a convenience sample, a positive association between daily consumption of fruit and visual memory was observed. The same study also found a positive correlation between fruit intake, higher standardized test scores, and increased academic performance — similar to the well-known correlation between improved cognition and long-chain n-3 polyunsaturated fatty acid (mainly found in fish) consumption (Pilato et al., 2020). Pilato et al. (2020) also reported an increase in both verbal and visual memory tied to hydration. Similar findings were shown in the small clinical trials reviewed by Kris-Etherton et al. (2021), which highlighted a relationship between improved cognition and a decrease and improvement in symptoms of anxiety tied to the consumption of long-chain n-3 polyunsaturated fatty acids, and in particular of Atlantic salmon. Several other micronutrients have been tied to mental health and cognition: folic acid, vitamin D, vitamin B12, zinc, magnesium, L-Arginine, and L-Lysine all play a role in the production of neurotransmitters that regulate mood and mental health status (Kris-Etherton et al., 2021).

On top of dietary interventions, several well being programs and meditative practices have been showing results in lowering the incidence of maladaptive behaviors and the onset of disorders. In their article, Oswalt et al. (2020) stated: “A focus on primary prevention efforts — like sleep, stress management, mindfulness, and physical activity — could directly benefit students and could help reduce some of the strain college counseling centers are experiencing as they attempt to serve a growing number of students” (p. 48); the scholars then proceeded to highlight the benefits of mindfulness and sleep health programs such as Koru and Refresh, which have both been linked to a documented reduction in stress and depressive symptoms (Oswalt et al., 2020). In a 2021 observational cross-sectional study based in India, Parimala & Kanchibhotla, analyzing the 956 answers gathered through an online questionnaire, found that Sudarshan Kriya Yoga (SKY) participants were almost 50% less likely to experience anxiety and develop anxiety symptoms compared to their non-practitioning counterparts. The study also highlighted how 56.21% of non-SKY practitioners reported negative changes within their mood and mental health, compared to the lower proportion in SKY participants (40.6%) (Parimala & Kanchibhotla, 2021). Similar findings were found across several Wellness Programs student populations within the United States: for example, in their study, Copeland et al. (2021) reported that when “Using the Brief-Problem Monitor (BPM) — a survey comprised of 18 items, meant to evaluate internalizing, attention, and externalizing problems in adults aged 18-59” (p. 136-137) — researchers noticed that although BPM results were consistent through different demographics, Wellness Program involvement moderated changes in BPM scores. Participants of the Wellness Program showed a lesser degree of attention degeneration compared to their peers as well as an improvement in internalizing symptoms (Copeland et al., 2021). Overall, the recent nature of these studies seems to indicate that a strong correlation between Wellness Programs — and their practices — and reduced incidence of mental disorders has been maintained throughout the pandemic and should be further explored.

Current findings indicate that there is a significant, concerning increase in the incidence of mental disorders worldwide as a result of the pandemic and the stayat-home orders. Given the current state of the mental health system, considering its limited accessibility as well as the lack of adequate personnel, it is mandatory to explore options to tend to the needs of college students limiting the need for individual therapy. Unfortunately, despite the extensive amount of research concerning student well being in the academic setting, very little changes have been implemented to this day; pre-COVID studies have often highlighted the importance of fundamental factors including restful sleep, self-care, meditation, and diet, as shown in the literature review by Kris-Etherton et al. (2021), yet these factors often remain overlooked through the socio-academic demands imposed on members of the Academy. While most studies conducted following the outbreak of the COVID-19 virus may have obvious limitations — including voluntary or response bias, concerns circa the consistency of the results — they have confirmed the pre-COVID findings: meditative practices and well being programs have shown promise in increasing resilience against anxiety and depressive disorders alike, as seen in Copeland et al.’s (2021) and Parimala & Kanchibhotla’s (2021) studies.

Overall, although attempts have been made to address students’ well being during these trying times, there is a generalized lack of applicable prevention plans and techniques that can be used to strengthen and help students during their return to in-person education, especially as the pandemic still rages on. The current knowledge on this topic is far from adequate, let alone comprehensive. Most available studies centered around prevention are limited to authors’ suggestions; the ones that are not, instead, often lack baseline parameters that could assess their effectiveness. In light of the limited amount of the knowledge currently available, further research is needed to assess the degree and type of changes that can be implemented within the collegiate academic setting.