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 ^3-5. 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 ^11-13. 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

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 °/o (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).

Figure 1 Categories of anxiety, depression and stress in university students in coronavirus quarantine in Peru. 

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 lock-down. 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 ^28-31. 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.