mental health of students in the philippines pandemic essay

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Study Protocol

Assessing the effect of the COVID-19 pandemic, shift to online learning, and social media use on the mental health of college students in the Philippines: A mixed-method study protocol

Roles Funding acquisition, Writing – original draft

Affiliation College of Medicine, University of the Philippines, Manila, Philippines

Roles Methodology, Supervision, Visualization, Writing – original draft, Writing – review & editing

Affiliations Department of Clinical Epidemiology, College of Medicine, University of the Philippines, Manila, Philippines, Institute of Clinical Epidemiology, National Institutes of Health, University of the Philippines, Manila, Philippines

Roles Methodology

Affiliation Department of Psychiatry, College of Medicine, University of the Philippines, Manila, Philippines

Roles Conceptualization, Funding acquisition, Project administration, Supervision, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Leonard Thomas S. Lim,
Zypher Jude G. Regencia,
J. Rem C. Dela Cruz,
Frances Dominique V. Ho,
Marcela S. Rodolfo,
Josefina Ly-Uson,
Emmanuel S. Baja

Published: May 3, 2022
https://doi.org/10.1371/journal.pone.0267555
Peer Review
Reader Comments

Introduction

The COVID-19 pandemic declared by the WHO has affected many countries rendering everyday lives halted. In the Philippines, the lockdown quarantine protocols have shifted the traditional college classes to online. The abrupt transition to online classes may bring psychological effects to college students due to continuous isolation and lack of interaction with fellow students and teachers. Our study aims to assess Filipino college students’ mental health status and to estimate the effect of the COVID-19 pandemic, the shift to online learning, and social media use on mental health. In addition, facilitators or stressors that modified the mental health status of the college students during the COVID-19 pandemic, quarantine, and subsequent shift to online learning will be investigated.

Methods and analysis

Mixed-method study design will be used, which will involve: (1) an online survey to 2,100 college students across the Philippines; and (2) randomly selected 20–40 key informant interviews (KIIs). Online self-administered questionnaire (SAQ) including Depression, Anxiety, and Stress Scale (DASS-21) and Brief-COPE will be used. Moreover, socio-demographic factors, social media usage, shift to online learning factors, family history of mental health and COVID-19, and other factors that could affect mental health will also be included in the SAQ. KIIs will explore factors affecting the student’s mental health, behaviors, coping mechanism, current stressors, and other emotional reactions to these stressors. Associations between mental health outcomes and possible risk factors will be estimated using generalized linear models, while a thematic approach will be made for the findings from the KIIs. Results of the study will then be triangulated and summarized.

Ethics and dissemination

Our study has been approved by the University of the Philippines Manila Research Ethics Board (UPMREB 2021-099-01). The results will be actively disseminated through conference presentations, peer-reviewed journals, social media, print and broadcast media, and various stakeholder activities.

Citation: Lim LTS, Regencia ZJG, Dela Cruz JRC, Ho FDV, Rodolfo MS, Ly-Uson J, et al. (2022) Assessing the effect of the COVID-19 pandemic, shift to online learning, and social media use on the mental health of college students in the Philippines: A mixed-method study protocol. PLoS ONE 17(5): e0267555. https://doi.org/10.1371/journal.pone.0267555

Editor: Elisa Panada, UNITED KINGDOM

Received: June 9, 2021; Accepted: April 11, 2022; Published: May 3, 2022

Copyright: © 2022 Lim et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Funding: This project is being supported by the American Red Cross through the Philippine Red Cross and Red Cross Youth. The funder will not have a role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

The World Health Organization (WHO) declared the Coronavirus 2019 (COVID-19) outbreak as a global pandemic, and the Philippines is one of the 213 countries affected by the disease [ 1 ]. To reduce the virus’s transmission, the President imposed an enhanced community quarantine in Luzon, the country’s northern and most populous island, on March 16, 2020. This lockdown manifested as curfews, checkpoints, travel restrictions, and suspension of business and school activities [ 2 ]. However, as the virus is yet to be curbed, varying quarantine restrictions are implemented across the country. In addition, schools have shifted to online learning, despite financial and psychological concerns [ 3 ].

Previous outbreaks such as the swine flu crisis adversely influenced the well-being of affected populations, causing them to develop emotional problems and raising the importance of integrating mental health into medical preparedness for similar disasters [ 4 ]. In one study conducted on university students during the swine flu pandemic in 2009, 45% were worried about personally or a family member contracting swine flu, while 10.7% were panicking, feeling depressed, or emotionally disturbed. This study suggests that preventive measures to alleviate distress through health education and promotion are warranted [ 5 ].

During the COVID-19 pandemic, researchers worldwide have been churning out studies on its psychological effects on different populations [ 6 – 9 ]. The indirect effects of COVID-19, such as quarantine measures, the infection of family and friends, and the death of loved ones, could worsen the overall mental wellbeing of individuals [ 6 ]. Studies from 2020 to 2021 link the pandemic to emotional disturbances among those in quarantine, even going as far as giving vulnerable populations the inclination to commit suicide [ 7 , 8 ], persistent effect on mood and wellness [ 9 ], and depression and anxiety [ 10 ].

In the Philippines, a survey of 1,879 respondents measuring the psychological effects of COVID-19 during its early phase in 2020 was released. Results showed that one-fourth of respondents reported moderate-to-severe anxiety, while one-sixth reported moderate-to-severe depression [ 11 ]. In addition, other local studies in 2020 examined the mental health of frontline workers such as nurses and physicians—placing emphasis on the importance of psychological support in minimizing anxiety [ 12 , 13 ].

Since the first wave of the pandemic in 2020, risk factors that could affect specific populations’ psychological well-being have been studied [ 14 , 15 ]. A cohort study on 1,773 COVID-19 hospitalized patients in 2021 found that survivors were mainly troubled with fatigue, muscle weakness, sleep difficulties, and depression or anxiety [ 16 ]. Their results usually associate the crisis with fear, anxiety, depression, reduced sleep quality, and distress among the general population.

Moreover, the pandemic also exacerbated the condition of people with pre-existing psychiatric disorders, especially patients that live in high COVID-19 prevalence areas [ 17 ]. People suffering from mood and substance use disorders that have been infected with COVID-19 showed higher suicide risks [ 7 , 18 ]. Furthermore, a study in 2020 cited the following factors contributing to increased suicide risk: social isolation, fear of contagion, anxiety, uncertainty, chronic stress, and economic difficulties [ 19 ].

Globally, multiple studies have shown that mental health disorders among university student populations are prevalent [ 13 , 20 – 22 ]. In a 2007 survey of 2,843 undergraduate and graduate students at a large midwestern public university in the United States, the estimated prevalence of any depressive or anxiety disorder was 15.6% and 13.0% for undergraduate and graduate students, respectively [ 20 ]. Meanwhile, in a 2013 study of 506 students from 4 public universities in Malaysia, 27.5% and 9.7% had moderate and severe or extremely severe depression, respectively; 34% and 29% had moderate and severe or extremely severe anxiety, respectively [ 21 ]. In China, a 2016 meta-analysis aiming to establish the national prevalence of depression among university students analyzed 39 studies from 1995 to 2015; the meta-analysis found that the overall prevalence of depression was 23.8% across all studies that included 32,694 Chinese university students [ 23 ].

A college student’s mental status may be significantly affected by the successful fulfillment of a student’s role. A 2013 study found that acceptable teaching methods can enhance students’ satisfaction and academic performance, both linked to their mental health [ 24 ]. However, online learning poses multiple challenges to these methods [ 3 ]. Furthermore, a 2020 study found that students’ mental status is affected by their social support systems, which, in turn, may be jeopardized by the COVID-19 pandemic and the physical limitations it has imposed. Support accessible to a student through social ties to other individuals, groups, and the greater community is a form of social support; university students may draw social support from family, friends, classmates, teachers, and a significant other [ 25 , 26 ]. Among individuals undergoing social isolation and distancing during the COVID-19 pandemic in 2020, social support has been found to be inversely related to depression, anxiety, irritability, sleep quality, and loneliness, with higher levels of social support reducing the risk of depression and improving sleep quality [ 27 ]. Lastly, it has been shown in a 2020 study that social support builds resilience, a protective factor against depression, anxiety, and stress [ 28 ]. Therefore, given the protective effects of social support on psychological health, a supportive environment should be maintained in the classroom. Online learning must be perceived as an inclusive community and a safe space for peer-to-peer interactions [ 29 ]. This is echoed in another study in 2019 on depressed students who narrated their need to see themselves reflected on others [ 30 ]. Whether or not online learning currently implemented has successfully transitioned remains to be seen.

The effect of social media on students’ mental health has been a topic of interest even before the pandemic [ 31 , 32 ]. A systematic review published in 2020 found that social media use is responsible for aggravating mental health problems and that prominent risk factors for depression and anxiety include time spent, activity, and addiction to social media [ 31 ]. Another systematic review published in 2016 argues that the nature of online social networking use may be more important in influencing the symptoms of depression than the duration or frequency of the engagement—suggesting that social rumination and comparison are likely to be candidate mediators in the relationship between depression and social media [ 33 ]. However, their findings also suggest that the relationship between depression and online social networking is complex and necessitates further research to determine the impact of moderators and mediators that underly the positive and negative impact of online social networking on wellbeing [ 33 ].

Despite existing studies already painting a picture of the psychological effects of COVID-19 in the Philippines, to our knowledge, there are still no local studies contextualized to college students living in different regions of the country. Therefore, it is crucial to elicit the reasons and risk factors for depression, stress, and anxiety and determine the potential impact that online learning and social media use may have on the mental health of the said population. In turn, the findings would allow the creation of more context-specific and regionalized interventions that can promote mental wellness during the COVID-19 pandemic.

Materials and methods

The study’s general objective is to assess the mental health status of college students and determine the different factors that influenced them during the COVID-19 pandemic. Specifically, it aims:

To describe the study population’s characteristics, categorized by their mental health status, which includes depression, anxiety, and stress.
To determine the prevalence and risk factors of depression, anxiety, and stress among college students during the COVID-19 pandemic, quarantine, and subsequent shift to online learning.
To estimate the effect of social media use on depression, anxiety, stress, and coping strategies towards stress among college students and examine whether participant characteristics modified these associations.
To estimate the effect of online learning shift on depression, anxiety, stress, and coping strategies towards stress among college students and examine whether participant characteristics modified these associations.
To determine the facilitators or stressors among college students that modified their mental health status during the COVID-19 pandemic, quarantine, and subsequent shift to online learning.

Study design

A mixed-method study design will be used to address the study’s objectives, which will include Key Informant Interviews (KIIs) and an online survey. During the quarantine period of the COVID-19 pandemic in the Philippines from April to November 2021, the study shall occur with the population amid community quarantine and an abrupt transition to online classes. Since this is the Philippines’ first study that will look at the prevalence of depression, anxiety, and stress among college students during the COVID-19 pandemic, quarantine, and subsequent shift to online learning, the online survey will be utilized for the quantitative part of the study design. For the qualitative component of the study design, KIIs will determine facilitators or stressors among college students that modified their mental health status during the quarantine period.

Study population

The Red Cross Youth (RCY), one of the Philippine Red Cross’s significant services, is a network of youth volunteers that spans the entire country, having active members in Luzon, Visayas, and Mindanao. The group is clustered into different age ranges, with the College Red Cross Youth (18–25 years old) being the study’s population of interest. The RCY has over 26,060 students spread across 20 chapters located all over the country’s three major island groups. The RCY is heterogeneously composed, with some members classified as college students and some as out-of-school youth. Given their nationwide scope, disseminating information from the national to the local level is already in place; this is done primarily through email, social media platforms, and text blasts. The research team will leverage these platforms to distribute the online survey questionnaire.

In addition, the online survey will also be open to non-members of the RCY. It will be disseminated through social media and engagements with different university administrators in the country. Stratified random sampling will be done for the KIIs. The KII participants will be equally coming from the country’s four (4) primary areas: 5–10 each from the national capital region (NCR), Luzon, Visayas, and Mindanao, including members and non-members of the RCY.

Inclusion and exclusion criteria

The inclusion criteria for the online survey will include those who are 18–25 years old, currently enrolled in a university, can provide consent for the study, and are proficient in English or Filipino. The exclusion criteria will consist of those enrolled in graduate-level programs (e.g., MD, JD, Master’s, Doctorate), out-of-school youth, and those whose current curricula involve going on duty (e.g., MDs, nursing students, allied medical professions, etc.). The inclusion criteria for the KIIs will include online survey participants who are 18–25 years old, can provide consent for the study, are proficient in English or Filipino, and have access to the internet.

Sample size

A continuity correction method developed by Fleiss et al. (2013) was used to calculate the sample size needed [ 34 ]. For a two-sided confidence level of 95%, with 80% power and the least extreme odds ratio to be detected at 1.4, the computed sample size was 1890. With an adjustment for an estimated response rate of 90%, the total sample size needed for the study was 2,100. To achieve saturation for the qualitative part of the study, 20 to 40 participants will be randomly sampled for the KIIs using the respondents who participated in the online survey [ 35 ].

Study procedure

Self-administered questionnaire..

The study will involve creating, testing, and distributing a self-administered questionnaire (SAQ). All eligible study participants will answer the SAQ on socio-demographic factors such as age, sex, gender, sexual orientation, residence, household income, socioeconomic status, smoking status, family history of mental health, and COVID-19 sickness of immediate family members or friends. The two validated survey tools, Depression, Anxiety, and Stress Scale (DASS-21) and Brief-COPE, will be used for the mental health outcome assessment [ 36 – 39 ]. The DASS-21 will measure the negative emotional states of depression, anxiety, and stress [ 40 ], while the Brief-COPE will measure the students’ coping strategies [ 41 ].

For the exposure assessment of the students to social media and shift to online learning, the total time spent on social media (TSSM) per day will be ascertained by querying the participants to provide an estimated time spent daily on social media during and after their online classes. In addition, students will be asked to report their use of the eight commonly used social media sites identified at the start of the study. These sites include Facebook, Twitter, Instagram, LinkedIn, Pinterest, TikTok, YouTube, and social messaging sites Viber/WhatsApp and Facebook Messenger with response choices coded as "(1) never," "(2) less often," "(3) every few weeks," "(4) a few times a week," and “(5) daily” [ 42 – 44 ]. Furthermore, a global frequency score will be calculated by adding the response scores from the eight social media sites. The global frequency score will be used as an additional exposure marker of students to social media [ 45 ]. The shift to online learning will be assessed using questions that will determine the participants’ satisfaction with online learning. This assessment is comprised of 8 items in which participants will be asked to respond on a 5-point Likert scale ranging from ‘strongly disagree’ to ‘strongly agree.’

The online survey will be virtually distributed in English using the Qualtrics XM™ platform. Informed consent detailing the purpose, risks, benefits, methods, psychological referrals, and other ethical considerations will be included before the participants are allowed to answer the survey. Before administering the online survey, the SAQ shall undergo pilot testing among twenty (20) college students not involved with the study. It aims to measure total test-taking time, respondent satisfaction, and understandability of questions. The survey shall be edited according to the pilot test participant’s responses. Moreover, according to the Philippines’ Data Privacy Act, all the answers will be accessible and used only for research purposes.

Key informant interviews.

The research team shall develop the KII concept note, focusing on the extraneous factors affecting the student’s mental health, behaviors, and coping mechanism. Some salient topics will include current stressors (e.g., personal, academic, social), emotional reactions to these stressors, and how they wish to receive support in response to these stressors. The KII will be facilitated by a certified psychologist/psychiatrist/social scientist and research assistants using various online video conferencing software such as Google Meet, Skype, or Zoom. All the KIIs will be recorded and transcribed for analysis. Furthermore, there will be a debriefing session post-KII to address the psychological needs of the participants. Fig 1 presents the diagrammatic flowchart of the study.

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https://doi.org/10.1371/journal.pone.0267555.g001

Data analyses

Quantitative data..

Descriptive statistics will be calculated, including the prevalence of mental health outcomes such as depression, anxiety, stress, and coping strategies. In addition, correlation coefficients will be estimated to assess the relations among the different mental health outcomes, covariates, and possible risk factors.

mental health of students in the philippines pandemic essay

Several study characteristics as effect modifiers will also be assessed, including sex, gender, sexual orientation, family income, smoking status, family history of mental health, and Covid-19. We will include interaction terms between the dichotomized modifier variable and markers of social media use (total TSSM and global frequency score) and shift to online learning in the models. The significance of the interaction terms will be evaluated using the likelihood ratio test. All the regression analyses will be done in R ( http://www.r-project.org ). P values ≤ 0.05 will be considered statistically significant.

Qualitative data.

After transcribing the interviews, the data transcripts will be analyzed using NVivo 1.4.1 software [ 50 ] by three research team members independently using the inductive logic approach in thematic analysis: familiarizing with the data, generating initial codes, searching for themes, reviewing the themes, defining and naming the themes, and producing the report [ 51 ]. Data familiarization will consist of reading and re-reading the data while noting initial ideas. Additionally, coding interesting features of the data will follow systematically across the entire dataset while collating data relevant to each code. Moreover, the open coding of the data will be performed to describe the data into concepts and themes, which will be further categorized to identify distinct concepts and themes [ 52 ].

The three researchers will discuss the results of their thematic analyses. They will compare and contrast the three analyses in order to come up with a thematic map. The final thematic map of the analysis will be generated after checking if the identified themes work in relation to the extracts and the entire dataset. In addition, the selection of clear, persuasive extract examples that will connect the analysis to the research question and literature will be reviewed before producing a scholarly report of the analysis. Additionally, the themes and sub-themes generated will be assessed and discussed in relevance to the study’s objectives. Furthermore, the gathering and analyzing of the data will continue until saturation is reached. Finally, pseudonyms will be used to present quotes from qualitative data.

Data triangulation.

Data triangulation using the two different data sources will be conducted to examine the various aspects of the research and will be compared for convergence. This part of the analysis will require listing all the relevant topics or findings from each component of the study and considering where each method’s results converge, offer complementary information on the same issue, or appear to contradict each other. It is crucial to explicitly look for disagreements between findings from different data collection methods because exploration of any apparent inter-method discrepancy may lead to a better understanding of the research question [ 53 , 54 ].

Data management plan.

The Project Leader will be responsible for overall quality assurance, with research associates and assistants undertaking specific activities to ensure quality control. Quality will be assured through routine monitoring by the Project Leader and periodic cross-checks against the protocols by the research assistants. Transcribed KIIs and the online survey questionnaire will be used for recording data for each participant in the study. The project leader will be responsible for ensuring the accuracy, completeness, legibility, and timeliness of the data captured in all the forms. Data captured from the online survey or KIIs should be consistent, clarified, and corrected. Each participant will have complete source documentation of records. Study staff will prepare appropriate source documents and make them available to the Project Leader upon request for review. In addition, study staff will extract all data collected in the KII notes or survey forms. These data will be secured and kept in a place accessible to the Project Leader. Data entry and cleaning will be conducted, and final data cleaning, data freezing, and data analysis will be performed. Key informant interviews will always involve two researchers. Where appropriate, quality control for the qualitative data collection will be assured through refresher KII training during research design workshops. The Project Leader will check through each transcript for consistency with agreed standards. Where translations are undertaken, the quality will be assured by one other researcher fluent in that language checking against the original recording or notes.

Ethics approval.

The study shall abide by the Principles of the Declaration of Helsinki (2013). It will be conducted along with the Guidelines of the International Conference on Harmonization-Good Clinical Practice (ICH-GCP), E6 (R2), and other ICH-GCP 6 (as amended); National Ethical Guidelines for Health and Health-Related Research (NEGHHRR) of 2017. This protocol has been approved by the University of the Philippines Manila Research Ethics Board (UPMREB 2021-099-01 dated March 25, 2021).

The main concerns for ethics were consent, data privacy, and subject confidentiality. The risks, benefits, and conflicts of interest are discussed in this section from an ethical standpoint.

Recruitment.

The participants will be recruited to answer the online SAQ voluntarily. The recruitment of participants for the KIIs will be chosen through stratified random sampling using a list of those who answered the online SAQ; this will minimize the risk of sampling bias. In addition, none of the participants in the study will have prior contact or association with the researchers. Moreover, power dynamics will not be contacted to recruit respondents. The research objectives, methods, risks, benefits, voluntary participation, withdrawal, and respondents’ rights will be discussed with the respondents in the consent form before KII.

Informed consent will be signified by the potential respondent ticking a box in the online informed consent form and the voluntary participation of the potential respondent to the study after a thorough discussion of the research details. The participant’s consent is voluntary and may be recanted by the participant any time s/he chooses.

Data privacy.

All digital data will be stored in a cloud drive accessible only to the researchers. Subject confidentiality will be upheld through the assignment of control numbers and not requiring participants to divulge the name, address, and other identifying factors not necessary for analysis.

Compensation.

No monetary compensation will be given to the participants, but several tokens will be raffled to all the participants who answered the online survey and did the KIIs.

This research will pose risks to data privacy, as discussed and addressed above. In addition, there will be a risk of social exclusion should data leaks arise due to the stigma against mental health. This risk will be mitigated by properly executing the data collection and analysis plan, excluding personal details and tight data privacy measures. Moreover, there is a risk of psychological distress among the participants due to the sensitive information. This risk will be addressed by subjecting the SAQ and the KII guidelines to the project team’s psychiatrist’s approval, ensuring proper communication with the participants. The KII will also be facilitated by registered clinical psychologists/psychiatrists/social scientists to ensure the participants’ appropriate handling; there will be a briefing and debriefing of the participants before and after the KII proper.

Participation in this study will entail health education and a voluntary referral to a study-affiliated psychiatrist, discussed in previous sections. Moreover, this would contribute to modifications in targeted mental-health campaigns for the 18–25 age group. Summarized findings and recommendations will be channeled to stakeholders for their perusal.

Dissemination.

The results will be actively disseminated through conference presentations, peer-reviewed journals, social media, print and broadcast media, and various stakeholder activities.

This study protocol rationalizes the examination of the mental health of the college students in the Philippines during the COVID-19 pandemic as the traditional face-to-face classes transitioned to online and modular classes. The pandemic that started in March 2020 is now stretching for more than a year in which prolonged lockdown brings people to experience social isolation and disruption of everyday lifestyle. There is an urgent need to study the psychosocial aspects, particularly those populations that are vulnerable to mental health instability. In the Philippines, where community quarantine is still being imposed across the country, college students face several challenges amidst this pandemic. The pandemic continues to escalate, which may lead to fear and a spectrum of psychological consequences. Universities and colleges play an essential role in supporting college students in their academic, safety, and social needs. The courses of activities implemented by the different universities and colleges may significantly affect their mental well-being status. Our study is particularly interested in the effect of online classes on college students nationwide during the pandemic. The study will estimate this effect on their mental wellbeing since this abrupt transition can lead to depression, stress, or anxiety for some students due to insufficient time to adjust to the new learning environment. The role of social media is also an important exposure to some college students [ 55 , 56 ]. Social media exposure to COVID-19 may be considered a contributing factor to college students’ mental well-being, particularly their stress, depression, and anxiety [ 57 , 58 ]. Despite these known facts, little is known about the effect of transitioning to online learning and social media exposure on the mental health of college students during the COVID-19 pandemic in the Philippines. To our knowledge, this is the first study in the Philippines that will use a mixed-method study design to examine the mental health of college students in the entire country. The online survey is a powerful platform to employ our methods.

Additionally, our study will also utilize a qualitative assessment of the college students, which may give significant insights or findings of the experiences of the college students during these trying times that cannot be captured on our online survey. The thematic findings or narratives from the qualitative part of our study will be triangulated with the quantitative analysis for a more robust synthesis. The results will be used to draw conclusions about the mental health status among college students during the pandemic in the country, which will eventually be used to implement key interventions if deemed necessary. A cross-sectional study design for the online survey is one of our study’s limitations in which contrasts will be mainly between participants at a given point of time. In addition, bias arising from residual or unmeasured confounding factors cannot be ruled out.

The COVID-19 pandemic and its accompanying effects will persistently affect the mental wellbeing of college students. Mental health services must be delivered to combat mental instability. In addition, universities and colleges should create an environment that will foster mental health awareness among Filipino college students. The results of our study will tailor the possible coping strategies to meet the specific needs of college students nationwide, thereby promoting psychological resilience.

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Down but Never Out! Narratives on Mental Health Challenges of Selected College Students During the COVID-19 Pandemic in the Philippines: God, Self, Anxiety, and Depression

Affiliation.

1 Department of the Theology and Religious Education (DTRE), De La Salle University, Manila, Philippines. [email protected].
PMID: 35034252
PMCID: PMC8761098
DOI: 10.1007/s10943-021-01476-3

The COVID-19 pandemic is continuously causing serious effects on the mental health of college students due to the series of lockdowns and sudden shifting of face-to-face classes to fully online. The study aims to determine and explore the various themes that play a significant role in the development of this issue by an in-depth study of selected reflection papers submitted in class. These texts were interpreted and analyzed using interpretative phenomenological analysis. Findings revealed three major themes: anxiety and depression as serious effects of the pandemic, God/Higher Being as the first and/or last source of support and, the essentiality of self-awareness and self-acceptance in improving mental health. These themes which are contextualized in nature hope to contribute to future research in formulating effective interventions and strategies in the war against the negative effects of the pandemic most especially for the welfare of college students.

Keywords: COVID-19 pandemic; God/higher being; Mental health; Self-acceptance; Self-awareness; Support.

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Conflict of interest statement

The author declares that he has no conflict of interest.

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Impact of covid-19 on poor mental health in children and young people ‘tip of the iceberg’ – unicef, new analysis indicates lost contribution to economies due to mental disorders among young people estimated at nearly $390 billion a year.

Belmopan, Belize. June 2021. Baby and her mother during routine check up with the pediatrician.

NEW YORK, 5 October 2021 – Children and young people could feel the impact of COVID-19 on their mental health and well-being for many years to come, UNICEF warned in its flagship report today.

According to The State of the World’s Children 2021; On My Mind: promoting, protecting and caring for children’s mental health – UNICEF’s most comprehensive look at the mental health of children, adolescents and caregivers in the 21st century – even before COVID-19, children and young people carried the burden of mental health conditions without significant investment in addressing them.

According to the latest available estimates, more than 1 in 7 adolescents aged 10–19 is estimated to live with a diagnosed mental disorder globally. Almost 46,000 adolescents die from suicide each year, among the top five causes of death for their age group. Meanwhile, wide gaps persist between mental health needs and mental health funding. The report finds that about 2 per cent of government health budgets are allocated to mental health spending globally.

“It has been a long, long 18 months for all of us – especially children. With nationwide lockdowns and pandemic-related movement restrictions, children have spent indelible years of their lives away from family, friends, classrooms, play – key elements of childhood itself,” said UNICEF Executive Director Henrietta Fore. “The impact is significant, and it is just the tip of the iceberg. Even before the pandemic, far too many children were burdened under the weight of unaddressed mental health issues. Too little investment is being made by governments to address these critical needs. Not enough importance is being placed on the relationship between mental health and future life outcomes.”

Children’s mental health during COVID-19

Indeed, the pandemic has taken its toll. According to early findings from an international survey of children and adults in 21 countries conducted by UNICEF and Gallup – which is previewed in The State of the World’s Children 2021 – a median of 1 in 5 young people aged 15–24 surveyed said they often feel depressed or have little interest in doing things.

As COVID-19 heads into its third year, the impact on children and young people’s mental health and well-being continues to weigh heavily. According to the latest available data from UNICEF, globally, at least 1 in 7 children has been directly affected by lockdowns, while more than 1.6 billion children have suffered some loss of education. The disruption to routines, education, recreation, as well as concern for family income and health, is leaving many young people feeling afraid, angry, and concerned for their future. For example, an online survey in China in early 2020, cited in The State of the World’s Children , indicated that around a third of respondents reported feeling scared or anxious.

Cost to society

Diagnosed mental disorders, including ADHD, anxiety, autism, bipolar disorder, conduct disorder, depression, eating disorders, intellectual disability, and schizophrenia, can significantly harm children and young people’s health, education, life outcomes, and earning capacity.

While the impact on children’s lives is incalculable, a new analysis by the London School of Economics in the report indicates that lost contribution to economies due to mental disorders that lead to disability or death among young people is estimated at nearly $390 billion a year.

Protective factors

The report notes that a mix of genetics, experience and environmental factors from the earliest days, including parenting, schooling, quality of relationships, exposure to violence or abuse, discrimination, poverty, humanitarian crises, and health emergencies such as COVID-19, all shape and effect children’s mental health throughout their lifetime.

While protective factors, such as loving caregivers, safe school environments, and positive peer relationships can help reduce the risk of mental disorders, the report warns that significant barriers, including stigma and lack of funding, are preventing too many children from experiencing positive mental health or accessing the support they need.

The State of the World’s Children 2021 calls on governments, and public and private sector partners, to commit, communicate and act to promote mental health for all children, adolescents and caregivers, protect those in need of help, and care for the most vulnerable, including:

Urgent investment in child and adolescent mental health across sectors, not just in health, to support a whole-of-society approach to prevention, promotion and care.
Integrating and scaling up evidence-based interventions across health, education and social protection sectors - including parenting programmes that promote responsive, nurturing caregiving and support parent and caregiver mental health; and ensuring schools support mental health through quality services and positive relationships.
Breaking the silence surrounding mental illness, through addressing stigma and promoting better understanding of mental health and taking seriously the experiences of children and young people.

“Mental health is a part of physical health - we cannot afford to continue to view it as otherwise,” said Fore. “For far too long, in rich and poor countries alike, we have seen too little understanding and too little investment in a critical element of maximizing every child’s potential. This needs to change.”

Multimedia content available to download here

Notes to Editors

Estimates on causes of death among adolescents are based on data from the World Health Organization (WHO) 2019 Global Health Estimates. Estimates on prevalence of diagnosed mental disorders are based on the Institute of Health Metrics and Evaluation’s (IHME) 2019 Global Burden of Disease Study.

Survey findings on feelings of depression or having little interest in doing things are part of a larger study conducted jointly between UNICEF and Gallup to explore the intergenerational divide. The Changing Childhood Project interviewed approximately 20,000 people by telephone in 21 countries. All samples are probability-based and nationally representative of two distinct populations in each country: people aged 15-24 and people aged 40 and older. The coverage area is the entire country, including rural areas, and the sampling frame represents the entire civilian, non-institutionalized, population within each age cohort with access to a telephone. The full findings of the project will be released by UNICEF in November.

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Additional resources.

UNICEF State of the World's Children Report 2021

About UNICEF

UNICEF promotes the rights and wellbeing of every child, in everything we do. Together with our partners, we work in 190 countries and territories to translate that commitment into practical action, focusing special effort on reaching the most vulnerable and excluded children, to the benefit of all children, everywhere.

For more information about UNICEF and its work for children in the Philippines, visit www.unicef.ph .

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Mental at Emotional Journey ni Baby: Ang Unang Limang Taon

UNICEF Guide to caring for baby's mental health

When silence isn’t golden: Kausapin ang iyong teenager

A UNICEF guide to caring for teens’ mental health

UNICEF SEA-PLM secondary research reveals link between learning and well-being of children in Southeast Asia

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Covid-19 related mental health issues growing among the youth

October 13, 2021
5 minute read

The onset of the Covid-19 pandemic forced many people to stay at home due to restrictions in mobility.

While parents were happy about this development, little did they know that being locked down at home would become a growing problem, especially among the youth. They were forced to stop all their usual activities, which later led to stress, anxiety, among others.

Going online helped—attending online classes, talking to friends, family, enjoying online games—but was temporary and even became a double-edged sword. Fake news online changed their perspectives and only added to the trouble. Health issues also emerged as they forgot to become physically active because of too much screen time.

Dr. Cornelio Banaag Jr. Professor Emeritus, Child and Adolescent Psychiatry, University of the Philippines- Philippine General Hospital (UP-PGH) noted that even before the pandemic, an alarming global increase in mental health problems was already noted.

He said the World Health Organization (WHO) estimates that 10 to 20 percent of children and adolescents suffer from various forms of mental disorders, with most happening among adults starting at age 14 and remain unrecognized until it’s too late. The risk of suicide is highest in ages 15 to 24 years old.

Dr. Banaag cited a global school-based Student Health Survey done in collaboration with the WHO and private groups, including the US Centers for Disease Control and Prevention from January to March 2021. He said 17 percent of high school students (13 to 15 years old) attempted to commit suicide at least once, 12 percent admitted they seriously considered attempting suicide, and 11 percent made plans on how they would commit suicide.

“Social Media Envy” was also alluded to as a moderate significant predictor of symptoms of depression among Filipino high school students. Then came an emerging mental health crisis with a serious lack of mental health facilities (only 60) in the country, and only about 7 percent of all public and private hospitals have a psychiatric ward, and the ratio of mental health workers (psychiatrists, psychologists, social workers) with only two per 100,000 population.

The advent of Coronavirus 2019

“None of us realized we would deal with this difficult time. There is an invisible enemy that can only be seen in terms of morbidity and mortality numbers, which we constantly monitor in the news, further adding to the burden of mental health because of the negative news.”

How visible are these impacts on mental health? What can be seen are elevated levels of stress and anxiety. “A lot of people are now experiencing toxic anxiety, marked by signs such as constant worrying, changes in sleep and eating habits, changes in emotion.”

He pointed to factors that contributed to the rise of mental health problems, essentially those related to “uncertainty” and “isolation.”

In uncertainty, Dr. Banaag said no one knows how all these happened, how it started; it just descended on us, and no one knows when it will end. “The kids keep asking when they will go back to school and play with their playmates, the teenagers languish in their rooms wishing to meet their friends but cannot due to the pandemic. We’re scared to go out for fear of contracting the virus and if we get it, are we going to be hospitalized? For how long? Will our savings suffice? Too much uncertainty makes us feel we are not in control.”

When it comes to “isolation,” it is something horrible for Filipinos who are used to be connected to each other, he said, and it brought a lot of loneliness and grief.

Filipinos living in the new normal

People are now living in what is called a “new normal,” which Dr. Banaag referred to as a “constantly shifting normal.” He said distance learning and work from home became major sources of stress. Distance learning changed the context of school for both parents and children and presented unique challenges. “Unfortunately, going to school has become a matter of compliance now, not of learning.”

The “work from home” setup presented problems on managing and balancing responsibilities, especially for mothers where playing multiple roles added to their stress. The pandemic also changed humans’ experiences of loss, grief and bereavement, Dr. Banaag said. When a family member gets sick or hospitalized, no one is allowed to be with them. “And when we lose them to Covid-19, we can’t even exercise the normal grieving process, another risk factor for depression, anxiety, post-traumatic stress disorder. There is so much complicated grief going around.”

In the Philippines, the pandemic’s impact on Filipino students’ mental health in terms of stress, depression, anxiety and impact of the event itself, based on a study by the Philippine One Health University Network and the Southeast Asian One Health University Network released in August 2021, showed that National Capital Region students experienced high levels of stress with 19 percent, 22 percent admitted feeling depressive symptoms, 36 percent admitted to anxiety, and close to 26 percent admitted to having a terrible time coping with the pandemic’s impact.

Compared to other students from other areas, Dr. Banaag said it did not change much but when compared to non-students, the numbers dropped to about 50 percent, which showed that students are the most stressed group, even higher than other groups like employees, farmers, and others.

And the instances of suicide among the youth is increasing. In “The State of the World’s Children 2021” by UNICEF, it said suicide is now the world’s 4th leading cause of death among 15 to 19-year-olds, almost 46,000 children aged 10 to 19 commit suicide annually, or one in every 11 minutes. “That’s scary, alarming and very, very sad.”

An important first step when suicide and depression is noticed is through “screening for depression” to prevent deeper mental health problems and suicide. “Screening helps provide accurate diagnosis, effective treatment and appropriate follow up.”

Young people taking action

They are aware of Y4MH or Youth for Mental Health, whose task is to push back the darkness beginning to envelop young people. The group called “Student Solidarity Network to Survive Covid-19 2020” wrote a petition for the issuance of Memorandum Order to implement other measures to address issues of accessibility, financial, physical and mental stress amid the Covid-19 pandemic. It’s a plea by students to not just look at their academic performance but also other concerns like poor Internet, unavailability of devices, poor learning conduciveness, physical, mental and financial stress on their families, coping with requirements.

In everything that is happening, Dr. Banaag said the WHO expressed it all: “There is no health without mental health.”

Protect elderly against the ‘twindemic’–experts

Unattended Mental Health Needs: Adult Students in the Philippines during the Early Weeks of the COVID-19 Pandemic

Norman B. Mendoza 1 , Allan B. I. Bernardo 2* , and John Ian Wilzon T. Dizon 3

1 The Education University of Hong Kong, Hong Kong 2 De La Salle University, Manila, Philippines 3 Angeles University Foundation, Angeles City, Philippines

https://doi.org/10.57043/transnastphl.2021.1135

A survey of 3,032 university students in the Philippines during the beginning of the COVID-19 lockdown in the country (March to April 2020) revealed that 44.66% met the cutoff score for generalized anxiety symptoms (GAD-2) and 62.40% reported having very bad to bad sleep quality; these symptoms are also negatively correlated with measures of psychological well-being. We also found that, among those screened by the GAD-2, 40% ( n = 542) and 51.55% ( n = 698) met the cutoff score for moderate and severe anxiety on the GAD-7, respectively. The sector of the Philippine population lost their usual access to mental health services in their school campuses, and the paper describes how their mental health needs during the pandemic remain unattended, as university campuses remain closed even eighteen months after.

*Correspondence: Allan B. I. Bernardo, [email protected]

Number of students suffering from mental health issues growing

Crisis Support

National suicide prevention lifeline.

1-800-273-8255

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Text NAMI to 741-741 to connect with a trained crisis counselor to receive free, 24/7 crisis support via text message.

NAMI HelpLine

Call 1-800-950-NAMI (6264) M–F, 7 a.m.–3 p.m. PT for free mental health info, referrals and support.

School During the Pandemic: Mental Health Impacts on Students

The COVID-19 pandemic has presented many challenges to students, educators, and parents. Children already coping with mental health conditions have been especially vulnerable to the changes, and now we are learning about the broad impacts on students as a result of schools being closed, physically distancing guidelines and isolation, and other unexpected changes to their lives.

The California Parent and Youth Helpline : 1-877-427-2736

Webinars with Useful Information

In-Person, Virtual and Everything In-Between: Supporting Families and Children Returning to School (NAMI Webinar)

Supporting Distance Learning (Parents and Caregivers for Wellness webinar)

“Bluesky: Building a Healthier California Through Youth Resilience in a COVID-19 World” (Commonwealth Club panel Discussion, featuring NAMI California CEO, Jessica Cruz)

More Resources

“ How to Help Students Cope and Deal with Stress” (California Department of Mental Health)

“School’s Out Parents’ Guide to Meeting the Challenge During the COVI19 Pandemic” (NYU Langone Health)

“An Educator’s Tips for Online Learning” (LA Times)

Social-Emotional Learning Is the Elephant in the Room: Three Challenges to Consider (Education Week)

How to effectively manage your child’s back-to-school fears (Washington Times Herald)

Back to School in a Pandemic: Tips to Foster Mental Health: Part 1 and Part 2 (Psychology Today)

Helping Children Cope (CDC)

Stress Relief for Caregivers and Kids during COVID-19 (California Surgeon General)

Helping Children Cope With Changes Resulting From COVID-19 (National Association of School Psychologists)

NAMI Resources How to Help a Friend (NAMI) Student Guide to Mental Health (NAMI) Find out about NAMI On Campus for High Schools and College Find out about NAMI’s Ending the Silence Presentation for Schools; find your local NAMI California affiliate to request a virtual presentation for your school Site Logo NAMI California Sacramento, CA T. (916) 567-0163 F. (916) 567-1757 E. [email protected] For NAMI Affiliates For Media Career Opportunities Sign up for our newsletter!

Open access
Published: 11 November 2021

An evaluation of eye movement desensitization and reprocessing therapy delivered remotely during the Covid–19 pandemic

Iain W. McGowan 1 ,
Naomi Fisher 2 ,
Justin Havens 3 &
Simon Proudlock 4

BMC Psychiatry volume 21 , Article number: 560 ( 2021 ) Cite this article

11k Accesses

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In addition to having a negative impact on the physical and emotional health of the population, the global Covid–19 pandemic has necessitated psychotherapists moving their practice to online environments. This service evaluation examines the efficacy of Eye Movement Desensitization and Reprocessing (EMDR) Therapy delivered via the internet.

A real–world service evaluation was conducted from a self–selecting group of EMDR therapists that subscribe to either a JISCMail discussion list or either the UK or All Ireland National EMDR Associations. Author designed questionnaires were used to gather information on the efficacy of EMDR delivered online as well as client and therapist characteristics.

Thirty-three therapists provided efficacy data on a total of 93 patients. Statistically significant and clinically meaningful reductions were found in all four-psychometrics used both in adult and children and young people populations. Client outcome was not related to therapist experience.

Conclusions

EMDR delivered via the internet can be an effective treatment for clients experiencing mental health issues.

Peer Review reports

Eye Movement Desensitization and Reprocessing therapy (EMDR) is an effective, evidence–based treatment for the treatment of several mental health issues including post–traumatic stress disorder (PTSD), depression, anxiety and eating disorders. It is recommended as a first line intervention for people experiencing symptoms associated with PTSD by the ISTSS [ 1 ] and the World Health Organization [ 2 ]. The UK, National Institute of Health and Care Excellence (NICE) [ 3 ] recommend using EMDR where trauma focused Cognitive Behavioural Therapy (CBT) is unsuccessful or the client declines CBT.

EMDR is guided by the adaptive information processing model [ 4 ] The model posits that current PTSD symptomatology is a result of maladaptive information processing of unprocessed memories stored in the brain. EMDR therapy suggests that after a traumatic experience, information processing is developed using bilateral stimulation of each brain hemisphere “resulting in new learning, elimination of emotional distress, and development of cognitive insights” [ 5 ].

The Covid–19 pandemic has had a negative impact on the mental health of the general population. In the last year, several meta–analyses have been published reporting the negative impact Covid–19 has had on the general public [ 6 ], healthcare workers [ 6 ], people living with physical health problems such as cancer [ 7 ] and those with pre–existing mental health issues [ 8 ]. This impact has been felt globally. In China, Hao et al. (2020) [ 8 ] surveyed 76 people currently in treatment for a mental health problem and 109 without. They found statistically significant differences between the group in levels of PTSD symptoms experienced, depression, anxiety and insomnia. Similar findings are reported in Saudi Arabia [ 9 ], Pakistan [ 10 ] and the Philippines [ 11 ]. In the United Kingdom, Pierce et al. [ 12 ] report a significant decline of the mental health of the general population between the start of the pandemic and April 2020. Negative impacts of Covid 19 are found in the general population in Spain [ 13 ], amongst the student population in Greece [ 14 ] and the Philippines [ 11 ], and amongst healthcare workers in Italy [ 6 ].

Most Government responses to the Covid 19 pandemic included some form of, what became colloquially known in the UK as ‘lockdown’. However, social isolation and withdrawal have long been associated with the onset of mental health problems [ 15 ]. Consequently, the potential for harm from protective policies is apparent. Tien– Huy et al. (2021) [ 16 ] conducted a global survey across 63 countries to assess the impact of quarantine/ isolation on the psychological well–being of individuals ( n = 1871). They found a statistically significant positive association between the number of days in quarantine and increased perceived stress levels. A significant positive association was also found between perceived stress levels and being exposed to a suspected or a confirmed positive case of Covid–19 [ 16 ].

Similar findings are reported by the TMGH–Global COVID–19 Collaborative (2021) [ 17 ]. This collaborative sought to examine the presence of PTSD in individuals in insolation/ quarantine. Drawing on results from 944 responses across 57 countries, they report that people experiencing symptoms of Covid − 19 and were forced to isolate reported more PTSD than those isolating for other reasons. Being made to isolate also increased the risk of developing PTSD in comparison to voluntarily entering a period of quarantine (OR: 2.92: 95% CI: 1.84–4.74: p < 0.001).

It is important to recognise that, in addition to the pandemic, governments and their populations have also had to manage natural and man-made disasters that have had an impact on the mental health of individuals. For example, during 2020, the Philippines was hit by 22 tropical cyclones [ 18 ]. Rocha et al. (2021) [ 18 ] suggest that has resulted in population displacement, increased socio– economic burden on individuals and families and sudden bereavement which coupled with the pandemic may increase susceptibility to psychological distress.

Islam et al. (2021) [ 19 ] considered the psychological impact of multiple “converging systems” (p112) on the healthcare workforce. In a commentary article they argue that Yemeni healthcare workers are faced with longer working hours, no or delayed salary payments, exposure to traumatic events (either from Covid or as a result of war), an increased risk of catching Covid–19 and stigmatization. This, they contend has ed. to increased levels of PTSD, anxiety disorders, lower self-efficacy and “increased detachment from the workplace” (p113).

This has resulted in not only increased demand, but also limited access to mental health services due to mental health staff reallocation to Covid related duties, closure of out–patient services and restriction on businesses providing in person services. The initial United Kingdom Government response to the pandemic necessitated the closure of the majority of publicly funded and all private providers therapy offices requiring therapists to move their practice online.

Online psychotherapy is not new. For example, Christensen et al. [ 20 ] reported the effectiveness of the computerized MoodGym CBT programme for anxiety and depression over 15 years ago. More recently, Kuhn et al. [ 21 ] explored the effectiveness of a CBT based app designed to reduce PTSD symptoms. They report statistically significant improvements in PTSD symptoms, depressive symptoms and social functioning. NICE produced guidelines for the remote delivery of psychological therapies and recommended a number of ‘digital therapies’ for various mental health problems including depression, anxiety, substance misuse and body dysmorphic disorder [ 22 ]. Interestingly, no digital interventions for trauma specific presentations have been assessed. Additionally, these studies focus on therapy delivered through an app or webpage, where no therapist has direct involvement in the treatment.

Remote delivery of psychotherapy, where the client works with a therapist online or via the telephone [ 23 ] has been found to be both effective and acceptable to clients experiencing PTSD symptoms. Knaevelsrud & Maercker [ 24 ] compared CBT delivered via the internet against a waitlist control. They found statistically significant differences in PTSD symptomatology between the two groups after ten sessions delivered over a five-week period. Khun & Owen [ 21 ] carried out a systematic review. They found that PTSD therapy delivered remotely was as effective as in–person treatment although they note that the samples for the papers included in their reviews were primarily military veterans and male, limiting the generalization of their findings.

It is possible that online delivery of therapy could address some of the factors associated with dropout from therapy [ 25 ]. Low/ hourly paid work and travel time and cost have previously been identified as factors that drive attrition rates from therapy [ 26 ]. The flexibility afforded by online therapy may improve retention rates and, theoretically, clinical outcome [ 27 ].

Online EMDR

EMDR therapists have been successfully treating clients remotely over the internet [ 28 ]. However, peer reviewed reports on the efficacy of EMDR delivered via the internet are scant. Lenferink Meyerbroker & Boelen [ 29 ] specifically sought papers investigating the efficacy on EMDR online. They found a single uncontrolled study [ 30 ] that used internet-based CBT with a web based EMDR tool– iEMDR. The iEMDR is reported to be based on the standard eight–phase protocol outlined by Shapiro [ 4 ] adapted for internet delivery. The web link provided in the paper ( https://www.rapidtables.com/tool/EMDR.html ) is inactive, thus it is not possible to verify this claim. Fifteen participants started the intervention with 11 completing. Nine participants completed the follow up questionnaires, although the time to follow up is not reported. Spence et al. [ 30 ] reported statistically significant improvements in PTSD and anxiety symptoms. The small sample size and lack of control group should counsel against generalizing their findings.

Tarquinio et al. [ 31 ] investigated the efficacy of a single EMDR session in reducing anxiety and depression levels as well as the perceived subjective level of disturbance. Seventeen nurses who were in treatment for non–Covid related issues in France had a single session of EMDR, through a video conferencing platform, using the URG–EMDR protocol [ 24 ]. They report statistically significant reductions in anxiety, depression, subjective distress, fear of returning to their workplace and fearing for their safety in relation to Covid ( p < 0.05).

Lazzaroni et al. (2021) [ 32 ] used the EMDR protocols for Acute and Recent Traumatic events [ 33 ] with a group of adolescents and young adults currently receiving mental healthcare services ( n = 50 (age 13– 24 years)). The participants received 3 × 1 h sessions delivered online. Lazzaroni et al. report significant improvements in anxiety levels and post–traumatic symptomatology ( p = 0.05) post intervention.

The small sample sizes and lack of control groups in the two studies above should impress the need for caution when interpreting these findings. However, the studies provide some evidence to support the use of EMDR online.

The bilateral stimulation inherent in EMDR therapy can be delivered in several ways from asking clients to follow the therapists’ hand or wand as the therapist moves it from side to side [ 34 ]. Alternate hand taps and butterfly hugs can also be used, as can smartphones applications that deliver sounds to alternate ears [ 35 ].

We are aware of on–going RCT’s investigating the effectiveness of EMDR in an online environment [ 36 ]. This paper seeks to expand the published literature on using EMDR online.

The aim of this service evaluation was to determine evaluate the efficacy of the online delivery of EMDR therapy. Specifically, we sought to answer the following questions;

Does EMDR delivered online reduce clinical symptoms of common mental health presentations?

Does the level of EMDR accreditation or number of years’ experience using EMDR influence the overall client outcome?

Recruitment of therapists & clients

EMDR therapists were recruited through the EMDR UK and Ireland JISCMail mailing list, and direct email from the EMDR UK Association (circulation 4200 therapists). The JISCMail list is an opt–in discussion forum where subscribers engage in discussion regarding EMDR. It currently has circa 1700 subscribers. Members of both the UK EMDR Association and the JISCMail mailing list are required to have undergone an approved training course and to be practicing under supervision in accordance with EMDR Europe and/or the EMDR International Association standards. We adopted a full population approach to the evaluation and as such all members of either organization were eligible to take part. No exclusion criteria were applied.

A generic mail was sent to all subscribers inviting them to take part. Interested therapists were directed to an online form that detailed the evaluation. Therapists deciding to participate provided details in respect of their level, EMDR experience, and clinical assessment tools used. Participating therapists were then asked to complete an online form giving anonymized information of client’s presentation and outcome. As the authors had no direct contact with the clients, therapists were instructed to ensure that clients had given informed consent for their anonymized data to be used. The EMDR UK Association provided support for a random draw of participating therapists where the prize was one of three £20 gift vouchers. Suggested text regarding consent for therapists to include in their treatment plans/ consent forms was provided. Recruitment of therapists and data collection took place from May 2020–Dec 2020. Google Forms was used to collect data.

Using the algorithm provided by the UK National Health Research Authority and UK Policy Framework for Health and Social Care Research definition of research [ 37 ] this project was not classified as research but as a service evaluation [ 38 ]. As such formal IRB ethical approval was not required [ 38 ]. All participants were provided with an electronic information sheet that detailed the background and the aims of the study as well as the requirements of taking part. Respondents gave written informed consent to take part in the evaluation, and all processes undertaken in the evaluation were carried out in accordance with relevant guidelines and policies.

Data collection and analysis

Author designed surveys were used to collect the data. Data collected from the therapists is reported below and participating therapists then provided anonymized data on their clients including their gender, age, primary psychiatric reason for referral, pre– and post–treatment scores and the outcome measures used in practice. Given the heterogeneity of the assessment and outcomes tools used by EMDR therapists, and this project’s status as an evaluation of existing practice we did not put any restriction on the measures used by the therapist. We asked participating therapists to provide overall pre and post treatment scores in relation to the Impact of Events Scale– Revised (IES–R) [ 39 ], the General Anxiety Disorder 7 scale (GAD–7) [ 40 ], the Public Health Questionnaire 9 scale (PHQ–9) [ 41 ] and the PTSD Checklist (PCL–5) [ 42 ] and any other assessment scales they normally use for each of their clients.. Thesescales are widely used in PTSD research and clinical practice and have been shown to have good reliability and validity. Twenty five of the 33 therapists used one of the four scales above.

Of the eight that did not use any of these scales, the Subjective Units of Distress and Validity of Cognition scales [ 4 ] used routinely in EMDR therapy were reported as outcomes by one of the therapists. Other scales used by therapists were the HADS ( n = 1) [ 43 ], the CORE ( n = 1) [ 44 ], GHQ ( n = 1) [ 45 ], BDI ( n –1) [ 46 ], BAI ( n = 1) [ 47 ], AUDIT ( n = 1) [ 48 ], DES–II ( n = 1) [ 49 ], the Worry about Sexual Outcomes scale ( n = 1) [ 50 ], ITQ ( n = 2) [ 51 ], the Moral Disengagement Scale ( n = 1) [ 52 ], the Work and Social Adjustment Scale ( n = 2) [ 53 ], the Driving Cognitions Questionnaire ( n = 1) [ 54 ], and the CRIES 13 ( n = 1) [ 55 ]. Recognizing the very small numbers using these different assessment tools we have not reported these in this paper.

Descriptive statistics are reported for both therapists and clients. The Shapiro–Wilk test for normality returned non–significant statistics suggesting normal distribution of data. Accordingly, Student t–test was used to identify significant differences between pre– and post–treatment scores. Statistical significance was set at 0.05 throughout. Minimal clinically important differences were calculated using the distribution method [ 56 ] where a difference of half the standard deviation is recognised as being clinically important. In order to address the second research question, a third dataset was constructed combining the therapist and client details to allow for cross tabulation of outcome and anonymized therapist details. The Pearson r correlation statistic was used to explore relationships between the length of time the therapist had been practicing EMDR and each of the clinical outcomes. Analysis of variance (ANOVA) was used to ascertain differences between level of accreditation and clinical outcome. A dichotomous variable of aged 18 or over and under the age of 18 was created. ANOVA was used to explore any differences in outcome by age of the client. JASP software was used to conduct the statistical analysis.

Thirty-three therapists provided data on a total of 93 different clients. The therapists’ mean length of time since training in EMDR was 8.5 years (sd: 4.8 yrs.: range (0.5–17.5 yrs). Eight of the therapists were trained to Consultant Level, 10 were accredited EMDR therapists and the 12 had completed initial EMDR training and were working towards accreditation.

Of the 93 clients for whom data was provided, 62 (66%) identified as female, 30 (33%) as male and 1 as non–binary (1%). Ages ranged from 10 years to 72 (mean 35.5 sd 15.6 years). Thirteen (14%) of the clients were under the age of 18 years.

Psychological trauma (simple and complex) was the most common reason for seeking help, followed by anxiety and depression. Table 1 shows the reasons for referral. One of the 93 participants sought help for Covid related problems.

Statistically significant and clinically important reductions in the reported client mean scores of the IES(R), the GAD–7, the PHQ–9 and the PCL–5 checklist was found (Table 2 ). Large effect sizes post–treatment was also found. Minimal clinically important difference thresholds were set at 9.10 (IES(R)), 2.61 (GAD–7), 3.64 (PHQ–9) and 6.64 (PCL–5). No significant relationship was found between length of time trained in EMDR and any of the clinical outcomes, nor was there any significant difference in the association between level of accreditation and clinical outcome. No significant differences were found in any of the four outcomes between genders or between those aged under 18 years and clients aged 18 and over.

This appears to be the first evaluation to report the efficacy of using the standard eight phase EMDR protocol delivered through an online medium. Using real world data, we have shown that EMDR can reduce symptomatology regardless of the age, gender or clinical presentation of the client. The findings also show that length of time practicing EMDR and level of accreditation in EMDR are not associated with outcome, suggesting that EMDR can be used successfully regardless of experience after EMDR training.

Notwithstanding the limitations outlined below, the large effect sizes found are encouraging. A recent systematic review [ 57 ] reported a small to moderate pooled effect size (Hedges g = 0.33) [ 57 ] across 23 studies using EMDR delivered in the same room as the client for the treatment of PTSD, and a large pooled effect size across 10 studies for the treatment of anxiety disorders (Hedges g = 1.07) [ 57 ].

We are also encouraged by the apparent similarities in efficacy reported by therapists working with children and young people and those working with the adult population. This is in keeping with studies that report EMDR as an effective treatment for children and young people (CYP) that have experienced a traumatic event and that clinical improvement using EMDR is independent of demographic variables such as age [ 58 ]. For example, in a meta– analysis comparing trauma based approaches to treating PTSD in CYP Khan et al. [ 58 ] reported EMDR to be more effective than CBT in reducing PTSD symptoms (SDM (95% CI) = − 0.43 (− 0.73 – –0.12), p = 0.006) and anxiety symptoms (SDM (95% CI) = − 0.71 (− 1.21 – –0.21), p = 0.005). Lazzaroni et al. (2021) [ 32 ] and Jeon et al. (2017) [ 59 ] have shown that age is not correlated with either reductions in PTSD symptoms [ 32 ] or Post Traumatic growth [ 59 ].

Our findings allude to EMDR being as effective when delivered remotely as face to face, in line with the findings of Kuhn & Owen [ 21 ] We also note that the effect sizes reported here are in excess of those reported in meta–analyses of the CBT interventions (0.66 < g < 0.83) delivered via the internet when compared to passive controls (no treatment or wait list control) [ 60 ]. Interestingly, they also found that internet CBT was superior to active control groups [ 60 ].

As with other psychotherapies, remote delivery of EMDR has significant potential benefits to clients including the reduction in travel time to and from appointments and loss of salary to attend appointments [ 25 ] as well as a reduction in stigma associated with mental health treatment [ 61 ]. Clients have control over their environment and smartphone apps that deliver clicks via earphones alternately give the client more control of the session [ 23 ]. Other applications such as bilateralstimulation.io also provide online platforms for the delivery of the bilateral stimulations used in EMDR. Additionally, internet delivered interventions have been found to be a cost–effective way to deliver psychological interventions [ 39 ].

Conversely, when considering working with clients remotely therapists need to be cognisant of potential distractions such as children, deliveries and phone calls during the sessions [ 23 ] [ 27 ]. Fisher (2021) [ 23 ] also acknowledges that the home environment may not always be a safe environment for the client to undergo EMDR therapy and therapists need to be cognisant of this when considering online work with clients.

Having access to the internet is, obviously, a pre–requisite for online therapy. Cleofas et al. (2021) [ 62 ] surveyed 952 college students and report that computer ownership and access to the internet are associated with lower levels of Covid–19 related anxieties. Rubin (2021) [ 63 ] argues that internet access should now be a social determinant of health. She notes that internet access increases with income. Subsequently, therapists need to be cognisant of the stigma associated with poverty [ 64 ] and the potential for those living in poverty to portray a more positive outlook than their current situation [ 65 ] when considering moving therapy online.

Limitations

This evaluation has several limitations. There is a potential for ‘gatekeeper bias’, where there is the possibility that therapists providing data may only have submitted data for clients that showed improvement. We also recognise that despite high initial interest, a relatively small number of therapists provided client data. This may suggest a self–selecting group with a bias toward online EMDR. The lack of a control group and small sample size of both therapists and clients also precludes us making any generalised claims. Although we note above that client outcome appears to be independent of level of experience as an EMDR therapist, we did not collect data on previous experience of online therapy undertaken by therapist prior to the pandemic. Subsequently, we cannot comment on therapist experience working online and the impact that that may have on clinical outcome. As noted above, we are aware of several on–going Randomised Controlled Trials exploring the effectiveness of EMDR in an online environment that may address these limitations.

This evaluation appears to be the first paper to report the efficacy of EMDR delivered online using real world practice data. Our findings show that a reduction in clinical symptoms can be achieved using EMDR online, however recognising the limitations of this evaluation we would urge caution in interpreting the findings. Clinical trials examining the clinical and cost effectiveness of online EMDR are required.

The Covid 19 pandemic required EMDR therapists to adopt creative and flexible responses to help meet the needs of the clients [ 18 ]. Office closures and travel restrictions to and from work meant that therapists had to move their work to online. The findings of this evaluation suggest that they did so successfully.

Availability of data and materials

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

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McGowan, I.W., Fisher, N., Havens, J. et al. An evaluation of eye movement desensitization and reprocessing therapy delivered remotely during the Covid–19 pandemic. BMC Psychiatry 21 , 560 (2021). https://doi.org/10.1186/s12888-021-03571-x

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Bending not breaking: coping among Filipino University students experiencing psychological distress during the Global Health Crisis

Jennifer o. serrano.

1 The Graduate School, University of Santo Tomas, Manila, Philippines

3 Department of Guidance and Counseling, Quirino State University, Quirino, Philippines

Marc Eric S. Reyes

2 Department of Psychology, College of Science, University of Santo Tomas, Manila, Philippines

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The impact of the global health crisis on students’ mental health has been well documented. While most of the studies looked into the psychological impact of the coronavirus disease, the process of coping with psychological distress as experienced by university students in the Philippines remains unexamined. Cognizant of the dearth in literature, this grounded theory study purports to investigate and understand the coping processes among 20 Filipino university students. A comprehensive model highlights Filipino university students’ coping techniques with psychological distress through vertical and horizontal analysis of the field text, open, axial, and selective coding. To ensure the trustworthiness and truthfulness of the theory and for refinement and consistency, triangulation, peer debriefing, and member checking validation strategies were likewise employed. The novel and distinct B.E.N.D. Model of Coping with Psychological Distress illustrates a substantive four-phased process symbolic of the challenges that a bamboo tree underwent, namely: (1) B efuddling Phase, (2) E nduring Phase, (3) N avigating Phase, and (4) D eveloping Phase. The phases that emerged had the advanced appreciable understanding of the university students’ coping processes that may provide evidence-based information in crafting programs and specific interventions to support and safeguard students’ mental health.

The coronavirus disease (COVID-19) brought about a pandemic that negatively impacted individuals’ mental health (Sameer et al., 2020 ). It led to the experience of psychological stress, fear (Arvidsdotter et al., 2016 ), accumulated anxiety, and worries about health. The pandemic has led to significant psychological distress for everyone. Psychological distress (PD) is a state of poor psychological well-being, characterized by undifferentiated mixtures of symptoms extending from depression and anxiety symptoms (Drapeau et al., 2012 ). Its occurrence is detrimental to mental health and well-being (Deasy et al., 2014 ) and needs prevention and early intervention measures.

Young people, particularly university students, are at greater risk for psychological distress in health emergencies (Bert et al., 2020 ) and traumatic events (Villani et al., 2021 ). Previous studies have reported that due to the COVID-19 pandemic, university students experienced mental health challenges (Mudenda, 2021 ; Cao et al., 2020 ) and high levels of psychological distress (Hughes et al., 2022 ; Akbar & Aisyawati, 2021 ). Psychological distress was identified as the most prevalent mental health problem for university students (Gibbons et al., 2019 ). Anxiety, depression, and stress are among the psychological issues university students experience (Waseem et al., 2020 ; Khan et al., 2020 ; Aruta et al., 2022 ). Restrictions could have caused these psychological problems during pandemic-related lockdown (Alzueta et al., 2021 ).

Psychological distress poses a threat to the safety and well-being of university students. It is linked with risk behaviors and physical illness (Deasy et al., 2014 ), reduced students’ academic performance (Mudenda, 2021 ), and was strongly associated with suicide ideation and attempts (Eskin et al., 2016 ). Moreover, they are at risk for suicidal behavior and often search for information and news on the internet regarding self-harm and suicidal behavior (Solano et al., 2016 ). Additionally, measures of affective temperament types were more independently and strongly associated with negative clinical outcomes than a diagnosis of major affective disorder suggesting affective temperaments as possible contributors to university students’ psychological distress and suicidality (Baldessarini et al., 2017 ). What is alarming is that if it is experienced with high intensity on a long-term basis, the distress may jeopardize one’s mental health condition or lead to mental health disorders (Mubasyiroh et al., 2017 ).

As university students widely experience psychological distress, their way of coping is also of interest. In stressful situations, such as during a pandemic, coping behavior is an internal protective factor to overcome distress (Akbar & Aisyawati, 2021 ). Coping is a critical variable in reducing, minimizing, or tolerating stress (Gustems-Carnicer & Calderón, 2013 ) and preventing psychological distress. There are adaptive or protective factors for psychological distress (e.g., social support) and maladaptive strategies to manage stress (e.g., escape/avoidance) employed by students (Chao, 2012 ).

Despite the needed attention devoted to young adults’ mental health needs (Eskin et al., 2016 ), they are at risk of experiencing frequent mental health issues and psychological concerns. Literature is scarce on the context of coping with psychological distress, particularly among Filipino university students. Although there are studies in the Philippines that dealt with university students; still, the focus of their investigations was the cause, effects of stress and coping mechanisms (Mazo, 2015 ), academic performance and coping mechanisms (Yazon et al., 2018 ), mental health literacy and mental health (Argao et al., 2021), psychological impact (Tee et al., 2020 ), distinct associations of fear of COVID-19 and financial difficulties, mediating role of psychological distress (Aruta et al., 2022 ) and the different factors linked with psychological distress (Marzo et al., 2020 ).

This present grounded theory design study is conceptualized to explore and develop a theory on coping with psychological distress culturally unique to Filipino university students during a global health crisis. Our grounded theory study will address the central question: “ What theory explains the coping processes for psychological distress among a select group of Filipino university students? We believe that our current study will contribute to existing literature and deeply understand the phenomenon of coping with psychological distress, particularly in the Philippine context during the pandemic. The findings of this qualitative inquiry are expected to provide evidence-based information to students, parents, university officials, and mental health professionals that will aid them in understanding, developing, and strengthening programs and interventions that support and safeguard students’ mental health.

This qualitative study was conducted using grounded theory as its research design, driven by the purpose to move beyond description and discover a theory, a “unified theoretical explanation“(Corbin & Strauss, 2007 ) for a process, particularly coping with psychological distress. Grounded theory, particularly the analytic procedure, was used to investigate the coping techniques of Filipino university students with psychological distress during the pandemic.

Participants

Eligible participants for this study were 20 university students who fulfilled the set inclusion criteria: (a) Filipino undergraduate students at selected universities in the National Capital Region (NCR), (b) enrolled during the Academic Year 2020–2021, (c) with ages 18 to 21 years old, and (d) had high levels of psychological distress. Those who did not give their consent, who were having prior mental health diagnoses, and with incomplete/missing responses in the measure were excluded from the study. Further, Kessler Psychological Distress Scale-6 (K6) was used to screen the participants and those who were a high level of psychological distress were chosen to be part of the study. Our participant’s age ranges from 18 to 21 years old (M = 19.6; SD = 0.99), majority were female (n = 12; 60%), in a relationship (n = 15; 75%) and enrolled in BS Psychology program (n = 9; 45%).

Purposive sampling was used to intentionally select the participants representing the university students and give meaning to their lived experiences (Creswell & Plano Clark, 2018 ). McCrae and Purssell ( 2016 ) emphasized that to develop a theory, one must base it on theoretical concerns such as data saturation and not on the number of participants. Participation was voluntary and without remuneration. Each university student gave informed consent before completing the measures and participating in the interviews. Their willingness to answer the screening tool and their openness to sharing their experiences is essential in capturing the phenomenon’s essence under investigation.

Kessler Psychological Distress Scale-6 (K6). The K6 which is a short version of the K10 developed by Kessler and colleagues ( 2002 ) was used as a screening tool in selecting the participants. The K6 is a well-validated clinical measure, with good psychometric properties and is practical to use in assessing psychological symptoms (Krynen et al., 2013 ). It is a 6-item questionnaire that measures whether a person feels nervous, hopeless, restless, jumpy, sad, and worthless (e.g., “During the last 30 days, how often did you feel hopeless? “ ). Each item of the K6 self-report format is answered on a 5-point Likert-type scale from 1-None of the time to 5-All of the time. The total score ranges from 1-to 30. Those whose sum scored from 1-to 15 were students experiencing a low level of psychological distress, while those who scored 16-to 30 were students experiencing high levels of psychological distress (Serrano et al., 2022 ). Participants experiencing a high level of psychological distress were used as a reference in selecting participants for the current study.

Robotfoto. The robotfoto was used in obtaining the basic demographic profile of each participant and was used to ensure that the participants met the predetermined inclusion criteria. It specifically sought the participant’s age, gender, course, relationship status, and course.

Aide-Memoire . The aide-memoire was an interview guide developed for the present study to direct the semi-structured interview to capture Filipino university students’ lived experiences. The interview guide is process-oriented, revolving around the participant’s experience (Villamor et al., 2016 ). The aide-memoire was guided by the central question: “ What theory explains the coping processes for psychological distress among a select group of Filipino university students?

The data gathering started after obtaining approval from the Ethics Board of the University of Santo Tomas Graduate School. Permission from the presidents of the universities was secured before participants’ recruitment and selection. Twenty participants were purposely selected who met the study’s inclusion criteria. Informed consent was sought from each participant before scheduling the virtual interview. The virtual interviews took place online via Zoom or Google Meet video or voice conferencing calls in a mutually agreed schedule by both parties. With the participants’ prior consent, video and audio recording was done to document the interview.

The initial minutes of the interview focused on building rapport as well as presentation of the nature and objectives of the study. Such practice was observed to ensure a more natural, honest and open atmosphere between the participants and the researchers. The interview progressed, using the aide-memoire as a guide, and additional questions were also raised other than the key questions further to explore the participants’ responses during the interview. Each interview lasted for one and a half hours, depending on the participant’s experience. Follow-up interviews were also conducted that lasted 40 min with most participants to understand the phenomenon under investigation in-depth. The entire data gathering process for the second phase lasted three to six weeks. Moreover, the information shared by the participants was assured with utmost confidentiality, objectivity, and anonymity by using pseudo initials in place of their actual names and other identifying details.

Data analysis followed immediately after data collection. Recorded narratives were individually transcribed verbatim in English and were subjected to open, axial, and selective coding following Corbin and Strauss ( 2007 ) analytical framework. Preliminarily, each verbalization was assigned condensed codes, and through open coding, both anchors and phenomenal referents from the field text were identified, forming categories. Second, relationships between and among categories were correlated from the open codes and categories identified themes . The data after open coding was assembled in new ways in axial coding. Finally, the identification of conceptual ideas that integrated the existing categories was made in selective coding. We were able to develop a comprehensive model that highlights the coping processes of Filipino university students with psychological distress. Moreover, the themes that emerged in this study were further subjected to triangulation, peer debriefing, and member checking validation strategies to employ refinement and consistency and ensure the trustworthiness and truthfulness of the theory. Reflexivity was likewise observed to ensure that no bias and subjective judgment influenced the qualitative interpretations.

Through analyzing the data of participants’ significant statements and verbalizations, the findings of this grounded theory study yielded the B.E.N.D. Model of Coping with Psychological Distress (See Fig. 1 ) consists of four distinct phases: (1) b efuddling, (2) e nduring, (3) n avigating, and (4) d eveloping phases. The model is likened to the processes that a bamboo tree goes through to survive during a storm, as it bends harmoniously in the angry blasts of the blustering wind, remaining standing tall and still. Verily, the university students were like bamboo. Even with the widespread havoc that the global health crisis has created, they use a bending, not breaking process to continuously adjust, adapt and cope with everyday vagaries of life.

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B.E.N.D. Model of coping with psychological distress

(1) Befuddling Phase

In this study, the participants had a high level of psychological distress. Unsurprisingly, the drastic changes brought about by the global health crisis triggered the distressed experiences of students. They were emotionally and mentally disturbed as they faced an unusual situation. As participants shared,

“I have anxieties and fears; then the pandemic has brought me problems that I didn’t know existed. It feels like I’m inside a room and can’t do anything to get out. There are many ideas running through my head, but I can’t think clearly, which makes me upset.“ (P6) ”There’s an emptiness inside of me. It is very difficult, and it drives me crazy. I thought of stopping school because I lost focus on everything.“ (P13)

This experience is the onset of the process of the befuddling phase wherein Filipino university students collectively described themselves as facing a crisis, confused about whether to continue or discontinue their schooling as they were experiencing psychological distress. As participants articulated,

“I don’t know if I should go on or let go of my dreams. I’m at a point where I’m not sure what will I do or where am I going. It’s very hard on my part, and as if there’s no one that I can turn to . “ (P2).

“I feel very down, and it’s like I’m all by myself. I feel I’m at a crossroads. I want to continue, but I don’t know how.“ (P7).

Additionally, due to the abrupt change, participants were confronted with the feeling of self-doubt. They perceive themselves as weak in facing their distress, underestimating what they can do, as shared:

“I have the feeling that I am not doing much of anything. If I do something, I feel I am doing it wrong… It’s very hard for me to keep trying and trying.“ (P10).

“Life is difficult, and most of the time, I think I can’t make it. There are others who can do it, but who am I anyway? I am nowhere beyond perfection.“ (P9).

Besides self-doubt, participants also shared that they felt they were stuck, experiencing emptiness and losing direction in life. As verbalized:

“It’s really hard to get myself to focus. I feel I’m not doing anything to move forward. It’s very hard for me.“ (P16).

“There are days I’m emotionally flat, and I just want to be alone. I don’t want to engage in conversations or see anybody. I don’t even know where I am headed for.“ (P20).

Further, they engage in self-blame and even humiliate themselves. They even turn to vices to boost their self-esteem, as stated:

“I guess blaming myself to the point where it was unhealthy about different things. I feel weak and sometimes I calm myself by drinking some wine. At times it helps. It makes me feel more confident.“ (P3).

“When I think about many things, smoking calms me. I smoke without the knowledge of my parents. I know it’s bad for my health, but it ables me to become more confident in the choices I make.“ (P12).

However, it is interesting to note the participants make sense of their initial feelings. Their acknowledgment that they are torn between stopping schooling or furthering their education during the health crisis led them to reflect on how to adapt to the new normal and identify their sources of strengths as a factor for their distress experience. As participants shared,

“I know I just have to go with the flow, it’s never easy, but if I stop, my whole life will be worst. I need to continue. It’s difficult, but I must continue; I know my parents are there for me.“ (P8).

“My family keeps me going. The crisis I am into is indescribable, yet I have many reasons not to give up…others were also experiencing the same. Maybe I just need to change some things in my life…definitely, not giving up on my dreams in life.“ (P15).

The participants’ statements reveal that this phase is typified by their experiences of confusion, self-doubt, self-blame, and self-humiliation. Their distress was triggered by their struggles and difficulties as they find it hard to open themselves to what is new and what is different. They were trying their best to adapt and go with the flow by understanding the dynamics of the new normal situation.

(2) Enduring Phase

As the participants’ struggles and difficulties continued, they expressed their lives were full of twists and turns. It becomes complicated and unpredictable. They admitted that it was excruciating and fearful as shared:

“I thought it was easy at first, but it was difficult, very far from my imagination. I feel lonely and isolated. At night, all I can do is cry. It’s tearing me up inside.“ (P1).

“This part was tough, there were setbacks, and I was afraid. I’m disappointed in myself. What’s hard is I’m not thinking only about myself but also about the people around me. What will happen if I give up.“ (P4).

Aside from that, they also experience tensions all over; physiologically, emotionally, and mentally which affects their overall health, causing them to have infections and be hospitalized, as verbalized:

“My health is suffering; I have palpitations and signs of a panic attack. I hardly can’t breathe. My parents were alarmed, so I had to be brought to the hospital. Knowing the current scenario of the pandemic, my exposure to the virus, especially in the hospital, added to my fears. I have to take medicine to calm down my emotions.“ (P5).

“I know I’m experiencing stress because I develop rashes on my skin. I also had unnatural shedding of hair, as evident on lots of hair strands on my pillows in the morning. This makes me irritable at home. It was very shameful to admit, but others-especially my family were affected because of how I felt.“ (P19).

Consequently, their self-esteem becomes very low as their mind is bombarded with negative thoughts.

“I complain about everything and as if I don’t appreciate anything. I feel I’m not effective in doing anything, and if I do something, it is done poorly.“ (P2).

“There were embarrassments and discouragements. I feel blue about myself and my future. I have consistent worries and am depressed… I lack control over my situation, so everything that goes wrong is my fault.“ (P14).

This experience also affected the participants’ motivation to study and to lose courage, but they were also alarmed by the possible outcome as articulated:

“I feel I fail in achieving my goals. I’m not doing anything, so I fear that an undesirable outcome will be the results…” (P7).

“I am experiencing a great deal of sadness and stress…I have a lackluster attitude towards my studies. Anyway, it feels so hopeless and helpless.“ (P16).

They felt they had slowed progress in all aspects, and at times, they were stuck, as shared:

“I am disheartened because there’s no progress in anything that I want. If ever there is, it’s hard for me to pinpoint it.“ (P4).

“I feel disappointed because as if there’s no improvement in myself. I feel I’m not moving forward. It seems to take forever for progress to come around.“ (P18).

Notably, with all the participants’ experience of facing and overcoming difficult situations, it creates the confidence and resilience in them to deal with the things that go their way, as articulated in the following statements:

“It’s very hard, but I’m able to move on from the very painful circumstance. I take it as a challenge, and I go on believing in what I can do.“ (P8).

“When I discovered that the struggles of my friends were very similar to my struggles, it normalized my thoughts that students should go through this. What’s important is you’re doing something to move forward.“ (P17).

This enduring phase refers to the process by which the participants face personal and social circumstance which makes them suffer and prevent them from achieving their dreams. Still, they never quit, and an attitude is developed to keep going and decide not to give up on realizing their hidden strength and potential.

(3) Navigating phase

As the participants decided not to give up, they reflected on how they will continue to be in motion moving forward. They chose to be open to what is new and what is different, as verbalized:

“I reflect most of the time. Where am I now? What should I do? These are the questions I ask myself, and I ended up reminding myself to plan, strategize and learn.

I ask my friends often. If I do this and that, what will happen. I also asked them what they were doing. I’m trying it, and thanks to God, it works.“ (P11).

They established social connections to ease feelings of loneliness and increase their motivation and happiness. They started with their roots, their family, and relatives. They tried their best to get along with people. They realized that the challenge for them is to remain mobile and flexible and, at the same time, exert effort to become involved and deeply rooted in their own family and in the local community where they belong, as shared:

“What helps me the most is having a strong social support system-my family. What I am grateful for is that they are always there for me, especially at times wherein I feel very low. I am telling them everything that is happening to me, and I’m glad that they are very understanding.“ (P17).

“Connecting with someone and talking about school and life is really helpful. We have that group chat in our barangay wherein; as students, we share ideas and experiences. Honestly, It makes me feel better. It gives me the feeling that I belong. Sometimes just talking makes me feel better. I don’t have my parents, so I share my thoughts and experiences with my relatives.“ (P3).

They observe how they can do their best to be ready for any situation. As verbalized, university students engage in training and practice developing a state of being ever ready.

“I silently observe how others do it, then I try. I make myself ready. It was never easy, but I just went with the flow, and I don’t regret it…I feel I’m used to it. Whatever happens, I know I can adapt.“ (P16).

They empty their minds with their preconceived notions of anxiety and fear. They become open to possibilities and accommodate interests and preferences. They also accept that they do not need to be perfect, but only to be resilient. They become more creative and resilient through persistence and practice. They shared,

“I choose to be open to possibilities. It’s a rational choice. Maybe at times, I felt very weak, afraid, but I’m sure I’ll keep going.“ (P5).

“At first, I felt like I am alone in this situation. Hearing the sharing of my friends and classmates, it’s just really validating to hear from others that we all seem to be struggling with the same things.“ (P1).

“I expected too much from myself, but I learned to lower these expectations because it might kill me. What I expect now for myself is to survive from all of these as others were also doing.“ (P10).

They are motivated by feeling appreciated, and their progress is externally validated. They also adjust to adapt. Adaptation allowed them to broaden their perspective, as verbalized:

“It’s great to have solidarity in many things. Others were simply reminding me that I am doing great. They don’t know, but it means so much to me.“ (P15).

“Every day I try something new. I try to reinvent myself. This lets me feel I’m in motion and I’m deciding whether I move forward or backward in every circumstance that I have.“ (P11).

In this study, the navigating phase is the process where students establish connections, make observations and adaptations to overcome their psychological distress, and understand the dynamics of the new normal situation.

(4) Developing phase

Finally, the participants in this study arrived at the final stage of the coping process, the developing phase , wherein achieving a more “developed self” in various aspects of life becomes more evident. The participants were one to claim that they first recognized the need to identify areas where they wanted to improve within themselves. They shared:

I’m using a journal, listing down my personal qualities. I reflect from within. Admitting my weaknesses was the hardest thing to do…It always makes me cry. But then, I have in mind, clearly, what should I do or change.“ " (P14).

“I lacked the knowledge of the technological aspect before, but I did I tried to master the use of gadgets and the internet, which helped me in my tasks and increased my performance at school. " (P13).

Consequently, once the participants were already aware of the areas that need betterment, they also have a more precise grasp of the contributory factors to their distress experience, which they need to overcome.

“Fear is what I have; this causes me to panic, experience anxiety, and overthink. I believe that fear prevents me from growing and progressing. It hinders me to do whatever I have in my mind and learning to overcome it is really a big deal for me. " (P12).

“At some point, I was afraid to change. What if it goes wrong? But I pulled myself together and started to do something about my situation. " (P9).

They are one in believing advocacy for work-life balance as this reduces their distress and increases their motivation to perform their responsibilities as students. As shared:

“I give myself time, a space. Sometimes, after long periods of time studying and working on my school projects, I feel unmotivated. I make sure to take a break and recharge. I’m reminding myself to take a deep breath, take it easy. " (P13).

The participants expressed that self-guided improvement is a must in developing themselves and enhancing their skills and characteristics. They were committed to continuous learning and improvement. It may not be giant leaps and bounds, but quite remarkable as a sign of growth and improvement. They started to see their capabilities and embrace their weaknesses. They shared:

“I give myself random rewards for even my simplest achievement and accomplishments. This way, I make myself motivated to get my task completed. It really feels good inside. " (P1).

“I include in my habit or as part of my daily life reading books, watching videos on the internet, and collecting relevant pieces of information that I can use. " (P18).

They set realistic goals and gradually achieve their aspirations in life. They claim they struggle a lot, but they succeed by broadening their perspective and signifying a commitment to change. They shared:

“When doing my schoolwork, the single best thing that I do is to ensure that I am not falling behind schedule. what I’m doing is breaking down my tasks into small and easily achievable tasks with a set deadline. " (P3).

“When I begin to set goals, I know myself…so I don’t overwhelm myself. I consider my strengths and weaknesses, limitations, and capacity. I’m also telling it to others. For me, telling someone we know about our goals also seems to increase the likelihood that we will stick to them. " (P12).

The participants were very hopeful about achieving their goals. They also track their progress each day. Understand what motivates them, what distracts them, and how they best perform and become more productive at school. They were not discouraged by what they perceived as their lacking potential. Instead, their main concern is implementing proactive actions and moving forward. They also reflect if they seem to get going or if there is a need for additional support.

“I write my goals and constantly check on how far I have accomplished. At times, I realized my movement is not always forward. So, I reflect and try to recall what went wrong. Identifying what’s wrong, I seek advice from my friends. There I will realize what I need to do. " (P7).

The participants shared that it was never easy and very challenging. However, they are determined to do it as they recognize it is for their future. They also developed the skills of mindset reappraisal, which they believe would help them persevere in their education and later in life. They shared,

“It’s always a struggle, but nobody will do it for me. I try to listen to myself most of the time. I also talk about my feelings. You know, talking about my feelings keeps me sane and helps me deal with times I feel troubled.“ (P18).

“There were a few hurdles where I would get upset, yet giving up is not an option. If I feel I must do it, I will be doing it. No regrets. It’s like every day; I reinvent myself. I have the feeling of happiness and excitement in everything that I do. I am in motion, and I know it’s for my future.“ (P11).

They also enhanced their relationships with others and seeking social support. Participants felt that they were being cared for as a whole person, as verbalized:

“I ensure that I maintain close communication with people important to me. Whether my experiences or feelings are good or bad, I share them with them. They always support me, and this helps me ease my burden.“ (P5).

Also, enhancing their spirituality and devotion to God helped them deal successfully with their problems and difficulties. With this, they could find meaning even during the most challenging times, go with the flow without resistance, and feel at peace.

“I always involved myself in praying activities. There were prayer chains in my chat groups and even novena with my family in messenger. It calms me and lightens my burdens in life.“ (P1).

“If I find myself bored in a task that I’m doing, I pray. I also attend online-based masses. This enlightens me and motivates me to avoid piled up works left unfinished…” (P14).

Summarily, the developing phase is indicative of the coping process in dealing with psychological distress and the participants’ empowerment to thrive and survive. This last phase is recreating themselves and beginning to develop new attitudes while freeing themselves from preconceived notions causing them to be distressed, such as fear and uncertainties. They were also exploring and opening rooms for greater possibilities and adapting to what is new and what is different.

This grounded theory inquiry successfully afforded the emergence of the substantive B.E.N.D. Model of Coping with Psychological Distress. A model that involves four distinct yet interrelated phases: b efuddling , e nduring , n avigating , and d eveloping . This four-phased theoretical model provides a valuable aid in understanding the manner Filipino university students underwent in coping with psychological distress during a global health crisis. The B.E.N.D. Model of Coping with Psychological Distress could be used to design proactive interventions, specifically for university students.

The first phase, the befuddling phase, describes how university students acknowledge the crisis they are into, between continuing or discontinuing their education despite the psychological and mental disturbances they were experiencing. At the onset, the participants in this study admitted that their distress was triggered by their academic concerns, such as increased workload (Realyvásquez-Vargas et al., 2020 ), the volume of assignments given (Al-Salman & Haider, 2021 ), and lack of guidance in every aspect of their lives. The drastic changes brought about by the global health crisis made university students struggle and encounter difficulties. However, the potential impact of the health crisis is still unknown as it is described as an exceptional and novel situation (Baltà-Salvador et al., 2021 ). In their study, Barrot and colleagues ( 2021 ) posited that the global health crisis impacted the quality of the learning experience and students’ mental health. It has also brought university students various mental health challenges and psychological problems such as anxiety, depression, and stress (Khan et al., 2020 ; Cao et al., 2020 ).

Since university students are preoccupied with their problems, this study also revealed the widespread belief that students turn to vices and engage in stress eating to feel better and boost their self-esteem. Moreover, the crisis has significantly influenced the behavior of university students, which reduced their motivation and even lost direction in life, as they feel helpless, uncertain, and have self-doubts (Yilmaz et al., 2020 ). This study supports the findings of empirical research that highlighted students’ difficulties which affected their academic performance, making them less motivated and intensifying their negative feelings such as anger, fear, worry, boredom, stress, anxiety, and frustration (Gillis & Krull, 2020 ; Aristovnik et al., 2020 ).

In light of the findings from this study, the university students who experienced psychological distress felt that they were stuck; they experienced confusion, emptiness, and losing direction in life. They are prone to drop out of school which made them at higher risk for academic failure (Ishii et al., 2018 ) as their education and career plans have been affected negatively. University students find it hard to open themselves to what is new and different. Still, they were trying their best to adapt and go with the flow by understanding the dynamics of the new normal situation. They embraced their emotions, whatever they are, and they shared it is comparable to welcoming oneself.

Interestingly, university students suffering from this global health crisis leads them to be aware of the need to seek any source of support from others. In the navigating phase, the coping process is generally characterized by university students actively dealing with the distressful situation by seeking help from others, seeking external validations, and making some observations. They observed that it is necessary to have social connections to ease feelings of loneliness and increase their motivation and happiness. This finding runs parallel with the results of previous literature that students’ coping mechanism was fulfilled by seeking support from others, especially informal social support, such as material or emotional support, which has a significant impact on their ability to overcome distress (Bøen et al., 2012 ; Son et al., 2020 ). Moreover, Taylor ( 2015 ) found out that social support reduced cortisol response to stress and improved immunity. Receiving support, getting along with others, and feeling appreciated both in person or virtually can foster bonding and bridging social connections (Robin & Tiechty , 2020 ; Jones et al., 2020 ). These experiences have a powerful effect on helping the participants cope with distress as this gives them external validation and a sense of comfort and stability. On the contrary, passive coping and not having somebody as a source of social support during a health crisis result in high psychological distress (Yu et al., 2020 ).

Finally, the university student participants eventually realize that they will attain total adjustment and adaptation to their psychological distress experienced in the developing phase. They shifted their thoughts from catastrophizing to a more helpful mindset, increasing their well-being, decreasing negative health symptoms, and boosting physiological functioning (Crum et al., 2017 ). They were challenged but still determined, as they paid attention to their feelings, thoughts, and behaviors to identify their goal-related obstacles (Kreibich et al., 2020 ). University students accepted themselves with imperfections and uniqueness and were prone to stresses and challenges. The findings in this study fit well with previous literature reporting that thought-provoking circumstances, such as the global health crisis lead the way for positive impacts such as increased motivation and enhanced performance (Rheinberg & Engeser, 2018 , Gonzalez et al., 2020 ), as students set and achieve their goals.

On the one hand, this investigation infers that a small amount of stress can also be significant. The right sort of stress encourages university students to make some changes in their lives and progress, preventing them from experiencing more severe psychological distress. On the other hand, if university students cannot adapt to stress successfully, they can feel burdensome (Ganesan et al., 2018 ). Their learning experience is disrupted (Kapasia et al., 2020 ), and they are prone to experiencing mental health problems and societal dysfunction associated with suicide (Tang et al., 2018 ).

Consequently, the university students also built positive relationships with others, which served as their social support avenue. Building positive relationships lowered the level of loneliness (Bernardon et al., 2011 ) and fostered a sense of hope, purpose, and meaning. Specifically, support from peers protects the mental health of university students’ (Alsubaie et al., 2019 ). Surprisingly, family support which has great importance on life satisfaction of the participants, becomes less influential and critical than peer support (Alsubaie et al., 2019 ; Kim, 2020 ), because they have more frequent interactions and similar experiences with their peers than their families (Bernardon et al., 2011 ).

Further, as university students continuously adapt and improve, they also ensure the balance between studying and relaxing, hence they engage in recreational activities (Fawaz et al., 2021 ). Moreover, they undertake self-diverting actions and engage in spiritual activities through prayers and meditation . All of these then lead to the university students’ continuous use of coping strategies, which, in turn, improved their efficiency for adjustment and adaptation to achieve a more developed self in various aspects of their lives.

Conclusion, theoretical contributions, and practical implications

This grounded theory study was purported to explore and develop a theoretical model on the coping processes culturally unique to Filipino university students during a global health crisis. Interestingly, the substantive B.E.N.D. Model of Coping with Psychological Distress that emerged from this present study vividly describes the phases of coping processes symbolic of the challenges that a bamboo tree underwent, namely, befuddling, enduring , navigating , and developing phases.

The findings of this current study extend some relevant implications, most especially to university students’ behavior, theory, research, and practice. The data was collected during times of uncertainty and crisis. An alarming rate of psychological distress among students was reported, thereby questioning the preparedness and implementation of mitigation measures and proactive strategies in universities to lessen or prevent the distress experiences of students. The phases that emerged had an advanced appreciable understanding of the university students coping experiences that helped them improve during the health crisis. Universities must ensure preventive programs so that students suffering from psychological distress will be identified and given proper intervention to prevent other problems.

Furthermore, our research is novel, and to the best of our knowledge, no prior studies on Filipino university students during the global health crisis have considered the process of coping with psychological distress. Finally, this investigation offers evidence-based information that can be used by future researchers, practitioners, and mental health advocates. Our study can help them design and craft intervention programs, policies, and guidelines that will address the psychological distress of university students and enhance their ability to cope.

This study was limited to students of the National Capital Region of the Philippines only and the researchers recommend a broader coverage of participants, such as but not limited to public and private universities nationwide, and compared the findings in different cultural contexts. Moreover, a follow-up study may also be conducted with the same participants to determine the sustainability of the emerging process.

Finally, the findings of this study gave a proposed model that may serve as a basis in crafting specific interventions for university students’ distress which was not provided in this study. Likewise, psychologists and other mental health practitioners handling cases of university students’ psychological distress have given an idea of their coping processes.

No funding was received for conducting this study.

Data Availability

Code availability, statements and declarations.

The authors have no conflicts of interest to declare relevant to the content of this article.

All procedures performed in the present study that involved human participants were per the ethical standards of the Ethics Board of the University of Santo Tomas Graduate School.

Each participant in the current study gave informed consent before voluntary participation. In addition, participants were briefed on the nature of the study, were assured that all data collected would be kept confidential, and that participation was purely voluntary without remuneration.

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