research paper on depression in college students

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Depression and anxiety among college students: Understanding the impact on grade average and differences in gender and ethnicity

Affiliations.

1 PhD Candidate, Brown School, Washington University in St. Louis, St. Louis, Missouri, USA.
2 Associate Professor, Brown School, Washington University in St. Louis, St. Louis, Missouri, USA.
3 Research Scientist, Buffalo Center for Social Research, Buffalo, New York, USA.
PMID: 34242525
DOI: 10.1080/07448481.2021.1920954

Objective : Psychiatric disorders, such as depression and anxiety, can hinder academic performance among college-age individuals. Participants : Mental health among college students is a growing public health concern, with some scholars describing collegiate mental health as a crisis (Chen et al., Psychiatr Serv. 2019;70(6):442-449). Methods : This study analyzes data from four annual administrations of the American College Health Association (ACHA)'S NCHA (n = 117,430). Results : Overall, anxiety and depression were the most common conditions, at 9.2% and 8.7%, respectively. Of students reporting the focal symptom, 17.87% were treated for depression and 12.91% were treated for anxiety. Compared to not-treated students, diagnosed only students, had significantly lower grade averages, with effect sizes of -0.30 and -0.20 for depression and anxiety, respectively. Conclusions : Given the prevalence of depression and anxiety among college-aged students, continued research into help seeking behaviors and their effects on outcomes like grade average is an essential part of understanding the toll these disorders take.

Keywords: Academic success; anxiety; college students; depression; grade average (GPA).

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A Literature Review of Studies of Depression and Treatment Outcomes Among U.S. College Students Since 1990

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research paper on depression in college students

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ORIGINAL RESEARCH article

Depression and academic engagement among college students: the role of sense of security and psychological impact of covid-19.

$\r\nYuxi Tang$

College of Social Sciences, Shenzhen University, Shenzhen, China

Background: The negative consequences of depression in college students have garnered global attention, especially in relation to academic achievement during the COVID-19 pandemic, which need critical assessment.

Aim: This study investigated whether a sense of security mediated the relationship between depression and academic engagement among college students during the pandemic and whether the moderating psychological impact of COVID-19 has a moderating effect on this relationship.

Methods: In this cross-sectional study, we recruited 466 college students from 30 provincial-level administrative regions in China via the Internet and used established scales to measure depression, academic engagement, a sense of security, and the psychological impact of COVID-19. The mediating and moderating effects were tested using the bootstrap method.

Results: Depression was found to negatively influence academic engagement, with a sense of security partially mediating this relationship. Moreover, the psychological impact of COVID-19 was shown to have a moderating effect on this mediating process.

Conclusion: This study could aid in crafting pertinent strategies to mitigate the adverse effects of depression on learning amid unexpected public health crises and foster better mental health among college students.

1. Introduction

The COVID-19 pandemic, an unprecedented public health crisis, not only posed a grave threat to people's physical safety, but also cast a significant shadow on their mental wellbeing ( 1 , 2 ). This was particularly detrimental to those already in a fragile psychological state, such as those suffering from depression, which exacerbated their condition ( 3 ). College students, who are a high-risk group for depression, faced significant challenges during the ongoing waves of the virus ( 4 ), with a rapid global rise in depressive symptoms reported among young adults, typically those with lower resilience to psychological stress ( 5 ). This deterioration in mental health is a cause of concern, and the question of how to intervene and reduce the negative psychological aftermath following such pandemic events has become a focal point of research. Analysis of depression among college students is often tied to their academic commitment, which is central to their lives ( 6 ). Academic struggles caused by depression may, in turn, impact mental health, potentially exacerbating anxiety and depressive states, thus creating a vicious cycle ( 7 ). Some college students feel hopeless and distressed, often exhibiting confusion and avoidance in their studies ( 8 ). Investigating the mechanisms by which depression affects college students' academic engagement is of paramount importance. Not only can it provide fresh insights for more effective interventions targeting student depression, but it can also improve student learning, thus laying a solid foundation for promoting students' mental health and academic progress.

Depression is an emotional disorder characterized by frequent experiences of intense feelings such as pain, emptiness, and hopelessness ( 9 – 12 ). It often disrupts people's mental states and leads to an array of difficulties in their studies and lives, with severe cases resulting in self-harm and other harmful consequences ( 13 ). As an unprecedented public health crisis, the pandemic caused an incalculable disruption to students' lives and studies, coupled with increased uncertainty about their future, which increased their susceptibility to depression ( 14 ). For students with a predisposition to depression or a history of illness, the pandemic undoubtedly acted as an adverse stimulus, potentially leading to heightened feelings of despair and sorrow ( 15 ). During the pandemic, home isolation measures may have confined students to a single space for extended periods, preventing them from engaging in outdoor activities, possibly heightening their feelings of repression and irritability, and triggering more frequent depressive episodes ( 16 ). With the pandemic having increased the prevalence of depression, understanding the mechanisms through which depression affects academic engagement can provide a reference for better targeted interventions. Such interventions would not only be beneficial in addressing students' academic problems, but also in promoting their mental health.

Academic engagement refers to the interest or enthusiasm that students hold toward their studies, coupled with the time and energy they dedicate to learning ( 17 – 19 ). Pandemic-related pressures burdened students in dealing with issues in terms of academic setbacks, lifestyle inconveniences, and future uncertainties ( 20 ). These pressures not only brought about distress among the student population, but also potentially affected students' academic engagement ( 21 ) given the unprecedented number of issues arising during the pandemic ( 22 ). For instance, some students reported increased fatigue during study sessions, whereas others experienced diminished interest in learning, even to the point of actively avoiding it ( 23 ). The interplay between mental health issues and learning problems became evident during this pandemic ( 24 ), with both a rapid increase in the number of students exhibiting symptoms of depression and a noticeable decline in their academic engagement compared with pre-pandemic levels ( 25 ).

Investigating the mechanisms affecting academic engagement and identifying the variables that could serve as mediators or moderators during the pandemic can aid in understanding the complex interplay between depression and other factors under such novel circumstances. Determining the mediating or moderating mechanisms is likely to provide a more profound theoretical understanding of depression issues faced by adolescents, especially from an educational perspective, which is likely to be beneficial for formulating effective interventions.

Some students grappled with the profound grief of losing friends and family to COVID-19, coupled with significant setbacks in their academic and personal lives ( 26 ), which could potentially exacerbate depressive states. The pandemic drastically reduced students' interest in outdoor activities and social interactions, leading to extended periods of emptiness and loneliness ( 27 ). Additionally, economic support for college students was severely affected by the pandemic, with some students' family financial circumstances deteriorating rapidly ( 28 ). In addition to dealing with boredom due to social isolation and an uncertain future, the modes of learning for these students underwent considerable changes. Online learning became the dominant mode of emergency education worldwide. However, this abrupt shift in learning modalities left many students feeling lost, thereby intensifying their anxiety ( 29 ). This situation may have led to an increased prevalence of depressive disorders, making students more susceptible to mental health issues ( 30 ), which, in turn, may have exacerbated their already difficult predicaments. Therefore, it is imperative to study depression-related issues, particularly how depression influences academic engagement, and determine appropriate interventions.

Academic engagement reflects the level and willingness of students to invest in various learning resources ( 31 ), often involving a strong desire for knowledge, proficiency in applying various effective learning strategies, and a sense of achievement in their studies. These qualities may positively contribute to mental health ( 32 ). However, during the pandemic, students' academic engagement was severely affected ( 33 ). Students faced the challenges of online, home-based, and isolated learning due to substantial changes in their learning environments ( 34 ). Discomforting feelings, including anxiety and unease, may have dampened students' enthusiasm for learning, making it difficult for them to concentrate and causing them to lose interest in their studies ( 35 ).

Depression may influence students' academic engagement through three potential pathways. During the pandemic, college students may have experienced serious psychological distress, particularly negative emotions and feelings of hopelessness triggered by depressive symptoms ( 36 ), leading to a lack of interest and an inability to gain a sense of achievement in their studies ( 37 ). The pandemic forced students to change their learning methods in a short period, and educators may have struggled to provide sufficient support through new online teaching methods, leading to potential learning burnout due to adaptation difficulties in the online learning environment ( 38 ). Some students may have significantly altered their lifestyles due to the pandemic, such as indulging in Internet use and excessively focusing on negative news about the pandemic, intensifying their negative feelings toward the pandemic ( 39 ), which could in turn have make it more difficult for them to concentrate on their studies. Therefore, it can be conjectured that college students' academic engagement may have been more influenced by depression during the pandemic.

A sense of security refers to the affirmative and positive sensations related to experiences of trustworthiness, reliability, and tranquility that arise due to one's active ability to tackle issues, have a comprehensive understanding of individuals or events, and to effectively engage with familiar environments ( 40 – 43 ). Among college students, insecurity is a common psychological issue ( 44 ), stemming from their lack of experience in dealing with external environments and their perceived lack of sufficient ability and resources to resolve multiple complex problems ( 45 ). Particularly during the pandemic, college students faced unprecedented events such as health threats, disruptions in their learning status, and future employment difficulties, which could have made them feel helpless ( 46 ). Under these circumstances, many students may have experienced feelings of insecurity. Among students who already had poor psychological conditions or emotional disorders, this insecurity could have potentially exacerbated their psychological issues ( 47 ), thereby severely affecting their regular learning.

During the pandemic, a sense of security among college students may have served as a mediating variable between depression and academic engagement. First, depression among college students could have potentially increased the frequency of feelings of insecurity ( 48 ). Depression is often characterized by excessive pessimism toward external matters, which can trigger worry or even panic. Moreover, long-term experiences of insecurity can negatively impact mental health, leading to increased negativity and suppression ( 49 ). Hence, there may be a strong correlation between depression and sense of security. For some students, insecurity stems mainly from the uncertainty and risks of the external environment, requiring them to expend more energy dealing with threats and risks, making it difficult to concentrate on academic challenges ( 50 ). Other students may feel insecure because of inadequacies or difficulties in their academic abilities, which may have led to potential stagnation in their learning during the pandemic, thereby exacerbating academic problems ( 51 ). These factors foster anxiety rather than enthusiasm in learning, potentially leading to a reluctance to learn. Therefore, there may be a correlation between students' sense of security and academic engagement ( 52 ). While depression in college students may have been directly linked to academic engagement during the pandemic, it may also have influenced academic engagement through feelings of insecurity, which involve distinct and intense negative emotional experiences that often directly affect students' life status and learning behavior ( 53 ). Students' depression may further amplify their feelings of insecurity, which may negatively impact their academic engagement. Based on these considerations, we inferred that a sense of security might serve as a mediator between depression and academic engagement.

The psychological impact of COVID-19 refers to psychological problems, such as distress and avoidance, caused by the pandemic ( 54 , 55 ). The pandemic disrupted people's normal lives, causing some to have strong emotional reactions ( 56 ), with prolonged negative psychological effects as well as sometimes triggering anorexia, frequent nightmares, and insomnia ( 57 ). Some college students may have been prone to feelings of panic and evasion as well as a strong aversion to pandemic-related matters ( 58 ). Such increased psychological stress likely posed more challenges to their academic pursuits ( 59 ).

When the psychological impact of COVID-19 was high, college students' psychological states and normal learning may have been affected. Their mental health already faced many challenges, especially for those with depression who were struggling with emotional regulation ( 60 ). Excessive worry about the pandemic might have induced more feelings of insecurity, thereby impacting academic engagement ( 61 ). Furthermore, the psychological impact of COVID-19 may not only have potentially increased the psychological pressure on students but also affected academic engagement by diminishing learning motivation and draining energy, leading to student fatigue or a sense of futility toward studying ( 62 ). From this perspective, the psychological impact of COVID-19 may have moderated the mediating effect of a sense of security between depression and academic engagement.

Previous research has reported an association between depression and academic engagement ( 63 , 64 ). While academic engagement may be adversely affected by depression directly ( 65 , 66 ), it has also been reported that this relationship is contingent on specific conditions, suggesting the existence of mediating variables ( 67 ). Further studies are needed to improve understanding of the association between these factors.

Existing research has reported an association between depression and a sense of security, with individuals in depressed groups being more prone to feelings of insecurity ( 68 – 70 ). Academic performance is strongly correlated with student insecurity ( 71 , 72 ). Individuals experiencing insecurity have been found to have their energy and interest in learning negatively affected ( 73 , 74 ). Furthermore, while insecurity has been reported to mediate between psychological problems and learning ( 75 ), further investigation is required to establish whether a sense of security acted as a mediator between depression and academic engagement during the pandemic.

The psychological effects of COVID-19 could potentially have become a risk factor ( 76 – 78 ), possibly exacerbating adverse emotional effects ( 79 , 80 ), and negatively affecting students' learning ( 38 , 81 , 82 ). These studies suggest that the psychological impact of COVID-19 may have served as a moderating variable.

Based on an analysis of previous related research and to help ensure better targeted interventions for depression and enhance the mental wellbeing of college students, we considered it of fundamental importance to investigate how depression affected academic engagement among college students during the COVID-19 pandemic and whether a sense of security played a mediating role under the conditions of the pandemic. Additionally, while the psychological impact of COVID-19 could potentially have acted as a moderator in this mediating relationship, this area remains relatively unexplored in existing research; therefore, we also investigated this factor. The three hypotheses of this study are as follows:

Hypothesis 1. Depression can negatively predict college students' academic engagement.

Hypothesis 2. A sense of security in college students mediated the relationship between depression and academic engagement.

Hypothesis 3. The psychological impact of COVID-19 moderated the relationship between depression and academic engagement.

The research hypothesis model diagram is shown in Figure 1 .

Figure 1 . Research hypothesis model diagram.

2.1. Process and participants of the survey

2.1.1. design.

This study focused on college students aged 18 years and older studying in China. This study adopted a cross-sectional design to assess the current state and associations of variables in a single time point. The sample was composed of currently enrolled, full-time college students from diverse academic disciplines across China. Inclusion criteria were: being a college student, being 18 years of age or older, currently residing in China, and being willing to participate in an online survey. Exclusion criteria included: students who were not currently enrolled, those under the age of 18, those who did not currently reside in China, and those who did not provide informed consent to participate. However, during the pandemic period in China, it was challenging to conduct offline surveys of college students from different regions across the country. Convenience sampling was therefore adopted. College students were recruited using various online platforms. College students viewed recruitment information online and voluntarily participated in the survey, with participation covering multiple regions.

2.1.2. Procedure

The survey was conducted in December 2022 when normal life was affected in China due to the ongoing COVID-19 pandemic. Prior to conducting the survey, our institution conducted an ethical review and approved the study. A professional online questionnaire research platform was used to recruit college students from 30 provinces across China. We provided the participants with informed consent forms and participation was dependent on these being completed. A total of 471 people completed the questionnaire, five of whom were excluded because their response time was <3 min, and 466 questionnaires were retained. The questionnaire included four scales and collected basic demographic information. Monte Carlo analysis revealed that the sample size needed to exceed 232 for 0.8 statistical power ( 83 ). Therefore, the sample size was adequate.

2.1.3. Sample characteristics

Of the final 466 questionnaire respondents included in this study, 355 were female, 111 were male, with ages ranging from 18 to 32 years (average, 21.1 ± 1.97 years), and comprising 381 undergraduates (81.76%), 76 master's students (16.31%), and 9 doctoral students (1.93%).

2.2. Measurement

Depression was assessed using a scale developed by Spitzer et al. ( 84 ). The Chinese version of this scale has proven reliable ( 85 ). A 4-point Likert scale is used to score each of the nine items in the scale, such as “Over the past 2 weeks, have you experienced a loss of appetite or overeating?,” where a higher total score indicates a greater level of depression. In this study, the Cronbach's α coefficient was 0.85, the McDonald's omega coefficient was 0.885, and the Kaiser-Meyer-Olkin (KMO) coefficient was 0.885.

Academic engagement was evaluated using a scale developed by Schaufeli et al. ( 86 ). The reliability of the Chinese version of this scale has been verified ( 87 ). This scale includes nine items, such as “Does your study inspire you?,” rated on a 7-point Likert scale, with a higher score reflecting higher levels of academic engagement. In this study, the Cronbach's α coefficient was 0.93, the McDonald's omega coefficient was 0.945, and the KMO coefficient was 0.932.

A sense of security was measured using a scale developed by Cong and An ( 87 ). The reliability of this scale in its Chinese version has been verified ( 88 ). The scale consists of 16 items, for instance, “Do you often feel unlucky?,” scored on a 4-point Likert scale, where a higher cumulative score signifies a stronger sense of security. The Cronbach's alpha, McDonald's omega, and KMO coefficients for this study were 0.881, 0.901, and 0.866, respectively.

The psychological impact of COVID-19 was measured using a scale developed by Vanaken et al. ( 89 ). The reliability of this scale has been verified ( 90 ). This scale includes 15 items, such as “Have you had dreams about the pandemic in the past week?,” rated on a 5-point Likert scale, with the interpretation being that a higher total score indicates a greater psychological impact of COVID-19. The Cronbach's alpha, McDonald's omega, and KMO coefficients for this study were 0.872, 0.894, and 0.898, respectively. For the questionnaire used in this study, we computed the composite reliability (CR) index, which came out to be 0.875, indicating a high degree of validity. We also carried out a confirmatory factor analysis, and found that the Parsimony Goodness of Fit Index (PGFI) was 0.586, the Parsimony Normed Fit Index (PNFI) was 0.625, the Parsimony Comparative Fit Index (PCFI) was 0.645, and the Standardized Root Mean Square Residual (SRMR) was 0.091. These model fit indices reflect a good overall fit of the model.

2.3. Data analysis

The scores of the college students on the four scales of academic engagement, depression, sense of security, and the psychological impact of COVID-19 were tallied, and their means ( M ) and standard deviations ( SD ) were calculated. Pearson's correlation coefficients were used to analyze the correlations. Given that the sample size was >300, kurtosis and skewness values were used to estimate the multivariate normal distribution. To test the moderated mediation effect, we used Model 14 of the microprocess plugin developed by Hayes ( 91 ) for the mediation analysis and moderation effect. A moderated mediation effect can be considered when the bootstrap confidence interval excludes zero.

A normality test was conducted on the data of the four variables: academic engagement, depression, a sense of security, and the psychological impact of COVID-19. The skewness values were 0.426, −0.166, −0.008, and 0.170, respectively, and the kurtosis values were −0.326, −0.523, −0.162, and −0.134 respectively, indicating that all the variables conformed to a normal distribution. In addition to the skewness and kurtosis assessments, visual inspection of the histograms also confirmed the normal distribution, further substantiating that all four variables exhibited essential normality. Analysis of the correlations among the four variables revealed a negative correlation between depression and academic engagement (r = −0.457, p < 0.01) and a negative correlation with a sense of security (r = −0.258, p < 0.01). A significant correlation was also found between a sense of security and academic engagement (r = 0.297, p < 0.01). The specifications are listed in Table 1 .

Table 1 . Correlation analysis of the four variables.

Regression analysis showed that depression could significantly negatively affect a sense of security (B = −0.5669, t = −5.7535, p < 0.001). A sense of security (B = 0.1741, t = 0.0379, p < 0.001) and depression (B = −0.8084, t = −9.7212, p < 0.001) significantly affected academic engagement (R 2 = 0.2430, F = 74.3092, p < 0.001). These results suggest that depression negatively affected academic engagement and that this relationship was mediated by a sense of security. Furthermore, depression (B = −1.028, t = −11.969, p < 0.001), a sense of security (B = −0.246, t = −1.893, p = 0.059), the psychological impact of COVID-19 (B = −0.267, t = −1.446, p = 0.149), and the interaction between a sense of security and the psychological impact of COVID-19 (B = 0.012, t = 3.419, p < 0.001) significantly affected academic engagement (R 2 = 0.317, F = 53.4556, p < 0.001). The test results of the mediated model with moderation proposed in this study are shown in Figure 2 . In this model, the interaction between a sense of security and the psychological impact of COVID-19 was significant (95% confidence interval [CI] = [0.0051,0.0191]), indicating that a sense of security and academic engagement were moderated by the psychological impact of COVID-19 (See Table 2 ).

Figure 2 . Test results of the mediator model with moderation. *** p < 0.001.

Table 2 . Summary of regression models.

When analyzing the moderating effect of the psychological impact of COVID-19, it was found that at a low level of impact ( M – 1 SD ) with an effect value of −0.042 and 95%CI = [−0.110,0.010], there was no mediation. However, the mediation was significant at both M and high M levels ( M + 1 SD ) in relation to the psychological impact of COVID-19, with effect values of −0.098 and −0.154, and 95%CIs of [−0.168, −0.042] and [−0.251, −0.068], respectively (See Table 3 ). Therefore, the mediating role of a sense of security varied at different levels in terms of the psychological impact of COVID-19, indicating moderated mediation.

Table 3 . Results of the conditional indirect effect.

Simple slope analysis revealed that under high levels of the psychological impact of COVID-19, as the level of depression increased, the level of academic engagement was noticeably poorer compared to the group with low levels (See Figure 3 ). This finding indicates that the psychological impact of COVID-19 significantly moderated the mediating role of depression and academic engagement.

Figure 3 . Mediating moderating effect between depression and academic engagement.

4. Discussion

This study found that depression negatively influenced college students' academic engagement during the COVID-19 pandemic, with a sense of security playing a mediating role and the psychological impact of COVID-19 having a moderating effect. As a result of these findings, hypothesis 1 and hypothesis 3 were both supported, and hypothesis 2 was partially supported. Notably, theoretical understanding of how depression affects college students in the context of sudden public health crises has been strengthened by this new insight into the relationship between depression and academic engagement.

This study found that college students' depression was negatively associated with academic engagement, supporting the first hypothesis, which accords with previous studies reporting that college students' depression affects their academic engagement ( 92 , 93 ). However, in this study conducted during the pandemic, college students' depression was found to have a stronger effect on academic engagement. This finding implies that, in the context of new environmental variables, the risk factors for college students' depression affecting academic engagement are likely to be exacerbated, such as psychological difficulties, academic challenges, and financial issues, which could intensify this relationship ( 94 ).

Several factors may explain why depression negatively affects college students' academic engagement. First, depression severely affects students' psychological and emotional states ( 95 ). This emotional instability and the frequent experience of low mood can compromise learning effectiveness ( 35 ) and significantly undermine academic self-efficacy in the long run ( 96 ). Second, an enthusiastic attitude toward learning is crucial for academic engagement ( 97 ). Depression can lead to a loss of interest in learning and doubts about its importance, especially during crises such as the pandemic when students faced an uncertain future, further diminishing their enthusiasm for learning ( 98 ). Additionally, students had to deal with sudden shifts to online learning, prolonged Internet usage, and an inability to consult teachers face-to-face. Among those with depression, these substantial learning challenges and unprecedented pressures could have become overwhelming, possibly leading to avoidance or refusal to learn ( 99 ). Depression among college students during the pandemic could have intensified, significantly affecting their sleep quality and mental states and making it difficult for them to concentrate on academic issues ( 100 ). Therefore, students' academic engagement was more likely to be significantly affected by depression, with the pandemic having a further exacerbating effect.

This study found that under certain levels of psychological impact of COVID-19, a sense of security partially mediated the relationship between depression and academic engagement, partially confirming the second hypothesis. Previous research has suggested that depression may influence feelings of insecurity ( 101 ), which aligns with the results of the present study. This study also found a correlation between college students' sense of security and academic engagement, further corroborating previous studies ( 102 , 103 ).

Symptoms of depression in college students usually form over a long period owing to the combined influence of various factors, and their impact on students' learning and life may require other elements to unfold further ( 104 , 105 ). Depression in college students is often characterized by significant emotional issues ( 106 ), which alter their perceptions of and attitudes toward their surroundings. During the pandemic, students exhibiting depressive symptoms were more likely to worry about their personal safety and future prospects ( 107 ), which negatively affected their passion for learning. Students' heightened sense of insecurity during the pandemic indicates that they faced challenges in terms of adapting and problem-solving, which may have disrupted their learning mindset. In the complex pandemic environment, college students required a calm and stable mindset for academic engagement ( 108 ). The greater insecurity induced by depression imposed enormous pressure on some of them, preventing them from focusing on their studies ( 109 ). Importantly, depression makes students more susceptible to perceived threats. When students are highly anxious and fearful, learning is not a priority in their subconscious, especially during crises such as the pandemic when they had to divide their attention ( 110 ). Consequently, the psychological resources that can be allocated to learning naturally decrease, thereby affecting academic engagement.

This study found that depression and academic engagement in college students were moderated by the psychological impact of COVID-19, thereby verifying the third hypothesis. There was a greater likelihood that depression would affect academic engagement among those who experienced a high level of psychological impact from COVID-19, supporting previous findings ( 111 – 114 ). This finding suggests that in college students with depression, sudden major public health crises may further disrupt mental states; therefore, along with routine depression interventions, it is crucial to address heightened emotional stress due to crises such as the pandemic.

There are several key reasons why the psychological impact of COVID-19 mediated the relationship between depression and academic engagement. First, the psychological impact of COVID-19 involved short-term and intense negative emotions ( 115 ). These types of emotion could have amplified negative feelings among depressed college students, causing them to experience more anxiety and pressure, which depleted their energy for learning. Second, among those experiencing strong pandemic-related stress, their ability to regulate emotions may have been significantly affected ( 116 ), with emotional dysregulation becoming more severe. This outcome could have weakened their ability to manage their feelings of insecurity, thereby reducing their enthusiasm for learning. Good cognitive abilities are necessary for academic engagement. In groups that reacted excessively to the pandemic, their cognitive abilities might have been further weakened ( 117 ), thus exacerbating the negative influence of depression on academic engagement.

4.1. Main contributions

This study provides novel theoretical insights. First, it was found that college students' sense of security partially mediated the relationship between depression and academic engagement. The degree to which COVID-19 impacted students psychologically was also found to moderate this mediating effect. This study offers a fresh perspective on the mechanisms underlying the interaction between depression and learning among college students. Second, the analysis of the psychological impact of COVID-19 provides new evidence for understanding depression-related issues during major public health crises. Finally, this study enhances understanding of the mechanisms underlying the negative effects of depression, which can help generate new ideas for the development of better targeted intervention strategies.

4.2. Practical implications

In accordance with the findings of this study, during critical events such as the COVID-19 pandemic, the mental health support for college students should be brought to the forefront. It has been observed that during such severe public health crises, not only does the prevalence of depression among college students significantly rise, but mental health of already depressed individuals is further impacted. Hence, a concerted effort to educate college students about their mental health, as well as the provision of timely psychological counseling support, becomes vital. Firstly, in the face of the pandemic, institutions should ramp up their psychological aid services to assist students in handling the mental pressures triggered by the crisis. This would include proffering counseling and targeted assistance, incorporating both individual and group psychological therapies. Secondly, educational institutions should proactively disseminate pandemic-centric mental health education. This can take the form of online mental health seminars, aimed at enlightening students about the psychological repercussions of the pandemic, equipping them with methods to assuage the mental stress incited by the situation, and instructing them on preserving their academic engagement amidst these arduous circumstances. Additionally, fostering tighter collaboration between an institution's mental health services department and its basic academic units can be beneficial. This partnership, expressed through the organization of relevant activities, can boost students' psychological resilience, enhance their mental health literacy, and arm them with the tactics to effectively navigate through similar crises. Moreover, the institutions bear the responsibility of ensuring a secure environment for the students' living and learning needs. For those students whose in-person learning has been obstructed due to the pandemic, schools should guarantee a safe, stable online platform to ensure the seamless continuation of their studies. It would also be advantageous to schedule frequent online social events, allowing students to experience the warmth and support of their community, even while confined at home. Lastly, and most importantly, institutions need to create an exhaustive protocol to manage student mental health crises during public health emergencies. This could entail setting up mental health records, offering active interventions for students grappling with depression during ordinary times, and emphasizing the provision of psychological counseling services, online learning resources, and flexible academic policies in the event of sudden public health emergencies. In doing so, institutions can secure students' sense of safety and academic involvement during crises, thereby mitigating the potential risks associated with depression. This study uncovered that the academic engagement of college students was severely challenged during the pandemic. This necessitates focused interventions to ensure these students receive additional attention and assistance, fostering a supportive learning environment that diminishes feelings of insecurity and encourages active academic involvement. It underlines that during unexpected public health crises, students should be offered counseling and specific assistance to address their psychological needs. Overall, these steps can significantly contribute to the mitigation of adverse effects on learning due to depression and foster better mental health among college students.

4.3. Limitations

This study had some limitations. The data collected in the research were derived from self-reporting, which may have resulted in bias as students may have avoided providing truthful responses due to perceived social conformity constraints. Future studies should employ multiple data collection methods to obtain more comprehensive and accurate datasets. All participants in this study were from China and, because of cultural differences, the findings may not be generalizable to other cultures. Further validation of these findings in other countries is warranted. This study used convenience sampling. Although a wide range of students from different regions was recruited online to increase the breadth of the sample, future studies should employ more systematic sampling methods for a more accurate representation of Chinese college students. Female participants constituted a large proportion of the investigation, which might have introduced some bias. Future studies could control for the gender ratio of the participants. In addition to a sense of security and the psychological impact of COVID-19, other factors and mechanisms may have been involved in terms of the relationship between depression on student engagement, which should be explored further in future studies. In addition, the investigation was cross-sectional; therefore, causal inferences could not be made, suggesting the need for experimental or longitudinal research designs in future investigations.

5. Conclusion

This study revealed that during the COVID-19 pandemic, depression among college students negatively affected their academic engagement. A sense of security partially mediated this relationship, with the psychological impact of COVID-19 found to moderate this mediating effect. Furthermore, the indirect negative effect of depression on academic engagement through a sense of security was found to be stronger in students who experienced a higher psychological impact from COVID-19. These findings provide new insights into the mechanisms through which depression affects academic engagement among college students and new evidence of the negative impact of depression on students. This study can help inform the development of more effective intervention strategies during crisis events such as the pandemic that can reduce the negative effects of depression and promote students' academic engagement.

Data availability statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics statement

The studies involving human participants were reviewed and approved by Academic Committee of Shenzhen University's College of Social Sciences. The patients/participants provided their written informed consent to participate in this study.

Author contributions

YT responsible for the execution of the methodology, securing the required funding, and drafting the original document. WH conducts formal analysis, provides review and editing of the manuscript, and manages the project. The investigation aspect has seen contributions from both YT and WH.

Shenzhen Academy of Social Sciences (SZ2022C001), Guangdong Education Science Planning Leading Group Office (2022GXJK077), and Shenzhen Education Science Planning Leading Group Office (dwzz22171) provided funding.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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Keywords: academic engagement, college students, COVID-19, depression, psychological impact of COVID-19, sense of security

Citation: Tang Y and He W (2023) Depression and academic engagement among college students: the role of sense of security and psychological impact of COVID-19. Front. Public Health 11:1230142. doi: 10.3389/fpubh.2023.1230142

Received: 28 May 2023; Accepted: 24 July 2023; Published: 04 August 2023.

Reviewed by:

Copyright © 2023 Tang and He. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Weiguang He, hwg@szu.edu.cn

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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Psychotherapy for depression in college students

A protocol for systematic review and network meta-analysis.

Zhang, Xiu MN a ; Niu, Ming-Ming MN b ; Ma, Pei-Fen MN c,d ; Du, Li MD e ; Wan, Lin MN a,∗

a Department of Orthopedics, Second Hospital of Lanzhou University

b Evidence-Based Nursing Center, School of Nursing, Lanzhou University

c Department of Nursing, Second Hospital of Lanzhou University

d School of Nursing, Lanzhou University

e The Third People's Hospital of Lanzhou city, Lanzhou, China.

∗Correspondence: Lin Wan, Department of Orthopedics, Second Hospital of Lanzhou University, No. 82, Cuiyingmen, Chengguan District, Lanzhou City, Gansu Province, China (e-mail: [email protected] ).

Abbreviations: ACT = acceptance and commitment therapy, BA = behavioral activation, BDI = beck depression inventory, CBT = cognitive-behavioral therapy, CESD-R = center for epidemiologic studies depression scale revised, CSCT = comprehensive self-control training, DSM = diagnostic and statistical manual of mental disorders, HRSD = Hamilton Rating Scale for depression, ICD = International Classification of Diseases, NMA = network meta-analysis, RCTs = randomized controlled trials, SASS = social adaptation self-evaluation scale, SMD = standard mean difference, SNRIs = serotonin norepinephrine reuptake inhibitors, SSRIs = selective serotonin reuptake inhibitors, SUCRA = surface under the cumulative ranking area, TAU = treatment as usual, TCAs = tricyclic antidepressants, WLC = waiting-list control.

How to cite this article: Zhang X, Niu MM, Ma PF, Du L, Wan L. Psychotherapy for depression in college students: a protocol for systematic review and network meta-analysis. Medicine . 2020;99:39(e22344).

XZ and M-MN contributed equally to this work.

This study is based on a network meta-analysis of published studies, so ethical approval and patient consent are not required. And this systematic review and network meta-analysis will be published in a peer-reviewed journal.

This study is supported by Gansu Province Health Industry Scientific Research Project (No. GSWSKY-2019-102), Lanzhou University Second Hospital Cuiying Technology Project (No. CY2018-HL18) and Development and promotion of mental health tracking and intervention database for pediatric medical staff in Gansu Province (No. 2018-RC-52).

There are no potential conflicts of interest to disclose.

Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.

This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://creativecommons.org/licenses/by/4.0

Background:

Depression is a disease with a high incidence and easy to relapse. It not only affects the work and life of patients, but also brings a heavy economic burden. University is the peak of depression, and the prevalence of depression among college students is much higher than that of ordinary people. The purpose of this research is to evaluate depression symptoms, life satisfaction, self-confidence, substance use, social adjustment, and dropout rates of the use of psychological intervention for college students.

Methods:

We will identify relevant trials from systematic searches in the following electronic databases: PubMed, Embase, Web of Science and The Cochrane Library. We will also search Clinical Trials.gov, the WHO International Clinical Trials Registry Platform for unpublished data. Additional relevant studies will be searched through search engines (such as Google), and references included in the literature will be tracked. All relevant randomized controlled trials (RCTs) will be included. There are no date restrictions. Use Cochrane Collaboration's Risk of bias tool to conduct risk of bias analysis. Use the Grades of Recommendation, Assessment, Development, and Evaluation to assess the quality of evidence. All statistical analysis will be performed using Stata (V.15.0.) and Review Manager (V.5.2.0).

Results:

A total of 6238 records were obtained by searching the database and 27 records were obtained by other sources. After removing duplicate records, there are 4225 records remaining. We excluded 3945 records through abstract and title, leaving 280 full-text articles.

Conclusion:

This will be the first study to compare the effects of different psychological treatments on depression in college students. We hope that this study will guide clinical decision-making of psychotherapy to better treat depression in college students.

Protocol Registration:

INPLASY202070134.

1 Introduction

Depression is a common mental health disorder, which is mainly manifested by significant and lasting depression, slow thinking, sleep disturbance, loss of appetite, etc. In severe cases, suicide attempts or behaviors may occur. [1] Each episode of depression lasts at least two weeks. In severe cases, it may last for several years. This has a serious impact on work and life, and has caused a heavy financial burden. According to the World Health Organization, more than 350 million people worldwide suffer from depression. [2] The current incidence of depression in China is 6.1%. [3] By 2020, depression may become the second largest disease after heart disease. [4] And depression has become the main reason for people's loss of social function and ranks third in the global burden of disease. [5] Studies have shown that in the United States alone, the annual cost exceeds $43.7 billion. [6,7] College students are faced with the pressure from interpersonal communication, arduous learning tasks and adaptation to the new environment and lifestyle, which makes them prone to produce strong psychological conflicts and lead to depression. [8] Therefore, compared with their peers, college students have a higher risk of depression. [9]

At present, the treatment of depression is mainly divided into medication and psychotherapy. Drug therapy mainly includes selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), serotonin norepinephrine reuptake inhibitors (SNRIs), etc. [10] Psychotherapy is to establish a relationship with the patient through a structured and purposeful connection and use a series of specific techniques to improve the patient's mental state. [11] It plays an important role in the treatment of depression. At present, the common psychotherapy in clinical treatment methods include cognitive behavior therapy, group psychotherapy, interpersonal behavior therapy, mindfulness therapy, etc. Previous studies showed that there are few systematic reviews and meta-analysis of depression in college students. However, the relevant evidence for the effectiveness of psychotherapy is still unclear, and there is no evidence to directly compare different psychological interventions. Therefore, this field urgently needs a Bayesian network meta-analysis (NMA) method that combines direct evidence with indirect evidence from multiple treatment comparisons to estimate the correlation between all treatments. [12] In this study, we will conduct a systematic review and NMA to evaluate depression symptoms, life satisfaction, self-confidence, substance use, social adjustment, and dropout rates of the use of psychotherapy for college students.

2.1 Eligibility criteria

2.1.1 type of study.

We will include all relevant randomized controlled trials (RCTs) including crossover trials. There are no language restrictions.

2.1.2 Type of patient

The patients we will include are college students diagnosed with depression according to any diagnostic criteria, such as Diagnostic and Statistical Manual of Mental Disorders (DSM)-III, [13] DSM-IV, [14] and International Classification of Diseases, 10th Revision (ICD-10). [15] Studies in which participants have a diagnosis of bipolar disorder, psychotic depression will be excluded. In addition, studies where participants are not clearly diagnosed with depression will also be excluded.

2.1.3 Type of interventions

We will include RCTs comparing one psychological intervention with another control conditions for depression in college students. For psychotherapy, mindfulness therapy, cognitive-behavioral therapy (CBT), meditation therapy, comprehensive self-control training (CSCT), [16] acceptance and commitment therapy (ACT), [17] and behavioral activation (BA) will be included. There will be no limit to the treatment session. In terms of control conditions, waiting-list control (WLC), [18] non-treatment control, physical exercise, bibliotherapy, [19] treatment as usual (TAU) will be included.

2.1.4 Type of outcomes

Primary outcome

Depression symptoms that mean the change in severity of depression from baseline to end point which is measured by the depression scale, such as Beck Depression Inventory (BDI), [20] The Center for Epidemiologic Studies Depression Scale (CESD-R), [21] Hamilton Rating Scale for Depression (HRSD). [22]

Second outcomes

1. self-confidence, life satisfaction was assessed using visual rating scale
2. social adjustment was assessed using the Social Adaptation Self Evaluation Scale (SASS) [23] and the Social Adjustment Scale-Self Report for Youth. [24]
3. substance use was measured with 10 items to assess the use of eight substances, quantity per drinking and smoking day. [25]
4. Dropout rates from the beginning of the study to the end of the intervention.

2.2 Data source

We will identify relevant trials from systematic searches in the following electronic databases: PubMed, Embase, Web of Science and The Cochrane Library. We will also search Clinical Trials.gov, the WHO International Clinical Trials Registry Platform for unpublished data. The search terms will include “depression”, “depressive disorder”, “students”, “university student”, “college student”. Additional relevant studies will be searched through search engines (such as Google), and references included in the literature will be tracked. There is no date restriction. Detail of search strategy of PubMed is shown in Table 1 as well as detail of search strategy of Embase is shown in Table 2 .

2.3 Study selection

All records identified in the databases will be collected in the reference management software EndNote X8 for data screening. Two (MMN and PFM) reviewers will use data extraction tables to extract data from the original report independently, including research characteristics (such author information, publication year, journal and country), patient characteristics, intervention and outcome. Any disagreements will be resolved by the third member of our review team.

2.4 Risk of bias analysis

According to Cochrane Collaboration's Risk of bias tool, we will assess risk of bias as ‘low risk’, ‘unclear risk’ or ‘high risk’. [26] The following items will be evaluated: sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessors, incomplete outcome data and selective outcome reporting and other sources of bias. [27] The evaluation will be conducted by two independent raters (PFM and LD). Any disagreements will be resolved by a third review author.

2.5 Statistical analysis

2.5.1 pairwise meta-analysis.

We will use Review Manager (V.5.2.0) to perform traditional pairwise meta-analysis. Dichotomous data will be expressed as relative risk (RR) with 95% confidence interval (CI), and continuous outcomes will be expressed as standard mean difference (SMD) with 95% CI. [28]

2.5.2 Network meta-analysis

To simultaneously assess the comparative effects of more than 2 psychotherapy, an NMA will be performed. An NMA synthesizes direct and indirect comparisons over an entire network of psychotherapy, allowing for all available evidence to be considered in one analysis. Based on the network development process as outlined above, the outcome variable for the NMA is the standardized mean change in the DSST (measured using Hedge's G) from baseline to end of study. The standardization is based on the pooled (across treatment arms within study) estimate of the SDs. The NMA will be carried out using a frequentist's approach, and a 2-way ANOVA model is used. As the residual variances between treatment groups are known, it is possible for random effect estimates to be produced, which account for the between-trial heterogeneity. The model is used to perform ordinary pairwise meta-analysis comparing the different psychotherapy based on direct evidence from the clinical studies. Ranking probabilities will be calculated based on the joint distribution of the estimates of relative efficacy. [29]

Consistency will be addressed through the principle of node splitting by using a network meta-regression model. The purpose of node-splitting is to investigate if the relative effect of 2 psychotherapy based on direct comparisons is comparable with the same effect based on indirect comparisons. Statistically, the model is an extension of the NMA, which allows for a different relative effect between the 2 psychotherapy that are being split in head-to-head trials compared with all other trials. NMA will be implemented by the mvmeta software package in Stata (15.0; Stata Corporation, College Station, TX, USA Stata), [30] If P value <.1 and I 2 > 50%, it is considered that there is heterogeneity in the study, and sensitivity analysis or subgroup analysis will be performed to detect the source of heterogeneity. Funnel plot and Egger linear regression analysis will be used to assess publication bias. Using Review Manager (V.5.2.0) to analyze the risk of bias in the included studies, where the green, yellow, and red in the image represent low, unclear, and high risks, respectively. [31,32]

2.5.3 Subgroup analysis

If statistical heterogeneity is evident, we will analyze the causes of heterogeneity, if there is enough data (such as differences between sexes, comparison between different countries, studies sponsored versus not sponsored by companies).

2.5.4 Sensitivity analysis

We will use the exclusion method to conduct sensitivity analysis:

(1) exclude low-quality studies;
(2) exclude studies with comorbid physical or mental illnesses;
(3) exclude trials with missing data.

2.6 Quality of evidence

We will use Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework to assess the quality of evidence for the primary outcomes. [33,34] The quality of evidence is assessed as ‘high’, ‘moderate’, ‘low’ or ‘very low’. The following item will be evaluated: limitations, inconsistency, imprecision, indirectness, and publication bias. [35]

2.7 Summary of findings

A “summary of finding” table will be created for the major outcome. We will also add absolute and relative percentage changes to the “summary of finding”. For detailed information, see Table 3 ; we have listed partial summary of findings for the main comparison.

3.1 Results of the search

A total of 6238 records were obtained by searching the database and 27 records were obtained by other means. After removing duplicate records, there are 4225 records remaining. We excluded 3945 records through abstract and title, leaving 280 full-text articles. The document screening flowchart is shown in Figure 1 .

3.2 Characteristic of included studies

In a preliminary trial, we included 8 studies. The average age of patients was 18 to 26, with a maximum sample size of 181 and a minimum sample size of 32. The research period ranges from one month to 12 months. For more detailed information, see Table 4 .

4 Discussion

At present, although some studies have evaluated the intervention effects of psychotherapy, there is no NMA to compare the therapeutic effects of different psychological interventions for college students. Therefore, this systematic review and NMA will summarize the direct comparison and indirect comparison evidence to evaluate different psychological interventions. We hope that this study will help guide clinical decision-making for psychotherapy to better treat depression in college students.

Author contributions

Conceptualization: Xiu Zhang, Lin Wan.

Data curation: Xiu Zhang, Ming-Ming Niu, Pei-Fen Ma, Li Du, Lin Wan.

Methodology: Xiu Zhang, Lin Wan.

Software: Xiu Zhang, Ming-Ming Niu, Pei-Fen Ma, Li Du.

Writing – original draft: Xiu Zhang, Ming-Ming Niu, Lin Wan.

Writing – review & editing: Xiu Zhang, Lin Wan.

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Student mental health is in crisis. Campuses are rethinking their approach

Amid massive increases in demand for care, psychologists are helping colleges and universities embrace a broader culture of well-being and better equipping faculty to support students in need

Vol. 53 No. 7 Print version: page 60

Mental Health

college student looking distressed while clutching textbooks

By nearly every metric, student mental health is worsening. During the 2020–2021 school year, more than 60% of college students met the criteria for at least one mental health problem, according to the Healthy Minds Study, which collects data from 373 campuses nationwide ( Lipson, S. K., et al., Journal of Affective Disorders , Vol. 306, 2022 ). In another national survey, almost three quarters of students reported moderate or severe psychological distress ( National College Health Assessment , American College Health Association, 2021).

Even before the pandemic, schools were facing a surge in demand for care that far outpaced capacity, and it has become increasingly clear that the traditional counseling center model is ill-equipped to solve the problem.

“Counseling centers have seen extraordinary increases in demand over the past decade,” said Michael Gerard Mason, PhD, associate dean of African American Affairs at the University of Virginia (UVA) and a longtime college counselor. “[At UVA], our counseling staff has almost tripled in size, but even if we continue hiring, I don’t think we could ever staff our way out of this challenge.”

Some of the reasons for that increase are positive. Compared with past generations, more students on campus today have accessed mental health treatment before college, suggesting that higher education is now an option for a larger segment of society, said Micky Sharma, PsyD, who directs student life’s counseling and consultation service at The Ohio State University (OSU). Stigma around mental health issues also continues to drop, leading more people to seek help instead of suffering in silence.

But college students today are also juggling a dizzying array of challenges, from coursework, relationships, and adjustment to campus life to economic strain, social injustice, mass violence, and various forms of loss related to Covid -19.

As a result, school leaders are starting to think outside the box about how to help. Institutions across the country are embracing approaches such as group therapy, peer counseling, and telehealth. They’re also better equipping faculty and staff to spot—and support—students in distress, and rethinking how to respond when a crisis occurs. And many schools are finding ways to incorporate a broader culture of wellness into their policies, systems, and day-to-day campus life.

“This increase in demand has challenged institutions to think holistically and take a multifaceted approach to supporting students,” said Kevin Shollenberger, the vice provost for student health and well-being at Johns Hopkins University. “It really has to be everyone’s responsibility at the university to create a culture of well-being.”

Higher caseloads, creative solutions

The number of students seeking help at campus counseling centers increased almost 40% between 2009 and 2015 and continued to rise until the pandemic began, according to data from Penn State University’s Center for Collegiate Mental Health (CCMH), a research-practice network of more than 700 college and university counseling centers ( CCMH Annual Report , 2015 ).

That rising demand hasn’t been matched by a corresponding rise in funding, which has led to higher caseloads. Nationwide, the average annual caseload for a typical full-time college counselor is about 120 students, with some centers averaging more than 300 students per counselor ( CCMH Annual Report , 2021 ).

“We find that high-caseload centers tend to provide less care to students experiencing a wide range of problems, including those with safety concerns and critical issues—such as suicidality and trauma—that are often prioritized by institutions,” said psychologist Brett Scofield, PhD, executive director of CCMH.

To minimize students slipping through the cracks, schools are dedicating more resources to rapid access and assessment, where students can walk in for a same-day intake or single counseling session, rather than languishing on a waitlist for weeks or months. Following an evaluation, many schools employ a stepped-care model, where the students who are most in need receive the most intensive care.

Given the wide range of concerns students are facing, experts say this approach makes more sense than offering traditional therapy to everyone.

“Early on, it was just about more, more, more clinicians,” said counseling psychologist Carla McCowan, PhD, director of the counseling center at the University of Illinois at Urbana-Champaign. “In the past few years, more centers are thinking creatively about how to meet the demand. Not every student needs individual therapy, but many need opportunities to increase their resilience, build new skills, and connect with one another.”

Students who are struggling with academic demands, for instance, may benefit from workshops on stress, sleep, time management, and goal-setting. Those who are mourning the loss of a typical college experience because of the pandemic—or facing adjustment issues such as loneliness, low self-esteem, or interpersonal conflict—are good candidates for peer counseling. Meanwhile, students with more acute concerns, including disordered eating, trauma following a sexual assault, or depression, can still access one-on-one sessions with professional counselors.

As they move away from a sole reliance on individual therapy, schools are also working to shift the narrative about what mental health care on campus looks like. Scofield said it’s crucial to manage expectations among students and their families, ideally shortly after (or even before) enrollment. For example, most counseling centers won’t be able to offer unlimited weekly sessions throughout a student’s college career—and those who require that level of support will likely be better served with a referral to a community provider.

“We really want to encourage institutions to be transparent about the services they can realistically provide based on the current staffing levels at a counseling center,” Scofield said.

The first line of defense

Faculty may be hired to teach, but schools are also starting to rely on them as “first responders” who can help identify students in distress, said psychologist Hideko Sera, PsyD, director of the Office of Equity, Inclusion, and Belonging at Morehouse College, a historically Black men’s college in Atlanta. During the pandemic, that trend accelerated.

“Throughout the remote learning phase of the pandemic, faculty really became students’ main points of contact with the university,” said Bridgette Hard, PhD, an associate professor and director of undergraduate studies in psychology and neuroscience at Duke University. “It became more important than ever for faculty to be able to detect when a student might be struggling.”

Many felt ill-equipped to do so, though, with some wondering if it was even in their scope of practice to approach students about their mental health without specialized training, Mason said.

Schools are using several approaches to clarify expectations of faculty and give them tools to help. About 900 faculty and staff at the University of North Carolina have received training in Mental Health First Aid , which provides basic skills for supporting people with mental health and substance use issues. Other institutions are offering workshops and materials that teach faculty to “recognize, respond, and refer,” including Penn State’s Red Folder campaign .

Faculty are taught that a sudden change in behavior—including a drop in attendance, failure to submit assignments, or a disheveled appearance—may indicate that a student is struggling. Staff across campus, including athletic coaches and academic advisers, can also monitor students for signs of distress. (At Penn State, eating disorder referrals can even come from staff working in food service, said counseling psychologist Natalie Hernandez DePalma, PhD, senior director of the school’s counseling and psychological services.) Responding can be as simple as reaching out and asking if everything is going OK.

Referral options vary but may include directing a student to a wellness seminar or calling the counseling center to make an appointment, which can help students access services that they may be less likely to seek on their own, Hernandez DePalma said. Many schools also offer reporting systems, such as DukeReach at Duke University , that allow anyone on campus to express concern about a student if they are unsure how to respond. Trained care providers can then follow up with a welfare check or offer other forms of support.

“Faculty aren’t expected to be counselors, just to show a sense of care that they notice something might be going on, and to know where to refer students,” Shollenberger said.

At Johns Hopkins, he and his team have also worked with faculty on ways to discuss difficult world events during class after hearing from students that it felt jarring when major incidents such as George Floyd’s murder or the war in Ukraine went unacknowledged during class.

Many schools also support faculty by embedding counselors within academic units, where they are more visible to students and can develop cultural expertise (the needs of students studying engineering may differ somewhat from those in fine arts, for instance).

When it comes to course policy, even small changes can make a big difference for students, said Diana Brecher, PhD, a clinical psychologist and scholar-in-residence for positive psychology at Toronto Metropolitan University (TMU), formerly Ryerson University. For example, instructors might allow students a 7-day window to submit assignments, giving them agency to coordinate with other coursework and obligations. Setting deadlines in the late afternoon or early evening, as opposed to at midnight, can also help promote student wellness.

At Moraine Valley Community College (MVCC) near Chicago, Shelita Shaw, an assistant professor of communications, devised new class policies and assignments when she noticed students struggling with mental health and motivation. Those included mental health days, mindful journaling, and a trip with family and friends to a Chicago landmark, such as Millennium Park or Navy Pier—where many MVCC students had never been.

Faculty in the psychology department may have a unique opportunity to leverage insights from their own discipline to improve student well-being. Hard, who teaches introductory psychology at Duke, weaves in messages about how students can apply research insights on emotion regulation, learning and memory, and a positive “stress mindset” to their lives ( Crum, A. J., et al., Anxiety, Stress, & Coping , Vol. 30, No. 4, 2017 ).

Along with her colleague Deena Kara Shaffer, PhD, Brecher cocreated TMU’s Thriving in Action curriculum, which is delivered through a 10-week in-person workshop series and via a for-credit elective course. The material is also freely available for students to explore online . The for-credit course includes lectures on gratitude, attention, healthy habits, and other topics informed by psychological research that are intended to set students up for success in studying, relationships, and campus life.

“We try to embed a healthy approach to studying in the way we teach the class,” Brecher said. “For example, we shift activities every 20 minutes or so to help students sustain attention and stamina throughout the lesson.”

Creative approaches to support

Given the crucial role of social connection in maintaining and restoring mental health, many schools have invested in group therapy. Groups can help students work through challenges such as social anxiety, eating disorders, sexual assault, racial trauma, grief and loss, chronic illness, and more—with the support of professional counselors and peers. Some cater to specific populations, including those who tend to engage less with traditional counseling services. At Florida Gulf Coast University (FGCU), for example, the “Bold Eagles” support group welcomes men who are exploring their emotions and gender roles.

The widespread popularity of group therapy highlights the decrease in stigma around mental health services on college campuses, said Jon Brunner, PhD, the senior director of counseling and wellness services at FGCU. At smaller schools, creating peer support groups that feel anonymous may be more challenging, but providing clear guidelines about group participation, including confidentiality, can help put students at ease, Brunner said.

Less formal groups, sometimes called “counselor chats,” meet in public spaces around campus and can be especially helpful for reaching underserved groups—such as international students, first-generation college students, and students of color—who may be less likely to seek services at a counseling center. At Johns Hopkins, a thriving international student support group holds weekly meetings in a café next to the library. Counselors typically facilitate such meetings, often through partnerships with campus centers or groups that support specific populations, such as LGBTQ students or student athletes.

“It’s important for students to see counselors out and about, engaging with the campus community,” McCowan said. “Otherwise, you’re only seeing the students who are comfortable coming in the door.”

Peer counseling is another means of leveraging social connectedness to help students stay well. At UVA, Mason and his colleagues found that about 75% of students reached out to a peer first when they were in distress, while only about 11% contacted faculty, staff, or administrators.

“What we started to understand was that in many ways, the people who had the least capacity to provide a professional level of help were the ones most likely to provide it,” he said.

Project Rise , a peer counseling service created by and for Black students at UVA, was one antidote to this. Mason also helped launch a two-part course, “Hoos Helping Hoos,” (a nod to UVA’s unofficial nickname, the Wahoos) to train students across the university on empathy, mentoring, and active listening skills.

At Washington University in St. Louis, Uncle Joe’s Peer Counseling and Resource Center offers confidential one-on-one sessions, in person and over the phone, to help fellow students manage anxiety, depression, academic stress, and other campus-life issues. Their peer counselors each receive more than 100 hours of training, including everything from basic counseling skills to handling suicidality.

Uncle Joe’s codirectors, Colleen Avila and Ruchika Kamojjala, say the service is popular because it’s run by students and doesn’t require a long-term investment the way traditional psychotherapy does.

“We can form a connection, but it doesn’t have to feel like a commitment,” said Avila, a senior studying studio art and philosophy-neuroscience-psychology. “It’s completely anonymous, one time per issue, and it’s there whenever you feel like you need it.”

As part of the shift toward rapid access, many schools also offer “Let’s Talk” programs , which allow students to drop in for an informal one-on-one session with a counselor. Some also contract with telehealth platforms, such as WellTrack and SilverCloud, to ensure that services are available whenever students need them. A range of additional resources—including sleep seminars, stress management workshops, wellness coaching, and free subscriptions to Calm, Headspace, and other apps—are also becoming increasingly available to students.

Those approaches can address many student concerns, but institutions also need to be prepared to aid students during a mental health crisis, and some are rethinking how best to do so. Penn State offers a crisis line, available anytime, staffed with counselors ready to talk or deploy on an active rescue. Johns Hopkins is piloting a behavioral health crisis support program, similar to one used by the New York City Police Department, that dispatches trained crisis clinicians alongside public safety officers to conduct wellness checks.

A culture of wellness

With mental health resources no longer confined to the counseling center, schools need a way to connect students to a range of available services. At OSU, Sharma was part of a group of students, staff, and administrators who visited Apple Park in Cupertino, California, to develop the Ohio State: Wellness App .

Students can use the app to create their own “wellness plan” and access timely content, such as advice for managing stress during final exams. They can also connect with friends to share articles and set goals—for instance, challenging a friend to attend two yoga classes every week for a month. OSU’s apps had more than 240,000 users last year.

At Johns Hopkins, administrators are exploring how to adapt school policies and procedures to better support student wellness, Shollenberger said. For example, they adapted their leave policy—including how refunds, grades, and health insurance are handled—so that students can take time off with fewer barriers. The university also launched an educational campaign this fall to help international students navigate student health insurance plans after noticing below average use by that group.

Students are a key part of the effort to improve mental health care, including at the systemic level. At Morehouse College, Sera serves as the adviser for Chill , a student-led advocacy and allyship organization that includes members from Spelman College and Clark Atlanta University, two other HBCUs in the area. The group, which received training on federal advocacy from APA’s Advocacy Office earlier this year, aims to lobby public officials—including U.S. Senator Raphael Warnock, a Morehouse College alumnus—to increase mental health resources for students of color.

“This work is very aligned with the spirit of HBCUs, which are often the ones raising voices at the national level to advocate for the betterment of Black and Brown communities,” Sera said.

Despite the creative approaches that students, faculty, staff, and administrators are employing, students continue to struggle, and most of those doing this work agree that more support is still urgently needed.

“The work we do is important, but it can also be exhausting,” said Kamojjala, of Uncle Joe’s peer counseling, which operates on a volunteer basis. “Students just need more support, and this work won’t be sustainable in the long run if that doesn’t arrive.”

Contact APA

Nationwide study, co-led by BU researcher Sarah Ketchen Lipson, reveals a majority of students say mental health has impacted their academic performance

Kat j. mcalpine.

A survey by a Boston University researcher of nearly 33,000 college students across the country reveals the prevalence of depression and anxiety in young people continues to increase, now reaching its highest levels, a sign of the mounting stress factors due to the coronavirus pandemic, political unrest, and systemic racism and inequality.

“Half of students in fall 2020 screened positive for depression and/or anxiety,” says Sarah Ketchen Lipson , a Boston University mental health researcher and a co–principal investigator of the nationwide survey , which was administered online during the fall 2020 semester through the Healthy Minds Network. The survey further reveals that 83 percent of students said their mental health had negatively impacted their academic performance within the past month, and that two-thirds of college students are struggling with loneliness and feeling isolated—an all-time high prevalence that reflects the toll of the pandemic and the social distancing necessary to control it.

Lipson, a BU School of Public Health assistant professor of health law, policy, and management, says the survey’s findings underscore the need for university teaching staff and faculty to put mechanisms in place that can accommodate students’ mental health needs.

“Faculty need to be flexible with deadlines and remind students that their talent is not solely demonstrated by their ability to get a top grade during one challenging semester,” Lipson says.

She adds that instructors can protect students’ mental health by having class assignments due at 5 pm, rather than midnight or 9 am, times that Lipson says can encourage students to go to bed later and lose valuable sleep to meet those deadlines.

Especially in smaller classroom settings, where a student’s absence may be more noticeable than in larger lectures, instructors who notice someone missing classes should reach out to that student directly to ask how they are doing.

“Even in larger classes, where 1:1 outreach is more difficult, instructors can send classwide emails reinforcing the idea that they care about their students not just as learners but as people, and circulating information about campus resources for mental health and wellness,” Lipson says.

And, crucially, she says, instructors must bear in mind that the burden of mental health is not the same across all student demographics. “Students of color and low-income students are more likely to be grieving the loss of a loved one due to COVID,” Lipson says. They are also “more likely to be facing financial stress.” All of these factors can negatively impact mental health and academic performance in “profound ways,” she says.

At a higher level within colleges and universities, Lipson says, administrators should focus on providing students with mental health services that emphasize prevention, coping, and resilience. The fall 2020 survey data revealed a significant “treatment gap,” meaning that many students who screen positive for depression or anxiety are not receiving mental health services.

“Often students will only seek help when they find themselves in a mental health crisis, requiring more urgent resources,” Lipson says. “But how can we create systems to foster wellness before they reach that point?” She has a suggestion: “All students should receive mental health education, ideally as part of the required curriculum.”

It’s also important to note, she says, that rising mental health challenges are not unique to the college setting—instead, the survey findings are consistent with a broader trend of declining mental health in adolescents and young adults. “I think mental health is getting worse [across the US population], and on top of that we are now gathering more data on these trends than ever before,” Lipson says. “We know mental health stigma is going down, and that’s one of the biggest reasons we are able to collect better data. People are being more open, having more dialogue about it, and we’re able to better identify that people are struggling.”

The worsening mental health of Americans, more broadly, Lipson says, could be due to a confluence of factors: the pandemic, the impact of social media, and shifting societal values that are becoming more extrinsically motivated (a successful career, making more money, getting more followers and likes), rather than intrinsically motivated (being a good member of the community).

The crushing weight of historic financial pressures is an added burden. “Student debt is so stressful,” Lipson says. “You’re more predisposed to experiencing anxiety the more debt you have. And research indicates that suicidality is directly connected to financial well-being.”

With more than 22 million young people enrolled in US colleges and universities, “and with the traditional college years of life coinciding with the age of onset for lifetime mental illnesses,” Lipson stresses that higher education is a crucial setting where prevention and treatment can make a difference.

One potential bright spot from the survey was that the stigma around mental health continues to fade. The results reveal that 94 percent of students say that they wouldn’t judge someone for seeking out help for mental health, which Lipson says is an indicator that also correlates with those students being likely to seek out help themselves during a personal crisis (although, paradoxically, almost half of students say they perceive that others may think more poorly of them if they did seek help).

“We’re harsher on ourselves and more critical of ourselves than we are with other people—we call that perceived versus personal stigma,” Lipson says. “Students need to realize, your peers are not judging you.”

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Boston University moderates comments to facilitate an informed, substantive, civil conversation. Abusive, profane, self-promotional, misleading, incoherent or off-topic comments will be rejected. Moderators are staffed during regular business hours (EST) and can only accept comments written in English. Statistics or facts must include a citation or a link to the citation.

There are 25 comments on Depression, Anxiety, Loneliness Are Peaking in College Students

first of all, excellent writing! This report is extremely triggering for a few reasons. Obviously students are NOT okay at the moment, now confirmed by the student. But what does the university do about it? They micro-manage EVERY aspect of students’ life to mitigate Covid risk. Here, tell me why the university took away household table seating in the dining hall? That was one of the ONLY places on campus where students can eat with each other and actually see their friends’ faces. What type of modeling was used to make this decision and its impact on covid spread on campus. Same thing for the green badge, was there a statistical difference in case before and after students have to walk around showing that? The university’s policies are simply incentivizing off-campus, more dangerous gatherings because the university won’t facilitate anything like that on campus. Oh, and the university response? ‘you’re doing great sweetie’ type of deal – absolutely ridiculous. I know BU can’t keep this up much longer, they are losing far too much money because of Covid and less students on campus – there will be a reckoning. Students, stand up.

BU will acknowledge this but then still won’t do anything to actually help.

Great, but this school is doing absolutely nothing to help it

I appreciate this article because I feel that the issue of mental health isn’t talked about enough amongst students and just college culture in general. I don’t see any concerns coming from college faculty, at least clearly. It’s so important to talk about mental health, especially during a pandemic.

This article is definitely going in the right direction. That being said, as the other comments have also mentioned, BU needs to do MUCH more than just publishing an article telling students, “well, at least you aren’t alone.” If 83% of your student body reports their mental health affects their school work, then if not for them, at least change something for the benefit of the school’s name. To put it bluntly, this does not look good. Also referencing BU’s response to sexual harassment, BU now has a track record of acknowledging issues that significantly impact its students in an article or maybe a speech to only do NOTHING about it. Please, I implore the school to act. Act or we will.

We know mental health stigma is going down

Actually, we know support for those taught and teaching that prejudice is diminishing, though that does not mean by any stretch of the imagination it is not still being taught. It continues to be taught (often resolutely) at Boston University. The above sentence is one manner in which it continues to be taught, Passive Reference. It is also actively taught. “Perceived stigma” is another interesting Passive Reference, directed prejudices are intended by their directors to be perceived. “perceived” stigma is an obfuscation of the process whereby it is perceived. It surprises me, that so many women, eschewing “the stigma” of rape, continue to declare “the stigma” of mental illnesses. Sometimes history does not inform us. A few years ago 5 students died by suicide at a Canadian college, blamed was “the stigma” of mental illnesses, not those conveying it. When a young man at U Penn died by suicide it prompted his sister to set up a now national organization protesting “the stigma” of mental illnesses, not those conveying it. National organizations abound conveying “the stigma” of mental illnesses to eagerly awaiting audiences. Publications abound, but to my knowledge not one single publication directly addresses how it is taught or who teaches it. Nor, to my knowledge is there a campus in the US, or any English speaking country, where someone is given guidance on how to address those directing it. Whom to approach. How to resolve it. [email protected] offers no such guidance. I invite each of you to return to 1972, when a small group of personally empowered women said, “Stop directing the term stigma at rape, you have done enough harm” and take that lesson to heart: We stopped.

And I invite [email protected] to take a role in bringing about that change.

Harold A Maio, retired mental health editor

Wow – so what is BU doing about this when we have pleaded with admin and offered so many ideas and solutions to helping here since September 2020?

The silence is deafening BU.

The Well Being Project is stagnate.

The Dean is silent.

The provost says students are happy based on some survey they did just before holidays when students knew they were going home.

The Director of Mental Health says appts for mental health are down – that’s the sign everything is fine?

We are hearing the opposite and many students have just lost their faith in support from BU as well as just returning home for LFA where they have a support system.

Where are the social in person safe activities outside and inside?

Where are the RAs and their weekly activities and support of their residents or are they just there to write students up?

Where are the self-care tips and resources offered daily to students?

Where in the daily MANDATORY self-check survey of their health – are any questions about their emotional well being including their mood, stress levels, sleep and appetite?

Where is the support for faculty who are seeing these issues and trying to reach out?

Where are the therapy dogs from pre-pandemic we asked for weekly or biweekly to come outside and offer unconditional emotional support during this tough time?

Where are some campus wide concerts or comedy relief concert paid for by BU – virtually or outside so students have anything to look forward to? If it’s down to money / the $70,000 Tuition or should cover some of it or funds from housing since many were not reimbursed when they returned home for support.

Where is any work with this amazing wise resource Dr. Lipson to take any of her guidance since last summer instead of just posting it here?

Is anyone listening to the isolation and pain of so many terriers? I have heard troubling stories for months since we began our BU Parent group that is NOT monitored by the Deans office unlike others. I have helped refer and counsel families worried if they speak up there might be some retaliation. There is no retaliation just a deaf ear to making any changes to improve morale and well being of our terriers during a pandemic. And then posting this article is the ultimate hutzpah when no one has listened to Dr.Lipson / your own shining star about these issues.

Why not shine as you have with COVID testing? What if this were your family member feeling isolated and disillusioned with their dreams at BU with no outreach from BU except an occasional ZOOM message.

BU can do so much better and be the example for the rest of the nation. Why test so stringently if you will not allow any safe activities except for favorites like sports teams and band members?

Terriers are ZOOMED OUT. Don’t wait for a suicide or more depression to appear in students. It’s almost too late to be proactive / but you can try and we ask that you try hard. Be an example for other colleges.

We are not giving up on being heard. We are parents who care and love BU and know it can do better.

A lot of good points made – I wanted to touch upon when you mentioned that appointments for mental health are apparently down. As a student actively seeking mental health resources, my experience is that it has been extremely difficult to even schedule any sort of mental health appointments or counseling; we are unable to make an appointment online or in-person anymore, and the only information we are given is a phone number to call (the Behavioral Medicine number). I find this frustrating as many of us need more than just a phone conversation to help – even a zoom meeting would be helpful, but why aren’t there zoom appointments for SHS like there are for almost every other service on campus (e.g., pre-professional advising, financial aid, etc.)? I’ve noticed that the loneliness and isolation is affecting not only me but my roommates as well, who have stronger support systems and more friends on campus than I do – we’ve all been lacking motivation to do any of our work and they’ve mentioned that they feel like they need a break (spring break canceled due to pandemic concerns). Even some of my professors seem burnt out – forgetting class, getting behind on their syllabus, etc. In my opinion, BU should be more proactive in giving students resources instead of making it difficult to find said resources. Lastly, I wanted to add that I understand a lot of services are probably very different now due to the pandemic, but a single “wellness week” and emails about it do not do much to actually help students – I find it comparable to “self care” where the self care is just drinking wine and putting on a skincare mask and pushing all your real problems aside.

I agree with those who are asking for BU to do more to support students. I’m a faculty member who is trying to do my best to support my students. I’m more than willing to give extensions, modify assignments, and lower my expectations this semester. I’m checking in on students who miss class to make sure they’re okay. I’m trying to cut as much material as I can while still meeting my course learning objectives. At the same time, I don’t think it’s fair to expect faculty to do everything when it comes to students’ wellbeing. I’ve been in meetings where faculty were asked (both implicitly and explicitly) to help students make friends and socialize during class. I know faculty who are doing this in their courses (and I applaud them for their efforts), but shouldn’t Res Life and other staff at BU be providing opportunities for students to safely socialize? Sure, it’s cold, but certainly BU can be creative and think of ways to encourage students to get out of their dorms and make friends. Faculty are struggling too, and BU’s administration can help us by helping our students.

This is an excellent article, and though not surprising, it is shocking that the BU administration has not done anything to remedy this mental health crises. This is a mental health pandemic happening and it should be as high of a priority for BU as the trying to control the virus. If BU doesn’t step up and come up with a plan to address this then our students will suffer for years to come. This should have happened months ago. You can’t have a healthy individual/society if you are only concerned with physical health. It has to be a holistic approach.

Nice article I hope all instructors read this article I am one of the students sometimes fell a depression and live in the anxiety that is effectives on my life and do not have the energy to do anything particularly during what we live now

First, I would like to focus on the positive and thank BU mental health staff for being there for my son when he was in urgent need of mental health support back in the Fall semester. My call was answered right away and my son was able to speak with a professional with in 15 minutes. I was very impressed and relieved. They were there when we needed them.

On the other hand, I’m hearing from my son and all of his friends that the academic culture of rigor for the sake of rigor, grade deflation and the purposeful weeding out of students from core classes rather than supporting and helping each student succeed, not only continues but has been increased during COVID. These students have a sense that professors are concerned about online cheating so have ramped the rigor to address this. Not sure if this is real or perceived and I’m sure this is not going on in all classes as I also heard examples of supportive professors, but this is definitely a theme I am hearing from students. This style of academics is known to be outdated and ineffective, yet it continues, even at a higher level, during a pandemic.

I’m hoping this feedback can serve helpful to administration.

THANK YOU!!!! As a college student, who has survived the past year with a 4.0, attending full-time to obtain my degree in IT. I am struggling for the first time. After technology issues that set me behind four days, I really thought my instructors would understand. One of my instructors couldn’t care less. The workload is beyond overwhelming, her curriculum seems almost cruel. I graduate next month and I feel like I am losing my mind. I already suffer from severe anxiety, so the level I’m at now is almost debilitating. I have been obtaining degrees since 1998, and familiar with online learning. I’ve never had issues. This morning I received an email from her reminding me of the due date, in all bold caps, followed by some !!!! … She made it clear she is not available on the weekend, but expects us to be flexible. So my dilemma is this, I am failing my coding class now, but I don’t feel that I should be financially responsible to pay for having to retake it, as well as have it impact my financial aid and scholarships I receive for my academic performance.

Hi. I’m a BU alumna, a college professor, and mom to 4 college-aged sons. WONDERING… Do students feel there is explicit and implicit prejudice against college students as “purveyors of COVID?” I think this adds to the discomfort or enjoyment of being a college student and part of a university community. Thoughts? Thanks!

I notice that the students like to complain on here. One thing that university researchers on mental health have a difficult time assessing is knowing the familial support system (or lack thereof) students come into university life with. Psychologists will affirm that this plays a huge role in the mental health of students, at any age. Just as elementary through high schools today are expected to be the emotional, parental, physical, educational, and social supporter of each student, so too are universities being given this sort of expectation. Don’t get me wrong…I believe in striving for mental health and making resources available on campuses. However, within the communities of students – whether their friends or family – we have to realize that the internal conversation around mental health for many cultures is either non-existent or looked down upon. We can sing mental health from the rooftops all day long and hope that students are listening…..and I hope they do.

ECT/Electroshock use has been on the rise last 5 years or so and not just used for depression nor as a last resort. No FDA testing ever done of devices used or the procedure itself. Increase risk for suicide following as many cannot find help for their repeated brain injuries after consenting to this. Lawsuits taking place in the US and England around these damages covered up. See site ectjustice to learn more. Please speak out on social media so others are made aware of the truth of this practice.

People shouldn’t hesitate to ask for psychological help. I think it’s one of the main problems why people struggle mentally. Maybe, it’s a matter of self-critique, and society says sometimes that we should be strong… But when someone gets in an emotional crisis, only a professional can help. And I also never see when students/educators judge their peers/colleagues if someone contacted mental health support. I looked through the list of different affordable mental health services across English-speaking countries – https://ivypanda.com/blog/mental-health-resources – I was shocked how many problems we can have, and how many professionals exist to help with them. Maybe, it may be helpful to others too. Let’s take care of ourselves.

I tried to find the source for “83 %” of college students say their performance was negatively affected by mental health. Did you just pull that number out of thin air? I tried to go through everything I could and could not find this number anywhere in any actual published writing.

Please see page six of the report, the pie chart listed under Academic Impairment.

I think you just made up certain elements of this article and they actually have 0 foundation whatsoever. It has led me down a rabbit hole of attempting to try to find the published support for some of the claims you make. Including the 83 % figure. If you’re going to write articles that will be heavily referenced (which this is, because other idiots went on to quote this article), you should at least get the facts straight.

Please see page 6 of the report, the pie chart listed under Academic Impairment: https://healthymindsnetwork.org/wp-content/uploads/2021/02/HMS-Fall-2020-National-Data-Report.pdf

That is a misrepresentation of the data, in my opinion. Including students who reported mental health impacting their academic performance 1-2 days out of the week is insufficient to be grouped in with 83% of students. The way it is presented in this article makes it seem much more drastic than that. It should say, “28% of students felt 1-2 days out of the week had been negatively impacted by their mental health in the past month..” and report the other percentages. Not combined into one group and twisted in a sensationalistic way. I was attempting to use this information for a research paper of my own and was sent down a rabbit hole trying to find a source. Other people have cited this article, and that is your responsibility as a researcher.

Reading it because to help a friend with his assignment. He studies in FAST, Islamabad, Pakistan. If anyone of his class fellows are here, good luck to you

It is 3:12 in the morning and I just got off the phone with son. He called because he was riddled with anxiety and suffering with loneliness and a seeming inability to form meaningful connections. This is his first year at BU. He loves the University; However, in addition to the rigorous academic challenges, he is crushed by the seeming inability to form connections with others. This, on so many levels, surprises me. He is intelligent, interesting, friendly, handsome and well rounded. Upon my introduction to the University’s logistical layout, I was immediately aware that it not appear easily conducive to meeting people… As opposed to a smaller private college if you will. Clearly, BU had an obligation to address the many challenges brought about as a result of Covid. Understandable, but perhaps a bit extreme, ie: The students not being allowed to eat or congregate. Regardless, what I also observed is that there are few, if any, common rooms.. areas for students to hang out, play board games, ping pong, darts, tell jokes, b.s. and share common concerns. Or My point being, there should be multiple places (Besides sneaking into local clubs, or drinking Alone in your dorm) where kids can go..day or night. Organized events as well, aside from sports. As aforementioned, my son also found it very challenging and frustrating to contact a counselor through your service. When you do, the schedules are booked…… I have been heartbroken. Nonetheless, the consistent voice if encouragement. I want more from the school. I, like all others noted before me. More social emotional support. More access to social opportunities. More professors understanding and working with the challenges our children are struggling to navigate. In closing, it’s not just a BU crisis. I listen to very similar difficulties from many other University families…. PLEASE be more proactive. PLEASE care PLEASE help It is imperative and essential to a successful college experience and outcome. Thank you. And thank you all aforementioned

very very nice

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Published: 13 July 2021

Systematic review and meta-analysis of depression, anxiety, and suicidal ideation among Ph.D. students

Emily N. Satinsky 1 ,
Tomoki Kimura 2 ,
Mathew V. Kiang 3 , 4 ,
Rediet Abebe 5 , 6 ,
Scott Cunningham 7 ,
Hedwig Lee 8 ,
Xiaofei Lin 9 ,
Cindy H. Liu 10 , 11 ,
Igor Rudan 12 ,
Srijan Sen 13 ,
Mark Tomlinson 14 , 15 ,
Miranda Yaver 16 &
Alexander C. Tsai 1 , 11 , 17

Scientific Reports volume 11 , Article number: 14370 ( 2021 ) Cite this article

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University administrators and mental health clinicians have raised concerns about depression and anxiety among Ph.D. students, yet no study has systematically synthesized the available evidence in this area. After searching the literature for studies reporting on depression, anxiety, and/or suicidal ideation among Ph.D. students, we included 32 articles. Among 16 studies reporting the prevalence of clinically significant symptoms of depression across 23,469 Ph.D. students, the pooled estimate of the proportion of students with depression was 0.24 (95% confidence interval [CI], 0.18–0.31; I 2 = 98.75%). In a meta-analysis of the nine studies reporting the prevalence of clinically significant symptoms of anxiety across 15,626 students, the estimated proportion of students with anxiety was 0.17 (95% CI, 0.12–0.23; I 2 = 98.05%). We conclude that depression and anxiety are highly prevalent among Ph.D. students. Data limitations precluded our ability to obtain a pooled estimate of suicidal ideation prevalence. Programs that systematically monitor and promote the mental health of Ph.D. students are urgently needed.

Prevalence of depression among Chinese university students: a systematic review and meta-analysis

A repeated cross-sectional analysis assessing mental health conditions of adults as per student status during key periods of the COVID-19 epidemic in France

Relationship between depression and quality of life among students: a systematic review and meta-analysis

Introduction.

Mental health problems among graduate students in doctoral degree programs have received increasing attention 1 , 2 , 3 , 4 . Ph.D. students (and students completing equivalent degrees, such as the Sc.D.) face training periods of unpredictable duration, financial insecurity and food insecurity, competitive markets for tenure-track positions, and unsparing publishing and funding models 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 —all of which may have greater adverse impacts on students from marginalized and underrepresented populations 13 , 14 , 15 . Ph.D. students’ mental health problems may negatively affect their physical health 16 , interpersonal relationships 17 , academic output, and work performance 18 , 19 , and may also contribute to program attrition 20 , 21 , 22 . As many as 30 to 50% of Ph.D. students drop out of their programs, depending on the country and discipline 23 , 24 , 25 , 26 , 27 . Further, while mental health problems among Ph.D. students raise concerns for the wellbeing of the individuals themselves and their personal networks, they also have broader repercussions for their institutions and academia as a whole 22 .

Despite the potential public health significance of this problem, most evidence syntheses on student mental health have focused on undergraduate students 28 , 29 or graduate students in professional degree programs (e.g., medical students) 30 . In non-systematic summaries, estimates of the prevalence of clinically significant depressive symptoms among Ph.D. students vary considerably 31 , 32 , 33 . Reliable estimates of depression and other mental health problems among Ph.D. students are needed to inform preventive, screening, or treatment efforts. To address this gap in the literature, we conducted a systematic review and meta-analysis to explore patterns of depression, anxiety, and suicidal ideation among Ph.D. students.

Flowchart of included articles.

The evidence search yielded 886 articles, of which 286 were excluded as duplicates (Fig. 1 ). An additional nine articles were identified through reference lists or grey literature reports published on university websites. Following a title/abstract review and subsequent full-text review, 520 additional articles were excluded.

Of the 89 remaining articles, 74 were unclear about their definition of graduate students or grouped Ph.D. and non-Ph.D. students without disaggregating the estimates by degree level. We obtained contact information for the authors of most of these articles (69 [93%]), requesting additional data. Three authors clarified that their study samples only included Ph.D. students 34 , 35 , 36 . Fourteen authors confirmed that their study samples included both Ph.D. and non-Ph.D. students but provided us with data on the subsample of Ph.D. students 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 . Where authors clarified that the sample was limited to graduate students in non-doctoral degree programs, did not provide additional data on the subsample of Ph.D. students, or did not reply to our information requests, we excluded the studies due to insufficient information (Supplementary Table S1 ).

Ultimately, 32 articles describing the findings of 29 unique studies were identified and included in the review 16 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 (Table 1 ). Overall, 26 studies measured depression, 19 studies measured anxiety, and six studies measured suicidal ideation. Three pairs of articles reported data on the same sample of Ph.D. students 33 , 38 , 45 , 51 , 53 , 56 and were therefore grouped in Table 1 and reported as three studies. Publication dates ranged from 1979 to 2019, but most articles (22/32 [69%]) were published after 2015. Most studies were conducted in the United States (20/29 [69%]), with additional studies conducted in Australia, Belgium, China, Iran, Mexico, and South Korea. Two studies were conducted in cross-national settings representing 48 additional countries. None were conducted in sub-Saharan Africa or South America. Most studies included students completing their degrees in a mix of disciplines (17/29 [59%]), while 12 studies were limited to students in a specific field (e.g., biomedicine, education). The median sample size was 172 students (interquartile range [IQR], 68–654; range, 6–6405). Seven studies focused on mental health outcomes in demographic subgroups, including ethnic or racialized minority students 37 , 41 , 43 , international students 47 , 50 , and sexual and gender minority students 42 , 54 .

In all, 16 studies reported the prevalence of depression among a total of 23,469 Ph.D. students (Fig. 2 ; range, 10–47%). Of these, the most widely used depression scales were the PHQ-9 (9 studies) and variants of the Center for Epidemiologic Studies-Depression scale (CES-D, 4 studies) 63 , and all studies assessed clinically significant symptoms of depression over the past one to two weeks. Three of these studies reported findings based on data from different survey years of the same parent study (the Healthy Minds Study) 40 , 42 , 43 , but due to overlap in the survey years reported across articles, these data were pooled. Most of these studies were based on data collected through online surveys (13/16 [81%]). Ten studies (63%) used random or systematic sampling, four studies (25%) used convenience sampling, and two studies (13%) used multiple sampling techniques.

Pooled estimate of the proportion of Ph.D. students with clinically significant symptoms of depression.

The estimated proportion of Ph.D. students assessed as having clinically significant symptoms of depression was 0.24 (95% confidence interval [CI], 0.18–0.31; 95% predictive interval [PI], 0.04–0.54), with significant evidence of between-study heterogeneity (I 2 = 98.75%). A subgroup analysis restricted to the twelve studies conducted in the United States yielded similar findings (pooled estimate [ES] = 0.23; 95% CI, 0.15–0.32; 95% PI, 0.01–0.60), with no appreciable difference in heterogeneity (I 2 = 98.91%). A subgroup analysis restricted to the studies that used the PHQ-9 to assess depression yielded a slightly lower prevalence estimate and a slight reduction in heterogeneity (ES = 0.18; 95% CI, 0.14–0.22; 95% PI, 0.07–0.34; I 2 = 90.59%).

Nine studies reported the prevalence of clinically significant symptoms of anxiety among a total of 15,626 Ph.D. students (Fig. 3 ; range 4–49%). Of these, the most widely used anxiety scale was the 7-item Generalized Anxiety Disorder scale (GAD-7, 5 studies) 64 . Data from three of the Healthy Minds Study articles were pooled into two estimates, because the scale used to measure anxiety changed midway through the parent study (i.e., the Patient Health Questionnaire-Generalized Anxiety Disorder [PHQ-GAD] scale was used from 2007 to 2012 and then switched to the GAD-7 in 2013 40 ). Most studies (8/9 [89%]) assessed clinically significant symptoms of anxiety over the past two to four weeks, with the one remaining study measuring anxiety over the past year. Again, most of these studies were based on data collected through online surveys (7/9 [78%]). Five studies (56%) used random or systematic sampling, two studies (22%) used convenience sampling, and two studies (22%) used multiple sampling techniques.

Pooled estimate of the proportion of Ph.D. students with clinically significant symptoms of anxiety.

The estimated proportion of Ph.D. students assessed as having anxiety was 0.17 (95% CI, 0.12–0.23; 95% PI, 0.02–0.41), with significant evidence of between-study heterogeneity (I 2 = 98.05%). The subgroup analysis restricted to the five studies conducted in the United States yielded a slightly lower proportion of students assessed as having anxiety (ES = 0.14; 95% CI, 0.08–0.20; 95% PI, 0.00–0.43), with no appreciable difference in heterogeneity (I 2 = 98.54%).

Six studies reported the prevalence of suicidal ideation (range, 2–12%), but the recall windows varied greatly (e.g., ideation within the past 2 weeks vs. past year), precluding pooled estimation.

Additional stratified pooled estimates could not be obtained. One study of Ph.D. students across 54 countries found that phase of study was a significant moderator of mental health, with students in the comprehensive examination and dissertation phases more likely to experience distress compared with students primarily engaged in coursework 59 . Other studies identified a higher prevalence of mental ill-health among women 54 ; lesbian, gay, bisexual, transgender, and queer (LGBTQ) students 42 , 54 , 60 ; and students with multiple intersecting identities 54 .

Several studies identified correlates of mental health problems including: project- and supervisor-related issues, stress about productivity, and self-doubt 53 , 62 ; uncertain career prospects, poor living conditions, financial stressors, lack of sleep, feeling devalued, social isolation, and advisor relationships 61 ; financial challenges 38 ; difficulties with work-life balance 58 ; and feelings of isolation and loneliness 52 . Despite these challenges, help-seeking appeared to be limited, with only about one-quarter of Ph.D. students reporting mental health problems also reporting that they were receiving treatment 40 , 52 .

Risk of bias

Twenty-one of 32 articles were assessed as having low risk of bias (Supplementary Table S2 ). Five articles received one point for all five categories on the risk of bias assessment (lowest risk of bias), and one article received no points (highest risk). The mean risk of bias score was 3.22 (standard deviation, 1.34; median, 4; IQR, 2–4). Restricting the estimation sample to 12 studies assessed as having low risk of bias, the estimated proportion of Ph.D. students with depression was 0.25 (95% CI, 0.18–0.33; 95% PI, 0.04–0.57; I 2 = 99.11%), nearly identical to the primary estimate, with no reduction in heterogeneity. The estimated proportion of Ph.D. students with anxiety, among the 7 studies assessed as having low risk of bias, was 0.12 (95% CI, 0.07–0.17; 95% PI, 0.01–0.34; I 2 = 98.17%), again with no appreciable reduction in heterogeneity.

In our meta-analysis of 16 studies representing 23,469 Ph.D. students, we estimated that the pooled prevalence of clinically significant symptoms of depression was 24%. This estimate is consistent with estimated prevalence rates in other high-stress biomedical trainee populations, including medical students (27%) 30 , resident physicians (29%) 65 , and postdoctoral research fellows (29%) 66 . In the sample of nine studies representing 15,626 Ph.D. students, we estimated that the pooled prevalence of clinically significant symptoms of anxiety was 17%. While validated screening instruments tend to over-identify cases of depression (relative to structured clinical interviews) by approximately a factor of two 67 , 68 , our findings nonetheless point to a major public health problem among Ph.D. students. Available data suggest that the prevalence of depressive and anxiety disorders in the general population ranges from 5 to 7% worldwide 69 , 70 . In contrast, prevalence estimates of major depressive disorder among young adults have ranged from 13% (for young adults between the ages of 18 and 29 years in the 2012–2013 National Epidemiologic Survey on Alcohol and Related Conditions III 71 ) to 15% (for young adults between the ages of 18 and 25 in the 2019 U.S. National Survey on Drug Use and Health 72 ). Likewise, the prevalence of generalized anxiety disorder was estimated at 4% among young adults between the ages of 18 and 29 in the 2001–03 U.S. National Comorbidity Survey Replication 73 . Thus, even accounting for potential upward bias inherent in these studies’ use of screening instruments, our estimates suggest that the rates of recent clinically significant symptoms of depression and anxiety are greater among Ph.D. students compared with young adults in the general population.

Further underscoring the importance of this public health issue, Ph.D. students face unique stressors and uncertainties that may put them at increased risk for mental health and substance use problems. Students grapple with competing responsibilities, including coursework, teaching, and research, while also managing interpersonal relationships, social isolation, caregiving, and financial insecurity 3 , 10 . Increasing enrollment in doctoral degree programs has not been matched with a commensurate increase in tenure-track academic job opportunities, intensifying competition and pressure to find employment post-graduation 5 . Advisor-student power relations rarely offer options for recourse if and when such relationships become strained, particularly in the setting of sexual harassment, unwanted sexual attention, sexual coercion, and rape 74 , 75 , 76 , 77 , 78 . All of these stressors may be magnified—and compounded by stressors unrelated to graduate school—for subgroups of students who are underrepresented in doctoral degree programs and among whom mental health problems are either more prevalent and/or undertreated compared with the general population, including Black, indigenous, and other people of color 13 , 79 , 80 ; women 81 , 82 ; first-generation students 14 , 15 ; people who identify as LGBTQ 83 , 84 , 85 ; people with disabilities; and people with multiple intersecting identities.

Structural- and individual-level interventions will be needed to reduce the burden of mental ill-health among Ph.D. students worldwide 31 , 86 . Despite the high prevalence of mental health and substance use problems 87 , Ph.D. students demonstrate low rates of help-seeking 40 , 52 , 88 . Common barriers to help-seeking include fears of harming one’s academic career, financial insecurity, lack of time, and lack of awareness 89 , 90 , 91 , as well as health care systems-related barriers, including insufficient numbers of culturally competent counseling staff, limited access to psychological services beyond time-limited psychotherapies, and lack of programs that address the specific needs either of Ph.D. students in general 92 or of Ph.D. students belonging to marginalized groups 93 , 94 . Structural interventions focused solely on enhancing student resilience might include programs aimed at reducing stigma, fostering social cohesion, and reducing social isolation, while changing norms around help-seeking behavior 95 , 96 . However, structural interventions focused on changing stressogenic aspects of the graduate student environment itself are also needed 97 , beyond any enhancements to Ph.D. student resilience, including: undercutting power differentials between graduate students and individual faculty advisors, e.g., by diffusing power among multiple faculty advisors; eliminating racist, sexist, and other discriminatory behaviors by faculty advisors 74 , 75 , 98 ; valuing mentorship and other aspects of “invisible work” that are often disproportionately borne by women faculty and faculty of color 99 , 100 ; and training faculty members to emphasize the dignity of, and adequately prepare Ph.D. students for, non-academic careers 101 , 102 .

Our findings should be interpreted with several limitations in mind. First, the pooled estimates are characterized by a high degree of heterogeneity, similar to meta-analyses of depression prevalence in other populations 30 , 65 , 103 , 104 , 105 . Second, we were only able to aggregate depression prevalence across 16 studies and anxiety prevalence across nine studies (the majority of which were conducted in the U.S.) – far fewer than the 183 studies included in a meta-analysis of depression prevalence among medical students 30 and the 54 studies included in a meta-analysis of resident physicians 65 . These differences underscore the need for more rigorous study in this critical area. Many articles were either excluded from the review or from the meta-analyses for not meeting inclusion criteria or not reporting relevant statistics. Future research in this area should ensure the systematic collection of high-quality, clinically relevant data from a comprehensive set of institutions, across disciplines and countries, and disaggregated by graduate student type. As part of conducting research and addressing student mental health and wellbeing, university deans, provosts, and chancellors should partner with national survey and program institutions (e.g., Graduate Student Experience in the Research University [gradSERU] 106 , the American College Health Association National College Health Assessment [ACHA-NCHA], and HealthyMinds). Furthermore, federal agencies that oversee health and higher education should provide resources for these efforts, and accreditation agencies should require monitoring of mental health and programmatic responses to stressors among Ph.D. students.

Third, heterogeneity in reporting precluded a meta-analysis of the suicidality outcomes among the few studies that reported such data. While reducing the burden of mental health problems among graduate students is an important public health aim in itself, more research into understanding non-suicidal self-injurious behavior, suicide attempts, and completed suicide among Ph.D. students is warranted. Fourth, it is possible that the grey literature reports included in our meta-analysis are more likely to be undertaken at research-intensive institutions 52 , 60 , 61 . However, the direction of bias is unpredictable: mental health problems among Ph.D. students in research-intensive environments may be more prevalent due to detection bias, but such institutions may also have more resources devoted to preventive, screening, or treatment efforts 92 . Fifth, inclusion in this meta-analysis and systematic review was limited to those based on community samples. Inclusion of clinic-based samples, or of studies conducted before or after specific milestones (e.g., the qualifying examination or dissertation prospectus defense), likely would have yielded even higher pooled prevalence estimates of mental health problems. And finally, few studies provided disaggregated data according to sociodemographic factors, stage of training (e.g., first year, pre-prospectus defense, all-but-dissertation), or discipline of study. These factors might be investigated further for differences in mental health outcomes.

Clinically significant symptoms of depression and anxiety are pervasive among graduate students in doctoral degree programs, but these are understudied relative to other trainee populations. Structural and clinical interventions to systematically monitor and promote the mental health and wellbeing of Ph.D. students are urgently needed.

This systematic review and meta-analysis follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) approach (Supplementary Table S3 ) 107 . This study was based on data collected from publicly available bibliometric databases and did not require ethical approval from our institutional review boards.

Eligibility criteria

Studies were included if they provided data on either: (a) the number or proportion of Ph.D. students with clinically significant symptoms of depression or anxiety, ascertained using a validated scale; or (b) the mean depression or anxiety symptom severity score and its standard deviation among Ph.D. students. Suicidal ideation was examined as a secondary outcome.

We excluded studies that focused on graduate students in non-doctoral degree programs (e.g., Master of Public Health) or professional degree programs (e.g., Doctor of Medicine, Juris Doctor) because more is known about mental health problems in these populations 30 , 108 , 109 , 110 and because Ph.D. students face unique uncertainties. To minimize the potential for upward bias in our pooled prevalence estimates, we excluded studies that recruited students from campus counseling centers or other clinic-based settings. Studies that measured affective states, or state anxiety, before or after specific events (e.g., terrorist attacks, qualifying examinations) were also excluded.

If articles described the study sample in general terms (i.e., without clarifying the degree level of the participants), we contacted the authors by email for clarification. Similarly, if articles pooled results across graduate students in doctoral and non-doctoral degree programs (e.g., reporting a single estimate for a mixed sample of graduate students), we contacted the authors by email to request disaggregated data on the subsample of Ph.D. students. If authors did not reply after two contact attempts spaced over 2 months, or were unable to provide these data, we excluded these studies from further consideration.

Search strategy and data extraction

PubMed, Embase, PsycINFO, ERIC, and Business Source Complete were searched from inception of each database to November 5, 2019. The search strategy included terms related to mental health symptoms (e.g., depression, anxiety, suicide), the study population (e.g., graduate, doctoral), and measurement category (e.g., depression, Columbia-Suicide Severity Rating Scale) (Supplementary Table S4 ). In addition, we searched the reference lists and the grey literature.

After duplicates were removed, we screened the remaining titles and abstracts, followed by a full-text review. We excluded articles following the eligibility criteria listed above (i.e., those that were not focused on Ph.D. students; those that did not assess depression and/or anxiety using a validated screening tool; those that did not report relevant statistics of depression and/or anxiety; and those that recruited students from clinic-based settings). Reasons for exclusion were tracked at each stage. Following selection of included articles, two members of the research team extracted data and conducted risk of bias assessments. Discrepancies were discussed with a third member of the research team. Key extraction variables included: study design, geographic region, sample size, response rate, demographic characteristics of the sample, screening instrument(s) used for assessment, mean depression or anxiety symptom severity score (and its standard deviation), and the number (or proportion) of students experiencing clinically significant symptoms of depression or anxiety.

Risk of bias assessment

Following prior work 30 , 65 , the Newcastle–Ottawa Scale 111 was adapted and used to assess risk of bias in the included studies. Each study was assessed across 5 categories: sample representativeness, sample size, non-respondents, ascertainment of outcomes, and quality of descriptive statistics reporting (Supplementary Information S5 ). Studies were judged as having either low risk of bias (≥ 3 points) or high risk of bias (< 3 points).

Analysis and synthesis

Before pooling the estimated prevalence rates across studies, we first transformed the proportions using a variance-stabilizing double arcsine transformation 112 . We then computed pooled estimates of prevalence using a random effects model 113 . Study specific confidence intervals were estimated using the score method 114 , 115 . We estimated between-study heterogeneity using the I 2 statistic 116 . In an attempt to reduce the extent of heterogeneity, we re-estimated pooled prevalence restricting the analysis to studies conducted in the United States and to studies in which depression assessment was based on the 9-item Patient Health Questionnaire (PHQ-9) 117 . All analyses were conducted using Stata (version 16; StataCorp LP, College Station, Tex.). Where heterogeneity limited our ability to summarize the findings using meta-analysis, we synthesized the data using narrative review.

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Acknowledgements

We thank the following investigators for generously sharing their time and/or data: Gordon J. G. Asmundson, Ph.D., Amy J. L. Baker, Ph.D., Hillel W. Cohen, Dr.P.H., Alcir L. Dafre, Ph.D., Deborah Danoff, M.D., Daniel Eisenberg, Ph.D., Lou Farrer, Ph.D., Christy B. Fraenza, Ph.D., Patricia A. Frazier, Ph.D., Nadia Corral-Frías, Ph.D., Hanga Galfalvy, Ph.D., Edward E. Goldenberg, Ph.D., Robert K. Hindman, Ph.D., Jürgen Hoyer, Ph.D., Ayako Isato, Ph.D., Azharul Islam, Ph.D., Shanna E. Smith Jaggars, Ph.D., Bumseok Jeong, M.D., Ph.D., Ju R. Joeng, Nadine J. Kaslow, Ph.D., Rukhsana Kausar, Ph.D., Flavius R. W. Lilly, Ph.D., Sarah K. Lipson, Ph.D., Frances Meeten, D.Phil., D.Clin.Psy., Dhara T. Meghani, Ph.D., Sterett H. Mercer, Ph.D., Masaki Mori, Ph.D., Arif Musa, M.D., Shizar Nahidi, M.D., Ph.D., Arthur M. Nezu, Ph.D., D.H.L., Angelo Picardi, M.D., Nicole E. Rossi, Ph.D., Denise M. Saint Arnault, Ph.D., Sagar Sharma, Ph.D., Bryony Sheaves, D.Clin.Psy., Kennon M. Sheldon, Ph.D., Daniel Shepherd, Ph.D., Keisuke Takano, Ph.D., Sara Tement, Ph.D., Sherri Turner, Ph.D., Shawn O. Utsey, Ph.D., Ron Valle, Ph.D., Caleb Wang, B.S., Pengju Wang, Katsuyuki Yamasaki, Ph.D.

A.C.T. acknowledges funding from the Sullivan Family Foundation. This paper does not reflect an official statement or opinion from the County of San Mateo.

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A.C.T. conceptualized the study and provided supervision. T.K. conducted the search. E.N.S. contacted authors for additional information not reported in published articles. E.N.S. and T.K. extracted data and performed the quality assessment appraisal. E.N.S. and A.C.T. conducted the statistical analysis and drafted the manuscript. T.K., M.V.K., R.A., S.C., H.L., X.L., C.H.L., I.R., S.S., M.T. and M.Y. contributed to the interpretation of the results. All authors provided critical feedback on drafts and approved the final manuscript.

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Satinsky, E.N., Kimura, T., Kiang, M.V. et al. Systematic review and meta-analysis of depression, anxiety, and suicidal ideation among Ph.D. students. Sci Rep 11 , 14370 (2021). https://doi.org/10.1038/s41598-021-93687-7

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Essay on Depression Among College Students

How it works

In college, where academic stress meets the ups and downs of finding oneself, depression is becoming a big issue. This essay looks into what causes depression in students and suggests ways to help them cope and feel better.

1 The Hidden Struggle: What is Depression?
2 Why is This Happening?
3 Finding a Way to Help: Solutions and Support
4 Conclusion

The Hidden Struggle: What is Depression?

Depression, often called the “invisible illness,” shows up in many ways. It can be constant sadness, feeling hopeless, or even physical stuff like being tired all the time or not being able to sleep. For college students, depression can hit hard because of the unique problems they face.

There’s the stress of classes, social pressures, money worries, and growing up. Trying to keep up with schoolwork, while feeling like you have to be the best, can make students feel like they’re not good enough. Social life in college isn’t easy either. Making new friends and fitting in can leave students feeling lonely.

One of the toughest things about depression in college is the stigma. Even though people are talking more about mental health now, lots of students still don’t ask for help because they’re scared of being judged or seen as weak. This makes things worse because not getting help can make depression symptoms stronger, making it harder to handle school and personal life.

Why is This Happening?

To really tackle depression in college, we need to know what’s causing it. Academic pressure is a big one. The load of homework, exams, and keeping grades up can lead to constant stress and feeling burned out. At top schools, this pressure can be even worse, making students feel like they always have to outdo their classmates.

Money problems are another big cause. College is expensive, and student loans can make students feel very insecure about their finances. Many students work part-time jobs while studying, which throws off their balance and adds more stress.

The social side of college also affects students’ mental health. Trying to fit in, make friends, and feel like you belong can be a lot. Social media doesn’t help either, with its perfect pictures making students feel even more inadequate and lonely. Moving from high school to college often means leaving behind family and old friends, causing homesickness and a sense of losing touch, which can add to depression.

Finding a Way to Help: Solutions and Support

Helping depressed college students needs a bunch of different efforts, like raising awareness, having good support systems, and making changes at the school level. First, creating a culture where mental health is openly talked about and understood is really important. Schools should focus on mental health education, using workshops, seminars, and support groups to spread awareness and reduce stigma. By making it normal to talk about mental health, students might feel more at ease asking for help without fearing judgment.

Good mental health services are crucial. Colleges need to make sure counseling is easy to get, well-staffed, and able to handle all kinds of student needs. Adding mental health resources to academic advising can help too, offering a complete approach to student well-being, covering both school and emotional problems.

Making a supportive campus environment is key to reducing factors that lead to depression. Schools can have policies that help balance work and life, like flexible deadlines, mental health days, and activities to relieve stress. Encouraging students to join extracurriculars and creating inclusive communities can help them make meaningful connections and feel less isolated.

On a bigger scale, tackling financial stress is necessary. Schools should look into financial aid, scholarships, and affordable housing to ease the load of student loans and reduce money stress. Offering resources for financial literacy and budgeting can also help students manage their money better.

Depression among college students is a complicated issue that needs a kind and thorough approach. By understanding the special challenges students face and addressing the root causes of depression, we can create a supportive environment that promotes mental well-being and academic success. It’s everyone’s job—schools, lawmakers, parents, and friends—to make sure students have the resources and support they need to handle the pressures of college and come out stronger and more resilient.

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Front Psychiatry

Family and Academic Stress and Their Impact on Students' Depression Level and Academic Performance

1 School of Mechatronics Engineering, Daqing Normal University, Daqing, China

2 School of Marxism, Heilongjiang University, Harbin, China

Jacob Cherian

3 College of Business, Abu Dhabi University, Abu Dhabi, United Arab Emirates

Noor Un Nisa Khan

4 Faculty of Business Administration, Iqra University Karachi Pakistan, Karachi, Pakistan

Kalpina Kumari

5 Faculty of Department of Business Administration, Greenwich University Karachi, Karachi, Pakistan

Muhammad Safdar Sial

6 Department of Management Sciences, COMSATS University Islamabad (CUI), Islamabad, Pakistan

Ubaldo Comite

7 Department of Business Sciences, University Giustino Fortunato, Benevento, Italy

Beata Gavurova

8 Faculty of Mining, Ecology, Process Control and Geotechnologies, Technical University of Kosice, Kosice, Slovakia

József Popp

9 Hungarian National Bank–Research Center, John von Neumann University, Kecskemét, Hungary

10 College of Business and Economics, University of Johannesburg, Johannesburg, South Africa

Associated Data

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Current research examines the impact of academic and familial stress on students' depression levels and the subsequent impact on their academic performance based on Lazarus' cognitive appraisal theory of stress. The non-probability convenience sampling technique has been used to collect data from undergraduate and postgraduate students using a modified questionnaire with a five-point Likert scale. This study used the SEM method to examine the link between stress, depression, and academic performance. It was confirmed that academic and family stress leads to depression among students, negatively affecting their academic performance and learning outcomes. This research provides valuable information to parents, educators, and other stakeholders concerned about their childrens' education and performance.

Introduction

Higher education institutions (HEIs) are believed to be one of the strongest pillars in the growth of any nation ( 1 ). Being the principal stakeholder, the performance of HEIs mainly relies on the success of its students ( 2 ). To successfully compete in the prevailing dynamic industrial environment, students are not only supposed to develop their knowledge but are also expected to have imperative skills and abilities ( 3 ). In the current highly competitive academic environment, students' performance is largely affected by several factors, such as social media, academic quality, family and social bonding, etc. ( 4 ). Aafreen et al. ( 2 ) stated that students continuously experience pressure from different sources during academic life, which ultimately causes stress among students.

Stress is a common factor that largely diminishes individual morale ( 5 ). It develops when a person cannot handle their inner and outer feelings. When the stress becomes chronic or exceeds a certain level, it affects an individual's mental health and may lead to different psychological disorders, such as depression ( 6 ). Depression is a worldwide illness marked by feelings of sadness and the inability to feel happy or satisfied ( 7 ). Nowadays, it is a common disorder, increasing day by day. According to the World Health Organization ( 8 , 9 ), depression was ranked third among the global burden of disease and predicted to take over first place by 2030.

Depression leads to decreased energy, difficulty thinking, concentrating, and making career decisions ( 6 ). Students are a pillar of the future in building an educated society. For them, academic achievement is a big goal of life and can severely be affected if the students fall prey to depression ( 10 , 11 ). There can be several reasons for this: family issues, exposure to a new lifestyle in colleges and universities, poor academic grades, favoritism by teachers, etc. Never-ending stress or academic pressure of studies can also be a chief reason leading to depression in students ( 12 ). There is a high occurrence of depression in emerging countries, and low mental health literacy has been theorized as one of the key causes of escalating rates of mental illness ( 13 ).

Several researchers, such as ( 6 , 14 , 15 ) have studied stress and depression elements from a performance perspective and reported that stress and depression negatively affect the academic performance of students. However, Aafreen et al. ( 2 ) reported contradictory results and stated that stress sharpens the individual's mind and reflexes and enables workers to perform better in taxing situations. Ardalan ( 16 ) conducted a study in the United States (US). They reported that depression is a common issue among students in the US, and 20 percent of them may have a depressive disorder spanning 12 months or more. It affects students' mental and physical health and limits their social relationships and professional career.

However, the current literature provides mixed results on the relationship between stress and performance. Therefore, the current research investigates stress among students from family and academic perspectives using Lazaru's theory which describes stress as a relation between an individual and his environment and examines how it impacts students' depression level, leading to their academic performance. Most of the available studies on stress and depression are from industrial perspectives, and limited attention is paid to stress from family and institutional perspectives and examines its impact on students' depression level, leading to their academic performance, particularly in Pakistan, the place of the study. Besides, the present study follows a multivariate statistical technique, followed by structural equation modeling (SEM) to examine the relationship between stated variables which is also a study's uniqueness.

This paper is divided into five main sections. The current section provided introduction, theoretical perspective, and background of the study. In the second section, a theoretical framework, a detailed literature review and research hypotheses of the underlying relationships are being proposed. In the third and fourth section, methodology and analysis have been discussed. Finally, in the last section, the conclusion, limitations, implications, and recommendations for future research have been proposed.

Theory and Literature

The idea of cognitive appraisal theory was presented in 1966 by psychologist Richard Lazarus in Psychological Stress and Coping Process. According to this theory, appraisal and coping are two concepts that are central to any psychological stress theory. Both are interrelated. According to the theory, stress is the disparity between stipulations placed on the individuals and their coping resources ( 17 ). Since its first introduction as a comprehensive theory ( 18 ), a few modifications have been experienced in theory later. The recent adaptation states that stress is not defined as a specific incitement or psychological, behavioral, or subjective response. Rather, stress is seen as a relation between an individual and his environment ( 19 ). Individuals appraise the environment as significant for their well-being and try to cope with the exceeding demands and challenges.

Cognitive appraisal is a model based on the idea that stress and other emotional processes depend on a person's expectancies regarding the significance and outcome of an event, encounter, or function. This explains why there are differences in intensity, duration, and quality of emotions elicited in people in response to the environment, which objectively, are equal for all ( 18 ). These appraisals may be influenced by various factors, including a person's goals, values, motivations, etc., and are divided into primary and secondary appraisals, specific patterns of which lead to different kinds of stress ( 20 ). On the other hand, coping is defined as the efforts made by a person to minimize, tolerate, or master the internal and external demands placed on them, a concept intimately related to cognitive appraisal and, therefore, to the stress-relevant person-environment transactions.

Individuals experience different mental and physiological changes when encountering pressure, such as stress ( 21 , 22 ). The feelings of stress can be either due to factors in the external environment or subjective emotions of individuals, which can even lead to psychological disorders such as anxiety and depression. Excess stress can cause health problems. A particularly negative impact has been seen in students due to the high level of stress they endure, affecting their learning outcomes. Various methods are used to tackle stress. One of the methods is trying to pinpoint the causes of stress, which leads us to different terms such as family stress and academic stress. The two factors, stress and depression, have greatly impacted the students' academic performances. This research follows the Lazarus theory based on stress to examine the variables. See the conceptual framework of the study in Figure 1 .

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Conceptual framework.

Academic Stress

Academic issues are thought to be the most prevalent source of stress for college students ( 23 ). For example, according to Yang et al. ( 24 ), students claimed that academic-related pressures such as ongoing study, writing papers, preparing for tests, and boring professors were the most important daily problems. Exams and test preparation, grade level competitiveness, and gaining a big quantity of knowledge in a short period of time all contribute to academic pressure. Perceived stress refers to a condition of physical or psychological arousal in reaction to stressors ( 25 , 26 ). When college students face excessive or negative stress, they suffer physical and psychological consequences. Excessive stress can cause health difficulties such as fatigue, loss of appetite, headaches, and gastrointestinal issues. Academic stress has been linked to a variety of negative effects, including ill health, anxiety, depression, and poor academic performance. Travis et al. ( 27 ), in particular, discovered strong links between academic stress and psychological and physical health.

Family Stress

Parental participation and learning effect how parents treat their children, as well as how they handle their children's habits and cognitive processes ( 28 ). This, in turn, shapes their children's performance and behaviors toward them. As a result, the parent-child relationship is dependent on the parents' attitudes, understanding, and perspectives. When parents have positive views, the relationship between them and their children will be considerably better than when they have negative attitudes. Parents respond to unpleasant emotions in a variety of ways, which can be classified as supportive or non-supportive ( 29 ). Parents' supportive reactions encourage children to explore their emotions by encouraging them to express them or by assisting them in understanding and coping with an emotion-eliciting scenario. Non-supportive behaviors, such as downplaying the kid's emotional experience, disciplining the child, or getting concerned by the child's display, transmit the child the message that expressing unpleasant emotions is inappropriate and unacceptable. Supportive parental reactions to unpleasant emotions in children have been linked to dimensions of emotional and social competence, such as emotion comprehension and friendship quality. Non-supportive or repressive parental reactions, on the other hand, have been connected to a child's stored negative affect and disordered behaviors during emotion-evoking events, probably due to an inability or unwillingness to communicate unpleasant sentiments ( 30 , 31 ).

Academic Stress and Students' Depression Levels

Generally, it is believed that mental health improves as we enter into adulthood, and depression disorder starts to decline between the age of 18 and 25. On the other hand, excessive depression rates are the highest pervasiveness during this evolution ( 15 ), and many university students in the particular screen above clinical cut-off scores for huge depression ( 14 , 32 ). Afreen et al. ( 2 ) stated that 30% of high school students experience depression from different perspectives. This means a major chunk of fresh high school graduates are more likely to confront depression or are more vulnerable to encountering depression while enrolling in the university. As the students promote to a higher level of education, there are many factors while calculating the stress like, for example, the syllabus is tough to comprehend, assignments are quite challenging with unrealistic deadlines, and accommodation problems for the students who are shifted from other cities, etc. ( 33 ). Experiences related to university can also contribute while studying depression. The important thing to consider is depression symptoms vary from time to time throughout the academic years ( 34 ); subjective and objective experiences are directly connected to the depression disorder ( 6 ), stress inherent in the university situation likely donates to the difference in university students' depressing experiences.

Stress negatively impacts students' mental peace, and 42.3% of students of Canadian university respondents testified devastating levels of anxiety and stress ( 35 , 36 ). Moreover, there were (58.1%) students who stated academic projects are too tough to handle for them. In Germany, Bulgaria, and Poland, a huge sample of respondents consider assignments a burden on their lives that cannot stand compared to relationships or any other concern in life ( 14 ).

In several countries, university students were studied concerning stress, and results show that depression disorder and apparent anxiety are correlated to educational needs and demands ( 37 ). In their cross-sectional study conducted on a sample of 900 Canadian students, Lörz et al. ( 38 ) concluded that strain confronted due to academic workload relatively has high bleak symptoms even after controlling 13 different risk affecting factors for depression (e.g., demographic features, abusive past, intellectual way, and personality, currently experienced stressful trials in life, societal support). Few have exhibited that students who are tired of educational workload or the students who name them traumatic tend to have more depressing disorders ( 15 ).

These relations can be described by examining the stress and coping behaviors that highlight the role of positive judgments in the stress times ( 39 ), containing the Pancer and colleagues' university modification framework ( 40 , 41 ). The evaluation concept includes examining the circumstances against the available resources, for instance, the effectiveness of coping behavior and societal support. As per these frameworks, if demand is considered unapproachable and resources are lacking, confronted stress and interrelated adverse effects will be high, conceivably giving birth to difficulties in an adjustment like mental instability. Stress triggering situations and the resources in the educational area led to excessive workload, abilities, and study and enhanced time managing skills.

Sketching the overall evaluation frameworks, Pancer et al. ( 40 ) established their framework to exhibit the constructive and damaging adjustment results for the university students dealing with the academic challenges. They stated that while students enroll in the university, they evaluate all the stress-related factors that students confront. They consider them manageable as long as they have sufficient resources. On the other hand, if the available resources do not match the stress factors, it will surely result in a negative relationship, which will lead students to experience depression for sure. Based on the given arguments, the researcher formulates the following hypothesis:

H1: Increased academic stress results in increased depression levels in students.

Family Stress and Students' Depression Levels

According to Topuzoglu et al. ( 42 ), 3% to 16.9% of individuals are affected by depression worldwide. There are fewer chances for general people to confront depression than university students ( 43 , 44 ). In Mirza et al.'s ( 45 ) study, 1/3 of students encounter stress and depression (a subjective mean occurrence of 30.6%) of all participant students, which suggests students have a 9% higher rate of experiencing depression than general people. Depression can destroy life; it greatly impacts living a balanced life. It can impact students' personal and social relationships, educational efficiency, quality of life, affecting their social and family relationships, academic productivity, and bodily operations ( 46 , 47 ). This declines their abilities, and they get demotivated to learn new things, resulting in unsatisfactory performances, and it can even result in university dropouts ( 48 ). Depression is a continuous substantial risk aspect for committing suicide for university students ( 49 ); thus, it is obliged to discover the factors that can give rise to students' depression.

Seventy-five percentage of students in China of an intermediate school are lucky enough to enroll in higher education. The more students pursue higher education, the more they upsurge for depression (in 2002, the depression rate was 5 to 10%, 2011 it rises 24 to 38%) ( 5 ). Generally, University students' age range is late teens to early twenties, i.e., 18–23 years. Abbas ( 50 ) named the era of university students as “post-adolescence. Risk factors for teenage depression have several and complicated problems of individual characteristics and family and educational life ( 51 ). Amongst the huge depression factors, relationship building with family demands a major chunk of attention and time since factors like parenting and family building play an important role in children's development ( 52 , 53 ). Halonen et al. ( 54 ) concluded that factors like family binding play a major role in development, preservation, and driving adolescent depression. Generally speaking, depressed teenagers tend to have a weaker family relationship with their parents than non-depressed teenagers.

There are two types of family risk factors, soft and hard. Hard factors are encountered in families with a weak family building structure, parents are little to no educated at all, and of course, the family status (economically). Several studies have proved that students of hard risk factors are more likely to encounter depression. Firstly, students from broken families have low confidence in every aspect of life, and they are weak at handling emotional breakdowns compared to students from complete and happy families ( 55 – 57 ). Secondly, the university students born in educated families, especially mothers (at least a college degree or higher degree), are less likely to confront depression than the university students born in families with little to no educated families. Secondly, children born with educated mothers or mothers who at least have a college degree tend to be less depressive than the children of less-educated mothers ( 58 ). However, Parker et al. and Mahmood et al. ( 59 , 60 ) stated a strong relationship between depression and mothers with low literacy levels.

On the other hand, Chang et al. ( 46 ) couldn't prove the authentication of this relationship in university students. Thirdly, university students who belong to lower class families tend to have more unstable mental states and are more likely to witness depression than middle or upper-class families ( 61 ). Jadoon et al. and Abbas et al. ( 62 , 63 ) said that there is no link between depression and economic status. Their irrelevance can be because medical students often come from educated and wealthy families and know their jobs are guaranteed as soon as they graduate. Therefore, the relationship between the hard family environment and depression can be known by targeting a huge audience, and there are several factors to consider while gauging this relationship.

The soft family environment is divided into clear factors (parenting style example, family guidelines, rules, the parent with academic knowledge, etc.) and implied factors (family norm, parent-child relationship, communication within the family, etc.). The soft factor is the key factor within the family that cannot be neglected while studying the teenagers' mental state or depression. Families make microsystems within the families, and families are the reason to build and maintain dysfunctional behavior by multiple functional procedures ( 64 ). Amongst the soft family environmental factors, consistency and struggles can be helpful while forecasting the mental health of teenagers. The youth of broken families, family conflict, weak family relationships, and marital issues, especially unhappy married life, are major factors for youth depression ( 65 ). Ruchkin et al. ( 66 ) stated that African Americans usually have weak family bonding, and their teenagers suffer from depression even when controlling for source bias. Whereas, few researchers have stated, family unity is the most serious factor while foreseeing teenagers' depression. Eaton noted that extreme broken family expressions might hurt emotionality and emotional regulation ( 67 , 68 ).

Social circle is also considered while studying depression in teenagers ( 69 – 71 ). The traditional Pakistani culture emphasizes collectivism and peace and focuses on blood relations and sensitive sentiments. Adolescents with this type of culture opt to get inspired by family, but students who live in hostels or share the room with other students lose this family inspiration. This transformation can be a big risk to encounter depression ( 72 ). Furthermore, in Pakistan securing employment is a big concern for university students. If they want a good job in the future, they have to score good grades and maintain GPA from the beginning. They have to face different challenges all at once, like aggressive educational competition, relationships with peers and family, and of course the biggest employment stress all alone. The only source for coping with these pressures is the family that can be helpful for fundings. If the students do not get ample support the chances are of extreme depression. The following hypothesis is suggested:

H2: Increased family stress level results in increased depression levels in students.

Students' Depression Levels and Students' Academic Performance

University students denote many people experiencing a crucial conversion from teenagers to adulthood: a time that is generally considered the most traumatic time in one's ( 73 ). This then gets accumulated with other challenges like changes in social circle and exams tension, which possibly puts students' mental health at stake. It has been concluded that one-third of students experience moderate to severe depression in their entire student life ( 74 ). This is the rate that can be increased compared to the general people ( 75 , 76 ). Students with limited social-class resources tend to be more helpless. Additionally, depressed students in attainable-focused environments (for instance, higher academic institutes) are likely to score lower grades with a sense of failure and more insufficient self-assurance because they consider themselves failures, find the world unfair, and have future uncertainties. Furthermore, students with low self-esteem are rigid to take on challenging assignments and projects, hence they are damaging their educational career ( 77 ).

Depression can be defined as a blend of physical, mental, bodily processes, and benightedness which can make themselves obvious by symptoms like, for example, poor sleep schedule, lack of concentration, ill thoughts, and state of remorse ( 78 , 79 ). But, even after such a huge number of depressions in students and the poor academic system, research has not explored the effect of depression on educational performance. A study has shown that the relationship between emotional stability and academic performance in university students and financial status directly results in poor exam performance. As the study further concluded, it was verified depression is an independent factor ( 80 ). Likewise, students suffering from depression score poor grades, but this relationship vanished if their depression got treated. Apart from confidence breaking, depression is a big failure for their academic life. Students with depression symptoms bunk more classes, assessments, and assignments. They drop courses if they find them challenging than non-depressed peers, and they are more likely to drop out of university completely ( 81 ). Students suffering from depression can become ruthless, ultimately affecting their educational performance and making them moody ( 82 ).

However, it has been stated that the association between anxiety and educational performance is even worse and ambiguous. At the same time, some comprehensive research has noted that the greater the anxiousness, the greater the student's performance. On the other hand, few types of research have shown results where there is no apparent relationship between anxiety and poorer academic grades ( 83 ). Ironically, few studies have proposed that a higher anxiety level may improve academic performance ( 84 , 85 ). Current research by Khan et al. ( 86 ) on the undergraduate medical students stated that even though the high occurrence of huge depression between the students, the students GPA is unharmed. Therefore, based on given differences in various research findings, this research is supposed to find a more specific and clear answer to the shared relationship between students' depression levels and academic performance. Based on the given arguments, the researcher formulates the following hypothesis:

H3: Students' depression level has a significant negative effect on their academic performance.

Methodology

Target population and sampling procedure.

The target audience of this study contains all male and female students studying in the public, private, or semi-government higher education institutions located in Rawalpindi/Islamabad. The researchers collected data from undergraduate and postgraduate students from the management sciences, engineering, and computer science departments. The sampling technique which has been used is the non-probability sampling technique. A questionnaire was given to the students, and they were requested to fill it and give their opinion independently. The questionnaire is based on five points Likert scale.

However, stress and depression are the most common issue among the students, which affects their learning outcomes adversely. A non-probability sampling technique gathered the data from February 2020 to May 2020. The total questionnaires distributed among students were 220, and 186 responses were useful. Of which 119 respondents were females, 66 males, and 1 preferred not to disclose. See Table 1 for detailed demographic information of respondents.

Respondent's demographic profile.


Total received responses	Public	36	19.35%
	Private	117	62.90%
	Semi-government	33	17.74%
Gender	Male	66	35.48%
	Female	119	63.97%
	Prefer not to disclose	1	0.54%
Age	Less than 20	29	15.59%
	21–30	146	78.49%
	31–40	11	5.91%
Qualification	Undergraduates	116	62.36%
	Postgraduates	70	37.63%
Degree Program	Management sciences	68	36.55%
	Engineering	8	4.30%
	Computer science	21	11.29%
	Others	89	47.84%
Semester	1 year	23	12.36%
	2 year	40	21.50%
	3 year	37	19.89%
	4 year	48	25.80%
	More than 4 year	38	20.43%

Measurement Scales

We have divided this instrument into two portions. In the first section, there is demographic information of respondents. The second section includes 14 items based on family stress, academic stress, students' depression levels, and students' academic performance. Academic and family stress were measured by 3 item scale for each construct, and students' depression level and academic performance were measured by 4 item scale for each separate construct. The five-point Likert scale is used to measure the items, in which one signifies strongly disagree (S.D), second signifies disagree (D.A), third signifies neither agree nor disagree (N), fourth signifies agree (A.G), and the fifth signifies strongly agree (S.A). The questionnaire has been taken from Gold Berg ( 87 ), which is modified and used in the given questionnaire.

Data Analysis and Results

The researchers used the SEM technique to determine the correlation between stress, depression, and academic performance. According to Prajogo and Cooper ( 88 ), it can remove biased effects triggered by the measurement faults and shape a hierarchy of latent constructs. SPSS v.23 and AMOS v.23 have been used to analyze the collected data. Kaiser-Meyer-Olkin test is used to test the competence of the sample. The value obtained is 0.868, which fulfills the Kaiser et al. ( 89 ), a minimum requirement of 0.6. The multicollinearity factor was analyzed through the variance inflation factor (VIF). It shows the value of 3.648 and meets the requirement of Hair et al. ( 90 ), which is < 4. It also indicates the absence of multicollinearity. According to Schwarz et al. ( 91 ), common method bias (CMB) is quite complex in quantitative studies. Harman's test of a single factor has been used to analyze CMB. The result obtained for the single factor is 38.63%. As stated by Podsakoff et al. ( 92 ), if any of the factors gives value < 50% of the total variance, it is adequate and does not influence the CMB. Therefore, we can say that there is no issue with CMB. Considering the above results are adequate among the measurement and structural model, we ensure that the data is valued enough to analyze the relation.

Assessment of the Measurement and Structural Model

The association between the manifest factors and their elements is examined by measuring model and verified by the Confirmatory Factor Analysis (CFA). CFA guarantees legitimacy and the unidimensional of the measurement model ( 93 ). Peterson ( 94 ) stated that the least required, i.e., 0.8 for the measurement model, fully complies with its Cronbach's alpha value, i.e., 0.802. Therefore, it can confidently be deduced that this measurement model holds satisfactory reliability. As for the psychological legitimacy can be analyzed through factor loading, where the ideal loading is above 0.6 for already established items ( 95 ). Also, according to the recommendation of Molina et al. ( 96 ), the minimum value of the average variance extracted (AVE) for all results is supposed to be >0.5. Table 2 gives detail of the variables and their quantity of things, factor loading, merged consistency, and AVE values.

Instrument reliability and validity.

			reliability
Academic stress	3	0.818–0.941	0.863	0.698
Family stress	3	0.852–0.897	0.778	0.721
Student's depression level	4	0.776–0.921	0.897	0.685
Student's academic performance	4	0.779–0.918	0.914	0.693

A discriminant validity test was performed to ensure the empirical difference of all constructs. For this, it was proposed by Fornell and Larcker ( 97 ) that the variance of the results is supposed to be greater than other constructs. The second indicator of discriminant validity is that the square root values of AVE have a greater correlation between the two indicators. Hair et al. ( 90 ) suggested that the correlation between the pair of predictor variables should not be higher than 0.9. Table 3 shows that discriminant validity recommended by Hair et al. ( 90 ) and Fornell and Larcker ( 97 ) was proved clearly that both conditions are fulfilled and indicates that the constructs have adequate discriminant validity.

Discriminant validity analysis.


Acd. Strs	0.835
Fam. Strs	0.543	0.849
Std. Dep. Lev	0.622	0.583	0.827
Std. Acd. Perf	0.623	0.629	0.579	0.832

Acd. Strs, Academic Stress; Fam. Strs, Family Stress; Std. Dep. Lev, Student's Depression Level; Std. Acd. Perf, Student's Academic Performance .

Kaynak ( 98 ) described seven indicators that ensure that the measurement model fits correctly. These indicators include standardized root mean squared residual (SRMR), root means a square error of approximation (RMSEA), comparative fit index (CFI), normative fit index (NFI), adjusted goodness of fit index (AGFI), the goodness of fit index (GFI) and chi-square to a degree of freedom (x 2 /DF). Tucker-Lewis's index (TLI) is also included to ensure the measurement and structural model's fitness. In the measurement model, the obtained result shows that the value of x 2 /DF is 1.898, which should be lower than 2 suggested by Byrne ( 99 ), and this value also meets the requirement of Bagozzi and Yi ( 100 ), i.e., <3. The RMSEA has the value 0.049, which fully meets the requirement of 0.08, as stated by Browne and Cudeck ( 101 ). Furthermore, the SRMR acquired value is 0.0596, which assemble with the required need of < 0.1 by Hu and Bentler ( 102 ). Moreover, according to Bentler and Bonett ( 103 ), McDonald and Marsh ( 104 ), and Bagozzi and Yi ( 100 ), the ideal value is 0.9, and the values obtained from NFI, GFI, AGFI, CFI, and TLI are above the ideal value.

Afterward, the structural model was analyzed and achieved the findings, which give the value of x 2 /DF 1.986. According to Browne and Cudeck ( 101 ), the RMSEA value should not be greater than 0.08, and the obtained value of RMSEA is 0.052, which meets the requirement perfectly. The minimum requirement of Hu and Bentler ( 102 ) should be <0.1, for the structural model fully complies with the SRMR value 0.0616. According to a recommendation of McDonald and Marsh ( 104 ) and Bagozzi and Yi ( 100 ), the ideal value must be up to 0.9, and Table 4 also shows that the values of NFI, GFI, AGFI, CFI, and TLI, which are above than the ideal value and meets the requirement. The above results show that both the measurement and structural models are ideally satisfied with the requirements and the collected data fits correctly.

Analysis of measurement and structural model.


Recommended value	≤ 3	≥0.9	≥0.9	≥0.9	≥0.9	≥0.9	≤0.08	≤0.08
Measurement model	1.898	0.9	0.91	0.914	0.91	0.91	0.049	0.0596
Structural model	1.986	0.91	0.91	0.918	0.92	0.92	0.052	0.0616

Testing of Hypotheses

The SEM technique is used to examine the hypotheses. Each structural parameter goes along with the hypothesis. The academic stress (Acd. Strs) with the value β = 0.293 while the p -value is 0.003. These outcomes show a significant positive relationship between academic stress (Acd. Strs) and students' depression levels (Std. Dep. Lev). With the β = 0.358 and p = 0.001 values, the data analysis discloses that the family stress (Fam. Strs) has a significant positive effect on the students' depression level (Std. Dep. Lev). However, the student's depression level (Std. Dep. Lev) also has a significant negative effect on their academic performance (Std. Acd. Perf) with the values of β = −0.319 and p = 0.001. Therefore, the results supported the following hypotheses H 1 , H 2 , and H 3 . The sub-hypotheses analysis shows that the results are statistically significant and accepted. In Table 5 , the details of the sub-hypotheses and the principals are explained precisely. Please see Table 6 to review items with their mean and standard deviation values. Moreover, Figure 2 represents the structural model.

Examining the hypotheses.

				-value
H	Acd. Strs → Std. Dev. Lev	0.201	2.021	0.039	Accepted
H	Fam. Strs → Std. Dep. Lev	0.358	3.997	0.001	Accepted
H	Std. Dep. Lev → Std. Acd. Perf	−0.319	−3.402	0.001	Accepted

Description of items, mean, and standard deviation.


Mental health has a valuable impact on students' academic learning.	3.26	1.752
Academic pressure leads to stress in students' life.	3.25	1.530
I have difficulty in understanding basic concepts.	2.95	1.272
I have to revise the things again and again to develop an understanding.	3.14	1.352
I have lost interest in academic aspects that used to be important for me.	2.83	1.351
Family issues leads to stress in students' life.	3.37	1.504
Because of family issues I cannot concentrate on my studies.	3.19	1.468
I am not able to sleep properly because of family issues.	3.02	1.424
Depression negatively affects a student's motivation to learn.	3.37	1.405
Unfair treatment by teachers causes academic depression in students.	3.12	1.620
Depression has negatively affected my learning capabilities.	2.99	1.280
Depression has negatively affected my academic grades.	3.19	1.201
Sometimes I don't see value in my life. I feel depressed in the class.	2.96 2.91	1.398 1.310

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Structural model.

Discussion and Conclusion

These findings add to our knowledge of how teenage depression is predicted by academic and familial stress, leading to poor academic performance, and they have practical implications for preventative and intervention programs to safeguard adolescents' mental health in the school context. The outcomes imply that extended academic stress positively impacts students' depression levels with a β of 0.293 and a p -value sof 0.003. However, according to Wang et al. ( 5 ), a higher level of academic stress is linked to a larger level of school burnout, which leads to a higher degree of depression. Satinsky et al. ( 105 ) also claimed that university officials and mental health specialists have expressed worry about depression and anxiety among Ph.D. students, and that his research indicated that depression and anxiety are quite common among Ph.D. students. Deb et al. ( 106 ) found the same results and concluded that depression, anxiety, behavioral difficulties, irritability, and other issues are common among students who are under a lot of academic stress. Similarly, Kokou-Kpolou et al. ( 107 ) revealed that depressive symptoms are common among university students in France. They also demonstrate that socioeconomic and demographic characteristics have a role.

However, Wang et al. ( 5 ) asserted that a higher level of academic stress is associated with a higher level of school burnout, which in return, leads to a higher level of depression. Furthermore, Satinsky et al. ( 105 ) also reported that university administrators and mental health clinicians have raised concerns about depression and anxiety and concluded in his research that depression and anxiety are highly prevalent among Ph.D. students. Deb et al. ( 106 ) also reported the same results and concluded that Depression, anxiety, behavioral problems, irritability, etc. are few of the many problems reported in students with high academic stress. Similary, Kokou-Kpolou et al. ( 107 ) confirmed that university students in France have a high prevalence of depressive symptoms. They also confirm that socio-demographic factors and perceived stress play a predictive role in depressive symptoms among university students. As a result, academic stress has spread across all countries, civilizations, and ethnic groups. Academic stress continues to be a serious problem impacting a student's mental health and well-being, according to the findings of this study.

With the β= 0.358 and p = 0.001 values, the data analysis discloses that the family stress (Fam. Strs) has a significant positive effect on the students' depression level (Std. Dep. Lev). Aleksic ( 108 ) observed similar findings and concluded that many and complicated concerns of personal traits, as well as both home and school contexts, are risk factors for teenage depression. Similarly, Wang et al. ( 109 ) indicated that, among the possible risk factors for depression, family relationships need special consideration since elements like parenting styles and family dynamics influence how children grow. Family variables influence the onset, maintenance, and course of juvenile depression, according to another study ( 110 ). Depressed adolescents are more likely than normal teenagers to have bad family and parent–child connections.

Conversely, students' depression level has a significantly negative impact on their academic performance with β and p -values of −0.319 and 0.001. According ( 111 ), anxiety and melancholy have a negative influence on a student's academic performance. Adolescents and young adults suffer from depression, which is a common and dangerous mental illness. It's linked to an increase in family issues, school failure, especially among teenagers, suicide, drug addiction, and absenteeism. While the transition to adulthood is a high-risk period for depression in general ( 5 ), young people starting college may face extra social and intellectual challenges that increase their risk of melancholy, anxiety, and stress ( 112 ). Students' high rates of depression, anxiety, and stress have serious consequences. Not only may psychological morbidity have a negative impact on a student's academic performance and quality of life, but it may also disturb family and institutional life ( 107 ). Therefore, long-term untreated depression, anxiety, or stress can have a negative influence on people's ability to operate and produce, posing a public health risk ( 113 ).

Theoretical Implications

The current study makes various contributions to the existing literature on servant leadership. Firstly, it enriches the limited literature on the role of family and academic stress and their impact on students' depression levels. Although, a few studies have investigated stress and depression and its impact on Students' academic performance ( 14 , 114 ), however, their background i.e., family and institutions are largely ignored.

Secondly, it explains how the depression level impacts students' academic learning, specifically in the Asian developing countries region. Though a substantial body of empirical research has been produced in the last decade on the relationship between students' depression levels and its impact on their academic achievements, however, the studies conducted in the Pakistani context are scarce ( 111 , 115 ). Thus, this study adds further evidence to prior studies conducted in different cultural contexts and validates the assumption that family and academic stress are key sources depression and anxiety among students which can lead toward their low academic grades and their overall performance.

This argument is in line with our proposed theory in the current research i.e., cognitive appraisal theory which was presented in 1966 by psychologist Richard Lazarus. Lazarus's theory is called the appraisal theory of stress, or the transactional theory of stress because the way a person appraises the situation affects how they feel about it and consequently it's going to affect his overall quality of life. In line with the theory, it suggests that events are not good or bad, but the way we think about them is positive or negative, and therefore has an impact on our stress levels.

Practical Implications

According to the findings of this study, high levels of depressive symptoms among college students should be brought to the attention of relevant departments. To prevent college student depression, relevant departments should improve the study and life environment for students, try to reduce the generation of negative life events, provide adequate social support for students, and improve their cognitive and coping capacities to improve their mental qualities.

Stress and depression, on the other hand, may be managed with good therapy, teacher direction, and family support. The outcomes of this study provide an opportunity for academic institutions to address students' psychological well-being and requirements. Emotional well-being support services for students at Pakistan's higher education institutions are lacking in many of these institutions, which place a low priority on the psychological requirements of these students. As a result, initiatives that consistently monitor and enhance kids' mental health are critical. Furthermore, stress-reduction treatments such as biofeedback, yoga, life-skills training, mindfulness meditation, and psychotherapy have been demonstrated to be useful among students. Professionals in the sector would be able to adapt interventions for pupils by understanding the sources from many spheres.

Counseling clinics should be established at colleges to teach students about stress and sadness. Counselors should instill in pupils the importance of positive conduct and decision-making. The administration of the school should work to create a good and safe atmosphere. Furthermore, teachers should assume responsibility for assisting and guiding sad pupils, since this will aid in their learning and performance. Support from family members might also help you get through difficult times.

Furthermore, these findings support the importance of the home environment as a source of depression risk factors among university students, implying that family-based treatments and improvements are critical in reducing depression among university students.

Limitations and Future Research Implications

The current study has a few limitations. The researcher gathered data from the higher education level of university students studying in Islamabad and Rawalpindi institutions. In the future, researchers are required to widen their region and gather information from other cities of Pakistan, for instance, Lahore, Karachi, etc. Another weakness of the study is that it is cross-sectional in nature. We need to do longitudinal research in the future to authoritatively assert the cause-and-effect link between academic and familial stress and their effects on students' academic performance since cross-sectional studies cannot establish significant cause and effect relationships. Finally, the study's relatively small sample size is a significant weakness. Due to time and budget constraints, it appears that the capacity to perform in-depth research of all firms in Pakistan's pharmaceutical business has been limited. Even though the findings are substantial and meaningful, the small sample size is predicted to limit generalizability and statistical power. This problem can be properly solved by increasing the size of the sample by the researchers, in future researches.

Data Availability Statement

Ethics statement.

Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.

Author Contributions

All authors contributed to conceptualization, formal analysis, investigation, methodology, writing and editing of the original draft, and read and agreed to the published version of the manuscript.

This work was funded by the 2020 Heilongjiang Province Philosophy and Social Science Research Planning Project on Civic and Political Science in Universities (Grant No. 20SZB01). This work is supported by the Scientific Grant Agency of the Ministry of Education, Science, Research, and Sport of the Slovak Republic and the Slovak Academy Sciences as part of the research project VEGA 1/0797/20: Quantification of Environmental Burden Impacts of the Slovak Regions on Health, Social and Economic System of the Slovak Republic.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's Note

Acknowledgments

Authors would like to thank all persons who directly or indirectly participated in the completion of this manuscript.

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Depression In College Students
How Do Culture and Gender Affect Students with Depression
College Students and Mental Health: Confronting an Emerging Crisis
Life After 12th Be Like 😂 #shorts #ytshorts #depression #students

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Stress, Anxiety, and Depression Among Undergraduate Students during the
The coronavirus 2019 (COVID-19) has brought significant changes to college students, but there is a lack of empirical studies regarding how the pandemic has affected student mental health among college students in the U.S. To fill the gap in the literature, this study describes stress, anxiety, and depression symptoms for students in a public ...
Influencing factors, prediction and prevention of depression in college
INTRODUCTION. The prevalence of depression among college students has gradually increased in recent years, even exceeding that of the general public, which has become a global phenomenon[].Mounting research has focused on the topic, and the consensus is that the high prevalence of depression among college students cannot be ignored.
The Prevalence of Depression, Anxiety and Stress and Their Associated
College students are at risk of experiencing stress, anxiety and depression, which cause psychological distress and may impact on their academic performance . Worldwide, it is estimated that 12-50% of college students present at least one diagnostic criterion for one or more mental disorders [ 14 ].
Depression, anxiety, and student satisfaction with university life
We found that depression among college students negatively predicts their satisfaction with university life; that is, lower levels of depression in the junior year correspond to higher levels of ...
An Exploratory Study of Students with Depression in Undergraduate
Depression is a top mental health concern among undergraduates and has been shown to disproportionately affect individuals who are underserved and underrepresented in science. As we aim to create a more inclusive scientific community, we argue that we need to examine the relationship between depression and scientific research. While studies have identified aspects of research that affect ...
Relationship between depression and quality of life among students: a
In a sample of Chinese students, depression was more prevalent among medical students, followed by engineering and arts students 69. Seven studies evaluated depression and QOL of students during ...
Depression and anxiety among college students: Understanding the impact
Abstract. Objective: Psychiatric disorders, such as depression and anxiety, can hinder academic performance among college-age individuals.Participants: Mental health among college students is a growing public health concern, with some scholars describing collegiate mental health as a crisis (Chen et al., Psychiatr Serv. 2019;70(6):442-449).Methods: This study analyzes data from four annual ...
Addressing the Increase in Depression in College Students
Yet a 2017 survey by the American College Health Association revealed that 39% of college students felt so depressed within the last 12 months that it was "difficult for them to function" (cited in Reilly, 2018, p. 41). In the same survey, 10% admitted that they had "seriously considered suicide" (p. 41).
Prevalence and associated factors of depression and anxiety symptoms
Background: To evaluate the global prevalence of depression and anxiety symptoms among college students and potential associated factors. Methods: PubMed and Web of Science were searched from their inception to March 28, 2021. Random-effects models were used to calculate the pooled prevalence of depression and anxiety. Subgroup analyses were conducted to explore potential heterogeneity.
Depression and anxiety among college students: Understanding ...
Objective: Psychiatric disorders, such as depression and anxiety, can hinder academic performance among college-age individuals.Participants: Mental health among college students is a growing public health concern, with some scholars describing collegiate mental health as a crisis (Chen et al., Psychiatr Serv. 2019;70(6):442-449).Methods: This study analyzes data from four annual ...
PDF Depression Among College Students: Trends in Prevalence and Treatment
1997). Unfortunately, many young adults, including college students, do not typically seek professional consultation on their own accord when such concerns arise. For example, in a study of depressed college students, Oswalt and Finkelberg (1995) reported that less than one-third sought assistance through the college counseling center.
Psychotherapy for depression in college students
University is the peak of depression, and the prevalence of depression among college students is much higher than that of ordinary people. The purpose of this research is to evaluate depression symptoms, life satisfaction, self-confidence, substance use, social adjustment, and dropout rates of the use of psychological intervention for college ...
A Literature Review of Studies of Depression and Treatment Outcomes
According to the fall 2007 American College Health Association-National College Health Assessment ( 1), a national survey of approximately 20,500 college students on 39 campuses, 43.2% of the students reported "feeling so depressed it was difficult to function" at least once in the past 12 months.More than 3,200 university students reported being diagnosed as having depression, with 39.2% of ...
Frontiers
College of Social Sciences, Shenzhen University, Shenzhen, China; Background: The negative consequences of depression in college students have garnered global attention, especially in relation to academic achievement during the COVID-19 pandemic, which need critical assessment. Aim: This study investigated whether a sense of security mediated the relationship between depression and academic ...
Psychotherapy for depression in college students
rdinary people. The purpose of this research is to evaluate depression symptoms, life satisfaction, self-confidence, substance use, social adjustment, and dropout rates of the use of psychological intervention for college students. Methods: We will identify relevant trials from systematic searches in the following electronic databases: PubMed, Embase, Web of Science and The Cochrane Library ...
Student mental health is in crisis. Campuses are rethinking their approach
By nearly every metric, student mental health is worsening. During the 2020-2021 school year, more than 60% of college students met the criteria for at least one mental health problem, according to the Healthy Minds Study, which collects data from 373 campuses nationwide (Lipson, S. K., et al., Journal of Affective Disorders, Vol. 306, 2022).In another national survey, almost three quarters ...
Supporting mental health and wellbeing of university and college
A systematic review and meta-analysis of RCTs (rated as higher methodological quality) of different interventions for common mental health problems in 3396 university and college students found that MBIs were effective in reducing both depression and generalized anxiety disorder in the short term but were not durable . In their meta-analysis ...
Depression, Anxiety, Loneliness Are Peaking in College Students
February 17, 2021. 25. Kat J. McAlpine. A survey by a Boston University researcher of nearly 33,000 college students across the country reveals the prevalence of depression and anxiety in young people continues to increase, now reaching its highest levels, a sign of the mounting stress factors due to the coronavirus pandemic, political unrest ...
Systematic review and meta-analysis of depression, anxiety, and
Among 16 studies reporting the prevalence of clinically significant symptoms of depression across 23,469 Ph.D. students, the pooled estimate of the proportion of students with depression was 0.24 ...
(PDF) Students and Depression
The research is done on both gender, male and female. 29 students are female and. male students are 112. This portion of research is to check whether female students can have more chances. of ...
Essay on Depression Among College Students
Depression among college students is a complicated issue that needs a kind and thorough approach. By understanding the special challenges students face and addressing the root causes of depression, we can create a supportive environment that promotes mental well-being and academic success. ... 19 students ordered this very topic and got ...
Academic Stress and Mental Well-Being in College Students: Correlations
College students are exposed to novel academic stressors, such as an extensive academic course load, substantial studying, ... Stress, anxiety, and depression among undergraduate students during the COVID-19 pandemic and their use of mental health services. Innovat. High. Educ. 1-20. 10.1007/s10755-021-09552-y ...
Family and Academic Stress and Their Impact on Students' Depression
Academic issues are thought to be the most prevalent source of stress for college students ... according to Yang et al. , students claimed that academic-related pressures such as ongoing study, writing papers, preparing for tests, and boring professors were the most important daily problems. Exams and test preparation, grade level ...

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A Literature Review of Studies of Depression and Treatment Outcomes Among U.S. College Students Since 1990

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ORIGINAL RESEARCH article

1. Introduction

2.1. Process and participants of the survey

2.1.2. Procedure

2.1.3. Sample characteristics

2.2. Measurement

2.3. Data analysis

4. Discussion

4.1. Main contributions

4.2. Practical implications

4.3. Limitations

5. Conclusion

Data availability statement

Ethics statement

Author contributions

Conflict of interest

Publisher's note

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Psychotherapy for depression in college students

Background:

Methods:

Results:

Conclusion:

Protocol Registration:

1 Introduction

2.1 Eligibility criteria

2.1.2 Type of patient

2.1.3 Type of interventions

2.1.4 Type of outcomes

2.2 Data source

2.3 Study selection

2.4 Risk of bias analysis

2.5 Statistical analysis

2.5.2 Network meta-analysis

2.5.3 Subgroup analysis

2.5.4 Sensitivity analysis

2.6 Quality of evidence

2.7 Summary of findings

3.1 Results of the search

3.2 Characteristic of included studies

4 Discussion

Author contributions

Student mental health is in crisis. Campuses are rethinking their approach

Higher caseloads, creative solutions

The first line of defense

Creative approaches to support

A culture of wellness

Further reading

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Nationwide study, co-led by BU researcher Sarah Ketchen Lipson, reveals a majority of students say mental health has impacted their academic performance

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Risk of bias

Eligibility criteria

Search strategy and data extraction