Impact of COVID-19 mitigations on anxiety and depression amongst university students: A systematic review and meta-analysis

Abstract

Background: While much research has addressed mental health concerns related to the coronavirus disease 2019 (COVID-19) pandemic, there remains a scarcity of studies specifically exploring the changes in anxiety and depression among university students before and after the implementation of COVID-19 mitigation measures.

Methods: In this systematic review and meta-analysis, we searched databases including MEDLINE (Ovid), EMBASE (Ovid), PsycINFO (Ovid), CINAHL (EBSCO), ERIC (EBSCO), the WHO COVID-19 database, Scopus, and Science Citation Index (Web of Science) as of 15 February 2023. We included studies that used a validated tool to measure changes in anxiety or depression at two distinct time points - before (T1) and during (T2); during (T2) and after (T3); or before (T1) and after (T3) COVID-19 mitigation. The quality of studies was assessed using an adapted Joanna Briggs Institute Checklist for longitudinal studies. Utilising random-effects models, we synthesised changes in continuous outcomes as standardised mean difference (SMD) with 95% confidence interval (CI) and binary outcomes as risk difference (RD) with 95% CI.

Results: In total, 15 studies were included in this review, with eight of moderate and seven of high quality. In most of the included studies (n = 13), the majority of participants were women. Eleven studies analysed mental health outcomes between T1 and T2 of COVID-19 mitigations. Continuous symptom changes were a minimal or small improvement for anxiety (SMD = -0.03, 95% CI = -0.24 to 0.19, I² = 90%); but worsened for depression (SMD = 0.26, 95% CI = -0.01 to 0.62). However, the proportions of students reporting moderate-to-severe symptoms, defined by specific cut-offs, increased during COVID-19 mitigation measures for both anxiety (RD = 0.17, 95% CI = -0.04 to 0.38, I² = 95%) and depression (RD = 0.12, 95% CI = 0.03 to 0.22, I² = 72%). Sensitivity analyses, which distinguished between baseline periods based on awareness of COVID-19, demonstrated an exacerbation of both symptoms when comparing the period before the global awareness of the COVID-19 outbreak (before December 2019) with the period during the implementation of mitigation measures.

Conclusions: Mental health outcomes, especially depressive symptoms, were observed to worsen in university students during COVID-19 mitigations. Despite considerable heterogeneity requiring careful interpretation of results, the impact of COVID-19 mitigations on mental health in university students is evident.

Registration: PROSPERO (CRD42021266889).

Figure 1

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram.

Figure 2

Overall change in continuous anxiety or depression score between different time points. Panel A. Anxiety. Panel B. Depression.

Figure 3

Risk differences in proportions of participants reporting moderate-to-severe anxiety or depression score between different time points. Panel A. Change in proportions of participants reporting moderate-to-severe anxiety. Subpanel a: change in proportions of moderate-to-severe anxiety between before (T1) and during (T2) COVID-19 mitigation measures; subpanel b: change in proportions of moderate-to-severe anxiety between before (T1) and after (T3) COVID-19 mitigation measures. Panel B. Change in proportions of participants reporting moderate-to-severe depression. Subpanel a: change in proportions of moderate-to-severe depression between before (T1) and during (T2) COVID-19 mitigation measures; subpanel b: change in proportions of moderate-to-severe depression between before (T1) and after (T3) COVID-19 mitigation measures.

Figure 4

Change in anxiety and depression during the lockdown. Panel A. Change in continuous outcomes. Subpanel a: anxiety; subpanel b: depression between before (T1) and during (T2) the lockdown. Panel B. Change in proportions of participants reporting moderate-to-severe. Subpanel a: anxiety; subpanel b: depression between before (T1) and during (T2) the lockdown.