COVID-19 and common mental disorders among university students in South Africa

The COVID-19 pandemic significantly impacted global economic, educational, and mental health landscapes. Vulnerable groups, including young people in low- and middle-income countries (LMICs), experienced disproportionate effects due to educational disruptions and restrictions. While studies documented increased rates of depression and anxiety in the general population and among university students following the pandemic's outbreak, the impact on South African university students remained unclear. Prior to the pandemic, concerns about student mental health were already prevalent globally, with studies indicating higher vulnerability to mental disorders compared to the general population. This study aimed to fill this knowledge gap by examining the impact of COVID-19 on first-year students at two South African universities, comparing changes in the prevalence and age of onset of three common mental disorders (major depressive episode, generalized anxiety disorder, and suicidal ideation) before and during the pandemic, and comparing these to changes between 2015 and 2017. Understanding this impact is crucial for developing interventions to mitigate the pandemic's psychological consequences on higher education and contribute to economic recovery in LMICs. The study builds upon previous research highlighting the high prevalence of common mental disorders and suicidal behavior among university students globally and in South Africa, even before the COVID-19 pandemic. Previous research showed that effective treatment for mental disorders among students could significantly reduce academic failure, underscoring the importance of mental health promotion in improving educational attainment. The global increase in depressive and anxiety disorders following the pandemic is well-documented, but the South African context requires specific investigation due to pre-existing socio-economic stressors and challenges faced by students.

The introduction extensively reviews existing literature on the impact of COVID-19 on mental health, particularly among university students globally. It cites studies showing increases in depression and anxiety but also some indicating no significant change in suicide rates. The review also highlights the pre-existing concerns about mental health among university students worldwide, citing studies that reported high prevalence rates of common mental disorders and suicidal ideation before the pandemic. Specifically, research on South African university students' mental health is mentioned, emphasizing the challenges they face and the potential impact of effective interventions on academic performance and success. The literature cited supports the study's focus on the South African context, acknowledging the unique socio-economic and political factors influencing student well-being.

This study employed a cross-sectional survey design, collecting data from first-year students at Stellenbosch University (SU) and the University of Cape Town (UCT) at three time points: 2015 (SU only), 2017 (SU and UCT), and 2020 (SU and UCT). Data were collected through anonymous online surveys sent directly to students via email by the respective institutions. The 2020 data collection occurred between April 14 and July 10, 2020. Inclusion criteria required participants to be enrolled as first-year students and provide informed consent. The survey gathered sociodemographic data (age, parents' education level, physical impairments, chronic illnesses, gender, population group, sexual orientation) and assessed lifetime and 12-month prevalence, as well as age of onset, for major depressive episode (MDE), generalized anxiety disorder (GAD), and suicidal ideation. Measures used included adapted items from the Composite International Diagnostic Interview Screening Scales (CIDI-SC) and a modified version of the Columbia Suicidal Severity Rating Scale (C-SSRS). Data analysis involved weighting by population group and gender to adjust for differences between survey respondents and the student body populations, as well as changes in the demographic profile of students over time. The analysis calculated lifetime and 12-month prevalence estimates for MDE, GAD, suicidal ideation, and any of these three outcomes. It also examined 12-month persistence among prior lifetime cases and age of onset curves for each disorder. Regression analysis was conducted to determine if changes in prevalence were attributable to shifts in the demographic profile of students. Ethical clearance was obtained from the Health Sciences Research Ethics Committees at SU and UCT, with institutional permission secured prior to data collection.

The study's analysis of weighted data revealed no clear or consistent increase in the prevalence of MDE, GAD, and suicidal ideation among first-year students at SU and UCT before and during the initial waves of the COVID-19 pandemic. While there were significant increases in lifetime prevalence observed at SU between 2015 and 2017 for MDE and suicidal ideation, and between 2017 and 2020 for all three disorders, similar increases were observed in the period between 2015 and 2017. These increases were not consistently larger than the pre-pandemic increases. The 12-month prevalence showed no significant changes at either institution between 2017 and 2020, except for an increase in MDE prevalence at SU and a decrease in suicidal ideation at UCT. The age of onset curves for all disorders indicated that students were developing symptoms at increasingly younger ages over time. Regression analysis, controlling for demographic changes in student enrollment, indicated significant increases in lifetime prevalence for MDE and suicidal ideation at SU between 2017 and 2020, even after accounting for demographic changes. At UCT, only MDE showed a significant increase. In 2020, the 12-month prevalence of at least one of the three disorders was notably high at both universities (53.7% at SU and 58.5% at UCT), exceeding rates observed in the general population. MDE was the most prevalent disorder in both institutions, followed by suicidal ideation and GAD. The analysis indicated that increases in lifetime prevalence largely predated the pandemic, and that while there was an impact on some students' mental health, it wasn't consistently observed across all outcomes or institutions.

The findings challenge the assumption of a significant and widespread surge in mental health issues among South African university students directly attributable to COVID-19. The study suggests that pre-existing socio-economic challenges, including food insecurity, housing insecurity, violence, and trauma, may be more significant contributing factors to high rates of mental illness than the pandemic itself. The ongoing adversities faced by students, such as the impact of the #FeesMustFall movement, may have created a baseline of high stress and vulnerability. COVID-19, in this context, could be viewed as one stressor amongst many. The research also considered alternative interpretations, such as potential student resilience, limitations of diagnostic criteria in capturing all forms of psychological distress, and the possibility that the data collection period may have been too early to fully capture the pandemic's long-term effects. The high prevalence rates underscore the necessity for comprehensive and readily available campus-based mental health interventions.

This study provides novel insights into the impact of COVID-19 on university students' mental health in South Africa. While the pandemic may have contributed, the findings suggest that pre-existing socio-economic factors played a more significant role. The high rates of mental health issues necessitate sustainable campus-based interventions. Future research should explore the long-term effects of the pandemic and include diverse student populations across various university settings to enhance generalizability.

The study's limitations include a relatively low response rate, which could introduce bias. Significant changes in prevalence rates before the pandemic complicate the assessment of pandemic effects. The data primarily reflect the first year of the pandemic; long-term effects may differ. The sample included only first-year students at two well-resourced universities, limiting generalizability to other student populations and institutions.