COVID: Why some students’ mental health did not deteriorate

A study has revealed that COVID-19 did not bring about a serious increase in mental health issues at two South African universities. Where increases were observed, they were before the pandemic.

The study’s findings suggest that, in the face of ongoing adversity and disruptions on South African university campuses in recent years, COVID-19 may be just one more stressor local students face, and that its impact on student mental health may not have been as marked in South Africa compared with other regions.

The researchers assert that understanding the impact of COVID-19 on the mental health of university students in low- and middle-income countries (LMIC), is important, in order to plan interventions to improve the psychological consequences of the pandemic on higher education. In this regard, the need for effective and accessible campus-based interventions to promote student wellness is highlighted.

The study was based on data collected from first-year students at Stellenbosch University (SU) and the University of Cape Town (UCT) before and during the COVID-19 pandemic. It suggests that there has not been a clear pattern of increases in serious mental health issues.

The study, titled, ‘COVID-19 and common mental disorders among university students in South Africa’ was published in the January 2023 edition of the South African Journal of Science.

The research team from the South African Medical Research Council, Stellenbosch University and the University of Cape Town comprised Jason Bantjes, Sonja Swanevelder, Esme Jordaan, Christine Lochner and Dan Stein; as well as Nancy Sampson, Maria Petukhova and Ronald Kessler of the Department of Health Care Policy, Harvard Medical School, Boston, United States.

The researchers examined the impact of COVID-19 on the mental health of first-year students at these universities by analysing changes in the prevalence and onset of three common mental disorders: major depressive episode (MDE), generalised anxiety disorder (GAD) and suicidal ideation, during the outbreak of the global pandemic, and comparing these to the changes observed between 2015 and 2017, at the time of the violent #FeesMustFall protests.

The researchers point out that this “study is the first to explore COVID-19’s impact on university students’ mental health in South Africa, using data collected before and during the pandemic”. Many of the studies on mental health and COVID-19 have relied on cross-sectional data at a single point in time, with no direct comparisons to data collected in the same population and with the same methods before COVID-19.

Their analysis of cross-sectional survey data showed no consistent pattern of increases in the prevalence of MDE, GAD and suicidal ideation before and during the first two waves of COVID-19.

“There were no significant changes in the 12-month prevalence of common mental disorders at either institution before and after the outbreak of COVID-19, except for an increase in prevalence of MDE at SU and a decrease in suicidal ideation at UCT.”

They explain that, in 2020 “the 12-month prevalence for any of the three common mental disorders assessed was 53.7% and 58.5% at SU and UCT, respectively. MDE was the most common mental health problem reported in the past 12 months (SU: 40.3%; UCT: 45.3%), followed by suicidal ideation (SU: 32.7%; UCT: 36.0%) and GAD (SU: 27.6%; UCT: 29.7%).”

This suggests that, while COVID-19 had an impact on the mental health of some students, it was not consistently observed across both institutions or across all mental health outcomes, “and, where increases were observed between 2017 and 2020, these were mostly no larger than increases previously observed between 2015 and 2017.”

Common mental disorders ‘prevalent’

Participants were asked their age, parents’ level of education, whether they had a serious physical impairment, whether they suffered from any chronic illnesses, and how they identify in terms of gender, population group and sexual orientation. “We identified students as ‘first-generation students’ if neither of their parents had completed tertiary education.”

The researchers indicate that the survey data highlight the prevalence of common mental disorders among university students in South Africa and the need for effective campus-based support.

They point out that COVID-19 had serious economic, social and health implications, with vulnerable groups disproportionally affected. “Even before the COVID-19 pandemic, concern was expressed about university students’ mental health, with global data suggesting students are more vulnerable than the general population to mental disorders.”

The study’s findings suggest that students have faced many stressors during the past few years. They point out that, between 2015 and 2017, university students across South Africa participated in mass protests as part of the #FeesMustFall movement that aimed to resist fee increases and to decolonise universities.

These protests disrupted learning countrywide, resulting in damage to property, and the cancellation of exams. Students were involved in clashes with riot police and the military, resulting in some of them being killed. “The disruptions and trauma caused by these protests no doubt had a profound impact on student mental health and likely attributed to the high rates of mental disorders we observed in 2017, especially at UCT where the #FeesMustFall campaign was prolonged and intense,” explained the researchers.

They assert that, with this political context in 2017 in mind, “it is unsurprising that very few changes were observed in the prevalence of common mental disorders between 2017 and 2020, even though there was a global pandemic in this time”.

Globally, universities had been increasingly concerned about the prevalence of common mental disorders and suicidal behaviour among undergraduate students even before COVID-19.

The researchers refer to a pre-COVID-19 survey of students from 19 universities across eight countries (Australia, Belgium, Germany, Mexico, Northern Ireland, South Africa, Spain, USA) which reported 12-month prevalence rates of 35% for at least one common mental disorder among first-year students, and 12-month prevalence rates for suicidal ideation, plan, and attempt of 17.2%, 8.8%, and 1%, respectively.

Stressors affecting South African students

However, South African undergraduate students have much to navigate when they go to university: there are stressors associated with greater academic demands, leaving home for the first time, increased exposure to substances and financial pressures.

Furthermore, the onset of mental disorders is typically in late adolescence or early adulthood. “Depression, anxiety and suicidal ideation are the most common symptoms of mental disorders reported by students” and affect academic performance.

The researchers refer to previous studies that indicate that university students in South Africa face a myriad of challenges that pre-date COVID-19, including food insecurity, housing insecurity and the stress associated with living in a country where violence, crime and trauma are ubiquitous.

Furthermore, it is possible that growing up with the constant presence of multiple life-threatening infectious diseases may have desensitised some South African university students to the psychological impact of COVID-19.

“In the context of these adversities, COVID-19 is just one more challenge among many. South Africans have had exposure to the enduring HIV and TB syndemic [which has] long affected the lives of many South Africans, including university students.”

The country has the highest number of people living with HIV in the world, with infection rates of 20.4% among 15 to 49-year-olds and an estimated 80,000 TB-related deaths each year, they point out.

Local historical, health and socio-environmental factors have shaped the impact of COVID-19 in South Africa and also students’ experiences of the pandemic.

“It is possible that growing up with the constant presence of multiple life-threatening infectious diseases may have desensitised some students to the psychological impact of COVID-19.”

The researchers assert that understanding the impact of COVID-19 on the mental health of university students in low- and middle-income countries is important.

This is because students’ mental health can affect their academic performance. Promoting university students’ mental health (and, therefore, educational retention and academic success) in the post-COVID-19 period will be integral to stimulating economic recovery, especially in LMICs where the economic wrecking ball of the pandemic has hit hard.

However, they caution that their study has limitations in that there are much higher numbers of students who were distressed by COVID-19 but do not meet the threshold for a disorder “and are, thus, not included in our prevalence estimates”.

“The model of the pandemic as a trauma that leads to psychopathology may not be the most appropriate way to conceptualise the impact of the pandemic on students, despite the widespread usage of the trauma model in this context. The data we collected in 2020 was collected between April and July (... during the first waves of the pandemic) and this may have been too soon to capture the full impact of the pandemic on students’ mental health.”

Furthermore, the (non)-effects they observed are based on data collected in the first year of the pandemic and it is possible that effects may have increased by the following year.

Finally, they considered data collected only from first-year students at two well-resourced universities in the Western Cape. “It is possible that a different pattern would be observed among senior students and those attending rural and less well-resourced institutions.”

The researchers refer to their earlier work in South Africa which suggested that providing effective treatment to first-year students with major depressive disorder and-or attention deficit hyperactivity disorder could yield a 23% proportional reduction in prevalence of academic failure, highlighting the importance of promoting mental health as a strategy for raising pass rates.