Depression Among University Students in Jordan After the COVID-19 Pandemic: A Cross-Sectional Study

Introduction

Depression is a significant mental health disease that needs more worldwide attention from the public health sector, as it affected more than 300 million people on a global scale in 2017.¹ In addition, depression is one of the most significant contributors to worldwide disability (about 7.5% in 2015) and a significant contributor to about 800,000 suicides every year.² Depression is a common and treatable disorder usually recognized by frequent changes in mood and cognitive and physical symptoms for two weeks or more.³

The primary symptoms of depression are the loss of positive interactions, sleep disturbances, low self-care, low concentration, anxiety, and a lack of interest in daily life and new experiences.⁴ Depression can be diagnosed clinically through traditional diagnostic interviews, but in studies measuring the prevalence of depression, researchers usually use a validated self-report screening instrument.⁵ The prevalence of depression is affected by socio-demographic factors such as sex, age, environment, and personal character.⁶ It also changes with personal income and health-related behaviors.⁷

University students experience high academic and non-academic stressors, making them vulnerable to developing mental health issues, including depression. Studies indicate that university students have higher levels of depression than other populations.^5,8,9 The COVID-19 epidemic has had a multifaceted impact on the overall well-being of society, including several dimensions such as social, emotional, economic, and educational aspects.^10–19

Previous research conducted among nursing students revealed the presence of notable levels of distress within this population.²⁰ Stress level found a significant association with first-year academic level and family members in the medical profession. The utilization of acceptance and religious/spiritual coping methods enabled students to effectively manage stress.²⁰ Another study found that the majority of nursing students experienced stress ranging from moderate to high levels. It has been proven that there is a significant but weak negative correlation between self-esteem and depression.²¹ A previous study compared the distress levels in the general population to those of university students and found them to be significantly higher in students in the 18 to 34 year age group.²² In Jordan, scant studies about this issue existed before the onset of the COVID-19 pandemic. One study in 2008 found the prevalence of depression among university students to be 75%.²³

In contrast, research conducted during the COVID-19 pandemic revealed a substantial frequency of depression among university students as a result of the challenges experienced during that period. The aforementioned research employed diverse methodologies in order to assess the prevalence, employing varying criteria for defining the phenomenon. In 2020, a research study conducted in Jordan aimed to examine the psychological ramifications of quarantine on university students. The findings revealed a notable prevalence of depression symptoms, with 71% of participants exhibiting such symptoms. Further analysis indicated that 34% of participants experienced severe depressive symptoms, while 37% reported high levels of depressive symptoms. Notably, female participants displayed a larger percentage of depressive symptoms compared to their male counterparts.^24,25 Another study by Hamaideh, S.H.et al reported a prevalence rate of 78.7%.²⁶ Nowadays, after the end of pandemic restrictions and the return to in-person teaching and hands-on training, it is crucial to have an updated estimate of depression prevalence among university students in Jordan and to study its association with other factors in students’ lives to take steps to prevent and manage this critical health issue.

Materials and Methods

Study Design

This is an online cross-sectional survey study that examined the prevalence of depression among university students in Jordan. The data were collected from 02/01/2022 to 31/03/2022 and targeted students aged 18 and above.

Participants Recruitment

The convenience sampling technique was used in this study to recruit the participants. The social media websites (Facebook, WhatsApp, Snapchat, and Instagram) were used to invite the study participants. The inclusion criteria for the study population are university students from any specialty currently studying at a Jordanian university. There was no restriction on the year of the study or the field of the study. The inclusion criteria were highlighted in the cover letter of the study. Participants who met the inclusion criteria were asked to participate in the study. The study’s aims and objectives were highlighted in the cover letter. Participants were asked to participate after giving their consent.

Data Collection and Measures

We used the Patient Health Questionnaire-9 (PHQ-9) questionnaire in this research. The PHQ-9 is a tool recommended by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) to make a provisional diagnosis and assess the severity of depression. It comprises nine items answered on a four-point scale. PHQ-9 scores range from 0 to 27, with higher scores indicating a higher severity of depression. We made a provisional diagnosis of depressive disorder if the PHQ-9 score was four or more.²⁷ The study questionnaire included three parts: The first concerns demographic information, including age, sex, university specialty, grade, residency status, and place. The second is about behaviors and previous illnesses that include smoking, coffee drinking, energy drink consumption, exercise performance, previous diagnosis of a mental disorder, previous psychological evaluation by a specialist, and COVID-19 infection diagnosed by a polymerase chain reaction (PCR) test.

The third part consists of the questions from the PHQ-9; we used the validated Arabic version. For each question, the answers range from 0 to 3, where 0 means “not at all” and 3 means “almost every day”. The total scores were categorized as follows: minimal or no depression (0–4), mild depression (5–9), moderate depression (10–14), moderately severe depression (15–19) and severe depression (20–27).

Pilot Study

We conducted a pilot study by approaching 10 participants who met our inclusion criteria; those participants were not included in the final study sample. The pilot study examined participants’ understanding of the questionnaire and asked them whether they faced any difficulties in filling it out.

Questionnaire Validity

Cronbach’s alpha was used to ensure the reliability of the questions. The acceptable factor loading was 0.70 or above.²⁸ We calculated Cronbach’s alpha internal consistency coefficients for mental health on a factor basis. The Cronbach’s alpha values were determined to be 0.88 for depression, which reflects good internal consistency.

Ethical Statement

We obtained approval for our study from the Institutional Review Board (IRB) of the Jordan University of Science and Technology (number 2021/678). Study participants voluntarily accepted and participated by filling out the online questionnaire. We ensured the confidentiality and anonymity of the participants and restricted the data collected to the research team. Our methods followed the relevant guidelines and regulations.

Data Analysis

Collected data were analyzed using the statistical analysis program SPSS version 26. Descriptive analysis was implemented to present the data for this study. Categorical variables were presented as percentages and frequencies. Continuous variables were presented as mean and standard deviation (SD) as the data were normally distributed. The normality of the depression score was checked using skewness and kurtosis measures and the histogram. Therefore, we used analysis of variance (ANOVA) and t-tests to examine the difference in the mean depression score. Predictors of depression were identified using binary logistic regression analysis, where the dummy variable was defined as the mean depression score for the study sample. A 95% confidence interval (p ≤ 0.05) was applied to indicate the statistical significance of the results, and a significance level of 5% was assigned.

Results

Participants Demographic Characteristics

This study included 535 students. The mean age of the students was 22.2 (SD: 3.3) years. We sorted the participants into three groups according to their ages: 18–20 years (32%), 21–23 years (46%), and ≥24 years (22.1%). Females represented 72.5% of our study sample. Most participants were Jordanians (93.3%). The highest percentage of the students were from the faculty of engineering (22.4%), followed by medicine (14.8%), and computer and information technology (13.1%), with only (0.7%) in veterinary medicine. Regarding residency status, 84.7% of participants lived with their families, while the remainder lived alone or in student parties. About half of the students (48.4%) reported excellent academic performance, while only (0.9%) reported a fair degree of academic achievement. Most participants were non-smokers (82.4%) and did not consume energy drinks (79.4%). 44.9% of participants did not drink coffee, while 18.7% drank three or more cups daily. Only 39.8% of students performed exercise.

Regarding past illnesses, 46% of participants had a previous COVID-19 infection, 15.3% were diagnosed with a mental illness, and 10.8% had a psychological state evaluation by a specialist. Table 1 presents the demographic characteristics of the study participants.

Table 1 Participants’ Demographics Characteristics

Depression Screening and Severity

Figure 1 shows the percentages of depression according to severity: 10% of the study participants had minimal or no depression, 18.7% had mild depression, 26.2% had moderate depression, 19.3% had moderately severe depression, and 25.8% had severe depression.

Figure 1 Percentages of depression according to severity.

Depression Score Stratified by Participants’ Demographic Characteristics

Table 2 shows participant demographics characteristics and their associated mean depression scores. The mean depression score significantly differed across participants based on different demographical characteristics (p<0.05) Younger university students (aged 18–20 years), females, consumers of energy drinks, students who had a previous psychological evaluation by a specialist, those diagnosed with any mental illness, and those who encountered very or extreme difficulties in their lives tend to have higher depression mean scores compared with others (p<0.05). On the other hand, students from the faculty of medicine and those practicing exercise tend to have lower depression mean scores than others (p<0.05), Figure 2.

Table 2 Depression Score Stratified by Participants’ Demographic Characteristics

Figure 2 Depression score according to the college of students.

Nationality, residence nature, academic performance, smoking, coffee consumption, and previous COVID-19 infection did not show any statistical differences in mean depression scores (p>0.05) (Table 2).

Predictors of Participants’ Higher Depression Score

The mean depression score for the study participants was 13.9 (SD: 7.1) out of 27, representing a moderate level of depression. Binary logistic regression analysis identified that those who drink 3 or more cups of coffee per day, those who have had an evaluation of their psychological state by specialists before, and those who have been diagnosed with any mental illness were more likely to have a higher depression score compared to others (p<0.05). On the other hand, students who were aged 24 years and older, and those who practiced regular exercise were less likely to have a higher depression score compared to others (p<0.05) (Table 3).

Table 3 Binary Logistic Regression Analysis

Discussion

In our study, we addressed the gap in the literature on depression among Jordanian university students post-COVID-19 pandemic, and we examined multiple factors that may be associated with this mental issue. Of the 535 participants in our study, the prevalence of depression (ranging from minimal to severe) was 89.9%. Previous studies in Asia indicate a range of between 4% and 79.2% among university students.^29–31 A previous study conducted in Jordan in 2008 showed a 75% prevalence of depression among university students.²³ During the COVID-19 pandemic home quarantine in 2021, the prevalence of depression was 78.7% among students of Jordanian universities.²⁶ Previous research examined the psychological burden of the pandemic and reported that nursing students demonstrated notable levels of distress.²⁰ Stress level found a significant association with first-year academic level and family members in the medical profession. The utilization of acceptance and religious/spiritual coping methods enabled students to effectively manage stress.²⁰ Another study found that the majority of nursing students experienced stress ranging from moderate to high levels. It has been proven that there is a significant but weak negative correlation between self-esteem and depression.²¹

Due to the different methods used in previous studies to diagnose depression, we cannot accurately predict the actual increase in its prevalence. The high percentages of depression in our study may result from the shift in learning methods to online and hybrid learning, which puts high pressure on the students in front of this new challenge. Also, many families lost their occupations after the pandemic, which caused financial difficulties. These results need more attention from the decision-makers in the universities and the healthcare system to take steps to minimize this problem.

We found that the severity of depression symptoms also increased compared to previous studies; moderately severe and severe depression were 45.1% in our study compared to 22.3% in a study conducted during the pandemic that used the same PHQ-9 scale.³² In our study, the PHQ-9 score was higher in female than male students. This result is consistent with Centers for Disease Control and Prevention (CDC) reports showing that women were almost twice as likely as men to have had depression during 2013–2016. Similar results were found in recent studies,^25,33,34 which indicated higher depression values among females compared to males. Gender differences in depression have been described previously, and several studies have demonstrated that female gender is a risk factor for developing depression. This difference could be due to the increased frequency of hormonal changes in women compared with men.³⁵ Social differences between males and females may also explain these differences.³⁶

We found an inverse relationship between the student’s age and the depression score. The same was noted in a previous study on medical students in Saudi Arabia, where depression was higher in the first two years and then dropped in the third year.³⁷ Another study in China showed that depression is higher in the first three academic years and then decreases in the fourth year³⁸ This result was also shown in other studies.^39,40 This result may be due to the new challenges the junior students encounter at their university, separation from family, change of friends, academic pressure, and engagement in more social activities.^40–42

Many studies discuss depression in medical students,^36,43 but very few deal with other faculties. In our study, medical students had the lowest depression scores compared with other faculties mentioned in the result section. Our result was like that of a study that revealed that medical students had a lower severity of depression compared with non-medical students.⁴⁴ This may be attributed to the hypothesis that medical students are afraid of the stigma of being diagnosed and treated for depression or a similar psychiatric condition. They are afraid that a diagnosis of psychiatric illness could interfere with academic standing and the acquisition of competitive residency positions.⁴⁵ Art and science faculty students had a higher mean depression score. A previous study in the art and science faculty showed high depression in these specialties.⁴⁶ In literature, most universities have an art faculty alone or with music; the same is true for the science faculty, which is usually a separate faculty. The art faculty may have more depressive symptoms attributed to factors associated with the stress of college life, financial problems, and the uncertainties of future careers associated with this chosen faculty.⁴⁷

Students who consumed energy drinks had a higher mean depression score than those who did not; one study found a relationship between the frequency of energy drink consumption and depression, but the study does not ensure the cause-result relationship.⁴⁸ Another study held over two years to investigate the effects of energy drink consumption on depression found an increase in depression among male participants.⁴⁹ Depression decreases after the ingestion of energy drinks transiently, but it is the most common psychological side effect of energy drink use; probably, it is an initial effect that will then change.⁵⁰

In our study, practicing exercise was associated with a decrease in the mean depression score. In the literature, exercise is considered one of the non-pharmacological treatments for several mental illnesses, including depression.^51–53 Exercise training causes an increase in anti-inflammatory and anti-oxidant enzymes⁵⁴ and a decrease in IL-6 levels.⁵⁵ These markers are altered in depressed people. Individuals previously diagnosed with mental illness displayed a higher average score on the PHQ-9 than those without such diagnoses. A prospective national study revealed that not only was the relative risk of depression particularly high within the first year following a non-affective disorder diagnosis, but it also remained significantly elevated for more than five years compared to young individuals without such disorders.⁵⁶

Our results revealed that students who had previously undergone psychological assessments by a specialist exhibited greater depressive symptoms. Numerous studies have explored the various psychological facets that are linked to depression, such as adverse self-perception, susceptibility to rejection, neuroticism, excessive contemplation, negative emotional tendencies, and other related factors.⁵⁷ This is logical since those who complain of depressive symptoms will seek medical attention to assess their psychological state. Depression makes it difficult for the affected person to deal with daily life and work.⁴ In our study, the difficulty encountered by the person in his life increased with his depression score, so the greater the depression severity, the greater the effect on his life. Consumption of three or more cups of coffee was associated with an increased depression score. Previous studies showed that heavy consumption of coffee was associated with a higher risk of depression,^58,59 as most people will have sleep problems that will affect their minds. Also, depressed people might choose to consume more caffeine as a form of self-medication.

Our study has limitations in that it is an observational study conducted using an online questionnaire. This might have affected the generalizability of our study findings due to the restriction of our study population to social media users. The cross-sectional study design restricted our ability to explore causality among our study variables.

Conclusion

Depression is a prevalent mental health issue observed among university students globally, which has been exacerbated by the onset of the COVID-19 pandemic. This psychological condition has a significant impact on the overall psychological well-being of people within the community. The likelihood of experiencing higher depression scores is greater among students who use three or more cups of coffee daily, have undergone a pre-evaluation of their psychological condition by professionals, and have received a diagnosis of a mental disorder, in comparison to their counterparts. In contrast, individuals who were 24 years of age or older and engaged in regular exercise exhibited a decreased likelihood of having elevated depression scores in comparison to their counterparts. It is imperative for policymakers at Jordanian institutions to develop comprehensive strategies aimed at offering necessary mental support to these populations following the end of the pandemic.