Factors Associated With Mental Health Disorders Among University Students in France Confined During the COVID-19 Pandemic

IMPORTANCE The coronavirus disease 2019 (COVID-19) pandemic and quarantine measures have raised concerns regarding their psychological effects on populations. Among the general population, university students appear to be particularly susceptible to experiencing mental health problems. OBJECTIVES To measure the prevalence of self-reported mental health symptoms, to identify associated factors, and to assess care seeking among university students who experienced the COVID-19 quarantine in France. DESIGN, SETTING, AND PARTICIPANTS This survey study collected data from April 17 to May 4, 2020, from 69054 students living in France during the COVID-19 quarantine. All French universities


Introduction
According to the US Centers for Disease Control and Prevention, quarantine consists of separating and restricting the movement of people who have been exposed to a contagious disease to check whether symptoms occur. 1 Large-scale quarantine appears to be the most appropriate term to refer to a compulsory physical separation, including the restriction of movement, of populations who have been potentially exposed to a contagious disease. 2 Large-scale quarantines are presented as strategies for reducing contact among people, and therefore, the spread of a contagion obliges, under pain of economic or criminal sanctions, a population to stay home. 1 On January 30, 2020, the World Health Organization declared the global outbreak of the coronavirus disease 2019 (COVID-19) a public health emergency. Following several countries, such as China or Italy, the French government mandated a quarantine from March 17 to May 11, 2020. Citizens were asked to confine themselves to their homes, and unnecessary travel was prohibited. Based on lockdown experiences that were recorded in response to previous epidemics, a recent review of the literature concluded that quarantine measures could have negative psychological effects, including symptoms of posttraumatic stress, stress, anxiety, and depression. 3 Among the general population, university students appear to be particularly susceptible to the negative impacts of quarantine. [4][5][6][7][8][9][10] Indeed, before the COVID-19 outbreak, the mental health of young adults was already a global concern. In France, as in most high-income countries, suicide is the second-leading cause of death among individuals aged 15 to 25 years. 4 In a 2016 national survey of 18 875 French university students, 37% of the participants declared having experienced an episode of depression, and 8% reported having suicidal thoughts in the past 12 months. 5 Furthermore, the COVID-19 pandemic threatens to disrupt the provision of mental health services, 6 and the most at-risk populations-primarily young individuals-are already the least likely to seek help. 7,8 Finally, quarantine poses social and economic consequences, increasing the usual barriers to seeking care. 6 During previous lockdowns, young adults (aged 16-24 years) had been shown to be especially at risk of mental health issues. 9 During the initial stage of the COVID-19 epidemic, Wang et al 10 found that students in China were at a greater risk of stress, anxiety, and depression in response to the COVID-19 outbreak than older adults.
This raises the question of the mental health burden of the pandemic on quarantined university students in France and of the factors associated with this. To our knowledge, this study is the first nationwide survey dedicated to students during the COVID-19 pandemic. It was conducted to establish the prevalence of self-reported suicidal thoughts and symptoms of distress, stress, depression, and anxiety; to identify potential factors associated with these concerns; and to assess the rate at which students sought mental health care.

Study Design and Population
The study used data from the repeated cross-sectional university-based survey Conséquences du contexte pandémique sur la santé mentale des étudiant (COSAMe), which we began conducting nationally on April 17, 2020. Measurement intervals are planned for a period of 1 year.

Outcomes
We focused on the prevalence of the following 5 outcomes. First, we measured the prevalence of suicidal thoughts by asking participants whether they had experienced suicidal thoughts during the preceding month. Distress resulting from a traumatic life event was measured with the 22-item Impact of Events Scale-Revised (IES-R). 11 Participants rate the extent to which each item applies to their experiences during the preceding 7 days, from 0 to 4. The total score ranges from 0 to 88.
Thresholds established in the literature were as follows: normal distress level, 0 to 23; mild, 24 to 32; moderate, 33 to 36; and severe, greater than 36. 10 Third, we used the 10-item Perceived Stress Scale (PSS-10) to measure stress. Respondents rate how often each item applies to their experiences during the preceding month, from 0 to 4. The total score ranges from 0 to 40. 12 Thresholds used in the literature consider the stress level low for scores between 0 and 13; moderate, between 14 and 26; and high, greater than 26. 13, 14 We measured depression using the 13-item Beck Depression Inventory (BDI-13). Each question is rated from 0 to 3 to obtain a score ranging from 0 to 39. 15 The authors of the BDI-13 recommend using the following classification: 0 to 3 (no depression), 4 to 7 (mild depression), 8 to 15 (moderate depression), and greater than 15 (severe depression). 16 Anxiety was measured using the 20-item State-Trait Anxiety Inventory, State subscale (STAI Y-2). 17 Participants rate items from 1 to 4 to obtain a score ranging from 20 to 80. The intensity of the state of anxiety increases with the score. Thresholds used in the French literature are as follows: low, less than 46; moderate, between 46 and 55; and high, greater than 55. 18 Outcomes were the presence of severe self-reported symptoms, ie, the presence of suicidal thoughts or a high score on at least 1 scale (ie, IES-R >36; PSS-10 >26; BDI-13 >15; or STAI-Y2 >55). [10][11][12][13][14][15][16][17][18] Regarding the factors associated with mental health outcomes, we considered sociodemographic, economic, social, and health-related factors classically associated with mental disorders as well as factors associated more directly with the pandemic context (eg, reduction in physical activity, isolation, economic consequences, level of exposure to a stressful event). 3 were asked to indicate whether they sought treatment for mental health reasons during the quarantine and, if yes, whether they accessed the university medical service or another health professional.

Statistical Analysis
Only fully completed questionnaires were analyzed. First, we described the sample using medians with interquartile ranges (IQRs) for scores on measurement tools and quantitative covariates, given that they were mostly not normally distributed, and using numbers and percentages for the scores classified by level and other qualitative variables. Mental health outcome scores and distributions were described for the global sample and stratified by gender. Multivariable logistic regression analyses were performed to determine the potential risk factors of reporting at least 1 mental health outcome. Then, similar analyses were performed for each mental health outcome, ie, self-reported suicidal thoughts and severe self-reported symptoms of distress, stress, depression, and anxiety. All explanatory variables were included except age because of collinearity with the year of study.
Associations between risk factors and outcomes are presented as odds ratios (ORs) and 95% CIs.
Data analysis was performed using R version 3.6.1 (R Project for Statistical Computing). The significance level was set at α = .05, and all tests were 2-tailed.

Sample Characteristics
In total, 96 681 students opened the questionnaire.  Finally, participants rated the quality of the information related to COVID-19 and quarantine they received a median (IQR) score of 6 (4-7) of 10. They reported spending a median (IQR) of 20 (7-50) minutes a day accessing COVID-19 and quarantine information.

Mental Health Outcomes
The prevalence rates of self-reported suicidal thoughts and severe distress (IES-R), perceived stress (PSS-10), depression (BDI-13), and anxiety (STAI-Y2) were 11.4% (7891 students), 22 Concerning detailed outcomes, female and nonbinary genders were associated with an increased risk for all outcomes. Students just beginning their university education were at increased risk of self-reported suicidal thoughts, severe depression, or severe distress; the more advanced the students were, the less at risk. Concerning perceived stress and anxiety, an increased risk was identified among students in their second or third year and fourth or fifth year, whereas students in their sixth year or higher appeared less likely to report these symptoms. Being a foreign student was associated with a lower likelihood of self-reported suicidal thoughts and perceived stress but an increased risk of distress. For students living in the worst-hit areas, a slightly increased risk was observed for all outcomes except suicidal thoughts. Finally, living in rural areas was associated with a lower likelihood of self-reported suicidal thoughts and severe distress than living in an urban area.

Precariousness Indicators
Students who experienced a loss of income were at higher risk of reporting at least 1 mental health outcome compared with those who did not (OR, 1.28; 95% CI, 1.22-1.33; P < .001), and the lower the quality of the accommodation was, the higher the risk of experiencing mental health symptoms (medium quality vs high quality: OR, 1.66; 95% CI, 1.58-1.75; P < .001; low quality vs high quality: OR, 2.30; 95% CI, 2.06-2.57; P < .001). Similar results were found for all outcomes.

Health-Related Data
Reporting at least 1 outcome was associated with history of psychiatric follow-up (OR, 3.28; 95% CI, Concerning detailed outcomes, having children was associated with lower risk of all outcomes except severe distress. A higher level of worry was associated with an increased risk of all outcomes except suicidal thoughts; students reporting medium or high levels of worry had a lower risk of reporting suicidal thoughts. For other variables (housing conditions, feeling of integration, and quality of the social bonds), results were globally similar for each outcome.

Information and Media
The more time students spent consulting the news, the more likely they were to report at least 1

Use of Mental Health Care
Among all students, 4682 (6.8%) reported seeing a professional for mental health reasons, and 1037 (1.5%) reported having requested the university health service. Of the 29 564 students with at least 1 outcome, 3675 (12.4%) consulted a mental health professional, and 810 (2.7%) used the university service. The rates of mental health disorders are consistent with preliminary data recently reported among the Chinese general population during the initial stage of the COVID-19 epidemic, 10 and they appear to be higher than the estimates obtained among students before quarantine. Indeed, the results of a national survey conducted among French students in 2016 found that 15% reported a depressive episode in the last 4 weeks. 5 Here, we found that 16.1% reported severe symptoms of depression. The proportion reached 74.4% when considering mild to severe self-reported symptoms. The same survey found that 8% of students had suicidal thoughts during the last 12 months. 5 In the present study, the prevalence was at 11.4% during a shorter period of only 1 month.

Limitations
Some limitations should be considered in the interpretation of these results. First, although the number of respondents is large, it represents 4.3% of students contacted, and self-selection bias may have altered the results. There was notably an overrepresentation of women. Nevertheless, this problem is encountered in all large epidemiologic studies. 25 This justified the choice to stratify the prevalence results by gender. This overrepresentation was considered in the multivariate analysis; gender was included as a covariate. It has also been shown that a low response rate in epidemiological surveys only marginally affects prevalence and association measures. When the studies focus on stigmatized behaviors or diseases, it is difficult to recruit participants who are affected by those behaviors or diseases. 25,26 These results must be considered in the context of the acute phase of the pandemic, while people were quarantined at home. This appears particularly important for the interpretation of the high rate of severe self-reported distress symptoms evidenced here. Posttraumatic stress disorder is known to be a potential consequence of major disasters. In the study by Wang et al, 10 53.8% of participants reported moderate or severe symptoms of distress during the initial stage of the COVID-19 pandemic. Using the same threshold for the IES-R (ie, Ն33), we found 28.1%. These proportions are particularly high compared with the usual proportions of posttraumatic stress disorder in these countries (ie, <1%). 20,27 Therefore, it appears to support the concern expressed by Dutheil et al 28 about the risk of posttraumatic stress disorder as the second tsunami of the COVID-19 pandemic. 28 However, the IES-R is not a diagnostic tool, and diagnostic criteria for posttraumatic stress disorder require symptoms to last for more than 1 month. 29 Therefore, it would be important to determine whether posttraumatic stress disorder develops later, which is what is planned in the COSAMe study.
Furthermore, the present study cannot establish the direct association between the high rates of severe self-reported mental health symptoms and the COVID-19 pandemic and quarantine.
However, high rates were also found during previous quarantines and in China during the COVID-19 pandemic. 3,10

Conclusions
In this study, university students in France reported high rates of suicidal thoughts and severe symptoms of distress, depression, anxiety, and perceived stress while quarantined during the COVID-19 pandemic. Protecting the mental health of students is a public health issue that appears even more critical in the context of a pandemic. The results suggest that special attention must be paid to women and nonbinary students as well as students with a history of psychiatric follow-up. It also appears important to maintain contact with students, to ensure they have good quality housing conditions, to provide for their basic needs, to allow them to maintain physical activity and social ties, and to give them adequate information. Measures promoting access to care should be encouraged.