East Asian Arch Psychiatry 2023;33:21-7 | https://doi.org/10.12809/eaap2257
ORIGINAL ARTICLE
Abstract
Introduction: This study aims to investigate depressive symptoms and its association with resilience, pessimistic bias of COVID-19, lifestyle changes, and family conflicts among undergraduates in a Hong Kong university.
Methods: 1020 undergraduates in The University of Hong Kong completed the online survey between May and August 2020. Severity of depressive symptoms was assessed using the Patient Health Questionnaire-9. Resilience was assessed using the Connor-Davidson Resilience Scale. Pessimistic bias was assessed using two questions on the perceived risks of contracting COVID-19 and of dying from COVID-19. Changes in lifestyles and the presence of family conflicts were measured. Multivariable and mediation analyses were performed to examine association of depressive symptoms with other variables. Results: 61.7% of the respondents reported having mild to severe depressive symptoms. 18.5% of the variance in depressive symptoms was explained by resilience, pessimistic bias, changes in the frequency of sleep, studying at home, and family conflict. Pessimistic bias partially mediated the association between resilience and depressive symptoms.
Conclusion: The proportion of undergraduates with mild to severe depressive symptoms during the pandemic was high. Measures to reduce family conflict, maintain healthy daily habits, adjust pessimistic bias, and enhance resilience may help to improve the mental well-being of undergraduates during the pandemic.
Key words: COVID-19; Depression; Pessimism; Resilience, psychological
Gloria Hoi Yan Wong, The State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Hong Kong SAR, China
Sherry Kit Wa Chan, Department of Psychiatry, The University of Hong Kong, Hong Kong SAR, China
Address for correspondence: Dr Sherry Kit Wa Chan, Room 219, New Clinical Building, Department of Psychiatry, The University of Hong Kong, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong SAR, China. Email address: kwsherry@hku.hk
Submitted: 22 November 2022; Accepted: 13 March 2023
Introduction
The COVID-19 pandemic has a significant impact on the mental well-being of the general population.1,2 In March 2020, approximately one-third of the world’s population was under lockdown. Schools and universities were closed, and teaching was conducted online. The mental health of university students was significantly affected during the pandemic.3-5 Approximately 10% to 20% of psychiatric disorders occur in youth and young adults, with depression being the leading disorder.6
Resilience refers to the process of adapting to significant stressors and maintenance of mental wellness.7 Resilience is negatively associated with severity of depressive symptoms.8,9 Resilience helps individuals to cope with stresses associated with the pandemic.10
The Health Belief Model provides a framework to investigate the association of health-related behaviour with health beliefs.11 The perception of risks affects an individual’s engagement in preventive behaviour towards an illness. Most people tend to underestimate their risk of getting a disease, which is known as optimistic bias, which is associated with preventive measures taken during the pandemic.12-14 However, few studies examined how overestimation of the risk of COVID-19 (pessimistic bias) may affect mental health. In multiple cities in China, COVID-19 related pessimistic bias has been reported to be associated with higher levels of stress, anxiety, and depression.15 In 10th-grade students in Oman, resilience and pessimistic bias are negatively associated.16 The associations between resilience and pessimistic bias and mental well-being in young adults during the pandemic has yet to be examined.
In Hong Kong, on 25 January 2020, universities started online teaching. By late May, on-campus learning resumed with strict social distancing measures enforced. However, in late July 2020, further social restrictions including suspension of physical classes in universities were implemented, owing to a new wave of COVID-19 cases. In Hong Kong, both the social unrest that started in June 2019 and the pandemic affected the mental wellbeing of the general public.17 During the pandemic, people’s frequency of physical activities decreased, and the amount of time spent at home increased,18 which resulted in more family conflicts.19 In university students in Greece during the pandemic, sleep quantity increased, but sleep quality worsened.3
This study aims to determine the incidence of depressive symptoms and the associations between resilience and depressive symptoms and pessimistic bias in undergraduates from The University of Hong Kong during the COVID-19 pandemic. Lifestyle changes and family conflict as predictors of depressive symptoms were also determined after controlling for government response to the pandemic.
Methods
This cross-sectional survey was approved by the Human Ethics Research Committee of The University of Hong Kong (reference: EA2004023). Informed consent was obtained from each respondent. The survey was conducted anonymously using the Qualtrics software (Qualtrics, Provo [UT], United States). Between 16 May and 28 August 2020 during the period between the second wave and the third wave, invitation emails with a hyperlink to the questionnaire were sent to all undergraduates at The University of Hong Kong. Repeated emails (eight emails in total) were sent biweekly to improve the response rate. Those who accepted the invitation had 1 week to complete the survey. Multiple entries from the same respondent were not allowed. 99.6% of first-year full-time undergraduates were aged 16 to 24 years. Respondents aged 16 to 30 years were included, whereas responses with ambiguous demographic information were excluded.
Sociodemographic data (age, sex, marital status, and living conditions) were collected. Perceived safety in the residing community was assessed on a five-point Likert scale; higher scores indicate higher perceived community safety. In addition, respondents were asked if they knew someone under quarantine or had contracted COVID-19.
Severity of depressive symptoms over the past 2 weeks was assessed using the self-report Patient Health Questionnaire-9 (PHQ-9).20,21 Total score ranges from 0 to 27; higher scores indicate higher levels of depression severity: <5 minimal, 5 to 9 mild, 10 to 14 moderate, 15 to 19 moderately severe, and ≥20 severe.
Resilience was assessed using the 10-item self-report Connor-Davidson Resilience Scale (CD-RISC).22-25 Each item was rated on a five-point Likert scale. Total score ranges from 0 to 40; higher scores indicate higher levels of resilience.
Pessimistic bias towards COVID-19 was assessed using two questions: “I have a higher risk of contracting COVID-19 than others” and “I have a higher risk of dying than others if I have COVID-19”. Respondents were categorised into four groups based on their responses.26 Those who perceived having higher risks of both contracting COVID-19 and dying from COVID-19 were categorised as overall pessimistic; those who did not perceive having higher risks were categorised as overall optimistic; those who perceived having higher risk of dying from COVID-19 but not having higher risk of contracting COVID-19 was categorised as outcome pessimistic; and those who perceived having higher risk of contracting COVID-19 but not having higher risk of dying from COVID-19 was categorised as outcome optimistic.
COVID-19 knowledge was assessed using six questions about availability of cure and vaccine, infectiousness of asymptomatic patients, and measures to reduce the risk of contracting COVID-19 such as wearing a mask in public, conducting proper hand hygiene, and well- ventilated spaces. One point was given for every correct answer. Perceived recovery rate and death rate of COVID-19 were also assessed.
Frequency of exercise, studying at home, and sleep as well as frequency of family conflicts during the pandemic were assessed using slider questions with values ranging from -10 to 10. Negative and positive values indicate decrease and increase in the activities, respectively, whereas 0 indicates no change.
The stringency index of the government response to the pandemic was obtained from the Oxford Coronavirus Government Response Tracker. Total score ranges from 1 and 100; higher scores indicate higher stringency.27 The number of new confirmed COVID-19 cases in Hong Kong per week was obtained in the data.gov.hk website.28
The four pessimistic/optimistic bias groups were compared using the Chi-squared test or Kruskal-Wallis H test as appropriate. Associations between PHQ-9 and variables of interest were assessed using Spearman correlation (for continuous variables) and Mann-Whitney U test (for categorical variables). Multivariable analysis was performed to identify predictors for depression, after controlling for demographics and the stringency index of the government response to the pandemic. Pairwise deletion was used to account for incomplete data. A mediation analysis was conducted using the Lavaan Package version 0.6-7 in R (version 3.5.1) to determine the effect of pessimistic bias on the association between resilience and depression severity. Other analyses were conducted using SPSS (Windows version 25; IBM Corp, Armonk [NY], United States).
Results
Of 1178 undergraduates (6.8% of all undergraduates of the university enrolled in 2019/2020)29 responded to the online survey, 1020 (86.6%) fulfilled the inclusion criteria and were included in the analysis. Most respondents were female, single, and living with their family/partner. 61.7% of the respondents had mild to severe depressive symptoms. 13.9% of the respondents had pessimistic bias. 87.9% of respondents reported increase in studying at home; 66.8% of respondents reported increase in sleep; 58.4% of respondents reported increase in family conflict; and 49.3% of respondents reported decrease in exercise (Table 1).
The four pessimistic/optimistic bias groups were comparable in terms of sex and COVID-19 knowledge but differed significantly in terms of perceived recovery rate and death rate of COVID-19, perceived overall physical health, perceived safety in community, CD-RISC, and PHQ-9 (Table 2). After Bonferroni correction, there were significant differences in CD-RISC between the overall pessimistic group and the overall optimistic group (p < 0.001) and between the overall optimistic group and the outcome pessimistic group (p < 0.001), and in PHQ-9 between the overall pessimistic group and the overall optimistic group (p < 0.001), between the overall optimistic group and the outcome pessimistic group (p = 0.02), and between the overall pessimistic group and the outcome optimistic group (p = 0.02).
Depression symptom severity (PHQ-9) was negatively associated with age, resilience (CD-RISC), and perceived safety in the community, and positively associated with pessimistic bias, and frequency of sleep, studying at home, and family conflict (Table 3). In multivariate analysis, resilience, pessimistic bias, increase and decrease in sleep, decrease in studying at home, and increase in family conflict explained 18.5% of the variance in PHQ-9 (Table 4). Pessimistic bias partially mediated the association between resilience and depressive symptoms (Figure). Based on 10 000 bootstrap samples, the indirect effect was -0.04 (95% confidence interval = -0.06 to -0.01), which was significant. Higher resilience was associated with lower depressive symptoms even after adjusting for indirect effect of resilience through pessimistic bias (-0.31, p < 0.001).
Discussion
In 1020 undergraduates, 61.7% had mild to severe depression. The mean CD-RISC score for resilience was 22.9 ± 7.4, which is similar to the 23.8 ± 5.9 reported in undergraduate nursing students prior to the pandemic.25 The association between resilience and depression severity was partially mediated by pessimistic bias. More severe depressive symptoms were associated with lower resilience, more pessimistic bias, increase and decrease in sleep, increase in family conflict, and decrease in studying at home.
The proportion of undergraduates with severe depressive symptoms was 3.6%, which is higher than the 2.1% reported in a study before the pandemic.21 Although there were no significant associations between the number of COVID-19 cases, the stringency index of government policy, and the PHQ-9 score, the association between COVID-19 and mood among undergraduates may be indirect and delayed.5
Most undergraduates were optimistic about not contracting COVID-19 or dying from COVID-19; optimism helps in times of austerity.30 Undergraduates in the pessimistic bias group had more severe depressive symptoms and lower resilience. They were more likely to perceive having less safety in their community. Lower resilience was associated with more severe depressive symptoms, and the association was partially mediated by COVID-19-related pessimistic bias. In the general population in China, resilience was negatively associated with psychological distress, including depression, during the pandemic.8 Resilience is a predictor for mental health status in young adults.31,32 High resilience is associated with higher cognitive flexibility; individuals with low resilience tend to have negative cognitive bias.33,34 Positive expectations are associated with a reduced risk for depression.35 These findings suggest that adjusting the cognitive bias of undergraduates (taking into account their resilience level) may be an intervention target to improve mental well-being.
In the present study, undergraduates reported changes in lifestyle and family conflict during the pandemic. Increase in depressive symptoms was associated with increase and decrease in sleep, decrease in studying at home, and increase in family conflicts. This is consistent with a study reporting association between increased family conflict and higher level of depression during the pandemic.36 Family conflicts are a major stressor interacting with adverse life events to increase depression.37 In Hong Kong, the population density is high, and the average living space per person is 160 square feet.38 Given that 88.5% of the undergraduates were living with families, a study environment appropriate for effective online learning during the pandemic is essential to alleviate stresses of the students. Providing online training and tips on conflict management may also help improve familial relations. Only 8.7% of respondents reported a decrease in studying at home, which was associated with a higher level of depressive symptoms. Students with poor mental health may have less motivation to study in general and hence report a decrease in studying at home. Both increase and decrease in sleep were associated with higher depressive symptoms; however, the causality could not be determined owing to the cross-sectional nature of the study.
The present study had several limitations. The two questions to assess optimistic/pessimistic bias may be affected by other factors such as underlying health conditions. Furthermore, optimistic/pessimistic bias was examined as opposite on a continuum, but optimistic/pessimistic bias may be independent constructs that are related.39 Hence, further investigation to elucidate the concept of optimistic/ pessimistic bias using validated scales is warranted. The significantly more female respondents suggested a selection bias. The online survey may also incur selection and non-response bias, but this may be the most appropriate approach during the pandemic. The sample was from one university and comprised only 6.8% of undergraduates of the university. Thus, generalisation of study findings may be limited. In addition to frequency of sleep, quality and actual amount of sleep should have been assessed. The regression model only accounted for 18.5% of the variance of the depressive symptoms. This suggested involvement of other factors such as the impact of the pandemic on study in the university, social contacts, and economic downturns. These may affect family conflicts, and undergraduates’ previous relationships with their family were not assessed. Although duplicate entries were not allowed in Qualtrics, respondents could disable their cookies to assess the survey multiple times. The causal relationship between variables could not be established because of the nature of the cross-sectional study. The association between pessimistic bias and depressive symptoms could be bi-directional, as pessimistic thoughts could be a feature of depressive cognition. Future studies are warranted to examine the longitudinal relationships between variables and their causal relationships.
Conclusion
61.7% of undergraduates reported mild to severe depressive symptoms. More severe depressive symptoms were associated with lower resilience, pessimistic bias of COVID-19, increase in family conflict, decrease in studying at home, and increase and decrease in sleep. Pessimistic bias partially mediated the association between resilience and depressive symptoms. Measures to reduce family conflicts, maintain healthy daily habits, adjust cognitive bias, and improve resilience may help improve mental well-being of undergraduates during the pandemic.
Contributors
SKWC and GHYW designed the study. All authors acquired the data. MYS and SKWC analysed the data and drafted the manuscript. GHYW provided support with interpretation of the data. All authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.
Conflicts of interest
As the editor of the journal, SKWC was not involved in the peer review process. Other authors have disclosed no conflicts of interest.
Funding/support
This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Data availability
All data generated or analysed during the present study are available from the corresponding author on reasonable request.
Ethics approval
This study was approved by the Human Ethics Research Committee of the University of Hong Kong (reference: EA2004023).
References
- Ran MS, Gao R, Lin JX, et al. The impacts of COVID-19 outbreak on mental health in general population in different areas in China. Psychol Med 2022;52:2651-60. Crossref
- Talevi D, Socci V, Carai M, et al. Mental health outcomes of the CoViD-19 pandemic. Riv Psichiatr 2020;55:137-44.
- Kaparounaki CK, Patsali ME, Mousa DV, Papadopoulou EVK, Papadopoulou KKK, Fountoulakis KN. University students’ mental health amidst the COVID-19 quarantine in Greece. Psychiatry Res 2020;290:113111. Crossref
- Cao W, Fang Z, Hou G, et al. The psychological impact of the COVID-19 epidemic on college students in China. Psychiatry Res 2020;287:112934. Crossref
- Zhang Y, Zhang H, Ma X, Di Q. Mental health problems during the COVID-19 pandemics and the mitigation effects of exercise: a longitudinal study of college students in China. Int J Environ Res Public Health 2020;17:3722. Crossref
- Kieling C, Baker-Henningham H, Belfer M, et al. Child and adolescent mental health worldwide: evidence for action. Lancet 2011;378:1515-25. Crossref
- Southwick SM, Bonanno GA, Masten AS, Panter-Brick C, Yehuda R. Resilience definitions, theory, and challenges: interdisciplinary perspectives. Eur J Psychotraumatol 2014;5. Crossref
- Ran L, Wang W, Ai M, Kong Y, Chen J, Kuang L. Psychological resilience, depression, anxiety, and somatization symptoms in response to COVID-19: a study of the general population in China at the peak of its epidemic. Soc Sci Med 2020;262:113261. Crossref
- Ziaian T, de Anstiss H, Antoniou G, Baghurst P, Sawyer M. Resilience and its association with depression, emotional and behavioural problems, and mental health service utilisation among refugee adolescents living in South Australia. Int J Popul Res 2012;2012:485956. Crossref
- Killgore WDS, Taylor EC, Cloonan SA, Dailey NS. Psychological resilience during the COVID-19 lockdown. Psychiatry Res 2020;291:113216. Crossref
- Rosenstock IM. The Health Belief Model and preventive health behavior. Health Educ Monogr 1974;2:354-86. Crossref
- Park T, Ju I, Ohs JE, Hinsley A. Optimistic bias and preventive behavioral engagement in the context of COVID-19. Res Social Adm Pharm 2021;17:1859-66. Crossref
- Fontaine KR, Smith S. Optimistic bias in cancer risk perception: a cross-national study. Psychol Rep 1995;77:143-6. Crossref
- Bottemanne H, Morlaàs O, Fossati P, Schmidt L. Does the coronavirus epidemic take advantage of human optimism bias? Front Psychol 2020;11:2001. Crossref
- Wang C, Pan R, Wan X, et al. A longitudinal study on the mental health of general population during the COVID-19 epidemic in China. Brain Behav Immun 2020;87:40-8. Crossref
- Alkhawaja AS, Alshabibi ISA. Optimism and pessimism during coronavirus pandemic and its relationship with psychological resilience on a sample of tenth grades students in Al-Sharqiya North at Sultanate of Oman. J Educ Psychol Sci 2021;5:151-63. Crossref
- Ni MY, Yao XI, Leung KSM, et al. Depression and post-traumatic stress during major social unrest in Hong Kong: a 10-year prospective cohort study. Lancet 2020;395:273-84. Crossref
- Wang J, Yeoh EK, Yung TKC, et al. Change in eating habits and physical activities before and during the COVID-19 pandemic in Hong Kong: a cross-sectional study via random telephone survey. J Int Soc Sports Nutr 2021;18:33. Crossref
- Li AC, Cheung PCG, Lee KCG. The situation in Hong Kong during the COVID-19 pandemic. Psychol Trauma 2020;12:576-8. Crossref
- Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med 2001;16:606-13. Crossref
- Lun KW, Chan CK, Ip PK, et al. Depression and anxiety among university students in Hong Kong. Hong Kong Med J 2018;24:466-72. Crossref
- Campbell-Sills L, Stein MB. Psychometric analysis and refinement of the Connor-Davidson Resilience Scale (CD-RISC): validation of a 10-item measure of resilience. J Trauma Stress 2007;20:1019-28. Crossref
- She R, Yang X, Lau MMC, Lau JTF. Psychometric properties and normative data of the 10-item Connor–Davidson Resilience Scale among Chinese adolescent students in Hong Kong. Child Psychiatry Hum Dev 2020;51:925-33. Crossref
- Notario-Pacheco B, Solera-Martínez M, Serrano-Parra MD, Bartolomé-Gutiérrez R, García-Campayo J, Martínez-Vizcaíno V. Reliability and validity of the Spanish version of the 10-item Connor- Davidson Resilience Scale (10-item CD-RISC) in young adults. Health Qual Life Outcomes 2011;9:63. Crossref
- Chow KM, Tang WKF, Chan WHC, Sit WHJ, Choi KC, Chan S. Resilience and well-being of university nursing students in Hong Kong: a cross-sectional study. BMC Med Educ 2018;18:13. Crossref
- Asimakopoulou K, Hoorens V, Speed E, et al. Comparative optimism about infection and recovery from COVID-19; implications for adherence with lockdown advice. Health Expect 2020;23:1502-11 Crossref
- Hale T, Angrist N, Emily CB, et al. Coronavirus Government Response Tracker. Blavatnik School of Government. Oxford COVID- 19 Government Response Tracker. Available from: https://www.bsg.ox.ac.uk/research/research-projects/coronavirus-government-response-tracker#data.
- Department of Health. Data in Coronavirus Disease (COVID-19). Available from: https://data.gov.hk/en-data/dataset/hk-dh-chpsebcddr-novel-infectious-agent.
- The University of Hong Kong. Enrolment of Students on All Programmes in Headcount 2019 / 2020. Available from: https://www.cpao.hku.hk/qstats/student-profiles.
- Nikunen M, Korvajärvi P. Being positive, being hopeful, being happy: young adults reflecting on their future in times of austerity. Eur J Cult Stud 2020;25:136754942093590. Crossref
- Satici SA. Psychological vulnerability, resilience, and subjective well-being: the mediating role of hope. Pers Individ Dif 2016;102:68-73. Crossref
- Goldstein AL, Faulkner B, Wekerle C. The relationship among internal resilience, smoking, alcohol use, and depression symptoms in emerging adults transitioning out of child welfare. Child Abuse Negl 2013;37:22-32. Crossref
- Hoorelbeke K, Marchetti I, De Schryver M, Koster EH. The interplay between cognitive risk and resilience factors in remitted depression: a network analysis. J Affect Disord 2016;195:96-104. Crossref
- Hildebrandt LK, McCall C, Engen HG, Singer T. Cognitive flexibility, heart rate variability, and resilience predict fine-grained regulation of arousal during prolonged threat. Psychophysiology 2016;53:880-90. Crossref
- Kleiman EM, Chiara AM, Liu RT, Jager-Hyman SG, Choi JY, Alloy LB. Optimism and well-being: a prospective multi-method and multi- dimensional examination of optimism as a resilience factor following the occurrence of stressful life events. Cogn Emot 2017;31:269-83. Crossref
- Guo Y, Cheng C, Zeng Y, et al. Mental health disorders and associated risk factors in quarantined adults during the COVID- 19 outbreak in China: cross-sectional study. J Med Internet Res 2020;22:e20328. Crossref
- Avison WR. Family structure and women’s lives: a life course perspective. In: Avison WR, Aneshensel CS, Schieman S, Wheaton B, editors. Advances in the Conceptualization of the Stress Process: Essays in Honor of Leonard I Pearlin. New York: Springer; 2010:71-92. Crossref
- Stevenson A, Wu J. Tiny apartments and punishing work hours: the economic roots of Hong Kong’s protests. New York Times. Available from: https://www.nytimes.com/interactive/2019/07/22/world/asia/hong-kong-housing-inequality.html
- Kubzansky LD, Kubzansky PE, Maselko J. Optimism and pessimism in the context of health: bipolar opposites or separate constructs? Pers Soc Psychol Bull 2004;30:943-56. Crossref