Journal of Affective Disorders Reports 5 (2021) 100179

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Journal of Affective Disorders Reports

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Research Paper

Prevalence and socio-demographic correlates of depression, anxiety, and

co-morbidity during COVID-19: A cross-sectional study among public and
private university students of Bangladesh
Jeenat Mehareen a, 1, *, Mahir A. Rahman b, Tahia Anan Dhira c, Abdur Razzaque Sarker b
a
Department of Economics, East West University, A/2, Jahurul Islam Avenue, Jahurul Islam City, Aftabnagar, Dhaka 1212, Bangladesh
b
Bangladesh Institute of Development Studies, E-17 Agargaon, Sher-e- Bangla Nagar, Dhaka 1207, Bangladesh
c
Department of Economics, University of Dhaka, Dhaka 1000, Bangladesh

A B S T R A C T

Background: COVID-19 has significantly impacted the mental health of students. However, in the context of Bangladesh, no study has explored whether students from
public and private universities have been affected differently. Therefore, the aim of the study is to focus on the prevalence of depression, anxiety, and co-morbidity
among both types of university students and identify their potential correlates.
Methods: The study applied convenience sampling to collect data from 333 university students. Patient Health Questionnaire-9 (PHQ-9) and General Anxiety
Disorder-7 (GAD-7) were used to assess depression and anxiety respectively along with co-morbidity. Descriptive analysis and multivariate logistic regression were
conducted to examine the association of variables.
Results: Among public university students, 59.16% had depression, 53.99% had anxiety and 46.95% had co-morbidity ranging from moderate to severe level. 30.83%,
33.33% and 24.17% of the private university students showed moderate to severe levels of depression, anxiety, and co-morbidity respectively. Overall, female
students, students enrolled in third and fourth year, living in nuclear families, and students who spent less time with family reported having higher level of
depression, anxiety, and co-morbidity.
Limitations: Due to the cross-sectional nature of the study, we were unable to make causal inferences. Also, data collected through snowball-sampling were prone to
selection bias.
Conclusions: COVID-19 pandemic imposes a greater burden on mental health of students with different socioeconomic characteristics and university type. Therefore,
appropriate psychological interventions are needed to address these differences.

1. Introduction other crowded spaces (Anderson et al., 2020; Nussbaumer-Streit et al.,

The novel Coronavirus (SARS-CoV2), or COVID-19 is the most recent
pandemic to affect the human race. Since the first recorded case of the
disease in the province of Wuhan, China in December, 2019, it has
spread worldwide and was declared a pandemic by the World Health
Organization (WHO) in March, 2020 (Mahase, 2020). As of November,
2020, COVID-19 has claimed the lives of about 1.3 million people
worldwide, while cases of infection are numbered at about 57.8 million
(World Health Organization, 2020a). Chances of infection by COVID-19
is higher when people are in close physical proximity to each other
(World Health Organization, 2020b). As a result, preventive measures to
minimize close contact among individuals include social and physical
distancing through methods of quarantines, lockdown measures like
travel restrictions, closure of educational institutions, workplaces and
2020). Apart from the possible fatal impact of COVID-19 on physical
health, the continuation of lockdown induced a new wave of mental
health issues due to isolation, loss of income, fear, bereavement, etc.
(Mortazavi et al., 2020). Besides, COVID-19 infection itself can lead to
neurological and mental health complications, such as delirium, agita­
tion, and stroke (World Health Organisation, 2020). Hence, the conse­
quences of COVID-19 pandemic on mental health have received much
attention among public health experts (Amerio et al., 2020; Holmes
et al., 2020). Adverse impacts of epidemics and/or pandemics on mental
health is well-established in the literature. Studies on earlier global in­
fectious disease outbreaks, such as the Severe Acute Respiratory Syn­
drome (SARS) and the Middle East respiratory syndrome (MERS) have
indicated that the spread of infectious disease is linked to deteriorating
mental health within and across populations (Jeong et al., 2016; Lee

* Corresponding author.
E-mail address: jeenat.mehareen@ewubd.edu (J. Mehareen).
1
ORCID: 0000-0001-9433-202X.

https://doi.org/10.1016/j.jadr.2021.100179
Received 21 December 2020; Received in revised form 11 February 2021; Accepted 13 June 2021
Available online 16 June 2021
2666-9153/© 2021 The Author(s). Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
J. Mehareen et al.
et al., 2007, 2018; Robertson et al., 2004).
Among mental health disorders, depression and anxiety globally
affect about 264 million and 284 million people, respectively (World
Health Organization, 2017). In the context of COVID-19, evidence
regarding increasing prevalence of depression and anxiety symptoms
has been found by several studies (Bueno-Notivol et al., 2020; Pappa
et al., 2020; Rajkumar, 2020; Pablo et al., 2020). Indeed, it has been
observed that quarantine during the COVID-19 pandemic has increased
individuals’ stress and has aggravated feelings of fear, anger, guilt and
panic which can trigger many forms of mental distress (Ahorsu et al.,
2020; Mukherjee et al., 2020; Qiu et al., 2020; Torales et al., 2020; White
and Van Der Boor, 2020; Zhang and Ma, 2020; Islam et al., 2020c).
Therefore, the pertinence of analyzing the status of mental health during
COVID-19 is beyond question.
Owing to the vulnerability of students during lockdown, a few
studies have also specifically focused on the impact of COVID-19 on the
mental health of students (Akdeniz et al., 2020; Sahu, 2020). Given that
educational institutions remain closed and students have been advised
to stay at home during lockdown, their mental health can be affected in
several ways: i) lack of direct interactions with friends and classmates,
ii) uncertainty regarding completion of degree and career path (Sun­
darasen et al., 2020), iii) fear and stress due to possibility of getting
infected (Mamun et al., 2021), iv) financial distress arising from loss of
earning from jobs (Paul and Moser, 2009), and v) exposure to increasing
rate of domestic violence due to stay-at-home lifestyle (Pelcovitz et al.,
2000), etc. Carlos et. al (2020) observed a higher prevalence of anxiety
and depression among medical students (Sartor et al., 2020). Another
web-based study targeting university employees in USA observed that
the COVID-19 pandemic has had a negative effect on mental health and
well-being among both clinical and non-clinical workers (Evanoff et al.,
2020). Similar evidence has been found in studies where mental health
of college students was evaluated (Cao et al., 2020; Son et al., 2020).
To tackle the spread of COVID-19, lockdown measures including
closure of all educational institutions were imposed in Bangladesh on
March 16, 2020. Consequently, around 40.28 million students who are
studying in various primary, secondary, and tertiary educational in­
stitutions were confined in their homes during the ongoing COVID-19
pandemic (BANBEIS, 2017; Directorate of Primary Education, 2020).
A couple of studies during the pandemic targeting Bangladeshi adults
(Banna et al., 2020) as well as university students (Islam et al., 2020a)
observed higher prevalence rates of both depression and anxiety
symptoms compared to studies conducted before COVID-19 (Hossain
et al., 2014; Mamun et al., 2019). Against this backdrop, this paper
sought to identify the prevalence of depression and anxiety symptoms
among university students of Dhaka, Bangladesh using internationally
recognized and validated screening tools (Ahmad et al., 2018; Kocale­
vent et al., 2013). The study added several novelties to the literature.
Firstly, we analyzed the prevalence and levels of depression and anxiety
symptoms separately among students. We additionally employ
co-morbidity measure to detect simultaneous prevalence of both
symptoms. Secondly, we have explored whether prevalence and severity
of these symptoms differ across students from public and private uni­
versities. Therefore, we examined variation in socioeconomic correlates
along with university type to address the effect on these major psy­
chological disorders.
2. Methods
2.1. Procedure and participants
A cross-sectional survey design was used to assess the mental health
of the target population of university students during COVID-19
pandemic. Data collection took place in between the period of July
18th, 2020 to July 31st, 2020 using the survey administration software
Google Form (Rayhan et al., 2013). A snowball sampling strategy was
utilized in order to capture both public and private university students.
2
Journal of Affective Disorders Reports 5 (2021) 100179
To be eligible for the study, the participants had to meet the following
criteria: (a) be willing to participate in the study; (b) be enrolled in any
public or private university in Bangladesh; (c) have internet access; and
(d) be able to read, write, and comprehend the questionnaire which is
written in English. The sample is significant based on the sample size
2
calculation formula: n= z p(1− p)
; where, n is the sample size, z is the
e2
selected critical value of the desired confidence level, p is the estimated
proportion of an attribute that is present in the population, and e is the
desired level of precision. Bangladesh has roughly 1.3 million students
currently pursuing higher education in 47 public and 107 private uni­
versities (LightCastle Analytics Wing, 2019; List of Private Universities,
2020; List of Public Universities, 2020). Considering this population, we
calculated the sample size to be 384 where margin of error was 5%,
confidence level was 95%, and response distribution was 50%. After
excluding the response forms that were submitted within the time frame
but contained missing data, 333 participants from two public and three
private universities were included in the final analysis. Students from
these universities were most likely to have access to a suitable internet
connection owing to their residential location and used English as mode
of learning, so it was convenient for us to reach them during country­
wide lockdown and to identify their mental health status.
We shared the questionnaire (Google Form link) with faculty mem­
bers and/or departmental heads of Department of Economics from the
selected universities and asked them to distribute the questionnaire
(Google form link) in their respective classrooms either via e-mail or
through any course material sharing platform that they were using for
communication. We also asked them to encourage the students to pass
on the survey link among their classmates to ensure maximum data
collection.
2.2. Survey instrument
The questionnaire consisted of 47 questions and was divided into two
sections: demographic and socioeconomic characteristics followed by
questions which assessed the participants’ depression and anxiety
severity. Queries on demographic covariates including age, gender,
residential location during pandemic, average monthly income, and
household size, etc. were answered by participants. Respondents also
stated the type of university they are attending along with current
enrollment level (undergraduate or graduate study). In addition, there
were queries about the respondents’ smoking habits as well as their
experience on domestic violence, if any, during the pandemic.
The original (English) version of the self-administered Patient Health
Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7)
was used for measuring depression and anxiety, respectively (Ahmad
et al., 2018; Kocalevent et al., 2013). The PHQ-9 assesses the frequency
and severity of symptoms of depression using nine 4-point Likert-scaled
items ranging from 0 (not at all) to 3 (nearly every day) (Kroenke et al.,
2001). A total score ranging from 0 to 27 is obtained by summing across
all items. As a cut point of 10 or greater had a sensitivity of 88% and a
specificity of 88% for major depression, we categorized the outcome
variable of depression by this threshold score to differentiate between
minimal/mild versus moderate/severe depression (Kroenke et al., 2010,
2009, 2001).
The GAD-7 includes seven items to measure the frequency and
severity of anxiety disorder symptoms with a response format similar to
PHQ-9 such that the total score ranges from 0 to 21 (obtained by sum­
ming all items) (Spitzer et al., 2006). Identical to PHQ-9 (Depressed
when PHQ-9>=10), to optimize the test’s sensitivity and specificity for
diagnosing generalized anxiety disorder, we used the cut point of 10
(Anxious when GAD-7>=10) as an outcome variable for GAD (Kroenke
et al., 2010; Löwe et al., 2008). In addition, using the same cut-off
scores, co-morbidity (PHQ-9>=10 and GAD-7>=10) was used to
document the existence and severity of both these disorders.
PHQ-9 and GAD-7 scales are proven to be reliable and relevant for
J. Mehareen et al. Journal of Affective Disorders Reports 5 (2021) 100179

assessing mental health of the general population (Bártolo et al., 2017;
Loewe et al., 2008), and specifically university students (Adewuya et al.,
2006; Kim and Lee, 2019; Lee and Kim, 2019). Additionally, both before
and during COVID-19 pandemic, these two scales have been used in
numerous studies to determine the psychological impact and thus was
deemed most appropriate for use in the current study (Choi et al., 2020;
dos Santos et al., 2019; Paz et al., 2020; Quon et al., 2015; Shittu et al.,
2014; Islam et al., 2020b). In this regard, Cronbach’s alpha value of
0.827 and 0.905 respectively for PHQ-9 and GAD-7 indicate the reli­
ability of both scales for our study (Supplementary Table).
2.3. Statistical analysis
Statistical analysis was performed in two phases. First, we carried out
a descriptive analysis to illustrate the demographic and other selected
characteristics of the respondents (Table 1). Frequency table summa­
rized basic information of the participants using categorical variables.
Chi-square test was then applied to explore the statistical significance of
associations between sample characteristics and the prevalence of
depression, anxiety, and co-morbidity symptoms. Additionally, fre­
quency tabulation was used to summarize the overall percentage of
students in the sample where severity of depression, anxiety and co-
morbidity was addressed. Simultaneously, proportion test was con­
ducted to evaluate the association of the different levels of mental health
disorders with university type, namely public and private university
(Table 2).
Second, to explore factors associated with the occurrence of
depression, anxiety, and co-morbidity, we preformed both univariate
and multivariate logistic regression models using the binary outcomes of
PHQ-9, GAD-7 and co-morbidity as dependent variables, respectively.
The estimates of the strengths of associations were demonstrated by
both adjusted and unadjusted odds ratio (OR) with a 95% confidence
interval (CI) (Table 3). Data cleaning, validation, and all statistical an­
alyses were performed using Stata/SE 15.0 (StataCorp, College Station,
TX, USA).
2.4. Ethical considerations
Ethical permission for data collection was taken from respective
faculty and department heads of the universities where the question­
naire was distributed. Furthermore, the research is approved by the
Department of Economics, East West University. Before responding
anonymously to the online survey, all participants voluntarily gave their
informed consent to participate in the study. In the consent form,

Table 1
Demographic and socio-economics characteristics and association with depression, anxiety, and co-morbidity.
Variables Categories % in the Depression P Anxiety P Co-morbidity P
sample (%) (%) (%)
(PHQ-9>=10) (GAD-7>=10) (PHQ-9>=10 and GAD-
7>=10)

Gender Male 48.05 41.04 0.003 39.31 0.006 33.53 0.042

Female 51.95 57.5 54.38 44.38
Age 18–22 years 77.78 49.81 0.558 49.42 0.049 40.54 0.207
23–27 years 22.22 45.95 36.49 32.43
Type of University Public University 63.96 59.15 0 53.99 0 46.95 0
Private University 36.04 30.83 33.33 24.17
Level of Education First year 25.53 24.71 0 28.24 0 18.82 0
Second year 12.01 54 50 36
Third year 11.71 61.34 60.5 54.62
Fourth year 15.02 57.5 47.5 45.00
Masters 35.74 48.72 38.46 30.77
Type of dwelling during COVID-19 Apartment 79.58 48.68 0.833 44.91 0.473 36.98 0.423
Hostel/ Mess 15.62 51.92 51.92 46.15
Other Temporary 4.80 43.75 56.25 43.75
accommodation
Joint Family Yes 19.52 35.38 0.015 33.85 0.022 27.69 0.042
No 80.48 52.24 49.63 41.42
Family Size <=4 members 51.35 53.8 0.069 49.71 0.235 43.27 0.081
>4 members 48.65 43.83 43.21 33.95
Siblings in the family Yes 93.99 49.52 0.409 46.96 0.545 38.98 0.723
No 6.01 40.00 40.00 35.00
Principal Source of Income Government Service Holder 27.63 51.09 0.251 47.83 0.01 39.13 0.1
Organized Trade/Business 24.32 38.27 30.86 27.16
Pension/ Rent 16.22 50 46.3 38.89
Private Service Holder 29.43 55.1 57.14 46.94
Others 2.4 50 62.5 50
Family monthly income <25,000 BDTa 16.22 44.44 0.337 44.44 0.742 37.04 0.966
25,000–54,999 BDTa 43.24 54.17 46.53 39.58
55,000–99,999 BDTa 27.33 42.86 50.55 37.36
>=1,00,000 BDTa 13.21 50 40.91 40.91
Household economic condition during Very poor 2.7 66.67 0.001 66.67 0.004 66.67 0.004
Covid-19 Poor 31.83 58.49 53.77 46.23
Average 51.65 49.42 47.09 38.37
Good 11.41 23.68 28.95 21.05
Excellent 2.4 12.5 0 0
Most time spent during lockdown (ref: Alone 24.92 62.65 0.006 65.06 0.001 55.42 0.001
Alone) Family 64.26 42.06 38.79 30.84
Friends 9.31 61.29 51.61 48.39
Pets 1.5 40 40 40
Smoker Yes 22.82 47.37 0.754 47.37 0.87 42.11 0.493
No 77.18 49.42 46.3 37.74
Domestic violence in family Yes 9.31 54.84 0.491 54.84 0.331 51.61 0.122
No 90.69 48.34 45.7 37.42
a
Abbreviation: BDT (Bangladeshi Taka).

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J. Mehareen et al. Journal of Affective Disorders Reports 5 (2021) 100179

Table 2 3.2 Prevalence of depression, anxiety, and co-morbidity by university type

Prevalence of depression, anxiety, and co-morbidity by university type.
I II III IV We observe that the mental health of university students was affected
Overall N Private Public Difference to varying degrees during the outbreak (Table 2). Of the 333 university
(%) University University (II-III) (%) students, about 18% had no or minimal symptoms of depression and
(%) (%)
24% had no or minimal symptoms of anxiety. Moreover, 163 students
Categorized had depressive symptoms (48.95%),155 students had anxiety symptoms
PHQ-9 scores (46.55%), 129 students were found to have co-morbidity (38.74%),
Minimal 59 25.83 13.15 12.68***
Depression (17.72)
ranging from moderate to severe level.
Mild Depression 111 43.33 27.7 15.63*** Additionally, Table 2 reveals the severity of depression, anxiety, and
(33.33) co-morbidity across public and private university students. Among
Moderate 70 15.83 23.94 -8.11* public university students, 59.16% showed moderate to severe depres­
Depression (21.02)
sion symptoms and 53.99% had moderate to severe symptoms of anxi­
Moderately 58 10 21.6 -11.6***
Severe (17.42) ety. These rates were much higher when compared to those of private
Depression university students. We found that 30.83% private university students
Severe 35 5 13.62 -8.62** had depressive symptoms and 33.33% had anxiety symptoms, ranging
Depression (10.51) from moderate to severe level. The results are statistically significant
Categorized
with the exception of moderate level of anxiety (Column IV, Table 2). In
GAD-7 scores
Minimal anxiety 81 30.83 20.66 10.18** consistence with the results for depression and anxiety severity, we
(24.32) observe that a higher percentage of public university students (46.95%)
Mild anxiety 97 35.83 25.35 10.48** suffered from moderate to severe co-morbidity compared to private
(29.13)
university students (24.17%) and the difference was statistically sig­
Moderate anxiety 64 17.5 20.19 -2.69
(19.22) nificant (p<0.01).
Severe anxiety 91 15.83 33.8 -17.97***
(27.33) 3.3. Multivariate logistic regression model to determine factors associated
Co-morbidity with depression, anxiety, and co-morbidity
Scores
PHQ-9<10 and 204 75.83 53.05 22.78***
GAD-7<10 (61.26) Table 3 shows the covariates associated with depression, anxiety and
PHQ-9>=10 and 129 24.17 46.95 -22.78*** co-morbidity based on the socioeconomic and demographic character­
GAD-7>=10 (38.74) istics of the participants. We observe that, female students had higher
***
p<0.01. chances of suffering from moderate to severe depression (aOR: 1.975;
**
p<0.05. 95% CI: 1.218, 3.202; p<0.01), anxiety (aOR: 1.881; 95% CI: 1.173,
*
p<0.1. 3.016; p<0.01) and co-morbidity (aOR: 1.565; 95% CI: 0.962, 2.544;
p<0.1) symptoms while comparing with male students. Students from
participants were provided with information concerning the purpose, the older age group (>=23 years) were found to have less depressive
procedure and nature of the study, the option to take part as well as the (aOR: 0.463; 95% CI: 0.216, 0.990; p<0.05) as well as anxiety symptoms
right to revoke their data at any point of the study. The procedures of (aOR: 0.804; 95% CI: 0.638, 1.012; p<0.1) in contrast to the younger
this study complied with the provisions of the Declaration of Helsinki age group (<=22 years). Assessing by university type, we observe that
(1989) regarding research on human participants. students from public university had significantly higher probability to
suffer from depression (aOR: 1.886; 95% CI: 0.922, 3.857; p<0.1). The
3. Results results were also analogous for anxiety and co-morbidity, but
insignificant.
3.1. Demographic and socioeconomic characteristics and association with Additionally, to explore the severity of mental health disorders, we
depression, anxiety, and co-morbidity compared all successive years of university study in reference to first
year. Students from all other undergraduate years were more likely to
Distribution of participants and the depression and anxiety preva­ suffer from depression (p<0.05). In particular, as opposed to first-year
lence rates across demographic and socioeconomic variables is pre­ students, second- (p<0.1) and third-year (p<0.05) students suffered
sented in Table 1. Of the 333 university students, more female students more from anxiety and third- (p<0.01) and fourth-year (p<0.05) stu­
(52%) participated in this study and the mean age of all respondents was dents experienced higher co-morbidity. Specifically, among all tertiary
21.49 years (SD 1.567). Almost one-third of the students were from level students, participants from third year had the highest odds of
public university (63.96%) and undergraduate students (64.27%) made suffering from depression (aOR: 3.078; 95% CI: 1.269, 7.464; p<0.05),
up majority of the sample. Four out of five students lived in apartments anxiety (aOR: 2.849; 95% CI: 1.195, 6.789; p<0.05) and co-morbidity
(79.58%) and half of the students lived in nuclear families (<=4 (aOR: 3.889; 95% CI: 1.551, 9.750; p<0.01).
members) (51.35%). Most of the students were non-smokers (77.18%) Students who live in joint families were less likely to suffer from
and faced no domestic violence (90.69%) during lockdown period. moderate to severe depression (aOR: 0.507; 95% CI: 0.271, 0.951;
Chi-square test indicated that students’ gender (p<0.01), the type of p<0.05), anxiety (aOR: 0.511; 95% CI: 0.274, 0.954; p<0.05) and co-
university they are attending (p=0), their current undergraduate/ morbidity (aOR: 0.511; 95% CI: 0.265, 0.987; p<0.05) counter to
graduate enrollment year (p=0), family size and structure (p<0.1), those who do not. Likewise, students who live in nuclear families (<=4
perception regarding economic condition (p<0.01) and their choice of members) were significantly more likely to suffer from moderate to se­
companion during lockdown (p<0.01) were potential factors related to vere depression (aOR: 1.676; 95% CI: 1.036, 2.711; p<0.05) as well as
depression, anxiety and also co-morbidity. Moreover, age (p=0.049) co-morbidity (aOR: 1.705; 95% CI: 1.049, 2.773; p<0.05). Furthermore,
and principal source of income (p=0.01) were found to be contributing we observe that students’ own assessment of their families’ financial
factors to anxiety and family size was linked to depression and co- situation had significant impact on the prevalence of moderate to severe
morbidity. depression, anxiety, and co-morbidity. Students who perceive their
families’ economic condition as poor and very poor were more prone to
having higher levels of depression (poor: p<0.01; very poor: p<0.05),

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J. Mehareen et al. Journal of Affective Disorders Reports 5 (2021) 100179

Table 3
Multivariate logistic regression model to determine factors associated with depression, anxiety, and co-morbidity.
Variables Depression (PHQ-9>=10) Anxiety (GAD-7>=10) Co-morbidity (PHQ-9>=10 and GAD-7>=10)
Model I Model II Model III Model IV Model V Model VI
Un-adj. OR(95% Adj. OR(95% CI) Un-adj. OR(95% Adj. OR(95% CI) Un-adj. OR(95% CI) Adj. OR(95% CI)
CI) CI)

Gender (ref. male) 1.944*** 1.975*** 1.84*** 1.881*** 1.582** 1.565*

(1.257–3.006) (1.218–3.202) (1.190–2.845) (1.173–3.016) (1.015–2.465) (0.962–2.544)
Age (ref. 18–22 years) 0.857 0.463** 0.588* 0.804* 0.704 0.844
(0.510–1.438) (0.216–0.990) (0.345–1.001) (0.638–1.012) (0.408–1.216) (0.666–1.070)
Type of University (ref: Private 3.249*** 1.886* 2.347*** 1.394 2.778*** 1.438
University) (2.022–5.219) (0.922–3.857) (1.474–3.740) (0.685–2.837) (1.689–4.565) (0.691–2.990)
Level of education (ref: First year)
Second year 3.578*** 2.798** 2.542** 2.119* 2.426** 2.066
(1.702–7.522) (1.140–6.866) (1.227–5.265) (0.883–5.082) (1.097–5.362) (0.804–5.307)
Third year 4.836*** 3.078** 3.894*** 2.849** 5.191*** 3.889***
(2.613–8.952) (1.269–7.464) (2.140–7.084) (1.195–6.789) (2.703–9.970) (1.551–9.750)
Fourth year 4.123*** 2.828** 2.3** 1.934 3.528*** 2.815**
(1.857–9.153) (1.073–7.455) (1.054–5.016) (0.746–5.015) (1.543–0.067) (1.038–7.631)
Master (Graduate) 2.895*** 1.526 1.589 1.031 1.917 1.297
(1.303–6.432) (0.541–4.303) (0.714–3.534) (0.368–2.895) (0.802–4.478) (0.433–3.887)
Joint family (ref: No) 0.501** 0.507** 0.519** 0.511** 0.542** 0.511**
(0.285–0.878) (0.271–0.951) (0.295–0.915) (0.274–0.954) (0.299–0.982) (0.265–0.987)
Family Size (ref: member >4) 1.493* 1.676** 1.3 1.381 1.484* 1.705**
(0.969–2.300) (1.036–2.711) (0.843–2.001) (0.866–2.202) (0.952–2.314) (1.049–2.773)
Average monthly income (ref:
<25,000 BDT)
25,000–54,999 BDT 1.477 1.639 1.088 1.128 1.114 1.236
(0.787–2.771) (0.823–3.265) (0.580–2.040) (0.573–2.219) (0.584–2.124) (0.614–2.488)
55,000–99,999 BDT 0.938 0.866 1.278 1.196 1.014 0.976
(0.476–1.848) (0.415–1.809) (0.650–2.512) (0.580–2.464) (0.505–2.035) (0.461–2.067)
>=1,00,000BDT 1.25 1.456 0.865 0.886 1.177 1.32
(0.563–2.777) (0.600–3.537) (0.387–1.937) (0.369–2.126) (0.520–2.662) (0.530–3.235)
Household economic condition
during Covid-19 (ref: Excellent)
Good 1.61 1.813 7.109 11.088 4.738 6.579
(0.241–10.759) (0.260–12.638) (0.378–133.670) (0.552–222.596) (0.248–90.672) (0.332–130.121)
Average 4.886* 6.972** 15.142* 27.422** 10.615 17.400*
(0.825–28.919) (1.108–43.863) (0.861–266.45) (1.449–518.891) (0.603–186.943) (0.949–319.164)
Poor 7.022** 13.033*** 19.747** 42.604** 14.635* 29.199**
(1.167–42.259) (1.982–85.687) (1.111–350.850) (2.195–826.756) (0.824–260.014) (1.553–548.917)
Very poor 9.286** 19.842** 31.571** 79.872*** 31.571** 70.835***
(1.047–82.32) (1.967–200.167) (1.374–725.201) (3.072–2076.61) (1.374–725.201) (2.798–1793.565)
Most time spent during lockdown
(ref: Alone)
Family 0.359*** 0.388*** 0.340*** 0.297*** 0.359*** 0.330***
(0.213–0.604) (0.215–0.698) (0.201–0.577) (0.165–0.532) (0.213–0.604) (0.184–0.589)
Friends 0.754 0.979 0.573 0.586 0.754 0.806
(0.330–1.724) (0.393–2.438) (0.248–1.322) (0.243–1.414) (0.330–1.724) (0.335–1.935)
Pets 0.536 0.37 0.358 0.337 0.504 0.528
(0.085–3.379) (0.047–2.9) (0.057–2.266) (0.047–2.432) (0.085–3.379) (0.070–3.962)
Smoker (ref: No) 0.921 1.218 1.044 1.313 1.2 1.379
(0.552–1.538) (0.662–2.241) (0.625–1.743) (0.723–2.387) (0.713–2.019) (0.747–2.543)
Domestic Violence (ref: No) 1.297 1.379 1.443 1.608 1.784 1.93
(0.617–2.726) (0.600–3.167) (0.687–3.033) (0.720–3.592) (0.850–3.747) (0.852–4.373)

Abbreviation: CI (Confidence Interval); Un-adj. OR (Unadjusted Odds Ratio); Adj. OR (Adjusted Odds Ratio); BDT (Bangladeshi Taka).
***
p<0.01.
**
p<0.05.
*
p<0.1.

anxiety (poor: p<0.05; very poor: p<0.01) and co-morbidity (poor:
p<0.05; very poor: p<0.01) than those who characterized their families’
economic condition as excellent. Besides, we find statistically significant
evidence that students who spent more time with their family members
were less likely to suffer from depression (aOR: 0.388; 95% CI: 0.215,
0.698; p<0.01), anxiety (aOR: 0.297; 95% CI: 0.165–0.532; p<0.01)
and co-morbidity (aOR: 0.330; 95% CI: 0.184, 0.589; p<0.01), ranging
from moderate to severe level. Lastly, we find that students who smoke
and witnessed domestic violence in their families were more likely to
suffer from depression and anxiety symptoms, but these results were not
statistically significant.
4. Discussion
As COVID-19 spreads rapidly, educational institutions have been
temporarily closed in an effort to curb the spread of infections. The study
examined the possible repercussions on mental health as a result of these
preventive measures by exploring prevalence of depression, anxiety and
co-morbidity as well as performing separate comparative analysis of
students from public and private universities.
This study showed that over 70% of the students suffered from mild
to severe depression and anxiety (Table 2). A study conducted during the
pandemic observed that approximately 82% of Bangladeshi university
students suffered from moderate to severe depression and anxiety
(Islam et al., 2020a). Similar to our study, the study also used both
PHQ-9 and GAD-7 scales to assess depression and anxiety, respectively.

5
J. Mehareen et al.
These figures are significantly higher compared to the findings of
contemporary studies focused on this area throughout countrywide
lockdown. A recent study assessing mental health by DASS-21 measure
reported that 33.7% Bangladeshi adults (mainly in between 24–39 years
old) experience mild to extremely severe levels of anxiety symptoms
whereas the rate is 57.9% for depressive symptoms (Banna et al., 2020).
These findings suggest that the psychological impact of COVID-19 on
Bangladeshi university students has been worse compared to that on
general people.
The surge in mental health issues during lockdown is further evi­
denced by earlier studies where the reported prevalence of mental dis­
orders varied from 6.5% to 31.0% among adults (Hossain et al., 2014).
In particular, pre-COVID studies targeted on vulnerable group such as
first-year university students found that more than half of the students
experienced moderate to extremely moderate depression and anxiety
(Islam et al., 2020b). Moreover, studies conducted on Bangladeshi
medical college students found the presence of depressive and anxiety
symptoms, but the prevalence rates were much lower (Alim et al., 2017;
Sadiq et al., 2019; Sultana, 2014). In addition, it is worth noticing that
the prevalence rates in our study were considerably higher compared to
the findings of the nationwide survey of mental health conducted on
adult population (aged >18 years) using the Mini International Neuro­
psychiatric Interview (MINI) following the DSM-5 criteria where 6.7%
had depressive disorders and 4.5% had anxiety disorders (National
Mental Health Survey in Bangladesh, 2019). The substantial deteriora­
tion of mental health detected in studies during the COVID-19 pandemic
mainly pointed out COVID-19 related fear as well as prolonged unem­
ployment, together with financial insecurity due to lockdown as sig­
nificant stressors (Banna et al., 2020; Islam et al., 2020a).
Considering global context, compared to studies on students of other
countries, the high severity of depression and anxiety found in our
sample is noticable. For example, almost 35% and 39% of undergradu­
ate and graduate students at research universities in USA screened
positive for depressive and anxiety disorder respectively (Chirikov et al.,
2020). Furthermore, the prevalence of anxiety symptoms in the present
study was higher than in the studies conducted among college students
in China (Cao et al., 2020), university students in Malaysia (Sundarasen
et al., 2020), medical and non-medical students in the United Arab
Emirates (Saddik et al., 2020). Also, university students in South Korea,
China, and Japan reported worse depressive states than our sample
(Zhao et al., 2020).
A possible reason behind the rise of depression and anxiety symp­
toms among our participants can be attributed to “stay-at-home” order
during lockdown. In France, when mandatory confinement was intro­
duced during COVID-19, a study observed that university students
experienced severe mental stress and anxiety (Husky et al., 2020).
Specifically, university students are particularly vulnerable during the
pandemic as their stressors shifted from examination pressure (Arusha
and Biswas, 2020; Kumaraswamy, 2013), fear of missing out on social
life (O’connell, 2020) to worries about health and their future (e.g.,
uncertainty about academic progress, job prospects) (Elmer et al.,
2020).
Aside from the issues discussed above, in terms of gender, we found
that the prevalence of depression, anxiety and co-morbidity was
significantly higher among women as opposed to men, which is similar
to other studies conducted in Bangladesh (Hossain et al., 2019). Anal­
ogous findings were also observed in Poland indicating significantly
higher scores of depression, anxiety and stress levels of females
compared to males during this pandemic (Debowska et al., 2020). Such
finding is not unexpected as according to several studies the gender
difference in incidence of psychological disorders is pervasive as found
in different studies during the pandemic (Liu et al., 2020; Özdin and
Bayrak Özdin, 2020; Rakhmanov and Dane, 2020). However, a number
of studies documented equal suffering among males and females on
depression, anxiety and stress irrespective of gender (Rehman et al.,
2020; Islam et al., 2020a).
6
Journal of Affective Disorders Reports 5 (2021) 100179
Focusing on socio-demographic characteristics, in line with earlier
studies, university students aged 18 to 22 years old were significantly
more likely to suffer from depression and anxiety .(Banna et al., 2020;
Islam et al., 2020a). Apart from COVID-19 related stress, students from
this age group might be more susceptible to mental illness as they have
to adapt to a new range of emotional state (e.g., loneliness, personal
autonomy) and physical environment (e.g., transition from college to
university) (Smith et al., 2020). We also observe that students who
perceived their families’ economic condition as poor are more
depressed, anxious, and co-morbid compared to those who think that
they are financially well-off, and the results are statistically significant.
Students judge their economic well-being in terms of how well-off their
friends and other classmates are. In this era of social media, people are
constantly engaging in comparison of their own purchasing capacity
against others (Manstead, 2018). In case of students in our sample, such
perception seemed to be more important compared to quantifiable levels
of income.
Analogous to an earlier study, we found that students who lived in
nuclear families (<=4 members) were more likely to suffer from
depression and co-morbidity compared to students who lived in larger
families (Banna et al., 2020). This result is likely explained by the fact
that since the lockdown was imposed, students could engage in close
interactions with their family and had to stay at home for extended
period of times. Therefore, those who lived in larger families could at
least have chances of meaningful conversations and interactions with
their family members. This reasoning is further supported by our finding
that those who spent most of their time with family members rather than
on their own were significantly less depressed, anxious and co-morbid
(Collins and Laursen, 2004; Ellis et al., 2020; Sundarasen et al., 2020).
While, this is also true for those who spent their time with friends and
pets, the finding is not statistically significant (Cohen and Wills, 1985).
On the other hand, studies conducted among residents of Ethiopia and
India reveal that having more than three or four family members in­
crease the chance of experiencing psychological problems (Ahmad et al.,
2020; Kassaw and Pandey, 2020), but such association is not always
observed (Khan et al., 2020). Our results also indicate that students who
witnessed domestic violence in the family are more likely to suffer from
depression and anxiety compared to those who did not (Guessoum et al.,
2020; Luthra et al., 2009), although the results were not significant.
In case of level of education, we observe that, students enrolled in
their second- to fourth-year of undergraduate study were significantly
more likely to have moderate or higher level of depression compared to
those enrolled in first-year (Tang et al., 2020). Students in their
advanced undergraduate years often face tougher courses compared to
previous years which results in a gradual increase in depression.
Furthermore, initiation of online classes without technical support (from
institutions and instructors) might have elevated their distress. A study
on college students in Bangladesh revealed that compared to traditional
classroom methods, challenges in the nature of e-Learning (limited time,
interpretation, and assessment methods) and inadequate access to
technology makes student mentally frustrated (Hasan and Bao, 2020).
Moreover, second- to fourth-year students are more conscious about
their future career compared to first-year students. Therefore, they are
likely to be more depressed about the impact of the pandemic on their
learning experiences and career. Studies on undergraduate students in
USA also associated depression with such difficulties (Kecojevic et al.,
2020). We observe a similar pattern when we consider measures of
anxiety where second- and third-year students are significantly more
likely to suffer from moderate or higher level of anxiety compared to
first-year students (Mamun et al., 2019). Factors such as frustration
regarding possible academic delay, failure in love affairs, lack of
self-confidence and familial problems might contribute to increasing
depression and anxiety but were not explored in this study.
Regarding the type of university, we observed that the extent of
depression, anxiety, and co-morbidity (mild to severe) is significantly
higher for students from public universities. This may be due to the
J. Mehareen et al.
uncertainty of completion of their undergraduate degree caused by the
pandemic. As private universities are often better equipped than public
universities in terms of holding online educational activities, students
enrolled in the latter type of university are more likely to face an aca­
demic delay which will further hamper their future job-prospects (The
Business Standard, 2020a). Furthermore, private universities have been
more efficient in quickly planning a system of online classes and ex­
aminations to keep the progress as smooth as possible (The Business
Standard, 2020b). Public universities, however, have been slow to
respond in this regard (The Financial Express, 2020). Therefore, fear of
delayed completions of degree, setback in starting a career, etc. are
likely to cause higher levels of depression and anxiety among public
university students.
5. Limitations
The study has several limitations which should be considered while
interpreting the results. Firstly, this study is based on a cross-sectional
survey, thus causal relationship among the variables under investiga­
tion was not established. As discussed, students are particularly
vulnerable to mental health issues compared to other groups of popu­
lation due to several socioeconomic factors. As a result, without
considering a longitudinal survey design where the same group of stu­
dents is observed before and during pandemic, the worsening of mental
health status among the students cannot be directly attributed to the
impact of COVID-19. Secondly, all data in this study was collected from
selected university students through self-reported responses based on an
online questionnaire. As a result, the sample might not be representative
of the true population because of both selection bias and reporting bias.
Furthermore, students who do not have access to internet have not been
included in the study due to snowball sampling strategy, which limited
the findings by introducing sampling bias. Therefore, generalizations of
mental health conditions among the university students at a country
level should be made cautiously.
6 Conclusions
This study explored the mental health status of university students in
Bangladesh during the COVID-19 pandemic, specifically categorizing
students based on the type of university they are enrolled in. Overall, the
mental health condition of university students is considerably more
vulnerable compared to the adult population of Bangladesh observed in
previous studies. Female students, students in advanced levels of their
undergraduate studies, living in nuclear families, with poor perceived
economic condition are found to have significant association with
depression, anxiety, and co-morbidity symptoms. The study also found a
higher prevalence of severe levels of depression and anxiety symptoms
among public university students compared to private university stu­
dents, thus addressing a knowledge gap regarding this issue. The find­
ings of this study not only remind researchers and government officials
to be more concerned about the mental health of students but also
emphasize the need of targeted psychological interventions for better­
ment of their mental health.
Author statement
No conflict of interest exists in the submission of this manuscript, and
manuscript is approved by all authors for publication.
Role of the funding source
This research did not receive any grant from funding agencies in the
public, commercial, or not-for-profit sectors.
7
Journal of Affective Disorders Reports 5 (2021) 100179
CRediT authorship contribution statement
Jeenat Mehareen: Conceptualization, Methodology, Investigation,
Data curation, Formal analysis, Writing - review & editing, Validation,
Supervision. Mahir A. Rahman: Conceptualization, Methodology,
Formal analysis, Writing - original draft, Writing - review & editing,
Validation. Tahia Anan Dhira: Formal analysis, Writing - review &
editing, Data curation, Validation. Abdur Razzaque Sarker: Writing -
review & editing, Supervision.
Declaration of Competing Interest
None.
Acknowledgements
We would like to thank all the participants who voluntarily offered
their time to complete the questionnaire. We are also grateful to the
personnel from different departments of both public and private Uni­
versities who helped us to distribute the questionnaire for online data
collection.
Supplementary materials
Supplementary material associated with this article can be found, in
the online version, at doi:10.1016/j.jadr.2021.100179.
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