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Evaluating Student Mental Health During COVID-19

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Evaluating Student Mental Health During COVID-19
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Smith, Krystal
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The prevalence of mental health issues on college campuses is steadily increasing, and the demand for resources exceeds what most colleges can provide. It was also predicted that the COVID-19 pandemic would have a significant impact on mental health. In order to explore student mental health during COVID-19, contributing factors, barriers to treatment, and evaluate resources, a survey was administered to a sample of students (N=116) from a large urban university. Results imply that many students struggle with depression and anxiety, but not substance use. Analyses of Variance were conducted to determine if there are differences between mental health and grade point average, classification year, age, gender identity, socioeconomic status, employment status, and student statuses. There was a significant difference between students’ employment status in relation to anxiety. Seventy-two percent of students knew about the free counseling on campus, while around 50% knew about the therapy groups and self-help resources. Students’ barriers were ranked from most to least impeding, beginning with lack of knowledge about resources, other reasons, stigma, accessibility and personal beliefs or attitudes, and ending with availability of resources. These results indicate the need for reformed mental health resources on campus, to provide better access, communication, and understanding of resources.
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Collected for Auraria Institutional Repository by the Self-Submittal tool. Submitted by Krystal Smith.
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Thesis (B.S.)--Metropolitan State University of Denver, 2020

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EVALUATING STUDENT MENTAL HEALTH DURING COVID 19 1 Evaluating Student Mental Health During COVID 19 By Krystal B. Smith Department of Psychological Sciences, Metropolitan State University of Denver An undergraduate thesis submitted in partial completion of the MSU Denver Honors Program December 2020 Jovan Hernandez Megan Hughes Zarzo Primary Advisor Honors Program Director

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EVALUATING STUDENT MENTAL HEALTH DURING COVID 19 2 Abstract The prevalence of mental health issues on college campuses is steadily increasing, and the demand for resources exceeds what most colleges can provide. It was also predicted that the COVID 19 pandemic would have a significant impact on mental health. In or der to explore student mental health during COVID 19 , contributing factors, barriers to treatment , and evaluate resources , a survey was administered to a sample of students ( N =116) from a large urban university . Results imply that many students struggle with depression and anxiety, but not substance use . Analyses of Variance were conducted to determine if there are differences between mental health and grade point average , classification year, age, gender identity, socio economic status , employment status, and student statuses . There was a significant difference between students employment status in relation to anxiety. Seventy two percent of students knew about the free counseling on campus, while around 50% knew about t he therapy groups and self help resources. beginning with lack of knowledge about resources, other reasons, stigma, accessibility and personal beliefs or attitudes, and ending with availability of resources . These results indicate the need for reformed mental health resources on campus, to provide better access, communication , and understanding of resources . Keywords: COVID 19, college students, mental health, resources, barriers, contributing fact ors

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EVALUATING STUDENT MENTAL HEALTH DURING COVID 19 3 Evaluating Student Mental Health During COVID 19 Recent studies point to an increase in college student mental health concerns, internationally. In 2018, the World Health Organization conducted an international study of college student mental health in eight countries , across nineteen college campuses (Auerbach et al. , 2018 ). Over a third of the sample met criteria for at least one mental disorder. Most of the campuses involved saw a large demand for mental health resources due to the in crease in anxiety, depression, and substance use concerns . Two prominent studies examining trends in college student mental health outline d the historical increase in incidence rates and the need for reformed resources (Oswalt et al., 2020; Porter, 2018). From 2009 to 2015, a study found a significant increase in diagnosis and treatment across several mental health diagnoses (Oswalt et al., 2020). Along with this, there was an increased demand for mental health services. Within her three year study of menta l health crises on a college campus, Porter (2018) addressed the need for reformed resources to account for the high frequency of mental health incidence reports. The data collected from mental health studies could be used to review institutional policies regarding student mental health, safety, and confidentiality, a s well as to reform resources through student feedback and identified student needs. Barriers to Mental Health Treatment Oswalt et al. (2020) pointed to studies that found between 50 % and 80 % of students did not seek treatment when they were struggling with their mental health. These studies indicated that students were unlikely to seek services because they either did not have time, did not think they needed services, or thought they could handle their struggles on their own. Another study sought to define the types of stigma around mental health and identify which affected college

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EVALUATING STUDENT MENTAL HEALTH DURING COVID 19 4 stigma per sonal stigma and perceived stigma. Personal stigma is internal and based on a health and likely to get any kind of treatment for mental health issues . Ebert et al. (2019) determined through an international study that barriers related to personal attitudes and beliefs had a larger effect on treatment seeking. Attitudinal barriers include the desire to use self help or help from family and peers, or embarrassment. Influencing Help Seeking Many studies that researched student mental healt h and resource usage pointed towards different strategies that may influence help seeking. One study showed that students whose friends had used counseling services were more likely to also use services (Russe l l et al., 2008). Students reported a lack of k nowledge about the resources available to them, indicating a need . This study also suggested using outreach programs to engage students in actively seeking help. To determine how to best promote help seeking, researchers distributed messages to first year college students and measured their perception of each (Pace et al., 2018). This study used four different messages, each with a different theme and topic. One message used the theme that therapy did not have to involve laying on a couch, which is a common misconception. The second message provided reference to a religious group o n campus that was open to talking about mental health. Another message showed an image of the school mascot and counseling center, with a quote about being a family across the university. The final message used two friends talking about mental health and t ips on what to do if students knew of struggling peers.

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EVALUATING STUDENT MENTAL HEALTH DURING COVID 19 5 M essages that normalized help seeking and promoted it were highly regarded by the students . Students thought that the messages targeting the misconception about therapy involving couches and helping f riends were the most influential to seeking help. Another study described a n idea of using health promotion campaigns to influence help seeking (Eisenberg et al., 2009). This study used a campaign in which it was shown that 90% of students did not think le ss of others that used counseling resources. Campaigns that target biased social norms have been used across a variety of institutions and have successfully influenced students to seek help from available resources . A different study suggested that online self help resources may be best for people that struggle with stigma and attitudinal barriers, which were defined in the previous section (Ebert et al., 2019). Factors Contributing to Mental Health Previous research shows numerous factors that contribute to poorer college student mental health. Effrig et al. (2011) foun d that transgender college students experienced more psychological distress than gender binary students. Harassment on campus, safety concerns, instances of violence, and discrimi nation contributed to the stress and suicide attempts in these transgender students. For international students in the United States, depression is common due to many cultural, societal, and personal challenges (Jung et al., 2007). Feeling homesick, experi encing culture shock, minimized support and social interaction, discrimination, identity crises, and more can contribute to depression in international students. Another study also showed th ese outcome s for students with temporary documentation o r those wh o are undocumented, suggesting that undocumented or temporarily documented students have poorer mental health (Alif et al., 2020). Elevated stress, anxiety, and depression is common in undocumented or temporarily documented students. Risk factors that also contribute to

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EVALUATING STUDENT MENTAL HEALTH DURING COVID 19 6 psychological distress in undocumented or temporarily documented students include financial problems, low socioeconomic status , systemic and political problems, prejudice and discrimination, ostracization, and fear of deportation. Transfer students typically experience a period of adjustment that has been known to cause psychological distress (Laanan, 2001). Their GPA usually drops temporarily, they are thrown into a new environment, and they may feel alienated. Since some studies have poin ted to the idea that additional stressors can negatively impact psychological functioning, transfer students may experience more psychological distress. Much research has been done to describe the effect of class level on mental health. The majority of r esearch focuses on freshman students . One study found that self harm and suicidal ideation was a large concern for first year students, while higher class levels seemed to suffer from different mental health issues closely related with academics (Wyatt et al., 2017). A different study surveyed first year students and determined that many freshmen use high amounts of alcohol, which was positively correlated with depression (Geisner et al., 2012). One study in particular looked at mental health across each year in school and found that second yea r students saw the highest increase in mental health problems across each of the years (Macaskill, 2013). Pandemic Effects on Mental Health Although it is a new experience in the United States, research has been conducted in other countries to determine how pandemics affect mental health. Quarantine and isolation are also a part of most pandemics, so the effects of these on mental health are also important to mention. Fiorillo and Gorwood (2020) stated that stress f ro m the COVID 19 pandemic could cause an xiety and trauma, especially for people who are exposed to the virus , who are vulnerable

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EVALUATING STUDENT MENTAL HEALTH DURING COVID 19 7 to the virus and mental health issues , who are essential personnel, or who are engrossed in media coverage. Containment measures like isolation, quarantine, and social distancing were hypothesized to have negative effects on mental health. Research done on the psychological effects of social isolation concluded that being dis connected from previous social supports resulted in poorer mental health ( Rohde et al., 2016). T he majority of research done on the psychological impact of quarantine and isolation due to infectious diseases has been done in Canada with Severe Acute Respiratory Syndrome ( SARS ) , in the Middle East with Middle Eastern Respirator y Syndrome ( MERS ) , and in China with the H1N1 flu ( Jeong et al., 2016; Hawryluck et al., 2004; Wang et al., 2011). People who were quarantined experienced significant distress, including Post Traumatic Stress Disorder (PTSD), depression , anxiety , and anger during and after th e quarantine period ( Jeong et al., 2016; Hawryluck et al., 2004; Wang et al., 2011 ). Risk factors for experiencing anxiety and anger included physical illness, limited supplies, social networking, history of mental health issues, and fi nancial problems. In contrast, t he study done in China concluded that there were no significant psychological concerns as a result of being quarantined (Wang et al., 2011). Current Study Prior research has not investigated college student mental health during a pandemic. This study s ought to identify the areas of mental health in which students struggl ed during the COVID 19 pandemic , using the Patient Health Questionnaire ( PHQ 9 ) , Generali zed Anxiety Disorder questionnaire ( GAD 7 ) , and Simple Screening Instrument for Substance Abuse ( SSI SA ) . Also, this study tried to identify how many students knew about the resources available to them, as well as barriers to seeking help .

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EVALUATING STUDENT MENTAL HEALTH DURING COVID 19 8 Method Partici pants A total of 1 16 undergraduate students participated in this research study. All were 18 years of age or older and current students. Participants were asked which age group they fell into. Sixty seven percent were aged 18 to 25 , 23% were aged 26 to 35 , and 10% were 36 or older . Participants were recruited across disciplines and from all four class levels. Twelve percent of participants were f reshman , 17% were s ophomores , 34% were j uniors , and 37% were s eniors . Many participants identified as mixe d ethnicities, though 5% identified as American Indian or Alaska Native, 6% identified as Black or African American, 19% identified as Hispanic or Latino/x or Spanish, 2% identified as Middle Eastern or North African, 66% identified as Wh ite, 2% identified as o ther or preferred not to answer. Seventy two percent of participants identified as female, 25% as male, and 4% as gender nonconforming . Research Design First, t his study was approved by the Institutional Review Board (IRB). A survey was created and sent out through an email or announcement to classrooms at a large urban university . The survey consisted of demographic questions, college related variable questions, the PHQ 9 to assess depression symptoms , t he GAD 7 to assess anx iety symptoms , the SSI SA to assess substance use , resource knowledge check questions, and a question to assess student barriers. The survey was created through Qualtrics and distributed through an anonymous link. The settings were arranged so that IP addr esses, names, locations, and personal data would not be collected from those that decided to take the survey. Students were presented with a consent form and a document with hotlines and counseling resources prior to starting the survey . Students could re ad the consent f or m , decide if

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EVALUATING STUDENT MENTAL HEALTH DURING COVID 19 9 they wanted to participate , and use the anonymous link to go to the survey. Participants could exit out of the survey at any time and their data would not be collected. If participants answered all questions through the end o f the survey , their data was collected and analyzed . At the end of the survey, students were presented with a debriefing statement , thanking the participant and reiterating the hotlines and resources. Measures Three psychological assessments were used in this study. T he Patient Health Questionnaire ( PHQ 9 ; Pfizer Incorporation, 2005 ) is a 9 item Likert type scale (0 = not at all to 3 = nearly every day) that assesses depressi ve symptoms . The items are totaled to form an overall scor e . The PHQ 9 has been shown to have excellent internal reliability with alpha coefficients between .86 and .89 in multiple studies (K roenke et al., 2001) . The current study found an alpha of .90 for the PHQ 9. The Generalized Anxiety Disorder (GAD 7 ; Spitzer et al., 2006 ) questionnaire is a 7 item Likert type scale (0 = not at all to 3 = nearly every day) that assesses anxiety symptoms . The items are totaled to form an overall score . The GAD 7 was found to be internally consistent with an alpha of .89 (Lowe et al., 20 08). The current study found an alpha of .92 for the GAD 7. The Simple Screening Instrument for Substance Abuse (SSI SA ; Center for Substance Abuse Treatment, 2005 ) is a 1 point, 14 item dichotomous scale (0 = no and 1 = yes) that assesses substance use o ver a six month time period and level of risk for substance abuse . Items are totaled to an overall score. Studies have found the SSI SA to be highly sensitive in determining risk for substance abuse issues , with percentages ranging from 87 % to 97 % . The SSI SA has high reliability, with studies showing an alpha coefficient of .97. The current study found an alpha of .86 for the SSI SA.

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EVALUATING STUDENT MENTAL HEALTH DURING COVID 19 10 Data Analysis Data analyses were preformed using Jamovi software ( The Jamovi Project, 2020 ) . A reliability analysis was conducted for each assessment. scored and classified according to scoring instructions. Resource awareness questions were analyzed based on what percentage of people knew abo ut the resource and what percentage did not know about the resource. Student barriers were assessed by looking at the number of students that chose each answer choice. One w ay ANOVAs were conducted to determine if there we re differences between a ge, class level, employment status, gender identity, and living situations on each of the three assessments . A correlation matrix was used with PHQ 9 scores, GAD 7 scores , and SSI SA scores to see if these three measures have any relationship. Alpha levels below .05 were considered significant. Results Reliability Analys e s and Correlation Matrix The PHQ 9 was found to be highly reliable (9 items; = .90). The GAD 7 was also highly reliable (7 items; = .92), as was the SSI SA (14 items; = .86). Table 1 shows the correlation matrix for the psychological assessme nts. Scores on the PHQ 9 and GAD 7 were significantly correlated, r ( 114) = .83, p < .001. Table 1 Table of Correlations , Descriptives, and Reliability of Assessments Assessment 1 2 3 1. PHQ 9 score 2. GAD 7 score .83***

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EVALUATING STUDENT MENTAL HEALTH DURING COVID 19 11 3. SSI SA score .07 .00 Mean 10.33 9.34 1.49 SD 6.69 5.97 2.52 Range 0 27 0 21 0 14 Alpha .90 .92 .86 Note . *** p < .001 . PHQ 9 = 9 Item Patient Health Questionnaire; GAD 7 = 7 Item Generalized Anxiety Disorder Questionnaire ; SSI SA = Simple Screening Instrument for Substance Abuse. Prevalence of Depression, Anxiety, and Substance Use Participants scores on the PHQ 9 ranged from 0 to 27 ( M = 10.33, SD = 6.69 ) . Scores between 1 and 4 are classified as minimal depression, 5 to 9 is classified as mild dep ression, 10 to 14 is classified as moderate depression, 15 to 19 is classified as moderately severe depression, and 20 to 27 is classified as severe depression (Kroenke et al., 2001). Twenty three percent of participants classified as minimal, 24% classifi ed as mild, 26% classified as moderate, 15% classified as moderately severe, and 12% classified as severe. Scores on the GAD 7 ranged from 0 to 21 ( M = 9.34, SD = 5.97). If between 0 and 4, scores are classified as minimal anxiety, 5 to 9 is mild anxiety , 10 to 14 is moderate anxiety, and 15 to 21 is severe anxiety (Spitzer et al., 2006). Twenty three percent of participants classified as minimal, 33% classified as mild, 22% percent classified as moderate, and 22% percent classified as severe. Scores on the SSI SA ranged from 0 to 14 ( M = 1.49, SD = 2.52) . Scores from 0 to 1 are classified as none to low risk, scores 2 to 3 are minimal risk, and scores equal to or above 4 are moderate to high risk (Center for Substance Abuse Treatment, 2005). Se venty one percent of

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EVALUATING STUDENT MENTAL HEALTH DURING COVID 19 12 participants classified as none to low risk, 13% classified as minimal risk, and 16% classified as moderate to high risk. Demographics and College Related Variables One way analyses of variance and Tukey post hoc tests were conducted between each affiliated statuses, and living situations in order to deter mine if there were differences between groups, and where those differences occurred. The main significant effect was of employment status on GAD 7 scores [ F (3, 55.43) = 3.68, p = .017] . Post hoc analyses using the Tukey HSD test indicated that the mean score for the unemployed group ( M = 11.12, SD = 6.29) was significantly different from the full time group ( M = 6.7, SD = 4.44). The unemployed group did not significantly differ from the part time group ( M = 9.95 , SD = 5.99 ) or the more than one job group ( M = 8.2 , SD = 6.02 ) . The part time group did not significantly differ from the full time group or the more than one job group. The full time group did not significantly differ from the more than one job group. Resource Awareness and Student Barriers Seventy two percent of students knew about the free counseling resources on campus prior to the survey; 28% did not know. Fifty five percent of students knew about the groups on campus for therapy and support; 45% did not know. Fifty one percent of students knew about the self help resources provided by the Counseling Center; 49% did not know. Student barrier s were ranked by percentages of the chosen answer choice. Thirty one percent of students chose lack of knowledge about resources, 28% of students chose other, 10% of students chose stigma of mental health, 9% of students chose personal beliefs or attitudes ,

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EVALUATING STUDENT MENTAL HEALTH DURING COVID 19 13 another 9% of students chose accessibility of resources, 9% of students chose availability of resources, and 3% of students did not mark a response. Figure 1 Seeking Discussion The results of this study indicate that many students are struggling with their mental health. Over half (53%) of students fell above the minimal or mild interpretation for the PHQ 9, meaning that these students may be struggling with depression. More than a third (44%) of students fell above the minimal or mild interpretation for the GAD 7, indicating that these students also struggle with anxiety. These results are consistent with the previous research in student mental health ( Auerbach et al., 2018; Oswalt et al., 2020; Porter, 2 018 ) . What is not consistent with other student mental health research, though, is the number of students who have moderate to high risk for substance abuse in this study (16%). This number is much less than 31% 28% 10% 9% 9% 9% 3% Lack of Knowledge Other Stigma Personal Beliefs/Attitudes Accessibility Availability No Response

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EVALUATING STUDENT MENTAL HEALTH DURING COVID 19 14 other research has found in studying college stu dent substance use ( Geisner et al., 2012 ) . Further research is needed to determine what factors contribute to this difference. Results also showed that students who were unemployed experienced greater anxiety symptoms than students who were employed durin g the time of this study. Research supports the finding that unemployment is linked with anxiety (Howe et al., 2012; Yasar & Turgut, 2020). College students, particularly during their last year, experience unemployment anxiety, as shown in the study by Yas ar and Turgut (2020). Sudden and involuntary unemployment is linked to increase d anxiety and depression, most likely due to stress (Howe et al., 2012). Sudden and involuntary unemployment occurred for many during the COVID 19 pandemic, so it is possible that this could contribute to anxiety. Results from the barrier question and indicates a need for better communication of these resources. Almost three quarters (72%) of students knew about the free counseling resources, which was more than what was originally predicted . Almost half of students (45% and 49%) did not know about the other resources, such as groups for therapy and support and self help resou rces. Lack of knowledge about resources seeking. Using previous research on influencing mental health treatment seeking, universities could work on educating and spreading messages to stud ents about their mental health treatment options. As mentioned earlier, campaigns and providing easier accessibility of information could be beneficial in solv ing this barrier. informati on. These students were typically receiving therapy on campus already, receiving therapy outside of campus already, or did not think that they needed to use counseling services at all. Stigma was the third most chosen barrier. A study in the influencing he lp seeking section

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EVALUATING STUDENT MENTAL HEALTH DURING COVID 19 15 mentioned that students with barriers like stigma and personal attitudes would most benefit from self help resources (Ebert et al., 2019). Given that only 49% of students know about the self help resources available, this is another big area of concern that campus es should work towards solving. Overall, it is clear that students are struggling with mental health at this time and need more knowledge about the resources available to them. Universities can largely overcome many services easily available. As this study was conducted during the COVID 19 pandemic, it is possible that the percentages of students s truggling with mental health are inflated. This makes it even more important for universities to use outreach and provide students with information about the services they provide, not only for mental health. This study can be used in future research on ho w COVID 19 affected mental health, and it can also be used by universities as a source of information on student mental health and how to proceed. This study adds to the general literature of student mental health, since some of the findings surrounding co ntributing factors to mental health and substance use are different than previous research. Future research should examine these contributing factors in greater detail. Future studies should also take place after the pandemic period and compare mental heal th scores and results. Limitations for this study include taking place entirely online and relying on a convenience sample.

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EVALUATING STUDENT MENTAL HEALTH DURING COVID 19 16 References Alif, A., Nelson, B. S., Stefancic, A., Ahmed, R., & Okazaki, S. (2020). Documentation status and psychological dist ress among New York City community college students. Cultural Diversity and Ethnic Minority Psychology, 26 (1), 11 21. https://psycnet.apa.org/doi/10.1037/cdp0000290 Auerbach, R. P., Mortier, P., Bruffaerts, R., Alonso, J., Benjet, C., Cuijpers, P., Demyttenaere, K., Ebert, D. D., Green, J. G., Hasking, P., Murray, E., Nock, M. K., Pinder Amaker, S., Sampson, N. A., Stein, D. J., Vilagut, G., Zaslavsky, A. M., Kessler, R. C., & WHO WMH ICS Collaborators. (2018). WHO World Mental Health Surveys International College Student Project: Prevalence and distribution of mental disorders. Journal of Abnormal Psychology, 127 (7), 623 638. http://dx.doi.org/10.1037/abn0000362 Center for Substance Abuse Treatment. (2005). Appendix H: Screening instruments. In Substance abuse treatment for persons with co occurring disorders [eBook edit ion] . NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK64187/?report=printable Ebert, D. D., Mortier, P., Kaehlke, F., Bruffaerts, R., Baumeister, H., Auerbach, R. P., Alons o, J., Vilagut, G., Martinez, K. U., Lochner, C., Cuijpers, P., Kuechler, A. M., Green, J., Hasking, P., Lapsley, C., Sampson, N. A., & Kessler, R. C. (2019). Barriers of mental health treatment utilization among first year college students: First cross na tional results from the WHO World Mental Health International College Student Initiative. International Journal of Methods in Psychiatric Research, 28 (1782). https://doi.org/ 10.1002/mpr.1782

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EVALUATING STUDENT MENTAL HEALTH DURING COVID 19 17 Effrig, J. C ., Bieschke, K. J., & Locke, B. D. (2011). Examining victimization and psychological distress in transgender college students. Journal of College Counseling, 14 (2), 143 157. https://doi.org /10.1002/j.2161 1882.2011.tb00269.x Eisenberg, D., Downs, M. F., Golberstein, E., & Zivin, K. (2009). Stigma and help seeking for mental health among college students. Medical Care Research and Review, 66 (5), 522 541. https://doi.org/10.1177/1077558709335173 Fiorillo, A., & Gorwood, P. (2020). The consequences of the COVID 19 pandemic on mental health and the implications for clinical practice. European Psychiatry, 63 (1), 1 2. https://doi.org/10.1192/j.eurpsy.2020.35 Geisner, I. M., Mallett, K., & Kilmer, J. R. (2012). An examination of depressive symptoms and drinking patterns in first year college students. Issues in Mental Health Nursing, 33 (5 ), 280 287. https://doi.org/10.3109/01612840.2011.653036 Hawryluck, L., Gold, W., Robinson, S., Pogorski, S., Galea, S., & Styra , R. (2004). SARS control and psychological effects of quarantine, Toronto, Canada. Emerging Infectious Diseases, 10 (7), 1206 1212. Retrieved April 19, 2020, from https://www ncbi nlm nih gov.aurarialibrary.idm.oclc.org/pmc/articles/PMC3323345/pdf/03 0703.pdf Howe, G. W., Hornberger, A. P., Weihs, K., Moreno, F., & Neiderhiser, J. M. (2012). Higher order structure in the trajectories of depressio n and anxiety following sudden involuntary unemployment. Journal of Abnormal Psychology, 121 (2), 325 338. https://doi.org/10.1037/a0026243 Jeong, H., Yim, H. W., Song, Y. J., Ki, M., Min, J. A., Cho, J., & C hae, J. H. (2016). Mental health status of people isolated due to Middle East Respiratory Syndrome. Epidemiology and Health, 38 . https://doi.org/10.4178/epih.e2016048

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EVALUATING STUDENT MENTAL HEALTH DURING COVID 19 18 Jung, E., Hecht, M. L., & Wadsworth psychological well being in the United States: A model of depression level, identity gaps, discrimination, and acculturation. International Journal of Intercultural Relations, 31 , 605 624. https://doi.org/10.1016/j.ijintrel.2007.04.001 Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The PHQ 9: Validity of a brief depression severity measure. Journal of General Internal Medici ne, 16 , 606 613. https://dx.doi.org/10.1046%2Fj.1525 1497.2001.016009606.x Laanan, F. S. (2001). Transfer student adjustment. New Directions for Community Colleges, 114 , 5 13. https://doi.org/10.1002/cc.16 Lowe, B., Decker, O., Muller, S., Brahler, E., Schellberg , D., Herzog, W., & Herzberg, P. Y. (2008). Validation and standardization of the Generalized Anxiety Disorder Screener (GAD 7) in the general population. Medical Care, 46 (3), 266 274. Retrieved March 20, 2020, from https://www.jstor.org/stable/40221654?seq=1&cid=pdf reference#references_tab_contents Macaskill, A. (2013). The mental health of university students in the United Kingdom. British Journa l of Guidance & Counseling, 41 (4), 426 441. https://doi.org/10.1080/03069885.2012.743110 Oswalt, S. B., Lederer, A. M., Chestnut Steich, K., Day, C., Halbritter, A., & Ortiz, D. (2020). Trends in 2015. Journal of American College Health, 68 (1), 41 51. https://doi.org/10.1080/07448481.2018.1515748

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EVALUATING STUDENT MENTAL HEALTH DURING COVID 19 19 Pace, K., Silk, K., Nazione, S., Fournier, L., & Collins Eaglin, J. (2018). Promoting mental health help seeking behavior among first year college students. Health Communication, 33 (2), 102 110. https://doi.or g/10.1080/10410236.2016.1250065 Pfizer Incorporation. (2005). Patient Health Questionnaire (PHQ 9) [PDF file]. Retrieved March 24, 2020, from http://med.stanford.edu/fastlab/research/imapp/msrs/_jcr_content/main/accordion/accordi on_content3/download_256324296/file.res/PHQ9%20id%20date%2008.03.pdf Porter, S. (2018). A descriptive study of post secondary student mental health crises. College Quarterly, 21 (3). Retrieved February 13, 2020, from https://eric.ed.gov/?id=EJ1203541 Rohde, N., Ambrosio, C. D., Tang, K. K., & Rao, P. (2016). Estimati ng the mental health effects of social isolation. Applied Research Quality Life, 11 , 853 869. https://doi org.aurarialibrary.idm.oclc.org/10.1007/s11482 015 9401 3 Russell, J., Thomson, G., & Rosenthal, D. (2008). International student use of university health and counselling services. Higher Education, 56 , 59 75. https://doi.org/10.1007/s10734 007 9089 x Spitzer, R. L., Kroenke, K., Williams, J. B., & Lowe, B. (2006). GAD 7 Anxiety [PDF file]. Retrieved March 24, 2020, from https://adaa.org/sites/default/files/GAD 7_Anxiety updated_0.pdf The Jamovi Project (2020). Jamovi . (Version 1.2). https://www.jamovi.org Wang, Y., Xu, B., Zhao, G., Cao, R., He, X., & Fu, S. (2011). Is quarantine related to immediate negative psychological consequences during the 2009 H1N1 epidemic? General Hospital Psychiatry, 33 , 75 77. https://doi org.aurarialibrary.idm.oclc.org/10.1016/j.genhosppsych.2010.11.001

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EVALUATING STUDENT MENTAL HEALTH DURING COVID 19 20 Wyatt, T. J., Oswalt, S. B., & Ochoa, Y. (2017). Mental health and academic performa nce of first year college students. International Journal of Higher Education, 6 (3), 178 187. https://doi.org/10.5430/ijhe.v6n3p178 Yasar, O. M., & Turgut, M. (2020). Unemployment anxiety of last year c ollege students. Cypriot Journal of Educational Sciences, 15 (1), 56 64. https://doi.org/10.18844/cjes.v15i1.4588