MAMC Journal of Medical Sciences

ORIGINAL ARTICLE
Year
: 2022  |  Volume : 8  |  Issue : 2  |  Page : 113--120

Anxiety and Depression in Undergraduate Students Due to Altered Screen Time and Physical Activity Patterns in COVID Times: A Survey


Aditya Gupta, Siddharth Trivedi, Keshave Singh, Sagar Bagwe, Lalit Maini 
 Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India

Correspondence Address:
Siddharth Trivedi
Senior Resident, Room no. 600, Department of Orthopaedics, Lok Nayak Hospital, New Delhi 110002
India

Abstract

Objective: This study was done to assess anxiety and depression in undergraduate students due to altered levels of screen time (ST) and physical activity (PA) during the COVID-19 pandemic. Various studies have been carried out about the mental health impacts of ST and PA, but there is a paucity of literature when it comes to exploring these parameters in undergraduate students and the Indian population. This study aims to address this gap. Methods: Data were collected through a survey using an online questionnaire. Participants reported daily ST and weekly PA, both moderately vigorous physical activity (MVPA) and vigorous physical activity (VPA). Symptoms of anxiety and depression were ascertained using the Hospital Anxiety and Depression Score. Results: Out of the total 165 students analyzed, we found that 63% had borderline or pathological anxiety levels while 41.2% had borderline or pathological depression levels. There was a negative correlation between depression score and PA, for both MVPA (r = –0.233, P = 0.001) and VPA (r = –0.268, P = 0.0002). A negative correlation was found between anxiety score and PA for MVPA (r = –0.151, P = 0.024). There was a positive correlation between ST and scores of anxiety (r = 0.305, P = 0.006) and depression (r = 0.257, P = 0.02) in females but no correlation was found in males. Conclusion: The present study suggests that there is a high prevalence of borderline and pathological anxiety and depression amongst undergraduate students. High levels of PA and low levels of ST are separately associated with a lesser risk of anxiety and depression.



How to cite this article:
Gupta A, Trivedi S, Singh K, Bagwe S, Maini L. Anxiety and Depression in Undergraduate Students Due to Altered Screen Time and Physical Activity Patterns in COVID Times: A Survey.MAMC J Med Sci 2022;8:113-120


How to cite this URL:
Gupta A, Trivedi S, Singh K, Bagwe S, Maini L. Anxiety and Depression in Undergraduate Students Due to Altered Screen Time and Physical Activity Patterns in COVID Times: A Survey. MAMC J Med Sci [serial online] 2022 [cited 2022 Nov 30 ];8:113-120
Available from: https://www.mamcjms.in/text.asp?2022/8/2/113/354342


Full Text



 Introduction



The COVID-19 pandemic has caused significant morbidity and mortality around the globe. Apart from the evident physical symptoms in infected cases, it has had a significant impact on the public lifestyle.[1]

Like other countries, India also implemented a nationwide lockdown to contain and curb the transmission of the virus. Undergraduate students, thus, have been forced to remain in the confines of their homes and have had to follow online curriculums. This has caused serious damage to their mental health in the form of increased stress, anxiety, and depression.[2]

Any event that threatens to disrupt our homeostasis has a detrimental effect on our physical and emotional well-being. This is known as stress. The fear of the unknown is referred to as anxiety, which is the body’s natural response to stress. Depression is a state wherein a person loses interest in his/her daily activities.[1]

WHO defines physical activity (PA) as any bodily movement produced by skeletal muscles that require energy expenditure.[3] PA refers to all movements including that done during leisure time, for transport, or as part of other daily activities.

Both moderate and vigorous intensity PA and low levels of sedentary time spent in front of screens and monitors (screen time [ST]) have been associated with improved physical, psychosocial, and mental health.[3]

There is existing literature talking about the mental health impacts of COVID and the effect of PA and ST on the same, but there are very few studies that specifically talk about undergraduate students and there are virtually no studies that explore the effects of PA and ST on mental health in the Indian population.

Thus, our research is a pilot study that aims to plug this gap by exploring psychological distress and indulgence in physical activities and ST among undergraduate students in India during the COVID lockdown.

We are doing a cross-sectional study using a Google forms-based questionnaire to conduct a survey and then the responses will be analyzed and compared with the existing literature.

 Materials and Methods



A self-designed questionnaire on Google forms was used to conduct a survey to study the effects of PA and ST on anxiety and depression. This questionnaire was sent via WhatsApp and email to 312 undergraduate students across Delhi and national capital region.

The participants included were aged between 18 to 24 years and were actively pursuing an undergraduate course in physical mode before the COVID-19 pandemic. These participants were from various fields such as Medicine, Engineering, Law, Humanities, Chartered Accountancy, and Business Management.

Participants were asked about any physical disability, whether they were suffering from any disease or ailment, or whether they were diagnosed with cases of anxiety and/or depression. All these participants were excluded from the study.

The survey link was sent in the third week of July 2021 and the participants were asked to respond within a week of receiving the link. They were advised to respond based on their routine in the preceding 2 weeks.

Sample size (n) was calculated using the following formula:

[INLINE:1]

where for 95% confidence, Z = 1.96; s (standard deviation) = 0.08; and e (acceptable error) = 0.05.Using the above formula, n = 112.8.

 Measurement of physical activity



Weekly moderately vigorous physical activity (MVPA) and vigorous physical activity (VPA) were assessed using a standard recall questionnaire methodology. The questions were formulated based on the WHO guidelines.[4]

For MVPA, the question was worded, “In a typical week, how much time do you spend in total on moderate and vigorous physical activities where your heartbeat increases and you breathe faster (brisk walking, cycling, jogging, or recreational sport).”

For VPA, the question was worded, “How much of the time that you spend on physical activities in a typical week, which you indicated above, do you spend in total on vigorous physical activities? This includes activities that get your heart racing, make you sweat and leave you so short of breath that speaking becomes difficult (e.g. swimming, running, cycling at high speeds, cardio training, weight training, or sports such as football, tennis, cricket etc.).”

 Measurement of screen time



Daily ST was assessed using a standard recall questionnaire methodology. The question was worded, “On a typical day, what is your average screen time….”

The participants were instructed to include in their responses the time they spent on their cell phones, computers, gaming consoles, and watching television. Any ST related to online classes or work was to be excluded.

On the basis of the reported PA and ST, we divided the respondents into five categories each [Table 1].{Table 1}

 Assessment of anxiety and depression



Anxiety and depression were assessed using the Hospital Anxiety and Depression Score (HADS).

HADS is a self-assessment questionnaire that is commonly used in clinical practice and research to detect states of anxiety and depression. The questionnaire consists of seven questions for anxiety and seven for depression and takes about 2 to 5 minutes to complete. The scoring for each question ranges from zero to three, with three denoting the highest anxiety or depression level.[5]

The scores for anxiety and depression were calculated separately and then compared with the cutoff values.

 Analysis



The correlation between MVPA, VPA, and ST with anxiety and depression was established by calculating the correlation coefficient (r) for each relation.

Using r, standard deviation (SD) and tcal were calculated using the formula

[INLINE:2]

Using SD and tcal values, the P value was calculated in Microsoft Excel (MS Office 2010) and the significance of the correlations was tested.

 Results



Out of the 312 people to whom the link was sent, we received 200 responses and after applying the exclusion criteria, the final sample size was n = 165, out of which 101 were males and 64 were females. Out of the 165, there were 96 medical students and 69 nonmedical students.

1. Anxiety and depression levels

We assessed the anxiety and depression levels of respondents. Out of the total 165 students, 63% had borderline or pathological anxiety levels while 41.2% had borderline or pathological depression levels. There was equal gender predilection as far as anxiety symptoms are concerned; however, depression was nearly twice more common in girls (72% girls as compared to 40% boys were having depressive symptoms). Among the two groups, nonmedicos had a prevalence of 43.4% pathological anxiety and 21.7% pathological depression as compared to 28% and 10% pathological anxiety and depression, respectively, in the medico group. The most adversely affected group was nonmedico girls and the least affected group was medico boys [Table 2], [Figure 1].{Table 2}{Figure 1}

2. Activity – Screen time; MVPA and VPA

We assessed the ST and moderate and vigorous physical activities in our population set. We plotted a gender-specific bar diagram of ST, MVPA, and VPA across the time [Table 3], [Figure 2].{Table 3}{Figure 2}

WHO recommends at least 150 to 300 minutes of moderate intensity aerobic PA, at least 75 to 150 minutes of vigorous intensity aerobic PA, or an equivalent combination of moderate and vigorous intensity activity throughout the week.[4]

3. Correlations

Anxiety and depression both had a statistically significant negative correlation with moderate and vigorous physical activities. The correlation was more significant for depression as compared to anxiety. For anxiety, there was a stronger negative correlation with MVPA, whereas for depression, there was a stronger negative correlation with VPA [Figure 3], [Table 4].{Figure 3}{Table 4}

The boys and girls showed a contrasting association of anxiety and depression with ST. While the boys had no significant correlation, the girls showed a positive correlation. This indicates that ST doesn’t have much of an effect on the mental health of boys, whereas it has a detrimental effect on the mental health of girls. This may be due to the difference in the quality of on-screen content they consume [Figure 4], [Table 5].{Figure 4}{Table 5}

 Discussion



In the survey conducted to assess anxiety and depression in undergraduate students due to altered ST and PA patterns in COVID times, we found that 63% had borderline or pathological anxiety levels while 41.2% had borderline or pathological depression levels. There was a negative correlation between PA and symptoms of anxiety and depression for MVPA, but the correlation with VPA is only significant for depression. There was a positive correlation between ST and symptoms of anxiety and depression in females, but no such correlation was found in the case of males.

 Anxiety and depression



People tend to feel anxious and unsafe when the environment changes. Fear and isolation of those who are sick or quarantined, breakdown of social support structures, disruption of everyday life that we take for granted, and the mental health impact on students are real and anticipated outcomes of this pandemic.

India imposed nationwide lockdown and mass quarantine measures to curb the spread of the virus. Being social is a human tendency that facilitates social interaction, and thus when our movements are curtailed, psychological distress results.[6],[7]

Our study shows a high prevalence of anxiety and depression among undergraduate students, which is probably borne out of this psychological distress. These findings are in line with other studies that show high levels of psychological distress among individuals in India and China during the COVID-19 outbreak.[2],[8]

Similarly, people’s mental health was also badly affected during the Severe Acute Respiratory Syndrome (SARS) pandemic. Studies[9],[10] found that people who were quarantined during SARS reported a high level of psychological distress. This further stresses the fact that it is very important to thoroughly investigate the short-term and long-term mental health impacts of the COVID-19 pandemic.

During COVID-19 pandemic, when the cause and progression of the disease and outcomes are unclear, rumors grow leading to an increase in stress and anxiety. Rumors fuel feelings of uncertainty and are linked to issues such as stress, anxiety and depression. The people who don’t understand the disease transmission, progression, and consequences are more likely to panic and believe the rumors circling in digital and print media. As medical students have a basic knowledge about infectious diseases like COVID-19, it is likely that they do not experience this problem and thus have lower anxiety levels than nonmedical students.

Moreover, undergraduate students all over the world are experiencing distress because of the uncertainty of examinations in their colleges and with regard to the availability of jobs and so on. In spite of teachers trying their level best to teach students online, the impact of such teaching is not optimum. The reason is that all students are unable to afford online platforms usage and smoothly transition to online learning. A study[11] opined that anxiety issues among students during COVID-19 are related to their poor economic conditions, hampered academic activities, and uncertainty about their futures.

 Physical activity



Studies have shown that due to COVID-19 and the consequent lockdown, PA levels have declined.[3] This can be accounted to the fact that for youth, PA is closely linked to the daily commute, participation in structured sports, and other day-to-day activities; all of which were not possible due to the lockdown.[12]

But still, those individuals who were involved in organized and habitual PA found ways to maintain their PA levels through walking, yoga, home workout sessions, dancing, and so on.[3]

Boys tend to be involved in such organized and habitual PA more than girls, and thus, probably, the MVPA and VPA levels of boys were found to be higher than that of the girls.

Moreover, there seems to be a bidirectional association between PA and symptoms of anxiety and depression. Poor mental health can prevent students from achieving the PA recommendations. These students may lack the motivation and drive required to take up PA; they may even be cut off or isolated making them far less likely to take up PA.[13] It is evident from our study that anxiety and depression are more prevalent in girls as compared to boys, and thus this poor mental health may prevent girls from achieving the PA recommendations.

PA can have a beneficial effect on the mental health of an individual on a psychological level by improving self-esteem and body image.[14] PA is associated with the upregulation of mood-regulating neurotransmitters[15] and growth factors such as brain-derived neurotrophic factor. These promote neurogenesis and improve cognition.[16],[17]

Pro-inflammatory cytokines such as tumour necrosis factor alpha (TNF-α) and interleukin one beta (IL-1β) have been implicated in the pathogenesis of depression. PA has an anti-inflammatory action by the production of IL-6, which inhibits the formation of TNF-α.[18] This anti-inflammatory action of PA also helps reduce C-reactive protein, which has been known to cause chronic inflammation in patients suffering from anxiety disorders.[19]

Regarding the intensity of exercise, we found that VPA had a stronger negative correlation with depression as compared to MVPA, whereas MVPA had a stronger negative correlation with anxiety as compared to VPA. Very few studies have mentioned about intensity of exercise but the possible mechanism for our finding could be that MVPA has an anti-inflammatory action and reduces symptoms of both anxiety and depression, and although VPA also has a similar effect on depression, VPA increases the level of perceived stress and inflammation and thus may not be ideal for preventing or reducing the symptoms of anxiety.[18] Further research to ascertain the ideal intensity of exercise required to promote mental health should be carried out.

 Screen time



Observational studies have shown that more than 2 hours of recreational ST on a daily basis can have a detrimental impact on the mental health of an individual.[12]

Excessive social media use has been linked to body image concerns, disordered eating,[20] and high rates of self-harm and suicidal behavior.[21] Moreover, social media allows the user to compare themselves with people who are seemingly higher up the social ladder, thus fuelling jealousy and hatred, eventually leading to anxiety and depression.[22]

Another possible explanation is that people who reported high levels of ST may be victims of Cyber Bullying via the Internet, thus accounting for their anxious or depressed state.[23]

The use of smartphones and electronic devices, especially at bedtime, has been shown to increase sleep latency, decrease melatonin secretion, and interfere with the circadian rhythm.[24] The mere presence of a smartphone in the bedroom has been linked to more sleep disruptions, probably because of the urge to check the device for any notification.[24] This decreased duration and quality of sleep indirectly affects mental health and can lead to the development of anxiety and depression.[25]

Our findings are consistent with this for females who have a significant positive correlation of ST with symptoms of anxiety and depression, but we found that ST had no significant effect on the mental health of male respondents. This underlines the importance of differentiating between generalized and specific forms of problematic ST vis-à-vis the quality of on-screen content while predicting the impact of ST on mental health.[26]

Thus, girls who spend more of their time on social networking sites[12] are prone to the hazards of excessive ST, whereas boys who spend most of their ST watching television or playing games cope better as gaming and other such group activities have been found to have prosocial effects.[27]

To sum up, increasing PA levels and reducing sedentary behaviors through public health policies and college curriculums may have a beneficial effect on the mental health of students.

 Lacunae



This is a cross-sectional study and allows no causal conclusions. Two measurement points (before vs in COVID-19 lockdown) would have been more accurate to study the changes in mental health.

We only assessed the total recreational ST of the respondents and did not take into account the content that they consumed on screen.

Our data were self-reported and thus are susceptible to cognitive bias. Moreover, the sample size was small.

Thus, further interventional and longitudinal research should be carried out to assess the causal relationships between PA, ST, and mental health.

 Conclusion



The present study suggests that there is a high prevalence of borderline and pathological anxiety and depression among undergraduate students. High levels of PA and low levels of ST are separately associated with a lesser risk of anxiety and depression.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Rehman U, Shahnawaz MG, Khan NH et al. Depression, anxiety and stress among Indians in times of Covid-19 lockdown. Community Ment Health J 2021;57:42–48.
2Roy D, Tripathy S Kar SK, Sharma N, Verma SK, Kaushal V. Study of knowledge, attitude, anxiety & perceived mental healthcare need in Indian population during COVID-19 pandemic. Asian J Psychiatry 2020;51:102083.
3Schmidt SCE, Anedda B, Burchartz A et al. Physical activity and screen time of children and adolescents before and during the COVID-19 lockdown in Germany: a natural experiment. Sci Rep 2020;10:21780.
4Bull FC, Al-Ansari SS, Biddle S et al. World Health Organization 2020 guidelines on physical activity and sedentary behaviour. Br J Sports Med 2020;54:1451–62.
5Djukanovic I, Carlsson J, Årestedt K. Is the Hospital Anxiety and Depression Scale (HADS) a valid measure in a general population 65–80 years old? A psychometric evaluation study. Health Qual Life Outcomes 2017;15:193.
6Usher K, Durkin J, Bhullar N. The COVID-19 pandemic and mental health impacts. Int J Ment Health Nurs 2020;29:315–8.
7Kumar A, Nayar KR. COVID 19 and its mental health consequences. J Ment Health 2021;30:1–2.
8Wang C, Pan R, Wan X, Tan Y, Xu L, Ho CS, Ho RC. Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) epidemic among the general population in China. Int J Environ Res Public Health 2020;17:1729.
9McAlonan GM, Lee AM, Cheung V et al. Immediate and sustained psychological impact of an emerging infectious disease outbreak on health care workers. Can J Psychiatry 2007;52:241–7.
10Hawryluck L, Gold WL, Robinson S, Pogorski S, Galea S, Styra R. SARS control and psychological effects of quarantine, Toronto, Canada. Emerg Infect Dis 2004;10:1206–12.
11Cao 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.
12Abi-Jaoude E, Naylor KT, Pignatiello A. Smartphones, social media use and youth mental health. CMAJ Can Med Assoc J 2020;192:E136–41.
13Azevedo Da Silva M, Singh-Manoux A, Brunner EJ et al. Bidirectional association between physical activity and symptoms of anxiety and depression: the Whitehall II study. Eur J Epidemiol 2012;27:537–46.
14Hrafnkelsdottir SM, Brychta RJ, Rognvaldsdottir V et al. Less screen time and more frequent vigorous physical activity is associated with lower risk of reporting negative mental health symptoms among Icelandic adolescents. PLoS ONE 2018;13:e0196286.
15Heijnen S, Hommel B, Kibele A, Colzato LS. Neuromodulation of aerobic exercise—a review. Front Psychol 2016;6:1890.
16Kandola A, Vancampfort D, Herring M et al. Moving to beat anxiety: epidemiology and therapeutic issues with physical activity for anxiety. Curr Psychiatry Rep 2018;20:63.
17Anderson E, Shivakumar G. Effects of exercise and physical activity on anxiety. Front Psychiatry 2013;4:27.
18Paolucci EM, Loukov D, Bowdish DME, Heisz JJ. Exercise reduces depression and inflammation but intensity matters. Biol Psychol 2018;133:79–84.
19Moylan S, Eyre HA, Maes M, Baune BT, Jacka FN, Berk M. Exercising the worry away: how inflammation, oxidative and nitrogen stress mediates the beneficial effect of physical activity on anxiety disorder symptoms and behaviours. Neurosci Biobehav Rev 2013;37:573–84.
20Holland G, Tiggemann M. A systematic review of the impact of the use of social networking sites on body image and disordered eating outcomes. Body Image 2016;17:100–10.
21Marchant A, Hawton K, Stewart A et al. A systematic review of the relationship between internet use, self-harm and suicidal behaviour in young people: the good, the bad and the unknown. PLoS ONE 2017;12:e0181722.
22Seabrook EM, Kern ML, Rickard NS. Social networking sites, depression, and anxiety: a systematic review. JMIR Ment Health 2016;3:e50.
23Ortega R, Elipe P, Mora-Merchán JA et al. The emotional impact of bullying and cyberbullying on victims: a European cross-national study. Aggress Behav 2012;38:342–56.
24Carter B, Rees P, Hale L, Bhattacharjee D, Paradkar M. A meta-analysis of the effect of media devices on sleep outcomes. JAMA Pediatr 2016;170:1202–8.
25Vernon L, Modecki KL, Barber BL. Mobile phones in the bedroom: trajectories of sleep habits and subsequent adolescent psychosocial development. Child Dev 2018;89:66–77.
26Hökby S, Hadlaczky G, Westerlund J et al. Are mental health effects of internet use attributable to the web-based content or perceived consequences of usage? A longitudinal study of European adolescents. JMIR Ment Health 2016;3:e31.
27Kovess-Masfety V, Keyes K, Hamilton A et al. Is time spent playing video games associated with mental health, cognitive and social skills in young children? Soc Psychiatry Psychiatr Epidemiol 2016;51:349–57.