The present study revealed notable levels of anxiety, depression, and stress in this Mexican university undergraduate student population. There was a sex difference with respect to symptom severity, with women in general reporting more severe symptoms, and younger students showing more severe symptoms than older ones. There were also differences in symptom severity among the different academic majors: students of biological sciences showed higher depression scores than did students of psychotherapy and odontology. Similar trends were observed for OC symptoms: women showed more severe ordering symptoms than men, psychotherapy majors showed lower overall OC scores, and younger students reported more severe symptoms than older ones. Obsessing subscale scores were significantly associated with depression and anxiety while tension/stress was associated with ordering.
Prevalence and severity of depression, anxiety, tension/stress, and obsessive-compulsive symptoms.
According to the severity categories that have been established for the DASS-21, approximately 22%, 13%, and 20% of the present sample reported moderate, severe, and extremely severe depression respectively, while 21%, 10%, and 45% reported moderate, severe, and extremely severe anxiety respectively, and 24%, 24%, and 16% reported moderate, severe, and extremely severe tension/stress, respectively. Overall, these prevalences were similar to those reported in pre-pandemic studies of university students of Saudi Arabia (Basudan et al 2017), Pakistan (Asif et al 2020), Turkey (Bayram and Bilgel, 2008), India (Iqbal et al., 2015), Malaysia (Shamsuddin et al., 2013), China (Hall et al., 2018), and Lebanon (Younes et al., 2016). However, compared to these and other pre-pandemic studies, our sample comprised greater proportions of students that presented severe and extremely severe symptoms, particularly with respect to anxiety and depression. This finding is consistent with many post-pandemic studies of university students, which in general have reported increased severe and extremely severe anxiety and depression, compared to those carried out prior to the pandemic. Thus, if one compares data from pre-pandemic studies (data collected prior to December of 2019) to those in which data were collected post-pandemic (from January of 2021 onward), one observes almost a doubling in the proportion of individuals within the extremely severe anxiety category (See Table 5, and supplementary material2). Notably, the timing of post-pandemic studies generally corresponded to the reinitiation of on-site classes; such a drastic change from remote learning under pandemic restrictions to quasi-normalcy could be particularly conducive to anxiety symptoms, as recently suggested by Bhakat et al., (2023).
A recent study of Mexican university students reported that those individuals within the “extremely severe” category of anxiety symptoms were markedly more likely to have a chronic illness, live with a chronically ill person, have themselves been infected with COVID-19 or had contact with infected person, or have experienced the death of someone close to them by COVID-19 (Dosil-Santamaría et al., 2022). These same factors were also associated with extremely severe depression and stress. Interestingly, a clear characteristic of those within the “extremely severe” anxiety category was that they were much more likely to perceive that public compliance with COVID-19 restrictions was low (Dosil-Santamaría et al., 2022). This latter finding suggests that perceived lack of controllability with regards to protecting oneself from COVID-19 infection and may have been an important factor that promoted extreme anxiety in these students.
A number of studies have identified factors associated with increased DASS-21 scores of depression, anxiety, and stress in university students during and since the pandemic. These factors include younger age (Andrades-Tobar et al., 2021), being a sexual minority (Martínez-Libano et al., 2023), financial worries (Hasan Khan et al., 2020; Rahman et al., 2022,), lack of access to accurate information about COVID-19 (Simegne et al., 2021), and lack of satisfaction with the educational experience during the pandemic (Hamaideh 2021, Islam et al., 2021, Rhaman et al., 2022). Other factors included having a pre-existing chronic disease (Ghazaway et al., 2020; Rezende Lopes 2021; Woon 2021,), the illness or death of a close family member or friend (Alanzi et al., 2022; Halat et al., 2022; Hamaideh et al.,2021; Mohammed et al., 2021), excessive internet use and media attention to pandemic-related themes (Ghazaway et al., 2020; Islam et al., 2021; Mohammed et al., 2021; Wong et al., 2023), the loss of one's daily routine (Woon et al., 2021), poor sleep (Andrades-Tobar et al., 2021; Fariz Fauzi et al., 2021; Hamaideh et al., 2022; Mohammed et al., 2021; Ramon Arbuos et al., 2020), and lack of physical exercise (Hasan Khan et al., 2020; Islam et al., 2021; Najjuka et al., 2022; Talapko et al., 2021; Wong et al., 2023). Finally, pre-existing psychological and emotional factors were also important determinants of the severity of pandemic depression, anxiety and stress; these factors include suffering from a pre-existing mental disorder or family history of depression (Alanzi et al., 2022; Dalky et al., 2022; Wong et al., 2023,), dysfunctional coping mechanisms (El Monshed et al., 2021, Rezende Lopes et al., 2021), loneliness (Andrades-Tobar et a., 2021; El Monshed et al., 2021; Halat et al., 2022; Hamaideh et al., 2022;), lack of talking about pandemic fears and problems (Andrades-Tobar et al., 2021) fear of infection (El Monshed et al., 2021, Halat et al., 2022: Hamaideh et al., 2022); and lack of family and/or social support (Ghazaway et al., 2020; Mohammed et al., 2021; Rezende Lopes et al., 2021; Woon et al., 2021). In future pandemics, the effects of these factors might be mitigated by government (local, state, federal) and university policy, as well as by preventative programs aimed at physical and mental health.
In the present study, women showed higher mean anxiety and stress scores than did men, while they did not differ from men with respect to depression. Likewise, a greater proportion of women than men fell within the severe and extremely severe categories of anxiety and stress. This difference between the sexes has been consistently reported in studies that have applied the DASS-21 scale (e.g., Basudan et al., 2017; Bayram 2008; Ramon Arbues 2020; Iqubal 2015; Shamsuddin 2013; Andrades-Tobar et al., 2021). In the present study, women also showed significantly higher scores on the ordering dimension of the OCI-R and trended toward higher scores on the checking dimension, while their total OCI-R scores did not differ significantly from men. This same sex difference was also observed in Smari et al (2007), in which checking and ordering scores were signficantly elevated in women compared to men.
There was a clear effect of the students' age on DASS-21 scores: younger students (17–20 years old) had significantly greater anxiety compared to older students, and this general trend was also observed for tension/stress. In a number of different countries, younger university students and/or those in the initial years of undergraduate study have been reported to have more severe depression, anxiety, and tension/stress (e.g., Andrades-Tobar et al., 2021; Bayram and Bilgel, 2008; Iqbal et al., 2015). In the present study, younger students also showed more severe OC symptoms, particularly in the obsessing subscale. It is likely that young adults just entering the university require some time to adapt to the academic and social conditions that university studies entail, and difficulties in dealing with the transition to university education might affect their mental health and academic performance.
Although the present OCI-R scores were similar to those of a pre-pandemic Turkish study (Aydin et al., 2014), in general they were slightly higher than in the sample of university students in which the OCI-R was originally validated (Hajcak et al., 2004), as well as compared to many other studies published prior to the pandemic (Fullana et al., 2005; Smari et al., 2007; Woo et al., 2010). Much of this increase in OCI-R scores is likely due to stress provoked by the COVID-19 pandemic and the measures put in place to mitigate its spread. Khosravani et al (2021) reported that COVID-19 related stress accounted for pandemic-related increases in OC symptoms across symptom dimensions, in a sample of patients with OCD. Similarly, Fontanelle et al (2021) found that OC symptoms in a general population sample during the pandemic were predicted by female gender, the number of COVID-19 related stressful events, as well as by prior OC symptoms related to fear of harm and symmetry.
Relationship between obsessive compulsive symptoms and depression, anxiety and tension/stress.
Depression and OCD share certain “transdiagnostic emotional vulnerabilities” with respect to distress tolerance, anxiety sensitivity, and hedonic responsiveness (Chassen et al., 2017). In the present study, we observed a selective positive association between the OCI-R obsessing subscale, and DASS-21 depression and anxiety. The OCI-R obsessing subscale comprises three items that are respectively related to: 1) the perceived lack of control over intrusive thoughts, 2) negative emotional appraisal of intrusive thoughts, and 3) frequency and persistence of intrusive thoughts. This subscale is selectively associated with low distress tolerance (Cougle et al., 2011); conversely, lower distress tolerance predicted greater obsessions in individuals that experienced a greater number of negative daily life events (Makatee et al., 2013). Low distress tolerance is suggested to be associated with internalizing symptoms (negative self-evaluation, rumination) in females and externalizing symptoms (substance use disorder, delinquency) in males (Daughters et al., 2013). Although we did not assess the construct of distress tolerance in the present sample, we did observe that the obsessing subscale item that reflects the frequency and persistence of intrusive thoughts (Item #18) was selectively associated with depression and anxiety. In future studies it will be important to assess distress tolerance, obsessing and depression/anxiety in the same population, in order to clarify the relationships between these constructs; specifically, one might predict that low distress tolerance might have a unique relationship with frequency and persistence of intrusive thoughts, and particularly in women.
The present study also revealed relationships between DASS-21 tension/stress and the OCI-R ordering subscale. This finding is consistent with a number of studies that have reported significant associations between stressful or traumatic life events and the onset of symmetry/ordering and checking OC symptoms, particularly in women (Cromer et al., 2007; Rosso et al., 2012). Indeed, a recent study (Destrée et al., 2023) reported a specific association between stressful experiences and OC symmetry symptoms.