Mental health and sleep in the post-covid-19 era among thai undergraduate students

ABSTRACT The purpose of this study was to examine mental health problems and sleep quality among undergraduate students in the post-COVID-19 era, as well as related factors. This

cross-sectional study involved 627 undergraduate students from Chiang Mai University in northern Thailand between October and December 2022. Data were collected using a self-administered

online questionnaire that included the General Health Questionnaire-12 (GHQ-12), the Center for Epidemiologic Studies-Depression Scale (CES-D), and the Pittsburgh Sleep Quality Index (PSQI).

The study found that 57.9% of participants experienced mental health problems (95% CI: 54.0–61.8), 32.2% experienced depression (95% CI: 28.5–35.9), and 68.1% reported poor sleep quality

(95% CI: 64.4–71.8). Multiple logistic regression analysis revealed that medical conditions, relationships with family members, relationships with friends or other people, having problems

while studying at university, and self-perceived COVID-19 impact score were all associated with mental health problems and poor sleep quality (_p_ < 0.05). Depression was associated with

the field of study, relationships with family members, relationships with friends or other people, having problems while studying at university, and self-perceived COVID-19 impact score (_p_

 < 0.05). The findings highlight a significant occurrence of poor sleep and mental health issues, including depression, among undergraduate students in the post-COVID-19 era, underscoring

the need for ongoing mental health monitoring and interventions to mitigate negative outcomes. SIMILAR CONTENT BEING VIEWED BY OTHERS SELF-REPORTED SLEEP QUALITY AND MENTAL HEALTH MEDIATE

THE RELATIONSHIP BETWEEN CHRONIC DISEASES AND SUICIDAL IDEATION AMONG CHINESE MEDICAL STUDENTS Article Open access 06 November 2022 MENTAL HEALTH OF NEW UNDERGRADUATE STUDENTS BEFORE AND

AFTER COVID-19 IN CHINA Article Open access 22 September 2021 CROSS SECTIONAL ASSOCIATIONS OF PHYSICAL ACTIVITY AND SLEEP WITH MENTAL HEALTH AMONG CHINESE UNIVERSITY STUDENTS Article Open

access 30 December 2024 INTRODUCTION In December 2019, a new type of coronavirus disease (COVID-19) emerged in Wuhan and rapidly spread around the world1. The COVID-19 pandemic forced many

countries to implement emergency plans and impose social and public restrictions. During the pandemic, people worldwide had to follow public health measures such as staying at home,

practicing social distancing, and wearing masks or face coverings. This pandemic has had a profound impact on people’s lives, well-being, and mental health2. Undergraduate students are

particularly vulnerable to high levels of stress due to factors such as academic pressure, developing and maintaining relationships, establishing independence, lifestyle changes, and

financial issues. The accumulation of these stressors can increase the likelihood of developing mental health disorders3. During the COVID-19 pandemic, stress levels intensified as students

were isolated from others, unable to engage in external activities, and faced fears of infection along with uncertainty about the disease, all of which contributed to mental health

challenges4. Recent studies have highlighted that COVID-19 has negatively impacted students’ mental health, including increased instances of depression5,6,7,8,9,10,11, as well as their sleep

quality6,10,11. A meta-analysis found that 39% of undergraduate students experienced depression during the pandemic12. Key factors linking COVID-19 to poor mental health among university

students include academic stress and loss of social connections13, with insomnia mediating the relationship between perceived stress and depression6. In Thailand, nationwide public health

measures during the COVID-19 outbreaks led to a shift from on-campus to remote learning for the 2020–2021 academic year. Students had to leave their university dormitories, and on-campus

activities were suspended. By mid-2022, with more than 70% of Thais having received at least one dose of the COVID-19 vaccine and a reduction in the disease’s severity14, Thailand

reclassified COVID-19 from ‘a dangerous communicable disease’ to ‘a communicable disease under surveillance’ in October 202214. Consequently, most universities, including Chiang Mai

University, resumed on-campus learning in the first semester of the 2022 academic year. Given the transition to the post-COVID-19 era and the lack of data on mental health and sleep issues

among undergraduate students in Thailand during this period, this study aimed to fill this gap. The aims of this study were to describe the prevalence of mental health problems, depression,

and poor sleep among undergraduate students and to identify the factors associated with these issues in the post-COVID-19 context. The findings are expected to inform interventions aimed at

preventing and addressing mental health disorders, thereby improving students’ well-being throughout their university experience. METHODS STUDY DESIGN AND SETTING This cross-sectional study

was conducted online among undergraduate students at Chiang Mai University, Thailand, from October to December 2022. PARTICIPANTS The study targeted undergraduate students at Chiang Mai

University. The sample size was calculated to estimate a population proportion with maximum variability (50%), a 5% absolute precision, and a 95% confidence level. After adjusting for a 10%

expected rate of incomplete or missing data, the final sample size was set at 424. To enhance data representativeness, we aimed to collect as many samples as possible during the study

period. Ultimately, 627 samples were collected using convenience and snowball sampling methods. DATA COLLECTION An anonymous, self-administered questionnaire was distributed via a link and

QR code to all Chiang Mai University faculty offices. Interested students could access the study information sheet and informed consent form online. Participants provided informed consent by

clicking on the first page of the online questionnaire, which then directed them to the survey. MEASUREMENT AND INTERPRETATION A four-section self-administered online questionnaire was used

to collect data. The first section gathered demographic information from participants, including gender, age, faculty, year of study, medical conditions, health insurance status, and

characteristics of their primary residence. It also explored relationships with family members and others, as well as problems encountered while attending university. Additionally, this

section inquired about the history of COVID-19 infection for both the participants and their family members, and assessed the self-perceived impact of the COVID-19 outbreak using a visual

analog scale (0–100). The second section utilized the General Health Questionnaire-12 (GHQ-12) to assess participants’ health status over the previous two to three weeks. It included

questions such as “You have been able to concentrate on what you’re doing for the past two or three weeks” and “You have had difficulty sleeping due to anxiety for the past two or three

weeks”15. The bimodal scoring method (0-0-1-1) was applied to the four response categories, resulting in a total score range of 0–12 points15. A score of 2 or higher indicates a potential

mental health issue or risk for psychiatric disorders. The third section employed the Center for Epidemiologic Studies-Depression Scale (CES-D), a depression screening tool for Thai

university students16,17. It consists of 20 questions where participants rate the frequency of depression-related symptoms experienced in the previous week, such as restless sleep, poor

appetite, and loneliness. Example questions include “During the past week, I was bothered by things that usually don’t bother me” and “During the past week, I did not feel like eating; my

appetite was poor.” Responses range from 0 to 3 (0 = Never, 1 = Some of the Time, 2 = Much of the Time, 3 = Most of the Time). The scale ranges from 0 to 60, with higher scores indicating

more depressive symptoms. A score greater than 22 indicates depression17. The fourth section used the Thai version of the Pittsburgh Sleep Quality Index (PSQI)18, a widely used

self-administered questionnaire that measures sleep quality over the past month. It evaluates sleep disturbances across seven dimensions: subjective sleep quality, sleep latency, sleep

duration, sleep efficiency, sleep disturbances, use of sleep medication, and daytime dysfunction. The PSQI contains 19 questions with a total score range of 0–21, where higher scores reflect

poorer sleep quality. A score exceeding 5 indicates poor sleep18. STATISTICAL ANALYSIS The data were analyzed using SPSS-29 software, employing both descriptive and inferential statistics.

Descriptive statistics, including frequency, percentage, mean, standard deviation, median, and interquartile range, summarized the data. Spearman’s rank correlation coefficient (rs) assessed

the relationships between scores for mental health, depression, and sleep quality. To evaluate associations between demographic characteristics and mental health status, depression, and

sleep quality, we used the chi-square test for categorical data (such as gender) and the unpaired t-test for continuous variables (such as age and self-perceived COVID-19 impact). The

significance level was set at _p_ < 0.05. Significant factors identified were entered into a multiple logistic regression model to explore their associations with mental health problems,

depression, and poor sleep quality. The final model reported the odds ratios (OR) for all variables with p-values < 0.05. ETHICS STATEMENT The studies involving human participants were

reviewed and approved by the Committee of Research Ethics, Faculty of Public Health, Chiang Mai University (Approval No. ET009/2022, July 30, 2022). All methods were performed in accordance

with the Declaration of Helsinki. The research information sheet and informed consent form were made available to participants online. To participate in the study, participants were required

to sign the informed consent form by clicking on it; the questionnaire would then appear on the screen. RESULTS DEMOGRAPHIC CHARACTERISTICS OF THE PARTICIPANTS In this study, 641 people

were approached, and 627 provided complete data for analysis (97.8%). The majority of participants (66.3%) were female. The mean age of the participants was 20.17 (± 1.63); 544 (86.8%) had

no medical conditions, and 511 (81.5%) had health insurance coverage. Regarding study information, 300 participants (47.9%) were studying humanities and social sciences, and 210 (33.5%) were

in their second year. In terms of residence, 299 participants (47.7%) lived in a university dormitory, while 232 (37.0%) lived with close friends. Additionally, 521 participants (83.1%)

reported having a good relationship with their family members, and 540 (86.1%) had a good relationship with their friends or other people. When asked about problems encountered while

attending university, the majority of participants (85.5%) reported having at least one problem, including financial problems (79.3%), study problems (64.4%), interpersonal problems (33.6%),

and university life-related problems (29.7%). In terms of COVID-19-related information, 367 participants (58.5%) had a history of COVID-19 infection, and 453 participants (72.2%) had

parents or family members with a history of COVID-19 infection. The mean self-perceived impact of COVID-19 was 65.67 (± 20.90) (Table 1). MENTAL HEALTH This study found that the overall

prevalence of mental health problems was 57.9% (95% CI: 54.0–61.8). Mental health issues were consistent across gender, age, health insurance status, field of study, residence

characteristics, living conditions, and COVID-19 infection histories. However, prevalence varied based on medical conditions (p-value = 0.002), year at university (p-value = 0.045),

relationships with family members (p-value < 0.001), relationships with friends or other people (p-value < 0.001), and the presence of problems while studying at university (p-value 

< 0.001) (Table 1). When comparing the self-perceived impact of COVID-19 between undergraduate students with and without mental health problems, the results revealed a statistically

significant difference in mean scores between the two groups (68.06 ± 20.91 vs. 62.39 ± 20.46) (p-value = 0.001) (Table 1). DEPRESSION The prevalence of depression was found to be 32.2% (95%

CI: 28.5–35.9). Depression was comparable across gender, medical conditions, health insurance status, year at university, residence characteristics, living conditions, and COVID-19

infection histories. However, it differed by field of study, relationships with family members, relationships with friends or other people, and the presence of problems while studying at

university (p-values: < 0.001 for all) (Table 1). When comparing the self-perceived impact of COVID-19 between undergraduate students with and without depression, the results showed that

students with depression had a mean score of 69.30 (± 20.12), while those without depression had a mean score of 63.95 (± 21.06), with a statistically significant difference (p-value = 

0.003) (Table 1). SLEEP The findings revealed that 427 participants (68.1%) had poor sleep quality (95% CI: 64.4–71.8). Sleep quality was consistent across gender, age, health insurance

status, field of study, university year, residence characteristics, living conditions, and COVID-19 infection histories. However, it varied based on medical conditions (p-value < 0.001),

relationships with family members (p-value = 0.001), relationships with friends or other people (p-value < 0.001), and having problems at university (p-value < 0.001) (Table 1). When

comparing the self-perceived impact of COVID-19 between undergraduate students with poor and good sleep, the results revealed that students in the poor sleep group had a mean score of 67.89

(± 20.75), while those in the good sleep group had a mean score of 60.95 (± 20.48), with a statistically significant difference (p-value < 0.001) (Table 1). RELATIONSHIP BETWEEN MENTAL

HEALTH, DEPRESSION, AND SLEEP The findings revealed that the prevalence of depression among undergraduate students with mental health problems was 53.2% (_n_ = 193), compared to 3.4% (_n_ = 

9) among those without mental health problems. Spearman’s rank correlation showed positive correlations between mental health and depression (rs = 0.770), mental health and sleep quality (rs

= 0.617), and depression and sleep quality (rs = 0.608), all with p-values < 0.001 (Table 2). FACTORS ASSOCIATED WITH MENTAL HEALTH PROBLEMS, DEPRESSION AND POOR SLEEP QUALITY When using

multiple logistic regression analysis to determine the factors associated with mental health problems, depression, and poor sleep quality, this study identified several key associations.

For mental health problems, significant factors included the presence of medical conditions, relationships with family members, relationships with friends or other people, the presence of

problems while studying at university, and the self-perceived COVID-19 impact score (p-values: 0.003, 0.020, < 0.001, < 0.001, and 0.004, respectively). For depression, the associated

factors were field of study, relationships with family members, relationships with friends or other people, the presence of problems while studying at university, and the self-perceived

COVID-19 impact score (p-values: 0.021, 0.006, < 0.001, < 0.001, and 0.011, respectively). Additionally, the study found that poor sleep quality was associated with the presence of

medical conditions, relationships with family members, relationships with friends or other people, the presence of problems while studying at university, and the self-perceived COVID-19

impact score (p-values: <0.001, 0.027, 0.012, < 0.001, and < 0.001, respectively) (Table 3). DISCUSSION To the best of our knowledge, this is the first study in Thailand to

investigate mental health problems and sleep among undergraduate students, as well as the factors contributing to these issues in the post-COVID-19 era. This study found that the prevalence

of mental health problems, depression, and poor sleep quality was 57.9%, 32.2%, and 68.1%, respectively. Despite Thai people returning to normal life after the COVID-19 pandemic, this study

found a higher prevalence of mental health problems among undergraduate students compared to studies conducted during the pandemic using GHQ-12 in Spain19 and Palestine20. Poor sleep quality

was also more prevalent in this study than in previous studies using PSQI among university students during COVID-19 in Germany21, China22, and Saudi Arabia23, as well as in studies

conducted in many countries prior to the pandemic24,25. However, the prevalence of depression measured by CES-D was lower than in studies conducted in Jordan26, Nepal27, and the United

States28. When comparing the prevalence of mental health problems, depression, and poor sleep among different groups, this study found that students with medical conditions were more likely

to experience higher levels of both mental health issues and poor sleep. This suggests that their health conditions may negatively impact their mental well-being and sleep quality.

Additionally, students with strained relationships with family members, friends, and others were more likely to report higher levels of mental health problems, depression, and poor sleep

compared to those with positive relationships. Moreover, students who encountered problems while studying at university were also more likely to experience elevated levels of mental health

issues, depression, and poor sleep compared to those who did not face such problems. Although the prevalence of mental health problems, depression, and poor sleep was similar between

students with and without a history of COVID-19 infection (either themselves or their family members), this study found that students experiencing these issues reported a higher

self-perceived impact of COVID-19. This suggests that the negative effects of COVID-19 may persist over time, contributing to ongoing mental health and sleep problems. Despite the overall

prevalence of depression among undergraduate students being 32.2%, this study found that students with mental health problems (GHQ-12 ≥ 2) had a higher prevalence of depression (53.2%)

compared to those without mental health problems (3.4%). This suggests that the GHQ-12 could be effectively used as an initial screening tool for depression, aligning with findings from a

study conducted in multiple countries29. Correlation analysis revealed a significant relationship between mental health, depression, and sleep quality scores. This indicates that students

with higher GHQ-12 scores are more likely to experience elevated levels of depression (as indicated by high CES-D scores) and poorer sleep quality (as indicated by high PSQI scores), and

vice versa. This finding aligns with a study conducted in the United States, which found that sleep quality, as measured by the PSQI, was consistently associated with mental health issues30.

Additionally, students with higher CES-D scores are more likely to report poor sleep quality (as indicated by high PSQI scores), consistent with research from the United Kingdom that shows

a strong correlation between increased depression symptoms and poor sleep quality9,31. Multiple logistic regression analysis revealed that students with medical conditions experienced higher

levels of mental health issues and poor sleep compared to those without medical conditions (OR 2.38; 95% CI 1.35–4.20 for mental health issues, OR 3.49; 95% CI 1.77–6.89 for poor sleep).

This could be attributed to the impact of their illness on both their mental health and sleep quality. In terms of field of study, this study found that undergraduate students in the

humanities and social sciences were 1.82 times more likely to experience depression compared to those in health sciences (OR 1.82; 95% CI 1.09–3.04). Unfortunately, there is a lack of

research investigating the prevalence and risk factors of depression or suicidal ideation specifically among students in the humanities and social sciences31. Students who encountered

problems while studying at university had higher levels of mental health issues, depression, and poor sleep compared to those who did not face such problems (OR 4.68; 95% CI 2.75–7.97 for

mental health issues, OR 11.83; 95% CI 3.66–38.24 for depression, OR 3.27; 95% CI 2.02–5.29 for poor sleep). Financial difficulties, study-related issues, interpersonal conflicts, and

challenges related to university life were notably prevalent in this study. Previous research indicates that undergraduate students are particularly vulnerable to high levels of stress from

academic pressure, relationship dynamics, establishing autonomy, lifestyle changes, and financial concerns. These stressors, when combined, can contribute to mental health disorders3.

Additionally, this study found a significant positive relationship between mental health issues, depression, and poor sleep quality. This suggests that stressors contributing to mental

health problems and depression may be mediated by insomnia, which plays a role in the association between perceived stress and depression6. Students with strained relationships with family

members and friends were more likely to experience mental health problems, depression, and poor sleep compared to those with positive relationships. Strong social support, particularly from

family and close friends, is associated with better mental health outcomes. Literature supports that social relationships impact various health outcomes, including mental health, physical

health, health behaviors, and mortality risk32,33. Additionally, a study in China highlighted the influence of support from friends, family, and classmates on sleep quality34. Furthermore,

each one-point increase in the self-perceived impact of COVID-19 score was associated with a 1.01 increase in the likelihood of experiencing mental health problems (95% CI 1.00–1.02).

Although the world, including Thailand, has transitioned to a post-COVID-19 era and undergraduate students have largely returned to normal life, the lingering negative effects of COVID-19

may continue to contribute to mental health issues such as depression and sleep disturbances. Mental health issues, depression, and poor sleep are prevalent among undergraduate students,

whether related to the COVID-19 pandemic or not7,8,35. These problems remain a public health concern due to their potential negative impact on students. Students with mental health issues

are more likely to miss classes, tests, and assignments, and they may be at a higher risk of dropping out of college compared to their non-depressed peers, especially if they find their

courses too challenging36. Depression can also lead to mood disturbances that affect academic performance37. Additionally, poor sleep quality can impair learning capacity, academic

performance, and test scores38,39,40. Chronic sleep deprivation is linked to a range of adverse outcomes, including obesity, cardiometabolic dysfunction, mood disturbances such as increased

suicidal ideation, higher risk of engaging in health-risk behaviors like alcohol and substance abuse, and a greater likelihood of car accidents, occupational injuries, and sports-related

injuries40. This study has several limitations. First, due to its cross-sectional design, causality cannot be established. Second, the data collection through an online questionnaire

precludes calculation of actual response rates and distribution. Third, while the study utilized self-reported questionnaires to assess psychiatric symptoms, it did not involve clinical

diagnosis. All questionnaires serve as preliminary screening tools, and a more accurate diagnosis requires professional evaluation. Nevertheless, the findings underscore the need for ongoing

mental health monitoring and preventive measures for undergraduate students, particularly those at higher risk of mental health disorders—such as those experiencing academic difficulties,

poor relationships with family or friends, or high perceived impact of COVID-19. DATA AVAILABILITY All data supporting the findings of this study are available from the corresponding author

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consequences. _Minerva Pediatr._ 69(4), 326–336 (2017). Article  PubMed  Google Scholar  Download references ACKNOWLEDGEMENTS This study was financial supported by CMU Junior Research

Fellowship Program, Chiang Mai University. The article processing charge was supported by the Faculty of Medicine Vajira Hospital, and Navamindradhiraj University, Bangkok, Thailand. We

would also like to thank Dr.Kannikar Intawong and her team for their assistance with online questionnaire solutions and data management requirements. AUTHOR INFORMATION AUTHORS AND

AFFILIATIONS * Faculty of Public Health, Chiang Mai University, Chiang Mai, 50200, Thailand Sineenart Chautrakarn & Ekachai Jaiprom * Department of Research and Medical Innovation,

Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, 10300, Thailand Parichat Ong-Artborirak Authors * Sineenart Chautrakarn View author publications You can also

search for this author inPubMed Google Scholar * Ekachai Jaiprom View author publications You can also search for this author inPubMed Google Scholar * Parichat Ong-Artborirak View author

publications You can also search for this author inPubMed Google Scholar CONTRIBUTIONS Conceptualization: SC, PO. Data curation: SC, PO, EJ. Formal analysis: PO, SC. Funding acquisition: SC.

Methodology: SC, PO. Project administration: SC, PO, EJ. Visualization: SC. Writing - original draft: SC. Writing - review & editing: SC, PO. All authors reviewed the manuscript.

CORRESPONDING AUTHOR Correspondence to Parichat Ong-Artborirak. ETHICS DECLARATIONS COMPETING INTERESTS The authors declare no competing interests. ADDITIONAL INFORMATION PUBLISHER’S NOTE

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http://creativecommons.org/licenses/by-nc-nd/4.0/. Reprints and permissions ABOUT THIS ARTICLE CITE THIS ARTICLE Chautrakarn, S., Jaiprom, E. & Ong-Artborirak, P. Mental health and sleep

in the post-COVID-19 era among Thai undergraduate students. _Sci Rep_ 14, 26584 (2024). https://doi.org/10.1038/s41598-024-78559-0 Download citation * Received: 22 January 2024 * Accepted:

31 October 2024 * Published: 04 November 2024 * DOI: https://doi.org/10.1038/s41598-024-78559-0 SHARE THIS ARTICLE Anyone you share the following link with will be able to read this content:

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Mental health * Depression * Sleep * Undergraduate student * post-COVID-19