**8. Discussion**

The rapid outbreak of the COVID-19 pandemic has forced many countries to introduce specific social distancing and lockdown measures. Such restrictions have a significant impact on the overall well-being and might develop and progress in the form of symptoms related to depression, anxiety, or stress [48]. The SARS-CoV-2 virus, as an unknown agent with undefined mortality and infectivity, undoubtedly had an impact on mental health. The contemporary world is not used to the situation that has arisen. Moreover, frequent media releases about new infection incidents and deaths could heighten the fear of the threat.

The main aim of this cross-sectional study, including a population of more than two thousand Polish students, was to assess depression, stress, and anxiety during the first weeks after the outbreak of the SARS-CoV-2 pandemic and the lockdown in Poland. We also searched for possible risk factors that may intensify students' emotional responses. Results of our study showed that moderate to extremely severe scores of depression, anxiety, and stress were reported by 43.4%, 27.3%, and 41.0% of the respondents, respectively.

After processing the results of our research, we decided to compare the DASS-21 results received in our study with those obtained by researchers in the period before the COVID-19 pandemic. The study was conducted in the winter semester 2018/2019 at the Jagiellonian University among Polish medicine students showed that the level of overall emotional distress was lower than those in our study. Unexpectedly, we noticed a lower severity of anxiety in comparison to the results obtained before the pandemic in the above-mentioned study. However, the authors of the study did not present the percentage distribution of the results achieved, making further comparisons in this matter impossible [49]. In a study by Martinotti et al. using an Italian population, the depression rate was lower (22.9%), whereas anxiety was greater (30.1%) compared to the results of our study. Besides, the authors also showed irritability (31.6%) and post-traumatic stress symptoms (5.4%) as one of the most prevalent during the quarantine period [50]. What is intriguing and might be interesting for further research is that negative emotions (fear, anxiety, and sadness) experienced less intensely but not less frequently could constitute a protective role of trait emotional intelligence during the COVID-19 pandemic, according to the Polish study performed by Moro ´n and Biolik-Moro ´n [51].

It seemed interesting to compare the intensity of the emotional distress presented by Polish students with the reaction of students from other countries during the coronavirus pandemic. We have reviewed the available literature and selected four countries from different parts of the world, including Spain, China, India, and Bangladesh, which also performed similar studies primarily on populations of students and used the DASS-21 scale (Figure 1).

Considering the time frames, China was the first to measure the intensity of the emotional response in the student population. The study in China was conducted three days after the WHO announced COVID-19 as a public health emergency [48]. Our study was conducted at the end of the lockdown in Poland, whereas the Chinese study—only after one week of the lockdown. Polish students presented significantly higher emotional distress compared to Chinese students. Compared to the other analyzed countries, China was the one with the lowest percentage of students with moderate to extremely severe depression. This result was consistent with Selye's Theory of Stress—General Adaptation Syndrome, in which anxiety and stress dominate in the initial alarm reaction stage, and depression appears only in the third phase—exhaustion stage [52]. In a meta-analysis conducted by Salari et al., which aimed to investigate the rates of depression, anxiety, and stress during the COVID-19 pandemic by particular continents, it turned out that Asia presented the highest prevalence of anxiety and depression, whereas the most intensified stress levels were observed in a population from Europe [24].

The researchers from India conducted a study on a date after the lockdown that was similar to ours since it was four and six weeks, respectively [53]. Surveys were distributed in both countries during the end of the lockdown period. The results showed that students from both countries differed significantly in terms of comparing the number of students experiencing the severity of emotional disorders from moderate to extremely severe. In the population of Polish students, depression and anxiety were mostly enhanced, while anxiety dominates in the profile of emotional distress in Indian students. Perhaps these differences can be explained by the large disparity in the rates of the number of infected and the number of deaths per million.

Researchers from Bangladesh achieved a surprising result, especially considering that Bangladesh had the lowest mortality and infection rates among all compared countries. Namely, Bangladeshi students reported the highest percentage level in the subscale from moderate to extremely severe stress [54]. Furthermore, students from Bangladesh showed significantly higher levels of depression, stress, and anxiety compared to Poland and Spain. DASS-21 scores were significantly higher among women aged 25 to 29 who live in urban

areas, who were dissatisfied with their sleep, spent more hours browsing the Internet, were dissatisfied with academic studies in the current COVID-19 circumstances, and smoked. In each of the compared countries, women completed the survey more often than men. Only in the Bangladeshi population, the majority of respondents were men; nevertheless, female students showed higher levels of emotional distress similarly to all compared countries [53]. These results suggest that women, despite the country of origin, are more vulnerable to experience enhanced depressive, anxiety, and stress symptoms.

**Figure 1.** The results of the studies from Poland, Spain, China, India, and Bangladesh performed applying the DASS-21 scale. Legend: *n* = total number of the respondents, %M = percentage of male respondents, Tot cases/1M pop = total number of cases of COVID-19 per 1 million population on the first day of study, Tot deaths/1M pop = total number of deaths caused by COVID-19 per 1 million population on the first day of study, x = mean score of DASS-21, SD = standard deviation, % moderate to extremely severe = percentage of participants with Dass-21 score form moderate to extremely severe for depression (D), anxiety (A), and stress (S).

From all the above-analyzed countries, an unexpected situation was observed in Spain, where the highest rates of total confirmed cases and deaths of COVID-19 per 1 million population were noted. The percentage of students showing clinically significant levels of depression and stress was similar in the Spanish and Indian studies, although these countries significantly differed in terms of the mortality rates and the number of infections [38,53]. Comparing to Polish students, the respondents from Spain showed significantly lower results in all of the DASS-21 subscales (depression, anxiety, and stress). This observation indicates that there might be many different variables that may affect mental health except for the ones associated with COVID-19.

In our study, females showed statistically higher emotional distress levels compared to males. Generally, depressive [55] and anxiety [56,57] symptoms are more prevalently observed in females; therefore, increased levels of emotional distress in females compared to males seem not to be surprising.

Regarding the field of study, the greatest emotional response was shown by students of arts and humanities in both Poland and Spain; Spanish students who study either arts and humanities or social sciences and law presented the highest depression, anxiety, and stress levels [38]. In our study, we observed that being a science (OR = 2.04) or an art and humanities student (OR = 1.98) was associated with approximately 2-fold higher odds of more intensified total emotional distress. It is also worth emphasizing that the lowest intensity of the emotional response in both studies was observed among medical students, which is a very favorable phenomenon in the context of the nature of their future professional work and the potential risk of exposure to various stressors, including those related to the pandemic.

The results of our study showed that 'living with roommates' (OR = 1.25) constituted one of the risk factors that considerably intensifies the emotional distress among students. Such a high frequency of this chosen answer could be associated with numerous factors such as different emotional reactions of the roommates and their behaviors that could possibly cause negative thoughts and feelings in the respondents. Besides, it is worth noting that the students who were living with roommates could additionally worry about their family members or friends who were not living with them during the pandemic, contributing to the increased emotional distress of this group. Cao et al. pointed out that living with parents could potentially constitute a protective factor against anxiety symptoms [17]. Additionally, not living with a family during a pandemic has been associated with a greater risk of reporting at least one mental health outcome [58]. Isolation from family and friends and living with roommates during the lockdown could increase the emotional distress of participants, which was also confirmed in the studies by Wathelet et al. and Wang et al. [58,59]. Nevertheless, we do not have additional information about who the roommates actually were and whether they were rather a support or an emotional burden for the respondents. However, when we take into consideration the fact that amongst nine of the most stress-related situations, 'fear of infection of the loved ones' was one of the most strongly correlated with the general intensity of anxiety, then the isolation from the family due to lockdown and living with a roommate (other than family or any close relatives) might be an additional factor intensifying emotional distress.

In our study, loneliness turned out to be the greatest difficulty for Polish students during the outbreak of the COVID-19 pandemic (OR = 293.31), which is generally considered as a risk factor implicated in either development or progression of depression [60]. Due to the introduction of epidemiological restrictions, loneliness might significantly contribute to the higher intensity of depressive symptoms. Moreover, there is evidence that the feeling of loneliness because of the COVID-19 pandemic is more experienced in young people [61,62]. Interestingly, Sundarasen et al. showed that loneliness contributed to the increase in the anxiety levels in the group of students from Malaysia [36]. In a meta-analysis, Loades et al. pointed out that there was an association between loneliness and/or social isolation and exacerbation of depressive symptoms, especially in childhood/adolescence; the researchers observed that intensified depressive symptoms are more pronounced in females rather than males [63].

In the studied group, the co-occurrence of any mental disorder was associated with higher levels of emotional distress, depression, anxiety, as well as stress. However, we cannot completely assume whether such high levels of the above-mentioned variables were due to the pandemic itself or whether they were increased at baseline (before the outbreak of the pandemic); it was shown that generally, high levels of stress were related to numerous mental disorders, at the same time increasing the intensity of depressive and anxiety symptoms [64,65]. Those who used psychological and/or psychiatric support before the outbreak of the pandemic also showed significantly higher levels of emotional

distress along with all of the DASS-21 subscales. Our results are consistent with those obtained by Vindegaard et al., who indicated that people who had preexisting psychiatric disorders are reported to experience worsening psychiatric symptoms during the COVID-19 pandemic [66]. Like the above-mentioned information, it is speculative whether it was associated with the pandemic or due to potentially increased depression and/or anxiety and/or stress symptoms at baseline of the possible psychological or psychiatric condition. Moreover, the observed relationship should be interpreted with caution; anxiety and depressive symptoms could be potentially intensified by the fear of illness and increased loneliness during the pandemic, respectively. It is extremely important for health workers to be aware of such associations, especially during the pandemic.

Regarding the economic situation, the respondents with stable family income presented the lowest emotional distress levels, contrary to those who had to start borrowing money during the pandemic. Low income is generally associated with greater psychological distress; therefore, the results of our study seem consistent [67]. Although the majority of the respondents were not working (neither physically nor mentally), the remaining (those who were working during the pandemic) mostly presented with increased depression levels. Working mentally or physically during the pandemic was related to a 0.5 and 0.4-fold lower odds of increased overall emotional distress, respectively. Therefore, it might be assumed that having a job by the students could be a potentially protective factor against increased overall emotional distress.

Already during the pandemic, Larionov and Mudło-Głagolska (2020) conducted a study on the Polish population and showed that females, families with a household of at least two persons, persons with children, unemployed individuals, and those with chronic diseases were at risk of a stronger emotional response during a pandemic [68]. The researchers presented percentage results that were quite close to those obtained in our study, although the average age of their respondents was 35.15 years (SD = 12.53). The DASS total score for this group was equal to 35.89 ± 33.74. In the depression subscale, the percentage of respondents ranging from moderate to extreme severe was 37.25%, whereas, in our study, it was 43.40%. On the anxiety subscale, 39.08% of respondents presented with moderate to extremely severe anxiety, and in our study, it was 27.3% of students. In the above-mentioned study, 34.12% of respondents ranged from moderate to extremely severe on the stress subscale, compared to 41% of the students in our study. The conclusion is that in the group with higher age, the intensity of anxiety was more intense than in the group of students.

Islam et al. (2020) showed that the male gender, living in the countryside, having satisfactory sleep (7–8 h per day), low Internet use (less than 2 h a day), and physical exercise might constitute potential protective factors against emotional distress. The authors also showed that tobacco smoking might be associated with higher levels of depression, anxiety, and/or stress and thus might constitute one of the potential risk factors. Besides, living in a nuclear family was assumed to be a potential risk factor for depression and stress [54]. It should be taken into consideration that the results of all of these studies differ due to several reasons. Firstly, it was because all of the surveys were launched on different dates and the time that had passed from the start of the lockdown in a particular country also differed, and the release of the survey was not standardized. Thus, the impact of SARS-CoV-2 spread on the mental health of the respondents might differ. What is more, the results might differ because of the restrictions introduced by a particular country that might be more or less strict and severe depending on both—the decisions of the government as well as the time when the survey was performed since the expansion of particular restrictions also differ in time. What could also affect the respondents' reactions and depression, anxiety, and stress levels could be the form of providing information for the societies that might differ between the local social media.
