Depression, Depression, Anxiety, and Stress among Students of Sriwijaya University

. The prevalence of Major Depressive Disorder (MDD) among students was the highest (18.5%), followed by anxiety (16.7%). Psychosocial stressors and academic pressure on students require them to be able to adjust themselves in order to cope with the mental stress that occurs. The aims to descriptions of mental health, especially depression, anxiety, and stress in students. An analytic observational study with a cross sectional design used. As much 1564 students from 10 faculties filled out the DASS-42 questionnaire distributed via social media in January 2020−24 August 2020. The analyzed using chi square, Mann Whitney, and binary logistic regression with significance of 0.05. Students who have a risk to depression, anxiety, and steress are 46%, 74.2%, and 57.9%. There is a significant relationship between the incidence of depression with GPA, faculty, semester and place of residence (p<0.05). Gender, faculty, and religion factors associated with the anxiety (p<0.05). While the gender, place of residence and faculty associated with stress (p<0.05). History of chronic illness and family history of mental disorders influenced the depression, anxiety disorders, and stress (p < 0.001). Mostly, Sriwijaya University students have an increase in depression, anxiety, and stress, especially during the Covid-19 pandemic. The gender, semester, marital status, history of chronic disease, and a history of mental disorders in the family affect the incidence of depression, anxiety, and stress. The mean GPA of students with a tendency to depression, anxiety, and stress was lower by ± 0.03 points. The university stakeholders needs to implement mental health interventions to maximize student potential. carried out by the


INTRODUCTION
Students are a vulnerable population group to mental health problems and disorders. They are categorized with a transitional phase from adolescence to young adulthood which is surely highlighted by distress and various adjustments. Packed class schedules, different educational systems, new environmental and social situations, and demands to be independent and adaptive often become stressors for students (Bruffaerts et al., 2018).
WHO through the World Mental Health Surveys International College Student Project found that major depressive disorder (MDD) had the highest prevalence rate of mental health University students had not been identified in previous studies. This research was also carried out during the Covid-19 pandemic where many campus activities in Indonesia were diverted through online media. Therefore, this study aims to analyze mental disorders in students to understand the idea of number of mental health problems, especially depression, anxiety, and stress that often arise in this phase. These results can be used as the basis for interventions related to mental health that will be carried out by the university.
Mental health, similar to other health aspects, can be affected by various factors (Ayuningtyas et al., 2018). Previous studies have stated that there is a relationship between respondent characteristics and depression, anxiety, and stress disorders (Astutik et al., 2020;Hamaideh et al., 2021). Therefore, the hypothesis in this study is that there is a relationship between respondent characteristics and the occurrence of depression, anxiety, and stress in Sriwijaya University students.

METHOD
This study is an analytic observational study with a cross-sectional design. The population in this study involved all active students of Sriwijaya University. The research sample was carried out using a convenience sampling technique, the respondents comprised 1564 students from 10 faculties who filled out online questionnaires distributed through social media Line, Whatsapp, Instagram, and Twitter. Data collection was conducted from January 2020 to August 24, 2020.
This study employed the DASS-42 questionnaire, a self-assessment instrument, consisting of 42 questions designed to measure three negative emotional states related to depression, anxiety, and stress. The DASS-42 questionnaire was issued by the Psychology Foundation Australia and has been translated into Indonesian by Damanik (Damanik, 2006). The validity and reliability tests of the questionnaire were administered on 60 students of Sriwijaya University taken from every faculty in December 2019 using Corrected Item-Total Correlation analysis and obtained a validity value of 0.406-0.785 and a reliability value of 0.96, hence it was declared valid and reliable. Respondents were given a score of 0-3 for each answer to the question on the questionnaire. The answer scores were then summed and categorized as 'depressed' (>9) and not depressed, 'anxiety' (>7) and 'no anxiety', and 'stressed' (<14) and 'not stressed'. The independent variables were grouped based on the characteristics of the respondents in the field.
The data were analyzed using the IBM SPSS Statistics 24 program. The data were calculated operating the Mann-Whitney and Chi-Square statistical hypothesis analysis techniques with a significance value of p and an alpha significance of 0.05. The Mann-Whitney test is used to analyze the means difference between two populations that come from the same population and are not normally distributed. While the Chi-Square test is used since the data is categorical and the sample is large. This analysis technique is to determine the relationship between socio-demographic factors and mental status. Binary logistic regression test was performed to investigate the most influential variables on the occurrence of depression, anxiety, and stress.

RESULTS AND DISCUSSION
From 1564 respondents, it is known that the average age of the respondents was 19.83 (±1.35) years. The majority of respondents were female (n=1165, 74.5%), students of the Faculty of Public Health Sciences (n=247, 15.8%), third semester (n=600, 38.4%), Muslim (n=1451, 92.8%), living in a boarding house (n=765, 48.9%) and unmarried (n=1557, 99.5%). From 1564 respondents, it is known that the average GPA value was 3.350 (±0.561) with the vast majority From table 1, it can be determined that the mental status of students based on the DASS-42 questionnaire shows that of 1564 respondents, 729 (46%) appeared to be more likely to experience depression, anxiety with 1160 (74.2%) respondents and stress totaling 906 (57.9%) respondent. The results of the analysis showed that there was a significant relationship between the occurrence of depression with age, GPA, faculty, semester, and place of residence (p-value <0.05). Several factors were significantly related to the anxiety events including gender, faculty, and religion (p-value <0.05). Meanwhile, the factors that were significantly related to stress were gender, faculty, semester, and place of residence (p-value <0.05). History of chronic diseases and family history of mental disorders were very significantly associated with depression, anxiety, and stress (p-value = 0.000).   Table 2, the results of logistic regression analysis using the backward LR method obtained four independent variables with the most influence on the occurrence of depression. Students with a family history of mental disorders were 2.33 times more likely to experience depression than those without family history of mental disorders. Students with a history of chronic illness were 1.79 times more likely to experience depression than those without history of chronic illness. Early semester students were 0.93 times more prone to experience depression than those who were not and married students were 0.17 times more vulnerable to depression From Table 3, four independent variables had the most impact on students' anxiety. Students with a history of chronic illness were 3.16 times more prone to experiencing anxiety than those without it. Students with a history of mental disorders in the family were 2.98 times more likely to experience anxiety. Female was 0.57 times more vulnerable to anxiety than male, and married students were 0.23 times more likely to suffer from anxiety than those who were not. There are four independent variables with the most effect on stress in students based on Table 4. Students with a history of chronic pain were 3.52 times more prone to stress than those without it. Students with a history of mental disorders in the family were at risk of anxiety disorders 1.76 times higher. Females were 0.57 times more prone to anxiety disorders than men, and married students were 0.23 times more open to anxiety disorders than those who were not. Early semester students were 0.94 times more at risk of experiencing stress.
From the research, it can be interpreted that the occurrence of depression, anxiety, and stress at Sriwijaya University is two to four times higher than the world student depression and anxiety rate of 18.5% and 16.7% and the rate of mental disorders in Indonesia is 6.2% (World Health Organization, 2019; Data Center and Information from the Ministry of Health of Indonesia, 2019). The depression, anxiety, and stress rates at Sriwijaya University are higher than studies related to  Students of freshmen are more susceptible to mental disorders since they go through two transition phases; the developmental transition from adolescents to young adults and the academic transition from high school to college which displays a different learning system (Cheung et al., 2020;Beiter et al., 2015;Prasetio et al., 2019). In general, stress is a natural stage experienced by every individual but it can develop into a pathological condition if the individual cannot adapt well. There are two common stressors in students. The first is academic stressors, namely academic pressure to meet class requirements, abundant learning materials, and time management. The second is non-academic stressors such as feeling dissatisfied with self-appearance, discontent with life, and low self-esteem towards others (Beiter et al., 2015).
Apart from the transition period and academic pressure, in this study, the Covid-19 pandemic was also suspected to have contributed to an increase in depression, anxiety, and stress disorders in students since the lectures were conducted online. This result is in line with previous research that there was a decline in the mental health condition of students during the pandemic (Savage et al., 2020;Grubic et al., 2020;C Wang et al., 2020). This condition can lead to decreased learning motivation, increased pressure for independent study, neglect of daily routines, and a higher potential for dropout (Grubic et al., 2020). In addition, those with pre-prevailing mental health conditions may be more susceptible to negative emotional responses in the context of Covid-19, resulting in relapse or aggravating of existing mental illness (Yao et al., 2020).
Online learning in the Covid-19 pandemic hampers students to do various assignments. In addition to the loaded individual assignments, students also have difficulty working on group assignments, due to the insufficient environment, obstacles to the internet network, and feeling tired of studying online (Deliviana et al., 2021). Students also begin to endure anxiety about academic delays, the economic impact of the pandemic, and the effect on daily life (Grubic et al., 2020) (Natalia & Syakurah, 2021a).
The female students in the study were found to experiences more mental disorders such as depression, anxiety, and stress. Several studies, such as Mahmoud et al., 2012 andBayram et al., 2008, reported that female students were more likely to experience stress and anxiety disorders (Mahmoud et al., 2012;Blanco et al., 2008). As for the frequency of depression, research by Liu et al., (2019); Sun et al., (2017); Tung et al., (2018) discovered a higher prevalence rate among female students. It can happen due to at least two biological and environmental factors. The first is the biological factor -the American College of Obstetricians and Gynecologists found that 20% to 40% of women of reproductive age were susceptible to mood disorders such as irritability, stress, anxiety, and emotional instability in the period before menstruation (Kornstein et al., 1995). Women are more prone to stress and pain, making mental disorders more likely to occur. Second, there are views of femininity and masculinity. Women tend to be described as femininity e-ISSN: 2541-450X p-ISSN: 0854-2880 Indigenous: Jurnal Ilmiah Psikologi 2021, 6(3), 23-35 that is characterized by caring, gentle, and sensitivity to others. While masculinity is described as individualism and assertiveness. As a result of this concept, women are more likely to experience 'internalized' disorders such as depression and anxiety, while men are 'externalized' such as drug and alcohol abuse (Gao et al., 2020;Thériault & Perreault, 2019;Van Droogenbroeck et al., 2018). The average GPA of students suffering from depression, anxiety, and stress in this study was lower than the average GPA of students overall. Depression, anxiety, and stress were reported to reduce the percentage of student attendance, enthusiasm in submitting assignments, and loss of interest in socialization (Mehr & Daltry, 2016;Ibrahim et al., 2013). Research conducted by Murphy JM et al., 2015 in Chile andGrøtan K. et al., 2019 in Norway unveiled students who had poor mental health (depression, anxiety disorders, or stress) had relatively lower grades and academic achievement compared to those who had not (Murphy et al., 2015;Grøtan, K., Sund & Bjerkeset, 2019).
History of chronic illness and family history of mental disorders presented a significant relationship with all dependent variables (depression, anxiety, and stress). A history of chronic disease may cause changes in daily activities, especially in chronic diseases that result in disability. Research by Siboni et al., 2019 suggests several attributes that may lead to mental disorders in someone with a chronic disease including, a long treatment period, high treatment cost, limitation in daily activities, and fear of death (Siboni et al., 2019). Family history of mental disorders is an important factor in the emergence of mental disorders of depression, anxiety, and stress. The most plausible reason is that those with a family history of mental disorders inherit genes that may prompt psychiatric disorders and manifest once they are under stressful situations (Cheung et al., 2020;Rasic et al., 2014).
Medical students have lower mental health averages than other faculties. It may be due to the high workload, many exams, and competitive setting in the medical environment which precipitates mental health disorders among medical students (Moir et al., 2018;Jafari et al., 2012;Zeng et al., 2019). It is reported that there is a relationship between anxiety and depression with feelings of self-dissatisfaction, exam schedules that are deemed too burdensome, and pressure to pass exams (Rehmani et al., 2018;Alvi et al., 2010). Asian family culture tends to encourage physicians as a profession which then provokes medical students to feel compelled to meet family expectations regarding academic achievement in the faculty of medicine. Depression, anxiety, and stress among medical students are also often overlooked and untreated. Medical students rarely seek professional help, mainly because of diffidence and taboo perception on mental health (Menon et al., 2015;Kumar et al., 2019;Natalia & Syakurah, 2021b).
Age had no significant effect on mental health in this study because the age range of the respondents was not too significant, varying from 17 to 25 years (Data and Information Center of the Ministry of Health of Indonesia, 2019). In fact, the prevalence of depression, anxiety, and stress intensify along with age. Mental health problems in college students are more common in freshmen and sophomores (Beiter et al., 2015). Several features related to this are an adaptation to the new learning system in lectures, living separated far away from their parents, and having to adjust to the new environment and people. These factors will eventually become distressed if students are unable to cope. Moreover, female students appear to experience more mental health problems because females tend to have lower self-esteem than males, but this conclusion requires further research (Moksnes & Espnes, 2013).
This study is limited to in which data collection was carried out using convenience sampling to avoid transmission of Covid-19, thus allowing for bias. Data collection during the Covid-19 pandemic also allowed for higher rates of depression, anxiety, and stress. In a study conducted e-ISSN: 2541-450X p-ISSN: 0854-2880 Indigenous: Jurnal Ilmiah Psikologi 2021, 6(3), 23-35 during the early phase of the Covid-19 outbreak in China, more than half of the respondents rated psychological disorders as moderate to severe, and about one-third reported moderate to severe anxiety (Cuiyan Wang et al., 2020). While a systematic review study found an increase in the occurrence of depression, stress, anxiety disorders, and fear during the pandemic (Brooks et al.,2020).

CONCLUSION
Based on the results of this study, there was an increase in depression, anxiety, and stress in Sriwijaya University students, especially amid the Covid-19 pandemic. Several factors affecting mental health disorders are gender, semester, marital status, history of chronic illness, and family history of mental disorders. These features show extended action needed for awareness, education, and intervention in the university context. Further, these factors can be used as indicators of periodic screening related to mental health from the university so that it can monitor, intervene, and manage to improve students' mental health.