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Tunnell NC, Corner SE, Roque AD, Kroll JL, Ritz T, Meuret AE. Biobehavioral approach to distinguishing panic symptoms from medical illness. Front Psychiatry 2024; 15:1296569. [PMID: 38779550 PMCID: PMC11109415 DOI: 10.3389/fpsyt.2024.1296569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 03/19/2024] [Indexed: 05/25/2024] Open
Abstract
Panic disorder is a common psychiatric diagnosis characterized by acute, distressing somatic symptoms that mimic medically-relevant symptoms. As a result, individuals with panic disorder overutilize personal and healthcare resources in an attempt to diagnose and treat physical symptoms that are often medically benign. A biobehavioral perspective on these symptoms is needed that integrates psychological and medical knowledge to avoid costly treatments and prolonged suffering. This narrative review examines six common somatic symptoms of panic attacks (non-cardiac chest pain, palpitations, dyspnea, dizziness, abdominal distress, and paresthesia), identified in the literature as the most severe, prevalent, or critical for differential diagnosis in somatic illness, including long COVID. We review somatic illnesses that are commonly comorbid or produce panic-like symptoms, their relevant risk factors, characteristics that assist in distinguishing them from panic, and treatment approaches that are typical for these conditions. Additionally, this review discusses key factors, including cultural considerations, to assist healthcare professionals in differentiating benign from medically relevant symptoms in panic sufferers.
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Affiliation(s)
- Natalie C. Tunnell
- Department of Psychology, Southern Methodist University, Dallas, TX, United States
- Department of Psychiatry & Behavioral Sciences, The University of Kansas Medical Center, Kansas City, KS, United States
| | - Sarah E. Corner
- Department of Psychology, Southern Methodist University, Dallas, TX, United States
| | - Andres D. Roque
- Department of Psychology, Southern Methodist University, Dallas, TX, United States
- Primary Care Department, Miami VA Healthcare System, Miami, FL, United States
| | - Juliet L. Kroll
- Department of Psychology, Southern Methodist University, Dallas, TX, United States
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Thomas Ritz
- Department of Psychology, Southern Methodist University, Dallas, TX, United States
| | - Alicia E. Meuret
- Department of Psychology, Southern Methodist University, Dallas, TX, United States
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Lemyre A, Palmer-Cooper E, Messina JP. Wellbeing among university students during the COVID-19 pandemic: a systematic review of longitudinal studies. Public Health 2023; 222:125-133. [PMID: 37542997 DOI: 10.1016/j.puhe.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 05/19/2023] [Accepted: 07/04/2023] [Indexed: 08/07/2023]
Abstract
OBJECTIVES The objectives of this study were to investigate the wellbeing trajectories of university students during the COVID-19 pandemic and identify associated protective factors. Results from the study aimed to inform wellbeing-promotion strategies and crisis-response plans in university settings. STUDY DESIGN Systematic review. METHODS A review of articles published in English language was conducted in PubMed, PsycINFO, Scopus, Web of Science, and ERIC databases from 1 December 2019 to 15 December 2022. Longitudinal and repeated cross-sectional studies that assessed wellbeing among university students during the COVID-19 pandemic using a validated instrument were included. Article and data extraction were performed by the primary reviewer, with a random subset verified by a second reviewer. Study quality was assessed using the National Institutes of Health 'Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies'. RESULTS Of 6651 titles screened without duplicates, 181 underwent full-text review, of which 19 were included in the current study (15 longitudinal and 4 repeated cross-sectional studies, with a total of 19,206 participants). A significant decrease in the wellbeing of university students was observed across studies during the early stages of the pandemic compared to prepandemic times; however, mixed findings were found in later phases of the pandemic, with some studies presenting an improvement in wellbeing, others no change, and two studies finding impairments. Overall, wellbeing was greater among males and was also associated with socioeconomic status, more sleep and physical activity, greater social connectedness, less alcohol use, and less social media activity. CONCLUSION The study showed varying wellbeing trajectories across different periods of the COVID-19 pandemic. Results provide relevant information for researchers, public health professionals, and higher education institutions in charge of promoting student wellbeing and crisis preparedness. PROSPERO REGISTRATION CRD42022383941.
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Affiliation(s)
- Anaïs Lemyre
- School of Geography and the Environment, University of Oxford, OX1 3QY, United Kingdom.
| | - Emma Palmer-Cooper
- Centre for Innovation in Mental Health, School of Psychology, University of Southampton, SO17 1PS, United Kingdom.
| | - Jane P Messina
- School of Geography and the Environment, University of Oxford, OX1 3QY, United Kingdom.
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Fernandez JR, Sherchan JS, Cho YJ, Nanaw J, Joseph NT, Forde AT. College students' underlying perceptions of COVID-19 threat, healthcare discrimination, and healthcare system inequities associated with self-rated health across racial/ethnic groups in the U.S. Front Public Health 2023; 10:1028344. [PMID: 36684993 PMCID: PMC9853174 DOI: 10.3389/fpubh.2022.1028344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 11/23/2022] [Indexed: 01/09/2023] Open
Abstract
Background COVID-19-related health perceptions may differentially impact college students' stress, and in turn, their mental and physical health. This study examined racial/ethnic differences in college students' underlying perceptions of COVID-19 threat, healthcare discrimination, and U.S. healthcare system inequities and their associations with self-rated mental and physical health. Methods Four-hundred-thirty-two university students completed an online survey (December 2020-December 2021). Latent class analyses identified classes of perceived COVID-19 threat (i.e., severity, susceptibility), healthcare discrimination, and U.S. healthcare system inequities. Regression analyses examined whether class membership varied by race/ethnicity and was associated with self-rated mental and physical health. Results Class 1 members (27.3% of the sample) were more likely to identify as Hispanic or Latino, Non-Hispanic Asian, Non-Hispanic Black or African American, and Non-Hispanic Multiracial vs. Non-Hispanic White (vs. Class 4). Class 1 had high perceived COVID-19 threat, medium perceived healthcare discrimination, and high perceived U.S. healthcare system inequities, as well as higher odds of poorer mental and physical health (vs. Class 4). Conclusions College students' underlying perceptions of COVID-19 threat, healthcare discrimination, and U.S. healthcare system inequities were associated with poorer health. Given that students with these perceptions were more likely to belong to minoritized racial/ethnic groups, concerns over COVID-19 risk and healthcare may partially explain racial/ethnic disparities in college students' health. This study contributes to a limited body of evidence on college students' perceptions of the U.S. healthcare system and suggests important ways that structural inequalities and racial/ethnic disparities in COVID-19 risk, healthcare discrimination, and concerns over U.S. healthcare system inequity may affect college students' health.
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Affiliation(s)
- Jessica R. Fernandez
- Division of Intramural Research, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD, United States
| | - Juliana S. Sherchan
- Division of Intramural Research, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD, United States
- Department of Psychology, University of Maryland, College Park, MD, United States
| | - Yong Ju Cho
- Division of Intramural Research, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD, United States
| | - Judy Nanaw
- Division of Intramural Research, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD, United States
| | - Nataria T. Joseph
- Division of Social Science, Seaver College, Pepperdine University, Malibu, CA, United States
| | - Allana T. Forde
- Division of Intramural Research, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD, United States
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Respiratory psychophysiology and COVID-19: A research agenda. Biol Psychol 2023; 176:108473. [PMID: 36535514 PMCID: PMC9756651 DOI: 10.1016/j.biopsycho.2022.108473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 12/03/2022] [Accepted: 12/04/2022] [Indexed: 12/23/2022]
Abstract
After multiple waves of the COVID-19 pandemic, it has become clear that the impact of SARS-CoV-2 will carry on for years to come. Acutely infected patients show a broad range of disease severity, depending on virus variant, vaccination status, age and the presence of underlying medical and physical conditions, including obesity. Additionally, a large number of patients who have been infected with the virus present with post-COVID syndrome. In September 2020, the International Society for the Advancement of Respiratory Psychophysiology organized a virtual interest meeting on 'Respiratory research in the age of COVID-19', which aimed to discuss how research in respiratory psychophysiology could contribute to a better understanding of psychophysiological interactions in COVID-19. In the resulting current paper, we propose an interdisciplinary research agenda discussing selected research questions on acute and long-term neurobiological, physiological and psychological outcomes and mechanisms related to respiration and the airways in COVID-19, as well as research questions on comorbidity and potential treatment options, such as physical rehabilitation.
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Geyer RB, Magee JC, Clerkin EM. Anxiety sensitivity and panic symptoms: the moderating influence of distress tolerance. ANXIETY, STRESS, & COPING 2022:1-18. [DOI: 10.1080/10615806.2022.2146102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
| | | | - Elise M. Clerkin
- Student Health and Wellness, University of Virginia, Charlottesville, VA, USA
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Interoceptive anxiety-related processes: Importance for understanding COVID-19 and future pandemic mental health and addictive behaviors and their comorbidity. Behav Res Ther 2022; 156:104141. [PMID: 35752013 PMCID: PMC9212258 DOI: 10.1016/j.brat.2022.104141] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 05/18/2022] [Accepted: 06/03/2022] [Indexed: 01/08/2023]
Abstract
The COVID-19 pandemic is associated with an increased prevalence of mental health problems and addictive behaviors. There is a growing theoretical and empirical evidence that individual differences in interoceptive anxiety-related processes are a one set of vulnerability factors that are important in understanding the impact of pandemic-related mental health problems and addictive behavior. However, there has not been a comprehensive effort to explore this rapidly growing body of research and its implications for public health. In this paper, we discuss why interoceptive anxiety-related processes are relevant to understanding mental health and addictive behaviors during the COVID-19 pandemic. We then provide a narrative review of the available COVID-19 literature linking interoceptive fear and anxiety-related processes (e.g., anxiety sensitivity, health anxiety, and COVID-19 anxiety, fear, and worry) to mental health and addictive behaviors. We then propose a novel transdiagnostic theoretical model that highlights the role of interoceptive anxiety-related processes in mental health and addictive behavior in the context of the present and future pandemics. In the final section, we utilize this conceptualization to underscore clinical implications and provide guidance for future research initiatives in the management of COVID-19 mental health and addictive behaviors and inform the public health field for future pandemics.
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Peng X, Liu L, Liang S, Chen J, Zhao J. Longitudinal changes in fear and anxiety among Chinese college students during the COVID-19 pandemic: a one-year follow-up study. CURRENT PSYCHOLOGY 2022:1-10. [PMID: 35910238 PMCID: PMC9323878 DOI: 10.1007/s12144-022-03487-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2022] [Indexed: 11/03/2022]
Abstract
There is growing evidence that levels of fear and anxiety have increased during the COVID-19 pandemic. However, given regular epidemic prevention and control measures, longitudinal changes and causal factors in the incidence of fear and anxiety need to be measured and explored. College students completed online surveys in two wave studies a year apart. The participants who completed both of the surveys numbered 22,578. The online surveys were completed at the pandemic's normalization/prevention stage (T1, from June 1 to 15, 2020) and during a phase of new local transmission of the disease in Guangdong Province (T2, from June 10 to 18, 2021). Multiple linear regressions were used to examine fear and anxiety predictors from demographic characteristics. Fear related to COVID-19 had significantly decreased at T2 (t = 66.64, p < 0.001), however, anxiety had significantly increased at T2 (t = -5.03, p < 0.001). In particular, not implementing preventive measures (e.g., handwashing) during the COVID-19 pandemic had the greatest impact in predicting the change in fear levels. By contrast, prior poor mental health status contributed the most in predicting the change in degree of anxiety. These results suggest different changes in anxiety levels (deterioration) and degree of fear (mitigation) occurred as the COVID-19 pandemic progressed. These findings have implications for planning mental health crisis provisions and have long-term impact beyond this pandemic.
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Affiliation(s)
- Xiaodan Peng
- Department of Psychology, School of Public Health, Southern Medical University, Guangzhou, Guangdong China
| | - Lili Liu
- Department of Psychology, School of Public Health, Southern Medical University, Guangzhou, Guangdong China
| | - Shunwei Liang
- Mental Health Education and Counseling Center, Guangzhou Academy of Fine Arts, Guangzhou, China
| | - Jianbin Chen
- Department of Psychology, School of Public Health, Southern Medical University, Guangzhou, Guangdong China
| | - Jingbo Zhao
- Department of Psychology, School of Public Health, Southern Medical University, Guangzhou, Guangdong China
- Mental Health Center, School of Public Health, Southern Medical University, Guangzhou, China
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Klonoff-Cohen H. College Students’ Opinions About Coping Strategies for Mental Health Problems, Suicide Ideation, and Self-Harm During COVID-19. Front Psychol 2022; 13:918891. [PMID: 35874328 PMCID: PMC9296780 DOI: 10.3389/fpsyg.2022.918891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 06/17/2022] [Indexed: 11/26/2022] Open
Abstract
Background Mental health problems have emerged as a significant health complication in United States colleges during COVID-19, and as a result, they have been extensively investigated in the United States and internationally. In contrast, research on coping among the college population during the pandemic is scant. Hence, this study investigated coping strategies proposed by undergraduate students attending a Midwestern university. Objectives The purpose of this preliminary study was to obtain college students’ feedback/opinions about coping strategies for mental health problems, suicide ideation, and self-harm during COVID-19. Methods In December 2021, one-hundred and four undergraduate students (ages 18–22 years) completed an online survey on coping strategies using Qualtrics. Major topics included: (1) Types of coping strategies/styles expressed by students for general mental health problems, (2) Types of coping strategies for suicide ideation and self-harm behaviors, (3) Preferred platforms for receiving coping therapy, and (4) Reasons for accepting or refusing parent involvement with mental health problems. Results The most beneficial coping strategies for mental health were ranked by college students as follows: (1) a skills training development program (30%), (2) meditation (19%), and (3) mindfulness exercises (15%), and physical education (11%). The respondents’ best coping strategies for preventing self-harm and suicide ideation/behaviors during COVID-19 were ranked as: (1) improving support from friends (32%), (2) building self-esteem (29%), and (3) addressing anger, depression, stress, and loneliness (25%). Finally, a total of 50% of participants felt that parents should be involved in college student interventions. Students stated that the most important type of support that they received from their parents were: (1) emotional support (31%), (2) direction and/or assistance with solutions (27%), and problem-solving (16%). Conclusion This study identified potential avenues which could be implemented into action during future outbreaks. Specifically, employing interventions that: (i) train undergraduate students to employ more effective skills training coping strategies or practicing mindfulness or meditation; (ii) integrate mental health, suicide, and self-harm prevention into the curriculum; (iii) offer more in-person campus services targeted toward the psychological and emotional effects of a pandemic, and (iv) involve support persons (e.g., family) in students’ lives to enhance their well-being during and after COVID-19.
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Zhang S, Zhu K, Wang S, Jin X, Li Y, Ding K, Zhang Q, Li X. A cross-sectional study about coronavirus fear of Chinese college students in school lockdowns during the COVID-19 pandemic. Heliyon 2022; 8:e09892. [PMID: 35821965 PMCID: PMC9263676 DOI: 10.1016/j.heliyon.2022.e09892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 02/28/2022] [Accepted: 07/01/2022] [Indexed: 11/26/2022] Open
Abstract
Objective To remove the phobic psychological situation of Chinese college students who were in school lockdowns during the COVID-19 outbreak, and to provide a theoretical basis for college student psychological intervention. Methods Online survey conducted from December 9, 2021, to December 11, 2021. The seven-item Fcv-19s was employed to assess fear of COVID-19 on a Likert five-point scale. Categorical data were reported as number and percentage, whereas continuous data were reported as mean ± standard deviation. Multivariate logistic regression models were used to assess the association between different factors and anxiety symptoms. Results The study population consisted of 26.02% (268) male and 73.98% (762) female, of whom approximately 84% were undergraduates. The overall mean score of the questionnaire was 16.04 ± 5.28. Significantly more study populations reported high levels of fear (54.8%), while age, cost of life, professional category, education background (P < 0.05) revealed significant differences based on fear levels. Conclusions More than half of the Chinese college students developed fear symptoms during the COVID-19 epidemic. Appropriate psychological interventions for college students should be implemented promptly to reduce the psychological harm induced by the COVID-19 epidemic.
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Affiliation(s)
- Shipeng Zhang
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, 610072, PR China
| | - Kun Zhu
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, 610072, PR China
| | - Shuting Wang
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, 610072, PR China
| | - Xin Jin
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, 610072, PR China
| | - Yaqi Li
- School of Public Health, Chengdu University of Traditional Chinese Medicine, Chengdu, 611137, China
| | - Kaixi Ding
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, 610072, PR China
| | - Qinxiu Zhang
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, 610072, PR China.,School of Medical and Life Sciences, Chengdu University of Traditional Chinese Medicine, Chengdu, 611137, China.,World Health Organization Collaborating Centre (WHOCC), CHN-56, Chengdu, 610041, China
| | - Xinrong Li
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, 610072, PR China
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Shekriladze I, Javakhishvili N, Butsashvili N, Lortkipanidze M. Anxiety, Worry, Life Satisfaction and Coping During the Acute VS Prolonged Pandemic Stress: Evidence From a Repeated Cross-Sectional Study. Int J Public Health 2022; 67:1604650. [PMID: 35719738 PMCID: PMC9198216 DOI: 10.3389/ijph.2022.1604650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 05/13/2022] [Indexed: 11/13/2022] Open
Abstract
Objectives: The COVID-19 pandemic remains a continuous stressor worldwide. Our study aimed at comparing the data of waves from two lockdowns in Georgia, one in the acute stress phase (May 2020) and the other in the prolonged stress phase (December 2020).Methods: In total, 750 and 716 individuals participated in the study with a repeated cross-sectional design. Sample equivalence was reached via controlling demographic variables. Anxiety, COVID-19 worry, and life satisfaction were measured along with coping behaviors and four coping styles—information-accessing/processing and action-planning (two problem-focused coping styles), and passive-submissive and avoidant (two emotion-focused coping styles).Results: As pandemic prolonged, mental health indicators worsened, the action-planning style and behavioral coping decreased, while the information-accessing/processing style increased. The link between the COVID-19 worry and the action-planning coping style was strong in the acute stage and dissapeared in the prolonged stage. The individual context, namely, a history of coronavirus in the household, accounted for lower protective behaviors and higher information seeking in the prolonged phase.Conclusion: The findings highlighted the importance of timing and general and individual contexts in coping with the pandemic.
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Wang F, Zhang L, Ding L, Wang L, Deng Y. Fear of COVID-19 Among College Students: A Systematic Review and Meta-Analysis. Front Public Health 2022; 10:846894. [PMID: 35299699 PMCID: PMC8921101 DOI: 10.3389/fpubh.2022.846894] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 01/31/2022] [Indexed: 12/20/2022] Open
Abstract
Background Mental health issue among college students is routinely a major public health concern, and coronavirus disease 2019 (COVID-19) pandemic may have exacerbated the students' mental health issues which include psychological distress, panic disorder, insomnia, and posttraumatic stress symptoms. However, few studies reached a consensus on the impact of COVID-19 fear on mental health among college students. Therefore, we aimed to conduct a systematic review and meta-analysis that quantitatively synthesized the fear among college students during the COVID-19 pandemic. Methods PubMed, EMBASE, CINAHL, and PsycINFO electronic databases were systematically searched to identify cross-sectional study reporting the state of COVID-19 fear examined by the Fear of COVID-19 Scale (FCV-19S) published up until November 20, 2021. Methodological quality was complied with the evaluation criteria of the Agency for Healthcare Research and Quality. The random effects model was employed to estimate the pooled mean of FCV-19S score. Subgroup analysis and meta-regression analysis were also conducted. Publication bias was assessed by Begg's test and funnel plot. Results A total of 16 studies with a sample size of 11,872 were included. A pooled mean of FCV-19S score was 17.60 [95% confidence interval (CI): 16.41–18.78]. The mean of COVID-19 fear in women (17.11, 95% CI: 16.59–17.64) was higher than that in men (15.21, 95% CI: 14.33–16.08). The highest and lowest pooled means of FCV-19S score were observed in the studies conducted in multiple countries that include Israel, Russian, and Belarus (21.55, 95% CI: 20.77–22.33) and in Europe (16.52, 95% CI: 15.26–17.77), respectively. No significant publication bias was detected by Begg's test. Conclusions College students experienced a moderate level of fear caused by COVID-19 pandemic. It is necessary to design and implement prevention programs that target the mental health of college students. Systematic Review Registration https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021287017, identifier: CRD42021287017.
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Affiliation(s)
- Fang Wang
- School of Public Health, Shandong First Medical University & Shandong Academy of Medical Sciences, Tai'an, China
| | - Le Zhang
- School of Public Health, Shandong First Medical University & Shandong Academy of Medical Sciences, Tai'an, China
| | - Lu Ding
- Department of Public Health, Second Affiliated Hospital of Shandong First Medical University, Tai'an, China
| | - Lei Wang
- School of Pharmaceutical Sciences, Shandong First Medical University & Shandong Academy of Medical Sciences, Tai'an, China
| | - Yang Deng
- School of Public Health, Shandong First Medical University & Shandong Academy of Medical Sciences, Tai'an, China
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