Network analysis of anxiety and depressive symptoms among nursing students during the COVID-19 pandemic

Abstract

Background: The 2019 coronavirus disease (COVID-19) pandemic has impacted the mental health and well-being of medical personnel, including nursing students. Network analysis provides a deeper characterization of symptom-symptom interactions in mental disorders. The aim of this study was to elucidate characteristics of anxiety and depressive symptom networks of Chinese nursing students during the COVID-19 pandemic. Method: A total of 932 nursing students were included. Anxiety and depressive symptom were measured using the seven-item Generalized Anxiety Disorder Scale (GAD-7) and two-item Patient Health Questionnaire (PHQ-2), respectively. Central symptoms and bridge symptoms were identified via centrality indices and bridge centrality indices, respectively. Network stability was examined using the case-dropping procedure. Results: Irritability, Uncontrollable worry, Trouble relaxing, and Depressed mood had the highest centrality values. Three bridge symptoms (Depressed mood, Nervousness, and Anhedonia) were also identified. Neither gender nor region of residence was associated with network global strength, distribution of edge weights or individual edge weights. Limitations: Data were collected in a cross-sectional study design, therefore, causal relations and dynamic changes between anxiety and depressive symptoms over time could not be inferred. Generalizability of findings may be limited to Chinese nursing students during a particular phase of the current pandemic. Conclusions: Irritability, Uncontrollable worry, Trouble relaxing, and Depressed mood constituted central symptoms maintaining the anxiety-depression network structure of Chinese nursing students during the pandemic. Timely, systemic multi-level interventions targeting central symptoms and bridge symptoms may be effective in alleviating co-occurring experiences of anxiety and depression in this population.

Psychological Adjustment Among Chinese International Students During COVID-19: A Network Analysis

“…Liang et al (2020) also identified "tense" or "I found it difficult to relax" in a Chinese population, although they used DASS-21 to assess symptoms. Nevertheless, while symptoms like "sadness", "unstoppable worry", and "irritability" were identified in other studies (e.g., Bai et al, 2021;Kaiser et al, 2020;Ren et al, 2021), our study did not. Regarding bridge nodes that may play important roles in the development and maintenance of comorbidity, perhaps our biggest novel finding is anxiety symptom of "afraid" being the strongest bridge symptom.…”

“…This finding generates the hypothesis that alleviating this symptom in students suffering from anxiety may reduce the likelihood of their developing comorbid depressive symptoms. A closer examination reveals that except for anxiety nodes, "afraid" is most strongly connected to depressive symptom of "worthlessness", which was the most strongly connected node to "suicide", a finding similar to Bai et al (2021). In other words, feeling afraid or fearful when anticipating the future is tied to worthlessness and suicidal ideation.…”

“…Our findings are both consistent with and different from previous literature using PHQ-9 and GAD-7/GAD-2. For example, Bai et al (2021) also found "tense" a central symptom. Liang et al (2020) also identified "tense" or "I found it difficult to relax" in a Chinese population, although they used DASS-21 to assess symptoms.…”

“…For example, applying both PHQ-9 and GAD-7/GAD-2, several recent studies generated critical insights. Depressive symptoms of "sadness", anxiety symptoms of "unstoppable worry" and "irritability" were found to be highly central symptoms twice among three such studies (Bai et al, 2021;Kaiser et al, 2020;Ren et al, 2021). With advances in network analysis (Jones et al, 2019), these studies also identified bridge nodes (nodes most connected to nodes from a different community) with depressive symptom of "sadness" identified in two studies; other bridge nodes identified included anxiety symptoms of "anxious mood", "restlessness", and "irritability", and depressive symptoms of "anhedonia", "psychomotor agitation/retardation", and "inattention".…”

Psychometric Properties of the Generalized Anxiety Disorder Scale-7 Item (GAD-7) in a Large Sample of Chinese Adolescents

“…Such a correlation between these two mental health problem measures supports some empirical research exploring the comorbidity between anxiety and depression symptoms (measured by the GAD-7 and PHQ-9). For example, increasing studies found that the symptoms of anxiety (measured by the GAD-7) and depression (measured by the PHQ-9) are intercorrelated and directly interacted [ 42 , 43 , 44 ]. Moreover, researchers have found the GAD-7 performed well beyond measuring generalized anxiety disorder, but is also a useful measure in the mixed anxiety–depression sample [ 12 ].…”