In the present cross-sectional study, students from four universities in south-western Uganda during the COVID-19 pandemic were surveyed, and the prevalence of depression (at a cut-off of 10) was 20% and suicidal ideation was 13.89%. Relationship issues and a history of sexual abuse were the two factors most significantly associated with depression among students while being in the fifth year of academic study and being satisfied with current academic performance were associated with reduced depression. Smoking cigarettes and/or marijuana, and having financial tuition constraints increased the likelihood of reporting suicidal ideation. However, similar to depression, satisfaction with the current academic performance reduced the likelihood of reporting suicidal ideation.

During the COVID-19 pandemic, higher mental health problems have been reported among students. For instance, the prevalence of depression ranged from 46.92% to 82.4% among Bangladeshi students, as reported in a systematic review (13). Moreover, a recent meta-analysis reported a pooled prevalence of 37% depression among 436,799 students in studies published before September 20, 2020 (12). However, the depression prevalence of the present study (20%) was markedly lower than the previously reported prevalence rate of 80.7% during the first wave of the pandemic (June to July 2020) in a Ugandan study among 321 university students using the 21-item Depression, Anxiety and Stress Scale (4). The difference may be because the present study used a different instrument to screen for depression, with different sensitivities and specificities for assessing depression. In addition, Najjuka et al.’s (4) study involved all university students during the complete institutional lockdown in the first wave of the pandemic, when the levels of uncertainty about the disease were higher and there was associated higher levels of depression among students as reported by other studies (14).

The prevalence of depression in the present study was higher than that reported among non-medical undergraduate university students prior to the introduction of the peer counseling services at Makerere university, 2000–2001 at 16.2%; and medical undergraduate university students following peer counseling introduction (2002) at 4.0% (7). Despite the present study being conducted during a period when peer counseling and other psychological intervention for student mental ill-health is well established among all Ugandan universities, the prevalence of depression reported by Ovuga et al. (7) may have been lower because the study was conducted before the COVID-19 pandemic—a period that significantly increased negative psychological effects among many students (11). However, the depression prevalence of 20% in the present study is slightly lower than 21.5% reported in a study done the year before the pandemic (May–July 2019) among 331 Makerere University medical students using the same instrument (6). The similarity between the study findings and Olum et al. (6), coupled with the significant difference from the only study assessing depression among university students during the pandemic in Uganda (4), could possibly indicate that students have adjusted to the COVID-19 situation and associated stressors, the so-called “new normal,” as reported by other researchers (39). Therefore, depression may be associated with other stressors rather than being pandemic-related.

For instance, in the present study, depression among students was associated with having a history of sexual abuse, a finding similar to other studies among university students. It is also known that individuals who experience sexual abuse during childhood often experience associated depression in adulthood (40). In addition, the severity of depression can be accelerated by the abusive behaviors of the current sexual partner (17, 41). Since students in an abusive relationship have fewer protective factors against depression associated with a supportive romantic relationship, such as comfort, emotional support, and companionship (42). In addition, relationship problems cause significant psychological distress due to disappointment and unmet expectations (43).

Satisfaction with academic grades appeared to be a protective factor against depression and suicidal ideation. Good academic performance is associated with being successful in life (44); therefore, an individual feels positive about their future when their performance is good, and this may help protect them from depression. Conversely, poor academic performance has consistently been associated with depression (45). In Uganda, education is considered the “key to success” (46). Students are expected to meet extremely high expectations from their parents and society to succeed (47). Therefore, it is perhaps unsurprising that students with financial tuition constraints had an increased likelihood of reporting suicidal ideation because if they do not have the ability to fully pay for their university fees, they may lose hope for the future and experience suicidal ideation. However, it has also been reported that some students use their tuition fees to gamble, therefore, they have financial problems if they lose, leading to suicidal behaviors and suicide (48). In Uganda, law and medicine degree programs are pursued for a minimum of 5 years, and culturally these courses are associated with a successful future. Therefore, studying in the fifth-year means being near the end of the undergraduate studies for students, and the dream of future success in life is also nearing. Other researchers studying Ugandan university students have also reported the protective nature of being in the final year against depression during the COVID-19 pandemic (4). Also, by the time a student reaches the fifth year of study, they have been more likely to be exposed to all the conditions around campus and developed coping mechanisms against depression. For example, some have already coped with experiencing romantic breakups, poverty while on campus, and have gotten a peer support system through the friends they acquired over the years.

Just under half of the participants who screened positive for depression reported suicidal ideation in the past 2 weeks (45.37%). This was similar to 48.4% of individuals with major depressive disorder at a mental health facility in Ethiopia (49). The prevalence of suicidal ideation in the present study (13.89%) was lower than 22.7% from a study conducted among university students in another African country, Libya, during the COVID-19 pandemic in the months of April and May 2020 based on Item 9 of the PHQ-9 (50). This difference in prevalence rates may be due to the following reasons: (1) during the time of data collection, Libya was still experiencing a civil war which comes with multiple mental challenges, including thoughts of suicide, (ii) the study was done at a period when individuals worldwide were having higher levels of stress, anxiety, suicidal behaviors and other mental challenges (i.e., early stages of the pandemic) (51); and (iii) the sample only involved medical students who have been reported to experience higher suicidal behaviors compared to other students (52–54).

The prevalence of suicidal ideation in the past 2 weeks in the present study was also lower than 18.04% in a US study involving college students during the month of May 2020 (55). However, the prevalence was higher than 12.9 and 7.3% from studies among university students in China during February and March 2020, respectively (56, 57). Despite the studies in China being conducted earlier, the students were exposed to constant sources of stress during the pandemic, and they would have developed coping strategies to overcome stress complications such as depression and related suicidal behaviors. Smoking cigarettes and/or marijuana was associated with suicidal ideation, a finding consistent with other studies prior to the COVID-19 pandemic (58). Substance use increased during the COVID-19 pandemic and led to multiple mental challenges, including suicide (59–63). Many individuals use addictive substances to cope with stress, and marijuana, in particular, was believed by some Ugandans to treat COVID-19 symptoms (61). Some of the individuals trying to cope with stress by using psychoactive substances could have had suicidal ideation not secondary to the smoking of substances.