Exploring the influence of COVID-19 stress on mental health among international undergraduate and graduate students: A mixed-methods approach

International college students in the United States are at increased risk of developing mental health disorders and are less likely to seek mental health services. However, little is known about the effects of stress during the COVID-19 pandemic on the mental health of international undergraduate students compared to their graduate counterparts studying in the US. This study examined the associations between COVID-19 stress, anxiety, and depression and whether education level moderates these associations in international undergraduate and graduate students. A cross-sectional online survey containing psychometric scales and open-ended questions was completed by 219 international undergraduate and graduate students. Validated psychometric scales used included the Depression, Anxiety, and Stress Scale (DASS-21), COVID-19 Stress Scale (CSS), and Perceived Stress Scale 4 (PSS-4). Path analysis was used to assess whether education level moderated the relationships between COVID-19 stress and anxiety and depression. Applied thematic analysis was conducted to qualitatively determine COVID-19-related stressors affecting students' mental health. We found that COVID-19 stress was significantly associated with students' anxiety and depression, and education level moderated the relationship between COVID-19 stress and anxiety, but not depression. Major themes of COVID-19-related stressors affecting mental health included academic performance, financial difficulties, travel constraints, social isolation, and grief. Findings highlighted the influence of stress during the COVID-19 pandemic on the mental health of international students studying in the US. Graduates and undergraduates experienced stress differently, particularly related to anxiety. Additionally, pandemic-related stressors were multifaceted in nature. Adequate mental health interventions and support tailored for graduates and undergraduates are needed to address students affected during global crises.