|Year : 2021 | Volume
| Issue : 2 | Page : 158-163
COVID-19 impact on mental health, sleep quality and various aspects of life of medical students and interns, and nonmedical students: A comparative study in Indian scenario
Vaishali Baburao Nagose1, Dharmishta Naman Soni2, Shivanand Shriram Rathod3, Yaminee Avinash Yelne4
1 Department of Pathology, Dr. Ulhas Patil Medical College and Hospital, Jalgaon, Maharashtra, India
2 Department of MBBS Student, Dr. Ulhas Patil Medical College and Hospital, Jalgaon, Maharashtra, India
3 Department of Physiology, Dr. Ulhas Patil Medical College and Hospital, Jalgaon, Maharashtra, India
4 Department of Psychiatry, Central Hospital, Gondia, Maharashtra, India
|Date of Submission||02-Jul-2021|
|Date of Decision||25-Jul-2021|
|Date of Acceptance||06-Aug-2021|
|Date of Web Publication||28-Oct-2021|
Dr. Vaishali Baburao Nagose
Flat No. 306, B Wing, Gyan Chetna Residency, Opposite Godavari College of Engineering, Jalgaon - 425 001, Maharashtra
Source of Support: None, Conflict of Interest: None
Context: The COVID-19 pandemic has affected all the age groups, especially worsening the already stressful life of college students. Aims: The aims are to study the differences in the COVID-19 impact on mental health including depression, sleep quality, and various areas of life in undergraduate students (medical and nonmedical) and medical interns. Subjects and Methods: A cross-sectional study in the form of an online survey was conducted through Google Form containing the questionnaire having Kessler Psychological Distress Scale (K10), Pittsburgh Sleep Quality Index (PSQI), questions pertaining to the different aspects of life affected due to COVID-19. Statistical Analysis Used: The results of the groups were compared using two sample t-test and one-way ANOVA. Results: A total of 355 students responded (202 medical and 101 nonmedical students and 52 medical interns). The difference in psychological distress and sleep quality was statistically significant in all three groups. The average scores of K10 depicted psychological distress being moderate in nonmedical and mild in medical students and interns; of PSQI showed the prevalence of poor sleep quality being maximum in interns and minimum in medical students. 40% medical students reported positive impact on diet and about half of the medical and nonmedical students on familial relationships. Conclusions: Statistically significant differences in the three study groups with respect to psychological distress, sleep quality, and COVID-19 impact on various aspects of life indicate the requirement of identification of their different needs and required interventions including mental health support, possibly at the institutional levels are the need of the hour.
Keywords: College students, COVID-19, medical students, mental health, sleep quality
|How to cite this article:|
Nagose VB, Soni DN, Rathod SS, Yelne YA. COVID-19 impact on mental health, sleep quality and various aspects of life of medical students and interns, and nonmedical students: A comparative study in Indian scenario. Ann Indian Psychiatry 2021;5:158-63
|How to cite this URL:|
Nagose VB, Soni DN, Rathod SS, Yelne YA. COVID-19 impact on mental health, sleep quality and various aspects of life of medical students and interns, and nonmedical students: A comparative study in Indian scenario. Ann Indian Psychiatry [serial online] 2021 [cited 2021 Dec 6];5:158-63. Available from: https://www.anip.co.in/text.asp?2021/5/2/158/329435
| Introduction|| |
The COVID-19 pandemic has been found to have affected all the age groups, including the college students, especially the medical ones who are having even more demanding academic schedules.,, However, the comparison of the effect in various groups simultaneously has not been studied. The present work is done in undergraduate students (including medical and nonmedical) and medical interns to study the differences in the COVID-19 impact on mental health including depression, sleep quality, and various areas of the life in these groups after considerable 9 months of the beginning of the pandemic in India.
| Subjects and Methods|| |
This was a cross-sectional study carried out over a period of 2 weeks in October 2020 after obtaining institutional ethical committee clearance. The study was conducted in three sets of students – medical students, medical interns, and nonmedical college students.
A questionnaire was prepared pertaining to the objectives of the study consisting of Kessler Psychological Distress Scale (K10), Pittsburgh Sleep Quality Index (PSQI), multiple-choice and open-ended questions pertaining to the different aspects of life affected due to COVID-19, followed by an additional comments section. An online survey through Google Forms was conducted among the undergraduate students who voluntarily participated in it. A WhatsApp message containing the attachment of the Google Form of questionnaire gave details of this project requesting to filling out the form if the subjects consented to participate in the study. Their answers were recorded. A thorough analysis of the answers was done, data being recorded in an excel sheet using Microsoft Excel and percentage of the students responding to the various categories, stress levels, and sleep quality score were calculated, and their concerns were noted. After analyzing the above data, a general statement regarding the mental health emphasizing on stress and sleep quality in them was obtained. K10 scores were interpreted as: likelihood of having a mental disorder (psychological distress) (a) 10–19: likely to be well; (b) 20–24: likely to have a mild disorder; (c) 25–29: likely to have a moderate disorder; and (d) 30–50: likely to have a severe disorder. Good sleep quality was defined as PQSI score ≤5, while scores above 5 were taken as poor quality. Two sample t-test and one-way ANOVA were used for comparison between the groups. The individual K10 and PSQI scores were correlated using Pearson correlation.
As this survey was carried out after approximately 7 months of initiation of lockdown due to COVID-19 in India, we expected many of the subjects to have adjusted to the new normal. A question was placed in addition to K10 and PSQI each to mention if the participants experienced minimum of one of the symptoms of the psychological distress or sleep disturbances which formed the components of K10 or PSQI, respectively, if not in the past month.
| Results|| |
A total of 355 respondents participated in the survey, of which 303 were undergraduate students (202 medical and 101 nonmedical) and 52 medical interns. Age ranged from 18 to 25 years for medicos, 18–26 years for nonmedicos, and 23–28 years for interns. The maximum number of participants belonged to Maharashtra (86.2%), Kerala (5.07%), and Telangana (3.1%).
Mental health and psychological distress (Kessler Psychological Distress Scale)
More than half of the students (52.9% – medical students, 54.4% – nonmedical, and 53.7% – interns) accepted that they experienced depressive thoughts, and a significant fraction (11.54% interns, 9.9% medical students, 6.9% nonmedical) from all the three groups did encounter suicidal thoughts [Figure 1].
The Kessler Psychological Distress Scale results obtained illustrated that approximately half of nonmedical students (49.5%) (10.89% – moderate and 38.61% – severe), one third of medical students (36.14%) (9.9% – moderate and 26.24% – severe), and a quarter of interns (26.92%) (7.69% – moderate and 19.23% – severe) were psychologically distressed [Figure 2]. The average scores of K10 were college students – 26.15 ± 24.0, medical students – 23.396 ± 21.0, and interns – 21.35 ± 18.0, indicating a general presence of moderate to mild psychological distress. The difference was statistically significant in all three groups (P = 0.011). Category-wise distribution demonstrated clustering of cases in category I (no distress) and then category IV (severe distress) in the medical students and interns; conversely the nonmedical students were maximum in category IV (severe distress) and the in category I (no distress) depicting opposite trends in them.
The majority of subjects (83% medicos, 79% nonmedicos, and 73% interns), had experienced minimum of one of symptoms of the psychological distress which formed the component of K10 if not in the past 4 weeks. This included feeling depressed, tired out for no good reason, feeling nervous, feeling restless or fidget, feeling hopeless, and feeling that everything was an effort.
Respondents also specified in the open-ended questions answers that they experienced multiple new complaints such as weight gain and increased screen time because of being hooked onto social media. Many mentioned that they suffered headaches, mental and physical exhaustion, and feeling like they were being held captive. Some raised concerns due to social distancing norms, disturbed routine, and bouts of overthinking. A handful of them also felt exacerbating episodes of anxiety, also possibly manifesting in the form of gastroesophageal reflux disease, skin allergies, etc.
Pittsburgh Sleep Quality Index
The prevalence of poor sleep quality (PSQI Score ≥5) was found to be in 73.7% interns (38/52), 65.4% nonmedicos (66/101), and 50.5% medicos (102/202) in decreasing order [Table 1]. The mean PSQI scores were for interns – 7.654, nonmedical students – 7.089, and medical students – 4.960. The difference in three groups was statistically significant (ANOVA, P = 0.000). However, on comparing two groups (unpaired t-test), a significant difference was found between medical versus nonmedical students (P = 0.000) and medical students versus medical interns (P = 0.000). 12.9% of nonmedicos, 7.7% of the interns, and 6.6% of medicos consumed sleep medications in past week. Selfreporting of sleep qualities showed medical students having better sleep quality than nonmedical students.
|Table 1: Pittsburgh sleep quality index scores and Pittsburgh sleep quality index and Kessler Psychological Distress Scale correlation|
Click here to view
Majority of the participants confirmed that they experienced minimum of one of the symptoms of sleep disturbances which formed the component of PSQI if not in the past month. It constituted 60% of interns and two-thirds of nonmedical as well as medical students. The most common complaints were inability to sleep within 30 min and waking up in the middle of the night or early morning.
In all three groups, a significant correlation between K10 and PSQI scores (P = 0.000) was evident [Table 1].
Impact of COVID-19 on different domains of life as follows:
All the three groups expressed negative impact on social connectedness. Majority were worried about the traveling restrictions. Respondents also raised concerns on how difficult it would be for them to go back to normal [Figure 3]a.
|Figure 3: (a and b) Impact of COVID-19 on the various aspects of the life|
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A large number of medical students (91%), nonmedical students (81%), and interns (76.9%) expressed that their studies suffered a negative effect, with concern that this would, in turn, affect their academic performance. About half of the students were afraid that they would not being able to complete their degree and not getting graduated, in contrast to 40% of the interns [Figure 3]a.
Almost half of the students experienced a positive impact on familial relationships. However, only 30% of interns experienced a positive effect on the same. Regarding friendships, 41.5% medical students and 54.4% of nonmedical students felt an adverse impact [Figure 3]a.
Diet, physical health, COVID-19 testing
The physical health, diet, and workout were revealed to be impacted negatively in all the three groups except that diet was shown to have been impacted positively in about 40% of medical students. All three groups expressed the willingness of being more health-conscious than they used to be earlier. Again, majority of the subjects were extremely worried about themselves and their families testing positive for COVID-19 [Figure 3]a and [Figure 3]b.
| Discussion|| |
There are many studies conducted all over the world regarding the mental health and sleep quality of the undergraduate students, including some specific to medical or college students only., After the advent of the COVID-19 pandemic, there has been an upsurge in the psychological distress and worsening of sleep quality in the student's sector.,,,, The uncertainty of the upcoming events, impending academic year, extension of the courses, the newer modalities of teaching including online, absence of routine or traditional teaching, and constant brooding about their careers have naturally lead to an increased sense of perturbation and a nerve-racking situation for them.
This study discloses the different levels of stress, prevalence of poor sleep quality, and the negative impact of COVID-19 on various aspects of life in the three groups.
- Psychological distress and mental health.
The survey demonstrated a massive increase in psychological concerns including anxiety and stress due to COVID-19. The frightening numbers of more than half of all the students and interns selfreporting depressive thoughts and the evaluation of K10 also demonstrating approximately half of nonmedical students, one third of medical students, and a quarter of interns being psychologically distressed emerged [Figure 1] and [Figure 2]. One-third of medical students are known to be depressed globally in the prepandemic era, which was much more than general population, and it worsens when they enter workforce. The present results are showing reversal of the situation. The other college students may be stressed the most out of the three groups due to the high level of apprehension and the lack of knowledge about the disease which medical students are well versed with. Constantly staying indoors, isolating within the four walls, and inability to distract themselves by going out may also have led to physical and mental weariness. In interns, the confidence which they developed while working with COVID patients may have an additional role in the lowest levels of stress.
The average scores of K10 indicate a general statement of moderate distress in other college students while mild distress in medical students and interns. The higher levels in the former group may be due to the greater fear of the pandemic, and lower scores in medical students may be due to returning to their families relieving their anxiety and the interns actually working for the COVID patients may have boosted their confidence to some extent allaying anxiety.
The researches done in the initial phase of the pandemic demonstrated that all the students experienced moderate levels of psychological distress,, and about two-third medical students reported a deterioration of mental well-being. In the present work, the fraction of the student community showing moderate to severe stress is slightly less possibly owing to the time that has lapsed since the pandemic began. This window might have been enough for some participants for adjustment to the new environment. However, the majority of subjects are still manifesting mental distress, emphasizing the strong need of mental health support for them.
Category-wise distribution depicting opposite trends in the medical and other students groups demonstrating the clustering of majority of cases in category I (no distress) and then category IV (severe distress) in the medical students and interns; conversely the maximum nonmedical students being in category IV (severe distress) and then in category I (no distress) may be due the reasons proposed above.
Disturbing figure of about one-tenth of the medicos including the interns also self-reported having suicidal thoughts, the number being slightly less in the nonmedicos was evident. In the college students, 3%–7% of the population have been found to harbor suicidal thoughts outside of the pandemic situation, and it has increased to 8%–18.04% in the present pandemic in various researches., The present findings of about 7% reporting of suicidal thoughts in college students and 12% and 10% in medical students and interns, respectively, indicate higher suicidal ideation among medical students, concordant with the pre-COVID works. The junior medical students being more at risk of suicidal thoughts or attempts than the seniors may reflect the increased likelihood to engage in active coping by their final year.
Pittsburgh Sleep Quality Index
Sleep disturbances are long known to be prevalent in the college students, medical and nonmedical both.,, The one-third of the students are known to have poor sleep quality globally,,, few studies in medical students finding as high prevalence as 63.5% and 76% also,, with insomnia ranging from 26% to 33%., However, the prevalence has increased in COVID era, in college students to 70.7% having poor sleep quality and 86% with disruption of sleep pattern. The present study is concordant with them with showing 65.4% of college students having poor sleep quality. The finding of about half of the medical students with poor sleep quality is higher than the non-COVID era but discordant with the works in the present pandemic in being lower than the initial COVID one. This may indicate their adjustment with the changed scenario. The limited studies comparing the sleep of medical and other university students demonstrated more intense sleep difficulties in the former subjects, probably owing to challenging, highly demanding and potentially stressful academic program of medicine in nonpandemic times. The contrasting findings of the present study with less prevalence of the poor sleep quality in the medical students than others may be attributed to getting away from the stressful schedule due to the lockdown. This emphasizes the need of possible modifications in it to bring down high anxiety levels in them, which may also include vacations at regular intervals. On the other hand, demanding and exhausting work pattern and timings in the present times also may be the reason for the higher prevalence of worse PSQI scores in the interns. It is also known that sleep in a hospital is not able to restore chronic sleep deprivation. Thus, this issue should be addressed seriously, and good monitoring of the duty schedule and hours in them is mandated.
COVID-19 impact on different domains of life
The social interaction has gone down which can be attributed to precautions for COVID-19 including to maintain a safe distance and lesser physical interaction, this finding is similar to other studies. Present analysis suggested that majority of students felt that academics were adversely affected and that rose concerns about the academic performance. Due to the lockdown, many students did not have their books, and the absence of the physical classes also added to the insecurity. This study denotes that familial relationships grew better for all the students, however, medical interns spending day and night serving the COVID-19 patients did not get time to bond with their families. Subjects returning to their homes might have a role in former case. Friendships might have been affected due to the restriction of the lockdown as students did not get to meet up with their pals. Concerns regarding physical health were attributed to a disturbed routine, an irrational diet, and lack of adequate physical activity. However, medical students residing in hostels returned home and thus experienced a better dietary plan and another small subset of students paid more attention to their health. The time spent indulging in hobbies including cooking, playing indoor games, and spending a lot of fun family time increased and studies took a back seat. Not only were they concerned about themselves but also their family members testing positive for COVID-19. The overall findings are similar to other recent works.
It is suggested that there should be formation of psychological support bodies, also consisting of the volunteer students, for the institute level mental health care as it is the need of the hour. Correlation studies between stress and sleep in the medical students and interns also need to be done at a larger scale as the number of the interns was limited in the present work.
| Conclusions|| |
Statistically significant difference has been found in the three undergraduate student groups with respect to psychological distress and sleep quality indicating the difference in the impact of COVID-19 on their lives. In contrast to the worst sleep quality in interns, the psychological distress was least prevalent in them. The other college students were maximally psychologically distressed with moderate distress against mild distress in other two. Medical students showing least poor sleep quality and majority showing positive impact on diet may indicate the highly stressful academic program. Thus, there is a strong need of individualized intervention including measures to allay anxiety and subsequent sleep disturbances in the medical students and interns as is providing mental health support to all the three groups possibly at the institutional levels.
We would like to thank all the participants of this study for their cooperation and support. Furthermore, we especially thank our statistician Mr. More for his support.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Brick CA, Seely DL, Palermo TM. Association between sleep hygiene and sleep quality in medical students. Behav Sleep Med 2010;8:113-21.
Saraswathi I, Saikarthik J, Senthil Kumar K, Madhan Srinivasan K, Ardhanaari M, Gunapriya R. Impact of COVID-19 outbreak on the mental health status of undergraduate medical students in a COVID-19 treating medical college: A prospective longitudinal study. PeerJ 2020;8:e10164.
Martínez-Lezaun I, Santamaría-Vázquez M, Del Líbano M. Influence of confinement by COVID-19 on the quality of sleep and the interests of university students. Nat Sci Sleep 2020;12:1075-81.
Kessler RC, Barker PR, Colpe LJ, Epstein JF, Gfroerer JC, Hiripi E, et al.
Screening for serious mental illness in the general population. Arch Gen Psychiatry 2003;60:184-9.
Buysse DJ, Reynolds CF, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh Sleep Quality Index (PSQI): A new instrument for psychiatric research and Practice. Psychiatry Res 1989;28:193-213.
Moir F, Yielder J, Sanson J, Chen Y. Depression in medical students: Current insights. Adv Med Educ Pract 2018;9:323-33.
Azad MC, Fraser K, Rumana N, Abdullah AF, Shahana N, Hanly PJ, et al
. Sleep disturbances among medical students: A global perspective. J Clin Sleep Med 2015;11:69-74.
Benham G. Stress and sleep in college students prior to and during the COVID-19 pandemic. Stress Health. 2021;37(3):504-515.
Lyons Z, Wilcox H, Leung L, Dearsley O. COVID-19 and the mental well-being of Australian medical students: Impact, concerns and coping strategies used. Australas Psychiatry 2020;28:649-52.
Marelli S, Castelnuovo A, Somma A, Castronovo V, Mombelli S, Bottoni D, et al
. Impact of COVID-19 lockdown on sleep quality in university students and administration staff. J Neurol 2021;268:8-15.
Naser AY, Dahmash EZ, Al-Rousan R, Alwafi H, Alrawashdeh HM, Ghoul I, et al
. Mental health status of the general population, healthcare professionals, and university students during 2019 coronavirus disease outbreak in Jordan: A cross-sectional study. Brain Behav 2020;10:e01730.
Son C, Hegde S, Smith A, Wang X, Sasangohar F. Effects of COVID-19 on college students' mental health in the United States: Interview survey study. J Med Internet Res 2020;22:e21279.
Puthran R, Zhang MW, Tam WW, Ho RC. Prevalence of depression amongst medical students: A meta-analysis. Med Educ 2016;50:456-68.
Rotenstein LS, Ramos MA, Torre M, Segal JB, Peluso MJ, Guille C, et al.
Prevalence of depression, depressive symptoms, and suicidal ideation among medical students: A systematic review and meta-analysis. JAMA 2016;316:2214-36.
Dyrbye LN, Thomas MR, Shanafelt TD. Medical student distress: Causes, consequences, and proposed solutions. Mayo Clin Proc 2005;80:1613-22.
Zivin K, Eisenberg D, Gollust SE, Golberstein E. Persistence of mental health problems and needs in a college student population. J Affect Disord 2009;117:180-5.
Wang X, Hegde S, Son C, Keller B, Smith A, Sasangohar F. Investigating mental health of US college students during the COVID-19 pandemic: Cross-sectional survey study. J Med Internet Res 2020;22:e22817.
Molodynski A, Lewis T, Kadhum M, Farrell SM, Lemtiri Chelieh M, Falcão De Almeida T, et al.
Cultural variations in wellbeing, burnout and substance use amongst medical students in twelve countries. Int Rev Psychiatry 2021;33:37-42.
Léger D, Partinen M, Hirshkowitz M, Chokroverty S, Hedner J; EQUINOX (Evaluation of Daytime QUality Impairment by Nocturnal Awakenings in Outpatient's eXperience) Survey Investigators. Characteristics of insomnia in a primary care setting: EQUINOX survey of 5293 insomniacs from 10 countries. Sleep Med 2010;11:987-98.
Bhandari PM, Neupane D, Rijal S, Thapa K, Mishra SR, Poudyal AK. Sleep quality, internet addiction and depressive symptoms among undergraduate students in Nepal. BMC Psychiatry 2017;17:106.
Rathod SS, Nagose VB, Kanagala A, Bhuvangiri H, Kanneganti J, Annepaka E. Sleep duration and its association with obesity and overweight in medical students: A cross-sectional study. Natl J Physiol Pharm Pharmacol 2018;8:113-7.
Alsaggaf MA, Wali SO, Merdad RA, Merdad LA. Sleep quantity, quality, and insomnia symptoms of medical students during clinical years. Relationship with stress and academic performance. Saudi Med J 2016;37:173-82.
Basu M, Saha SK, Majumder S, Chatterjee S, Misra R. A study on sleeping pattern among undergraduate medical students of a tertiary care teaching hospital of Kolkata. Int J Med Public Health 2019;9:118-24.
Almojali AI, Almalki SA, Alothman AS, Masuadi EM, Alaqeel MK. The prevalence and association of stress with sleep quality among medical students. J Epidemiol Glob Health 2017;7:169-74.
Alqudah M, Balousha SMA, Al-Shboul O, Al-Dwairi A, Alfaqih MA, Alzoubi KH. Insomnia among medical and paramedical students in Jordan: Impact on academic performance. Biomed Res Int 2019;2019:7136906.
Palatty PL, Fernandes E, Suresh S, Baliga MS. Comparison of sleep pattern between medical and law students. Sleep Hypn 2011;13:1-2.
Richardson GS, Wyatt JK, Sullivan JP, Orav EJ, Ward AE, Wolf MA, et al.
Objective assessment of sleep and alertness in medical house staff and the impact of protected time for sleep. Sleep 1996;19:718-26.
[Figure 1], [Figure 2], [Figure 3]