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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 6  |  Issue : 3  |  Page : 238-243

Mental health of medical students during corona virus disease-19 pandemic: A cross-sectional study


1 Department of Physiology, Government Medical College, Pali, Rajasthan, India
2 Department of Psychiatry, Government Medical College, Pali, Rajasthan, India
3 Department of Physiology, SN Medical College, Jodhpur, Rajasthan, India

Date of Submission01-Oct-2021
Date of Decision15-Dec-2021
Date of Acceptance08-Jan-2022
Date of Web Publication31-Oct-2022

Correspondence Address:
Dr. Ankit Awasthi
Department of Psychiatry, Government Medical College, Pali, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aip.aip_120_21

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  Abstract 


Context: Human population is afflicted with Coronavirus disease (COVID-19) pandemic for last more than 1 year. Various measures were taken and restrictions were imposed by countries to break the chain of infection and to control this pandemic. Medical education has conventionally been considered challenging. Adding to it; hassles in teaching and fears and uncertainty about COVID-19 adversely affected the mental health of medical students during this pandemic. Aim: The present study aimed to investigate the mental health of undergraduate medical students during the COVID-19 pandemic. Settings and Design: This cross-sectional online survey was carried out on medical undergraduate students of Western Rajasthan using Google Form. Informed consent (online) was taken before enrolment for study. Materials and Methods: The students were sent the link to respond to the Google Form, which comprised questions seeking demographic details and items from depression, anxiety, and stress scale (DASS-21). Statistical Analysis Used: Frequencies and mean scores of depression, anxiety, and stress components of the DASS-21 scale were computed for the severity of scale according to the guidelines. The sociodemographic reasons predisposing the students to depression, anxiety, and stress were assessed using the Chi-square test. Statistical significance was set a priori at P < 0.05. Results: About 32.3% of the participants reported moderate-to-extremely severe depression, 41.5% reported moderate-to-extremely severe anxiety; while 11.6% reported moderate-to-extremely severe stress. Participants in the higher age group, younger batch, and urban residents were more likely to have depression. On the other hand, participants in higher age groups and females were more likely to have anxiety. Stress was found statistically higher in females and younger batch students. Conclusion: Students are facing challenging times and need to adapt to newer ways of distance education. Efficient time management, e-learning skills, following COVID norms, and getting vaccinated timely are the need of the hour for medical students. They should be provided regular psychological counseling and guidance to deal with stressful situations to prevent any untoward incidences.

Keywords: Anxiety, coronavirus disease, depression, medical students, stress


How to cite this article:
Maheshwari M, Awasthi A, Tilwani K, Jangid P. Mental health of medical students during corona virus disease-19 pandemic: A cross-sectional study. Ann Indian Psychiatry 2022;6:238-43

How to cite this URL:
Maheshwari M, Awasthi A, Tilwani K, Jangid P. Mental health of medical students during corona virus disease-19 pandemic: A cross-sectional study. Ann Indian Psychiatry [serial online] 2022 [cited 2022 Dec 10];6:238-43. Available from: https://www.anip.co.in/text.asp?2022/6/3/238/360069




  Introduction Top


The human population is currently afflicted with Corona Virus disease (COVID-19), which emerged in China in December 2019. The World Health Organization soon announced the COVID-19 outbreak as a public health emergency of international concern on January 30, 2020; and later declared it a pandemic on March 11, 2020.[1] In India, the first COVID-19 case was reported in Kerala on January 30, 2020, and by May 2020 the number of cases had crossed one hundred thousand.[2] The first case in Rajasthan was reported on March 1, 2020.[3]

Almost all countries initiated a series of measures to break the chain of infection and control the pandemic, including local and international travel bans, restricting large gatherings, suspension of public transport, closure of schools and universities and of business, social distancing, stay-at-home orders, and curfews.[4] The educational and economic sectors were almost paralyzed.[5],[6] Eventually, all kinds of in-person communications, travel, meetings, etc., were switched over to virtual ones. These restrictions, the changes brought about with time and the uncertain trend of the disease significantly affected the mental well-being of many.

The mental health of the medical students was affected to a larger extent when compared to the general population.[7] Medical education is more demanding than other professional programs in terms of both academic and emotional components.[8] The larger duration and enormous syllabus make it more stressful. Medical students are further stressed due to the increasing need of doing specialization courses. Globally, one in three medical students has been found to report anxiety, which is higher than the general population.[9]

Traditional medical learning starts with classroom teaching along with clinical bedside teaching. Due to the COVID-19 pandemic and subsequent nationwide lockdown; all the colleges were shut, putting the classroom and clinical bedside teaching to halt for a long duration. The resultant delay in learning procedures led to uncertainty among the medical students toward their future.[10] With COVID-19 cases witnessing a sharp decline, most of the medical colleges across the country resumed physical classes for their students. Medical colleges, closed since March 2020, were reopened after official orders from the Central and the State governments in mid-February 2021. To begin with, students were given online classes during the lockdown, later were asked to attend college in person.

We hypothesized that during the COVID-19 pandemic, suspension of in-person learning for a long period caused immense course workload, uncertainty about the examination, lesser preparation time, delay in course completion; along with the fear of corona infection, leading to adverse effects on students' mental health and well-being as well as education. Hence, we conducted a cross-sectional online survey to investigate the mental health of undergraduate medical students.

Study settings and design

This cross-sectional online survey was carried out between May 1 and May 30, 2021, after the institutional ethical clearance, on medical students in western Rajasthan to assess their mental health. A total of 355; 18–25 years old students participated voluntarily in the study through an online survey link created by the researchers (MM, AA, KT) on Google Form. All the students in various medical colleges in the western part of the state were sent the link to respond to the Google form survey. Those who completed the form were included in the study data, while incomplete responses were excluded. The students who had a history of psychiatric illness or who were receiving psychiatric treatment were not included in the study.


  Materials and Methods Top


The structured questionnaire (Google Form) assessed the basic information and mental health status of the participants and comprised two sections: basic demographic questions and items from depression, anxiety, and stress scale (DASS-21).[11] Basic demographic questions gathered information on age, gender, college, year of the study, type of residence, and family status. To assess mental health we used DASS-21 which is available in the public domain and validated. It has 21 items, 4-point Likert scale where 0 = does not apply to me at all; 1 = applies to me to some degree, or some of the time; 2 = applies to me to a considerable degree, or a good part of my life; and 3 = applies to me very much, or most of the time.

The higher score of depression sub-scale indicates a higher level of depression, categorized by scores as normal (0–9), mild (10–13), moderate (14–20), and severe (21–27); scores of 28 and above indicate extremely severe depression. The anxiety scores are classified as normal (0–7), mild (8, 9), moderate (10–14), and severe (15–19), with scores of 20 or more indicating extremely severe anxiety. The Stress sub-scale is categorized into normal (0–14), mild (15–18), moderate (19–25), and severe (26–33), with scores of 34 or more indicating extremely severe stress.

Statistical analysis

The data collected in Google Forms were transferred to an Excel sheet and exported to SPSS for analysis (IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY, USA: IBM Corp.). The participants were categorized according to various sociodemographic variables. Internal consistency of DASS-21 as a whole and each of its sub-scale was calculated using Cronbach's alpha. The responses to DASS-21 were assessed for depression, anxiety and stress components. Frequencies and mean scores of all the three components of the scale were computed for the severity of DASS-21 scale according to the guidelines. The socio-demographic reasons predisposing the students to depression, anxiety and stress were assessed using Chi-square test. Statistical significance was set a priori at P < 0.05.


  Results Top


This was an online survey, wherein 355 students from various medical colleges in Rajasthan participated. After removal of missing data, responses from 343 participants were included as final data, which had 182 (53%) male and 161 (47%) female students. The socio-demographic characteristics of the participants have been presented in [Table 1]. The age of the participants ranged from 17 to 27 years, with the average being 20 (±1.5) years. Majority of the students were from GMCP (225, 65.6%) and SNMC (99, 29%) with the remaining few from other colleges in the state (18, 6%). Around 193 (56.3%) students studied in 2020 batch, 94 (27.5%) were from 2019 batch and 56 (16.3%) from 2018 batch. Over 88% (304) students were Hindus, remaining few were Muslims, Jains, etc., A larger section lived in the urban area (184, 54%). About 226 (66%) students lived in the nuclear family. [Table 2] presents the internal consistency of the DASS scale.
Table 1: Distribution of participants according to sociodemographic characteristics (n=343)

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Table 2: Internal consistency of Depression, Anxiety and Stress Scale and subscales

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The responses of the participants for the DASS questionnaire have been presented in [Table 3]. Depression, anxiety, and stress scores were computed according to the guideline. The mean depression score was 10.19 (±9.0), mean Anxiety score was 8.24 (±7.44), and mean Stress score was 10.24 (±7.9). [Table 4] shows the distribution of the DASS scale according to various categories of independent variables. Around 43% of students had depression, 49% had anxiety and 26% had stress. Of which, about 32.3% of the participants reported moderate-to-extremely severe depression, 41.5% of the participants reported moderate-to-extremely severe anxiety; while 11.6% of the participants reported moderate-to-extremely severe stress.
Table 3: Responses to Depression, Anxiety and Stress Scale (n=343)

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Table 4: Socio-demographic distribution of the participants according to Depression, Anxiety and Stress Scale

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Chi-square test was run for comparing the students with and without depression, anxiety, and stress [Table 5]. Participants in the higher age group, younger batch, and urban residents were more likely to have depression. On the other hand, participants in higher age groups and females were more likely to have anxiety. Stress was found statistically higher in females and younger batch students.
Table 5: Comparison of normal respondents with those having positive Depression, Anxiety, and Stress Scale scores (Chi-square test)

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  Discussion Top


This study was among the first studies to assess the psychological status of medical students during the COVID pandemic. Medical students were affected by this situation both academically and psychologically. Our study attempted to assess the mental status of medical students in Rajasthan and responses were sought from students in all the medical colleges in the state.

While DASS-21 was used, the mean depression score in this study was found to be 10.19 (±9.0), mean anxiety score was 8.24 (±7.44), and mean stress score was 10.24 (±7.9). Contrasting results have been reported by other studies, where Saraswathi et al. reported lower average scores of depression, anxiety, and stress, both during the baseline survey as 7.55 (±7.86), 4.6 (±6.19), and 7.31 (±7.34), as well as in follow-up survey as 8.16 (±8.9), 6.11 (±7.13), and 9.31 (±8.18), respectively;[12] while Kumar B, et al. reported the much higher mean scores as 18 (±11.5), 19.15 (±11.2), and 20.92 (±11.2), respectively.[13]

On assessing the prevalence as per DASS-21, over 43% of students had depression, 49% had anxiety and 26% had stress. Various other studies reported contrasting prevalence, as Al Omari O, et al. reported the total prevalence of 57%, 40.5%, and 38.1%, respectively,[14] which was relatively higher; and in the study by Saraswathi et al., during baseline, the prevalence (95% confidence interval) was found to be 33.2% (27%–39.9%), 21.2% (16%–27.2%) and 20.7% (15.5%–26.7%); while during follow-up, the prevalence was 35.5% (29.1%–42.2%), 33.2% (27%–39.9%), and 24.9% (19.3%–31.2%), respectively;[12] which was overall lower in both situations than our study results. In a Brazilian study, 34.6% of participants reported depressive symptoms, 37.2% showed anxiety symptoms, and 47.1% had stress symptoms; pointing toward a larger section reporting stress symptoms.[15] In a multiethnic study, the prevalence of depression, anxiety, and stress was high (43%, 63%, and 41%, respectively) before examination, similar to our study results, and reduced (30%, 47%, and 30%, respectively) to some extent after examinations.[16]

About 32.3% of the participants reported moderate-to-extremely severe depression, 41.5% reported moderate-to-extremely severe anxiety; while 11.6% reported moderate-to-extremely severe stress in our study. Al Ateeq, et al. reported that in Saudi Arabia, more than half of the participants showed moderate levels of stress (55%), while 30.2% registered high levels of stress.[17] In a study in Bangladesh, around 15% of the students reportedly had moderately severe depression, whereas 18.1% were suffering from severe anxiety, much lower than reported in our study.[18] Kumar B, et al. reported that 57.6% of the students suffered from moderate-to-extremely severe depression, 74% suffered from moderate to extremely severe anxiety, and 57.7% students had moderate to extremely severe stress, which is quite high comparatively.[13]

The results in our study indicated that students from higher age groups, 2020 batch and urban residents were more likely to report depression. Similar results were reported by Islam et al. in Bangladesh, where older students reported greater depression (odds ratio = 2.89).[18]

Our results presented that higher age groups and females were more likely to have anxiety. In Bangladesh, the study found no significant differences between male and female students with relation to depression or anxiety.[18] In Brazilian study, course semester has been shown related to complaint of anxiety.[15]

In our results, stress was found to be statistically higher in females and 2020 batch students. In Saudi Arabia, females and university students showed a significant association with stress levels, though most of them had moderate levels of stress.[17] In an Indian online survey, stress score was found to be higher in the group who was not using digital online e-learning methods during this COVID-19 pandemic lockdown.[10] Females have also been shown to have more stress by Moutinho et al.[15]

Pressure of following COVID appropriate norms, adoption of online mode of learning as well as clinical exposure to the patients probably infected with the virus might be the major factors causing stress and anxiety to students. Social isolation itself was affecting the mental wellbeing of many individuals. In our study, it was found that students from batch 2020 were more likely to report depression and stress; possible reason may be the fact that batch 2020 students were affected most by lockdown restrictions and subsequent delay in commencement of their MBBS curriculum. Female students reported more anxiety and stress which is in accordance with gender predisposition for these disorders. Other reasons for our findings may include fear of exams and perceived uncertainty in almost every sphere of life due to pandemics.

Limitations

There were certain shortcomings in our study set-up, which could not be eliminated. Convenient sampling was used for data collection, along with online distribution of the questionnaire, leading to the possibility of selection bias. However, as maintaining social distancing was the need of the hour, it was considered to be the most appropriate way of data collection. Self-reporting by students would have caused bias in self-assessment and interpretation of psychological status. As cross-sectional study design was used, causal relation could not be assessed. A further investigation needs to be performed to assess variation in DASS scores with a change in the pandemic situation along with the vaccination of students. Nevertheless, as this is the first survey assessing the psychological impact of COVID-19 on medical students in this region, further studies can be taken up using these results as a baseline to investigate the impact of COVID-19 on students.


  Conclusion Top


Our way of living has changed considerably during this pandemic phase. Students are facing challenging times and need to adapt to newer ways of distance education. Efficient time management, e-learning skills, following COVID norms, and getting vaccinated timely are the need of the hour for medical students. They should be provided regular psychological counseling and guidance to deal with stressful situations to prevent any untoward incidences. Social media should be regularized to prevent the spread of misinformation during crisis periods. Medical students should consider this phase as a learning stage to deal with future difficulties and come out stronger psychologically.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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WHO Director-General's Opening Remarks at the Media Briefing on COVID-19 – March 11, 2020. World Health Organization. Available from: https://www.who.int/dg/speeches/detail/who-director-general-sopening-remarks-at-the-media-briefing-oncovid-19-11-march-2020. [Last accessed on 2020 Apr 27].  Back to cited text no. 1
    
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Andrews MA, Areekal B, Rajesh KR, Krishnan J, Suryakala R, Krishnan B, et al. First confirmed case of COVID-19 infection in India: A case report. Indian J Med Res 2020;151:490-2.  Back to cited text no. 2
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Khatatbeh M. Efficacy of nationwide curfew to encounter spread of COVID-19: A case from Jordan. Front Public Health 2020;8:394.  Back to cited text no. 4
    
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Lovibond SH, Lovibond PF. Manual for the Depression Anxiety Stress Scales. 2nd ed. Sydney: Psychology Foundation; 1995.  Back to cited text no. 11
    
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Al Omari O, Al Sabei S, Al Rawajfah O, Abu Sharour L, Aljohani K, Alomari K, et al. Prevalence and predictors of depression, anxiety, and stress among youth at the time of COVID 19: An online cross sectional multicountry study. Depress Res Treat 2020;2020:8887727.  Back to cited text no. 14
    
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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