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ORIGINAL ARTICLE
Year : 2020  |  Volume : 47  |  Issue : 3  |  Page : 158-163

Prevalence of depression, anxiety, and stress among medical students in a developing country during the COVID-19 pandemic: A pilot study


1 Department of Physiology, Burdwan Medical College, Burdwan, India
2 Department of Community Medicine, Calcutta Medical College, West Bengal, India
3 Department of Physiology, Lady Hardinge Medical College, Delhi, India

Date of Submission23-Jun-2020
Date of Acceptance18-Jul-2020
Date of Web Publication21-Jan-2021

Correspondence Address:
Dr. Arunima Chaudhuri
Krishnasayar South, Borehat, Burdwan - 713 102, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jss.JSS_59_20

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  Abstract 


Background: COVID-19 pandemic has the potential to significantly affect the mental health of Medical professionals as well as Medical students, as they stand in the frontline during this hour of crisis. Aims: The aim is to assess mental health of undergraduate medical students and particularly in relation to the prevalence of anxiety, depression and stress in a Medical College of Eastern India. Materials and Methods: This cross-sectional pilot study was conducted in a Medical College of Eastern India after taking Institutional clearance and informed consent of the subjects. Three hundred and nine-two subjects participated in the present study. A link was created with the help of a Google form with depression, anxiety and stress scale-21 and demographic variables. The students were also asked to give a feedback on the online teaching program provided by the college. Statistical Analysis: Data were tabulated into excel sheet and analysis was done. Results: Among the 392 subjects who participated in the study 278 (70.92') subjects had normal stress scores, i.e., between 0 and 14; 114 (28.97') had stress score 15 or more; 6 (1.5') had stress scores 34+ (extremely severe stress), 14 (3.5') had stress scores between 26 and 33 (severe stress), 29 (7.39') had stress scores between 19 and 25 (moderate stress), 65 (16.58') had scores between 15 and 18 (mild stress). Two hundred and sixty-three (67.091') had normal anxiety scores between 0 and 7; 129 (32.9') had anxiety scores 8 or more. 15 (3.82') had anxiety score 20+ (extremely severe anxiety); 11 (2.81') had anxiety scores between 15 and 19 (severe anxiety); 64 (16.33') had anxiety scores between 10 and 14 (moderate anxiety); 39 (9.85') had anxiety scores between 8 and 9 (mild anxiety). Two hundred and sixteen (55.11') had normal depression scores between 0 and 9; 176 (44.89') had depression scores 10 or more. 24 (6.1') had depression score 28+ (extremely severe anxiety); 23 (5.86') had depression scores between 21 and 27 (severe depression); 70 (17.85') had depression scores between 14 and 20 (moderate depression); 59 (15.05') had depression scores between 10 and 13 (mild depression). Depression and stress scores were positively correlated with r = 0.765; depression and anxiety scores were positively correlated with r = 0.63; stress and anxiety scores were positively correlated with r = 0.73.77.4' of the students felt that during the lockdown period online support, regular assessment, feedback provided by the college were satisfactory. Conclusions: High scores of depression, stress and anxiety were observed among Medical students in this pilot cross sectional study. Longitudinal follow-up is necessary to study the impact of the present crisis on medical students.

Keywords: COVID-19, medical students, mental health


How to cite this article:
Chaudhuri A, Mondal T, Goswami A. Prevalence of depression, anxiety, and stress among medical students in a developing country during the COVID-19 pandemic: A pilot study. J Sci Soc 2020;47:158-63

How to cite this URL:
Chaudhuri A, Mondal T, Goswami A. Prevalence of depression, anxiety, and stress among medical students in a developing country during the COVID-19 pandemic: A pilot study. J Sci Soc [serial online] 2020 [cited 2021 Mar 1];47:158-63. Available from: https://www.jscisociety.com/text.asp?2020/47/3/158/307604




  Introduction Top


A highly infectious serious acute respiratory syndrome caused by a novel coronavirus (SARS-CoV-2) emerged in Wuhan, China, in the month of December 2019. COVID-19 was declared as a pandemic on March 11, 2020 by World Health Organization. This pandemic has the potential to significantly affect the mental health of Medical professionals as well as medical students, as they stand in the frontline of this hour of crisis.[1],[2]

Medical education is inherently stressful and in the hour of present crisis medical students have to stay back home and continue their studies online.[1],[2],[3],[4],[5],[6] In developing counties with poorly developed infra structures and deficiency of economic resources providing online education by Medical educators has posed a great challenge as they are also the forefront fighters in the pandemic. The students are not able to attend their usual clinical classes in the present situation as the virus is highly contagious. Their resilience may be further compromised by isolation and loss of social support, risk or infections of friends and relatives and unsettling changes in the working conditions. Medical students are therefore, especially vulnerable to mental health problems, including stress, anxiety, and depression.[1],[2]

There is increasing in concerns about the mental health of health care workers treating and caring for patients with COVID-19 worldwide. The goal of a narrative review was to provide up-to-date information on potential mental health risks associated with exposure of health professionals to the COVID-19 pandemic. They highlighted most relevant data concerning the disease characteristics, the organizational factors and personal factors that may contribute to developing psychological distress and other mental health symptoms. The disease characteristics of the current COVID-19 pandemic provoked a generalized climate of wariness and uncertainty, particularly among health professionals, due to a range of causes such as the rapid spread of COVID-19, the severity of symptoms it can cause in a segment of infected individuals, the lack of knowledge of the disease, and deaths among health professionals. Stress may also be caused by organizational factors, such as depletion of personal protection equipment, concerns about not being able to provide competent care if deployed to new area, concerns about rapidly changing information, lack of access to up-to-date information and communication, lack of specific drugs, the shortage of ventilators and intensive care unit beds necessary to care for the surge of critically ill patients, and significant change in their daily social and family life. Further risk factors have been identified, including feelings of being inadequately supported, concerns about health of self, fear of taking home infection to family members or others, and not having rapid access to testing through occupational health if needed, being isolated, feelings of uncertainty and social stigmatization, overwhelming workload, or insecure attachment. In addition, they discussed positive social and organizational factors that contribute to enhance resilience in the face of the pandemic. There is a consensus in all the relevant literature that health care professionals are at an increased risk of high levels of stress, anxiety, depression, burnout, addiction and posttraumatic stress disorder, which could have long-term psychological implications.[2]

In the long run, this tragic health crisis should significantly enhance our understanding of the mental health risk factors among the health professionals who are facing the COVID-19 pandemic. Reporting information such as this is essential to plan future prevention strategies. Protecting health care professionals is indeed an important component of public health measures to address large-scale health crisis. Thus, interventions to promote mental well-being in health care professionals exposed to COVID-19 need to be immediately implemented, and to strengthen prevention and response strategies by training health care professionals on mental help and crisis management.[2]

In many places, medical students are collaborating with health care workers to deliver patient management and care in emergencies during the COVID-19 pandemic. In other situations, medical students are experiencing an unintended pause in their education due to global university closure over COVID-19 concerns. In either situation, students may find difficulties in coping with mental and emotional issues, including stress, anxiety, and depression, that may require significant psychological and physical effort. The medical students of today will be doctors of tomorrow. So attention to their mental health is of immense importance to make them ready for multiple unprecedented challenges in future. Hence, it is important that medical schools not only care about students' mental health but also implement strategies to support their understanding of crisis management, self-mental care, and other principal measures to strengthen their coping skills and mental preparedness.[1],[7]

The impact of the current unprecedented crisis on the psychological well-being of medical students needs to be further established in developing countries. The aim of this pilot project was to examine the emerging evidence of the effects of the COVID-19 outbreak on the mental health of medical students and particularly in relation to the prevalence of anxiety, depression, and stress in a Medical College of Eastern India.


  Materials and Methods Top


This pilot study was conducted in a Medical College of Eastern India after taking Institutional Clearance (Memo No: BMC/I. E. C/127: Dated March 12, 2020) and informed consent of the subjects in a time span of 1 month in May 2020. There are 650 undergraduate students studying in this college. Using online sample size calculator available at calculator, net sample size was calculated. Sample size calculated was 330 or more at confidence level 99'; margin of error 5'. 392 subjects participated in the present study.

Inclusion criteria

All Undergraduate Medical students of the College who were willing to participate in the study were included.

Exclusion criteria

Students who were already having major psychiatric problems previously and taking medications due to major psychiatric problems were excluded.

The students are continuing their studies on online mode during the time of present pandemic. They are used to attending lecture and practical sessions, so a sudden change to online sessions is creating a huge pressure for the young medical undergraduate students. They also have to appear for online assessments regularly during this period. They face network problems as many of them are residents of remote areas having poor network connectivity. Many could not bring their books from their hostel along with them due to the sudden lockdown. Hence, they had to solely depend on the online study materials provided to them by the faculties. They were facing social isolation and uncertainty regarding semester and final exams. All these factors were increasing their mental burden. Taking these into consideration, the present study was initiated to assess their mental health and if possible to provide them with some support.

A link was created with the help of a Google form with depression, anxiety, and stress scale-21 (DASS-21) and demographic variables. Faculties of all batches were requested to share this link with their students.

DASS-21 Items:[8] The DASS-21 Items is a set of three self-report scales designed to measure the emotional states of depression, anxiety and stress. The DASS-21 was used to assess the mental status of the subjects.

Each of the three DASS-21 scales consists of seven items which are divided into subscales with similar content. Scores for depression, anxiety, and stress are calculated by summing the scores for the relevant items. Scores on the DASS-21 needs to be multiplied by two to calculate the final score.

The depression scale assesses the following: Dysphoria, hopelessness, devaluation of life, self-deprecation, lack of interest/involvement, anhedonia, and inertia.

The anxiety scale assesses: Autonomic arousal, skeletal muscle effects, situational anxiety, and subjective experience of anxious affect.

The stress scale is sensitive to levels of chronic nonspecific arousal. It assesses difficulty in relaxing, nervous arousal, and being easily upset/agitated, irritable/over-reactive and impatient.

The DASS-21 is based on a dimensional rather than a categorical conception of psychological disorder. The assumption on which the DASS-21 development was based is that the differences between the depression, anxiety, and the stress experienced by normal subjects and clinical populations are essentially differences of degree.

Recommended cut off scores for conventional severity labels are as follows:

Depression (D), Anxiety (A), Stress (S):

  • Normal: (D) 0–9; (A) 0–7; (S) 0–14
  • Mild: (D) 10–13; (A) 8–9; (S) 15–18
  • Moderate: (D) 14–20; (A) 10–14; (S) 19–25
  • Severe: (D) 21–27; (A) 15–19; (S) 26–33
  • Extremely severe: (D) 28+ (A) 20+ (S) 34+.


Subjects were assured that their individual scores will be kept strictly confidential and they will be contacted and provided with help if problems were detected while assessing their mental health. E-mail addresses of the subjects were used to communicate with them. All subjects who participated in the study were given a training of progressive muscle relaxation and asked to practice daily for 20 min. Training involved tensing the specific muscle groups of body for 7–10 s, followed by releasing them for 15–20 s.[9] Training was given by trained and expert professional. The training included a power point presentation along with voice recording. They were repeatedly requested to follow the stress management program in this hour of crisis.

The students were also asked to give a feedback on the online teaching program by the college.

Statistical analysis

Data were tabulated into excel sheet and analysis was done.


  Results Top


This pilot study was conducted in a time span of 1 month. Undergraduates medical students from different batches participated in the study. Age of the subjects was between 18 and 22 years. Two hundred and sixty-two males and 130 females participated in the survey. Among the 392 subjects who participated in the study 278 (70.92') subjects had normal stress scores i.e., between 0 and 14; 114 (28.97') had stress score 15 or more; 6 (1.5') had stress scores 34+ (extremely severe stress), 14 (3.5') had stress scores between 26 and 33 (severe stress), 29 (7.39') had stress scores between 19 and 25 (moderate stress), 65 (16.58') had scores between 15 and 18 (mild stress) [Table 1] and [Figure 1]. 263 (67.091') had normal anxiety scores between 0 and 7; 129 (32.9') had anxiety scores 8 or more. Fifteen (3.82') had anxiety score 20+ (extremely severe anxiety); 11 (2.81') had anxiety scores between 15 and 19 (severe anxiety); 64 (16.33') had anxiety scores between 10 and 14 (moderate anxiety); 39 (9.85') had anxiety scores between 8 and 9 (mild anxiety) [Table 2] and [Figure 2]. 216 (55.11') had normal depression scores between 0 and 9; 176 (44.89') had depression scores 10 or more. 24 (6.1') had depression score 28+ (extremely severe anxiety); 23 (5.86') had depression scores between 21 and 27 (severe depression); 70 (17.85') had depression scores between 14 and 20 (moderate depression); 59 (15.05') had depression scores between 10 and 13 (mild depression) [Table 3] and [Figure 3]. Depression and stress scores were positively correlated with r = 0.764573199; depression and anxiety scores were positively correlated with r = 0.629140419; stress and anxiety scores were positively correlated with r = 0.726503091 [Figure 4]. 77.4' of the students felt that during the lockdown period online support, regular assessment, feedback provided by the college were satisfactory while 22.6' were not satisfied with the online teaching program. 18.1' reported that they were scared of their teachers and felt uneasy to approach, so they failed to share their problems with their teachers. 71.9' students reported that they could contact their teachers whenever they had any problem, 9.5' reported that they did not have any problem on any topic that was taught. 86.4' reported that the online teaching program was beneficial to them.
Table 1: Stress scores of the subjects

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Figure 1: Stress level of the subjects

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Table 2: Anxiety scores of the subjects

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Figure 2: Anxiety level of the subjects

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Table 3: Depression scores of the subjects

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Figure 3: Depression level of the subjects

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Figure 4: Correlation of depression, stress and anxiety

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  Discussion Top


Depression, anxiety, and stress are common mental health problems among medical students worldwide. The present study was conducted to assess mental health problems during the present crisis of pandemic among undergraduate medical students. Depression is one of the most common mental health issues among medical students worldwide due to the high intensity of training. Systematic reviews and meta-analysis have indicated that the prevalence of depression among medical students worldwide to be around 28', and suicidal ideation was 11.1'.[3],[4],[5],[6] We also observed high rate of depression among medical students in the present study.

A cross-sectional study was conducted on medical students in Vietnam[7] from November 2015 to January 2016 by Pham et al. Students had to complete a questionnaire including demographic characteristics, patient health questionnaire 9, academic motivation scale, and international physical activity questionnaire short form. Among 494 participants, the prevalence of self-reported depression was 15.2'. In the present study, Depression rate was 44.89'. We had conducted the present study during the COVID-19pandemic. This may be the cause of increase in percentage of depression among our subjects.

To estimate the prevalence of depression, depressive symptoms, and suicidal ideation a systematic review was conducted by Rotenstein et al. in 2016.[5] Depression or depressive symptom prevalence data were extracted from 167 cross-sectional studies and 16 longitudinal studies across 43 countries. The overall pooled crude prevalence of depression was 27.2' and that of suicidal ideation was 11.1'. In the present study, depression rate was 44.89'. This increase in prevalence of depression in the present study may be correlated with the present crisis, but it needs further follow-up. In the present study, severe to extreme severe depression was observed in 11.96' of the studied population.

Many studies have found significantly high-stress levels among medical students and the high stress has been reported across multiple countries, spanning several continents. This indicates to certain extent that high stress among medical students is a phenomenon that transcends sociocultural factors, economic status, course patterns, and the alike.[10],[11],[12],[13],[14],[15],[16],[17],[18] Indian studies are no different and have shown significant morbidity with stress in medical students. Self-rated depression is also found to be significantly higher in Indian medical students.[19] These findings are similar to the present study.

The aim of a study by Garg et al.[20] was to assess stress among medical students and the relationship of stress to the year of study and gender. The study was done using the higher education stress inventory. A total of 251 students were included in the study. Worry about future endurance and capacity was rated the highest by the final year students while faculty shortcomings and insufficient feedback were rated highest by the 2nd year students and financial concerns the highest by the 1st year students. Males rated financial concerns higher than females. In the present study, 28.97' of the subjects were found to be stressed. We used DASS 21 to assess mental health of our students.

A study by Kumar et al.[19] was aimed to assess the prevalence of depression and its associated factors among medical students. Four hundred students were assessed using beck depression inventory by investigators, while we used DASS-21 and our sample size was 392. The overall prevalence of depression was found to be 71.25' in the previous study. Among those with depression, a majority (80') had mild and moderate degree of depression. In the present study among those with depression 73.29' had mild or moderate degree of depression. 6.7' were considered to have very severe depression as per scores in the study conducted by Kumar et al. In the present study, 6.1' had scores showing extreme severe depression and 5.86' had severe depression.

The COVID-19 global pandemic has resulted in unprecedented public health challenges. This has impacted the medical education sector as well. The aim of a study conducted in the UK was to identify the impact of COVID-19 on final year medical student examinations and placements and how it might impact on confidence going into foundation training. Four hundred and forty-one students from 32 UK medical schools responded. Thirty-eight percent of respondents had their final objective structured clinical examinations (OSCEs) cancelled; 47' had already completed their final OSCEs before restrictions. Fifty percent of assistantship placements were postponed; 77' of electives were cancelled. The impact on medical student education has been significant. Despite this, many were willing to assist in hospitals earlier than expected.[21]

At present in India, undergraduate teaching is now being conducted by various methods using various online platforms by different medical colleges without uniformity. In this complex situation, the trial access/free version of various online streaming/conferencing tools and free/less costly internet data packages from telecom companies have made it possible to reach individual students and teach them even with our low economic resources.[22]

In the present study, 77.4' of the students felt that during the lockdown period online support, regular assessment, feedback provided by the college were satisfactory while 22.6' were not satisfied with the online teaching program. 18.1' reported that they were scared of their teachers, so they failed to share their problems with their teachers. Hence, there was a communication gap among the students and the teachers which needs to be addressed. The students who reported to be scared of their teachers were not able to clear their doubts on different problems and they mostly responded that the online support system was not satisfactory. 71.9' students reported that they could contact their teachers whenever they had any problem, 9.5' reported that they did not have any problem on any topic that was taught. 86.4' reported that the online teaching program was beneficial to them.

Limitations and future scope

This pilot project was conducted in a very short time span. Future longitudinal follow-up is necessary to establish the current findings.


  Conclusions Top


High scores of depression, stress and anxiety were observed among undergraduate medical students in this pilot cross sectional study. Longitudinal follow-up is necessary to study the impact of the present crisis on medical students and medical education.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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