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

Abstract

Background: The COVID-19 pandemic is found to affect the mental health of the population. Undergraduate medical students are especially prone to mental health disorders and hence could be more vulnerable to the impact of the pandemic.

Methods: A prospective longitudinal study was conducted on 217 undergraduate medical students in a medical college at Chennai, India. Depression, anxiety, and stress levels were recorded using Depression Anxiety Stress Scale 21 Items (DASS21) before and during the COVID-19 outbreak in India in December 2019 and June 2020, respectively. In the follow-up survey, in addition to DASS21, the Pittsburgh Sleep Quality Index to assess sleep quality and a self-administered questionnaire to assess the impact of COVID-19 related stressors were used. The self-administered questionnaire assessed the status of COVID-19 testing, interactions with COVID-19 patients, self-perceived levels of concerns and worries related to academics (COVID-19-AA (academic apprehensions)) and those pertaining to the self and family/friends (COVID-19-GA (general apprehensions)). Cross-sectional and longitudinal comparison of overall scores of depression, anxiety, and stress and scores stratified by gender, year of study, place of residence and monthly family income were performed. Predictors for depression, anxiety, and stress during COVID-19 were investigated using adjusted binary logistic regression analysis and results were expressed as adjusted odds ratio with 95% confidence interval (CI). A P value < 0.05 was considered statistically significant.

Results: The average scores of depression, anxiety, and stress during the baseline survey were 7.55 ± 7.86, 4.6 ± 6.19 and 7.31 ± 7.34 with the prevalence (95% Cl) of 33.2% [27-39.9%], 21.2% [16-27.2%] and 20.7% [15.5-26.7%]; in follow-up survey, the mean scores were 8.16 ± 8.9, 6.11 ± 7.13 and 9.31 ± 8.18 with the prevalence being 35.5% [29.1-42.2%], 33.2% [27-39.9%] and 24.9% [19.3-31.2%] for depression, anxiety, and stress respectively. There was a significant increase in both the prevalence and levels of anxiety and stress (P < 0.001), with depression remaining unchanged during COVID-19, irrespective of gender, year of study, place of residence and family's monthly income. Poor sleep quality, higher levels of baseline depression, anxiety, and stress, higher COVID-19-GA, COVID-19 patients in family/friends and direct interactions with COVID-19 patients were found to be significant predictors of negative mental health in undergraduate medical students. COVID-19-AA was not significantly associated with depression, anxiety, and stress.

Conclusion: The COVID-19 pandemic appears to negatively affect the mental health of the undergraduate medical students with the prevalence and levels of anxiety and stress being increased, and depression symptoms remaining unaltered. Addressing and mitigating the negative effect of COVID-19 on the mental health of this population is crucial.

Keywords: Anxiety; COVID-19; DASS21; Depression; Longitudinal study; Mental health; PSQI; Sleep quality; Stress; Undergraduate medical students.

Figure 1. Flow chart illustrating the sample selection from baseline to follow-up.

DASS21, Depression, Anxiety, Stress Scale 21 items; PSQI, Pittsburgh Sleep Quality Index.

Figure 2. Distribution of responses to self-administered questionnaire (in %).

Items 4 to 12: Likert scale score, 1 through 5; from minimum to maximum COVID-19-GA scores (5 to 25) = 4 + 5 + 6 + 7 + 8; COVID-19-AA scores (4 to 20) = 9 + 10 + 11 + 12.

Figure 3. Percentage distribution of baseline and follow-up depression, anxiety and stress levels and sleep quality in follow-up survey.

*Severity ranking scores DASS‐42. Depression: normal; 0–9, mild; 10–13, moderate; 14–20, severe; 21–‐27, extremely severe ≥ 28. Anxiety: normal; 0–7, mild; 8–9, moderate; 10–14, severe; 15–19, extremely severe ≥ 20. Stress: normal; 0–14, mild; 15–18, moderate; 19–25, severe; 26–33, extremely severe ≥ 34. DASS21 mean scores are doubled to calculate severity ranking (Lovibond & Lovibond, 1995). **Global PSQI score above five is considered to be poor sleep quality (Buysse et al., 1989).

Figure 4. Forest plot showing adjusted binary logistic regression analysis of follow-up PSQI scores (cross sectional).

aOR adjusted odds ratio; odds ratio adjusted for age, gender, year of study, urban/rural residential status, family’s monthly income; 95%CI 95% confidence interval. Significant P values are shown in bold.

Figure 5. Forest plot showing adjusted binary logistic regression analysis of follow-up depression scores.

aOR adjusted odds ratio; odds ratio adjusted for age, gender, year of study, urban/rural residential status, family’s monthly income; 95%CI 95% confidence interval. Significant P values are shown in bold.

Figure 6. Forest plot showing adjusted binary logistic regression analysis of follow-up anxiety scores.

aOR adjusted odds ratio; odds ratio adjusted for age, gender, year of study, urban/rural residential status, family’s monthly income; 95%CI 95% confidence interval. Significant P values are shown in bold.

Figure 7. Forest plot showing adjusted binary logistic regression analysis of follow-up stress scores.

aOR adjusted odds ratio; odds ratio adjusted for age, gender, year of study, urban/rural residential status, family’s monthly income; 95%CI 95% confidence interval. Significant P values are shown in bold.