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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 37  |  Issue : 1  |  Page : 105-110

Assessment of mental health in indian medical students during the coronavirus disease-2019 pandemic


1 Department of Pathology, Army College of Medical Sciences and Base Hospital, New Delhi, India
2 Department of Pathology, Shri M. P. Shah Government Medical College, Jamnagar, Gujarat, India

Date of Submission17-Jun-2020
Date of Decision18-Jun-2020
Date of Acceptance24-Jun-2020
Date of Web Publication31-Mar-2021

Correspondence Address:
Dr. Sharmila Dudani
7/41, Vikram Vihar, 3rd Floor, Lajpat Nagar-4, New Delhi - 110 024
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijsp.ijsp_166_20

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  Abstract 


Context: Medical students are more anxious and depressed than their peers, and the prevalence of various mental health problems is on the rise. The coronavirus disease-2019 (COVID-19) pandemic has had far-reaching psychosocial consequences on the Indian population. Aim: The aim of this study is to assess the mental health status of Indian medical students during the COVID-19 pandemic and lockdown. Settings and Design: A questionnaire-based, cross-sectional study of medical students from across India. Methodology: The general health questionnaire with 28 items (GHQ-28) was adapted to GoogleForms® and circulated extensively to medical students in various colleges across India among the nationwide lockdown that began from March 22, 2020. A total of 1000 responses were collected for a period of 1 month from May 12 to June 11. Other questions included uncertainty due to the pandemic about one's career as a medical student, satisfaction with the field of medicine, the year of training, and how long the student believed the effects of the pandemic would last. Statistical Analysis Used: A Chi-square test was applied to compare the proportions, and Mann-Whitney U or Kruskal–Wallis test was used to compare the continuous variables between the groups. Results: A total of 60.3% (57.2–63.2) of students had GHQ-28 scores above the cutoff of >23 and had mental health problems. Female sex, smoking, alcohol, dissatisfaction with medicine, and uncertainty due to the pandemic were associated with mental distress. GHQ-28 scores increased uniformly with the year of training of the student, except in the case of IInd year, where scores were the least. Similar trends existed for the somatic, anxiety, social-dysfunction, and depression score components of the GHQ-28. Conclusions: Mental health issues are very common among medical students, particularly now during the COVID-19 pandemic. Early identification along with guidance and counselling is essential for all-round development of medical professionals.

Keywords: Coronavirus disease 2019, depression, medical students, mental health


How to cite this article:
Mangalesh S, Dudani S, Dave ND. Assessment of mental health in indian medical students during the coronavirus disease-2019 pandemic. Indian J Soc Psychiatry 2021;37:105-10

How to cite this URL:
Mangalesh S, Dudani S, Dave ND. Assessment of mental health in indian medical students during the coronavirus disease-2019 pandemic. Indian J Soc Psychiatry [serial online] 2021 [cited 2021 Jun 19];37:105-10. Available from: https://www.indjsp.org/text.asp?2021/37/1/105/312860




  Introduction Top


Mental health issues among medical students are well recognized worldwide, with medical education accounting for one the most stressful of learning environments. Medical students are more anxious and depressed than their peers, and the prevalence of various mental health problems is on the rise.[1],[2] With an ever increasingly competitive climate, mental morbidity and stress are seen to increase along with the years of training.[3] While the factors such as heavy workload and concerns about the examinations may even be essential for all-round development, they result in burnout, lack of sleep, and have an adverse effect on academic performance.[4],[5]

Physician and medical student suicides have become alarmingly common in the present day. Much priority is not afforded to the mental health of health-care personnel, despite growing evidence of untreated mental disorders in this group.[4] Mental health issues among medical students are also often unreported owing to stigma due to several factors, such as, fear of being evaluated poorly by faculty members, diminished respect from peers, or being perceived as unable to handle responsibilities.[6] A higher incidence of substance abuse is also noted in medical students, and these habits are usually new and persist throughout adulthood.[7] As future health-care providers, medical students require early attention and support systems for their well-being during medical school.

The severe acute respiratory syndrome coronavirus-2 pandemic has had far reaching psychosocial effects globally.[8],[9] In March 2020, the government of India announced a nationwide lockdown, as an essential and effective measure for breaking the coronavirus disease 2019 (COVID-19) transmission cycle. The psychosocial effects of the pandemic as well as the lockdown, such as depression, anxiety, and panic have taken a toll on the entire population and medical students have been no exception. The pandemic marked an end to normal day-to-day life. Uncertainty and uneasiness have pervaded in the medical student community, who have now not been exposed to classroom or clinical experience for almost 3 months due to the lockdown restrictions. Ambiguity about the future, especially in relation to examinations, curriculum, promotion to the next semester, commencement of internship, competitive examinations, and finding employment, is likely to aggravate any preexisting mental health problems in the medical student, adding to the feelings of anxiety, and self-doubt.

This study assesses the mental health of Indian medical students during the COVID-19 pandemic by employing a general health questionnaire (GHQ). The prevalence of mental health issues is estimated, and associations between mental health status and other demographic variables are also studied.


  Methodology Top


This was a cross-sectional study conceptualized and designed at a tertiary-care teaching hospital in Northern India. Sample size was calculated taking prevalence value = 50%, precision = 4%, α = 0.05, and 95% confidence interval, and the minimum required sample size was 601. This study included a sample of 1000 medical students from across India, from the first year to fifth (internship) year of medical training. The GHQ-28 was adapted to GoogleForms® and administered to the medical students across India. The survey was circulated extensively across various Indian medical colleges, and the responses were collected for a period of 1 month from May 12, 2020 to June 11, 2020 amidst the national lockdown. Informed consent was obtained along with the survey responses, and confidentiality issues were explained to all the respondents of the survey. Surveys with incomplete responses were excluded. Ethical approval was obtained before the conduct of the study.

The questionnaire is divided into four parts by the factor analysis. Questions (Q) 1 to Q7 are for somatic symptoms, Q8 to Q14 are for anxiety/insomnia, Q15 to Q21 are for social dysfunction, and Q22 to Q28 are for depression. Hence, a somatic symptoms score, anxiety/insomnia score, social dysfunction score, depression score, and total GHQ score are calculated. Each of the four subscores and the total score were treated as continuous measures and analyzed for association with other variables.

A Likert scale ranging from 0 to 3, signifying “not at all,” “no more than usual,” “rather more than usual,” and “much more than usual” was employed for the GHQ-28. The total score hence ranged from 0 to 84. The GHQ-28 has been translated and validated in over 38 different languages since its introduction, and this study utilized the English version. We used a cutoff score of >23 to define an abnormal GHQ score. The Cronbach's alpha of reliability for the GHQ-28 has been reported to vary from 0.78 to 0.95.[10],[11]

Demographic parameters such as age, gender, living arrangements, number of family members, and number of siblings were recorded. Details such as smoking status and alcohol consumption were also recorded and analyzed. Some other questions included whether the students felt uncertain or uneasy about their medical school career due to the COVID-19 pandemic, whether the student is satisfied with their field of study and career choice, and how long the students felt the COVID-19 pandemic would continue to impact their lives and the country.

Statistical analysis was performed using the SPSS software version 21.0 (IBM Corp, Armonk, NY, USA). Categorical variables are expressed as percentage and continuous variables as mean with standard deviation. Normality was assessed using the Shapiro–Wilk test, and homogeneity of variances was assessed by the Levene's test. Independent samples t-test or Mann–Whitney U-test was used as appropriate to compare the two groups. One-way ANOVA or Kruskal–Wallis test was used as appropriate to compare the continuous measures between the multiple groups. A Spearman correlation coefficient was used to study the relationship between the two continuous variables. A Chi-square test was used to compare the proportions. P < 0.05 has been taken to be statistically significant.


  Results Top


This study included 1000 medical students from the first (I) to fifth (V) year of training from across India. The mean age for the study population was 20.65 ± 1.67 years. There were 557 (55.7%) males and 443 (44.3%) females. A total of 405 (40.5%) of the responses were from medical colleges in Northern India. There were 332 (33.2%), 123 (12.3%), and 140 (14.0%) responses each from the West, East, and South, respectively. The number of participants from each year of training from I to Vth was 150 (15.0%), 470 (47.0%), 154 (15.4%), 153 (15.3%), and 73 (7.3%), respectively. Only 30 (3%) of the participants were smokers, and 77 (7.7%) consumed alcohol. In our study, 60.3 (57.2%–63.2%) of participants scored >23 on the GHQ-28 and had mental health issues.

A total of 149 (14.9%) participants also reported that they were unsatisfied with their field of study or career of choice. A Chi-square test showed this dissatisfaction to be strongly associated with an abnormal GHQ-28 score. Both smoking and alcohol consumption were also strongly associated with a higher GHQ-28 score. Females were also more likely than males to have higher GHQ-28 scores. When asked about living arrangements, 680 (68.0%) lived in college/hostel dormitories with family situated in a distant area, 112 (11.2%) lived in hostels with family situated nearby, and 208 (20.8%) were day scholars who attended college from home. Living arrangements did not have any association with mental health. When asked if the COVID-19 pandemic made them feel uneasy or uncertain about their medical school career, 338 (33.8%) of students answered “yes,” 264 (26.4%) “somewhat,” and 398 (39.8%) answered “no” [Figure 1]. Compared to students that answered “no,” students that did feel uneasy were more likely to have an abnormal GHQ-28 score. These results are summarized in [Table 1].
Figure 1: Recorded responses to the questionnaire item “Does the COVID-19 pandemic make you feel uncertain or uneasy about your medical school career?”

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Table 1: Association of categorical variables with abnormal general health questionnaire-28 scores

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A Mann–Whitney U-test was used to compare the median GHQ-28 scores between the categorical variables discussed above [Table 2]. Significant differences in GHQ-28 scores were observed for smoking.
Table 2: Median general health questionnaire-28 scores between groups

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When the respondents were asked how long, they believed the COVID-19 pandemic would continue to affect their lives and the country, 259 (25.9%) responded with “>1 year,” 292 (29.2%) with “6 months to 1 year,” 413 (41.3%) responded with “up to six months,” and only 36 (3.6%) responded with “1 month or less.” The Kruskal–Wallis test was used to compare GHQ-28 scores within these four groups, but no statistical difference emerged (H = 5.382, P = 0.1460) [Figure 2].
Figure 2: Median GHQ-28 scores between groups defined by medical student perceptions on how long the COVID-19 pandemic will continue to affect student lives and the country; No statistically significant differences emerged

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A correlation coefficient was computed to assess the relationship between GHQ-28 scores and age, number of family members, and number of siblings. A very weak but statistically significant positive correlation emerged between GHQ-28 scores and age (r = 0.086, P = 0.0060). There was no statistically significant correlation observed for the number of family members (r = −0.025, P = 0.426) and number of siblings (r = 0.023, P = 0.472).

A Kruskal–Wallis test was conducted to assess the difference in GHQ-28 scores, somatic symptoms scores, anxiety/insomnia scores, social dysfunction scores, and depression scores between the students at different years of training from the Ist to Vth. Statistically significant differences existed between the students at different levels of training for all the scores. The average scores for each group are represented in [Table 3].
Table 3: Median somatic, anxiety, social dysfunction, depression, and total general health questionnaire -28 scores between medical students grouped according to year of training

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On performing pairwise comparisons, somatic score was significantly higher among Vth year students compared to IInd year students (P = 0.002). Anxiety/insomnia scores varied significantly between Ist and Vth (P = 0.004), IInd and Vth (P < 0.0001), IIIrd and Vth (P = 0.001), and IVth and Vth (P = 0.004) year students. Social dysfunction scores varied significantly between Ist and IInd (P < 0.0001) and IInd and IVth (P = 0.029) year students. Depression scores varied significantly between IInd and Vth (P = 0.001), IIIrd and Vth (P = 0.001), and IVth and Vth (P = 0.001) year students. Finally, the total GHQ-28 score varied significantly between Ist and IInd (P = 0.016), IInd and Vth (P < 0.0001), IIIrd and Vth (P = 0.002), and IVth and Vth year students (P = 0.003). Overall, the total GHQ-28 score was minimum among the students of IInd year and maximum for the students of Vth year of training [Figure 3].
Figure 3: Median GHQ-28 scores between groups defined by medical students' year of training; Kruskal–Wallis test showed statistically significant differences between groups

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  Discussion Top


This study assessed psychological morbidity among Indian medical students during the COVID-19 pandemic, and several findings have emerged. A staggering 60.3% of medical students studied had an abnormal GHQ score, which was higher than the prevalence rates reported by other authors in similar studies in India and worldwide.[12],[13],[14],[15] Medical training-related distress is a well-known phenomenon and goes hand in hand with the difficulty and the challenges of the profession. In the present day, competition in the field of medicine is at an all-time high, and failure to contend against over 100,000s of others carries a steep cost. The realization that the pandemic is here to stay has set in, with most students believing that the pandemic will continue to affect them for 6 months or more, and only 3.6% who answered 1 month or less. This study found that almost two-thirds of medical students felt, particularly uneasy and uncertain about their careers and future on account of this pandemic, and these students were twice as likely to score higher on the GHQ questionnaire. It is noteworthy that while 60.3% of students did report mental health problems, it remains largely unclear if these problems were pre-existing or have surfaced as a result of the COVID-19 pandemic. Similar studies after the pandemic ends may be warranted for insight on what role the pandemic played.

Our study found that GHQ scores steadily increased along with the year of training the medical student was currently in. This was in accordance with the findings of previous studies.[11] Students in the first year of training had slightly higher scores than those in the second year, but students in the final year of training (interns) exhibited the maximum GHQ scores. Initial difficulties in adjustment among to medical school life for a fresher and the relatively relaxed curriculum in the 2nd year might be a cause for this difference. Similar trends of higher scores were observed among interns for the four subscores of the GHQ-28, namely the somatic, anxiety, social dysfunction, and depression scales. This is perhaps due to the nature of the responsibilities bestowed upon them, as newly commissioned medical personnel in amidst a pandemic. With the advent of online modalities of learning, including clinical simulations and skills laboratories, life is returning to normal for medical students. However, several obvious disadvantages exist, as even the best-developed simulations cannot substitute interaction with real patients.[16]

Expectedly, we found a significant association between smoking and alcohol use and GHQ scores. Students with mental health issues were five and ten times more likely to smoke and drink, respectively. While a cause and effect relationship cannot be established using observational data, medical students are certainly prime targets for developing detrimental habits that last throughout their adult lives. A transition to stronger substances with abuse potential can have both social and health consequences for the young medical professionals. Our study also saw females being two times as likely to have mental health issues. Females may tend to show the higher levels of psychological distress due to a decreased sense of coherence and less social support, as hypothesized and described in other studies.[13],[17]

Satisfaction with their choice of career or field of study was also a key player in determining mental health in this study. Students unsatisfied with medicine were about six times more likely to have mental health issues than those who were. The new medical curriculum introduced by the Medical Council of India better spaces out participants by year, emphasizes skill acquisition, and stresses on the importance of early clinical exposure.[18] This step could mean progress, leading to a more holistic learning environment for the student, and similar studies on medical students are necessitated a few years down the line.

Despite the several years of education that entails choosing medicine, little can be said about the certainty of success in the medical profession, with adverse consequences on the career of a medical student despite all efforts. Indeed, a culture of unhealthy competitiveness is bred even before medical school admissions. Medical student burnout, depression, somatic distress, loss of empathy, poor academic performance, thoughts of leaving medical school, and suicidal ideations together result in stunted all-round personality development. This leads to poor-quality health-care providers for tomorrow. While baseline mental problems are likely to pre-exist in student populations, these can be aggravated in the face of adversities such as this pandemic and can trigger severe consequences. Besides identifying causes and consequences, the psychological well-being of the student population must be addressed with robust solutions.

An emphasis on early intervention and an open culture that permits the expression of personal grievances and struggles is of paramount importance. A learning environment that punishes a student for underperformance is counterproductive and not conducive to personal improvement. On the other hand, the medical profession is one that demands intense resilience and patience, and it is through friendly guidance from faculty that this goal becomes achievable for a medical student. The inclusion of mentorship programs between faculty and students and mandatory appointment of trained counsellors in medical schools is a step in the right direction. The role of yoga, meditation, and mindfulness has also been studied extensively as a means to reduce the stress and anxiety.[19],[20] Widespread application of these modalities for the psychological well-being of medical students could prove promising and are the need of the hour if we want the health of our future generations in capable hands.


  Conclusions Top


Mental health issues are very common among medical students, which may be aggravated now during the COVID-19 pandemic. The factors such as uncertainty caused by pandemic, dissatisfaction with the field of study, smoking, alcohol intake, and female sex were associated with greater mental health issues. Even disregarding the pandemic as a stressor, guidance and counselling, and intervention at the individual, group and community levels are still essential for the all-round development of medical professionals. Further studies utilizing various tools to assess mental health may be warranted.

Limitations

This study was an open survey of medical students from across India, and thus a systematic approach to sampling could not be followed. Equal representation was also not possible in the survey from the students of all the five years of training. The GHQ-28 was merely a single tool used in this study to assess mental health and may not accurately depict the complete picture. While uncertainty due to the COVID-19 pandemic was strongly associated with mental health problems in this study, it cannot be determined what proportion of these problems was pre-existing, to arrive at a cause-effect relationship between the pandemic and mental health problems.

Acknowledgments

The authors would like to acknowledge Ms. Apoorva Srinivasan, Clinical Psychologist, for her guidance in the conduct of this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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[PUBMED]  [Full text]  


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