Abstract
Background:
The coronavirus disease emerged in 2019, spread in Turkey as all over the world rapidly. In this process, young people began to experience some mental problems due to the fear of contagion, as well as some changes in their lifestyles.
Aims:
In this study it is aimed to investigate anxiety and depression levels of medical school students and the factors associated with these mental problems.
Method:
The forms were sent over the internet to the officials responsible for medical education at universities in various regions of Turkey. A total of 2,778 medical faculty students were included in the study. Students were asked to fill out the sociodemographic data form, the Patient Health Questionnaire – 9 (PHQ-9), and the Generalized Anxiety Disorder-7 (GAD-7) Test.
Results:
Students’ 67.3% were female and 31.7% were male. About 90.2% of the students in the PHQ-9 scale had depressive symptoms in the major depressive disorder (MDD) dimension, and 44.5% in the GAD-7 scale had moderate/severe anxiety symptoms. Gender, being a preclinical student, history of psychiatric treatment in the past, currently receiving psychiatric treatment, death of someone due to pandemic, economic and health situation, perception of mental health were found associated with MDD and Moderate/Severe Anxiety symptoms. Students with Anxiety and MDD reported significantly more anxiety about contamination and negative beliefs about precautions’ sufficiency.
Conclusions:
It was determined that medical school students in our country showed anxiety and depression at a remarkable level during the pandemic. Examining the underlying causes of these high rates will be beneficial in terms of taking precautions during the long-term pandemic. In literature, there are a limited number of studies on this subject in our country, we believe that our study will be useful in future studies to determine the underlying causes of mental illnesses and what can be done to help students.
Introduction
The coronavirus disease (COVID-19) emerged in 2019, spread all over the world in a short time, and was declared a ‘pandemic’ by the World Health Organization (WHO, 2020). The COVID-19 pandemic has affected all people directly or indirectly. The pandemic process has affected people’s mental health due to changes in life, as well as posing a risk of death due to infection for themselves or their relatives. The first case was seen in our country on March 11, 2020, and with the increase in the number of cases in the following period, some measures were taken across the country. Some of these measures are the cancellation of classes and exams in schools at all levels, including universities, the transition to distance education, the lockdown for children and young people under the age of 20, the restriction of intercity travel, the closure of shopping centers, cinemas, restaurants, and sports centers. It is unavoidable that such a new and sudden change in routine will have an impact on people’s mental health (Duman, 2020). Moreover, fears of catching the disease or that his/her family will be caught, uncertainties about the course of the process, and evaluations that the place of residence is unsafe have also been sources of intense anxiety (Kaya, 2020). These changes have led to a definite increase in mental health problems, including anxiety, depression, stress, sleep disorders, and substance abuse, especially among college students (Ferrel & Ryan, 2020). In the literature (Huang & Zhao, 2020; Liu, Zhang et al., 2020; Sønderskov et al., 2020; Wang, Pan et al., 2020, 2020) there are results regarding increased anxiety, depression and stress symptoms in the general population and in some special groups. In a study (Huarcaya-Victoria et al., 2021) conducted with 1,238 university students, 74% of the participants had depressive symptoms, 57% had anxiety symptoms, and 65% had stress symptoms. In a study (Sheshtawy et al., 2021), conducted with medical school students in Egypt, the depression, anxiety, and stress scale (DASS-21) was administered to 1,181 students. It was observed that 62.2% of the participants experienced moderate-to-extreme stress according to DASS-21, and more than 33% of them marked the option of severe anxiety symptoms. 46.4% of the sample was defined as having severe depression according to their cut-off scores. Similarly, a study (Essangri et al., 2021) done in Morocco, reported high rates of anxiety, depression, insomnia, and stress.
While the COVID-19 pandemic has an impact on the mental health of the whole society, it also puts medical school students under a serious psychological pressure (Essangri et al., 2021). On the one hand, students were exposed to similar restrictions with the general society, on the other hand, they had to struggle with changes in teaching methods and uncertainties about their academic future (Ferrel & Ryan, 2020; Representatives of the STARSurg Collaborative et al., 2020). It is thought that these critical changes in their lives may also affect their mental health, and our study aimed to determine the anxiety and depression levels of medical school students and the factors associated with these mental problems. When the literature has been reviewed, it has been observed that there are a limited number of studies on this subject in our country, and it is thought that the results of the study will be beneficial in terms of interventions to improve the mental health of the medical students.
Method
Data collection tools
Generalized
Statistical method
All statistical analyses were performed using IBM SPSS for Windows version 20.0 (IBM Corp., Armonk, NY, USA). G*Power version 3.1.9.2 (Kiel University, Kiel, Germany) software was used to determine study power. Kolmogorov-Smirnov tests were used to test the normality of data distribution. Continuous variables were expressed as mean ± standard deviation, median (25th–75th percentiles), and categorical variables were expressed as counts (percentages). Comparisons of normally distributed continuous variables between the materials/groups were performed using the Student’s t test, One Way Analysis of Variance, and Tukey Post Hoc Test. Comparisons of nonnormally distributed continuous variables between the groups were performed using the Mann Whitney U Test and Kruskal Wallis One Way Analysis of Variance and Dunn’s Post Hoc test. Comparisons of categorical variables between the groups were performed using the Fisher’s Exact Chi Square test. p < .05 was considered as statistically significant. The data that support the findings of this study are deposited on TURCOSA Analytics web site (www.turcosa.com.tr). They will be available to bona fide researchers by the corresponding author upon reasonable request and subsequent agreement by the authors.
Findings
Of the 2,778 students who participated in the cross-sectional survey, 1,869 (67.3%) were female and 881 (31.7%) were male, with a mean age of 20.69 ± 2.15 years. It was determined that 1,808 participants were pre-clinical (65.1%) and 970 (34.9%) clinical students. It was observed that the marital status of 99.7% of the study group was single and 2,075 (74.4%) of these students lived alone. When the chronic disease status was questioned, it was observed that 242 (8.7%) of the participants had a chronic disease and 2,536 (91.3%) did not.
When the mental health histories of the students were questioned, it was determined that 593 (21.3%) received mental support before the pandemic, and 199 (7.2%) were still receiving mental treatment. Considering the mental status evaluations in the last 2 weeks, it was observed that 1,423 (51.3%) students scored their mental status as 5 or below (1: very poor, 10: excellent). When the personal perceptions of those who marked their mental status evaluations of the last 2 weeks as 5 and below (Group 1) and those who marked 6 and above (Group 2) were compared regarding their health status in the last month, it was determined that the moderate/poor responses were significantly higher in Group 1 (p = .0001).
About 585 (21.1%) of the students reported that they had lost an acquaintance due to COVID-19 disease. When the relationships of students with a history of loss of acquaintance were analyzed in terms of their fear of becoming a COVID-19 patient and losing a family member due to COVID-19 disease, the reported fear levels were found to be higher in those who experienced a loss (p = .022). In the group who lost an acquaintance due to COVID-19 disease, the fear of losing a family member due to COVID-19 was higher (p = .0001). It was observed that the difference between the group who lost a relative due to COVID-19 and did not experience loss was found to be significant (p = .0001).
Women in the study group stated that they were significantly more likely to contract COVID-19 than men (p = .000) and fear that one of their family members might catch COVID-19 and die because of it (p = .000). Again, while the beliefs of women compared to men that adequate precautions were taken for themselves and their environment within the framework of the rules recommended by the WHO were found to be significantly different (p = .000), their belief that sufficient precautions were taken for the society was not found significantly different (p = .065). There was no significant difference between preclinical and clinical students in terms of their fears that they or one of their family members might catch COVID-19 and die because of it, and their belief that adequate precautions were taken for the society, themselves, and their environment (p = .234).
When their depression and anxiety levels were evaluated, it was observed that 2,422 (90.2%) students marked depressive symptoms in the major depressive disorder dimension on the PHQ-9 scale, and 1,235 (44.5%) students marked moderate/severe anxiety symptoms in the GAD-7 scale. The numbers associated with major depressive disorder and anxiety symptoms were presented in Table 1.
Number of students showing signs of major depressive disorder and moderate/severe anxiety disorder.
Note. MDD = major depressive disorder.
The relationships between MDD and anxiety levels and the characteristics in the sociodemographic data form are demonstrated in Tables 2 and 3.
The relationship between MDD and sociodemographic characteristics.
Chi-square test was used to evaluate the variables.
The relationship between anxiety level and sociodemographic characteristics.
Chi-square test was used to evaluate the variables.
Students with anxiety reported significantly more that they were afraid of contracting COVID-19 themselves (p = .000) and of having a family member contracting it and might die because of it (p = .005). The scores given by the students with anxiety to their belief that adequate precautions are taken for the society and that they take adequate precautions for themselves and their environment were found to be significantly lower (p = .000). Similarly, students with MDD also reported significantly more that they were afraid of contracting COVID-19 themselves and of having a family member contracting it and might die because of it (p = .000). The scores given by the students with MDD to their belief that adequate precautions are taken for the society (p = .000) and that they take adequate precautions for themselves and their environment were found to be significantly lower (p = .000) (Table 4).
Scores on MDD and anxiety, and COVID-19-related concerns and measures taken.
Discussion
In our study, the rate of MDD or moderate/severe anxiety symptoms in 2,778 medical school students and the relationship between these mental problems with sociodemographic characteristics were evaluated. About 2,422 (87.2%) of the students stated that they had symptoms at the level of MDD diagnosis in PHQ-9. In studies conducted with medical school students, mild/severe depression symptoms were found in 64.4% of students in Brazil, 74.6% in Morocco, and 41% in Russia (Essangri et al., 2021; Isralowitz et al., 2021; Sartorao Filho et al., 2020). In our study, the rate of depression in the medical faculty students during the pandemic process was found to be higher than in other countries. When we look at the studies conducted before the pandemic in our country, the rate of depression in medical school students has been reported in the range of 34.7% to 41% (Doğan et al., 1994; Güleç et al., 2005; Öncü et al., 2013). The results of the study, it is noteworthy that there is an increase in the rate of depression in medical school students compared to the pre-pandemic period, and these rates are considerably higher than the prevalence of depression in the general population, which is stated to be between 3% and 8.7% (Kroenke et al., 2009; Reeves et al., 2011). Such a high rate of depression may be related to the decrease in peer relations that occur during the distance learning process, not getting a good education, professional concerns, restrictions on the pandemic, uncertainty regarding the end of the pandemic, and burnout. It was thought that the higher rate of depression than the general population may be due to reasons such as the medical school education process being an academically and emotionally difficult process, or the students’ personality structure being more perfectionist (Leung et al., 2003; Rahman, 2021; Yakar et al., 2020). Preclinical students marked a significantly higher rate of depression symptoms compared to clinical students. A similar result was found in a study by Halperin et al. (2021). This may be due to the facts that students in the first years of university education did not choose the school voluntarily, their expectations about the university were not realized, they could not develop friendships yet, or they could not adapt to the school and the effects of the pandemic process on education.
In our study, female students reported significantly more depression. It is observed that this result is compatible with the literature (Alsairafi et al., 2021; Essangri et al., 2021; Sartorao Filho et al., 2020). Studies (Bore et al., 2016; Fawzy & Hamed, 2017; Moutinho et al., 2017) before the pandemic show similar results. The high rate of depression in women after the pandemic may be related to the high prevalence of depression in women in the normal population, regardless of the pandemic (Brody et al., 2018; Kuehner, 2017; Pratt & Brody, 2014). Moreover, cultural factors such as the greater exposure of female students to family interventions in our country due to their residence at home, the greater restriction on maintaining their social relationships and leisure activities may have supported these rates. In a study (Kılıç et al., 2013), the perspectives of the participants on personality traits by gender were examined, and as a result, it was determined that women believed that they were softer and more affectionate, while men were more authoritative and determined. As an extension of this view, it was stated that the idea that women and girls should be protected is dominant. Moreover, it was stated in the study that the surveillance and control effort on girls continued and this situation turned into a kind of ‘controlled freedom’ during adolescence. A study (Cerik, 2002) of college students found that families are more influential in their daughters’ decisions, depending on current traditionalism.
Students with MDD reported significantly more fear of contracting COVID-19 (p = .002) and fears that a family member might catch COVID-19 and die because of it (p = .001). The scores of students with MDD for their belief that adequate precautions are taken for the society (p = .000) and their belief that they take adequate precautions for themselves and their environment (p = .036) were found to be significantly lower. As it is known, one of the most emphasized topics, which is thought to be related to the formation and maintenance of psychiatric disorders such as depression and anxiety disorders, is the concept of ‘Cognitive Distortion’. The concept of cognitive distortion is evaluated as ‘specific biases and tendencies in the process of information processing’ (Köroğlu & Türkçapar, 2015). People tend to see and evaluate themselves less than they actually are in cognitive distortions. This leads to erroneous assumptions and false thoughts named cognitive impairments. People who experience emotional difficulties, such as depression, are characteristically inclined to make logical errors (Corey, 2009). In our study group, cognitive distortions such as perceiving the current risks and the precautions taken by the students more negatively, and perceiving the measures they take as incomplete and inadequate may have led to this result.
When we look at the anxiety status of the study group, 44.4% of the group stated that they experienced moderate/severe anxiety in the GAD-7 test. In a study (Liu, Zhu et al., 2020) conducted in China, the prevalence of anxiety in medical school students was found to be 22.1%. In Morocco, on the other hand, 62.3% of students reported anxiety symptoms (Essangri et al., 2021). In a study conducted in Iran by Nakhostin-Ansari et al. (2020), this rate was reported as 38.1%, while it was reported as 17.2% in India and 22.7% in the United Arab Emirates (Vala et al., 2020; Saddik et al., 2020). In another study (Sartorao Filho et al., 2020), moderate-to-severe anxiety symptoms were observed with a rate of 46.17%. When the literature (Cao, Fang et al., 2020; Li, Wang et al., 2021; Saraswathi et al., 2020) is examined, it is seen that medical school students report higher rates of anxiety during the COVID-19 process. According to DSM-5, the prevalence of all diseases under the heading of anxiety disorders is reported to be around 6% to 7% (Kafes, 2021). When the anxiety level of the study group was evaluated, a higher rate was found than both medical school students in many other countries and the general population. This situation may have occurred due to reasons such as the adaptation process to distance education, feeling of academic inadequacy, lack of support from peers and teachers, and restrictions. In our study, female students reported significantly more anxiety symptoms. When we look at the literature, it has been observed that there are similar results in studies (Al-Rabiaah et al., 2020; Conklin et al., 2018; Essangri et al., 2021; Harkness et al., 2010; Sartorao Filho et al., 2020; Yakar et al., 2020) and it has been reported that women are more affected by stressful life events than men. In another study (Rahman, 2021), besides the high general anxiety levels, the level of anxiety about COVID-19 transmission of female students studying in the fifth and sixth grades of medical school were also found to be significantly higher than that of males.
Preclinical students reported significantly higher anxiety levels than clinical students. This result is compatible with the literature (Essangri et al., 2021; Halperin et al., 2021). Preclinical students may have developed higher anxiety levels possibly due to their uncertainty about the educational method and exam dates, the new distance education process that they have not experienced before, their difficulty focusing their attention at home, and their lack of experience in medical school. Moreover, the fact that clinical period fourth and fifth-grade students should be working in the hospital under normal conditions, but not being in the hospital, reducing the risk of infecting themselves and their environment, and the fact that they can study for the specialty exam (the exam for the selection of specialty after basic medical education) at home more easily can be interpreted as reducing the pressure on them and lowering their anxiety levels. However, the fact that the number of clinical students in our study group was less than the number of preclinical students may have led to this result. Mainly sixth-grade students may not have had the opportunity to participate in the study and express their problems due to their intense work in the hospital.
Students who stated that their general health status was worse in the last month marked significantly higher anxiety symptoms. Experiencing some symptoms of health problems during the pandemic may have caused health anxiety, or may have caused students to experience anxiety about the possibility of being infected with COVID-19 and the following processes. Fear of losing a family member due to COVID-19, depression, and anxiety levels were significantly higher in the group who lost an acquaintance due to COVID-19 disease. Looking at the literature (Bruce et al., 1990; Clayton, 1990; Köroğlu, 1997), it is known that losses or the fear of losing someone trigger depression and anxiety.
Students who received psychiatric treatment in the past and present also marked significantly more depression and anxiety symptoms. A similar result was found in another study (Özdin & Bayrak Özdin, 2020) conducted in our country. In the study of Kessler et al. (2005), anxiety came to the fore as the most common mental disorder with a rate of 18.1% in the general population. Most Anxiety Disorders develop in childhood and continue if left untreated (American Psychiatric Association, 2013). The age of early onset of anxiety disorder was found to be proportional to the chronic course (Kessler et al., 2007). An anxiety disorder that starts at an early age tends to follow a longer course (Shores et al., 1992). Children with anxiety disorders are at higher risk for anxiety disorders in the transition from childhood to adolescence or from adolescence to adulthood (Bittner et al., 2007; Pine et al., 1998). In a study by Gregory et al. (2007), it was reported that more than 64% of adults with anxiety disorder were diagnosed before the age of 18. In addition, there are also longitudinal research data (Cole et al., 1998) showing that anxiety symptoms in childhood predict symptoms of depression in later life. Major depressive disorder is also one of the most common chronic mental illnesses, affecting more than 264 million people around the world (GBD 2017 Disease and Injury Incidence and Prevalence Collaborators, 2018). High levels of depression and anxiety among the participant students, who have received psychiatric treatment in the past, may be related to having similar psychiatric diagnoses in the past, and the chronic course of these disorders, as well as being triggered by reasons such as the pandemic, which is a stressful life event, and changes in life due to it, and the uncertainty of the process.
When the economic status of the students was evaluated, anxiety was found to be significantly higher in the students whose economic status was worse than before the pandemic. In the literature (Cao, Fang et al., 2020; Sartorao Filho et al., 2020), it has been reported that the levels of anxiety and depression are higher in medical school students who have financial difficulties during the pandemic period. On the other hand, in a study by Nguyen et al. (2020), it was stated that COVID-19-related anxiety was less common in students who could afford the significant treatment and care service fees. In a study (Torun & Torun, 2020) conducted in our country, it was determined that the fact that the families of the students have a monthly income lower than the minimum wage causes an increase in the anxiety of contracting the COVID-19 infection and the perceived stress. Similarly, in our study, the deterioration in the economic situation of the students may cause concerns about their livelihoods and the future, as well as increase the concerns about meeting the treatment and care services fee to be received as a result of infection.
According to a study (Leung et al., 2003), participants who adopted high levels of preventative measures during the SARS-CoV outbreak experienced less depression, anxiety, and stress. Similarly, the fact that the students in our study thought that adequate measures were not taken for society during the pandemic process may have increased the rates of anxiety and depression. In our country, the COVID-19 phobia status of 311 medical school students was evaluated, and as a result, it was determined that medical school students who paid attention to precautions such as masks and social distance during the COVID-19 pandemic had a significantly higher level of anxiety (Rahman, 2021).
In conclusion, it was determined that medical school students in our country showed signs of anxiety and depression at a remarkable level during the pandemic period. Examining the underlying causes of these high rates seen in students will be beneficial in terms of taking necessary precautions during the long-term pandemic period. However, even though students have insight into their mental problems, it is thought-provoking that the rate of a pre-pandemic psychiatric treatment history, which was at the level of 21.3%, was as low as 7.2% during the pandemic period. Evaluating whether students have issues such as being unable to attend a check-up due to the pandemic, anxiety about being labeled, or difficulty reaching a physician, and determining the underlying problems of not being able to receive psychiatric support will be beneficial in terms of supporting students’ mental health. Since depression and anxiety can have a significant impact on students’ social relations, academic achievement, and quality of life, we believe that our study will be useful in future studies aimed at determining the underlying causes of mental illnesses and what can be done to help students receive treatment if they need it.
