This study provides an in-depth analysis of data collected from a survey conducted on medical school students who experienced the massive local outbreak of COVID-19 in 2020 during the initial spread of the virus in South Korea. The study aims to examine the effect of COVID-19 on students’ mental health. Our findings identified the following important facts, which demonstrated how COVID-19 had a multifaceted effect on the mental health of students.
The extent of Students’ Experiences of COVID-19
Most students had experienced the local spike in confirmed cases and were exposed to the continuous spread of COVID-19. It is interpreted that the first reason is that 76% of the students were residing in Daegu from February to March 2020. When the first confirmed case of COVID-19 in the Republic of Korea was found in Daegu, the people’s attention was focused on the city. During this period, the students saw how the infectious disease spread differently every day as well as Daegu residents’ emotional responses, such as anxiety, in their neighborhoods.
Second, as of October 4, 2020, the last day of the second survey, the Daegu and Gyeongbuk areas accounted for 36% (n = 8,701) of the national cumulative confirmed cases (n = 24,091) [26]. Lastly, the COVID-19 vaccination administration had still not begun, and social distancing measures, indoor and outdoor mask mandates, and online lectures were in place, along with increasing anxiety and concerns about COVID-19. Nevertheless, 2% of the students had experienced a confirmed case of COVID-19 in their families, including the respondents themselves, up to the time the survey was conducted, which indicates that most students followed the infectious diseases prevention guidelines.
The tendency of Students’ Unbearable Stress over Time
28% and 16% of the survey respondents reported experiencing unbearable stress in February–March, and August–October 2020, respectively. Notably, although the rate of students who endured unbearable stress had decreased at the time of the survey compared to the time of the initial spike in confirmed cases, they reported ongoing unbearable stress. The largest stress factors were unusual experiences related to COVID-19 and the fear of COVID-19 infection during the spike in confirmed cases. Over time, these factors shifted to limited leisure and social activities. The same questionnaire item was included in the survey conducted on middle and high school students in Daegu in May 2020 [27]. Approximately 16% and 13% of middle and high school students reported unbearable stress in February–March and May 2020, respectively, which is similar to the figures for the medical students.
Rate of Students Who Experienced Psychological Distress, the Tendency of Experience over Time, and the Relevance of Students’ Anxiety, Depression, and Resilience to Their Psychological Distress
The rate of medical students who had experienced psychological distress in February–March 2020 was 56%, which decreased to 29% in August–October. The most difficult emotions they felt (in descending order) were helplessness, depression, and anxiety. The same questionnaire item was included in the mental health survey [9] conducted in June 2020 on 1,000 sampled adult residents in Daegu. Seventy percent of respondents reported psychological distress in February–March in retrospect, and 40% continued experiencing psychological distress in June when the survey was conducted. The most prominent emotions they felt were anxiety, fear, helplessness, and depression (again in descending order). During the survey periods, the general public and medical students experienced similar levels of psychological distress. With respect to the most pervasive emotions, the general public reported anxiety and fear, whereas medical students reported helplessness. The rationale for this is that medical students have a better scientific understanding of diseases than the general public. However, while they have less anxiety and fear based on uncertainty, they experience a greater sense of helplessness as individuals. Medical students experiencing psychological distress had higher levels of anxiety and depression and lower resilience than those who were not experiencing psychological distress, a trend that has lasted throughout the pandemic.
Although the rate of medical students experiencing psychological distress decreased in August–October 2020 compared to February–March, anxiety remained the same with higher depression and lower resilience. This trend has been similarly observed in other surveys, such as the survey conducted on middle and high school students in Daegu [27], the mental health survey conducted on adult residents in Daegu [9], and a national mental health survey [10]. The assumption is that as the COVID-19 pandemic continues, people experience anxiety over uncertainties related to infectious diseases and secondary difficulties (in terms of financial conditions, interpersonal relationships, personal achievements at school or work, etc.), with increased stress and depression, and decreased tolerance.
As for students experiencing psychological distress, higher anxiety and depression were found among those who experienced unbearable stress before the local outbreak of COVID-19. Similarly, according to a survey conducted on students at the Mexican School of Medicine of La Salle University in April and December 2020 using the same depression scale as this study, the rate of students with depression increased from 20% to 40% [28]. Students experiencing unbearable stress exhibit different levels of emotional regulation according to their stress vulnerability. It is known that those vulnerable to stress have a high prevalence of anxiety and depression, exhibit low resilience, and experience difficulty regulating their emotions [29]. Taking the aforementioned factors into account, it is necessary to manage high-risk students who often experience unbearable stress, have underlying conditions, exhibit low resilience, and are under psychological distress.
The extent of Students’ Anxiety and Variables Affecting Their Anxiety
The mean score of the BAI to assess anxiety was within the normal range for all grades, although 2% (n = 9) of the students exhibited moderate or greater anxiety. Anxiety was not correlated with the factors of grade level, gender, religion, place of residence, and living-alone status. However, for those students experiencing unbearable stress, anxiety was high. Also, students who experienced unbearable stress before the outbreak of COVID-19 were found to have an odds ratio of anxiety that was significantly high, indicating vulnerability to anxiety. Unlike the results of this study, other studies that used the same assessment tools to measure medical students or doctors’ anxiety levels reported higher percentages of respondents with mild or greater anxiety as well as differences depending on gender and grade level. A study by Ansari et al. assessed the anxiety of medical students and interns in April 2020, two months after COVID-19 broke out. Of 323 subjects, 23% (n = 77) had mild or greater anxiety, and females had higher anxiety than males [16]. H. Guze et al. assessed the anxiety of medical students in December 2020 and reported that 35% of subjects had anxiety. They also found that more females had severe anxiety than males and that pre-clinical-stage students had higher anxiety than clinical-stage students. According to a study [14] conducted in June–July 2020 that used the Generalized Anxiety Disorder Scale-7 (GAD-7) to survey 1,139 students of 16 medical schools located in the U.S. states of Washington and New York, 61% of respondents reported depression (37% mild, 15% moderate, 6% moderately severe, 3% severe), and 58% reported anxiety (38% mild, 13% moderate, 7% severe). The National Mental Health Survey for COVID-19, administered in September 2020, used the GAD-7 scale to assess anxiety. According to the survey, 48% experienced mild or greater anxiety, and females had significantly higher anxiety than males.
The extent of Students’ Depression and Variables Affecting Their Depression
In this study, 15% (n = 60) of the respondents exhibited mild or greater depression, and 7% (n = 29) exhibited moderate or greater depression. Depression was not correlated with such factors as grade level, gender, religion, place of residence, and living-alone status. However, for students experiencing unbearable stress at the time of the survey, anxiety was highly correlated with such factors. Students with underlying conditions were found to have an odds ratio of depression that was significantly high; therefore, it could be said that an underlying condition is a factor correlated with vulnerability to depression.
Unlike the results of this study, other studies conducted on medical students abroad reported higher percentages of respondents with depression. Ansari et al. [16] reported in their study that 28% of the respondents had mild or greater depression, and there was no difference in depression in relation to gender. In a study that employed the Patient Health Questionnaire (PHQ) [14] to survey medical students in the U.S. states of Washington and New York, 61% of the respondents reported that they experienced some depressive symptoms. According to other studies performed on medical students in Japan [15], Iran [16], India [17], and China [18], 29%, 28%, 33%, and 36%, respectively, reported that they had experienced depression. The National Mental Health Survey for COVID-19 performed in September 2020 used the PHQ to assess depression. According to the survey, 49% of participants experienced mild or greater depression, and females had higher anxiety than males at a statistically significant level.
Compared to other studies or surveys conducted in South Korea and abroad, this study reported relatively fewer students exhibiting anxiety and depression and no difference in relation to gender. The rationale for the reported reduced anxiety and depression includes medical students’ higher resilience compared to that of the standard group, their more skillful response and substantially greater COVID-19 training and education at the time of the survey compared to the early pandemic days (which enabled them to acquire a better understanding of COVID-19 than that of other groups) rapid information provision, and psychological counseling support. Further assessment and monitoring are required to explore and verify these assumptions.
Depression scores were higher than anxiety scores although the scores were mostly mild and more students reported moderate or greater depression than students with moderate or greater anxiety. These findings require continuous monitoring, counseling support, or intervention. The evidence is inconclusive as to whether the COVID-19 pandemic is the direct cause of the subjects’ depression. However, the pandemic caused them to have significantly less contact with friends, worsened study conditions, lowered academic achievement, and exposed them to unusual social environments. Thus, there is a possibility that such factors worsened their depression. The mean depression scores of the second-year pre-medical course students and first and second-year medical course students were higher than that of first-year pre-medical course students. In addition, the mean depression score of the second-year medical course students was higher than those of third and fourth-year medical course students. Notably, the second-year medical course students had the highest mean depression scores among the different grade levels. As the second-year medical course focuses on clinical medicine and its students tend to experience more stress due to the heavy academic pressure and load, students at this level likely experienced more academic stress due to the disrupted curriculum operations and online classes. As a result of the curricular reorganization, some clinical medicine subjects were moved to the second-year pre-medical and the first-year medical course curricula. This also can explain how academic stress affected students’ emotions.
Implications: School’s Support to Promote Mental Stability among Students
Based on the results of this study, we consider it necessary to manage academic affairs and introduce emotional intervention, stress management training, and continuous student management suitable for the unique characteristics of each grade level. We also suggest the following support programs.
First, the school should use faculty mentors to increase individual counseling for students. The school should provide administrative and financial support so that faculty mentors can meet with students more often online or offline. In individual counseling, faculty mentors should identify students’ personal and emotional difficulties that they find difficult to share when getting help. In particular, they should find out if there are students who need specialized counseling. To that end, the school should provide faculty mentors with student counseling guidelines and training on counseling methods so that they can be equipped at counseling students.
Second, the school needs to provide a camp or a group counseling program to promote the collective emotional recovery of students. According to the results of this study, the mental health index of most students was in the normal range but they experienced long-term depression and anxiety. To facilitate their emotional recovery, the school needs to provide a range of programs, such as a camp, a special lecture, and a counseling program.
Third, in addition to the aforementioned programs provided by the school, encouraging social exchange and communication among students can help reduce their emotional difficulties. The school needs to encourage students to participate in group activities and form study groups by increasing administrative and financial support. This way, the school can help students overcome peer disconnection and invigorate communication among colleagues and between juniors and seniors.
Fourth, in the long term, a workforce or a department in charge of providing support for students’ mental health and emotional management should be developed in preparation for a future pandemic. It will be necessary to develop a mental health support system for students in preparation for the prolonged pandemic and resurgence of infectious diseases. One way to build the mental health support system is to establish a student mental health center for promoting mental health and deploy dedicated personnel for performing systematic research. The student mental health center needs to collect data on students’ mental health by performing a student mental health check-up, which is currently managed by the vice dean of students and the Mental Health Department. It must also systematically manage the data, perform research on students’ mental health, and continuously monitor mental health to provide timely support for students in need of assistance. In particular, this study has found that there are a small number of students who exhibited symptoms of moderate or greater severity, and therefore, professional personnel needs to perform continuous management of those students to help them with their school life and studies.
Fifth, the school can develop a non-face-to-face online counseling platform that guarantees anonymity. This is considering that students tend to hesitate to get counseling and that Generation MZ students are accustomed to using online services. Recently, there have been many attempts to use the metaverse for a virtual class, an online orientation, and an online entrance or graduation ceremony. If the metaverse is used for counseling, virtual avatars representing students can visit a virtual counseling center. This can help students who find it difficult to attend in-person counseling sessions by facilitating access to counseling voluntarily without the barriers of time and space.
Sixth, it is necessary to develop an academic or emotional support program for students who have low academic performance due to stress or repeaters. As students were unable to attend offline classes due to temporary school closures during the COVID-19 pandemic, they attended online classes. As a result, some students saw their grades fall due to poor daily life management or inadequate academic communication between colleagues. Therefore, the school can provide students with time and daily life management training and run a student tutor-tutee system in which seniors can give academic support to juniors who saw their grades fall.
Strengths and Limitations
This study is meaningful because the survey was conducted on medical students who are the potential future medical personnel of a major city (Daegu) in Korea that experienced a massive local outbreak of COVID-19. Moreover, their experiences related to COVID-19 were assessed from more varying angles compared to other studies.
This study has some limitations. First, it is difficult to generalize the results of the one-time survey. Second, the students’ emotional state reported in February–March 2020 was assessed in retrospect, which can limit the reliability of the results. Third, the voluntary online participation format can limit the reliability of the results and it is possible that students experiencing emotional difficulties did not respond to the survey. Fourth, the survey was conducted in two separate periods to increase the response rate, which can also limit the reliability of the results. Fifth, the respondents were limited to students of one medical school; therefore, it is difficult to generalize the results to the entire medical school population in Daegu.
Future research
This study found that a small number of students experienced anxiety and depression of moderate or greater severity. For future research, follow-up studies need to be performed to determine whether they have regained emotional stability after face-to-face classes were resumed. We also believe that a cohort study with students of this generation after they graduate is necessary. This study type will be essential to understand the impact of COVID-19 experiences on their career choice, identity establishment as doctors, as well as their life and performance as doctors after graduation.