DOI: https://doi.org/10.21203/rs.3.rs-2066788/v1
Background: In February 2020, a local outbreak of COVID-19 occurred in Daegu, South Korea. It was the first outbreak of COVID-19 in South Korea and confirmed cases increased sharply, sparking intense anxiety among residents. In circumstances like this, it is important to assess the effect of an infectious disease pandemic on medical students’ mental health, develop mental health intervention materials at schools, and set the direction for future medical education. This study analyzed the data of a mental health survey on students enrolled at a medical school located in Daegu in 2020.
Methods: An online survey was administered to 654 medical school students (pre-medical course: 220 students, medical course: 434 students) from August to October 2020, with 61.16% (n = 400) valid responses. The questionnaire included items about COVID-19 related experiences, stress, stress resilience, anxiety (Beck Anxiety Inventory (BAI)), and depression (Beck Depression Inventory-II (BDI-II))
Results: Of the survey participants, 15.5% had experienced unbearable stress, with the most significant stress factors (in descending order) being limited leisure activities, unusual experiences related to COVID-19, and limited social activities. Approximately 28.8% reported psychological distress, and their most experienced negative emotions were helplessness, depression, and anxiety (in descending order). The mean BAI and BDI-II scores were 2.44 and 6.08, respectively, both within normal ranges. Approximately 8.3% had mild or greater anxiety, and 15% had mild or greater depression. For students under psychological distress, the experience of unbearable stress before COVID-19 affected anxiety (OR 0.198, p<0.05), and having an underlying condition affected depression (OR 0.190, p<0.05). With respect to their psychological distress during August–October 2020 compared with that during February–March 2020 (two months from the initial outbreak), anxiety stayed the same while depression increased and resilience decreased at a statistically significant level.
Conclusions: It was found that some medical students were suffering from psychological difficulties related to COVID-19, and there were several risk factors for them. This finding suggests that medical schools need to not only develop academic management systems but also provide programs that can help students manage their mental health and emotions in preparation for an infectious disease pandemic.
The COVID-19 virus broke out in Wuhan, China in late 2019, and sporadic confirmed cases were reported in South Korea in January 2020 [1]. The first confirmed case in Daegu was announced on February 17, 2020. Thereafter, the number of confirmed cases surged to 600–800 daily confirmed cases [2]. On March 5, 2020, the number of cumulative confirmed cases in and around Daegu was 5,187, accounting for 90% of the national cumulative confirmed cases [3]. As Daegu faced a significant spike in COVID-19 cases, the Korean government declared Daegu as a special disaster area on March 15, 2020, and began to take more active measures to prevent the national spread of COVID-19 [4].
Highly contagious new variants of the coronavirus are emerging and driving surges around the world [5], impacting individuals’ lives in terms of economy, culture, society, and education [6]. Notably, researchers have reported that the ongoing pandemic continues to affect some individuals’ psychology and emotions [7]. According to a meta-analysis reported in 2021, 32% of the general public have experienced depression; 30% anxiety; 31% distress; and 18% insomnia [8]. A mental health survey conducted on Daegu residents in May 2020 found that 40% of respondents had experienced emotional difficulties, with 32% and 23% in the depression and anxiety risk groups, respectively [9]. The proportions of the anxiety and depression risk groups were higher than the proportions found in the national mental health survey with sampled participants [10], which was conducted during the same period, by 9% and 14%, respectively. This indicates that many Daegu residents are experiencing mental health problems.
Students at a medical school located in Daegu, began their first academic semester of 2020 in February. However, in March 2020, the school was closed following government guidelines, as a result of which all lectures were shifted to an online format and clinical training was suspended [11,12]. Generally, medical students are likely to suffer from hypochondriasis or nosophobia as their extensive knowledge of diseases makes them prone to be sensitive to physical changes, exaggerate perceived physical changes, and self-diagnose [13]. In addition, medical students felt more burdened by their studies due to the restricted lecture environment in combination with an immense academic load. Likewise, more senior-level students undergoing clinical training at hospitals experienced peak stress levels due to the high possibility of coronavirus exposure and strictly limited activities. Several studies have been conducted to examine medical students’ mental health in relation to COVID-19. Christophers et al. performed a survey on 1,139 students at 16 medical schools in the United States and reported that they had similar levels of depression and anxiety owing to COVID-19 as frontline workers [14]. Moreover, in a survey conducted at a Tokyo medical school, 28% of respondents reported experiencing psychological distress [15]. A study by Ansari et al. found that 28% of 234 medical students at the Tehran University of Medical Sciences (TUMS), Iran, had depression [16]. Furthermore, 33% and 36% of medical students reported having depression in studies conducted in India and China, respectively [17,18]. As most of these studies do not go beyond examining levels of medical students’ anxiety and depression, it is necessary to perform an in-depth and multifaceted study.
Medical students are potential future doctors who will experience infectious diseases similar to COVID-19 on the frontline of medical care. They are considered as experiencing the COVID-19 pandemic with a sensitivity that differs from that of the general public. Therefore, it is necessary to assess the current conditions of medical students in a multifaceted manner to help set the appropriate direction for medical education. Daegu, in particular, is the first city to experience the COVID-19 outbreak in South Korea and thus has significance in studies on COVID-19-related mental health. This study provides an in-depth analysis of mental health data collected from a survey conducted on students at a medical school in Daegu.
Survey participants
A survey was conducted in 2020 on medical students enrolled at a national medical school in Daegu. The school teaches a 6-year medical education curriculum. Of 654 students, 220 were pre-medical course students (First year: 109 students, second year: 111 students), and 434 were medical course students (First year: 114 students, second year: 110 students, third year: 102 students, fourth year: 108 students). Of the total students, 588 (89.9%) responded to the survey, and 400 (61.2%) submitted valid responses. Surveys with incomplete or inadequate responses were excluded.
Data collection and ethical considerations
The survey was administered via SurveyMonkey, an online survey platform. It was first conducted on 1st to 6th year students from August 3 to September 11, 2020, and repeated from September 25 to October 4, 2020, for students who did not respond during the previous period. The chief-in researcher explained the purpose of the research to the student representatives with survey information (such as the purpose and methods of the study) and asked for cooperation. The survey took approximately 15–20 minutes to complete and participants who completed the questionnaire were sent a drink gift icon worth about USD 5.00. After sending a message transmission, the contact was immediately deleted and no personal information was collected. The collected data were kept and managed by serial number.
The online based survey and this study were approved by the Bioethics Committee of Kyungpook National University in July 2020 (KNU-2020-0069). The online survey questionnaire was designed to ensure respondents carefully read the survey information and provided participation consent before proceeding with the survey. Informed consent was obtained from all subjects. All methods were carried out in accordance with relevant guidelines and regulations.
Research instrument
The questionnaire consisted of three sections with a total of 81 items. The first section pertained to sociodemographic information (11 items); the second section pertained to COVID-19-related experiences at the time of the survey in comparison with those from February to March 2020; and the third section assessed participants’ psychological conditions (Stress: 5 items, Anxiety: 9 items, Depression: 21 items, Resilience: 25 items).
Experiences related to COVID-19
This questionnaire consisted of questions regarding unbearable stress and psychological distress related to COVID-19. It was developed by a research team consisting of four professors (one each representing the disciplines of mental health, student education, medical humanities, and pedagogy) using existing materials. To compare students’ experiences related to COVID-19 at the time of the survey (August–October 2020) with those when the number of confirmed cases surged in Daegu (February–March 2020), respondents were asked to retrospectively assess their experiences during the spike in confirmed cases.
Unbearable stress and types of unbearable stress
This questionnaire asked respondents to identify at which point in time they experienced unbearable stress. For the survey, the term “unbearable stress” was defined as “stress that causes such serious psychological and physical reactions that your daily life and studies are uncontrollably affected.” The questionnaire comprised two Yes/No questions: “Did you experience unbearable stress during the COVID-19 outbreak in Daegu (Feb.– Mar. 2020)?” and “Are you experiencing unbearable stress these days?” Participants who responded “yes” to these questions were asked to select three out of a total of 11 stress factors derived from a previous survey on factors causing unbearable stress: fear of contracting the COVID-19 virus, negative experiences related to COVID-19 (melancholy mood, despair, anxiety, depression, etc.), unusual experiences related to COVID-19 (mask mandate, social distancing, etc.), health concerns (excluding COVID-19), limited social activity, limited leisure activity (hobby, trip, etc.), family conflict, academic anxiety, conflict with friends (including school friends), future career anxiety, and financial difficulty.
Psychological distress and types of psychological distress
Respondents who reported psychological distress were asked to identify its possible causes as well as their coping strategies during the COVID-19 outbreak in Daegu and at the time of the survey. For the survey, the term “psychological distress” was defined as “a state in which you feel a negative emotion for any reason to the extent that you have difficulty controlling yourself.” Respondents were first asked the Yes/No question: “Have you experienced psychological distress since COVID-19 broke out in Daegu?” Those who responded “yes” were asked to select two out of a total of six emotions that they had felt. The six emotions listed were depression, anxiety, anger, despair, fear, and helplessness.
Beck Anxiety Inventory (BAI)
BAI was developed to measure anxiety symptoms, such as thoughts, physical condition, and panic experience in the preceding week, with minimal overlap with symptoms of depression. The BAI is a 21-item scale, with items rated on a 4-point Likert scale ranging from 0 (not at all) to 3 (very severe). The total score ranges from 0 to 63, with higher total scores indicating a stronger severity of anxiety symptoms. Scores of 0–7, 8–15, 16–25, and 26–63 indicate anxiety of normal, mild, moderate, and severe levels, respectively. This survey used the standardized Korean version of the BAI-II (Cronbach’s α = 0.91) [19].
Beck Depression Inventory-Second Edition (BDI-II)
BDI-II is a 21-item scale that assesses the cognitive, behavioral, affective, and somatic components of depression and measures depression type and severity based on clinical depressive symptoms. Using the scale, respondents were instructed to choose statements that best describe how they had felt in the preceding week. The items on the BDI-II are rated on a 4-point scale ranging from 0 to 3, with higher scores indicating more severe levels of depression. The total score ranges from 0 to 63. Scores of 0–13, 14–19, 20–28, and 29–63 indicate depression of normal, mild, moderate, and severe levels, respectively. This study used the validated Korean version of the BDI-II to assess the occurrence and severity of depressive symptoms (Cronbach’s alpha [α] = 0.91) [20].
Primary Care PTSD Screen for DSM-5 (PC-PTSD-5)
The PC-PTSD-5 was designed to screen for posttraumatic stress disorder (PTSD) in a primary care setting. The screening tool was developed based on the DSM-5 symptoms of PTSD by Prins et al [21]. Respondents answer five Yes/No questions about PTSD symptoms in relation to a traumatic event they experienced. If they respond “yes” to at least three questions, their symptoms are considered statistically significant. The version standardized by Yeom [22] was used in this study.
Connor-Davidson Resilience Scale (CD-RISC)
The CD-RISC was developed to study how people cope with stress and their response to physical and mental diseases. The scale comprises 25 items, each rated on a 5-point scale (0–4). The total score ranges from 0 to 100, with higher scores reflecting greater resilience. The scale has five subfactors: hardness, persistence, optimism, support, and spirituality. This study used the standardized Korean version by Baek et al. (Cronbach’s α 0.93) [24], who performed a study on 576 participants comprising university students, university hospital nurses, and firefighters, aged 18 to 65 years. Their average age was 27.4 ± 5.16 and the mean score was 61.2 ± 13.0.
Data analysis
Descriptive statistics were used to analyze subjects’ general characteristics and the total score of each index, which revealed a normal distribution. To verify differences related to gender, grade level, and place of residence among demographic variables, Levene’s test was performed to evaluate the homogeneity of variance between different groups. Next, the χ₂-test or one-way analysis of variance (ANOVA) was performed. For a post hoc test, LSD or Scheffe’s test was performed. Lastly, logistic regression was used to identify factors affecting the depression and anxiety of 400 students who experienced psychological distress. The cut-off scores of 16 and 20 were used for the BAI and the BDI-II, respectively, when comparing the depression and anxiety data of February–March 2020 with that of August–October 2020. The demographic data and factors affecting psychological distress were designated as independent variables in the analysis. A p-value less than 0.05 was considered statistically significant for all statistics applied, and the IBM SPSS Statistics for Windows, version 25.0 (IBM Corp, Armonk, NY, USA) was used.
Participant demographics
The average rate of valid participant responses was 61.2%. Fincham [25] advised that response rates approximating 60% for most research should be the goal when designing surveys. In this study, the valid response rate of 61% is acceptable and indicates the study has high reliability.
The average rate per grade level was 48.0%–78.9% and the average age was 22.5±2.75. Of the respondents, 66.3% were male, 98.9% were single, and 75.9% were residing in Daegu at the time of the local COVID-19 spike. A total of 1.5% of participants had experienced a confirmed case of COVID-19 personally or in their families. The demographic characteristics of respondents per grade level are summarized in Table 1.
Experiences related to COVID-19: comparison of experiences during the local COVID-19 peak and at the time of the survey
27.8% of the participants had experienced unbearable stress in February–March 2020, and the figure decreased to 15.5% at the time of the survey indicating a statistically significant change (p<0.001). In February–March, the three largest causes of unbearable stress (in descending order) were unusual experiences related to COVID-19, limited leisure activities, and fear of becoming infected with COVID-19. At the time of the survey, they were identified as limited leisure activities, unusual experiences related to COVID-19, and limited social activities (in descending order). In February–March, 56.0% experienced psychological distress, but this significantly decreased to 28.7% in August–October (p<0.001). The three emotions respondents experienced most frequently (in descending order) in both periods were helplessness, depression, and anxiety (Table 2).
Comparison of students’ emotional state for each grade level
Table 3 shows the verification of differences between students of each grade level in relation to anxiety, depression, PTSD, and resilience. The mean BAI score of the participants was 2.44, and the mean scores of all grade levels were within the normal range of anxiety, with no differences between students of different grade levels (p=0.163). Nine students exhibited symptoms of moderate or greater anxiety (a BAI score of at least 16). The mean BDI-II score of the participants was 6.08, and the mean scores of all grade levels were within the normal range of depression. Nineteen students exhibited moderate or greater depression (a BDI-II score of at least 20). With respect to the mean BDI-II score of each grade level, the mean scores of the second-year premedical course students and first and second-year medical course students were higher than the mean score of first-year pre-medical course students. The mean BDI-II score of second-year medical course students was significantly higher than the mean scores of third and fourth-year medical course students. Notably, the second-year medical students scored the highest mean BDI-II score among the different grade levels (p=0.004).
Participants’ mean PC-PTSD-5 score was 0.55, and the mean scores of all grade levels were within the normal range. Thirty-four students exhibited moderate or greater PTSD (a PC-PTSD-5 score of at least 10). With respect to the mean PC-PTSD-5 score of each grade level, the mean scores of the second-year pre-medical course students and first-year medical course students were significantly higher than the mean score of first-year pre-medical course students. The mean score of second-year pre-medical course students was significantly higher than the mean scores of second, third, and fourth-year medical course students. The second-year pre-medical students scored the highest of all mean PC-PTSD-5 scores among the different grade levels (p=0.004). The mean CD-RISC score of the participants was 94.62, which was higher than the mean score of the standardized Korean CD-RISC, with no differences between grade levels (Table 3).
Comparison of anxiety, depression, and resilience between students who did and did not experienced psychological distress
The anxiety, depression, and resilience of students who had experienced psychological distress were compared with those of students who had not. The comparison revealed that students who experienced psychological distress had significantly higher anxiety (p=0.000), depression (p=0.000), and lower resilience (p=0.002) than students who did not. This trend was found among students who experienced psychological distress both in February–March and in August–October 2020. The non-significant findings showed that students who experienced psychological distress in the latter period had higher depression (p=0.001) and lower resilience (p=0.021) (Table 4).
Distribution of students with anxiety and depression in relation to major variables
Among the survey participants, 8.3% (n = 33) exhibited mild or greater anxiety, and 2.3% (n = 9) exhibited moderate or greater anxiety. There was no difference in the frequency of anxiety in relation to gender, grade level, religion, and living-alone status, while a statistically significant difference was found in relation to unbearable stress (p=0.018). A high rate of anxiety was found in the group who experienced unbearable stress (Table 5).
Of all participants, 15.0% (n = 60) exhibited mild or greater depression and 7.3% (n = 29) exhibited moderate or greater depression. There was no difference in the frequency of depression in relation to gender, grade level, religion, and living-alone status, while a statistically significant difference was found in relation to unbearable stress (p=0.022). A high rate of depression was revealed in the group who experienced unbearable stress (Table 6).
Logistic regression was conducted to identify the major factors that can affect anxiety (BAI) and depression (BDI-II) among students who reported experiencing psychological distress during the COVID-19 pandemic. For students who experienced psychological distress, unbearable stress before COVID-19 affected their anxiety (OR 0.198, p<0.05), and having an underlying condition affected depression (OR 0.190, p<0.05) (Table 7).
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.
This study found that the COVID-19 pandemic caused limited leisure activities, unusual experiences related to COVID-19, and limited social activities, giving unbearable stress to the students and causing helplessness, depression, and anxiety to some of them. Most students were in the normal range but a small number of students exhibited moderate or greater anxiety and depression and thus needed appropriate assistance. Particularly, students who had experienced unbearable stress before the pandemic exhibited high anxiety, and students having underlying conditions exhibited high depression. The comparison of students’ mental health during the early pandemic days and 6-7 months later found that the anxiety level did not change; depression increased, and resilience decreased on a statistically significant level.
Based on the results of this study, we consider it necessary for the school to provide multilateral support that can help with students’ emotional recovery. To that end, the school can provide individual and group counseling programs, promote exchange among students, run a mental health support center, build a virtual counseling room, and provide daily life management training.
This study has historically significant value as research on the mental health of medical students who resided in a city where the first confirmed case of COVID-19 in Korea was found and the number of COVID-19 patients surged. We are confident that this study is meaningful and will provide important data for further studies. Examples include a study that follows this COVID-19 cohort and examines changes in medical students’ mental health, as well as a study on the effect of their COVID-19 experiences on their identities and careers as doctors.
COVID-19: coronavirus disease 2019; BAI: Beck anxiety inventory; BDI-II: Beck depression inventory-second; PC-PTSD-5: primary care PTSD screen for DSM-5; CD-RISC: Connor-Davison resilience scale; GAD-7: generalized anxiety disorder scale-7; PHQ: patient health questionnaire
Acknowledgments
The authors would like to thank former medical school dean Jongmyung Lee and former medical school alumni chairman Ingu Kang for their great help in this study.
Authors’ contributions
Conceptualization: S. Won, J Kim, E Choi, S Yeo. Methodology: S Yeo, E Choi S Won. Software: S. Won Validation: S. Won, Formal analysis: S Yeo, E Choi, S Won Investigation: S Yeo, E Choi Resources: J Kim, S Won Data curation: S Yeo, E Choi Writing-original draft: S Yeo, S Won Writing-review & editing: S Yeo, S Won, E Choi, J Kim Project administration: S. Won Funding acquisition: J Kim, S. Won
Authors’ information
SANGHEE YEO, PhD., is an assistant professor of the department of medical education in the School of Medicine, Kyungpook National University. She is also working at the Kyungpook National University Hospital, Daegu, South Korea. She teaches medical education to undergraduate medical students, and participates in this school. Her research interests in educational technology, curriculum development, and evaluation of curriculum for medical schools.
EUN KYUNG CHOI, MD., PhD., is a professor of medical humanities in the medical education center in the School of Medicine, Kyungpook National University. She teaches history of medicine, medical ethics, and medical humanities in medical school and hospital of Kyungpook National University. Her research interests are the history of medicine in modern Korea, public health ethics, and medical humanities education.
JUNGMIN KIM, MD., PhD., is a professor of the department of microbiology in the School of Medicine, Kyungpook National University. She also served as an Associate Dean for Medical Education Affairs at Kyungpook National University School of Medicine from August 2014 to July 2020.
SEUNGHEE WON, MD., PhD., is a professor of the department of psychiatry in the School of Medicine, Kyungpook National University. He is also working at the department of psychiatry in the Kyungpook National University Hospital, Daegu, South Korea. He teaches psychiatry to undergraduate and graduates medical students, and psychiatric residents in the hospital. His research interests in mood disorders, trauma, and emotional regulation
Funding
The study was supported by the 2020 COVID-19 Research Fund from the Kyungpook Medical University Alumni Association.
Availability of data and materials
Availability of data and materials Datasets supporting the conclusions of this study are included within the article. Additional data at the level of individual students is not publicly available because of the potential for compromising student privacy but is available from the corresponding author on reasonable request.
Ethics approval and consent to participate
The online based survey and this study were approved by the Bioethics Committee of Kyungpook National University in July 2020 (KNU-2020-0069). The online survey questionnaire was designed to ensure respondents carefully read the survey information and provided participation consent before proceeding with the survey. Informed consent was obtained from all subjects. All methods were carried out in accordance with relevant guidelines and regulations.
Consent for publication
The study contains no information that identifies individuals so consent for publication is not applicable
Competing interests
The authors declare no conflict of interest
Tables 1 to 7 are available in the Supplementary Files section