Mental Health of Undergraduate Health Science Students during and after the COVID-19 Lockdown
Corresponding Author: Gokul G Krishna, Department of Respiratory Therapy, Batterjee Medical College, Jeddah, Saudi Arabia, e-mail: email@example.com
Received on: 23 July 2023; Accepted on: 31 August 2023; Published on: 30 October 2023
Introduction: The health, economic, social, and educational systems worldwide have been seriously impacted by the coronavirus disease of 2019 (COVID-19). Students’ academic results and mental health were greatly impacted by the lack of traditional face-to-face lectures, access to digital learning, and possibilities for networking and socializing. The study’s outcome was to investigate the stress, depression, and anxiety experienced by undergraduate health science students during and after the COVID-19 lockdown.
Materials and methods: We collected data from 470 students using three validated questionnaires: the Kessler Psychological Distress Scale (K10) for stress, the Generalized Anxiety Disorder (GAD-7) for anxiety, and the Patient Health Questionnaire (PHQ-9) for depression. The questionnaires were sent to potential participants via e-mail during the COVID-19 lockdown. After the lockdown, a follow-up was made.
Results: A total of 368 (78.3%) participants completed the questionnaires; 30.7% (n = 113) vs 19.8% (n = 73) experienced severe stress during and after the lockdown, respectively. The mean scores for stress, anxiety, and depression during the lockdown vs postlockdown were 22 (11) vs 20 (11), 9 (7) vs 9 (6), and 7 (6) vs 7 (6.5), respectively.
Conclusion: During the COVID-19 lockdown, undergraduate health science students experienced serious mental health issues, especially those under medication for psychological disorders. A significant improvement was observed postlockdown in overall mental health among students, but the number of students experiencing mental health issues remained high.
How to cite this article: Alahmari AD, Krishna GG, Jose AM, et al. Mental Health of Undergraduate Health Science Students during and after the COVID-19 Lockdown. Indian J Respir Care 2023;12(3):248–253.
Source of support: Nil
Conflict of interest: Dr Gokul G Krishna is associated as Associate Editor of this journal and this manuscript was subjected to this journal’s standard review procedures, with this peer review handled independently of the Associate Editor and his research group.
Keywords: Anxiety, Coronavirus disease 2019, Depression, Education, Health Science, Lockdown, Stress, Students, Undergraduate
Coronavirus disease of 2019 (COVID-19) is an infectious disease caused by severe acute respiratory syndrome coronavirus 2, and in March 2020, the World Health Organization declared COVID-19 a pandemic and recommended precautionary measures.1 The public was significantly affected by strict lockdowns and self-isolation policies, along with the uncertainty of COVID-19 and fear for one’s life.2
The COVID-19 pandemic had a severe impact on education as schools and universities closed in response to the lockdown measures. Although higher educational institutions were quick to transform face-to-face lectures into online learning, the lack of accessibility to digital learning and the absence of networking and socializing opportunities significantly affected educational outcomes.3 Furthermore, university students experienced great disruption in their living situations. Concerns regarding the impact of the pandemic on academic progress and ability to enter the workforce, the need to adjust to the new online learning, and the fear of transmitting the virus to their family members all led to unprecedented stress.4 Studies from China, France, the United States, and Australia all demonstrated a negative impact on the mental health of university students, with symptoms such as posttraumatic stress, anxiety, and depression.5-7
Although traditional classes have resumed postlockdown, some students could not adapt to the postlockdown academic life and experienced psychological issues.8,9 Even before the pandemic, there have been reports worldwide of university students struggling with mental health crises. A study from Saudi Arabia conducted by Bahhawi et al. reported that before the pandemic, 34.3, 65.7, and 53.8% of university students experienced stress, anxiety, and moderate depression, respectively.10 Hence, it is important to recognize that an increase in psychological consequences postlockdown may go unrealized.
This study has the following objectives—to investigate the effects of COVID-19 on the mental health of undergraduate health science students during and after the lockdown, to examine the students who are already under medication for psychological disorders and their outcomes, and to study the association between demographic and contextual factors with the occurrence of stress, anxiety, and depression.
MATERIALS AND METHODS
We collected data for the current questionnaire-based study in two phases. In phase I, data were collected during the COVID-19 pandemic when precautionary measures such as lockdowns, curfews, and social distancing were implemented (May–July 2021). In phase II, we followed up the participants postlockdown when the precautionary measures were lifted (January–March 2022). The participants were undergraduate health science students enrolled at universities in Saudi Arabia and were aged above 18 years. We excluded those who were pursuing master’s or higher degrees and those from nonmedical professions. A nonprobability convenient sampling technique was employed. The online questionnaires were sent to the participants via e-mail, and a follow-up was made postlockdown. We included three validated questionnaires and collected data regarding sociodemographic characteristics.
Assessment of stress: We used the Kessler Psychological Distress Scale (K10), which includes 10 questions, each measured on a scale of 1–5.11
Assessment of anxiety: We used the Generalized Anxiety Disorder (GAD-7) questionnaire, which includes seven questions, each measured on a scale of 0–3.12
Assessment of depression: We used the Patient Health Questionnaire (PHQ-9), which includes nine questions, each measured on a scale of 0–3. This questionnaire was administered twice, during and after the COVID-19 lockdown.13
This study was conducted according to the Declaration of Helsinki. Participation was completely anonymous and voluntary. The participants provided consent forms virtually before the study participation. Furthermore, the collected data were kept confidential.
We analyzed data using Statistical Package for the Social Sciences version 25 for Windows (Chicago, Illinois, United States of America). The normality of the data was assessed using the Shapiro–Wilk test; data were considered nonnormally distributed. Continuous data were expressed as median and interquartile range (IQR), and categorical data as frequency and percentages. The Wilcoxon signed-rank test and Mann–Whitney U test were employed to determine the differences among the groups. We analyzed the association between sociodemographic variables and the variables of interest using the Chi-squared test. p ≤ 0.05 was considered to indicate statistical significance.
We obtained ethical consent from the Institutional Review Board of the university (BMC RES 2021-42).
A total of 470 students participated in the survey. Of them, 368 were finally included in the analysis after excluding 102 either because they did not complete the surveys during or after the COVID-19 lockdown or because they had missing data. The proportion of men to women was 51.9–48.1%; 47.8% of the participants were in the 19–21 age group, and 16% were under medication for psychological disorders. After the lockdown, 96.7% of the universities used a combination of online and traditional classroom teaching, whereas 56% adopted online teaching alone. The participants’ characteristics are presented in Table 1.
|Characteristics||Number of participants (%)|
|19–21 years||176 (47.8%)|
|22–25 years||146 (39.7%)|
|26–30 years||46 (12.5%)|
|Use of any medication for any psychological disorder|
|During the past 3 weeks, have you tested positive for COVID-19?|
|I don’t know||34 (9.2%)|
|Under which program are you enrolled?|
|Allied health professionals||161 (43.75%)|
In the observation of students to detect changes in stress, anxiety, and depression during and after the lockdown, the Wilcoxon signed-rank test showed a statistically significant positive change (p < 0.001). The median (IQR) scores for stress, anxiety, and depression levels were 23 (13) vs 20 (11), 7.5 (6) vs 7 (6), and 9 (7.25) vs 9 (7), respectively, as presented in Figure 1.
We conducted secondary analyses based on medication received for any psychological disorder. To compare stress, anxiety, and depression between the group receiving medication and the group not receiving medication, we used the Mann–Whitney U test. The test indicated a significant difference between the groups with high scores in the lockdown group (p < 0.001) (Table 2). Furthermore, we compared the changes in stress, anxiety, and depression between the groups during and after lockdown using the Wilcoxon signed-rank test. The test indicated a significant positive change (p < 0.001) in both groups (Figs 2 and 3).
|During the COVID-19 lockdown||After the COVID-19 lockdown|
|Subjects receiving medication (n = 59); median (IQR)||Subjects without medication (n = 309); median (IQR)||p-value*||Subjects receiving medication (n = 59); median (IQR)||Subjects without medication (n = 309); median (IQR)||p-value*|
|Stress||34 (15.50)||22 (11)||<0.001||24 (12.25)||20 (11)||0.084|
|Anxiety||14 (10.25)||9 (7)||<0.001||10 (7.25)||9 (6)||0.314|
|Depression||12 (8.25)||7 (6)||<0.001||7 (6.50)||7 (5)||0.018|
*Mann–Whitney U test
On further categorized assessment, we found that 113 (30.7%) participants had experienced severe stress during the lockdown compared with 73 (19.8%) postlockdown. In the severe anxiety and depression categories, the numbers of cases during and postlockdown were 64 (17.4%) vs 35 (9.5%) and 37 (10%) vs 23 (6.25%), respectively. The majority of the participants experienced mild stress, anxiety, and depression during and postlockdown (Table 3).
|Stress category||During the COVID-19 lockdown n (%)||Post-COVID-19 lockdown n (%)|
|Well (<20)||115 (31.3%)||149 (40.48%)|
|Mild (20–24)||92 (25.0%)||95 (25.81%)|
|Moderate (25–29)||48 (13.0%)||51 (13.85%)|
|Severe (30 and more)||113 (30.7%)||73 (19.86%)|
|None (0–4)||76 (20.65%)||102 (27.7%)|
|Mild (5–9)||156 (42.4%)||172 (46.8%)|
|Moderate (10–14)||72 (19.56%)||59 (16.0%)|
|Severe (15–21)||64 (17.39%)||35 (9.5%)|
|None (0–4)||58 (15.76%)||77 (20.92%)|
|Mild (5–9)||128 (34.78%)||144 (39.13%)|
|Moderate (10–14)||92 (25%)||88 (23.91%)|
|Moderately severe (15–19)||53 (14.4%)||36 (9.78%)|
|Severe (21–27)||37 (10.05%)||23 (6.25%)|
We examined the association of the sociodemographic factors with mental health variables using the Chi-squared test. No significant association was observed with gender, age, university level, or type of program. However, we found a significant association between factors such as positive COVID-19 test, direct contact with COVID-19 patients, and use of medication during the lockdown on the one hand, and the occurrence of stress, anxiety, or depression on the other (Table 4).
|During the COVID-19 lockdown||Post-COVID-19 lockdown|
|Stress (n = 253)||Anxiety (n = 292)||Depression (n = 310)||Stress (n = 219)||Anxiety (n = 266)||Depression (n = 291)|
|During the past 3 weeks, have you tested positive for COVID-19?||78||93||100||11||11||13|
|During the past 3 weeks, have you had any direct contact with COVID-19 patients?||66||74||77||12||12||13|
|Use of any medication for any psychological disorder||44||50||51||36||41||47|
This study is one of the few follow-up studies reporting the changes in the mental health of individuals during and after the COVID-19 lockdown. We found that the levels of stress, anxiety, and depression were high among undergraduate health science students during the lockdown but significantly reduced postlockdown. Students who were under medication for psychological disorders had higher scores during the lockdown compared with healthy ones. Exposure to a COVID-19 patient, a positive COVID-19 test, and the use of medication for any psychological disorder were associated with a higher risk of experiencing mental health issues.
Several researchers have reported a significant increase in the levels of stress, anxiety, and depression during the COVID-19 lockdown. Dial et al. reported a significant mental health challenge during the lockdown, with one-third and two-fifths of the students testing positive for major depressive disorders and generalized anxiety disorders, respectively.14 Furthermore, a study from Spain by Odriozola-González et al. demonstrated moderate to extremely high scores of stress, anxiety, and depression (28.14, 21.34, and 34.19%, respectively), with 50.43% showing moderate to severe impact of the outbreak.15
In our study, we observed higher scores for stress, anxiety, and depression among students (68.7, 79.3, and 84.8%, respectively); 30.7% of the students experienced severe stress, 17.4% had severe anxiety, and 10% had severe depression. Existing evidence clearly proves that the grade point average and overall academic performance of university students were negatively affected by perceived stress and anxiety.16,17 The possible contributing factors to stress and anxiety include nutrition, exercise routine, sleep patterns, social activities, and class attendance, which were significantly affected during the COVID-19 pandemic. In our study, we focused on the occurrence of mental health issues and investigated the changes postlockdown in mental health. However, we observed a significant association between the use of any medication for psychological disorders and the occurrence of stress and anxiety.
People’s mental health differed at various stages of the pandemic. A study in China demonstrated that the prevalence of psychopathological manifestations increased during the outbreak and at the beginning of COVID-19 remission.18 A longitudinal survey conducted on first-year college students from the United States, which compared the depression and anxiety scores from the beginning of the pandemic to mid-pandemic, demonstrated increases in the incidence of moderate to severe depression from 21.5 to 31.7% and of moderate to severe anxiety from 18.1 to 25.3%.19 Marcén-Román et al. showed the persistence of stress and anxiety even after almost 1 year of the COVID-19 lockdown, but the reported symptoms were less severe.9 Furthermore, we observed a significant reduction in the mean scores for stress, anxiety, and depression from lockdown to postlockdown. In the severe categories, a greater decrease in stress, anxiety, and depression scores from 30.3 to 19.8%, 17.4 to 9.5%, and 10 to 6.25%, respectively, was observed. The availability of more information on COVID-19, successful vaccination drives, and reopening of universities could be the contributing reasons for such a decrease. Contrarily, the limited information about the disease, the fear of getting infected, self-isolation, and lifestyle modification were possible contributors to the increase in stress, anxiety, and depression levels during the lockdown.20
The association between sociodemographic factors, which can negatively affect individuals’ mental well-being, has been extensively studied. Female gender, a positive COVID-19 test, and direct or indirect exposure to COVID-19 patients were proven to be significantly associated.21,22 Jardon and Choi’s study on nursing students found that loneliness during COVID-19 isolation was associated with higher odds of mental health problems.23 A study from Malaysia conducted by Sundarasen et al. reported that being younger than 18 years old and being alone were also associated with increased anxiety levels.24 In our study, we did not find any impact of gender on mental health, but we did observe an effect on mental health of a positive COVID-19 test and direct or indirect exposure to COVID-19 patients during the lockdown.
The incidence of reported psychiatric morbidities during the COVID-19 lockdown was similar to that during the severe acute respiratory syndrome outbreak in 2003.25 Chatterjee et al. observed that the relapse rate of any preexisting mental health problem during the COVID-19 pandemic had increased, which necessitated psychiatric support.26 Although we observed a significant reduction in stress, anxiety, and depression levels postlockdown, the total percentage of affected students remained high. Moreover, the levels of stress, anxiety, and depression were significantly higher in participants who were under medication for psychological disorders than in healthy subjects, indicating the need for psychological support for university students.
The strength of our study is that we had an attrition rate of 78% in the postlockdown follow-up group. In addition, our study provided insights into the stress, anxiety, and depression experienced by university students who were under medication for psychological disorders. It also examined the changes that occurred postlockdown on mental health.
The limitations of the study include the absence of a predetermined sample size and the reporting bias associated with the survey. Also, only participants from Saudi Arabia were included. However, during the strict COVID-19 lockdown, the self-reporting questionnaire was the most appropriate tool. The lockdown measures and timelines were different in other countries; hence, we could not include participants from other countries. Moreover, we were not able to collect relevant information regarding the medication and dosage used, which would have provided valuable insights.
During the COVID-19 lockdown, students experienced great mental health issues, especially those who were already under medication for psychological disorders. Although a significant improvement in mental health was observed postlockdown, the number of students experiencing mental health issues remained high. University-level students experienced greater stress, anxiety, and depression, thus necessitating psychological services. Future studies are warranted to assess the degree of involvement of mental health issues in students’ academic performance and to develop effective strategies for improving students’ mental health and well-being.
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