ORIGINAL ARTICLE |
https://doi.org/10.5005/jp-journals-11010-1063 |
Mental Health of Undergraduate Health Science Students during and after the COVID-19 Lockdown
1–3,5–7Department of Respiratory Therapy, Batterjee Medical College, Jeddah, Saudi Arabia
4Department of Respiratory Therapy, King Abdulaziz University, Jeddah, Saudi Arabia
8Department of Rehabilitation Science, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia
Corresponding Author: Gokul G Krishna, Department of Respiratory Therapy, Batterjee Medical College, Jeddah, Saudi Arabia, e-mail: gokulrescare@gmail.com
Received on: 23 July 2023; Accepted on: 31 August 2023; Published on: 30 October 2023
ABSTRACT
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
INTRODUCTION
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.
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Assessment of stress: We used the Kessler Psychological Distress Scale (K10), which includes 10 questions, each measured on a scale of 1–5.11
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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
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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.
Statistical Analysis
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.
Ethics Approval
We obtained ethical consent from the Institutional Review Board of the university (BMC RES 2021-42).
RESULTS
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 (%) |
|---|---|
| Gender | |
| Male | 191 (51.9%) |
| Females | 177 (48.1%) |
| Age | |
| 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 | |
| Yes | 59 (16.0%) |
| No | 309 (84.0%) |
| During the past 3 weeks, have you tested positive for COVID-19? | |
| Yes | 84 (22.8%) |
| No | 250 (67.9%) |
| I don’t know | 34 (9.2%) |
| Under which program are you enrolled? | |
| Medicine | 144 (39.13%) |
| Dentistry | 33 (8.97%) |
| Nurse | 30 (8.15%) |
| 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.
Figs 1A to C: This is a figure comparing the median score for the responses from the time of lockdown to after lockdown for stress, anxiety, and depression; (A) Shows the median scores for stress during and after lockdown; (B) Shows the median scores for anxiety during and after lockdown; (C) Shows the median scores for depression in subjects during and after lockdown
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
Fig. 2: This is a figure comparing the stress, anxiety, and depression scores during and after lockdown in subjects who received medications for psychological reasons
Fig. 3: This is a figure showing a comparison of stress, anxiety, and depression scores during and after lockdown in subjects without any medications for psychological disorders
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%) |
| Anxiety category | ||
| 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%) |
| Depression category | ||
| 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 |
| χ2 test | 0.858 | 4.267 | 8.034 | 0.593 | 0.104 | 0.048 |
| p-value | 0.354 | *0.039 | *0.005 | 0.441 | 0.74 | 0.82 |
| During the past 3 weeks, have you had any direct contact with COVID-19 patients? | 66 | 74 | 77 | 12 | 12 | 13 |
| χ2 test | 4.072 | 4.011 | 3.356 | 1.665 | 0.062 | 0.048 |
| p-value | 0.44 | *0.045 | 0.67 | 0.298 | 0.804 | 0.82 |
| Use of any medication for any psychological disorder | 44 | 50 | 51 | 36 | 41 | 47 |
| χ2 test | 5.868 | 8.492 | 6.70 | 1.819 | 0.79 | 3.45 |
| p-value | *0.015 | *0.004 | 0.10 | 0.17 | 0.372 | 0.063 |
DISCUSSION
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.
CONCLUSION
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.
REFERENCES
1. Pfefferbaum B, North CS. Mental health and the COVID-19 pandemic. N Engl J Med 2020;383(6):510–512. DOI: 10.1056/nejmp2008017
2. Marazziti D. The COVID-19 outbreak: the latest challenge to psychological and psychiatric intervention. Clin Neuropsychiatry 2020;17(2):39–40. DOI: 10.36131/clinicalnpsych20200201
3. Aguilera-Hermida AP, Quiroga-Garza A, Gómez-Mendoza S, et al. Comparison of students’ use and acceptance of emergency online learning due to COVID-19 in the USA, Mexico, Peru, and Turkey. Educ Inf Technol (Dordr) 2021;26(6):6823–6845. DOI: 10.1007/s10639-021-10473-8
4. Akdeniz G, Kavakci M, Gozugok M, et al. A survey of attitudes, anxiety status, and protective behaviors of the university students during the COVID-19 outbreak in Turkey. Front Psychiatry 2020;11:695. DOI: 10.3389/fpsyt.2020.00695
5. Husky MM, Kovess-Masfety V, Swendsen JD, et al. Stress and anxiety among university students in France during COVID-19 mandatory confinement. Compr Psychiatry 2020;102:152191. DOI: 10.1016/j.comppsych.2020.152191
6. Liu C, McCabe M, Dawson A, et al. Identifying predictors of university students’ wellbeing during the COVID-19 pandemic—a data-driven approach. Int J Environ Res Public Health 2021;18(13):6730. DOI: 10.3390/ijerph18136730
7. Luberto CM, Goodman JH, Halvorson B, et al. Stress and coping among health professions students during COVID-19: a perspective on the benefits of mindfulness. Glob Adv Health Med 2020;9:216495612097782. DOI: 10.1177/2164956120977827
8. Cao W, Fang Z, Hou G, et al. The psychological impact of the COVID-19 epidemic on college students in China. Psychiatry Res 2020;287:112934. DOI: 10.1016/j.psychres.2020.112934
9. Marcén-Román Y, Gasch-Gallen A, Vela Martín de la Mota II, et al. Stress perceived by University Health Sciences students, 1 year after COVID-19 pandemic. Int J Environ Res Public Health 2021;18(10):5233. DOI: 10.3390/ijerph18105233
10. Bahhawi TA, Albasheer OB, Makeen AM, et al. Depression, anxiety, and stress and their association with khat use: a cross-sectional study among Jazan University students, Saudi Arabia. Neuropsychiatric Disease and Treatment 2018;14:2755–2761. DOI: 10.2147/ndt.s182744
11. Andrews G, Slade T. Interpreting scores on the Kessler Psychological Distress Scale (K10). Aust N Z J Public Health 2001;25(6):494–497. DOI: 10.1111/j.1467-842x.2001.tb00310.x
12. Dhira TA, Rahman MA, Sarker AR, et al. Validity and reliability of the Generalized Anxiety Disorder-7 (GAD-7) among university students of Bangladesh. PLoS One 2021;16(12):e0261590. DOI: 10.1371/journal.pone.0261590
13. Kroenke K, Spitzer RL, Williams JB, et al. Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Ann Intern Med 2007;146(5):317–325. DOI: 10.7326/0003-4819-146-5-200703060-00004
14. Dial LA, DeNardo FA, Fevrier B, et al. Comparing mental health and well-being of US undergraduate and graduate students during the early stages of the COVID-19 pandemic. J Am Coll Health 2021:1–11. DOI: 10.1080/07448481.2021.1996372
15. Odriozola-González P, Planchuelo-Gómez Á, Irurtia MJ, et al. Psychological effects of the COVID-19 outbreak and lockdown among students and workers of a Spanish University. Psychiatry Res 2020;290:113108. DOI: 10.1016/j.psychres.2020.113108
16. Tedesco LA. A psychosocial perspective on the dental educational experience and student performance. J Dent Educ 1986;50(10):601–605.
17. Trockel MT, Barnes MD, Egget DL. Health-related variables and academic performance among first-year college students: implications for sleep and other behaviors. J Am Coll Health 2000;49(3):125–131. DOI: 10.1080/07448480009596294
18. Li Y, Zhao J, Ma Z, et al. Mental health among college students during the COVID-19 pandemic in China: a 2-wave longitudinal survey. J Affect Disord 2021;281:597–604. DOI: 10.1016/j.jad.2020.11.109
19. Fruehwirth JC, Biswas S, Perreira KM. The COVID-19 pandemic and mental health of first-year college students: examining the effect of COVID-19 stressors using longitudinal data. PLoS One 2021;16(3):e0247999. DOI: 10.1371/journal.pone.0247999
20. Gómez-Salgado J, Andrés-Villas M, Domínguez-Salas S, et al. Related health factors of psychological distress during the COVID-19 pandemic in Spain. Int J Environ Res Public Health 2020;17(11):3947. DOI: 10.3390/ijerph17113947
21. Özdin S, Bayrak Özdin Ş. Levels and predictors of anxiety, depression and health anxiety during COVID-19 pandemic in Turkish society: the importance of gender. Int J Soc Psychiatry 2020;66(5):504–511. DOI: 10.1177/0020764020927051.
22. Solomou I, Constantinidou F. Prevalence and predictors of anxiety and depression symptoms during the COVID-19 pandemic and compliance with precautionary measures: age and sex matter. Int J Environ Res Public Health 2020;17(14):4924. DOI: 10.3390/ijerph17144924
23. Jardon C, Choi KR. COVID-19 experiences and mental health among graduate and undergraduate nursing students in Los Angeles. J Am Psychiatr Nurses Assoc 2022:10783903211072222. DOI: 10.1177/10783903211072222
24. Sundarasen S, Chinna K, Kamaludin K, et al. Psychological impact of COVID-19 and lockdown among University Students in Malaysia: implications and policy recommendations. Int J Environ Res Public Health 2020;17(17):6206. DOI: 10.3390/ijerph17176206
25. Dong L, Bouey J. Public mental health crisis during COVID-19 pandemic, China. Emerg Infect Dis 2020;26(7):1616–1618. DOI: 10.3201/eid2607.200407
26. Chatterjee SS, Barikar CM, Mukherjee A. Impact of COVID-19 pandemic on pre-existing mental health problems. Asian J Psychiatry 2020;51:102071. DOI: 10.1016/j.ajp.2020.102071
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