Although the COVID-19 pandemic, like many other public health emergencies, is likely to have a significant psychological impact on all healthcare workers, to date, only a handful of studies have sought to examine medical student’s mental health in relation to COVID-19 [14, 15]. The results of this study, which to our knowledge is the first one from Pakistan, has shown that medical students are experiencing a severe level of psychological distress with more than two-third reporting a deterioration in their emotional health and well-being since the onset of the pandemic in Pakistan.
Prevalence of anxiety and depression among medical students
Our results indicated that an alarming 48.6% and 48.1% of medical students were having anxiety and depressive symptoms during the COVID-19 outbreak. These prevalence estimates are not only much higher than recent reports of COVID-related self-reported anxiety and distress (25–27%) of medical students, but also in comparison to the reported global prevalence of depression (27.2%) and anxiety (33.8%) among medical students as well as from Pakistan [1, 2, 7,8,9]. Although it is no surprise that medical students in Pakistan experience a much higher level of anxiety and depression than the general population as well as age-matched peers during COVID-19, but the findings are quite alarming. Possible explanations for results may be excessive fear and anxiety in the community during the COVID outbreak along with plans for recruiting medical students in corona units in case of shortage of healthcare workers as well as lack of preparedness to shift to virtual learning. Medical students and teachers both faced challenges regarding online learning, and uncertainty regarding exams/electives, etc. may also have contributed to their symptoms.
Anxiety and depressive disorders are more likely to occur and worsen in the absence of interpersonal communication as seen during lockdowns. The present study builds on our recent work demonstrating a high prevalence of depression and anxiety among postgraduate trainees in Pakistan, which in comparison to medical students is still significantly less (48.1 and 48.6% in medical students’ vs 26.4% and 22.6% in postgraduate residents) suggesting that mental health problems are an issue affecting all levels of the medical workforce [16]. It also focuses on the need to intervene early in medical colleges to prevent an adverse long-term impact on physician’s health. Female medical students had higher psychological morbidity, in line with previous literature suggesting women as more vulnerable possibly due to cultural practices and societal attitudes especially in traditional societies like Pakistan. Apart from biological contribution, high rates of sexual and emotional abuse, low income, and less opportunities to work in their desired fields are all factors that contribute to higher rates of depression in females [8, 17]. However, one may also need to consider that while the rates reported by female students are high, their male counterparts may be reluctant in opening up about symptoms or asking for professional help due to societal attitudes. We also noted higher anxiety and depression in preclinical students which may be because of adjustment issues when medical students first enter medical colleges. Some studies like Chandavarkar et al. (2007) found that students transitioning from preclinical to clinical years displayed more anxiety and depressive symptoms, while other studies reported an increase in stress levels and psychological morbidity as students advance in their medical school years [18, 19]. On the other hand, another cross-sectional study noted that senior medical students exercised more, slept for a longer duration, and had more friends suggesting the possibility of better self-care skills and the ability to maintain balance in personal and professional lives during clinical years [20]. Systematic reviews and meta-analysis have found no statistically significant difference in depression and anxiety by gender and year of study [1, 2]. Consistent with findings of other reviews, students with preexisting mental health issues were more adversely impacted by the pandemic [21].
Suicidal risk and suicidal ideation among medical students
Another major finding of this study is that on Risk Assessment Suicidality Scale (RASS) items, one in 5 medical students (approximately 20%) thought that it would be better if they were dead and 8% admitted to often think of committing suicide if they have the chance during a previous 2-week period. On the PHQ-9 item about suicidal ideation, 11.8% of medical students admitted to having suicidal thoughts nearly every day with a further 13.1% having such thoughts on almost half the days in the last 2 weeks. This frequency of suicidal ideation is quite higher than the 2-week frequency reported by Sobowele et al. and comparable (11.1–17.4%) to other reports [19, 21, 22]. Mean scores on the suicidal risk assessment scale were also extremely high in comparison to studies in the general population with significant association with past psychiatric history and female gender with suicidal ideation [13]. In view of the high prevalence of suicide ideation in the current study, it is clear that medical colleges need to develop robust systems for screening, prevention, and treatment of psychiatric issues and suicidal risk in our future physicians on a priority basis.
Reluctance to seek help and strategies for combatting stigma
It was striking to see a limited number of medical students receiving psychiatric treatment despite the high rate of depressive and anxiety symptoms. Literature highlights various reasons for not seeking psychiatric help including poor insight, denial of illness, stigma of psychiatric illness, and fear of negative impact of students’ academic record and future career [22, 23] Realizing the high level of psychological morbidity among medical students, participating institutions and affiliated hospitals administration established and publicized dedicated confidential support services under the leadership of psychiatry faculty to help medical students during the pandemic situation. Regular webinars were coordinated to engage students through various institutional and medical students’ forums promoting healthy lifestyle strategies, better social interactions, and ensuring access to psychological interventions. All medical students were encouraged to seek counseling help at any time, if feeling distressed. Interventions also included fostering close contact through regular phone contact and real-time video conferencing through tele-psychiatry services. This was much appreciated as it provided a sense of safety and security at a time of great psychological distress.
Clinical and policy implications of research
Study findings have important clinical and policy implications and serve to raise awareness that depression, anxiety, and suicidal ideation among medical students in Pakistan are prevalent and are unaddressed. There should be student wellness initiatives in medical colleges around the country to help with this dire situation. Regular reminders through official website/emails about proactive participation in self-care activities like exercise, good sleeping habits, balanced diet, engaging in relaxing enjoyable activities, and fulfilling relationships can act as a buffer against stress especially in vulnerable students. Uncertainty during the pandemic related to examinations and future career, etc. intensifies the students’ stress and anxiety, and institutions and educational leaders can mitigate this by regularly updating students about the future course of actions and plans. Provision of social support through virtual platforms and casual checking in e-mails/forums cannot be neglected as they help faculty and students to be there for one another in these challenging times without being physically present. They also allow students to reach out if needed. Clear and publicized policy by medical institutions about medical students who have a psychiatric history not to impact the medical college or residency applications in a negative way may help in reducing barriers for seeking help for mental health issues. Furthermore, the provision of confidential access to mental health professionals free of cost and preferably onsite as well as virtual access in medical colleges should be encouraged. Structured evidence-based programs as part of a formal wellness curriculum that are shown to reduce depression and anxiety like life skills training and mindfulness therapy may be considered by medical colleges in addition to the creation of student’s wellness committee and students mentoring from faculty [24, 25]. Discussion about mental health in campus by senior faculty including psychiatrists and psychologists on regular basis is likely to have a positive impact on help-seeking when students are feeling overwhelmed by stress, depression, and anxiety. These are particularly pertinent in Pakistan, where “concealing emotions” is the norm and there is a significant stigma towards seeking help from mental health professionals and is wrongly perceived by some students as a form of weakness [2, 26]. Well-coordinated campaigns at all levels to fight mental health stigma could be extremely useful.
Limitations
The study has several limitations. These include cross-sectional design, the possibility of selective participation being web-based survey, students’ own or their family members’ COVID infection history affecting their well-being, and the possibility of reluctance of students to report depressive symptoms and suicidal thoughts leading to underreporting, despite the survey being anonymous. It is also important to recognize that data synthesized in this study is based on self-reported inventories and disadvantages associated with self-report data (like response bias, sampling bias) may exist. Non-exclusion of respondents with a psychiatric history may also contribute to selection bias. Additionally, although standardized screening instruments were used, full diagnostic interviews based on Diagnostic and Statistical Manual-5 (DSM-5) criteria were not done. Despite the limitations, the present study has many notable strengths, including a large sample from five medical colleges, data from both public and private sector medical colleges, representation of medical students across all the academic years, and use of standardized and validated tools for screening of depression, anxiety, and suicidal risk.