|Year : 2021 | Volume
| Issue : 2 | Page : 27-32
Psychological effects of the coronavirus disease 2019 epidemic on medical students: A national cross-sectional survey of Mainland China
Qinghua Guan, Lianrui Guo, Zhu Tong, Yingfeng Wu, Yongquan Gu, Jianming Guo
Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
|Date of Submission||11-Feb-2021|
|Date of Decision||27-Feb-2021|
|Date of Acceptance||02-Mar-2021|
|Date of Web Publication||28-Jun-2021|
Dr. Jianming Guo
Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, Beijing
Source of Support: None, Conflict of Interest: None
OBJECTIVE: This study investigated the psychological effect of the coronavirus disease 2019 (COVID-19) outbreak on medical students in China.
METHODS: In February 2020, an online survey was performed using a WeChat app with an online survey program to collect and analyze the effects of the COVID-19 outbreak on the mental health of medical students across China.
RESULTS: Overall, 757 medical students responded to the survey. About 2.24% reported middle and high levels of anxiety since the COVID-19 outbreak began, and 14.40% reported middle and high levels of depression. Bachelor's students and those whose residence registration was located in a rural area were more likely to have anxiety and depression, compared with postgraduates and students whose residence registration location was an urban area, respectively.
CONCLUSIONS: The COVID-19 epidemic is associated with a low but real rate of psychological trauma in the medical students of China, and protective programs are needed to lessen this adverse effect.
Keywords: Anxiety, China, coronavirus disease 2019, depression, infectious disease outbreak, medical students
|How to cite this article:|
Guan Q, Guo L, Tong Z, Wu Y, Gu Y, Guo J. Psychological effects of the coronavirus disease 2019 epidemic on medical students: A national cross-sectional survey of Mainland China. Vasc Invest Ther 2021;4:27-32
|How to cite this URL:|
Guan Q, Guo L, Tong Z, Wu Y, Gu Y, Guo J. Psychological effects of the coronavirus disease 2019 epidemic on medical students: A national cross-sectional survey of Mainland China. Vasc Invest Ther [serial online] 2021 [cited 2021 Jul 27];4:27-32. Available from: https://www.vitonline.org/text.asp?2021/4/2/27/319595
| Introduction|| |
Since December 2019, the outbreak of coronavirus disease 2019 (COVID-19) in Wuhan, China has attracted worldwide attention. As of March 2, 2020, there were 80,174 confirmed cases of COVID-19 nationwide. The outbreak has caused unpredictable stress. The disease poses a great threat to people's life and safety, and this has brought psychological pressure on the residents of the affected areas and the entire country. In the face of large-scale infections of the public, medical staffs around the world have actively performed medical assistance that reflects their professional spirit. In normal times, medical personnel suffer daily high mental stress, and during epidemics the risk of psychological distress is often higher than that of the public.,,, Medical students generally have heavy academic burdens, and at the time of the outbreak many were already in teaching hospitals beginning internship rotation and participating in clinical practice.
This survey sought understanding of the presence and degree of anxiety and depression of medical students during this unusual time of disease outbreak, and provides a scientific basis for psychological crisis intervention.
| Methods|| |
This psychological questionnaire was a cross-sectional survey, open to all provinces of Mainland China. Each participant who filled out the questionnaire was effectively a volunteer. The research design, implementation, and evaluation were conducted by Professor Gu Yongquan's team at China National Clinical Center for Geriatric Disorders (Xuanwu Hospital Capital Medical University).
All the enrolled medical students were in Mainland China. Subgroup analyses were by education (undergraduate and postgraduate), gender, and region of residence (urban and rural).
Method and observe index
Each participant was required to provide demographic data including age, gender, place of residence, income, marital status, and education level. The survey tools for assessing psychological distress were the internationally recognized self-rating anxiety scale (SAS) and the Self-Rating Depression Scale (SDS)., SDS standard scores ≥50 were considered to reflect depressive symptoms, and scores of 50–59, 60–69, and ≥70 were defined as mild, moderate, and severe depression, respectively. SAS scores revealed levels of anxiety, and scores of 50–59, 60–69, and ≥70 were adjudged mild, moderate, and severe.
Data collection and statistical methods
All the collected data were processed by SPSS (20.0) software. The SAS and SDS scales were each analyzed to determine mean ± standard deviation. The means of the two groups were compared using the t-test, and the subgroup analyses were performed using the Mann-Whitney U test.
| Results|| |
Overall, there were 757 valid survey questionnaires collected, from 245 men (32.3%) and 512 women [67.6%; [Table 1]. Of them, 558 (73.71%) were 20-to-30 years old; and 698 (92.21%), 58 (7.66%), and 1 (0.13%) were unmarried, married, and divorced, respectively. The urban and rural populations were represented by 474 (62.62%) and 283 (37.38%) students.
Among the total study population of 757 students [Table 1], 425 (56.14%) were undergraduates; and among the 332 postgraduates, there were 278 and 54 in masters and doctoral programs, respectively, i.e., 36.72% and 7.13% of the total population. In addition, the study population comprised 126 scientific research graduates (37.55%), and 206 professional graduates (62.05%).
The source area covered all provinces in Mainland China [Table 2]. The top five regions were: Henan (358, 47.29%); Shanghai (52, 6.86%); Beijing (51, 6.73%); Shandong (30, 3.96%); and Hebei (27, 3.56%).
Among all the subjects, 576 (76.09%) acknowledged feeling anxiety and panic during the epidemic, while 181 (23.91%) never experiencing anxiety [Table 3]. The main factors leading to anxiety and panic included: Aggravation of the epidemic (463; 67.69%); lack of personal protective equipment (420, 61.40%), and reports by the media (263, 38.45%). Many participants (425, 62.13%) recognized they had no suitable method to solve their psychological distress, and so must endure or solve this on their own. A large majority (608, 80.32%) of participants believed that psychological interventions were necessary. Most participants (427, 56.41%) believed that psychological interventions should have been available during the initial outbreak to alleviate psychological distress.
The overall score of this study population for anxiety based on the SAS was 30.64 ± 7.71, which was significantly higher than the normal in China [29.78 ± 10.07, n = 1158; T anxiety = 3.07, P = 0.002; [Table 4]. The overall SDS score for depressive symptoms in the present population was 42.06 ± 12.33, which is statistically comparable with the general population (41.88 ± 10.57, n = 1340, t depression = 0.418, P = 0.676).
|Table 4: Self-rating depression scale and self-rating anxiety scale score distribution|
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The overall research sample of 757 students was divided into three sub-groups for analysis by education (undergraduate and graduate), gender, and residence area (urban and rural).
Undergraduate compared with graduate students
The median SDS score in the undergraduate group was 40, and the median SDS score in graduates was 39; the Mann-Whitney U test showed that the difference in SDS scores between the two groups was statistically significant [U = 64122.5, Z =–2.155, P = 0.031; [Table 5].
|Table 5: Self-rating depression scale and self-rating anxiety scale scores of undergraduates and postgraduates, n (%)|
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The median SAS score for undergraduates was 38, and the median SAS score for graduates was 35; the Mann-Whitney U test showed that the difference in SAS scores between the two groups was statistically significant [U = 62399.5, Z =–2.735, P = 0.006; [Table 5]. Thus, undergraduates had both higher SDS and higher SAS scores than did graduate students.
Men compared with women
The median SDS score in men was 39, and the median SDS score in women was 40 [Table 6]. The Mann-Whitney U test showed that there was no significant difference in SDS score between the two groups (U = 62317.5, Z =–0.143, P = 0.886).
|Table 6: Self-rating depression scale and self-rating anxiety scale scores of men and women*|
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The median SAS score in men was 38, and the median SAS score in women was 36 [Table 6]. The Mann-Whitney U test showed that there was no significant difference in SAS score between the genders (U = 58230, Z =–1.598, P = 0.110). There were no significant differences in SAS scores between men and women.
Comparison between students in residential towns and rural areas
The median SDS score in the urban group was 39, and the median SDS score in the rural group was 40 [Table 7]. The Mann-Whitney U test showed that there was a statistically significant difference in SDS scores between the two groups (U = 60481.5, Z =–2.266, P = 0.023). That is, the SDS score of the urban population was lower than that of the rural population.
|Table 7: Self-rating depression scale and self-rating anxiety scale scores by urban and rural residences*|
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However, the median SAS scores in both the rural and urban groups were 36, and the Mann–Whitney U-test results show that there was no significant difference in SAS scores between the two groups [U = 66147.5, Z = −0.318, P = 0.751; [Table 7].
| Discussion|| |
Mental support has been offered in medical school in China in recent years. Considering that medical education is in itself a stressful process, a previous study reported that local medical students showed elevated levels of depression, anxiety, and stress, and which differed by year or stage of education. Specifically, the levels of depression, anxiety, and stress were relatively low in the 1st year, but students in both the third and 5th year experienced considerable levels of these negative psychological states. Students' mental health may affect their academic attainment, social life, and the quality of service they provide to the community as future doctors. Furthermore, their own mental distress may influence the way they perceive mental health and pursuit of help in the care of their future patients.
The severe acute respiratory syndrome (SARS) outbreak occurred in China in 2003, and a large number of medical staff responded to this health crisis emergency. Wong et al. reported a cross-sectional questionnaire study that investigated perceived stress and psychological responses to the SARS outbreak in healthcare students, at the height of the outbreak in Hong Kong in 2003. All the groups reported high levels of perceived stress. In the context of the current new coronavirus pneumonia epidemic, medical students also are at high risk of psychological problems. Mass psychogenic illness can be difficult to differentiate from bioterrorism, rapidly spreading infection, or acute exposure to toxic substances. Early recognition and the appropriate response to such incidents can substantially benefit the outcome.
On January 27, 2020, the National Health Commission of China published a national guideline for psychological crisis intervention in response to the heightened spread of COVID-19, the disease caused by SARS coronavirus 2 infection. This publication marks the first time that guidance to provide multifaceted psychological protection of the mental health of medical workers was initiated in China. Studying the psychological situation of medical students in the context of this epidemic is very important to guide subsequent interventions.
The present study found that 76.09% of medical students said they experienced anxiety and panic associated with the COVID-19 epidemic. Indeed, the data showed that the SAS and SDS scores of medical students at this time were higher than normal in China. This indicates that this new coronavirus pneumonia can undermine the psychological state of medical students.
The subgroup analysis found that medical undergraduates had higher levels of psychological distress than did graduate students. This may be related to factors in the Chinese medical training system of undergraduates, including longer duration of studies, higher number of memory learning tasks, and more exams, relative to the work of graduates.
In this study, the men and women medical students were statistically similar with regard to scores for anxiety and depression. These results are in accord with that of Shuo and Zhengtu However, other studies in China found that men had higher rates of anxiety and depression symptoms,,, putatively because the genders differed in response to new situations and perception of subjective and objective pressures. In addition, the general social role expectation is that men should be more independent than women. Society or families have higher expectations for success of men. Thus, men have raised expectations for their futures, and levels of anxiety and depression are higher.
In the present study, the students in rural areas had a higher depression score compared with that of those in urban areas. This is consistent with Dechun et al., and may be related to the poorer public health conditions in rural areas and lack of personal protection materials. Thus, socioeconomic, cultural, and environmental factors also affect students, an important factor in mental health. This suggests that mental health support should help students cope with the effects of differences in socioeconomic culture, and help students from rural areas establish self-confidence and self-reliance.
Among the medical students surveyed in the present study, 78 (10.30%) expressed both anxiety and depression. The overlap between these two psychological problems may be due to subjective fear and have motoric dimensions.
This project found that 425 medical students (62.13%) had no outside means of coping with their psychological distress, and could only endure on their own. Of the 757 students overall, 608 (80.32%) thought that they needed psychological intervention, and 536 (76.68%) said they would seek help from a psychologist and use psychological counseling techniques and methods to help solve psychological problems, if available. In addition, 427 (56.41%) of the students responded that psychological intervention should be immediately offered when an epidemic emerges.
There are some limitations in this study. As a nationwide cross-sectional study, the sample size is small. Secondly, for assessing the mental distress of medical staff in response to the new coronavirus pneumonia, a scale should address particular features of this epidemic such as suddenness and lack of treatments. However, only the internationally recognized SDS and SAS scales were available, which are relatively simple with low sensitivity. Thus, the specific psychological pressures faced by medical students were difficult to sample.
| Conclusions|| |
Facing this epidemic, medical students reported a higher risk of anxiety. Timely psychological support and intervention is needed while fighting the epidemic, especially for undergraduates and medical students living in rural areas.
This project was supported by the Medjaden Academy and Research Foundation for Young Scientists (Grant No. COVID-19-MJA20200318).
Financial support and sponsorship
This work is supported by the National Key RandD Program of China (2017YFC1104100), the Beijing Municipal Administration of Hospitals Climbing Talent Training Program (DFL20150801), the Beijing Municipal Administration of Hospitals Incubating Program (PX2018035), and the Beijing Municipal Administration of Hospitals' Youth Program (QML20180804).
Conflicts of interest
There are no conflicts of interest.
| References|| |
Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al
. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020;395:497-506.
Shijin S. Social Psychology Shanghai Fudan University Press; 2003. p. 79-102.
Ling Y. Follow up study on the mental health of Ebola soldiers in Liberia [D].Third Mil Med Univ 2015,1:1-150.
Juan D, Yan Y, Tilong D, Tingting C. Participate in the survey of psychological status of nursing staff during emergency outbreak Treatment[J] .Nurs J Chin People's Liberation Army 2014;:49 51.
Association among character attributes and mental health among the staff in Medical Sciences Kermanshah University in 2015. J Med Life 2015;8:122-8.
Zung WW. A rating instrument for anxiety disorders. Psychosomatics 1971;12:371-9.
Zung WW. A self-rating depression scale. Arch Gen Psychiatry 1965;12:63-70.
Zhang MY. Handbook of Psychiatric Rating Scales, Hunan Science and Technology Press; 1993.
Wong JG, Patil NG, Beh SL, Cheung EP, Wong V, Chan LC, et al
. Cultivating psychological well-being in Hong Kong's future doctors. Med Teacher 2005;27:715-9.
Wong JG. Doctors and Stress. Hongkong Med Diary 2008;13:4-7.
Wong JG, Cheung EP, Cheung V, Cheung C, Chan MT, Chua SE, et al
. Psychological responses to the SARS outbreak in healthcare students in Hong Kong. Med Teach 2004;26:657-9.
Jones TF, Craig AS, Hoy D, Gunter EW, Ashley DL, Barr DB, et al
. Mass psychogenic illness attributed to toxic exposure at a high school [J]. N Engl J Med 2000;342:96-100.
Shuo L, Zhengtu C. Survey of anxiety and depression of freshmen and sophomores in medical schools [j].China Higher Med Educ 2014;07:7 8.
Weimin D, Yueqin H, Zhaorui L, Shuran L. Analysis of anxiety and depression symptoms and related factors of students in three universities in beijing during the SARS epidemic [j].Chin J Behav Med Sci 2004;(04):81 3.
Lin M, Fengyun Z, Yi L, Benyan Z, Xiangqun W. Tan Huanran. Investigation on emotional status of medical students and non medical students [j].China Med Equip 2006;03;46-48.
Fenglian F, Chunyang W, Yuran W, Suwan H, Haihai S. Investigation and analysis of anxiety and depression of medical college students [J]. J Hebei Med Univ 2018;39:636-9.
Dechun Z, Xiudan P, Huiying L, Jun M, Xusong Z. Investigation on the psychosocial factors of depression in medical college students [j].China Public Health 2005;04: 12 13.
Ying L. Depression and anxiety among elderly earthquake survivors in China [J]. J Health Psychol 2017;22:1869-79.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]