High psychological distress among med students during pandemic: Local study 

• Researchers note need to design supportive strategies focused on students mental health needs 

BY Ruwan Laknath Jayakody

Since high rates of psychological distress were detected among medical students during the Covid-19 pandemic, supportive strategies that focus on the mental health needs of this population need to be designed. 

This recommendation was made in an original paper on the “Psychological impact and coping strategies of medical students during university closure due to Covid-19 in a State university in Sri Lanka” which was authored by Y.M. Rohanachandra, P.S. Alles and L. Amarakoon (all three attached to the University of Sri Jayewardenepura’s Medical Sciences Faculty’s Psychiatry Department) and S. Prathapan (attached to the same faculty’s Community Medicine Department) and published in the Sri Lanka Journal of Psychiatry 12 (2) in December 2021.

In an effort to prevent the spread of Covid-19, the Government closed universities on 13 March 2020, and thereby, all clinical rotations, lectures, small group discussions and practical sessions of medical students were temporarily suspended, while distant learning methods were employed to conduct lectures, tutorials and small group discussions. 

According to a Syrian study and “The global prevalence of anxiety among medical students: A meta analysis” by T.T.C. Quek, W.W.S. Tam, B.X. Tran, M. Zhang, Z. Zhang, C.S.H. Ho and R.C.M. Ho, highly competitive training, academic pressure, exposure to patients in clinical settings, financial constraints and the lack of sleep have been reported as factors that may contribute to medical students being an especially vulnerable group for the development of mental health problems such as psychological distress and anxiety. The global prevalence of depression among medical students, per R. Puthran, M.W. Zhang, W.W. Tam and R.C. Ho’s “Prevalence of depression amongst medical students: A meta analysis”, is as high as 28%. Also, per “Cultural variations in well-being, burnout and substance use amongst medical students in 12 countries” by A. Molodynski, T. Lewis, M. Kadhum, S.M. Farrell, M.L. Chelieh, T.F.D. Almeida, R. Masri, A. Kar, U. Volpe, F. Moir, J. Torales, J.M. Castaldelli-Maia, S.W.H. Chau, C. Wilkes and D. Bhugra, medical students are also at a higher risk of suicidal ideation, burnout, substance abuse and stress. C.E. Wimberly, H. Rajapakse, L.P. Park, A. Price, R.J. Proeschold-Bell and T. Ostbye’s “Mental well-being in Sri Lankan medical students: A cross sectional study” has demonstrated distress rates in Sri Lankan students to be higher than in other countries. 

Rohanachandra et al. noted that the loss of routines, structure and peer support networks due to the pandemic may also add to the psychological distress in medical students. Adapting to distant learning methods could also lead to additional psychological distress, especially in lower middle income countries, due to, as noted in S. Barteit, D. Guzek, A. Jahn, T. Bärnighausen, M.M. Jorge and F. Neuhann’s “Evaluation of electronic learning for medical education in low and middle income countries: A systematic review” and a South African study, difficulty in accessing online teaching as a result of narrow broadband widths and unreliable internet connectivity (the latter especially in rural areas), owing to many students only having basic smartphones to access the online learning content, electricity supply and limited resources such as laptops.

Therefore, Rohanachandra et al.’s study was carried out among medical students from the first to the final year of the University of Sri Jayewardenepura. A specifically designed questionnaire was used to collect data. 

The questionnaire was emailed to 939 students with a response rate of 56.1% (527). The majority of the respondents were female (369 – 70%). The mean (average) age of the participants was 23.48 years. The majority of the respondents were Sinhalese (467 – 88.6%). The highest number of respondents were students in their first year (158 – 30%), and of them, 31/5.9% had a past history of psychiatric disorders. 

The main worries among the medical students were about upcoming examinations (389 – 74.4%), taking a longer time than expected to complete their undergraduate career (356 – 68.1%), worries about contracting Covid-19 (239 – 45.7%), and concerns about difficulties in participating in distant learning (79 – 15.1%).

Of the respondents, 362/68.7% experienced difficulties in working up the initiative to engage in daily activities, 330/62.6% had the tendency to overreact to situations, 302/57.3% found it difficult to relax and 299/56.7% were unable to experience any positive feeling at all.

Of the participants, 40.8% had depressive symptoms, 34% had anxiety and 24.7% had high levels of stress. Depression, anxiety and stress were significantly higher in students with a past history of psychiatric disorders. Depressive symptoms were also significantly higher in first and second year students compared to fourth year students. Depression, anxiety or stress was not associated with gender, ethnicity, family income (above Rs. 25,000, between Rs. 25,000 and Rs. 50,000, between Rs. 50,000 and Rs. 100,000, between Rs. 100,000 and Rs. 250,000, or below Rs. 250,000) or the living circumstances (living arrangements during university attendance included travelling from home, residing at the hostel, residing at a boarding house or living with relatives).

The main reported coping strategies of participants during university closure was engaging more with the family (384 – 73.4%), watching television and movies (366 – 70%), preparing for examinations (348 – 66.5%) and listening to music (337 – 64.4%). Only about half of the students used social media networking as a coping mechanism.

Half of the students (267 – 50.7%) reported that they participate in all distant teaching sessions, while another 220/41.7% claimed to participate in most sessions (92.4% participated in all or most distant learning sessions, while only 2.5% participated in less than half of the distant learning sessions). The reasons for missing online teaching sessions, thus failing to participate in distant learning, were difficulties in affording data (43 – 8.2%, universities later took measures to create facilities such as Zoom accounts for all staff members through the Lanka Education and Research Network, thus allowing staff to host Zoom meetings free-of-charge for students while recorded lectures were uploaded on to the Learning Management System which could be accessed free-of-charge by the students), the lack of motivation for distant learning (38 – 7.2%) and the lack of internet facilities (14 – 2.7%).

None of the participants contacted the investigators for psychological support despite the contact details of the investigators being provided, with an invitation to contact the investigators if they feel that support is needed. Only 214/40.5% of all students provided their contact details and consented to be contacted by the investigators to provide support if high levels of depression, anxiety or stress were detected.

Discussing the findings, Rohanachandra et al. noted that less than half of the students (45.7%) were worried about contracting Covid-19 which may be explained by the fact that almost half of the sample (47.1%) comprised of first and second year students, who have not yet commenced clinical rotations, making them less likely to worry about contracting Covid-19. 

Despite challenges, participation in distant learning was satisfactory in the sample of students.

Since a majority of the medical students in Sri Lanka reside away from home during their university education, the lockdown may have provided them with an opportunity to spend more time with their family, which according to Rohanachandra et al. may explain why spending time with the family emerged as a more popular coping mechanism.

Although high levels of psychological distress were found in the participants, only 40.5% provided their contact details and consented to be contacted by the investigators of the Psychiatry Department to obtain support. This reluctance for low help seeking among medical students may be due to, per a South Indian study, stigma, fears about confidentiality, the fear of social exclusion and the lack of knowledge about the location of mental health services. In the current setting, Rohanachandra et al. explained, students get minimal face-to-face contact with the staff of the Psychiatry Department until they start their clinical appointments in the third year, and therefore, unfamiliarity with the department staff may also contribute to the low help seeking behaviour, with students, they opine, may be resorting to seeking help from their assigned personal tutor instead.

Moreover, Rohanachandra et al. added that the findings of this study also support previous recommendations made by C.I.S. Filho, W.C.D.L.V. Rodrigues, R.B.D. Castro, A.A. Marçal, S. Pavelqueires, L. Takano, W.L.D. Oliveira and C.I.S. Neto in the “Impact of the Covid-19 pandemic on the mental health of medical students: A cross sectional study using Generalised Anxiety Disorder Assessment – Seven and Patient Health Questionnaire – Nine Depression Test Questionnaires” that medical undergraduates should be screened for psychological disturbances and receive timely interventions during a pandemic. Rohanachandra et al. further recommended that since psychological distress was found to be much higher in students with a past history of mental health issues, arrangements should be made to closely monitor the mental health status of such students. 

“Furthermore, incorporating discussions on how Covid-19 may affect mental health as a part of distant learning may encourage help seeking behaviour in students. Providing information on how and where to obtain mental health services may also be useful, especially for first and second year pre-clinical students, who may be unfamiliar with mental health services. The Psychiatry Department plays a key role in providing such information and should take the lead in designing appropriate psychological support services within the Faculty. Department staff could offer to be freely available for in-person or online consultations for students and to refer to alternative mental health services when necessary. They can also take the lead in initiating discussions on the impact of Covid-19 on mental health and encourage help seeking behaviour in students,” the study concluded. 

If you feel that you or someone you know may be dealing with mental health issues and/or suicidal thoughts, the following institutions would assist you to deal with it: 

The National Institute of Mental Health: 1926 

Sri Lanka Sumithrayo: 0112 682 535 

Shanthi Maargam: 0717 639 898 

Courage Compassion Commitment (CCC) Foundation: 1333