161 International Journal of Human and Health Sciences Vol. 06 No. 02 April’22 Original Article A Cross Sectional Study on Scaling the Depression, Anxiety and Stress Level of Medical Students During COVID-19 in A Tertiary Level Medical Institution in India Anamika Nath 1 , Amarantha Donna Ropmay2, Daunipaia Slong3, Amar Jyoti Patowary4, Dev Ashis Ramu Damu5, Ankith Jonpelly6, Kishanth Shankar6, Prabal Das6 Abstract Background: Social distancing, closure of institutions and lockdown has impacted the minds of all. Medical students are no exception to this. Objective: This study was taken up to find out the level of depression, anxiety and stress of medical students during COVID-19. Methods: It was a cross- sectional study done at a tertiary institute for a period of one month in the middle of 2021. An online questionnaire, based on DASS 21 (Depression, Anxiety, and Stress Scale 21) scale, consisted of 7 questions each for each category viz. depression, anxiety and stress. While completing the DASS 21 questionnaire, each individual was required to indicate the presence of a symptom over the previous week. Chi-square test was used to analyze between the categorical variables. Results: Out of 183 study subjects, 16.39% had extremely severe depression, 13.66% extremely severe anxiety and 7.65% extremely severe stress. Development of anxiety with sex (p=0.04), and age (p=0.03), depression with age (p=0.02), development of depression with place of stay (p=0.04), and year of MBBS (p=0.0007) and anxiety with year of MBBS (p=0.0006) were found to be statistically significant. Conclusion: Development of depression, anxiety and stress in medical students must be recognized by the institution and measures for prevention like counselling facilities should be provided. Keywords: Depression, anxiety, stress, medical students, COVID-19. Correspondence to: Dr. Amar Jyoti Patowary, Professor & Head, Department of Forensic Medicine & Toxicology, North Eastern Indira Gandhi Regional Institute of Health & Medical Sciences (NEIGHRIMS), Shillong, Meghalaya, India, Email: drajpatowary@gmail.com 1. Demonstrator, Department of Forensic Medicine & Toxicology, Tezpur Medical College and Hospital (TMCH), Tezpur, Assam, India. 2. Associate Professor, Department of Forensic Medicine & Toxicology, North Eastern Indira Gandhi Regional Institute of Health & Medical Sciences (NEIGHRIMS), Shillong, Meghalaya, India. 3. Assistant Professor, Department of Forensic Medicine & Toxicology, North Eastern Indira Gandhi Regional Institute of Health & Medical Sciences (NEIGHRIMS), Shillong, Meghalaya, India. 4. Professor & Head, Department of Forensic Medicine & Toxicology, North Eastern Indira Gandhi Regional Institute of Health & Medical Sciences (NEIGHRIMS), Shillong, Meghalaya, India. 5. Assistant Professor, Department of Forensic Medicine & Toxicology, Sikkim Manipal Institute of Medical Sciences (SMIMS), Sikkim, India. 6. Postgraduate Trainee, Department of Forensic Medicine & Toxicology, North Eastern Indira Gandhi Regional Institute of Health & Medical Sciences (NEIGHRIMS), Shillong, Meghalaya, India. International Journal of Human and Health Sciences Vol. 06 No. 02 April’22 Page : 161-167 DOI: http://dx.doi.org/10.31344/ijhhs.v6i2.439 Introduction COVID-19 is a pandemic which has been spreading like a wildfire. There is no country which is spared from it. Along with any pandemic, comes the aftermaths of scarcity of resources, mortality and morbidity. One such morbidity is psychiatric and psychological diseases. On top of it, social distancing has made humans crave for human interactions and as such isolations and quarantines have possibly affected the minds of all. Restrictions on social gatherings and festivities have created a new normal situation. Social stigmas and taboos towards healthcare professionals are also seen to increase in recent times. Adjusting to this current scenario is a herculean task for all. Medical students who are the future care providers must be mentally strong in order to overcome any inadvertent situations that may arise during their International Journal of Human and Health Sciences Vol. 06 No. 02 April’22 162 trainings, medical practice or home affairs. WHO in its preamble to the constitution has taken a holistic approach of health, which includes a state of complete physical, mental and social wellbeing and not merely absence of disease or deformity as stated by the World Health Organization in its definition of health.1 Also, this pandemic has shown us increase in suicide rates amongst medical professionals. Also worries regarding completion of medical graduation may be there. Hence, the future doctors should be assessed for any psychological or psychiatric symptoms from time to time, in order to prevent any misadventure or tragedies. This study intended to assess the depression, anxiety and stress level in medical students of a centralized medical college in the northeast part of India. Depending on the results obtained from it, preventive measures and lifestyle modifications will be suggested. This research is the need of the hour as COVID-19 and the new normal situation it has brought, has affected the minds of all. Anxiety and depression are on the rise. Medical students, who are the future doctors, are no exception in this. This is the first of its kind research in Meghalaya state, India. Methods This was a cross-sectional study done in a tertiary level medical institution in India for a period of one month in the middle of 2021. Medical students who gave consent for participation in this research study were taken as study participants. Convenience sampling method was used. Online google forms were provided to them through their email address. Age, sex, study year of MBBS, place of stay – all were noted as independent variables. The dependent variables were the level of depression, anxiety and stress. The participation was totally anonymous. Consent forms were provided before the questionnaires if they agreed to participate in this study and then they were given an option to select and accordingly the page of questionnaire consisting of 21 questions; each could have been opened. Questionnaires were based on DASS 21 (Depression, Anxiety, and Stress Scale 21) scale and scores were given accordingly.2 It consisted of 7 questions each for each category viz. depression, anxiety and stress. While completing the DASS 21 questionnaire, each individual was required to indicate the presence of a symptom over the previous week. Each item was scored from 0 (did not apply to me at all over the last week), 1(Applied to me to some degree, or some of the time), 2(Applied to me to a considerable degree or a good part of time) and 3(applied to me very much or most of the time over the past week). Based on the scores, level of depression, anxiety and stress were determined. For depression, scores of 0-9 were considered normal, 10-14 as mild, 14-20 as moderate, 21-27 as severe, and more than 27 as extremely severe. For anxiety, scores of 0-7 were considered normal, 8-9 as mild, 10-14 as moderate, 15-19 as severe, and more than 19 as extremely severe. For stress, scores of 0-14 were considered normal, 15-18 as mild, 19-25 as moderate, 26-33 as severe, and more than 33 as extremely severe. Data were entered in Microsoft Excel software and had been analysed accordingly. Chi-square test was used to compare the categorical variables. Results Out of 183 participants, 22 (12.02%) were found to be having mild depression, 32 (17.49%) were found to have moderate depression and 22 (12.02%) were found to have severe depression, 30 (16.39%) were found to have extremely severe depression (Tables 1-4). Out of 183 participants, 8 (4.37%) were found to have mild anxiety, 36 (19.67%) were found to have moderate anxiety, 22 (12.02%) were found to have severe anxiety and 25 (13.66%) were found to have extremely severe anxiety (Tables 5-8). Out of 183 participants, 23 (12.56%) were found to have mild stress, 33 (18.03%) were found to have moderate stress, 28 (15.30%) were found to have severe stress, 14 (7.65%) were found to have extremely severe stress (Tables 9-12). Chi-square test was conducted to test significance of age, sex, year of MBBS and place of stay with development of depression, anxiety and stress. There was no statistically significant difference in development of depression with sex (p=0.866) and stress (p=0.564), but significant difference found in case of anxiety (p=0.04). Development of depression and anxiety with age was statistically significant (p=0.03 and p=0.02 respectively), but not with stress (p=0.11). Development of depression with place of stay was found to be statistically significant (p=0.04) except in anxiety (p=0.14) and stress (p=0.78). Difference in development of depression and anxiety with year of MBBS was found to be statistically significant (p=0.0007 and p=0.0006 respectively), except in stress (p=0.45). 163 International Journal of Human and Health Sciences Vol. 06 No. 02 April’22 Table 1: Distribution of levels of depression among participants based on sex Level of depression Male Female Total Percentage Normal 42 (44.21%) 35 (39.77%) 77 42.08 Mild 12 (12.63%) 10 (11.36%) 22 12.02 Moderate 16(16.84%) 16 (18.18) 32 17.49 Severe 12 (12.63%) 10 (11.36%) 22 12.02 Extremely severe 13 (13.68%) 17 (19.31%) 30 16.39 Total 95 88 183 100 Table 2: Distribution levels of depression among participants against age Level of depression 18 years 19 Years 20 Years 21 Years 22 Years 23 Years 24 Years 25 Years 26 Years Total Percentage Normal 0 2(20%) 7 (25.92%) 13 (40.62%) 21 (42%) 22 (64.70%) 10 (52.63%) 2 (25%) 0 77 42.08 Mild 0 2(20%) 4 (14.81%) 3 (9.37%) 4 (8%) 3 (8.82%) 3 (15.79%) 2 (25%) 1 (50%) 22 12.02 Moderate 0 0 4(14.81%) 9 (4.92%) 9 (18%) 5 (14.70%) 1 (5.26%) 3 (37.5%) 1 (50%) 32 17.49 Severe 1(100%) 3 (30%) 4 (14.81%) 1 (3.12%) 7 (14%) 2 (5.88%) 4 (21.05%) 0 0 22 12.02 Extremely severe 0 3 (30%) 8 (29.63%) 6 (18.75%) 9 (18%) 2 (5.88%) 1 (5.26%) 1 (12.5%) 0 30 16.39 Total 1 10 27 32 50 34 19 8 2 183 100 Table 3: Distribution levels of depression among participants against place of stay Level of depression Home Institution Total Percentage Normal 26 (45.61%) 51 (40.48%) 77 42.08 Mild 3 (5.26%) 19 (15.08%) 22 12.02 Moderate 14 (24.56%) 18 (14.28%) 32 17.49 Severe 9 (15.79%) 13 (10.32%) 22 12.02 Extremely severe 5 (8.77%) 25 (19.84%) 30 16.39 Total 57 126 183 100 Table 4: Distribution levels of depression among participants against year of MBBS Level of depression 1st year 2nd Year 3rd year part-I 3rd year part-II Total Percentage Normal 11 (25.58%) 15 (35.71%) 35 (66.04%) 16 (35.55%) 77 42.08 Mild 2 (4.65%) 8 (19.05%) 4 (7.55%) 8 (17.77%) 22 12.02 Moderate 8 (18.60%) 10 (23.81%) 7 (13.21%) 7 (15.55%) 32 17.49 Severe 7 (16.28%) 4 (9.52%) 4 (7.55%) 7 (15.55%) 22 12.02 Extremely severe 15 (34.88%) 5 (11.90%) 3 (5.66%) 7 (15.55%) 30 16.39 Total 43 42 53 45 183 100 International Journal of Human and Health Sciences Vol. 06 No. 02 April’22 164 Table 5: Distribution level of anxiety among participants based on sex Level of anxiety Male Female Total Percentage Normal 56(58.95%) 36 (40.91) 92 50.28 Mild 2(2.10%) 6 (6.81) 8 4.37 Moderate 19(20%) 17 (19.32) 36 19.67 Severe 10(10.53%) 12 (13.64) 22 12.02 Extremely severe 8(8.42%) 17 (19.32) 25 13.66 Total 95 88 183 100 Table 6: Distribution levels of anxiety among participants against age Level of anxiety 18 Years 19 Years 20 Years 21 Years 22 Years 23 Years 24 Years 25 Years 26 Years Total Percentage Normal 0 6 (60%) 9 (33.33%) 13 (40.62%) 23 (46%) 26 (76.47%) 12 (63.16%) 2 (25%) 1(50%) 92 50.28 Mild 0 0 1 (3.70%) 1 (3.12%) 2 (4%) 2 (5.88%) 1 (5.26%) 1 (12.5%) 0 8 4.37 Moderate 0 0 4 (14.81%) 10 (31.25%) 10 (20%) 4 (11.76%) 4 (21.05%) 3 (37.5%) 1 (50%) 36 19.67 Severe 1 (100%) 0 5 (18.52%) 5 (15.62%) 7 (14%) 2 (5.88%) 0 2(25%) 0 22 12.02 Extremely severe 0 4 (40%) 8 (29.63%) 3 (9.37%) 8 (16%) 0 2 (10.52%) 0 0 25 13.66 Total 1 10 27 32 50 34 19 8 2 183 100 Table 7: Distribution levels of anxiety among participants against place of stay Level of anxiety Home Institution Total Percentage Normal 28 (49.12%) 64 (50.79%) 92 50.28 Mild 1 (1.75%) 7 (5.55%) 8 4.37 Moderate 15 (26.31%) 21 (16.66%) 36 19.67 Severe 9 (15.79%) 13 (10.32%) 22 12.02 Extremely severe 4 (7.01%) 21 (16.66%) 25 13.66 Total 57 126 183 100 Table 8: Distribution levels of anxiety among participants against year of MBBS Level of anxiety 1st year 2nd year 3rd professional part-I 3rd professional part-II Total Percentage Normal 14 (32.56%) 21 (50%) 35 (66.03%) 22 (48.88%) 92 50.28 Mild 2 (4.65%) 1 (2.38%) 2 (3.77%) 3 (6.66%) 8 4.37 Moderate 5 (11.63%) 9 (21.43%) 8 (15.09%) 14 (31.11%) 36 19.67 Severe 7 (16.28%) 7 (16.66%) 6 (11.32%) 2 (4.44%) 22 12.02 Extremely severe 15 (34.88%) 4 (9.52%) 2 (3.77%) 4 (8.88%) 25 13.66 Total 43 42 53 45 183 100 165 International Journal of Human and Health Sciences Vol. 06 No. 02 April’22 Table 9: Distribution of levels of stress among participants based on sex Level of stress Male Female Total Percentage Normal 46 (48.92%) 39 (44.32%) 85 46.46 Mild 14 (14.74%) 9 (10.22%) 23 12.56 Moderate 15 (15.79%) 18 (20.45%) 33 18.03 Severe 15 (15.79%) 13 (14.77%) 28 15.30 Extremely severe 5 (5.26%) 9 (10.22%) 14 7.65 Total 95 88 183 100 Table 10: Distribution levels of stress among participants against age Level of stress 18 Years 19 Years 20 Years 21 Years 22 Years 23 Years 24 Years 25 Years 26 Years Total Percentage Normal 0 3 (30%) 9 (33.33%) 13 (40.62%) 24 (48%) 20 (58.82%) 11 (57.89%) 5 (62.5%) 0 85 46.46 Mild 0 2 (20%) 6 (22.22%) 3 (9.37%) 4 (8%) 4 (11.76%) 1 (5.26%) 1 (12.5%) 2 (100%) 23 12.56 Moderate 1 (100%) 3 (30%) 4 (14.81%) 8 (25%) 10 (20%) 2 (5.88%) 4 (21.05%) 1 (12.5%) 0 33 18.03 Severe 0 1 (10%) 6 (22.22%) 3 (9.37%) 7 (14%) 8 (23.53%) 2 (10.53%) 1 (12.5%) 0 28 15.30 Extremely Severe 0 1 (10%) 2 (7.41%) 5 (15.62%) 5 (10%) 0 1 (5.26%) 0 0 14 7.65 Total 1 10 27 32 50 34 19 8 2 183 100 Table 11: Distribution levels of stress among participants against place of stay Level of stress Home Institution Total Percentage Normal 23 (40.35%) 62 (49.20%) 85 46.46 Mild 9 (15.79%) 14 (11.11%) 23 12.56 Moderate 11 (19.30%) 22 (17.46%) 33 18.03 Severe 10 (17.54%) 18 (14.28%) 28 15.30 Extremely severe 4 (7.01%) 10 (7.94%) 14 7.65 Total 57 126 183 100 Table 12: Distribution levels of stress among participants against year of MBBS Level of stress 1st Year 2nd year 3rd professional part-I 3rd professional part-II Total Percentage Normal 15 (34.88%) 18 (42.85%) 31 (58.49%) 21 (46.66%) 85 46.46 Mild 5 (11.62%) 6 (14.28%) 8 (15.09%) 4 (8.88%) 23 12.56 Moderate 10 (23.25%) 7 (16.66%) 9 (16.98%) 7 (15.55%) 33 18.03 Severe 8 (18.60%) 7 (16.66%) 3 (5.66%) 10 (22.22%) 28 15.30 Extremely severe 5 (11.62%) 4 (9.52%) 2 (3.77%) 3 (6.66%) 14 7.65 Total 43 42 53 45 183 100 International Journal of Human and Health Sciences Vol. 06 No. 02 April’22 166 Discussion On March 18, 2020, WHO has released one pamphlet named “Mental health and psychosocial considerations during the COVID-19 outbreak”, where special mention has been given to mental wellbeing of healthcare professionals since it is expected that they will be under increased pressure of work and deprivation of sleep. Many might cope up stress by unhelpful strategies like addiction to tobacco, alcohol, drugs also being victims of taboos and social stigma from family members and community; they might undergo anxiety and mental depression.3 One article published in Journal of Intensive and critical care published on 10 June, 2020 stated that “During the COVID-19 out-break, the front-line Health Care Workers have experienced various levels of stress, anxiety, and insomnia. Targeted interventions are needed to enhance psychological wellbeing of Health Care Workers and strengthen the healthcare systems’ capacity during pandemic.4 Another article published in Journal of Experimental and Therapeutic medicine states similar scenarios where healthcare workers are dealing with unparalleled amount of stress during COVID-19.5 Many researchers are promoting digital learning packages for healthcare workers on how to cope up with stress as per an article published in International Journal of Environmental and Public Health.6 One research conducted on Australian Medical Students show that there was moderate psychological distress amongst them. There were main concerns about returning back to normal procedures of study and graduation. Deterioration of mental health since the onset of COVID-19 was reported by 68% of students. Main negative impacts were on social connectedness, studies and stress levels.7 One systemic review and meta- analysis shows that even before COVID-19 the overall prevalence of depression or depressive symptoms among medical students was 27.2%, and the overall prevalence of suicidal ideation was 11.1%. Among medical students who screened positive for depression, 15.7% sought psychiatric treatment.8 In Pakistan journal of medical sciences, one article was published regarding the impact of quarantine on medical students’ mental wellbeing and learning behaviours had findings that 44.1% showed a sense of being emotionally detached from family, friends and fellow students, 23.5% medical students felt disheartened. 56.2% of the total students stated that they had difficulty in studying and the time of studying was remarkably reduced. Medical students of both sexes has been found to have done work which were not satisfactory as compared to their earlier individual performances.9 Nicholas et al. summarized different studies conducted by researchers on medical students’ wellbeing and found out that near about 25% experienced tension manifestations, which were emphatically associated with expanded worries about scholarly deferrals, monetary impacts of the pandemic, and effects on day by day life.10 Hence anxiety and depression has been seen on rise amongst medical students therefore, this current study will provide an insight about similar conditions here and hence remedial measures can be taken. In our study we have found out that 42.08% of the subjects were normal while remaining had some levels of depression. In our study it is stated that 50.28% of the study subjects were normal while the rest had some levels of anxiety. Moreover, it was found out that 46.46% of the study participants were normal while the others had some levels of stress. It is, indeed, a sad state of affair that nearly half of the medical students have some or other levels of depression, anxiety and stress. A study conducted at Kathmandu University School of Medical Sciences, Nepal, revealed that 11.8% of students had anxiety, 5.5% had depression, and 9.4% had both anxiety and depression.11 Another study conducted at Jamnagar City by Vala and colleagues only on 1st year MBBS students during COVID-19 pandemic found that 17.20% of the students had anxiety, 15.60% of them had stress, and 10.80% had depression.12 Another study conducted by Pandey and colleagues, they found female medical students had higher anxiety and depression as compared to their male counterparts.13 In our study, females had more extreme levels of depression, anxiety and stress than the male participants. Those who lived in the institutional campus during the lockdown and could not go to their respective homes bore extreme levels of depression, anxiety and stress as compared to their friends who stayed at their homes with their families. Another study conducted by Saraswathi et al. found that levels of stress and anxiety in medical students had increased in COVID-19 and had factors affecting like gender, age, year of MBBS and place of stay but not prevalence of depression.14 All these studies put a light on the dark situation of medical students on matters of the mind which are often ignored by the institution, their teachers and even their family 167 International Journal of Human and Health Sciences Vol. 06 No. 02 April’22 and friends. These issues need to be addressed by formation of counselling cells for medical students and appointment of psychologists and psychiatrists who would be devoted for upliftment of mind and treating mental illnesses of medical students in every institute. Limitations This study was conducted on undergraduate students in a single medical institution. More studies in different institutes can be compiled for a better understanding on the levels of depression, anxiety and stress born by medical students in the current COVID-19 pandemic. Conclusion Our data suggest that among 183 study subjects, 16.39% had extremely severe depression, 13.66% extremely severe anxiety and 7.65% extremely severe stress. Development of anxiety with sex (p=0.04), and age (p=0.03), depression with age (p=0.02), place of stay (p=0.04), and year of MBBS (p=0.0007) and anxiety with year of MBBS (p=0.0006) were found to be statistically significant. Development of depression, anxiety and stress in medical students must be recognized by the respective institution and measures for prevention like counselling facilities should be provided. Conflict of interest: None declared. Ethical clearance: Ethical clearance received from institutional ethics committee of North Eastern Indira Gandhi Regional Institute of Health & Medical Sciences (NEIGHRIMS), Shillong, Meghalaya, India (NEIGR/IEC/M13/F3/2020). Funding statement: No funding. Authors’ contribution: Concept and design: AN, ADR, DS, AJP; data collection and analysis: AN, DARD, AJ, KS, PD; manuscript writing and revision: AN, ADR, DS, AJP, DARD, AJ, KS, PD. References: 1. World Health Organization (WHO). WHO_ constitution_en.pdf [Internet]. [cited Jan 12, 2021]. Available from: https://www.who.int/governance/eb/ who_constitution_en.pdf. 2. Lovibond PF, Lovibond SH. The structure of negative emotional states: comparison of the Depression Anxiety Stress Scales (DASS) with the beck depression and anxiety inventories. Behav Res Ther. 1995;33(3):335-43. 3. World Health Organization (WHO). Mental-health- considerations.pdf [Internet]. [cited Jan 8, 2021]. Available from: https://www.who.int/docs/default- source/coronaviruse/mental-health-considerations.pdf. 4. Jansson M, Rello J. Mental health in healthcare workers and the COVID-19 pandemic era: Novel challenge for critical care. J Intensive Crit Care. 2020;6(2):6. 5. Tsamakis K, Rizos E, Manolis AJ, Chaidou S, Kympouropoulos S, Spartalis E, et al. COVID-19 pandemic and its impact on mental health of healthcare professionals. Exp Ther Med. 2020;19(6):3451-3. 6. Blake H, Bermingham F, Johnson G, Tabner A. Mitigating the Psychological Impact of COVID-19 on healthcare workers: a digital learning package. Int J Environ Res Public Health. 2020;17(9):2997. 7. Lyons Z, Wilcox H, Leung L, Dearsley O. COVID-19 and the mental well-being of Australian medical students: impact, concerns and coping strategies used. Australas Psychiatry. 2020;28(6):649-52. 8. Puthran R, Zhang MWB, Tam WW, Ho RC. Prevalence of depression amongst medical students: A meta-analysis. Med Educ. 2016;50(4):456-68. 9. Meo SA, Abukhalaf AA, Alomar AA, Sattar K, Klonoff DC. COVID-19 pandemic: impact of quarantine on medical students’ mental wellbeing and learning behaviors. Pak J Med Sci. 2020;36(COVID19- S4):S43-8. 10. Grubic N, Badovinac S, Johri AM. Student mental health in the midst of the COVID-19 pandemic: A call for further research and immediate solutions. Int J Soc Psychiatry. 2020;66(5):517-8. 11. Risal A, Shikhrakar S, Mishra S, Kunwar D, Karki E, Shrestha B, et al. Anxiety and depression during COVID-19 pandemic among medical students in Nepal. Kathmandu Univ Med J (KUMJ). 2020;18(72):333-9. 12. Vala N, Vachhani M, Sorani A. Study of anxiety, stress, and depression level among medical students during COVID-19 pandemic phase in Jamnagar city. Natl J Physiol Pharm Pharmacol. 2020;10(12):1043-5.