This online survey indicates that almost one-third of the medical students in Nepal are mentally affected by covid-19 as a stressor in their daily lives. This applies even to those with no experience of exposure to covid-19. As a stressor, the virus represents a major unseen threat to life and to the health of the students, their families, friends, and community.
During the pandemic outbreak, the students’ levels of anxiety and depression go up. Around one-tenth score above the thresholds for comorbid anxiety and depression; and this group of students reported a high degree of possible covid-19 exposure. The potential contact with the virus leads to the highest reported distress in this population. The finding underscores the “dose-response” link between stressor exposure and the distress levels. Moreover, it is publicly well known that those who die from covid-19 often have an additional diagnosis [32]. In our study, those with a concurrent physical illness have higher occurrence of the comorbid HADS caseness.
Regarding caseness for anxiety only, more than 10% score above the threshold, and 5.5% do so for depression only. The frequency of anxiety cases is twice that of the depressive ones. In the stress paradigm when faced with threats, arousal, sympathetic activation of the fight-flight mode is the expected response, which is closely related to anxiety [33]. The high correlation between anxiety and depression among the students is in line with findings of a high co-occurrence of the two related to PTSD [34].
In their short lives, 13.5% of the medical students reported anxiety-related mental problems in the past, and 8.2% depression. In terms of point prevalence at the outbreak of the pandemic by means of HADS, 11.8% showed caseness of anxiety and 5.5% displayed caseness for depression. When looking at the figures from these two sources – past and now – the first figures reflect the numbers from an extended time period while the other is a momentary measure. Fear of infection among students may be one probable explanation for the high point prevalence found [6]
The Nepali government enforced social-distancing in addition to the shutdown and later a complete or partial lockdown in areas to combat the spread of the virus [20]. Schools, colleges and universities have been closed since March 2020, and most people including students are staying at home in self-quarantine. These restrictions may have been more stressful among the medical students in the higher classes, i.e., those in higher age bracket (> 22 years) displayed more anxiety and depression than their younger fellow students. With higher age and maturity, they may have recognized more fully what the covid-19 pandemic may entail. In addition, sedentary habits due to prolonged lockdown may have contributed to psychological distress [25].
Few or no classes and insufficient online teaching may have escalated the already high academic stresses of medical students and increased the uncertainty about their academic future [28]. Nepalese medical students tend to enjoy directly supervised teaching-learning rather than self-studies. A prior comparative study of medical students showed that a self-administered or non-authoritarian learning format was culturally less popular among the Nepalese students than in Western countries [35].
In the binary analysis, the number of days of self-quarantine was positively linked to the levels of anxiety. The perception of their adequacy of basic needs was negatively correlated with both anxiety and depression. These facts are in keeping with findings in a review which underscored that the length of the quarantine and insufficient basic living conditions or facilities, were linked to a negative psychological outcome [6]. However, the days in quarantine and the adequacy of basic needs did not emerge with significance in the multivariate analyses.
However, there were clear links between a history of mental problems and the medical students’ current levels of distress. This is in line with a case-control study from the hospital designated for covid-19 patients in China; it showed higher anxiety and depression scores among psychiatric patients than in healthy controls [15].Within the stress paradigm, research findings have shown that those with former anxiety and/or depression problems are more PTSD prone when exposed to major stressors [34, 36].
High prevalence of anxiety and depression in general among the adult population in Nepal has been well documented in a nationwide study [31]. The recent global burden of disease (GBD) survey data revealed depression and anxiety to be among the top ten disabling conditions in the world; extrapolated data in South Asia and Nepal also support these findings [37]. Higher degrees of general psychological distress in the form of anxiety and depression have also been reported among medical students in Nepal [27, 28]. The current global pandemic has added a sense of threat with surmounting stress [6, 11]. The levels of stress have gone up among college students, who during the pandemic were isolated in their homes, perhaps suffering from boredom and frustrations, loneliness due to limited social activities and learning opportunities. In addition comes the escalating academic and career-oriented uncertainties and pressures [25, 26].
An online survey in Nepal among healthcare workers involved in the pandemic revealed high levels of anxiety in almost 40% and depression in the 8% of the participants [21]. These healthcare workers were predominantly younger (mean age 29.5), close in age to the medical students. Another study assessing the psychological impacts of the lockdown in Nepal showed 25.4% of the participants to have anxiety and 7% reporting depression [22]. The findings of both studies are relevant, as the majority of the participants were doctors, and the participants in our study are the ‘future doctors’.
The study has some limitations. Being cross-sectional research, cause-effect relationships cannot be established. The population of medical students is not a representative drawn sample. However, the medical students form a fairly homogeneous group with regard to age and socio-demographic status, and in our study, they come from colleges from several parts of the country. Probably this makes the studied sample not too different from a representative sample. The findings may not easily be generalized to the general population but more likely to other kinds of health workers.
Face-to-face diagnostic interviews would have been preferable for establishing the frequencies of psychiatric disorders. However, that procedure for data collection would not have been advisable during the current pandemic. HADS has clearly demonstrated to be a valid screening instrument, both internationally [38] and in Nepal [30]. In this study, it indicates that the medical students experience an increase in mental burden in the context of the covid-19 pandemic. The above-mentioned national [21, 22, 24] and international [15, 25] studies also used online surveys; previous research has demonstrated that online surveys function as well as paper-and-pencil surveys [39]. In addition; online studies are safer for all parties during a pandemic. Also, online surveys are more convenient for the informant as they can choose the time and location for responding, which is assumed to lower the threshold for participating. Another issue of concern may be the self-rating of the adequacy of basic needs, which is an entirely a subjective expression.
Despite these limitations, we were able to form an understanding about the psychological impact of covid-19 as a mental stressor in a sample of medical students in Nepal. These students, being a literate group, were easily amenable for an online survey and self-administration of the HADS [29, 30]. The findings of this study call for a coordinated health strategy with special emphasis on upholding the mental health of health workers during times of a pandemic. Society is particularly dependent on their work in crisis of this kind.