Symptoms of Anxiety, Depression, Stress, and Associated Variables Among Medical StudentsAbstract
Psychiatric disorders are more frequently reported in medical students when compared to other university students. This study aimed to investigate the prevalence of anxiety, depression and stress symptoms among medical students and associated variables. A hundred students responded to a Google forms questionnaire, including the instrument DASS-21, which was analyzed with Excel and Scipy. Results revealed a greater prevalence of stress (67,85%) and depression (67,86%) in the clinical cycle and anxiety (57,69%) in the basic cycle. The most associated factors included female gender, lower socioeconomic conditions, irregular eating habits, considering dropping out or taking a leave of absence, and no perceived support. Results showed a high prevalence of the symptoms, suggesting the need for new intervention techniques in the area.
Keywords:
anxiety; depression; stress; medical students
Resumo
Transtornos psiquiátricos são mais reportados entre acadêmicos de medicina, comparados a outros universitários. O objetivo deste estudo foi investigar a prevalência de sintomas de ansiedade, depressão e estresse entre estudantes de medicina e as variáveis associadas. Cem estudantes responderam a um questionário do Google Forms, incluindo a DASS-21, analisado com Excel e SciPy. Resultados mostraram predomínio de sintomas de estresse (67,85%) e depressão (67,86%) no ciclo clínico e de ansiedade (57,69%) no básico. As variáveis mais associadas aos sintomas foram sexo feminino, condições socioeconômicas inferiores, prática de atividades físicas e hábitos alimentares irregulares, consideração de abandonar ou trancar o curso e não percepção de apoio. Os resultados apontaram alta prevalência dos sintomas estudados, sugerindo a necessidade de novas técnicas interventivas na área.
Palavras-chave:
ansiedade; depressão; estresse; estudante; medicina
Mental disorders, including depression and anxiety, are recurrent in modern society and often associated with stress. According to the World Health Organization (WHO, 2022a), in 2019, there were 280 million people in the world living with depression and 301 million with anxiety. These disorders can compromise the quality of life in general, as in the case of depression, where there are risks of worsening and progression to suicide, whose statistics point to about 800,000 cases per year (Ribeiro et al., 2020).
Mental disorders affect all segments of the population, including 15% to 25% of university students, among whom anxiety and depression disorders predominate (Ribeiro et al., 2020). The highest frequency occurs among medical students (Puthran et al., 2016; Shawahna et al., 2020), generally associated with suicide, recognized as the second cause of death among them, and frequent in cases of major depression (Asfaw et al., 2020; Machado et al., 2019).
Multiple variables have been associated with mental disorders among these students, involving academic, sociodemographic, and psychosocial aspects. The conditions related to medical school itself are stressful, such as the extensive workload, highly complex curricular and extracurricular activities, competitiveness among peers, in addition to personal variables such as fear of failure, personal demand for high performance, and the need to meet socio-family expectations (Machado et al., 2019; Pacheco et al., 2017).
Among the stressors inherent to the study routine, exposure to peers during seminars and oral exams, and entering the internship period are mentioned, which implies new practices with patients, for which the still-inexperienced student fears the possibility of error (Machado et al., 2019). As the curriculum advances, exposure to human suffering and death increases, which is even more impactful for those unfamiliar with these situations (Brito et al., 2020). The structure of the program and the moment in which the practices begin are relevant aspects in this sense, as the older, fragmented, and very theoretical curricular structure is more associated with the impairment of the student's mental health (Pacheco et al., 2017).
The sociodemographic and psychosocial factors most associated with the risk of mental health impairment include female gender (Puthran et al., 2016), financial difficulties, maladaptive personality, and pre-existing mental health conditions (Pacheco et al., 2017); being non-heterosexual, non-white, having limited family income, low access to psychological support, and living alone or with peers (Demenech et al., 2021; Sacramento et al., 2021); and little social interaction, due to the use of time in academic activities, which limits the chances of being welcome and of well-being offered by third parties (Machado et al., 2019). The perception of being welcomed by colleagues involves the emotional, informative, material, social, and affective support that the individual understands as available when needed. This implies, in addition to the group’s behavior, each student’s personal characteristics and pattern of social interaction. The personal understanding of one's academic abilities, including performance or output and learning capacity, is another relevant variable that students frequently compare with those observed in other colleagues (Sherbourne & Stewart, 1991).
The mental health impairments of physicians and medical students are associated with academic and work conditions because they are generally identified in this context, but studies also show situations in which relevant symptoms are reported before entering college. A significant period is the preparation for university entrance exams, which implies changes in life routine, great competitiveness, failures, and concern with the expectations of family and friends (Machado et al., 2020). When researching indicators of anxiety, depression, and factors associated with these conditions, Ribeiro et al. (2020) applied the Hospital Anxiety and Depression Scale (HADS) to 355 medical students and found indicators of anxiety in 41.4% of them, followed by depression (8.2%) and the two simultaneous conditions (7.0%). The factors associated with the highest risk for anxiety were feeling lonely, having a history of psychiatric/psychological follow-up before entering medical school, and feeling morally injured in school. For depression and for the two simultaneous conditions, the main risk factors were also feeling alone and having a history of receiving psychiatric/psychological care before entering university.
Reviewing the literature on diagnosable mental health conditions among medical students, Pacheco et al. (2017) highlighted stress, anxiety, depression, sleep disorders, burnout, eating disorders, and alcohol use as dangerous. The studies showed a higher prevalence of anxiety (89.6%) and also pointed to the possibility of preexisting conditions at the time of entry into medical school. These findings suggest that the high rates of mental health problems among students can be associated with personal characteristics in a context of high competitiveness and not necessarily with the adverse characteristics of the academic environment. Another relevant study reported fewer depressive symptoms in the last years of the program. In this case, the possibility that students are undergoing psychological or psychiatric treatment and feel more confident in caring for patients, or that they have developed effective coping modes in the process of adapting to medical school, should be considered.
To assess the impact of new academic experiences, Brito et al. (2020) applied a questionnaire on the experience and perception of the topic of death and dying to 60 medical students at UNIVÁS in Minas Gerais. Among participants, 58% said they did not yet feel able to deal with terminality due to their inexperience in the area, the psychological aspects involved, and the repercussions of this work in the academic context. Another 16% reported being prepared to experience death, but not to act in the process of death and dying, which was attributed to little training in communicating bad news, including terminality.
As the literature shows, the mental health of medical students has been the focus of interest in several universities, considering the high prevalence of impairment among these students (Chiesa, 2020; Conceição et al., 2019; Moir et al., 2018). In this already worrying context, the COVID-19 pandemic emerged in 2020 as a variable that compromises health and quality of life in all social, academic, and hospital sectors.
In 2020, before the pandemic, the WHO estimated that 193 million people in the world suffered from major depressive disorder and 298 million suffered from anxiety, which meant, respectively, 2,471 and 3,825 cases for every 100,000 people. Considering the pandemic period, the initial estimate rose to 246 million, with 3,153 cases per 100,000 people for depressive disorders and 347 million with 4,802 cases for anxiety disorders (WHO, 2022b).
This new situation has led to the need for social distancing and has intensified aspects such as poor sleep quality due to an irregular routine and significantly increased time in front of electronic screens (Saraswathi et al., 2020). The pandemic demanded rapid adaptations, many of which were insufficient for teaching, where students began to depend on their own resources, on the personal search for study material, and had limited interactions with classmates and professors, increasing symptoms of stress, anxiety, and depression (Arima et al., 2020).
The pandemic situation emphasized the need for proposals that enable adequate psychological care for future professionals. To this end, it is essential to identify the compromised mental health conditions and the factors associated with this impairment in academic situations, which will allow the development of proposals appropriate to the general and specific demands of each context. Thus, this study was conducted to investigate the prevalence of symptoms of anxiety, depression, and stress among medical students, associated with the routine, academic semester of study, perception of support in the university environment, and self-perception of social and academic skills.
Method
Participants
The study included 100 undergraduate medical students of female and male genders, and the inclusion criterion was to be over 18 years of age and to be actively enrolled in the participating university during the period of data collection. Answers that were incompatible with the questions asked were excluded.
Instruments
The Google Forms platform was used for data collection. It included a questionnaire containing (a) the Informed Consent Form (ICF); (b) sociodemographic variables; (c) stressful variables or causes discomfort to the participant, with four blocks of questions related to interpersonal relationships at the university; activities, routines and habits; academic life; and well-being and the (d) Depression, Anxiety and Stress Scale (DASS-21).
The four blocks of questions included the following sub-themes: 1. Interpersonal relationships at the University, with 15 items on interaction with colleagues, professors, and administrative technicians; 2. Activities, Routine and Habits, with 7 items on the use of time for academic and personal activities such as physical exercise, sleep routine, and stress management; 3. Academic Life, with 10 items about the current semester, including stress in specific situations, consideration of withdrawing or taking a leave of absence, comparison with colleagues in the activities performed; and 4. Well-being and Mental Health, with 12 items, including perception of general stress, history of diagnosed mental health disorders, use of licit and illicit substances, and knowledge about the care service offered by the university.
The DASS-21 contains 21 items in Likert format, ranging from 0 (did not apply to me at all) to 4 (applied to me most of the time), which investigates the presence of symptoms of anxiety, depression, and stress, with 7 items for each factor. DASS-21 has been validated for use in Brazil, with a Cronbach's alpha of 0.92 for depression, 0.90 for stress, and 0.86 for anxiety, which indicates good internal consistency for each subscale (Vignola & Tucci, 2014). Higher scores indicate higher levels of anxiety, depression, and stress symptoms.
Procedure
Data collection
This is a cross-sectional study with non-probabilistic sample recruitment by convenience among medical students from the University of Brasília. To this end, invitations were sent via personal and institutional email to all 397 students actively enrolled in the university's undergraduate medical program, from October through December 2021. The emails and enrollment information were obtained from the coordination office and the academic center of the medical school. In all, 100 students aged 18 and over agreed to participate. The e-mail invitation included the questionnaire, which began with the ICF, which guaranteed anonymity and confidentiality, and asked for the indication of acceptance to participate in the research. Upon acceptance, the instrument opened with the questions. The last item of the questionnaire asked whether, if severe symptoms of the conditions evaluated were identified, the participant agreed to be contacted for referral to psychological or psychiatric care. If so, it was possible to include a telephone number or e-mail for contact. The estimated time to answer the questionnaire was 15 minutes. After selecting "send" at the end of the questionnaire, the completed instrument was sent directly to the responsible researcher.
Data analysis
The data analysis was descriptive and quantitative, conducted with resources from Microsoft Excel, Google SpreadSheets, and Python libraries pandas (McKinney, 2010; The pandas development team, 2022) and SciPy (Virtanen, P. et al., 2020). Mean and standard deviation were calculated for parametric data; the mode and statistical significance of differences in prevalence by the chi-square test of independence for non-parametric data; and a correlational analysis was performed between the symptoms and the questionnaire variables. For analysis, the data were grouped into three cycles, according to the current semester: (a) basic cycle, from the 1st to the 3rd semester; (b) clinical cycle, from the 4th to the 8th semester; and (c) internship, from the 9th to the 12th semester.
Ethical Considerations
This is a descriptive, quantitative, cross-sectional study, approved by the Research Ethics Committee in the Human and Social Sciences, in accordance with Resolutions 466/2012 and 510/2016.
Results
Among the 100 participants, 57 were female and 42 male (one did not declare), aged between 19 and 38 years (M = 23.1, SD = 3.97), 75% heterosexual, 47% white (83.3% white in the internship group), 31% brown, 14% black, 5% indigenous (one did not inform). The predominant socioeconomic level was high or medium-high (45%), followed by medium (32%) and medium-low or low (23%). In the internship group, the high and high-medium levels were more frequent (72.2%; p = 0.022) than in the other cycles; frequencies were 42.86% in the clinical and 30.77% in the basic cycle. Paid activities not linked to medical school were performed by 23 students, of whom 11 had completed a different degree; another 12, also graduates, did not work. Answers were obtained from all semesters, with the majority being in the 8th (n = 19), followed by the 4th (n = 15) and the 2nd (n = 11). The lowest participations were in the 11th (n = 1), 12th (n = 3), 5th (n = 5) and 9th (n = 5) semesters. Among the participants, 26 were in the basic cycle, 56 in the clinical cycle, and 18 in the internship.
The mean scores on DASS-21 were higher for stress symptoms (21.06), followed by depression (16.62) and anxiety (11.62), with frequencies of 63% for stress, 61% for depression, and 51% for anxiety, at different levels of severity (Table 1). Symptoms above the normal in the three factors were observed in 39 participants, with an extremely severe level in 13. Severe or extremely severe levels predominated in female students for stress (F = 53%; M = 26%; p = 0.015), depression (F = 40%; M = 29%; p = 0.3178) and anxiety (F = 35%; M = 21%; p = 0.2104); and among white participants (40%), with an average score one point above black, brown or indigenous people.
Students who performed work activities not associated with medical school had frequencies of 65.22% for stress, 65, 22% for depression, and 56.52% for anxiety. Those with a previous degree in a different program had frequencies of 74%, 69,56%, and 56.52%, and for those attending their first undergraduate program, the frequencies were 60%, 58.44%, and 50.65%, respectively.
Among the 63 students with stress symptoms above threshold, 42 had severe or extremely severe levels, with frequencies of 67.85% in the clinical cycle, 61.54% in the basic cycle, and 50% in the internship group (p = 0.387). The highest prevalence (80%) was in the sixth (87.5%) and fourth (75%) semesters.
Anxiety symptoms occurred for 51 participants, with a severe or extremely severe level for 30 of them. The highest prevalence at all levels occurred in the basic (57.69%) and clinical (57.14%) cycles. In the internship, this prevalence was 22.22%, with a significant difference in relation to the other cycles (p = 0.026). The highest frequencies occurred in the 1st (83.33%), 4th (73.33%), and 6th semesters (70%), with a predominance of the severe or extremely severe level in the 4th semester (46.67%), reaching 64.64% of the participants. The highest prevalence above threshold anxiety occurred in female students (F = 61.4%; M = 35.71%; p <0.05) and the lowest in the high and upper socioeconomic level (35.56% vs. 64.64%, p = 0.0095).
Depressive symptoms were reported by 36 students at severe or extremely severe levels, and by 25 others at the moderate or mild levels. The highest frequency was in the clinical cycle (67, 86%), followed by basic (61, 54%) and internship (38, 89%) (p = 0.09), and the lowest was in the high and upper socioeconomic levels (44.4% x 74.54%, p = 0.0042).
Variables associated with symptoms of depression, anxiety, and stress
The self-perception of sadness, anxiety, and stress corresponded, respectively, to the symptoms of depression, anxiety, and stress in DASS-21. Most of the participants who stated that they did not present these symptoms frequently also presented scores below the pathological threshold for symptoms. For anxiety alone, 40% of those who considered themselves anxious had normal symptoms according to DASS-21. Most of those who recognized symptoms of depression (38.24%), anxiety (37.8%), and stress (33.75%) said they had these symptoms "forever." Symptom onset was associated with the COVID-19 pandemic by 25 respondents, including sadness (n = 14), stress (n = 11), and anxiety (n = 7). Among them, 21 had some of these symptoms above threshold in the DASS; 2 were in the 12th semester and had normal or mild symptoms; and 19 were in the clinical cycle, most of them in the 4th (n = 7) and 8th (n = 6) semesters.
Having a history of psychiatric diagnosis was reported by 38 students, of whom 13 reported two or more diagnoses, the most frequent being Generalized Anxiety Disorder (n = 21) and Major Depressive Disorder (n = 21). Other diagnoses were Obsessive Compulsive Disorder (n = 4), Bipolar Disorder (n = 2), Attention Deficit Hyperactivity Disorder (n = 1), Social Anxiety Disorder (n = 1), and Panic Disorder (n = 1). Most were diagnosed after entering medical school, three of them during the pandemic, with higher frequencies for Generalized Anxiety Disorder (n = 15) and Major Depressive Disorder (n = 15). The mean DASS-21 scores were higher among those already diagnosed (20.47 ± 13.44) than among the others (12.95 ± 11.76). The occurrence of diagnoses was higher in the internship (55.6%), followed by the basic (39%) and clinical (36.5%) cycles.
Having already undergone psychiatric treatment was reported by 42 participants, among whom 3 reported never having received a diagnosis, and 3 preferred not to answer. Among the 38 diagnosed, 24 had undergone drug and psychotherapeutic treatment; 7 only drug treatment; 5 only had psychotherapeutic treatment, and 2 had no treatment at all. Those who received only drug treatment had the lowest mean symptom scores. In the basic and clinical cycles, depression and stress scores were higher among those who did not receive treatment, whether they were diagnosed or not. In the internship, all those already diagnosed (n = 10) had undergone some treatment, and their scores were higher than those of those who had not been diagnosed.
Having an irregular eating pattern was reported by 85 participants, among whom the levels of severe or extremely severe symptoms were 40% for depression, 34.12% for anxiety, and 47.06% for stress. Among the 15 who reported regular eating habits, these levels were 13.33%, 6.67%, and 13.33%, respectively (Table 2).
Physical activity was also associated with symptoms, with higher levels of severe or extremely severe activity among those who did not practice regularly. Among these, 60% had depression (p = 0.0046) and stress, and 40% had anxiety (Table 2).
Among the participants who used social networks for more than 2 hours a day, 46.67% had severe or extremely severe depressive symptoms. Among those who invested less time, 27.27% had the same symptoms (Table 2).
The perception of peer welcoming and support by professors was also associated with severe or extremely severe depressive symptoms, presented by 53% of those who did not feel included and by 19.61% of those who perceived themselves as included. Depressive symptoms were also presented by 52% of those who did not perceive support from professors and by 30.67% of those who perceived this support (Table 3).
Having considered taking a leave of absence or withdrawing from medical school was reported by 64 participants, among whom severe or extremely severe symptoms of stress (53%; p = 0.0052), depression (52%; p = 0.00004) and anxiety (38%; p = 0.051) were identified, with a similar proportion in the three cycles (61.1% to 66.1%). Among those who never considered these possibilities, the prevalence of the same symptoms and levels was 22%, 8%, and 16%, respectively (Table 3).
The reasons cited for considering a leave of absence or withdrawal from medical school were academic overload (n = 41), personal and/or family health problems (n = 26), and unsatisfactory academic performance (n = 25). The impeding factors were identification with medicine (n = 38), the most frequently reported, especially in the basic cycle (n = 12); the need to graduate quickly (n = 38), the most frequently reported in the clinical cycle (n = 26) and in the internship period (n = 8); having welcoming colleagues (n = 31); fear of stigma (n = 31); and family pressure (n = 27).
Sexual orientation, use of licit or illicit substances, religion, time spent studying (considering a cut-off time of 4 hours/day), and hours of sleep (considering a cut-off time of 7 hours/day) did not show a variation of more than two points in the mean scores of any of the symptoms evaluated.
Discussion
This study was conducted to investigate the levels of depression, anxiety, stress, and variables associated with symptoms among medical students at a Brazilian university. The findings are compatible with the literature (Barbosa-Medeiros & Caldeira, 2021), and the prevalence of depression (61%) and anxiety (51%) was even higher than those already documented in Brazil, such as 28.5% for depression and 37.7% for anxiety (Demenech et al., 2021). For stress, the prevalence found (63%) was similar to other high estimates that point, for example, to rates of 66.3% (Costa et al., 2020), 65% (Kam et al., 2019), and 60.09% (Lima et al., 2016). Among the symptoms assessed, 42% of stress, 36% of depression, and 30% of anxiety were in the severe and extremely severe levels, suggesting the severity of the current symptoms among the participants.
Some of the factors associated with symptoms were also consistent with the literature, such as considering a leave of absence or withdrawal from medical school (Nogueira et al., 2021), and the predominance among female students. Factors associated with this predominance were not investigated in this study but may be related to variables inherent to the demands of medical school, or to the female condition itself, as both the literature and the WHO report a higher frequency of these symptoms among women, without the cause being clear (Sacramento et al., 2021). The highest scores for anxiety and depression occurred among students of lower socioeconomic status, who have a lower prevalence in the internship group, and, thus, may be associated with the differences observed between cycles.
The COVID-19 pandemic may have favored the worsening of the mental health of the participants, especially considering the context of distance learning during this period and the consequent social isolation. WHO estimates by the Global Burden of Disease Study showed a 27.6% increase in cases of major depressive disorder and a 25.6% increase in anxiety disorders in the general population during the pandemic in 2020, with women and young people between 20 and 24 years old being more affected (WHO, 2022b). The findings of two studies supported this possible relationship with the pandemic. The first of these, conducted at the beginning of the pandemic, showed levels of anxiety and depression among students similar to those reported internationally in the pre-COVID literature (27.2 vs. 28% and 22.6 vs. 27.5%) (Ernst et al., 2021). In the second study, conducted during the pandemic, 81.4% of 656 students reported psychological or behavioral changes (Teixeira et al, 2021). In the present study, the data do not allow us to assess the influence of the pandemic context on the results; however, this possibility should be considered, comparing the results obtained with those found by Ernst et al. and Teixeira et al.
The prevalence of symptoms suggests greater impairment of participants' mental health during the clinical cycle, followed by the basics. In the internship, the rates were lower for the three symptoms, suggesting better psychological conditions. However, the report of psychiatric diagnoses was higher in the internship and lower in the clinical cycle, which may be due to conditions not yet diagnosed in the first two cycles. This possibility is consistent with data from the 6th semester, in which only one student reported having a diagnosis, and most had above-threshold symptomatology. It is also possible that some variables included in the questionnaire are not encompassed in DASS-21, such as ADHD or some other anxiety disorders, whose symptoms are not evaluated by the scale. It may be that students with prior diagnoses already had their symptoms minimized by treatment, although it would not account for all the cases, as some participants in the internship group who reported having undergone treatment had high scores. It should also be considered that the DASS-21 is a symptomatic assessment tool, and not a diagnostic tool. Because there was only one assessment, the results may describe a momentary condition that does not meet the criteria for a disorder.
The quality of life of medical students at the same university where this study was conducted was assessed in 2010-2011 using the WHOQOL-BREF and a sociodemographic questionnaire with academic and health data. A total of 84 students participated, of whom 92.5% reported symptoms of bad mood, despair, anxiety, and depression, which were considered frequent by 50% of them (Bampi et al., 2013). In our study, carried out 10 years later, using another instrument and after changes in the curricular structure, the mental health conditions of the students are similar. Even considering the pandemic period, the results reported here support the recurrence of risks to students' mental health and demand intervention proposals that change the context, avoiding possible adverse outcomes.
The prevalence of symptoms did not vary with hours of sleep, religious practice, and reported use of licit or illicit substances. Due to the small sample size and the low number of affirmative answers for substance use, the data are insufficient to suggest a possible non-association between the variables, which requires further studies focused on the topic.
The data here obtained demonstrate the possible association between the variables studied and symptoms of depression, anxiety, and stress, even though they do not imply a cause-and-effect relationship. The lower rates of symptoms among students who practiced physical activity, had better eating patterns and perceived more support from classmates and professors, for example, may be due to these behaviors. On the other hand, having fewer symptoms may have favored these students' interest in physical activity, better nutrition, and may have mediated the perception of the type of support offered by colleagues and professors. Thus, studies with specific and quasi-experimental designs, which allow the comparison between groups that present and those that do not present symptoms, are necessary for a better understanding of the possible correlations and causal relationships between the symptoms and the variables involved.
The promotion of a welcoming environment, evaluation and reduction of adverse situations by multidisciplinary teams and the revision of curricular structures can minimize the perception of the variables referred to as compromising well-being, favoring the way in which future physicians will conduct their own training. Procedures that stimulate and facilitate the relationship between peers and between students and professors, the inclusion of breaks in the timetables, and the alternation between longer and shorter, as well as more complex and simpler, activities would be adequate. Differentiated attention to these students’ health and hours of sleep is relevant and should be discussed among supervisors and professors, including sleep specialists.
A schedule that allows time for personal use, such as sports and leisure activities, could avoid the use of legal or illegal substances in the search for relief from symptoms of anxiety and depression. Possibilities already pointed out in the literature include offering courses on medical psychology, conversation circles, and training professors to deal with the context (Bassols et al., 2014). Initiatives of this nature may include psychological care, new activities, and curricular techniques with theoretical-practical support that favor training that stimulates greater confidence and serenity among future physicians. The individual search for psychotherapy, when necessary, is relevant and should be encouraged by professors themselves, which would facilitate the reduction of the recognized stigma on the subject among physicians.
This study showed consistency on the subject in different contexts and points to the great relevance of the mental health of these professionals, as well as the variables associated with them, for the medical scenario. As relevant contributions, updated data from a large university were presented, emphasizing the importance of developing procedures that can ensure better mental health conditions among medical students. In addition, the data were collected during the pandemic period, which emphasizes the high demand for work by these students and professionals, even during critical periods. As limitations, we have a small number of participants, which does not allow generalization of the results to the medical university community, and we do not have recent data in the country that allow comparison between samples from different universities. Another limiting point is the fact that the number of students in each semester of the program varied, and, especially, the participation of students from the internship period was low.
We also emphasize the fact that the pandemic scenario in which the study was conducted may have impacted the mental health of the general population, as pointed out by the literature review conducted by Min et al. (2021) on the possible long-term consequences of COVID-19. When comparing data from the pre- and post-pandemic periods and the long-term psychiatric implications observed in South Korea, the authors observed an increase in the rates of depression, anxiety, and psychological stress in all countries studied. Possible reasons for these results would be the occurrence of post-traumatic stress, long-term consequences of social restrictions, and maladaptive response to the "new normal". The crisis was global and so far unique, pointing to the need for more international research to understand, treat and prevent its effects on long-term mental health.
References
-
Arima, M., Takamiya, Y., Furuta, A., Siriratsivawong, K., Tsuchiya, S., & Izumi, M. (2020). Factors associated with the mental health status of medical students during the COVID-19 pandemic: a cross-sectional study in Japan. BMJ Open, 10(12), e043728 . https://doi.org/10.1136/bmjopen-2020-043728
» https://doi.org/10.1136/bmjopen-2020-043728 -
Asfaw, H., Yigzaw, N., Yohannis, Z., Fekadu, G., & Alemayehu, Y. (2020). Prevalence and associated factors of suicidal ideation and attempt among undergraduate medical students of Haramaya University, Ethiopia. A cross sectional study. PloS One, 15(8), e0236398. https://doi.org/10.1371/journal.pone.0236398
» https://doi.org/10.1371/journal.pone.0236398 -
Bampi, L. N. da S., Baraldi, S., Guilhem, D., Araújo, M. P. de, & Campos, A. C. de O. (2013). Qualidade de vida de estudantes de medicina da Universidade de Brasília. Revista Brasileira de Educação Médica, 37(2), 217-225. https://www.scielo.br/j/rbem/a/SDHzbdxpJ5ykdjndnYgqZ4K
» https://www.scielo.br/j/rbem/a/SDHzbdxpJ5ykdjndnYgqZ4K - Bassols, A. S. M., Okabayashi, L. S., Silva, A. B., Carneiro, B. B, Feijó, F., Guimarães, G. C., Cortes, G. N., Rohde, L. A., & Eizirik, C. L. (2014). First- and last-year medical students: Is there a difference in the prevalence and intensity of anxiety and depressive symptoms? Revista Brasileira de Psiquiatria, 36(3), 233-240.
-
Barbosa-Medeiros, M. R., & Caldeira, A. P. (2021). Mental health in medical students: longitudinal study. Brazilian Journal of Medical Education, 45(3), e187. https://doi.org/10.1590/1981-5271v45.3-20190285
» https://doi.org/10.1590/1981-5271v45.3-20190285 -
Brito, P.C.C., Sobreiro, I. M., von Atzingen, D. A. N. C., Silva, J.V., & Mendonça, A. R. A. (2020). Reflections on the terminality of life with undergraduate medical students. Brazilian Journal of Medical Education , 44(1), e033. https://doi.org/10.1590/1981-5271v44.1-20190213
» https://doi.org/10.1590/1981-5271v44.1-20190213 -
Chiesa, D. (2020). Mental health of Brazilian medical students [online]. SciELO in Perspective - Press Releases https://pressreleases.scielo.org/blog/2020/06/19/saude-mental-dos-estudantes-de-medicina-brasileiros/
» https://pressreleases.scielo.org/blog/2020/06/19/saude-mental-dos-estudantes-de-medicina-brasileiros/ -
Costa, D. S., Medeiros, N. S. B., Cordeiro, R. A., Frutuoso, E. S., Lopes, J. M., & Moreira, S. M. T. (2020). Symptoms of depression, anxiety and stress in medical students and institutional coping strategies. Brazilian Journal of Medical Education , 44(1) e040. https://doi.org/10.1590/1981-5271v44.1-20190069
» https://doi.org/10.1590/1981-5271v44.1-20190069 -
Demenech, L. M., Oliveira, A. T., Neiva-Silva, L., & Dumith, S. C. (2021). Prevalence of anxiety, depression and suicidal behaviors among Brazilian undergraduate students: A systematic review and meta-analysis. Journal of Affective Disorders, 282, 147-159. https://doi.org/10.1016/j.jad.2020.12.108
» https://doi.org/10.1016/j.jad.2020.12.108 -
Ernst, J., Jordan, K.-D., Weilenmann, S., Sazpinar, O., Gehrke, S., Paolercio, F., Petry, H., Pfaltz, M. C., Méan, M., Aebischer, O., Gachoud, D., Morina, N., von Känel, R., & Spiller, T. R. (2021). Burnout, depression and anxiety among Swiss medical students - A network analysis. Journal of Psychiatric Research, 143, 196-201. https://doi.org/10.1016/j.jpsychires.2021.09.017
» https://doi.org/10.1016/j.jpsychires.2021.09.017 -
Kam, S. X. L., Toledo, A. L. S., Pacheco, C. C., Souza, G. F. B., Santana, V. L. M., Bonfá-Araujo, B., & Custódio, C. R. S. N. (2019). Stress in undergraduate medical students. Brazilian Journal of Medical Education , 43(1 suppl 1), 246 - 253. https://doi.org/10.1590/1981-5271v43suplemento1-20180192
» https://doi.org/10.1590/1981-5271v43suplemento1-20180192 -
Lima, R. L., Soares, M. E. C., Prado, S. N., & Albuquerque, G. S. C. (2016). Stress among medical students and academic performance. Brazilian Journal of Medical Education , 40(4), 678-684. https://doi.org/10.1590/1981-52712015v40n4e01532015
» https://doi.org/10.1590/1981-52712015v40n4e01532015 -
Machado, S. L. M., Sirico, N. S., Barbosa, P. F., & Rosa, R. R. M. (2019). Ansiedade e depressão em estudantes de medicina [Anxiety and depression in medical students]. Revista Saúde Multidisciplinar, 6(2), 1-5. https://www.fampfaculdade.com.br/wp-content/uploads/2019/10/Art-14.pdf
» https://www.fampfaculdade.com.br/wp-content/uploads/2019/10/Art-14.pdf -
McKinney, W. (2010). Data structures for statistical computing in python. In van der Walt, S., & Millman, J. (Eds.), Proceedings of the 9th Python in Science Conference (pp. 56- 61). SciPy. https://doi.org/10.25080/Majora-92bf1922-00a
» https://doi.org/10.25080/Majora-92bf1922-00a -
Min, S., Jeong, Y. H., Kim, J., Koo, J. W., & Ahn, Y. M. (2021). The Aftermath: Post-pandemic psychiatric implications of the COVID-19 pandemic, a South Korean perspective. Frontiers in Psychiatry, 12, 671722. https://doi.org/10.3389/fpsyt.2021.671722
» https://doi.org/10.3389/fpsyt.2021.671722 -
Moir, F., Yielder, J., Sanson, J., & Chen, Y. (2018). Depression in medical students: current insights. Advances in Medical Education and Practice, 7(9), 323-333. https://doi.org/10.2147/AMEP.S137384
» https://doi.org/10.2147/AMEP.S137384 -
Nogueira, É. G., Matos, N. C. de, Machado, J. N., Araújo, L. B. de, Silva, A. M. T. C., & Almeida, R. J. de. (2021). Evaluation of anxiety levels and their associated factors in medical interns. Brazilian Journal of Medical Education , 45(1). https://doi.org/10.1590/1981-5271v45.1-20200174
» https://doi.org/10.1590/1981-5271v45.1-20200174 -
Pacheco, J. P., Giacomin, H.T., Tam, W. W., Ribeiro, T. B., Arab, C., Bezerra, I. M., & Pinasco, G. C. (2017). Mental health problems among medical students in Brazil: A systematic review and meta-analysis. Revista Brasileira de Psiquiatria , 39(4), 369-378. https://doi.org/10.1590/1516-4446-2017-2223
» https://doi.org/10.1590/1516-4446-2017-2223 -
Puthran, R., Zhang, M. W. B., Tam, W. W., & Ho , R. C. (2016). Prevalence of depression amongst medical students: a meta-analysis. Medical Education, 50(4), 456-468. https://doi.org/10.1111/medu.12962
» https://doi.org/10.1111/medu.12962 -
Ribeiro, C. F., Lemos, C. M. C., Alt, N. N., Marins, R. L. T., Corbiceiro, W. C. H., & Nascimento, M. I. (2020). Prevalence of and factors associated with depression and anxiety in Brazilian medical students [Prevalência de fatores associados à depressão e ansiedade em estudantes de medicina Brasileiros]. Revista Brasileira de Educação Médica , 44(1), e021. https://doi.org/10.1590/1981-5271v44.1-20190102.ING
» https://doi.org/10.1590/1981-5271v44.1-20190102.ING -
Sacramento, B. O., Anjos, T. L. dos, Barbosa, A. G. L., Tavares, C. F., & Dias, J. P. (2021). Symptoms of anxiety and depression among medical students: study of prevalence and associated factors. Brazilian Journal of Medical Education , 45(1), e021. https://doi.org/10.1590/1981-5271v45.1-20200394.ing
» https://doi.org/10.1590/1981-5271v45.1-20200394.ing -
Saraswathi, I., Saikarthik, J., Senthil Kumar, K., Madhan Srinivasan, K., Ardhanaari, M., & Gunapriya, R. (2020). Impact of COVID-19 outbreak on the mental health status of undergraduate medical students in a COVID-19 treating medical college: a prospective longitudinal study. PeerJ, 8, e10164. https://doi.org/10.7717/peerj.10164
» https://doi.org/10.7717/peerj.10164 -
Shawahna, R., Hattab, S., Al-Shafei, R., & Tab’ouni, M. (2020). Prevalence and factors associated with depressive and anxiety symptoms among Palestinian medical students. BMC Psychiatry, 20(1), 244. https://doi.org/10.1186/s12888-020-02658-1
» https://doi.org/10.1186/s12888-020-02658-1 -
Teixeira, L. de A. C., Costa, R. A., Mattos, R. M. P. R. de, & Pimentel, D. (2021). Mental health during coronavirus disease 2019 pandemic. Brazilian Journal of Psychiatry, 70(1), 21-29. https://doi.org/10.1590/0047-2085000000315
» https://doi.org/10.1590/0047-2085000000315 -
The pandas development team (2022).Pandas-dev/pandas: Pandas 1. 4. 3(Version v1.4.3) [Computer software]. Zenodo. https://doi.org/10.5281/zenodo.6702671
» https://doi.org/10.5281/zenodo.6702671 -
Vignola, R. C. B., & Tucci, A. M (2014). Adaptation and validation of the depression, anxiety and stress scale (DASS) to Brazilian Portuguese. Journal of Affective Disorders , 155, 104-109. http://doi.org/10.1016/j.jad.2013.10.031
» http://doi.org/10.1016/j.jad.2013.10.031 -
Virtanen, P., Gommers, R., Oliphant, T. E., Haberland, M., Reddy, T., Cournapeau, D., Burovski, E., Peterson, P., Weckesser, W., Bright, J., Van Der Walt, S. J., Brett, M., Wilson, J., Millman, K. J., Mayorov, N., Nelson, A. R. J., Jones, E., Kern, R., Larson, E., … Vázquez-Baeza, Y. (2020). SciPy 1.0: Fundamental algorithms for scientific computing in Python. Nature Methods, 17(3), 261-272. https://doi.org/10.1038/s41592-019-0686-2
» https://doi.org/10.1038/s41592-019-0686-2 -
World Health Organization (WHO) (2022a). World mental health today. In World mental health report: Transforming mental health for all (pp. 35-65). World Health Organization. https://iris.who.int/bitstream/handle/10665/356119/9789240049338-e ng.pdf?sequence=1
» https://iris.who.int/bitstream/handle/10665/356119/9789240049338-e ng.pdf?sequence=1 -
World Health Organization (WHO) (2022b). Mental health and COVID-19: Early evidence of the pandemic’s impact: scientific brief World Health Organization. https://apps.who.int/iris/handle/10665/352189
» https://apps.who.int/iris/handle/10665/352189
Research data is available on request from the corresponding author.
