Mental Distress after 1 Wave of COVID-19 among Medical Students

Aim: The aim of the current study is to evaluate the mental distress facing by the MBBSs students during the first wave of COVID-19. Study Design: Cross-sectional. Place and Duration of Study: Study was conducted at Quaid-e Azam medical college Bahawalpur during the period of May 2020 to July 2020. Methodology: MBBS undergraduate students were included in the study. For assessing mental Original Research Article Khurram et al.; JPRI, 32(44): 7-12, 2020; Article no.JPRI.64495 8 stress, the questionnaire used was the modified form of Impact of Event Scale Revised (IES-R). The proforma was prepared by using Google Docs and disseminated through the student’s WhatsApp groups. Data was analyzed by using Special Package for Social Science version-20. Frequency and percentages were calculated for the qualitative variables while association was analyzed by using Chi-square test. p-value ≤0.05 was considered as significant. Results: About half of the participants were female students i.e. 55.2%. The frequency distribution of stress level among students showed that the majority of participants were facing mild level of stress i.e. 130 participants out of total 310 participants (41.9%), 112 participants were having moderate stress level (36.2%), followed by 53 participants with severe level of stress (17.1%) while 15 participants (4.8%) were having extremely severe intensity of stress. It was also found out that the gender and socioeconomic status have a significant association with the mental stress but the year of study has no any association with the mental stress as reported statistically non-significant p-value. Conclusion: The current study concluded that the mental distress experienced by medical undergraduate during COVID-19 is more severe than that of the general population and the female students are more prone to develop depressive symptoms. So there is a need of counselling session to improve the mental health of our medical under graduates as they are the future handlers of medical profession.


INTRODUCTION
Unfortunately, the pandemic situation of Corona virus disease-2019 (COVID-19) made the year 2020, a very stressful year with the fear of disease, uncertainty of living and the grief of losing the beloved ones [1]. This pandemic disease started from Wuhan, a city of China in 2019 and within no time spread out globally, causing an unrepairable damage. The COVID-19 enveloped the Pakistan also with its disastrous effects [2]. Till date the cases in Pakistan reaching up to 477,240 positive cases out of total 6,656,373 cases which were tested for COVID-19 [3]. These are the cases which were affected by the disease physically but there are number of people who are mentally stressed as well leading to anxiety and depression. People belonging to different socioeconomic status or occupation are facing different level of mental stress depending upon how the COVID-19 influencing their daily routine like most of the people lose their job or business due to the lockdown [4].
Mental health is one of the most important concern during the current pandemic situation as WHO alarmed the increase burden of depression globally [5]. Looking over the younger generation, the students are also affected physically as well as mentally, specifically the MBBS medical students. Due to increased rate of infectivity the medical colleges suspended all of their educational activities as a preventive measure and started online classes which created mental distress and uncertainty about their future and fear of being at high risk of infection [6].
Medical students are usually at higher risk of developing mental distress because of few reasons including studies burden, risk of infection, exposure to infected people [7]. MBBS students are actually the cream among the students, the most brilliant mind so their mental health is of main concern as they are the future doctors to hold the disease burden on their shoulders [8]. The aim of the current study is to evaluate the mental distress facing by the MBBSs students during the first wave of COVID-19.

METHODOLOGY
A cross-sectional study was conducted at Quaide Azam medical college Bahawalpur during the period of May 2020 to July 2020. Convenient sampling technique was used. Only MBBS undergraduate students were included in the study. Those who either refused to give consent or not completely filled the form or started house job or graduated or post-graduated or previously diagnosed cases of Psychiatric disorders were excluded. For assessing mental distress, the questionnaire used was the modified form of Impact of Event Scale Revised (IES-R) [9]. IES-R scale is the most reliable method to assess the mental distress after any traumatic event. The proforma was prepared by using Google Docs and disseminated through the student's WhatsApp groups.
Data was analyzed by using Special Package for Social Science (SPSS) version-20. Frequency and percentages were calculated for the qualitative variables while association of mental stress with the gender, socioeconomic status and year of study was calculated by using Chi-square test. p-value ≤0.05 was considered as significant.

RESULTS
About 400 students were enrolled in the study out of which 310 students fill the proforma completely. Among them, majority were female students i.e. about 55.2% while the males were 44.8%. MBBS students from all years were included in the study, the majority were from 3 rd year (31.6%) followed by 2 nd year (25.5%), then 4 th year (18.1%) followed by final year (13.5%) and the minimum participants were from 1 st year (11.3%) as mentioned in Table 1. Looking over the association between demographic variables and the mental stress, it was found out that the gender has a significant association with the mental stress with p-value 0.013, in the same way socioeconomic status also showed a strong association with mental stress as p-value was 0.002 but the year of study has no any association with the mental stress as reported statistically non-significant p-value.
The mental stress experienced by medical students after 1 st wave of COVID-19 was categorized on the basis of severity level as mild, moderate, severe and extremely severe stress. The frequency distribution of stress level among students showed that the majority of participants were facing mild level of stress i.e. 130 participants out of total 310 participants (41.9%), 112 participants were having moderate stress level (36.2%), followed by 53 participants with severe level of stress (17.1%) while 15 participants (4.8%) were having extremely severe intensity of stress as mentioned in Fig. 1.
Finally, the severity of mental stress among different years of MBBS students were calculated. The results showed that the majority of 1 st year students have mild level of stress (37.1%) followed by moderate intensity (29.4%) then severe intensity (22.3%) and the minimum number (11.2%) of cases with extremely severe level of stress. Looking over the 2 nd year students, the intensity of stress among cases were followed the same sequence as that of 1 st year students with frequency of mild, moderate, severe and extremely severe level of stress (33.1%, 31.4%, 22.3% and 13.2% respectively). Among 3 rd year students, majority of students were facing moderate level of stress (30.4%) followed by mild level (27.1%) then severe level (25.3%) and minimum number with extremely severe level (17.2%). Focusing 4 th year students, the cases of moderate and severe stress level were almost equal (29.4% and 27.3% respectively), followed by mild level (24.1%) then extremely severe level of stress (19.2%). The final year students were having more cases of severe intensity of stress (29.3%) followed by moderate (26.4%) and extremely severe stress (25.2%) and then mild stress level (19.1%). The results showed that severity of mental stress were increasing with the graduating year as presented in Fig. 2.

Fig. 1. Level of mental stress among MBBS students after COVID-19
Mild Moderate Severe Extremely sever

DISCUSSION
Current study reported that majority of study participants were female because in all over Pakistan there are more female MBBS students in the medical colleges as compare to the male students. This finding is supported by many other studies done among medical students of different medical colleges in different cities of Pakistan [10,11]. In current study majority of the participants were from 3 rd year and 2 most possible explanation for this might be due to the interest of these students in research study while the remaining years are overburdened because of the tough schedule of lectures and clinical rotations. One of the study done in Sahiwal reported more students were from 4 year while another study from Karachi reported majority students were from final year, because of their participation in data collection  year, the most possible explanation for this might be due to the interest of these students in research study while the remaining years are overburdened because of the tough schedule of lectures and s. One of the study done in Sahiwal reported more students were from 4 th her study from Karachi reported majority students were from final year, because of their participation in data collection [10,12].
Literature review revealed great level of stress among medical undergraduate students because of their somehow medical knowledge about COVID, increasing death rate, closure of universities and spread of fear [13] on MBBS students of Sahiwal medical college reported stress rate of about 54.10% same way Rajkumar et.al reviewed the overall literature to find out the mental health during COVID-19 and he calculated the stress rate of about 53.20% [14]. Current study also reported that majority of the participants were having mild to moderate level of mental stress i.e. 41.9%. All the studies manifested the poor mental health of undergraduate students, studying in different medical colleges of Pakistan. Such level of mental distress causing COVID pathogenicity to be more lethal, resulting in more outspread of fear [15].  [16] and the current study favored this finding by reporting 55.2% of the female students with significant association. Looking over the stress level among different years of MBBS, the current study manifested that 3 rd year and 2 nd year students were having moderate to severe level of mental stress during COVID-19 because of sudden closure of medical colleges, lockdown situation and uncertainty for professional exam [17,18].

CONCLUSION
The current study concluded that the mental distress experienced by medical undergraduate during COVID-19 is more severe than that of the general population and the female students are more prone to develop depressive symptoms. So there is a need of counselling session to improve the mental health of our medical under graduates as they are the future handlers of medical profession.

CONSENT AND ETHICAL APPROVAL
As per international standard or university standard written ethical approval has been collected and preserved by the author(s). An informed consent was taken prior to starting the study.