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ORIGINAL RESEARCH ARTICLE
Year : 2022 | Volume
: 35
| Issue : 2 | Page : 41-47
Medical student anxiety and depression in the COVID-19 Era: Unique needs of underrepresented students
Sheryl Lin1, Albert C Chong1, Erin H Su1, Sabrina L Chen2, Won Jong Chwa3, Chantal Young1, Jacob Schreiber1, Stephanie K Zia1
1 Department of Medical Education, Keck School of Medicine of USC, Los Angeles, CA, USA
2 Department of Internal Medicine, NYU Grossman School of Medicine, New York, NY, USA
3 Department of Medical Education, St. Louis University School of Medicine, St. Louis, MO, USA
Correspondence Address:
Stephanie K Zia
1975 Zonal Ave, KAM 105, Los Angeles, CA. 90089
USA
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/efh.efh_112_22
Background: The COVID-19 pandemic has caused significant morbidity, mortality, and mental health consequences. Few studies have examined the mental toll of COVID-19 on United States (US) medical students, who experience greater rates of depression and anxiety than the general population. Students who identify as underrepresented in medicine (URM) may experience even greater mental health adversities than non-URM peers. This study examines COVID-19's impact on preclinical medical student anxiety and depression and unique challenges disproportionately affecting URM students during the initial phase of the pandemic. Methods: Medical students at four US institutions completed an anonymous survey including the Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7) questionnaires for depression and anxiety. Participants provided information on demographics, past mental health difficulties, and concerns during the pandemic. Chi-square and Mann–Whitney U tests were performed using SPSS. Results: During the initial phase of the pandemic, URMs were 3.71 times more likely to be in the at-risk category on GAD-7 than non-URM peers. Before COVID-19, there was no significant difference between self-reported feelings or diagnoses of anxiety between groups. During the COVID-19 pandemic, there were significant differences in feelings of increased anxiety between URM (Mdn = 76) and non-URM (Mdn = 49) students, U = 702.5, P < 0.001, feelings of increased sadness between URM (Mdn = 49) and non-URM (Mdn = 34) students, U = 1036.5, P = 0.042, concern for new financial difficulty between URM (Mdn = 50) and non-URM students (Mdn = 7), U = 950.5, P = 0.012, and concern about lack of mental health support from their academic institution between URM (Mdn = 18) and non-URM students (Mdn = 9), U = 1083, P = 0.036 (one-tailed). Discussion: Large-scale crises such as COVID-19 may exacerbate mental health disparities between URM and non-URM students. Medical schools should consider increasing financial and mental health support for URM students in response to these significant adverse events.
Keywords: Anxiety, COVID-19, depression, medical education, underrepresented, wellness
The COVID-19 pandemic is a major health crisis that has resulted in significant mortality and morbidity, including adverse mental health consequences. As COVID-19 spread across the United States (US), marginalized populations, in particular ethnic minorities and individuals of low socioeconomic status, have been especially impacted.[1] These groups experience risk factors for COVID-19 at higher rates, including diabetes, hypertension, and cardiovascular disease.[2] It follows that infection rates and severe complications from COVID-19 are greater among Black and other minority ethnic groups.[3] Since minority ethnic groups have disproportionately worse mental health outcomes,[4],[5],[6],[7] a mental health disparity may not only be present but also widened during this time.
Medical students are another population vulnerable to mental health difficulties.[8],[9] Before the COVID-19 pandemic, studies suggest that medical students demonstrate higher rates of depression, suicidal ideation, and stigmatization around depression compared to the general population, while being less likely to seek support.[10] One in three medical students globally suffers from anxiety, a proportion greater than in the general population.[9] This may be attributed to factors such as an overwhelming curriculum, feelings of lack of control, or exposure to death and dying for the first time.[11] With the pandemic, medical students have been subject to strict isolation measures that have limited on-campus learning, peer interactions, professional development opportunities, and direct patient care, as well as postponed major educational events.[12],[13],[14],[15] To date, few studies have assessed the impact of COVID-19 on the mental health of US medical students.
At the intersection of these two adversely affected groups are students who identify as underrepresented in medicine (URM). The Association of American Medical Colleges identifies URM as racial and ethnic populations that are inadequately represented relative to their numbers in the general population.[16] URM students include those who identify as African American or Black, Hispanic or Latinx, American Indian, Alaska Native, Native Hawaiian, and/or Pacific Islander. This study assesses COVID-19's impact on medical student anxiety and depression and the unique challenges disproportionately affecting URM students via four research questions: (1) Do URM and non-URM students differ in terms of subjective feelings or diagnoses of anxiety and depression before the pandemic? (2) Do the groups have different Generalized Anxiety Disorder-7 (GAD-7) and Patient Health Questionnaire-9 (PHQ-9) scores during the pandemic? (3) Do the groups differ in increased feelings of anxiety, feelings of depression, and substance use during the pandemic? (4) Do the groups differ in levels of institution-and pandemic-related concerns during the pandemic? We predicted there would be increased mental health disparities among URM compared to non-URM students due to COVID-19. Further, we hypothesized that institutional and pandemic-related concerns could help explain disparities in mental health between URM and non-URM students.
MethodsWith approval from the USC Institutional Review Board, we distributed an anonymous survey through class listservs and social media groups (Facebook, GroupMe) to a sample of 1st and 2nd year medical students across the US at the Keck School of Medicine of USC (USC), New York University Grossman School of Medicine (NYU), Oregon Health and Science University (OHSU) School of Medicine, and University of Central Florida (UCF) School of Medicine. Our convenience sample included students who viewed these announcements and subsequently chose to participate in the study. The survey was administered electronically through Qualtrics between December 2, 2020 and December 18, 2020. Students who completed the survey were directed to a separate form where they could enter their contact information for a chance to receive a store gift card worth 10 US Dollars. For each participating institution, three gift cards were sent to randomly-selected respondents who provided contact information for the raffle.
The first part of the survey included the PHQ-9 screening questionnaire to measure depression and the GAD-7 questionnaire to measure anxiety.[17] The second part asked participants to rate (0–100) how much the pandemic increased their feelings of anxiety, feelings of sadness, and alcohol/recreational drug usage. We established a baseline for anxiety and depression between URM and non-URM students before the pandemic by asking about subjective feelings and diagnoses of anxiety and depression before December 2019. Furthermore, we asked participants to rate their level of concern (0–100) about pandemic- and institution-related factors. Respondents were additionally given the option to enter custom responses. The last part of the survey queried demographic information, including race, gender identification, training level, institution, household size, hours spent exercising per week, distance of residence from campus, hours of virtual and in-person social interaction, and time spent in clinic for educational activities.
GAD-7 and PHQ-9 scores were used to assess respondents' risk for GAD and major depressive disorder (MDD). GAD-7 scores range from 0 to 21, stratifying anxiety risk as minimal (0–4), mild (5–9), moderate (10–14), and severe (15–21).[18] While the authors of the GAD-7 recommend a cutoff of 10 or greater,[18] a separate study later recommends a cutoff of 8 or greater.[17] Our study interpreted a score of 9 or greater on the GAD-7 as “at risk” for GAD. The possible scores on the PHQ-9 range from 0 to 27, stratifying depression risk as minimal (0–4), mild (5–9), moderate (10–14), moderately severe (15–19), and severe (20–27).[17] These risk groups were analyzed as categorical variables against demographics.
To establish URM and non-URM groups, a dummy variable was generated to indicate whether students were URM or non-URM based on their responses to the question about race. If a respondent selected any racial category that met the criteria to be included as URM, they were associated with that group in the analysis.
Statistical tests were performed using IBM Statistical Package for the Social Sciences (SPSS) Version 27.[19] Only complete survey responses were included in our analyses. Chi-square analyses were used to determine significant differences between URM and non-URM students regarding self-reported feelings of anxiety and depression before the pandemic, self-reported diagnosis of GAD and/or MDD before the pandemic, and levels of risk on the PHQ-9 and GAD-7 during the pandemic. Mann–Whitney U tests were performed to determine significant differences between URM and non-URM students regarding self-reported increase in anxiety, depression, and substance use. Likewise, scores for pandemic- and institution-related concerns were compared to determine whether levels of concern over these factors differed between groups.
ResultsSubject demographics
In total, 154 1st and 2nd year medical students completed the survey. Based on participants' self-report of their racial identity, 15% (n = 23) were classified as URM, 80% (n = 123) were classified as non-URM, and 5% (n = 8) preferred not to identify their race and were treated as missing data in the analyses. Selected demographics including URM status, age, gender, medical school level, and institution are presented in [Table 1]. More than half of the respondents, 63.0% (n = 97) were female and 62.3% (n = 96) were between the ages of 23 and 25. Four institutions were represented: USC (32.5%, n = 50), NYU (24.0%, n = 37), OHSU (24.7%, n = 38), and UCF (18.8%, n = 29). There were no significant differences in the following characteristics: household size, hours of exercise per week, distance of housing from campus, hours of virtual social interaction, hours of in-person social interaction, and time spent in clinic.
Anxiety and depression before the pandemic
To establish a baseline for anxiety and depression between URM and non-URM students prior to the COVID-19 pandemic, subjective feelings and diagnoses of anxiety and depression before December 2019 were surveyed. More than three-fourths (78.3%, n = 18) of URM students and more than half (55.3%, n = 68) of non-URM students reported subjective feelings of anxiety before December 2019. There was no significant association between URM status and feelings of anxiety before the pandemic (χ2 = 4.459, df = 2, P = 0.116). 26.1% (n = 6) of URM students and 14.6% (n = 18) of non-URM students reported a prior diagnosis of GAD. There was no statistically significant association between URM status and diagnosis of GAD before December 2019 (χ2 = 3.490, df = 2, P = 0.157). Regarding depression, 39.1% (n = 9) of URM students and 28.5% (n = 35) of non-URM students reported feelings of depression before December 2019. There was no statistically significant association between URM status and feelings of depression before the pandemic (χ2 = 2.208, df = 2, P = 0.287). Regarding MDD, 34.8% (n = 8) of URM students reported prior diagnosis of MDD, compared to 15.4% (n = 19) of non-URM students. Diagnosis of MDD before the COVID-19 pandemic demonstrated a statistically significant association with URM status (χ2 = 6.804, df = 2, P = 0.035). Specifically, URM students were 2.92 times more likely to report a diagnosis of MDD before the COVID-19 pandemic than non-URM students.
Anxiety and depression during the COVID-19 pandemic
Our survey results from December 2020 revealed that URM students (Mdn = 11) scored higher on the GAD-7 than non-URM students (Mdn = 5), U = 731.5, P < 0.001, during the initial phase of the pandemic [Figure 1]. URM students (Mdn = 10) also scored higher than non-URM students on the PHQ-9 (Mdn = 6), U = 914.0, P = 0.007. Specifically, URM students were more often in the moderate, moderately-severe, or severe depression categories (56.5%, n = 13) than were non-URM students (25.3%, n = 31).
Figure 1: Left: percentage of non-URM versus URM students at risk for GAD based on their GAD-7 scores. Right: percentage of non-URM versus URM students at risk for MDD based on their PHQ-9 scores. Asterisk indicates statistical significance determined by Chi-squared test. URM: Underrepresented in medicine, GAD: Generalized anxiety disorder, MDD: Major depressive disorderChi-square analyses were performed to determine whether there were differences in the proportions of students at-risk for GAD and MDD between URM and non-URM groups. The proportion of URM students at risk for GAD (56.5%, n = 13) differed significantly from that of non-URM students (26.0%, n = 32) (χ2 = 9.823, df = 2, P = 0.006) [Figure 1]. An odds ratio calculation determined URM students were 3.71 times more likely to be at risk for GAD than non-URMs. From PHQ-9 results, 34.8% (n = 8) of URM students and 12.2% (n = 15) of non-URM students were at risk for moderate depression. Meanwhile, 21.7% (n = 5) of URM students and 9.8% (n = 12) of non-URM students were at risk for moderately severe depression [Figure 1]. The association between URM status and PHQ-9 risk status was not statistically significant (χ2 = 16.455, df = 10, P = 0.087).
Increases in feelings of anxiety and sadness due to the pandemic
Mann–Whitney-U tests revealed significant differences in reported feelings of increased anxiety due to the COVID-19 pandemic between URM (Mdn = 76) and non-URM (Mdn = 49) students, U = 702.5, P < 0.001 [Figure 2]. There was also a significant difference in reported feelings of increased sadness due to the pandemic between URM (Mdn = 49) and non-URM (Mdn = 34) students, U = 1036.5, P = 0.042. There was no significant difference in reported increase in substance use due to the pandemic between the two groups, U = 1203.5, P = 0.235.
Figure 2: Median self-reported increase in feeling anxious, feeling sad, and alcohol/recreational drug use due to the COVID-19 pandemic in non-URM versus URM students. A score of 0 represents “not at all” and a score of 100 represents “a great deal.” Asterisks indicate statistical significance determined by Mann–Whitney-U test. URM: Underrepresented in medicinePandemic-and institution-related concerns
Two-tailed Mann–Whitney-U tests demonstrated that URM students (Mdn = 50) reported a greater level of concern with new financial difficulty compared to non-URM students (Mdn = 7), U = 950.5, P = 0.012 [Figure 3]. However, levels of concern about other pandemic-related factors did not differ significantly between URM and non-URM students. Specifically, there were no significant differences in reports of lack of social interaction, U = 1103.5, P = 0.092, worries about contracting COVID-19, U = 1061, P = 0.057, and worries about transmitting COVID-19, U = 1383, P = 0.865. Regarding institution-related factors, URM students (Mdn = 18) reported a greater level of concern with the lack of mental health support from their respective institutions compared to non-URM students (Mdn = 9), U = 1083, P = 0.036 (one-tailed) [Figure 3]. Concern over lack of academic support, U = 1309.5, P = 0.57, lack of financial support, U = 1133, P = 0.128, delayed medical training, U = 1143, P = 0.144, and decreased quality of medical training, U = 1194.5, P = 0.236, did not differ significantly between URM and non-URM students.
Figure 3: Left: Median levels of concern about pandemic-related factors on a scale of 0–100. Right: Median levels of concern about institutional support on a scale of 0–100. A score of 0 represents “none at all” and a score of 100 represents “a great deal.” Asterisks indicate statistical significance determined by Mann–Whitney U-test Discussion Subject demographics regarding underrepresented in medicine status
Our study included 15% URM students [Table 1], which is overall consistent with the proportion of enrollment of URM students at the four surveyed institutions (10.7% at UCF, 13.2% at OHSU, 19.5% at USC, and 21% at NYU).[20] This suggests that despite using a convenience sample, our study captured a reasonably representative sample of medical students with regards to URM status.
Mental health disparities between underrepresented in medicine and non-underrepresented in medicine students in the COVID-19 era
Regarding anxiety, our results reveal that URM students had significantly higher risk of GAD than non-URM peers during the initial phase of the pandemic. Given there was no difference between groups in reported feelings or diagnoses of anxiety prior to December 2019, our results suggest that disparities in anxiety between URM and non-URM students increased during the study period. This change may be attributed to the COVID-19 pandemic since URM students reported significantly greater increase in anxiousness specifically due to the pandemic, compared to non-URMs.
Regarding depression, URMs did not have significantly higher risk for MDD than non-URMs during the pandemic using the multi-level cutoff scores for PHQ-9 risk. However, the trend in risk categories suggests that a significant difference may have manifested with a larger sample size [Figure 1]. Furthermore, the median PHQ-9 score was significantly greater for URMs compared to non-URMs during the pandemic, and URM students reported significantly greater increases in feelings of depression due to the pandemic than non-URM peers. While URMs thus may have experienced greater levels of depression than non-URMs during the pandemic, whether the pandemic exacerbated URM depression is unclear, particularly given that this group reported a higher rate of MDD diagnosis at baseline compared to non-URMs.
Disparities increase underrepresented in medicine student need for mental health resources from academic institutions
Ethnic minorities face disparities with regards to COVID-19 infection rates, mortality, and other related outcomes,[2],[21] and minorities in the US have faced disparities in both access to and quality of mental health services.[22],[23] It is conceivable that URM students would face similar disparities, including access to quality mental health services, in the context of COVID-19. Our survey revealed that URM students had greater concern about the lack of mental health support from their institutions than non-URM students. Given the greater increase in feelings of anxiety and depression among URM students due to the pandemic, our results suggest that these students could benefit from increased mental health support from their institution.
Financial disparities may exacerbate underrepresented in medicine student mental health disparities
Another factor that may contribute to the observed mental health disparities was new financial difficulty, which was rated as a greater concern among URM students than non-URM students. The COVID-19 pandemic has caused widespread economic consequences at the individual and global levels and has led to greater economic concern, especially among minority groups.[24],[25] While our survey did not query specific personal or familial financial circumstances of students, disproportionate rates of COVID-19 infection, job loss, and hospitalization for URM family members may all have contributed to increased financial disparities for URM students during the pandemic.[26],[27],[28],[29]
Exploring how medical schools may help their students
Our results identify two key areas in which medical schools may target interventions for URM students during significant adverse events such as the COVID pandemic: mental health resources and financial support. However, there is a need for further research on how these targeted interventions may best be implemented.
Integration of programs for improving URM mental health into the curriculum should be approached strategically, as amount and timing of sessions may cause increased student stress if sub-optimally scheduled.[30] For example, requiring large-group mindfulness courses during preclinical medical training did not improve medical student mental health and quality of life.[31] Flexible scheduling may enable medical students to better incorporate resources into their busy, fluctuating schedules. Institutions may also consider granting discretionary time for each student to pursue activities they already know to improve their mental well-being.
Options to improve financial support include bursaries, grants, housing fee credits, access to a financial advisor, and student debt reduction.[31] A study on financial support for medical students based in London found that housing fee credits and cash bursaries provided a financial “buffer” for students and allowed them to focus on their studies or extracurricular activities.[32] Notable barriers to accessing financial resources among underrepresented college students include lack of: financial literacy, trust in resources and services, and reliable online resources.[33] Conversely, financial workshops, interactive online resources, and individual advising may increase financial capability[33] and should be considered for reducing disparities.
Limitations
While our study queried experiences with anxiety and depression prior to the pandemic, we could not directly compare participants' GAD-7 and PHQ-9 scores before and after the pandemic started, as participants were not surveyed prior to the pandemic. Reliance on recalled symptoms of anxiety and depression are subject to recall bias.
While this study attempted to represent a national sample, geographic areas such as mid-America were left unaccounted for and should be included in future studies. Furthermore, while our study encompasses a large geographic footprint, the number of responses from each institution was relatively small. Since our survey was voluntary, it is possible that our respondent population may have been skewed towards students who felt more strongly about mental health or had experienced worse mental health outcomes in the setting of COVID-19. Additionally, while it is possible that students with greater financial need may have been more likely to participate due to the financial nature of the incentive, we believe such an effect would have been limited given the low value of our raffle prize.
Our study was also conducted during a time of social unrest, notably in the several months following the murder of George Floyd. While we cannot directly distinguish whether concerns related to COVID-19 or societal unrest contributed more or equally to respondents' mental health, we took two strategies to reduce confounding. First, we asked specifically how much the COVID-19 pandemic (as opposed to other factors) had increased feelings of anxiety and depression. Second, we included a custom response box for concerns beyond preset options; only one respondent mentioned racial discrimination as a significant concern.
ConclusionURM students face unique challenges as both racial/ethnic minorities and medical students. Our study revealed an increase in mental distress for all students, but particularly for URMs, after the onset of the COVID-19 pandemic. In particular, URM students experienced a significantly greater increase in feelings of anxiety and depression than non-URMs and were more likely to be at risk for GAD than non-URMs during the study period. Our results suggest that the COVID-19 pandemic exacerbated disparities regarding anxiety and risk for GAD but are less clear for depression and MDD. New financial difficulty and insufficient mental health support were particularly significant contributors to mental health disparities. While medical schools may already intervene in these specific areas, prioritizing them may increase success with reducing mental health disparities among students during times of significant adversity.
Acknowledgments
We would like to thank Lilly Hou and Inga Van Buren for their generous assistance in data collection from UCF School of Medicine and OHSU School of Medicine.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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