The Psychological Impact of Covid-19 Pandemic on Medical Undergraduates: A Study from BPKIHS, Dharan

Since the start of the COVID-19 pandemic, the impact that it can have on mental health has been consistently highlighted. Subsequently there have been calls for universi�es to monitor the mental health of their students considering the unique set of stressors faced by them. This study is an a�empt to understand how our students are doing and to plan appropriate psychological interven�ons to help them METHODOLOGY Online ques�onnaires of Depression, Anxiety, Stress Scale (DASS-21) and Impact of Event Scale (IES) were distributed to the students currently pursuing MBBS and BDS in BP Koirala Ins�tute of Health Sciences. RESULT 409 students responded to the ques�onnaires.The prevalence of depression, anxiety and stress among the respondents were 39.1%, 35.7% and 35.0% respec�vely. All three were more common in ﬁrst and second year students and in those with past history of mental illness (p<0.05). 68.5% students were impacted by the pandemic with moderate to severe impact present in 33.2%. Students from ﬁrst and second years were more impacted than others. (p<0.01). Students from our ins�tute were suﬀering from considerable amount of distress. Those in early years of medical schooling and those with past history of mental illness were doing par�cularly worse than others. It is important that we give due importance to their mental health and develop interven�ons to help them.


INTRODUCTION
In December of 2019, a cluster of cases were discovered in China with atypical features of pneumonia. The causa ve organism was later iden fied to be as a new strain of coronavirus. Since then the infec on has spread all over the 1 world. The World Health Organiza on declared the spread as public health concern on 30 January 2020 and a pandemic th on 11 March 2020. As of 20 October 2020 the infec on th 2,3 th has spread across 216 countries with over 40 million infected and 1.1 million deaths. Nepal recorded it's first coronavirus 4 case on 23 January 2020. Almost 2 months later, Nepal rd 5 recorded it's second coronavirus case. Since then the 6 number of cases in the country is steadily increasing. As of 20 October 2020 Nepal has 15,259 cases with 32 deaths. th 7 In response to the pandemic, countries across the world have responded with a combina on of containment and mi ga on strategies with the aim of preven ng a surge in the number of pa ents while protec ng the most vulnerable such as the elderly and those with comorbidi es. Most na onal response strategies include self isola on, contact tracing, promo on of public health measures, prepara on of health systems,

INTRODUCTION
postponement of large scale public gatherings. Several 8 countries have resorted to more extreme measures such as complete lockdown of countries.
The impact of a pandemic of this scale on mental health is largely unknown. Though researches are being conducted to study the mental health impact of current pandemic, we need to go beyond popula on level and try to understand the individualized disrup on of lives. With regard to this several 9 studies are being conducted on the mental health impact of at risk popula on such as the elderly and the front line workers, but we should not ignore other groups who have been affected by the current pandemic. One such group are the university students, who, in addi on to the usual stresses related to current pandemic also have addi onal stressors unique to them. These can lead to unfavourable learning and nega ve psychological consequences. Considering this 10 ques ons are being raised whether universi es are taking proac ve measures to support the mental health and wellbeing of students. This study is an a empt to understand 11 how our own students are faring during this global crisis and to plan appropriate strategies to help them.

MATERIALS AND METHODS
The study was conducted a er obtaining ethical approval from the Ins tu onal Review Commi ee (IRC), BPKIHS, Dharan. The study was conducted during the lockdown period. Students currently pursuing Bachelor of Medicine and Surgery (MBBS) and Bachelor in Dental Surgery (BDS) were assessed using a sociodemographic proforma, DASS-21 and Impact of Event (IES) scale. DASS-21 is a 21 item divided into three subscales -depression, anxiety and stress. Each subscale consists of 7 items and each item is scored on a 4 point likert scale. The cumula ve scores give the prevalence of stress, depression and anxiety among the students. The IES is a 15 item scale used to assess subjec ve distress resul ng from exposure to major life events. Each item is scored on a 4 point likert scale as 0 (not at all), 1 (rarely), 3 (some mes), o en . A score above 8 indicates presence of impact while 5 more than 44 indicates severe impact. The scale can be divided into the intrusion subscale, consis ng of 7 items and the avoidance subscale consis ng of 8 items. The students were also asked to report their major concerns during this pandemic. Online ques onnaires were distributed to the students through the class representa ves.Data obtained was entered in Microso Excel 2007 and was converted into SPSS version 11.5 for stas cal analysis.

RESULTS
A total of 409 students responded to the ques onnaires. Table 1 shows the sociodemographic characteris cs of the par cipants. Majority of the par cipants were in the age group 21-25 years, male, pursuing MBBS and were working as interns. 21 students (5.1%) had a past history of mental illness while 54 (13.2%) had a family history of mental illness.  Table 2 shows the distribu on of the par cipants according to the severity of symptoms. Majority of the students reported suffering from mild depressive symptoms, moderate anxiety and moderate stress. Students with past history of mental illness and family history of mental illness were more likely to report depressive symptoms. Presence of stress and anxiety was found to be more common in those with past history of mental illness and those in earlier year of medical schooling. No other significant associa on was found between sociodemographic factors and presence of depression, anxiety and stress. st Table 3: Socio-demographic profiles of 1 contact Psychiatric out-pa ents *p value <0.05, **p value <0.01 Results from IES showed that 280 students (68.5%) reported to be impacted by some degree by the pandemic. Of these 144 (35.2%), 91 (22.2%) and 45 (11.0%) reported mild, moderate and severe level of impact respec vely. Those in first and second years of study reported to have been impacted more than other students. Table 4: Mean scores of different coping strategies used Some of the major concerns reported by the students were disrup on in academics (66.5%), fear of passing on the infec on to family (65.5%), fear of contrac ng infec on (54.3%), delay in examina ons (52.6%), mely comple on of curriculum (45.2%), separa on from friends (35%), access to laptop/internet for online classes (23.2%), transi on to other academic modali es (21.5%).

DISCUSSION
The findings from our study shows that the prevalence of depression, anxiety and stress among the respondents were 39.1%, 35.7% and 35.0% respec vely. Moderate to extremely severe depression, anxiety and stress was present Original Research Article J Psychiatrists' Association of Nepal Vol. 10, No.2, 2021 in 23.7%, 28.1% and 22.8% students respec vely. The prevalence of moderate to severe depression and stress was higher than that reported by Wang et al (16.5% and 8.1% 12 respec vely) but lower than that of Gonzalez et al (34.19% 13 and 28.14% respec vely). The prevalence of moderate to extremely severe anxiety in our study was similar to that of Wang et al (28.8%) but higher than that of Gonzalez et al (21.34%). The differences could be due to the sample size and the target popula on. The study by Wang et al included 1210 people from general popula on, however, authors have reported that student status was associated with higher depression, anxiety and stress. On the other hand the target popula on in the study conducted by Gonzalez et al included 2530 members of the university, both students and staff. The authors here have reported that students scored higher in all aspects compared to administra ve and academic staff.
Two other studies have looked into the psychological impact of the pandemic on students. However they have only looked into the prevalence of anxiety and have reported prevalence rates of 15.43% and 24.9%. The prevalence of anxiety in 14 15 our study is higher than both. The differences could be due to differences in sample size and the screening methods used in these studies.
The prevalence of students impacted by the pandemic in our study was 68.5% with moderate to severe impact present in 33.2%. When compared to the studies by Wang et al and Gonzalez et al, the prevalence of moderate to severe impact 13 in our study was lower than both. Again the differences could be due to differences in popula on involved resul ng in different sociodemographic characteris cs. The popula on in our study was much younger and included only students.
We found that 81% students with past history of mental illness reported depressive symptoms. Similarly 61.9% and 71.4% of students with past history of mental illness reported suffering from anxiety and stress respec vely. The finding that people with a history of mental illness are more prone to develop adverse effects during this pandemic has been 16,17 shown in two other studies. There can be a number of reasons for this worsening such as usual concerns related to pandemic, disrup on in mental health services and inadequate coping strategies. This finding also has neuro immunological implica on. There have been studies repor ng an increase in pro-inflammatory cytokines during 18 depression and stress Further studies can be carried out to monitor the rela on between their levels and depressive symptoms during a pandemic.
We also found that the more number of students in early years of medical schooling were suffering from mental health related issues. This could be due to a rela vely new environment while those in later years may have developed strategies to cope with stressful events through experience.
So far our study has shown that students suffered from considerable amount of depression, stress , anxiety. We need to heed some cau on while interpre ng these findings as medical school is well known to be a stressful environment and medical students in early years are known to suffer from more severe depression and anxiety than in later years. This 19 is par cularly true for findings from DASS-21. Though the scale measures events during past one week, these events cannot be specifically a ributed to the pandemic. Hence DASS-21 is considered as a non specific measure of the psychological impact of the pandemic. This is less true for 20 IES as it contains ques ons specific to a par cular event. A few scales have been developed for covid specific stressors but they have been validated for use in middle age and 20 hence were not used in this study.

CONCLUSION
The prevalence of depression, anxiety and stress during the pandemic and the impact of pandemic among the students was high. The students in early years of medical schooling and those with past history of mental illness were doing par cularly worse than others. The findings reflect the need for formula ng psychological interven ons to help the students during this pandemic.

FUNDING
None