Mental health evaluation in medical students during academic activity suspension in the pandemic

Abstract: Introduction: During the Sars-CoV-2 pandemic, social distancing measures and various other stress factors may have been responsible for impacts on medical students’ mental health. Objective: The purpose of this study is to describe the mental health status of medical students at a college in northeastern Brazil, in the context of the COVID-19 pandemic, investigate symptoms of anxiety and depression, and assess resilience, as well as its possible associated factors. Methodology: A cross-sectional qualitative and quantitative method was used. Data were collected using an online questionnaire among students enrolled in the medical school; data were further processed using quantitative and qualitative statistical analysis separately. The following scales were applied: Generalized Anxiety Disorder Screener (GAD-7), Patient Health Questionnaire-9 (PHQ-9), and Wagnild and Young’s Resilience Scale (RS-25). Results: About one-third of the students lived with moderate or severe anxiety symptoms, almost half had moderate to severe depressive symptoms, and more than half were classified as having low or moderately low resilience. Conclusion: Our findings highlight the difficulty in maintaining high levels of resilience and that the presence of depression or anxiety would be related to lower resilience scores in medical students during remote education. Further studies are needed to establish a causal link with the pandemic.


INTRODUCTION
In December 2019, the first cases of Covid-19 were detected in the city of Wuhan in China, and the disease quickly became a worldwide concern, leading to the declaration of a pandemic state by the World Health Organization in March 2020 1 .With the subsequent application of social distancing measures, medical educators faced the dilemma of how to circumvent the problem of the lack of face-to-face activities and maintain a commitment to the technical and ethical training of their future professionals 2 .Brazil, as well as other countries, established the suspension of curricular internships, and, according to the specificities of each institution, remote teaching activities were implemented 3,4 .Following the recommendation of higher health agencies, academic activities at the Bahia School of Medicine of the Federal University of Bahia (FMB-UFBA) were interrupted, both for the 1 st to 8 th semesters, in March 17, 2020, and for the internship (9 th to 12 th semesters), in March 18, 2020.The pandemic also brought challenges related to student mental health, which has been a concern for higher education institutions (HEIs) around the world 5,6 .The mental health impacts of the pandemic on students during quarantine involve higher numbers of cases of anxiety disorders and depression, as well as stress 7,8 .This conjuncture may have been caused by stressful events, such as the increase in the number of cases of COVID-19, the perception of uncertainty in the face of the pandemic, the adaptation to the remote teaching model, and the likely unfavorable impacts the pandemic would cause on their academic trajectories 9 , as well as the excessive use of social media -and access to a lot of information about the pandemic -and the feeling of loneliness caused by social isolation 7 .Considering that medical students already represented a group with a high incidence of anxious and depressive conditions before the Covid-19 pandemic 10,11 , the concern about how pandemic-related stressors would affect them would be even greater.
The concept of resilience can be defined in the literature as the ability to adapt in the face of adversity and stressors, resulting in adaptation with the least possible negative impact 12,13 .This characteristic is affected by the individual's internal resources, such as the ability to control their emotions and the efficiency of their communication; lifestyle, such as work-life balance and healthy amounts of quality free time; external resources such as the ability to ask for and receive support from others, and good social support; in addition to the active mediation of other agents, with teaching and training to build resilience in students being carried out by the educational institution itself 13 .Resilience is shown as the ability to regain balance after encountering difficulties 14 .It allows the individual's recovery from experienced adverse circumstances through positivity and emotional skills and adapting and evolving during the process 15 .Therefore, resilience would in itself be a very helpful skill for medical students, although a Canadian study has shown that this population has lower levels of resilience than their age-and gender-matched peers in the general population 16 .
Therefore, this study aims to analyze and describe the mental health of medical students at the Federal University of Bahia (UFBA) in the context of the COVID-19 pandemic, the suspension of curricular activities, and the uncertainty regarding the deadline for the resumption of in-person classes and its implementation format.

METHODOLOGY
This is a cross-sectional, qualitative and quantitative study, whose data were collected through an online questionnaire, applied between July and August 2020, to a convenience sample.This work is part of a larger research project that yielded another study about the hidden curriculum during this period and it is currently in the process of publication.The umbrella project was approved by the Research Ethics Committee of Faculdade de Medicina da Bahia (FMB), UFBA, under the Certificate of Ethical Appraisal Submission (CAAE -Certificado de Apresentação de Apreciação Ética) n. 33225020.1.0000.5577.
The inclusion criteria were: being a medical student attending from the 2 nd to the 12 th semesters of the FMB-UFBA, located on the campus of Salvador -Bahia, with the name on the enrollment list of the undergraduate medical course; having completed at least 1 period of the FMB-UFBA curricular grid; being at least 18 years old.The exclusion criteria were: refusal to sign the Informed Consent Form; refusal to fill out all the multiple-choice questions on the electronic form and being in a current situation of enrollment withdrawal or total leave of absence of curricular components.The questionnaires were sent to all students attending from the 2 nd to 12 th semesters via e-mail and WhatsApp®.
The collected variables included sociodemographic profile (gender, color/ethnicity, average family income), academic status (current semester/class and graduation delays), study habits, subjects studied during the period of academic activity suspension and opinion about the remote teaching model, as well as perceptions about the graduation progress and the government programs Telecoronavírus and Brasil Conta Comigo -Acadêmico.These perceptions were evaluated using Likert-type scales, in which the responses to the statements included: "strongly disagree" (1), "disagree" (2), "neither agree nor disagree" (3), "agree" (4), or "strongly agree" (5).
To provide an overview of the students' mental health status during the COVID-19 pandemic, the following scales were applied: Generalized Anxiety Disorder Screener (GAD-7), Patient Health Questionnaire-9 (PHQ-9), and Wagnild and Young's Resilience Scale (RS-25).The GAD-7 is validated for diagnosing or screening patients with probable anxiety disorder, with 7 questions whose answers range from 0 (never) to 3 (most days), with a result greater than 10 suggesting the diagnosis of some anxiety disorder 17 .The PHQ-9 is used to screen for depression and contains 9 questions about depressive symptoms, with answers between 0 (never) and 3 (most days), with the following depression classifications: severe (20 or more points), moderately severe (15-19 points), moderate (10-14 points), mild (5-9 points), and minimal (<5 points) 18 .The Wagnild and Young Resilience scale measures the degree of resilience using 5 components as its basis, assessed through 25 questions, with answers ranging from 1 (strongly disagree) to 7 (strongly agree) 19 ; and the following classifications were adopted: high (>145 points), moderate (125 to 145 points), moderately low (120 to 124 points), and low (<120 points).
The questionnaire was applied through the Google Forms online platform and the statistical analysis of the data was carried out using the IBM SPSS (Statistical Package for the Social Science) Statistics software, version 20.Regarding the quantitative variables, normality was verified using the Shapiro-Wilk test.In case of the absence of distribution normality, the selected variables were described according to their measurement level, with the calculation of median and interquartile range.In the case of qualitative variables, the frequency of these variables was calculated and the Fisher's Exact Test was performed to verify the independence of groups.
The significance level adopted was 5%.
Since this is a study that used an online form as a data collection method, there is the risk of selection bias, either due to a lack of access to the technology or the possibility of attracting students who are somehow concerned about their mental health.The students' enrollment numbers were checked, decreasing the risk of imputing false or duplicate data.

RESULTS
There were 314 responses to the questionnaire, with three duplicate responses and one irregular enrollment, which were excluded, resulting in 310 eligible responses to the study, among the approximately 880 students attending from the 2 nd to 12 th semesters.
Regarding the sociodemographic profile (Table 1), 178 (57.4%) students were female, with a mostly urban place of residence (95.8%).One hundred and forty-two (45.8%) students identified themselves as light-skinned 1 .Ninety-seven participants had a family income between 1 and 3 minimum wages (MW), being the main income group (31.3%), while

Remote Education
Of the participants, 269 (86.8%) reported having the necessary tools for an adequate remote teaching-learning process (stable internet access, adequate and quiet space for studying) and 251 (81%) were in favor of the adoption of the remote model by UFBA during the pandemic.
As for the reasons for being in favor of adopting the remote model ( As for the reasons for being against remote education (Table 3), they agreed about the damage to the teaching of some

Mental Health
As for anxiety symptoms indicated by the GAD-7 scale (Table 4), the average score was 7.83±5.40,ranging from 0 to white and white groups (PR=1.00;95% CI: 0.77; 1.31).There was no difference between the mean scale scores between these groups according to Student's t-test.
Regarding educational aspects, students with PHQ-9>10 were more likely to respond negatively to the question "Would you like the UFBA to adopt the remote learning or distance learning model to continue classes during the pandemic period?"than those with lower scores (PR=1.42;95% CI 1.08; 1.86).On the other hand, those with GAD-7>10 were less likely to use the increased time available from the suspension of face-to-face classes to study topics outside the health sciences (PR=1.51;95% CI 1.02; 2.24.P=0.031, Pearson's Chi-square).
As for the resilience scale (Table 6), the Shapiro-Wilk test was performed, which confirmed the normality of the distribution of the results (p= 0.245).The mean score of the resilience scale was 122.73, with a standard deviation of 18.643 and values ranging from 47 to 172, corresponding to the moderately low resilience rating.

DISCUSSION
The studied sample had a sociodemographic profile compatible with other studies of the same target audience, conducted at the same or other medical education institutions [20][21][22][23] .
In contrast, a study that also used the GAD-7 scale in medical students during the COVID-19 pandemic in the state of São Paulo in May 2020, found that 46.17% of the participants had GAD-7>10.The mean GAD-7 score in the study was 9.18 (a standard deviation of 4.75), while the present study found a mean of 7.83, with a standard deviation of 5.40 24 .Another study conducted in March 2020 with medical students in Germany obtained an average GAD-7 score of 5.43, with a standard deviation of 4.30 25 .The differences can be due to numerous factors, such as pandemic-related epidemiological parameters, cultural, educational, socioeconomic factors, and access to adequate information, among others 26 .
These percentages are higher than those seen in studies analyzing the general Brazilian population, which estimate the prevalence of anxiety disorders between 19.9% and 28.1% 26 .
There was no statistically significant difference in the prevalence of GAD-7 scores > 10 between genders, in contrast to another study carried out with medical students, which showed a higher frequency in the female population 24 .
Less than half (42.6%) of the students indicated the presence of moderate to severe depressive symptoms (PHQ-9>10), in agreement with similar studies performed before the pandemic, which obtained values between 34.6% and 38.2% 10,26 .However, as with GAD-7, the finding is discrepant from the data found in another study, also carried out in Brazil, but conducted during the pandemic, which found a prevalence of PHQ-9>10 in 64.4% of medical students 24 .
A study conducted in 2018 at the same educational institution also applied the PHQ-9 and the RS-25 with a similar methodology.This study found a slightly higher prevalence of depressive symptoms according to the PHQ-9: 47.1% of participants had PHQ-9≥10 22 .Some studies suggest that professional stability is positively linked to higher resilience, which could have been negatively affected by the current moment 22 .
However, when comparing the levels of resilience between the two studies, the present study showed a lower percentage of students classified as having low resilience, a higher percentage of moderate resilience, and equal high resilience.These results could be explained because, despite the distress of the pandemic and the uncertainty of return to normal activities, at the time the students were not exposed to classes, while in the 2018 study the students were attending school, and taking time for oneself is linked with higher resilience 22,27,29 .
Despite numerous investigations on depression and anxiety, the number of studies assessing resilience among medical students, considering both the pre-pandemic and the pandemic periods, especially using the Wagnild and Young resilience scale (RS-25), is still incipient for a more robust comparison, which strengthens the relevance of the present study and raises the need for further research in this context.
Regarding the educational aspects, students with PHQ-9>10 were more likely to disagree with the ongoing classes during the pandemic period, an attitude that suggests the association of depression with the discontinuity of activities, which is in agreement with other studies 23,30 .This finding may be related to the impaired functionality and avoidance, which are consequent to depressive symptoms, more specifically resulting from the loss of enjoyment of meaningful activities, difficulty concentrating, fatigue, sleep alterations, as well as the increase in cases of depressive disorders during the pandemic and its relationship to work discontinuity 31,32 .
Another important factor that may have led to a large number of medical students with low resilience and the presence of anxiety and depression in the present study is the health situation at the time, as the need for social isolation and physical distancing brings about changes in ways of coping with suffering 33 .

LIMITATIONS
Our main limitations are: the study design was crosssectional, making it impossible to assess causality; the use of self-applied scales, which by definition involves limitations regarding the accuracy of the collected data.In addition, one should take into consideration the heterogeneity of curricula and teaching methodologies among medical institutions around the world, requiring extra attention to attempts to extrapolate the results to these different contexts.

CONCLUSION
Regarding mental health status, about one-third of the students had high scores for anxiety and depression, as well as low scores for resilience.Due to the study methodology, it is not possible to assess the relationship between the pandemic and these findings.The results related to PHQ-9 and RS-25 were similar to those found in the pre-pandemic period.It is necessary to develop studies with different methodologies that can explore the perceptions and effects of the pandemic in this population.

Table 2 .
Reasons for being in favor of adopting the remote model.

Table 3 .
Reasons for being against the adoption of the remote teaching model.

Table 5 .
PHQ-9 results according to the academic status.

Table 6 .
Resilience Scale results according to the academic status.