Prevalence of depression, anxiety, stress and its relationship with knowledge about COVID-19 in medical and laboratory medicine students of Umm-Al-Qura University: a cross-sectional survey

Introduction Coronavirus disease 2019 (COVID-19) pandemic has continued relentlessly for over one and half years now, causing a threat to life, fear of falling sick, helplessness, anxiety, depression and, pessimism about the future. There has been an increasing concern over student mental health in higher education. Our study was designed to measure current mental health status and its relationship with sociodemographic variables and level of knowledge about COVID-19 in Saudi Arabia. Method A cross-sectional survey was conducted among laboratory medicine students of Makkah city, Saudi Arabia from October, 2020 to January, 21. A semi-structured questionnaire was circulated through mail and What’s App. Data collected included sociodemographic details and level of knowledge towards the COVID-19 among the students. Depression anxiety and stress-21 item (DASS 21) was used to assess psychological status. Result Our study reported 51.4% depressive symptoms, 57.9% anxiety symptoms, and 48.5% stress in the study participants. History of being hospitalized with COVID-19 and ICU reported high anxiety (p = 0.0003) and depression scores (p = 0.04). Respiratory droplet as a mode of transmission revealed higher scores on anxiety subscale (p = 0.007), whereas surface contamination reported high score of stress (p = 0.004) and anxiety (p = 0.002). Knowing that COVID-19 can also clinically present with gastrointestinal symptoms was found to show high stress (p = 0.005) and anxiety (p = 0.01) scores than any other way of clinical presentation. Conclusion COVID-19 is likely to cause negative effect on the psychological health of students.


Introduction
The novel coronavirus disease 2019 ("COVID-19") has gripped the world, causing alarm and dread across the world. Since the start of the pandemic through December 1st, 2020, there have been 347,157 confirmed (Covid- 19) cases in Saudi Arabia, with 5907 fatalities [1]. Most cross-sectional surveys [2][3][4][5][6] of the general population showed increased symptoms of depression, anxiety, and stress-related to "COVID-19" due to its lethality, drastic change in lifestyle, social isolation, economic burden and, pessimism about the future, fear and worry about contracting the illness [7]. Studies from the Kingdom of Saudi Arabia reported high levels of stress, anxiety and, depression among the general population [8][9][10] and in particular university students [10,11] during the pandemic. A survey of the mental health of college students during the 2019-2020 academic year, both before and after the COVID-19 pandemic, found a startlingly high prevalence of depression and anxiety [11]. Health education transition from face-to-face sessions to video lectures or live streams [12] lead to the stress and anxiety [13]. Although lecture-based teaching is simply transitioned to an online format, clinical exposure and providing authentic patient experiences are not as easily replicated. Such circumstances have an adverse effect on the mental health of medical and paramedical students. Pre-pandemic evidence suggests that medical and paramedical students have reported higher levels of perceived stress, anxiety, and depression than general population [13], which further increased during the pandemic. Increased anxiety, depression [14,15] PTSD [16] and stress [17] symptoms were found in college and university students. Although the institutional response to "COVID-19" has been rapid, with a commitment to deliver academic services uninterruptedly, such a sudden change may cause more stress for students who are already under high levels of academic stress [18].
Adequate knowledge about pandemic may show reduced negative impact (anxiety and stress) in vulnerable population [19,20]. Recognizing the psychological impact of the "COVID-19" outbreak in the general population and high-risk population like students and health care workers is pivotal in guiding policymakers and formulating interventions to maintain positive mental health. Reliable information about mental health changes associated with the pandemic will help service providers make decisions that are underpinned by knowledge of the scale of changes in population mental health and recognize who is most vulnerable to symptoms of mental distress. This study aimed to investigate the psychological outcome of "COVID-19" in university students. Furthermore, an association of these outcomes with sociodemographic variables and knowledge factors were determined.

Participants
A cross-sectional study through an online survey was conducted at Umm-Al-Qura University between October 1st to December 1st, 2020. The questionnaires were distributed to the target sample of university students through social media platforms using snowball-sampling technique. Platforms including Facebook, WhatsApp, and Twitter, as well as personal e-mail, were used for the recruitment and dissemination. The participants of this survey were mainly young people aged 18-25 years.
We calculated the sample size based on the assumption prevalence of 24% psychological impact according to Alkhamees et al. [10] at 5% absolute precision, power at 80% and a confidence interval of 95%. Taking into consideration a 20% non-response rate, the minimal sample size required was 345 participants. However, we intended to send the study questionnaires to 400 potential participants.
The inclusion criteria were current university students in Saudi Arabia who spoke and understood English and had access to the online questionnaire.

Data collection sheet
A semi-structured study questionnaire was developed by researchers to obtain general information of the participants as such as gender, age, education, marital status, occupation, income. The Latter half of the questionnaire included questions related to general and mental health, "COVID 19" exposure and, knowledge regarding "COVID-19". Knowledge questions included ten items inquiring about knowledge regarding mode of spread, ways of prevention and, symptoms. The participants could select "yes or no" options. A pilot study was done on 50 participants to check the validity and reality of the scale.

Statistical analysis
All the data collected through google forms were converted to excel spreadsheets and analysis was performed using IBM SPSS Statistics for Windows, version 22.0 (IBM Corp., Armonk, NY, USA). The data were cleaned, sorted, and processed before the commencement of analyses. The survey's answers fields were designed to be mandatory to be filled before proceeding to the next section, options such as "None" or "I don't know" were provided wherever necessary to minimize missed data. Kolmogorov-Smirnov (K-S) test was used to check normality of the data distribution. Descriptive analyses were performed for sample characteristics, history of "COVID-19" in self or family, history of contact with "COVID-19" positive patient, knowledge towards various aspects of "COVID-19" and concerns, and precautionary measures. The results of these analyses were presented as frequencies and percentages for categorical variables and as means and standard deviations for continuous variables.
The psychological burden of the "COVID-19" pandemic was measured using scores on the three subscales of the DASS; the scores were presented as means with standard deviations. Bivariate analyses were performed to find the relationship between the individual variables and scores on each of the three scales (DASS-stress, DASS anxiety, and DASS-depression) using independent t-test to compare two groups. All tests of associations were carried out at a significance level of < 0.05.

Participant's characteristics
Out of the 400 students who were invited to participate in the survey through the online link, 369 agreed to participate and completed the study questionnaire giving a response rate of 92.2%. Among the participants 269 (72.8%) belonged to department of laboratory medicine and 100 (27.1%) to department of medicine. The demographic information for the 369 participants (323 [87.5%] females and 46 [12.5%] males) is shown in Table 1. Their ages ranged from 18 to 30 years but most of the participants were between 18 and 25 years (91.3%). Besides, 91.8% of the participant were undergraduate students and 8.2% were post-graduate students. Most of the participants were unmarried (91.3%). History of psychiatric illness was found in 14.6% and 18.7% reported a positive family history of psychiatric illness. The "COVID 19" exposure information revealed 16% got infected with the virus, 40.1% reported family members getting infected, 30.9% reported, quarantine due to contact with the positive patient and, 15.7% reported hospitalization with 24.4% landing up in the intensive care unit (ICU) ( Table 1).

Knowledge regarding "COVID-19" among students
Regarding the knowledge on various aspects of "COVID-19", the majority (94.6%) of the participants knew correctly that "COVID-19" can be prevented by the use of face mask, social distancing, and handwashing and 94.0% knew its mode of transmission, whereas only 39.6% of the participants knew that 56 °C for 30 min, diethyl ether, 75% ethanol, peracetic acid and, other lipid solvents can effectively kill the virus causing "COVID-19". The Majority of the participants exhibited good knowledge about general symptoms related to "COVID-19" illness (91.6%) including the knowledge about breathlessness and low oxygen saturation (85.9%), whereas 74.3% of the participants knew about gastrointestinal symptoms as the presentation of "COVID-19". Awareness about psychological balance and its relation with improved immunity was found in 77.8% (Table 2).

Psychological impact
Using the specified cut-offs of the DASS-21 scoring system to screen for depression, anxiety and, stress. We found depressive symptoms in 190 (51.4%), anxiety symptoms in 214 (57.9%) and, stress in 179 (48.5%) study participants. The overall mean DASS-21 depression subscale score was 11.25 ± 10.86. Among the 190 students who screened positive for depressive symptoms, 22.6% scored mild, 38.4% moderate, 15.8% severe and, 23.2% extremely severe on the DASS sub-score for depressive symptoms. The overall mean DASS-21 anxiety symptoms subscale score was 10.16 ± 9.62. Of the 214 patients who screened positive for anxiety, 13.6% of them showed mild anxiety, 38.8% moderate, 11.2% severe and, 36.4% extremely severe anxiety symptoms. In terms of the DASS-21 stress subscale, the overall mean score was 11.55 ± 10.36. Stress was mild in 49.7%, moderate in 27.9%, severe in 16.2% and, extremely severe in 6.2% participants screened positive for stress (n = 179) ( Table 3).

Sample characteristics and psychological impact
There was no significant statistical association found between the DASS-21 score and sociodemographic factors like age, sex, marital status and, educational levels. The history of psychiatric illness in the participants showed higher scores on depressive symptoms (p = 0.001), anxiety symptoms (p = 0.01) and, stress (p = 0.04) symptoms. Positive family history of psychiatric illness was significantly related with a high score on depressive symptoms (p = 0.03), anxiety (p = 0.005) and, stress (p = 0.02) symptoms. While the history of  reported significantly high anxiety scores (p = 0.0003) and stress scores (p = 0.04) ( Table 4).

Knowledge variables and psychological impact
Most of the knowledge variables were not associated with significantly increased scores on DASS-21. The knowledge about the agents that can effectively kill the virus causing "COVID-19" showed significantly high scores on the depression subscale (p = 0.01) and respiratory droplet as a mode of transmission was associated with higher scores on the anxiety subscale (p = 0.007).
Knowledge regarding the surface contamination as a mode of spread was associated with a significantly high score of stress (p = 0.004) and anxiety (p = 0.002).
Knowing that "COVID-19" can also clinically present with gastrointestinal symptoms showed significantly high scores on stress (p = 0.005) and anxiety (p = 0.01) subscale than any other way of clinical presentation (Table 5).

Discussion
Previous studies in Saudi Arabia have shown a high prevalence of anxiety and depression in medical students [23], and college students [24] irrespective of any emergency or epidemic. Studies worldwide have shown an increased psychological impact on college and university students during the "COVID-19" pandemic [14][15][16][17]. Overall, we found higher stress, anxiety, and depressive symptoms in the study participants when compared to previous studies in the region of Saudi Arabia [25,26]. Contrary to this, few studies found higher level of stress than our study participants [27,28]. The higher prevalence in our sample could be because of the fact that our sample consisted of purely university students and female participants which is in line with previous studies reporting a higher prevalence of anxiety and depression in female gender and university students [8][9][10]. Moreover, we found significant number of subjects with positive past and, family history of psychiatric illness respectively, which could be another reason for higher prevalence as compared to previous studies. Nonetheless, factors like coping styles, social  support [29], personality [30] and religiosity [31] could be among other factors affecting the psychological heath of students. Interestingly, depression, anxiety, and stress have not only been highly prevalent during the "COVID-19" pandemic, but also after the movement lockdown was lifted [32]. Our study indicates that university students are having a considerable amount of mental health burden. However, these findings may be confounded by the time and type of examination in different years, different studying materials and different studying years. The ambiguity about the future and detrimental effect on academic progression could be the cause for mental health issues among students. Participants getting infected with SARS-CoV-2 irrespective of admission showed significantly high levels of depression and anxiety while those admitted to hospital and ICU reported significantly high levels of anxiety and stress. This finding is similar to studies reporting a high level of anxiety, depression and, PTSD in patients diagnosed with "COVID-19" [33]. Nonetheless, coronavirus infections are also known as neurotropic viruses due to their affinity to the nervous system [34]. SARS-CoV-2 neuro-invasion was demonstrated in human cell cultures and post-mortem studies [35]. Thus, the neuroinflammation caused by SARS-CoV-2 may cause neuropsychiatric illness [36].
It was found that most of the participants had good knowledge (90-95%) about "COVID-19" for most of the knowledge variables when compared to a Chinese study (50-60%) [37]. The knowledge regarding the ability of solvents like diethyl ether, 75% ethanol, peracetic acid, other lipid solvents and, 56 °C heat effectively killing the virus causing "COVID-19" was found in 39.6%, which is comparable to the finding of a Chinese study reporting 30% participants knowing the same factor [37]. Our study found that 77.8% of the participants knew that psychological balance improves immunity, whereas a similar study from China revealed only 37% of participants knew about this fact [37]. Our findings suggest that knowledge regarding the incubation period, preventive measures, early signs of "COVID-19" and, the effect of psychological balance on immunity was not s depression, anxiety and, stress symptoms. Similarly, previous studies have suggested that overall knowledge about "COVID 19" had a protective psychological effect [38][39][40]. A previous study reported a higher level of anxiety and depression in individuals having good knowledge about handwashing as a preventive measure for "COVID-19" [32], whereas our study reported high levels of anxiety and stress in individuals knowing about surface contamination and respiratory droplet as a mode of spread. Research and clinical observations suggested that during pandemics increased anxiety and stress in association with fear of coming in contact with infected objects or surfaces [40]. However, descriptive findings of this study indicate that university students possessed an adequate level of knowledge related to "COVID-19" at the time of the survey administration. Additionally, our sample included students from medical and paramedical courses hence, more likely to be attuned to correct information related to "COVID-19". Adequate pandemic-related knowledge, teaching psychological strategies (e.g., training of resilience factors and coping strategies) and social support help reduce negative psychological affect [41][42][43]. Besides, biofeedback, mindfulness techniques (e.g., meditation) [42] and cognitive behavioral therapy [44] are useful measures to combat psychological affect of "COVID-19". Online psychological counselling services by mental health professionals in medical institutions, universities, and academic societies and online psychological self-help intervention systems, including online cognitive behavioral therapy for depression, anxiety, and insomnia have shown to be effective in combating the mental health issues [45].

Limitations
Our study had few limitations worth mentioning. Since the study design is cross-sectional, the causal association cannot be established. Thus, findings need to be supported by well-designed longitudinal studies. Further studies about the impact of COVID-19 with follow-up these students may help shed some light on the psychological effect among students. Since the data collection was online, the reliability and accuracy of information provided may be limited. Furthermore, the recruitment of subjects via social media could also induce a selection bias of those students that experience more than average mental health issues. There is a possibility of self-rating bias and issues of subjectivity and reliability since the measure used to assess psychological impact was a self-rating scale. The higher scores were not further evaluated by a psychiatrist to confirm the presence of a psychiatric disorder. Moreover, the questionnaire and scale were not translated in Arabic.

Conclusion
Our study findings reflect the increased mental health burden among the university students due to the "COVID-19" pandemic. The Government should consider incorporating mental health and psychological intervention within the "COVID-19" outbreak prevention and mitigation program for vulnerable groups such as health care professionals and students. To alleviate the mental health burden of the "COVID-19" pandemic, mental health interventions and professionally trained counsellors shall be made available within the campus. Future research should be aimed at targeting multiple universities for longer periods to identify the full spectrum and course of student mental disorders. Longitudinal studies in the future may help answer whether direct or indirect exposure to the "COVID-19" virus added to mental health disorders. Continuation of face-to-face academic activities and social interaction may be of paramount importance to protect the psychological wellbeing of university students.