Introduction

The world has confronted the COVID-19 outbreak for the first time in December 2019, when a new SARS-CoV-2 coronavirus was identified in the Chinese province of Hubei, in the city of Wuhan [1]. The pandemic scale of this novel coronavirus has led to the world’s biggest public health crisis in over one hundred years and thus opened many unresolved issues. It has resulted in millions of dead people [2] and in the middle of 2020 there was an increase in COVID-19 cases among adults aged between 18 and 22 years [3].

As one of the main measures in the fight against this plague is physical distancing, along with the obligatory maintenance of hygienic measures and isolation from other people, the pandemic has caused a number of mental problems around the world. Italian researchers identified elevated levels of stress, anxiety and depression in the general population in response to the COVID-19 pandemic [4]. People with a history of psychiatric disorders were particularly affected during a pandemic [5], and their mental health is further impaired due to the long-term presence of the virus in the population. Also, single people showed severe symptoms of depression, while married people, especially females, showed high levels of anxiety [6].

The COVID-19 pandemic is currently one of the biggest public health threats and challenges for professionals’ mental health [7]. It caused the closure or reorganization of most educational institutions around the world, including higher education institutions, and had a negative effect on students’ mental health [8]. Among students in Italy, in addition to the concerns about the organization of studies and discomfort due to social distancing, results suggested that female students were more likely to complain of anxiety than male students [9]. A study from Serbia showed the negative impact of the COVID-19 disease pandemic on the psychological state of students [10]. Mental health problems and the occurrence of anxiety and affective emotional problems were also found in the student population of Slovakia [11]. A special problem was created among medical students who, due to the pandemic, could not have practical classes and contact with patients [12] and thus self-reported increased levels of anxiety and stress [6]. Their level of anxiety was even higher compared to the general population [13]. During the pandemic medical students from the Department of Public Health University in Northern New Jersey, US showed problems with mental health due to difficulty in coping with changed daily and student activities [14].

To our best knowledge, this is the first study in Serbia that examines the effects of the COVID-19 epidemic on students’ mental health and the first study to observe its effects on the mental health of the medical student population.

Therefore, the aim of this paper is to assess the level of self-reported stress, anxiety, and depression of the student population in Serbia in relation to the demographic characteristics, living and studying conditions, students’ activities during the epidemic, potential coronavirus infection, and general, mental and physical health.

Method

Results

Table 1 shows the distribution of demographic variables, as well as variables related to both study and living conditions and the health status of the study participants.

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Table 1. Distribution of demographic variables, variables related to students medical studies and health status during the coronavirus epidemic, as well as, scales of depression, anxiety and stress.

https://doi.org/10.1371/journal.pone.0275167.t001

They were predominantly female (80.3%), aged between 21 and 30 (68.4), religious (63.3%), and from urban areas (85.9%). More than one-third of participants (37.1%) had few organized online classes during the pandemic, 32.4% had problems with e-learning platforms, and 25.5% of students were infected with SARS-CoV-2 by the time of the survey. Out of all examined students, 71.9%, 66.7% and 50.5% self-perceived their general, physical and mental health as good, respectively. Severe symptoms of depression were recognized by 65.5% of students, 90.9% of students suffered from severe anxiety, and 85.6% were under severe stress.

A total of 64.5%, 66.8% and 66.7% of students between the ages of 21 and 30 reported severe depressive symptoms, severe degree of anxiety, and a severe stress, respectively (Table 2).

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Table 2. Distribution of self-assessed depression, anxiety and stress, as well as their differences in relation to students demographic variables, their medical studies and health status during the coronavirus epidemic.

https://doi.org/10.1371/journal.pone.0275167.t002

The percentage of women who perceived their anxiety as severe was 81.4%, while the percentage of women who perceived their stress as severe was 83.1%. The most severe symptoms of depression, anxiety, and stress were among students in the first (21.6%; 19.5% and 20.2%, respectively) and sixth (19.5%, 23.1%, and 21.8%, respectively) year of study, while the least severe symptoms occur in fifth-year students (10.8%, 12.5%, and 12.7%, respectively). Also, 60% of students with severe depressive symptoms were religious and 36.3% of them did not have adequate online learning platforms. Among students who self-reported severe depressive symptoms, 32.4% rated their mental health as good, and of those with severe anxiety, 65.1% considered their physical health to be good. Of all the participants who rated their general health as good, 69% of the participants self-reported severe stress.

The results of the bivariate logistic regressions are shown in Table 3.

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Table 3. Associations of scales of depression, anxiety and stress with students’ demographic variables, their medical studies and health status during the coronavirus pandemic–results of bivariate logistic regressions.

https://doi.org/10.1371/journal.pone.0275167.t003

Students between the ages of 21 and 30, as well as fifth and sixth-year students, were less likely to rate their depression as severe compared to students under the age of 20, and first-year students, respectively. The same pattern was observed for the self-assessment of anxiety. On contrary, non-religious students were one and a half times more likely to experience a major depressive episode (OR = 1.52) compared to religious students. Students who did not have problems with online learning platforms were less likely to assess their depression as severe. Students who rated their mental health as average or good, as well as those who rated physical health as good, were less likely to experience a severe depressive reaction, compared to students who rated their physical and mental health as poor. Compared to men, women almost twice as often (OR = 1.89) and almost two and a half times more women (OR = 2.39) perceived their anxiety and stress as severe, respectively.

As indicated in Table 4, sixth-year (OR = 0.21) and fifth-year students (OR = 0.12) were less likely to perceive their depression as severe as first-year students. Students of the second (OR = 0.18), third (OR = 0.11), fifth, and sixth year (OR = 0.09) evaluated less frequently stressful reactions as severe, compared to students of the first year of medicine. Students who rated their mental health as good (OR = 0.01) or average (OR = 0.06) were also less likely to rate their depression as severe. Women more than twice (OR = 2.21) and more than three times (OR = 3.37) times more often assessed their anxiety or stress reactions as severe compared to men.

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Table 4. Associations of scales of depression, anxiety and stress with students’ demographic variables, their medical studies and health status during the coronavirus pandemic–results of multivariate logistic regressions.

https://doi.org/10.1371/journal.pone.0275167.t004

Discussion

The current study indicates that 65.5%, 85.6%, and 90.9% of students self-reported severe depressive, stress, and anxiety reactions, respectively. Our results are in line with the study from Russia where students showed higher levels of depression and higher levels of stress during the pandemic, but the opposite compared to students from Belarus, where social distance measures were not effective in the first months of the pandemic [18]. A study conducted on students in Switzerland showed that depressive symptoms were present among more than a quarter of the student population [19]. Similar results, but with lower levels of depression, anxiety, and stress (42%, 44.5%, and 66.0%, respectively) were obtained in another study conducted among the general population in Serbia [10]. A possible explanation for higher levels in our study may be attributed to the population that participated. Namely, medical students and medical personnel were more than the general population in contact with patients, moved to places where the virus transmission was higher, and generally knew more about the virus than other people, which could have further compromised their mental health [20].

The results of our study showed that only 32.4% of students with self-reported severe depressive reactions had good mental health. In a study with Switzerland’s students, depressive symptoms occurred more often in female students than in males, as well as in students who cared more about their health or already had some health problems [19]. In our study, no gender difference was found in terms of self-reported depressive reactions, although, a study conducted among Italian students [9] showed a significant difference between men and women, that is, women showed more depressive reactions.

Our study showed that first year students self-reported more severe depressive reactions than their older colleagues at the second, third, fifth, and sixth years of studies. Similar results were obtained in an extensive study conducted in nine countries by Ochnik et al. [21], which showed that students worldwide did not differ much in their reactions to the pandemic, but also that students in their younger years were more likely to self-report more depressive reactions. Students from our study who did not have problems with online learning platforms during the pandemic were 0.58 times less likely to self-report severe depressive reactions compared to students who had certain problems. For students who had problems with online learning platforms, professors from Belgrade Medical Faculty might organize additional consultations on weekly basis, so they can catch up on the material. Also, medical students who were non-religious self-reported severe depressive symptoms one and a half times more often (OR = 1.52) than religious students, which is in line with the findings of a study conducted with students in Malaysia [22] who generally turned to religion as a mechanism of coping stressful situations. Students from our study who aren’t religious can be referred to attend courses at the Department of Humanities that include topics in religion (like Health Psychology) and the content like this may help them find some answers on how to cope with stress during the days of the pandemic.

The results of this study showed that anxiety in our students was present in 90.9%, which indicates the high vulnerability of Serbian students to pandemic conditions. A study conducted among Chinese medical students [12] showed that 25% of students had problems with anxiety due to the virus pandemic and its consequences on everyday life and education. Anxiety was also a reaction of US students to the pandemic and its uncertainties, such as financial problems, unemployment, social isolation, concerns related to study conditions, and the organization of distance learning [23]. In our study, female students were more likely to self-report anxiety, that is, 2.21 times more often than male students, which is in line with data from a study conducted in New York [24]. Anxiety also occurred among adolescents and students during the pandemic in Pakistan [25], and the possible cause may be complete isolation, which was especially difficult for students who are by their nature very active, curious, and friendly. Medical students from Jordan [8], showed a higher degree of anxiety during the pandemic due to the way the studies were organized, that is, the difficulty of organizing primarily practical classes.

In our study, 17.8% of students stated that they have poor mental health, and self-perceived poor mental health was a predictor of higher levels on the anxiety scale. Research with students from Bangladesh showed that mental health problems can predict some psychopathological symptoms [26] and that there is a link between fear and anxiety about the virus and anxiety reactions. High anxiety levels, were also found in medical students from Mexico [27], and consequently, the students stated that anxiety and depressive reactions in that period were the main problems in normal everyday life. Health-related anxiety also occurred in students in Germany [28], where half of them reported increased concerns during the COVID-19 pandemic. Students from Serbia self-reported more intense and more often anxiety reactions at the beginning of their studies compared to those of older students and such findings are consistent with results in some other countries such as Slovenia, Germany, Turkey or Israel [21].

Our findings showed that 85.6% of medical students from Serbia self-reported severe stress due to the SARS-CoV-2 virus pandemic and 3.37 times more often female medical students compared to their male counterparts, which is in line with the student population in China [29]. At the beginning of their studies, students more often self-reported severe stress reactions compared to their older colleagues, which was also confirmed in a study by Ochnik et al. [21]. Our study did not confirm that social support in family life has a protective effect on mental health. Students who lived with their family were two and a half times (OR = 2.57) more likely to self-report severe stress in relation to their colleagues who lived alone and perceived their stress as moderate or mild. On the contrary, research conducted in Thailand [30] showed that stress reduction is more successful if students are provided with some form of social support and assistance. The transition of society, the lack of social support within some families, and the value system that has reigned in Serbia recently might be partly responsible for the ongoing situation, while in countries with a very expressed collectivist culture, such as Indochina, the value of social support has not declined.

During the pandemic, the University did not provide any organized activities of assistance to students. The students themselves organized support groups through social networks. The primary focus of the University was the organization of online classes while taking care of students’ mental health was of secondary importance.

In Belgrade, the students can get specialist consultative services (covered by health insurance) for the protection of their mental health at the Institute for students’ healthcare as primary health care institution. There is no program or center for psychological counseling at Belgrade University so the creation of a network of centers for counseling and psychological help for students as an integrated part of the health system is of crucial importance for the prevention and protection of mental health, but also for young people in general. The individual, group, and workshop activities for students could be provided in those centers by teachers, assistants, final year students, psychotherapists, and other psychologists, but also experts and researchers from numerous other institutions. Basic activities would be direct counseling, peer counseling, SOS telephone service, internet counseling (through an online Faculty platform), organization of forums, seminars, round tables, the realization of empirical research, training and education, etc. Also, if one student needs hospital treatment, professional help would be provided. The support program should be available to students throughout the year and could start at the beginning of the academic year. For those students with poor mental health it must take into consideration the specificities of the population to which it refers and all other contextual specificities [31]. During the orientation week or mental health gatekeeper training, younger students can learn from professors or senior colleagues how to recognize the first signs of mental problems, how to successfully deal with stress and use coping mechanisms, and where to find professional help [32, 33].

According to our best knowledge, this is the first study in Serbia that examines the effects of the COVID-19 pandemic on students’ mental health and the first study to observe the mental health of the medical student population. Also, the advantage of this study was the random sampling process, and consequently representative sample. However, there are several limitations that need to be stressed. The generalization of results cannot be applied to students of other faculties of the University of Belgrade or to students in the rest of Serbia. Due to the epidemiological situation, the study was conducted online, which could have led to uneven conditions for completing the questionnaire. This was partially avoided by detailed written instructions and those related to the conditions in which the completion of the questionnaire should be organized, but still, we assume that some of the participants may have ignored these instructions. Students could also be dishonest in their responses.

Conclusion

As a consequence of the SARS-CoV-2 virus pandemic, students attending undergraduate medical studies in Belgrade developed mental health problems. The majority of students assessed their anxiety and depressive reactions as moderate or severe, while stress reactions were sometimes assessed as mild, but more often as moderate or severe. The COVID-19 pandemic had a great impact on the overall mental health of medical students and therefore it is important to pay attention to preserving their mental health and to launch programs that would provide, primarily social support and assistance in the form of consultative work.

Supporting information