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Year : 2023  |  Volume : 21  |  Issue : 1  |  Page : 31-36

Anxiety, depression and stress among female medical students during the second wave of the COVID-19 pandemic and their association with family functioning, coping and personality

1 Department of Psychiatry, Sri Padmavathi Medical College for Women, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
2 Department of Psychiatry, ACSR Government Medical College and Government General Hospital, Nellore, Andhra Pradesh, India
3 Department of Psychiatry, Christian Medical College, Vellore, Tamil Nadu, India

Date of Submission31-Jul-2022
Date of Decision23-Oct-2022
Date of Acceptance01-Nov-2022
Date of Web Publication17-Jan-2023

Correspondence Address:
Dr. Dheeraj Kattula
Department of Psychiatry, Christian Medical College, Vellore - 632 002, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/cmi.cmi_81_22

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Background and Aims: This research examined anxiety, depression, and stress levels in female medical students during the second wave of coronavirus disease 2019 (COVID-19) and the association between these variables and family functioning, coping, and personality factors. Materials and Methods: The cross-sectional online observational study was conducted using Google Forms. Anxiety, depression, and stress were assessed using the Depression, Anxiety, and Stress Scale (DASS-21), family functioning using Family Adaptability, Partnership, Growth, Affection, and Resolve, coping using Brief COPE, and personality using the Big Five Inventory 10-item version. Results: Out of 750 students, 500 thoroughly responded to the online survey. Based on the DASS-21 scores, 57.6% of participants had some stress, 63.4% had some anxiety, and 54.8% had some degree of depression. Anxiety, depression, and stress were highly correlated with each other. Stress, anxiety, and depression were weakly linked with problem-focused coping, moderately correlated with emotion-focused coping, and strongly correlated with avoidant coping. Better family functioning was associated with lesser self-reported stress, anxiety, and depression. Neuroticism was associated with higher anxiety, depression, and stress, while agreeableness and conscientiousness were with lower psychological distress. Conclusion: High level of psychological suffering was prevalent among medical students during the COVID-19 pandemic. Their anxiety, depression, and stress must be adequately managed.

Keywords: Anxiety, coping, coronavirus disease 2019, depression, medical student, personality, stress

How to cite this article:
Mallaram GK, Shaik S, Kattula D. Anxiety, depression and stress among female medical students during the second wave of the COVID-19 pandemic and their association with family functioning, coping and personality. Curr Med Issues 2023;21:31-6

How to cite this URL:
Mallaram GK, Shaik S, Kattula D. Anxiety, depression and stress among female medical students during the second wave of the COVID-19 pandemic and their association with family functioning, coping and personality. Curr Med Issues [serial online] 2023 [cited 2023 Jun 6];21:31-6. Available from: https://www.cmijournal.org/text.asp?2023/21/1/31/367865

  Introduction Top

India's government announced a countrywide lockdown in March 2020 as an important and effective way to contain the spread of coronavirus disease 2019 (COVID-19). The pandemic and the lockdown have had an impact on the mental health of everyone including medical students.[1],[2],[3],[4] Uncertainty and uneasiness have invaded the medical student community, with physical exposure to patients and other students increasing the risk of infection and lack of exposure leading to inadequate training and a sense of alienation. Ambiguity about the future, particularly regarding examinations, curriculum, and promotion to the next semester, can cause stress, anxiety, and depression, aggravating preexisting psychiatric illnesses.[5],[6]

Medical students' mental health issues are well recognized. They have a greater burden than other students.[7] This is so even during the time of COVID-19.[8] Physician and medical student suicidal ideation have become alarmingly common in this epidemic.[9],[10],[11],[12] The mental health of health-care staff receives less attention, despite mounting evidence of untreated mental problems in this population. Medical students with mental health problems are also often afraid to talk about them or get help because of stigma.[13]

Symptoms of psychological distress often relate to coping methods.[14],[15] Similarly, family functioning can be linked with stress, depression, and anxiety.[16],[17] The personality features of an individual also have a bearing on the genesis and persistence of psychological distress. Understanding the symptoms of anxiety, depression, and stress can be more holistic by finding the relationship between these symptoms and coping, family functioning, and personality factors. Hence, we studied all these variables in the current study.

  Materials and Methods Top

Study design

We used a cross-sectional study design.

Setting and participants

It was an Internet-based survey through Google Forms. It was conducted among MBBS students of Sri Padmavathi Medical College for Women in Sri Venkateswara Institute of Medical Sciences, Tirupati. The college has a repository of the e-mail addresses of the students. The present study included medical students who stayed at home during the second wave of the COVID-19 pandemic. The students who were excluded from the study were those who were not willing to give consent, those who were not residing at home, and those who completed their course and started their internship.

Aims and objectives

We aimed to estimate anxiety, depression, and stress levels in female medical students during the second wave of the COVID-19 pandemic and study the association between these variables and family functioning, coping skills, and personality factors.

Data sources/measurement

The link to the online survey, which was created on Google Forms, was circulated to the students through e-mail. They were sent three reminder e-mails if no responses were received.


The survey collected information about demographic details and whether the student had any mental illness. The survey also assessed depression, anxiety, and stress symptoms using the Depression, Anxiety, and Stress Scale (DASS-21), family functioning using the Family Adaptability, Partnership, Growth, Affection, and Resolve (APGAR), coping using Brief COPE, and personality using the Big Five Inventory (BFI) 10-item version. The DASS-21 comprises three self-reported scales which measure anxiety, depression, and stress.[18],[19] It is reliable, valid, and easy to administer. The psychometric properties of the scales are well-validated. The higher the score, the higher is the levels of anxiety, depression, and stress symptoms. The BFI 10 Questionnaire is a shorter version of the Big Five personality inventory and covers the domains of openness to experience, agreeableness, neuroticism, extraversion, and conscientiousness.[20],[21] It has got good psychometric properties. The Brief COPE is a self-report questionnaire with 28 items which measures different ways to deal with a stressor. “Coping” can be broadly defined as a means to decrease distress linked with negative events in life. Currently, it is one of the most validated and utilized measures of coping strategies.[22] The 14 coping strategies can be clubbed into three domains of problem-focused coping (PC), emotion-focused (EC) coping, and avoidance coping (AC). There were four strategies in the PC and AC domains and there were six strategies in the emotion-focused domain.[23] The acronym APGAR was applied to the functional aspects of the family which are APGAR. Family APGAR questionnaire has got good psychometric properties and so it was used to measure self-reported family dysfunction.[24]

The study was conducted in the period between August 2021 and March 2022.


Duplicate entries were deleted by verifying respondents' e-mail addresses.

Study size

Assuming the prevalence of psychiatric comorbidity conditions such as anxiety, depression, and stress in an MBBS student population during the pandemic was 50%, at a precision of 5% with a 95% confidence interval, the estimated sample size calculated was 385 using online sample size calculator sampsize.sourceforge.net.

Statistical methods

To conduct this research, we used SPSS version 20 (Armonk, NY, USA). Descriptive data were provided using the mean, standard deviation, frequency, and percentages. The mean and standard deviation were used to characterize the sub-scale scores. To determine normality, the Kolmogorov–Smirnov test was used. The relationship between the variables was assessed using the Spearman correlation test. Missing value imputation was not done, and cases with missing values were eliminated from the analysis. P < 0.05 was considered significant for inferential statistics.

  Results Top

There were 763 responses, out of which 579 were completed forms. Of those, 79 were second responses with the same phone number, leading to 500 responses being analyzed. These completed forms were used for further analysis. The participant characteristics are presented in [Table 1]. The majority of them were in their early twenties. Second- and final-year students were the most common participants, and all were unmarried except one. Based on the DASS-21 scores, 212 (42.4%) participants had everyday stress, 146 (29.2%) had mild stress, 85 (17.0%) had moderate stress, 48 (9.6%) had severe stress, and 9 (1.8%) had highly extreme stress. Similarly, 173 (34.6%) had standard scores for anxiety, 44 (8.8%) had mild anxiety, 121 (24.2%) had moderate anxiety, 45 (9.0%) had severe anxiety, and 117 (23.4%) had highly severe anxiety. Furthermore, 226 (45.2%) participants had standard scores for depression, 61 (12.2%) had mild depression, 97 (19.4%) had moderate depression, 55 (11.0%) had severe depression, and 61 (12.2%) had extremely severe depression scores according to DASS-21.
Table 1: Characteristics of the respondents

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The scores on the scales of anxiety, depression, stress, coping, family functioning, and personality factors are presented in [Table 2]. The anxiety, depression, and stress sub-scale mean scores were around 12–13. AC was less frequently endorsed as compared to PC or EC. Among the BFI sub-scales, agreeableness was scored highest.
Table 2: Responses on the psychological symptoms, family functioning, coping, and personality

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In [Table 3], the relationships between symptoms of psychological distress, family functioning, coping, and personality features are presented. It was seen that stress, anxiety, and depression had a high degree of correlation with each other. Stress, anxiety, and depression were weakly correlated with PC, moderately correlated with EC, and strongly correlated with AC. Better family functioning was associated with lower self-reported stress, anxiety, and depression, with correlation coefficients in the moderate range. Personality traits such as agreeableness, conscientiousness, and neuroticism were weakly related to stress, anxiety, and depression, with neuroticism associated with higher psychological distress, and agreeableness and conscientiousness were associated with lower levels of psychological distress.
Table 3: Correlation of psychological symptoms, family functioning, coping, and personality

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  Discussion Top

The present study suggests that symptoms of anxiety, depression, and stress were present in a significant proportion of medical students. The rates of anxiety, depression, and stress seem to be higher than in previous studies using similar tools.[25],[26],[27] Studies using other instruments have also found lower rates of anxiety and depression.[28] However, similar levels of anxiety and depressive symptoms have been noted among medical students in some other research as well.[29],[30] The differences in prevalence rates may be due to the differential impact of COVID-19 on psychological functioning across the globe, differences in sample selection, different tools of assessment, and potential responder biases. One of the reasons for the high rates could have been the fact that the present sample was comprised exclusively of females.[30] It has been seen that the rates of anxiety, depression, and stress are higher among women as compared to men. Nevertheless, a significant proportion of the students are affected, as reflected by the existing literature. Using the instrument DASS-21, a significantly higher number of medical students were found to have symptoms of psychological distress as compared to those who had a history of psychiatric illness (about 5% of the population).

It was seen that AC and EC were linked with greater rates of anxiety, depression, and stress. Previous literature also suggests that AC and, to some extent, EC are associated with symptoms of anxiety, depression, and stress.[31],[32] PC, on the other hand, has been less frequently associated with psychological distress. This could potentially be attributed to PC dealing with addressing stressful situations. At the same time, AC leads to an accumulation of stress due to not addressing them in time. EC is likely to stimulate affective changes due to the difficulties in day-to-day life.

In the present sample, better family functioning was linked to lower rates of anxiety, depression, and stress. It is quite possible that good family functioning may be a buffer against experiencing psychological distress. Alternately, symptoms of anxiety, depression, and stress may lead to a negative appraisal of family functioning, and the appraisal of family functioning may turn positive as these symptoms recede. From this cross-sectional study, we are unable to infer causality. Some of the personality attributes also contribute to the appraisal of psychological stress. It is well known that neuroticism is associated with anxiety and depression.[33],[34] This study also showed that agreeableness and conscientiousness were negatively associated with anxiety, depression, and stress, a finding that is similar to other previous literature.[33]

The implications of the present findings are several. First, the study suggests that a considerable proportion of medical students had anxiety, depression, and stress. Thus, mental health-care services need to be operational and accessible.[35] Even telemedicine services can be a potential solution for providing care during the pandemic.[36],[37] Second, coping strategies and, to some extent, personality dimensions are associated with psychological distress. When they foreshadow the emergence of distress, coping can be gradually altered. Hence, student wellness services can help medical students focus on changing maladaptive coping patterns. Third, students who experience mental health distress may need special consideration or time off to recuperate. Providing administrative assistance, confidential care, and avoiding penalization, which may affect careers, would seek help with fewer barriers.

Some of the limitations of the current study deserve to be mentioned. The present study was cross-sectional. The completion rate was suboptimal. The findings relate to a single center, with medical students comprising only the female gender. Hence, generalizations should be made with caution. There could have been responder bias, which cannot be totally eliminated in such a study. The data collection period took a long time, and it was hard to figure out how COVID-19 had different effects at different times.

Despite the limitations, the present study suggests that anxiety, depression, and stress were present in a significant proportion of medical students during the COVID-19 pandemic. Avoidant coping was particularly related to such things as anxiety, depression, and stress. Based on the present data, efforts are needed to handle psychological distress among medical students more effectively. Further studies can look at the longitudinal outcomes of stress, anxiety, and depression among medical students, their effects on academic performance and social functioning, the trajectories and predictors of these symptoms of psychological distress, and whether students seek to help for their symptoms of anxiety and depression.

  Conclusion Top

There had been high level of psychological burden due to anxiety, depression and stress among students during the COVID-19 pandemic. This could be addressed by offering student mental health services which could have promotive, preventive and curative services.


We want to acknowledge Prof. B Vengamma, Director cum Vice Chancellor and Prof Alladi Mohan, Dean of SVIMS University, Tirupathi, for giving permission to conduct the study and for continuous encouragement and support.

Ethical statement

The Institutional Ethics Committee Clearance was obtained in August 2021 (IEC No 1189]. Online informed consent was taken from the students. The study complied with the Indian Council of Medical Research Good Clinical Practice Guidelines and followed medical research ethics as per the Declaration of Helsinki.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3]


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