key: cord-0931802-rbk4c65v authors: Mirhosseini, Seyedmohammad; Grimwood, Samuel; Dadgari, Ali; Basirinezhad, Mohammad Hasan; Montazeri, Rasoul; Ebrahimi, Hossein title: One‐year changes in the prevalence and positive psychological correlates of depressive symptoms during the COVID‐19 pandemic among medical science students in northeast of Iran date: 2022-01-12 journal: Health Sci Rep DOI: 10.1002/hsr2.490 sha: 9ac80a27bf77239bedf283cb286a5fb673ed7789 doc_id: 931802 cord_uid: rbk4c65v OBJECTIVES: The COVID‐19 pandemic has imposed a significant psychological burden on many across society especially students studying medical sciences. This study intended to investigate the one‐year changes in the prevalence and correlates of depressive symptoms during the COVID‐19 pandemic among medical science students. METHODS: A cross‐sectional study in Shahroud, Iran administering a convenience sampling method (January to February 2021). Online self‐reported questionnaires included Rosenberg Self‐Esteem Scale, Paloutzian‐Ellison Spiritual Well‐Being Questionnaire, Diener's Satisfaction with Life Scale and the University Student Depression Inventory. Data analyzed using descriptive and inferential statistics (Independent t‐test and Multiple Regression Analysis). RESULTS: A total of 306 medical science students were investigated in this study. The mean scores 1 year after the outbreak of COVID‐19 were for depression (81.25 ± 26.04), spiritual well‐being (80.98 ± 18.06), self‐esteem (26.89 ± 2.20), and life satisfaction (19.68 ± 6.81). The results indicated that depression mean score was significantly higher in post outbreak assessment (71.92 ± 22.94 vs 81.25 ± 26.04) (P < .001). Fifty percentage of changes in depression can be predicted by studied variables. A high score of depression was directly associated with a higher level of self‐esteem. Moreover, increased interest in the field, scores of spiritual well‐being, and life satisfaction were inversely and significantly associated with depression. CONCLUSIONS: Iran's education system has been significantly affected, with the addition to the COVID‐19 pandemic imposing a psychological burden such as depression, exacerbating this within medical science students compared to a year ago. Spiritual well‐being and life satisfaction as positive psychology constructs were recognized as protective factors against depression during the pandemic. Spiritual and social support should be integrated in psychological interventions within university settings for medical science students. affected the mental health aspects of communities and imposed a heavy psychological burden, resulting in public psychological distress with a detrimental effect on psychological well-being and a rise in psychological symptoms in the general population in Iran and other countries, [3] [4] [5] negatively impacting on physical health 6 and social well-being. 7, 8 According to a literature review people in quarantine reported depression, anxiety, stress, and irritability during the COVID-19 pandemic. [9] [10] [11] The lockdown policy implemented after COVID-19 pandemic such as closure and change of policy of educational and evolving the approach of virtual and online education instead of face-to-face education has brought new challenges in teaching and learning strategies 12 which has been associated with psychological consequences. 13 One of the most prevalent psychological problems resulting from social isolation and quarantine following COVID-19 pandemic is depression, which has been studied in different communities especially in Iranian general population, that has a high prevalence. 14 Some groups (such as college students) are known to be at high risk for mental health problems. According to Halperin et al, 15 24 .3% of medical students in the United States experienced depression during the corona epidemic. The prevalence of this condition among medical students in Iran is estimated to be 27.6%. 16 Depression in medical sciences students can manifest as slowed thinking, difficulty concentrating, feelings of inadequacy 17 anxiety and suicidal ideation, 18 all of which have negative consequences for academic satisfaction, and academic achievement. 19 Moreover, they may be suffering from other psychological problems, such as anxiety, burnout, suicidal ideation, and substance abuse. 20 There is a growing literature investigating the correlates of psychological burden among medical sciences students. It is suggested that wellbeing promotion can play an important role to alleviate the problem. 21 Furthermore, during the COVID-19 pandemic, spiritual well-being is one of the protective factors against a variety of psychological distress, such as anxiety and particularly depression. 22 Spirituality is defined as "a dynamic aspect of humanity through which individuals seek meaning, purpose, and relationships with themselves, their families, others, and society." Spiritual well-being is defined as an intrinsic and dynamic aspect of human's health and spiritual maturity, which emphasizes both religious and existential dimension. 23 In other words, spiritual well-being, along with spiritual practices, is seen as an important component in almost all cultures. In fact, spiritual well-being helps people cope with stressful life events 24 and deal with depression. 25 In this regard, the results of studies indicate low level of spiritual well-being is associated with higher levels of fear to COVID-19 and disturbed sense of the meaning and purpose of life, and lower level of life satisfaction in individuals who have experienced COVID-19 disease. 26, 27 In general, various factors are involved in exacerbating or alleviating depressive symptoms, including positive psychological constructs (hope, optimism, life satisfaction, self-efficacy, self-esteem, meaning of life, mindfulness). Positive psychological constructs have a significant and inverse relationship with negative mental health outcomes such as depression. 28 The Positive Psychology Framework is appropriate for addressing the mental health of medical science students because of its emphasis on individual strengths, positive aspects of life, and satisfaction. 29 Positive psychology is the scientific study of pleasurable experiences and positive personal characteristics (as human strengths as a protector against mental disorders). 30 Positive psychology is a useful framework for understanding students' academic achievement, mental health, and career advancement. When researchers use a positive psychological framework to understand the factors that predict important outcomes, researchers can identify appropriate interventions to target those factors that contribute to academic achievement or mental health. Positive psychology focuses on those strategies that enhance happiness, positive emotions, and wellbeing. Other important areas of positive psychology deal with how to process past experiences, create positive feelings about the present, recognize and use strengths, and grow hope and optimism toward the future. 30 Life satisfaction as one of the constructs of positive psychology is one of the predictors of depression in medical science students so that lower life satisfaction is associated with more severe symptoms of depression. 31 According to Diener, 32 life satisfaction can be defined as the feeling of satisfaction with the whole-of-life. The results of studies show that higher life satisfaction is associated with greater happiness and resilience in students. 33 According to the findings of studies conducted during the COVID-19 pandemic, higher levels of life satisfaction, meaning in life, and hope were also significantly associated with lower levels of anxiety and stress caused by COVID-19 and deteriorated health status. 34, 35 Self-esteem as another construct of positive psychology, according to Rosenberg, 36 is defined as the favorable or unfavorable attitude that people have toward themselves, which is one of the preventive and protective factors against depression. Lower levels of self-esteem play a crucial role in the development of depressive symptoms, and in studies of the etiology of depression, low self-esteem is a known factor, based on the vulnerability model have confirmed this finding. 37 Therefore, higher levels of self-esteem can act as a protective factor and decrease depressive symptomology, which has been confirmed by Rossi et al. 38 Participants that had a higher level of self-esteem during COVID-19 acted as a protective factor, decreasing the impact of the pandemic, specially decreasing the development, and maintenance of depressive symptomology. Since the COVID-19 pandemic has intensified the imposition of psychological burden and distress on medical science students, it is imperative to investigate the psychological distress within medical science students, in addition to determining the effect of the COVID-19 pandemic on the prevalence of depression. Despite of previous research on the issue, there is lack of knowledge on the relationship between the prevalence of depression among medical sciences students with spiritual well-being and positive psychology constructs (including satisfaction with life and self-esteem). This study aims to investigate the consequences of the COVID-19 pandemic on changes in the prevalence of depression, and its relationship with spiritual well-being, life satisfaction, and self-esteem among Shahroud University of Medical Sciences medical science students in 2021. This online cross-sectional survey was performed to compare the prevalence of depression within a year, before (January 20 to February 19, 2020) and during the COVID-19 pandemic (from January 7 to February 7, 2021) among the medical sciences students of Shahroud University of Medical Science, Iran. Sampling of the present study was performed after passing the third wave of COVID-19 in Iran which was the largest wave with the highest incidence and mortality than previous waves in Iran. The participants were college students in nursing, medicine, surgical technology, environmental health, radiology, laboratory sciences, midwifery, and anesthesia fields. The present study's sample size was estimated to be 282 students according to Rezanejad et al 39 study with a = 10%, and power = 85%. Predicting a probable withdrawal rate of 10%, 310 students were finally included. The following standard formula was used to calculate the sample size. Results related to the prevalence of depression and the related factors before the outbreak have been reported elsewhere. 19 The second phase of the study was performed 1 year after the outbreak of COVID-19. In addition, the prevalence of depression, some variables as possible related factors related to depression were measured such as self-esteem, life satisfaction, and spiritual well-being. Out of 310 forms, 306 students filled the form completely (the four uncompleted forms were excluded from the study) ( Figure 1 ). The inclusion criteria of the study were defined as aged 18 and over, access to the internet and cyberspace, no known psychiatric disorders, and use of neuroleptic medications. Eligible participants were selected by the convenient sampling method. In order to better access the participants and prevent the spread of the disease, the participants were invited to participate in the study by sending invitation messages via WhatsApp and Telegram (two popular chat applications in Iran) by convenience sampling method. Access to students was possible through online class groups on men- consists of 30 questions in three subscales which are lethargy, cognitive-emotional, and academic motivation. Each question is scored from 1 to 5, respectively (strongly disagree = 1 and strongly agree = 5). The lower and higher score was between 30 and 150, respectively. Higher scores indicate a higher level of depression. 40 The Persian version of the USDI was validated in terms of content, concurrent, divergent, predictive, discriminated, and construct The total score of spiritual well-being is the sum of the scores of these two subscales. Moreover, the spiritual well-being of individuals is divided into three categories based on the obtained score: low , medium (41-99) and high (100-120). 44 Table 2 . According to the results of The possible reasons for changes in students' mental health status may be rooted in the fact that the usual method of the educational system in assigning homework and taking exams, had fundamental changes, and during these changes students were faced with conflicting information. 60 This contributed to feelings of confusion and uncertainly that affected their mental health. 61 According to the findings of the present study, spiritual well-being There are several possible justifications for this finding. One possible reason could be that the students in the study may have experienced "Pseudo-self-esteem" or "Excessive self-esteem," which is not true and has led to increased depression. According to Makowski, 65 those with pseudo-self-esteem are prone to emotional distress. Another possible reason is that students have more access to social media during the COVID-19 pandemic to attend classes and do their homework. The results of Donchi and Moore study (2004) showed that self-esteem has a positive relationship with social media use. 66 Also media exposure may play when people try to learn more about traumatic events such as COVID-19, may experience stress reduction because it acts as a coping strategy to reduce psychological stress. Therefore, media coverage in disasters may play an important role in improvement of people's mental health. 67 In this regard, the results of Trifiro's study (2018) show that people who used the social network Instagram more, showed higher levels of self-esteem and well-being. 68 Other possible reasons include differences in personality types and the presence of narcissistic personality type. The results of the present study showed that depression had a signif- The results of the current study showed that depression during the COVID-19 pandemic was significantly and inversely related to interest in their field of study. Findings from studies prior to COVID-19 also confirmed such findings in medical science students. 19 Feeling sad and grief in line with depression eventually leads to a loss of interest in activities that were previously important. 71 On the other hand, an individual's lack of interest in the field of study, in the long run may will affect their academic satisfaction, as well triggering depressive symptoms and maintaining low levels of motivation. In this regard, it can be considered to use mental health promotion strategies during the COVID-19, such as internet based cognitive-behavioral therapies (CBT) or online psychoeducational supports. 72, 73 The results of the present study showed that depression during the COVID-19 pandemic significantly increased within 1 year period before and during COVID-19 pandemic. Spiritual well-being, life satisfaction, and self-esteem are significantly associated with perceived depression during COVID-19. The participation of medical students in the prevention and con- The two stages of the present study were cross-sectional and there pandemic. 75 This study has shown the psychological burden that has been triggered by the COVID-19 pandemic within medical students. Depression has been exacerbated compared to 12 months previous, prior to the onset of the pandemic, which is consistent within existing literature. It is vitally important that the findings from this study are applied within university settings, to help maintain well-being and to decrease psychological distress, especially post COVID. The psychological support should have the addition of spiritual well-being and social support integrated into a unified intervention. The findings from the study cannot be generalized to larger communities, so to investigate the broader aspects of mental health in medical science students during the COVID pandemic, it is recommended to conduct further research. For example, from a qualitative exploration stance of the impact of post COVID pandemic and the everlasting impact of the significant changes in the delivery of medical education, as well as the psychological impact on the medical science students. At the time of the study, vaccination had not been performed on participants, so it is recommended that future studies examine various aspects of mental health in medical science students with respect to vaccination. The present study was a result of a research project approved by the This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The authors declare that they have no conflict of interest. Hossein Ebrahimi had full access to all the data in the study and takes complete responsibility for the integrity of the data and the accuracy of the data analysis. Hossein Ebrahimi affirms that this manuscript is an honest, accurate, and transparent account of the study being reported and all aspects of the study have been reported. 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