exam stress management during covid essay

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Open Access

Peer-reviewed

Research Article

University students’ strategies of coping with stress during the coronavirus pandemic: Data from Poland

Contributed equally to this work with: Anna Babicka-Wirkus, Lukasz Wirkus, Krzysztof Stasiak, Paweł Kozłowski

Roles Conceptualization, Formal analysis, Methodology, Project administration, Supervision, Visualization, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Institute of Pedagogy, Pomeranian University in Słupsk, Słupsk, Poland

Roles Conceptualization, Data curation, Investigation, Project administration, Resources, Software, Writing – original draft, Writing – review & editing

Affiliation Institute of Pedagogy, Faculty of Social Science, University of Gdańsk, Gdańsk, Poland

Roles Investigation, Resources, Software, Supervision, Writing – review & editing

Affiliation Department of Material Criminal Law and Criminology, Faculty of Law and Administration, University of Gdańsk, Gdańsk, Poland

Roles Data curation, Software, Validation, Writing – review & editing

• Anna Babicka-Wirkus, 
• Lukasz Wirkus, 
• Krzysztof Stasiak, 
• Paweł Kozłowski

• Published: July 26, 2021
• https://doi.org/10.1371/journal.pone.0255041
• Reader Comments

The COVID-19 pandemic has changed the functioning of universities worldwide. In Poland, the transfer to online teaching was announced without prior warning, which radically changed students’ daily functioning. This situation clearly showed the students’ helplessness and difficulties with coping with this new, stressful situation, highlighted in many previous studies. A sudden and far-reaching change in daily functioning caused anxiety, depression, and stress in this group. Thus, from a pedagogical and psychological point of view, it is pertinent to examine the students’ strategies of coping with stress caused by the COVID-19 pandemic. To this end, in 2020, a sample of Polish students was anonymously measured using the Mini-COPE questionnaire. Data was gathered from 577 students from 17 universities. The statistical analysis showed that during the coronavirus pandemic, Polish students most often used the coping strategies of: acceptance, planning, and seeking emotional support. Such factors as age, gender, and place of residence influenced the choice of specific strategies of coping with stress during the COVID-19 pandemic. The results also showed that the youngest students had the lowest coping skills. The results allow for concluding that the students’ maladaptive strategies of coping with stress, especially during the pandemic, may result in long-term consequences for their psychophysiological health and academic achievements. Thus, based on the current results and on the participatory model of intervention, a support program for students is proposed which would involve psychological, organizational, and instrumental support.

Citation: Babicka-Wirkus A, Wirkus L, Stasiak K, Kozłowski P (2021) University students’ strategies of coping with stress during the coronavirus pandemic: Data from Poland. PLoS ONE 16(7): e0255041. https://doi.org/10.1371/journal.pone.0255041

Editor: Shah Md Atiqul Haq, Shahjalal University of Science and Technology, BANGLADESH

Received: March 24, 2021; Accepted: July 9, 2021; Published: July 26, 2021

Copyright: © 2021 Babicka-Wirkus et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its Supporting Information files.

Funding: The author(s) received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Introduction

University studies are a stressful period as they mean the transition to independent, adult life. Beginning studies can be stressful to many students, since it means the necessity to establish new relationships, develop new studying habits related to the chosen program, cope with overwork, learn time management, and often also change one’s place of residence [ 1 , 2 ]. In its later stages, university education is related to new, further stressors, such as concern over being able to find employment after graduation. Studies thus far show that many students struggle to cope with these stressors and that the incidence of stress among students is increasing [ 3 , 4 ]. Among other consequences, it has a negative impact on mental health [ 2 , 5 ]. In the US, around 10% of university students reported suffering from depression [ 2 ], and this proportion has increased to 15% since 2000 [ 6 – 9 ]. A significant causal factor behind this increase is the stress related to studying.

Stress is undoubtedly a part of students’ lives and it may impact their ways of coping with the demands of university life. Their daily responsibilities involve numerous challenges which lead to stress [ 10 ]. Results from various studies carried out thus far show a clear increase in mental health problems among students [ 11 ]. As some of them indicate, there is also an urgent need to assess the impact of the current pandemic on students’ mental health and wellbeing [ 12 ], which legitimizes carrying out such studies in various countries, including Poland.

In 2020, a new situation appeared which necessitates a different approach to stress and its causal factors–the SARS-CoV-2 virus. Data published by the Johns Hopkins University indicates that thus far, over 100 million people have become infected with COVID-19, and around 2.5 million have died [ 13 ]. The COVID-19 disease affects everyone, including students [ 14 , 15 ], since even those who have not been infected are subject to various restrictions which many countries have implemented to limit the spread of the disease. The reality of the pandemic has also negatively impacted the students’ quality of social life. Studying at a university is also a period of establishing new relationships and intense social life. This is facilitated by the fact that young people exhibit greater levels of extraversion and openness to experience than do older people [ 16 ]. Studies show that contacts with others positively influence quality of life [ 17 ]. Lack of regular contact with friends throughout all phases of the coronavirus pandemic, results in loneliness, which might not be fully mitigated by regular contacts via telephone or other means [ 18 ]. These conclusions are supported by evidence from studies carried out in Great Britain (with participants aged between 13 and 25 years), in which young people reported having lost support, daily routine, social ties, and experiencing anxiety, loneliness, and loss of motivation and aim. Higher incidence of depression and anxiety, both during as well as after periods of social isolation, was also confirmed [ 19 , 20 ]. This may lead to harmful social and psychological consequences [ 21 – 23 ].

In response to the pandemic, most countries have implemented severe restrictions in societal functioning which comprise many spheres of life: social, economic, cultural, and educational. They led to limited interpersonal contacts, changes in the mode of education (online teaching), and reduced economic activity. As a result, an economic recession has affected nearly all countries (including Poland) [ 24 ], which worsened the material conditions of many people (increased unemployment). This significantly impacts students, as it intensifies their concerns about being able to find or retain a job and thus support themselves during their studies and after graduation. Essen and Owusu showed that work and studies are the most frequent causes of stress for students [ 25 ]. Historical data shows that previous pandemics have negatively impacted young people’s material conditions, which had long-term consequences for their physical and mental health as well as academic achievement [ 26 ]. For many students, COVID-19 has additionally complicated their current plans and changed their mode of functioning.

More recently, Matthew H. E. M. Browning et al. identified a range of psychological consequences of the COVID-19 pandemic on students’ psychosocial functioning. All students in the sample indicated that the pandemic impacted them negatively, with 59% reporting a high level of psychological impact [ 27 ]. Other studies on the effects of the pandemic on student mental health also show greater stress, anxiety, depression symptoms, concerns for own and one’s family’s health, reduced social interactions, and increased concerns over academic achievements. Students try to cope with stress, seek support from others, and prefer either negative or positive coping strategies [ 11 , 28 ].

The COVID-19 situation, its rapid spread, insufficient preparation, and significant changes in everyday functioning, including university culture, may contribute to increased stress among students. When not managed properly, chronic stress leads to emotional and psychosomatic consequences which manifest through physical, cognitive, and emotional exhaustion as well as depersonalization and lowered professional–in case of students, academic–efficiency [ 29 ]. The consequences of stress lower efficiency, productivity, and engagement in life activities as well as the satisfaction with their results [ 30 , 31 ]. As Adler and Park point out, effective coping with stress might buffer the impact of stressful events on the physical and mental health, and individuals differ with regards to the coping strategies they use [ 32 ]. Therefore, the aims of the study were: identifying the students’ dominant strategies of coping with stress in the pandemic situation, assessing the influence of sociodemographic factors on the dominant coping strategies, and diagnosing differences in the students’ coping strategies depending on expected social support and its sources.

The stress and coping concept is the most popular study approach, also explaining the mechanisms mediating between personality and disease. Currently, the transactional model of stress by Lazarus and Folkman [ 33 ] is employed increasingly frequently. It posits mutual interactions between people and their environment. This model served as the theoretical basis of the current study. The perception of stress is a subjective and variable phenomenon. Particular attention is paid to the processes of coping with stress, which decide the positive and negative impact of stress on the individual. Using different strategies of coping with stress involves mobilizing cognitive and behavioral resources to meet the demands which are subjectively perceived as surpassing personal capabilities. The course of the coping process depends on personal resources and social support. It can also lead to various behaviors which have negative health effects (substance use) or are maladaptive [ 34 ]. Also, according to Lazarus and Folkman, coping with stress might be related to negative health behaviors [ 35 ]. Metzger et al. analyzed the frequency of negative health behaviors among students. They found that increased alcohol consumption and risky sexual behaviors are typical for people at risk for significant stress [ 36 ]. Styles of coping with stress are determined by gender, education, age, health, well-being, the nature of the stressful situation, personality factors, and others [ 20 ]. Efficient use of emotions allows for more effective problem solving, while venting anger and frustration and denial of reality are potentially destructive reactions to stress [ 37 ]. Expressing emotions might also lead to lower depression and hostility levels in stressful situations [ 38 ]. Some authors distinguish between emotion-focused and problem-focused coping styles, while others distinguish active and avoidant coping or identify maladaptive coping strategies (denial, substance use, venting of negative emotions) which allow for lowering subjectively experienced stress [ 39 – 41 ].

Research questions

The study concerned students’ strategies of coping with stress during the pandemic. The following research questions were put forward:

• What strategies of coping with stress are most often used by students during the coronavirus pandemic?
• What is the relationship between sociodemographic variables and the dominant coping strategies among students?
• How does anticipated support differentiate the coping strategies used by students?

Study population and procedure

In 2019, 1.230 million students studied at around 400 universities in Poland. Sixty-five percent were full-time students. Seventy-three percent studied at public (national) universities. The number of foreign students is relatively low in Poland, being only 61 thousand in 2019. Moreover, a decisive majority—around 60%—of students in Poland are women [ 42 , 43 ]. This proportion reaches 65% for MA studies. Meanwhile, in the EU in general, women comprise around 54% of students [ 44 ].

In early spring of 2020, soon after online teaching was instituted, the questionnaire was distributed to students of four randomly chosen Polish universities. Those students who filled out the online questionnaire were also asked to share it with their acquaintances from other universities. Using snowball sampling method was determined by difficulties in reaching students directly, as well as by their reluctance, especially in the first phase of the pandemic in Poland, to take part in studies and fill out online questionnaires. Having students to invite their acquaintances to also take part in the study allowed for gathering a relatively large sample in a short time. There were no missing data, since the online platform did not allow for submitting incomplete questionnaires.

Participation in the study was voluntary. Informed written consent was obtained from every participant. Before participants started to fill out the online study questionnaire, they had to read the information about the project and its aims and checked the option ’I agree to take part in the study’. The data were analyzed anonymously. The research project and its procedure were approved by the Commission of Bioethics and Human Rights.

Using the snowball sampling method, data from 17 Polish institutions was obtained: universities, technical universities, medical universities, and higher vocational schools. This allowed for measuring coping strategies during the pandemic among students from various universities in various regions of Poland. However, it has to be noted that snowball sampling does not allow for generalizing the results to the entire student population in Poland. Nevertheless, based on the obtained data, certain trends in coping strategies among social sciences students can be shown.

The study took place in April-May 2020. Five hundred and seventy-seven complete questionnaires were collected. Table 1 shows the demographic characteristics of the sample divided by universities.

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https://doi.org/10.1371/journal.pone.0255041.t001

The data was divided into six groups based on the number of students from each given university who took part in the study. The largest group were the students from the University of Gdańsk (UG). Next, the sample comprised students from: Adam Mickiewicz University in Poznań (UAM) - 22.2%, University of Warsaw (UW) - 17.2%, Jan Kochanowski University of Kielce (UJK- 13.7%, and Pomeranian University in Słupsk (5.9%). Due to a low number of students from other universities, an additional group (different universities—DU) was created, which comprised 6.0% of the total sample.

Polish universities vary with respect to their size and educational profile. There are relatively few large universities with over 20 thousand people (roughly 20 out of 400). Most universities are of medium or small size. The largest university in Poland is the University of Warsaw. It also has one of the broadest selections of programs. A characteristic aspect of Polish universities is that they offer specific educational profiles, for example, universities focusing on medical education. Another example is the Pomeranian University, which specializes in teaching education. Table 2 shows basic characteristics of universities which were widely represented in the research sample [ 45 – 50 ].

https://doi.org/10.1371/journal.pone.0255041.t002

In the current study, women represented 89.6% of the sample. Participants between 21 and 24 years of age and those living in large cities represented the largest group (59.5% and 36.7%, respectively) Over 80% of the participants were full-time students, which reflected the general population distribution of students in Poland [ 51 ]. Undergraduate students also represented a larger group.

The multidimensional COPE inventory by Carver et al [ 52 , 53 ] is one of the most popular measures of strategies of coping with stress. It can be used to measure dispositional (typical) and situational coping. The Mini-COPE inventory in a Polish adaptation by Juczyński and Ogińska-Bulik [ 54 ] was used in the current study. The internal consistency of the Polish version of the Mini-COPE was estimated based on a sample of 200 people aged between 25 and 60. The split-half reliability was 0.86 (Guttman’s coefficient = 0.87). The repeatability was satisfactory for the majority of the scales. The Polish version of the Mini-COPE comprises 28 items, which form 14 coping strategies. It is used to measure typical reactions in situations of intense stress. The main question is: What do you usually do when you are stressed by a problem? The coping strategies are described in statements such as “I work or do other things in order not to think about the problem.” Each statement is graded on a four-point Likert scale: 1 = very seldom, 2 = fairly seldom, 3 = fairly often, 4 = very often. Each of the 14 coping strategies is measured by two items.

The Mini-COPE inventory was supplemented with two other semi-open questions. The first concerned the type of support the students expected during the pandemic. The available answers were: psychological, emotional, financial, organizational support, no support needed, and other (to be filled out by the students if necessary). The second supplemental question concerned the sources from which the students expected support during the pandemic. In this case, the students could select the closest appropriate answer from among: family, friends, the university, the government, and other (to be filled out by the students if necessary). Fig 1 shows the distribution of the students’ answers to the supplementary questions about support.

https://doi.org/10.1371/journal.pone.0255041.g001

Regarding the source of support, 5.0% of the students chose “other.” This category comprised the following answers: significant other (0.9%), nobody (1.2%), psychologist/therapist (0.5%), myself (1.4%), all of the above (0.3%), and other combinations indicating two sources, for example, family and the government (0.7%).

Statistical analyses were carried out using the IBM SPSS Statistics 25.0 software. The program was used to calculate basic descriptive statistics together with the Kolmogorov-Smirnov test of normality. Additionally, the Cronbach’s α coefficient was used to calculate the reliability of the Mini-COPE scales. To compare coping strategies between two groups, Mann-Whitney’s U test was used. To compare a higher number of groups, a one-way analysis of variance (ANOVA) was used, and if variance was not equal between the groups, Welch’s correction was additionally applied. Tukey’s HSD test (if variance was homogenous) or Dunnett’s T3 test (if variance was heterogenous) was used for post hoc analyses. To estimate intergroup differences in coping strategies, Pearson’s r correlation analysis was carried out. The significance level was set at α = 0.05. In order to distinguish the groups of participants in terms of coping strategies, a two-step cluster analysis was carried out.

Students’ dominant strategies of coping with stress during the pandemic

Based on the descriptive statistics and the results of the Kolmogorov-Smirnov test of normality, it was concluded that neither of the analyzed variables assumed a distribution close to the Gaussian curve. Skewness values were within the <-2;2> range, which means that it was not significant [ 55 ]. Additionally, the Cronbach’s α coefficient was used to calculate the reliability of the Mini-COPE scales. The analysis showed satisfactory reliability for most of the scales. Relatively low reliability was obtained for the scales of acceptance, humor, self-distraction, and venting of emotions. Detailed results are shown in Table 3 .

https://doi.org/10.1371/journal.pone.0255041.t003

The dominant coping strategies among Polish students were: acceptance, planning, and seeking emotional support. The least frequent strategies were: substance use, denial, behavioral disengagement, and religious coping.

Pearson’s correlation analysis was used to examine the relationships between individual coping strategies in the current sample ( Table 4 ). Active coping was positively correlated with the following coping strategies: planning (strong correlation), positive reframing, religious coping, emotional support seeking, instrumental support seeking, self-distraction, venting of emotions, and self-blame (weak correlations). The higher the frequency of active coping, the higher the frequencies of the above strategies as well. Active coping was moderately and negatively correlated with behavioral disengagement, which means that the higher the frequency of active coping, the lower the frequency of behavioral disengagement.

https://doi.org/10.1371/journal.pone.0255041.t004

Another coping strategy—planning—was positively and weakly-to-moderately correlated with positive reframing, acceptance, religious coping, emotional support seeking, instrumental support seeking, self-distraction, and self-blame. A weak, negative correlation occurred between planning and denial, and a moderate one between behavioral activation—the higher the frequency of planning, the lower the frequency of denial and behavioral disengagement.

Positive reframing was positively and weakly-to-moderately correlated with acceptance, humor, religious coping, emotional support seeking, instrumental support seeking, and self-distraction. This coping strategy was also weakly and negatively correlated with behavioral disengagement and self-blame.

Acceptance was weakly and positively correlated with humor and negatively with denial, behavioral disengagement, and self-blame. In turn, humor was weakly and positively correlated with emotional support seeking, self-distraction, and substance use. A weak and positive correlation also occurred between religious coping and emotional support seeking, instrumental support seeking, and venting of emotions. Religious coping was also weakly and negatively correlated with substance use.

Another strategy—emotional support seeking—was strongly and positively correlated with instrumental support seeking. A weak and positive correlation occurred between the following coping strategies: self-distraction and venting of emotions. Emotional support seeking was weakly and negatively correlated with behavioral disengagement.

On the other hand, seeking instrumental support was weakly-to-moderately and positively correlated with self-distraction, venting of emotions, and self-blame.

Self-distraction was weakly-to-moderately and positively correlated with denial, venting of emotions, substance use, behavioral disengagement, and self-blame.

Denial, venting of emotions, substance use, behavioral disengagement, and self-blame were positively correlated with each other on a weak-to-moderate level (the relationship between behavioral disengagement and self-blame).

The remaining correlations between the coping strategies were not statistically significant.

Students’ strategies of coping with stress–cluster analysis

To distinguish groups of participants based on their coping strategies, a two-step cluster analysis was carried out. It allowed for distinguishing two clusters ( Fig 2 ) for which the silhouette value was 0.2, indicating a satisfactory quality of clustering. From among the coping strategies included in the model, the most important ones were: seeking instrumental support, seeking emotional support, and planning. These strategies differentiated the two clusters to the highest degree. The least important strategies were substance use, denial, and self-blame.

https://doi.org/10.1371/journal.pone.0255041.g002

Table 5 shows the comparison of the clusters with regard to the analyzed strategies. The analysis showed no statistically significant differences for denial, substance use, and self-blame. Differences for other coping strategies were statistically significant, with Cluster 1 participants scoring higher on active coping, planning, positive reframing, humor, religious coping, seeking emotional and instrumental support, self-distraction, and venting of emotions, and lower on behavioral disengagement compared to Cluster 2 participants.

https://doi.org/10.1371/journal.pone.0255041.t005

Sociodemographic factors and strategies of coping with stress

To estimate the gender differences in coping strategies, Mann-Whitney’s U test was used. The analysis showed statistically significant gender differences for humor, emotional support seeking, instrumental support seeking, self-distraction, denial, and venting of emotions. Men in the current sample reported using humor significantly more often than women, but they reported using religious coping, emotional support seeking, instrumental support seeking, self-distraction, and denial less frequently. The results of the analysis are shown in Table 6 .

https://doi.org/10.1371/journal.pone.0255041.t006

Gender differences could result from differences in gender role socialization [ 56 , 57 ]. Women are socialized to be more emotional and seek support in interpersonal relationships. On the other hand, men are socialized to cope with their problems on their own or use humor.

Using a one-way analysis of variance (ANOVA), coping strategy use was compared between age groups ( Table 7 ). The analysis showed statistically significant differences for six strategies: active coping, planning, positive reframing, venting of emotions, behavioral disengagement, and self-blame. To estimate the character of the intergroup differences, an additional post hoc analysis using Tukey’s HSD test was carried out when the variance was equal between the groups, and Dunnett’s T3 test, when the variance was unequal. This type of post hoc analysis was used due to the disproportions in the size of the compared groups. In the case of unequal variances, the Welch correction was also applied.

https://doi.org/10.1371/journal.pone.0255041.t007

18-20-year-olds reported statistically significantly less frequent active coping than did 25-30-year-olds ( p = 0.032) and those 31 and over ( p = 0.032). The youngest participants also reported less frequent planning than did 25-30-year-olds ( p = 0.039) and those 31 and over ( p = 0.045), while 21-24-year-olds reported significantly less frequent planning than 25-30-year-olds ( p = 0.015) and those 31 and over ( p = 0.030). The coping strategy of positive reframing was more frequent in the oldest group compared to the younger groups (p ≤ 0.013). Those 31 and over also reported significantly less frequent venting of emotions compared to 18-20-year-olds ( p = 0.007) and 21-24-year-olds ( p = 0.002). Behavioral disengagement differed significantly between the youngest and the oldest group ( p = 0.014), with the higher frequency of this strategy being reported in the 18-20-year-olds group. Those 31 and over reported less frequent self-blame than did 18-20-year-olds ( p = 0.036) and 25-30-year-olds ( p = 0.019).

The current data show that the oldest students used active coping strategies more often during the pandemic than did the younger students. The aim of these strategies is to solve the problem causing difficult internal tension rather than to avoid the situation altogether. This effect may be related to the older students having greater life experience, including academic experience, at 31 years of age.

In the next step, differences in coping strategy use depending on the place of residence were examined ( Table 8 ). To this end, a one-factor ANOVA was carried out. It showed significant intergroup differences for the following coping strategies: active coping, planning, humor, religious coping, denial, and substance use. Participants living in cities with over 100 thousand residents reported using planning significantly more often than those living in villages ( p < 0.001) or towns up to 20 thousand residents ( p = 0.006).

https://doi.org/10.1371/journal.pone.0255041.t008

Participants living in towns up to 20 thousand residents reported using humor significantly less frequently than those living in cities with over 100 thousand residents ( p = 0.021). Participants living in villages reported using religious coping significantly more often than those living in cities with over 100 thousand residents ( p = 0.004). This is related to a more traditional upbringing and culture in Polish rural regions, where religious rituals play a significant role. Participants living in cities with over 100 thousand residents reported using denial significantly less frequently than those living in villages ( p = 0.002) and in towns with between 20 and 100 thousand residents ( p = 0.034). Substance use was reported more frequently among participants living in biggest cities compared to participants living in villages ( p = 0.002). This is because various psychoactive substances are more easily available in large cities.

After the correction for multiple comparisons was applied, a post hoc analysis using Tukey’s HSD test did not reveal statistically significant intergroup differences in active coping.

To compare full-time and extramural students’ use of coping strategies, Mann-Whitney’s U test was used. It showed that extramural students reported using active coping and positive reframing more frequently, and humor, instrumental support seeking, self-distraction, venting of emotions, substance use, and self-blame less frequently compared to full-time students. The results of the analysis are presented in Table 9 .

https://doi.org/10.1371/journal.pone.0255041.t009

Using a one-factor ANOVA, coping strategies were compared between students in different program years. The analysis showed significant differences for four strategies: active coping ( Fig 3 ), planning ( Fig 4 ), positive reframing ( Fig 5 ), and behavioral disengagement ( Fig 6 ).

I U–I Undergraduate (n = 142), II U–II Undergraduate (n = 100), III U–III Undergraduate (n = 104), I G–I Graduate (n = 66), II G–II Graduate (n = 70), I-III M–I-III uniform Master’s studies (n = 64), IV-V M–IV-V uniform Master’s studies (n = 31).

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* Welch’s correction was applied.

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A detailed post hoc analysis showed that first year undergraduate students reported using active coping less frequently compared to second year graduate students ( p = 0.048), first-third year uniform Master’s students ( p = 0.009), and fourth-fifth year uniform Master’s students ( p < 0.001). Second year undergraduate students also reported using active coping less frequently than did fourth-fifth year uniform Master’s students ( p = 0.001), similar to third year undergraduate students ( p = 0.004). First year undergraduate students reported using planning less frequently compared to second year graduate students ( p = 0.006) and fourth-fifth year uniform Master’s students ( p < 0.001). Fourth-fifth year uniform Master’s students reported using planning more frequently than second year ( p = 0.018) and third year ( p = 0.007) undergraduate students. A significant difference in the frequency of using behavioral disengagement occurred between first year undergraduate students and fourth-fifth year uniform Master’s students ( p = 0.015). First year undergraduate students reported using behavioral disengagement more frequently than did fourth-fifth year uniform Master’s students. For positive reframing, after applying the correction for multiple comparisons, Dunnett’s T3 test did not show statistically significant intergroup differences. A statistical trend ( p = 0.053) was observed between third year undergraduate students and first year graduate students—first year graduate students reported a slightly higher frequency of using positive reframing than did third year undergraduate students.

Students’ strategies of coping with stress and the type and source of needed social support

A one-way ANOVA was used to estimate the differences in coping strategy use depending on the need for a given type of social support ( Table 10 ). The post hoc analysis showed that participants who indicated a need for psychological support reported using the coping strategy of positive reframing less frequently than those who did not indicate any need for support ( p = 0.027). Also, those who indicated a need for financial support reported using positive reframing less frequently than those who did not indicate any need for support ( p = 0.034). Those who did not indicate any need for support used the coping strategy of acceptance more frequently than those who indicated a need for psychological ( p = 0.013) and emotional ( p = 0.002) support. This is due to the fact that these individuals cope with the pandemic-related difficulties on their own. Those who indicated a need for financial support also used religious coping less frequently than those who indicated a need for emotional support ( p = 0.007). Participants who indicated a need for emotional support reported using the coping strategy of emotional support seeking more frequently than those who indicated a need for financial support ( p = 0.004) and those who did not indicate any need for support ( p = 0.034). Analogous differences were observed for instrumental support seeking. Participants who indicated a need for emotional support reported using this coping strategy more often than did those who indicated a need for financial support ( p < 0.001) and those who did not indicate any need for support ( p = 0.001). Those who did not indicate any need for support reported using self-distraction less frequently than those who indicated needing psychological ( p = 0.014) and emotional ( p = 0.003) support. Also, participants who did not indicate any need for support reported using the coping strategy of denial less frequently than did those who indicated a need for psychological ( p = 0.002) or emotional ( p = 0.002) support. Participants who did not indicate any need for support reported using venting of emotions less frequently than did those who indicated a need for psychological ( p < 0.001) and emotional ( p < 0.001) support, whereas participants who indicated a need for financial support reported using venting of emotions less frequently than did those who indicated a need for emotional support ( p = 0.003). Participants who indicated a need for psychological support reported more frequent substance use than did those who did not indicate any need for support ( p = 0.002). Participants also used behavioral disengagement more often than did those who indicated a need for financial ( p = 0.001) and organizational support ( p = 0.001), or did not indicate any need for support ( p < 0.001). In turn, those participants who indicated a need for emotional support reported using behavioral disengagement more frequently than those who did not indicate any need for support at all ( p = 0.006).

https://doi.org/10.1371/journal.pone.0255041.t010

Participants who indicated a need for psychological support and emotional support reported using self-blame more often than did those who indicated a need for financial ( p < 0.001, p = 0.003 respectively). Self-blame is a cognitive judgment related to a belief that not making mistakes is extremely important. However, self-blame causes withdrawal from interpersonal relationships and prevents learning from one’s mistakes. Thus, normal sadness and guilt becomes transformed into depressive disorders [ 58 ]. In this case, seeking psychological support seems warranted. People seek to relieve their suffering and solve their problems through utilizing psychological consultations or therapy. However, in contrast to seeking emotional support from significant others within close relationships, individuals seeking psychological support may discount their own agency, responsibility for their decisions, and independent solution-seeking to a greater extent. Additionally, when describing the pandemic situation, it is worth to consider another context of self-blame, namely, the phenomenon of guiltless guilt, that is, guilt without any specific influence on a given situation which is the source of self-blame. This creates a vicious circle which depends psychological suffering [ 59 ].

A one-factor ANOVA also revealed significant differences between the groups distinguished by the source of expected support. These differences were significant for three coping strategies: religious coping ( Fig 7 ), substance use ( Fig 8 ), and self-blame ( Fig 9 ). A detailed post hoc analysis revealed that those participants who expected support from the government used religious coping less frequently than those who expected support from their families ( p = 0.043) or their universities ( p = 0.026). Participants who expected support from their families reported using the coping strategy of substance abuse significantly less frequently than those who expected support from their friends ( p = 0.013). In turn, participants who expected support from their friends reported using self-blame significantly more often than did those who expected support from the government ( p = 0.027).

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https://doi.org/10.1371/journal.pone.0255041.g009

The aim of the current study was to examine the strategies of coping with stress among Polish university students during the coronavirus pandemic, as well as to assess the type of support they expected. An analysis of the empirical results allows for drawing conclusions on this topic.

The transactional model of stress [ 33 ] allowed for identifying a specific relation formed between an individual and their surroundings. The participants in the currents study found themselves in a stressful transaction in which they experienced a real risk in the form of the pandemic situation. Coping is a specific adaptative reaction chosen during the secondary appraisal. It emerges when an individual appraises the situation in terms of harm or risk, that is, as a difficulty. Students differed with respect to their tendency to use specific coping strategies, which does not mean that a given individual’s coping strategies are the same in every situation. Emotion-oriented coping strategies seek to reduce tension and unpleasant emotions which arise in reaction to stressful situations. They are unavoidable particularly when the individual has no influence on the external events. Problem-focused coping involves cognitive and behavioral efforts to reduce stress by trying to solve the problem [ 33 ]. Thus, the main condition for appropriate functioning is to develop optimal strategies of coping with stress.

The results of the current study showed that during the stressful situation of the pandemic, which can cause feelings of uncertainty and crisis [ 60 ], Polish students mainly chose such coping strategies as acceptance, planning, and seeking emotional support. The current studies showed that students more often use coping strategies which, according to Lazarus and Folkman’s theory [ 33 ] are emotion-focused (acceptance, seeking emotional support). On the other hand, planning is a problem-focused coping strategy. These three main strategies seem constructive as they direct people towards a future temporal perspective and might facilitate a reorganization of the values–goals–life plans triad driving the dynamic character of the personality [ 61 ], especially in decisive periods of personal crises [ 62 ]. It is also related to reframing one’s own life situation. Substance use, denial, behavioral disengagement, and religious coping were used the least frequently by Polish students to cope with stress during the pandemic.

Among all groups of people in education, students exhibited higher levels of emotional problems and pressure related to the changes in the educational and social situation during the pandemic than did primary and high school students [ 63 , 64 ]. Thus, it was important to assess their need for support and the sources they expect this support from. The results showed that 78% of the students needed support, while 22% did not express such needs. The greatest proportion of students—25%—needed emotional support. This type of support was mainly sought from family (38%) and friends (26%). Participants who expected emotional support simultaneously chose strategies of support seeking and religious coping. Their search for personal resources which would facilitate coping was oriented at close interpersonal relationships. They most likely allowed for conversations which supported another coping strategy preferred by this group, namely, venting and self-blame. Students seeking emotional support–in contrast to those seeking psychological support–likely maintained closer and deeper interpersonal relationships. On the other hand, psychological support was expected by 16% of the participants. They scored the lowest on the strategy of positive reframing. However, they scored higher on substance use, denial, and venting, as well as self-blame. Such a pattern of coping strategies suggests that use of professional psychological help is warranted. These participants showed such difficulties in coping with the pandemic situation that they concluded they should seek professional help from a psychologist.

Those students who expected organizational (18%) and financial (17%) support reported using different coping strategies than did those who expected emotional and psychological support. Such coping strategies as religious coping, support seeking, venting, substance use, behavioral disengagement, and self-blame were lower in this group. Rather, these participants were oriented at gaining concrete material support and support related to organizing their life in the city where they studied, and sometimes also worked to support themselves financially.

Further analyses showed that those students who indicated a need for emotional and social support reported using the coping strategies of positive reframing and acceptance of the pandemic situation less frequently. Need for emotional, organizational, and psychological support was related to typical stressors (studying, pressure to achieve high grades, pass exams, and qualify for scholarships) [ 65 , 66 ], which remained at similar levels during online teaching. However, it was also related to additional limitations stemming from the digitalization of the teaching process [ 67 ]. Moreover, the need for support was also increased by isolation, limitations in social relationships with peers, and limited possibilities for establishing new relationships and realizing affiliative needs [ 68 , 69 ]. Importantly, these needs concern direct relationships rather than telephone or online contact, as these do not fully mitigate loneliness and do not provide the same amount of support [ 18 ]. Seeking real, direct support, the students expressed a perspective of building psychological resilience and improving their emotional state, which corresponds with the results of Bernabé and Botia [ 70 ]. Students mainly expressed a need for emotional, organizational, and psychological support from their families and friends in order to maintain a high level of functioning, which might be explained through the perspective of the resilience theory [ 71 , 72 ]. This is because resilience is strongly related to, among others, perceived emotional support and close, safe relationships with one’s family and friends [ 73 , 74 ], which create networks of emotional and social support [ 75 , 76 ]. The ability to use support serves as a buffer for stress and its negative consequences. It can also prevent the deepening of the problems by providing resources for coping when stress occurs. Studies confirm that people with access to support show less reactivity to stress factors and enjoy higher mental health [ 77 ].

Next, it was showed that the chosen strategies of coping with stress were related to sociodemographic variables such as gender, age, and place of residence, which was confirmed by Cantor [ 61 ]. A detailed analysis revealed gender differences in the use of some specific coping strategies, which is also supported by other studies [ 78 – 80 ]. Women used the strategies of emotional and instrumental support seeking statistically significantly more often than did men. On the other hand, men used humor as a coping strategy more often than did women.

Regarding age, it was shown that younger people who began studying (18-20-year-olds) reported using active coping and planning statistically significantly less frequently than older students (21-24-year-olds, 25-30-year-olds, and those 31 and above). In turn, the higher frequency of using positive reframing and the lowest frequency of using venting of emotions was reported by the oldest students (31 and above). These age-related differences are difficult to relate to previous studies due to methodological differences [ 81 – 83 ]. The strategy of active coping, characteristic for older students, was positively correlated with planning (strong relationship), positive reframing, religious coping, and emotional and instrumental support seeking, which was confirmed by the cluster analysis. Cluster 1 results (statistically significantly higher active coping, planning, positive reframing, humor, religious coping, emotional and instrumental support seeking, self-distraction, and venting, and lower behavioral disengagement) correspond to this profile of active coping.

The youngest students (18–20 years old) did not choose active (adaptive) coping strategies, in contrast to the older students. It is worth noting that, as the youngest persons in the academic community, they have less life and experience and less environmental resources due to the fact that they did not yet develop close and deep social and emotional relationships. This is related to identity development [ 84 , 85 ]. Additionally, the university is a new setting for such students, which makes it more difficult for them to perceive it as a source of instrumental and organizational support. Thus, the youngest students in particular should be the recipients of complex (psychological, instrumental, possibly also spiritual) support from the university intended to shape appropriate adaptive conditions.

Comparing the full-time and extramural students with respect to their coping strategies, it was found that extramural students scored higher on active coping and positive reframing, and lower on humor, instrumental support seeking, self-distraction, venting, substance use, and self-blame compared to full-time students. It is worth noting that extramural students are usually older than full-time students. Thus, they are at a different developmental period in their lives. They often live with their own families, including their children. They attend classes only during the weekends and are most often employed and financially independent Thus, they have different areas of life activities and exhibit different strategies of coping with stress.

Analyzing the variable of place of residence, it was found that students living in cities with over 100 thousand residents used the coping strategies of planning, humor, and substance use more frequently than did students from smaller towns and villages. These results can be interpreter with reference to Bronfebrenner’s [ 86 ] ecological theory. Larger cities have more (both on the mesosystem and the exosystem levels) infrastructural resources, opportunities related to social life, and institutional offers (even during the periods of pandemic-related restrictions). Thus, people living in large cities were subjected to less social isolation during the pandemic than were the people living in rural areas. However, they used religious coping and denial less frequently, which was used more often by students living in villages. Studies on Polish students carried out before the pandemic using the Mini-COPE did not show differences in coping strategies related to place of residence.

The results of the current study allowed for the identification of coping strategies among students. This is important for the process of designing support strategies at universities. Our study also identified the mechanisms of active (adaptive) and passive (maladaptive) coping and directions of support seeking.

Taking into account the current results, future empirical studies can focus on more detailed examinations of the relationships between specific coping strategies used by students. Additional studies on the influence of the later stages of the pandemic on students’ mental health are necessary, as the consequences of this difficult situation may last for a long time, beyond the most intense period of the pandemic.

Strengths and limitations

The strengths of the current study include an examination of students’ strategies of coping with stress during the pandemic as a global situation which, to some extent, warrants the introduction of monitoring and prevention of the “post-COVID syndrome” in the context of students’ coping with stress and rebuilding social and emotional relationships.

The current results might also serve as a point of reference and comparison for further studies on coping strategies among students in other countries. In turn, this could support the development of local strategies of supporting students in organizing their academic careers and personal lives. This is especially important considering the fact that the occurrence of subsequent pandemics is only a matter of time, as was cautioned by the Director General of the World Health Organization, Tedros Adhanom Ghebreyesus. The UN resolution naming December 27 as the International Day of Epidemic Preparedness acknowledges the disproportional harm they cause in people’s lives and highlights the need for increased awareness, exchange of scientific knowledge, and searching for the best solutions on both the local and national levels. This message finds direct expression in the topic of the current study.

A limitation of the current study is the high proportion of female students of social sciences and humanities in the current sample. In Poland, these programs are more often chosen by women (73%) than men (27%) [ 87 ]. This resulted in a high gender imbalance in the current sample.

Recommendations for universities

The results of the current study lead to formulating several recommendations for universities regarding the organization of teaching in ways that consider the students’ psychosocial functioning to a greater extent. These suggestions include: implementing assessments of students’ psychosocial functioning in order to determine the potential need for emotional, social, and psychological support, and establishing psychological consultation points for students requiring such support.

It also seems warranted to introduce interpersonal training and stress coping workshops for individual student groups. Regarding organizational support, the current results are an argument for providing material support and career counseling in part-time employment for students.

The current results serve as a basis for designing a model of support and-self support solutions for students during the pandemic. The participatory model of intervention development [ 88 ] may be particularly useful in this regard. The Participatory Intervention Model (PIM), rooted in participatory action research, provides aa mechanism for integrating theory, research and practice and for promoting involvement of stakeholders in intervention efforts [ 88 ]. Based on this model, it seems pertinent to revise the role of the year mentor ( opiekun roku ; in Polish universities, students at each year of their academic program are assigned an academic teacher who meets with the students, acquaints them with the university’s structure and the program, etc.) by including screening assessments of the students’ expected sources of support. Additionally, the role of the university counselor should be created. It is worth noting that the youngest students in particular should be incorporated in the design process for such solutions. This is because the presented study shows that the youngest full-time students showed passive and maladaptive coping strategies. Support solutions designed through the participatory model of intervention should be useful for students, should address their specific needs, and should consider the students’ cultural, organizational, and social contexts, including the context of the pandemic and its consequences. Efforts towards designing adequate interventions may prove insufficient if no attempts are made to understand the students’ beliefs, motivations, practices, language, and culture. Such practices can help universities offer more comprehensive support to students of specific populations. Thus, the particular attention should be draw to the notion of acceptability within PIM, which reflects the perception of the beneficiaries (mainly the university inn this context) as partners in identifying problems and developing the offer of psychological, organizational, and instrumental support solutions created through the process of researching the specificity of the pandemic situation and post-pandemic adaptation. Identifying problems, as well as the scope and range of partnership between the university and its personal and infrastructural resources in planning psychological, organizational, and infrastructural support for students requires an evidence base.

The necessity of carrying out research that would lead to effective practical solutions through PIM is also underscored by Nastasi (et. al.) [ 89 ]. The study presented in this article fits this proposal. The current study results showed also that 10% of the sample expecting support from the university. This situation indicates that the current support offer could be insufficient in the context of the pandemic. Thus far, support given to students has been limited mainly to material support–financial support and academic scholarships. Verifying its role as a source of support and an important social environment for its students is also a significant new challenge for universities in the pandemic and post-pandemic reality.

Conclusions

Studies in this direction should continue in order to examine how students cope with subsequent stages of studying both during the pandemic as well as after its end.

Despite the limitations indicated above, the current results contribute to understanding the social and emotional changes related to the coronavirus pandemic, especially in the area of higher education. Studies on stress and coping among students carried out thus far have not sufficiently considered a range of factors such as the study system (paid vs. free), sources of institutional support (scholarships, student loans, material support), unemployment, or job prospects after graduation. Additionally, similarities and differences in the experience of stress and coping strategies between students in various countries (ethnic and cultural differences) have not been researched to an appropriate degree.

The current study indicates, among others, that younger students who are in the beginning stages of their academic careers cope with stress less effectively. This is largely a consequence of the fact that they do not yet possess appropriate life experience, and thus do not have sufficient competences in coping with difficult situations. This suggests that university administrations should pay particular attention to this group. An obligatory course on coping skills should be recommended for the first year curriculum. This could improve students’ competences, wellbeing, and resilience.

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Writing about COVID-19 in a college admission essay

by: Venkates Swaminathan | Updated: September 14, 2020

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For students applying to college using the CommonApp, there are several different places where students and counselors can address the pandemic’s impact. The different sections have differing goals. You must understand how to use each section for its appropriate use.

The CommonApp COVID-19 question

First, the CommonApp this year has an additional question specifically about COVID-19 :

Community disruptions such as COVID-19 and natural disasters can have deep and long-lasting impacts. If you need it, this space is yours to describe those impacts. Colleges care about the effects on your health and well-being, safety, family circumstances, future plans, and education, including access to reliable technology and quiet study spaces. Please use this space to describe how these events have impacted you.

This question seeks to understand the adversity that students may have had to face due to the pandemic, the move to online education, or the shelter-in-place rules. You don’t have to answer this question if the impact on you wasn’t particularly severe. Some examples of things students should discuss include:

• The student or a family member had COVID-19 or suffered other illnesses due to confinement during the pandemic.
• The candidate had to deal with personal or family issues, such as abusive living situations or other safety concerns
• The student suffered from a lack of internet access and other online learning challenges.
• Students who dealt with problems registering for or taking standardized tests and AP exams.

Jeff Schiffman of the Tulane University admissions office has a blog about this section. He recommends students ask themselves several questions as they go about answering this section:

• Are my experiences different from others’?
• Are there noticeable changes on my transcript?
• Am I aware of my privilege?
• Am I specific? Am I explaining rather than complaining?
• Is this information being included elsewhere on my application?

If you do answer this section, be brief and to-the-point.

Counselor recommendations and school profiles

Second, counselors will, in their counselor forms and school profiles on the CommonApp, address how the school handled the pandemic and how it might have affected students, specifically as it relates to:

• Grading scales and policies
• Graduation requirements
• Instructional methods
• Schedules and course offerings
• Testing requirements
• Your academic calendar
• Other extenuating circumstances

Students don’t have to mention these matters in their application unless something unusual happened.

Writing about COVID-19 in your main essay

Write about your experiences during the pandemic in your main college essay if your experience is personal, relevant, and the most important thing to discuss in your college admission essay. That you had to stay home and study online isn’t sufficient, as millions of other students faced the same situation. But sometimes, it can be appropriate and helpful to write about something related to the pandemic in your essay. For example:

• One student developed a website for a local comic book store. The store might not have survived without the ability for people to order comic books online. The student had a long-standing relationship with the store, and it was an institution that created a community for students who otherwise felt left out.
• One student started a YouTube channel to help other students with academic subjects he was very familiar with and began tutoring others.
• Some students used their extra time that was the result of the stay-at-home orders to take online courses pursuing topics they are genuinely interested in or developing new interests, like a foreign language or music.

Experiences like this can be good topics for the CommonApp essay as long as they reflect something genuinely important about the student. For many students whose lives have been shaped by this pandemic, it can be a critical part of their college application.

Want more? Read 6 ways to improve a college essay , What the &%$! should I write about in my college essay , and Just how important is a college admissions essay? .

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Student stress during the pandemic.

High school students are experiencing rising stress levels and lower engagement with learning since the start of the COVID-19 pandemic, according to a new study by NBC News and Challenge Success, a nonprofit affiliated with Stanford Graduate School of Education (GSE).

Kids feel that “they are more stressed than they were before the pandemic, they have more work, they are less engaged in school, and their relationships with teachers and [other] kids are strained,” says Denise Pope, a senior lecturer at Stanford GSE and co-founder of Challenge Success.

On this episode of  School’s In , Pope talks with show co-host and GSE Dean Dan Schwartz about the study – one of the largest national research projects to shed light on the pandemic’s impact on student connection, engagement and mental health. She also shares what parents and educators might take from its findings in the days and years ahead.

In addition to grades, workload and time management, the study found that one of the top sources of stress for students was lack of sleep. This surprised Pope, who thought remote learning would give students more flexibility and time to sleep. But 43 percent of the students reported sleeping less, and about 5 percent said they were getting less than four hours a night.

Other sources of stress included college and the future, finances and a lack of time to play and relax. Females and students of color in particular experienced high levels of stress and pressure.

Some good news: “People are now much more aware of these problems,” says Pope. “I think more teachers recognize the importance of checking in on mental health and how it’s connected to academics, and how it’s part of their job.”

You can listen to School's In   on SiriusXM , Apple Podcasts , Google Podcasts , Spotify , Stitcher and Soundcloud .

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The impact of the prolonged COVID-19 pandemic on stress resilience and mental health: A critical review across waves

Mirko manchia.

a Section of Psychiatry, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy

b Unit of Clinical Psychiatry, University Hospital Agency of Cagliari, Cagliari, Italy

c Department of Pharmacology, Dalhousie University, Halifax, NS, Abbreviation:

Anouk W. Gathier

d Department of Psychiatry (GGZ inGeest), Amsterdam UMC (location VUmc), Vrije University, Amsterdam Public Health and Amsterdam Neuroscience research institutes, Amsterdam, Netherlands

Hale Yapici-Eser

e Department of Psychiatry, Koç University School of Medicine, Istanbul, Turkey

f Research Center for Translational Medicine, Koç University, Istanbul, Turkey

Mathias V. Schmidt

g Research Group Neurobiology of Stress Resilience, Max Planck Institute of Psychiatry, Munich, Germany

Dominique de Quervain

h Division of Cognitive Neuroscience, Department of Psychology, Department of Medicine, University of Basel, Switzerland

Therese van Amelsvoort

i Department of Psychiatry and Neuropsychology, Maastricht University, Maastricht, Netherlands

Jonathan I. Bisson

j Division of Psychological Medicine and Clinical Neurosciences, Cardiff University School of Medicine, Cardiff, United Kingdom

John F. Cryan

k Dept Anatomy & Neuroscience, University College Cork, Cork, Ireland & APC Microbiome Ireland, University College Cork, Cork, Ireland

Oliver D. Howes

l King's College London, London, SE5 8AF Imperial College London, London, W12 0NN Lundbeck A/v, Valby, Denmark

Luisa Pinto

m Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga, Portugal

n Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal

Nic J. van der Wee

o Department of Psychiatry, Leiden University Medical Center, LUMC Neuroscience and Leiden Institute for Brain and Cognition, Leiden, Netherlands

Katharina Domschke

p Department of Psychiatry and Psychotherapy, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany

q Center for Basics in NeuroModulation, Faculty of Medicine, University of Freiburg, Freiburg, Germany

Igor Branchi

r Center for Behavioral Sciences and Mental Health, Istituto Superiore di Sanità, Rome, Italy

Christiaan H. Vinkers

s Department of Psychiatry (GGZ inGeest), Amsterdam UMC (location VUmc), Vrije University, Amsterdam Public Health and Amsterdam Neuroscience research institutes, Amsterdam, Netherlands

t Department of Anatomy and Neurosciences, Amsterdam UMC (location VUmc), Vrije University, Amsterdam, Netherlands

The global public health crisis caused by COVID-19 has lasted longer than many of us would have hoped and expected. With its high uncertainty and limited control, the COVID-19 pandemic has undoubtedly asked a lot from all of us. One important central question is: how resilient have we proved in face of the unprecedented and prolonged coronavirus pandemic? There is a vast and rapidly growing literature that has examined the impact of the pandemic on mental health both on the shorter (2020) and longer (2021) term. This not only concerns pandemic-related effects on resilience in the general population, but also how the pandemic has challenged stress resilience and mental health outcomes across more specific vulnerable population groups: patients with a psychiatric disorder, COVID-19 diagnosed patients, health care workers, children and adolescents, pregnant women, and elderly people. It is challenging to keep up to date with, and interpret, this rapidly increasing scientific literature. In this review, we provide a critical overview on how the COVID-19 pandemic has impacted mental health and how human stress resilience has been shaped by the pandemic on the shorter and longer term. The vast literature is dominated by a wealth of data which are, however, not always of the highest quality and heavily depend on online and self-report surveys. Nevertheless, it appears that we have proven surprisingly resilient over time, with fast recovery from COVID-19 measures. Still, vulnerable groups such as adolescents and health care personnel that have been severely impacted by the COVID-19 pandemic do exist. Large interindividual differences exist, and for future pandemics there is a clear need to comprehensively and integratively assess resilience from the start to provide personalized help and interventions tailored to the specific needs for vulnerable groups.

Key messages

• • The early stages of the COVID-19 pandemic were often associated with increased levels of distress and depressive and anxiety symptoms in the general population.
• • A substantial group of individuals has been either largely unaffected or is even doing better during the pandemic.
• • Longitudinal follow up showed remarkable signs of resilience.
• • Health care workers appear to be at an increased risk of stress-related psychological symptoms.
• • The mental health of children, adolescents, and students has been particularly affected by the pandemic.
• • Elderly people are more vulnerable to the physical effects of COVID-19, but also report lower psychopathology during the pandemic.
• • Individuals with an existing psychiatric disorder are experiencing detrimental impact on their mental health from the COVID-19 pandemic, but do not seem to have further increased symptom severity compared with their pre-pandemic levels.
• • A high risk exists for psychiatric sequelae following a COVID-19 infection.
• • Many methodological shortcomings occur in the current literature which is often cross-sectional and relies on self-report, and it is moreover hard to directly compare results across many of the studies.
• • There is an urgent need for a personalized approach when it comes to identifying individuals at risk or resilient for the stressful effects of the COVID-19 pandemic.
• • The effects of stress and the resilience capacity are dependent on (neuro)biological, psychological, and environmental factors and also are heavily dependent on an individual's unique context.

1. Introduction

In 2020 many of us had hoped that the COVID-19 pandemic would be over in 2021, and that normal life would have resumed. The situation is clearly different: the pandemic is still ongoing with novel and more contagious variants leading to increased infection rates across the globe, with consequently more stringent restrictions in social interactions and more lockdowns. By the spring of 2021, over 156 million confirmed cases and more than 3.2 million deaths of COVID-19 have been reported ( https://covid19.who.int/ ), with health care systems worldwide being overburdened at certain times. As in 2020, summer was expected to be associated to a reduced impact of the pandemic. However, new variants of the virus emerged, such as the Delta variant and there is still concern for what will occur during fall and winter. The pandemic and the accompanying measures have led to changes in people's daily routines, limited social interactions, as well as formed tensions among families in lockdown together, and fear of getting ill and/or spreading the virus. At the same time, the prospect of mass vaccination efforts has given rise to hope. Undoubtedly, the pandemic has asked a lot from all of us given the high uncertainty and limited control over the situation. For mental health professionals, the key questions are: what are the effects of the COVID-19 pandemic on mental health, and what have we learnt from this unprecedented and prolonged pandemic regarding resilience at the individual and societal level? During the first wave of the pandemic, our Thematic Working Group on Resilience from the European College for Neuropsychopharmacology (ECNP) wrote an overview of stress resilience during the early stages of the pandemic ( Vinkers et al., 2020 ). Now, almost a year later, there has been a second wave and, in many countries, a third wave. Numerous studies have attempted to identify how the stressful pandemic has impacted mental health in the shorter and longer term across a wide range of populations. In fact, by April 2021, a staggering 120,000 publications on COVID-19 had appeared, with over 5,000 dealing with the impact of the pandemic on mental health and how stress resilience is shaped during the prolonged COVID-19 pandemic. Given that the pandemic is continuing, and there is the risk of future outbreaks, it is timely to consider its impact on mental health and factors that are linked to resilience against mental illness to guide the ongoing response to it. In view of this, we aim to provide a critical overview of how the pandemic has affected mental health in general, and how human stress resilience has shaped its impact on the shorter and longer term. Moreover, we aim to summarize whether there are specific effects of the COVID-19 pandemic on stress resilience across groups that may be more vulnerable (such as health care workers and adolescents), and what we can learn for possible future pandemics. In this selective review, we did not apply a systematic approach but rather used a targeted Medline search strategy related to COVID-19 topics complemented with a thorough search of references in key publications. A general premise should be made in the interpretation of the results of this review as several caveats impact on the interpretation of the evidence here summarized. First, most of the studies were conducted in the first wave of the pandemic, often with limited duration of follow-up, and are based on cross-sectional assessments and online surveys. Secondly, and possibly more importantly, the impact of the pandemic (as measured in terms of infections and death rates) as well as lockdown measures varied significantly from country to country. However, although these methodological limitations could reduce the robustness of the findings as well as their comparability among different countries, we believe this data synthesis might guide the reader in interpreting the impact of the pandemic on mental health and the modulating role of resilience.

2. The general population

The pandemic has affected almost every individual directly or indirectly, either due to (or fear of) COVID-19 infection, or because of the effects of far-reaching measures and their economic and social impact. Consequently, the impact of the pandemic on mental health outcomes has been frequently examined in the general population. In a study conducted in April 2020, using a probability sample ( N  = 1468) and the Kessler-6 psychological distress scale (0–24 with 13 as a cutoff for serious distress), 13.6% of US adults reported symptoms of serious psychological distress, relative to 3.9% in 2018 ( McGinty et al., 2020 ). In another study among 9565 individuals from 78 countries, during the height of the lockdown (April – June 2020), the pandemic was experienced as at least moderately stressful for most people, and 11% reported the highest levels of stress. Symptoms of depression were also high, including 25% of the sample indicating that the things they did were not reinforcing, 33% reporting high levels of boredom, and nearly 50% indicating they wasted a lot of time ( Gloster et al., 2020 ). In a similar study which also used the Kessler-6 psychological distress scale ( N  = 2555), distress levels did not increase, with equal numbers of US adults experienced serious psychological distress in February 2019 (prior to the pandemic) as in May 2020 ( Breslau et al., 2021 ). In the UK Household Longitudinal Study (UKHLS, N  = 17,452), mental health was assessed with the 12-item General Health Questionnaire (GHQ-12) before and during the pandemic ( Pierce et al., 2020 ). In this study, the population prevalence of clinically significant levels of mental distress rose from 19% in 2018–19 to 27% in April 2020 (1 month into the UK lockdown). In a later report on the UKHLS, most individuals had either consistently good (39% of the participants) or consistently very good (38%) mental health across the first 6 months of the pandemic ( Pierce et al., 2021 ). A recovering group (12%) showed worsened mental health during the initial shock of the pandemic and then returned to pre-pandemic levels of mental health. The two remaining groups were characterized by poor mental health throughout the observation period, either with initial but sustained worsening in mental health (4%) or a steady and sustained decline in mental health over time (7%). Concerning major affective disorders, a nationally representative survey study of US adults (March – April 2020, N  = 1,441) showed that the prevalence of depressive symptoms was more than three-fold higher during the COVID-19 pandemic when compared to the pre-pandemic prevalence (2017 – 2018) ( Ettman et al., 2020 ). Indeed, a recent quantitative data synthesis, conducted by the Global Burden of Disease (GBD) Resource center, has shown that the pandemic has impacted substantially on the risk of major depressive disorder and anxiety disorders, estimating an additional 53.2 million cases of major depressive disorder and an additional 76.2 million cases of anxiety disorders globally due to the COVID-19 pandemic ( COVID-19 Mental Disorders Collaborators, 2021 ; Santomauro et al., 2021). Further support for the link between the COVID-19 pandemic and the onset of affective disturbances comes from the large cohort study of Lob et al. (March – April 2020, N  = 51,417), showing that severe depressive symptoms were developed by 11% of their sample equaling 5656 participants, while moderate symptoms were experienced by 29% of the subjects during the COVID-19 pandemic ( Iob et al., 2020a ). In Italy ( N  = 130), quarantine resulted in increased internalizing symptoms, particularly in those individuals with pre-existing psychopathology or experiencing negative economic consequences ( Castellini et al., 2021 ). In another study conducted in the US (March – June 2020, N  = 7138), both increases and decreases in distress during the pandemic, assessed with the Patient Health Questionnaire-4 (PHQ-4), could be explained by perceived infection risk and risk of death, perceived financial risks, lifestyle changes resulting from the virus, perceived discrimination, and changes in substance use and employment status (explained variation: 70% for the increase in distress between March and April 2020, and 46% for the decline in April and June 2020) ( Robinson and Daly, 2020 ). Among Chinese students ( N  = 68,685), levels of stress decreased after remission of the first outbreak (end of March – beginning of April), even though anxiety symptoms (22 to 26%) and depressive symptoms (11 to 15%) still increased, particularly in those with limited physical exercise and perceived social support ( Li et al., 2021b ). This indicates that the pandemic may have longer-lasting negative effects on mental health outcomes that might take time to fully emerge. Finally, a survey performed in 1,310 Spanish adults during the first lock-down period (March 2020) showed that regression models containing a series of variables (i.e. being female, having a younger age, having negative self-perceptions about aging, more time being exposed to news about COVID- 19, having more contact with relatives different to those that participants co-reside with) explained 48% and 33% of the variance of distress and loneliness respectively ( Losada-Baltar et al., 2021 ). Although the methodological quality of studies was quite heterogeneous, with sometimes limited sample size, no longitudinal measures, and only sparse information about mental health status, adaptive responses after the first wave of the pandemic were frequently reported.

In contrast to studies showing increases in mental health problems in the general population, there is also convincing evidence that most individuals are sufficiently able to cope with the pandemic and its associated measures and even that increased resilience building in the general population may have occurred. In the Netherlands, for example, a longitudinal study among adults ( N  = 3,983) showed no apparent increase was found in anxiety and depression symptoms between March 2019 and March 2020 when the pandemic broke out ( van der Velden et al., 2020 ). Moreover, in a Chinese general population study ( N  = 1738), which was conducted during the initial outbreak (end of January – beginning of February 2020) and the epidemic's peak four weeks later, there were no significant longitudinal changes in stress, anxiety and depression levels ( Wang et al., 2020a ). In Switzerland, a survey study ( N  = 10,472) documented increased stress in 50% of participants, but 24% showed no change and 26% even felt less stressed during the lockdown in April 2020 compared to the pre-pandemic period ( https://osf.io/jqw6a/ ). More encouraging news stems from the UCL COVID-19 Social Study showing that, between March and August 2020, in over 36,500 adults, the highest levels of depression and anxiety occurred in the early stages of lockdown but declined fairly rapidly as individuals adapted to the changing circumstances, even though the sample is not representative of the national population ( Fancourt et al., 2021 ). In Spain ( N  = 3480), after the confinement was lifted, depressive symptoms rapidly decreased after an initial increase during the confinement, but no clear effects on anxiety were found ( Gonzalez-Sanguino et al., 2020 ). In Germany, worrying and depressive symptoms among the general population ( N  = 2376) decreased on average between March and June 2020 ( Bendau et al., 2020b ). Another US sample ( N  = 7319) found increased psychological distress (PHQ-4) between March and April 2020 as the COVID-19 crisis emerged and lockdown restrictions began, which subsequently declined to mid-March (baseline) levels by June 2020 ( Daly and Robinson, 2020 ). In 1166 UK adults, a low-stable profile characterized by little-to-no psychological distress was the most common trajectory for both anxiety-depression and COVID-19-related PTSD ( Shevlin et al., 2021 ). Assessment of loneliness in 1545 American adults in January, March, and April 2020 showed no significant changes in loneliness but rather increased perceived support from others ( Luchetti et al., 2020 ).

Conclusion: In the general population, the early stages of the COVID-19 pandemic were often associated with increased levels of distress and depressive and anxiety symptoms. However, the effects of the pandemic on mental health in the general population have been quite heterogeneous from the beginning, and a substantial group has been either largely unaffected or is even doing better during the pandemic period. More importantly, longitudinal follow up has shown signs of resilience in the general population, with surprising ability to bounce back and adapt. For an overview of findings from cross-sectional and longitudinal studies on the impact of COVID-19 on stress resilience and mental health in the general population, see Table 1 .

The impact of COVID-19 on stress resilience and mental health in the general population.

3. Health care personnel

Health care personnel have been particularly affected by the COVID-19 pandemic and exposed to more stressful circumstances than many other professional groups. This is due to several factors, including the increased infection risk, fear of infecting other people and being isolated from their families, working overtime, demanding work conditions with lengthy shifts, directly witnessing the suffering and death of patients, and witnessing the crowded and challenging situations in hospitals. Hence, it is not surprising that many studies on stress resilience and mental health outcomes during the COVID-19 pandemic have specifically focused on health care personnel. A meta-analysis of COVID-19-related stress and psychiatric symptoms in nurses already identified 93 studies published between January to September 2020 ( Al Maqbali et al., 2021 ). In this meta-analysis, over one third of over 90,000 nurses reported stress, sleep disturbances and increased mood and anxiety symptoms. This seems considerably higher than findings from studies in nurses working during smaller-scale pandemics like SARS or when compared to the general population at the same time period ( Chen et al., 2005 ). A similar picture arises from other studies. A survey of dental academics across 28 countries (March – May 2020, N  = 1862) indicated considerable psychological impact of the COVID-19 pandemic with significantly increased worries and altered individual behavior ( Ammar et al., 2020 ). Moreover, in a Spanish cohort of health care workers (April 2020, N  = 1422) over half of the participants reported symptoms of post-traumatic stress disorder (PTSD) and anxiety disorders, and nearly 50% reported symptoms of depression, with women and younger people showing an even higher risk ( Luceno-Moreno et al., 2020 ). A study of medical staff in China (February – March 2020, N  = 899) indicated a significantly increased prevalence of psychiatric symptoms such as depression, anxiety and insomnia compared to the general population ( Liang et al., 2020 ). A longitudinal study among Japanese adults (March 2020 and May 2020, N  = 1015) showed that indices of fatigue, anxiety and depression increased among health care compared to non-health care workers during the COVID-19 outbreak ( Sasaki et al., 2020 ). In Portugal, a cross-sectional study (May 2020) showed that physicians working at the frontline of COVID-19 ( N  = 420) presented worse mental health outcomes (anxiety, depression, stress and obsessive-compulsive symptoms) than other physicians. Moreover, this study found that being female and working at the frontline are risk factors for increased stress, while having a garden at home was a protective factor for anxiety and stress symptoms ( Ferreira et al., 2021 ). In Turkey, when 939 health care workers were assessed cross-sectionally in April-May 2020, more than 60% of the participants reported anxiety and depression symptoms ( Sahin et al., 2020 ). These studies stress the need for successful intervention or prevention strategies for health care personnel. To avoid long-term effects of stress, strategies to counteract the negative impact of the COVID-19 pandemic on mental health, particularly in highly affected populations, may be helpful. For instance, in a group of Italian general practitioners ( N  = 102), Di Monte and colleagues found that the implementation of task-orientated project management seemed protective against symptoms of burnout during the pandemic ( Di Monte et al., 2020 ). In another study, specific pandemic-related stress factors were identified in health care personnel, including workload burden and fear of infection ( Mosheva et al., 2020 ). Heath and colleagues reviewed several strategies to increase resilience among health care workers during and after the COVID-19 pandemic, also guided by the experiences of previous pandemics ( Heath et al., 2020 ). They identified several interventions and approaches, ranging from individual strategies without professional help (e.g. increased self-care or mindfulness practice) to strategies implemented at the group or organizational level (e.g. competency / resilience training, availability of psychological first aid or implementation of effective leadership and organizational justice). Importantly, some of these intervention strategies, including computer-assisted resilience training, have already been developed and successfully tested ( Aiello et al., 2011 ; Maunder et al., 2010 ; Weerkamp-Bartholomeus et al., 2020 ).

Conclusion: Overall, health care workers appear to be at an increased risk of stress-related psychological symptoms during a pandemic, compared to the general population. However, longitudinal studies are still largely lacking, and it remains to be seen whether the increase in symptoms is transient and can be considered a normal response to an abnormal temporally limited situation. For more solid conclusions, large-scale prospective longitudinal studies on the specific risk of health care personnel during and after a pandemic are needed. Such studies are already being planned ( Roberts et al., 2020 ). This is particularly relevant as the COVID-19 pandemic has been present over a prolonged period and already spans several waves of infection. Importantly, specific prevention and intervention strategies at the individual as well as at the organizational level may be crucial, with studies already showing beneficial effects of these strategies. See Table 2 for an overview of findings from cross-sectional and longitudinal studies on the impact of COVID-19 on stress resilience and mental health in health care personnel.

The impact of COVID-19 on stress resilience and mental health in health care personnel.

4. Children, adolescents, and college students

It is plausible that the impact of the COVID-19 pandemic on mental health might vary as a function of age and levels of educational attainment. In this section, we present findings focusing first on the effects of the pandemic on mental health in children and their parents, and subsequently we discuss findings in studies performed in adolescents and college students.

4.1. Children and their parents

Due to measures to decrease the spread of the COVID-19 virus, schools have been closed and the opportunity to interact with peers, play outdoors and exercise decreased ( de Lannoy et al., 2020 ; Moore et al., 2020 ), whereas sleep and screen time have increased ( Orgiles et al., 2020 ). Parental stress significantly increased after the school closures ( Hiraoka and Tomoda, 2020 ). Parents experienced financial and health problems and needed to comply with home schooling in addition to their own responsibilities, which affected parental routines. Parents’ financial concerns increased verbal aggression, increased loneliness was associated with child neglect, whereas worries increased physical abuse of the children. In general, wellbeing of the parents significantly affected children's mental health ( Carroll et al., 2020 ). A national survey from the US in June 2020 ( N  = 1011) reported worsening of mental health for 26.9% of the parents and 14.3% of the children, whereas the reported effect on physical health was smaller. Lost regular health care and delay in health care visits added to the worsening of children's mental health ( Patrick et al., 2020 ). In Italy (April – May 2020, N  = 463) ( Cusinato et al., 2020 ) and in Spain (April 2020, N  = 1049) ( Romero et al., 2020 ), parental stress was associated with more conduct problems of their children. In Hong Kong (March 2020, N  = 29,202 families), children with special education needs, chronic illnesses, mothers with mental illness, and children coming from single-parent and low income families were reported as more vulnerable to the increased stress levels as a result of the pandemic ( Tso et al., 2020 ). In Brazil (April - May 2020, N  = 289), parents reported anxiety in 19.4% of their children. In particular, children living with a person other than their parents reported higher anxiety levels, especially when a guardian had a lower age and lower educational level ( Garcia de Avila et al., 2020 ). Having a house without an outdoor exit to a garden or terrace significantly predicted psychiatric symptomatology ( Francisco et al., 2020 ). Overall, there are concerns that the risk of child maltreatment might be heightened during the COVID-19 pandemic due to a range of stressors such as increased loneliness, reduced physical activity, economic stress, social distancing, homeschooling, marital conflicts and violence, and intensified child–parent relationships ( Katz et al., 2020 ). In a recent study of 169 preschoolers, increased depressive and externalizing symptoms were observed compared to pre-COVID levels. A structured, predicable home environment adherent to family routines appears to mitigate these adverse effects ( Glynn et al., 2021 ).

4.2. Adolescents

In adolescents, determinants of resilience are less related to the parental situation and stressors associated with parental stress. A large-scale cross-sectional study from China (during the COVID-19 outbreak, N  = 3613) revealed that among 3254 adolescents, anxiety and depressive symptoms were common during the COVID-19 pandemic ( Duan et al., 2020 ), as assessed by the Chinese version of the Spence Child Anxiety Scale (SCAS). In another cross-sectional study conducted in China (February – March 2020, N  = 1784), following almost 30 days of confinement, depressive and anxiety symptoms were reported in around 23% of adolescents, with an association with less optimism about the pandemic and with being more worried about being infected with COVID-19 ( Xie et al., 2020 ). A Swiss survey study (November 2020, during the second pandemic wave, N  = 11,612) found that the youngest age group (14–24 years old, including students) were at higher risk for moderate-severe depressive symptoms (PHQ-9 ≥ 15) compared to individuals over 24 years old, and that this age-dependent effect became more prominent over the course of the pandemic ( https://osf.io/6cseh/ ). A cross-sectional study from China (March -April 2020, N  = 7890) reported a prevalence of 21.7% for anxiety and 24.6% for depression symptoms (HADS subscale score >7) ( Li et al., 2021a ). Another study from China (March 2020, N  = 8079) revealed that the prevalence of mild to severe depressive symptoms was 43.7% (assessed by the PHQ-9) and anxiety symptoms were 37.4% (assessed by the GAD-7) ( Zhou et al., 2020a ). Being in senior high school ( Zhou et al., 2020a ), female gender ( Zhou et al., 2020a ) ( Chen et al., 2020 ), lack of physical exercise ( Chen et al., 2020 ), and less social support increased the risk for depressive and anxiety symptomatology ( Qi et al., 2020 ). Furthermore, adverse childhood experiences, being exposed to COVID-19 and the presence of fear of exposure to COVID-19 were predictive of elevated levels of PTSD and anxiety in a Chinese cross-sectional cohort (February 2020, N  = 6196) ( Guo et al., 2020 ). Moreover, a longitudinal study among Australian adolescents ( N  = 248) showed that adolescents experienced significant increases in depressive and anxiety symptoms and a decrease in life satisfaction during the epidemic compared to 12 months leading up to the COVID-19 outbreak. COVID-19 related worries, online learning difficulties, and increased conflict with parents negatively affected the mental health outcomes, whereas adherence to lockdown measures and feeling socially connected during lockdown were protective factors ( Magson et al., 2020 ). In Indonesia, decreased parental support was associated with total mental health difficulties, whereas anxiety due to the COVID-19 pandemic was associated with higher pro-social problems (April –May 2020, N  = 113) ( Wiguna et al., 2020 ).

The previous findings seem to imply that the effects of the COVID-19 pandemic were unanimously negative regarding stress, coping and mental outcomes. However, the literature is more nuanced. A longitudinal study from the US ( N  = 322) reported significantly lower internalizing, externalizing, and attention problems in adolescents during the lockdown (April 2020) compared to January 2020 (prior to the spread of COVID-19 in the US), which was associated with better family functioning in youth that reported elevated mental health problems before the pandemic ( Penner et al., 2020 ). Even though a decrease in physical activity and an increase in sleep and screen time were reported for adolescents in a Chinese cross-sectional study (May 2020, N  = 10,082) ( Yang et al., 2020a ), an Italian study (April 2020, N  = 306) showed that the great majority of the adolescents did not notice or only noticed very little changes in psychological well-being in the early phase of the pandemic ( Pigaiani et al., 2020 ). In Belgium and Italy (April - May 2020, N  = 825), 5% of the participants reported having increased mental health care needs during the pandemic and 44% reported stability in needs for mental health care, with another 52% of the assessed youth reported no need for mental health care either before or after the pandemic ( Marchini et al., 2020 ). A study from Japan focusing on monthly suicide rates of people younger than 20 years old (January – May 2020, N  = 138), found that suicide rates from March 2020 to May 2020 slightly decreased during the school closure time and were not significantly different from the previous two years ( Isumi et al., 2020 ). In Canada (March 2020, N  = 683), almost half of a study sample of adolescents reported that the pandemic also exerted positive effects, with more time to spend with family and more time for exercise and hobbies. In addition, suicidal thoughts were reported to be lower than 6%. The type of motivation for social distancing was found to be associated with psychiatric symptomatology: social distancing due to fear of personally getting sick or to avoid judgement was related to higher anxiety, whereas social distancing due to the preference of staying home was associated with less anxiety and depressive symptoms ( Oosterhoff et al., 2020 ).

4.3. College students

Among university students in Spain (March 2020, N  = 2530), moderate to extremely severe levels of anxiety, depression, and stress were reported by 21%, 34%, and 28% of the participants, respectively ( Odriozola-Gonzalez et al., 2020 ). In a Chinese cross-sectional study (February – March 2020, N  = 407), the incidence of concerns about somatic symptoms, assessed by a somatic self-rating scale among college students, was 35%, mainly related to concerns regarding COVID-19 ( Liu et al., 2020a ). In Bangladesh (May 2020, N  = 476), over 80% of students exhibited any form of (mild to severe) depressive and anxiety symptoms, also related to worrying about academic activities ( Islam et al., 2020 ). In France (April – May 2020, N  = 69,054), the prevalence of suicidal thoughts, severe depression, and high levels of anxiety were 11%, 16%, and 28%, respectively ( Wathelet et al., 2020 ). In separate studies, female gender, social isolation, low quality of social relations were found as risk factors for lower mental health ( Wathelet et al., 2020 ). In a US study (April 2020, N  = 195), 71% of college students reported increased stress and anxiety, worry about their own and loved ones’ health, sleep disruptions, difficulty with concentration, and concerns about academic performance as pandemic-related stressors ( Son et al., 2020 ). For Chinese college students, 25% of the students reported mild to moderate anxiety when cross-sectionally assessed during the pandemic ( N  = 7143), with living in urban areas, income stability, social support, and living with parents as protective factors against anxiety ( Cao et al., 2020 ). Worry about the economic influences of the pandemic, the academic delays and the influence of the pandemic on daily life also contributed to students’ anxiety ( Cao et al., 2020 ). In a Dutch study which ecologically followed students before and during the lockdown (March 2020, N  = 78), mood homeostasis decreased significantly during lockdown, a finding that was in turn associated with lower mood and decreased engagement in activities that improved mood. Also, participants with previous mental illness showed a significantly higher decrease in mood homeostasis ( Taquet et al., 2020 ). In Italy (March – April 2020, N  = 934), students’ concerns about the COVID-19 pandemic increased PTSD symptoms, whereas positive thoughts about managing the epidemic showed the opposite effect ( Nania et al., 2020 ). Another longitudinal study conducted in the US ( N  = 675) showed that a group of college students reported a slight improvement in internalizing symptoms, but worsening of externalizing symptoms and attention when assessed before (beginning of Spring semester 2020) and during the pandemic (end of Spring semester 2020) ( Copeland et al., 2021 ). Around 70% of a sample of 950 US students (March 2020) reported that using a coping strategy such as staying connected, trying to relax, keeping busy, having a day-to-day routine, hobbies, doing school work and exercising, were protective factors during the pandemic ( Waselewski et al., 2020 ). A cohort from the Zurich Project on the Social Development from Childhood to Adulthood ( N  = 768) was assessed before the pandemic at the age of 20 and during the pandemic at the age of 22, and it was found that even though internalizing symptoms decreased, stress levels and anger increased during the pandemic. Moreover, only 30.5% reported feeling notably worse, whereas others were either feeling the same or better ( Shanahan et al., 2020 ).

Conclusion: In general, the pandemic has had negative effects on the mental health of children, adolescents, and students. Nevertheless, the effects vary widely within and across groups, and there are many methodological shortcomings in the current literature which is often cross-sectional and relies on self-report. Moreover, it is difficult to directly compare results across many of the studies. In children and younger adolescents, parental stress and decreased physical activity seem to be important risk factors for worse mental health, but for adolescents and students, COVID-19-and academic related worries, familial conflicts, loneliness, and not engaging in health behaviors seem to be important risk factors. Although children, adolescent, and students seem particularly vulnerable for the negative effects of the pandemic in general, there are also some studies finding signs of resilience, such as the use of effective coping strategies. Findings from cross-sectional and longitudinal studies on the impact of COVID-19 on stress resilience and mental health in children, adolescents and college students are presented in Table 3 .

The impact of COVID-19 on stress resilience and mental health in parents, children, adolescents, and college students.

5. Elderly people

Elderly people have been more directly affected by the pandemic than younger age groups as the physical impact of COVID-19 is substantially higher in this population. In addition, even though elderly people have higher levels of comorbidities that need to be taken care of, the availability of physician appointments and medical care has also been negatively impacted by the lockdown periods ( Spalletta et al., 2020 ). In general, elderly people have lower access to technology and social media, which can make it more difficult to compensate for lockdown-related changes and have adequate access to food, news, and social interaction ( Martins Van Jaarsveld, 2020 ). They are more isolated from their families and social connections, leading to an increased risk of developing psychiatric symptoms and therefore impairing their cognitive performance and daily functioning ( Yang et al., 2020b ). Elderly people also have been subject to change in health behaviors. A Cross-sectional study on the psychological, social and health-related challenges in Spanish older adults during the first COVID-19 wave (March 2020, N  = 528) showed that while a quarter of the elderly people could increase their intellectual activity during the first lockdown, more than 60% of them reported decreased physical activity ( Rodriguez-Gonzalez et al., 2020 ). In Greece, 80% of the elderly reported moderate to severe anxiety and depression levels three weeks after a national lockdown (March 2020, N  = 103) ( Parlapani et al., 2020 ), and these effects were also apparent in elderly with dementia in Argentina after the first 8 weeks of quarantine ( N  = 119) ( Cohen et al., 2020 ). A German study (March – May 2020, N  = 15,308) showed that while generalized anxiety significantly decreased with age, COVID-19 related fear significantly increased in elderly participants ( Schweda et al., 2021 ), even though this was not found in other studies.

In contrast, despite all the challenges that the elderly population faces, lower rates of psychiatric symptoms in this population compared to younger age groups were reported. During the COVID-19 pandemic in Germany, older individuals showed higher life satisfaction and quality of life and lower levels of trait anxiety compared to younger age groups (March – April 2020, N  = 494) ( Bidzan-Bluma et al., 2020 ). A cross-sectional study in the US (March – April 2020, N  = 833) showed that subjects of 60–70 years of age reported higher stress levels compared to older people (>71 years) ( Emerson, 2020 ). Another US survey study with elderly (March 2020, N  = 825) revealed that less than 15% of the participants reported pandemic-related stress from confinement/restrictions, isolation, loneliness and concern for others and the unknown future. In particular, stress from concern for others and the unknown future was associated with poorer psychological well-being ( Whitehead and Torossian, 2021 ). In Spain (March - April 2020, N  = 1639) ( Garcia-Fernandez et al., 2020 ) and the UK (April - May 2020, N  = 15,530) ( Li and Wang, 2020 ), elderly people reported less psychopathology compared to younger people. Also, when compared to younger age groups, lower COVID-19 Peritraumatic Distress Index (CPDI) scores (Brazil, March 2020, N  = 638) ( Zhang et al., 2021 ), lower rates of suicidal ideation (Greece, April - May 2020, N  = 5116) ( Papadopoulou et al., 2021 ), and lower rates of depression, anxiety and stress (Northern Spain, March - April 2020, N  = 1933), were reported in the elderly ( Ozamiz-Etxebarria et al., 2020 ). These findings might indicate that at least a sub-population of the elderly is remarkable resilient, potentially due to their complex experiences during their previous lives. The discrepancy of the findings in elderly people might heavily depend on the geographical location, timing of the measurements, and the nature of the assessed sample.

5.1. Elderly with cognitive symptoms and dementia

Elderly with cognitive symptoms may be more prone to the mental effects of the pandemic. In Italy (April – May 2020, N  = 126), daily physical activity and adherence to a healthy diet were found to be decreased in this population. However, less than 20% of the participants reported depression and anxiety, which was related to living alone, having less social interaction and reduction in leisure activities ( Di Santo et al., 2020 ). Based on a review on patients with a dementia diagnosis (summarizing 20 studies from March 2020 and June 2020), anxiety, apathy, and agitation were the most reported neuropsychiatric symptoms during the COVID-19 pandemic, probably due to decreased social interaction ( Simonetti et al., 2020 ).

Conclusion: Recent evidence points out that even though elderly people are more vulnerable to the physical effects of COVID-19, they also report lower psychopathology during the pandemic period compared to younger age groups. In the elderly population, patients with cognitive decline may be more vulnerable to the mental health effects of the pandemic. However, there is quite some heterogeneity within groups, and a significant proportion of the elderly people may still be at risk for worse mental health outcomes. Table 4 presents findings from cross-sectional and longitudinal studies on the impact of COVID-19 on stress resilience and mental health in elderly people.

The impact of COVID-19 on stress resilience and mental health in elderly people.

6. Pregnant women

During the first days of the pandemic, it was not clear whether a COVID-19 infection would affect pregnant women and whether the virus would be transmitted to the fetus. Many pregnant women therefore avoided visiting hospitals, and obstetricians in India reported that a great majority of their pregnant patients experienced anxiety about their hospital visits during the first wave of the COVID-19 pandemic (April - May 5, 2020, N  = 118) ( Nanjundaswamy et al., 2020 ). These worries in pregnant women were related to COVID-19-related concerns about being present in public places, perceived infection risk, visiting hospitals, health of the fetus, delivery concerns, a family member being infected, or transmission of COVID-19 to the baby during delivery ( Akgor et al., 2021 ; Taubman-Ben-Ari et al., 2020 ; Zhang et al., 2020 ). A nationwide cross-sectional study from Mexico (May – June 2020, N  = 503) found that 33.2% of pregnant women reported being stressed based on the Perceived Stress Scale, with perceived stress being significantly correlated with later gestational age ( Medina-Jimenez et al., 2020 ). In China (February – March 2020, N  = 560), over half of pregnant women reported feeling horrified, apprehensive, or helpless during the pandemic ( Zhang and Ma, 2020 ). A Turkish study reported that half of the 172 enrolled pregnant women in the third trimester reported feeling vulnerable to the effects of the pandemic (April 2020) ( Yassa et al., 2020a ). In a Pakistani (August 2020, N  = 552) and Chinese study (February 2020, N  = 1947), more than 80% of the pregnant women reported that they themselves and their fetuses were more vulnerable to the effects of the pandemic compared to the general population ( Liu et al., 2020b ; Shahid et al., 2020 ), but moderate to severe anxiety was reported in only 3% ( Liu et al., 2020b ). A systematic review, that included 15 studies examining depression and anxiety symptoms in pregnant or delivered women during the COVID-19 pandemic, reported a pooled overall prevalence of 30% for depression and of 34% for anxiety ( Sun et al., 2020 ). In addition, the prevalence of depression and anxiety symptoms was around two times higher compared to non-pregnant women ( Sun et al., 2020 ). Another systematic review and meta-analysis that included 19 studies about the mental health status of pregnant women during the COVID-19 pandemic reported a prevalence between 5 and 38% for depression and anxiety symptoms (overall prevalence of 25%) and a pooled overall prevalence of anxiety of 42% ( Fan et al., 2020 ). A rare longitudinal study in Argentina confirmed significant increases in depressive, anxiety and negative affect in 102 pregnant women at 2, 14, and 47 days after the start of the lockdown compared to 102 non-pregnant women ( Lopez-Morales et al., 2021 ). During the pandemic, 1754 pregnant women in Canada reported significantly higher levels of depressive, anxiety, dissociative and post-traumatic stress symptoms compared to a pre-COVID-19 cohort of pregnant women ( Berthelot et al., 2020 ). However, again, conflicting results are reported. A Turkish study (April 2020) found lower state anxiety in 203 pregnant women compared to 101 non-pregnant women ( Yassa et al., 2020b ). In China (February - March 2020, N  = 859;), pregnancy was associated with a lower risk for depression, anxiety, insomnia, and PTSD ( Zhou et al., 2020b ). Another Israelian study (March – May 2020, N  = 369) also reported lower rates of depression in pregnant women hospitalized during the pandemic, compared to pregnant women that were hospitalized before the pandemic ( Sade et al., 2020 ). Pre-existing psychiatric disorders appear to increase the experience of depressive, anxiety and dissociative symptoms in pregnant women during the pandemic ( Berthelot et al., 2020 ; Liu et al., 2021 ; Ravaldi et al., 2020 ), and previous anxiety disorders increases health-related and society-related anxiety levels ( Berthelot et al., 2020 ; Ravaldi et al., 2020 ).

There are several factors that may impact on the level of stress resilience specifically in pregnant women. Maternal social support in China and Ethiopia significantly decreased anxiety levels in pregnant women ( Yue et al., 2020 ), and also increased health-related quality of life ( Dule et al., 2021 ). Social support in Canada was also negatively correlated with depression and insomnia, whereas negative cognitive appraisal positively correlated with these symptoms ( Khoury et al., 2021 ). Risk of COVID-19 infection ( Bo et al., 2020 ), social isolation ( Durankus and Aksu, 2020 ), financial and relationship difficulties ( Bo et al., 2020 ; Khoury et al., 2021 ; Lebel et al., 2020 ; Matsushima and Horiguchi, 2020 ; Mortazavi et al., 2021 ), marital life satisfaction ( Effati-Daryani et al., 2020 ), intimate partner violence ( Almeida et al., 2020 ), sleep difficulties ( Lin et al., 2021 ), were reported factors that relate to psychopathology in pregnant women during the COVID-19 pandemic. In addition, having a relative with COVID-19 infection, a history of abortion, and an age below 30 increased pregnant women's worries ( Mortazavi et al., 2021 ). In the US (April – May 2020, N  = 787), compared to white women, black women reported significantly higher rates of depression, more pregnancy-related worries, more worries about the financial burden of the pandemic and having a job that is negatively affected by the pandemic ( Gur et al., 2020 ). Finally, a report from Iran (March – April 2020, N  = 580) showed that fear of COVID-19 was associated with suicidal ideation, quality of life and depression in 290 pregnant women ( Ahorsu et al., 2020 ).

Conclusion: Although several cross-sectional studies, mostly surveys, report that pregnant women experienced higher levels of stress, depression and anxiety during the pandemic period compared to non-pregnant women, several other studies found comparable or even better mental health outcomes. It remains quite challenging to assess the prevalence of anxiety and depression in pregnant women during the COVID-19 pandemic compared to the pre-pandemic period. Regarding risk factors, lack of social support and fear about pandemic-related issues reduced the stress resilience of pregnant women. An important aspect for future studies will be to assess the impact of the pandemic-related stress exposure during pregnancy on the children of these mothers. For an overview of findings from cross-sectional and longitudinal studies on the impact of COVID-19 on stress resilience and mental health in pregnant women, see Table 5 .

The impact of COVID-19 on stress resilience and mental health in pregnant women.

7. Patients with a psychiatric disorder

7.1. adults with a psychiatric disorder.

Whilst facing the COVID-19 pandemic has important negative consequences in terms of mental health and increases the vulnerability for psychological problems, severe mental illness in turn has been shown to represent a vulnerability factor for COVID-19 infection. Several studies have shown that patients affected by severe mental illness have an increased risk to become infected compared to the general population (odds ratios ranging from 5.7 to 7.6) ( Lee et al., 2020 ; Li et al., 2020 ; Wang et al., 2020b ), which is linked to poorer environmental conditions, such as socioeconomic deprivation. Furthermore, they might have more difficulties with being compliant to the rules and obligations established to fight the pandemic and tend to be generally exempt by wearing personal protective equipment such as masks ( Ayuso-Mateos et al., 2020 ). Indeed, in their analysis of anonymized electronic health records of 62,354 US patients affected by COVID-19 (January – August 2020), Taquet et al. clearly showed that the presence of a pre-existing psychiatric illness was significantly associated with a higher risk of a COVID-19 diagnosis (RR=1.65, 95% CI: 1.59–1.71, p  < 0.0001), independent of known physical health or economic and housing risk factors ( Taquet et al., 2021 ). This finding was confirmed by a recent analysis of de-identified population-level electronic health records data ( N  = 61,783,950) from US hospitals, which showed that individuals with a recent diagnosis of a mental disorder had a significantly increased risk for COVID-19 infection, with an effect strongest for depression (OR=7.6) and schizophrenia (OR=7.34) ( Wang et al., 2020b ). Of interest, this increased risk was further exacerbated among African Americans and women. It is plausible that these patterns of associations might be also related to the effect that COVID-19 has exerted on the levels of clinical care in psychiatry which showed a substantial decrease since the start of the pandemic ( Carpiniello et al., 2020 ; Yao et al., 2020 ).

In this context, stress resilience appears among one of the many plausible moderators of the identified increased risk of infection in patients affected by severe mental illness ( Ameis et al., 2020 ; Jacob et al., 2020 ). This is of relevance given that building resilience in the general population and at-risk patient populations will be a key instrument to decrease the impact of the COVID-19 related socioeconomic shock ( Jacob et al., 2020 ). Indeed, there is evidence that specific factors such as having a higher academic level, being autonomous, having self-efficacy, and the presence of optimism have been shown to be significant predictors of resilience in the general population during the COVID-19 pandemic ( Robles-Bello et al., 2020 ), protecting individuals from the development of mental disorders. This points to the importance of building resilience in at risk population such as those affected by severe mental disorders. Indeed, the work from Burrai et al. has shown that Italian psychiatric patients in residential community (April – May 2020, N  = 82) scored lower than healthy individuals in levels of stress although, as expected, they showed higher levels of anxiety, perceived risk of getting infected with COVID-19 and worry about the emergency situation ( Burrai et al., 2020 ). This finding is probably justified by the perceived and experienced support that residential patients receive from mental health workers and peers.

At the same time, there is evidence that COVID-19 has exerted a role as a precipitating factor for an exacerbation of existing psychiatric disorders, particularly in those disorders where stress is a key trigger, such as PTSD, mood disorders, and schizophrenia ( Ettman et al., 2020 ; Horn et al., 2020 ; Jolly et al., 2020 ; Ma et al., 2020 ; Pinkham et al., 2020 ; Rutherford et al., 2021 ). For instance, in China (January – April 2020), 30 patients with schizophrenia who were socially isolated after having close contact with a COVID-19 case showed a higher severity of symptoms, including higher levels of perceived stress and anxiety and lower quality of sleep, as well as a higher inflammatory load compared to 30 patients with schizophrenia not subjected to quarantine measures ( Ma et al., 2020 ). Of interest, there is anecdotal evidence of two cases in the US where symptoms of PTSD might have been exacerbated by public masking ( Jolly et al., 2020 ). However, Pinkham et al. showed in 148 US individuals with severe mental illness (92 with schizophrenia spectrum illnesses and 56 with affective disorders) that affective symptoms and sleep were stable after five months from the start of the pandemic ( Pinkham et al., 2020 ). Convincing evidence stems from three longitudinal Dutch case-control cohorts (NESDA: N  = 2329 cases and N  = 652 controls; NESDO: N  = 378 cases and N  = 132 controls; NOCDA: N  = 419 cases), showing that patients with depressive, anxiety, or obsessive-compulsive disorders are not experiencing a large detrimental impact on their mental health during the COVID-19 pandemic compared to before, even though symptom severity remained substantially high – and many more times higher than healthy controls, indicating the burden and severity of psychiatric disorders compared to general population symptom levels ( Pan et al., 2021 ). With regard to suicidality, a series of studies have shown that the suicide risk increased significantly during the pandemic ( Iob et al., 2020b ; John et al., 2020 ; Nomura et al., 2021 ; Sáiz et al., 2020 ; Singh, 2020 ; Tanaka and Okamoto, 2021 ). While the grim forecast from predictive models showed increased rates of suicide during the pandemic ( John et al., 2020 ), data emerging from epidemiological observations in countries as the Netherlands and Japan found that monthly suicide rates declined during the first months of the pandemic, even though levels in Japan increased by 16% during the second wave ( Tanaka and Okamoto, 2021 ). Other studies showed increased rates of various suicidal behavior components in the general population including passive suicidal ideation ( Sáiz et al., 2020 ) and self-harm ( Iob et al., 2020b ).

7.2. Children and adolescents with a psychiatric disorder

Children and adolescents with an eating disorder diagnosis represent a vulnerable group. Reactivation of eating disorder symptoms occurred in 42% of 365 young patients followed up in an eating disorder clinic in Spain during the first 8 weeks of COVID-19, particularly in adolescents (March – May 2020, N  = 365). In half of the cases, the clinical worsening was associated with eating restriction and excessive exercising due to reactivation of weight phobia. Social isolation and increase in family conflicts were reported as relevant factors ( Graell et al., 2020 ). Obsessive compulsive disorder symptoms were also reported to increase in the first months of the pandemic in most children and adolescents diagnosed with OCD, in addition to increased anxiety and depressive symptoms (Denmark, April-May 2020, N  = 67) ( Nissen et al., 2020 ). In a Turkish study, 61 participants aged 6–18 years who had been diagnosed with OCD were assessed in April 2020. 54% reported worsening of their symptoms and 36% reported more than a 30% increase in CY-BOCS scores. On the other hand, 11.4% of the patients reported decreased symptoms. More than half of the patients who were in remission also reported increased symptoms that reached a clinically significant threshold. Among the factors that predicted worsening of OCD symptoms during the pandemic were daily preoccupation with COVID-19, searching on social media about COVID-19, duration of OCD diagnosis and a diagnosis of COVID-19 in someone familiar ( Tanir et al., 2020 ).

Children with neurodevelopmental disorders such as attention deficit hyperactivity disorder (ADHD) and autism have shown to be at risk during the COVID-19 outbreak. A survey completed by 241 Chinese parents of children aged 6–15 years old who were diagnosed with ADHD, showed that ADHD symptoms significantly worsened during the lockdown ( Zhang et al., 2020a ). In a survey study in Italy (April 2020, N  = 527), parents reported that respectively 36% and 42% of children diagnosed with an autism spectrum disorder (ASD) experienced more intense and more frequent behavioral problems compared to the period before the pandemic ( Colizzi et al., 2020 ). Further, Turkish children diagnosed with ASD reported more sleep problems during the home confinement period which mediated autism symptom severity (May 2020, N  = 46)) ( Turkoglu et al., 2020 ). In another Turkish study that included 87 ASD patients (aged 3 to 29 years old), it was found that parents’ anxiety levels were significantly correlated with the child's total score on the ABC (Aberrant Behavior Checklist). Half of the parents reported that their children became more aggressive, around one third of the parents reported sleep and appetite changes in their children and a quarter of the parents reported that their child's tics increased, or new tics emerged ( Mutluer et al., 2020 ).

Conclusion: Overall, people with existing psychiatric disorders are experiencing a detrimental impact on their mental health from the COVID-19 pandemic, for example in OCD and PTSD, which requires close monitoring in clinical practice. The COVID-19 pandemic, however, does not seem to have further increased symptom severity in adult patients with depressive and anxiety disorders compared to their pre-pandemic levels ( Pinkham et al., 2020 );( Pan et al., 2021 ). Longitudinal observations with adequate time of follow-up suggest an increased risk for suicidality associated with the pandemic, even though there are conflicting reports. Regarding children and adolescents diagnosed with a psychiatric disorder, studies have generally reported a worsening of symptoms in young patients with eating disorders, obsessive compulsive disorders, and neurodevelopmental disorders such as ADHD and ASD. Severe mental illness in turn has been shown to represent an important vulnerability factor for COVID-19 infection. Basing on the increased vulnerability to COVID-19 in psychiatric patients, several European countries have prioritized them for vaccination. Many other countries are currently evaluating this option ( De Picker et al., 2021 ). See Table 6 . for an overview of findings from cross-sectional and longitudinal studies on the impact of COVID-19 on stress resilience and mental health in patients with a psychiatric disorder.

The impact of COVID-19 on stress resilience and mental health in patients with a psychiatric disorder.

8. COVID-19 patients

Previous SARS and MERS pandemics have shown that infection with the virus itself can be associated with increased symptoms as well as new diagnoses/symptoms of anxiety, depression, impaired memory, fatigue and insomnia in the acute as well as post-illness phase, and there is burgeoning evidence for substantial psychiatric symptoms related to COVID-infection ( Rogers et al., 2020 ; Taquet et al., 2021 ). An electronic health record network cohort study using data from 69 million individuals showed that in the three months following testing positive for COVID-19, 1 in 5 survivors was recorded as having a first time diagnosis of anxiety, depression or insomnia. This was about twice as likely as for other groups of patients in the same period ( Taquet et al., 2021 ). Furthermore, Horn et al. found that the prevalence of PTSD in patients with COVID-19 was around 6.5%, and a similar rate was also reported in COVID-19 patients discharged from hospitals in Wuhan ( Horn et al., 2020 ). In an Italian cross-sectional study (April - October 2020) that included 381 patients who had recovered from COVID-19 within 30 to 120 days, a PTSD prevalence of 30.2% was reported after acute COVID-19 infection ( Janiri et al., 2021 ). It is crucial to determine protective factors increasing resilience against mental health impairment following infection with COVID-19. This is illustrated by findings in a sample of 296 Chinese patients with mild symptoms of COVID-19, where higher resilience measured with the Connor-Davidson Resilience Scale was correlated with lower anxiety ( r  = −0.391, p  < 0.001) and depression ( r  = −0.472, p  < 0.001) scores. Patients with high resilience (upper 27%) were much less likely to display symptoms of anxiety (OR = 0.362, p  < 0.001) or depression (OR = 0.301, p  < 0.001) ( Zhang et al., 2020b ). Education about disease-related facts, emotional support and confidence of rehabilitation may enhance resilience in COVID-19 affected patients ( Zhang et al., 2020b ). Following up on these first data, longitudinal studies correcting for potential confounders such as pre-existing mental disorders, concomitant somatic disorders, severity of infection, degree of physiological compromise, immunological response, extent of medical interventions and socioeconomic situation, are warranted to further elucidate the role of resilience and its determining factors in promoting mental health in COVID-19 patients in order to develop targeted preventive interventions strengthening coping skills, self-efficacy, will power, daily routines and opportunities to share the emotional burden ( Richards and Scowcroft 2020 ).

Conclusion: In sum, given the high risk of psychiatric sequelae of COVID-19 infection, preventive measures promoting mental health as well as intensified screening for symptoms of mental disorders should be routinely implemented in the standard care of COVID-19 patients to increase resilience towards mental disorders particularly in this patient group. Table 7 presents findings from cross-sectional and longitudinal studies on the impact of COVID-19 on stress resilience and mental health in COVID-19 patients.

The impact of COVID-19 on stress resilience and mental health in COVID-19 patients.

9. Interindividual differences in stress resilience: implications for the pandemic

From the previous sections it is apparent that the effects of the pandemic, either related to COVID-19 itself or the associated measures, are surprisingly heterogeneous across populations. Trajectories of mental distress varied markedly by resilience level during the early months of the COVID-19 pandemic ( Riehm et al., 2021 ). It is thus of paramount importance to understand which individuals are resilient or vulnerable to apply a personalized medicine approach ( Willis and Lord, 2015 ). This approach harnesses the individual's genetic, genomic, proteomic, clinical, socioeconomic and lifestyle information to identify the factors causing the differential resilience/vulnerability to the virus. Such information allows to define resilient/vulnerable subpopulations, to refine targeted therapeutic strategies and to develop an effective public health approach. A meta-analysis examining 68 studies comprising 288,830 participants from 19 countries on factors associated with psychological distress during the COVID-19 pandemic (December 2019 - July 2020), showed that being female, being younger than 35 years old, living in rural areas, lower socioeconomic status, higher COVID-19 infection risk, longer social media exposure and having pre-existing physical or mental conditions were associated with higher anxiety and depression odds ( Wang et al., 2020c ). Higher social/family support, physical activity and positive coping strategies were associated with lower odds of anxiety and depression and thus a reduced risk of psychological distress ( Wang et al., 2020c ).

With regard to mental health, psychological attitudes towards how to manage the risk of infection, as well as towards specific medical, socioeconomic, personality and lifestyle factors, have been suggested to be key for the individual's resilience to distress and psychiatric disorders during a pandemic ( Chen and Bonanno, 2020 ; WHO, 2020 ; Zager Kocjan et al., 2021 ). Individual trait resilience and well-being scores, measured respectively with the 10-item Connor-Davidson Resilience Scale and the Recovery from War Scale, have been found to predict effective coping with the COVID-19 threat ( Kimhi et al., 2020 ; Ran et al., 2020 ). In addition, strategies aimed at reducing psychological distress such as paying attention to a healthy lifestyle, social support, good quality of sleep, acceptance of negative emotions, and avoidance of suppression and substance abuse, have been suggested to increase psychological resilience and may be key in coping with the COVID-19 related distress ( Bozdag and Ergun, 2020 ; Petzold et al., 2020 ). By contrast, loneliness, or negative psychological reactions, including panic response, hysteria, hopelessness and desperation, have been associated with negative outcomes, including suicidal ideation ( Killgore et al., 2020a ; Lee, 2020 ; Serafini et al., 2020 ; Thakur and Jain, 2020 ). Although the impact of the pandemic is still under investigation and initial large scale data analysis show that suicide numbers have remained largely unchanged or declined in the early months of the pandemic compared with the expected levels based on the pre-pandemic period in high-income and upper-middle-income countries it is plausible that more accurate figures will be detected in the long-term even after the pandemic will decrease its burden globally. Mental distress can be exacerbated by being quarantined ( Xin et al., 2020 ). It is worth noting that young people have reported to experience greater psychological distress than adults ( McGinty et al., 2020 ; Pierce et al., 2020 ; Varma et al., 2020 ). Unfortunately, to the best of our knowledge, no data on potential genetic, epigenetic, or brain function markers of resilience to mental illness in the face of the pandemic have been published yet. However, it can be hypothesized that neurobiological factors usually involved in the stress response, emotion-regulation, and the ability to adapt to new life conditions, such as immune system activation, hypothalamic-pituitary-adrenal axis activity and neural plasticity processes, might be involved ( Branchi and Giuliani, 2020 ; Zorn et al., 2017 ).

The three-dimensional vulnerability-stress-coping model may help understanding risk and resilience for mental disorders in relation to stress during the COVID-19 pandemic. This gene x environment x coping (G x E x C) model has been proposed to include the three factors a) genetic vulnerability, b) risk-increasing external stressors and c) resilience-increasing coping mechanisms, such as self-efficacy buffering the impact of a high genetic vulnerability and/or adverse environment. Exemplary studies have demonstrated this complex, three-fold interaction regarding risk or resilience towards anxiety phenotypes ( Schiele et al., 2020 , 2016 ). Finally, epigenetic mechanisms at the interface between biology and biography and impacting on stress-response and emotion-regulating capacities might add another level to confer individual risk as well as resilience towards mental disorders under adverse and advantageous environmental conditions ( Vinkers et al., 2015 ). Therefore, an extended (Epi) G x E x C model might prove useful in informing future personalized preventive interventions increasing resilience towards mental disorders. At the same time, existing hypotheses as the stress inoculation or match/mismatch hypothesis for psychiatric disorders may help to understand why selected population groups show increased resilience levels, for instance due to previous life experiences that now enable them to deal appropriately with the current challenges ( Nederhof and Schmidt, 2012 ; Schmidt, 2011 ).

Conclusion: There is an urgent need for a personalized approach when it comes to identifying individuals at risk or resilient for the stressful effects of the COVID-19 pandemic. The effects of stress and the resilience capacity are dependent on (neuro)biological, psychological, and environmental factors and are heavily dependent on an individual's unique context. Intensified research into (epi)genetic, proteomic, immunological, clinical, neuropsychological, socioeconomic and lifestyle factors conveying mental disorder risk or resilience in the context of the present pandemic is urgently warranted to provide individually tailored and thus most efficient resilience-increasing preventive measures. Findings from cross-sectional and longitudinal studies on interindividual differences in stress resilience are presented in Table 8 .

Interindividual differences in stress resilience: implications for the pandemic.

10. Conclusions and future perspective

We believe resilience research is in a unique position to make a significant contribution to understand the psychological and psychiatric impact of this pandemic and inform future clinical and research directions. This is not limited to the current COVID-19 pandemic but also applies to other local or global challenges. From the current literature, a surprising level of resilience is apparent across populations, even though there are individuals and groups that are at increased risk for the stressful effects of the COVID-19 pandemic ( Fig. 1 ). Nevertheless, firm conclusions cannot be drawn as most of the current literature has major methodological limitations. Most studies on stress resilience and mental health outcomes during the pandemic are observational, cross-sectional, using convenience samples with often rather small sample sizes and rather limited assessment of contextual and personal characteristics that are essential to understand stress vulnerability and resilience. Interpretation of observational studies from non-representative samples is likely to suffer from bias, particularly regarding collider bias ( Griffith et al., 2020 ). There is a stark contrast between the very limited number of extensive longitudinal studies with pre-pandemic assessments and a broad array of outcomes, and the vast number of cross-sectional studies with one or two outcomes. Where newer cohorts lack baseline data from before the pandemic, large established cohorts move relatively slowly and mostly sample infrequently. This makes more fine-grained assessments of resilience and mental health more challenging. Finally, there is lack of observational data on how the general public and patients with psychiatric disorders actually deal with self‐care, nutrition, physical activity or restorative sleep during confinement ( Balanza-Martinez et al., 2020 ). Thus, public policies will need to be informed by data gathered in observational studies of lifestyle behaviors during the compulsory isolation ( Balanza-Martinez et al., 2020 ). This research gap has been partly filled by very recent data confirming that psychiatric patients, particularly those affected by depression and anxiety tended to have higher levels of psychopathological distress ( Sole et al., 2021 ), and that the presence of depressive symptoms was a predictor of poorer resilience ( Verdolini et al., 2021 ).

Resilience and mental health related to the COVID-19 pandemic.

Nevertheless, studies during the pandemic consistently show that children and young people are the most vulnerable group with increased psychological distress, probably because their needs for social interactions are stronger. Moreover, young women appear to be more vulnerable than young men, and parents with young children appear to be at particularly high risk for mental health problems. However, these are rather broad conclusions which cannot be used at the individual level. There is still an urgent need to identify individuals and populations with higher risk of psychological distress during the COVID-19 pandemic to offer targeted mental health care and to improve social support, physical activity, and coping strategies in these individuals. These approaches are needed to boost resilience factors protecting the individual against psychological distress. For example, social support from and connectedness with family, friends, and a special caring loved one were each independently associated with greater resilience ( Killgore et al., 2020b ; Nitschke et al., 2020 ) ( South et al., 2020 ) ( Prime et al., 2020 ). Moreover, there seems to be a role for media with regard to resilience and mental health during the pandemic. Nuanced and balanced news coverage around the COVID-19 pandemic is essential in order that nocebo effects as a result of negative and alarming news coverage occur ( Bendau et al., 2020a ). Next, employers are taken up on their promise to assist their employees by building up resilience strategies at the organizational level. It remains to be seen how stress resilience will be shaped because of longer-term effects of the pandemic, or when society will need to find a new balance after the lockdown and pandemic. This is particularly pressing considering possible economic sequelae that will emerge while at the same time individuals will be forced to change from a lockdown situation to a more proactive attitude when all societal processes will start to function again.

About the methodological quality of the resilience literature during the COVID-19 pandemic, several lessons can be learned for future research to provide a more detailed and fine-grained picture, with possibilities for targeted prevention and intervention. First, the use of longitudinal data and large samples is important to identify potentially causal relationships, and changes over time ( Kalisch et al., 2017 ). How we respond to stress is a surprisingly dynamic process. Stress initiates a cascade of behavioral, (neuro)biological, and physiological changes. To this end, we need prospective data of adequate duration and of sufficient temporal resolution to observe (dis)continuous changes in resilience. Second, concerning outcomes and context, biological, psychological, and environmental data should be combined and integrated to understand the impact of (pandemic-related) stress at different levels with understanding of the individual's unique context. Third, we would encourage interdisciplinary collaborations, for example between physicians treating COVID-19 patients, psychiatrists, sociologists, advanced data experts, and neurobiologists. Fourth, we need not only to identify how stress resilience is shaped during a (prolonged) pandemic, but also develop efficient mental health interventions at a governmental, institutional, and individual level to minimize its long-term consequences. In conclusion, it is apparent that we have shown a remarkable level of resilience during the prolonged COVID-19 pandemic, but that large interindividual differences exist. Above all, it provides an opportunity but also an imperative for scientists and clinicians to work together to help understanding and addressing the pandemic.

Contributions

CV wrote the first draft. All authors provided critical input and revisions.

Conflicts of Interest

There are no conflicts of interest

Acknowledgements

No acknowledgements.

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The Many Faces of Stress During the COVID-19 Pandemic

Emerging themes from population-based studies on stress during the pandemic..

Posted November 25, 2020 | Reviewed by Devon Frye

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Prior to the global pandemic, America had already been dealing with a host of pervasive stressors such as health care access, mass shootings , climate change , rising suicide rates, and an opioid epidemic. Fast forward to the present day, as our country continues to struggle with our new reality amidst the global pandemic, select groups of our country are facing greater stress and poorer outcomes. It’s important to consider the many factors that create stress and related mental health issues so we can find new solutions in an increasingly complex time.

There are two recent studies that help shed light on the trends creating increased challenges for many people:

Two months ago, the CDC published a study by Czeisler et al. that identified potential epidemiological trends in mental health amongst adults in the U.S. throughout a several-month period of the COVID-19 pandemic. This month, the American Psychological Association (APA), through its Stress in America initiative conducted by the Harris Poll on behalf of the APA, published their findings based on surveys of people across the United States focusing on how stress has been impacting their lives.

There are inherent limitations to both studies, including measurement bias due to self-reporting of symptoms without a clinician-based assessment and sampling bias. This limits the degree of generalizations we can make to the larger U.S. population.

However, we can identify themes based on these two studies and then examine how these have expressed themselves through individual patient narratives. These include:

Uncertainty of the Future

One of the greatest human fears is that of uncertainty, or loss of our sense of control. The pandemic has introduced a significant amount of stress due to uncertainty for Gen Z adults (ages 18-23) who are unable to attend college on campus or are encountering limited open jobs and career opportunities upon graduating. Gen Z adults report that the future of our nation is a significant source of stress with the majority also citing the U.S. presidential election as a stressful source of uncertainty.

Moral Injury as a Result of Human Injustice

Moral injury is defined as an inner mental conflict that results when one’s actions or obligations are in direct opposition to a person's values and beliefs. Largely due to the pandemic and sociopolitical climate, 2020 has brought increased awareness of systemic racism in our nation. Nearly 2 in 3 adults—regardless of race—report police violence towards minorities as a significant source of stress, up from 1 in 3 adults who responded with the same answer in 2016. Furthermore, minorities, in particular Black Americans, are most likely to report discrimination as a stressor.

Disruption of Customs and Traditions

Traditions offer us a way to celebrate, reflect, grieve, and commemorate milestones in our lives. Young individuals in particular are sacrificing their graduations, college experiences, and social celebrations, making them feel lost and without a sense of belonging. For some young adults, the pandemic has disrupted wedding celebrations which represent a major milestone being postponed or reduced in scope. Across all walks of life, funeral services for loved ones have been greatly limited in attendance, often being performed virtually. These impacts on religious ceremonies and holidays have created a great deal of grief and separation where there was once celebration and togetherness.

Caretaking Overload and Burnout

For many, the mandated sheltering-at-home orders have magnified the duties and responsibility of caregivers. If the caregiver has previously relied on a combination of school and professional care, the COVID-19 pandemic has introduced a larger source of stress of balancing work and family. This has led to fatigue, stress, and—in some cases— depression .

Grief and Loss

The pandemic has brought loss into the forefront. For many Americans, the pandemic has resulted in a loss of jobs leading to financial instability. The drastic reduction in social interactions has led to increasing loneliness . And the loss of loved ones—in some cases without having a chance to sit at a bedside or say goodbye—has led to an overwhelming sense of dread, pessimism , and a lack of closure. For all of us, the pandemic has changed the way that we live our lives and we have had to grapple with and grieve the loss of our “normal” lives.

Trauma Due to COVID-19 Exposure

Studies of frontline health care workers during the COVID-19 pandemic have shown that rates of trauma-related symptoms, depression, and anxiety have increased during the pandemic. These have been related to experienced helplessness related to treating severely ill patients in a stressed and overwhelmed health system that has not yet identified effective and consistent treatments. In addition, the experience of continually exposing themselves (and family) to a virus that can lead to a life-threatening illness creates elevated stress levels in front-line workers.

With all of these factors in play, it can feel overwhelming to support ourselves and others through this challenging time. It’s important to remember that we are resilient as humans and that there are solutions we can turn to.

Czeisler MÉ , Lane RI, Petrosky E, et al. Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic — United States, June 24–30, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1049–1057.

https://www.apa.org/news/press/releases/stress/2020/report-october

Marc Lener, MD, is a psychiatrist in private practice in New York City and Founder and Chief Executive Officer of Singula Institute, a 501(c)(3) organization, whose vision is to transform mental health diagnostics and treatment for individuals at risk for anxiety and depression.

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• Volume 47, Issue 6
• Levels of stress in medical students due to COVID-19
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• http://orcid.org/0000-0003-3700-2782 Lorcan O'Byrne 1 ,
• http://orcid.org/0000-0002-5338-906X Blánaid Gavin 2 ,
• http://orcid.org/0000-0003-1315-1695 Dimitrios Adamis 3 , 4 ,
• You Xin Lim 1 ,
• http://orcid.org/0000-0001-9428-6908 Fiona McNicholas 2 , 5
• 1 School of Medicine , University College Dublin , Dublin , Ireland
• 2 Department of Child and Adolescent Psychiatry, SMMS , University College Dublin , Dublin , Ireland
• 3 Department of Psychiatry , National University of Ireland Galway , Galway , Ireland
• 4 Department of Psychiatry , University of Limerick , Limerick , Ireland
• 5 Department of Child and Adolescent Psychiatry , Our Lady's Children's Hospital , Crumlin , Dublin , Ireland
• Correspondence to Lorcan O'Byrne, University College Dublin, Dublin 4, Ireland; lorcan.obyrne{at}ucdconnect.ie

For medical schools, the COVID-19 pandemic necessitated examination and curricular restructuring as well as significant changes to clinical attachments. With the available evidence suggesting that medical students’ mental health status is already poorer than that of the general population, with academic stress being a chief predictor, such changes are likely to have a significant effect on these students. This online, cross-sectional study aimed to determine the impact of COVID-19 on perceived stress levels of medical students, investigate possible contributing and alleviating factors, and produce recommendations for medical schools to implement during future healthcare emergencies. The majority (54.5%) of respondents reported levels of stress ranging from moderate to extreme. Higher levels of stress were significantly associated with female gender (p=0.039) and international status (p=0.031). A significant association was also noted between reported stress and the transition to online learning (p<0.0001) and online assessment formatting (p<0.0001), concerns for personal health (p<0.0001) and for the health of family members (p<0.0001). Students who reported higher stress levels were less confident in their government’s management of the crisis (p=0.041). Additionally, students who reported lower stress agreed highly that their medical school had an appropriate response to the crisis (p<0.0001), had provided sufficient information regarding the crisis (p=0.015), that they trust their school in handling the continuing of their education (p=0.020) and that their school had appropriate plans in place to support the continuing of education (p=0.017)

Data availability statement

Data are available upon request.

This article is made freely available for use in accordance with BMJ’s website terms and conditions for the duration of the covid-19 pandemic or until otherwise determined by BMJ. You may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained.

https://doi.org/10.1136/medethics-2020-107155

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Contributors Conception or design of the work—LO’B, FMcN and BG. Acquisition of data for the work—LO’B, FMcN, BG and YXL. Analysis of data for the work—LO’B, YXL and DA. Interpretation of data for the work—LO’B and DA. Drafting the work or revising it critically for important intellectual content—LO’B, FMcN, BG, YXL and DA. Final approval of the version to be published—LO’B, FMcN, BG, YXL and DA. Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved—LO’B, FMcN, BG, YXL and DA.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

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• Open access
• Published: 28 March 2024

Medical student wellbeing during COVID-19: a qualitative study of challenges, coping strategies, and sources of support

• Helen M West   ORCID: orcid.org/0000-0001-8712-5890 1 ,
• Luke Flain   ORCID: orcid.org/0000-0001-7296-6304 2 ,
• Rowan M Davies 3 , 4 ,
• Benjamin Shelley 3 , 5 &
• Oscar T Edginton   ORCID: orcid.org/0000-0001-5298-9402 3 , 6  

BMC Psychology volume  12 , Article number:  179 ( 2024 ) Cite this article

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A Publisher Correction to this article was published on 26 June 2024

This article has been updated

Medical students face challenges to their mental wellbeing and have a high prevalence of mental health problems. During training, they are expected to develop strategies for dealing with stress. This study investigated factors medical students perceived as draining and replenishing during COVID-19, using the ‘coping reservoir’ model of wellbeing.

In synchronous interactive pre-recorded webinars, 78 fourth-year medical students in the UK responded to reflective prompts. Participants wrote open-text comments on a Padlet site. Responses were analysed using reflexive thematic analysis.

Analysis identified five themes. COVID-19 exacerbated academic pressures, while reducing the strategies available to cope with stress. Relational connections with family and friends were affected by the pandemic, leading to isolation and reliance on housemates for informal support. Relationships with patients were adversely affected by masks and telephone consultations, however attending placement was protective for some students’ wellbeing. Experiences of formal support were generally positive, but some students experienced attitudinal and practical barriers.

Conclusions

This study used a novel methodology to elicit medical students’ reflections on their mental wellbeing during COVID-19. Our findings reinforce and extend the ‘coping reservoir’ model, increasing our understanding of factors that contribute to resilience or burnout. Many stressors that medical students typically face were exacerbated during COVID-19, and their access to coping strategies and support were restricted. The changes to relationships with family, friends, patients, and staff resulted in reduced support and isolation. Recognising the importance of relational connections upon medical students’ mental wellbeing can inform future support.

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Medical students are known to experience high levels of stress, anxiety, depression and burnout due to the nature, intensity and length of their course [ 1 ]. Medical students are apprehensive about seeking support for their mental wellbeing due to perceived stigma and concerns about facing fitness to practise proceedings [ 2 ], increasing their vulnerability to poor mental health.

Research has identified that the stressors medical students experience include a demanding workload, maintaining work–life balance, relationships, personal life events, pressure to succeed, finances, administrative issues, career uncertainty, pressure around assessments, ethical concerns, and exposure to patient death [ 3 , 4 ]. In March 2020, the COVID-19 pandemic introduced additional stressors into medical students’ lives. These included sudden alterations to clinical placements, the delivery of online teaching, uncertainty around exams and progression, ambiguity regarding adequate Personal Protective Equipment (PPE), fear of infection, and increased exposure to death and dying [ 5 , 6 ]. Systematic reviews have reported elevated levels of anxiety, depression and stress among medical students during COVID-19 [ 7 ] and that the prevalence of depression and anxiety during COVID-19 was higher among medical students than in the general population or healthcare workers [ 8 ].

While training, medical students are expected to develop awareness of personal mental wellbeing and learn healthy coping strategies for dealing with stress [ 9 ]. Developing adaptive methods of self-care and stress reduction is beneficial both while studying medicine, and in a doctor’s future career. Protecting and promoting psychological wellbeing has the potential to improve medical students’ academic attainment, as well as their physical and mental wellbeing [ 10 ], and it is therefore important for medical educators to consider how mental wellbeing is fostered. Feeling emotionally supported while at medical school reduces the risk of psychological distress and burnout, and is related to whether students contemplate dropping out of medical training [ 11 ]. In their systematic narrative review of support systems for medical students during COVID-19, Ardekani et al. [ 12 ] propose a framework incorporating four levels: policies that promote a supportive culture and environment, active support for students at higher risk of mental health problems, screening for support needs, and provision for students wishing to access support. This emphasis on preventative strategies aligns with discussions of trauma-informed approaches to medical education, which aim to support student learning and prevent harm to mental wellbeing [ 13 ]. Dunn et al. [ 14 ] proposed a ‘coping reservoir’ model to conceptualise the factors that deplete and restore medical students’ mental wellbeing (Fig.  1 ). This reservoir is drained and filled repeatedly, as a student faces demands for their time, energy, and cognitive and emotional resources. This dynamic process leads to positive or negative outcomes such as resilience or burnout.

Coping reservoir model– adapted from Dunn et al. [ 14 ], with permission from the authors and Springer Nature

At present we have limited evidence to indicate why medical students’ mental wellbeing was so profoundly affected by COVID-19 and whether students developed coping strategies that enhanced their resilience, as suggested by Kelly et al. [ 15 ]. This study therefore sought to conceptualise the challenges medical students experienced during COVID-19, the coping strategies they developed in response to these stressors, and the supportive measures they valued. The ‘coping reservoir’ model [ 14 ] was chosen as the conceptual framework for this study because it includes both restorative and depleting influences. Understanding the factors that mediate medical students’ mental wellbeing will enable the development of interventions and support that are effective during crises such as the pandemic and more generally.

Methodology

This research study is based on a critical realist paradigm, recognising that our experience of reality is socially located [ 16 ]. Participant responses were understood to represent a shared understanding of that reality, acknowledging the social constructivist position that subjective meanings are formed through social norms and interactions with others, including while participating in this study. It also draws on hermeneutic phenomenology in aiming to interpret everyday experienced meanings for medical students during COVID-19 [ 17 ]. The use of an e-learning environment demonstrates an application of connectivism [ 18 ], a learning theory in which students participate in technological enabled networks. We recognise that meaning is co-constructed by the webinar content, prompts, ‘coping reservoir’ framework and through the process of analysis.

The multidisciplinary research team included a psychologist working in medical education, two medical students, and two Foundation level doctors. The team’s direct experience of the phenomenon studied was an important resource throughout the research process, and the researchers regularly reflected on how their subjective experiences and beliefs informed their interpretation of the data. Reflexive thematic analysis was chosen because it provides access to a socially contextualised reality, encompasses both deductive and inductive orientations so that analysis could be informed by the ‘coping reservoir’ while also generating unanticipated insights, and enables actionable outcomes to be produced [ 19 ].

Ethical approval

Approval was granted by the University of Liverpool Institute of Population Health Research Ethics Committee (Reference: 8365).

Participants

Fourth-year medical students at the University of Liverpool were invited to participate in the study during an online webinar in their Palliative Medicine placement. During six webinars between November 2020 and June 2021, 78 out of 113 eligible students participated, giving a response rate of 69%. This was a convenience sample of medical students who had a timetabled session on mental wellbeing. At the time, these medical students were attending clinical placements, however COVID-19 measures in the United Kingdom meant that academic teaching and support was conducted online, travel was limited, and contact with family and friends was restricted.

Students were informed about the study prior to the synchronous interactive pre-recorded webinar and had an opportunity to ask questions. Those who consented to participate accessed a Padlet ( www.padlet.com ) site during the webinar that provided teaching on mental wellbeing, self-care and resilience in the context of palliative medicine. Padlet is a collaborative online platform that hosts customisable virtual bulletin boards. During this recording, participants were asked to write anonymous open-text responses to reflective prompts developed from reviewing the literature (Appendix 1 ), and post these on Padlet. The Padlet board contained an Introduction to the webinar, sections for each prompt, links to references, and signposting to relevant support services. Data files were downloaded to Excel and stored securely, in line with the University of Liverpool Research Data Management Policy.

The research team used the six steps of reflexive thematic analysis to analyse the dataset. This process is described in Table  1 , and the four criteria for trustworthiness in qualitative research proposed by Lincoln and Guba [ 20 ] are outlined in Table  2 . We have used the purposeful approach to reporting thematic analysis recommended by Nowell et al. [ 21 ] and SRQR reporting standards [ 22 ] (Appendix 2 ).

Five themes were identified from the analysis:

COVID-19 exacerbated academic pressures.

COVID-19 affected students’ lifestyles and reduced their ability to cope with stress.

COVID-19 changed relationships with family and friends, which affected mental wellbeing.

COVID-19 changed interactions with patients, with positive and negative effects.

Formal support was valued but seeking it was perceived as more difficult during COVID-19.

COVID-19 exacerbated academic pressures

‘Every day feels the same, it’s hard to find motivation to do anything.’

Many participants reported feeling under chronic academic pressure due to studying medicine. Specific stressors reported were exams, revision, deadlines, workload, specific course requirements, timetables, online learning, placement, and communication from University. Some participants also reported negative effects on their mental wellbeing from feelings of comparison and competition, feeling unproductive, and overthinking.

Massive amounts of work load that feels unachievable.

COVID-19 exacerbated these academic stresses, with online learning and monotony identified as particularly draining. However, other students found online learning beneficial, due to reduced travelling.

I miss being able to see people face to face and zoom is becoming exhausting. My mental wellbeing hasn’t been great recently and I think the effects of the pandemic are slowly beginning to affect me.

I also prefer zoom as it is less tiring than travelling to campus/placement.

Clinical placements provided routine and social interaction. However, with few social interactions outside placement, this became monotonous. A reduction in other commitments helped some students to focus on their academic requirements.

‘Most social activity only taking place on placement has made every day feel the same’.

Some students placed high value on continuing to be productive and achieve academically despite the disruption of a pandemic, potentially to the detriment of their mental wellbeing. Time that felt unproductive was frustrating and draining.

‘Having a productive day i.e. going for a run and a good amount of work completed in the day’.

‘Unproductive days of revision or on placement’.

COVID-19 affected students’ lifestyles and reduced their ability to cope with stress

‘Everyone’s mental well-being decreased as things they used for mental health were no longer available’.

Students often found it difficult to sustain motivation for academic work without the respite of their usual restorative activities challenging.

‘Not being able to balance work and social life to the same extent makes you resent work and placement more’.

The competing demands medical students encounter for their time and energy were repeatedly reported by participants.

‘Sometimes having to go to placement + travel + study + look after myself is really tough to juggle!’

However, removing some of the boundaries around academic contact and structure of extracurricular activities heightened the impact of stressors. Many participants focused on organising and managing their time to cope with this. Students were aware that setting time aside for relaxation, enjoyment, creativity, and entertainment would be beneficial for their wellbeing.

‘Taking time off on the weekends to watch movies’.

However, they found it difficult to prioritise these without feeling guilty or believing they needed to ‘earn’ them, and academic commitments were prioritised over mental wellbeing.

‘Try to stop feeling guilty for doing something that isn’t medicine’. ‘Would like to say I’d do more to increase my mental wellbeing but finals are approaching and that will probably have to take priority for the next few months’.

Medical students were generally aware that multiple factors such as physical activity, time with loved ones, spiritual care, nourishment and hobbies had a positive impact on their mental wellbeing. During COVID-19, many of the coping strategies that students had previously found helpful were unavailable.

‘Initially it improved my mental well-being as I found time to care for myself, but with time I think everyone’s mental well-being decreased as things they used for mental health were no longer available e.g. gym, counselling, seeing friends’.

Participants adapted to use coping strategies that remained available during the pandemic. These included walks and time spent outdoors, exercise, journaling, reflection, nutrition, and sleep.

‘Running’. ‘Yoga’. ‘Fresh air and walks’.

A few students also reported that they tried to avoid unhelpful coping strategies, such as social media and alcohol.

‘Not reading the news, not using social media’.

‘Avoiding alcohol as it leads to poor sleep and time wasted’.

Many participants commented on increased loneliness, anxiety, low mood, frustration, and somatic symptoms.

‘Everyone is worn out and demotivated’. ‘Feel that as I am feeling low I don’t want to bring others down’. ‘Feel a lot more anxious than is normal and also easily annoyed and irritable.’

However, not all students reported that COVID-19 had a negative effect on wellbeing. A small minority responded that their wellbeing had improved in some way.

‘I think covid-19 has actually helped me become more self reliant in terms of well-being’.

COVID-19 changed relationships with family and friends, which affected mental wellbeing

‘Family are a huge support for me and I miss seeing them and the lack of human contact.’

Feeling emotionally supported by family and friends was important for medical students to maintain good mental wellbeing. However, COVID-19 predominantly had a negative impact on these relationships. Restrictions, such as being unable to socialise or travel during lockdowns, led to isolation and poor mental wellbeing.

‘Not being able to see friends or travel back home to see friends/family there’.

Participants frequently reported that spending too much time with people, feeling socially isolated, being unable to see people, or having negative social experiences had an adverse effect on their mental wellbeing. Relationships with housemates were a key source of support for some students. However, the increased intensity in housemate relationships caused tension in some cases, which had a particularly negative effect.

‘Much more difficult to have relationships with peers and began feeling very isolated’. ‘Talk about some of the experiences I’ve had on placement with my housemates’. ‘Added strain on my housemates to be the only ones to support me’.

Knowing that their peers were experiencing similar stressors helped to normalise common difficulties. The awareness that personal contacts were also struggling sometimes curtailed seeking informal support to avoid being a burden.

‘Actually discussing difficulties with friends has been most helpful, as it can sometimes feel like you’re the only one struggling, when actually most people are finding this year really difficult’. ‘Family and friends, but also don’t want to burden them as I know I can feel overwhelmed if people are always coming to me for negative conversations’.

COVID-19 changed interactions with patients, with positive and negative effects

‘With patients there has been limited contact and I miss speaking to patients.’

Some students reported positive effects on relationships with patients, and feeling a sense of purpose in talking to patients when their families were not allowed to visit. Medical students felt a moral responsibility to protect patients and other vulnerable people from infection, which contributed to a reduction in socialising even when not constrained by lockdown.

‘Talking to patients who can’t get visitors has actually made me feel more useful’. ‘Anxiety over giving COVID-19 to patients or elderly relatives’.

Students occasionally reported that wearing PPE made interactions with patients more challenging. Students’ contact with patients changed on some placements due to COVID-19, for example replacing in-person appointments with telephone consultations, and they found this challenging and disappointing.

‘Masks are an impediment to meaningful connections with new people’. ‘GP block when I saw no patients due to it all being on the telephone’.

Formal support was valued but seeking it was perceived as more difficult during COVID-19

‘Feel a burden on academic and clinical staff/in the way/annoying so tend to just keep to myself.’

Many participants emphasised the primary importance of support from family and friends, and their responses indicated that most had not sought formal support. While staff remained available and created opportunities for students to seek support, factors such as online learning and increased clinical workloads meant that some students found it harder to build supportive relationships with academic and placement staff and felt disconnected from them, which was detrimental for wellbeing and engagement.

‘Staff have been really helpful on placement but it was clear that in some cases, staff were overwhelmed with the workload created by COVID’. ‘Even though academic staff are available having to arrange meetings over zoom rather than face to face to discuss any problem is off putting’.

A few students described difficulty knowing what support was available, and identifying when they needed it.

‘It’s difficult to access support when you’re not sure what is available. Also you may feel your problems aren’t as serious as other people’s so hold off on seeking support’.

Formal support provided within the University included meetings with Academic Advisors, the School of Medicine wellbeing team, and University counselling service and mental health advisory team. It was also available from NHS services, such as GPs and psychological therapies. Those who had accessed formal support mostly described positive experiences with services. However, barriers to seeking formal support, such as perceived stigma, practicalities, waiting times for certain services, and concern that it may impact their future career were reported by some participants.

‘It is good that some services offer appointments that are after 5pm- this makes it more accessible to healthcare students’. ‘Had good experience with GPs about mental health personally’. ‘Admitting you need help or asking for help would make you look weak’. ‘Reassurance should be provided to medical students that accessing the wellbeing team is not detrimental to their degree. If anything it should be marketed as a professional and responsible thing to do’.

Some students preferred the convenience of remote access, others found phone or video impersonal and preferred in-person contact.

Students expressed that it was helpful when wellbeing support was integrated with academic systems, for example Academic Advisors or placement supervisors.

‘My CCT [primary-care led small group teaching] makes sure to ask how we are getting on and how our placements are going, so I think small groups of people with more contact with someone are more useful then large groups over zoom’. ‘Someone to speak to on palliative care placement, individual time with supervisor to check how we are doing (wellbeing, mental health) - would be a nice quick checkup’.

Participants typically felt able to share openly in an anonymous forum. Reading peers’ comments helped them to see that other students were having similar experiences and challenged unhealthy comparisons.

‘I definitely shared more than I would have done on a zoom call’. ‘I loved this session as it makes you feel like you’re not alone’. ‘Reassuring to know that there are others going through similar things as you’.

Our findings demonstrate that the COVID-19 pandemic exacerbated the stressors medical students experience, and removed some rewarding elements of learning, while reducing access to pre-existing coping strategies. The results support many aspects of the ‘coping reservoir’ framework [ 14 ]. Findings corroborate the restorative effects of psychosocial support and social/healthy activities such as sleep and physical activity, and the depletion of wellbeing due to time and energy demands, stress, and disruptions relating to the pandemic such as online teaching and limited social interaction. Feeling a sense of purpose, from continuing studying or interactions with patients for example, was restorative for wellbeing. Mentorship and intellectual stimulation were present in the responses, but received less attention than psychosocial support and social/healthy activities. Internal conflict is primarily characterised by Dunn et al. [ 14 ] as ambivalence about pursuing a career in medicine, which was not expressed by participants during the study. However, participants identified that their wellbeing was reduced by feeling unproductive and lacking purpose, feeling guilty about taking time for self-care, competing priorities, and comparison with peers, all of which could be described as forms of internal conflict. Different restorative and draining factors appeared to not be equally weighted by the participants responding to the prompts: some appear to be valued more highly, or rely on other needs being met. Possible explanations are that students may be less likely to find intellectual stimulation and mentorship beneficial if they are experiencing reduced social support or having difficulty sleeping, and internal conflict about pursuing a career in medicine might be overshadowed by more immediate concerns, for example about the pandemic. This prioritisation resembles the relationship between physiological and psychological needs being met and academic success [ 23 ], based on Maslow’s hierarchy of needs [ 24 ]. A revised ‘coping reservoir’ model is shown in Fig.  2 .

Coping reservoir model - the effects of COVID-19 on restorative and depleting factors for medical students, adapted from Dunn et al. [ 14 ], with permission from the authors and Springer Nature

Relational connections with family, friends, patients, and staff were protective factors for mental wellbeing. Feeling emotionally supported by family and friends is considered especially important for medical students to maintain good mental wellbeing [ 11 ]. These relationships usually mitigate the challenges of medical education [ 25 ], however they were fundamentally affected by the pandemic. Restrictions affecting support from family and friends, and changes to contact with patients on placement, had a negative effect on many participants’ mental wellbeing. Wellbeing support changed during the pandemic, with in-person support temporarily replaced by online consultations due to Government guidelines. Barriers to seeking formal support, such as perceived stigma, practicalities, and concern that it may impact their future career were reported by participants, reflecting previous research [ 26 ]. Despite initiatives to increase and publicise formal support, some students perceived that this was less available and accessible during COVID-19, due to online learning and awareness of the increased workload of clinicians, as described by Rich et al. [ 27 ]. These findings provide further support for the job demand-resources theory [ 28 , 29 ] where key relationships and support provide a protective buffer against the negative effects of challenging work.

In line with previous research, many participants reported feeling under chronic academic pressure while studying medicine [ 3 ]. Our findings indicate that medical students often continued to focus on achievement, productivity and competitiveness, despite the additional pressures of the pandemic. Remaining productive in their studies might have protected some students’ mental wellbeing by providing structure and purpose, however students’ responses primarily reflected the adverse effect this mindset had upon their wellbeing. Some students felt guilty taking time away from studying to relax, which contributes to burnout [ 30 ] , and explicitly prioritised academic achievement over their mental wellbeing.

Students were aware of the factors that have a positive impact on their mental wellbeing, such as physical activity, time with loved ones, spiritual care, nourishment and hobbies [ 31 ]. However, COVID-19 restrictions affected many replenishing factors, such as socialising, team sports, and gyms, and intensified draining factors, such as academic stressors. Students found ways to adapt to the removal of most coping strategies, for example doing home workouts instead of going to the gym, showing how they developed coping strategies that enhanced their resilience [ 15 ]. However, they found it more difficult to mitigate the effect of restrictions on relational connections with peers, patients and staff, and this appears to have had a particularly negative impact on mental wellbeing. While clinical placements provided helpful routine, social interaction and a sense of purpose, some students reported that having few social interactions outside placement became monotonous.

Our findings show that medical students often felt disconnected from peers and academic staff, and reported loneliness, isolation and decreased wellbeing during COVID-19. This corresponds with evidence that many medical students felt isolated [ 32 ], and students in general were at higher risk of loneliness than the general population during COVID-19 lockdowns [ 33 ]. Just as ‘belongingness’ mediates subjective wellbeing among University students [ 34 ], feeling connected and supported acts as a protective buffer for medical students’ psychological wellbeing [ 25 ].

Translation into practice

Based on the themes identified in this study, specific interventions can be recommended to support medical students’ mental wellbeing, summarised in Table  3 . This study provides evidence to support the development of interventions that increase relational connections between medical students, as a method of promoting mental wellbeing and preventing burnout. Our findings highlight the importance of interpersonal relationships and informal support mechanisms, and indicate that medical student wellbeing could be improved by strengthening these. Possible ways to do this include encouraging collaboration over competition, providing sufficient time off to visit family, having a peer mentor network, events that encourage students to meet each other, and wellbeing sessions that combine socialising with learning relaxation and mindfulness techniques. Students could be supported in their interactions with patients and peers by embedding reflective practice such as placement debrief sessions, Schwartz rounds [ 35 ] or Balint groups [ 36 ], and simulated communication workshops for difficult situations.

Experiencing guilt [ 30 ] and competition [ 4 ] while studying medicine are consistently recognised as contributing to distress and burnout, so interventions targeting these could improve mental wellbeing. Based on the responses from students, curriculum-based measures to protect mental wellbeing include manageable workloads, supportive learning environments, cultivating students’ sense of purpose, and encouraging taking breaks from studying without guilt. Normalising sharing of difficulties and regularly including content within the curriculum on self-care and stress reduction would improve mental wellbeing.

In aiming to reduce psychological distress among medical students, it is important that promotion of individual self-care is accompanied by reducing institutional stressors [ 11 , 29 ]. While the exploration of individual factors is important, such as promoting healthy lifestyle habits, reflection, time management, and mindset changes, this should not detract from addressing factors within the culture, learning and work environment that diminish mental wellbeing [ 37 ]. Heath et al. [ 38 ] propose a pro-active, multi-faceted approach, incorporating preventative strategies, organisational justice, individual strategies and organisational strategies to support resilience in healthcare workers. Similarly, trauma-informed medical education practices [ 13 ] involve individual and institutional strategies to promote student wellbeing.

Students favoured formal support that was responsive, individualised, and accessible. For example, integrating conversations about wellbeing into routine academic systems, and accommodating in-person and remote access to support. There has been increased awareness of the wellbeing needs of medical students in recent years, especially since the start of the pandemic, which has led to improvements in many of these areas, as reported in reviews by Ardekani et al. [ 12 ] and Klein and McCarthy [ 39 ]. Continuing to address stigma around mental health difficulties and embedding discussions around wellbeing in the curriculum are crucial for medical students to be able to seek appropriate support.

Strengths & limitations

By using qualitative open-text responses, rather than enforcing preconceived categories, this study captured students’ lived experience and priorities [ 4 , 31 ]. This increased the salience and depth of responses and generated categories of responses beyond the existing evidence, which is particularly important given the unprecedented experiences of COVID-19. Several strategies were used to establish rigour and trustworthiness, based on the four criteria proposed by Lincoln and Guba [ 20 ] (Table  2 ). These included the active involvement of medical students and recent medical graduates in data analysis and the development of themes, increasing the credibility of the research findings.

Potential limitations of the study are that participants may have been primed to think about certain aspects of wellbeing due to data being collected during a webinar delivered by medical educators including the lead author at the start of their palliative medicine placement, and the choice of prompts. Data was collected during the COVID-19 pandemic, and therefore represents fourth year medical students’ views in specific and unusual circumstances. Information on this context is provided to enable the reader to evaluate whether the findings have transferability to their setting. Responses were visible to others in the group, so participants may have influenced each other to give socially acceptable responses. This process of forming subjective meanings through social interactions is recognised as part of the construction of a shared understanding of reality, and we therefore view it as an inherent feature of this methodology rather than a hindrance. Feedback on the webinar indicated that students benefitted from this process of collective meaning-making. Similarly, researcher subjectivity is viewed as a contextual resource for knowledge generation in reflexive thematic analysis, rather than a limitation to be managed [ 19 ]. The study design meant that different demographic groups could not be compared.

Padlet provided a novel and acceptable method of data collection, offering researchers and educators the potential benefits of an anonymous forum in which students can see their peers’ responses. The use of an interactive webinar demonstrated a potential application of connectivist pedagogical principles [ 18 ]. Researchers are increasingly using content from online forums for qualitative research [ 40 ], and Padlet has been extensively used as an educational tool. However, to the authors’ knowledge, Padlet has not previously been used as a data collection platform for qualitative research. Allowing anonymity carried the risk of students posting comments that were inappropriate or unprofessional. However, with appropriate guidance it appeared to engender honesty and reflection, provided a safe and collaborative learning environment, and student feedback was overwhelmingly positive. It would be useful to evaluate the effects of this reflective webinar on medical students’ mental wellbeing, given that it acted as an intervention in addition to a teaching session and research study.

Students were prompted to plan what they would do following the webinar to improve their mental wellbeing. A longitudinal study to determine how students enacted these plans would allow a more detailed investigation of students’ self-care behaviour.

While we hope that the stressors of COVID-19 will not be repeated, this study provides valuable insight into medical students’ mental wellbeing, which can inform support beyond this exceptional time. The lasting impact of the pandemic upon medical education and mental wellbeing remains to be seen. Nevertheless, our findings reinforce and extend the coping reservoir model proposed by Dunn et al. [ 14 ], adding to our understanding of the factors that contribute to resilience or burnout. In particular, it provides evidence for the development of interventions that increase experiences of relational connectedness and belonging, which are likely to act as a buffer against emotional distress among medical students.

Data availability

The datasets generated and analysed during the study are available from the corresponding author on reasonable request.

Change history

26 june 2024.

A Correction to this paper has been published: https://doi.org/10.1186/s40359-024-01813-7

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Acknowledgements

We would like to thank Dr P Byrne for providing guidance, Mrs A Threlfall and Professor VCT Goddard-Fuller for commenting on drafts, and the medical students who participated in the webinars.

This study was unfunded.

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Helen M West

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Rowan M Davies, Benjamin Shelley & Oscar T Edginton

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HMW conceptualised the study and collected the data. HMW, LF, RMD, BS and OTE conducted data analysis. HMW, LF, RMD and OTE wrote the manuscript. All authors reviewed the manuscript.

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Approval was granted by the University of Liverpool Institute of Population Health Research Ethics Committee (Reference: 8365). Students were fully informed about the study prior to the workshop and had an opportunity to ask questions. Participants provided informed consent, completing an electronic consent form before responding to prompts. The study was conducted in accordance with relevant guidelines and regulations, including the University of Liverpool Research Ethics and Research Data Management Policies, and the Declaration of Helsinki.

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West, H.M., Flain, L., Davies, R.M. et al. Medical student wellbeing during COVID-19: a qualitative study of challenges, coping strategies, and sources of support. BMC Psychol 12 , 179 (2024). https://doi.org/10.1186/s40359-024-01618-8

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Received : 12 December 2023

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DOI : https://doi.org/10.1186/s40359-024-01618-8

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