The Anxiety and Depression of International Medical Students during COVID-19 Pandemic: A Cross-Sectional Study

. Te COVID-19 pandemic has inficted physical harm and exacerbated a signifcant mental health crisis, warranting greater attention. Tis study investigated the prevalence of anxiety and depression among international medical students (IMSs) during the pandemic and explored its correlation with demographic factors. Participants completed a comprehensive questionnaire encompassing demographic details, the Zung self-rating anxiety scale, and the Zung self-rating depression scale. Te fndings revealed that 23.27% of IMSs reported anxiety, while 48.52% experienced symptoms of depression. Multivariate logistic regression analysis identifed poor health conditions and limited access to the family as independent risk factors for anxiety. At the same time, depression was associated with both compromised health and notable fnancial burdens. Tis study provides crucial insights for policymakers, college administrators, and government authorities, urging proactive measures to support and manage the wellbeing of IMSs during pandemic situations.


Introduction
Te outbreak of large-scale epidemics, such as the MERS epidemic in the Middle East in 2012 and the Ebola outbreak in West Africa in 2014, poses not only a risk of death but also exacerbates mental health issues [1].Research suggests that the physiological damage caused by these public health emergencies can be recovered quickly, but the psychological efects may persist longer [2].Terefore, it is crucial to provide early psychological intervention to the public.In 2020, the COVID-19 outbreak was declared a pandemic by the World Health Organization (WHO) [3,4], with subsequent reports highlighting adverse efects on the mental well-being of the general population [5].Additionally, the pandemic has signifcantly afected various sectors, notably higher education, thereby infuencing the performance of students and aggravating social challenges they faced [6,7].Also, colleges implemented lockdown measures and shifted to online teaching to prevent the spread of COVID-19 to campuses [8].However, these measures amplifed the psychological burden on students, leading to increased levels of anxiety, depression, and stress [9][10][11][12].Moreover, COVID-19 restrictions contributed to their uncertainty about the future [13,14], and improper management of personal time and space [6,15].All these conditions, plus inadequate communication between students and institutions further exacerbated mental health issues [16,17].
Te international medical students (IMSs), as a special group, were among the most vulnerable categories [18].During the pandemic, some IMSs were confned to campus, while others were stuck in their homelands as many countries prohibited foreigners from entering in order to avoid cross infection [19].Numerous studies have documented that medical students experienced more anxiety and depression compared to their peers in other majors due to massive academic pressure and other factors [20][21][22].Furthermore, the suspension of clinical practice and laboratory activities during the pandemic further disrupted their educational process and daily routines [23].As future healthcare professionals, medical students also grappled with the added stress of potential frontline involvement in pandemic response eforts.Terefore, their mental health deserved more attention [24].However, little research on the mental health status of IMSs facing the pandemic has been conducted so far [25].

Methods
2.1.Design and Participants.Tis cross-sectional, online questionnaire-based study for IMSs at Xuzhou Medical University (China) was done from June 16, 2020 to June 23, 2020.Participants were eligible to participate if they were international students of Xuzhou Medical University who had not been diagnosed with psychological or mental illnesses before the pandemic.Students meeting the inclusion criteria received a message about the study in class online groups.Tey were informed about the study's goal, and their participation was entirely optional.Te questionnaires were completed anonymously, and confdentiality was ensured.Te study was authorized by Xuzhou Medical University's Ethics Committee and was carried out following the Helsinki Declaration (as revised in 2013).Consent from each student was obtained at the beginning of the online survey.

Research Tools.
Te self-report questionnaire used in this study comprised three sections, including demographic information, the Zung Self-Rating Anxiety Scale (Zung SAS), and the Zung self-rating depression Scale (Zung SDS).

General Condition
Questionnaire.Te general condition questionnaire consisted of demographic information of IMSs, including gender, age, grade, major, marital status, fnancial burden, health condition, physical exercise, time spent on study per day, the continent of origin, current location, clinical practice experience, and protective equipment condition for the pandemic.

Te Zung Self-Rating Anxiety Scale (Zung SAS).
Te psychological anxiety among IMSs was measured via the SAS, a 20-item self-report scale with items rated on a 4-point Likert scale (from 1 "a little of the time" to 4 "most of the time"), which was developed by Zung in 1971 [26].Te total score of each item is the raw score, which is then multiplied by 1.25 to obtain the standard score.Te cutofs for the SAS standard scores were classifed as less than 50, no anxiety; 50-59, minimal to mild anxiety; 60-69, moderate to marked anxiety; and greater than 70, severe anxiety [27].

Te Zung Self-Rating Depression Scale (Zung SDS).
Te SDS is a self-rating scale with 20 questions assessing emotional symptoms in the past week.Each item is scored on a Likert scale that ranges from 1 to 4 according to the frequency of symptoms in the past 7 days.Te score from each question is calculated to obtain the raw score, and the standard score is equivalent to the raw score multiplied by 1.25.A standard score ≥50 indicates "psychological depression"; 50-59, minimal to mild depression; 60-69, moderate to marked depression; and greater than 70, severe depression.[28] In this study, the SDS scale was used to evaluate the prevalence and level of depression of IMSs [27].

Statistical Analysis.
Statistical analysis was performed using the Statistical Package for Social Science (SPSS Inc., version 22.0, IBM).Descriptive analysis was used to describe the status of anxiety and depression and the distributions of the demographic characteristics of students.Te SAS and SDS scores were expressed as mean ± standard deviation.After the normality test of variables, a t-test or ANOVA was used if meeting the parametric test requirements.Otherwise, non-parametric tests (Mann-Whitney U-test) were performed as appropriate.A t-test or ANOVA was used for normally distributed data, whereas a Mann-Whitney U-test was applied for non-normally distributed data.All demographic data were analyzed and presented as frequency and percentage.A univariate analysis (chi-squared test) and multivariate logistic regression analysis were used to explore the associations between sample characteristics and anxiety as well as depression symptoms.Test level α � 0.05, P < 0.05 was considered statistically signifcant.

Distributions of Anxiety and Depression Scores among
IMSs during the COVID-19.In the current study, a total of 211 students completed the questionnaire.At the end, 202 questionnaires (95.73%) were fully flled out and considered valid.Among them, 57 students were in China, 145 were in their home countries, 131 were Asian, and 71 were from Africa.Levels of anxiety and depression of participants are demonstrated in Table 1.Te prevalence rates of anxiety and depression symptoms among the IMSs in this study were 23.27% (SAS index score ≥50) and 48.52% (SDS index score ≥50), respectively, though the mean scores of SAS and SDS indexes were 46.9 ± 7.7 points and 51.9 ± 10.1 points separately.For anxiety and depression status, the prevalence of each classifcation was 12.87% and 21.29% (minimal to mild), 6.93% and 19.31% (moderate to marked), and 3.47% and 7.92% (severe).

Te Diferences between the Demographic Variables and Anxiety as Well as Depression among IMSs during the COVID-19
Pandemic.Anxiety and depression scores were related to diferent demographic characteristics of students, which are presented in Table 2. Students with fnancial burdens were more prone to be anxious and depressed than those with good fnancial situations (P � 0.002; P � 0.001).However, there was no signifcant diference in anxiety and depression levels by sex, age, major, and marital status.In addition, poor health condition was associated with more anxiety (P < 0.001) and depression (P < 0.001).Also, short exercise and study time had a signifcant efect on anxiety (P � 0.044; P � 0.038) and depression (P � 0.011; P � 0.007).IMSs with short exercise and study time had increased anxiety and depression, respectively.However, clinical practice experience had no signifcant diference on 2 Perspectives in Psychiatric Care

Correlation between IMSs' Anxiety and Depression When
Facing the Pandemic.Another fnding of the study suggested a signifcant positive correlation between anxiety and depression (Table 5).Tis fnding is supported by previous studies which revealed that people with high anxiety were more likely to be more depressed [29].And among the general population, major depressive disorders were highly comorbid with various anxiety disorders [30].

Discussion
Te fndings of the survey indicated that the pandemic affected 23.27% and 48.52% of IMS with anxiety and depression respectively.Tis fgure is lower than the percentage reported in earlier studies of Chinese college students, which was 41.1% and 60.5% for anxiety and depression, respectively [31,32].Tis diference may be because most of the international students at Xuzhou Medical University come from West Asia and Africa and have several siblings.In contrast, most Chinese college students are only children.Siblings can provide social support and help with emotional regulation, whereas only children may experience more anxiety and depression due to a lack of social support [33].Additionally, cross-cultural experiences can activate and further enhance their adaptability and facilitate adaptation to new environments, which enabled IMSs to better cope with the pandemic's sudden changes [34].All these reasons may lead to lower rates of anxiety and depression compared to local Chinese students during the pandemic.Te survey revealed that the anxiety of IMSs regarding this pandemic was related to their fnancial situation, health condition, length of exercise and study every day, current location and sufciency of protective equipment.On the other hand, the fnancial situation, health condition, daily duration of exercise and study, continent of origin, current location, and adequacy of protective equipment were associated with the depression of IMSs during the pandemic.Nevertheless, there were no signifcant diferences in gender, age, major, marital status, or clinical practice experience on negative emotions and psychological issues when facing the pandemic.
Health condition was a signifcant factor infuencing IMSs' anxiety and depression.Tose with poor health conditions exhibited more anxiety and depression.Te results were supported by Wang et al. who found that physical symptoms, very poor self-rating of health status, and chronic illness history were signifcantly associated with higher anxiety or depression level [25].Another study also indicated that poor health condition such as having organic disease was a common risk factor for anxiety, depression, and other mental health problems among medical health workers.Excessive health concerns may lead to psychological problems for these people [35,36].In the face of the pandemic, they tend to be more anxious and worried about becoming vulnerable groups.
Another factor contributing to IMSs' depression during the COVID-19 pandemic was fnancial hardship.Some families lost their source of income, and students were anxious about their tuition and living expenses.A previous study in Germany also showed that expected fnancial hardships were greatly correlated to psychological disorders and psychosomatic symptoms among medical students [37].Tus, colleges should pay more attention to these groups and help them by addressing some modifable factors.For example, information about a healthy lifestyle and its efect on mental health can be introduced frequently to IMSs by holding themed class meetings, sending emails, etc.Additionally, teachers can communicate more with IMSs identifed as fnancially burdened (e.g., students on tuition loans or fnancial aid) to determine if they require additional fnancial help in time.
Te current location was also a main factor that afected IMSs' anxiety.Tose who stayed in China and were unable to contact their families during the pandemic experienced greater anxiety than those who remained at home.Tis may be because many of the IMSs in China were concerned about their families' well-being, as the COVID-19 pandemic continued to be severe in their homeland.Furthermore, college students are still young and have not yet reached psychological maturity [38].Family is an crucial support source, economically and psychologically, for most of college students [39,40].As such, a lack of family support can negatively impact their psychological status, leading to increased levels of anxiety and depression [8,41].It is recommended that colleges provide more support to IMSs by organizing various extracurricular activities, such as online singing competitions, speech competitions, medical comic competitions, etc. to improve their well-being and reduce feelings of loneliness.
Tere are several limitations to current study.First, the scope was confned to IMSs enrolled in a single Chinese medical university, thereby constraining the generalizability of the fndings to broader contexts.Second, participation in the study was voluntary for IMSs, potentially introducing 4 Perspectives in Psychiatric Care Perspectives in Psychiatric Care a self-selection bias whereby individuals with heightened levels of anxiety or depression may have been less inclined to participate or, conversely, more likely to engage due to the relevance of the topic to their experiences.In summary, the study revealed that IMSs who experienced poor health, fnancial strain, or separation from family during the pandemic reported elevated levels of anxiety and depression.Tese outcomes underscore the profound impact of the pandemic on the mental wellbeing of IMSs.It is recommended that governmental bodies and educational institutions should prioritize the mental health of IMSs and devise comprehensive intervention strategies tailored to their needs during stressful situations [42][43][44].Perspectives in Psychiatric Care

Table 2 :
Diferences in anxiety and depression based on students' demographic characteristics.
a t-test.b ANOVA.c Mann-Whitney test.d Kruskal-Wallis test.

Table 1 :
Number of students with diferent levels of anxiety and depression (n � 202). in Psychiatric Care student's anxiety or depression.Furthermore, those who stayed on campus and those with insufcient protective equipment were more likely to report anxiety (P � 0.005; P � 0.008) and depression (P � 0.003; P � 0.001).Although no signifcant diferences were found in the continent of origin with respect to symptoms of anxiety, African students did show greater symptoms of depression as compared to Asian students (P � 0.048).After performing a univariate analysis for factors according to the personal number of IMSs' anxiety and depression (Table3), multivariate logistic regression analysis was used to further investigate the factors that infuenced students' anxiety and depression during the COVID-19 crisis (Table4).Te results indicated that two independent variables signifcantly predicted anxiety n: number.Perspectives symptoms: health condition (odds ratio � 3.264, p � 0.001) and current location (odds ratio � 0.202, p � 0.024).Additionally, fnancial situation (odds ratio � 1.892, p � 0.010) and health condition (odds ratio � 2.365, p � 0.015) are independent predictors of students' depression symptoms.

Table 3 :
Te relationship between students' anxiety and depression and demographic characteristics about the pandemic.

Table 4 :
Multivariate logistic regression analysis of factors infuencing students' anxiety and depression.: Std.error, OR: Odds ratio, and CI: Confdence interval. SE

Table 5 :
Correlation analysis between IMSs' anxiety and depression when facing the pandemic.