Since December 2019, reports of an illness with a novel coronavirus disease 2019 (COVID-19) had been accumulating from the Wuhan region of China and infections had been multiplying at a rapid rate worldwide (Zhu et al., 2020), prompting the World Health Organization (2020a) to declare an international the COVID-19 pandemic. The COVID-19 pandemic has been affecting many areas of life. Due to the rapid increase in the number of COVID-19 infections, many governments around the world have imposed strict rules on domestic quarantine and social isolation.

On January 27, 2020, the German Federal Ministry of Health (2020) announced the first COVID-19 case had been detected in Germany. Since then, the epidemiological situation has deteriorated sharply. As of May 31, 2020, more than 180,000 people in Germany had already been infected with COVID-19, of which 8,500 cases (4.7% of all the confirmed cases) have been fatal (Robert-Koch-Institut, 2020). At that time, Hamburg was the third most affected German state in terms of population (cases/100,000 inhabitants) (Robert-Koch-Institut, 2020). Worldwide, there were nearly 6 million confirmed cases at that time, including 367,166 deaths, according to the World Health Organization (2020b). At this time, the COVID-19 pandemic was spreading most rapidly in North and South America. The United States and Brazil were affected the most, with more than 100,000 new infections within 7 days (May 25–31, 2020). Most new infections were measured in Germany from mid-March to around mid-April 2020 (Robert-Koch-Institut, 2020). The rapid increase in the number of infections noticeably restricted the everyday life of the population. Since mid-March 2020, the German government announced several restrictions with respect to public life to suppress the spread of COVID-19 by increasing social distancing, i.e., school, daycare, and nonessential shop closures, bans on public meetings (Steinmetz et al., 2020). Depending on the federal state in Germany, people were not allowed to meet more than one person from another household, and schools, daycare and nonessential shops were closed. Temporarily people were not allowed to leave their homes without a reason (Steinmetz et al., 2020). At universities, lectures and seminars have been held predominantly digitally to reduce interpersonal contact and protect patients, students, and faculty (HRK German Rectors’ Conference, 2020). Consequently, the spread of the COVID-19 pandemic has caused major changes in undergraduate medical education, too (Whelan et al., 2020). Many medical schools disrupted their undergraduate medical education and transitioned most of their teaching to digital formats (Rose, 2020). In Germany, it was agreed in March 2020 that medical lectures were held predominantly in digital form until further notice (Deutsche Hochschulmedizin, 2020). In this context, the learning environment as well as the study and examination conditions for students changed significantly.

A recent conceptual framework proposed a learning environment that encompasses a psychosocial dimension with a personal, social, and organizational component in addition to a material dimension that includes physical and virtual spaces (Gruppen et al., 2019). According to Gruppen et al. (2019), these five core components overlap and interact with each other. The personal and social components strongly shape perceptions of the learning environment of the students. Furthermore, the personal component reflects the psychological characteristics of the learners, e.g., quality of life, moral distress, and worries about future endurance. The social component describes the quality of interactions between peers, students and faculty, and students and patients (Gruppen et al., 2019). These interactions of learners include, for example, cooperation and competition with peers, feedback by and communication with faculty, and responsibility for and acceptance by the patients. In light of the COVID-19 pandemic, the personal and social components, in particular, could be seriously compromised. Previous studies highlighted the impact of the learning environment on well-being of the medical students (Dyrbye et al., 2009, 2020). Learning environments that are perceived as unsupportive and less nurturing are typically associated with decreased mental health among medical students (Dyrbye et al., 2009; Schwenk et al., 2010; Wasson et al., 2016). An international study has explored the impact of favorable perceptions of the learning environment (LE) on self-reported quality of life, burnout, and empathy of the undergraduate students at three different medical schools (Tackett et al., 2017). In total, 62% of the sample reported more favorable than unfavorable LE perceptions, which were positively correlated with better quality of life, lower emotional exhaustion, and less depersonalization in adjusted models. The domain “community of peers” as one factor of the applied instrument was the only factor that was independently associated with better quality of life scores, less emotional exhaustion, and less depersonalization (Tackett et al., 2017). A recent systematic review explored the association between learning environment interventions and improved mental health among undergraduate medical students (Wasson et al., 2016). The study group identified 28 of 4,207 published articles including more than 8,000 participants that met the inclusion criteria of their review. The results indicated that pass/fail grading systems (compared to grading systems with three or more intervals), formal mentoring/advisor programs, mental health and wellness programs were associated with improved emotional well-being among medical students.

Even before the COVID-19 pandemic, high mental burden of medical students had frequently been reported in the literature (Dyrbye et al., 2006; Hope and Henderson, 2014; Heinen et al., 2017). Additional pandemic-specific stressors could exacerbate this situation. In a study conducted in March 2020, 25% of the college students at a medical school in China reported anxiety related to COVID-19 (Cao et al., 2020). Previous research had reported the negative impact of past pandemics (Hawryluck et al., 2004) and the COVID-19 pandemic (Wang et al., 2020) on the general population and on specific groups, e.g., medical students (Elmer et al., 2020) and health professionals (Lai et al., 2020). Health professionals may be particularly affected (Bao et al., 2020) because of additional stressors on top of the general pandemic-specific ones (Inter-Agency Standing Committee (IASC), 2020). A number of recent studies have shown that mental burden during the COVID-19 pandemic was highest among women and young adults (Elmer et al., 2020; Pieh et al., 2020; Dale et al., 2021). For example, an Austrian study investigated mental health in the Austrian population during a strict lockdown in December 2020/January 2021 and found a prevalence of 26% for moderate depression, 23% for moderate anxiety, and 18% for moderate insomnia (Dale et al., 2021). For all the measures, women reported a higher mental burden than men. Likewise, the youngest age group (18–24 years) reported statistically significant more mental health symptoms in comparison to the oldest age group (65+ years) (Dale et al., 2021).

This study aimed to assess mental health outcomes among medical students during COVID-19 and perception of the students with respect to how learning environment has changed in a large sample of undergraduate medical students in Germany. It was conducted with the purpose of better understanding their levels of distress, anxiety, and depression as well as their perception of the learning environment during the first semester after the COVID-19 outbreak. This study is exploratory in nature. We investigated demographic and mental health factors associated with serious worries about the study situation during the COVID-19 pandemic and addressed the following two research questions: (1) Do female and male students differ with regard to mental burden and study worries during the COVID-19 pandemic? and (2) Do students in different years of study differ in terms of psychological distress and study worries during the COVID-19 pandemic? Based on recent studies (Elmer et al., 2020; Pieh et al., 2020; Dale et al., 2021), it is expected that female students might be higher burdened in contrast to male students, and students in the first study years might be higher burdened than students in year 2–4 as age increases with study year.

In this study, we investigated mental health outcomes among medical students during the initial phase of the COVID-19 pandemic and perceptions of the students on how the learning environment had changed in a large sample of undergraduate medical students in Germany. Overall, our findings suggest that medical students experienced significant levels of distress and mental burden during the COVID-19 pandemic.

A previous study conducted at the same medical school with the same measures served as a valid context to frame our findings (Heinen et al., 2017). Comparing our results to the findings of Heinen et al. (2017), the substantial decline in all mental health measures could be attributed to the impact of the COVID-19 pandemic. Consistent with earlier findings of other studies, we found significantly higher levels of anxiety and depression among medical students compared to the German norm population (Löwe et al., 2010; Stormon et al., 2019). First year students reported the highest levels of mental burden according to the DT and PHQ-4. Previous studies found that people in their early 20s—the most common age group in students—are particularly burdened during the COVID-19 pandemic (Brooks et al., 2020; Pieh et al., 2020; Qiu et al., 2020; Dale et al., 2021).

In contrast to other studies during the COVID-19 pandemic (Lai et al., 2020; Park et al., 2020; Pieh et al., 2020; Qiu et al., 2020) and a general tendency in psychiatry research (Riecher-Rössler, 2017), we found that male students reported more frequently higher levels of depressive symptoms according to the PHQ-2 than female students. Additionally, male students were at higher risk for experiencing serious worries with respect to the study situation during the COVID-19 pandemic than females. Our qualitative data may serve as a valid context to frame these novel findings. Overall, the qualitative data indicated that worries about the lack of practical training, difficulties with self-regulated learning, study-related uncertainty, and the changed learning environment increased as the semester progressed. In this study, female students stated more frequently worries with respect to their undergraduate courses, health, financing, and general uncertainty as expected by the literature.

At first sight, it seems to be a contradiction in this study that depression was higher among males and serious worries were reported more often by male than by female students. On the other hand, with regard to qualitative data, females expressed more worries than males. It should be taken into account that completing open-ended response options require a greater amount of time and mental effort than most close-ended questions (Dillman, 2007). Thus, only 51.4 and 45.1% of all the respondents completed the two items with open-ended response options. Furthermore, the proportion of women who completed the two items with open-ended response options was higher in both the items (67.8 and 72.6%) compared to the proportion of women in the entire survey (63.4%).

Interestingly, females mentioned helpful strategies during the COVID-19 pandemic more often than male students. This might indicate the use of more efficient coping strategies during the initial phase of the COVID-19 pandemic compared to male students. Recent research showed that female students often relied on denser social networks even during the social distancing phase (Elmer et al., 2020). This strategy could have buffered the negative effects in terms of a decline in mental health among female students.

The decrease in study motivation was highest in year 2 students. These findings complement earlier empirical research indicating that undergraduate students adopted a different learning approach and a sharp decrease in intrinsic motives with the entry to clinical training (Wickramasinghe and Samarasekera, 2011; Lee et al., 2020). The curriculum structure of iMED allows the intermediate examination after the third semester. Thus, the amount of practical training increases sharply from the 4th semester, which corresponds to the second half of year 2 (Rheingans et al., 2019). The construction of the curriculum with more practical training after the 3rd semester could account for the high decrease of study motivation among 2nd year students in this study. Further, in previous research, it was discussed that motivation of male and female students differs with higher autonomous motivation among female students and higher controlled motivation among male students when compared with the opposite sex (Kusurkar et al., 2013).

Interestingly, our qualitative results mapped several scales of the Medical School Learning Environment Survey: among others, but not limited to “flexibility,” “student–student interaction,” “meaningful learning experience,” and “nurturance” (Rusticus et al., 2014). In line with recent studies, perception of the changed situation of the students included both negative and positive aspects (Elmer et al., 2020; Mohr et al., 2021). In this study, the flexibility due to digital teaching with few real-time courses is particularly noteworthy.

The COVID-19 pandemic and its accompanying burdens and restrictions with regard to daily, occupational, and student life constitutes an unprecedented global challenge. Thus, academia and other sectors of public life cannot resort to existing concepts on how to support students in the COVID-19 pandemic circumstances. However, there is an existing body of prepandemic research on the effectiveness of interventions such as mental health programs, curricular restructuring, and mentoring programs that are associated with improved mental health among medical students (Wasson et al., 2016). In the recent statements with respect to the situation of students during the current COVID-19 pandemic, medical education researchers proposed a framework to manage student–athlete mental health during the COVID-19 pandemic including “goal setting/motivation” and “support system/social network” as potential positive influencers (Grubic et al., 2021). These aspects could be addressed among others by mentoring and mental health programs and might be valuable medical education learning environment interventions to reduce the negative impact of the COVID-19 pandemic on students. Existing interventions should be redesigned and transitioned to digital formats to provide psychological and educational support to students during the COVID-19 pandemic, as they progress through medical school. Longitudinal research is required to monitor the mental health of medical students during the COVID-19 pandemic and after.

Underlying datasets of the data presented in this article are not available because, ethical approval was not obtained by the ethics board to make data sharing possible outside of the listed research team.

The local Ethics Board of the Center for Psychosocial Medicine at the University Medical Center Hamburg-Eppendorf approved the study (LPEK-0161). The participants provided their written informed consent to participate in this study.

JG designed the study, contributed to the analysis and interpretation of quantitative and qualitative data, wrote the first draft of the manuscript, and critically revised the manuscript during the internal revision process. IH contributed to the analysis and interpretation of the quantitative and qualitative data, involved in drafting the article, and critically revised the manuscript during the internal revision process. SM contributed to the acquisition and interpretation of the quantitative data, involved in drafting the article, and critically revised the manuscript during the internal revision process. CB designed the study, analyzed the quantitative data, contributed to the interpretation of the quantitative and qualitative data, and critically revised the manuscript during the internal revision process. All the authors gave their approval for the final version of the manuscript.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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