Coronavirus 2019 disease (COVID-19) is a viral infection that can lead to the potentially lethal severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It appeared in December 2019 in Wuhan, Hubei province of China, and since then it spread rapidly throughout the world (Hopkins, 2020; Yang and Wang, 2020; World Health Organization, 2022).

As to December 2022, the pandemic has caused more than 6.62 million deaths, and it has had a major economic impact coupled with a transformation of the daily life everywhere (World Health Organization, 2022). The social isolation that arose from the mandatory lockdown implemented by many countries has resulted in various psychological problems for the population (Wang et al., 2020). Recent reports show that COVID-19 lockdowns, including curfews, quarantines, and other societal restriction measures, are associated with symptoms of acute stress disorder (ASD) and posttraumatic stress disorder (PTSD), along with other issues such as emotional exhaustion, lack of interest, and mental disturbances including anxiety and depression (Brooks et al., 2020; Nelson et al., 2020).

Among students of medicine and other academic tracks, stress (i.e., the body’s reaction to physical, mental, or emotional pressure) is an important concern (Behere et al., 2011), whereas the events responsible for its occurrence are called stressors. Yet, people can react differently to the same stressor; the response can be physical, emotional, or behavioral, and it is usually framed within the physical and social environment of the individual. Such response appears when the assessment of an event appears as a threat to the individual’s wellbeing, and especially when he/she lacks the resources to face it and cope with it (Arribas Marín, 2013; Cohen et al., 2016).

Stress affects the lives of many people’s around the world, and it is linked to the psychopathology of various health conditions, and to their inability to adapt to challenging social environments (Eisenbarth et al., 2019). Stressful life experiences and the individuals’ psychological condition influence the clinical manifestations and course of many diseases (Straub and Cutolo, 2018). Back in 1948, Selye theorized that a stressor generally produces an acute response (alarm reaction stage) that can be adaptive (stage of resistance) and resolve or lead to an exhaustion stage with potentially chronic and irreversible physiological, psychological, and psychosocial consequences (Selye, 1948). A theoretical framework on the response to stress (i.e., allostasis) states that the allostatic load could accumulate resulting in an overexposure to stress mediators (immunologic, endocrine, and neural) triggering adverse organic effects that can lead to illnesses (McEwen, 1998). The theory of cognitive activation of stress is centered on the coping response that seems to determine the outcome, potentially resulting in stress-related illnesses if coping strategies are insufficient or inadequate (Ursin and Eriksen, 2010). Continuous thinking about negative events, passed or future (i.e., perseverative cognition), manifested through worry, rumination and brooding, has also been linked to stress-related problems, including cardiovascular, endocrine, and immunologic (Brosschot et al., 2006; Segerstrom et al., 2008).

Additionally, many university students experience academic stress associated with educational activities (e.g., exams, assessments, study load, etc.) and financial difficulties that have an impact on their learning performance (Crego et al., 2016). Students can also develop psychophysiological manifestations including memory and concentration difficulties, mental blocks, chronic fatigue, drowsiness, and despair (Barraza Macías, 2008).

Medical students are particularly prone to high levels of stress and psychological disorders such as anxiety and depression (Guthrie et al., 1995; Toews et al., 1997; Moffat et al., 2004). Studies have shown that most medical students experience different forms of psychological distress (Dyrbye et al., 2005, 2006; Heinen et al., 2017; Zvauya et al., 2017), some of which can lead to a higher risk of suicidal ideation and thoughts about quitting medical studies (Dyrbye et al., 2011). Students under stress try to deal with stressors by means of physical, psychological, or social behavioral responses; these coping strategies attempt to overcome or at least attenuate stress situations.

The social distancing policies implemented by the government and health authorities during the COVID-19 pandemic in Mexico and many other countries led to major changes in teaching strategies, including those for medical students, with internet-based learning becoming the cornerstone of these efforts for more than a year. However, so far there is limited data on what has been the impact of the lockdown on the mental health and academic stress in these medical students. Therefore, this study was undertaken to assess the occurrence of academic difficulties, anxiety, depression, and academic stressors that resulted in somatization and coping strategies linked to the pandemic in medical students from a Mexican university. The study proposal was reviewed and approved by the Ethics and Research Committee at the Academic Unit of Human Medicine and Health Sciences of the Autonomous University of Zacatecas (approval ID: AMC/CI/02-ORD/2020, CEICCL0121- ALGDEZA-03). All participant students provided signed informed consent.

From the 728 surveyed medical students from years 1 to 5, 301 (41.3%) were men and 427 women (58.7%). Most students (96%) were aged 18–24 years; differences in sex for grade was not significant (χ2 = 3.24, value of p = 0.52; Table 1).

This study was carried out to assess the presence of academic difficulties, anxiety and depression, and academic stressors that result in somatization and coping strategies linked to the COVID-19 pandemic in medical students in a Mexican university.

Stress, in general, is a complex multifactorial process that can result in somatic symptomatology, including gastrointestinal problems, insomnia, insulin resistance and overweight/obesity, as well as adaptative disorders, memory alterations, and depression, among others (Tafet and Nemeroff, 2016). When stress occurs in an educational context, it is known as academic stress (Putwain, 2007), which is characterized by physiological, emotional, cognitive, and behavioral stimuli that happens as consequence of a student’s inability to cope with difficulties in a school setting; stressors linked to school procedures can also trigger this reaction (Barraza Macías, 2008). Academic stress associated with poor coping strategies may affect academic performance, school homework, exams, and poor learning (Eva et al., 2015). Therefore, timely identification of academic stressors is essential to prevent somatization and the development of more serious physical and/or mental illnesses (Zhai and Du, 2020).

Academic stress has been widely linked to several negative effects on academic performance, school homework, exams, and learning.

Nearly one out of three students reported difficulties with internet connectivity as the main problem linked to the learning modality, and one in five said that the lack of clinical practice was the main concern. Lack of motivation (24%), concentration (18%), and clinical practice (17%) were the most common academic performance concerns.

Research has shown disproportionally higher levels of stress, anxiety, and depression among medical students compared to nonmedical undergraduates (Alzahrani et al., 2020). The incidence of psychological dysregulation in medical students is often attributed to the competitive and stressful environment along with other academic and professional demands which often lead to emotional exhaustion and psychological distress (Abdel Wahed and Hassan, 2017).

Screening for anxiety and depression resulted in an overall prevalence of 68 and 81%, respectively. Results also showed sex differences for both anxiety and depression with higher proportions in women. These results come from data collected in March 2021, right after the second wave of the pandemic, when mortality was at its highest levels. During this period, strict social distancing measures were in place, leading to complete online teaching in all educational system. However, it is important to consider that even before the COVID-19 pandemic, medical students already had relatively high levels of stress and depression (Dyrbye et al., 2006). A meta-analysis from 2016 had revealed a global prevalence of depression of 28% with first year medical students having the highest rate (Puthran et al., 2016), and with estimates ranging from 8% in American universities assessed with the Center For epidemiologic Studies-Depression scale (CES-D) to as high as 70% in medical schools of Pakistan using the Aga Khan University Anxiety and Depression Scale.

Whether the COVID-19 pandemic has resulted in higher incidence of anxiety and depression is still a contentious topic. For instance, a recent review concluded that the overall prevalence of anxiety in medical students did not increase with the outbreak, as high levels of resilience and healthy coping systems were put in place along with a reduction of academic load together with available family support (Lasheras et al., 2020). Conversely, another study reported that most medical students felt significantly more distressed about their studies due to COVID-19 (Loda et al., 2020). Previous research has shown that stress in preclinical medical students varies depending on the setting, ranging from 20.9% to more than 90% (Fares et al., 2016). In Mexico, before the pandemic, there is data associating high levels of academic stress in medical students with various psychological outcomes such as mental blocks, despair, feelings of depression and anxiety, restlessness, concentration and memory difficulties, and other physiological manifestations including chronic fatigue, drowsiness, headaches, insomnia, and muscle tremors (Pozos-Radillo et al., 2016).

Most relevant stressors, reported as always/nearly always, included professors’ evaluations (63.9%), and reading overload of academic papers (50.6%). Other stressors previously reported include poor academic performance (Zeppa and Linn, 1984), excessive academic workload, high pressure to perform, learning difficulties, poor time management, conflicts in work-life balance, conflictive personal relationships, inadequate peer relations, as well as health and financials problems (Hill et al., 2018). Cluster and factorial analyses led to identification of two groups with low and high stress, showing that women were more prone to stress than men. This is consistent with previous research showing higher distress in female students when exposed to human suffering (Hill et al., 2018), along with other findings pointing to gender differences in stress vulnerability, manifested through medical and psychiatric symptoms (Nechita et al., 2014).

Somatization resulting from of academic stress was higher in the group with high stress especially for drowsiness or increased need for sleep, anxiety, anguish, or desperation, chronic fatigue, and sleep disorders. An earlier study reported that early closure of academic institutions due to COVID-19 resulted in various psychological issues such as lack of sleep, need of emotional and mental support, and the search for social interactions (Nurunnabi et al., 2020).

Recent research on the psychological impact of the COVID-19 pandemic showed that individuals working in the clinical field had higher stress scores (Alkhamees et al., 2020), yet less was known about its impact among medical students. There is also evidence that female medical students had higher levels of stress, anxiety, and depression (Wang et al., 2020). Another study has shown that 71% of college students reported an increase in stress, anxiety levels, and depressive thoughts linked to the COVID-19 pandemic, which appeared to be associated with fear and concern with their own health and that of their loved ones; concentration difficulties, sleep disturbances, decrease in social interactions due to social distancing, and concern about their academic performance were also observed (Son et al., 2020).

In many settings, including the Mexican, medical students usually live in a high-stress environment, due in part to a rigid system that promotes competition. Thus, the COVID-19 pandemic seemed to aggravate this situation by adding new stress factors, including the concern and fear to the infection to oneself and relatives, and by limiting the benefits to engage in activities such as exercise and social interactions that would have reduced the stress; as a result, the lockdown and social distancing measures have led to radical lifestyle changes that took place in a very short period of time (Brooks et al., 2020).

This study found that the most common coping strategies included practicing a hobby, done always/nearly always by 65% of those with high stress and 34% of those with low stress, followed by getting company of a loved one (56 and 34%, respectively). Previous research on coping strategies among preclinical medical students highlight personal engagement, positive reinterpretation and expression of emotion, support programs delivered by senior students and extracurricular activities (mostly musical and physical activities) as valuable mechanisms to reduce anxiety, stress, and burnout (Fares et al., 2016). Other evidence has shown that medical students who adopt active coping, including planning and reality acceptance rather than avoiding strategies such as denial, alcohol and drug intake, and behavioral disengagement have better outcomes (Abouammoh et al., 2020). It has been seen that adaptive coping improves mental health while maladaptive coping strategies, such as negation, are predictors of depression among young adults (Mahmoud et al., 2012). Finally, another study with medical students from King Saud University also reported that mindfulness was associated with lower depressive symptoms (Alzahrani et al., 2020).

The results presented here reflect the impact of the prolonged COVID-19 pandemic in terms of the academic performance, occurrence of anxiety and depression, and stressors among medical students potentially linked to the lockdown accompanied with internet-based learning modality. Therefore, it is important to design and implement preventive strategies to deal with the effects of the online learning modality used during the COVID-19 lockdown.

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding authors.

Participation was voluntary. The questionnaire was administered via “Google forms.” Participants had to give informed consent in the first page of the questionnaire to be able to proceed with the survey. The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Institutional Review Board of Unidad Académica de Medicina Humana y C.S at Universidad Autónoma de Zacatecas (approval ID: AMC/CI/02-ORD/2020, CEICCL0121- ALGDEZA-03; approval date: November 6, 2020, and January 29, 2021).

LA-C and MM-F conceptualization. LA-C and DD-A methodology. PV-E, SV-R, JS-G, and AM-G software. AR-L, JM-E, and IG-V validation. AR-L and JM-E formal analysis. AR-L and LA-C data curation and visualization. LA-C and DD-A writing—original draft preparation. JM-E, IG-V, JS-G, and MM-F writing—review and editing. All authors contributed to the article and approved the submitted version.

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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