phd depression and anxiety

‘You have to suffer for your PhD’: poor mental health among doctoral researchers – new research

Lecturer in Social Sciences, University of Westminster

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PhD students are the future of research, innovation and teaching at universities and beyond – but this future is at risk. There are already indications from previous research that there is a mental health crisis brewing among PhD researchers.

My colleagues and I studied the mental health of PhD researchers in the UK and discovered that, compared with working professionals, PhD students were more likely to meet the criteria for clinical levels of depression and anxiety. They were also more likely to have significantly more severe symptoms than the working-professional control group.

We surveyed 3,352 PhD students, as well as 1,256 working professionals who served as a matched comparison group . We used the questionnaires used by NHS mental health services to assess several mental health symptoms.

More than 40% of PhD students met the criteria for moderate to severe depression or anxiety. In contrast, 32% of working professionals met these criteria for depression, and 26% for anxiety.

The groups reported an equally high risk of suicide. Between 33% and 35% of both PhD students and working professionals met the criteria for “suicide risk”. The figures for suicide risk might be so high because of the high rates of depression found in our sample.

We also asked PhD students what they thought about their own and their peers’ mental health. More than 40% of PhD students believed that experiencing a mental health problem during your PhD is the norm. A similar number (41%) told us that most of their PhD colleagues had mental health problems.

Just over a third of PhD students had considered ending their studies altogether for mental health reasons.

There is clearly a high prevalence of mental health problems among PhD students, beyond those rates seen in the general public. Our results indicate a problem with the current system of PhD study – or perhaps with academic more widely. Academia notoriously encourages a culture of overwork and under-appreciation.

This mindset is present among PhD students. In our focus groups and surveys for other research , PhD students reported wearing their suffering as a badge of honour and a marker that they are working hard enough rather than too much. One student told us :

“There is a common belief … you have to suffer for the sake of your PhD, if you aren’t anxious or suffering from impostor syndrome, then you aren’t doing it "properly”.

We explored the potential risk factors that could lead to poor mental health among PhD students and the things that could protect their mental health.

Financial insecurity was one risk factor. Not all researchers receive funding to cover their course and personal expenses, and once their PhD is complete, there is no guarantee of a job. The number of people studying for a PhD is increasing without an equivalent increase in postdoctoral positions .

Another risk factor was conflict in their relationship with their academic supervisor . An analogy offered by one of our PhD student collaborators likened the academic supervisor to a “sword” that you can use to defeat the “PhD monster”. If your weapon is ineffective, then it makes tackling the monster a difficult – if not impossible – task. Supervisor difficulties can take many forms. These can include a supervisor being inaccessible, overly critical or lacking expertise.

A lack of interests or relationships outside PhD study, or the presence of stressors in students’ personal lives were also risk factors.

We have also found an association between poor mental health and high levels of perfectionism, impostor syndrome (feeling like you don’t belong or deserve to be studying for your PhD) and the sense of being isolated .

Better conversations

Doctoral research is not all doom and gloom. There are many students who find studying for a PhD to be both enjoyable and fulfilling , and there are many examples of cooperative and nurturing research environments across academia.

Studying for a PhD is an opportunity for researchers to spend several years learning and exploring a topic they are passionate about. It is a training programme intended to equip students with the skills and expertise to further the world’s knowledge. These examples of good practice provide opportunities for us to learn about what works well and disseminate them more widely.

The wellbeing and mental health of PhD students is a subject that we must continue to talk about and reflect on. However, these conversations need to happen in a way that considers the evidence, offers balance, and avoids perpetuating unhelpful myths.

Indeed, in our own study, we found that the percentage of PhD students who believed their peers had mental health problems and that poor mental health was the norm, exceeded the rates of students who actually met diagnostic criteria for a common mental health problem . That is, PhD students may be overestimating the already high number of their peers who experienced mental health problems.

We therefore need to be careful about the messages we put out on this topic, as we may inadvertently make the situation worse. If messages are too negative, we may add to the myth that all PhD students experience mental health problems and help maintain the toxicity of academic culture.

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Managing While and Post-PhD Depression And Anxiety: PhD Student Survival Guide

Embarking on a PhD journey can be as challenging mentally as it is academically. With rising concerns about depression among PhD students, it’s essential to proactively address this issue. How to you manage, and combat depression during and after your PhD journey?

In this post, we explore the practical strategies to combat depression while pursuing doctoral studies.

From engaging in enriching activities outside academia to finding supportive networks, we describe a variety of approaches to help maintain mental well-being, ensuring that the journey towards academic excellence doesn’t come at the cost of your mental health.

How To Manage While and Post-Phd Depression

Why phd students are more likely to experience depression than other students.

The journey of a PhD student is often romanticised as one of intellectual rigour and eventual triumph.

However, beneath this veneer lies a stark reality: PhD students are notably more susceptible to experiencing depression and anxiety.

This can be unfortunately, quite normal in many PhD students’ journey, for several reasons:

Grinding Away, Alone

Imagine being a graduate student, where your day-to-day life is deeply entrenched in research activities. The pressure to consistently produce results and maintain productivity can be overwhelming. 

For many, this translates into long hours of isolation, chipping away at one’s sense of wellbeing. The lack of social support, coupled with the solitary nature of research, often leads to feelings of isolation.

Mentors Not Helping Much

The relationship with a mentor can significantly affect depression levels among doctoral researchers. An overly critical mentor or one lacking in supportive guidance can exacerbate feelings of imposter syndrome.

Students often find themselves questioning their capabilities, feeling like they don’t belong in their research areas despite their achievements.

Nature Of Research Itself

Another critical factor is the nature of the research itself. Students in life sciences, for example, may deal with additional stressors unique to their field.

Specific aspects of research, such as the unpredictability of experiments or the ethical dilemmas inherent in some studies, can further contribute to anxiety and depression among PhD students.

Competition Within Grad School

Grad school’s competitive environment also plays a role. PhD students are constantly comparing their progress with peers, which can lead to a mental health crisis if they perceive themselves as falling behind.

This sense of constant competition, coupled with the fear of failure and the stigma around mental health, makes many hesitant to seek help for anxiety or depression.

How To Know If You Are Suffering From Depression While Studying PhD?

If there is one thing about depression, you often do not realise it creeping in. The unique pressures of grad school can subtly transform normal stress into something more insidious.

As a PhD student in academia, you’re often expected to maintain high productivity and engage deeply in your research activities. However, this intense focus can lead to isolation, a key factor contributing to depression and anxiety among doctoral students.

Changes in Emotional And Mental State

You might start noticing changes in your emotional and mental state. Feelings of imposter syndrome, where you constantly doubt your abilities despite evident successes, become frequent.

This is especially true in competitive environments like the Ivy League universities, where the bar is set high. These feelings are often exacerbated by the lack of positive reinforcement from mentors, making you feel like you don’t quite belong, no matter how hard you work.

Lack Of Pleasure From Previously Enjoyable Activities

In doctoral programs, the stressor of overwork is common, but when it leads to a consistent lack of interest or pleasure in activities you once enjoyed, it’s a red flag. This decline in enjoyment extends beyond one’s research and can pervade all aspects of life.

The high rates of depression among PhD students are alarming, yet many continue to suffer in silence, afraid to ask for help or reveal their depression due to the stigma associated with mental health issues in academia.

Losing Social Connections

Another sign is the deterioration of social connections. Graduate student mental health is significantly affected by social support and isolation.

You may find yourself withdrawing from friends and activities, preferring the solitude that ironically feeds into your sense of isolation.

Changes In Appetite And Weight

Changes in appetite and weight can be a significant indicator of depression. As they navigate the demanding PhD study, students might experience fluctuations in their eating habits.

Some may find themselves overeating as a coping mechanism, leading to weight gain. Others might lose their appetite altogether, resulting in noticeable weight loss.

These changes are not just about food; they reflect deeper emotional and mental states.

Such shifts in appetite and weight, especially if sudden or severe, warrant attention as they may signal underlying depression, a common issue in the high-stress environment of PhD studies.

Unhealthy Coping Mechanisms

PhD students grappling with depression often feel immense pressure to excel academically while battling isolation and imposter syndrome. Lacking adequate mental health support, some turn to unhealthy coping mechanisms like substance abuse. These may include:

• Overeating, 
• And many more.

These provide temporary relief from overwhelming stress and emotional turmoil. However, such methods can exacerbate their mental health issues, creating a vicious cycle of dependency and further detachment from healthier coping strategies and support systems.

It’s essential for PhD students experiencing depression to recognise these signs and seek professional help. Resources like the National Suicide Prevention Lifeline are very helpful in this regard.

Suicidal Thoughts Or Attempts

Suicidal thoughts or attempts may sound extreme, but they can happen in PhD studies. This is because of the high-pressure environment of PhD studies.

Doctoral students, often grappling with intense academic demands, social isolation, and imposter syndrome, can be susceptible to severe mental health crises.

When the burden becomes unbearable, some may experience thoughts of self-harm or suicide as a way to escape their distress. These thoughts are a stark indicator of deep psychological distress and should never be ignored.

It’s crucial for academic institutions and support networks to provide robust mental health resources and create an environment where students feel safe to seek help and discuss their struggles openly.

How To Prevent From Depression During And After Ph.D?

A PhD student’s experience is often marked by high rates of depression, a concern echoed in studies from universities like the University of California and Arizona State University. If you are embarking on a PhD journey, make sure you are aware of the issue, and develop strategies to cope with the stress, so you do not end up with depression. 

Engage With Activities Outside Academia

One effective strategy is engaging in activities outside academia. Diverse interests serve as a lifeline, breaking the monotony and stress of grad school. Some activities you can consider include:

• Social gatherings.

These activities provide a crucial balance. For instance, some students highlighted the positive impact of adopting a pet, which not only offered companionship but also a reason to step outside and engage with the world.

Seek A Supportive Mentor

The role of a supportive mentor cannot be overstated. A mentor who adopts a ‘yes and’ approach rather than being overly critical can significantly boost a doctoral researcher’s morale.

This positive reinforcement fosters a healthier research environment, essential for good mental health.

Stay Active Physically

Physical exercise is another key element. Regular exercise has been shown to help cope with symptoms of moderate to severe depression. It’s a natural stress reliever, improving mood and enhancing overall wellbeing. Any physical workout can work here, including:

• Brisk walking
• Swimming, or
• Gym sessions.

Seek Positive Environment

Importantly, the graduate program environment plays a critical role. Creating a community where students feel comfortable to reveal their depression or seek help is vital.

Whether it’s through formal support groups or informal peer networks, building a sense of belonging and understanding can mitigate feelings of isolation and imposter syndrome.

This may be important, especially in the earlier stage when you look and apply to universities study PhD . When possible, talk to past students and see how are the environment, and how supportive the university is.

Choose the right university with the right support ensures you keep depression at bay, and graduate on time too.

Remember You Have The Power

Lastly, acknowledging the power of choice is empowering. Understanding that continuing with a PhD is a choice, not an obligation. If things become too bad, there is always an option to seek a deferment, pause. You can also quit your studies too.

Work on fixing your mental state, and recover from depression first, before deciding again if you want to take on Ph.D studies again. There is no point continuing to push yourself, only to expose yourself to self-harm, and even suicide.

Wrapping Up: PhD Does Not Need To Ruin You

Combating depression during PhD studies requires a holistic approach. Engaging in diverse activities, seeking supportive mentors, staying physically active, choosing positive environments, and recognising one’s power to make choices are all crucial.

These strategies collectively contribute to a healthier mental state, reducing the risk of depression. Remember, prioritising your mental well-being is just as important as academic success. This helps to ensure you having a more fulfilling and sustainable journey through your PhD studies.

Dr Andrew Stapleton has a Masters and PhD in Chemistry from the UK and Australia. He has many years of research experience and has worked as a Postdoctoral Fellow and Associate at a number of Universities. Although having secured funding for his own research, he left academia to help others with his YouTube channel all about the inner workings of academia and how to make it work for you.

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The Savvy Scientist

Experiences of a London PhD student and beyond

PhD Burnout: Managing Energy, Stress, Anxiety & Your Mental Health

PhDs are renowned for being stressful and when you add a global pandemic into the mix it’s no surprise that many students are struggling with their mental health. Unfortunately this can often lead to PhD fatigue which may eventually lead to burnout.

In this post we’ll explore what academic burnout is and how it comes about, then discuss some tips I picked up for managing mental health during my own PhD.

Please note that I am by no means an expert in this area. I’ve worked in seven different labs before, during and after my PhD so I have a fair idea of research stress but even so, I don’t have all the answers.

If you’re feeling burnt out or depressed and finding the pressure too much, please reach out to friends and family or give the Samaritans a call to talk things through.

Note – This post, and its follow on about maintaining PhD motivation were inspired by a reader who asked for recommendations on dealing with PhD fatigue. I love hearing from all of you, so if you have any ideas for topics which you, or others, could find useful please do let me know either in the comments section below or by getting in contact . Or just pop me a message to say hi. 🙂

This post is part of my PhD mindset series, you can check out the full series below:

• PhD Burnout: Managing Energy, Stress, Anxiety & Your Mental Health (this part!)
• PhD Motivation: How to Stay Driven From Cover Letter to Completion
• How to Stop Procrastinating and Start Studying

What is PhD Burnout?

Whenever I’ve gone anywhere near social media relating to PhDs I see overwhelmed PhD students who are some combination of overwhelmed, de-energised or depressed.

Specifically I often see Americans talking about the importance of talking through their PhD difficulties with a therapist, which I find a little alarming. It’s great to seek help but even better to avoid the need in the first place.

Sadly, none of this is unusual. As this survey shows, depression is common for PhD students and of note: at higher levels than for working professionals.

All of these feelings can be connected to academic burnout.

The World Health Organisation classifies burnout as a syndrome with symptoms of:

– Feelings of energy depletion or exhaustion; – Increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job; – Reduced professional efficacy. Symptoms of burnout as classified by the WHO. Source .

This often leads to students falling completely out of love with the topic they decided to spend years of their life researching!

The pandemic has added extra pressures and constraints which can make it even more difficult to have a well balanced and positive PhD experience. Therefore it is more important than ever to take care of yourself, so that not only can you continue to make progress in your project but also ensure you stay healthy.

What are the Stages of Burnout?

Psychologists Herbert Freudenberger and Gail North developed a 12 stage model of burnout. The following graphic by The Present Psychologist does a great job at conveying each of these.

I don’t know about you, but I can personally identify with several of the stages and it’s scary to see how they can potentially lead down a path to complete mental and physical burnout. I also think it’s interesting that neglecting needs (stage 3) happens so early on. If you check in with yourself regularly you can hopefully halt your burnout journey at that point.

PhDs can be tough but burnout isn’t an inevitability. Here are a few suggestions for how you can look after your mental health and avoid academic burnout.

Overcoming PhD Burnout

Manage your energy levels, maintaining energy levels day to day.

• Eat well and eat regularly. Try to avoid nutritionless high sugar foods which can play havoc with your energy levels. Instead aim for low GI food . Maybe I’m just getting old but I really do recommend eating some fruit and veg. My favourite book of 2021, How Not to Die: Discover the Foods Scientifically Proven to Prevent and Reduce Disease , is well worth a read. Not a fan of veggies? Either disguise them or at least eat some fruit such as apples and bananas. Sliced apple with some peanut butter is a delicious and nutritious low GI snack. Check out my series of posts on cooking nutritious meals on a budget.
• Get enough sleep. It doesn’t take PhD-level research to realise that you need to rest properly if you want to avoid becoming exhausted! How much sleep someone needs to feel well-rested varies person to person, so I won’t prescribe that you get a specific amount, but 6-9 hours is the range typically recommended. Personally, I take getting enough sleep very seriously and try to get a minimum of 8 hours.

A side note on caffeine consumption: Do PhD students need caffeine to survive?

In a word, no!

Although a culture of caffeine consumption goes hand in hand with intense work, PhD students certainly don’t need caffeine to survive. How do I know? I didn’t have any at all during my own PhD. In fact, I wrote a whole post about it .

By all means consume as much caffeine as you want, just know that it doesn’t have to be a prerequisite for successfully completing a PhD.

Maintaining energy throughout your whole PhD

• Pace yourself. As I mention later in the post I strongly recommend treating your PhD like a normal full-time job. This means only working 40 hours per week, Monday to Friday. Doing so could help realign your stress, anxiety and depression levels with comparatively less-depressed professional workers . There will of course be times when this isn’t possible and you’ll need to work longer hours to make a certain deadline. But working long hours should not be the norm. It’s good to try and balance the workload as best you can across the whole of your PhD. For instance, I often encourage people to start writing papers earlier than they think as these can later become chapters in your thesis. It’s things like this that can help you avoid excess stress in your final year.
• Take time off to recharge. All work and no play makes for an exhausted PhD student! Make the most of opportunities to get involved with extracurricular activities (often at a discount!). I wrote a whole post about making the most of opportunities during your PhD . PhD students should have time for a social life, again I’ve written about that . Also give yourself permission to take time-off day to day for self care, whether that’s to go for a walk in nature, meet friends or binge-watch a show on Netflix. Even within a single working day I often find I’m far more efficient when I break up my work into chunks and allow myself to take time off in-between. This is also a good way to avoid procrastination!

Reduce Stress and Anxiety

During your PhD there will inevitably be times of stress. Your experiments may not be going as planned, deadlines may be coming up fast or you may find yourself pushed too far outside of your comfort zone. But if you manage your response well you’ll hopefully be able to avoid PhD burnout. I’ll say it again: stress does not need to lead to burnout!

Everyone is unique in terms of what works for them so I’d recommend writing down a list of what you find helpful when you feel stressed, anxious or sad and then you can refer to it when you next experience that feeling.

I’ve created a mental health reminders print-out to refer to when times get tough. It’s available now in the resources library (subscribe for free to get the password!).

Below are a few general suggestions to avoid PhD burnout which work for me and you may find helpful.

• Exercise. When you’re feeling down it can be tough to motivate yourself to go and exercise but I always feel much better for it afterwards. When we exercise it helps our body to adapt at dealing with stress, so getting into a good habit can work wonders for both your mental and physical health. Why not see if your uni has any unusual sports or activities you could try? I tried scuba diving and surfing while at Imperial! But remember, exercise doesn’t need to be difficult. It could just involve going for a walk around the block at lunch or taking the stairs rather than the lift.
• Cook / Bake. I appreciate that for many people cooking can be anything but relaxing, so if you don’t enjoy the pressure of cooking an actual meal perhaps give baking a go. Personally I really enjoy putting a podcast on and making food. Pinterest and Youtube can be great visual places to find new recipes.
• Let your mind relax. Switching off is a skill and I’ve found meditation a great way to help clear my mind. It’s amazing how noticeably different I can feel afterwards, having not previously been aware of how many thoughts were buzzing around! Yoga can also be another good way to relax and be present in the moment. My partner and I have been working our way through 30 Days of Yoga with Adriene on Youtube and I’d recommend it as a good way to ease yourself in. As well as being great for your mind, yoga also ticks the box for exercise!
• Read a book. I’ve previously written about the benefits of reading fiction * and I still believe it’s one of the best ways to relax. Reading allows you to immerse yourself in a different world and it’s a great way to entertain yourself during a commute.

* Wondering how I got something published in Science ? Read my guide here .

Talk It Through

• Meet with your supervisor. Don’t suffer in silence, if you’re finding yourself struggling or burned out raise this with your supervisor and they should be able to work with you to find ways to reduce the pressure. This may involve you taking some time off, delegating some of your workload, suggesting an alternative course of action or signposting you to services your university offers.

Also remember that facing PhD-related challenges can be common. I wrote a whole post about mine in case you want to cheer yourself up! We can’t control everything we encounter, but we can control our response.

A free self-care checklist is also now available in the resources library , providing ideas to stay healthy and avoid PhD burnout.

Top Tips for Avoiding PhD Burnout

On top of everything we’ve covered in the sections above, here are a few overarching tips which I think could help you to avoid PhD burnout:

• Work sensible hours . You shouldn’t feel under pressure from your supervisor or anyone else to be pulling crazy hours on a regular basis. Even if you adore your project it isn’t healthy to be forfeiting other aspects of your life such as food, sleep and friends. As a starting point I suggest treating your PhD as a 9-5 job. About a year into my PhD I shared how many hours I was working .
• Reduce your use of social media. If you feel like social media could be having a negative impact on your mental health, why not try having a break from it?
• Do things outside of your PhD . Bonus points if this includes spending time outdoors, getting exercise or spending time with friends. Basically, make sure the PhD isn’t the only thing occupying both your mental and physical ife.
• Regularly check in on how you’re feeling. If you wait until you’re truly burnt out before seeking help, it is likely to take you a long time to recover and you may even feel that dropping out is your only option. While that can be a completely valid choice I would strongly suggest to check in with yourself on a regular basis and speak to someone early on (be that your supervisor, or a friend or family member) if you find yourself struggling.

I really hope that this post has been useful for you. Nothing is more important than your mental health and PhD burnout can really disrupt that. If you’ve got any comments or suggestions which you think other PhD scholars could find useful please feel free to share them in the comments section below.

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Prevalence and associated factors of depression and anxiety among doctoral students: the mediating effect of mentoring relationships on the association between research self-efficacy and depression/anxiety

1 Department of Clinical Epidemiology, Shengjing Hospital of China Medical University, Shenyang, China, gro.latipsoh-js@hyoahz

2 Department of Library and Medical Information, China Medical University, Shenyang, China

3 Department of Social Medicine, School of Public Health, China Medical University, Shenyang, China

4 Key Laboratory of Immunodermatology, Ministry of Health and Ministry of Education, China Medical University, Shenyang, China

5 Department of Dermatology, First Hospital of China Medical University, Shenyang, China

Weiqiu Wang

Shanshan jia.

6 Key Laboratory of Health Ministry for Congenital Malformation, Shengjing Hospital of China Medical University, Shenyang, China

Deshu Shang

7 Department of Developmental Cell Biology, Key Laboratory of Medical Cell Biology, Ministry of Education, China Medical University, Shenyang, China

8 Department of Developmental Cell Biology, Cell Biology Division, Key Laboratory of Cell Biology, Ministry of Health, China Medical University, Shenyang, China

Yangguang Shao

9 Department of Cell Biology, Key Laboratory of Cell Biology, National Health Commission of the PRC, China Medical University, Shenyang, China

10 Department of Cell Biology, Key Laboratory of Medical Cell Biology, Ministry of Education, China Medical University, Shenyang, China

Xinwang Zhu

11 Department of Nephrology, First Affiliated Hospital of China Medical University, Shenyang, China

Shengnan Yan

12 Graduate Division, School of Public Health, China Medical University, Shenyang, China

Yuhong Zhao

Although the mental health status of doctoral students deserves attention, few scholars have paid attention to factors related to their mental health problems. We aimed to investigate the prevalence of depression and anxiety in doctoral students and examine possible associated factors. We further aimed to assess whether mentoring relationships mediate the association between research self-efficacy and depression/anxiety.

A cross-sectional study was conducted among 325 doctoral students in a medical university. The Patient Health Questionnaire 9 and Generalized Anxiety Disorder 7 scale were used to assess depression and anxiety. The Research Self-Efficacy Scale was used to measure perceived ability to fulfill various research-related activities. The Advisory Working Alliance Inventory-student version was used to assess mentoring relationships. Linear hierarchical regression analyses were performed to determine if any factors were significantly associated with depression and anxiety. Asymptotic and resampling methods were used to examine whether mentoring played a mediating role.

Approximately 23.7% of participants showed signs of depression, and 20.0% showed signs of anxiety. Grade in school was associated with the degree of depression. The frequency of meeting with a mentor, difficulty in doctoral article publication, and difficulty in balancing work–family–doctoral program was associated with both the level of depression and anxiety. Moreover, research self-efficacy and mentoring relationships had negative relationships with levels of depression and anxiety. We also found that mentoring relationships mediated the correlation between research self-efficacy and depression/anxiety.

The findings suggest that educational experts should pay close attention to the mental health of doctoral students. Active strategies and interventions that promote research self-efficacy and mentoring relationships might be beneficial in preventing or reducing depression and anxiety.

Introduction

Recently, the mental health status of students has become a hot topic in public health, higher education, and research policy. 1 – 3 Depression and anxiety are two of the most common psychological disorders. Researchers have reported depression and anxiety among students in several countries and in numerous disciplines, such as counseling, medicine, law, and psychology. 4 – 14 Depression is defined as a mood that includes a feeling of hopelessness, helplessness, or worthlessness. 2 Anxiety is an emotion characterized by unpleasant inner feelings, which is accompanied by caution, complaints, meditation, nervousness, and worry. 5 Depression and anxiety can affect a person’s behavior, academic performance, and general health, as well as quality of sleep, eating habits, and well-being. 8 In addition, it has been confirmed that depression and psychological distress influence suicidal ideation in undergraduate and graduate students. 15 – 18 However, mental health among doctoral students has been relatively ignored by researchers and educational experts. It has only been in the last 2 years that this topic has begun to attract more and more attention.

A doctoral student’s school career is full of hardships and happiness. Doctoral students frequently feel a sense of urgency, worry, and stress as they work toward their doctoral degrees. In addition to financial support and future employment, doctoral students worry about writing a thesis, publishing papers, and handling relationships with advisors. In recent years, a few scholars have explored the prevalence of mental health problems among PhD students. 3 , 12 , 19 – 21 In 2013, Levecquea et al investigated PhD students in Belgium. They concluded that approximately half the PhD students in Flanders had at least two symptoms, and 32% reported at least four symptoms on the 12-item General Health Questionnaire (GHQ12). 3 According to a 2015 survey at the University of California, approximately half the PhD students in science and engineering were depressed. 12 Springer Nature did a survey of PhD students in 2017, and confirmed that 12% reported seeking help for anxiety or depression caused by PhD studies. 20 A 2018 survey of graduate students via social media revealed that 41% of graduate students scored in the moderate–severe range for anxiety and 39% scored in the moderate–severe range for depression. 21 Doctoral students with mental health issues are more likely to drop out of PhD programs. 22 The high attrition rate in PhD programs caused by the dropout of PhD students with psychological illness is damaging to research institutions and the whole research industry. 23 However, there have been few reports on the mental health of doctoral students in medical universities.

Students in medical schools engage in rigorous medical training. 24 , 25 Previous studies have demonstrated that medical students have more pressure, more burnout, and a greater prevalence of mental health disorders than the general population or students in other disciplines. 26 – 31 Medical training varies considerably by discipline, institution, and country. US and Canadian medical students enter medical education systems after they receive a bachelor’s degree. 32 , 33 In China, students can enter medical schools after graduating from high school (similarly to the UK and France). In general, there is an entrance examination required for students with a master’s degree who would like to study for doctoral degrees. Doctoral students need another 3 years to earn a doctoral degree, allowing for an extension of 3 years. Master’s degree candidates in grade two have the choice to apply for a master–doctor combined-training program (a total of 5 years for a doctoral degree, allowing an extension of 3 years). Doctoral students can be either full-time or part-time students. Part-time doctoral students are those who are studying doctoral courses while working in clinical settings or having another job. As such, for clinical doctoral students, some are still fully engaged in clinical work while earning their doctoral degree, whereas others are temporarily away from clinical work to concentrate on the doctoral program research. It is a bit too much to expect clinical doctoral students to do clinical work and research at the same time throughout their doctoral training.

Sociodemographic variables, such as age, sex, and marital status, have been reported to be associated with the mental health of postgraduate students. 8 , 10 However, sex differences in depression among medical students have also yielded mixed results, showing either no difference or high prevalence among female or male medical students. 27 , 29 , 33 Further exploration among doctoral students is still needed. The execution phase during doctoral study has been shown to be prone to mental health problems among doctoral students. 3 Additionally, researchers have suggested that work–life balance is the key factor related to the mental health problems of postgraduate students. 3 , 21 Employed doctoral students work full time or part time while they are studying for their doctoral degree. In this case, conflict concerns not only balancing family and work but also completing the doctoral program itself. Few scholars have focused on the conflicts among family, work, and a doctoral program. Getting married and raising children also puts a strain on doctoral students. Doing experiments, writing a doctoral thesis, and publishing doctoral qualification papers requires considerable time, energy, and financial resources.

Mentorship effectiveness and mentoring functions are thought to be vital to graduate-student programs. 34 , 35 Mentors have a great responsibility to guide their doctoral students through the doctoral program. Advisor mentoring affects student-research self-efficacy, productivity, and development as a scientist. 36 – 38 Recently, a study explored the effect of a supervisor’s leadership style on the mental health of graduate students. 3 Nearly half the doctoral students who withdrew from the doctoral program reported experiencing insufficient supervision, highlighting the fact that good supervision was important for completing the doctoral program. 39 , 40 A survey in 2018 indicated that a weak relationship with a mentor is a common characteristic of most graduate students who experience anxiety and/or depression. 21

Research self-efficacy refers to the individual’s confidence in the successful completion of various aspects of the scientific research process, 41 such as data collection, performing experimental procedures, and writing papers. 42 Studies have evaluated the important role of research self-efficacy in research training. Self-efficacy is a factor that affects how much effort students spend on research tasks and how long they persist when they experience difficulties. 43 Some universities in the US have used research self-efficacy to evaluate the effects of degree programs on graduate research ability. 44 A study has shown that research self-efficacy can predict the research interest and knowledge of doctoral students. 45 Some researchers have reported that high research self-efficacy is correlated with future research involvement and research productivity. 46 , 47 It was suggested that research self-efficacy could play a mediating role between the research-training environment and scientific research output. Furthermore, the relationship between stress and depression has been shown to be mediated by stress management self-efficacy. 48 Interestingly, the length of student–advisor relationships has been reported to be significantly correlated with student research self-efficacy. 36 Moreover, among agricultural students, research self-efficacy has been found to be negatively associated with research anxiety. 49 Therefore, the higher the students’ research self-efficacy, the lower their research anxiety. However, it is not clear whether scientific research self-efficacy is correlated with levels of generalized anxiety.

In this study, we aimed to investigate the prevalence of depression and anxiety among doctoral students in a medical university in China, determine factors that are associated with depression and anxiety, determine whether mentoring relationships and research self-efficacy are associated with depression and anxiety, and test whether mentoring relationships mediate the association between research self-efficacy and depression/anxiety.

Participants

We recruited doctoral students from October to November 2017 using a combination of snowball sampling and stratified sampling from five medical schools and four affiliated clinical hospitals at a medical university in northeast China. This university has the authority to grant doctoral degrees in six major disciplines (basic medicine, clinical medicine, biology, stomatology, public health and preventive medicine, and nursing), including 49 different majors. Our inclusion criteria were still studying at the medical university, had not yet earned a PhD degree, enrollment in a successive postgraduate and doctoral program, and no history of depression or anxiety before entering medical school. A total of 437 doctoral students (218 male, 219 female) were enrolled. This study received approval from the Committee for Human Trials of China Medical University (CMU17/375/R). Written informed consent was obtained from all participants before they entered the experiment. All questionnaires were filled out anonymously and confidentially.

Sociodemographic and doctoral factors

Doctoral students’ sociodemographic status included age, sex, marital status, children, and income. In addition, we selected some doctoral characteristics that might affect the mental health of doctoral students. We asked participants whether they had been employed before doctoral enrollment. Clinical doctoral students refers to students who were doing clinical work while earning their doctoral degree. Grade was measured assigned to one of four categories (1, first year; 2, second year; 3, third year; 4, fourth year or above). Mentors meet with their doctoral students regularly or irregularly. They come together and analyze the latest literature, discuss the research direction or experimental methods, and revise the thesis. Therefore, the frequency of these meetings can reflect the strength of the relationship from a certain quantitative angle. The frequency with which doctoral students met with mentors was measured with one item: “On average, how often do you meet with your advisor? (1, at least once a week; 2, at least once a month; 3, seldom)”. In most medical universities, doctoral students are required to publish at least one academic paper indexed by the Science Citation Index or Social Science Citation Index. Only when this qualification has been reached are doctoral students able to apply for a doctoral degree. The perceived difficulty in publishing a doctoral qualification paper was assessed by one item: “How much effort do you think it takes to publish doctoral qualification papers? (1, a little bit of effort; 2, some effort; 3, a lot of effort). Considering that the total time and energy of doctoral students is limited, we asked the doctoral students, “Do you have difficulty in balancing work, family, and the PhD program? (1, almost no difficulty; 2, some difficulty; 3, great difficulty)”.

Depression questionnaire

We chose the nine-item Patient Health Questionnaire (PHQ-9) 50 to evaluate depression among doctoral students. Each item is measured on a 4-point Likert-like scale (0, not at all; 3, almost every day) based on the frequency of depression symptoms over the last 2 weeks. Total scores range from 0 to 27. A higher PHQ-9 score represents more serious depression (0–4, none–minimal; 5–9, mild; 10–14, moderate; 15–19, moderately severe; 20–27, severe). In general, a diagnosis of depression can only be arrived at after clinical assessment by a mental health professional. With such questionnaires as the PHQ-9, it has been shown that at certain cutoffs there is good correlation with diagnostic interviews. PHQ-9 scores of 10 or above had a sensitivity of 88% and a specificity of 88% for major depressive disorder. 50 The Chinese version of the PHQ-9 has been used in older people and hospital inpatients, with sound reliability. In the current study, Cronbach’s alpha for the PHQ-9 scale was 0.918.

Anxiety questionnaire

We used the seven item Generalized Anxiety Disorder (GAD-7) to indicate the degree of anxiety among doctoral students. 51 The GAD-7 contains seven items that are rated on a 4-point Likert-like scale (0, not at all; 3, almost every day). The total score ranges from 0 to 21. A higher GAD-7 score indicates more serious anxiety (0–4, none–minimal; 5–9, mild; 10–14, moderate; 15–21, severe). Using a threshold score of 10, the GAD-7 has a sensitivity of 89% and a specificity of 82% for major generalized anxiety disorder. 51 The Chinese version of the GAD-7 has been used in outpatients with satisfactory reliability. In the present study, Cronbach’s alpha for the GAD-7 scale was 0.946.

Mentoring-relationship questionnaire

The 30-item Advisory Working Alliance Inventory-student version (AWAI-S) was used to assess the mentoring relationship from the student’s perspective. 36 This scale is a brief, self-reported measure designed on the basis of the Working Alliance model. Its developer, Schlosser, believed that a favorable supervisory alliance was vital to outcomes. 52 The scale has had good reliability in previous studies. 53 The AWAI-S consists of three domains: rapport (11 items), apprenticeship (14 items), and identification-individuation (5 items). Each item is rated on a 5-point Likert scale (1, strongly disagree; 5, strongly agree). The AWAI-S scale contains 16 reverse-scoring questions. High scores (after reverse scoring) suggest that the advisee has a strong mentoring relationship with the advisor. The internal consistency of AWAI-S scores from previous studies ranged from 0.84 to 0.95 36 , 54 and was 0.95 in this study.

Research Self-Efficacy Scale

The Research Self-Efficacy Scale (RSES) was used to measure the doctoral students’ perceived ability to fulfill various research-related tasks. 55 The RSES comprises 50 items with four subscales: conceptualization (18 items), implementation (19 items), early tasks (5 items), and presenting the results (8 items). Individuals were asked to mark the tasks they perceived they could perform. The strength of each item was rated on a 10-point scale ranging from 0 (no confidence) to 10 (complete confidence). A total RSES score was calculated, ranging from 75 to 500. A higher score indicates higher self-efficacy. The internal consistency of RSES scores was 0.98 in the present study.

Data analysis

We used SPSS 17.0 for all statistical analyses. We investigated demographic and doctoral characteristics using ANOVA for continuous variables and chi-squared for categorical data. Correlations among depression, anxiety, mentoring relationships, and research self-efficacy were examined by Pearson correlation. We performed hierarchical linear regression analysis to explore the association of mentoring relationship and research self-efficacy with depression/anxiety. In this study, depression and anxiety were modeled as dependent variables, RSES as an independent variable, AWAI-S as a mediator, and sociodemographic and doctoral variables as controlled variables. In step 1 of the regression, sociodemographic and doctoral variables were entered as controlled variables. Because linear hierarchical regression analysis requires continuous variables, the grade, frequency of meeting with a mentor, difficulty in publishing a doctoral qualification paper, and difficulty in balancing work–family–doctoral program was dummy coded. In step 2 of the regression, research self-efficacy was added. In step 3, the mentoring relationship was added. The asymptotic and resampling method was used to examine mentoring relationship as potential mediator in the association between research self-efficacy and depression/anxiety, based on 5,000 bootstrap samples. 56 A bias-corrected and accelerated (BC a ) 95% CI was used to estimate mediation. If the BC a 95% CI excludes 0, this indicates that the mediation is significant. All statistical tests were two-sided (α=0.05). P <0.05 was considered statistically significant.

Sociodemographic and doctoral characteristics of respondents

After exclusion of 45 doctoral students who refused to fill out questionnaires, the 392 who completed the questionnaires were included. A total of 67 questionnaires with missing values >10% were deemed invalid. As such, we collected 325 valid responses. The effective response rate was 74.37%. The mean age of the participants was 31.1±5.3 (23–47) years. Of the 325 respondents, 60.3% were female, 50.8% married or lived with a partner, and 40% had one or more child. The monthly income for 56.6% of respondents was <CN¥3,000 per month (equivalent of local per capita income), 50.8% had been employed before doctoral enrollment, and 40.6% were clinical doctoral students. Furthermore, 13.8% seldom met with their mentors, 37.2% thought they should try their best to publish a PhD qualification paper, and 31.1% reported that they had difficulty in balancing work–family–PhD ( Table 1 ).

Sociodemographic and doctoral characteristics of respondents (n=325)

Sociodemographic and doctoral characteristics by depression and anxiety

The prevalence of clinical depression was 23.7% (moderate, moderately severe, and severe) and the prevalence of clinical anxiety was 20.0% (moderate and severe; Tables 2 and ​ and3). 3 ). Factors that were significantly different among respondents at varying levels of depression included age, marital status, having children, employment, grade, frequency of meeting with mentors, difficulty in publishing, and difficulty in balancing work–family–doctoral program. Factors that were significantly different among respondents at varying levels of anxiety included being a clinical doctoral student, frequency of meeting with mentors, difficulty in publishing, and difficulty in balancing work–family–doctoral program.

Sociodemographic and doctoral characteristics by depression (n=325)

Sociodemographic and doctoral characteristics by anxiety (n=325)

Means and correlations among age and PHQ-9, GAD-7, AWAI-S, and RSES scores

Mean scores for the PHQ-9, GAD-7, and AWAI-S and their correlations with each other and age are presented in Table 4 . Age was positively associated with the PHQ-9. However, there was no significant effect of age on the GAD-7. Both PHQ-9 and GAD-7 scores were negatively associated with AWAI-S and RSES scores.

Correlations among age, AWAI-S, RSES, PHQ-9, and GAD-7 scores

Abbreviations: AWAI-S, Advisory Working Alliance Inventory-student version; GAD, Generalized Anxiety Disorder; PHQ, Patient Health Questionnaire; RSES, Research Self-Efficacy Scale.

Associations of mentoring relationship and research self-efficacy with depression/anxiety

As shown in Tables 5 and ​ and6, 6 , sociodemographic and doctoral variables contributed to 17.7% of the variance in PHQ-9 scores and to 18.3% of the variance in GAD-7 scores. Doctoral students in their fourth year had greater PHQ-9 and GAD-7 scores than first-year doctoral students. Compared with those who met with their mentors at least once a week, doctoral students who met with their mentors only once a month had higher PHQ-9 and GAD-7 scores. Moreover, respondents who reported that they had to try their best to publish doctoral qualification papers had higher PHQ-9 and GAD-7 scores than those who felt they only had to put forth a little effort. Finally, doctoral students who had great difficulty in balancing work–family–doctoral program exhibited a higher level of depression and anxiety than those who had almost no difficulty.

Factors related to depression using hierarchical regression analysis

Abbreviation: PHQ, Patient Health Questionnaire.

Factors related to anxiety using hierarchical regression analysis

Abbreviation: GAD, Generalized Anxiety Disorder.

After adjustment for controlled variables, the RSES was negatively associated with depression ( b =−0.211, P <0.001) and anxiety ( b =−0.242, P <0.001), and accounted for 3.8% of the variance for depression and 5.0% of the variance for anxiety. In step 3, the AWAI-S was negatively associated with depression ( b =−0.257, P <0.001) and anxiety ( b =−0.246, P <0.001), and accounted for 5.3% of the variance for depression and 4.9% of the variance for anxiety. In step 3, when the AWAI-S was added, the absolute value of RSES b was diminished. Therefore, the AWAI-S might be a mediator in the association between research self-efficacy and depression/anxiety.

Mediating role of mentoring relationship

As shown in Table 7 and Figure 1 , research self-efficacy had a significantly negative correlation with depression/anxiety (c). Research self-efficacy correlated with the mentoring relationship (a). Mentoring relationship correlated with depression/anxiety negatively (b). BC a 95% CI for a×b of the mentoring relationship did not include 0, indicating that mentoring relationship partially mediated the relationship between research self-efficacy and depression/anxiety (c’). Mentoring relationship explained 37.68% of the variance for depression and 29.73% of the variance for anxiety.

Theoretical model through which mentoring relationship mediates association between research self-efficacy and depression/anxiety.

Notes: c, Association between research a elf-efficacy and depression/anxiety; a, association between research self-efficacy and mentoring relationship; b, association between mentoring relationship and depression/anxiety; c’, association between research self-efficacy and depression/anxiety after adding mentoring relationship as a mediator. * P <0.05; ** P <0.01; *** P <0.001.

Bootstrapping test of indirect effect of mentoring relationship acting as mediator on association between research self-efficacy and depression/anxiety

Notes: a×b, indirect effect of research self-efficacy on depression/anxiety via mediator mentoring relationship; c, association between research self-efficacy and depression/anxiety; a, association between research self-efficacy and mentoring relationship; b, association between mentoring relationship and depression/anxiety; c’, association between research self-efficacy and depression/anxiety after adding mentoring relationship as mediator.

Abbreviations: BC a , bias-corrected and accelerated; GAD, Generalized Anxiety Disorder; PHQ, Patient Health Questionnaire.

We found that depression and anxiety symptoms are common among doctoral students in medical universities. Approximately 41.2% of doctoral students showed symptoms of mild depression and 23.7% showed signs of moderate–severe depression. Moreover, 33.5% of the students had mild anxiety symptoms and 20.0% had moderate–severe anxiety symptoms. Researchers worldwide have used the same scales to carry out epidemiological surveys on depression and/or anxiety. An investigation indicated that 53.8% of undergraduate college students at Emory University had moderate–severe depression. 57 In 2017, it was reported that 29.2% of medical students in Nepal had moderate–severe depression. 58 Evans et al conducted a survey that included 90% PhD students and 10% master’s students. Results suggested that 39% of postgraduates had moderate–severe depression and 41% moderate–severe anxiety. 21 Differences in terms of score and positive rate might be related to differing methodologies. Levesque et al found that 33.33% of doctoral students experienced a common psychiatric disorder (GHQ12), such as depression. A PhD candidate was 2.4 times more likely to develop psychiatric health problems than someone in the general population with a bachelor’s degree. 3 Bernstein reported that 42% of PhD students in science and 48% of PhD students in engineering at the University of California were depressed on the Center for Epidemiologic Studies Depression Scale. 12 The psychological stress of medical doctoral students is much higher than that of students with other majors, and students in medical schools have more symptoms of depression than the general population. 26 , 29 However, few reports have focused on the mental health of doctoral students in Chinese medical universities.

Research self-efficacy negatively correlated with depression and anxiety. However, few researchers have reported such an association. Mee found that self-efficacy mediated the relationship between smoking behavior and depression. 59 Pu et al verified that dispositional optimism partially mediated the relationship between self-efficacy and depression. 60 Razavi et al reported a negative relationship between self-efficacy (General Self-Efficacy Questionnaire) and research anxiety among master’s and PhD students at Islamic Azad University. 61 In addition, we found that research self-efficacy (RSES) and mentoring relationship (AWAI-S) correlated significantly. This result was consistent with a previous study. 64 Research self-efficacy has often been studied in relation to research-training environments and research productivity. 47 , 62 Lambie et al found that among PhD students, research self-efficacy was associated with research interest and knowledge. 45

Our study indicated that the association between research self-efficacy and depression/anxiety was partly mediated by the mentoring relationship. As for strategies for promoting research self-efficacy of doctoral students, Overall et al found that high levels of autonomy and strong levels of academic support were associated with higher levels of research self-efficacy. Likewise, students with lower research self-efficacy experienced lower levels of autonomy and lower levels of personal support. 44 Love et al reported that supportive peers or supervisors contributed to positive research experience. Positive team-research experiences were able to predict research self-efficacy. 63 As such, the correlation between mentoring relationship and research self-efficacy might be bidirectional.

Our results also indicated that mentoring relationship correlated with depression and anxiety. Studies suggest that the mentoring relationship is positively correlated with research self-efficacy and negatively correlated with student stress. 53 , 54 , 64 , 65 Peluso et al found that the academic advisor relationship played a role in protecting the mental health of experimental psychology students in Canada. 10 Gottschall also showed a significant association between a harmonious mentoring relationship (RHI-M subscale) and decreased depressive symptoms among Canadian graduate students. 66 In addition, Lunsford suggested that mentoring by doctoral advisors correlated with student outcomes, including satisfaction and academic production. 37

Most importantly, we found that mentoring relationship mediated the correlation between research self-efficacy and depression/anxiety. As far as we know, this issue has not been studied before. The empirical findings in this study have very important applications for general doctoral training strategies and specific interventions for depression and anxiety. The mediating effect suggests that active strategies and interventions that promote research self-efficacy and mentoring relationships might benefit the mental health of doctoral students. Developing courses related to choosing research topics, performing experiments, analyzing data, and writing papers are good strategies for improving research self-efficacy. We should encourage doctoral students to participate in research practices and academic exchange. In addition, we should monitor mentoring relationships, depression, and anxiety by mixed methods at regular intervals, with students’ permission. If we find poor relationships between mentors and their mentees, we must recognize this issue’s importance and adopt flexible methods to deal with it. For example, we should allow the student to change mentors or give them more research support from another faculty.

The percentage of scores that could be categorized as depression and anxiety in the fourth year or above was higher than that in any other grade. Senior students might face more pressure from the institution, the need to graduate, financial burdens, and finding a job than is faced by more junior students. Our findings are in line with a survey in Vietnam, which indicated that major depression and general anxiety rates of medical students were higher in the fifth grade than in the first grade. 67 In contrast, a study of undergraduates in Brazil discovered that 30.8% of first-year students and 9.4% of sixth-year students presented anxiety. 68 Levecque et al observed that mental health problems were more prevalent at the beginning of the PhD program than in the execution phase. This difference with our results could be due to cross-cultural differences in training systems and graduation requirements.

The frequency with which mentees met with their mentors showed a significant relationship with depression and anxiety. This measure is a function of the mentors in terms of quantity. Under great academic pressure, doctoral students who often met with their mentors were less stressed than those who seldom met with their mentors. An ideal situation is that the advisor is accessible at almost all times. Besides weekly group meetings, students should schedule a weekly one-on-one session with an advisor. Students who meet less frequently with their mentor are more likely to be depressed when they encounter difficulties. Moreover, the duration of each meeting and the content of the meeting might also play a vital role in completion of the doctoral program.

Our results also suggest that difficulty in publishing a doctoral qualification paper has a significant effect on depression and anxiety. This has also become one of the main factors preventing students from completing the doctoral degree. Certainly, doctoral students who have greater academic self-efficacy might have less academic pressure and a low risk of mental health problems. In recent years, many policies have been implemented to increase the number of doctoral students enrolled, develop master–doctor combined programs, and expand the requirements for a doctoral degree. However, the cultivation of mentoring ability, availability of funding for doctor training, and assistance for doctoral students in mastering experiments and writing papers are still lacking. Such problems might not only be related to increasing the risk of mental health disorders but might also correlate with deferred graduation, increased dropout rates, and academic misconduct.

Finally, it has been shown that doctoral students who have difficulty in balancing work–family–doctoral program will have a greater risk of depression and anxiety than those who have almost no difficulty. An imbalance among family, work, and doctoral program places great pressure on doctoral students and seriously hampers their progress in doctoral programs, which leads to poorer mental health and even poorer physical health. Although the effect of work–life balance on mental health has been identified in the past, 69 , 70 only in recent years has work–life–doctoral program balance been taken seriously. Sapey, a scientist in the UK, has pointed out that work–life balance in academia is a challenge for her. 71 – 73 She said that she has balanced two vocations (clinical and academic work) and a family (mother of a child), sometimes very badly, sometimes reasonably, and only very, very occasionally has she handled it very well. Is there any successful family–work–doctoral program balance experience from which to learn? Bellucci and Nancy performed a qualitative investigation of PhD nursing students in the US, and suggested that multiple time management and stress management strategies would play a crucial role in balancing the responsibilities of work, family, and a PhD program. 74 Martinez et al interviewed full-time doctoral education students and categorized balancing school–work–life into four themes: purposeful management, well-being, support, and tradeoffs. 75

Limitations

Several limitations of this study should be mentioned. First, we performed only an exploratory survey of doctoral students in a medical university. We will perform a multicenter investigation in multiple cities in the future. Second, it was a cross-sectional study. The results of this study did not reveal causality. We expect to conduct a longitudinal study on associated themes. Further studies should include qualitative measures as well.

Our study has provided insight into the prevalence and factors associated with depression and anxiety among doctoral students in China. Our study revealed that 23.7% of doctoral students showed signs of depression and 20.0% signs of anxiety. Our findings indicated that research self-efficacy and mentoring relationships were protective factors for depression and anxiety. Mentoring relationship mediated the association between research self-efficacy and depression/anxiety. In addition, we revealed that the frequency of meeting with mentors, difficulty in publishing a doctoral qualification paper, and difficulty in balancing work–family–doctoral program were significantly associated with both depression and anxiety. Our findings also indicated that year in school was also associated with depression and anxiety. These findings suggest that policymakers and managers in medical universities should pay close attention to the mental health of doctoral students. Potential interventions might include (but are not limited to) promoting research self-efficacy of doctoral students, monitoring the mentoring relationship, and developing courses that teach how to perform various tasks necessary for obtaining a doctoral degree.

Acknowledgments

This study was funded by the Liaoning Province Education Science 13th Five-Year Plan 2017 of China (No. JG17DB564) and the National Natural Science Foundation of China (No. 71473268). We would like to thank the experts who have offered us constructive suggestions. We would like to acknowledge all the faculty and students for their great help in distributing questionnaires and collecting data.

The authors report no conflicts of interest in this work.

Alarming Increase of Depression and Anxiety Among the PhD and Post-doctoral Researchers

PhD and post-doctoral researchers are feeling exhausted, overworked, and are worried about their future. If this is how you are feeling, you are not alone. The stress and pressure of academic life can be relentless, leading to depression and anxiety. Disturbingly, it is becoming common for young researchers to battle with mental health issues. This is especially prevalent in life sciences and engineering. Why is this happening?

Why are Researchers Struggling?

The American author Zig Ziglar summed up what people thrive on well: “ Research indicates that employees have three prime needs: Interesting work, recognition for doing a good job, and being let in on things that are going on in the company.”

Researchers tend to be passionate and enthusiastic about their work. They want to make a meaningful contribution to their field. Therefore, the above quote describes them well. The factors that contribute to stress and lead to anxiety and depression are listed below. It comes as no surprise that researchers, by nature, try too hard and fall victim to these stresses .

• Extended hours: As you know, academia comes with a considerable amount of responsibility. As you progress up the academic ladder, your responsibilities increase. You must balance teaching, admin, and research. You spend evenings and weekends working to keep up.
• Mentorship Relationship : Many researchers feel unsupported by their PIs. Some PIs expect a lot from their researchers, or PIs themselves are overwhelmed and therefore unable to offer the required
• Future: Uncertainty about your career prospects for the future can be frustrating and worrying.
• Financial uncertainty: Often, in academia, researchers are underpaid and funds are available for short time periods, leading to financial insecurity.
• Frequent evaluation: The constant reports to faculty and funders put extra pressure on researchers.
• Competitive atmosphere: Resources are scarce. Therefore, the competition for funding is enormous. Postdocs and PhDs are under more pressure to be productive.
• Management style: Researchers are at higher risk of mental health issues if their lab culture is bureaucratic. People are happier when they are part of the decision process, especially at D. and postdoc level where one expects to run with a project.
• Mental wellbeing of University staff:  Emotional and physical exhaustion among the PIs, negatively impact the students under them.

Stress intensifies as things become urgent towards the end of your project. Your submission deadlines are looming, and your funds are coming to an end. It can be overwhelming to complete a project as well as plan your future at the same time.

Signs that your mental health is in trouble include:

• Disrupted sleep
• Cognitive impairment
• Mood changes
• Working long hours at night
• Emotional outbursts
• Eating disorders

Mental Wellbeing Studies

The stats are high. Research on the mental health of Ph.D. students showed that 32 % are likely to develop depression. A 2016 survey found that 41 % of PhDs and postdocs were anxious, and 39 % were depressed. This is not new news, in 2013 and 2014, similar studies found that about one-third of postdocs were struggling with their mental health.

Mentors can Help

If you are a PI or a supervisor, you understand first-hand the pressures that your researchers are under. Here are some tips to help your students :

• This is a great prevention strategy. Mentors should be aware of their student’s mental health and educate them about the risks and signs of anxiety and depression.
• Training: Mentors could benefit from training on this subject so that they can identify a student who is struggling and assist them.
• Career Advice: Future employment opportunities are worrying Therefore, mentors should inform students of the low prospects of securing an academic position. Furthermore, they should advise them to research alternative career paths as possible options at the start of their project. It becomes too stressful to find employment when your deadline is approaching.
• Compassionate and kind leadership: Listen to your students and put yourself in their shoes.
• Be inspirational to your researchers. This will help create a happy team.

Keep Your Mind Healthy

We all know what we should be doing to keep physically and mentally healthy . Let me remind you.

• Get enough sleep.
• Exercise regularly, relieve stress.
• Eat healthy food.
• Connect with friends and family.
• Get professional help to resolve stress and anxiety.
• Make time for things you enjoy.

Get Help – Speak Out

It is time to get help if you start thinking about harming yourself, you feel overwhelmed about things that you usually cope with, you rely on drugs or alcohol to feel better, you still feel down even if something good happens, you are unsure why you are feeling down or you struggle with daily tasks.

If you are struggling, consult your healthcare practitioner or University counseling program. Chances are you are one of many academics suffering from a mild mental disorder. When researchers do eventually get help, they wonder why they waited so long. It is amazing to know how much better you will function with your daily tasks.

Remember, there is life outside the lab!

Academia can be a rewarding career. You just need to know what you are in for, manage your stress and remember your life outside the lab. Most of all, understand that you are not alone, a lot of researchers are feeling the same, but possibly not talking about it. Postdocs who have spoken up about their struggles have had many responses from researchers in similar situations. If everyone who struggled with mental health issues spoke up, we would realize how prevalent it is. This would go a long way toward fighting the stigma associated with mental health struggles.

Have you noticed that you or your colleagues are struggling with mental wellbeing? Help us fight the stigma by speaking out in the comments section below.

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Affiliations.

• 1 PhD Candidate, Brown School, Washington University in St. Louis, St. Louis, Missouri, USA.
• 2 Associate Professor, Brown School, Washington University in St. Louis, St. Louis, Missouri, USA.
• 3 Research Scientist, Buffalo Center for Social Research, Buffalo, New York, USA.
• PMID: 34242525
• DOI: 10.1080/07448481.2021.1920954

Objective : Psychiatric disorders, such as depression and anxiety, can hinder academic performance among college-age individuals. Participants : Mental health among college students is a growing public health concern, with some scholars describing collegiate mental health as a crisis (Chen et al., Psychiatr Serv. 2019;70(6):442-449). Methods : This study analyzes data from four annual administrations of the American College Health Association (ACHA)'S NCHA (n = 117,430). Results : Overall, anxiety and depression were the most common conditions, at 9.2% and 8.7%, respectively. Of students reporting the focal symptom, 17.87% were treated for depression and 12.91% were treated for anxiety. Compared to not-treated students, diagnosed only students, had significantly lower grade averages, with effect sizes of -0.30 and -0.20 for depression and anxiety, respectively. Conclusions : Given the prevalence of depression and anxiety among college-aged students, continued research into help seeking behaviors and their effects on outcomes like grade average is an essential part of understanding the toll these disorders take.

Keywords: Academic success; anxiety; college students; depression; grade average (GPA).

• Anxiety / epidemiology
• Depression* / epidemiology
• Depression* / psychology
• Ethnicity* / psychology
• Students / psychology
• Universities
• Young Adult

• Open access
• Published: 10 April 2024

The burden of anxiety, depression, and stress, along with the prevalence of symptoms of PTSD, and perceptions of the drivers of psychological harms, as perceived by doctors and nurses working in ICUs in Nepal during the COVID-19 pandemic; a mixed method evaluation

• Shirish KC 1 ,
• Tiffany E. Gooden 2 ,
• Diptesh Aryal 1 ,
• Kanchan Koirala 1 ,
• Subekshya Luitel 1 ,
• Rashan Haniffa 3 , 4 ,
• Abi Beane 3 , 4 on behalf of

Collaboration for Research, Implementation, and Training in Critical Care in Asia and Africa (CCAA)

BMC Health Services Research volume  24 , Article number:  450 ( 2024 ) Cite this article

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The COVID-19 pandemic resulted in significant physical and psychological impacts for survivors, and for the healthcare professionals caring for patients. Nurses and doctors in critical care faced longer working hours, increased burden of patients, and limited resources, all in the context of personal social isolation and uncertainties regarding cross-infection. We evaluated the burden of anxiety, depression, stress, post-traumatic stress disorder (PTSD), and alcohol dependence among doctors and nurses working in intensive care units (ICUs) in Nepal and explored the individual and social drivers for these impacts.

We conducted a mixed-methods study in Nepal, using an online survey to assess psychological well-being and semi-structured interviews to explore perceptions as to the drivers of anxiety, stress, and depression. Participants were recruited from existing national critical care professional organisations in Nepal and using a snowball technique. The online survey comprised of validated assessment tools for anxiety, depression, stress, PTSD, and alcohol dependence; all tools were analysed using published guidelines. Interviews were analysed using rapid appraisal techniques, and themes regarding the drivers for psychological distress were explored.

134 respondents (113 nurses, 21 doctors) completed the online survey. Twenty-eight (21%) participants experienced moderate to severe symptoms of depression; 67 (50%) experienced moderate or severe symptoms of anxiety; 114 (85%) had scores indicative of moderate to high levels of stress; 46 out of 100 reported symptoms of PTSD. Compared to doctors, nurses experienced more severe symptoms of depression, anxiety, and PTSD, whereas doctors experienced higher levels of stress than nurses. Most (95%) participants had scores indicative of low risk of alcohol dependence. Twenty participants were followed up in interviews. Social stigmatism, physical and emotional safety, enforced role change and the absence of organisational support were perceived drivers for poor psychological well-being.

Nurses and doctors working in ICU during the COVID-19 pandemic sustained psychological impacts, manifesting as stress, anxiety, and for some, symptoms of PTSD. Nurses were more vulnerable. Individual characteristics and professional inequalities in healthcare may be potential modifiable factors for policy makers seeking to mitigate risks for healthcare providers.

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Introduction

Between January 2020 and December 2021, the COVID-19 pandemic led to an estimated 18.2 million deaths [ 1 ]. Globally, healthcare systems were overwhelmed during the pandemic, with intensive care units (ICUs) receiving an unprecedented burden of patients [ 2 ]. In Nepal, the government first declared a lockdown on March 24, 2020, that lasted until July 21, 2020, and the second lockdown was announced on April 29, 2021, which was fully lifted on September 1, 2021 [ 3 ]. The first wave of the COVID-19 pandemic reached a peak of over 5000 cases a day in October 2020, and the second wave reached a peak of more than 9000 cases a day in May 2021, which was almost double [ 4 ]. Prior to the pandemic, Nepal reported a capacity of 1595 ICU beds across 194 hospitals and around 840 ventilators, equating to 2.8 ventilator-equipped ICU beds per 100,000 people [ 5 ]. To cope with the influx of COVID-19 patients, several existing postoperative wards and other high-dependency units of the hospitals were converted into improvised critical care units [ 6 ]. Globally, healthcare professionals (HCPs) and specifically those working in ICU and critical care services, arguably were at the frontline of the healthcare response. These HCPs faced the uncertainty of managing this new condition, extended working hours, limited personal protective equipment (PPE), and an increased risk of infection as they provide essential lifesaving interventions, including intubation and non-invasive respiratory management [ 7 , 8 ].

The impacts of the COVID-19 pandemic on the mental health and well-being of HCPs who worked during and after this global emergency are slowly becoming apparent. Research emerging from China, the USA, and Europe [ 9 ] describes a significant burden of psychological distress and symptoms synonymous with mental health conditions in HCPs. This is also evident from the limited studies that have been conducted in Nepal. For instance, one study conducted among 150 HCPs from outpatient clinics and inpatient wards caring for COVID-19 patients in Nepal reported that 38% of participants suffered from anxiety and/or depression [ 10 ]. Another Nepali study revealed that the prevalence of anxiety and depression among HCPs, including health assistants and support staff was 47% and 41%, respectively [ 11 ]. A larger online survey of 475 HCPs including pharmacists, paramedics and public health practitioners reported similar findings (42% had anxiety) and noted that nurses had a higher proportion of symptoms compared to other HCPs [ 12 ].. Whilst these studies, in conjunction with a meta-analysis, indicate that depression, anxiety, and post-traumatic disorder (PTSD) are highly prevalent among HCPs during the pandemic [ 9 , 10 , 11 , 12 , 13 ], fewer studies have explored the disparities between professionals’ roles, specifically among ICU workers, a group exposed to more advanced cases of COVID-19. Indeed a small study in Nepal comprising 96 nurses revealed that nurses who worked directly with COVID-19 patients experienced more severe symptoms of depression and anxiety [ 13 ]. The nature and characteristics of mental health symptoms appear to vary geographically, the HCPs’ role, their individual characteristics (age, gender) along with health system’s pre-existing resource capacity and ability to respond to increasing demand placed by events such as a pandemic. Understanding the mental health impact of ICU workers, any disparities between professional roles and drivers behind poor mental health in Nepal will help to identify what support is needed for ICU workers for pandemic preparedness; thus, providing important directions for investment in health systems strengthening.

We aimed to investigate the burden of anxiety, depression, stress, PTSD, and alcohol dependence among doctors and nurses in Nepal that worked in the ICU during the COVID-19 pandemic. We further sought to identify the factors driving the self-reported burden of psychological distress by exploring the lived experiences of these two different professional groups, and how these experiences impacted their psychological health and well-being.

Study design

We undertook a mixed-methods cross-sectional study [ 14 ] in Nepal with ICU doctors and nurses, combining an online questionnaire consisting of validated self-assessment tools combined with semi-structured interviews. The following self-reporting psychological assessment tools were used, given they have been used in previous studies in other settings and their widely validated in a variety of settings: Beck Anxiety Inventory (BAI) [ 15 ], Beck Depression Inventory (BDI) [ 16 ], Perceived Stress Scale (PSS) [ 17 ], PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders-5 (PCL-5) [ 18 ] and Alcohol Use Disorder identification Tool (AUDIT) [ 19 ]. BDI, BAI, and AUDIT have been validated in Nepal [ 20 , 21 , 22 ] and the PSS has been tested for reliability and correlation in Nepal [ 23 ]. Whilst the PCL-5 has not been validated in a Nepali setting, it was piloted (along with all other assessment tools used) with 20 people before the study commenced. Participants were given the flexibility to complete the questionnaire in either Nepali or English language. Despite this option, all participants opted to respond in English.

Ethics approval

was granted from the Nepal Health Research Council (approval number: 176/2021 P). All participants provided informed consent electronically before completing the online questionnaire. Participants from the qualitative component provided further informed verbal consent before the interview commenced.

In 2020, Nepal reported a capacity of 1595 ICU beds across 194 hospitals and around 840 ventilators, equating to 2.8 ventilator-equipped ICU beds per 100,000 people [ 5 ]. A year later, Nepal was under a state of health emergency, with patients being turned down due to a lack of ICU beds, oxygen, and ventilators [ 24 ].

Participants and recruitment

Doctors and nurses with experience in caring for COVID-19 patients in Nepalese ICUs were eligible for participation. Initially doctors registered with the Nepalese Society of Critical Care Medicine (NSCCM) [ 25 ] and nurses registered with the Critical Care Nurses Association of Nepal (CCNAN) [ 26 ] were contacted and invited to participate. Both organisations consist of voluntary memberships and represent the doctors and nurses working in a critical care setting in Nepal. At the time of recruitment, there were 187 doctors and 104 nurses registered at these organisations. This initial purposive sampling was augmented by snowballing techniques, whereby respondents were invited to forward the questionnaire link to other doctors or nurses working in ICUs [ 27 ]. Following completion of the questionnaire, respondents were invited to participate in a virtual interview. A convenience sample of 20 participants (a number which, based on the literature, was likely to provide saturation of findings [ 28 ]) was subsequently scheduled for an interview.

Study materials and data collection

The questionnaire was developed using an online survey platform (Google Forms) [ 29 ]. The questionnaire was piloted for readability and responder reliability with twenty HCPs based in Nepal, prior to roll out, who did not participate in the final analysis. Questionnaire content included socio-demographic information; age, sex, professional role and experience, degree of schooling, and home living arrangements; factors which had been identified as being important in the burden of psychological distress and impact on family life in similar research conducted during the previous SARS pandemic as well as the current COVID-19 event [ 30 ]. Participants could opt out of the study at any time. Participants could only complete the questionnaire once, and all survey responses were anonymous. Participants were signposted to healthcare services available to them should they be suffering from any distressing, mild, moderate or severe mental health symptoms. Invitations to participate in the questionnaire were sent out from 20th May 2021, and the questionnaire was closed to responses on 2nd October 2021.

The semi-structured interview topic guide was co-developed between doctors and nurses working in ICUs in Kathmandu. Co-design was used to ensure the sensitivity and appropriateness of the questions. None of the doctors and nurses involved in the codesign of the topic guide participated in the study proper. The qualitative component was aimed to augment the quantitative findings by providing an understanding of what social, organisational, and environmental factors were related to HCPs’ mental health. Topic guide questions focused on HCPs’ perceptions of their experiences of working during the pandemic and explored social, organisational, and environmental factors that may have influenced their self-reported burden and symptoms of psychological distress. These factors were selected from a review of the findings of the previously published meta-analysis and other studies conducted in Nepal [ 9 , 10 , 11 , 12 , 13 ]. The interview questions were piloted with five HCPs for interpretability and interviewer consistency. All interviews were conducted via video conferencing (Zoom) [ 31 ] between September 2021 and March 2022. Five ICU nurses with experience in conducting interviews and mixed methods research led the data collection following training on the topic guide. To ensure there was no prior relationship between the interviewer and the participant, interviewers were assigned to participants that worked in different ICUs than themselves and were not known to the interviewee. No one other than the interviewer and the participant was present for each interview, and interviews were conducted at the time chosen by the interviewee. Rapid assessment procedure (RAP) sheets were used for note-taking during the interviews [ 32 ]. Commonly used in rapid evaluations - designed to improve the rapidity and replicability of research during public health emergencies - RAP sheets help reduce the need for long-form transcription and encourage reflexivity for both interviewers and researchers, reduce interviewer bias, and enable validation of internal consistency with coding [ 33 ]. The RAP sheet contained the summary of questions from the topic guide, and the interviewers took notes of what the participants said regarding each question during the interview.

Data analysis

Descriptive statistics were used to describe participants’ demographics and professional profiles. Psychological health and well-being assessment tools from the questionnaire were analysed using published guidelines. For the BDI, each of the 21 items corresponding to a symptom of depression was summed for each participant to give a single total score [ 16 ]. With each item ranging from 0 to 3 points, a total score of 13 or less was considered minimal to no depression, 14 to 19 as mild depression, 20 to 28 as moderate depression, and 29 to 63 as severe depression [ 16 ]. Data is also presented separately for suicidality (question 9 from the BDI) whereby anyone that said they have thoughts about or plans to kill themselves is said to have experienced suicidality. The BAI scores reported included the 21 symptoms of anxiety that ranged between 0 and 63 points [ 15 ]. The values for each symptom were summed, and a total score of 0 to 7 was interpreted as a minimal level of anxiety, 8 to 15 as mild, 16 to 25 as moderate, and 26 to 63 as severe anxiety [ 15 ]. Scores on the PSS ranged from 0 to 40, with higher scores indicating higher perceptions of stress [ 17 ]: scores ranging from 0 to 13 were considered low descriptors of stress; 14 to 26 moderate; and 27 to 40 were considered higher levels of perceived stress. For alcohol use disorder reported using AUDIT [ 19 ], a score of 0 indicated no previous or current alcohol use; a score of 1 to 7 suggested low-risk consumption; 8 to 14 hazardous or harmful alcohol consumption; 15 or higher indicated the likelihood of alcohol dependence (moderate to severe alcohol use disorder). The PCL-5 included 20 items with a score range of 0 to 80 and a score of 33 or higher, indicating the presence of PTSD [ 18 ]. A sensitivity analysis was conducted for the BDI, BAI and AUDIT scores based on local validation studies whereby a score of 15 or lower from the BDI indicated no depression [ 20 ], 12 or lower from the BAI indicated no anxiety [ 21 ], and a score of 11 or above from the AUDIT indicated discriminate dependent drinkers [ 22 ].

RAP sheets, along with interviewer notes, were reviewed by the research team before analysis to ensure information was complete. SK, KK and AB used a constant comparative method, coding data following each round of interviews and then reflecting back on the summary of the codes together with the interviewers to promote the accuracy of findings and reduce recall and interviewer bias. In addition, emerging themes identified following each round of coding were used to guide subsequent interviews [ 34 ]. The broader research team met following each coding round to review the findings and reflexivity [ 35 ]. Categories and the subsequent themes (‘drivers’) were developed through the iterative process of interviewing, coding, analysing, and reviewing.

We invited 120 doctors and 341 nurses to participate. A total of 21 doctors and 113 nurses responded, all of which completed the BDI, BAI, PSS, and AUDIT questions; 100 completed the PCL-5 (16 doctors and 84 nurses). Nearly all nurses were female (99%, n  = 112), whereas most doctors were male (81%, n  = 17). The characteristics of respondents are described in Table  1 .

50% ( n  = 67) of respondents reported experiencing symptoms associated with moderate to severe anxiety, and a further 27% ( n  = 36) scored for mild anxiety as a result of working in the ICU during the COVID-19 pandemic (Table  2 ). Anxiety levels (and associated symptoms) were more pronounced in nurses than doctors, with 55% ( n  = 62) of the former scoring moderate to severe on the anxiety scale, compared to 24% ( n  = 6) of the latter. 21% ( n  = 28) of respondents described symptoms associated with moderate to severe depression, with a near-even split between nurses and doctors. Three-quarters of respondents ( n  = 114; 85%) had scores indicative of moderate to high levels of stress; this proportion was higher among doctors ( n  = 19; 91%) compared to nurses ( n  = 95; 84%). Of the 100 individuals that completed the PCL-5 assessment (16 doctors and 84 nurses), 45% ( n  = 46) reported a constellation of symptoms closely associated with PTSD, with a higher prevalence among nurses ( n  = 40; 47%) compared to doctors ( n  = 6; 38%).

Using cut-off scores from Nepali validation studies, 45 (34%) participants were experiencing mild, moderate or severe depressive symptoms, 80 (60%) were experiencing mild, moderate or severe anxiety symptoms, and 3 (2%) were considered discriminate dependent drinkers. These results are in line with our main analysis, including that a greater proportion of nurses were still found to suffer from depression and anxiety symptoms (supplementary Table 1 ).

Forty-six respondents to the online questionnaire volunteered to participate in the subsequent semi-structured interviews. Twenty participants were approached and consented to an interview: 16 were nurses (all female), and 4 were doctors (1 female, 3 male). On average, each interview resulted in 45 to 60 min of qualitative data. Saturation was met within the first 15 interviews, and findings were consistent between the coders and the research team. Analysis and synthesis of the interviews revealed nine themes, which, when codified, can be described as three key drivers of the psychological symptoms and impacts on mental well-being experienced by the interviewees: social stigmatism, physical and emotional safety, and organisational support. (Fig.  1 ). During the interviews, HCPs further described some of the coping strategies that they found helpful in mitigating the impacts experienced and may provide insights for future pandemic preparedness. These three themes, the drivers, and coping strategies, are explored below, along with quotes from the respondents.

Coding tree for the four main drivers for psychological distress

Social stigmatism

Interviewees described experiencing feelings of social stigmatisation as a result of interactions with their families, peers, as well as from the wider public. Examples of stigmatism experienced included physical avoidance from neighbours and community members when the HCP travelled to and from and around their home, especially when dwellings were in shared buildings and common areas.

“My house owner avoided talking and meeting me because I worked with COVID patients.” [N]. “I have an elderly family member, and I was afraid and worried [for them] when I came back from duty.” [N].

Interviewees described how rumours would spread within the community, notably related to concerns of risk of co-infection or cross-infection, either directly from parent to child or indirectly via friends and extended family. Some HCPs were asked or elected to stay away from their home so as to reduce the stigma to them and their family and in an attempt to reduce the risk of co-infection, particularly when they had vulnerable family members. Interviewees described how this self-selected or enforced separation and isolation resulted in feelings of rejection, physically and emotionally heightened feelings of stress and anxiety, alongside the threat to physical and emotional safety.

Physical and emotional safety

Increased workload and an enforced change in working pattern/ shift structures were experienced by all the HCPs interviewed. These longer overall working hours, increased duration of shift patterns, and enforced working rotas were perceived as resulting in a loss of physical and emotional safety by the interviewees. Feelings of loss of control, insomnia, or disruption to sleep patterns, alongside physical discomfort through sustained working in personal protective equipment, often in hot and humid temperatures. This physical and mental endurance contributed to feelings of emotional stress and anxiety.

“Shift frequency was increased, and I only got one night off in a week. Sometimes I had to work extra hours, which was very stressful.” [N]. “My sleep pattern had changed, I felt restless and was afraid about COVID” [D].

The change in shift structure and in working patterns meant for some HCPs enforced separation from family and friends whereby HCPs sought accommodation away from family or in temporary lodgings. This again resulted in isolation and additional strain on other family members so as to provide care for HCP’s dependents.

“I had to involve other family members to arrange for the medication and care of my grandmother” [N].

Increased working hours and changes in working patterns further had physical impacts; participants described skipping meals or having limited time to eat. The need to wear personal protective equipment (PPE), and indeed the risks to safety when PPE was not available, associated risks of non-availability of equipment, brought with it a risk to physical and emotional safety. HCPs interviewed reported skin lacerations, irritation, and discomfort whilst wearing equipment in hot, humid working environments.

“We had to frequently change the PPE and masks, which has caused skin problems that still exist.” [N].

Organisational support

Interviewees found the COVID-19 pandemic brought new and often enforced work responsibilities, some of which were associated with high levels of professional anxiety, stress, and uncertainty. A professionally challenging situation, even for those with many years of ICU working experience. HCPs faced emotionally challenging tasks such as dealing with end-of-life situations (particularly without relatives of the patient present) and having to comfort relatives over the phone, of which they received limited to no training or support on handling such situations.

“I went through an emotional breakdown while dealing with the end of the life situation of patients without the presence of family members in the COVID ICU… I felt sad when a young patient lost their lives” [D]. “Accommodation or isolation facilities should be provided by the hospital” [D]. “If incentives were provided in time and staff were provided with health insurance it would motivate us” [N].

Ever-changing role and responsibilities created anxiety for HCPs as to what care to deliver, and the rapidity and uncertainty of care were associated with feelings of vulnerability. Interviewees expressed how they wished there was a need for greater organisational support to better cope with the frequent updates and changes to practice. Furthermore, HCPs expressed concerns regarding a shortage of staff and the lack of mental health counselling and support, accommodation on-site at the hospital, and transportation to and from work.

“Mental health support or counselling facilities were not provided. It should be there… seniors and hospital staff should also talk to the staff to know the situation.” [N]. “Safety of healthcare workers should be the priority and nurse-patient ratio should be maintained to provide quality care to the patients… hospital should have recruited more staff.” [N].

Coping strategies

Participants described various ways in which they coped with the emotional, physical, social, and professional impacts of working through the pandemic. This included speaking with family and friends about the pressures they were under, taking up activities in their off time, such as gardening and reading, and using media entertainment such as music, movies, and shows. A few participants also mentioned that comparing the situation in Nepal to other countries (i.e., keeping up-to-date with the news) also helped them cope. Others mentioned that detachment from social media and more self-awareness through meditation helped.

“I ventilated my feelings with friends and family. Listening to soothing music also helped me cope with the stress.” [N]. “I coped by gardening with my sister in my home.” [N]. “I… watched the news that compared the death rates, which was low compared to others.” [D].

The COVID-19 pandemic’s impact on healthcare services and population health internationally is unprecedented in recent times. As healthcare professionals, policymakers, and researchers work to strengthen services in preparation for future pandemics now and mitigate the long-term impacts on individual and population health, understanding the impact on and perspectives of doctors and nurses at the frontline of care can provide important learning regarding the individuals characteristics and professional, social and economic drivers which may increase the risk of psychological impacts.

Mandated and enforced changes in role, specifically in working hours and shift patterns, were a key driver of psychological anxiety and distress. Within hospitals in Nepal, many departments were closed, and stay-at-home orders meant that outpatient or clinical services all but ceased. This resulted in an increased role and scope for critical care trained staff, and in contrast to other health systems (such as the UK) where healthcare staff were redeployed to ICU, there was a separation for ICU staff even from their professional peers working in other specialties. The increased scope and uncertainty of the HCP’s role, along with limited choice in redeployment in the ICU was another driver of poor mental health- and dominated nursing participants’ experiences. Interviewees described how these changes impacted not only themselves but the multigenerational families for whom many cared for. This enforcement of role change, and the related descriptions of the drivers for these impacts as experienced by participants in this study point not only to the differences in roles between nurses and doctors; but also highlights disparities in autonomy, advocacy for role change during international emergencies, and the implications of work on home and family life [ 36 ].

Giving staff choice to select shift patterns and ensuring the opportunity to have periods of rest to reconnect with family and have self-care is needed. Consultation and shared decision-making, even in times of restricted choice, are associated with improved perceptions of work from staff and may result in reducing psychological distress and promoting emotional safety, which is, in turn, associated with better outcomes for patients [ 37 , 38 ]. However, nurses in Nepal, as with many health systems, may have less opportunity for strategic and organisational decision making in response to public health emergencies. The impact of ongoing disparities between professionals and their agency to advocate for wellbeing and safety warrants further research.

Nurses were disproportionately burdened by both occurrence and severity of symptoms of anxiety and depression as a result of their work during the pandemic when compared to doctors.

Nearly half of all respondents had symptoms of anxiety and PTSD (again more prevalent in nurses), and the burden of anxiety symptoms was higher than the reported 22–33% from a recent umbrella review [ 39 ]. The burden of stress we report was also higher than a smaller study conducted in Nepal during the pandemic, which reported stress among 53.2% of healthcare professionals working in hospitals, primary health centres, pharmacies, and health posts in Nepal [ 40 ]; it was also higher than a meta-analysis of published studies exploring the incidence of both stress (57%) and PTSD (22%) among all cadres of healthcare workers [ 41 ]. One reason for the higher reported symptoms in our study may be the focus on ICU workers and their role in the management of end-of-life care. Indeed, our results for depression and anxiety are comparable to a study involving nurses working directly with COVID-19 in Nepal [ 13 ]. Studies conducted elsewhere in Asia have highlighted this positive relationship between ICU experiences and poor mental health [ 42 ].

Nurses in Nepal, as with many other countries, are more likely to be female, younger in age, and have less opportunity for graduate study; and have lower earning potential than physician colleagues [ 43 ]; all characteristics associated with increased risk of poorer mental health outcomes [ 44 ]. Exploration into the disparities of the psychological and health impacts of COVID-19 on different cadres of healthcare workers is emerging. A systematic review conducted in 2020, identified 27 studies which sought to explore the disparity in impacts of the pandemic on HCP’s psychological well-being. The findings from the review are in line with ours, indicating that the burden of symptoms for anxiety, depression, and PTSD is higher in nurses compared to doctors [ 45 ]. Notably only a few of these studies used validated tools for assessment of specific symptoms of anxiety, depression, or substance misuse [ 45 ]. Our study serves to strengthen the evidence of the vulnerability of nurses.

Nepal, like many other lower and middle-income countries in South and Southeast Asia, enforced large-scale lockdowns and restrictions of movement for all but essential healthcare and municipal staff [ 46 ]. As such, social stigmatism, physical and emotional safety, and organisational support were key drivers behind the elevated symptoms of psychological distress in ICU HCPs and may be a key determinant of differences between health systems internationally. Furthermore, the family responsibilities and social circumstances for nurses, contributed to their experiences of isolation, rejection, vulnerability, physical discomfort, and strain. These drivers mirrored those reported from Europe; and may reflect differences experienced by nurses as a result of their gender, and role norms of primary family carers within society [ 44 ].

Interviewees from both professional groups expressed concern at the absence of preparedness and support they felt from their employing institutions. This is notable given the ongoing investment in pandemic preparedness and the potential to make changes now to prepare for the next pandemic or public health emergency. Interventions such as resilience training, scenario-based simulation training, and group exercises based on psychoeducation and cognitive behavioural therapy (CBT) principles have proved effective in reducing anxiety, depression, stress, and PTSD among doctors and nurses while simultaneously improving their ability to work in unprecedented situations in other sectors [ 47 ]. Similar provisions may be valuable for ICU-based healthcare professionals and are deliverable online, making rollout potentially more feasible.

Strengths and limitations

A strength of this study is the exploration of participants’ perspectives on the drivers behind the burden of poor mental health described in ICU HCPs. This mixed methods approach offers insights into doctors’ and nurses’ unique individual, social and professional characteristics that may be associated with increased risk of distress. These differences and their potential for disparity in impacts on health and wellbeing should be of interest to policymakers and healthcare facility managers involved in future pandemic preparedness. However, the study has some limitations to acknowledge. Given the use of the snowball technique, we were able to ensure a high number of respondents, but as a consequence, we were unable to track the number of respondents that came from using this technique compared to those initially invited from the NSCCM and CCNAN. Therefore, a response rate and, subsequently, a non-response rate could not be reported. We did not collect information on the level of training in critical care that participants received; trained health professionals are likely to have additional skills in how to handle the potential stressful environment in critical care settings. Also, due to the lack of validation of the PCL-5 in Nepal, the results of this assessment tool should be interpreted with caution. The survey tools used for this study have not been validated in an online format. However, given these tools were self-reporting, and were piloted and administered in English, the online format is thought to have minimal impact on the results. Additionally, participants for the qualitative component were recruited based on convenience sampling; therefore, the diversity of the sample may not be optimised. We acknowledge that recall bias may be present in the participants during the interview, given they were recalling their experiences throughout the pandemic for up to 24 months prior to the interview; however, we hope the piloting of the interviews, the use of multiple researchers to code the data, and the constant comparative nature of the evaluation will mitigate this potential.

The COVID-19 pandemic negatively impacted the mental health of HCPs worldwide. This study strengthens existing evidence that nurses were (and may remain) at increased risk of both cross infection and may also be more vulnerable to psychological impacts including anxiety, depression and PTSD than their professional colleagues. In addition, critical care staff may be at even greater risk, due to the uniqueness of their role which includes prolonged periods of time with infected patients, frontline role in managing end of life care, and as described here, limited ability to advocate for changing role and working patterns during an emergency. Professional hierarchies, and social-economic and gender profiles unique to nurses, may be potential drivers for these disparities, and warrants further research. Learning from the ICU HCPs’ experiences during the COVID-19 pandemic may inform future preparedness strategies e to mitigate short and long-term mental illness among ICU HCPs in future pandemics.

Data availability

The interview guide is available in the Figshare repository,

https://doi.org/10.6084/m9.figshare.24247384.v1 .

The data supporting the conclusions of this article are available in the Figshare repository, https://doi.org/10.6084/m9.figshare.23999790.v1 .

Abbreviations

Coronavirus disease 2019

Intensive care unit

Healthcare professional

Personal protective equipment

Post-traumatic stress disorder

Nepalese Society of Critical Care Medicine

Critical Care Nurses Association of Nepal

Beck Anxiety Inventory

Beck Depression Inventory

Perceived Stress Scale

PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders-5

Alcohol Use Disorder Identification Tool

Rapid assessment procedure

Cognitive behavioural therapy

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Acknowledgements

We thank the volunteers who took the time to interview the participants: Radhika Maharjan, Dipika Khadka, Anita Bashyal, Samina Amatya, and Roshani Kafle. We also want to thank Dr. Rohini Nepal and Jugmaya Chaudhary of Rhythm Neuropsychiatry Hospital and Research Centre for their contribution to advising and reviewing the self-reporting psychological assessment tools used in the questionnaire. We would also like to thank Transcultural Psychosocial Organisation (TPO) Nepal and Dr. Nabaraj Koirala for the permission to use the Nepali-validated version of BDI I and BAI for the study. We additionally thank Nilu Dullewe, who helped in coding the qualitative data. For the ongoing mutual support for improvements in ICU care, we would also like to acknowledge and thank members of the CCAA.

CCAA members

Diptesh Aryal, Shirish KC, Kanchan Koirala, Subekshya Luitel, Rohini Nepal, Sushil Khanal, Hem R Paneru, Subha K Shreshta, Sanjay Lakhey, Samina Amatya, Kaveri Thapa, Radhika Maharjan, Roshani Kafle, Anita Bashyal, Reema Shrestha, Dipika Khadka and Nilu Dullewe.

This study was funded by a Wellcome Innovations Flagship Programme grant (Wellcome grant number: 215522/Z/19/Z). They had no role in the design, analysis, or reporting of this protocol.

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Shirish KC, Diptesh Aryal, Kanchan Koirala & Subekshya Luitel

Institute of Applied Health Research, University of Birmingham, Birmingham, UK

Tiffany E. Gooden

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• Diptesh Aryal
• , Shirish KC
• , Kanchan Koirala
• , Subekshya Luitel
• , Rohini Nepal
• , Sushil Khanal
• , Hem R Paneru
• , Subha K Shreshta
• , Sanjay Lakhey
• , Samina Amatya
• , Kaveri Thapa
• , Radhika Maharjan
• , Roshani Kafle
• , Anita Bashyal
• , Reema Shrestha
• , Dipika Khadka
•  & Nilu Dullewe

Contributions

All authors conceptualised this study. SK, DA, AB, RH, and SL developed the protocol, study methods, and materials. KK and SL facilitated the data collection, supervised by SK and DA. Data were analysed by SK, AB, KK, and TEG. SK and TEG wrote the drafts of the manuscript, and all authors reviewed the manuscript and consented to it being submitted. AB is the senior author.

Corresponding author

Correspondence to Diptesh Aryal .

Ethics declarations

Ethics approval and consent to participate.

Ethics approval was granted from the Nepal Health Research Council (approval number: 176/2021 P). All participants provided informed consent electronically before completing the online questionnaire. Participants from the qualitative component provided further informed verbal consent before the interview commenced.

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The authors declare no competing interests.

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Members of the CCAA are listed in the acknowledgments

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KC, S., Gooden, T.E., Aryal, D. et al. The burden of anxiety, depression, and stress, along with the prevalence of symptoms of PTSD, and perceptions of the drivers of psychological harms, as perceived by doctors and nurses working in ICUs in Nepal during the COVID-19 pandemic; a mixed method evaluation. BMC Health Serv Res 24 , 450 (2024). https://doi.org/10.1186/s12913-024-10724-7

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