{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,1]],"date-time":"2026-06-01T16:50:09Z","timestamp":1780332609444,"version":"3.54.1"},"reference-count":45,"publisher":"MDPI AG","issue":"6","license":[{"start":{"date-parts":[[2021,3,13]],"date-time":"2021-03-13T00:00:00Z","timestamp":1615593600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["IJERPH"],"abstract":"<jats:p>Medical education has been uniquely affected by the Novel Coronavirus Disease 2019 (COVID-19). As the pandemic\u2019s psychological impacts on medical students remain unclear, this study assessed COVID-19\u2019s impacts on undergraduate medical students\u2019 stress and anxiety. A nationwide, online survey was administered via email chains between June-August 2020 to first-fourth year medical students in the United States. Demographics, 4-point Perceived Stress Scale that measures stress, 7-point Generalized Anxiety Disorder Scale that measures anxiety, and the impacts of social, health, and academic stressors due to COVID-19 were collected. Of the 852 students who participated, 66.1% experienced mild, moderate, or severe anxiety. Mean PSS-4 score was 7.25\/16. Stress was highest in second- through fourth-year students. Students with preexisting mental health conditions had significantly higher stress and anxiety scores, and higher percentage of stress attributed to COVID-19. Trust in government institutions during COVID-19 was the highest stressor in first- and second-year students. Delay\/availability of standardized exams was the highest stressor for third-year students. Impact on rotations\/residencies was the highest stressor for fourth-year students. Understanding how students\u2019 anxiety and stress have changed due to COVID-19 will allow educators to identify students in need and guide recommendations on the implementation of psychological interventions and support strategies.<\/jats:p>","DOI":"10.3390\/ijerph18062952","type":"journal-article","created":{"date-parts":[[2021,3,14]],"date-time":"2021-03-14T22:13:10Z","timestamp":1615759990000},"page":"2952","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":60,"title":["Assessing the Psychological Impacts of COVID-19 in Undergraduate Medical Students"],"prefix":"10.3390","volume":"18","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-2310-7594","authenticated-orcid":false,"given":"Alyssa A.","family":"Guo","sequence":"first","affiliation":[{"name":"Department of Biomedical Sciences, School of Medicine Greenville, University of South Carolina, Greenville, SC 29605, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marissa A.","family":"Crum","sequence":"additional","affiliation":[{"name":"Department of Biomedical Sciences, School of Medicine Greenville, University of South Carolina, Greenville, SC 29605, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3494-6334","authenticated-orcid":false,"given":"Lauren A.","family":"Fowler","sequence":"additional","affiliation":[{"name":"Department of Biomedical Sciences, School of Medicine Greenville, University of South Carolina, Greenville, SC 29605, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2021,3,13]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"145","DOI":"10.7326\/M20-1281","article-title":"The Role of Medical Students during the COVID-19 Pandemic","volume":"173","author":"Miller","year":"2020","journal-title":"Ann. Intern. Med."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"2131","DOI":"10.1001\/jama.2020.5227","article-title":"Medical Student Education in the Time of COVID-19","volume":"323","author":"Rose","year":"2020","journal-title":"JAMA"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"57","DOI":"10.1186\/s12992-020-00589-w","article-title":"Prevalence of stress, anxiety, depression among the general population during the COVID-19 pandemic: A systematic review and meta-analysis","volume":"16","author":"Salari","year":"2020","journal-title":"Glob. Health"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"1121","DOI":"10.1007\/s11126-020-09808-4","article-title":"Past Epidemics, Natural Disasters, COVID19, and Mental Health: Learning from History as we Deal with the Present and Prepare for the Future","volume":"91","author":"Esterwood","year":"2020","journal-title":"Psychiatr. Q."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"891","DOI":"10.1097\/NMD.0b013e3181924d03","article-title":"Stress and Depressive Symptoms\/Dysphoria Among US Medical Students","volume":"196","author":"Compton","year":"2008","journal-title":"J. Nerv. Ment. Dis."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"354","DOI":"10.1097\/00001888-200604000-00009","article-title":"Systematic Review of Depression, Anxiety, and Other Indicators of Psychological Distress among U.S. and Canadian Medical Students","volume":"81","author":"Dyrbye","year":"2006","journal-title":"Acad. Med."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"2214","DOI":"10.1001\/jama.2016.17324","article-title":"Prevalence of Depression, Depressive Symptoms, and Suicidal Ideation Among Medical Students","volume":"316","author":"Rotenstein","year":"2016","journal-title":"JAMA"},{"key":"ref_8","doi-asserted-by":"crossref","unstructured":"Lasheras, I., Gracia-Garc\u00eda, P., Lipnicki, D.M., Bueno-Notivol, J., L\u00f3pez-Ant\u00f3n, R., De La C\u00e1mara, C., Lobo, A., and Santab\u00e1rbara, J. (2020). Prevalence of Anxiety in Medical Students during the COVID-19 Pandemic: A Rapid Systematic Review with Meta-Analysis. Int. J. Environ. Res. Public Health, 17.","DOI":"10.3390\/ijerph17186603"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"103","DOI":"10.1002\/da.20185","article-title":"Anxiety symptoms and perceived performance in medical students","volume":"24","author":"Chandavarkar","year":"2007","journal-title":"Depress. Anxiety"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"1266","DOI":"10.3201\/eid2606.200516","article-title":"Severe Acute Respiratory Syndrome Coronavirus 2 from Patient with Coronavirus Disease, United States","volume":"26","author":"Harcourt","year":"2020","journal-title":"Emerg. Infect. Dis."},{"key":"ref_11","unstructured":"(2021, January 30). Guidance on Medical Students\u2019 Participation in Direct In-person Patient Contact Activities. Available online: https:\/\/www.aamc.org\/system\/files\/2020-08\/meded-August-14-Guidance-on-Medical-Students-on-Clinical-Rotations.pdf."},{"key":"ref_12","first-page":"e7800","article-title":"COVID-19 Implications on Clinical Clerkships and the Residency Application Process for Medical Students","volume":"12","author":"Akers","year":"2020","journal-title":"Cureus"},{"key":"ref_13","doi-asserted-by":"crossref","unstructured":"Gabrielson, A.T., Kohn, J.R., Sparks, H.T., Clifton, M.M., and Kohn, T.P. (2020). Proposed Changes to the 2021 Residency Application Process in the Wake of COVID-19. Acad. Med., 95.","DOI":"10.1097\/ACM.0000000000003520"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"225","DOI":"10.32598\/bcn.11.covid19.2549.1","article-title":"Fear, Loss, Social Isolation, and Incomplete Grief Due to COVID-19: A Recipe for a Psychiatric Pandemic","volume":"11","author":"Mortazavi","year":"2020","journal-title":"Basic Clin. Neurosci. J."},{"key":"ref_15","first-page":"19","article-title":"Loneliness: A Signature Mental Health Concern in the Era of COVID-19","volume":"290","author":"Lopez","year":"2020","journal-title":"Psychiatry Res."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"102258","DOI":"10.1016\/j.janxdis.2020.102258","article-title":"Fear of the coronavirus (COVID-19): Predictors in an online study conducted in March 2020","volume":"74","author":"Mertens","year":"2020","journal-title":"J. Anxiety Disord."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"110233","DOI":"10.1016\/j.paid.2020.110233","article-title":"Personal economic anxiety in response to COVID-19","volume":"167","author":"Mann","year":"2020","journal-title":"Pers. Individ. Differ."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"2049","DOI":"10.1056\/NEJMsb2005114","article-title":"Fair Allocation of Scarce Medical Resources in the Time of Covid-19","volume":"382","author":"Emanuel","year":"2020","journal-title":"N. Engl. J. Med."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"1617","DOI":"10.1177\/1359105313508346","article-title":"New, normative, English-sample data for the Short Form Perceived Stress Scale (PSS-4)","volume":"18","author":"Warttig","year":"2012","journal-title":"J. Health Psychol."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"385","DOI":"10.2307\/2136404","article-title":"A global measure of perceived stress","volume":"24","author":"Cohen","year":"1983","journal-title":"J. Health Soc. Behav."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"e040620","DOI":"10.1136\/bmjopen-2020-040620","article-title":"Mental health in the UK during the COVID-19 pandemic: Cross-sectional analyses from a community cohort study","volume":"10","author":"Jia","year":"2020","journal-title":"BMJ Open"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"106395","DOI":"10.1016\/j.dib.2020.106395","article-title":"Psychometric data on knowledge and fear of coronavirus disease 2019 and perceived stress among workers of filipino origin in Hong Kong","volume":"33","author":"Li","year":"2020","journal-title":"Data Brief"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"266","DOI":"10.1097\/MLR.0b013e318160d093","article-title":"Validation and Standardization of the Generalized Anxiety Disorder Screener (GAD-7) in the General Population","volume":"46","author":"Decker","year":"2008","journal-title":"Med. Care"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"1092","DOI":"10.1001\/archinte.166.10.1092","article-title":"A Brief Measure for Assessing Generalized Anxiety Disorder","volume":"166","author":"Spitzer","year":"2006","journal-title":"Arch. Intern. Med."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"317","DOI":"10.7326\/0003-4819-146-5-200703060-00004","article-title":"Anxiety Disorders in Primary Care: Prevalence, Impairment, Comorbidity, and Detection","volume":"146","author":"Kroenke","year":"2007","journal-title":"Ann. Intern. Med."},{"key":"ref_26","unstructured":"(2021, January 30). American Osteopathic Association. Available online: https:\/\/osteopathic.org\/about\/aoa-statistics\/#:~:text=Number%20of%20new%20DOs%20sets%20a%20record%20in%202019&text=Nearly%207%2C000%20new%20physicians%20graduated,of%20the%20American%20physician%20population."},{"key":"ref_27","unstructured":"(2021, January 30). Association of American Medical Colleges. Available online: https:\/\/www.aamc.org\/data-reports\/students-residents\/interactive-data\/2020-facts-enrollment-graduates-and-md-phd-data."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"547","DOI":"10.1016\/S2215-0366(20)30168-1","article-title":"Multidisciplinary research priorities for the COVID-19 pandemic: A call for action for mental health science","volume":"7","author":"Holmes","year":"2020","journal-title":"Lancet Psychiatry"},{"key":"ref_29","doi-asserted-by":"crossref","unstructured":"Quek, T.T.-C., Tam, W.W.-S., Tran, B.X., Zhang, Z., and Ho, R.C.-M. (2019). The Global Prevalence of Anxiety Among Medical Students: A Meta-Analysis. Int. J. Environ. Res. Public Health, 16.","DOI":"10.3390\/ijerph16152735"},{"key":"ref_30","doi-asserted-by":"crossref","unstructured":"Mousa, O.Y., Dhamoon, M.S., Lander, S., and Dhamoon, A.S. (2016). The MD Blues: Under-Recognized Depression and Anxiety in Medical Trainees. PLoS ONE, 11.","DOI":"10.1371\/journal.pone.0156554"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"113098","DOI":"10.1016\/j.psychres.2020.113098","article-title":"Psychological Outcomes Associated with Stay-at-Home Orders and the Perceived Impact of COVID-19 on Daily Life","volume":"289","author":"Tull","year":"2020","journal-title":"Psychiatry Res."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"542","DOI":"10.1097\/00001888-199706000-00022","article-title":"A longitudinal study of students\u02bc depression at one medical school","volume":"72","author":"Rosal","year":"1997","journal-title":"Acad. Med."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"614","DOI":"10.1177\/0275074020941734","article-title":"A Failure of Political Communication Not a Failure of Bureaucracy: The Danger of Presidential Misinformation during the COVID-19 Pandemic","volume":"50","author":"Hatcher","year":"2020","journal-title":"Am. Rev. Public Adm."},{"key":"ref_34","doi-asserted-by":"crossref","unstructured":"Painter, M., and Qiu, T. (2020). Political Beliefs affect Compliance with COVID-19 Social Distancing Orders. SSRN Electron. J., 103\u2013119.","DOI":"10.2139\/ssrn.3569098"},{"key":"ref_35","doi-asserted-by":"crossref","unstructured":"Kahane, L.H. (2021). Politicizing the Mask: Political, Economic and Demographic Factors Affecting Mask Wearing Behavior in the USA. East. Econ. J., 1\u201321.","DOI":"10.1057\/s41302-020-00186-0"},{"key":"ref_36","unstructured":"(2021, January 30). American Medical Association. Available online: https:\/\/www.ama-assn.org\/residents-students\/usmle\/delays-miscommunications-add-even-more-stress-usmle-step-exams."},{"key":"ref_37","unstructured":"(2020, December 10). The Impact of COVID-19 on Mental, Neurological and Substance Use Services: Results of a Rapid Assessment. Available online: https:\/\/www.who.int\/publications\/i\/item\/978924012455."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"813","DOI":"10.1016\/S2215-0366(20)30307-2","article-title":"How mental health care should change as a consequence of the COVID-19 pandemic","volume":"7","author":"Moreno","year":"2020","journal-title":"Lancet Psychiatry"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"403","DOI":"10.1007\/s40615-015-0087-x","article-title":"Mental Well-Being in First Year Medical Students: A Comparison by Race and Gender","volume":"2","author":"Hardeman","year":"2015","journal-title":"J. Racial Ethn. Health Disparities"},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"94","DOI":"10.1097\/ACM.0b013e3181c46aad","article-title":"Burnout and Serious Thoughts of Dropping Out of Medical School: A Multi-Institutional Study","volume":"85","author":"Dyrbye","year":"2010","journal-title":"Acad. Med."},{"key":"ref_41","unstructured":"(2021, March 04). Association of American Medical Colleges. Available online: https:\/\/www.aamc.org\/media\/38916\/download."},{"key":"ref_42","doi-asserted-by":"crossref","unstructured":"Dalsania, A.K., Fastiggi, M.J., Kahlam, A., Shah, R., Patel, K., Shiau, S., Rokicki, S., and Dallapiazza, M. (2021). The Relationship Between Social Determinants of Health and Racial Disparities in COVID-19 Mortality. J. Racial Ethn. Health Disparities, 1\u20138.","DOI":"10.1007\/s40615-020-00952-y"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"94","DOI":"10.1080\/13557858.2020.1830035","article-title":"(Chuck) Testing three explanations for stigmatization of people of Asian descent during COVID-19: Maladaptive coping, biased media use, or racial prejudice?","volume":"26","author":"Cho","year":"2021","journal-title":"Ethn. Health"},{"key":"ref_44","unstructured":"(2021, March 04). American Psychological Association. Available online: https:\/\/www.apa.org\/topics\/anxiety."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"78","DOI":"10.1016\/j.cmrp.2020.03.011","article-title":"Effects of COVID-19 pandemic in daily life","volume":"10","author":"Haleem","year":"2020","journal-title":"Curr. Med. Res. Pr."}],"container-title":["International Journal of Environmental Research and Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1660-4601\/18\/6\/2952\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T05:35:20Z","timestamp":1760160920000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1660-4601\/18\/6\/2952"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,3,13]]},"references-count":45,"journal-issue":{"issue":"6","published-online":{"date-parts":[[2021,3]]}},"alternative-id":["ijerph18062952"],"URL":"https:\/\/doi.org\/10.3390\/ijerph18062952","relation":{},"ISSN":["1660-4601"],"issn-type":[{"value":"1660-4601","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,3,13]]}}}