Impact of the COVID-19 pandemic on the mental state of Polish students

Introduction: The COVID-19 pandemic has undoubtedly affected the mental health of the population. This issue has become the focus of interest of various research groups in recent years, resulting in a number of publications on the subject. Among other things, increases in anxiety, aggression, depression and other variables have been observed in different populations. Material and method: The authors of the present project conducted a web-based survey among university students in Poland. They used scales to assess the intensity of anxiety (GAD-7), aggressive behaviour (Buss-Perry Aggression Questionnaire - ABPQ), alcohol consumption (AUDIT test), and mental toughness (ER-89). The entire survey was conducted in two stages, with the second stage taking place by sending survey forms to email addresses previously provided by respondents. Results: In the first term of the study, higher levels of anxiety and anger and lower levels of alcohol consumption were observed among women compared to men. Medical students reported lower levels of verbal, physical and generalised aggression compared to non-medical students. A follow-up study conducted after three months showed a reduction in anxiety among students. Discussion: Adaptation to the COVID-19 pandemic among students did not differ from changes in other communities. Women are characterized by higher levels of anxiety and anger and less alcohol consumption compared to men. A significant decrease in anxiety intensity was observed in the follow-up study. Medical students were characterized by lower levels of verbal, physical and generalized aggression.


Introduction
Over the centuries, scientists have analysed the behaviour of society and the mental health of individuals in the face of various types of disasters [1][2][3].Epidemics, such as the plague or the Spanish flu, had a huge impact on the development of medicine [4][5].They also shaped society, forcing people to quickly change their behaviour, habits and to develop survival strategies [6].Climatic disasters, such as tsunamis and hurricanes, required immediate adaptation to radically changing living conditions.Refugees and war veterans often struggle with a variety of psychiatric disorders, often with a significant range of symptoms [7][8][9].Those affected by difficult experiences often need long-term psychotherapy and pharmacotherapy to cope with the personal effects of the armed conflict.Many of them in this situation develop unhealthy compensatory mechanisms, e.g.alcohol abuse, drug abuse, gambling and aggression [10].
One of the most recent events that has attracted a great deal of scientific interest is the COVID-19 pandemic, which broke out in late 2019 [11][12][13].Groups in a particular situation due to the artificial deprivation of social contact were schoolchildren and students.As previous studies have shown, they were particularly vulnerable to increased levels of stress, as well as anxiety, or depression [14][15].This article examines the reaction of Polish students to the COVID-19 pandemic.

Impact of the COVID-19 pandemic on society
COVID-19 is a viral disease that emerged in 2019, with the first cases reported in the city of Wuhan, China [16].The SARS-CoV-2 virus began to spread rapidly, resulting in the declaration of an epidemic and then a pandemic state.From its inception until September 2023, the disease has caused nearly 7 million deaths worldwide [17].
The first studies on the impact of the pandemic on society were published as early as in 2020.One of these was an article in The Lancet, which highlighted the main complaints associated with the pandemic and the lockdown it caused -these were stress, lowered mood and irritability [11].Other publications suggest that the population was significantly more likely to experience stress during the pandemic than in previous years.The possibility of developing post-traumatic stress disorder after experiencing COVID-19 [18] cannot be overlooked either.A UK study found that the prevalence of symptoms of depression, anxiety and insomnia during the pandemic was significantly higher compared to the pre-pandemic period.It was also observed that women reported the aforementioned symptoms more frequently than men.Of the age groups studied, younger people were most affected by the pandemic situation and older people aged 65 and over were least affected [13].Seniors were more likely to comply with the restrictions and recommendations associated with the pandemic.During the first month of the pandemic, they were also characterised as less likely to engage in risky behaviour; however, this relationship ceased to be noticeable as the pandemic progressed.It was also observed that female gender, membership of a racial or ethnic minority, high socio-economic status, a high number of COVID-19 cases in the place of residence, subjective perception of the pandemic as a major threat and even left-wing political views appeared to correlate positively with pandemic mitigation behaviour [19].
A US study analysed public behaviour at the start of a pandemic.The results showed that levels of depression and anxiety were significantly elevated at the beginning of April 2020, but decreased over time.This means that people initially experienced an increase in negative emotions related to the pandemic, but gradually adapted to the new situation.It was also noted that the severity of depression and anxiety was higher in people who experienced negative economic impacts associated with COVID-19 and in those who feared that the pandemic would last a very long time.The study found risk factors associated with higher levels of depression and anxiety, such as female gender, younger age, lower income and a previous diagnosis of a mental disorder.In addition, being in a relationship played an important role and was associated with lower levels of depression, although anxiety was not affected.Those who were better informed and more aware of the pandemic had lower levels of depression.However, increasing COVID-19 and heavy use of social media appeared to be associated with higher alkoholu wśród kobiet w porównaniu do mężczyzn.Studenci kierunków medycznych zgłaszali niższe poziomy agresji słownej, fizycznej i uogólnionej w porównaniu do studentów kierunków niemedycznych.Badanie follow-up przeprowadzone po 3 miesiącach wykazało zmniejszenie nateżenia lęku wśród studentów.
The deterioration of the public's mental state was also linked to the need for professional support.It appears that although medical prescriptions fell by 2.5 per cent during the pandemic, prescriptions for psychotropic drugs increased by 6.1 per cent.The study in question was carried out in Spain and was a cross-sectional study covering a region of 304,182 inhabitants, but prescriptions written to people under 25 years of age were excluded from the analysis.The most commonly prescribed drugs were anxiolytics and, in turn, sleeping pills and antidepressants.Pharmacotherapy was most commonly used by women, older people and the population living in rural areas.This study compared data from the prepandemic period (March 2019 -February 2020) with the corresponding period during the COVID-19 pandemic (March 2020 -February 2021) [21].

Material and methods
Our survey was conducted entirely via the Internet using Google Forms electronic forms, which, in order to reach as many respondents as possible, were made available, among others, in student groups on social networking sites such as Facebook.Prior to conducting the survey, the Bioethics Committee of the Silesian Medical University in Katowice issued a positive opinion on the conduct of this survey.Each time at the beginning of the study, respondents were asked to read the detailed rules of participation in the project, had the opportunity to accept them by ticking the appropriate option in the form, and were then redirected to the question on consent for participation in the study.
The acquisition of material for the study took place in two stages.The first was conducted from 24 April to 8 May 2020, when there were significant restrictions related to the ongoing epidemic and later pandemic state.During this time, all classes held at universities had to be suspended or conducted online.During this phase, 195 students (including 38 men and 157 women) participated in the study.The second stage -the follow-up -took place from 17 July to 31 August 2020.Respondents, who voluntarily provided their email addresses in the first stage, were sent messages asking them to participate in the next stage of the survey.Twenty-nine students participated (6 men and 23 women).Data characterising the study groups are summarised in Table 1 (Table 1).Place of residence was not included due to the location of the universities in large cities, which did not provide a basis for differentiating respondents in this respect.In addition to the scales presented below, respondents were asked whether they were studying medical faculties, with the explanation that, for the purposes of this study, medical faculties are understood in a relatively broad sense of subsequent professional contact with health care -so it should be assumed that this group includes people from faculties such as medicine, paramedicine, physiotherapy or medical analytics.Similarly, "non-medical" faculties were understood as those which did not have direct contact with health care -such as law, management or philology.This division was only applied to the first term of the study, and this aspect is discussed in detail in the chapter 'Limitations and strengths'.
A self-administered questionnaire containing a sociodemographic questionnaire and questions on inclusion and exclusion criteria, as well as the same questionnaires for the assessment of selected mental status parameters were used in both stages of the study.The GAD-7 (Generalised Anxiety Disorder Assessment 7) questionnaire is a relevant and effective tool for screening for generalised anxiety disorder and assessing its severity in clinical practice.It consists of 7 questions that can be answered by the respondent according to a 4-point scale [22].The Buss and Perry Aggression Questionnaire (ABPQ) is a test containing 29 questions that the respondent can answer according to a 5-point scale.It measures four aspects of aggression: physical and verbal aggression, hostility and anger.The total score determines the level of generalised aggression [23,24].The AUDIT test (The Alcohol Use Disorders Identification Test) consists of 10 questions to which the respondent  [25].All consenting adults who did not meet the exclusion criteria, which included events significantly affecting the respondents' lives in the 12 months before the survey and treatment with a psychiatrist in the 6 months before the survey, were included.A full description of the scales used and the inclusion and exclusion criteria are presented in a separate article [26].
Statistical analysis was performed for the collected data, using Excel 365 and Statistica 13.3.The Shapiro-Wilk test was used to verify the normality of the distributions.In the comparative analyses performed for the first stage of the study, the Mann-Whitney U test was used.However, for the comparative analyses of dependent variables -sign test for data from the follow-up phase, which was conducted limited to the group of 29 respondents.Statistical analyses were conducted at a significance level of α=0.05.

Results
The results of the first study showed that women reported higher levels of anxiety and anger and consumed less alcohol than men.For the scale of the GAD-7, the median score for women was 7 points (mean 7.81, SD ±4.67), while for men it was 4 points (mean 4.39, SD ±3.15).For the anger subscale of aggression, the median score for women was 19 points (mean 19.26, standard deviation [SD] ±5.63), while for men it was 17 points (mean 15.72, SD ±6.22).In the AUDIT test, on the other hand, the results were the opposite, with a median for women of 3 points (mean 3.92, SD ±2.81) and for men of 5 points (mean 6.50, SD ±5.65).Statistical analyses were performed for the above data using the Mann-Whitney U test, which showed statistically significant differences in the data described.
It was also observed that medical students had significantly lower levels of physical and generalised aggression compared to non-medical students.The difference in verbal aggression in this comparison was also statistically significant, but less than that described above.A detailed summary of the analysed data can be found in Table 2 (Tab.2).The follow-up study highlighted a statistically significant reduction in anxiety among the students compared to three months before (Fig. 1).

Discussion
The observed higher levels of anxiety among women are consistent with the results of other studies conducted during the COVID-19 pandemic, as a comprehensive meta-analysis clearly indicates higher levels of COVID-19-related anxiety specifically among women [27].Furthermore, another review study conducted in 2003, which analyses differences between men and women, also indicates higher levels of anxiety among women [28].This may mean that the differences between men and women observed in our study are characteristic of society as a whole, as they are reflected in the previously mentioned studies.Consequently, higher levels of anxiety may not be directly related to the COVID-19 pandemic, nevertheless, this issue requires further research in this regard.Another variable analysed is anger, which, in our study, was found to be higher in the group of female students compared to males.This is in line with the results of a study conducted on a group of Russian women, which showed high levels of aggression during the isolation caused by the COVID-19 pandemic [29].On the other hand, the results of one study conducted outside the pandemic period indicate that it is men who are more prone to react with anger even in situations involving a relatively small stimulus [30].It may be that the impact of pandemics and lockdowns has a different effect on individuals of different genders than other stressful situations.
Another difference by gender was noted in terms of alcohol consumption.In our study, it was male students who consumed more alcohol than females.Such a result is consistent with a large international study conducted outside the COVID-19 pandemic period [31].However, as another study indicates -women were significantly more exposed to stress than men.During the COVID-19 pandemic, they were significantly more likely to use alcohol and periodically equalled their When referring to the present study, cultural differences should be taken into account as it was conducted in the United States on a sample of 754 people (50% of whom were women) [32].The absence of this observation in our study may suggest that female students cope better with stress than women in the general population.Assuming a division between medical and non-medical students, no difference in alcohol consumption was highlighted.
Another study of first-and second-year psychology students in the UK showed a significant decrease in alcohol consumption.Importantly, the aforementioned study also used the AUDIT test [29].Medical students, compared to non-medical students, had lower levels of generalised, physical and verbal aggression.One likely reason for this observation may be the greater knowledge and awareness of the pandemic and COVID-19 disease itself among medical students, as evidenced by a study among Pakistani medical students [30].This attitude may translate into less pessimism, maintenance of safe practices and respect for restrictions [31].In the light of the research presented, it seems reasonable to have lower levels of aggression and its components in the group of students in question.
The observed reduction in anxiety intensity among all students noticed in the follow-up study should be interpreted with caution due to the small number of respondents.The study by Shuster et al. also suggests emotional adaptation among participants.Over a period of time from April to June 2020, levels of depression and anxiety were measured, which were initially high but began to decline significantly over time [20].Similarly, a study of UK students showed a significant decrease in anxiety and depression between July 2020 and March 2021 [32].This situation could be interpreted as an emotional adaptation of most social groups to the presence of the COVID-19 pandemic, but no such conclusion can be drawn based on the present study.For this reason, further projects are needed to identify the mechanisms of adaptation to the pandemic COVID-19 in different social groups.

Limitations and strengths of the work
First of all, the underrepresentation of students in the follow-up phase is noteworthy, which was the result of several variables.Firstly, the relatively small proportion of participants in the first term who voluntarily left their emails for use in the follow-up phase.Secondly, following the elimination of some participants who met the inclusion criteria in the first part of the study, but no longer met them in the second part.These two variables appear to have significantly affected the current status of the student group in the follow-up phase.Undoubtedly, the quantitative disproportion between the women and men taking part in the survey should also be noted.In both the first and second parts of the survey, it is easy to see a significant over-representation of women.This may be due to the fact that women were more willing to participate in the survey, perhaps also because they were more affected by the pandemic, which could affect the results of our analysis.
The study we conducted has also its strengths.First of all, it fits into the relatively few Polish studies involving a follow-up phase on the impact of the pandemic COVID-19 on students' mental health.Secondly, it should be noted that it is among the single studies on the intensity of aggression during the COVID-19 pandemic among Polish students.

Conclusions
1.In the first phase of the pandemic, female students were able to cope better with stress than women in the general population.2. Among students, adaptation to the COVID-19 pandemic did not differ from changes in other communities.3.With the passing of the COVID-19 pandemic and a reduction in restrictions, such as the ban on leaving the house even to the forest, or restrictions on the number of people in shops or other service points, a significant decrease in the severity of anxiety was observed among the study group of students.4. At the beginning of the COVID-19 pandemic, medical students were characterised by lower levels of verbal, physical and generalised aggression, which is probably related to having more medical knowledge compared to students in other disciplines.

Table 1 . Characteristics of the study groups Variable 1st phase (n=194) 2nd phase -follow-up (n=28) n % n %
answers on a 3-or 4-point scale.It aims to identify risky, harmful and dependent alcohol users

Table 2 .
Comparative analysis of generalized aggression and its subscales among medical and non-medical students *statistically significant result; SD -standard alcohol consumption with men as the stress increased.