Since the start of 2020, COVID-19, caused by the SARS-CoV-2 virus, has quickly spread worldwide, becoming a major global health crisis. This pandemic has led to unpredictable and mandatory transformations on a global scale, profoundly impacting the lives of individuals worldwide. ¹ The WHO has recommended implementing several preventive strategies, such as social distancing measures, restrictive regulations, self-quarantine, and transitioning to remote work, to reduce the spread of the COVID-19 pandemic and minimize mortality rates. ² In the realm of education, these changes have contributed to the new normal lifestyle where face-to-face and onsite learning have become impractical. Online lectures have become the standard, common, and fostering the widespread use of online meeting applications like Google Classroom, Google Meet, Zoom, Webex, and Microsoft Teams as major platforms for online learning. ³

Zoom emerged as one of the most popular videoconferencing platform for online learning during the COVID-19 pandemic. It is used for both personal and business purposes. The number of daily users skyrocketed from 10 million in December 2019 to 300 million in April 2020, making it the fastest-growing application in 2020. ⁴ However, excessive use of videoconferencing can lead to the novel phenomenon called “Zoom fatigue” or “Zoom exhaustion,” defined as physical and mental exhaustion from participating in virtual meetings through any online meeting application. ⁵ This condition may manifest in several domains, including general, emotional, visual, motivational, and social fatigue. ⁶

The study postulated the phenomenon of Zoom fatigue, linked to the excessive use of nonverbal communication in video conferencing. In comparison to regular meetings, video conferencing requires heightened concentration and attention. Various factors contribute to Zoom fatigue, including eye strain from prolonged close-range staring, increased cognitive load processing information in video calls, self-consciousness from constant self-reflection during calls, and restricted body movements in online sessions. Additionally, external factors beyond one’s control, such as internet disruptions, the pressure to respond to speaker questions, and environmental conditions, can exacerbate Zoom fatigue. Therefore, the condition of Zoom fatigue may impact individuals’ overall well-being. ⁷

A specific assessment tool to measure video-related fatigue, called the Zoom Exhaustion and Fatigue (ZEF) scale, was developed at Stanford University in 2021. ⁶ It comprises 15 items and assesses five domains: general fatigue, visual fatigue, social fatigue, motivation fatigue, and emotional fatigue. The scale has been translated into several languages. ^{8 , 9}

Medical students have faced profound challenges due to the COVID-19 pandemic and the transition to online learning. In a cross-sectional study conducted at a Brazilian medical school using the ZEF scale, findings revealed that up to 56% of participants experienced high levels of Zoom fatigue. ¹⁰ Beyond Zoom fatigue, studies also indicate a substantial increase in depression, anxiety, and mental problems, especially among university students, during the COVID-19 pandemic. ^{11 – 14} These findings suggest that university students, particularly medical students, are among the populations most affected by the mental health consequences of the pandemic, facing a heightened risk of developing depression and psychological problems. ¹⁴

In addition, several studies have demonstrated the relationship between Zoom fatigue and mental health conditions. A national survey conducted in the United States during the pandemic found a link between Zoom fatigue and depressive symptoms. ¹⁵ Another study also showed a positive correlation between Zoom fatigue and depression, anxiety, and stress, while showing a negative correlation between Zoom fatigue and life satisfaction and academic well-being. ¹⁶

However, to the best of our knowledge, to date, there are still few studies examining the prevalence of Zoom fatigue and its potential association with depression, with no such study conducted among medical students in Thailand. Therefore, our study aims to assess the prevalence of Zoom fatigue in medical students during the COVID-19 pandemic, identify associated potential risk factors, and investigate its correlation with depression.

A cross-sectional online survey was conducted among medical students during the academic year 2565 at Thammasat University, Thailand, from January to July 2022. This study received approval from the Human Research Ethics Committee of the Faculty of Medicine, Thammasat University (number 028/2565; date of approval: January 26, 2022), in accordance with the Declaration of Helsinki. Signed informed consent was waived by the Ethics Committee due to the online nature of the survey; however, participants were provided with study information on the first page.

To the best of our knowledge, this study represents the first investigation in Thailand into the prevalence of Zoom fatigue, associated factors, and its correlation with depression among Thai medical students during the COVID-19 pandemic. The results of the study reveal a 9.6% prevalence of Zoom fatigue among Thai medical students as a consequence of online learning during the pandemic. Furthermore, the study uncovers a significant relationship between Zoom fatigue and depression, emphasizing the importance of addressing both conditions, as they may impact students’ well-being and overall quality of life. ¹⁵

Our study revealed that the occurrence of Zoom fatigue among medical students was significant and supports the idea that it is a common phenomenon among individuals using online platforms for learning. The high prevalence may be explained by the implementation of social distancing measures throughout the country, with the university mandating the use of online learning for all lectures and restricting onsite sessions. This led to the necessity of attending at least two online sessions per day, each averaging over an hour per session. These online sessions demanded prolonged concentration, extended close-range staring, and a high cognitive load in learning and using videoconference programs. ^{5 , 6}

The prevalence in our study aligns with previous research conducted during the COVID-19 pandemic, which demonstrated moderately to high Zoom fatigue ranging from 48% to 68.6%. ^{10 , 19} Slight variations may be attributed to various factors such as videoconferencing time, study faculty, study type (hybrid or online only), and the type of online learning (lecture or more interactive meeting). Another crucial factor is that Zoom fatigue is a relatively new concept, lacking a worldwide standard criteria like major depressive disorder in DSM-5 or ICD-10. Therefore, the definition may vary between studies and depend on the questionnaires used. Consequently, it might be challenging at this time to directly compare the prevalence of Zoom fatigue between studies.

The study identified a significant correlation between Zoom fatigue and depression, with a substantial number of participants experiencing both Zoom fatigue and depression. Consistent with our findings, other studies, such as those by Elbogen et al. and Montag et al., also reported similar findings, indicating that depressive symptoms exhibited a significant association with Zoom fatigue, even when adjusting for demographic, psychosocial, and clinical covariates. ^{15 , 20} The connection between these two conditions might be explained by the overlapping symptoms observed in both Zoom fatigue and depression. For instance, social fatigue translates into an unwillingness to engage with others after videoconferences, while motivation fatigue reflects a diminished drive following such sessions. These symptoms bear a striking resemblance to the loss of interest commonly seen in major depressive disorders. Moreover, irritability and moodiness can also be found in depressive disorders. The connection between Zoom fatigue and depression may also be elucidated by the social isolation and loneliness associated with both conditions. Higher videoconference use might indicate increased social isolation and loneliness, contributing to the development or exacerbation of depression. Additionally, several studies have indicated that Zoom fatigue is linked not only to depression but also to psychological distress and lower life satisfaction. ¹⁶

This finding is unsurprising and aligns with the majority of previous studies that have demonstrated a correlation between an increased number of video conferencing sessions and higher fatigue. ^{6 , 19 , 21} Our study also identified lower academic years as another notable risk factor. This observation may be attributed to the relatively greater number of lecture hours in the preclinical years (1st – 3rd year) compared to the clinical years (4th – 6th year). Clinical medical students dedicate a substantial amount of time to engaging with patients in hospitals and participating in hands-on learning activities, including basic skill workshops and bedside teaching. Their education primarily focuses on real patient cases encountered in a hospital setting, rather than relying on theory-based lectures. Even during the pandemic, clinical students continue to work in hospitals and participate in bedside teaching, resulting in lower video conferencing usage. On the other hand, preclinical students mainly learn through lectures. Therefore, the challenges brought about by the transition to online learning during the pandemic may have affected preclinical students more than clinical students. This is consistent with previous studies conducted on both medical and non-medical students, which revealed that students in the lower academic years were more susceptible to experiencing mental distress related to their studies. ²²

Regular exercise has been identified as a protective factor against Zoom fatigue, suggesting that students consistently engaging in physical activity may exhibit better resilience to online learning challenges, reducing the likelihood of experiencing Zoom fatigue. This association can be explained by considering one of the underlying causes of Zoom fatigue—limited mobility or constrained body movements. Regular exercise promotes increased body movement, potentially mitigating the onset of Zoom fatigue. ⁷ Furthermore, compelling evidence indicates that exercise prevents various mental disorders, such as depression and anxiety disorders, offering multiple beneficial effects on both physical and mental health. Therefore, exercise may also play a role in preventing Zoom fatigue. ²³

To date, the use of video conferencing in education persists beyond the pandemic, becoming a part of our new normal lifestyle. It is imperative for instructors and users to recognize Zoom fatigue as a potential negative consequence. The significant prevalence of Zoom fatigue among medical students, along with its correlation with depression, emphasizes the importance of screening for both conditions, especially in lower academic years. Implementing proactive strategies, such as reducing session lengths and frequency, and promoting regular exercise, may contribute to symptom prevention.