Suicidal ideation in medical students: a worldwide problem

Dear editor

We commend Coentre and Góis¹ for their valuable review of suicidal ideation in medical students across different countries. It raised pertinent questions surrounding the concerning rate of suicidal ideation and the need for early effective prevention and treatment strategies. As senior medical students, we would like to offer additional insight. Suicide is the second leading cause of mortality in young people and rates have been increasing worldwide;² medical students being particularly at high risk.

Suicidal ideation ranged from 1.8% to 53.6%. This broad prevalence was attributed to the heterogeneity in selected studies, arising from different research instruments used and different time frames captured.¹ It would be interesting to investigate whether other factors were at work, such as differences in cultural attitudes toward mental health or toxic bedside teaching – reported to be experienced by 85% of medical students.³ Coentre and Góis¹ highlighted some major risk factors such as psychiatric disorders like depression, drug use, and financial adversity. However, triggers for suicidal ideation may be as simple as a student being told by a consultant that they would never become a doctor.⁴

Medical students are less likely to seek mental health support for worries of stigmatization and treatment impact on fitness to practice. Consequently, the high prevalence of suicidality in medical students underscores the need for research into preventative and treatment programs, which the authors have also emphasized. We agree that simple psychoeducation can be effective in reducing suicidal ideation and depression.¹ We believe that stress coping strategies should be integrated into the curriculum so that students can develop emotional resilience. Some universities have already incorporated this. For example, in Saint Louis University, St. Louis, MO, USA, medical students’ mental health was improved by longer electives, reducing class hours, and organizing mindfulness sessions.⁵ In the UK, the General Medical Council and Medical Schools Council have produced guidance to help universities support student’s mental health.⁴ Nightline, confidential counseling services, wellbeing and development weeks are advocated by our medical schools.

This review has some shortfalls in terms of reporting if or how the quality of studies was assessed and the limited databases searched – PsycINFO and CINAHL – may offer further literature to review. Furthermore, prevalence of suicidal ideation and year of study were inconclusive in this review;¹ therefore, future qualitative work in the form of interviews and focus groups for each year group could investigate reasons for poor help-seeking, stressors, and potential protective factors. For example, students on far away placements have less access to supportive networks like their family, friends, general practitioner, and mental health services. We speculate that a lack of care continuity combined with witnessing distressing clinical situations could lead to suicidal ideation in susceptible students. Therefore, an improved link between placement providers and university services is required. As suicidal ideation was reported in some first-year students,¹ entry-level screening should be established to deduce whether there is a causative relationship between suicidal ideation and medical school environment or whether the environment simply exacerbates pre-existing vulnerabilities or personality traits.

Disclosure

The authors report no conflicts of interest in this communication.

References

1.		Coentre R, Góis C. Suicidal ideation in medical students: recent insights. Adv Med Educ Prac. 2018;9:873–880.
2.		World Health Organization. Preventing Suicide: A Global Imperative. Geneva: World Health Organization; 2014; Available from: http://apps.who.int/iris/bitstream/10665/131056/1/9789241564779_eng.pdf?ua=1&ua=1. Accessed December 4, 2018.
3.		Olasoji HO. Broadening conceptions of medical student mistreatment during clinical teaching: message from a study of “toxic” phenomenon during bedside teaching. Adv Med Educ Prac. 2018;9:483–494.
4.		Student BMJ [webpage on the Internet]. Medical students and suicide; 2018. Available from: http://student.bmj.com/student/view-article.html?id=sbmj.j1460. Accessed December 4, 2018.
5.		Slavin SJ, Schindler DL, Chibnall JT. Medical student mental health 3.0. Acad Med. 2014;89(4):573–577.

Authors’ reply

Ricardo Coentre^1,2, Carlos Góis^1,2

¹Department of Psychiatry, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, EPE, Lisboa, Portugal; ²Psychiatric University Clinic, Faculty of Medicine, University of Lisbon, Lisboa, Portugal

Correspondence: Ricardo Coentre, Department of Psychiatry, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, EPE, Av. Professor Egas Moniz, 1649-035 Lisboa, Portugal
Tel +351 21 780 5000
Email [email protected]

Dear editor

This letter is in response to the letter made by Ahmed and Arzoky. We think that these senior medical students made helpful comments to our article. We agree that suicide is a major health problem in young people and medical doctors have high risk. Some points need to be addressed in future research, namely to clarify some factors associated with suicidality in medical students. Despite this we think that we have to start a new era where preventive and treatment interventions are needed in a generalized way on medical schools in the world. A good example of this is the referred program implemented in Saint Louis University, St. Louis, MO, USA, where simple changes in medical curriculum and interventions led to a better medical students’ mental health.

Disclosure

The authors report no conflicts of interest in this communication.

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