Over the last few years, there has been increasing interest in the psychological well-being of medical students in the wake of numerous scientific publications. A paper published in Journal of American Medical Association, reporting data on 129,000 medical students from 47 countries and pooled up findings from 167 studies, brought mental health issues of medical students to limelight. The results showed that 27% of medical students had clinical depression while 11.5% demonstrated suicidal ideations. Moreover, the findings confirmed that only 15% of depressed students had sought treatment accounting for a treatment gap of 85%. The review reinforced the pressing nature of depression and recommended urgent actions to meet the psychological needs of medical students.1
Traditionally choosing medicine as a prospective career remains a desirable aptitude among students for the reason that medicine is considered a noble and gratifying professional opportunity. Yet, the entry to medical school is highly competitive and study period usually is a taxing experience for students, whereby they undergo stressful and hierarchical discourse of learning. Ideally, medical school is expected to provide culture of professionalism and collegiality. However, the question is that whether this expectation is realistic or merely an idealistic statement? In addition, is it reasonable to believe that environment in medical school is free of stress, adjustment disorders, depression and other psychiatric disorders? Unfortunately, the fact is that prevalence of Common Mental Disorders (CMDs) like depression and anxiety is higher in medical students than community. For instance, a meta-analysis showed that depression may be higher in medical students than general population, estimated to be one third of them having clinical depression, mostly with additional co-morbidities like anxiety and substance abuse.2 Similarly, a longitudinal study published recently demonstrated that various factors including anxiety traits, burn out and interpersonal stress make the medical students emotionally vulnerable to persistent depressive symptoms.3 Likewise, a nationwide survey in Australia indicated that medical students have higher rates of depression and distress than Australian population, with female students being more vulnerable than males. The survey also reported that they have more stigmatizing attitudes towards mental health problems thus possibly barring them to seek professional help.4
The situation in Pakistan is not different rather worse than rest of the world, considering the relatively high prevalence of CMDs ranging from 35 to 45% in females and 15 to 35% in males. Additionally, meager resources, wide treatment gap, ubiquitous psychosocial stressors and stigma associated with mental illnesses make the situation even more complicated.5 In Pakistan there is dearth of research looking at medical student’s well-being. However, a growing amount of studies point towards shocking statistics. In a research published in 2009, we found that 30% of the surveyed medical students had depression, more than half (52%) knew about depression in their fellow students and less than 15% had the opportunity to seek professional help.6 Likewise, a survey of 500 medical students for screening of common mental disorders using Aga Khan University Anxiety and Depression Scale (AKUADS), showed that 39% of the students had anxiety and depression while more than half of the cases found in first two years of medical school.7 In a similar research, Nadia & colleagues reported that 19% of medical students in a private medical college had moderate to severe anxiety and depression while 37% showed mild depressive symptoms with significantly more female students suffering from the ailment.8
Depression is major contributor to global burden of disease with social, psychological and biological complications. One of the tragic complications is suicidal behavior which includes suicidal ideations (frequent thoughts of ending one’s life), suicide attempts (the actual attempt to kill one’s self) and completed suicide (death occurs). Numerous reports demonstrated that medical students are at higher of risk of exhibiting suicidal behavior than general population. For example a systematic review with sample size of 13244 medical students from both developed and developing countries revealed a range of 1.8% to 53% prevalence of suicidal ideation associated with depression.9
Pakistan is not an exception, where available research shows compelling evidence of psychiatric morbidity and suicidal behavior among medical students. A study conducted in Karachi, Pakistan looking at suicidal behavior among medical students of a public sector medical school, demonstrated that 35% students had suicidal ideation, 13% had an elaborate plan to kill themselves while 4.8% had history of attempted suicide.10 In another research by Haider & colleagues, the authors concluded that 9.5 % medical students in a private medical college had the desire to harm themselves while significant number had the difficulty to regulate their emotion. The study further reinforced that junior students were more likely to have suicidal ideation than seniors and less likely to seek help.11
Interestingly, there is enough literature elucidating the causative factors of depression in medical students sufficient to generate discussion. For instance, Brazeau CM, et al. 12 raised an important point indicating that medical students start their education with comparable mental health to students in other disciplines, but they go on to develop depression more frequently than their aged-matched peers. The authors asserted that there might be some kind of adversity within the educational environment, responsible for deterioration of mental health of medical students.
A research on well-being of medical students in Pakistan confirmed that in addition to workload, adjustment problems, financial and relationship issues contributing to depression in medical students, the consequences of bullying and harassment may be a source of serious mental health concerns. The study pointed out that two out of five students had insight that various environmental stressors in medical school affected their psychological health adversely.6 While bullying has many facets, the commonest denominator is persistence in belittling, intimidating an individual, undermining his/her self esteem and confidence. It aims to frighten a person or hurt him/her through rumors, insult, micro-aggression, sarcasm or even a physical attack.13 The lasting psychological effects of bullying reported to be an important antecedent factor for depression, anxiety, lower self-esteem and even suicidal behavior in medical students. In a cross-sectional survey in Pakistan, capturing data from all the provinces, Ahmer S, et al. reported that 52% of the medical students had faced bullying or harassment during their medical education and 28% facing them every month or more frequently. They also reported that the commonest perpetrators of bullying were consultants and faculty members.14 Similarly, another study conducted more recently demonstrated that 66% of the medical students had faced the bullying behavior during the past six months, the commonest bullying type was verbal abuse (63%) followed by gesturing (52%) and about 70% of the victims were females.15
In nutshell, medical students are vulnerable to common mental disorders and may be more prone to devastating complications like suicide. Over last two and half months, three medical students committed suicide in Pakistan, which is an eye-opening phenomenon for medical educationists and mental health professionals. During an in-depth interview with closed friends of two of the suicide victims, we had the chance to explore various psychosocial dimensions of the deceased students. Reportedly, they were intelligent students with excellent academic record, critical thinking and capacity to ask questions. Report also suggested that they had depression and were victims of bullying of one or another from. Their friends knew about their psychological sufferings but they had not sought any professional help. Except that one of the victims who called his closed friend the same night he committed suicide, asking for support, unfortunately he could not get the most needed help.
Looking at the current situation, it is right time to take action by raising awareness about mental illness among medical students, destigmatizing the psychological ailments at all levels and encouraging the affected students to seek help. It is an urgent call that medical schools need to set up counseling centers to address the mental health crisis, menace of bullying and make focus efforts to address the mental needs of medical students. By initiating a dialogue among medical educationists to focus mental health of medical students, perhaps we can bring radical change to have psychologically sound future physicians.
At the end, we want to mention the Facebook status of the recent suicide victim, a final year medical student, who publically shared the Brazilian author Paulo Coelho’s quote, 4 days before he ended his life. “It takes a huge effort to free yourself from memory”
Rotenstein LS, Ramos MA, Torre M, Segal JB, Peluso MJ, Guille C, et al. Prevalence of Depression, Depressive Symptoms, and Suicidal Ideation Among Medical Students-A Systematic Review and Meta-Analysis. JAMA 2016; 316(21):2214-36. DOI: 10.1001/jama.2016.17324.
Moir F, Yielder J, Sanson J, Chen Y. Depression in medical students: current insights. Adv Med Educ Pract 2018;7(9):323-33. DOI: 10.2147/AMEP.S137384.
Silva V, Costa P, Pereira I, Faria R, Salgueira AP, Costa MJ, et al. Depression in medical students: insights from a longitudinal study. BMC Med Educ 2017;17:184. DOI: 10.1186/s12909-017-1006-0.
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Anam A, Kazim M, Madiha H, Shafaq M, Neil M, Yousufzai AW. Prevalence of anxiety and depression among medical students of Shifa College of Medicine. Pak J Neurol Sci 2014;9(3):12-5.
Azad N, Shahid A, Abbas N, Shaheen A, Munir N. Anxiety and depression in medical students of a private medical college. J Ayub Med Coll Abbottabad 2017 Jan-Mar;29(1):123-7.
Coentre R, Gois C. Suicidal ideation in Medical Students: recent insight. Adv Med Educ Pract 2018 Nov;9:873-80. DOI: 10.2147/AMEP.S162626.
Osama M, Islam MY, Hussain SA, Masroor SM, Burney MU, Masood MA, et al. Suicidal ideation among medical student of Pakistan: a cross sectional study. J Forensic Leg Med 2014 Oct;27:65-8. DOI: 10.1016/j.jflm.2014.08.006.
Ghazanfar H, Hameed S, Ghazanfar A, Bhatti JRA, Haq IU, Saeed R, et al. Suicidal ideation among Pakistani medical students. Rawal Med J 2015; 40(4): 458-62.
Brazeau CM, Shanafelt T, Durning SJ, Massie FS, Eacker A, Moutier C, et al. Distress among matriculating medical students relative to the general population. Acad Med 2014 Nov;89(11):1520-5. DOI: 10.1097/ACM.0000000000000482.
Shiwani MH, Elenin H. Bullying and harassment at workplace: Are we aware? J Pak Med Assoc 2010; 60(7):516-7.
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Mukhtar F, Daud S, Manzoor I, Amjad I, Saeed K, Naeem M, et al. Bullying of medical students. J Coll Physicians Surg Pak 2010 Dec;20(12):814-8. DOI: 12.2010/JCPSP.814818.