International Journal of Medical Education. 2016;7:354-363
ISSN: 2042-6372
DOI: 10.5116/ijme.57f8.c468
Assessm ent of depression and suicidal behaviour
am ong m edical students in Portugal
Ricardo Coentre1 , Carlo Faravelli2, Maria Luísa Figueira1
1
Faculty of Medicine, University of Lisbon, Lisbon, Portugal
2
Department of Health Sciences, Psychology and Psychiatry Unit, University of Florence, Florence, Italy
Correspondence Ricardo Coentre, Faculty of Medicine, University of Lisbon, Portugal. Email: .
Accepted: October 08, 2016
Abstract
Objectives: To examine depression and suicidal behaviour higher in students with suicidal ideation
2
and associated factors in a sample of medical students in (χ =85.0,df=1,p<0.001), suicidal plan
2
Portugal. (χ =47.9,df=1,p<0.001) and suicidal attempt
Methods: We conducted a cross-sectional study design of (χ2=19.2,df=1,p<0.001). Suicidal behaviour was higher in
456 native Portuguese medical students from the 4th and 5th medical students who lived alone (χ2=16.936,df=3,p=0.001),
year at the University of Lisbon. Participants answered a who had poor physical health (χ2=18,929,df=2,p=0.001),
self-report survey including questions on demographic and poor economic status (χ2=9.181,df=2,p=0.01), who are/were
clinical variables. Statistical analyses were conducted using in psychopharmacology treatment (χ2=30.108,df
the chi-square test, with a Monte Carlo simulation when =1,p<0.001), and who had high alcohol use
appropriate. (χ2=7.547,df=2,p=0.023), severe depression
Results: Depression among medical students was 6.1% (χ2=88.875,df=3,p<0.001) and high anxiety levels
(n=28) and suicidal behaviour 3.9% (n=18). Higher depres- (χ2=50.343,df=3,p<0.001). The results also revealed that
sion scores were noted in female medical students there were no differences between students in the 4th and 5th
(χ2=4.870,df=2,p=0.027), students who lived alone years of medical school regarding rate of depression and
2
(χ =8.491,df=3,p=0.037), those with poor physical health suicidal behaviour.
(χ2=48.269,df=2,p<0.001), with poor economic status Conclusions: Since depression and suicidal behaviour are
mental health problems affecting a significant proportion of
(χ2=8.579,df=2,p=0.014), students with a psychiatric diag-
medical students, medical schools should implement
nosis (χ2=44.846,df=1,p=0.009), students with a family
programs that promote mental health wellness, physical
history of psychiatric disorders (χ2=5.284,df=1,p=0.022) and health and economic status between other factors.
students with high levels of anxiety (χ2=104.8, df=3, Keywords: Medical students, depression, suicidal
p<0.001). Depression scores were also behaviour, Portugal
Introduction
In addition to medical doctors, medical students have Medical students have academic, psychological and existen-
higher rates of depression and suicidal behaviour compared tial stressors. Additionally, school selection may favour
individuals with perfectionism, altruist traits and self-
to age-matched general population.1-6 The rate of depression
critical or performance-based self-esteem, which predispose
in medical students ranged from 2.9% to 38.2%.7,8 Studies
individuals to depression and suicidal behaviour.11 The
suggest that depression is higher in female medical stu-
consequences of untreated depression include substance
dents,6,9-14 younger students15-17 and students in their early use, school dropout, poor academic performance and
years in medical school.12,17-19 Mixed results have been negative repercussions on long-term patient care (more
obtained regarding the relationship between depression and cynical, less empathetic and less willing to care for chroni-
ethnicity.1,4,11,20 cally ill patients).7,21
354
© 2016 Ricardo Coentre et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution License which permits unrestricted use of
work provided the original work is properly cited. http://creativecommons.org/licenses/by/3.0
, Major depression is the most significant antecedent risk Methods
factor for suicide, but other factors, including other mood
disorders, substance abuse, hopelessness, adverse life events, Participants
personal history of physical or sexual abuse, and family A cross-sectional survey was conducted in 4th and 5th year
history of suicide, often play a role.22 Suicide is a major native Portuguese medical students of Faculty of Medicine,
public health challenge. Rates of suicide among physicians University of Lisbon, in Portugal, between October 2012
are high.23,24 In addition to knowledge and easy access to and July 2013. Survey responses were anonymous. Non-
means of suicide, these high rates of suicide in physicians Portuguese medical students were excluded from the
also reflect the effects of untreated psychological symptoms survey.
in medical students.25,26 Suicidal ideation in medical stu-
dents ranged from 4.4% to 23.1%, and suicidal attempts Procedures
from 0.0% to 6.4%.7 Suicide is an extreme consequence of The study was approved by the Ethics Committee of Faculty
mental health problems, so it is critical for medical schools of Medicine, University of Lisbon. Questionnaires and
to identify students at the greatest risk for suicide in the consent forms were given to each student. The question-
hope of intervening before a tragic outcome.27 Some studies naires were distributed during psychiatric lessons, which
have been published about depression, but there have been have an approximate duration of 120 minutes. We surveyed
few studies about suicidal behaviour in medical students. 10 classes during the 10-month duration of the research,
Studies have found that inadequate treatment is signifi- three from the 4th year and seven from the 5th year of medi-
cant amongst depressive medical students.1,28 Barriers to cal school. We used the last 20 minutes of each lesson to
seeking mental health care among medical students include administer the survey. Psychiatric lessons are mandatory
concerns about time, confidentiality, stigma, and the for all 4th and 5th year medical students. Student participa-
potential negative effects on their careers.28,29 Moreover, tion in our study was voluntary, and those who agreed to
medical students who report moderate to severe depression participate signed the consent form, completed the survey
are much more likely to endorse the opinion that a stigma is and submitted it separately to ensure confidentiality.
associated with depression compared with their non- Students who refused to participate submitted incomplete
depressed colleagues.9 This is the first research study to surveys in the same manner.
investigate depression and suicidal behaviour in a sample of
Portuguese medical students. Instruments
The aims of the present study were: 1) to determine the A paper questionnaire was used. We thought that a paper
rates of depression and suicidal behaviour in a sample of 4th questionnaire rather than an online questionnaire
- and 5th -year of native Portuguese medical students; 2) to warranted a higher response rate without significantly
compare rate of depression and suicidal behaviour to compromising confidentiality and anonymity. The ques-
general population and with medical students from other tionnaire included six sections with a total of 95 questions:
countries; 3) to investigate the relationships between personal data (25 questions), substance use (one question),
personal, epidemiological and clinical factors and depres- suicidal behaviour (three questions), alcohol use (25 ques-
sion and suicidal behaviour in medical students. We hy- tions), depression (21 questions) and anxiety (20 questions).
pothesised that the rate of depression and suicidal behav- The questionnaires were printed in self-administered forms
iour in medical students would be similar to or higher than based on the evidence that the self-report responses of
that of the general Portuguese population. Our hypothesis is potentially embarrassing behaviours (e.g., suicidal behav-
that female students, students who lived alone, students iour) were higher in self-administered questionnaires than
with poor economic status, students with poor physical in an interviewer-administered format.30
health, students with a personal or family psychiatric
history, and students with high levels of anxiety and sub- Depression
stance and alcohol use have higher prevalence of depres- The Beck Depression Inventory (BDI) was used to assess
sion. We hypothesised that male students, students who
depressive symptoms.31 It is a 21-question, multiple-choice,
lived alone, students with poor economic status, students
self-report inventory used to evaluate the incidence and
with poor physical health and students with high levels of
severity of depression symptoms. Scores of 0 to 13 indicate
depression, alcohol use and anxiety have higher rate of
suicidal behaviour. We also hypothesised that medical no or minimal depression, 14 to 19 indicate mild depres-
students in their 4th year of medical school have a higher sion, 20 to 28 indicate moderate depression, and 29 to 63
prevalence of depression and suicidal behaviour than 5th indicate severe depression. The version of the BDI scale that
year medical students as a result of the stress related to had been translated into Portuguese language and validated
beginning of their clinical years. for the Portuguese population was used.32,33
Int J Med Educ. 2016;7: 354-363 355
ISSN: 2042-6372
DOI: 10.5116/ijme.57f8.c468
Assessm ent of depression and suicidal behaviour
am ong m edical students in Portugal
Ricardo Coentre1 , Carlo Faravelli2, Maria Luísa Figueira1
1
Faculty of Medicine, University of Lisbon, Lisbon, Portugal
2
Department of Health Sciences, Psychology and Psychiatry Unit, University of Florence, Florence, Italy
Correspondence Ricardo Coentre, Faculty of Medicine, University of Lisbon, Portugal. Email: .
Accepted: October 08, 2016
Abstract
Objectives: To examine depression and suicidal behaviour higher in students with suicidal ideation
2
and associated factors in a sample of medical students in (χ =85.0,df=1,p<0.001), suicidal plan
2
Portugal. (χ =47.9,df=1,p<0.001) and suicidal attempt
Methods: We conducted a cross-sectional study design of (χ2=19.2,df=1,p<0.001). Suicidal behaviour was higher in
456 native Portuguese medical students from the 4th and 5th medical students who lived alone (χ2=16.936,df=3,p=0.001),
year at the University of Lisbon. Participants answered a who had poor physical health (χ2=18,929,df=2,p=0.001),
self-report survey including questions on demographic and poor economic status (χ2=9.181,df=2,p=0.01), who are/were
clinical variables. Statistical analyses were conducted using in psychopharmacology treatment (χ2=30.108,df
the chi-square test, with a Monte Carlo simulation when =1,p<0.001), and who had high alcohol use
appropriate. (χ2=7.547,df=2,p=0.023), severe depression
Results: Depression among medical students was 6.1% (χ2=88.875,df=3,p<0.001) and high anxiety levels
(n=28) and suicidal behaviour 3.9% (n=18). Higher depres- (χ2=50.343,df=3,p<0.001). The results also revealed that
sion scores were noted in female medical students there were no differences between students in the 4th and 5th
(χ2=4.870,df=2,p=0.027), students who lived alone years of medical school regarding rate of depression and
2
(χ =8.491,df=3,p=0.037), those with poor physical health suicidal behaviour.
(χ2=48.269,df=2,p<0.001), with poor economic status Conclusions: Since depression and suicidal behaviour are
mental health problems affecting a significant proportion of
(χ2=8.579,df=2,p=0.014), students with a psychiatric diag-
medical students, medical schools should implement
nosis (χ2=44.846,df=1,p=0.009), students with a family
programs that promote mental health wellness, physical
history of psychiatric disorders (χ2=5.284,df=1,p=0.022) and health and economic status between other factors.
students with high levels of anxiety (χ2=104.8, df=3, Keywords: Medical students, depression, suicidal
p<0.001). Depression scores were also behaviour, Portugal
Introduction
In addition to medical doctors, medical students have Medical students have academic, psychological and existen-
higher rates of depression and suicidal behaviour compared tial stressors. Additionally, school selection may favour
individuals with perfectionism, altruist traits and self-
to age-matched general population.1-6 The rate of depression
critical or performance-based self-esteem, which predispose
in medical students ranged from 2.9% to 38.2%.7,8 Studies
individuals to depression and suicidal behaviour.11 The
suggest that depression is higher in female medical stu-
consequences of untreated depression include substance
dents,6,9-14 younger students15-17 and students in their early use, school dropout, poor academic performance and
years in medical school.12,17-19 Mixed results have been negative repercussions on long-term patient care (more
obtained regarding the relationship between depression and cynical, less empathetic and less willing to care for chroni-
ethnicity.1,4,11,20 cally ill patients).7,21
354
© 2016 Ricardo Coentre et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution License which permits unrestricted use of
work provided the original work is properly cited. http://creativecommons.org/licenses/by/3.0
, Major depression is the most significant antecedent risk Methods
factor for suicide, but other factors, including other mood
disorders, substance abuse, hopelessness, adverse life events, Participants
personal history of physical or sexual abuse, and family A cross-sectional survey was conducted in 4th and 5th year
history of suicide, often play a role.22 Suicide is a major native Portuguese medical students of Faculty of Medicine,
public health challenge. Rates of suicide among physicians University of Lisbon, in Portugal, between October 2012
are high.23,24 In addition to knowledge and easy access to and July 2013. Survey responses were anonymous. Non-
means of suicide, these high rates of suicide in physicians Portuguese medical students were excluded from the
also reflect the effects of untreated psychological symptoms survey.
in medical students.25,26 Suicidal ideation in medical stu-
dents ranged from 4.4% to 23.1%, and suicidal attempts Procedures
from 0.0% to 6.4%.7 Suicide is an extreme consequence of The study was approved by the Ethics Committee of Faculty
mental health problems, so it is critical for medical schools of Medicine, University of Lisbon. Questionnaires and
to identify students at the greatest risk for suicide in the consent forms were given to each student. The question-
hope of intervening before a tragic outcome.27 Some studies naires were distributed during psychiatric lessons, which
have been published about depression, but there have been have an approximate duration of 120 minutes. We surveyed
few studies about suicidal behaviour in medical students. 10 classes during the 10-month duration of the research,
Studies have found that inadequate treatment is signifi- three from the 4th year and seven from the 5th year of medi-
cant amongst depressive medical students.1,28 Barriers to cal school. We used the last 20 minutes of each lesson to
seeking mental health care among medical students include administer the survey. Psychiatric lessons are mandatory
concerns about time, confidentiality, stigma, and the for all 4th and 5th year medical students. Student participa-
potential negative effects on their careers.28,29 Moreover, tion in our study was voluntary, and those who agreed to
medical students who report moderate to severe depression participate signed the consent form, completed the survey
are much more likely to endorse the opinion that a stigma is and submitted it separately to ensure confidentiality.
associated with depression compared with their non- Students who refused to participate submitted incomplete
depressed colleagues.9 This is the first research study to surveys in the same manner.
investigate depression and suicidal behaviour in a sample of
Portuguese medical students. Instruments
The aims of the present study were: 1) to determine the A paper questionnaire was used. We thought that a paper
rates of depression and suicidal behaviour in a sample of 4th questionnaire rather than an online questionnaire
- and 5th -year of native Portuguese medical students; 2) to warranted a higher response rate without significantly
compare rate of depression and suicidal behaviour to compromising confidentiality and anonymity. The ques-
general population and with medical students from other tionnaire included six sections with a total of 95 questions:
countries; 3) to investigate the relationships between personal data (25 questions), substance use (one question),
personal, epidemiological and clinical factors and depres- suicidal behaviour (three questions), alcohol use (25 ques-
sion and suicidal behaviour in medical students. We hy- tions), depression (21 questions) and anxiety (20 questions).
pothesised that the rate of depression and suicidal behav- The questionnaires were printed in self-administered forms
iour in medical students would be similar to or higher than based on the evidence that the self-report responses of
that of the general Portuguese population. Our hypothesis is potentially embarrassing behaviours (e.g., suicidal behav-
that female students, students who lived alone, students iour) were higher in self-administered questionnaires than
with poor economic status, students with poor physical in an interviewer-administered format.30
health, students with a personal or family psychiatric
history, and students with high levels of anxiety and sub- Depression
stance and alcohol use have higher prevalence of depres- The Beck Depression Inventory (BDI) was used to assess
sion. We hypothesised that male students, students who
depressive symptoms.31 It is a 21-question, multiple-choice,
lived alone, students with poor economic status, students
self-report inventory used to evaluate the incidence and
with poor physical health and students with high levels of
severity of depression symptoms. Scores of 0 to 13 indicate
depression, alcohol use and anxiety have higher rate of
suicidal behaviour. We also hypothesised that medical no or minimal depression, 14 to 19 indicate mild depres-
students in their 4th year of medical school have a higher sion, 20 to 28 indicate moderate depression, and 29 to 63
prevalence of depression and suicidal behaviour than 5th indicate severe depression. The version of the BDI scale that
year medical students as a result of the stress related to had been translated into Portuguese language and validated
beginning of their clinical years. for the Portuguese population was used.32,33
Int J Med Educ. 2016;7: 354-363 355
