Research report
Suicidal ideation among medical students and young physicians: a nationwide and prospective study of prevalence and predictors

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Abstract

Background: Despite an increased risk of suicide among physicians we lack studies on prevalence and predictors of suicidal ideation among medical students and young doctors. Method: A prospective study of Norwegian medical students (n=522) re-examined after the first postgraduate year, comprising suicidal thoughts and attempts, perceived study stress, job stress, and personality. Results: The previous year prevalence of suicidal thoughts was 14% at both points of time. The lifetime prevalence was 43%, while 8% had planned suicide, and 1.4% had attempted suicide. Suicidal ideation in medical school was predicted by lack of control, personality trait, single marital status, negative life events and mental distress (anxiety and depression). In the first postgraduate year, mental distress was the most important predictor, but before controlling for this variable, job stress, vulnerability (neuroticism), single status, and less working hours were independent predictors. Prospectively, suicidal thoughts and vulnerability as student predicted postgraduate suicidal ideation. Conclusions: The level of suicidal thoughts was high, but the level of attempts was low. Clinical implications: Preventive efforts should be directed both at the students’ abilities to cope with stress and at mental health services for young doctors. Limitations of study: The lower response rate at follow-up (57%) may reduce external validity.

Introduction

Physicians run an increased risk of committing suicide (Arnetz et al., 1987, Boxer et al., 1995, Lindeman et al., 1996, Aasland et al., in press), and better preventive efforts are needed. Suicidal ideation is a well-known suicidal risk factor (Vandivort and Locke, 1979, Pierce, 1981, Beck et al., 1985). However, studies focusing on prevalence and predictors of suicidal ideation among medical students and young doctors are lacking, and the issue is only dealt with in a few studies (Valko and Clayton, 1975, Firth-Cozens, 1987, Hendrie et al., 1990, Cullinane et al., 1997). One sole Egyptian study focuses on suicidal thoughts among medical students (Okasha et al., 1981). There is no prospective and nationwide study on the prevalence and predictors of suicidal thoughts among young physicians.

As to predictors, perceived study or job strain are obvious candidates, in addition to personality factors (Firth-Cozens, 1997), gender, social support (marital status) and life events (Paykel et al., 1974, Rudd, 1990, Weissman et al., 1999). Concerning prevention, we need to know whether stressful study or working conditions are connected to suicidal thoughts, also when controlled for personality traits, marital status, stressful life events, gender and age. Since suicidal ideation is supposed to be closely related to depression and anxiety (Paykel et al., 1974), it is also of interest to explore whether any of the predictors are related to suicidal ideation also when controlled for general mental distress.

With this as background, we conducted a prospective study of a nationwide representative sample of medical students, approached first in their final term of medical school, and secondly at the end of the first postgraduate (internship) year. Firstly, we explore the prevalence and stability of suicidal ideation among senior medical students and during the first postgraduate year. Secondly, we explore whether stressful working conditions are connected to the occurrence of suicidal thoughts at the two points of time, also when controlled for personality and other possible predictors. Thirdly, we have tried to identify predictors in medical school for suicidal ideation during internship. Since mental distress is expected to absorb much of the variance, this variable was not included until the final analyses.

Section snippets

Subjects

The students graduating in 1993 and 1994 from all four medical schools in Norway (n=631) received a postal questionnaire in their last term (T1), and after two mailed reminders 522 responded (overall response rate, 83%). Mean age was 28 years (S.D., 2.8), and 57% were women. One year later, at the end of their first postgraduate year at hospital (T2), they received the second questionnaire; 371 responded (71% of those responding at T1, 58% of the original cohort), mean age being 29 years (2.8),

Methods

We used Paykel’s instrument for measuring suicidal ideation and attempts (Paykel et al., 1974), an instrument developed to study suicidal ideation in the general population. It has also been used in two Swedish studies, among physicians (Sveriges läkarförbund, 1988), and in the general population (Renberg et al., 1986). It comprises the following questions implying increasing severity: (1) “Have you ever felt that life was not worth living?” (2) “Have you ever wished you were dead?” (3) “Have

Statistics

We used t-tests and odds ratios to study any differences between responders and non-responders at T2. To test the univariate associations between the predictor variables and suicidal thoughts at T1 and T2, we made use of logistic regression analyses. The predictors were controlled for each other in multivariate logistic regression analyses. The level of significance was chosen to be 5%, with 95% confidence intervals (CI) of odds ratios.

Prevalence of suicidal thoughts

The lifetime prevalence of suicidal thoughts at T1 (n=522) was 43.1%; hardly ever, 24.5%; sometimes, 17.6%; and often, 1.1%; with no gender differences. The last year prevalence was 14.2% at T1, and 14.0% at T2 (n=371), with no significant gender differences. At T1 the responses were: hardly ever, 4.2%; sometimes, 9.0%; often, 1.0%; and at T2: hardly ever, 8.6%; sometimes, 4.3%; often, 1.1%. The previous year prevalence at T2 of “have you ever felt that life was not worth living?” and “have you

Prevalence of suicidal ideation

The lifetime prevalence of suicidal thoughts among our senior medical students, 43.1%, far exceeds Paykel’s estimate for the general US population of 4.8% (Paykel et al., 1974). However, Paykel’s estimate was based on interviews, and one smaller Swedish survey of a general population sample shows a high estimate: 32% (Renberg et al., 1986). Likewise, prevalences among American and Australian university students are comparable, and even higher, than in our study (Rudd, 1989, Schweitzer et al.,

Acknowledgements

Grants by the Research Council of Norway and the Norwegian Medical Association in funding this research are gratefully acknowledged. We also thank Peter Laake, Department of Medical Statistics, University of Oslo, for statistical advice.

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