Suicidal Ideation, Psychological Distress and

Depression in Medical Students of Pakistan:

Surviving or Thriving
Anum Sarwar
Rawalpindi Medical University
Hira Waris
Rawalpindi Medical University
Hina Khan
Karachi Medical and Dental College
Muhammad Hamza Umar
Rawalpindi Medical University
Vikash kumar Karmani (  vikashkarmani@gmail.com )
Jinnah Sindh Medical University

Research Article

Keywords: Mental health of medical students, major depression, psychological distress, suicidal ideation.

Posted Date: January 25th, 2024

DOI: https://doi.org/10.21203/rs.3.rs-3881550/v1

License:   This work is licensed under a Creative Commons Attribution 4.0 International License.
Read Full License

Additional Declarations: No competing interests reported.

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Abstract
Background: In recent years, psychological stress has lead to increase in suicide cases readily among
medical students of many countries. This study aims determine the prevalence of psychological stress,
major depressive disorder, and suicidal ideation in Bachelor of Medicine and Bachelor of Surgery (MBBS)
students of a government setup medical university in Pakistan.

Methods: The data was gathered using a valid questionnaire containing 10 items Kessler psychological
distress scale. The scale consists of the severity of the psychological distress from well, mild, moderate,
and severe. Physical health questionnaire 2(PHQ2) was used for identifying the students with major
depressive illness. Suicidal ideation was assessed using item no. 9 from PHQ9 questionnaire.11,17

Results: The overall prevalence of suicidal ideation, distress and major depression among 353 students
of MBBS was 22.9%, 63.1%, 27.8% respectively. The students with major depression and
moderate/severe distress are more probable to think about suicide. Moreover, Students who choose
medicine under the family influence are more likely to have suicidal ideation. Besides this, we found that
particularly females experience higher psychological distress as compared to males.

Conclusion: In the overall study, it is identified that suicidal ideation is strongly correlated to depression
and distress. However, controlling these factors at an early stage can prevent the suicidal thoughts, which
inevitably can reduce the suicide attempts not only in medical students but could also be valuable for
students of different fields.

Introduction
Medical schools and universities in Pakistan are providing quality education to the students and
producing competent doctors who have proved their skills all around the world. Medicine, being a high
demand, tough and hectic field makes its learners vulnerable to increased psychological stress. It has
been known since the 20th century that medical students endure an increased degree of distress during
their academic courses which can seriously affect their mental health and put them at a higher risk of
depression, anxiety, and other mental health problems.1,2 In recent years, this readily has increased
suicide cases among college students which itself is very upsetting.3–5 the researchers are trying to
study the prevalence of depression, stress, burnout, anxiety disorder, and suicides in various assemble of
students. A Meta-Analysis shows that 27.2% of the medical students are suffering from depression and
overall suicidal ideation was found to be 11%.6 Prevalence of mental distress in medical students was
found to be 63% in Saudi Arabia, 61.3% in Iranian medical students, and 60% in Canadian medical
university, and only 1% students were found to be free of distress in Bangladesh.7–10 Depressive people
are more likely to experience suicidal thoughts. A study conducted in China showed a strong correlation
between suicidal ideation and depression. 30% of medical students with depression reported suicidal
ideation, 13.5% reported moderate to severe depression, and overall 7.5% are had suicidal ideation.11
And, in an American study, 58% of students are reported positive for depression in which 9.3% were found

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with suicidal ideation.12 In an Indian study, 21% of students were found to be suffering from moderate to
severe depression. 13 There is a rise in suicide cases in medical students of Pakistan recently, and local
data regarding the prevalence of depression, anxiety, distress, or suicidal ideation is not very much
available. Results from a recent study conducted in Karachi suggest 35.6% of medical students have
thought about suicide and 13.9% have actually planned to take their own life.14 In fact, suicidal ideation
is linked with several parameters such as distress, family issues, and living standards, etc., which are
remarkable to measure. The objective of this study is to determine the prevalence of psychological
distress, major depressive disorder, and suicidal ideation in MBBS students of a government set up
medical university in Pakistan. Therefore, the results generated thereby, will not only reveal the undetected
depression and distress but will also be helpful in making further strategies to combat the rising mental
health issues in doctors and students.

Research methodology
A cross-sectional study was conducted at Rawalpindi medical university Punjab Pakistan. Three hundred
and fifty-three participants from 1st year to 5th -year students of Bachelor of Medicine and bachelor of
Surgery (MBBS) were surveyed in this study after random sampling. We used the Kessler psychological
distress scale k10 for the assessment of psychological distress (Cronbach’s alpha 0.89).15 The scale
consists of a 10 item questionnaire that accesses the severity of the psychological distress from well,
mild, moderate, and severe distress with each question having five possible responses which go from
‘’none of the time’’ to ‘’all of the time’’. Physical health questionnaire 2(PHQ2) was used for identifying the
students with major depressive illness. PHQ score of ≥ 3 is taken as our cut-off value which has a
sensitivity of 83% and specificity of 92%.16 Suicidal ideation was assessed using item no. 9 from PHQ9
questionnaire, all the options except “not at all” are taken as positive for suicidal ideation.11,17
Demographic data and further questions about the cause of distress were also asked in the
questionnaire. Independent variables in our study are class year, gender, boarder (hostel
scholar)/nonboarder (day scholar), reason to choose medicine, and dependent variables are
psychological distress, depression and suicidal ideation. Mean-percentage is used for summarizing. Chi-
square test, the odds ratio is used for observing the association between dependent and independent
variables. Fischer's exact test is used when n < 5. Logistics regression analysis is used for multivariate
analysis and identifying risk factors. Alpha is set to 0.05 and confidence interval (CI) to 95%. Correlation
coefficient R is used to correlate depression, distress, and suicidal ideation. All the students were
informed about the nature and importance of the study and questionnaires were made anonymous to
remove the stigma attached to depression, distress, and suicidal ideation and to make students more
comfortable in participating.

Results
The questionnaire was completed by 353 students in total. The demographic characteristics of students
are given in Table 1. In total numbers of students, 255 (72.2%) participants were females and 98 (27.8%)

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were males. Further the total number of students classified into year of study (1st to 5th year), type of
accommodation (day and hostel scholar), supply and reason of choose medicine (interested, family
influence). The cause of distress is also clarified into four variables in which distress among students due
to family issues is 10.2%, because of study is 31.4%, 26.1% mentioned both and 32.3% marked other
reasons of distress. We chose these variables to distinguish the mental health of the medical students
during their study. Table 1 only shows the participation of students in counts and percentages for our
chosen study variables. The data for distress for several variables are given in Table 2. In data, 67.8% of
female students are found in distress and this value is higher than male students 51.0%. Noticeably, a
significant statistical association is found between distress and gender [X2 = 8.612, P = 0.003, OR = 2.03].
Similarly, the distress associated with depression is found more in females 93.9% as compared to males
51.4%. While, no significant difference is found between distress and year of study [X2 = 7.236, P = 0.124]
or between having a supply previously [X2 = 1.286, P = 0.257]. Chi-square test found no association
between the type of accommodation and distress (X2 = 0.918, P = 0.338). Furthermore, the level of
distress we graphically demonstrated in Fig. 1. The 26.9% (n = 95) of students are found with severe
distress and 15% (n = 53) with moderate distress whereas 21.2% (n = 75) of the students are noticed with
mild distress and 36.7% (n = 130) with no distress. The prevalence of distress of all levels is about 63.1%
(severe + moderate + mild) for n = 223 out of a total of 353 students. It is also identified that the distress
has a strong association with suicidal ideation (see Table 3). Total 35.4% distressed student have
suicidal ideation (X2 = 53.34, p = 0.000, OR = 35.11).

Table 3 shows the data for suicidal ideation in which no statistically significant association is found in
suicidal ideation between gender (X2 = 0.49, P = 0.48, OR = 1.23), year of study (X2 = 2.5, P = 0.64), and
type of accommodation (X2 = 1.23, P = 0.26). Students who selected medicine under the family influence
are more likely to experience suicidal ideation (X2 = 4.95, P = 0.026). Like distress, suicidal ideation is also
strongly correlated with depression (r = 0.43, P = 0.000) and distress (r = 0.389, P = 0.000) as given in
Table 4. 52.0% of the depressed students and 35.4% of distressed students reported suicidal ideation
compared to suicidal ideation reported by 11.8% having no depression and 1.5% with no distress.
Noticeably, the prevalence of suicidal ideation, distress, and depression were highest among 3rd -year
students. The values are 30.6% for suicidal ideation (Table 3), 73.5% for distress (Table 2), and 44.9% for
depression (not given in Tables). Data for the depression is not shown but a similar trend is observed
between depression and study variables (gender, type of accommodation, supply). Additionally, a
significant association was only observed in the depression between different year of study (X2 = 15.8, p
= 0.003). In overall data, 27.8% of student reports depression (see Figure (1) and totally, 22.9% of
students report suicidal ideation.

Discussion
Our objective was to determine the prevalence of distress, suicidal ideation, and depression among
medical students and its association with different study variables. The results of the study revealed high
levels of distress among medical students in Pakistan. The overall prevalence of distress was found to be
63.1% (severe + moderate + mild from Fig. 1) which is similar to a study conducted in the Islamic republic
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of Iran8 and a study in Saudi Arabia7 and Canada.9 We did not find any recent study on distress in
medical students in Pakistan. This high level of distress may cause high cholesterol levels, sleep
disturbances, negative mood, and hopelessness, which can further affect the decision-making skills.18–
21 In our study, we found 3rd -year students having more prevalence of distress, suicidal ideation, and
major depression. The reason might be the change of environment to clinical, exposure to wards, critical
patients, and noncritical patients, and change in curriculum. The distress was higher among 3rd -year
students (73.5%) as compared to 1st year (64.1%), 2nd year (65.2%), 4th year (67.7%), and final year
(53.1%). Nevertheless, no statistically significant association was found in distress between different
years of study. The finding concurs with study in Iran and Saudi Arabia but in Iranian study, 1st - year
students are more likely to experience distress, and Saudi study found final year students more likely to
be distressed.7,8 We also found no difference in distress levels between clinical and preclinical groups.
Both phases might be equally stressful for the students in different ways. A preclinical group might be
stressed about tough medical studies and repeated exams and a clinical group might have found
interacting with patients and the environment of hospitals generally stressfull. Our study found a
significant difference in distress between male and females, which are consistent with other worldwide
studies.7, 22,23 Although the study in malaysia24 and iran8 found no association. Having a supply
previously and type of accommodation does not significantly affect the levels of distress. The reason
might be that the study was conducted in no exam season to exclude the effect of annual and
supplementary exams on results. Another major finding of the study is that 22.9%, students were found to
have suicidal ideation and 27.8% in major depression recently. This frequency of suicidal ideation and
major depression is quite high in contrast to the 2-week frequency of suicidal ideation in China11 and 12-
month frequency in the USA.12 But in comparison to two Pakistani studies that were conducted in
Karachi the prevalence is quite low (35.6, 31.4).14,25 Major depression prevalence was also found higher
than other international studies.27 This area needs further research and comparison to find out the
protective and risk factors. Gender, year of study, type of accommodation, or having a supply previously
did not significantly affect the prevalence of suicidal ideation. Other Pakistani and international studies
also showed the similar results.25, 11 An Indian study found a significant association of suicidal ideation
with gender.26 Strong relation was found between suicidal ideation, stress, and depression. The
correlation coefficient between suicidal ideation and major depression was found to be 0.49 which is
exactly the same as found in a study in China.11 In Pakistan, families have a greater influence on their
children in choosing the field. Our study found that students who choose medicine solely under the family
influence are more likely to get depressed and have suicidal ideation. Lack of education and stigma
attached to these terms and provided no proper importance to mental health can lead to many
underground cases of suicidal ideation and depression, which may affect their excellence and can result
in suicide, unfortunately. So the need of the hour is to provide proper education and support to the
students through sessions by professional psychologists about its importance and to have a separate
cell devoted to their mental health. Moreover, frequent cross-sectional surveys can also help in identifying
those who need mental health sessions. Although the research data was collected in Pakistan but we
believe, this research can be valuable for worldwide male and female medical students. Further

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researches are needed in this field to find the associated risk factors, any protective factors and to
identify stigma attached to mental health issues in the world of medicine.

Limitations of the study

The study is conducted only in the one medical university of Punjab (Rawalpindi medical university)
within one year to exclude any stress of exams. Additionally, the survey was anonymous so the students
who were found to have suicidal ideation and major depression could not be identified leading to non-
delivery of professional psychiatrist help.

Conclusion
The medical students in Pakistan are subjected to higher distress, and depression leading to suicidal
ideation. Students who choose medicine under the family influence are more distressed. Students with
major depression and moderate and server distress are more proble to think about suicide. We found that
especially females experience more psychological distress as compared to males. Furthermore,
significantly 3rd -year students have a high prevalence of distress and suicidal ideation. Finding a high
level of suicidal ideation in medical students has made it clear that we need to give special attention to
the mental health of medical students. Students should be frequently screened and counseled about
mental health and related issues. Every medical university should establish mental health services as a
compulsory part of the clinical services provided to them and they should be made comfortable in
discussing any sign of a psychological issue with the center/council specially allocated to the student’s
mental health.

Declarations
Corresponding Author

Vikash Kumar Karmani

Vikashkarmani@gmail.com

Department of Internal Medicine

Jinnah Sindh Medical University, Karachi, Sindh, Pakistan

AUTHORS CONTRIBUTION:

M.H., H.W., H.K., and A.S. the concept and design of the study.

M.H., H.W., H.K., and A.S. data acquisition.

M.H., H.W., H.K., and V.K. statistical analysis.

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M.H., H.W., H.K., and V.K. performed the DNA extraction and interpreted the results.

M.H., H.W., H.K., and A.S. analyzed the data and drafted the manuscript.

AUTHORS DECLARATION:

The authors declared that this work is original and backed by scientific research and facts.

CONFLICT OF INTEREST:

The authors declare no conflict of interest.

DATA AVAILABILITY STATEMENT:

All data generated or analyzed during this study are included in the published article.

ETHICAL APPROVAL:

Ethical Approval Ethical approval for this study was obtained from the Institutional Review Board of the
Center for Research and Development, Rawalpindi Medical University. Confidentiality was kept by using
anonymous codes and de-identified study participants’ identifiers. All respondents were assured that the
data would not have any negative consequence on any aspect of their life.

Informed Consent: Informed written consent was obtained from all subjects before data collection.

FUNDING: The authors have received no funding for this article.

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Tables
Table 1: Characteristics of study variables

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Study variable Sub variable Count Percent %

Gender (n=353) female 255 72.2

male 98 27.8

1st year 78 22.1

2nd year 66 18.7

Year of study (n=353) 3rd year 49 13.9

4th year 62 17.6

5th year 98 27.8

Type of accommodation day scholar 236 66.9

(n=353) hostel 117 33.1

scholar

Supply (n=353) no 308 87.3

yes 45 12.7

Reason to choose medicine (n=353) interested 125 35.4

family 56 15.9

influence

both 152 43.1

none 20 5.7

Family 36 10.2

issues

studies 111 31.4

Cause of distress both 92 26.1

other 114 32.3

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Page 11/13
Figures

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Figure 1

Prevalence of distress suicidal ideation and depression in terms of percentage and counts.

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