Fpubh 11 1116616

TYPE Systematic Review
PUBLISHED 31 August 2023

DOI 10.3389/fpubh.2023.1116616
Prevalence of common mental

OPEN ACCESS disorders among medical
students in China: a systematic
EDITED BY
Iman Permana,
Muhammadiyah University of
Yogyakarta, Indonesia
REVIEWED BY
review and meta-analysis
Rebecca Erschens,
University of Tübingen, Germany
Bochra Nourhène Saguem, Jinxingyi Wang1† , Min Liu2† , Jian Bai3† , Yuhan Chen4 , Jie Xia1 ,
University of Sousse, Tunisia
Baolin Liang4 , Ruixuan Wei4 , Jiayin Lin5 , Jiajun Wu6 and
*CORRESPONDENCE
Peng Xiong Peng Xiong4*
paulxiongwhu@gmail.com
1
The Second Affiliated Hospital of Guizhou Medical University, Guizhou, China, 2 Zhuhai Center for
†
These authors have contributed equally to this Maternal and Child Health Care, Zhuhai Women and Children’s Hospital, Zhuhai, China, 3 School of
work Medicine, Jinan University, Guangzhou, China, 4 Department of Public Health and Preventive Medicine,
School of Medicine, Jinan University, Guangzhou, China, 5 School of Stomatology, Jinan University,
RECEIVED 05 December 2022 Guangzhou, China, 6 School of Nursing, Jinan University, Guangzhou, China
ACCEPTED 04 August 2023
PUBLISHED 31 August 2023
CITATION
Background: The prevalence of mental distress is common for medical students
Wang J, Liu M, Bai J, Chen Y, Xia J, Liang B,
Wei R, Lin J, Wu J and Xiong P (2023) in China due to factors such as the long duration of schooling, stressful
Prevalence of common mental disorders doctor-patient relationship, numerous patient population, and limited medical
among medical students in China: a systematic
resources. However, previous studies have failed to provide a comprehensive
review and meta-analysis.
Front. Public Health 11:1116616. prevalence of these mental disorders in this population. This meta-analysis aimed
doi: 10.3389/fpubh.2023.1116616 to estimate the prevalence of common mental disorders (CMDs), including
COPYRIGHT depression, anxiety, and suicidal behaviors, among medical students in China.
© 2023 Wang, Liu, Bai, Chen, Xia, Liang, Wei,
Lin, Wu and Xiong. This is an open-access
Methods: We conducted a systematic search for empirical studies on the
article distributed under the terms of the prevalence of depression, anxiety, suicide attempt, suicide ideation, and suicide
Creative Commons Attribution License (CC BY). plan in Chinese medical students published from January 2000 to December
The use, distribution or reproduction in other
forums is permitted, provided the original
2020. All data were collected pre-COVID-19. The prevalence and heterogeneity
author(s) and the copyright owner(s) are estimations were computed by using a random-effects model and univariate
credited and that the original publication in this meta-regression analyses.
journal is cited, in accordance with accepted
academic practice. No use, distribution or Results: A total of 197 studies conducted in 23 provinces in China were included
reproduction is permitted which does not in the final meta-analysis. The prevalence data of depression, anxiety, suicide
comply with these terms.
attempt, suicide ideation, and suicide plan were extracted from 129, 80, 21, 53,
and 14 studies, respectively. The overall pooled crude prevalence for depression
was 29% [38,309/132,343; 95% confidence interval (CI): 26%−32%]; anxiety, 18%
(19,479/105,397; 95% CI: 15%−20%); suicide ideation, 13% (15,546/119,069; 95%
CI: 11%−15%); suicide attempt, 3% (1,730/69,786; 95% CI: 1%−4%); and suicide
plan, 4% (1,188/27,025; 95% CI: 3%−6%).
Conclusion: This meta-analysis demonstrated the high prevalence of CMDs
among Chinese medical students. Further research is needed to identify targeted
strategies to improve the mental health of this population.
KEYWORDS
common mental disorders (CMDs), depression, anxiety, suicidal behaviors, medical

students, meta-analysis
Frontiers in Public Health 01 frontiersin.org

Wang et al. 10.3389/fpubh.2023.1116616
Introduction development (18), and impaired quality of life (19). Additionally,

there is an increased risk of engaging in unhealthy coping
Worldwide, medical schools aim to train and produce mechanisms such as alcohol and substance abuse, as well as an
competent medical doctors to meet healthcare needs and promote elevated risk of suicide (20). Furthermore, the presence of chronic
public health. This is achieved through arduous training that psychological distress among medical students can contribute to a
requires high motivation, intelligence, and endurance. Globally, decline in empathy and enthusiasm toward patients, resulting in
medical students usually experience high-pressure situations higher rates of medical errors and increased levels of job burnout
during school, such as the long duration of training (1), the heavy in future clinical practice (21). This, in turn, can further strain the
workload of intern clinical practice (2), sleep deprivation (3), doctor-patient relationship, diminish treatment quality (22), and
financial concerns (4), intensive exams, and career uncertainty (5). ultimately impact the overall culture of the medical profession (20).
Such pressures could cause negative effects on medical students’ It highlights the urgency of addressing mental health issues among
wellbeing (6) and academic performance (7) and precipitate mental medical students to prevent these detrimental consequences and
distresses such as depression, anxiety symptoms, and suicidal ensure the wellbeing of both students and the patients they will
behaviors (8, 9). A systematic review and meta-analysis including serve in their future medical careers.
167 cross-sectional empirical studies reported a global prevalence In China, the medical education system and healthcare
of depression or depressive symptoms and suicidal ideation in environment differ in certain areas compared to Western or other
medical students of 27.2 and 11.1%, respectively, indicating high Asian countries. China has great complexity in the levels of
psychological morbidities in this population (10). Furthermore, programs designed to train doctors. The main current medical
a meta-analysis involving 57 studies (n = 25,735) demonstrated education system in China comprises a 3-year junior college
a substantial prevalence of poor sleep quality of 52.7% among medical program, a 5-year medical bachelor’s degree program, a
medical students worldwide (11). Burnout among medical students “5 + 3” medical master’s degree program, and an 8-year medical
is common as well. A systematic review of 58 studies reported doctoral degree program (23). Usually, medical students have to
a wide range of burnout prevalence, varying from 7.0 to 75.2% go through the “5 + 3” model before gaining the formal job of
(12). Even before entering residency, the burden of burnout is a medical doctor. One type of “5 + 3” model is finishing 5 years
substantial, as demonstrated by a meta-analysis encompassing of undergraduate medical education first (leading to a bachelor’s
17,431 medical students, which found that 44.2% of global degree), then completing 3 years of standardized residency training
medical students experienced burnout, regardless of gender (13). (SRT). The other type of “5 + 3” model encompasses 5 years of
Anxiety is another significant concern affecting medical students, undergraduate education, the postgraduate entrance examination,
with a substantially higher prevalence compared to the general and 3 years of a professional master’s degree (master of medicine,
population. Globally, about one in three (33.8%) medical students MM) program (including SRT) (24). However, with the increasing
experience anxiety, with a higher prevalence observed among demands and expectations of society and the medical system for
medical students from the Middle East and Asia (14). Furthermore, doctors, more and more medical students choose to achieve a
as medical students advance to higher levels of training and enter doctoral degree. The long medical schooling cycle that the medical
residency, they continue to face a significant risk of experiencing students have to go through is undoubtedly a substantial burden
mental distress. A meta-analysis that incorporated data from 31 for them. The numerous patient populations and relatively limited
cross-sectional and 23 longitudinal studies revealed an overall medical resources cause overwhelming workload pressures, which
pooled prevalence of depression or depressive symptoms of 28.8% could further lead to burnout and low wellbeing (5). Recently,
among resident physicians (15). Moreover, another meta-analysis more stressful doctor-patient relationships for Chinese doctors in
involving 22,778 residents indicated that the prevalence of burnout work settings (25) have been common. This unstable relationship
was 51.0% (16). This further highlighted the enduring vulnerability frequently led to workplace violence, and with the patients as
of resident physicians to mental health challenges. perpetrators, healthcare workers experienced greater physical and
Undetected or untreated mental distress can have persistent mental health burdens. These factors are likely to contribute
and worsening effects, particularly for medical students (17). These to depression, anxiety symptoms, and suicidal behaviors (e.g.,
effects can manifest in various adverse outcomes, including poor suicidal ideation).
academic performance, a higher dropout rate, limited professional The above findings warrant broader awareness of and greater
attention to medical students’ mental health in China. Previous
meta-analyses have reported the pooled prevalence of mental
Abbreviations: SRT, standardized residency training; MM, master of medicine; distress in this population; however, some study limitations
CMDs, common mental disorders; SDS, Zung’s Self-Rating Depression exist. For example, a meta-analysis of Chinese medical students
Scale; CES-D, Center for Epidemiologic Studies Depression Scale; BDI, published in 2019 and including 21 empirical studies demonstrated
Beck Depression Rating Scale; SAS, Self-Rating Anxiety Scale; SCL-90, the a mean prevalence of depression and anxiety of 32.74 and
symptom checklist-90; GAD-7, Generalized Anxiety Disorder Scale-7; NCS, 27.22%, respectively (26). However, this study only investigated
National Comorbidity Survey; SBQ, Suicidal Behaviors Questionnaire; IES, psychological morbidities in undergraduate medical students,
Impact of Event Scale; DSI, Depression Status Inventory; HAMD, Hamilton excluding those at the graduate levels, who might bear a higher
Depression Scale; QSA, Questionnaire of Suicide Attitude; HAMA, Hamilton burden of mental distress due to higher academic pressure and
Anxiety Scale; SIOSS, Self-Rating Idea of Suicide Scale; PIL, Purpose in Life challenging working environments (27). Another review with 10
Test; EPQ, Eysenck Personality Questionnaire; SSI, Scale for Suicide Ideation; primary studies reported the pooled prevalence of depression,
CI, confidence interval; WPV, workplace violence. anxiety, and suicidal ideation as 29%, 21%, and 11%, respectively

Wang et al. 10.3389/fpubh.2023.1116616
FIGURE 1
PRISMA flow chart for study selection.
(28). However, the review did not provide a comprehensive analysis pooled estimate of one mental disease, i.e., depression, which failed
of prevalence in this population in China because it failed to search to provide an overview of CMDs in this population.
related articles in Chinese databases. A recent systematic review Given this serious public health problem and the limitations
and meta-analysis showed a 27% comprehensive prevalence of of previous reviews, we aimed to perform a systematic review and
depression in Chinese medical students (29), but reported only the meta-analysis by conducting a systematic search of English and

Wang et al. 10.3389/fpubh.2023.1116616
Chinese databases to (1) systematically assess the comprehensive Selection procedure and data extraction
prevalence of common mental distresses (including depression,
anxiety, suicide attempt, suicide ideation, and suicide plan) among First, two reviewers (JW and JB) independently identified
medical students in China; (2) conduct subgroup analysis; and (3) and screened the articles by title and abstract to determine
explore the sources of heterogeneity among studies. their eligibility for further examination. Then, the full texts were
assessed against eligibility criteria independently by two reviewers
(JW and JB), and any disagreement was resolved by a third
reviewer (ML or PX; Figure 1). Finally, two reviewers (JW and
Materials and methods JB) conducted data extraction from the final included studies. The
extracted data included first author, year of publication, study
This meta-analysis was conducted in accordance with the
location, sampling method, recall period, measurement tool and
standards of the Preferred Reporting Items for Systematic
cutoff score, study type, sample size, number of medical students
Reviews and Meta-Analyses (PRISMA) Statement (30) and
with mental problems (including depression, anxiety, and suicide
the Meta-Analyses Observational Studies in Epidemiology
attempt/ideation/plans), and sample characteristics (including age,
(MOOSE) guidelines (31). This study was registered with
grade, sex, school type, and major category).
the International Prospective Register of Systematic Reviews
(PROSPERO) (CRD42019142527).
Quality appraisal
Search strategy and study eligibility The quality appraisal was conducted independently by JW
and JB using the Joanna Briggs Institute (JBI) Critical Appraisal
An electronic search was conducted to identify original articles Quality Assessment Tool (32). The tool was validated well and
published from January 2000 to December 2020 that reported the was popularly used in previous studies (33, 34). JBI is a renowned
prevalence of depression, anxiety, and suicidal behaviors (including and efficient quality tool for assessing the credibility, relevance,
suicide attempt, suicide ideation, and suicide plan) in Chinese and outcomes of prevalence studies. It is composed of 10 items,
medical students. Databases searched included PubMed, Cochrane with each item scored from 0 to 2. A score of 0 represents “not
Library, Cumulative Index to Nursing and Allied Health Literature mentioned,” 1 represents “mentioned but not described in detail,”
(CINAHL), MEDLINE, PsycINFO, and the Chinese databases such and 2 represents “detailed and comprehensive description.” The
as China National Knowledge Infrastructure [CNKI], WANFANG higher the total score, the better the quality of the study in terms
Data, and Weipu (CQVIP) Data. The key terms were “common of credibility, relevance, and outcomes. The detailed scores of each
mental disorders,” “depression,” “anxiety,” “suicide,” and “Chinese included study are shown in the Supplementary material.
medical students.” The detailed search strategy is provided in the
Supplementary material. Due to COVID-19, we did not include
articles published after January 2021.
Data synthesis and analysis
The pooled prevalence estimates of depression, anxiety, and

Inclusion and exclusion criteria suicidal behaviors were calculated by using random-effects models,
which were applied when differences in study designs and
Studies were included in this meta-analysis if they (1) reported methodology were assumed to produce variations in effect sizes
original quantitative studies, including cross-sectional, cohort, across individual studies. The Q-statistic was used to evaluate the
and case-control studies; (2) were published in peer-reviewed heterogeneity of effect sizes across studies, and a significant p-
journals; (3) were written in English or Chinese language; (4) value indicated meaningful heterogeneity (35). The I 2 statistic, a
reported on the population comprised of medical students in variance ratio, which described the proportion of heterogeneity
China (including Hong Kong, Macao, and Taiwan); and (5) used observed in the total variability attributed to the heterogeneity
validated assessment tools with good reliability and validity to between the studies and not to chance, was calculated (36).
evaluate the level of depression, anxiety, and suicidal behaviors I 2 values of 25%, 50%, and 75% indicated low, middle, and
among medical students. high levels of heterogeneity, respectively. To further explore the
Studies were excluded if the (1) prevalence data could possible sources of heterogeneity, subgroup analysis and univariate
not be extracted by indirect calculation or by contacting the meta-regression analysis were performed based on the following
corresponding author; (2) publication format was a conference characteristics: study region, survey year, sample size, sampling
abstract, review, meta-analysis, export opinion, or letter; (3) method, recall period of suicidality, measurement tool, and
reported sample size was <30 individuals; (4) the reported cutoff score. Specifically, the regional classification was based on
participants were not from China; (5) reported population was China’s geographic divisions, including North China, East China,
non-medical students; and (6) reported mental health problems South China, Central China, Northeast China, Northwest China,
arose under emergency or special circumstances, such as severe Southwest China, and others (such as multiple regions and not
acute respiratory syndromes (SARS), Wenchuan earthquakes, reported). Sensitivity analyses were performed by serially excluding
and COVID-19. each study to determine the influence of individual studies on

Frontiers in Public Health
Wang et al.
TABLE 1 Characteristics of the 129 studies included on depression in this review.
Year First author Province Age, years Major Grade Sampling method Measurement Study type
tools and cutoff
score
2000 Lin Daxi Fujian Mean: 19 Medicine College students Cluster sampling SDS Cross-sectional study
2000 Du Zhaoyun Shandong Mean (SD): 20.4 (1.6) Medicine Undergraduates Simple random sampling BDI-13 Cross-sectional study
and cluster sampling
2000 Wu Hualin Shanxi Mean: 20.5 Medicine College students Simple random sampling SDS Cross-sectional study
2000 Yang Benfu NA Mean: 20.5 Medicine Undergraduates Stratified and cluster SDS Cross-sectional study
sampling
2001 Yu Miao Fujian Mean: 21 Medicine Undergraduates Cluster sampling CES-D Cross-sectional study
2001 Lin Zhiping Fujian Mean: 21.5 Medicine Undergraduates Cluster sampling CES-D Cross-sectional study
2001 Zhang Yushan Anhui Mean (SD): 21.8 (3.2) Medicine Undergraduates NA SDS Cross-sectional study
2001 Zhang Yunsheng Henan NA Pharmacy and nursing Undergraduates Simple random sampling SCL-90 Cross-sectional study
2002 Rao Hong NA Mean: 20 Medicine College students NA BDI Cross-sectional study
2002 Xu Limei NA Mean: 19 Medicine Undergraduates Stratified and cluster SDS Cross-sectional study
sampling
05
2003 Zhou Rong Guangdong Mean: 21 Medicine Undergraduates Simple random sampling SDS Cross-sectional study
2003 Wang Menglong Guangdong Mean: 20 Medicine Grades 1 and 3 NA SDS Cross-sectional study
2003 Gesang Zeren NA Mean: 16.5 Medicine and nursing NA NA CES-D Cross-sectional study
2004 Zhang Fuquan Hunan Mean (SD): 19.85 (1.18) Medicine Undergraduates Stratified and cluster SCL-90 Cross-sectional study
sampling
2004 Zhang Shuying NA Mean (SD): 21.8 (0.89) Medicine Undergraduates NA SCL-90 Cross-sectional study
2005 Shi Xiaoning Shanghai Mean (SD): 21.39 (1.46) Medicine Undergraduates Cluster sampling CES-D Cross-sectional study
2005 Gesang Zeren Sichuan Mean: 19.5 Public health and Undergraduates and Cluster sampling CES-D Cross-sectional study
pharmacy college students
2005 Ren Huaneng Hubei Mean (SD): 20.07 (1.36) Medicine College students Simple random sampling SDS Cross-sectional study
2005 Li Yingchun Anhui Mean (SD): 21.66 (1.15) Medicine Undergraduates NA SDS Cross-sectional study
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2005 Guo Rong Guizhou Mean (SD): 20.16 (1.43) Medicine Grade 2 Stratified and cluster SDS Cross-sectional study
sampling
2005 Xu Limei NA Mean: 23 Medicine Grade 5 Cluster sampling SDS Cross-sectional study
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2005 Yang Xiuzhen Shandong Mean: 20.5 Medicine Undergraduates Stratified sampling SDS Cross-sectional study
(Continued)
TABLE 1 (Continued)
Wang et al.
tools and cutoff
score
2005 Wei Xiaoqing Liaoning Mean: 20 Medicine Grades 1–2 Simple random sampling SDS Cross-sectional study
2005 Feng Fenglian Hebei NA Medicine Undergraduates NA SDS Cross-sectional study
2006 Jin ji Liaoning Mean (SD): 20.79 (1.28) Medicine Undergraduates Stratified and cluster SDS Cross-sectional study
sampling
2006 Zhang Zewu Guangdong Mean (SD): 21.4 (2.6) Medicine Undergraduates Cluster sampling DIS Cross-sectional study
2006 Zhai Dechun NA Mean (SD): 20.79 (1.28) Medicine Undergraduates Stratified and cluster SDS Cross-sectional study
sampling
2006 Wei Junbiao Henan Mean: 20 Medicine Undergraduates Cluster sampling SDS Cross-sectional study
2006 Zeng Qiang NA NA Medicine Undergraduates Cluster sampling SDS Cross-sectional study
2006 Zhang Zewu Guangdong Mean (SD): 21.5 (2.3) Medicine Undergraduates Cluster sampling DSI Cross-sectional study
2006 Mei Lin Beijing Mean: 21.5 Medicine Undergraduates Cluster sampling SDS Cross-sectional study
2006 Song Jing Hubei Mean: 22 Clinical medicine Undergraduates Cluster sampling SCL-90 Cross-sectional study
2006 Wu Yan Hubei NA Medicine Undergraduates NA BDI Cross-sectional study
2007 Meng Zhaoying NA Mean (SD): 20.71 (1.23) Medicine Undergraduates Stratified and cluster SDS Cross-sectional study
sampling
06
2007 Wang Tao NA Mean (SD): 20.82 (2.27) Medicine Undergraduates Cluster sampling SDS Cross-sectional study
2007 Deng Shusong Guangxi Mean: 20 Medicine Undergraduates Cluster sampling SCL-90 Cross-sectional study
2007 Sang Wenhua Hebei NA Medicine Grades 1–3 Cluster sampling SDS Cross-sectional study
2007 Liu Yulan Jilin Mean (SD): 22.6 (1) Medicine Undergraduates Simple random sampling SDS Cross-sectional study
2007 Li Li Liaoning NA Medicine Undergraduates Simple random sampling SCL-90 Cross-sectional study
2008 Chen Zehua Guangdong NA Medicine College students and Cluster sampling YRBSS Cross-sectional study
undergraduates
2008 Li Yaqin Hebei Mean: 19.5 Medicine College students Simple random sampling DSI Cross-sectional study
and cluster sampling
2009 Mu Yunzhen Yunnan Mean (SD): 21.86 (2.58) Medicine Undergraduates Simple random sampling SCL-90 Cross-sectional study
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2009 Shang Yuxiu Ningxia Mean (SD): 20.62 (1.64) Medicine Undergraduates Stratified and cluster SDS Cross-sectional study
sampling
2009 Zhou Xin Hebei, Jiangsu, Mean (SD): 21.48 (1.242) Nursing Undergraduates Cluster sampling SDS Cross-sectional study
and Ningxia
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2009 Li Wenwen Guangdong Mean: 25.5 Medicine Undergraduates Cluster sampling CES-D Cross-sectional study
2009 Yang Xiaohui Sichuan Mean: 21.5 Medicine Undergraduates NA BDI Cross-sectional study
2009 Jin Zhengguo Jining NA Medicine Undergraduates NA SCL-90 Cross-sectional study
(Continued)
Wang et al.
TABLE 1 (Continued)
tools and cutoff
score
2009 Zhao Shujuan NA NA Medicine Grade 1 Simple random sampling SDS Cross-sectional study
2010 Yanhui Liao China Mean (SD): 18.5 (0.8) Medicine Grade 1 Simple random sampling SDS Cross-sectional study
2011 Liang Sun Anhui Mean: 20 Medicine Grades 1–2 NA BDI Cross-sectional study
2011 Dong Guanbo Beijing NA Masters and doctors 8-year program student Cluster sampling SDS Cross-sectional study
2011 Jiang Qing Fujian NA Medicine Undergraduates Simple random sampling HAD Cross-sectional study
2011 Wei Yali Guizhou Mean: 20 Medicine Grade 1 Stratified and cluster CES-D Cross-sectional study
sampling
2011 Gao Shuhui Hebei Mean: 21 Medicine Undergraduates Stratified random sampling SDS Cross-sectional study
2011 Zhang Guifeng Guangdong Mean: 20.5 Medicine Undergraduates Stratified sampling BDI Cross-sectional study
2011 Zhao Qiuzhen Hebei NA Medicine Undergraduates Cluster sampling SDS Cross-sectional study
2011 Xu Limei NA Mean: 19 Medicine Undergraduates NA SDS Cross-sectional study
2011 Tan Erli NA Mean (SD): 20.3 (1.1) Medicine College students Cluster sampling NA Cross-sectional study
2012 Wang Na Beijing NA Medicine Undergraduates Stratified and cluster IVR(self-made) Cross-sectional study
07
sampling
2012 Li Wei Chongqing NA Medicine Undergraduates Cluster sampling SCL-90 Cross-sectional study
2012 Yang Chuanwei Henan Mean (SD): 20.67 (1.43) Medicine Undergraduates Stratified and cluster SDS Cross-sectional study
sampling
2012 Yang Yanfang Inner Mean: 21.5 Medicine Grade 1–3 NA SDS Cross-sectional study
Mongolia
2012 Shi Shenchao Henan Mean (SD): 20.67 (1.43) Medicine Undergraduates Simple random sampling SDS Cross-sectional study
2012 Ding Jianfei NA NA Medicine Undergraduates Cluster sampling CES-D Cross-sectional study
2012 Liu Xiuhua Hebei Mean: 21.5 Medicine Undergraduates Simple random sampling SDS Cross-sectional study
2013 Wang Dongping Henan Mean (SD): 19.98 (1.15) Medicine Undergraduates Simple random sampling SDS Rct
2013 Wang Jun Anhui Mean (SD): 19.66 (0.96) Medicine Undergraduates Cluster sampling SDS Cross-sectional study
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2013 Liu Rui Gansu NA Medicine Undergraduates Cluster sampling SDS Cross-sectional study
2013 Ren Xiaohui NA Mean (SD): 21 (1) Medicine Undergraduates NA SDS Cross-sectional study
2014 Fan Yang Hubei Mean: 20.5 Medicine Undergraduates Stratified cluster sampling SCL-90 Cross-sectional study
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2014 Yao Ran Guangdong Mean: 21 Medicine Undergraduates Stratified and cluster SDS Cross-sectional study
sampling
(Continued)
TABLE 1 (Continued)
Wang et al.
tools and cutoff
score
2014 Kunmi Sobowale Mainland NA Medicine Grades 2 and 3 NA PHQ-9 Cross-sectional study
China
2014 Qu Wei Anhui Mean (SD): 20.3 (2.09) Medicine Grades 1–2 Stratified and cluster SDS Cross-sectional study
sampling
2014 Tao Shuman Anhui Mean (SD): 20 (1) Medicine Grades 1–3 Convenience sampling SDS Cross-sectional study
2014 Xian Pengcheng Inner Mean: 21.5 Medicine Undergraduates Simple random sampling SDS Cross-sectional study
Mongolia
2014 Wang Feiran Hubei, Shanxi, Mean (SD): 21.45 (1.37) Medicine Undergraduates Stratified and cluster SCL-90 Cross-sectional study
and Hebei sampling
2014 Liu Mei Fujian NA Medicine Undergraduates Simple random sampling SDS Cross-sectional study
2014 Guo Kai Qinghai Mean (SD): 21.26 (1.20) Medicine Grades 2–4 Stratified and cluster SDS Cross-sectional study
sampling
2015 Xiongfei Panan 23 provinces Mean (SD): 20.7 (1.6) Medicine Undergraduates NA BDI Cross-sectional study
2015 Liu Yan Beijing Mean: 21.5 Medicine Undergraduate and Stratified sampling CES-D Cross-sectional study
postgraduate
2015 Chang Hong Xinan Mean (SD): 20.2 (1.5) Medicine Undergraduates Simple random sampling SDS Cross-sectional study
08
2015 C.-J.CHEN Taiwan Mean (SD): 17.42 (1.03) Nursing students College students NA ADI Cross-sectional study
2015 Meng Shi Liaoning Mean: 21.5 Medicine Undergraduates and Cluster sampling CES-D Cross-sectional study
postgraduates
2015 Yu Jiegen Anhui NA Medicine Undergraduates Simple random sampling SDS Cross-sectional study
2015 Zhao Chuan Henan Mean: 22.5 Medicine Undergraduates Stratified and cluster SDS Cross-sectional study
sampling
2015 Yu Linlu Beijing Mean: 22 Medicine Undergraduates Cluster sampling CES-D Cross-sectional study
2015 Yu Linlu Beijing Mean: 22 Medicine Undergraduates Cluster sampling CES-D Cross-sectional study
2015 Han Yashu Liaoning NA Medicine Undergraduates NA SDS Cross-sectional study
2016 Meng Shi Liaoning Mean (SD): 21.65 (1.95) Medicine Grades 1–7 Cluster sampling CES-D Cross-sectional study
2016 Gao Jie Anhui NA Medicine Undergraduates Cluster sampling SDS Cross-sectional study
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2016 Jiang Hongcheng Yunnan Mean (SD): 21.04 (1.84) Medicine Undergraduates Stratified and cluster SDS Cross-sectional study
sampling
2016 Huang Yalian Sichuan Mean: 21 Medicine Grades 1–3 Simple random sampling SDS Cross-sectional study
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2016 Qian Yunke Jiangsu NA Medicine Undergraduates Stratified and cluster SDS Cross-sectional study
sampling
2016 Lv Shixin Shandong NA Medicine Undergraduates Stratified and cluster SDS Cross-sectional study
sampling
(Continued)
TABLE 1 (Continued)
Wang et al.
tools and cutoff
score
2016 Qiu Nan Sichuan NA Medicine Undergraduates Convenience sampling and BDI Cross-sectional study
cluster sampling
2016 Wu Yingping NA NA Medicine Undergraduates Cluster sampling and BDI Cross-sectional study
convenience sampling
2017 Li Xue NA NA Medicine Undergraduates Stratified and cluster CES-D Cross-sectional study
sampling
2017 Chen Huan Ningxia NA Medicine Undergraduates Stratified and cluster SDS Cross-sectional study
sampling
2017 Xu Tao Sichuan and NA Medicine Undergraduates Cluster sampling BDI Cross-sectional study
Inner
Mongolia
2017 Dai Ruoyi Chongqing NA Medicine Undergraduates Stratified and cluster SDS Cross-sectional study
sampling
2018 Ching-Yen Chen Taiwan Mean: 23.5 Medicine Undergraduates Simple random sampling BDI Multi-staged sampling
2018 Lin Fen Hubei NA Medicine Undergraduates Stratified random sampling BDI Cross-sectional study
2018 Shi Junfang Shanxi Mean: 20.2 Medicine Undergraduates Stratified and cluster SDS/HAMD Cross-sectional study
09
sampling
2018 Li Xiaoping Jiangxi NA Medicine Grades 2–4 Stratified and cluster SDS Cross-sectional study
sampling
2018 Jiang Nan Liaoning NA Medicine Undergraduates Simple random sampling CES-D Cross-sectional study
2018 Li Xuanxuan Jilin Mean (SD): 21.54 (1.98) Medicine Undergraduates Cluster sampling SDS Cross-sectional study
2018 Sibo Zhao China Mean (SD): 20.25 (3.25) Medicine Undergraduates NA CES-D Cross-sectional study
2018 Feng Fenglian Hebei NA Medicine Grades 1–3 Simple random sampling SDS Cross-sectional study
2018 Wu Jinting Anhui Mean (SD): 19.39 (0.85) Medicine Undergraduates Stratified sampling BDI Cross-sectional study
2019 Jessica A Gold Hunan Mean (SD): 22 (1.5) Medicine Grades 3–6 Convenience sampling PHQ-2 Cross-sectional study
2019 Chunli Liu Northeast Mean (SD): 31.1 (5.3) Medicine Doctoral students Snowball sampling and PHQ-9 Cross-sectional study
stratified sampling
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2019 Ling Wang Anhui Mean: 20.5 Medicine College students and Simple random sampling DASS-21 Cross-sectional study
undergraduates
2019 Xiaogang Zhong China NA Medicine Postgraduates and doctors NA PRIME-MD Cross-sectional study
2019 Yanli Zeng Sichuan Mean (SD): 20.2 (1.2) Nursing students Grades 1–3 Stratified random cluster DASS-21 Cross-sectional study
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sampling
2019 Zhao Xiuzhuan Beijing NA Masters and doctors 8-year program student Simple random sampling SDS Cross-sectional study
(Continued)
Wang et al.
TABLE 1 (Continued)
tools and cutoff
score
2019 Xiong Lin Chongqing NA Medicine College students Stratified and cluster BDI Cross-sectional study
sampling
2019 Tang Siyao Guangdong Mean (SD): 20.07 (1.49) Medicine Undergraduates Convenience sampling PHQ-9 Cross-sectional study
2019 Cao Lei Chongqing Mean (SD): 18.56 (0.99) Medicine Undergraduates Stratified and cluster BDI Cross-sectional study
sampling
2019 Steven W. H. Chau HongKong NA Medicine NA Simple random sampling NA Cross-sectional study
2019 Lin Xin Xinjiang NA Medicine Grades 1–2 Stratified and cluster CES-D Cross-sectional study
sampling
2019 Ai Dong NA NA Medicine Undergraduates Stratified and cluster SDS Cross-sectional study
sampling
2020 Yanmei Shen Hunan Mean (SD): 18.77 (1.09) Medicine College students and Convenience sampling SDS Cross-sectional study
undergraduates
2020 Jing Guo Heilongjiang Mean (SD): 19.48 (0.85) Medicine Grades 2–3 Cluster sampling BDI-II Cross-sectional study
2020 Ruyue Shao Chongqing Mean (SD): 19.76 (1.17) Medicine Grades 1–3 NA SDS Cross-sectional study
2020 Chen Jun NA Mean (SD): 19.63 (1.28) Medicine Grades 1–2 Stratified and cluster SDS Cross-sectional study
10
sampling
2020 Yang Xueling Guangdong Mean (SD): 18.37 (0.73) Medicine Undergraduates Convenience sampling BDI-II Cross-sectional study
2020 Li Ningning Beijing NA Clinical medicine Grades 5–7 Cluster sampling Self-made questionnaire Cross-sectional study
2020 Xiao Rong Guangdong Mean (SD): 19.92 (1.04) Medicine Undergraduates Convenience sampling PHQ-9 Cross-sectional study
2020 Zhu Huiquan Hainan Mean: 14.5 Medicine Undergraduates Stratified and cluster SCL-90 Cross-sectional study
sampling
NA, not available; SD, Standard Deviation; SDS, Self-Rating Depression Scale; BDI, Beck Depression Rating Scale; BDI-II, Beck Depression Inventory-II; BDI-13, Beck Depression Inventory-13; CES-D, Center for Epidemiologic Studies Depression Scale; SCL-90, the
symptom checklist-90; HAMD, Hamilton Depression Scale; HAD, Hospital Anxiety and Depression Scale; IVR, interactive voice response; DSI, Depression Status Inventory; IDLS, the international depression literacy survey; ADI, Adolescent Depression Inventory;
DASS-21, Depression Anxiety Stress Scale 21; PRIME-MD, The 2-Item Primary Care Evaluation of Mental Disorders; YRBSS, Youth Risk Behavior Surveillance System Questionnaire.
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Wang et al.
TABLE 2 Characteristics of the 80 studies included on anxiety in this review.
tools and cutoff
score
2000 Lin Daxi Fujian Mean: 19 Medicine College students Cluster sampling SAS Cross-sectional study
2000 Yang Benfu NA Mean: 20.5 Medicine Undergraduates Stratified and cluster sampling SAS Cross-sectional study
2001 Huang Juan Guangdong Mean (SD): 21.02 (1.87) Medicine Undergraduates NA SAS Cross-sectional study
2001 Su Xiaomei Guangdong Mean (SD): 19.37 (1.3) Nursing Grades 1–4 Cluster sampling SAS Cross-sectional study
2001 Zhang Yushan Anhui Mean (SD): 21.8 (3.2) Medicine Undergraduates NA SAS Cross-sectional study
2001 Zhang Yunsheng Henan NA Pharmacy and nursing Undergraduates Simple random sampling SCL-90 Cross-sectional study
2002 Qi Yulong Anhui NA Medicine Grade 1 Simple random sampling SAS Cross-sectional study
2002 Xu Limei NA Mean: 19 Medicine Grade 1 stratified and cluster sampling SDS Cross-sectional study
2003 Zhang Xinwen Hebei NA Medicine Undergraduates NA MAS Cross-sectional study
2003 Zheng Wenjun Guangxi Mean: 20 Clinical medicine Undergraduates Cluster sampling S-AI Cross-sectional study
11
2004 Zhang Fuquan Hunan Mean (SD): 19.85 (1.18) Medicine Undergraduates Stratified and cluster sampling SCL-90 Cross-sectional study
2004 Zhang Shuying NA Mean (SD): 21.8 (0.89) Medicine Undergraduates NA SCL-90 Cross-sectional study
2005 Ren Huaneng Hubei Mean (SD): 20.07 (1.36) Medicine College students Simple random sampling SAS Cross-sectional study
2005 Li Yingchun Anhui Mean (SD): 21.66 (1.15) Medicine Undergraduates NA SAS Cross-sectional study
2005 Xu Limei NA Mean: 23 Medicine Grade 5 Cluster sampling SAS Cross-sectional study
2005 Yang Xiuzhen Shandong Mean: 20.5 Medicine Undergraduates Stratified sampling SAS Cross-sectional study
2005 Wei Xiaoqing Liaoning Mean: 20 Medicine Grades 1–2 Simple random sampling SAS Cross-sectional study
2005 Feng Fenglian Hebei NA Medicine Undergraduates NA SAS Cross-sectional study
2006 Jin ji Liaoning Mean (SD): 20.79 (1.28) Medicine Undergraduates Stratified and cluster sampling SAS Cross-sectional study
2006 Zhai Dechun NA Mean (SD): 20.79 (1.28) Medicine Undergraduates Stratified and cluster sampling NA Cross-sectional study
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2006 Wei Junbiao Henan Mean: 20 Medicine Undergraduates Cluster sampling SAS Cross-sectional study
2006 Wang Yanfang Guangdong NA Medicine Undergraduates Simple random sampling SAS Cross-sectional study
2006 Mei Lin Beijing Mean: 21.5 Medicine Undergraduates Cluster sampling SAS Cross-sectional study
(Continued)
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Wang et al.
TABLE 2 (Continued)
tools and cutoff
score
2006 Song Jing Hubei Mean: 22 Clinical medicine Undergraduates Cluster sampling SCL-90 Cross-sectional study
2007 Meng Zhaoying NA Mean (SD): 20.71 (1.23) Medicine Grades 1–3 college Stratified and cluster sampling SAS Cross-sectional study
students
2007 Liang xinrong Guangxi NA Medicine Undergraduates Simple random sampling and HAMA Cross-sectional study
cluster sampling
2007 Deng Shusong Guangxi Mean: 20 Medicine Undergraduates Cluster sampling SCL-90 Cross-sectional study
2007 Liu Yulan Jilin Mean (SD): 22.6 (1) Medicine Undergraduates Simple random sampling SAS Cross-sectional study
2007 Li Li Liaoning NA Medicine Undergraduates Simple random sampling SCL-90 Cross-sectional study
2009 Mu Yunzhen Yunnan Mean (SD): 21.86 (2.58) Medicine Undergraduates Simple random sampling SCL-90 Cross-sectional study
2009 Zhou Xin Hebei, Jiangsu, Mean (SD): 21.48 (1.242) Nursing Undergraduates Cluster sampling SAS Cross-sectional study
and Ningxia
2009 Liu Kerong NA Mean: 24 Medicine Undergraduates Stratified sampling HAMA Cross-sectional study
2010 Yanhui Liao China Mean (SD): 18.5 (0.8) Medicine Grades 1 Simple random sampling SIAS Cross-sectional study
12
2010 Feng Tianyi Ningxia NA Medicine Undergraduates Stratified sampling SAS Cross-sectional study
2010 Wang Fengsheng Anhui Mean (SD): 19.33 (1.18) Medicine Grades 1–2 Cluster sampling BAI Cross-sectional study
2010 Ge Xin Liaoning Mean: 17 Medicine College students Simple random sampling SCARED Cross-sectional study
2011 Ruan Ye Gansu NA Medicine Undergraduates Stratified and cluster sampling SAS Cross-sectional study
2011 Liang Sun Anhui Mean: 20 Medicine Grades 1–2 NA BAI Cross-sectional study
2011 Zhu Shuang Heilongjiang Mean (SD): 21.32 (1.4) Medicine Undergraduates Stratified sampling SAS Cross-sectional study
2011 Jiang Qing Fujian NA Medicine Undergraduates Simple random sampling HAD Cross-sectional study
2011 Pan Xin Shanxi Mean (SD): 20.96 (1.36) Medicine Undergraduates Stratified sampling SAS Cross-sectional study
2011 Zhao Qiuzhen Hebei NA Medicine Undergraduates Cluster sampling SAS Cross-sectional study
2011 Xu Limei NA Mean: 19 Medicine Undergraduates NA SAS Cross-sectional study
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2012 Li Wei Chongqing NA Medicine Undergraduates Cluster sampling SCL-90 Cross-sectional study
2012 Yang Chuanwei Henan Mean (SD): 20.67 (1.43) Medicine Undergraduates Stratified and cluster sampling SAS Cross-sectional study
2013 Wang Dongping Henan Mean (SD): 19.98 (1.15) Medicine Undergraduates Simple random sampling SAS Rct
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2014 Fan Yang Hubei Mean: 20.5 Medicine Undergraduates Stratified cluster sampling SCL-90 Cross-sectional study
(Continued)
Wang et al.
TABLE 2 (Continued)
tools and cutoff
score
2014 Qu Wei Anhui Mean (SD): 20.3 (2.09) Medicine Grades 1–2 Stratified and cluster sampling HAMA Cross-sectional study
2014 Chen Fuxun Shandong Mean (SD): 20.55 (1.34) Medicine Undergraduates Cluster sampling SAS Cross-sectional study
2014 Wang Feiran Hubei, Shanxi, Mean (SD): 21.45 (1.37) Medicine Undergraduates Stratified and cluster sampling SCL-90 Cross-sectional study
and Hebei
2015 Meng Shi Liaoning Mean: 21.5 Medicine Undergraduates and Cluster sampling SAS Cross-sectional study
postgraduates
2015 Tian Yunqing Beijing Mean: 21.5 Medicine Undergraduates Cluster sampling BAI Cross-sectional study
2015 Chang Hong Xinan Mean (SD): 20.2 (1.5) Medicine Undergraduates Simple random sampling SAS Cross-sectional study
2015 Li Qiang Henan NA Medicine Grades 2 and 3 Stratified and cluster sampling SAS Cross-sectional study
2015 Zhao Chuan Henan Mean: 22.5 Medicine Undergraduates Stratified and cluster sampling SAS Cross-sectional study
2016 Jiang Hongcheng Yunnan Mean (SD): 21.04 (1.84) Medicine Undergraduates Stratified and cluster sampling SAS Cross-sectional study
13
2016 Sun Weiwei NA Mean (SD): 22.12 (2.53) Medicine Undergraduates Simple random sampling SAS Cross-sectional study
2017 Feng Fenglian Hebei Mean: 20 Clinical medicine Grades 1–3 Cluster sampling SAS Cross-sectional study
2017 Li Xiang Liaoning Mean: 21.42 Medicine Undergraduates Simple random sampling SAS Cross-sectional study
2017 Chen Huan Ningxia NA Medicine Undergraduates Stratified and cluster sampling SAS Cross-sectional study
2017 Liang Peiyu Qinghai NA Medicine Undergraduates Stratified random sampling SAS Cross-sectional study
2017 Xu Tao Sichuan and NA Medicine Undergraduates Cluster sampling SAS Cross-sectional study
Inner
Mongolia
2018 Ching-Yen Chen Taiwan Mean: 23.5 Medicine Undergraduates Simple random sampling BAI Multi-staged sampling
2018 Zhao Fei China Mean (SD): 20.7 (1.6) Medicine Undergraduates Simple random sampling SAS Cross-sectional study
2018 Li Xuanxuan Jilin Mean (SD): 21.54 (1.98) Medicine Undergraduates Cluster sampling SAS Cross-sectional study
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2018 Feng Fenglian Hebei NA Medicine Grades 1–3 Simple random sampling SAS Cross-sectional study
2019 Chunli Liu Northeast Mean (SD): 31.1 (5.3) Medicine Doctoral students Snowball sampling and GAD-7 Cross-sectional study
stratified sampling
(Continued)
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TABLE 2 (Continued)
Wang et al.
tools and cutoff
score
2019 Ling Wang Anhui Mean: 20.5 Medicine College students and Simple random sampling DASS-21 Cross-sectional study
undergraduates
2019 Yanli Zeng Sichuan Mean (SD): 20.2 (1.2) Nursing students Grades 1–3 Stratified random cluster DASS-21 Cross-sectional study
sampling
2019 Zhao Xiuzhuan Beijing NA Masters and doctors 8-year program student Simple random sampling SAS Cross-sectional study
2019 Wang Zhe Heilongjiang NA Medicine Undergraduates Cluster sampling SAS Cross-sectional study
2019 Steven W. H. Chau Hong Kong NA Medicine NA Simple random sampling GHQ-12 Cross-sectional study
2019 Li Zhongcheng Guangdong NA Medicine Undergraduates Stratified and cluster sampling SAS Cross-sectional study
2019 Ai Dong NA NA Medicine Undergraduates Stratified and cluster sampling SAS Cross-sectional study
2020 Yanmei Shen Hunan Mean (SD): 18.77 (1.09) Medicine College students and Convenience sampling SAS Cross-sectional study
undergraduates
2020 Ruyue Shao Chongqing Mean (SD): 19.76 (1.17) Medicine Grades 1–3 NA SAS Cross-sectional study
2020 Chen Jun NA Mean (SD): 19.63 (1.28) Medicine Grades 1–2 Stratified and cluster sampling SAS Cross-sectional study
2020 Yang Xueling Guangdong Mean (SD): 18.37 (0.73) Medicine Undergraduates Convenience sampling BAI Cross-sectional study
14
2020 Li Ningning Beijing NA Clinical medicine Grades 5–7 Cluster sampling Self-made questionnaire Cross-sectional study
2020 Liu Xia NA Mean (SD): 20.38 (2.07) Medicine Undergraduates Stratified and cluster sampling SAS Cross-sectional study
NA, not available; SD, Standard Deviation; BAI, Beck Anxiety Inventory; DASS-21, Depression Anxiety Stress Scale 21; GAD-7, Generalized Anxiety Disorder-7; GHQ-12, 12-Item General Health Questionnaire; HAD, Hospital Anxiety and Depression Scale; HAMA,
Hamilton Depression Scale; MAS, Manifest Anxiety Scale; S-AI, State-Anxiety Inventory; SAS, Self-Rating Anxiety Scale; SCARED, Rating Scale Scoring Aide; SCL-90, the symptom checklist-90; STAI-6, the 6-item state version of the State-Trait Anxiety Inventory.
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Wang et al.
TABLE 3 Characteristics of the 21, 53, and 14 studies included on suicidal attempt, suicidal ideation, and suicidal plan in this review.
tools and cutoff
score
Suicide attempt
2002 Hu Liren NA Mean: 21 Medicine Undergraduates NA Self-made questionnaire Cross-sectional study
2005 Hu Liren NA Mean (SD): 21.22 (1.35) Medicine Undergraduates Stratified and cluster Self-made questionnaire Cross-sectional study
sampling
2005 Wang Dequan NA NA Medicine Undergraduates Stratified sampling Self-made questionnaire Cross-sectional study
sampling
2008 Ou Guangzhong Fujian Mean: 20 Medicine Grades 1 and 3 Cluster sampling QSA and Suicide ideation Cross-sectional study
question
2008 Chen Zehua Guangdong NA Medicine College students and Cluster sampling Based on YRBSS Cross-sectional study
undergraduates
2008 Hu Zhihong Shanghai Mean (SD): 21.36 (1.62) Clinical Undergraduates Stratified and cluster Self-made questionnaire Cross-sectional study
15
sampling
2008 Fan Yinguang Anhui Mean (SD): 20.15 (1.67) Medicine Undergraduates Stratified and cluster Cross-sectional study
sampling
2009 Shang Yuxiu Ningxia Mean (SD): 20.62 (1.64) Medicine Undergraduates Stratified and cluster Self-made questionnaire Cross-sectional study
sampling
2009 Cao Hongyuan Anhui Mean (SD): 19.33 (1.17) Medicine Grades 1–2 Simple random sampling Self-made questionnaire Cross-sectional study
2009 Zeng Zhuanping NA NA Medicine Grades 1–3 Stratified and cluster Self-made questionnaire Cross-sectional study
sampling
2010 Xin Shen Anhui Mean (SD): 20.56 (1.58) Medicine Undergraduates Cluster sampling SIOSS Cross-sectional study
2012 Wan Yuhui Anhui SD: 20.5 ± 1.1 Medicine Grades 1–2 Cluster sampling Self-made questionnaire Cross-sectional study
2013 Zhang Yuan Yunnan NA Medicine Undergraduates Stratified and simple random Self-made questionnaire Cross-sectional study
sampling
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2014 Yang Linsheng Anhui Mean (SD): 19.6 (1.3) Medicine Grades 1–2 Simple random sampling Self-made questionnaire Cross-sectional study
2014 Yang Linsheng Anhui Mean (SD): 19.6 (1.3) Medicine Grades 1–2 Cluster sampling Self-made questionnaire Cross-sectional study
2017 Long Sun NA Mean (SD): 20.25 (1.23) Medicine Undergraduates Simple random sampling Self-made questionnaire Cross-sectional study
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(Continued)
Wang et al.
TABLE 3 (Continued)
tools and cutoff
score
2018 Zeng Baoer Guangdong Mean (SD): 25.79 (4.47) Medicine Undergraduates NA SBQ-R Cross-sectional study
2020 Wanjie Tang NA NA Medicine Undergraduates Simple random sampling NCS Cross-sectional study
2020 Yanmei Shen Hunan Mean (SD): 18.77 (1.09) Medicine College students and Convenience sampling Self-made questionnaire Cross-sectional study
undergraduates
2020 Chen Jun NA Mean (SD): 19.63 (1.28) Medicine Grades 1–2 Stratified and cluster Self-made questionnaire Cross-sectional study
sampling
Suicide ideation
2004 Liang Duohong Liaoning Mean (SD): 20.8 (0.8) Medicine Grades 1–3 and college students Stratified and cluster Self-made questionnaire Cross-sectional study
sampling
sampling
16
2006 Wang Xuelian Fujian NA Medicine Grades 1–3 and 5 Simple random sampling Self-made questionnaire Cross-sectional study
sampling
2007 Zhang Xiaoyuan Guangdong Mean (SD): 20.3 (2.7) Medicine Undergraduates Cluster sampling EPQ Cross-sectional study
question
2008 Wang Xing Jiangxi Mean: 22 Medicine Undergraduates Simple random sampling EPQ Cross-sectional study
medicine sampling
2008 Yang Benfu NA NA Medicine Undergraduates Cluster sampling SIOSS Cross-sectional study
2008 Qian Wencai Huabei NA Medicine Grades 1–3 Cluster sampling AHRBI Cross-sectional study
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2008 Li Youzi Liaoning NA Medicine Undergraduates Simple random sampling SCL-90 Cross-sectional study
2008 Liu Baohua Beijing NA Medicine Grade 1 NA Medical Student Risk Cross-sectional study
Behavior Questionnaire
2008 Chen Zehua Guangdong NA Medicine College students and Cluster sampling YRBSS Cross-sectional study
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undergraduates
(Continued)
Wang et al.
TABLE 3 (Continued)
tools and cutoff
score
2008 Fan Yinguang Anhui Mean (SD): 20.15 (1.67) Medicine Undergraduates Stratified and cluster BSSI Cross-sectional study
sampling
sampling
2009 Cao Hongyuan Anhui Mean (SD): 19.33 (1.17) Medicine Grades 1–2 Simple random sampling Self-made questionnaire Cross-sectional study
2009 Yang Xiaohui Sichuan Mean: 21.5 Medicine Undergraduates NA SIOSS Cross-sectional study
2009 Zeng Zhuanping NA NA Medicine Grades 1–3 Stratified and cluster Self-made questionnaire Cross-sectional study
sampling
2010 Song Yumei Anhui Mean (SD): 21.8 (1.64) Medicine Undergraduates Stratified and cluster BSI-CV Cross-sectional study
sampling
2010 Xin Shen Anhui Mean (SD): 20.56 (1.58) Medicine Undergraduates Cluster sampling SIOSS Cross-sectional study
2010 Shen Liqin NA NA Medicine Undergraduates Simple random sampling Self-made questionnaire Cross-sectional study
2010 Wang Jian NA Mean (SD): 22 (1.23) Medicine Grade 3 NA SIBQ Cross-sectional study
17
2010 Yang Yanjie Heilongjiang SD: 21.32 ± 2.195 Medicine NA Stratified random cluster Self-made questionnaire Cross-sectional study
sampling
2012 Yang Chuanwei Henan Mean (SD): 20.67 (1.43) Medicine Undergraduates Stratified and cluster SIOSS Cross-sectional study
sampling
2012 Fan, A.P. Taiwan NA Medicine Undergraduates Simple random sampling Self-made questionnaire Cross-sectional study
2013 Wu Ling Hainan Mean (SD): 21.51 (1.67) Medicine and Undergraduates Multi-stages sampling SIOSS Cross-sectional study
others
2013 Liu Chang NA Mean (SD): 19.63 (0.85) Medicine Undergraduates Simple random sampling UPI Cross-sectional study
2013 Zhang Yuan Yunnan NA Medicine Undergraduates Stratified and simple random Self-made questionnaire Cross-sectional study
sampling
2014 Yang Linsheng Anhui Mean (SD): 19.6 (1.3) Medicine Grades 1–2 Simple random sampling Self-made questionnaire Cross-sectional study
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2014 Yao Ran Guangdong Mean: 21 Medicine Undergraduates Stratified and cluster Self-made questionnaire Cross-sectional study
sampling
2014 Kunmi Sobowale Mainland China NA Medicine Grades 2 and 3 NA PHQ-9 Cross-sectional study
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2014 Aiming Zheng China SD: 20.8 ± 1.36 Medicine Grades 3–5 NA BHS Cross-sectional study
(Continued)
Wang et al.
TABLE 3 (Continued)
tools and cutoff
score
2014 Yang Linsheng Anhui Mean (SD): 19.6 (1.3) Medicine Grades 1–2 Cluster sampling Self-made questionnaire Cross-sectional study
2014 Liu Yan Liaoning Mean (SD): 20.79 (1.19) Medicine Grades 1–3 Stratified and cluster Self-made questionnaire Cross-sectional study
sampling
2015 Zhang Kaili Hunan Mean: 20.5 Clinical and Undergraduates Stratified sampling PIL Cross-sectional study
nursing
2015 Guan Suzhen Xinjiang Mean: 21 Medicine Undergraduates Stratified and cluster SSI Cross-sectional study
sampling
2016 Dai Chengshu NA NA Medicine Undergraduates Cluster sampling BSSI Cross-sectional study
2016 Lv Shixin Shandong NA Medicine Undergraduates Stratified and cluster SIOSS Cross-sectional study
sampling
2017 Ma Xuan Anhui Mean (SD): 19.5 (1) Medicine Grades 1–2 Stratified and cluster Self-made questionnaire Cross-sectional study
sampling
18
2018 Dan Wu China NA Medicine Undergraduates Multi-staged sampling Single item Cross-sectional study
2018 Sibo Zhao China Mean (SD): 20.25 (3.25) Medicine Undergraduates NA SSI Cross-sectional study
2018 Zheng Chuanjuan Zhejiang NA Medicine Undergraduates and Stratified sampling Self-made questionnaire Cross-sectional study
postgraduates
2019 Liu Jing Anhui Mean (SD): 20 (1.5) Medicine Undergraduates Cluster sampling Self-made questionnaire Cross-sectional study
undergraduates
2020 Chen Jun NA Mean (SD): 19.63 (1.28) Medicine Grades 1–2 Stratified and cluster Self-made questionnaire Cross-sectional study
sampling
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Suicide plan
2004 Liang Duohong Liaoning Mean (SD): 2 (0.8) Medicine Grades 1–3 and college students Stratified and cluster Self-made questionnaire Cross-sectional study
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sampling
(Continued)
Wang et al.
TABLE 3 (Continued)
tools and cutoff
score
sampling
2006 Wang Xuelian Fujian NA Medicine Grades 1–3 and 5 Simple random sampling Self-made questionnaire Cross-sectional study
sampling
question
19
sampling
sampling
undergraduates
NA, not available; SD, Standard Deviation; NCS, National Comorbidity Survey; QSA, Suicide Attitude Questionnaire; SBQ-R, The Suicide Behaviors Questionnaire-Revised; SIOSS, Self-rating Idea of Suicide Scale; PHQ-9, the Patient Health Questionnaire-9; BHS,
Beck Hopelessness Scale; BSI-CV, Beck Scale for Suicide Ideation-Chinese Version; BSSI, Beck Scale for Suicidal Ideation; PIL, Purpose in Life Test; EPQ, Eysenck Personality Questionnaire; SIBQ, Suicidal Ideation and Behavior Questionnaire; SSI, Scale for Suicide
Ideation; AHRBI, the Adolescent Health-Related Risky Behavior Inventory; SCL-90, the symptom checklist-90; UPI, University Personality Inventory; YRBSS, Youth Risk Behavior Surveillance System Questionnaire.
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Wang et al. 10.3389/fpubh.2023.1116616
FIGURE 2
Forest plot of prevalence of depression in Chinese medical students.

Wang et al. 10.3389/fpubh.2023.1116616
the overall prevalence estimates. Egger’s test (37) and Begg’s test showed that no individual study significantly affected the overall
(38) were utilized to investigate publication bias, with p < 0.05 result (Supplementary material S5, Figure 1). In subgroup analysis,
demonstrating statistical publication bias. All statistical analyses heterogeneity was reduced in studies using BDI with a score ≥ 14
were performed using the Stata software (version 14.2; StataCorp, (I 2 = 87.97%), SCL-90 with a score ≥ 2 (I 2 = 81.69%), and SCL-90
College Station, TX, United States) (39). with a score ≥ 3 (I 2 = 47.42%; Table 4).
Subgroup analysis showed differences in prevalence based on
study regions, recall periods, sampling methods, measurement
Results tools, and cutoff scores. In this study, the pooled prevalence
of depression symptoms was higher in the northwest region of
Characteristics of the included studies China, with an estimate of 51% (95% CI: 37%−66%). Furthermore,
studies conducted between 2005 and 2010 found a higher
A total of 197 studies involving 294,408 medical students in prevalence of depression symptoms (31%; 95% CI: 23%−40%).
China were included in the final meta-analysis (Figure 1). The All studies that used a cluster sampling method reported a higher
median sample size was 690 (range: 100–10,344). Among the prevalence of depression symptoms than other sampling methods.
included studies, 129 reported the prevalence of depression, with In terms of measurement tool and cutoff score, studies using
a combined sample size of 132,343 individuals. The prevalence of the Depression Status Inventory (DSI) with a severity index
anxiety symptoms was reported in 80 studies, with a combined ≥ 0.5 and the BDI-13 with a score ≥ 5 reported a higher
sample size of 105,397 individuals. The prevalence of suicide estimated prevalence, with a pooled prevalence of 68% (95% CI:
attempt, suicide ideation, and suicide plan was reported in 21, 40%−90%) and 54% (95% CI: 52%−57%), respectively (Figure 3,
53, and 14 studies, respectively, with combined samples of 69,786, Table 4).
119,069, and 27,025 individuals. In all univariate meta-regression analyses, only
Of the included studies, 172 were written in Chinese and 26 the measurement tool and cutoff score could
were written in English. A cross-sectional design was used in 197 explain the heterogeneity between studies (p <
studies, and only one study used a randomized controlled trial 0.001). The result of Egger’s test showed publication
design. The JBI quality score of the 197 included studies ranged bias, with p < 0.01 (Supplementary material S6,
from 6 to 20, with a mean score of 15. Figure 1).
Publication years ranged from 2000 to 2020, and the study
regions covered 23 provinces on the mainland and Taiwan Province
of China. The most common sampling methods used were multiple
sampling methods (n = 58), cluster sampling (n = 55), and simple Anxiety
random sampling (n = 44). Other methods, such as convenience
sampling, stratified sampling, and multi-stage sampling, were also The anxiety symptoms reported in the 80 included studies
used in some of the included studies. With regard to measurement yielded a pooled prevalence of 18% (19,479/105,397; 95%
tools or items, 17, 13, and 19 types of tools were used to assess CI: 15%−20%), with substantial evidence of between-study
depression, anxiety symptoms, and suicidal behaviors (including heterogeneity (I 2 = 99.03%; Figure 4, Table 5). Sensitivity analysis
suicide attempt, suicide ideation, and suicide plan), respectively. showed that no individual study significantly affected the overall
Common measurement tools for depression were Zung’s Self- result (Supplementary material S5, Figure 2). In the subgroup
Rating Depression Scale (SDS), the Center for Epidemiologic analysis, heterogeneity was found to be reduced in the southwest
Studies Depression Scale (CES-D), and the Beck Depression Rating region (I 2 = 97.87%), south China (I 2 = 86.94%), and
Scale (BDI), which were used in 66, 17, and 17 of the included in studies using SCL-90 with a score ≥ 3 (I 2 = 77.66%;
studies, respectively. Anxiety measurement tools were the Self- Table 5).
Rating Anxiety Scale (SAS), the symptom checklist-90 (SCL-90), Subgroup analysis showed differences in prevalence based
and the Beck Anxiety Inventory (BAI), used in 52, 10, and 5 on study regions, survey years, sampling methods, measurement
of the included studies, respectively. The assessments used for tools, and cutoff scores. Among all study regions, the estimated
suicidal behaviors were self-made questionnaires or standardized prevalence of anxiety symptoms was highest in the northwest
scales, such as the National Comorbidity Survey (NCS) and Suicidal region (27%; 95% CI: 23%−31%), followed by the southwest
Behaviors Questionnaire (SBQ). The recall period to measure region (24%; 95% CI: 18%−31%). Furthermore, studies conducted
suicidal behavior included “past 1 week,” “past 6 months,” “past between 2015 and 2020 showed a higher prevalence of anxiety
1 year,” “past 2 years,” and “lifetime.” A detailed summary of the symptoms (22%; 95% CI: 18%−27%) than other years. Among all
characteristics of the included studies is provided in Tables 1–3. sampling methods, the estimated prevalence of anxiety symptoms
was highest in studies using stratified sampling methods (29%; 95%
CI: 13%−48%), followed by cluster sampling methods (19%; 95%
Depression CI: 13%−25%). In terms of measurement tools and cutoff scores,
the highest prevalence of anxiety symptoms was reported in the
Depression symptoms reported in the 129 included studies study using the Hamilton Depression Scale (HAMA) with a score
yielded a pooled prevalence of 29% (38,309/132,343; 95% ≥ 7 (82%; 95% CI: 75%−87%; Figure 5, Table 5).
CI: 26%−32%), with substantial evidence of between-study In all univariate meta-regression analyses, only the
heterogeneity (I 2 = 99.33%; Figure 2, Table 4). Sensitivity analysis measurement tool and cutoff score (p = 0.0010) could explain

Wang et al.
TABLE 4 Estimated depression prevalence among medical students in China.
Subgroup No. of studies No. of depression Sample size Subgroup analysis Meta-regression
Estimated rate (95% CI) Q I2 (%) p-value I2 (%) p-value
Study region
Northeast 12 4,299 11,188 0.28 (0.13, 0.45) 4,159.55 99.74% <0.01 99.50 0.1682
North China 19 2,442 8,718 0.25 (0.19, 0.32) 914.95 98.03% <0.01
East China 23 6,076 26,384 0.26 (0.21, 0.30) 1,255.88 98.25% <0.01
South China 14 2,853 9,506 0.33 (0.21, 0.48) 2,553.71 99.49% <0.01
Central China 14 4,923 16,743 0.23 (0.13, 0.34) 3,313.32 99.61% <0.01
Northwest 5 1,569 3,584 0.51 (0.37, 0.66) 280.58 98.57% <0.01
Southwest 15 5,911 18,134 0.35 (0.28, 0.41) 1,064.86 98.69% <0.01
Multiple regions 8 2,979 13,015 0.28 (0.19, 0.38) 642.10 98.91% <0.01
N 19 7,254 25,071 0.28 (0.20, 0.37) 3,484.46 99.48% <0.01
Survey year
2000–2005 24 3,882 14,293 0.25 (0.18, 0.32) 2,098.33 98.90% <0.01 99.51 0.6012
22
2005–2010 25 7,018 23,056 0.31 (0.23, 0.40) 4,270.98 99.44% <0.01
2010–2015 39 11,773 45,139 0.30 (0.25, 0.36) 5,682.24 99.33% <0.01
2015–2020 41 15,636 49,855 0.28 (0.23, 0.34) 6,736.96 99.41% <0.01
Sample size
<200 16 678 2,456 0.25 (0.17, 0.34) 363.84 95.88% <0.01 99.54 0.6346
201–400 26 2,562 7,266 0.33 (0.25, 0.42) 1,429.42 98.25% <0.01
401–600 26 3,881 12,778 0.30 (0.23, 0.37) 2,066.31 98.79% <0.01
601–800 11 1,971 7,358 0.26 (0.18, 0.34) 669.56 98.51% <0.01
801–1,000 16 3,662 14,181 0.25 (0.17, 0.34) 1,996.52 99.25% <0.01
>1,000 34 25,555 88,304 0.29 (0.24, 0.35) 12,430.00 99.73% <0.01
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Sampling methods
Simple 25 5,645 22,132 0.24 (0.18, 0.31) 2,603.18 99.08% <0.01 99.48 0.2927
Convenience 6 2,852 11,832 0.20 (0.14, 0.26) 293.03 98.29% <0.01

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Stratified 4 502 2,219 0.26 (0.13, 0.41) 165.74 98.19% <0.01
(Continued)
Wang et al.
TABLE 4 (Continued)
Cluster 34 9,086 22,692 0.34 (0.26, 0.42) 5,467.54 99.40% <0.01
Multiple sampling methods 39 12,687 42,280 0.29 (0.24, 0.34) 5,625.12 99.32% <0.01
N 21 7,537 31,188 0.29 (0.22, 0.36) 3,046.89 99.34% <0.01
Educational level
Undergraduate 122 36,181 1,27,448 0.29 (0.26, 0.32) 17,679.64 99.32% <0.01 99.51 0.7368
Postgraduate 6 2,041 4,387 0.32 (0.14, 0.52) 793.43 99.37% <0.01
Unclassified 1 87 508 0.17 (0.14, 0.21) – – –
Measurement tool and cutoff score

ADI score ≥ 8 1 204 625 0.33 (0.29, 0.36) – – – 98.76 <0.001
BDI score ≥ 5 7 2,040 4,719 0.46 (0.38, 0.54) 166.95 96.41% <0.01
BDI score ≥ 10 1 1,699 10,140 0.17 (0.16, 0.17) – – –
BDI score ≥ 14 5 2,124 11,028 0.19 (0.15, 0.22) 33.24 87.97% <0.01
23
BDI without cutoff score reported 1 177 945 0.19 (0.16, 0.21) – – –
BDI-13 score ≥ 5 1 767 1,414 0.54 (0.52, 0.57) – – –
BDI-II score ≥ 14 2 567 2,652 0.21 (0.20, 0.23) – – –
CES-D score ≥ 16 10 4,951 9,557 0.46 (0.34, 0.58) 1,231.06 99.27% <0.01
CES-D score ≥ 20 7 1,937 6,399 0.34 (0.22, 0.48) 612.45 99.02% <0.01
DASS-21 score ≥ 10 2 286 1,647 0.17 (0.15, 0.19) – – –
DSI severity index ≥ 0.5 3 1,407 2,148 0.68 (0.40, 0.90) – – –
GHQ-12 score ≥ 2 1 3 123 0.02 (0.01, 0.07) – – –
HAD score ≥ 9 1 31 181 0.17 (0.12, 0.23) – – –
IVR(self-made) score ≥ 10 1 21 204 0.10 (0.06, 0.15) – – –
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PHQ-2 score ≥ 3 1 20 142 0.14 (0.09, 0.21) – – –
PHQ-9 score ≥ 5 1 226 348 0.65 (0.60, 0.70) – – –
PHQ-9 score ≥ 10 3 438 2,505 0.18 (0.15, 0.22) – – –

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PRIME-MD answer “yes” 1 611 1,814 0.34 (0.32, 0.36) – – –
SCL-90 score ≥ 1.8 1 1,906 7,321 0.26 (0.25, 0.27) – – –
(Continued)
Wang et al.
TABLE 4 (Continued)
Sample size
SCL-90 score ≥ 2 5 678 3,795 0.18 (0.15, 0.21) 21.85 81.69% <0.01
SCL-90 score > 2 1 36 1,137 0.03 (0.02, 0.04) – – –
SCL-90 score ≥ 3 4 129 2,880 0.04 (0.03, 0.05) 5.71 47.42% 0.13
SCL-90 without cutoff score 1 30 1,286 0.02 (0.02, 0.03) – – –

reported
SDS score ≥ 5 1 163 537 0.30 (0.26, 0.34) – – –
SDS score ≥ 14 1 214 1,053 0.20 (0.18, 0.23) – – –
SDS score ≥ 40 2 150 656 0.22 (0.19, 0.25) – – –
SDS score ≥ 41 3 401 1,706 0.25 (0.11, 0.42) – – –

24
SDS score ≥ 42 1 144 485 0.30 (0.26, 0.34) – – –
SDS score ≥ 50 24 5,060 14,975 0.29 (0.23, 0.35) 1,413.90 98.37% <0.01
SDS score > 50 1 63 622 0.10 (0.08, 0.13) – – –
SDS score ≥ 52 1 303 940 0.32 (0.29, 0.35) – – –
SDS score ≥ 53 14 4,655 15,256 0.32 (0.25, 0.39) 976.16 98.67% <0.01
SDS severity index ≥ 0.5 12 4,548 9,083 0.38 (0.29, 0.48) 879.01 98.75% <0.01
SDS score ≥ 50 and HAMD 1 56 691 0.08 (0.06, 0.10) – – –
SDS without cutoff score reported 5 2,185 12,720 0.19 (0.13, 0.26) 147.09 97.28% <0.01
Self-made questions answers “yes” 1 14 164 0.09 (0.05, 0.14) – – –
YRBSS without cutoff score 1 65 445 0.15 (0.11, 0.18)

reported
10.3389/fpubh.2023.1116616
Overall 129 38,309 1,32,343 0.29 (0.26, 0.32) 19,186.54 99.33% <0.01
N, not reported; HAD, Hospital Anxiety and Depression Scale; BDI, Beck Depression Rating Scale; BDI-II, Beck Depression Inventory-II; BDI-13, Beck Depression Inventory-13; CES-D, Center for Epidemiologic Studies Depression Scale; DASS-21, Depression Anxiety
Stress Scale-21; DSI, Depression Status Inventory; GHQ, General Health Questionnaire; IDLS, the international depression literacy survey; IVR, interactive voice response; PHQ-2, The Patient Health Questionnaire-2; PHQ-9, The Patient Health Questionnaire-9;
SCL-90, the symptom checklist-90; PRIME-MD, The 2-Item Primary Care Evaluation of Mental Disorders; SDS, Self-Rating Depression Scale; HAMD, Hamilton Depression Scale; YRBSS, Youth Risk Behavior Surveillance System Questionnaire.
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Wang et al. 10.3389/fpubh.2023.1116616
the heterogeneity between studies. Publication bias was found

in the pooled prevalence analysis (p < 0.001 using Egger’s test;
Supplementary material S6, Figure 2).
Suicidal behaviors
Suicidal ideation
The pooled prevalence of suicide ideation reported in 53 studies
was 13% (15,546/119,069, 95% CI: 11%−15%), with significant
heterogeneity of 99.19% among included studies (Figure 6, Table 6).
Sensitivity analysis showed that no individual study significantly
affected the overall result (Supplementary material S5, Figure 3). In
the subgroup analysis, heterogeneity was found to be reduced in the
northeast region (I 2 = 85.58%), recall period of the past 1 week (I 2
= 84.33%), and in studies using the Self-rating Idea of Suicide Scale
(SIOSS) to identify suicide ideation (I 2 = 88.71%).
study regions, sampling methods, recall periods, and measurement
tools. The estimated prevalence of suicide ideation was highest
in central China (19%; 95% CI: 7%−34%), followed by south
China (17%, 95% CI: 9%−26%) and the southwest region (17%;
95% CI: 15%−18%). Furthermore, studies conducted between
2005 and 2010 had a higher prevalence of suicide ideation than
other survey years (15%; 95% CI: 11%−18%). The estimated
prevalence was higher in those studies using convenience sampling
methods (26%; 95% CI: 25%−28%) compared with other sampling
methods. Among all recall periods reported in the included
studies, those studies using the recall period “lifetime” reported
a higher estimated prevalence of suicide ideation (19%; 95% CI:
15%−24%). In terms of measurement tools, studies using the
Eysenck Personality Questionnaire (EPQ), SSI, and Purpose in Life
Test (PIL) reported higher pooled prevalence, with estimates of
27% (95% CI: 26%−28%), 24% (95% CI: 22%−27%), and 24% (95%
CI: 20%−29%), respectively (Figure 7, Table 6).
Univariate meta-regression analyses demonstrated that
measurement tools (p = 0.0282) could explain the potential
source of the heterogeneity. Publication bias was found in
the pooled prevalence analysis (p < 0.001 using Egger’s test;
Supplementary material S6, Figure 3).
Suicidal attempt
The pooled prevalence of suicide attempts reported in 21
studies was 3% (1,730/69,786, 95% CI: 1%−4%), with significant
heterogeneity of 99.01% among the included studies (Figure 8,
Table 7). Sensitivity analysis showed that no individual study
significantly affected the overall result (Supplementary material S5,
Figure 4).
study regions, survey years, sampling methods, recall periods, and
FIGURE 3 measurement tools. The estimated prevalence of suicide attempt
Subgroup analysis of depression in Chinese medical students based
was higher in central China (14%; 95% CI: 13%−15%) than other
on measurements tools.
regions. Studies conducted between 2015 and 2020 (4%; 95% CI:

Wang et al. 10.3389/fpubh.2023.1116616
FIGURE 4
Forest plot of prevalence of anxiety in Chinese medical students.

Wang et al.
TABLE 5 Estimated anxiety prevalence among medical students in China.
Subgroup No. of studies No. of anxiety Sample size Subgroup analysis Meta-regression
Study region
Northeast 11 3,482 11,681 0.19 (0.09, 0.32) 2,385.60 99.58% <0.01 99.25 0.6626
North China 10 1,130 5,258 0.18 (0.11, 0.27) 512.18 98.27% <0.01
East China 12 3,986 25,598 0.20 (0.16, 0.23) 381.33 97.12% <0.01
South China 9 804 6,069 0.12 (0.10, 0.15) 61.24 86.94% <0.01
Central China 11 2,803 14,682 0.15 (0.08, 0.23) 1,680.35 99.40% <0.01
Northwest 4 793 2,984 0.27 (0.23, 0.31) 20.60 85.43% <0.01
Southwest 6 2,580 11,651 0.24 (0.18, 0.31) 234.93 97.87% <0.01
Multiple regions 5 1,292 9,371 0.13 (0.06, 0.21) 179.87 97.78% <0.01
N 12 2,609 18,103 0.17 (0.11, 0.25) 1,199.99 99.08% <0.01

27
Survey year
2000–2005 18 1,082 9,057 0.12 (0.08, 0.16) 540.21 96.85% <0.01 99.21 0.0490
2005–2010 18 4,205 26,185 0.15 (0.10, 0.20) 1,583.38 98.93% <0.01
2010–2015 19 5,424 25,219 0.20 (0.15, 0.27) 2,294.95 99.22% <0.01
2015–2020 25 8,768 44,936 0.22 (0.18, 0.27) 3,125.67 99.23% <0.01
Sample size
<200 10 420 1,618 0.23 (0.11, 0.37) 395.94 97.73% <0.01 99.29 0.3992
201–400 16 653 4,363 0.14 (0.09, 0.18) 270.87 94.46% <0.01
401–600 15 1,249 7,741 0.14 (0.09, 0.21) 780.15 98.21% <0.01
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601–800 7 959 4,724 0.20 (0.13, 0.27) 244.11 97.54% <0.01
801–1,000 10 1,694 8,908 0.18 (0.12, 0.25) 548.94 98.36% <0.01
>1,000 22 14,504 78,043 0.20 (0.15, 0.25) 5,750.08 99.63% <0.01
(Continued)
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Wang et al.
TABLE 5 (Continued)
Sampling methods
Simple 21 5,007 27,087 0.16 (0.12, 0.22) 2,464.46 99.19% <0.01 99.25 0.3401
Convenience 2 1,225 7,133 0.17 (0.16, 0.18) – – –
Stratified 5 666 2,798 0.29 (0.13, 0.48) 430.75 99.07% <0.01
Cluster 20 5,299 23,598 0.19 (0.13, 0.25) 2,149.95 99.12% <0.01
Multiple sampling methods 23 4,835 29,037 0.18 (0.14, 0.23) 2,172.46 98.99% <0.01
N 9 2,447 15,744 0.12 (0.08, 0.17) 410.95 98.05% <0.01
Educational level
Undergraduate 77 17,973 1,01,934 0.17 (0.15, 0.19) 6,828.34 98.89% <0.01 99.20 0.1020
Postgraduate 3 1,506 3,463 0.31 (0.14, 0.51) – – –
Measurement tool and cutoff score

BAI score ≥ 8 1 34 143 0.24 (0.17, 0.32) – – – 98.94 0.0010
28
BAI score ≥ 10 2 2,882 20,480 0.14 (0.14, 0.15) – – –
BAI score ≥ 15 1 253 2,251 0.11 (0.10, 0.13) – – –
BAI score ≥ 50 1 50 372 0.13 (0.10, 0.17) – – –
DASS-21 score ≥ 8 2 480 1,647 0.29 (0.27, 0.31) – – –
GAD-7 score ≥ 10 1 65 325 0.20 (0.16, 0.25) – – –
GHQ-12 score ≥ 2 1 5 123 0.04 (0.01, 0.09) – – –
HAD score ≥ 9 1 39 181 0.22 (0.16, 0.28) – – –
HAMA score ≥ 7 1 159 195 0.82 (0.75, 0.87) – – –
HAMA score ≥ 14 2 318 1,152 0.27 (0.24, 0.29) – – –
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MAS without cutoff score reported 1 54 575 0.09 (0.07, 0.12) – – –
S-AI without cutoff score reported 1 30 196 0.15 (0.11, 0.21) – – –
SAS without cutoff score reported 1 1,456 10,340 0.14 (0.13, 0.15) – – –
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SAS score ≥ 40 3 197 1,790 0.11 (0.09, 0.13) – – –
SAS score ≥ 41 1 140 396 0.35 (0.31, 0.40) – – –
(Continued)
Wang et al.
TABLE 5 (Continued)
SAS score ≥ 47 3 151 976 0.15 (0.13, 0.18) – – –
SAS score ≥ 50 42 11,126 47,980 0.20 (0.17, 0.24) 4,378.44 99.06% <0.01
SAS score > 50 1 113 716 0.16 (0.13, 0.19) – – –
SAS score ≥ 51 1 68 197 0.35 (0.28, 0.42) – – –
SCARED score ≥ 23 1 41 389 0.11 (0.08, 0.14) – – –
SCL-90 score ≥ 1.8 1 1,390 7,321 0.19 (0.18, 0.20) – – –
SCL-90 score ≥ 2 3 264 1,698 0.16 (0.14, 0.17) – – –
SCL-90 score > 2 1 23 1,137 0.02 (0.01, 0.03) – – –
SCL-90 score ≥ 3 5 109 4,166 0.03 (0.02, 0.04) 17.91 77.66% <0.01
29
SIAS score ≥ 50 1 4 487 0.01 (0.00, 0.02) – – –
Self-made questions answers “yes” 1 28 164 0.17 (0.12, 0.24) – – –
Overall 80 19,479 1,05,397 0.18 (0.15, 0.20) 8,143.11 99.03% <0.01
N, not reported; BAI, Beck Anxiety Inventory; DASS-21, Depression Anxiety Stress Scale 21; GAD-7, Generalized Anxiety Disorder-7; GHQ-12, 12-item General Health Questionnaire; HAD, Hospital Anxiety and Depression Scale; HAMA, Hamilton Anxiety Scale;
MAS, Manifest Anxiety Scale; S-AI, State-Anxiety Inventory; SAS, Self-Rating Anxiety Scale; SCARED, Rating Scale Scoring Aide; SCL-90, the symptom checklist-90; STAI-6, the 6-Item State Version of the State-Trait Anxiety Inventory.
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Wang et al. 10.3389/fpubh.2023.1116616
FIGURE 5
Subgroup analysis of anxiety in Chinese medical students based on measurements tools.

Wang et al. 10.3389/fpubh.2023.1116616
FIGURE 6
Forest plot of prevalence of suicidal ideation in Chinese medical students.

Wang et al.
TABLE 6 Estimated suicide ideation prevalence among medical students in China.
Subgroup No. of studies No. of suicide ideation Sample size Subgroup analysis Meta-regression
Study region
Northeast 4 361 3,967 0.10 (0.07, 0.12) 20.81 85.58% <0.01 99.14 0.8519
North China 2 247 3,403 0.07 (0.06, 0.08) – – –
East China 16 5,929 51,045 0.13 (0.09, 0.18) 2,844.04 99.47% <0.01
South China 6 3,015 15,052 0.17 (0.09, 0.26) 794.93 99.37% <0.01
Central China 3 1,490 6,630 0.19 (0.07, 0.34) – – –
Northwest 2 395 2,330 0.17 (0.15, 0.18) – – –
Southwest 2 133 1,380 0.10 (0.08, 0.11) – – –
Multiple regions 4 816 11,225 0.11 (0.07, 0.15) 152.41 97.38% <0.01
32
N 13 3,160 24,037 0.12 (0.09, 0.15) 575.80 97.92% <0.01
Survey year
2000–2005 4 648 6,457 0.09 (0.06, 0.12) 53.76 94.42% <0.01 99.08 0.6095
2005–2010 21 5,995 37,020 0.15 (0.11, 0.18) 1,642.94 98.78% <0.01
2010–2015 14 3,124 32,061 0.11 (0.08, 0.16) 1,547.63 99.16% <0.01
2015–2020 14 5,779 43,531 0.13 (0.09, 0.18) 2,352.25 99.45% <0.01
Sample size
<200 1 12 148 0.08 (0.04, 0.14) – – – 99.24 0.0686
201–400 5 400 1,642 0.24 (0.14, 0.35) 98.53 95.94% <0.01
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401–600 6 374 3,030 0.12 (0.08, 0.16) 54.91 90.89% <0.01
601–800 9 1,094 6,111 0.17 (0.09, 0.27) 733.53 98.91% <0.01
(Continued)
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Wang et al.
TABLE 6 (Continued)
801–1,000 4 492 3,462 0.13 (0.05, 0.25) 242.27 98.76% <0.01
>1,000 27 13,174 1,04,676 0.10 (0.08, 0.13) 4,980.92 99.46% <0.01
Sampling methods
Simple 10 4,854 33,100 0.17 (0.12, 0.22) 1,373.24 99.27% <0.01 98.96 0.2339
Convenience 1 1,289 4,882 0.26 (0.25, 0.28) – – –
Stratified 3 640 3,694 0.21 (0.12, 0.31) – – –
Cluster 10 3,090 32,989 0.08 (0.04, 0.14) 2,144.67 99.58% <0.01
Multiple 18 4,044 32,574 0.12 (0.10, 0.15) 681.49 97.51% <0.01
Multi-stage sampling 1 107 696 0.15 (0.13, 0.18) – – –
N 9 1,152 11,134 0.12 (0.07, 0.19) 669.67 98.81% <0.01
Recall period
Past 1 week 4 671 5,460 0.12 (0.10, 0.15) 19.15 84.33% <0.01 98.46 0.0583
33
Past 6 months 1 58 2,498 0.02 (0.02, 0.03) – – –
Past 1 year 18 2,495 36,144 0.10 (0.08, 0.12) 824.66 97.94% <0.01
Past 2 years 1 51 2,498 0.02 (0.02, 0.03) – – –
Lifetime 13 8,546 43,898 0.19 (0.15, 0.24) 1,383.14 99.13% <0.01
N 18 3,834 33,567 0.12 (0.09, 0.15) 1,068.59 98.41% <0.01
Educational level
Undergraduate 51 15,096 1,12,897 0.13 (0.11, 0.15) 6,130.56 99.18% <0.01 99.21 0.4261
Postgraduate/doctor 1 15 820 0.02 (0.01, 0.03) – – –
Unclassified 2 286 1,399 0.20 (0.18, 0.22) – – –
Measurement tool
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NCS 1 136 662 0.21 (0.18, 0.24) – – – 99.26 0.0282
SBQ-R 2 1,028 6,424 0.15 (0.14, 0.16) – – –
QSA and Suicide ideation question 1 115 698 0.16 (0.14, 0.19) – – –
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PHQ-9 2 386 5,941 0.06 (0.06, 0.07) – – –
(Continued)
Wang et al.
TABLE 6 (Continued)
BHS 1 48 540 0.09 (0.07, 0.12) – – –
SIOSS 6 432 4,898 0.09 (0.07, 0.12) 44.30 88.71% <0.01
BSI-CV 1 210 2,062 0.10 (0.09, 0.12) – – –
BSSI 2 384 3,460 0.11 (0.10, 0.12) – – –
PIL 1 91 376 0.24 (0.20, 0.29) – – –
EPQ 2 2,150 7,813 0.27 (0.26, 0.28) – – –
SIBQ 1 73 628 0.12 (0.09, 0.14) – – –
SSI 2 272 1,118 0.24 (0.22, 0.27) – – –
AHRBI 1 122 2,199 0.06 (0.05, 0.07) – – –
SCL-90 1 64 541 0.12 (0.09, 0.15) – – –
UPI 1 38 830 0.05 (0.03, 0.06) – – –
YRBSS 1 30 445 0.07 (0.05, 0.09) – – –

34
Medical Student Risk Behavior 1 125 1,204 0.10 (0.09, 0.12) – – –

Questionnaire
Single item 1 283 4,446 0.06 (0.06, 0.07)
Self-made questionnaire 25 9,559 74,784 0.13 (0.10, 0.16) 3,300.26 99.27% <0.01
Overall 53 15,546 119,069 0.13 (0.11, 0.15) 6,382.63 99.19% <0.01

N, not reported; NCS, National Comorbidity Survey; SBQ-R, The Suicide Behaviors Questionnaire-Revised; QSA, Suicide Attitude Questionnaire; PHQ-9, the Patient Health Questionnaire-9; BHS, Beck Hopelessness Scale; SIOSS, Self-Rating Idea of Suicide Scale;
BSI-CV, Beck Scale for Suicide Ideation-Chinese Version; BSSI, Beck Scale for Suicidal Ideation; PIL, Purpose in Life Test; EPQ, Eysenck Personality Questionnaire; SIBQ, Suicidal Ideation and Behavior Questionnaire; SSI, Scale for Suicide Ideation; AHRBI, the
Adolescent Health related Risky Behavior Inventory; SCL-90, the symptom checklist-90; UPI, University Personality Inventory; YRBSS, Youth Risk Behavior Surveillance System Questionnaire.
10.3389/fpubh.2023.1116616
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Wang et al. 10.3389/fpubh.2023.1116616
FIGURE 7
Subgroup analysis of suicide ideation in Chinese medical students based on measurements tools.

Wang et al. 10.3389/fpubh.2023.1116616
FIGURE 8
Forest plot of prevalence of suicidal attempt in Chinese medical students.
1%−9%) had a higher prevalence of suicide attempt than other Suicidal plan
survey years. Furthermore, the estimated prevalence was higher in The pooled prevalence of suicide plan reported in 14
those studies using convenience sampling methods (14%; 95% CI: studies was 4% (1,188/27,025, 95% CI: 3%−6%), with significant
13%−15%) than other sampling methods. The studies with a recall heterogeneity of 97.12% among the included studies (Figure 10,
period of the past 1 month reported a significantly higher pooled Table 8). Sensitivity analysis showed that no individual study
prevalence (13%; 95% CI: 10%−16%) than other recall periods. As significantly affected the overall result (Supplementary material S5,
for measurement tools, the studies using SIOSS reported a higher Figure 5). In the subgroup analysis, heterogeneity was found to be
pooled prevalence of suicide attempt, with an estimate of 6% (95% reduced in the survey years from 2000 to 2005 (I 2 = 74.16%).
CI: 4%−7%; Figure 9, Table 7). Subgroup analysis showed differences in prevalence based on
Univariate meta-regression analyses demonstrated that study regions, survey years, sampling methods, and measurement
study region (p = 0.0294) and sampling method (p = 0.0402) tools. The estimated prevalence of suicide attempt was higher
could explain the potential source of the heterogeneity. in central China (8%; 95% CI: 7%−8%). Additionally, studies
Publication bias was found in the pooled prevalence analysis conducted between 2010 and 2015 had the lowest prevalence
(p < 0.001 using Egger’s test; Supplementary material S6, of suicide attempt (1%; 95% CI: 1%−2%) among all survey
Figure 4). years. The estimated prevalence was higher in those studies using

Wang et al.
TABLE 7 Estimated suicide attempt prevalence among medical students in China.
Subgroup No. of studies No. of suicide attempt Sample size Subgroup analysis Meta-regression
Study region
East China 8 425 39,282 0.01 (0.01, 0.02) 203.81 96.57% <0.01 96.45 0.0294
South China 2 46 3,657 0.01 (0.01, 0.02) – – –
Central China 1 682 4,882 0.14 (0.13, 0.15) – – –
Northwest 1 79 1,510 0.05 (0.04, 0.06) – – –
Southwest 1 24 697 0.03 (0.02, 0.05) – – –
N 8 474 19,758 0.03 (0.01, 0.05) 321.29 97.82% <0.01
Survey year
2000–2005 3 47 4,602 0.01 (0.00, 0.03) – – – 98.39 0.4842
2005–2010 9 479 18,536 0.03 (0.02, 0.06) 373.32 97.86% <0.01
2010–2015 4 232 25,354 0.01 (0.00, 0.02) 115.28 97.40% <0.01
2015–2020 5 972 21,294 0.04 (0.01, 0.09) 1,030.54 99.61% <0.01

37
Sample size
<600 2 75 935 0.07 (0.06, 0.09) – – – 98.52 0.2902
601–800 5 95 3,480 0.02 (0.01, 0.04) 50.15 92.02% <0.01
>1,000 14 1,560 65,371 0.02 (0.01, 0.04) 1,855.03 99.30% <0.01
Sampling methods
Simple 4 403 23,501 0.02 (0.01, 0.03) 61.58 95.13% <0.01 95.96 0.0402
Convenience 1 682 4,882 0.14 (0.13, 0.15) – – –
Stratified 1 10 2,498 0.00 (0.00, 0.01) – – –
Cluster 5 128 16,303 0.02 (0.01, 0.04) 129.61 96.91% <0.01
Multiple 8 456 18,381 0.03 (0.01, 0.06) 345.48 97.97% <0.01
10.3389/fpubh.2023.1116616
N 2 51 4,221 0.01 (0.01, 0.02) – – –
Recall period
Past 1 week 2 32 2,857 0.01 (0.01, 0.01) – – – 98.41 0.1190
Past 1 month 1 63 490 0.13 (0.10, 0.16) – – –

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Past 1 year 8 271 20,807 0.02 (0.01, 0.03) 309.87 97.74% <0.01
(Continued)
Wang et al.
TABLE 7 (Continued)
Subgroup No. of studies No. of suicide attempt Sample size Subgroup analysis Meta-regression
Lifetime 6 1,133 32,699 0.03 (0.01, 0.07) 1,308.39 99.62% <0.01
N 4 231 12,933 0.02 (0.01, 0.04) 42.70 92.97% <0.01
Educational level
Undergraduate 21 1,730 69,786 0.03 (0.01, 0.04) 2,022.20 99.01% <0.01 - -
Measurement tool
NCS 1 10 662 0.02 (0.01, 0.03) – – – 98.82 0.9576
QSA and Suicide ideation question 1 14 698 0.02 (0.01, 0.03) – – –
BSSI 1 8 2,160 0.00 (0.00, 0.01) – – –
SBQ-R 1 34 3,212 0.01 (0.01, 0.01) – – –
SIOSS 1 45 800 0.06 (0.04, 0.07) – – –

38
Self-made questionnaire 15 1,607 61,809 0.03 (0.01, 0.05) 1,924.10 99.27% <0.01
YRBSS 1 12 445 0.03 (0.01, 0.05) – – –
Overall 21 1,730 69,786 0.03 (0.01, 0.04) 2,022.20 99.01% <0.01

N, not reported; NCS, National Comorbidity Survey; QSA, Suicide Attitude Questionnaire; SBQ-R, The Suicide Behaviors Questionnaire-Revised; SIOSS, Self-rating Idea of Suicide Scale; YRBSS, Youth Risk Behavior Surveillance System.
10.3389/fpubh.2023.1116616
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Wang et al. 10.3389/fpubh.2023.1116616
FIGURE 9
Subgroup analysis of suicide attempt in Chinese medical students based on measurements tools.
convenience sampling methods (8%; 95% CI: 7%−8%) than other Significant results were not found in all univariate meta-
sampling methods. Among all measurement tools, studies using regression analyses to explain the heterogeneity between studies.
the Questionnaire of Suicide Attitude (QSA) and Suicide Ideation Publication bias was found in the pooled prevalence analysis
Question reported a higher prevalence (9%; 95% CI: 7%−11%; (p < 0.001 using Egger’s test; Supplementary material S6,
Figure 11, Table 8). Figure 5).

Wang et al. 10.3389/fpubh.2023.1116616
FIGURE 10
Forest plot of prevalence of suicidal plan in Chinese medical students.
Discussion reported studies (28.4 and 23.8%) in China (41, 42). This may
be because medical students may experience higher academic
Summary of results pressure due to the arduous training curriculum, less time for
relaxing or seeking psychological help (18, 43), and employment
To the best of our knowledge, this is the most comprehensive stress since pursuing a master’s or even doctoral degree is
systematic review and meta-analysis to estimate the prevalence commonly required to enter a hospital in China (44). These
of CMDs among Chinese medical students. Our study revealed two factors are unique to medical students (45). Furthermore,
that the pooled prevalence of depression, anxiety, suicidal ideation, our results revealed that the prevalence of depression symptoms
suicidal attempt, and suicidal plans was 29%, 17%, 13%, 3%, and among Chinese medical students was higher than the global
4%, respectively. The high prevalence values emphasize the need for prevalence in medical students (28.0%) (46). This finding could
CMD prevention and intervention for Chinese medical students. be the result of cultural differences among different countries.
Compared with Western countries, Asian countries with a
prominent Confucian Heritage Culture, such as China, emphasize
Depression academic excellence starting at a young age (47). Such high
expectations often result in excessive pressure on students, which
Our study demonstrated a pooled prevalence of depressive could influence their psychological wellbeing. In this situation,
symptoms among Chinese medical students of 29%, which was students, especially medical students, who bear more stressors
higher than that for general university students (24.4%) in from clinical curriculums and trainings, might report higher levels
low- and middle-income countries (LMICs) (40) and previously of depression.

Wang et al.
TABLE 8 Estimated suicide plan prevalence among medical students in China.
Subgroup No. of studies No. of suicide plan Sample size Subgroup analysis Meta-regression
Study region
Northeast 1 92 1,855 0.05 (0.04, 0.06) – – – 93.07 0.6759
East China 4 157 6,638 0.03 (0.01, 0.06) 87.76 96.58% <0.01
South China 1 52 3,212 0.02 (0.01, 0.02) – – –
Central China 1 371 4,882 0.08 (0.07, 0.08) – – –
Northwest 1 82 1,510 0.05 (0.04, 0.07) – – –
N 6 434 8,928 0.05 (0.03, 0.07) 68.38 92.69% <0.01
Survey year
2000–2005 4 244 6,457 0.04 (0.03, 0.05) 11.61 74.16% 0.01 97.19 0.5487
2005–2010 5 309 5,551 0.05 (0.02, 0.08) 113.35 96.47% <0.01
2010–2015 1 58 4,063 0.01 (0.01, 0.02) – – –
2015–2020 4 577 10,954 0.05 (0.02, 0.09) 180.12 98.33% <0.01

41
Sample size
601–800 3 109 1,983 0.05 (0.01, 0.11) – – – 97.29 0.614
>1,000 11 1,079 25,042 0.04 (0.03, 0.06) 389.51 97.43% <0.01
Sampling methods
Simple 3 184 4,114 0.04 (0.02, 0.07) – – – 95.81 0.7784
Convenience 1 371 4,882 0.08 (0.07, 0.08) – – –
Stratified 1 92 2,498 0.04 (0.03, 0.04) – – –
Cluster 2 121 4,761 0.02 (0.02, 0.03) – –
Multiple 5 339 6,549 0.04 (0.02, 0.07) 84.78 95.28% <0.01
N 2 81 4,221 0.02 (0.01, 0.02) – – –
10.3389/fpubh.2023.1116616
Recall period
During college 1 30 1,254 0.02 (0.02, 0.03) – – – 97.56 0.6329
Past 1 year 7 421 11,920 0.04 (0.02, 0.05) 142.20 95.78% <0.01
frontiersin.org
Lifetime 4 643 12,058 0.05 (0.02, 0.09) 221.57 98.65% <0.01
(Continued)
Wang et al. 10.3389/fpubh.2023.1116616
The prevalence of depression in our study was similar to that

reported by resident physicians worldwide (28.8%) (15), which
Meta-regression
p-value
0.2418
suggested that depression was a problem affecting all levels of
–
medical training. However, the result of our study was lower than
that found in nursing students (34.0%) of similar age and education
I2 (%)
level. The possible explanation is that nursing has been a female-
97.25
– dominated profession for decades, and it has been confirmed that
women tend to be more commonly affected by mental disorders
p-value
than men (48).

<0.01
<0.01
<0.01
–
–
Thus, it is suggested that more attention should be paid to
medical students with signs and symptoms of depression, and
timely screening and proper interventions are highly necessary.
I2 (%)
97.12%
97.07%
97.12%
–
–
Subgroup analysis
Anxiety
450.90
340.98
450.90
Q
–
This study demonstrated that the pooled prevalence of anxiety

Estimated rate (95% CI)
was 18%, which was much higher than that for Asian medical
students (7.04%) (49). Interestingly, our result was lower than
0.05 (0.04, 0.06)
0.04 (0.03, 0.06)
0.06 (0.04, 0.08)
0.09 (0.07, 0.11)
0.02 (0.01, 0.02)
0.04 (0.03, 0.06)
0,04 (0.03, 0.06)
the prevalence of anxiety worldwide and even in other LMICs.

For example, previous research has shown a pooled prevalence of
anxiety among medical students of 33.8% worldwide (14), 32.9% in
Brazil (50), and 34.5% in India (51). Different medical education
systems and healthcare working environments among different
countries could explain the discrepancies found in different areas.
However, anxiety among medical students was much higher
N, not reported; NCS, National Comorbidity Survey; QSA, Suicide Attitude Questionnaire; SBQ-R, The Suicide Behaviors Questionnaire-Revised.
Sample size
than in the general population. Available data suggest that the

27,025
22,453
27,025
1,793
3,212
prevalence of depressive and anxiety disorders in the general

662
698
population ranges from 5 to 7% worldwide (52, 53). The long-term

heavy academic burden (1), high intensity internships (2), complex
doctor-patient relationships (54), and future uncertainty (5) could
result in a higher prevalence of anxiety among medical students
No. of suicide plan
than the general population. Like depression, persistent anxiety

symptoms could also lead to many undesirable consequences,
such as poor academic performance, impaired cognitive function,
1,188
1,033
1,188
94
40
63
52
burnout, and even suicidality (18, 55, 56). Thus, the anxiety in this
population should be taken seriously and prevented effectively.
Suicidal behaviors
No. of studies
This study identified that the pooled prevalence of suicide

ideation, suicide attempt, and suicide plan was 13%, 3%, and 4%,
14
11
14
respectively. The pooled prevalence of suicide ideation in this study

2
was similar to the global pooled prevalence (11.1%) and the pooled
prevalence in China published in previous studies (11%) (10,
28). Furthermore, the pooled prevalence of suicide plan was also
similar to the results of a Chinese language meta-analysis, which
QSA and suicide ideation question
demonstrated that 4.4% of medical students reported suicidal

plans (57).
When compared with physicians worldwide, minor differences
Self-made questionnaire
Measurement tool
TABLE 8 (Continued)
Educational level
were found between our findings and a previous meta-analysis. In

this study, the summarized life-time prevalence of suicidal ideation
Undergraduate
Subgroup
was 17.4%, while the 1-year prevalence was 8.6% and the 6-month
prevalence was 11.9%. With respect to suicidal attempt, the lifetime
Overall
SBQ-R
NCS
prevalence was 1.8%, while the 1-year prevalence was 0.3% (58).
N
Combined with the above results, Chinese medical students in our

Wang et al. 10.3389/fpubh.2023.1116616
FIGURE 11
Subgroup analysis of suicide plan in Chinese medical students based on measurements tools.
study were less likely to report suicidal ideation (2% in recent 6 Limitations of this review and included
months) but more likely to report suicidal attempt (2% in recent studies
1 year) than physicians in recent recall periods.
These results suggested that Chinese medical students, similar Our study has some limitations. First, the data were mostly
to other populations with clinical training (such as physicians), derived from studies with a cross-sectional design, which limited a
had a higher risk for suicide-related thoughts and behaviors. The dynamic analysis of mental distress in this meta-analysis. Second,
possible reasons might be a high rate of depression, work burnout, the data from different specialties (e.g., clinical medicine, dental
medical adverse events and errors, and a lower likelihood of medicine, preventive medicine, and nursing) and grades could not
seeking psychological help among medical students and physicians be extracted for final analysis, leaving substantial heterogeneity
(10, 59, 60). Effective preventive efforts and the accessibility of among studies unexplained. Third, it was impossible to perform
mental health services for medical students should be developed in a gender analysis since many studies did not provide separate
the future. prevalences of mental disorders for men and women. Fourth, a

Wang et al. 10.3389/fpubh.2023.1116616
wide variety of screening instruments with different cutoff scores disorders but also create a positive and thriving learning
for mental distress were used in different studies, resulting in high environment for future healthcare professionals.
heterogeneity across individual studies. Fifth, current studies on
mental distress among Chinese medical students focused on limited
mental problems. The investigation of other mental distresses such Conclusion
as obsessive-compulsive disorder, irritable bowel syndrome, bipolar
disorders, and combinations of these was lacking in most studies. Our findings showed that Chinese medical students had a
Finally, publication bias existed in our study, and the results should high level of depression, anxiety, and suicidal behaviors. Thus,
be interpreted with caution. timely screening and targeted intervention programs in this
population to improve their mental health are needed. However,
high heterogeneity and publication bias across the included studies
Implications for further research were found in this review, suggesting that the results should be
interpreted with caution.
Most included studies used a cross-sectional design with
small sample sizes, which limits the generalization of the results Data availability statement
to a wider population. Thus, future research should include
prospective, randomized, multicenter studies with larger sample The original contributions presented in the study are included
sizes. Additionally, most included studies solely focused on in the article/Supplementary material, further inquiries can be
major mental health problems, such as depression, anxiety, directed to the corresponding author.
and suicidal behaviors. Future studies should investigate other
mental health disorders, such as bipolar, obsessive-compulsive, and
eating disorders, alone and in combination. More subgroup and Author contributions
stratified analyses are also suggested to identify the prevalence
of mental health problems in different subgroups of Chinese PX: conceptualization, data curation, formal analysis, funding
medical students, such as different grades, to provide targeted and acquisition, investigation, methodology, project administration,
personalized intervention programs. Finally, more interventional resources, software, supervision, validation, visualization,
studies are needed to find ways to address the poor mental health writing—original draft, and writing—review and editing. JWa, ML,
of this population. and JB: data curation, formal analysis, investigation, methodology,
software, visualization, and writing—original draft. YC, BL,
and RW: writing—original draft. JL and JWu: data curation,
Implications for practice investigation, and methodology. All authors contributed to the
article and approved the submitted version.
Given the high prevalence of mental health disorders among
medical students, there is a pressing need for further research
utilizing standardized screening instruments with valid cutoff Funding
scores to accurately assess those disorders. It is suggested
that medical schools implement regular monitoring of students’ PX was supported by the Guangdong Basic and Applied Basic
psychological wellbeing and establish comprehensive psychological Research Foundation (No. 2022A1515110261) and the Guangzhou
interventions or programs that have demonstrated effectiveness Basic and Applied Basic Research Project (No. 202201010205). JX
in reducing students’ mental health disorders. For instance, was supported by the grant of the Science and Technology Project
organizing structured programs with validated approaches like of Qiandongnan Prefecture (2022, No. 05). The funding bodies
life skills training (61) and mindfulness therapy (62) could had no role in the study design, data collection, data analysis, data
be implemented for medical students experiencing anxiety. interpretation, the writing of the manuscript, or the decision to
Additionally, providing mental support within the college setting, submit the paper for publication. The corresponding author had
including mental health-related courses and accessible counseling full access to all the data in the study and took responsibility for the
centers, is essential (26). Furthermore, continuous efforts are decision to submit it for publication.
necessary to destigmatize mental health issues among medical
students and promote a culture of help-seeking behavior. Medical Conflict of interest
schools can play a vital role in this by explicitly stating that
having mental health problems will not result in demerit points The authors declare that the research was conducted in the
or negative consequences for students. Sharing the successful absence of any commercial or financial relationships that could be
experiences of senior doctors in managing mental health challenges construed as a potential conflict of interest.
may also encourage medical students to approach their own mental
health struggles more positively (14). By prioritizing standardized
assessments, implementing evidence-based interventions, and Publisher’s note
fostering a supportive environment, medical schools can actively
address the mental health needs of their students. This multifaceted All claims expressed in this article are solely those
approach can not only alleviate the burden of mental health of the authors and do not necessarily represent those of

Wang et al. 10.3389/fpubh.2023.1116616
their affiliated organizations, or those of the publisher, Supplementary material

the editors and the reviewers. Any product that may be
evaluated in this article, or claim that may be made by The Supplementary Material for this article can be found
its manufacturer, is not guaranteed or endorsed by the online at: https://www.frontiersin.org/articles/10.3389/fpubh.2023.
publisher. 1116616/full#supplementary-material
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TYPE Systematic Review

PUBLISHED 31 August 2023

Prevalence of common mental

common mental disorders (CMDs), depression, anxiety, suicidal behaviors, medical

Frontiers in Public Health 01 frontiersin.org

Introduction development (18), and impaired quality of life (19). Additionally,

Frontiers in Public Health 02 frontiersin.org

Frontiers in Public Health 03 frontiersin.org

The pooled prevalence estimates of depression, anxiety, and

Frontiers in Public Health 04 frontiersin.org

2005 Feng Fenglian Hebei NA Medicine Undergraduates NA SDS Cross-sectional study

2006 Wu Yan Hubei NA Medicine Undergraduates NA BDI Cross-sectional study

2009 Jin Zhengguo Jining NA Medicine Undergraduates NA SCL-90 Cross-sectional study

2011 Xu Limei NA Mean: 19 Medicine Undergraduates NA SDS Cross-sectional study

2015 Han Yashu Liaoning NA Medicine Undergraduates NA SDS Cross-sectional study

2003 Zhang Xinwen Hebei NA Medicine Undergraduates NA MAS Cross-sectional study

2005 Feng Fenglian Hebei NA Medicine Undergraduates NA SAS Cross-sectional study

2011 Xu Limei NA Mean: 19 Medicine Undergraduates NA SAS Cross-sectional study

Frontiers in Public Health 20 frontiersin.org

Frontiers in Public Health 21 frontiersin.org

Northwest 5 1,569 3,584 0.51 (0.37, 0.66) 280.58 98.57% <0.01

Southwest 15 5,911 18,134 0.35 (0.28, 0.41) 1,064.86 98.69% <0.01

N 19 7,254 25,071 0.28 (0.20, 0.37) 3,484.46 99.48% <0.01

2005–2010 25 7,018 23,056 0.31 (0.23, 0.40) 4,270.98 99.44% <0.01

2010–2015 39 11,773 45,139 0.30 (0.25, 0.36) 5,682.24 99.33% <0.01

2015–2020 41 15,636 49,855 0.28 (0.23, 0.34) 6,736.96 99.41% <0.01

201–400 26 2,562 7,266 0.33 (0.25, 0.42) 1,429.42 98.25% <0.01

401–600 26 3,881 12,778 0.30 (0.23, 0.37) 2,066.31 98.79% <0.01

601–800 11 1,971 7,358 0.26 (0.18, 0.34) 669.56 98.51% <0.01

801–1,000 16 3,662 14,181 0.25 (0.17, 0.34) 1,996.52 99.25% <0.01

>1,000 34 25,555 88,304 0.29 (0.24, 0.35) 12,430.00 99.73% <0.01

Convenience 6 2,852 11,832 0.20 (0.14, 0.26) 293.03 98.29% <0.01

Stratified 4 502 2,219 0.26 (0.13, 0.41) 165.74 98.19% <0.01

N 21 7,537 31,188 0.29 (0.22, 0.36) 3,046.89 99.34% <0.01

Postgraduate 6 2,041 4,387 0.32 (0.14, 0.52) 793.43 99.37% <0.01

Unclassified 1 87 508 0.17 (0.14, 0.21) – – –

Measurement tool and cutoff score

BDI score ≥ 10 1 1,699 10,140 0.17 (0.16, 0.17) – – –

BDI-13 score ≥ 5 1 767 1,414 0.54 (0.52, 0.57) – – –

BDI-II score ≥ 14 2 567 2,652 0.21 (0.20, 0.23) – – –

DASS-21 score ≥ 10 2 286 1,647 0.17 (0.15, 0.19) – – –

DSI severity index ≥ 0.5 3 1,407 2,148 0.68 (0.40, 0.90) – – –

GHQ-12 score ≥ 2 1 3 123 0.02 (0.01, 0.07) – – –

HAD score ≥ 9 1 31 181 0.17 (0.12, 0.23) – – –

IVR(self-made) score ≥ 10 1 21 204 0.10 (0.06, 0.15) – – –

PHQ-9 score ≥ 5 1 226 348 0.65 (0.60, 0.70) – – –

PHQ-9 score ≥ 10 3 438 2,505 0.18 (0.15, 0.22) – – –

PRIME-MD answer “yes” 1 611 1,814 0.34 (0.32, 0.36) – – –

SCL-90 score ≥ 1.8 1 1,906 7,321 0.26 (0.25, 0.27) – – –

SCL-90 score > 2 1 36 1,137 0.03 (0.02, 0.04) – – –

SCL-90 without cutoff score 1 30 1,286 0.02 (0.02, 0.03) – – –

SDS score ≥ 5 1 163 537 0.30 (0.26, 0.34) – – –

SDS score ≥ 14 1 214 1,053 0.20 (0.18, 0.23) – – –

SDS score ≥ 40 2 150 656 0.22 (0.19, 0.25) – – –

SDS score ≥ 41 3 401 1,706 0.25 (0.11, 0.42) – – –

SDS score ≥ 42 1 144 485 0.30 (0.26, 0.34) – – –

SDS score > 50 1 63 622 0.10 (0.08, 0.13) – – –

SDS score ≥ 52 1 303 940 0.32 (0.29, 0.35) – – –

SDS score ≥ 50 and HAMD 1 56 691 0.08 (0.06, 0.10) – – –