Suicidal Ideation, Socioemotional Disorders and Coping Strategies in Medical Students

Abstract

Suicide is a serious public health problem whose causes are biological, psychological, social, and cultural, factors that are mostly preventable if they are known and treated on time. In the transition from adolescence to adulthood, the university population is vulnerable to developing emotional disorders. Among them, medical students are the ones who present higher levels of anxiety, depression, and suicidal ideation. In this essay, we analyze the prevalence of emotional disorders and suicidal ideation in medical students at our university and expose the efforts made to transform some psycho-emotional determinants by providing students with coping skills and strategies that allow them to manage their emotions and generate effective support networks among the student community, to increase the individual well-being and reduce the incidence of suicidal behavior.

1. Introduction

Medical schools have the mission of training highly qualified, ethical, critical, and humanistic doctors for the promotion and care of health. The medical school curriculum is considered one of the most academically and emotionally demanding. The high degree of stress the degree entails can negatively affect students’ mental health and well-being.

Mental health is a state of mental well-being that enables people to cope with the stresses of life, realize their abilities, learn well and work well, and contribute to their community. An integral component of health and well-being underpins our individual and collective abilities to make decisions, build relationships, and shape our world. Mental health is a fundamental human right. And it is crucial to personal, community, and socio-economic development [1]. It is a state of mind characterized by emotional well-being, reasonable behavioral adjustment, relative freedom from anxiety and disabling symptoms, and a capacity to establish constructive relationships and cope with life’s ordinary demands and stresses [2].

When a satisfactory state of mental health is not promoted and maintained, it can lead to social isolation, poor academic performance and achievement, school dropout, work absenteeism, low productivity and work quality, lack of healthy and functional interpersonal relationships and support networks, and stigmatization and discrimination, among other aspects [3]. Mental health deficiencies are also associated with a series of behaviors that are potentially harmful to health, such as violence (aggression, suicide, self-harm), the use and abuse of substances, and risky sexual behavior.

To achieve the global objectives set out in the WHO “Comprehensive mental health action plan 2013–2030” and the Sustainable Development Goals, we need to transform our attitudes, actions, and approaches to promote and protect mental health and to provide and care for those in need. We can and should do this by transforming the environments that influence our mental health and by developing community-based mental health services capable of achieving universal health coverage for mental health [4].

2. Socioemotional disorders in medical students

The period of university studies is a critical stage in the emotional development of young people transitioning from late adolescence to early adulthood [5]. In this period, between the ages of 17 and 24, the highest incidence of appearance of mental disorders occurs [6, 7]. Mental health problems during this period are robust predictors of low academic performance [8] and school dropout [9] and have profound consequences on interpersonal relationships [10] and the occurrence of suicidal ideation [11].

College students with mental disorders are more than twice as likely to drop out without earning a degree [12]. An international study conducted by the World Health Organization (WHO) on mental health in college students shows that more than a third of students surveyed tested positive for at least one mental disorder in their lifetime and that the vast majority of these students continued to be active cases in the last 12 months [13].

University students are vulnerable to developing emotional disorders due to the high academic demands and because they are transitioning to physical, emotional, and intellectual maturity, which is confronted and threatened by the demands of the university adult life, with its own social and work demands. Among the student community, medical students present the highest rates of anxiety and depression [14], and these rates could increase toward the last years of their academic training [15]. Systematic studies show that globally medical students have an anxiety rate of 33.8% with a 95% confidence interval of 29.2 to 38.7% [16] and depression of 27.2% with a 95% CI of 24.7 to 29.9% [17].

Major depressive disorder (MDD) has been ranked as the third leading cause of disease burden worldwide in 2008 by the WHO, which has projected that this disease will rank first by 2030 [18].

The prevalence rate of MDD in women is almost double than that in men. This divergence seems related to the physiological characteristics of women’s hormonal levels and fluctuations, the different types of psychosocial stressors between men and women, and the behavioral model of learned helplessness. Although until a few decades ago, the age of manifestation of the disease was around 40 years, recent studies show trends of increasing incidence in the younger population due to the consumption of alcohol and other drugs of abuse [19].

Among university students, those studying medicine have the highest prevalence of mental disorders. The main risk factors that contribute to the development of this disorder are excessive workload, financial stress, time management, imbalances between academic and family life, health problems [20], peer competition, constant exams, medical student abuse [21], lack of sleep hygiene [22], lack of healthy eating habits [23], and frequent experiences with agony and death [24].

Studies conducted in Mexico on the prevalence of MDD in medical students show discrepancies regarding the period in which the highest rate of this disorder occurs, which can place it in the preclinical stage [25] or during clinical training [14]. However, all the studies conclude that being a woman is a risk factor for developing MDD [14, 25, 26].

Burnout syndrome was first described in 1974 [27]. It is a syndrome conceptualized as a result of chronic work stress that has not been successfully managed. It is characterized by three dimensions: (1) feelings of exhaustion; (2) increased mental distance from one’s work or feelings of negativity or cynicism related to one’s work; and (3) a feeling of ineffectiveness and lack of accomplishment [28].

Although the Diagnostic and Statistical Manual of Mental Disorders-5 [DSM-5] does not consider burnout syndrome as a mental illness, the International Classification of Diseases [ICD-11] recently included it as a Problem associated with employment or unemployment [29]. Certainly, it can be classified as a mental health problem. It has been reported that this condition can be established from the beginning of medical studies [30]. It is estimated that among medical students in the United States, the prevalence of burnout is between 45 and 71% and that depressive symptoms and suicidal ideation are more intense among the student population of a medical career compared to that of active doctors [31, 32].

3. Suicide

Suicide is a complex phenomenon derived from the interaction of individual vulnerabilities and socio-environmental factors, ultimately leading the individual to end their existence. It is a tragic reaction to emotional distress from stressful life events or situations. According to the National Center for Injury Prevention and Control, suicide is death caused by injuring oneself with the intent to die, and a suicide attempt is when someone harms themselves with any intent to end their life, but they do not die due to their actions [33].

Every year 703,000 people take their own life, and many more attempt suicides. Every suicide is a tragedy that affects families, communities, and entire countries and has long-lasting effects on the people left behind. Suicide occurs throughout the lifespan and was the fourth leading cause of death among 15–29 year-olds globally in 2019. Suicide does not just occur in high-income countries but is a global phenomenon in all regions of the world. In fact, over 77% of global suicides occurred in low- and middle-income countries in 2019 [34].

Suicide is conceptualized as a continuum of processes beginning with suicidal ideation, defined as the presence of recurrent thoughts of committing suicide, progressing to the elaboration of a suicide plan, a suicide attempt, and, finally, the consummation of suicide [35]. All of these stages are aspects of suicidal behavior, and to prevent suicide at an early point, it is necessary to identify the risk factors that lead the individual to engage in suicidal ideation and then continue down the suicidal path [36].

In the last 45 years, the suicide rate worldwide has increased by 60 percent [37]. The data available from the WHO show that the global average of suicides is 10.6 per 100,000 inhabitants, 7.7 for women and 13.5 for men [38].

Suicide is a complex phenomenon derived from the interaction of individual vulnerabilities and socio-environmental factors, which ultimately lead the individual to end their existence, generally as a tragic reaction to emotional distress derived from stressful life events or situations.

In the systematic review carried out by Lindenman, it is estimated that the relative risk rate of suicide among physicians is 1.1 to 3.4 for men and 2.5 to 5.7 for women, compared to the general population, and from 1.5 to 3.8 for men and 3.7 to 4.5 for women when relative risk rates are compared with other professionals [39].

A recent systematic review and meta-analysis show that the medical profession carries a high risk of suicide, particularly for female physicians [40].

However, the scientific evidence does not show that the prevalence of death by suicide is higher in medical students than in the general population or among other university students. Still, there is increasing evidence linking suicidal ideation in medical students to perfectionism, anxiety, depression, and burnout syndrome [41]. A systematic review shows that the reports in the scientific literature on the suicide rate of medical students are very scarce, and the data collection techniques are very inconsistent. Studies on the suicide rate of medical students require taking into account historical and geographical contexts. Medical students must first obtain a bachelor’s degree in the United States and Canada. At the same time, in other nations, such as Latin America, they can enter after finishing high school while some students are still teenagers. In the last century, the ratio of men to women in medical schools has changed from predominantly male to majority female [42].

A multicenter study carried out in Peru shows that two out of 10 medical interns had a positive evaluation for suicide risk and that age and especially alcohol abuse were the associated variables [43]. In a recent meta-analysis on the prevalence of suicidal ideation among medical students, it was 11.1 percent [17].

Suicide prediction and prevention based on the identification of risk factors associated with suicide, including depression, poor coping skills, increased avoidance of stressors, and lack of close social relationships, have had limited success [44], due to that although many people experience similar negative situations, not all will consider suicide [45].

Emotional regulation and reaction to adverse life events have been postulated to moderate the link between mental pain and suicidal ideation [46]. Emotional regulation involves various strategies, such as cognitive reappraisal and emotional suppression, a form of response modulation involving continuous emotional expression behavior [47]. Johnson suggests that positive appraisals reduce the likelihood of stressful events leading to suicidality [48].

4. Socioemotional skills and coping styles

A systematic review and meta-analysis show that the prevalence of suicidal behavior among Brazilian undergraduate students is 9.1% [49]. Furthermore, in first-year medical students, suicide risk is significantly associated with high levels of family dysfunction and signs of depression and anxiety. It is also related to suspected alcohol problems, low self-esteem, and risk of violence [50].

Mental disorders are often accompanied by a lack of emotional regulation skills, as has been reported in studies of anxiety and depression [51], substance abuse [52], and alexithymia and self-harm [53].

Emotional regulation is related to the processes by which the person exerts an influence on the emotions they present, when they present them, and, above all, how they are experienced and expressed [54]. It can also be conceptualized as the processes that alert, assess, and modify our emotional reactions to meet our goals [55].

Generally, people activate emotional regulation processes to deal with a negative affective state, because it has become either intense or long-lasting. Sometimes, the goal may be to reduce a positive emotional state inappropriate to a given social situation, such as delivering bad news in the clinical setting.

Emotional regulation is aimed at being an adaptive process of the individual in the face of adverse affective conditions. However, people can present problematic behaviors such as alcohol abuse, illegal substance use, or self-injurious behaviors, which can be conceptualized as dysfunctional emotional regulation strategies.

From a psychological point of view, dysregulation of emotions is a transdiagnostic element for many affective disorders, the study of which has the potential to contribute significantly to the study of emerging psychopathologies [56]. Emotional dysregulation can be described as affective instability, which manifests as a vertiginous increase in emotion, with a slow return to the baseline emotional line; an overreaction to psychosocial cues with chaotic emotional turns; and overly dramatic expressions [57, 58].

The protective role of emotional regulation against anxiety and depression has been confirmed in studies conducted with various populations [59], including university students [60]. It has also been observed that there is a relationship between maladaptive emotional regulation behaviors, such as denial, avoidance, suppression, and rumination, with the increase in the severity of symptoms of emotional disorders and that adaptive emotional regulation strategies, such as reappraisal cognitive, problem solving, and acceptance, are associated with lower levels of anxiety and depression [61].

Coping strategies are cognitive or behavioral activities that aim to solve the problem and calm the emotional response that, in some cases, can be excessive and disturbing. It has been found that there is a direct relationship between negative coping and the symptoms caused by affective disorders [62].

Emotional regulation capacity is related to the emotional coping capacity, that is, to the actions that a person performs to face the demands of the environment to transform an uncomfortable situation into a more tolerable one, to less stress and conflictive charge, which allows appeasing a startled emotional response [63]. How the individual can estimate a stressful or conflictive environment and value the resources available is directly related to personal well-being. Those medical students who present healthy coping styles have low levels of anxiety and depression, while in students with maladaptive coping styles, we find higher levels of anxiety and depression [64]. Maladaptive coping styles are associated with emotional dysregulation, and functional coping strategies are correlated with positive emotional regulation skills [65].

In university students, there is a positive correlation between coping skills and emotional regulation [66]. It is observed that the participants with high emotional regulation showed high values in the use of active coping strategies such as positive reappraisal, search for support, and planning. In conflictive situations and psychological stress, medical students who use effective adaptive coping strategies have a lower risk of suicidal ideation. In these cases, it has been seen that the ability to regulate emotions through the cognitive restructuring of a situation is a beneficial way of coping with stressful situations [36].

It has been observed that students with suicidal risk lack strategies to transfer their emotions when faced with stressful situations and tend to resort to avoidant coping strategies [67]. It is necessary to identify risk factors and situations that trigger deep emotional pain or “psychalgia” within each individual’s life, poor coping skills, and a lack of close social relationships to protect the mental health of students with emotional disturbances.

5. Medical student formation

Physicians-in-training work in highly demanding physical, emotional, academic, and work environments, where stress is the constant that surrounds the environment, and the high prevalence of socioemotional disorders is the immediate consequence. In many cases, the way of dealing with these high demands involves maladaptive coping styles such as self-destructive behaviors, substance abuse, social isolation, risk behaviors, and so on.

In the medical profession, there is a profound stigmatization toward colleagues who present any emotional disorder because they assume the idea that the doctor is an infallible, unequivocal, indefectible, and safe being who, thanks to his knowledge of health, can self-care and medicate for any signs or symptoms that appear. However, this is far from reality and even more when it comes to mental problems. For this reason, for most doctors and medical students, prejudices based on negative stereotypes generate a self-stigma that makes it difficult for them to ask for help, and in many cases, they try to hide their mental suffering until it becomes severe or disabling consequences occur. Medical schools and faculties have set themselves the mission of training doctors with high ethical and humanistic standards, with extensive knowledge of the functioning of the human body and its interaction with the environment, capable of ensuring the health of the population, making progress in medical science and promoting public health with innovation and educational excellence for the benefit of human beings, the community, and the environment. Still, few of them include their preparation as integral human beings capable of overcoming the pressures of their profession and seeking the well-being of their patients and their own.

At our faculty, we consider promoting mental health as a substantive part of student training for its short-term benefits, which prevents the appearance and development of socioemotional disorders, promotes adequate emotional regulation, and allows the student to face career challenges. In the long term, training professionals with healthy mental health allows them to seek well-being and contribute productively to society.

Students who intend to study at the Mexican School of Medicine are subject to a rigorous selection system, whose last filter is a 16-week pre-medical course. This course offers scientific subjects such as Biology, Biochemistry, Anatomy, and Physiology. It has a Mental Health subject that guides students to recognize the signs and symptoms of emotional disorders that emerge during this course due to the stress generated by the high competition to obtain a place in the faculty. It also helps students identify and recognize the people who form their social support network, including family, friends, and teaching staff members.

6. Emotional coping workshop

A study carried out with the Mexican Faculty of Medicine student population shows that anxiety and emotional dysregulation has a significant direct influence on depression. Subsequently, during the COVID-19 epidemic, a longitudinal study was carried out to estimate the prevalence of emotional disorders during confinement, and it was observed that between April and December 2020, the prevalence of depression increased from 19.84 to 40.08% and that the ideation rate suicide remained relatively stable at around 18% [68].

These results reinforced the need to continue our commitment to promoting mental health among students. For this purpose, a Coping Workshop was designed for second-semester students, focused on promoting the well-being of students by equipping them with emotional coping skills that protect and help the student to manage their emotions in the face of adverse situations that favor the appearance of affective disorders such as anxiety, depression, and suicidal ideation.

The conception and design of this workshop were based on strength-focused cognitive behavioral therapy, as it is the therapeutic modality with the most significant theoretical-empirical evidence and has proven to be effective in inducing changes in the short, medium, and long terms. It has the theoretical framework of the Collaborative for Academic, Social, and Emotional Learning [Weissberg], which defines social and emotional learning as recognizing and managing emotions, solving problems effectively, and establishing positive relationships with others. It is the process by which the knowledge, attitudes, and skills necessary to learn functional emotional regulation strategies, develop empathy, make responsible decisions, establish healthy interpersonal relationships, and adaptively face situations both inside and outside the classroom are acquired and applied effectively. The key competencies of this learning are self-awareness, identification and recognition of one’s own emotions and strengths, self-efficacy, and self-confidence; social awareness, empathy, respect for others, and perspective taking; responsible decision making, evaluation, reflection, and personal and ethical responsibility; self-control, impulse control, stress management, perseverance, goal setting, and intrinsic motivation; and interpersonal skills, cooperation, search, and help, providing help and communication.

The workshop is given by the psychologists who participated in the course design, which is carried out during the second semester of the medical degree, in weekly sessions of 90 minutes, with groups of no more than 17 students.

The workshop has a Work Manual for the student, which supports the activities carried out in the classroom. It has theoretical information on the topics that are reviewed; biographies of doctors, scientists, and other relevant characters who knew how to overcome the difficulties they faced and fight to achieve their goals, such as neurosurgeon Ben Carson; nurse and sex education activist during the first half of the twentieth century, Margaret Sanger; the Brazilian indigenous activist Txai Surui; and Matilde Montoya, the first Mexican woman to receive a medical degree from the National School of Medicine of Mexico in 1887. It also has self-registration sheets for monitoring and recording activities, individual self-awareness tasks, and playful activities to relax. On the last page of the Manual, there are essential contacts to which students can communicate to receive personalized attention from professionals who can provide the emotional accompaniment that the student needs during a crisis or in more severe cases such as suicide risk, which require face-to-face intervention, and refer them to specialized health centers.

The first module deals with well-being and mental health, with which the student becomes aware of the risk factors for the appearance of conduct disorders that they face during their training and that can affect interpersonal relationships and academic performance and even induce school dropout. Topics such as anxiety and depression and the associated stigmas in society and more deeply among medical personnel about mental disorders, which in many cases lead to self-stigma, are addressed.

Modules 2 and 3 focus on working with the main stressors that students face during the first stage of their training, time management, and study strategies. Written record activities are presented so that the student can identify those activities that consume a significant amount of time and affect their academic performance, such as video games and social networks, and learn to establish a maximum use time. Exercises are carried out to elaborate daily work plans and study routines. In addition, different study techniques are presented and tested so that the student can recognize the ones that best suit their individuality, allowing them to achieve significant learning and delay the forgetting curve.

Module 4 shows the physiological imbalances that stress generates and the usefulness of learning relaxation techniques to prevent stress and fatigue and generate a sense of well-being by reducing emotional tensions and favoring the disarticulation of recurring disruptive negative thoughts. Activities such as diaphragmatic breathing and Jacobson’s progressive muscle relaxation are performed. So that the student can practice these and other relaxation techniques, there are QR codes to access videos and applications that reinforce the activities.

The following modules are focused on developing emotional regulation and raising awareness of its value in dealing with everyday problems, preventing the development of disorders, and promoting emotional well-being. Module 5 deals with emotions and their origin as the organism’s response to an external or internal event that, after an unexpected evaluation, generates physiological, psychological, and behavioral manifestations, which, when adequately regulated, have adaptive functions aimed at developing behaviors that favor intrinsic motivation and social interaction.

This module consists of various group activities and other individual and private activities aimed at recognizing emotions and developing emotional self-knowledge to understand the usefulness of regulating emotions to develop tolerance to frustration and thereby prevent anxiety and depression. Emphasis is placed on dysfunctional forms of emotional regulation, which, although reduce the intensity of an unpleasant experience, bring along maladaptive side effects such as alcohol and drug abuse or self-harm, which, therefore, cannot be considered emotional regulation behaviors.

The origin of negative automatic thoughts and the activities aimed at aligning thought schemes are addressed in Module 6, with multiple activities focused on the experiences that medical students commonly experience related to the emergence of cognitive distortions. Module 7 deals with the importance of assertiveness for reasonable control of conflict situations, and Module 8 focuses on the different types of coping to handle difficult situations.

Strategies focused on the problem are addressed, aimed at finding alternative solutions to a conflict, a topic seen in depth in the next chapter. Coping strategies focus on the emotions caused by a problem and how to adapt well to this situation. And it analyzes how inadequate coping strategies such as avoidance, rejection, and emotional suppression can result in harmful practices that generate more intense and uncontrolled reactions, so these attempts at regulation must be assessed as a problem.

The last modules deal with the actions that enrich daily life and help the student recognize the things with which he spends happy and enjoyable times and the importance of carrying out these activities to maintain a good state of mind and develop emotional well-being. They also deal with how to prevent relapses and communicate with a partner when he is in a conflictive emotional situation.

7. Conclusions

Society demands well-prepared doctors with cutting-edge knowledge and unquestionable ethical values. Medical schools must respond to this need and recognize that medical students face highly stressful educational and personal processes during their professional training, which pose severe challenges to maintaining physical and emotional well-being.

As medical educators, we know that our students’ comprehensive training is an enormous challenge. Implementing an emotional coping workshop in the second semester of the medical career responds to a need of the student population, probably more in need than ever. Supporting students to find adequate management of the stressors they face daily and to face the problems and difficulties of academic and hospital life through adequate emotional regulation will allow each of them to develop their potential and to lead a healthy, creative and productive life according to their needs and interests.

The transformation of the educational model based on studies that include the students’ perspective on their own training is also required, in order to generate innovative alternatives focused on the well-being of students that take into account current social and technological advances.

Conflict of interest

“The authors declare no conflict of interest.”