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 Table of Contents  
INVITED PERSPECTIVE/VIEWPOINT
Year : 2021  |  Volume : 37  |  Issue : 2  |  Page : 178-182

Suicidality among medical students


Department of Psychiatry, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India

Date of Submission26-May-2021
Date of Decision16-Jun-2021
Date of Acceptance17-Jun-2021
Date of Web Publication30-Jun-2021

Correspondence Address:
Dr. Abhijit R Rozatkar
All India Institute of Medical Sciences, Bhopal - 462 020, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijsp.ijsp_140_21

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  Abstract 


Medical training involves intense academic pressure and competition. Understandably, the prevalence of mental distress and suicidal behaviors is high among medical students. This article discusses the recognition and management of suicidal behavior at an individual as well as service/systems level. At the individual level, identification of common psychiatric symptoms, recognition of suicidal warning signs, adequate assessment, and appropriate referrals can prevent potential suicides. Various strategies have been successfully implemented at the population and high-risk group level. The introduction of technological methodologies may increase the reach of these preventive strategies. Student Wellness Centers can serve a significant role in preventing suicidal attempts and at-risk behaviors.

Keywords: Medical school, suicide prevention, suicide


How to cite this article:
Ghosh S, Kumar M, Rozatkar AR. Suicidality among medical students. Indian J Soc Psychiatry 2021;37:178-82

How to cite this URL:
Ghosh S, Kumar M, Rozatkar AR. Suicidality among medical students. Indian J Soc Psychiatry [serial online] 2021 [cited 2021 Nov 28];37:178-82. Available from: https://www.indjsp.org/text.asp?2021/37/2/178/320214




  Introduction Top


Suicide among doctors is a complex, multifactorial problem that continues to remain a serious concern for the medical community. Prevalence studies across the world have reported higher rates of suicide among the physicians and medical students compared to the general population.[1]

Medical trainees face multiple stressors. Academic and work pressure, distancing from family, emotional exhaustion, lowered efficiencies during the initial training, expectations from supervision, etc., work cumulatively to lead to burnout, depression, anxiety, and suicidal behavior. In India, caste-based discrimination and regionalism add to the tally of stressors.

Many studies conducted in the US have shown that recent negative life events, past trauma, emotional distress, burnout, mental disorders especially depression, and previous suicide attempts are strongly related to the risk of suicidal ideation among medical students.[2] The association between suicidal ideation and substance abuse among medical students has been reported but is less well established.[3]

In samples from developing countries, a study on medical undergraduates from Saudi Arabia reported that 41% of the students had depression, among which 19% had had suicidal ideas.[4] Depression, other mental disorders, substance use disorders, and multicomorbidity were associated with suicidality in studies from Nepal and Ethiopia.[5],[6]

Indian data also suggest high rates of emotional distress, burnout, and suicide behaviors among medical students.[7] A study on medical undergraduates in South India revealed that one-fifth of students reported a lifetime history of suicidal ideation, one-tenth of suicidal plans, and a little over 5% of suicide attempts.[8] A study from Delhi reported a higher rate (>50%) of suicidal ideation and a lower rate (2.6%) of suicide attempt.[9] Another study stated that 15.2% of the samples had injured themselves with an intent to die by suicide, often having acted impulsively.[10] Chahal et al. reported that, while 26% of medicos, in their 10-year register of students who had died by suicide; had exhibited suicide warning signs, only about half had sought psychiatric help before ending their lives.[11] They also stated that hanging was the most common means of death by suicide and that academic stress among medical students and residents was the most noticeable reason. Among medical undergraduates, those in clinical years were more likely to report suicidal ideation compared to preclinical students (8% vs. 2.8%). Significant negative correlations have been reported between mental well-being and suicidal ideation and academic stress and significant positive correlations between academic stress and suicidal ideation.[12]


  Attitudes toward Suicide among Medical Students Top


Suicide is stigmatized and gives rise to discrimination against those who survive suicide attempts.[13] An online cross-sectional survey among medical trainees in Australia found that suicide had the second highest stigma rating among various health conditions and was more stigmatized than depression. Suicide also recorded the highest frequency of respondents reporting that they would hide their condition, suggesting that stigma is a major barrier for treatment.[14]

Medical undergraduates hold ambivalent attitude toward suicide.[15] Exposure to clinical psychiatry helps change such attitudes in some countries, but not in others.[16] Fortunately, attitudes may be changing as some samples show favorable attitudes toward those who survive suicide, use of antidepressants to prevent suicide, and psychosocial/clinical care.[17] Female students generally are more supportive of empathic care for those who survive suicide attempts.[17]

Cross national differences have been noted with Indian medical students having a more rejecting attitude toward suicide compared to Austrian students[18] and Japanese students holding a more normative (right to die) attitude to suicide as compared to American students.[19]


  Barriers to Help-Seeking in Medical Students Top


A cross-sectional survey on medical students at the University of California found that very few students used mental health services, especially university-based services. The most cited barriers were lack of time and concern about confidentiality. Suicidal students frequently reported “fear of unwanted intervention.” The barriers reported, can be classified as:[20]

  • Patient based: Lack of time, perceived lack of empathy from professionals, stigma, fear of exposing their vulnerability, and giving less importance to their problems
  • System based: Lack of confidentiality, fear of unwanted intervention and inadvertent attention, difficulty to access care, and lack of services
  • Provider based: Lack of cultural sensitivity, more inclination toward pharmacotherapy.


A study among medical students at a university in Cameroon reported that some of the major barriers to service utilization were inability to pay for services, lack of awareness about health services, lack of mental health literacy, staff attitudes, and difficulty in accessing services.[21] Similar findings were reported in a study from India.[22] In addition, stigma and discrimination, fear of impact on academic performance, and concern about confidentiality were further barriers to seeking treatment for Indian students. As in other countries, keenness for self-diagnosis and preference for informal consultations also constituted barriers for uptake of services in India.[23]

A study suggested low scores on measures of suicide literacy in medical undergraduates. Suicide literacy was positively correlated with depression literacy suggesting a need for sensitization.[23]

A mistake commonly committed is waiting until a crisis occurs before pursuing treatment. It does not make sense to try to “tough it out” and hope things get better. As a part of preventive medicine, doctors need to care for themselves, especially in stressful environments because at the end, their well-being influences their patients' wellbeing.[24]

Suggested strategies to improve health services delivery in medical campuses were: adequate orientation to health issues; reviewing existing services and ways of accessing them; curtailment of stigma, myths, and misconceptions related to mental health; and accessible student clinics in the hostels, to resolve issues such as lack of time, nonawareness of locations, and satisfaction with services.[25]


  Suicide Risk Assessment for Medical Students Top


There is a difference between the concepts of suicide prediction and risk assessment. It is difficult to accurately predict suicide, but if a heightened state of risk can be recognized, appropriate responses can be delivered.[26] Risk assessment includes:

  • Factors predisposing to suicidal behavior: Prior history of psychiatric diagnoses, suicidal ideations/attempts, abuse, recent discharge from inpatient psychiatric treatment, same sex sexual orientation, and male gender
  • Identifiable precipitant or stressors: Significant relationship, financial, identity crises, and acute/chronic health problems
  • Symptomatic presentation: Depressive symptoms, bipolarity, anxiety, schizophrenia, borderline, and antisocial personality features [Box 1]
  • Presence of severe and long-standing hopelessness
  • The nature of suicidal thinking: Current ideation frequency, intensity, and duration, a specific suicidal plan, availability of lethal means, active suicidal behaviors, and explicit suicidal intent
  • Previous suicidal behavior: Frequency and context, perceived lethality and outcome, opportunity for rescue and help seeking, and preparatory behaviors
  • Impulsivity and self-control: Subjective and objective control (substance abuse, impulsive behaviors, and aggression)
  • Protective factors: Social support, problem-solving skills and good coping skills, active participation in treatment, presence of hopefulness, religious commitment, life satisfaction, intact reality testing, fear of social disapproval, and fear of suicide or death.[28]



The clinicians need to distinguish among the four risk categories:

  • Baseline (baseline risk for those with ideation, single attempts): Absence of an acute overlay with no significant stressors or prominent symptoms
  • Acute (risk for those with ideation, single attempts): The presence of acute overlay, significant stressor (s), and/or prominent symptoms
  • Chronic high risk (baseline risk for those with multiple attempts): The absence of acute overlay, no significant stressors, or prominent symptoms
  • Chronic high risk with acute exacerbation (risk for those with ideation, single attempts): The presence of acute overlay, significant stressor(s), and/or prominent symptoms.[26]



  Medical Students Training on Suicide Top


Encounters with a suicidal patient are not limited to only psychiatrists. Psychiatric symptoms of depression, anxiety, stress, and low coping skills remain under-recognized in emergency/hostel settings. Doctors and especially those in training can act as primary gatekeepers. Training can induce a favorable outcome for suicide prevention, with improvement in attitude, knowledge, communication skills, clinical skills (assessment and intervention), and confidence in dealing with suicidal patients.[29] On this regard, the Medical Council of India has prescribed a new competency-based syllabus for MBBS, implemented since 2019 which gives reasonable weightage to psychiatry.[30]


  Technology in Suicide Prevention Top


The Internet is ubiquitously associated with daily lives of the youth. It is estimated that less than half of youth with depression, anxiety, or suicidality enter face-to-face treatment.[31] Digital health interventions may be a promising avenue for suicide prevention efforts because it can remove the barrier of face-to-face treatment and can reach a large and diverse audience; through 24-h access, low cost, user autonomy, and anonymity, and actual/perceived access to social support.[32]

The most frequently used methods for digital health interventions of suicide are:

  • Web-based suicide prevention programs: Provide information (community discussion forums, blogs by experts, feedback, and contact information), self-help resources (self-assessment), and anonymous counseling services.[33] Talk campus is an online web-based Internet service provider, involving peer based and counseling-oriented technological protection. It helps facilitate social connections among peers, fosters supportive interactions with others, and creates a community facing similar challenges. Facebook's new “proactive detection” artificial intelligence technology will scan all posts for patterns of suicidal thoughts, and when necessary, send mental health resources to the user at risk or their friends, or contact local first responders and decrease the time taken to reach help
  • Personalized responses from counselors: Caring letters to clients, texts to report incidents, and seek help during crises
  • Smartphone applications (apps): Help users self-assess, monitor psychiatric symptoms, get personalized content, access hotline links and psychological tools (e.g., relaxation exercises), and get appointment reminders.[34]


Most of the newer techniques need more substantial evidence. An individual's right to privacy is important; hence, a patient's consent to take part in technology-based interventions and full awareness of methods of their data collection, storage, and usage is essential.


  Interventions for Suicide Prevention Top


The framework of prevailing prevention models is interdisciplinary, categorized depending on focus on the entire population to specific high-risk individuals.[35]

  • Universal strategies are initiated to address an entire population, through removing barriers, enhancing knowledge and easy access for help, and strengthening protective processes. These can be achieved with media campaigns; reducing access to means on firearms/medications; providing hotlines and crisis centers; awareness and skills training through learning modules such as suicideTALK, safeTALK, and Applied Suicide Intervention Skills Training;[36] and legislative policy
  • Selective strategies focus on at-risk groups with screening programs; gatekeeper training, consultation, and education services utilizing motivational interviewing, brief intervention, or Question, Persuade, Refer techniques; support/skills training;[37] and crisis response and referral resources with trained behavioral intervention team or crisis response team on campus
  • Indicated strategies are delivered to specific high-risk youth with evidenced need for urgent care and include family support training; skill-building support groups; case management/alternative programming; and referral resources for crisis intervention/treatment.



  Role of Student Wellness Clinic/Centre in Suicide Prevention Top


The essential steps to handle suicidal behavior in medical students include

  1. Early identification
  2. Appropriate intervention.


Identification

  • Preadmission counseling for past or current psychological symptoms, substance use, introversion, and family history of mental illness/suicide (students should be informed about the ready availability of Student Wellness services)
  • Evaluation during the course-periodic evaluation of students' mental health status (paper-pencil or web based) for stressors (e.g., financial strain, academic pressure), sleep pattern, mood state, involvement in group activities; feedback from teachers/hostel wardens/peers regarding absenteeism, deterioration in performance, obvious changes in behavior, etc.
  • Assessment of attitudes (focus groups) – stigma related to mental illness and attitudes toward suicidality.


Intervention

  • Group interventions: Stress management workshops, communication skills workshops, enhancing language skills, and yoga/meditation courses
  • Peer lead interventions: Senior students can help their juniors understand the rigors of the course, time management, adapting to the city, etc.
  • Individual interventions: Accommodating appropriate concerns related to privacy and confidentiality
  • In-patient admission-if required should be provided with due regard to privacy.



  Conclusion Top


Suicide and suicidal behaviors in medical students need to be assessed throughout the period of medical education (admission to convocation). This includes the identification of stress, burnout as well as risk states. Those in-charge of medical education need to proactively provide comprehensive mental health services in a confidential manner. Digital interventions are in nascent stages of development but may be considered if feasible.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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