In e na ional Jou nal o Medical Educa ion. 2016;7:354-363
ISSN: 2042-6372
DOI: 10.5116/ijme.57 8.c468
Assessmen o dep ession and suicidal beha iou
among medical s uden s in Po ugal
Rica do Coen e1, Ca lo Fa a elli2, Ma ia Luísa Figuei a1
1
Facul y o Medicine, Uni e si y o Lisbon, Lisbon, Po ugal
2
Depa men o Heal h Sciences, Psychology and Psychia y Uni , Uni e si y o Flo ence, Flo ence, I aly
Co espondence Rica do Coen e, Facul y o Medicine, Uni e si y o Lisbon, Po ugal. Email: Rica do.Coen e@ne c.p .
Accep ed: Oc obe 08, 2016
Abs ac
Objec i es: To examine dep ession and suicidal beha iou
and associa ed ac o s in a sample o medical s uden s in
Po ugal.
Me hods: We conduc ed a c oss-sec ional s udy design o
456 na i e Po uguese medical s uden s om he 4 h and 5 h
yea a he Uni e si y o Lisbon. Pa icipan s answe ed a
sel - epo su ey including ques ions on demog aphic and
clinical a iables. S a is ical analyses we e conduc ed using
he chi-squa e es , wi h a Mon e Ca lo simula ion when
app op ia e.
Resul s: Dep ession among medical s uden s was 6.1%
(n=28) and suicidal beha iou 3.9% (n=18). Highe dep es-
sion sco es we e no ed in emale medical s uden s
(χ2=4.870,d =2,p=0.027), s uden s who li ed alone
(χ2=8.491,d =3,p=0.037), hose wi h poo physical heal h
(χ2=48.269,d =2,p<0.001), wi h poo economic s a us
(χ2=8.579,d =2,p=0.014), s uden s wi h a psychia ic diag-
nosis (χ2=44.846,d =1,p=0.009), s uden s wi h a amily
his o y o psychia ic diso de s (χ2=5.284,d =1,p=0.022) and
s uden s wi h high le els o anxie y (χ2=104.8, d =3,
p<0.001). Dep ession sco es we e also
highe in s uden s wi h suicidal idea ion
(χ2=85.0,d =1,p<0.001), suicidal plan
(χ2=47.9,d =1,p<0.001) and suicidal a emp
(χ2=19.2,d =1,p<0.001). Suicidal beha iou was highe in
medical s uden s who li ed alone (χ2=16.936,d =3,p=0.001),
who had poo physical heal h (χ2=18,929,d =2,p=0.001),
poo economic s a us (χ2=9.181,d =2,p=0.01), who a e/we e
in psychopha macology ea men (χ2=30.108,d
=1,p<0.001), and who had high alcohol use
(χ2=7.547,d =2,p=0.023), se e e dep ession
(χ2=88.875,d =3,p<0.001) and high anxie y le els
(χ2=50.343,d =3,p<0.001). The esul s also e ealed ha
he e we e no di e ences be ween s uden s in he 4 h and 5 h
yea s o medical school ega ding a e o dep ession and
suicidal beha iou .
Conclusions: Since dep ession and suicidal beha iou a e
men al heal h p oblems a ec ing a signi ican p opo ion o
medical s uden s, medical schools should implemen
p og ams ha p omo e men al heal h wellness, physical
heal h and economic s a us be ween o he ac o s.
Keywo ds: Medical s uden s, dep ession, suicidal
beha iou , Po ugal
In oduc ion
In addi ion o medical doc o s, medical s uden s ha e
highe a es o dep ession and suicidal beha iou compa ed
o age-ma ched gene al popula ion.1-6 The a e o dep ession
in medical s uden s anged om 2.9% o 38.2%.7,8 S udies
sugges ha dep ession is highe in emale medical s u-
den s,6,9-14 younge s uden s15-17 and s uden s in hei ea ly
yea s in medical school.12,17-19 Mixed esul s ha e been
ob ained ega ding he ela ionship be ween dep ession and
e hnici y.1,4,11,20
Medical s uden s ha e academic, psychological and exis en-
ial s esso s. Addi ionally, school selec ion may a ou
indi iduals wi h pe ec ionism, al uis ai s and sel -
c i ical o pe o mance-based sel -es eem, which p edispose
indi iduals o dep ession and suicidal beha iou .11 The
consequences o un ea ed dep ession include subs ance
use, school d opou , poo academic pe o mance and
nega i e epe cussions on long- e m pa ien ca e (mo e
cynical, less empa he ic and less willing o ca e o ch oni-
cally ill pa ien s).7,21
354
© 2016 Rica do Coen e e al. This is an Open Access a icle dis ibu ed unde he e ms o he C ea i e Commons A ibu ion License which pe mi s un es ic ed use o
wo k p o ided he o iginal wo k is p ope ly ci ed. h p://c ea i ecommons.o g/licenses/by/3.0
Majo dep ession is he mos signi ican an eceden isk
ac o o suicide, bu o he ac o s, including o he mood
diso de s, subs ance abuse, hopelessness, ad e se li e e en s,
pe sonal his o y o physical o sexual abuse, and amily
his o y o suicide, o en play a ole.22 Suicide is a majo
public heal h challenge. Ra es o suicide among physicians
a e high.23,24 In addi ion o knowledge and easy access o
means o suicide, hese high a es o suicide in physicians
also e lec he e ec s o un ea ed psychological symp oms
in medical s uden s.25,26 Suicidal idea ion in medical s u-
den s anged om 4.4% o 23.1%, and suicidal a emp s
om 0.0% o 6.4%.7 Suicide is an ex eme consequence o
men al heal h p oblems, so i is c i ical o medical schools
o iden i y s uden s a he g ea es isk o suicide in he
hope o in e ening be o e a agic ou come.27 Some s udies
ha e been published abou dep ession, bu he e ha e been
ew s udies abou suicidal beha iou in medical s uden s.
S udies ha e ound ha inadequa e ea men is signi i-
can amongs dep essi e medical s uden s.1,28 Ba ie s o
seeking men al heal h ca e among medical s uden s include
conce ns abou ime, con iden iali y, s igma, and he
po en ial nega i e e ec s on hei ca ee s.28,29 Mo eo e ,
medical s uden s who epo mode a e o se e e dep ession
a e much mo e likely o endo se he opinion ha a s igma is
associa ed wi h dep ession compa ed wi h hei non-
dep essed colleagues.9 This is he i s esea ch s udy o
in es iga e dep ession and suicidal beha iou in a sample o
Po uguese medical s uden s.
The aims o he p esen s udy we e: 1) o de e mine he
a es o dep ession and suicidal beha iou in a sample o 4 h
- and 5 h -yea o na i e Po uguese medical s uden s; 2) o
compa e a e o dep ession and suicidal beha iou o
gene al popula ion and wi h medical s uden s om o he
coun ies; 3) o in es iga e he ela ionships be ween
pe sonal, epidemiological and clinical ac o s and dep es-
sion and suicidal beha iou in medical s uden s. We hy-
po hesised ha he a e o dep ession and suicidal beha -
iou in medical s uden s would be simila o o highe han
ha o he gene al Po uguese popula ion. Ou hypo hesis is
ha emale s uden s, s uden s who li ed alone, s uden s
wi h poo economic s a us, s uden s wi h poo physical
heal h, s uden s wi h a pe sonal o amily psychia ic
his o y, and s uden s wi h high le els o anxie y and sub-
s ance and alcohol use ha e highe p e alence o dep es-
sion. We hypo hesised ha male s uden s, s uden s who
li ed alone, s uden s wi h poo economic s a us, s uden s
wi h poo physical heal h and s uden s wi h high le els o
dep ession, alcohol use and anxie y ha e highe a e o
suicidal beha iou . We also hypo hesised ha medical
s uden s in hei 4 h yea o medical school ha e a highe
p e alence o dep ession and suicidal beha iou han 5 h
yea medical s uden s as a esul o he s ess ela ed o
beginning o hei clinical yea s.
Me hods
Pa icipan s
A c oss-sec ional su ey was conduc ed in 4 h and 5 h yea
na i e Po uguese medical s uden s o Facul y o Medicine,
Uni e si y o Lisbon, in Po ugal, be ween Oc obe 2012
and July 2013. Su ey esponses we e anonymous. Non-
Po uguese medical s uden s we e excluded om he
su ey.
P ocedu es
The s udy was app o ed by he E hics Commi ee o Facul y
o Medicine, Uni e si y o Lisbon. Ques ionnai es and
consen o ms we e gi en o each s uden . The ques ion-
nai es we e dis ibu ed du ing psychia ic lessons, which
ha e an app oxima e du a ion o 120 minu es. We su eyed
10 classes du ing he 10-mon h du a ion o he esea ch,
h ee om he 4 h yea and se en om he 5 h yea o medi-
cal school. We used he las 20 minu es o each lesson o
adminis e he su ey. Psychia ic lessons a e manda o y
o all 4 h and 5 h yea medical s uden s. S uden pa icipa-
ion in ou s udy was olun a y, and hose who ag eed o
pa icipa e signed he consen o m, comple ed he su ey
and submi ed i sepa a ely o ensu e con iden iali y.
S uden s who e used o pa icipa e submi ed incomple e
su eys in he same manne .
Ins umen s
A pape ques ionnai e was used. We hough ha a pape
ques ionnai e a he han an online ques ionnai e
wa an ed a highe esponse a e wi hou signi ican ly
comp omising con iden iali y and anonymi y. The ques-
ionnai e included six sec ions wi h a o al o 95 ques ions:
pe sonal da a (25 ques ions), subs ance use (one ques ion),
suicidal beha iou ( h ee ques ions), alcohol use (25 ques-
ions), dep ession (21 ques ions) and anxie y (20 ques ions).
The ques ionnai es we e p in ed in sel -adminis e ed o ms
based on he e idence ha he sel - epo esponses o
po en ially emba assing beha iou s (e.g., suicidal beha -
iou ) we e highe in sel -adminis e ed ques ionnai es han
in an in e iewe -adminis e ed o ma .30
Dep ession
The Beck Dep ession In en o y (BDI) was used o assess
dep essi e symp oms.31 I is a 21-ques ion, mul iple-choice,
sel - epo in en o y used o e alua e he incidence and
se e i y o dep ession symp oms. Sco es o 0 o 13 indica e
no o minimal dep ession, 14 o 19 indica e mild dep es-
sion, 20 o 28 indica e mode a e dep ession, and 29 o 63
indica e se e e dep ession. The e sion o he BDI scale ha
had been ansla ed in o Po uguese language and alida ed
o he Po uguese popula ion was used.32,33
In J Med Educ. 2016;7: 354-363 355
Coen e e al.  Dep ession and suicidal beha iou among medical s uden s
Table 1. Demog aphic and pe sonal cha ac e is ics o he s udy
pa icipan s (N=456)
Va iable
N %
Gende
Male
152
33.3
Female
304
66.7
Age (Yea s), M = 23.35 (SD = 3.02)
20 o 21
40
8.8
22
184
40.4
23
139
30.5
24 o 25
44
9.6
26 o 30
29
6.4
mo e han 30
20
4.4
Yea in Medical School
Fou h
133
29.2
Fi h
323
70.8
Race
Caucasian
453
99.3
Black
1
0.2
Indian
2
0.4
Ci il S a us
Single
422
92.5
Ma ied
32
7.0
Di o ced
1
0.2
Widow
1
0.2
Household
Alone
74
16.2
O iginal amily
208
45.6
Gi l/boy iend/ husband/wi e
36
7.9
F iends/ colleagues
138
30.3
Smoke
No
398
87.3
Yes
58
12.7
P e ious Uni e si y Deg ee
No
408
89.5
Yes
48
10.5
Physical Heal h
Poo
7
1.5
A e age
114
25.0
Good
335
73.5
Economic S a us
Poo
11
2.4
A e age
204
44.8
Good
240
52.7
Belie in God
No
198
43.4
Yes
258
56.6
Speciali y in end o choose
Medical special ies
148
32.5
Su gical special ies
109
23.9
Psychia y
11
2.4
Gene al P ac i ione
36
7.9
Paedia ics
46
10.1
Obs e ics and Gynaecology
37
8.1
Unknown
50
11.0
Oph halmology/ O o hinola yngology(ORL)
15
3.3
O he s
4
0.9
To al
456
100
Suicidal beha iou
Suicidal beha iou was assessed using a ques ionnai e o
dicho omous ques ions (yes/no). Suicidal beha iou was
de ined as suicidal idea ion (“Du ing medical school, ha e
you e e se iously hough abou commi ing suicide?”),
suicide plan (“Du ing medical school, ha e you e e made a
plan o commi ing suicide?”) and/o suicide a emp
(“Du ing medical school, ha e you e e a emp ed sui-
cide?”). S uden s we e conside ed o ha e suicidal beha iou
i one o he answe s was posi i e. This assessmen was
based on in en o ies de eloped by Meehan and colleagues
and Lee and colleagues, which we e used in o he s udies
in ended o assess suicidali y in medical s uden s and in
o he epidemiologic s udies.30,34
Pe sonal da a
This ques ionnai e included ques ions abou demog aphic
cha ac e is ics, icho omous ques ions o physical heal h:
“Wha is you gene al le el o physical heal h?” and eco-
nomic s a us: “Wha is you gene al le el o economic
s a us?” This ques ionnai e also included an open ques ion
abou u u e special y in en : “Wha special y do you hink
you will choose?” This sec ion included ques ions abou
pe sonal and amilial psychia ic his o y, namely,
pas /cu en pe sonal psychia ic diagnosis, pas /cu en
psychopha macological ea men , his o y o pe sonal
psychia ic admission, and amily psychia ic diagnosis.
The e was also a ques ion asking i he e was a suicide
a emp in a close pe sonal ela ionship, ollowed by a
ques ion iden i ying he ela ionship. Family his o y o
psychia ic diso de and suicidal beha iou a e well known
isk ac o s o psychia ic diso de s and suicidal beha -
iou .35,36
Anxie y symp oms
Fo he e alua ion o anxie y symp oms, he Zung Sel -
Ra ing Anxie y Scale (SAS) was used.37 The SAS is a sel -
a ed scale consis ing o 20 i ems. I is a ou -poin scale
( a ed 1-4) in which se e i y is assessed based on he
combina ion o in ensi y, equency and du a ion o symp-
oms. Some o he i ems a e e e sely sco ed. An index o
he scale is de i ed by di iding he sum o he alues ( aw
sco es) ob ained on he 20 i ems by he maximum possible
sco e o 80, con e ing o a decimal and mul iplying by 100.
The sco es ange om 20 o 80, whe e 20-44 is he no mal
ange, 45–59 indica es mild o mode a e anxie y le els, 60–
74 indica es ma ked o se e e anxie y, and 75–80 indica es
ex eme anxie y. The e sion ha had been ansla ed in o
Po uguese and alida ed o he Po uguese popula ion was
used.38
Alcohol use
Alcohol use was e alua ed using The Michigan Alcoholism
Sc eening Tes (MAST), which has been in e na ionally
alida ed o he assessmen o alcohol abuse.39 I is a 25-
i em sel - epo ques ionnai e, which includes ques ions
conce ning a ious p oblems associa ed wi h alcohol use,
including medical, in e pe sonal and legal consequences.
The o al MAST sco e can ange om 0 o 53, wi h i em
weigh s ha ange om 0 o 5. A sco e o h ee poin s o
less was conside ed non-alcoholic, a sco e o ou poin s
was sugges i e o alcoholism, and a sco e o i e poin s o
mo e indica ed alcoholism. A alida ed and ansla ed
e sion o he scale o he Po uguese language and
popula ion was used.40
356
Subs ance use
Subs ance use was assessed using he mul i-choice ques ion
“Du ing he las 12 mon hs ha e you used he ollowing
subs ance(s)?” The answe included i e op ions: canna-
bis/ma ijuana, cocaine, he oin, s imulan s o amphe amines
and seda i es o hypno ics no p esc ibed by a doc o .
Table 2. Dep ession a e by demog aphic and clinical
cha ac e is ics
Va iable
Dep ession
BDI≥14 p- alue
N %
Gende
Male
4
2.6
0.027*
Female
24
7.9
Age Yea
20 o 21
2
5.0
0.190
22
15
8.2
23
3
2.2
24 o 25
5
11.4
26 o 30
2
6.9
mo e han 30
1
5.0
Yea in Medical School
Fou h
7
5.3
0.617
Fi h
21
6.5
Ci il S a us
Single
27
6.4
0.751
Ma ied
1
3.1
Di o ced
0
0.0
Widow
0
0.0
Household
Alone
9
12.2
0.037*
O iginal amily
9
4.3
Gi l/boy iend/husband/wi e
0
0.0
F iends/ colleagues
10
7.2
Smoke
No
24
6.0
0.797
Yes
4
6.9
Physical Heal h
Poo
4
57.1
< 0.001†
A e age
15
13.2
Good
9
2.7
Economic S a us
Poo
2
18.2
0.014*
A e age
18
8.8
Good
8
3.3
Belie in God
No
12
6.1
0.950
Yes
16
6.2
Special y In end To Choose
Medical
7
4.7
0.416
Su gical
4
3.7
Psychia y
1
9.1
GP
3
8.3
Paedia ics
5
10.9
Obs e ics
1
2.7
Unknown
6
12.0
Oph halmology/ORL
1
6.7
Psychia ic Diso de
No
13
3.3
< 0.001†
Yes
15
25.9
Psychia y Diagnosis
Dep essi e Diso de
7
19.4
0.009†
Anxie y Diso de
2
15.4
O he
4
57.1
Bipola Diso de
2
100
Cu en /Pas Psychopha macology
No
15
3.7
< 0.001†
Yes
13
26.5
*S a is ically signi ican a p<0.05. †S a is ically signi ican a p<0.01.
BDI: Beck Dep ession In en o y.
Da a analysis
Da a we e analysed using IBM SPSS (S a is ical Package o
he Social Sciences) S a is ics so wa e e sion 21. P e a-
lence and summa y s a is ics we e calcula ed on all a iables
o in e es . BDI, SAS and MAST scale sco es we e collapsed
in o espec i e ca ego ies men ioned. Con inuous a iables
a e shown as he mean and s anda d de ia ion (SD). Using
he chi-squa e es (5% le el o signi icance), we compa ed
he p e alence o dep ession and suicidal beha iou by
se e al socio-demog aphic and clinical a iables. When
mo e han 20% o cells showed an expec ed equency o
less han 5, as he maximum alue can only be 20%, he
chi-squa e es wi h he Mon e Ca lo simula ion was used.
This was based on gene a ing andom samples, which
o e come he p oblem o classes wi h ew o no
obse a ions. In hese cases, he p- alue analysed was
ob ained by he Mon e Ca lo simula ion.
Resul s
Demog aphics
A o al o 456 o he 459 su eyed medical s uden s pa ici-
pa ed in his s udy ( esponse a e: 99.3%). The o al numbe
o medical s uden s en olled in he 4 h and 5 h yea s o
medical school was 767, app oxima ely 50 s uden s in each
class. Table 1 p o ides comple e demog aphic de ails and
pe sonal cha ac e is ics o he esponding s uden s.
A o al o 58 (12.7%) s uden s had a psychia ic
diagnosis, 36 (7.9%) had a dep essi e diso de , 13 (2.9%)
had anxie y diso de , wo (0.4%) had bipola diso de , and
se en (1.5%) had ano he psychia ic diagnosis (ea ing
diso de s, OCD, e c.). Se en (1.5%) pa icipan s had a
p e ious psychia ic admission. Fo y-nine (11%) o he
medical s uden s we e o a e in psychopha macologic
ea men .
In he sample, 168 (37%) s uden s had a psychia ic
amily his o y, and 51 (11.2%) had a suicide a emp in a
close ela ion. Twel e (2.6%) medical s uden s had a suicide
a emp in pa en s, wo (0.4%) in a sis e /b o he , ou
(0.9%) in a boy/gi l iend, i e (1.1%) in a iend and 28
(6.1%) in ano he close ela ion.
Dep ession
The o e all a e o dep ession was 6.1%, wi h mild dep es-
sion (14≤BDI≤19) ound in 14 (3.1%) o he s uden s and
mode a e dep ession (20≤BDI≤28) ound in 11 (2.4%).
Th ee (0.7%) o he s uden s had BDI sco es ≥29, placing
hem in he se e e dep ession ca ego y. Fou hund ed and
wen y-eigh (93.9%) medical s uden s had BDI sco es in
he ange o 0 o 13, indica ing no o minimal dep ession.
Table 2 shows he p e alence o dep ession by demog aphic
and clinical cha ac e is ics.
Dep ession (BDI sco e ≥14) was highe in emale medi-
cal s uden s (χ2= 4.870, d =2, p=0.027), in hose s uden s
who li ed alone (χ2=8.491, d =3, p=0.037), in hose wi h
poo physical heal h (χ2=48.269, d =2, p<0.001) and in hose
wi h poo economic s a us (χ2=8.579, d =2, p=0.014). A
highe p e alence o dep ession was also ound in s uden s
who had a psychia ic diagnosis (χ2=44.846, d =1, p=0.009),
who ha e cu en o pas psychopha macological ea men
(χ2=39.604, d =1, p<0.001), who ha e been diagnosed wi h
In J Med Educ. 2016;7: 354-363 357
Coen e e al.  Dep ession and suicidal beha iou among medical s uden s
bipola diso de (χ2=10.823, d =3, p=0.009) and who ha e a
psychia ic amily his o y (χ2=5.284, d =1, p=0.022).
The pe cen age o dep ession was highe o he ca ego-
y “ex eme anxie y le els”, ollowed by “ma ked o se e e
anxie y le els” and lowe o he ca ego y “no mal ange”, as
measu ed by SAS (χ2=104.8, d =3, p<0.001). Dep ession
p e alence was highe in s uden s wi h suicidal idea ion
(χ2=85.0, d =1, p<0.001), suicide plan (χ2=47.9, d =1,
p<0.001) o suicide a emp (χ2=19.2, d =1, p<0.001).
Table 3. Suicidal beha iou a e by demog aphic cha ac e is ics
Va iable
Suicidal Beha iou
p- alue
N %
Gende
Male
7
4.6
0.610
Female
11
3.6
Age Yea s
20 o 21
1
2.5
0.927
22
7
3.8
23
7
5.0
24 o 25
2
4.5
26 o 30
1
3.4
mo e han 30
0
0.0
Yea in Medical School
Fou h
4
3.0
0.508
Fi h
14
4.3
Ci il S a us
Single
17
4.0
0.986
Ma ied
1
3.1
Di o ced
0
0.0
Widow
0
0.0
Household
Alone
9
12.2
0.001†
O iginal Family
4
1.9
Gi l/boy iend/husband/wi e
0
0.0
F iends/colleagues
5
3.6
Smoke
No
18
4.1
0.217
Yes
0
0.0
P e ious Uni e si y Deg ee
No
18
4.4
0.138
Yes
0
0.0
Physical Heal h
Poo
2
28.6
0.001†
A e age
9
7.9
Good
7
2.1
Economic S a us
Poo
2
18.2
0.010*
A e age
11
5.4
Good
5
2.1
Belie in God
No
9
4.5
0.566
Yes
9
3.5
Special y In end o Choose
Medical
5
3.4
0.446
Su gical
2
1.8
Psychia y
1
9.1
GP
2
5.6
Paedia ics
3
6.5
Obs e ics
2
5.4
Unknown
1
2.0
Oph halmology/ORL
2
13.3
O he s
0
0.0
*S a is ically signi ican a p<0.05. †S a is ically signi ican a p<0.01.
Suicidal beha iou
The a e o suicidal beha iou du ing medical school was
3.9% in he sample. Se en een (3.7%) s uden s answe ed yes
o he ques ion abou suicidal idea ion, i e (1.1%) answe ed
yes o he suicide plan ques ion and h ee (0.7%) answe ed
yes o he suicide a emp ques ion. Medica ion o e dose
was he me hod used in he h ee medical s uden s who had
a emp ed suicide. Suicidal beha iou was highe in
s uden s who had poo physical heal h (χ2=18,929, d =2,
p=0.001) o a poo economic s a us (χ2=9.181, d =2, p=0.01)
and in s uden s who li ed alone (χ2=16.936, d =3, p=0.001).
Suicidal beha iou was also highe in hose pa icipan s
who had a psychia ic diagnosis (χ2=23.461, d =1, p<0.001),
who ha e cu en /pas psychopha macology ea men
(χ2=30.108, d =1, p<0.001) and who ha e been diagnosed
wi h bipola diso de (χ2=13.321, d =3, p=0.008). The
p e alence o suicidal beha iou was highe in s uden s wi h
a amily his o y o psychia ic diso de (5.4% e sus 3.1%),
bu he di e ences we e no s a is ically signi ican (χ2 =
1.394, d =3, p=0.238). Table 3 p o ides he p e alence o
suicidal beha iou by demog aphic cha ac e is ics.
Suicidal beha iou was highe o he ca ego y “alcohol-
ism” and lowe o he ca ego y “non-alcoholism” in he
MAST scale (χ2=7.547, d =2, p=0.023). The pe cen age o
suicidal beha iou was also highe o he ca ego y “se e e
dep ession” and lowe o he ca ego y “no o minimal
dep ession” in he BDI sco e (χ2=88.875, d =3, p<0.001). In
ega ds o anxie y symp oms measu ed by SAS he pe cen -
age o suicidal beha iou was highe o he ca ego y
“ma ked o se e e anxie y le els” and lowe o he ca ego y
“no mal ange” (χ2=50.343, d =3, p<0.001). Because he e is
only one case in he ex eme ca ego y, i s compa ison is no
ele an (Table 4).
Table 4. Suicidal beha iou by alcohol use, dep ession and
anxie y scales sco e
*S a is ically signi ican a p<0.05. †S a is ically signi ican a p<0.01.
Anxie y symp oms
The SAS esul s e ealed a mean alue sco e o 38.12
(dispe sion o 21.5%). In he sample, 366 (80.3%) o he
pa icipan s had a sco e in he no mal ange (sco e 20-44),
81 (17.8%) had mild o mode a e anxie y le els (sco e 45-
59), eigh (1.8%) had ma ked o se e e anxie y le els (sco e
60-74), and one (0.2%) had an ex eme anxie y le el (sco e
75-80).
Ca ego y
Suicidal Beha iou
p- alue
N
%
Alcohol Use (MAST sco e)
No appa en p oblem
8
2.4
0.023*
Sugges i e o alcoholism
4
7.4
Alcoholism
6
8.5
Dep ession (Beck Dep ession In en o y Sco e)
No o minimal dep ession
8
1.9
< 0.001†
Mild dep ession
4
28.6
Mode a e dep ession
4
36.4
Se e e dep ession
2
66.7
Anxie y (Zung Sel -Ra ing Anxie y Scale Sco e)
No mal ange
8
2.2
< 0.001†
Mild o mode a e anxie y le els
6
7.4
Ma ked o se e e anxie y le els
4
50.0
Ex eme anxie y le els
0
0.0
358

Alcohol use
Th ee hund ed and hi y-one (72.6%) o he esponden s
had a MAST sco e ≤3, placing hem in he non-alcoholic
g oup. Fi y- ou (11.8%) s uden s had a MAST sco e o 4,
sugges i e o alcoholism, and 71 (15.6%) had a MAST sco e
≥5, indica i e o alcoholism.
Subs ance use
In he sample, 143 (31%) s uden s admi ed o subs ance use
in he las 12 mon hs. O hese, 92 (64%) used cannabis, 37
(27%) used seda i es no p esc ibed by a doc o , h ee
(2.1%) used cannabis and s imulan s, h ee (2.1%) used
cocaine and seda i es, h ee (2.1%) used cannabis and
seda i es, wo (1.4%) used he oin, one (0.7%) used
s imulan s, and one (0.7%) used cannabis, cocaine and
s imulan s.
The esul s also e ealed ha he e we e no di e ences
be ween s uden s in he 4 h and 5 h yea s o medical school
ega ding alcoholism (p=0.944), dep ession (p=0.672),
anxie y (p=0.897) and suicidal beha iou (p=0.508).
Discussion
This is he i s Po uguese s udy in es iga ing dep ession
and suicidal beha iou in medical s uden s. E en in Eu ope,
his is one o he ew s udies ha add ess suicidal beha iou
in medical s uden s.
The esponse a e o 99.3% ende s an adequa e sample
o he popula ion s udied. We hink ha comple ing he
ques ionnai es du ing classes con ibu ed o he high
esponse a e ob ained.
P e ious s udies showed ha dep ession p e alence o
medical s uden s is simila o highe han ha o he
gene al popula ion.1-6 Compa ison wi h he Po uguese
gene al popula ion is di icul because o he sca ci y o
s udies. Somewha su p isingly, he p e alence ound in ou
cu en esea ch is in line wi h (no highe han) he a e o
dep ession in he gene al popula ion. The only majo s udy
e alua ing he p e alence o dep ession in Po ugal ound a
simila p e alence o ou s (6.8%) o majo dep essi e
diso de s in he gene al popula ion.51 Unexpec edly, his
s udy in a ep esen a i e sample o he Po uguese gene al
popula ion ound high a es o p e alence o men al heal h
diso de s, only lowe han hose o No he n I eland. In his
esea ch, Po uguese a es a e mo e in line wi h hose o
no he n Eu opean coun ies han hose o sou he n
Eu opean coun ies, whe e Po ugal is geog aphically
loca ed.52 Some me hodological limi a ions o his s udy
could con ibu e o he high a es o men al diso de s
obse ed.
P e ious s udies in o he coun ies ha used BDI o
measu e dep ession in medical s uden s yielded simila
esul s (5-35.1%) o he cu en esea ch.1,5,10,13–15,53–58 Recen ,
high-quali y s udies ha e epo ed a lowe p e alence o
dep ession ha p e ious s udies.59 Fu he , in he cu en
esea ch, a conse a i e cu -o o dep ession in he BDI
scale (14) was used ha su ely con ibu ed o a lowe a e o
dep ession in ou sample o medical s uden s.
Dep ession and suicidal beha iou a e de e mined by
mul iple ac o s, including pe sonal, biological and gene ic
ac o s, as well as social and cul u al ac o s.41–44 These la e
ac o s con ibu e o a ia ion in he p e alence o dep es-
sion and suicidal beha iou ac oss di e en cul u al con-
ex s.45-47 The e is e idence ha cul u al ac o s in luence he
cul u al a ia ion in he p e alence o dep ession. Cul u al
di e ences in s ess, s anda ds o li ing, unemploymen ,
s igma and epo ing bias a e among hose ac o s.48
Published esea ch shows ha , on a e age, he li e ime
p e alence o dep ession is highe in high-income han in
low- o middle-income coun ies.48 Fo example, he highes
a es we e in F ance, he Ne he lands, New Zealand and he
USA. I is also well ecognized ha people om sou he n
Eu ope, whe e Po ugal is loca ed, ha e low a es o dep es-
sion compa ed o hose in o he Eu opean coun ies.49
Independen o indi idual le el e ec s, mo e dep essi e
symp oms we e eco ded in coun ies wi h g ea e income
inequali y and wi h less indi idualis ic cul u es. Pe sonal
ci cums ances and belie s and he men ioned cul u al
ac o s may all con ibu e o dep essi e symp oms.50 In he
only s udy ha compa ed he p e alence o dep ession in
medical s uden s om di e en cul u es, he highes p e a-
lence was ound in he Middle Eas , ollowed by No h
Ame ica, Asia and Sou h Ame ica, and he lowes a es we e
obse ed in Eu ope.8 Taking all o hese ac o s in o ac-
coun , i was expec ed ha he p e alence o dep ession in
ou esea ch would be in he lowe limi s o p e ious s udies
o dep ession in medical s uden s. In line wi h hese esul s,
ou indings demons a e ha Po uguese medical s uden s
expe ience dep ession equen ly, bu in he lowe ange o
published s udies in o he coun ies. Based on indings om
p e ious s udies, we could specula e ha indi idualis ic
cul u e, a e age socio-economic backg ound and s igma
associa ed o men al heal h diso de s a e ac o s ha
explained ou obse ed incidence o dep ession in medical
s uden s.
Ano he signi ican inding o his s udy was a gende
di e ence ega ding he associa ion wi h dep ession, whe e
emale s uden s epo ed a signi ican ly highe p e alence o
dep ession han male s uden s. This gende a ia ion in he
dep essi e s a us in medical s uden s could be a e lec ion o
he usual end o highe p e alence o dep ession in
emales in he gene al popula ion.51
Ce ain isk ac o s a e ound o be widely associa ed
wi h dep ession in he gene al popula ion, such as smoking,
economic s a us and psychia ic diagnosis.52,53 This s udy
pa ially con i ms hese indings in medical s uden s, wi h
dep ession being highe in s uden s who epo ed poo
economic s a us and a psychia ic diagnosis. Rega ding
smoking, he p e alence o dep ession was highe in he
medical s uden s who smoked, bu wi h no s a is ically
signi ican di e ence.
In J Med Educ. 2016;7: 354-363 359
Coen e e al.  Dep ession and suicidal beha iou among medical s uden s
Anxie y symp oms a e equen ly obse ed wi h dep es-
sion,43,54 so i is no su p ising ha dep ession was highe in
hose medical s uden s wi h highe SAS sco es.
How he dep ession a e changes o e he yea s o med-
ical school is no comple ely clea . Some longi udinal
s udies sugges ed ha he dep ession a e is high du ing he
i s yea , ollowed by a g adual decline du ing he la e
yea s o medical school.55,56 In he i s yea o medical
school, ac o s such as incomple e adap a ion o a new
en i onmen , loneliness and di icul y in es ablishing a close
ela ionship wi h o he people could explain he high a es
o dep ession in his phase o medical school.57 O he
s udies indica e ha he i s yea o medical aining and
he beginning o he clinical phase, when en e ing he wa ds
(in he Po uguese sys em, his occu s in he ou h yea ),
a e associa ed wi h he highes a es o dep ession.20
Pa ien s´ su e ing, eache s´ c i icisms, neglec om
pa ien s and hei amilies could con ibu e o he high
le els o dep ession in he ou h yea o medical school.7
Cu en esea ch included 4 h and 5 h yea medical s uden s
in o de o compa e he p e alence o suicidal beha iou
and dep ession in he i s yea o he clinical phase o hei
medical deg ee ( ou h yea in he Po uguese medical
cu iculum) and ano he yea ( i h yea ). We did no ind
any signi ican di e ences in dep ession p e alence be ween
he ou h yea and i h yea o medical school, so we could
no conclude ha dep ession is highe in i s yea o he
clinical phase in Po uguese medical s uden s.
Suicidal beha iou (suicidal idea ion, suicide plan
and/o suicide a emp s) is a p ecu so o he inal ou come
o suicide, which may be p e en able i he signs a e
de ec ed ea ly.35 To p e en such occu ences, he e is a
need o unde s and he ex en o he p oblem in a ious
popula ions and cul u es, along wi h i s epidemiology.
The e is a conside able c oss-na ional a iabili y in he
p e alence o suicidal beha iou s in he gene al
popula ion.58 In e es ingly, he p e alence o suicidal
beha iou does no mi o he geog aphic pa e n o suicide
dea h. Namely, he e a e high a es in eas e n Eu ope, a
middle o low p e alence in sou he n Eu ope (whe e
Po ugal is loca ed) and low a es in Sou h Ame ica.58
Addi ionally, he e a e no signi ican di e ences be ween
de eloped and de eloping coun ies.59 Suicidal beha iou in
he p esen s udy is lowe han ha in he s udy o Jeon e
al. in Sou h Ko ea (23.1%), which used simila ques ions o
ou s udy. Howe e , in his las s udy, li e ime suicidal
beha iou was in es iga ed, no jus medical school ime as
in he cu en esea ch.60 The a e o suicidal idea ion
obse ed in ou esea ch was simila o he Schwenk e al.
(4.4%) US s udy9 and he I ish s udy by Cu an e al.
(5.9%).61 Rega ding suicide planning, compa ison is no
possible due o he lack o s udies in es iga ing i as an
ou come. Suicide a emp s ound du ing medical school was
highe han ha obse ed in o he s udies, such as in an
Aus ian sample (0.3%) 62 o in he Swedish s udy, whe e
no suicide a emp s in he las 12 mon hs we e epo ed.3
Because suicide a emp s a e an impo an p edic o o
suicide,22,35 we could specula e ha his high a e o suicide
a emp s in medical s uden s co esponds o a high a e o
suicide in medical s uden s. Un o una ely, he e a e no
published s a is ics ega ding comple ed suicides in Po u-
guese medical s uden s o con i m his heo y.
The cu en s udy ound highe a es o suicidal
beha iou in medical s uden s who li ed alone, who had
poo physical heal h and who had a poo economic s a us.
Con a y o he gene al popula ion, whe e i is well
demons a ed ha emales a e o e ep esen ed in non a al
suicidal beha iou and men in comple e suicide, which is
known as he “gende pa adox o suicidal beha iou ”,63,64
he e was a highe a e o suicidal beha iou in male s u-
den s (bu wi h no signi ican di e ences). This is con a y
o he known inc eased isk o suicidal idea ion, as well as
suicide comple ion, in emale physicians.23 As wi h dep es-
sion, he e was no ela ion be ween suicidal beha iou and
yea o medical school. Suicidal beha iou was highe bu
no signi ican ly di e en in medical s uden s who had a
amily his o y o psychia ic diso de and who had a suicide
a emp in a close ela ion ( he majo i y e e ed o amily
membe s). This is conco dan wi h he well-documen ed
ac ha a amily his o y o suicidal beha iou is a isk
ac o o suicidal beha iou .36
As expec ed, suicidal beha iou was highe in s uden s
in he ca ego ies sugges i e o alcoholism o alcoholism on
he MAST scale, dep essi e ca ego ies on he BDI and
ma ked o se e e anxie y le el ca ego ies in he SAS. This
sugges s ha suicidal beha iou is p esen in s uden s who
ha e clinically ele an men al diso de s. In ou sample,
suicidal beha iou was highe in conjunc ion wi h bipola
diso de , ollowed by dep essi e diso de s and o he
psychia ic diso de s. This is conco dan wi h p e ious da a
in he gene al popula ion indica ing ha a ec i e diso de s
a e he leading men al diso de s associa ed wi h suicide.35
One in e es ing inding o he cu en s udy was ha in
spi e o he lack o s a is ical signi icance, suicidal beha iou
was highe in medical s uden s who in end o choose
psychia y and oph halmology/o o hinola yngology in he
u u e. This is conco dan wi h he known da a ha among
physicians, psychia is s a e conside ed o be a a g ea e
isk o suicide, ollowed by oph halmologis s and
anaes hesiologis s.65
Compa isons be ween he p e alence o dep ession and
suicidal beha iou in Po uguese medical s uden s and
o he Po uguese uni e si y s uden s a e di icul due o he
pauci y o s udies in bo h popula ions. The e a e no
published s udies abou dep ession o suicidal beha iou in
Po uguese non-medical uni e si y s uden s. S udies om
o he coun ies ha e ound high a es o dep ession in o he
uni e si y s uden s, namely, business, nu sing and
pha macy s uden s.10,11,61,66 One possible explana ion is ha
360
medical s uden s main ain his high p e alence o dep es-
sion and suicidal beha iou a e comple ing hei medical
deg ee and h oughou hei p o essional li es, making he
medical p o ession one o he p o essions wi h he highes
a es o dep ession and suicidali y.23,67
Implica ions o he indings
Medical s uden s a e u u e doc o s and need o be p o ec -
ed om p e en able causes o mo bidi y and mo ali y,
such as dep ession o suicidal beha iou . Medical schools
should ha e a sys em o iden i y s uden s who a e cu en ly
dep essed o suicidal. Schools should also wo k o iden i y
s uden s a isk o u u e men al heal h diso de s. Some
epo s men ion simple, b ie ools o iden i y medical
s uden s who a e a isk o men al diso de s.68 Howe e ,
despi e he a ailabili y o sa e and e ec i e ea men ,
dep essed medical s uden s a e unde ea ed. Addi ionally,
hose who epo ed suicidal idea ion a e no mo e likely o
ecei e ea men o hei men al diso de s.1 Fo hese
easons, simply iden i ying medical s uden s a isk i is no
su icien . S uden s a isk o wi h iden i ied men al diso -
de s mus be ea ed. P o iding easy access o men al heal h
ca e, ideally ou side he acul y, main aining anonymi y and
educing he s igma ela ed o seeking men al heal h ea -
men a e impo an ac o s o be add essed.69 Medical
s uden s should ha e access o psychia y appoin men s in a
con iden ial and anonymous way.
I is ecommended ha medical schools implemen p o-
g ams and cu iculum modi ica ions o con ibu e o
lowe ing men al heal h p oblems. Howe e , i is un ealis ic
o comple ely elimina e ac o s (e.g., s ess) associa ed wi h
men al heal h p oblems. All medical schools should
implemen s uden wellness p og ams o p omo e and
p o ide esou ces o heal hy li ing mainly in he 1s yea
and p obably ecycle hem in he beginning o he clinical
yea s o medical school. These p og ams could include
cu icula changes, s ess managemen , psychoeduca ion,
coping s a egies, mind ulness p og ams, indi idual coun-
selling and managing inancial s esso s and alcohol use.6,69-
75 As ou esul s illus a e, he p omo ion o physical heal h
(e.g., p omo ing physical exe cise, easie access o gene al
heal h se ices) and economic s a us (e.g., expanding
schola ships) should be included in hese p og ams once
bo h a e associa ed wi h dep ession and suicidal beha iou .
Finally, we could specula e ha by p omo ing men al
heal h in medical s uden s and ea ing hose who need i ,
we a e also diminishing he known high a es o suicide in
medical doc o s.
Limi a ions o he s udy
This c oss-sec ional s udy had se e al me hodological
limi a ions. S uden conce ns abou he con iden iali y o a
s udy conduc ed by membe s o hei acul y could ha e
in luenced s uden s´ esponses. Addi ionally, a c oss-
sec ional design o he s udy was used a he han a longi u-
dinal one, which is mo e compelling o es ablish causali y
be ween he associa ions ound. Ano he limi a ion is ha
he s udy was conduc ed a a single ins i u ion. The use o
sel - epo ed measu es a he han clinical s uc u ed
in e iews could also be conside ed a limi a ion. Depending
on pe sonali y ai s, s uden s may exagge a e o igno e
hei symp oms. The occu ence o ecall bias and epo ing
e o s is also possible. Howe e , he su ey design ensu ed
anonymi y, and s uden s comple ed he ques ionnai e
olun a ily, which should ha e p omo ed hones esponses.
This also pe mi s access o a la ge sample o pa icipan s,
which cons i u es a clea ad an age. Fu he mo e, he
cu en s udy did no con ol he ime o comple ing
ques ionnai es by medical s uden s. Fo example, we could
specula e ha nea exam pe iods, sco es on he anxie y scale
would be highe . Finally, he use o he non- alida ed scales
o some a iables, namely, o physical heal h, economic
s a us and subs ance use was also a limi a ion.
To o e come some o he abo e-men ioned limi a ions,
u u e esea ch should ocus on longi udinal esea ch and
in ol e s a no belonging o he medical school in o de o
p o ide mo e obus con iden iali y o medical s uden s.
Cla i ying some o ou non-signi ican indings will also be
impo an , namely, he ela ionships be ween dep ession
and alcoholism, gende and suicidal beha iou and speciali-
y and suicidal beha iou .
Conclusions
This is he i s s udy o dep ession and suicidal beha iou
in a sample o Po uguese medical s uden s. This s udy
con i med ha dep ession and suicidal beha iou a e
men al heal h p oblems a ec ing a signi ican p opo ion o
medical s uden s, bu a a a e simila o he gene al Po u-
guese popula ion. Simila o he gene al Po uguese popula-
ion, ou esea ch ound a es o dep ession among medical
s uden s in he lowe limi o published s udies in o he
coun ies. Dep ession was highe in emale medical
s uden s, s uden s who li ed alone, s uden s wi h poo
physical heal h, s uden s wi h a poo economic s a us,
s uden s wi h a psychia ic diagnosis, s uden s wi h a amily
his o y o psychia ic p oblems and s uden s wi h high
le els o anxie y. Dep ession was also highe in s uden s
wi h suicidal idea ion, suicide plans o suicide a emp .
We ound qui e ala ming a es ega ding suicidal beha -
iou , namely suicide a emp s. Suicidal beha iou was
highe in medical s uden s who li ed alone, s uden s who
had poo physical heal h, s uden s who had a poo econom-
ic s a us, s uden s who a e/we e in psychopha macology
ea men and s uden s who had high alcohol use, se e e
dep ession and high anxie y le els. Medical schools should
implemen p og ams ha p omo e men al heal h wellness,
physical heal h and economy economic s a us be ween
o he modi iable ac o s associa ed.
In J Med Educ. 2016;7: 354-363 361
Coen e e al.  Dep ession and suicidal beha iou among medical s uden s
Acknowledgemen s
We would like o hank all medical s uden s who pa icipa -
ed and comple ed he su ey.
Con lic o In e es
The au ho s decla e ha hey ha e no con lic o in e es .
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