Little is known about the prevalence of suicidal ideation among U.S. medical students or how it relates to burnout.
To assess the frequency of suicidal ideation among medical students and explore its relationship with burnout.
Cross-sectional 2007 and longitudinal 2006 to 2007 cohort study.
7 medical schools in the United States.
4287 medical students at 7 medical schools, with students at 5 institutions studied longitudinally.
Prevalence of suicidal ideation in the past year and its relationship to burnout, demographic characteristics, and quality of life.
Burnout was reported by 49.6% (95% CI, 47.5% to 51.8%) of students, and 11.2% (CI, 9.9% to 12.6%) reported suicidal ideation within the past year. In a sensitivity analysis that assumed all nonresponders did not have suicidal ideation, the prevalence of suicidal ideation in the past 12 months would be 5.8%. In the longitudinal cohort, burnout (P < 0.001 for all domains), quality of life (P < 0.002 for each domain), and depressive symptoms (P < 0.001) at baseline predicted suicidal ideation over the following year. In multivariable analysis, burnout and low mental quality of life at baseline were independent predictors of suicidal ideation over the following year. Of the 370 students who met criteria for burnout in 2006, 99 (26.8%) recovered. Recovery from burnout was associated with markedly less suicidal ideation, which suggests that recovery from burnout decreased suicide risk.
Although response rates (52% for the cross-sectional study and 65% for the longitudinal cohort study) are typical of physician surveys, nonresponse by some students reduces the precision of the estimated frequency of suicidal ideation and burnout.
Approximately 50% of students experience burnout and 10% experience suicidal ideation during medical school. Burnout seems to be associated with increased likelihood of subsequent suicidal ideation, whereas recovery from burnout is associated with less suicidal ideation.
Center C, Davis M, Detre T, Ford DE, Hansbrough W, Hendin H, et al. Confronting depression and suicide in physicians: a consensus statement. JAMA. 2003;289:3161-6. [PMID: 12813122] CrossrefMedlineGoogle Scholar
Schernhammer ES, Colditz GA. Suicide rates among physicians: a quantitative and gender assessment (meta-analysis). Am J Psychiatry. 2004;161:2295-302. [PMID: 15569903] CrossrefMedlineGoogle Scholar
Schernhammer E. Taking their own lives—the high rate of physician suicide. N Engl J Med. 2005;352:2473-6. [PMID: 15958803] CrossrefMedlineGoogle Scholar
Hays LR, Cheever T, Patel P. Medical student suicide, 1989-1994. Am J Psychiatry. 1996;153:553-5. [PMID: 8599405] CrossrefMedlineGoogle Scholar
Pepitone-Arreola-Rockwell F, Rockwell D, Core N. Fifty-two medical student suicides. Am J Psychiatry. 1981;138:198-201. [PMID: 7457640] CrossrefMedlineGoogle Scholar
Clark DC, Zeldow PB. Vicissitudes of depressed mood during four years of medical school. JAMA. 1988;260:2521-8. [PMID: 3172426] CrossrefMedlineGoogle Scholar
Givens JL, Tjia J. Depressed medical students' use of mental health services and barriers to use. Acad Med. 2002;77:918-21. [PMID: 12228091] CrossrefMedlineGoogle Scholar
Tjia J, Givens JL, Shea JA. Factors associated with undertreatment of medical student depression. J Am Coll Health. 2005;53:219-24. [PMID: 15813232] CrossrefMedlineGoogle Scholar
Dahlin M, Joneborg N, Runeson B. Stress and depression among medical students: a cross-sectional study. Med Educ. 2005;39:594-604. [PMID: 15910436] CrossrefMedlineGoogle Scholar
Tyssen R, Vaglum P, Grønvold NT, Ekeberg O. Suicidal ideation among medical students and young physicians: a nationwide and prospective study of prevalence and predictors. J Affect Disord. 2001;64:69-79. [PMID: 11292521] CrossrefMedlineGoogle Scholar
Kessler RC, Borges G, Walters EE. Prevalence of and risk factors for lifetime suicide attempts in the National Comorbidity Survey. Arch Gen Psychiatry. 1999;56:617-26. [PMID: 10401507] CrossrefMedlineGoogle Scholar
Dyrbye LN, Thomas MR, Shanafelt TD. Systematic review of depression, anxiety, and other indicators of psychological distress among U.S. and Canadian medical students. Acad Med. 2006;81:354-73. [PMID: 16565188] CrossrefMedlineGoogle Scholar
Dyrbye LN, Thomas MR, Eacker A, Harper W, Massie FS, Power DV, et al. Race, ethnicity, and medical student well-being in the United States. Arch Intern Med. 2007;167:2103-9. [PMID: 17954805] CrossrefMedlineGoogle Scholar
Dyrbye LN, Thomas MR, Huntington JL, Lawson KL, Novotny PJ, Sloan JA, et al. Personal life events and medical student burnout: a multicenter study. Acad Med. 2006;81:374-84. [PMID: 16565189] CrossrefMedlineGoogle Scholar
Meehan PJ, Lamb JA, Saltzman LE, O'Carroll PW. Attempted suicide among young adults: progress toward a meaningful estimate of prevalence. Am J Psychiatry. 1992;149:41-4. [PMID: 1728183] CrossrefMedlineGoogle Scholar
Cooper-Patrick L, Crum RM, Ford DE. Identifying suicidal ideation in general medical patients. JAMA. 1994;272:1757-62. [PMID: 7966924] CrossrefMedlineGoogle Scholar
- 17. Suicidality. In: National Comorbidity Survey, Collaborative Psychiatric Epidemiology Surveys. Accessed at www.icpsr.umich.edu/cocoon/cpes/cpes/BLSUICIDALITY/all/section.xml on 15 May 2008. Google Scholar
- 18. National Center for Health Statistics. Youth Risk Behavior Survey. Hyattsville, MD: U.S. Department of Health and Human Services; 2007. Accessed at www.cdc.gov/nchs/datawh/nchsdefs/suicidalideation.htm on 15 May 2008. Google Scholar
Maslach C, Jackson SE, Leiter MP. Maslach Burnout Inventory Manual. 3rd ed. Palo Alto, CA: Consulting Psychologists Pr; 1996. Google Scholar
West CP, Huschka MM, Novotny PJ, Sloan JA, Kolars JC, Habermann TM, et al. Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study. JAMA. 2006;296:1071-8. [PMID: 16954486] CrossrefMedlineGoogle Scholar
Thomas NK. Resident burnout. JAMA. 2004;292:2880-9. [PMID: 15598920] CrossrefMedlineGoogle Scholar
Arthur NM. The assessment of burnout: A review of three inventories useful for research and counseling. J Couns Dev. 1990;69:186-89. CrossrefGoogle Scholar
Söderfeldt M, Söderfeldt B, Warg LE, Ohlson CG. The factor structure of the Maslach Burnout Inventory in two Swedish human service organizations. Scand J Psychol. 1996;37:437-43. [PMID: 8931397] CrossrefMedlineGoogle Scholar
Toppinen-Tanner S, Ojajärvi A, Väänänen A, Kalimo R, Jäppinen P. Burnout as a predictor of medically certified sick-leave absences and their diagnosed causes. Behav Med. 2005;31:18-27. [PMID: 16078523] CrossrefMedlineGoogle Scholar
Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med. 2002;136:358-67. [PMID: 11874308] LinkGoogle Scholar
Guthrie E, Black D, Bagalkote H, Shaw C, Campbell M, Creed F. Psychological stress and burnout in medical students: a five-year prospective longitudinal study. J R Soc Med. 1998;91:237-43. [PMID: 9764076] CrossrefMedlineGoogle Scholar
Thomas MR, Dyrbye LN, Huntington JL, Lawson KL, Novotny PJ, Sloan JA, et al. How do distress and well-being relate to medical student empathy? A multicenter study. J Gen Intern Med. 2007;22:177-83. [PMID: 17356983] CrossrefMedlineGoogle Scholar
Dyrbye LN, Thomas MR, Huschka MM, Lawson KL, Novotny PJ, Sloan JA, et al. A multicenter study of burnout, depression, and quality of life in minority and nonminority US medical students. Mayo Clin Proc. 2006;81:1435-42. [PMID: 17120398] CrossrefMedlineGoogle Scholar
Spitzer RL, Williams JB, Kroenke K, Linzer M, deGruy FV, Hahn SR, et al. Utility of a new procedure for diagnosing mental disorders in primary care. The PRIME-MD 1000 study. JAMA. 1994;272:1749-56. [PMID: 7966923] CrossrefMedlineGoogle Scholar
Whooley MA, Avins AL, Miranda J, Browner WS. Case-finding instruments for depression. Two questions are as good as many. J Gen Intern Med. 1997;12:439-45. [PMID: 9229283] CrossrefMedlineGoogle Scholar
Ware JE, Kosinski M, Dewey JE, Gandek B. How to Score and Interpret Single-Item Health Status Measures: A Manual for Users of the SF-8 Health Survey. Lincoln, RI: QualityMetric Incorporated; 2001. Google Scholar
Shanafelt TD, West C, Zhao X, Novotny P, Kolars J, Habermann T, et al. Relationship between increased personal well-being and enhanced empathy among internal medicine residents. J Gen Intern Med. 2005;20:559-64. [PMID: 16050855] CrossrefMedlineGoogle Scholar
Turner-Bowker DM, Bayliss MS, Ware JE, Kosinski M. Usefulness of the SF-8 Health Survey for comparing the impact of migraine and other conditions. Qual Life Res. 2003;12:1003-12. [PMID: 14651418] CrossrefMedlineGoogle Scholar
Freund RJ, Littell RC. SAS System for Regression. 2nd ed. Cary, NC: SAS Institute; 2000. Google Scholar
Crosby AE, Cheltenham MP, Sacks JJ. Incidence of suicidal ideation and behavior in the United States, 1994. Suicide Life Threat Behav. 1999;29:131-40. [PMID: 10407966] MedlineGoogle Scholar
Dahlin ME, Runeson B. Burnout and psychiatric morbidity among medical students entering clinical training: a three year prospective questionnaire and interview-based study. BMC Med Educ. 2007;7:6. [PMID: 17430583] CrossrefMedlineGoogle Scholar
Fletcher RH, Fletcher SW. Clinical Epidemiology: The Essentials. Philadelphia: Lippincott Williams & Wilkins; 2005. Google Scholar
- 38. Liaison Committee on Medical Education. Accreditation Standards. Chicago, IL and Washington, DC: Association of American Medical Colleges and American Medical Association; 2003. Accessed at www.lcme.org/standard.htm on 16 July 2008. Google Scholar
Mann JJ, Apter A, Bertolote J, Beautrais A, Currier D, Haas A, et al. Suicide prevention strategies: a systematic review. JAMA. 2005;294:2064-74. [PMID: 16249421] CrossrefMedlineGoogle Scholar
Kellerman SE, Herold J. Physician response to surveys. A review of the literature. Am J Prev Med. 2001;20:61-7. [PMID: 11137777] CrossrefMedlineGoogle Scholar
- 41. Association of American Medical Colleges. Medical School Graduation Questionnaire. Washington, DC: Assoc of American Medical Colleges; 1995. Accessed at www.aamc.org/data/gq/allschoolsreports/1995.pdf on 22 January 2007. Google Scholar
- 42. Association of American Medical Colleges. FACTS—Applicants, Matriculants and Graduates. Total Enrollment by Sex and School, 2001–2005. Washington, DC: Assoc of American Medical Colleges; 2005. Accessed at www.aamc.org/data/facts/2005/factsenrl.htm on 17 December 2007. Google Scholar
Author, Article, and Disclosure Information
Liselotte N. Dyrbye,
From the Mayo Clinic, Rochester, Minnesota; University of Alabama School of Medicine, Birmingham, Alabama; University of Minnesota Medical School, Minneapolis, Minnesota; University of Washington School of Medicine, Seattle, Washington; University of Chicago Pritzker School of Medicine, Chicago, Illinois; Uniformed Services University of the Health Sciences, Bethesda, Maryland; and University of California, San Diego, San Diego, California.
Grant Support: By an Education Innovation award from the Mayo Clinic.
Disclosures: None disclosed.
Corresponding Author: Liselotte N. Dyrbye, MD, 200 First Street Southwest, Rochester, MN 55905.
Current Author Addresses: Drs. Dyrbye, Thomas, Sloan, and Shadafelt; Mr. Szydlo; and Mr. Novotny: 200 First Street Southwest, Rochester, MN 55905.
Dr. Massie: 1530 Third Avenue South, FOT 720, Birmingham, AL 35294.
Dr. Power: University of Minnesota, 516 Delaware Street Southeast, Minneapolis, MN 55455.
Dr. Eacker: General Internal Medicine Center, 4245 Roosevelt Way Northeast, Seattle, WA 98105.
Dr. Harper: 5841 South Maryland Avenue, MC 3051, Chicago, IL 60637.
Dr. Durning: 4301 Jones Bridge Road, Bethesda, MD 20814-4799.
Dr. Moutier: University of California, San Diego School of Medicine, Medical Teaching Facility Room 180, 9500 Gilman Drive, 0606, La Jolla, CA 92093-0606.