Risks and Warning Signs for Medical Student Suicide Mortality: A Systematic Review

Figures & data

FIGURE 1. PRISMA diagram depicting workflow for the screening process (adapted from Page et al., 2021).

TABLE 1. Characteristics of all included studies.

Author (year)	Study setting	Date of suicide(s)	Source of data	Analyses conducted/data provided	Relative quality assessment score (%)
Chahal et al. (2022)	Across India	2010–2019	Retrospective news content analysis from online news portals and other publicly available sites.	Percentages, means and SD were calculated, alongside a usage of Pearson’s chi-square test; missing variables were excluded.	60.0%
Cheng et al. (2014)	Across USA	June 2006 – July 2011	Cross-sectional survey to 133 accredited US medical schools, with surveys being completed by a representative from the university.	Survey data stratified, with information by year and gender; comparisons made with national suicide rates.	54.5%
Hays et al. (1996)	Across USA	August 1989 – May 1994	Telephone interviews with US medical school representatives. Details obtained regarding suicide deaths if they were reported.	Survey data stratified, with information by year and gender; comparisons made with national rates.	54.5%
Jahan et al (2021)	Across the world (single medical student death reported in India)	Across 2020 (medical student death in March 2020)	Retrospective press of medical suicide reports worldwide among medical students and physicians.	Details of suicide reason and suicide method reported, along with age, gender and COVID-19 status.	80.0%
Jha et al. (2014)	Hospitals across India	2010, 2014	News reports of suicide deaths in India.	Details of suicide death and demographics provided.	40.0%
Kaltreider (1990)	San Francisco, USA	1988	University information regarding a suicide event, and interviews of students in the aftermath.	Details of suicide death and demographics provided, quantitative information (on scales) provided regarding student responses in the aftermath.	66.6%
Mamun et al. (2020)	Across Bangladesh	January 2018 – November 2019	Retrospective data from news reports in Bangla and English on medical student suicides.	Data described by death, with details provided regarding gender, city, age, year of study, method of suicide, and reasons for suicide.	50.0%
Pruthi et al. (2015)	Across India	January 2010 – March 2012	Retrospective data from India’s five leading daily newspapers on medical student suicides.	Reported data on medical student suicides, including place, alleged reason, date, and gender.	50.0%
Rockwell et al. (1981)	Across USA	1974 – 1981	Questionnaire sent to deans of student affairs for 116 medical schools across USA.	Suicide rates among medical students compared with national trends, with details provided on medical student gender, and age.	54.5%
Simon (1968)	Across USA and Canada	September 1947–June 1967	Letter requesting relevant mortality information to 65 medical schools across USA.	Mortality rates among medical students compared with national trends, with stratification provided for causes of death, and brief details provided regarding student suicides.	54.5%
Singh (2022)	Palanpur and Vandnagar medical colleges, in India	March 2022	Data obtained from news reports.	Brief details provided regarding student demographics and method of suicide.	40.0%
Uchida and Uchida (2017)	Across Japan	1989–2011	Annual surveys of dropouts, holdovers, and deaths among national university students between 1989 and 2012.	Analyzed annual mortality rates, as well as rates of suicide; details regarding suicide provided, with information on sex, major, psychiatric diagnoses, and methods of suicide. Chi-sqaure analysis completed to compare groups, followed by residual analysis.	90.9%
Zivanovic et al. (2018)	Across Canada	2006 – 2016	Survey of medical schools sent to deans/directors of student affairs; surveys included questions regarding the institution, suicide rates, and details of student suicides.	Data was reviewed and tabulated, and compared with an estimate provided for medical student suicide rates; details regarding gender and year of medical school for those who died by suicide.	62.5%

TABLE 2. Characteristics of medical students who died by suicide.

Study	Number of deaths	Gender	Setting	Date	Age	Means / Method of suicide	Year of MD/MBBS	Comorbidities	Other factors
Chahal et al. (2022)	125	Male = 78 Female = 47	Across India	2010–2019	Mean male = 21.2 (SD 2.3) Mean female = 21.1 (2.2) 17–29 years = 110	Hanging = 87 Jump from height = 16 Poisoning = 11 Jumped in front of train = 7 Other = 4	N/A	Mental health problems = 25 Physical illness = 1	Reasons (M:F ratio) Academic stress = 47 (1.35) Marital discord = 1 (0.0) Harassment/humiliation = 18 (2.60) Failed/troubled love affair = 13 (0.63) Family problems = 4 (3.80) Financial stress = 2 (2.00) Physical illnesses = 1 (1.00) Legal issues = 2 (2.00) Recent death of close one = 1 (1.00) More than one reason = 9 (2.00) Suicide warning signs (M:F ratio) Recent change in mood or behavior = 19 (1.71) Past suicide attempt = 7 (all male) Verbal/written note or communication regarding suicidal intent = 6 (1.00) Absenteeism from classes/work = 9 (8.00) More than one warning sign = 6 (all male)
Cheng et al. (2014)	6	M = 4 F = 2	Across USA (excluding Puerto Rica)	July 2006 – June 2011	Mean age for men 25.3yrs (range: 22–29) Mean age for female was 26.5yrs	Gunshot = 2 Hanging = 2 Overdose = 1 Unknown = 1	First year = 2 Second year = 2 Third year = 2 (one on leave)	Psychiatric comorbidity = 3 Major depression = 2	Caucasian = 5 Asian = 1 Single = 6 No substance/alcoholism = 6 Suicide notes = 3
Hays et al. (1996)	15	M = 14 F = 1	Across USA	1989 to 1994 Feb = 2, Aug = 2, Oct = 2, Dec = 2	Mean age for men 25.9yrs (Range 23-24) Woman (n = 1) age = 22	Firearm = 8 Overdose = 6 (2 by injection) Jumping from building = 1	First year = 3 Second year = 2 Third year = 6 Fourth year = 4	Psychiatric history = 9	Caucasian = 12 Middle Eastern = 2 Hispanic = 1 Single = 13 Married = 1 Divorced = 1 Left suicide notes = 6 Past alcohol/drug abuse = 3
Jahan et al. (2021)	1	F = 1	India	May 1, 2020	22	N/A	N/A	N/A	Cause = work-related stress (1) Occurred during COVID-19 pandemic (but did not have COVID-19)
Jha et al. (2014)	2	M = 1	India	2014	N/A	Jumped from building = 1 Went in front of train = 1	Final year MBBS = 2	Depressed = 1	Given zero on a practical paper = 1 Failed a subject and had to sit for a supplementary exam = 1
Kaltreider (1990)	1	M = 1	University of California – San Francisco, USA	Summer 1988	N/A	Jumped from building = 1	Third year = 1	N/A	Climbed in the morning = 1
Mamun et al. (2020)	13	M = 5 F = 8	Across Bangladesh Chittagong = 2 Mymensingh = 2 Dhaka = 3 Rajashahi = 2 Kushtia = 1 Comilla = 1 Bogra = 1 Sylhet = 1	January 1, 2018 – November 30, 2019 First half of the academic year = 10	20 = 1 21 = 1 22 = 1 24 = 2 25 = 1	Hanging = 11 Poisoning = 1	Final year of study = 7	Depression = 1	Reasons for suicide: Family pressure due to bad performance = 1 Mental disturbance = 1 Blackmail = 1 Extra-martial issue = 1 Quarrel with mother and parental divorce = 1 Failing final exam 11 times = 1 Failing final = 1 Excessive academic pressure = 1 Medical problem preventing from becoming a surgeon = 1 Public medical college = 9 Private medical college/medical technical institute/medical institute or paramedical i nstitute = 4
Pruthi et al. (2015)	16	M = 10 F = 6	Across India Total Urban = 11 Rural = 5 Male Urban = 7 Rural = 3 Female Urban = 4 Rural = 2	January 2010 – March 2014	N/A	N/A	N/A	Declining health = 1 Personality disorder = 1	Reason (total): Professional – stress due to poor performance = 7 Personality disorder = 1 Professional – unable to get postgraduate course of choice = 1 Social – ragging/hazing = 1 Personal – accused of stealing a phone = 1 Personal – breaking up with a partner = 1
Rockwell et al. (1981)	52	M = 34 F = 9	Across USA	1974 – 1981 January = 5 February = 2 March = 1 May = 1 June = 4 June 2 September = 1 October = 1 November = 4 December = 3	Men Mean = 24 Range = 21 – 26 Women Mean = 25 Range = 21 – 30	N/A	First = 3 Second year = 12 Third year = 7 Fourth year = 3	N/A	Single = 24 Not single = 8
Simon (1968)	31	N/A	Across USA and Canada	1950 = 3 1952 = 2 1953 = 2 1954 = 2 1958 = 3 1959 = 1 1960 = 3 1961 = 2 1962 = 1 1963 = 3 1964 = 3 1965 = 5	N/A	N/A	First year = 7 Second year = 6 Third year = 11 Fourth year = 7	N/A	N/A
Singh (2022)	4	F = 1 Unspecified = 3	India: Ahmedabad, Chandigarh, Palanpur, Vadnagar	March – April 2022	21 = 1	Hanging = 1	First year = 1	N/A	Within 24 hours of admission to medical school = 1 Occurred in her residence = 1
Uchida and Uchida (2017)	90	M = 65 F = 25	Across Japan	1989– 2012	N/A	N/A	There was a significant difference among academic years (p < 0.01), first-year students were significantly less likely to die by suicide (p < 0.05) Students in their final year were more likely to die by suicide (p < 0.01)	N/A	Medical students were significantly more likely to die by suicide than students of other majors (p < 0.01). Students repeating academic years of taking years of absence had higher rates of suicide death (p < 0.01)
Zivanovic et al. (2018)	6	M = 3 F = 3	Across Canada	2006 – 2016	N/A	N/A	Final years of study (3^rd/4^th/immediately prior to graduation) = 5	N/A	N/A

TABLE 3. Pooled totals of medical student suicide factors.

Factor	Deaths (%)
Total deaths (n = 362)
Sex (n = 318)
Male	215 (67.6)
Female	103 (32.4)
Country (n = 331)
India	148 (44.7)
Japan	90 (27.2)
USA	74 (22.4)
Bangladesh	13 (3.9)
Canada	6 (1.8)
Means/method of suicide (n = 157)
Hanging	101 (64.3)
Jumping from building	19 (12.1)
Overdose/poisoning	19 (12.1)
Firearm	10 (6.4)
Going in front of train	8 (5.1)
Comorbidities (n = 44)
Psychiatric morbidity/mental health problem	42 (95.5)
Unspecified physical comorbidity	2 (4.5)
Year of medical study (n = 93)
4^th/5^th/6^th/final year	28 (30.1)
3^rd year	27 (29.0)
2^nd year	22 (23.7)
1^st year	16 (17.2)
Factors contributing to motive (n = 98)
High levels of academic stress/academic failure	58 (59.2)
Harassment / humiliation / bullying / hazing	20 (20.4)
Relationship issues	20 (20.4)
Single/not in a relationship	45 (12.4^a)
Recent change in mood/behavior	19 (5.2^a)
Left a suicide note	21 (5.8^a)

^aPercentage of total deaths.

TABLE 4. Summary of key risk factors and warning signs for medical student suicide, and implementable strategies to support students.

Key risk factors for suicide amongst medical students Facing heavy academic stress or excessive academic pressure. Experiencing academic failure or repeating an academic year. Dealing with harassment, hazing, and/or bullying. Living with a psychiatric or mental health condition (e.g. depression). Having a past suicide attempt. Having personal relationship (e.g. partner, family) problems. Note: male students are at a higher risk than female students.

Key warning signs Recent change in mood behavior. Social withdrawal. Leaving a suicide note. Absenteeism from work/class.

Implementable strategies to support students Ensuring an availability of medical student counseling services, including relationship counseling services. Ensuring access to emergency crisis support. Providing additional academic support to students who are struggling / have experienced academic failure. Ensuring adequate accessibility to primary health care for medical students. Encouraging camaraderie and open discussion of mental health amongst students and staff. Addressing mental health stigma in medical schools and hospital settings. Development of supportive curriculums that encourage peer-support, involvement in extra-curricular activities, and development of student resilience.

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