Mental Health Disturbances

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This entry is adapted from the peer-reviewed paper 10.3390/medicina57010011

The presence of mental health problems in the population of medical students in Italy has been evaluated in several cross-sectional studies, which have used different methodologies and study designs. However, a global overview of the prevalence of mental health problems in Italian medical students is not available, although this would be essential for promoting preventive strategies and supportive treatments.

mental health problems medical school

1. Introduction

Up to 35% of university students suffer from common mental disorders or related health problems ^[1]. The transition from high school to university is a critical period in terms of biological, psychological, and social development, with the creation of new relationships, a new identity and an increase in autonomy and responsibility ^[2]. Moreover, most mental illnesses arise and develop during late adolescence.

The admission into medical school and the period of graduation are very competitive and highly stressful. In fact, compared with their peers, students from medical school show higher rates of mental health problems, including depressive and anxiety symptoms ^[3], and are at higher risk of using illicit substances ^[4] or of developing full-blown mental disorders ^[5]. Students reporting these symptoms have reduced academic performances and a consequent poor quality of provided healthcare and increased medical errors ^[6]. Risk factors for the development of psychiatric symptoms in this student population include female sex, exposure to recent stressful life events, excessive use of smartphone and low quality of sleep ^[7].

Tobacco consumption and smoking dependence represent a rising problem for medical students. In fact, Mas et al. ^[8] found that medical students’ tobacco consumption increases during the years of training in medical schools. Moreover, tobacco use has been associated with the risk of developing depressive symptoms ^[9]. Another unhealthy lifestyle behaviour frequently adopted by medical students is the consumption of energy drinks, which are used for their stimulatory effect and for claims of giving benefits, such as physical endurance reaction, concentration, and reduced need for sleep. Smoking represents a risk factor for the use of energy drinks in university students ^[10]^[11]^[12]. Therefore, the use of energy drink, smoking habits and alcohol consumption are considered “proxy” measures of the global mental health of medical students.

Despite medical students frequently have mental health problems, their levels of help-seeking are quite low ^[13]. It may be that their access to specialist care is delayed by the presence of stigma still attached to mental disorders, as recently documented by the American Psychiatric Association that more than 50% of medical students meeting the diagnostic criteria for a mental disorder are reluctant to seek professional help because of fear of exposure to stigma ^[14]. Moreover, after graduation, the fear of stigma and of financial and professional consequences are a significant barrier to seeking help among doctors ^[15]^[16]^[17]. In Italy, the levels of stigma attached to mental disorders are still quite high, particularly in specific socio-cultural contexts impacting negatively on the help-seeking. In particular, a survey carried out in the general population indicates that depression is usually seen as a reaction to significant life events. Moreover, the levels of stigma towards depression are quite high, as highlighted by the fact that participants report that it is embarrassing to report depressive symptoms to general practitioners and there are several concerns regarding the use of antidepressants ^[18].

2. Results

According to the search strategy, 873 records were identified. Based on title and abstract’s review, 296 were duplicates and were excluded. For the remaining 577 papers, the main reasons for exclusion were “topic not relevant” (N = 411) and “not the target population” (N = 146). The remaining 20 articles were retained, and seven additional eligible papers were identified by searching the references’ lists of the papers. Therefore, sixteen studies have been included in the review (Figure 1). In the majority of cases ^[20]^[21]^[22]^[23]^[24]^[25]^[26]^[27]^[28]^[29]^[30], the articles’ title was related to the use of cigarette, energy drink or alcohol. In 12 out 16 studies, the main aim was the evaluation of the consumption rate among Italian medical students and their knowledge and attitudes about substance use. Four studies ^[29]^[31]^[32]^[33] investigated the prevalence of alcohol, depressive symptoms and suicidal behavior, and evaluated the factors associated with these syndromes (Table 2).

The sample size of included studies ranged from 44 to 794 participants. Almost all studies adopted a cross-sectional design, while only three studies ^[24]^[27]^[30] used a multicenter cross-sectional design.

The prevalence rates were 15.3–31.4% for cigarette use, 22–75% for energy drink and 13–86% for alcohol use. The percentage of smokers was significantly higher in male than female students ^[21]. Moreover, male students were at higher risk of using multiple substances (drink, alcohol, nicotine and coffee) and of being heavy smokers compared to female students ^[28]. However, women showed a higher prevalence of depressive and anxiety symptoms ^[31].

On the global sample, the prevalence of depressive symptoms ranged between 2.5 and 21.4%, while severe suicidal thoughts were found in 17% of participants ^[32]. Depressive symptoms and deficit/hyperactivity symptoms were more likely to be present among students seeking counseling ^[33]. Students with severe suicidal behavior had higher rates of anxious and cyclothymic temperaments compared with non-severe suicidal group ^[31].

Only one study ^[33] with a small sample size (N = 44) found a higher prevalence rate of adaptation disorder (36%) and of psychotic disorder (14.3%), compared to dysthymia and panic disorder (7.1%).

The levels of knowledge regarding the risks of tobacco use, its epidemiological aspects and possible treatments were relatively low among Italian medical students.

Regarding data collection, thirteen studies ^[20]^[21]^[22]^[23]^[24]^[25]^[26]^[27]^[28]^[29]^[30]^[31]^[34][25–36,39] used self-reported instruments which had been administered during class time. In the remaining studies ^[32]^[33], data collection took place during a medical examination or at the counseling center. A 75–100% response rate was found for data collection during class time, while a lower response was found if the recruitment took place through email invitation.

3. Summary of Design Quality

The GRADE criteria were adopted to evaluate the quality of included studies. The majority of the studies (N = 10, 62.5%) were of moderate quality, being cross-sectional studies and conducted in one or two cities only. The remaining six papers were rated of low quality due to the small sample size and the lack of limitations or to the risk of reported bias. Since the overall quality of the included studies is moderate, we recommend that multicenter longitudinal studies involving students attending different years of training in the medical schools should be carried out.

Table 2. Selected characteristics of the studies on health-related behaviours among Italian medical students.

Author(s), Year

Study Design

Sample Size, Site(s)

Mean Age

Gender

Assessment Tool(s)

Main Aim(s)

Data Collection and Response Rate

Prevalence

Main Findings

Main Conclusions

Study Limitations

GRADE Criteria

Volpe et al. 2019

Cross-sectional

N = 360,

Ancona, Foggia

Not reported

F: 58.33%

M: 41.67%

Oldenburgh Burnout Inventory (OLBI); General Health Questionnaire (GHQ); CAGE (Cutdown/Annoyed/Guilty/Eye Opener)

To evaluate the general health and the levels of burnout

Online survey, invitation through institutional email to all university’s students. Response rate: Ancona 88.6%; Foggia: 11.4%

5%: anxiety disorder

2.5%: depression

0.28%: burnout syndrome

8.9%: alcohol related problems

33%: cognitive enhancers users

8.6% of participants reported mental health issues whilst at medical school, ranking as follows: Anxiety Disorders > Major Depression > Eating Disorders > ADHD > Burnout Syndrome.

The finding show that a certain percentage of Italian Medical students present psychological conditions with alcohol misuse and use of drugs to cope with their condition

Online survey; self-reporter instruments

MODERATE

Solano et al. 2019

Cross-sectional

N = 522, Genoa

23.6 ± 1.1 years

F:59%

M: 41%

Suicide Opinion Questionnaire (SOQ); Coping Orientation to Problem Experienced (COPE); Temperament Evaluation of the Memphis (TEMPS-A)

To evaluate the presence of suicidal thoughts/behaviors, coping strategies, temperament and attitude towards suicidality in medical students

Collection during classrooms activities from medical students Response rate: 82.3%

17%: severe suicidal thought and behavior

The participants with poor coping strategies were more likely to be males, with poor academic achievement and less likely to have a parent working in medical or mental health fields.

The clinicians need to consider the complex interplay of clinical features present in medical students with severe suicidal behavior

Self-reported questionnaire; cross-sectional study

MODERATE

Pighi et al. 2018

Cross-sectional

N = 433,

Modena and Reggio Emilia

22.4 years;

Range: 18–48 years

F: 55.9%

M: 44.1%

36-item ad-hoc validated questionnaire

To evaluate the prevalence of use of energy drinks and students’ attitudes

Collection during classrooms activities from medical students

Response rate: 83.8%

74.7%: energy drinks users

Italian medical students used energy drinks and psychostimulant substances (coffee and caffeine) as cognitive enhancers very frequently

The use of psychostimulants is low and the majority of students are worried about academic performance.

Low generalizability of results; no use a

standardized tool

MODERATE

Rapinesi et al. 2018

Case-control

N = 98 (N = 49, help-seekers; N = 49 control group), Sapienza-Rome

24.4 years

(students seeking counseling);

21.7 years

(non counseling controls)

Not

reported

Beck Depression Inventory-II; Temperament and Character Inventory-Revised; Adult ADHD Self-Report Scale

To evaluate temperament, attention deficit/hyperactivity disorder traits and depressive symptomatology

Students attending 6-year of medical school and/or attending the counseling program

Response rate: not available

17.1%: depressive symptoms in help-seeking group

10.1%: depressive symptoms in control group (p < 0.001)

ADHD total score: 3.7 (help-seeking group) vs. 2.5 (control group) (p < 0.001)

Help-seeking students were more likely to have attention deficit/hyperactivity symptoms, scored higher on the Beck Depression Inventory-II and on the Temperament and Character Inventory-Revised

Medical students attending counseling center need to be carefully assessed for mental disorders

Small sample size

LOW RATE

Lamberti et al. 2017

Cross-sectional

N = 641, Naples

26.2 ± 5.5 years

F:59.1%

M: 40.9%

Alcohol Use Disorders Identification Test (AUDIT -C)

To assess the prevalence of alcohol drinking in a large sample of students and residents

Collection during medical examinations in medical course students

Response rate: 100%

85.5%: regular alcohol users

16.6%: regular smokers

91%: habitual coffee consumption

Over two-thirds of the students use alcohol regularly. Medical students use alcohol more frequently than residents. Over 90% of student use coffee regularly, one out five is active smoker and less than 60% perform physical activity

The results shown a need to assess alcohol use in healthcare professionals and to recognize risky behaviors in order to develop effective preventive interventions

Cross-sectional design, not representative sample

MODERATE

Armstrong et al. 2017

Multicenter cross-sectional

N = 527,

Bologna

Not reported

M: 43.0%

International professional assessment of drinking and tobacco perceptions among young medical doctors

To evaluate the prevalence of medical students’ tobacco use, attitudes, clinical skills and tobacco-related curricula

Invitation through institutional email to all university’s students.

Response rate: less than 40%

29.5%: smoking habits

Italian students were less likely to receive smoking cessation training compared to American students. Students reported to want to receive smoking cessation training

There is the need to include training on smoking cessation in medical course in order to reduce smoking among medical students, physicians and patients

Recruitment bias

MODERATE

Casuccio et al. 2015

Cross-sectional

N = 794, Palermo

21.9 ± 2.7 years; Range: 19–41

F: 52.5%

M: 47.5%

Ad hoc questionnaire on consumption of energy drinks

To assess the levels of knowledge and attitudes related to energy drink consumption and the prevalence of side effects related to their use

Medical student of the 6- year course filling out the instruments during class time

Response rate: 75%

22%: energy drinks users

Female students present high levels of somatization, obsessive-compulsive, depressive and anxiety symptoms. Mental disorders are more common in students using energy drinks regularly

There is an association between specific psychopathological characteristics and alcohol consumption

Small sample, cross-sectional design

MODERATE

Luca et al. 2015

Cross-sectional

N = 200, Catania

21.8 ± 3.1 years

F: 52.5%

M: 47.5%

Alcohol Use Disorders Identification Test (AUDIT-C); Self-Report Symptom Inventory-Revised (SCL-90-R); General Symptomatic Index (GSI)

To assess the levels of alcohol consumption in relation with socio-demographic and psychopathological variables in a sample of medical students

Students attending the 6-year of medical school

Administration of the survey during classroom activities Response rate: 75%

27%: presence of mental health problems

13%: alcohol use disorder

Male students were most frequently regularly alcohol users

49% of participants consumed alcohol associated with energy drinks.

There is a great use of energy drinks among medical students, either alone or in combination with alcoholic beverages.

Cross-sectional design;

self-reported questionnaires

LOW RATE

Lia et al. 2013

Cross-sectional

N = 44, Sapienza University-Rome

Not reported

SCID-I -CV (The Structured Clinical Interview for DSM-IV Axis I Disorders-Structured clinical Interview)

To assess the prevalence of mental disorders among medical students attending a university counseling service

Students attending 6-year of medical school and/or attending the counseling program

Response rate: not available

31.8%: axis I diagnosis

21.4%: depressive syndrome

35.7%: adaptation dis.

14.3%: psychotic dis.

7.1%: dysthymia 7.1%: anxiety

7.1%: panic attacks dis.

7.1%: bipolar dis. 7.1%: episode of mania

Services for psychological counseling targeting medical students should be present in Italian universities.

The prevalence of mental distress and mental disorder appears to be higher in medical students compared to the prevalence of the same problems in students attending other faculties

Small sample size, lack of comparison with other counseling services

VERY LOW RATE

Saulle et al. 2013

Multicenter cross-sectional

N = 730,

Turin, Padua, Florence, Brescia, Ferrara, Varese

Udine, Palermo, Salerno

Range: 19–29 years

F: 19.1%

M: 22.4%

The Global Health

Professions Student Survey (GHPSS)

To evaluate smoking prevalence, knowledge and attitudes among Italian medical students

Students attending third year of medical school

Survey performed during classroom activities

Response rate: 100%

20.4%: current smokers

87.7% believed that health professionals need to receive specific training on smoking cessation.

65% believed that health professionals had a role in giving advice or information about smoking cessation.

There is a need to provide medical students with smoking cessation training

Cross-sectional study

design, self-reported data, recruitment bias (only third-year students)

MODERATE

Grassi et al. 2012

Cross-sectional

N = 439, Sapienza-Rome, Cattolica

University-Rome, Udine, Verona

23.3 ± 3.0 years; Range: 20–55 years

F:61%

M:49%

60-item ad-hoc validated questionnaire

To evaluate smoking behavior and to assess the levels of knowledge about smoking-related mortality, the harmful effects of cigarette smoking and the efficacy of counseling techniques

Self-administered questionnaires to students attending the course of pharmacology

and toxicology

Response rate: 40%

15.3%: current smokers

9.6%: previous smoker

The levels of knowledge on epidemiological aspects of tobacco use was low.

A great proportion of students did not know how to provide counselling to smokers

Italian medical students do not receive adequate training on tobacco dependence

Small sample size

MODERATE

Gualano et al. 2012

Multicentre cross-sectional

N = 744, Rome, La Sapienza, Rome,

Cattolica, Chieti, Turin, Palermo

Not reported

The Global Health Professions Student Survey

(GHPSS) questionnaire

To evaluate the prevalence of tobacco use, the levels of knowledge and attitudes about tobacco smoking cessation training

Self-administered questionnaires to all students interested

Response rate: 98%

31.4%: current smokers

The great majority considered health professionals as role models

for patients as well as they have a role in giving advice or information about smoking cessation

It should be useful to include smoking cessation training in the Italian medical course

Cross-sectional study, self-reported data, recruitment bias (only third year students)

MODERATE

La Torre et al. 2012

Multicenter cross-sectional

N = 655,

Chieti, Palermo, Rome Sapienza, Rome Cattolica and Turin

21.34 years;

Range: 20–44 years

F: 50.4%

M: 49,6%

Global Tobacco Surveillance System form

To assess smoking prevalence; the levels of knowledge and attitudes toward smoking; the availability of tobacco cessation training

Second semester of the third year of medical school

Response rate: 92%

29.3%: smoking habits

57.2% of participants believe that health professionals are role models for patients.

89.8% of them are aware of smoking cessation interventions.

The prevalence of smoking was higher among medical students than the general population. The training in smoking cessation techniques need to be provided to medical students.

Cross-sectional design, lack of representativeness

MODERATE

Lucenteforte et al. 2010

Cross-sectional

N = 194,

Florence

Not reported

F: 65.8%

M: 34.2%

Modified instrument of the World Health Organization about tobacco smoking for health caregivers

To assess the impact of university choice on smoking habits

First year students attending classroom lectures at the University of Florence

Response rate: 100%

20.1%: smoking habits

32.5% of medical students had at least one parent who uses smoking

The medical students seem to be more conscious about the negative effects of smoking and tobacco-related diseases in comparison with other students.

Small sample size; not representative sample

LOW RATE

Oteri et al. 2007

Cross-sectional

N = 450,

Messina

24.5 years;

Range: 19–30 years

F: 58.7%

M: 41.3%

Ad-hoc questionnaire about energy drink consumption

To evaluate the levels of knowledge related to the use of energy drinks (alone or in association with alcohol)

Anonymous survey

Response rate: 90%

56.9%: use of energy drink

48.4%: use of energy drink associated with alcohol

The use of energy drinks and alcohol is frequent. The usage combined is associated to a higher risk of developing alcohol dependence.

The consumption of alcohol and energy drinks is high in medical student population.

Not reported

LOW RATE

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1. Introduction

2. Results

3. Summary of Design Quality

References