Suicidality among medical students - a practical guide for staff members in medical schools.

Although suicidality in medical students is important, few studies dealt with this issue regarding German universities. Our aims were to describe the epidemiology as well as factors leading to suicidality in medical students. Furthermore we wanted to raise awareness for this topic among university employees and show options for handling suicidal crises in students. This manuscript especially aims to address university employees working in direct contact with students (such as student counselors or teachers).

Introduction and Epidemiology

While various international studies report high numbers for the prevalence of suicidal thought, suicide attempts and psychological problems among medical students [4], [27], [5], [8], [24], [40], the topic has received little attention in Germany so far. This review aims to present the frequency and epidemiology of suicidality among medical students as well as resulting implications for medical schools based on a selective review of literature published between the years 1993 and 2013. The research for this article was conducted via Ovid by using the data bases „„Medline“ and „PsycINFO“ and the keyword search „medical student“, „university“ „suicidality“, „suicide“, „burnout“ and „depression“. The selection was complemented by relevant literature cited in the respective articles.

International Studies on Suicidality among Medical Students

A study in Norway polled medical students (n=522, 57% female, average age 28 years) about suicidal thoughts at the conclusion of their studies and before their practical year (comparable to the Praktisches Jahr in German medial eduction PJ). 14% indicated that they had had suicidal thoughts during their last year of studies. The lifetime prevalence for suicidal thoughts amounted to 8.4%, for suicide attempts 1.4% [28]. Jeon and colleagues (2009) [13] report a lifetime prevalence of 23.1% with regard to suicidal thoughts, plans, or actions among medical students (n=6.986, 37,5% female, 1st – 4th year of study) in South Korea. A study from the USA presents annual prevalence rates of 11.2% for suicidal thoughts among medical students (n=2.248, 48,2% female, 1st – 4th year of study). Of those, 1.9% reported to have already attempted suicide once in their life. This means that suicidal thoughts are more prevalent than in the general population of comparable age (6.9%) [7]. Van Nierkerk and colleagues (2012) found significantly higher lifetime prevalence rates, namely 6.2%, for suicide attempts among 874 medical students polled in South Africa, with the majority being second- or third-year students (63% female). Therefore, the rate of attempted suicide markedly exceeded the rate of the South African general population (men 1.8%, women 3.8%) [40].

With regard to the actual number of suicides among medical students, two older studies from the USA are available. One of these studies (n=75.292), reports suicide rates of 18.4/100,000 medical students (men 15.6/100,000, women 18.9/100,000). The study states that compared to the general population of the same age, the rate for male students is somewhat lower, for female students significantly higher [26]. Another US-American study which polled 101 medical schools about suicides among their students, found no increased rate of suicide compared to the general population in the time between 1989 – 1994 [11]. It is certainly problematic that only a part of the studies mentioned above compares the reported prevalence numbers with those in the general population so that an increased risk of suicidality among medical students cannot necessarily be concluded. In addition, the comparability of studies is another problematic factor due to differences in methodological approaches, in the composition of the samples (age, year of study, gender proportionality) as well as in cultural contexts.

While it is true that existing suicidal thoughts and previous suicide attempts are indeed risk factors for actual suicides [15], actual suicide rates are reported exclusively in the two older studies from the USA, where only the study by Pepitone et al. (1981) was able to establish an increased suicide risk among female medical students in comparison to the general female population [26].

The same inconclusiveness applies to data in the German-speaking world. One study compares Austrian (n=320, 49.4% female) and Turkish (n=326, 41.4% female) medical students in their first to sixth year of study. The lifetime prevalence for suicide attempts amounted to 2.2% among the Austrian medical students and 5.8% among the Turkish medical students [9]. In an unpublished online poll conducted in the winter semester of 2010/11 among medical students at the University of Ulm with a response rate of 31% (n=714, 66. 6% female, age: 19-35 years, average age 23.06), the lifetime prevalence for suicide attempts among students between the first year of study and the Practical Year was 1.5%. In this study as in most others mentioned above, the numbers on lifetime prevalence provide little information on how many suicide attempts occurred while at medical school. There are no official statistics to be found which would allow estimates of the frequency of suicide attempts compared to the general population. An attempt to estimate the rate of suicide attempts within the general population was undertaken in the context of a WHO study with a sample in the city of Würzburg. It shows a 12-month prevalence for the year 1996 of 122/100,000 among men and of 152/100,000 among women [42].

Despite the scarcity of data on the actual prevalence of suicidality among medical students, one can at least presume, based on the few studies available, that they are a group at risk of suicidal behavior. The reasons may include several factors, which are closely associated with the epidemiology of suicidal behavior. For instance, medical students in Germany reported increased psychological stress with above-average frequency during their course of study [18], [37], and a cross-sectional survey of three cohorts showed an increase in behavior patterns of resignation and burnout-risk behavior in the course of study [41], [2]. Clinically relevant conspicuities such as depressive moods and anxiety syndromes occur in significantly higher numbers among medical students (n=390, 58.2% female) as compared to same-age peers in the general population [35]. In another study among medical students, 13.1% show mild and 5.8% clinically relevant symptoms of depression [16]. While medical students polled in a survey indicated that they wished for more support with problems [2], this is countered by the fact that medical students in particular are reluctant to accept help for psychological problems since their training rarely instructs them to attend to their own needs [2]. What is more, medical students associate psychological problems with a fear of stigmatization [19], [27]. This means that those affected do not avail themselves of professional help, which can cause the problems to reach a critical point or to continue beyond the years at the university. As a result, staff members at universities who are in direct contact with the students (teaching personnel, advisors) are confronted with these problems with increasing frequency. Some of these, such as staff members who in addition to teaching are also clinically active, have the necessary training to be able to help students. However, they often have very little personal contact to individual students so that students often feel inhibited to turn to them in a personal crisis. Staff members in advisory positions, however, whom students visit for specific purposes during their studies, do not have sufficient training in handling suicidal crises [29], as is presumably also the case for instructors in the basic subjects who do not have clinical training.

This article, then, is intended to provide staff members at universities with an overview of the development of suicidality, to provide support so that suicidality in students may be noticed and to present practical options for dealing with at risk students.

Development and Risk Factors of Suicidal Behavior

The epidemiology of suicidal behavior needs to be seen as the consequence of a complex interplay of personal factors such as a psychological disorder [3] or addiction, social circumstances (e.g., difficulties experienced in training or work environment, family issues) [15] and genetic disposition, for instance increased impulsivity [22]. Women and men who have already demonstrated suicidal behavior (suicide threats, earlier suicide attempts) are particularly at risk. Table 1 (Tab. 1) provides an overview of risk factors:

Table 1

Risk factors for suicidal behavior [1, 22, 45]

Based on existing studies of risk factors for suicidal behavior in medical students, one needs to proceed from the assumption that these risk factors do not differ from those in the general population. Increased suicidality was linked to fear and depression [28], [40], negative life experiences [28], [13] as well as impulsive behavior [28], female gender [13], physical discomfort [13], low economic status [13], low quality of life [7], [40] and perceived level of stress [7], [13], [6]. Moreover, such factors as developmental crises and difficulties separating from the parents can play a crucial role [15], in particular for students in the early semesters who have to confront the challenge of living on their own.

Ringel’s [31] and Pöldinger’s [28] classical developmental models for the origins of suicidality describe the development of suicidal actions independent of the underlying etiology. Nevertheless, they are able to provide important indicators for a better assessment of the course and acuteness of suicidality.

Ringel describes three stages of a pre-suicidal syndrome. Increased narrowing (situational, dynamic and in interpersonal relations), pent-up aggression and reversed aggression (turning aggression against oneself) and, in the end, suicidal fantasies. In contrast, Pöldinger describes a stage of contemplation in which suicidal thought might appear but the ability to control one’s behavior remains intact. This is followed by a stage of ambivalence in which suicidal impulses come to the fore and in which the ability to distance oneself from these impulses and to control one’s actions is limited. While indicators or appeals for help do not occur during the stage of contemplation, calls for help and announcements that can be perceived by outsiders occur during the stage of ambivalence. In the stage of decision-making, individuals experience a feeling of resignation but also of calm [28]. Joiner [14] lists three indicators that are present in the period preceding a suicidal action. When in a suicidal crises, individuals experience themselves as a burden to others, as isolated from fellow human beings, and they are intensely thinking about their intention to commit suicide. In addition, individuals who commit suicide have to be able to turn thoughts into action. Such individuals are under the impression that they cannot solve or accept the underlying problems and are no longer able to see alternatives during this stage of acute risk. When researching the origins of suicidal behavior, Henseler’s [12] crisis model could potentially play a significant role when researching the epidemiology of suicidal behavior. This model assumes that due to an innate disposition, individuals who experience crises that entail a feeling of having been insulted, view a suicide attempt as an attempt to compensate for this feeling. This can be especially important when students have the feeling that they are not fulfilling their own or others’ expectations during their studies, when an abrupt end to the studies is imminent, or when the student has a narcissistic personality disorder. In a poll of successful graduates of the third unit of study in the German federal state of Hesse (n=376, 55.3% female), 40.6% of female graduates indicated that they considered discontinuing their studies due to excessive workload and exam stress. Male students considered discontinuing their studies at a rate of 46.2% [18]. A poll of medical students at the University of Düsseldorf (n=171, average age 21.9 years, 99.58% female) shows that the most stressful aspects are having to sit for a long time, time pressures and lack of information, but also excessive demands and emotional burdens [21]. Increased psychosocial stress finds mention in other analyses as well.

Aster-Schenk and colleagues (2010) analyzed psychosocial resources and risk behavior for burnout in medical students of the second, fifth, and tenth semesters (n=360, average age 23 years, 58% female). The researchers describe an increase in the percentage of students who exhibit behavior patterns marked by resignation with burnout tendencies and self-protective patterns from the start of their studies (44%) until the tenth semester (65.2%) [2]. Kurth et al. (2007) find an impaired psychosocial state as compared to the general population in a sample of 157 medical students (average age 23.5 years, 62% female) [20]. Similarly, Voltmer et al. (2007) report that medical students in the first semester experienced stressful psychosocial constellations at a rate of 40%, accompanied by experiential and behavioral patters that put their health at risk (n=435) [41].

The available literature does not provide a clear answer to the question: to what extent do potential medical students begin their university studies with a certain susceptibility for stress coupled with high expectations of their own achievements, which could lead to long-term feelings of being overwhelmed when additional stressors are at play. It is important to note, though, that the acceptance into medical school presupposes that they graduated with excellent grades from high school. As such, one can assume that these individuals come with high expectations for their medical school achievements, for success and high prestige and tend to perceive excessive stress experienced during the course of study as a personal failure. Accustomed to success from their school years, these students also developed fewer coping strategies for stressful situations. It is exactly these strategies, e.g., opportunities to relax, to exercise and to move, which can be helpful in overcoming problems and in improving symptoms of depression, as a study of 651 medical students was able to show. In contrast, the consumption of alcohol, sleep aids and sedatives showed negative effects [16].

Assessing the risk of suicide

Even with increased attempts to operationalize the assessment of suicide risk (cf. SAD-PERSONS Scale [25]), there is no method that can assess suicidality with absolute certainty. When assessing the risk of suicide in a therapeutic setting, attempts are made to gauge the risk by looking at existing risk factors and psychopathological conspicuities as well as statements made. The most important instrument for such an assessment is the conversation with the at-risk individual. Almost all individuals who have suicidal thoughts make them known either directly or indirectly. It is crucial that the topic of suicide be openly addressed if there are indicators of suicidal ideation. In general, the individual will experience such an approach as a relief [1]. It is crucial that the topic of suicide be broached directly if there are relevant indicators. This can take place in a therapeutic setting where the affected person is asked directly whether he/she has had thoughts of suicide, whether these thoughts intrude more frequently, whether he/she has mentioned his suicidal thoughts to others, whether he/she has specific plans for committing suicide and corresponding preparations in his/her mind. These questions can also be posed by family members, friends or other individuals who are in contact with the student. The commonly-held fear that talking about suicidal thoughts causes such thoughts in the first place, is unfounded (see Table 2 (Tab. 2)).

Table 2

Questions in the context of suicidality

The most important indicator for the assessment of the risk of suicide is considered to be the direct expression of suicidal thoughts or intentions [22]. An increased risk of suicide is to be assumed when the affected individual expresses a wish to die or when he/she radiates a certain calm coupled with sadness, reports feelings of hopelessness or resignation or remains stuck in a continuing situation of feeling overburden (see Table 3 (Tab. 3)). In addition, it is important to pay attention to the classic development models [14], [28], [31], as they provide some guidance on the level of acuteness of the risk. An acute risk of suicide is always present in all cases where specific suicidal intentions have been made known, where plans have already been made, where psychiatric illnesses are present or where pronounced psychological distress causes an increased pressure to act.

Table 3

Warning signs for existing risk of suicide [22]

Overall, indicators of an increased suicide risk include: the joint presentation of suicidal thoughts with risk factors and current stressful situations, as well as psychopathological conspicuities which show themselves via excessive hopelessness, fears, irritation or anxiousness [22].

Intervention at universities and legal framework

Given that the issue of suicidality presents a challenge for experts such as psychotherapists and psychiatrists, one may justifiedly ask what contributions university staff members who lack a therapeutic background could possibly make when confronted with the topic.

It is obvious that the point is not that they provide a therapeutic offering. For treatment in this context, overview works are referenced below [22], [44], [15].

Rather, the goal consists in recognizing suicidality in students and in providing them with helpful further information.

In this context, staff members who are in contact with students can play an important role by paying attention to relevant signs in students. Such signs can present themselves in various situations where staff members and students interact. It is possible that suicidal thoughts are openly expressed during a consultation. However, such thoughts may also be expressed in a more hidden and indirect way via statements about feeling overwhelmed, for example when students talk about everything being too much for them, that they experience considerable pressure or feel overburdened in many areas, or if they radiate hopelessness and sadness. Sometimes, a third person may approach staff members with concerns about a fellow student’s suicidal ideation or conspicuous behavior. An indicator of suicidality can also become apparent in a student’s change of behavior, for instance, in increased depressive moods, fears, retreating from social contact and correspondingly increased absences [32], [45], [10].

Should there indeed be indirect signs of increased suicidality, then the topic should, in a first step, be broached in the context of a conversation which should take place, in as much as possible, without interruptions or time pressure, in a confidential, friendly atmosphere and not in passing [34], [10]. During such a conversation, it is advisable to show an understanding for the statements made by the student and to signal a willingness to support him/her. The goal of the initial conversation is to win time in order to ease the situation and to calmly discuss the potential underlying reasons. Offers for help can include specific assistance, for instance arranging for the postponement of exams through an official doctor’s note, tutoring arrangements or additional conversations set up to occur in short intervals. What is not helpful are superficial attempts to cheer up the affected individual, advice to find distractions or to consider presumed future perspectives which pretend to solve the situation quickly. Similarly, admonitions, appeals to the student’s individual responsibility and reproaches are of little help [33] (see Table 4 (Tab. 4)).

Table 4

Recommendations for dealing with suicidal crises [10, 32, 33]

In the end, the actions taken are always determined by the acuteness of the suicide risk. Dealing with suicidal crises can certainly put undue stress on professors and university staff members in academic advising. However, this group of university employees can provide valuable assistance by motivating affected students to avail themselves of existing further offers of help. Professional help can be provided by registered psychiatrists, psychotherapists, and counseling centers, in particular psychosocial counseling centers for students which offer low-threshold consultations.

Such an approach makes particular sense when suicidal thoughts are not yet present but when students express feelings of excessive stress and hopelessness.

When the student is at the point where she/he is already expressing suicidal thoughts, the interlocutor finds him/herself in a difficult situation. For at this point, she/he has to decide whether a specific and immediate risk is present. An immediate risk is always present when intentions to act are being communicated. In such a case, the student has to immediately be seen by a psychiatrist, potentially in conjunction with an emergency physician. The situation is difficult when suicidal ideation is present but no specific intentions to act have been communicated. This often means that a difficult decision has to be made: does the suicidal student have to be seen by a psychiatrist immediately, or will an appointment in the next few days suffice. Such a decision can be made with more confidence when several persons are involved in assisting the student: for instance if she/he can be motivated in the consultation to advise her/his family member or friends herself/himself of the situation or to do so with someone’s help; or, if she/he can be motivated to make an appointment with a psychiatrist right away.

Another step to provide significant relief to the student is to set up a subsequent appointment at the university within a short time period. At the conclusion of the conversation it is important that it be clear whether the individual feels that her/his stress level is reduced by talking, how the next days will unfold, and what further steps need to be taken. The approach, then, is principally no different from that recommended for the treatment of suicidal patients.

The situation is more difficult when a student expresses suicidal thought yet refuses to accept assistance. In this case, the Principle of Informational Self-Determination as spelled out in Article 1, Section 1 and Article 2, Section 1 of the German Basic Law (Art. 1 Abs. 1 and Art. 2 Abs. 1 Grundgesetz) must be observed. If additional persons are involved in the assistance provided, information may principally only be passed on with the individual’s permission (preferably in writing) [17], because teaching personnel and other staff members at German universities are legally bound to uphold the principle of confidentiality as set forth in § 203 of the German Criminal Code*.

Pursuant to this statues, it follows: Whoever passes on a secret entrusted to her/him (e.g., names, the fact that counseling has been sought, the individual’s thoughts) without the relevant permission, makes herself/himself liable for criminal prosecution, even if the passing on of the information presumable was for “the benefit” of the at risk individual. If, however, an individual’s life or health is acutely at risk, and if this risk can only be lowered by divulging and passing on confidential information, the contact person is authorized in emergencies to pass on a student’s personal data without her/his permission according to the Justified Emergency provision (§ 34 German Criminal Code, StGB) [17]. Generally, a legal review in cases of acute risk of life or health will come to the finding that a violation of confidentiality (by providing additional help without the permission of the affected individual) is justified in view of the significance of the threat. When proceeding in this way, it is particularly important to document with care and in a detailed manner the underlying considerations and processes (e.g., as notes to file), to limit the information divulged to what is factually necessary and to make transparent to the affected individual that information has been passed on, as long as this does not present a danger.

Conclusion

During their studies, medical students are confronted with high demands which often cause fear, depressive moods, lack of motivation or impairment of study behavior and achievement levels [5], [8], [35]. In the long-term, high levels of psychological stress and consistently excessive demands on personal resources can lead to chronification of psychological symptoms of excessive stress, psychiatric illness, or crises situations with suicidal behavior [44], [23], [1]. While there are indicators of increased suicidality in medical students, the issue has so far met with little interest in Germany. This may be partially due to the fact that doctors as well as medical students experience psychiatric illness and suicidality as stigmatizing [19].

Staff members at universities therefore carry a heavy responsibility and should be prepared to confront risk situations involving students as well as have basic knowledge of the issue of suicidality.

This knowledge, however, is not always available to them and in many instances they lack the practical confidence to effectively accompany students in crises situations [29]. In a project undertaken by us, we were able to show that by providing expert training, academic advisors at universities can be sensitized to recognize and deal with at risk students within a few days and to provide them with practical competences to act effectively in such situations [29]. Participants in such training workshops showed significant increases in their level of knowledge and their confidence in their own competence to act when pre- and post-training data were compared. In addition to strengthening offerings for stress reduction in affected students, the expansion of such training programs can make a crucial contribution to suicide prevention at universities [30], [37]. The goal of these training sessions should not be to train staff members to become therapists but rather to prepare them for encountering everyday situations that could result from suicidal crises and to provide them with more confidence and competence in their actions.

The action steps recommended in this article can be integrated into university life regardless of area of work and are also of interest for other disciplines in which the issue arises [36], [38], [43]. In this context, the present article seeks to be understood as an impetus to deal with suicidality on the university level and to encourage further measures in this regard. However, in order to make such measures more effective, it would at this point be useful to design and carry out studies, which can shed more light on the issue of suicidality specifically in medical students in Germany.

Note

*Those who have professional access to confidential information (e.g., doctors) have the duty to uphold this confidentiality according to § 203 Section 1 (German Criminal Code) (§ 203 Abs. 1 StGB) ; for all civil servants and employees in public service, this duty to uphold confidentiality according to § 203 Section 2 (German Criminal Code) (§ 203 Abs. 2 StGB) applies regardless of profession.

Competing interests

The authors declare that they have no competing interests.