Risk Factors Associated with Suicidal Ideation in Students of the Faculty of Medicine and Surgery, URSE

Abstract

Suicidal ideation is a process that is intertwined with suicidal behavior. It begins with the formation of an idea about whether it is worth continuing to live, an idea that can evolve and trigger a series of actions ranging from planning to the execution of the suicidal act. This is a descriptive observational study based on numerical measurements with its respective statistical analysis that established the behavioral patterns of the phenomenon studied. The research proposal was approved by the research committee of the Faculty of Medicine and Surgery, URSE; data collection was performed through the instruments: Beck Suicidal Ideation Scale, Beck Depression Inventory, Abbreviated Scale of School Bullying Questionnaire, Drug Dependence Identification Questionnaire, and Family Apgar. The prevalence of suicidal ideation was 5.4%; 19.7% of the medical students have been victims of bullying in any form; 22.2% reported regular use of alcohol, tobacco, drugs, and other addictive substances; in addition, 17.7% had mild family dysfunction, moderate in 9.9% and severe with 15.3%; depression was recorded to a mild degree with 6.4%, followed by moderate in 1.5% of cases. Suicidal ideation among medical students is of concern; these problems must be addressed comprehensively, promoting a supportive environment that promotes the mental health and well-being of medical students.

1. Introduction

The World Health Organization (WHO) defines suicide as an intentional behavior with varying characteristics in incidence and method depending on the region or country. Approximately 703,000 people commit suicide each year, and many more attempt suicide, according to 2021 figures. Each case is a tragedy that impacts families, communities, and countries and leaves lasting effects on the loved ones. Suicide can occur at any age, and in 2019, it was the fourth leading cause of death in the 15–29 age group worldwide, demonstrating the seriousness of this public health problem; suicides are not limited to high-income countries but are a phenomenon present in every region of the planet. Reducing the global suicide rate by one-third by 2030 is a goal shared by both the United Nations Sustainable Development Goals (SDGs) and the WHO Global Mental Health Action Plan. Urgent action is imperative to achieve this goal, and countries have committed to take concrete steps to achieve it [1].

Subjects who have suicidal thoughts often have contradictory beliefs, as many of them do not seek death but escape from pain and suffering [2,3]. Suicide has a tremendous psychological and economic impact on families, which makes it a sensitive issue that requires a thorough understanding of the social and psychological factors that contribute to its appearance [4,5]. Suicidal ideation is composed of a variety of thoughts that can lead to systematic planning of death and sometimes to attempted or completed suicide. The severity of these thoughts can vary and is more common in adolescents, who may perceive them as usual due to the existential challenges that arise at that stage [4,6]. The difference between suicidal ideation and attempted suicide lies in the intensity of emotions and social isolation experienced by the individual. Suicidal ideation may be an indicator of suicide risk in adolescents, and its understanding requires an analysis of the biopsychosocial changes that occur during adolescence [6].

Medical professionals’ suicide is a severe public health crisis worldwide. The medical profession is among those with the highest risk of death by suicide. Medical professionals are consistently among those professionals with the highest suicide rates [7,8,9]. Suicide in medical professionals occurs differently than in the general population since medical professionals’ work-related problems are more critical than other stressors, such as the death of family members or the presence of personal crises [10,11,12]. The medical professional’s identity is centered on their professional role, making them vulnerable to suffering from these work-related problems. The mediating role of work variables (work problems, lack of control over work conditions, patient demands, burnout syndrome, degrading experiences, and conflicts with collaborators) are significant risk factors and triggers for the development of suicidal ideation in medical professionals [13,14,15]. A poorly treated depression also leads to an increased risk of suicide, specifically in female medical professionals; different studies show that there is a similarity in psychiatric risk in both medical and nonmedical personnel [16,17,18,19].

Medical professionals tend to be reluctant to seek professional help because of the stigma they have internalized throughout their training and the fear that it will negatively impact their careers. It is estimated that at least 50% of medical professionals would be willing to seek professional support if faced with mental illness [20,21]. The psychosocial risks of medical professionals’ work, the stress derived from clinical activity, and job burnout have led to these being considered etiopathogenic factors of suicide; the workplace refers to the characteristics surrounding the work (organizational policies, physical characteristics, and behaviors or attitudes of people at work); these workplaces oscillate in dissatisfaction, hopelessness, overpressure, frustration, and isolation coupled with the lack of supervision [22,23]. The recognition of severe mental health problems has increased among students in medical-related fields. Depression is estimated to affect 27% of medical students, a figure that is surpassed by 50% for anxiety and burnout; among resident medical professionals, the leading causes of death are neoplastic diseases and suicide [24,25,26]. The objective of this study was to determine the risk factors associated with suicidal ideation in fourth- and fifth-year medical students of the Faculty of Medicine and Surgery, URSE.

2. Materials and Methods

2.1. Design

This is a descriptive observational cross-sectional study based on a numerical measurement with its respective statistical analysis, allowing for establishing the phenomenon’s behavioral patterns.

2.2. Participants

The study focused on 203 fourth- and fifth-year medical students enrolled at the Faculty of Medicine and Surgery, Universidad Regional del Sureste (URSE) from August 2023 to February 2024.

2.3. Instruments and Procedure

After having presented and obtained authorization for the execution of the research proposal from the research committee of the Faculty of Medicine and Surgery, URSE, we proceeded to request the corresponding permissions from each of the participants for the approval and execution of the research. Data collection was carried out over three months using the proposed instruments. The instruments for data collection were as follows.

(a)

Beck’s Suicidal Ideation Scale, a semi-structured scale consisting of 19 items to determine, assess, and evaluate the presence and severity of suicidal ideation and suicide attempts in each group of people, has a reliability with a Cronbach’s alpha between 0.83 and 0.89. This scale quantifies suicidal intentionality by assessing thoughts or ideas of self-harm. The scale is composed of 19 items; for each item, there are three response alternatives rated according to their intensity, from 0 to 2, indicating an increasing degree of severity and intensity of suicidal intentionality, the total sum indicating the severity of suicidal ideation, and the different items are distributed in 4 sections: Attitude towards life and death (items 1 to 5); characteristics of the imagination or death wish (items 6 to 11); characteristics of the planned attempt (items 12 to 15); actualization of the effort (items 16 to 19). Cutoff point: The proposed cutoff point is a score greater than or equal to 10, which would indicate suicidal ideation [27].

(b)

Beck Depression Inventory, which allows the treatment of depressive symptomatology, as it is an instrument proven to be reliable and valid for use in clinical and research settings. It consists of 21 elements, with the possibility of responses that range from less to more severity and score from 0 to 3, explicitly taking into account the opinion about symptoms presented since the previous week; it is mobilized in a range of 0–63 points, to classify the degree of depression, the scale is interpreted as follows: no depression (0–9 points), mild depression (10–18 points), moderate depression (19–29 points), severe depression (30 or more), regarding its psychometric characteristics [28].

(c)

The Abbreviated Scale of School Bullying Questionnaire is a validated survey that measures school bullying, allowing the identification of initial victimization by physical, verbal, social, and coercive bullying; the second part also consists of 12 questions about bullying by the respondents; and the third part also of 12 items, consists of questions to measure symptoms of anxiety, depression, post-traumatic stress, and also effects on self-esteem [29].

(d)

Drug Dependency Identification Questionnaire, developed ad hoc: this is an instrument made up of 10 questions designed to investigate the relationship between behaviors in adolescents involving the use, abuse, or dependence on addictive substances in general terms; it has a combined response format, where some items may have as answer alternatives yes or no to inquire: consumption of alcohol, tobacco, cocaine, marijuana, inhalants, and solvents, while others are aimed at obtaining the frequency of consumption such as daily, weekly, or monthly, finally some items seek to determine the reasons for consumption such as for fun, to experiment, to avoid feeling rejected, and for not being able to abandon it [30].

(e)

Family Apgar is an instrument that shows how family members perceive the level of functioning of the family unit globally; it is helpful to establish how an individual describes how his family environment functions at a given moment, achieving an approximation to the identification of families that present problems or dysfunctions; for this purpose, this test evaluates five primary functions of the family: Adaptation, Participation, Gradient of personal resources, Affection, and Resources. It has a correlation index of 0.8, and the answers have a score of 0 to 4: 0 = Never, 1 = Rarely, 2 = Sometimes, 3 = Almost Always, and 4 = Always. Interpretation is made according to the score obtained: regular: 17–20 points, slight dysfunction: 16–13 points, moderate dysfunction: 12–10 points, and severe dysfunction: less than or equal to 9 [31].

(f)

A survey establishing socioeconomic and demographic factors includes questions about background, ethnicity, household income, and family typology.

The information obtained during the study was meticulously organized through the Excel program and then entered the database using SPSS version 26.0. For the descriptive part of the qualitative variables, percentages, frequencies, and modes were obtained. For the analysis of quantitative variables in the descriptive part, measures of position were determined, such as central tendency and dispersion.

2.4. Ethical Aspects

The questionnaire was presented in a Google form so that medical students could respond from their devices. Medical student consent was required regarding the protection of personal property. The classrooms were visited to inform them about the study’s objective and provide them with the link to the questionnaire. The confidentiality and anonymity of the responses were guaranteed. Before starting the application, they were asked if there was anyone who did not wish to participate. All medical students agreed to answer the questionnaire.

3. Results

The study sample comprised 203 subjects, 36% fourth-year medical students and 64% fifth-year medical students. Concerning the demographic data, 63.5% were women, while 36.5% were men, with a mean age of 22.4 ± 1.7 years; 67.5% were from the Valles Centrales region, 8.4% from the Costa region, 9.4% from the Istmo de Tehuantepec region, 5.9% from the Mixteca region, 1.9% from the Papaloapan region, 4.4% from the Sierra Sur, 0.5% from the Sierra Norte, 1.5% from the Cañada region, and 0.5% from another state of the Mexican Republic.

The degree of depression in the study subjects was mild at 6.4%, followed by moderate in 1.4% of the cases. Subjects had mild family dysfunction in 17.7% of cases, moderate dysfunction in 9.9%, and severe dysfunction in 15.3% (see

Table 1. Data obtained from the Beck Depression Inventory and the family Apgar in the study subjects.

Level of Depression	Percentage (%)	Family Functionalism	Percentage (%)
Normal	92.1	Regular	57.1
Slight depression	6.4	Slight dysfunction	17.7
Moderate depression	1.4	Moderate dysfunction	9.9
Severe depression	0	Severe dysfunction	15.3
Total	100	Total	100

).

A total of 19.7% of the subjects reported having been victims of bullying in any form, while the majority, 80.3%, denied this condition. A total of 5.9% of the subjects reported participating in bullying by the respondents; that is, they were bullies and victimizers of their peers (

Table 2. Data obtained from the Abbreviated Scale of the Questionnaire on Bullying in the study subjects.

Bullying	Percentage (%)	Intimidation	Percentage (%)
Present	19.7	Present	5.9
Absent	80.3	Absent	94.1
Total	100	Total	100

).

The symptoms resulting from bullying were grouped into depression, anxiety, and post-traumatic stress disorder and were present in 31.5% of the cases. Of the total number of study subjects, only 22.2% reported regular use of alcohol, tobacco, drugs, and other addictive substances (see

Table 3. Distribution of cases according to symptoms of depression, anxiety, and post-traumatic stress disorder, as well as the use of addictive substances.

Symptomatology	Percentage (%)	Addictions	Percentage (%)
Present	31.5	Yes	22.2
Absent	68.5	No	77.8
Total	100	Total	100

).

The prevalence of suicidal ideation was present in 5.4% of the total cases (

Table 4. Distribution of cases according to the Beck Suicidal Ideation Scale.

Suicidal Ideation	Frequency	Percentage (%)
Yes	11	5.4
No	192	94.6
Total	203	100

).

Correlations were made with the Spearman coefficient, and it was found that there is a correlation between the depression scale and bullying, with which we can interpret that those subjects who suffered bullying derived as a primary factor for the tendency to suicidal ideation in our study population (see

Table 5. Correlation between the buying questionnaire, depression scale, and suicidal ideation.

Scale	Correlation Coefficient	Significance
Depression scale	0.498	0.000
Bullying scale	0.505	0.000

). A structural model was subsequently created between these three variables (see Figure 1); the model contributed 26% of the variance (R2 = 0.26) F (5, 203) = 36.00; p < 0.001.

4. Discussion

Despite efforts to reduce the stigma associated with mental health, there is still a culture in which seeking help can be perceived as a sign of weakness or incompetence. Medical students may be afraid to seek help due to stigma and concerns about the impact on their careers. The demanding nature of the medical program can lead to social isolation and a lack of time to maintain meaningful personal relationships.

Lack of social and emotional support can increase the risk of suicidal ideation. Medical training poses a significant challenge to the well-being of medical students. With the alarming trend toward student burnout, mental illness, and suicide, previous studies have reported possible risk factors associated with suicidal behaviors among medical students [32,33]. Medical programs are often intensive and demanding, with a large amount of material to learn in a limited period.

This can lead to high levels of stress and anxiety; medical students often experience intense pressure to perform well on exams and demonstrate competency in their clinical skills [34,35]. Fear of failure can be overwhelming. During medical training, students can face emotionally challenging situations, such as the death of patients or the suffering of the sick.

This can lead to emotional distress and contribute to depression. Family functionalism is a theoretical framework that examines the dynamics of family relationships and how they contribute to the well-being and functioning of individual members and the family. When family members do not provide adequate emotional support, this can increase the risk of suicidal ideation. Lack of support can make an individual feel isolated and hopeless, and poor communication within the family can make it challenging to express emotions and solve problems. Persistent family conflicts, such as verbal, physical, or emotional abuse, can hurt the mental health of individuals. Chronic conflict can lead to feelings of hopelessness and despair, increasing the risk of suicidal ideation [35,36].

Although studies have reported that depression is one of the factors most closely related to suicidal ideation, our results reflect that there is a more significant relationship between bullying and suicidal ideation. Our results reflect consistency with other studies regarding the relationship between bullying as a predictor of suicidal ideation; that is, the more the abuse, the greater the suicidal ideation the students will have [37,38]. Future lines of research should carry out more studies on bullying as a predictor of suicidal ideation. Sufficient evidence has been studied and has shown depression and anxiety to be moderators, but to our knowledge, bullying has not been sufficiently explored in medical students.

5. Conclusions

In conclusion, we can say that the prevalence of suicidal ideation in our study population was 5.4%. Suicidal ideation in medical students is a globally recognized public health problem; the prevalence of suicide in medical students is higher compared to other university students, which could be related to an increase in psychiatric disorders in this population. Academic training in medicine can be a source of stress and anxiety, which could contribute to the development of suicidal ideation. As a strategy to reduce the prevalence of suicidal ideation, the Universidad Regional del Sureste has a psycho-pedagogical support development coordination (CODEAP), which has overseen administering a psychometric test to incoming students as an initial requirement for their enrollment in the institution. During their academic training, medical students are accompanied by tutors who facilitate the learning process individually and in groups. The functions of the tutors are established in the institutional tutoring and counseling program (PITA). The tutors have a file for each tutored student where they record the work performed in the sessions, allowing them to know each student’s problems. Regarding academic or personal difficulties, tutors channel psycho-pedagogical issues to CODEAP for timely attention. This has been implemented based on the results of this work, which seeks to establish psychological support for the development of future doctors concerning the attitudes, values, and skills necessary to face the challenges of their careers and prevent mental health problems during their training.