Syndrome de burn out chez les étudiants en pré-externat de la faculté de médecine de Caen : prévalence et facteurs associés

Mental health in medical, dental and pharmacy students: A cross-sectional study

Background

The mental health of health students is considered a public health issue which increased dramatically with the COVID 19’s pandemic. Few studies have assessed the prevalence of depression in medical, pharmacy, and dental students. Our goal was to assess mental health in health students from the same university and identify the associated factors.

Methods

An online survey was sent to the health students of the University of Paris in 3 specialties (medicine, pharmacy, and dentistry). We used the Hospitalization Anxiety and Depression scale, the Composite International Diagnostic Interview-Short Form and the Maslach Burnout Inventory (with 2 versions: the Human Services Survey for clinical students and residents and the Student survey for the others). The presence of suicidal ideation, humiliation, sexual harassment, and sexual aggression over twelve-months was also measured. We performed multivariable logistic regression analyses to identify the associated factors of Major Depressive Episodes (MDE).

Findings

1925 students answered the survey. The overall prevalence of 7-day anxiety and depressive symptoms, MDE, suicidal ideation, humiliation, sexual harassment, and sexual aggression were 55%, 23%, 26%, 19%, 19%, 22%, and 5.5%, respectively. Burnout was present in 42% of nonclinical students and 65% of clinical students and residents. Multivariable logistic regression identified several associated factors of MDE: moderate (OR = 1.49,CI95[1.17-1.90]) or major (OR = 2.32,CI95[1.68-3.20]) subjective financial difficulties, humiliation (OR = 1.71,CI95[1.28-2.28]), sexual abuse (OR = 1.65,CI95[1.04-2.60]), and sexual harassment (OR = 1.60,CI95[1.19-2.16]).

Interpretation

This is one of the largest studies comparing dental, pharmacy and medical students from the same university. We found elevated prevalences of psychiatric symptoms with variation depending on specialty.

Mental health and working conditions among French medical students: A nationwide study

BACKGROUND

Medical students' mental health is a public health problem that has worsened with COVID 19's pandemic. There is a lack of French data. The principal aim was to assess French medical students' mental health.

METHODS

An online cross-sectional survey was performed between May 27 and June 27, 2021. An anonymous questionnaire was sent via academic email addresses by medical faculties and secondly on social media. We assessed 7-day anxiety and depressive symptoms were evaluated with the Hospitalization Anxiety and Depression scale, 12-month major depressive episode (MDE) with the Composite International Diagnostic Interview- Short Form, burnout with the Maslach Burnout Inventory, 12-month suicidal ideation, humiliation, sexual harassment, and sexual aggression during their curriculum. Multivariable logistic regression was performed to identify main MDE associated factors.

OUTCOMES

11,754 participants (response rate: 15.3%) were included. Prevalence of 7-day anxiety symptoms, 7-day depressive symptoms, 12-month MDE, and 12-month suicidal thoughts were 52%, 18%, 25%, and 19% respectively. Burnout syndrome concerned 67% of clinical students and residents and 39% of preclinical students. Prevalence of humiliation, sexual harassment, and sexual abuse during their curriculum were 23%, 25%, and 4%, respectively. Having important (OR = 1.44, IC 95 [1.31-1.58], p < 0.001) or very important financial issues (OR = 2.47, IC 95 [2.15-2.85], p < 0.001), experienced humiliation (OR = 1.63, IC 95 [1.46-1.81], p < 0.001), sexual harassment (OR = 1.43, IC 95 [1.28-1.59], p < 0.001) and sexual abuse (OR = 1.52, IC 95 [1.24-1.85], p < 0.001) were associated with an increased risk of MDE.

INTERPRETATION

This is the largest study on French medical students' mental health. These results point to very particular conditions in French students environment that need to be addressed to improve their mental health.

[Which interventions improve the well-being of medical students? A review of the literature]

Physician's psychological distress has been known for more than a century. A meta-analysis found an increase in the suicide rate among physicians, compared to the general population, with a relative risk of 1.41 for men and 2.27 for women. Among interns, the prevalence of depression or depressive symptoms is estimated at 28.8% (IC 95%=25.3%-32.5%). The suffering of medical students prior to internship has been recognized more recently. But now there are many studies, and a few meta-analyses, which have evaluated the prevalence of anxiety, depression, burnout and, more generally, the lack of well-being. Among medical students, the prevalence of depression or depressive symptoms is estimated at 27.2% (IC 95%=24.7-29.9) and that of suicidal ideation of 11.2% (CI at 95%=9.0-13.7). Another meta-analysis found a prevalence of burnout of 44.2 % (IC 95%=33.4-55.0). Since the problem has been known researchers have tested interventions to improve the well-being of students. Our work aims to review interventions to help medical students and use validated scales. A review was published in 2016 about interventions on the learning environment, and the well-being of medical students was published; 28 studies were identified. But they did not systematically use validated questionnaires allowing a quantitative approach. Interventions included: pass/fail scoring systems (n=3), mental health programs (n=4), psycho-corporal skills programs (n=7), curriculum structure (n=3), multi-component program reform (n=5), wellness programs (n=4), and counseling/mentoring programs (n=3). We chose to focus only on studies using validated questionnaires. A search was performed in the MEDLINE biomedical electronic database until July 31, 2018. The inclusion criteria were: original study, in French or English, concerning medical students prior to internship involving an intervention to improve the well-being of medical students by measuring at least one criterion of psychological distress (anxiety, burnout, depression…) using a validated scale. Thirty-six studies were included in this review. The quality of the studies is very heterogeneous. We can distinguish three types of intervention: institutional (modification of the system of notation, classification…), in-group (management of the stress, therapy full of conscience, relaxation, psychoeducation…) or individual (screening and support custom). These interventions encompass all levels of prevention (primary, secondary and tertiary). There is limited effectiveness of group interventions. This effectiveness disappeared after SIX months with the exception of institutional interventions. The data set encourages us not to favor a single type of intervention but to promote a global intervention acting at all levels. In particular, researchers can draw on studies of doctors and interns. France is late to come to the issue with few published studies on interventions to improve the well-being of students, but recent awareness seems to have taken place. Our study has some limitations: restriction to French and English, the choice to select only comparative studies using validated scales which limited the number of studies selected but also the type of interventions not all of which allow a quantitative evaluation. In the interventions not taken into account in this review, several seem promising. They mainly involve secondary prevention: improving the training of staff and students in the detection of symptoms of depression, burnout and psychological stress, screening at-risk populations, and communication campaigns to combat the stigma of psychiatric disorders and encourage students to consult. But tertiary prevention is also of interest: have psychologists and psychiatrists in the faculties accessible to students who feel the need and can also accommodate. Finally, a certain number of faculties have set up vocational guidance and selection aids that are appreciated by students but have not been evaluated for their impact on students' health. Recent studies and meta-analyses indicate a significant prevalence of outstanding medical students, however, there is reason to be optimistic. Many health professionals and researchers are interested in the problem as well as the means to remedy it. Most studies are effective in the short term. However, the methodological limitations (low number of subjects, limited follow-up time…) and the heterogeneity of studies concerning interventions (mindfulness, psychoeducation…) on students do not allow us to conclude that they are effective in the long term. It should therefore rather move towards comprehensive care acting on the three levels of prevention: primary (institutional interventions/speech groups/psycho education), secondary (screening of subjects at risk, speech groups/psycho education/others) and tertiary (individual interventions).