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Prevalence of Depression, Depressive Symptoms, and Suicidal Ideation Among Medical Students: A Systematic Review and Meta-Analysis

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Importance Medical students are at high risk for depression and suicidal ideation. However, the prevalence estimates of these disorders vary between studies. Objective To estimate the prevalence of depression, depressive symptoms, and suicidal ideation in medical students. Data Sources and Study Selection Systematic search of EMBASE, ERIC, MEDLINE, psycARTICLES, and psycINFO without language restriction for studies on the prevalence of depression, depressive symptoms, or suicidal ideation in medical students published before September 17, 2016. Studies that were published in the peer-reviewed literature and used validated assessment methods were included. Data Extraction and Synthesis Information on study characteristics; prevalence of depression or depressive symptoms and suicidal ideation; and whether students who screened positive for depression sought treatment was extracted independently by 3 investigators. Estimates were pooled using random-effects meta-analysis. Differences by study-level characteristics were estimated using stratified meta-analysis and meta-regression. Main Outcomes and Measures Point or period prevalence of depression, depressive symptoms, or suicidal ideation as assessed by validated questionnaire or structured interview. Results Depression or depressive symptom prevalence data were extracted from 167 cross-sectional studies (n = 116 628) and 16 longitudinal studies (n = 5728) from 43 countries. All but 1 study used self-report instruments. The overall pooled crude prevalence of depression or depressive symptoms was 27.2% (37 933/122 356 individuals; 95% CI, 24.7% to 29.9%, I² = 98.9%). Summary prevalence estimates ranged across assessment modalities from 9.3% to 55.9%. Depressive symptom prevalence remained relatively constant over the period studied (baseline survey year range of 1982-2015; slope, 0.2% increase per year [95% CI, −0.2% to 0.7%]). In the 9 longitudinal studies that assessed depressive symptoms before and during medical school (n = 2432), the median absolute increase in symptoms was 13.5% (range, 0.6% to 35.3%). Prevalence estimates did not significantly differ between studies of only preclinical students and studies of only clinical students (23.7% [95% CI, 19.5% to 28.5%] vs 22.4% [95% CI, 17.6% to 28.2%]; P = .72). The percentage of medical students screening positive for depression who sought psychiatric treatment was 15.7% (110/954 individuals; 95% CI, 10.2% to 23.4%, I² = 70.1%). Suicidal ideation prevalence data were extracted from 24 cross-sectional studies (n = 21 002) from 15 countries. All but 1 study used self-report instruments. The overall pooled crude prevalence of suicidal ideation was 11.1% (2043/21 002 individuals; 95% CI, 9.0% to 13.7%, I² = 95.8%). Summary prevalence estimates ranged across assessment modalities from 7.4% to 24.2%. Conclusions and Relevance In this systematic review, the summary estimate of the prevalence of depression or depressive symptoms among medical students was 27.2% and that of suicidal ideation was 11.1%. Further research is needed to identify strategies for preventing and treating these disorders in this population.
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Prevalence of Depression, Depressive Symptoms,
and Suicidal Ideation Among Medical Students
A Systematic Review and Meta-Analysis
Lisa S. Rotenstein, BA; Marco A. Ramos, MPhil; Matthew Torre, MD; J. Bradley Segal, BA, BS; Michael J. Peluso, MD, MPhil;
Constance Guille, MD, MS; Srijan Sen, MD, PhD; Douglas A. Mata, MD, MPH
IMPORTANCE Medical students are at high risk for depression and suicidal ideation. However,
the prevalence estimates of these disorders vary between studies.
OBJECTIVE To estimate the prevalence of depression, depressive symptoms, and suicidal
ideation in medical students.
DATA SOURCES AND STUDY SELECTION Systematic search of EMBASE, ERIC, MEDLINE,
psycARTICLES, and psycINFO without language restriction for studies on the prevalence of
depression, depressive symptoms, or suicidal ideation in medical students published before
September 17, 2016. Studies that were published in the peer-reviewed literature and used
validated assessment methods were included.
DATA EXTRACTION AND SYNTHESIS Information on study characteristics; prevalence of
depression or depressive symptoms and suicidal ideation; and whether students who screened
positive for depression sought treatment was extracted independently by 3 investigators.
Estimates were pooled using random-effects meta-analysis. Differences by study-level
characteristics were estimated using stratified meta-analysis and meta-regression.
MAIN OUTCOMES AND MEASURES Point or period prevalence of depression, depressive
symptoms, or suicidal ideation as assessed by validated questionnaire or structured interview.
RESULTS Depression or depressive symptom prevalence data were extracted from 167
cross-sectional studies (n = 116 628) and 16 longitudinal studies (n = 5728) from 43 countries.
All but 1 study used self-report instruments. The overall pooled crude prevalence of
depression or depressive symptoms was 27.2% (37 933/122356 individuals; 95% CI, 24.7% to
29.9%, I
2
= 98.9%). Summary prevalence estimates ranged across assessment modalities
from 9.3% to 55.9%. Depressive symptom prevalence remained relatively constant over the
period studied (baseline survey year range of 1982-2015; slope, 0.2% increase per year [95%
CI, −0.2% to 0.7%]). In the 9 longitudinal studies that assessed depressive symptoms before
and during medical school (n = 2432), the median absolute increase in symptoms was 13.5%
(range, 0.6% to 35.3%). Prevalence estimates did not significantly differ between studies of
only preclinical students and studies of only clinical students (23.7% [95% CI, 19.5% to
28.5%] vs 22.4% [95% CI, 17.6% to 28.2%]; P= .72). The percentage of medical students
screening positive for depression who sought psychiatric treatment was 15.7% (110/954
individuals; 95% CI, 10.2% to 23.4%, I
2
= 70.1%). Suicidal ideation prevalence data were
extracted from 24 cross-sectional studies (n = 21 002) from 15 countries. All but 1 study used
self-report instruments. The overall pooled crude prevalence of suicidal ideation was 11.1%
(2043/21 002 individuals; 95% CI, 9.0% to 13.7%, I
2
= 95.8%). Summary prevalence
estimates ranged across assessment modalities from 7.4% to 24.2%.
CONCLUSIONS AND RELEVANCE In this systematic review, the summary estimate of the
prevalence of depression or depressive symptoms among medical students was 27.2% and
that of suicidal ideation was 11.1%. Further research is needed to identify strategies for
preventing and treating these disorders in this population.
JAMA. 2016;316(21):2214-2236. doi:10.1001/jama.2016.17324
Editorial page 2195
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Author Affiliations: Author
affiliations are listed at the end of this
article.
Corresponding Author: Douglas A.
Mata, MD, MPH, Division of MPE
Molecular Pathological Epidemiology,
Department of Pathology, Brigham
and Women’s Hospital, Brigham
Education Institute, Harvard Medical
School, 75 Francis St, Boston, MA
02115 (dmata@bwh.harvard.edu).
Research
JAMA | Original Investigation
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Studies have suggested that medical students experi-
ence high rates of depression and suicidal ideation.
1
However, estimates of the prevalence of depression or
depressive symptoms among studentsvar y across studies from
1.4% to 73.5%,
2,3
and those of suicidal ideation vary from 4.9%
to 35.6%.
4,5
Studies also report conflicting findings about
whether student depression and suicidality vary by under-
graduate year, sex, or other characteristics.
6-11
Reliable estimates of depression and suicidal ideation
prevalence during medical training are important for inform-
ing efforts to prevent, treat, and identify causes of emotional
distress among medical students,
12
especially in light of recent
work revealing a high prevalence of depression in resident
physicians.
13
We conducted a systematic review and meta-
analysis of published studies of depression, depressive symp-
toms, and suicidal ideation in undergraduate medical trainees.
Methods
Search Strategy and Study Eligibility
Two authors (M.A.R. and D.A.M.) independently identified
cross-sectional and longitudinal studies published prior to Sep-
tember 17, 2016, that reported on the prevalence of depres-
sion, depressive symptoms, or suicidal ideation in medical stu-
dents by systematically searching EMBASE, ERIC, MEDLINE,
psycARTICLES, and psycINFO. In addition, the authors
screened the reference lists of identified articles and corre-
sponded with study investigators using the approaches im-
plied by the Preferred Reporting Items for Systematic Re-
views and Meta-analyses and Meta-analysis of Observational
Studies in Epidemiology reporting guidelines.
14,15
For the database searches, terms related to medical stu-
dents and study design were combined with those related to
depression and suicide without language restriction (com-
plete details of the search strategy appear in eMethods 1 in the
Supplement). Included studies (1) reported data on medical stu-
dents, (2) were published in peer-reviewed journals, and
(3) used a validated method to assess for depression, depres-
sive symptoms, or suicidal ideation.
16
A third author (L.S.R.)
resolved discrepancies by discussion and adjudication.
Data Extraction and Quality Assessment
Three authors (L.S.R., M.T., and J.B.S.) independently ex-
tracted the following data from each article using a standard-
ized form: study design; geographic location; years of sur-
vey; year in school; sample size; average age of participants;
number and percentage of male participants; diagnostic or
screening method used; outcome definition (ie, specific diag-
nostic criteria or screening instrument cutoff); and reported
prevalence estimates of depression, depressive symptoms, or
suicidal ideation. Whether students who screened positive for
depression sought psychiatric or other mental health treat-
ment also was extracted. When there were studies involving
the same population of students, only the most comprehen-
sive or recent publication was included.
The same 3 authors independently assessed the risk of
bias of these nonrandomized studies using a modified ver-
sion of the Newcastle-Ottawa scale, which assesses sample
representativeness and size, comparability between respon-
dents and nonrespondents, ascertainment of depressive or
suicidal symptoms, and thoroughness of descriptive statis-
tics reporting (complete details regarding scoring appear in
eMethods 2 in the Supplement).
17
Studies were judged to be
at low risk of bias (≥3 points) or high risk of bias (<3 points).
A fourth author (D.A.M.) resolved discrepancies through
discussion and adjudication.
Data Synthesis and Analysis
Prevalence estimates of depression or depressive symptoms
and suicidal ideation were calculated by pooling the study-
specific estimates using random-effects meta-analyses that
accounted for between-study heterogeneity.
18
The same
approach was used to estimate the summary percentage of
students screening positive for depression who sought treat-
ment. When studies reported point prevalence estimates
made at different periods within the year, the overall period
prevalence was used. Standard χ
2
tests and the I
2
statistic
(ie, the percentage of variability in prevalence estimates due
to heterogeneity rather than sampling error, or chance, with
values ≥75% indicating considerable heterogeneity) were
used to assess between-study heterogeneity.
19,20
Sensitivity analyses were performed by serially ex-
cluding each study to determine the influence of individual
studies on the overall prevalence estimates. Results from
studies grouped according to prespecified study-level charac-
teristics were compared using stratified meta-analysis (for
diagnostic criteria or screening instrument cutoff, study
design, undergraduate level, continent or region, country,
and Newcastle-Ottawa Scale components) or random-effects
meta-regression (for year of baseline survey, age, and
sex).
21,22
To isolate associations within the medical school
experience from associations with assessment tools, an
analysis restricted to longitudinal studies reporting both pre-
and intramedical school depressive symptom prevalence
estimates was performed.
Bias secondary to small study effects was investigated
using funnel plots and the Egger test.
23,24
All analyses were per-
formed using R version 3.2.3 (R Foundation for Statistical
Computing).
25
Statistical tests were 2-sided and used a sig-
nificance threshold of P< .05.
Key Points
Question Are medical students at high risk for depression and
suicidal ideation?
Findings In this meta-analysis, the overall prevalence of
depression or depressive symptoms among medical students was
27.2%, and the overall prevalence of suicidal ideation was 11.1%.
Among medical students who screened positive for depression,
15.7% sought psychiatric treatment.
Meaning The overall prevalenceof depre ssivesymptoms among
medical students in this study was higher than that reported in the
general population, which underscores the need for effective
preventive efforts and increased access to care for medical students.
Prevalence of Depression and Suicidal Ideation Among Medical Students Original Investigation Research
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Results
Study Characteristics
One hundred ninety-five studies
2-11,26-210
involving a total of
129 123 individuals in 47 countries were included in the
analysis (Figure 1). The median number of participants per
study was 336 (range, 44-10140). One hundred sixty-seven
cross-sectional studies
2-4,6-9,11,26-184
(n = 116 628) and 16
longitudinal studies
10,196-210
(n = 5728) in 43 countries
reported on depression or depressive symptom prevalence
(Table 1). Twenty-four cross-sectional studies (n = 21 002) in
15 countries reported on the prevalence of suicidal ideation
(Table 2).
4,5,34,62,65,73,74,79,112,160,165,167,174,185-195
Medical student training level, continent or region,
country, diagnostic criteria or screening instrument cutoff,
and total Newcastle-Ottawa scores for the studies appear in
eTable 1 in the Supplement. Newcastle-Ottawa score com-
ponents for all 195 individual studies appear in eTable 2 in
the Supplement.
Prevalence of Depression or Depressive Symptoms
Among Medical Students
Meta-analytic pooling of the prevalence estimates of
depression or depressive symptoms reported by 183 studies
yielded a crude summary prevalence of 27.2% (37 933/
122 356 individuals; 95% CI, 24.7%-29.9%), with significant
evidence of between-study heterogeneity (Q= 16721.1,
τ
2
=0.78,I
2
= 98.9%, P< .001) (Figures 2,3,4,5, and 6).
The prevalence estimates reported by the individual studies
ranged from 1.4% to 73.5%. Sensitivity analysis, in which
the meta-analysis was serially repeated after exclusion of
each study, demonstrated that no individual study affected
the overall prevalence estimate by more than 0.3% (eTable 3
in the Supplement).
To further characterize the range of depression or depres-
sive symptom prevalence estimates identified by these meth-
odologically diverse studies, meta-analyses stratified by screen-
ing instrument and cutoff score were conducted (Figure 7).
Summary prevalence estimates ranged from 9.3% (157/1234in-
dividuals [95% CI, 5.3%-15.7%]; Q=19.7
2
= 0.24, I
2
= 84.8%)
for the Hospital Anxiety and Depression Scale with a cutoff
score of 11 or greater to 55.9% (540/1039 individuals [95% CI,
45.1%-66.2%]; Q= 32.9, τ
2
= 0.18, I
2
= 90.9%) for the Aga Khan
University Anxiety and Depression Scale with a cutoff score
of 19 or greater. The median summary prevalence was 32.4%
(5042/19 160 individuals [95% CI, 25.8%-39.7%]; Q= 1665.3,
τ
2
= 0.62, I
2
= 98.6%) for the Beck Depression Inventory (BDI)
with a cutoff score of 10 or greater.
Among medical students who screened positive for depres-
sion, 15.7% (110/954 individuals [95%CI, 10.2%-23.4%]; Q=20.1,
τ
2
=0.26,I
2
= 70.1%)reportedly sought psychiatric or other men-
tal health treatment as assessed by a subset of 7 studies report-
ing this information (eFigure 1 in the Supplement).
Prevalence of Depression or Depressive Symptoms by
Study-Level Characteristics
No statistically significant differences in prevalence esti-
mates were noted between cross-sectional studies (36 632/
116 628 [27.3%; 95% CI, 24.7%-30.1%]) and longitudinal stud-
ies (1301/5728 [26.7%; 95% CI, 19.1%-36.1%]) (testfor subgroup
differences, Q= 0.02, P= .90) or studies performed in the
United States (14 356/36 249 [26.7%; 95% CI, 22.5%-31.3%])
compared with those performed outside the United States
(23 577/86107 [27.4%; 95% CI, 24.5%-30.6%]) (Q= 0.08,
P= .78). Studies were further stratified by continent or re-
gion in Figure 8. Prevalence estimates from studies limited to
preclinical students (4866/25462 [23.7%; 95% CI, 19.5%-
28.5%]) did not significantly differ from estimates from stud-
ies limited to clinical students (2917/13172 [22.4%; 95% CI,
17.6%-28.2%]) (Q= 0.13, P= .72).
Prevalence estimates did not significantly vary with base-
line survey year (survey year range, 1982-2015; slope = 0.2%
1-yearinc rease [95%CI, −0.2% to 0.7%]; Q=1.17,P= .28). There
were no significant associations between prevalence and mean
or median age (slope = 0.2% per 1-yearinc rease[95% CI, −1.4%
to 1.8%]; Q= 0.07, P= .79) or sex (slope = −1.1% per percent-
age increase in male study participants [95% CI, −15.9% to
13.7%]; Q= 0.02, P= .88).
When evaluated by Newcastle-Ottawa criteria, higher
prevalence estimates were found among studies with more
representative participant populations (24366/68 693; 36.3%
[95% CI, 29.9%-43.3%]) compared with those with less repre-
sentative participant populations (13567/53663; 25.4% [95%
CI, 22.8%-28.2%]) (Q=9.6,P= .002; Figure 9). There were
no statistically significant differences in prevalence estimates
when studies were stratified by sample size, respondent
and nonrespondent comparability, validity of ascertainment
of depression or depressive symptoms (details regarding
Figure 1. Study Identification and Selection
1603 Records excluded based on
review of title and abstract
971 Wrong population, outcome,
or subject matter
632 Duplicates
2316 Records identified through
database searching
977 MEDLINE
688 EMBASE
592 psycINFO
42 ERIC
17 psycARTICLES
17 Additional unique records
identified through reference
list searching
535 Records excluded after review
of full text
291 Wrong population or outcome
150 Commentary, editorial,
or review
85 Did not report prevalence
estimate of depression
9Reported on same population
195 Full-text articles included
730 Records screened
Research Original Investigation Prevalence of Depression and Suicidal Ideation Among Medical Students
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Table 1. Selected Characteristics of the 183 Studies of Depression or Depressive Symptoms
a
Source Country
Survey
Years
Year of
Training
No. of
Students Age, y
Men,
No. (%)
Instrument and
Cutoff Score
Bore et al,
52
2016 Australia 2013 1-5 127 Mean (SD): 23 (5.6) 32 (25.6) DASS-21 ≥10
De Sousa Lima et al,
67
2010 Brazil 2001 1-4 80 Range: 18-30 45 (56.3) BDI ≥10
de Melo Cavestro and Rocha,
65
2006
Brazil 2003 1-6 213 Mean (SD): 23.1 (2.3) 109 (51.2) MINI ≥ DSM IV
criteria
Amaral et al,
39
2008 Brazil 2006 1-6 287 Mean: 21.3 131 (45.7) BDI ≥10
Costa et al,
61
2012 Brazil 2008 5, 6 84 NR NR BDI ≥10
Serra et al,
147
2015 Brazil 2012 1-6 657 Mean: 22.7 255 (38.8) BDI ≥10
Castaldelli-Maia et al,
55
2012 Brazil 2001-2006 1-6 465 NR NR BDI ≥15
Alexandrino-Silva et al,
34
2009
Brazil 2006-2007 1-6 336 Mean (SD): 22.4 (2.5) 105 (31) BDI ≥21
Paro et al,
130
2010 Brazil 2006-2007 1-6 352 Mean (SD): 22.3 (2.4) 134 (38.4) BDI >9
Bassols et al,
49
2014 Brazil 2010-2011 1, 6 232 Mean (SD): 23.1 (3.2) 117 (50.4) BDI ≥11
Del-Ben et al,
200
2013 Brazil NR 1 85 Mean (SD): 19.1 (1.6) 58 (68.2) BDI ≥10
Leão et al,
66
2011 Brazil NR 6 111 Mean (SD): 24.6 (1.4) 87 (56) BDI ≥12
Hirata et al,
87
2007 Brazil NR 1-2 161 Mean (SD): 22.1 (2.1) 77 (47.8) BDI >10
Baldassin et al,
47
2008 Brazil NR 1-6 481 Mean (SD): 21.9 (2.4) 195 (40.5) BDI ≥10
Matheson et al,
117
2016 Canada 2013 1-4 232 NR NR K-10 ≥20
Helmers et al,
84
1997 Canada 1994-1995 1-4 356 Mean (SD): 23.5 (2.6) 185 (52) DSP >50
Berner et al,
51
2014 Chile 2012 1-5 384 Mean (SD): 20.8 (1.8) 224 (58.3) GHQ-12 ≥5
Tang,
163
2005 China 2003 2 121 NR 0 Zung-SDS ≥50
Shen et al,
151
2009 China 2006 1 313 Mean (SD): 23.8 (1.8) NR Zung-SDS ≥53
Wanetal,
4
2012 China 2010 1-5 4063 Mean (SD): 20.5 (1.1) 1895 (46.6) Zung-SDS ≥50
Sobowale et al,
160
2014 China 2012 2-3 348 NR NR PHQ-9 ≥10
Shi et al,
154
2015 China 2014 1-5 1738 Mean (SD): 21.4 (1.6) 586 (33.7) CES-D ≥16
Shi et al,
153
2016 China 2014 1-7 2925 Mean (SD): 21.7 (2) 1028 (35.2) CES-D ≥16
Pan et al,
129
2016 China 2013-2014 1-5 8819 Mean (SD): 20.7 (1.6) 3415 (37.9) BDI ≥14
Liao et al,
110
2010 China NR 1 487 Mean (SD): 18.5 (0.8) 181 (37.4) Zung-SDS ≥50
Sun et al,
162
2011 China NR 1-2 10140 Mean (SD): 19.6 (1.3) 4680 (46.2) BDI ≥10
Yang et al,
6
2014 China NR 1-5 1137 Range: 17-24 624 (54.9) SCL-90 >2
Pinzón-Amado et al,
137
2013 Colombia 2006 1-6 973 Mean (SD): 20.3 (2.3) 414 (43) CES-D ≥16
Amir and Gillany,
40
2010 Egypt 2010 1-6 311 Mean (SD): 20.7 (2.4) 164 (52.7) HADS-D ≥8
Ibrahim and Abdelreheem,
89
2015
Egypt 2013 1 164 NR 82 (50) BDI ≥17
Abdel Wahed and Hassan,
27
2016
Egypt 2015 1-4 442 Mean (SD): 20.2 (1.9) 172 (38.9) DASS-21 ≥10
Eller et al,
184
2006 Estonia 2003 1-6 413 Mean (SD): 21.3 (2.5) 95 (23) EST-Q ≥12
Vaysse et al,
171
2014 France 2012-2013 2 197 Mean (SD): 19.7 (0.9) 79 (39.9) HADS-D ≥8
Prinz et al,
2
2012 Germany 2008 4, 5 73 NR 54 (74) HADS-D ≥11
Voltmer et al,
172
2012 Germany 2010-2011 1, 2, 5 153 Mean (SD): 25.6 (3.1) 44 (28.7) HADS-D ≥11
Kötter et al,
107
2014 Germany 2011-2012 1 350 Mean (SD): 20.9 (3.2) 118 (33.7) HADS-D ≥8
Wege et al,
174
2016 Germany 2012-2013 1 590 Mean (SD): 21.1 (3.9) 177 (29.9) PHQ-9 >10
Jurkat et al,
100
2011 Germany NR 1, 4 651 NR 252 (38.7) BDI ≥11
Kohls et al,
105
2012 Germany NR NR 419 NR 122 (29.1) ADS-K >17
Nasioudis et al,
126
2015 Greece 2013 1-3 146 Mean (SD): 19.8 (1) 91 (62.3) Zung-SDS >45
Chan,
57
1992 Hong Kong NR 1 95 Mean (range): 19.6 (18-29) 64 (67.4) BDI ≥19
Chan,
56
1991 Hong Kong NR 1-4 335 Mean (SD): 20.1 (1.6) 239 (71.3) BDI ≥10
Kumar et al,
26
2012 India 2008 1-4 400 NR 217 (54.3) BDI ≥10
Gupta and Basak,
82
2013 India 2008 1-5 150 Range: 18-26 104 (69.3) BDI ≥10
David and Hamid Hashmi,
64
2013
India 2012 1 128 Mean (range): 17.9 (17-21) 46 (35.9) BDI ≥17
Vankar et al,
170
2014 India 2012 1-4 331 Mean (SD): 19.8 (1.4) 178 (53.8) PHQ-9 ≥10
Iqbal et al,
95
2015 India 2012 1-5 353 Mean (SD): 20.8 (1.5) 145 (41.1) DASS-42 ≥10
(continued)
Prevalence of Depression and Suicidal Ideation Among Medical Students Original Investigation Research
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Table 1. Selected Characteristics of the 183 Studies of Depression or Depressive Symptoms
a
(continued)
Source Country
Survey
Years
Year of
Training
No. of
Students Age, y
Men,
No. (%)
Instrument and
Cutoff Score
Ali and Vankar,
37
1994 India NR 1-3 215 Mean (range): 19.6 (17-25) 132 (61.4) Zung-SDS ≥50
Supe,
3
1998 India NR 1-3 238 NR 128 (53.8) Zung-SDS ≥40
Sidana et al,
156
2012 India NR 1-5 237 NR 126 (53.2) PHQ-9 ≥10
Bayati et al,
9
2009 Iran 2008 NR 172 NR NR GHQ-28 ≥23
Akbari et al,
31
2014 Iran 2011 NR 138 NR NR GHQ-28 >6
Farahangiz et al,
76
2016 Iran 2014 1-4 208 Mean (SD): 20.7 (1.1) 82 (39.4) GHQ-28 ≥23
Vahdat Shariatpanaahi
et al,
150
2007
Iran 2004-2005 NR 192 Mean (SD): 24.5 (1.6) 0 BDI ≥10
Aghakhani et al,
29
2011 Iran NR NR 628 Mean (SD): 22 (0.3) 334 (53.2) BDI ≥10
Ashor,
43
2012 Iraq 2010-2011 1-6 269 NR 147 (54.6) Zung-SDS ≥50
Lupo and Strous,
111
2011 Israel NR 1-6 119 Mean (SD): 25.1 (2.8) NR BDI-II ≥10
Peleg-Sagy and Shahar,
131
2012
Israel NR 1-7 60 Mean (SD): 27 (2.9) 0 CES-D ≥16
Peleg-Sagy and Shahar,
205
2013
Israel NR 1, 4, 7 192 Mean (SD): 26.6 (2.6) 0 CES-D ≥16
Yoon et al,
179
2014 Korea NR 2, 3, 5 174 Mean (SD): 23.3 (2.8) 96 (55.2) PHQ-9 ≥10
Naja et al,
125
2016 Lebanon 2014 2-5 340 NR 145 (42.6) PHQ-9 ≥10
Mehanna and Richa,
119
2006 Lebanon 2003-2004 1-6 356 NR NR BDI ≥8
Bunevicius et al,
53
2008 Lithuania 2005 NR 338 Mean (SD): 21 (1) 73 (21.6) HADS-D ≥8
Mancevska et al,
114
2008 Macedonia 2007-2008 1-2 354 NR 120 (33.9) BDI ≥17
Sherina et al,
152
2004 Malaysia 2002 1-5 396 Mean (range): 21.6 (18-29) 152 (38.4) GHQ-12 ≥4
Tanetal,
167
2015 Malaysia 2013 1-5 537 NR 188 (35) PHQ-9 ≥10
Yusoff et al,
46
2011 Malaysia 2008 5 92 NR 25 (27.2) BDI ≥9
Yusoff,
181
2013 Malaysia 2009-2010 1 194 NR 66 (34) DASS-21 ≥14
Yusoff et al,
210
2013 Malaysia 2010-2011 1 170 NR 57 (32.8) DASS-21 ≥10
Saravanan and Wilks,
145
2014 Malaysia NR 1-5 358 NR 177 (49.4) DASS-21 ≥10
Manaf et al,
113
2016 Malaysia NR 2-5 206 Mean (SD): 19.5 (2.6) 0 PHQ-9 ≥5
Guerrero López et al,
7
2013 Mexico 2007 1 455 Mean (SD): 18.3 (1.2) 139 (30.5) CES-D ≥16
Romo-Nava et al,
142
2016 Mexico 2011 1-5 1068 NR 421 (39.4) PHQ-9 ≥10
Melo-Carrillo et al,
120
2012 Mexico 2006-2007 1-4 302 NR NR BDI ≥10
Navaetal,
127
2013 Mexico 2010-2011 1, 5 1871 NR 707 (37.9) PHQ-9 ≥10
El-Gilany et al,
75
2008 Multiple 2007 1-6 588 Mean: 20.8 588 (100) HADS-D ≥12
Seweryn et al,
148
2015 Multiple 2015 1-6 1262 Median: 22 345 (27.3) BDI ≥10
Sreeramareddy et al,
161
2007
Nepal 2005-2006 NR 407 Mean (SD): 20.7 (1.8) 227 (55.8) GHQ-12 ≥4
Basnet et al,
48
2012 Nepal 2008-2009 1, 3 94 Mean (SD): 21.2 (1.7) 57 (60.6) Zung-SDS ≥50
Borst et al,
197
2015 Netherlands 2010-2011 1-6 951 Mean (SD): 23 (2.6) 279 (29) BSI-DEP >0.41
Carter et al,
54
2014 New Zealand 2010 4-6 198 Mean (SD): 23.5 (2.1) 75 (38.1) DASS-21 ≥14
Samaranayake
and Fernando,
144
2011
New Zealand 2008-2009 3 255 Median (range): 20 (18-36) 123 (48.2) PHQ-9 ≥10
Oku et al,
128
2015 Nigeria 2010 1, 2, 4, 5 451 Mean (SD): 23.4 (4.4) 288 (63.8) GHQ-12 ≥4
Aniebue and Onyema,
42
2008 Nigeria 2008-2009 NR 262 Mean (SD): 23.7 (2.7) 133 (50.8) Zung-SDS ≥50
Rab et al,
138
2008 Pakistan 2002 1-5 87 Mean (SD): 20.7 (1.9) 0 HADS-D ≥8
Jadoon et al,
97
2010 Pakistan 2008 1-5 482 Mean (SD): 20.7 (1.8) 257 (53.3) AKUADS ≥19
Marwat,
116
2013 Pakistan 2011 3 166 NR 73 (28.7) Zung-SDS ≥50
Imran et al,
92
2016 Pakistan 2013 NR 527 Mean (SD): 20.2 (2.3) 282 (53.5) GHQ-12 >15
Khan et al,
103
2015 Pakistan 2014 3 110 Mean: 21 55 (50) HADS-D ≥8
Ali et al,
36
2015 Pakistan 2014 1-2 182 NR 114 (62.6) AKUADS >19
Rizvi et al,
140
2015 Pakistan 2014 1-5 66 Mean (SD): 22.2 (1.3) 28 (40) DASS-42 ≥10
Alvi et al,
38
2010 Pakistan 2007-2008 2-5 279 Mean (SD): 21.4 (1.4) 77 (27.6) BDI-II ≥14
Waqas et al,
173
2015 Pakistan 2014-2015 1-5 409 Mean (SD): 19.9 (1.3) 123 (30) HADS-D ≥8
Inam et al,
93
2003 Pakistan NR 1-4 189 NR 60 (31.7) AKUADS ≥19
(continued)
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Table 1. Selected Characteristics of the 183 Studies of Depression or Depressive Symptoms
a
(continued)
Source Country
Survey
Years
Year of
Training
No. of
Students Age, y
Men,
No. (%)
Instrument and
Cutoff Score
Khan et al,
11
2006 Pakistan NR 1-5 142 Mean (SD): 21.3 (1.9) 59 (41.5) AKUADS ≥19
Perveen et al,
133
2016 Pakistan NR 1,5 1000 NR 431 (43.1) QIDS ≥9
Mojs et al,
122
2015 Pakistan NR NR 477 NR NR KADS ≥6
Phillips et al,
134
2006 Panama 2005 1-6 122 NR 63 (51.6) Zung-SDS ≥50
Pereyra-Elías et al,
132
2010 Peru 2010 1-4 590 Mean (SD): 19 (2.5) 184 (28.9) Zung SF ≥22
Valle et al,
169
2013 Peru 2010 1-6 615 Mean (SD): 22 (4.5) 357 (58) Zung-SDS ≥50
Walkiewicz et al,
209
2012 Poland 1999-2005 2 178 NR NR (69) MMPI-D >70
Adamiak et al,
28
2004 Poland NR 2, 4 263 Mean: 22.3 NR BDI ≥12
Inam,
94
2007 Saudi Arabia 2002 1-3 226 NR 149 (65.9) AKUADS ≥19
Aziz et al,
45
2011 Saudi Arabia 2010 1-5 295 Mean (SD): 21.6 (1.7) 0 BDI-II ≥20
AlFaris et al,
35
2014 Saudi Arabia 2011 1-2 543 NR 340 (62.6) BDI-II ≥14
Ibrahim et al,
91
2013 Saudi Arabia 2012 2-6 558 Mean (SD): 21.7 (1.8) 300 (50.3) HADS-D ≥11
Ibrahim et al,
90
2013 Saudi Arabia 2010-2011 2-6 450 Mean (SD): 21.1 (1.4) 0 HADS-D ≥11
Kulsoom and Afsar,
108
2015 Saudi Arabia 2012-2013 1-5 442 NR 274 (62) DASS-21 ≥14
Al-Faris et al,
8
2012 Saudi Arabia NR 1-5 797 Mean (SD): 21.6 (1.6) 590 (74) BDI ≥10
Saeed et al,
143
2016 Saudi Arabia NR NR 80 Mean (SD): 25.9 (1.5) 55 (68.8) K-10 ≥20
Ristić-Ignjatović et al,
139
2013
Serbia 2002-2012 4 615 Mean (SD): 23.6 (1.5) 239 (36.8) BDI ≥10
Miletic et al,
121
2015 Serbia 2012-2013 1, 3, 6 1294 Mean (SD): 21.9 (2.8) 500 (38.6) PHQ-9 ≥10
Pillay et al,
136
2016 South Africa NR 1-5 230 Mean: 21 66 (28.7) Zung-SDS >30
Jeong et al,
99
2010 South Korea 2008 1-2 89 NR 0 CES-D ≥16
Kim and Roh,
104
2014 South Korea 2011 1-2 122 NR 92 (75.4) BDI ≥10
Choi et al,
60
2015 South Korea 2013 1-4 534 NR 308 (57.7) BDI-II ≥17
Rohetal,
141
2009 South Korea 2006-2007 1-4 7357 NR NR BDI ≥16
Dahlin et al,
63
2011 Sweden 2006 NR 408 Median (range): 24 (22-27) 157 (36.5) MDI >27
Dahlin et al,
62
2005 Sweden 2001-2002 1, 3, 6 309 Mean (range): 26.1 (18-44) 126 (39.8) DSM-IV criteria A and
C
Kongsomboon,
106
2010 Thailand 2008 1-6 593 Mean (range): 20.7 (15-27) 243 (41) HRSRS ≥25
Angkurawaranon et al,
41
2016
Thailand 2013 2-6 1014 Mean (SD): 20.8 (1.5) 476 (46.9) PHQ-9 ≥9
N Wongpakaran and T
Wongpakaran,
177
2010
Thailand NR 1-5 368 Mean (SD): 20.8 (1) 155 (42) TDI >35
Youssef,
180
2016 Trinidad and
Tobago
NR 1-3 381 Mean (SD): 22.4 (3) 126 (0.3) PHQ-9 ≥10
Güleç et al,
81
2005 Turkey 1993 1-6 668 Mean (SD): 21.1 (2) 658 (96.2) BDI ≥17
Akvardar et al,
32
2003 Turkey 2002 1, 6 447 Mean (SD): 21 (1.2) 272 (39.1) HADS-D ≥7
Marakoğlu et al,
115
2006 Turkey 2006 1-2 331 Mean (SD): 19.5 (1.4) 186 (56.2) BDI ≥10
Mayda et al,
118
2010 Turkey 2009 1-5 202 Mean (SD): 20.5 (2.2) 85 (40.1) BDI ≥17
Yilmaz et al,
178
2014 Turkey 2010 1-6 995 Mean (SD): 21.1 (1.9) 517 (52) BDI ≥10
Aktekin et al,
196
2001 Turkey 1996-2002 1-2 119 NR NR GHQ-12 ≥4
Karaoğlu and Şeker,
101
2011 Turkey 2008-2009 1-3 485 Mean (SD): 19.5 (1.5) 272 (56.1) HADS-D ≥8
Baykan et al,
50
2012 Turkey NR 6 193 Mean (SD): 24.5 (1.5) 107 (55.4) DASS-42 ≥10
Akvardar et al,
33
2004 Turkey NR 1, 6 166 NR NR HADS-D ≥7
Kayaetal,
102
2007 Turkey NR NR 352 NR 226 (64.2) BDI ≥17
Ahmed et al,
30
2009 UAE 2008 1-5 165 NR 0 BDI ≥10
James et al,
98
2013 UK 2007 1 324 NR 194 (60) GHQ-12 ≥4
Honney et al,
88
2010 UK 2008 NR 553 Mean (SD): 21.6 (3) 220 (39.8) PHQ-9 ≥10
Ashton and Kamali,
44
1995 UK 1993-1994 2 186 Mean (SD): 20.4 (1.8) 77 (40.7) HADS-D ≥8
Newbury-Birch et al,
204
2001 UK 1995, 1998 5 114 NR 38 (33.3) HADS-D ≥8
Quince et al,
206
2012 UK 2007-2010 1-6 2155 NR 122 (43.2) HADS-D ≥8
Guthrie et al,
201
1998 UK NR 1 172 NR 88 (51.2) GHQ-12 ≥4
Pickard et al,
135
2000 UK NR 2 136 NR 46 (33.8) HADS-D ≥8
(continued)
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Table 1. Selected Characteristics of the 183 Studies of Depression or Depressive Symptoms
a
(continued)
Source Country
Survey
Years
Year of
Training
No. of
Students Age, y
Men,
No. (%)
Instrument and
Cutoff Score
Herzog et al,
86
1987 US 1985 1-2 200 Mean (range): 23.1 (19-31) NR BDI ≥10
Hendryx et al,
85
1991 US 1988 1 110 Mean (SD): 24.1 (3.1) 70 (63.6) BDI ≥10
Givens and Tjia,
78
2002 US 1994 1-2 194 NR 83 (43) BDI-SF ≥8
Thomas et al,
164
2007 US 2004 1-4 535 NR 248 (45.4) PRIME-MD
Dyrbye et al,
72
2006 US 2004 NR 545 NR 245 (45) PRIME-MD
Shah et al,
149
2009 US 2005 1-4 2683 Mean (SD): 26 (3.2) 1076 (40) CES-D ≥19
Dyrbye et al,
71
2007 US 2006 1-4 1691 NR 777 (46) PRIME-MD
Smith et al,
159
2011 US 2008 1-5 480 Mean (range): 26.3 (18-51) 480 (100) CES-D ≥16
Smith et al,
158
2010 US 2008 1-5 844 Mean (SD): 25.7 (4.1) 844 (100) CES-D ≥16
Shindel et al,
155
2011 US 2008 1-5 1241 Mean (SD): 25.4 (3.4) 0 CES-D ≥16
Schwenk et al,
146
2010 US 2009 1-4 504 NR 210 (41.6) PHQ-9 ≥10
Wimsatt et al,
175
2015 US 2009 1-4 505 NR 210 (41.6) PHQ-9 ≥10
Dyrbye et al,
69
2010 US 2009 1-4 2661 NR 1352 (51.4) PRIME-MD
Chang et al,
59
2012 US 2010 1-3 364 NR 160 (44) PRIME-MD
Jackson et al,
96
2016 US 2012 1-4 4354 Median (range): 25 (22-32) 1957 (45.3) PRIME-MD
Dyrbye et al,
68
2015 US 2012 2-4 870 NR 442 (50.9) PRIME-MD
Thompson et al,
166
2016 US 2013 1-4 153 NR 75 (46.6) PHQ-9 ≥10
Gold et al,
80
2015 US 2013 1-5 183 NR 79 (43.2) PRIME-MD
Lapinski et al,
109
2016 US 2014 1-4 1294 NR 681 (52.6) PHQ-9 ≥5
Zoccolillo et al,
183
1986 US 1982-1984 1-2 304 NR NR BDI ≥10
Vitaliano et al,
208
1988 US 1984-1985 1 312 Mean (SD): 25.6 (3.5) 196 (63) BDI ≥5
Rosal et al,
207
1997 US 1987-1993 2 171 NR 140 (51) CES-D ≥80th
percentile
Camp et al,
198
1994 US 1991-1993 1 232 NR 153 (65.9) Zung-SDS ≥50
Mosley et al,
123
1994 US 1992-1993 3 69 Mean (range): 26 (24-37) 47 (68) CES-D ≥16
Levine et al,
202
2006 US 2000-2003 2 330 NR NR BDI ≥8
Tjia et al,
168
2005 US 2001-2002 1-4 322 Mean (SD): 25.3 (2.6) 175 (54.4) BDI-SF ≥8
Thompson et al,
165
2010 US 2002-2003 3 44 NR NR CES-D ≥16
Goebert et al,
79
2009 US 2003-2004 1-4 1184 NR NR CES-D ≥16
Dyrbye et al,
70
2011 US 2006, 2007,
2009
4 1428 NR NR PRIME-MD
Haglund et al,
10
2009 US 2006-2007 3 101 Mean (SD): 25.4 (2.2) 47 (47) BDI-II ≥14
Dyrbye et al,
73
2008 US 2006-2007 1-4 2228 NR 1159 (51.6) PRIME-MD
Ghodasara et al,
77
2011 US 2008-2009 1-3 301 NR 154 (51) BDI-II ≥14
Hardeman et al,
83
2015 US 2010-2011 1 3149 NR 1592 (49.4) PROMIS-T >60
Ludwig et al,
203
2015 US 2010-2014 3 336 NR NR CES-D >16
Dyrbye et al,
74
2014 US 2011-2012 1-4 4402 Median: 25 1972 (45.1) PRIME-MD
Wolf and Rosenstock,
176
2016 US 2012-2013 1-4 130 NR NR PRIME-MD
Mousa et al,
124
2016 US 2013-2014 1-4 336 NR NR PRIME-MD
Clark and Zeldow,
199
1988 US NR 2 110 Mean (SD): 23.6 (2.9) 80 (73) BDI ≥8
MacLean et al,
112
2016 US NR 1-4 385 NR NR PRIME-MD
Chandavarkar et al,
58
2007 US NR 1-4 427 NR 145 (34) BDI-II ≥21
Zeldow et al,
182
1987 US NR NR 99 Mean: 25.4 67 (67.7) BDI-II ≥14
Smith et al,
157
2007 US NR NR 438 Mean (SD): 24.8 (2.8) 318 (72.6) BDI ≥10
Abbreviations: ADS-K, General Depression Scale Short Form (in German);
AKUADS, Aga Khan University Anxiety and Depression Scale; BDI, Beck
Depression Inventory; BDI-SF, BDI Short Form; BSI-DEP, Brief Symptom
Inventory Depression; CES-D, Center for Epidemiological Studies Depression
Scale; DASS, Depression Anxiety Stress Scale; DSM-IV,Diagnostic and Statistical
Manual of Mental Disorders,Fourth Edition; DSP, Derogatis Stress Profile;
EST-Q, Emotional State Questionnaire; GHQ, General Health Questionnaire;
HADS-D, Hospital Anxiety and Depression Scale; HRSRS, Health-Related
Self-Reported Scale; K-10, Kessler Psychological Distress Scale; KADS,Kutcher
Adolescent Depression Scale; MDI, Major Depression Inventory; MINI, Mini
International Neuropsychiatric Interview; MMPI-D, Minnesota Multiphasic
Personality Inventory-Depression Scale; NR, not reported; PHQ-9,9-item
Patient Health Questionnaire; PRIME-MD, Primary Care Evaluation of Mental
Disorders; PROMIS-T, Patient-Reported Outcomes Measurement Information
System; QIDS, Quick Inventory of Depressive Symptomatology;
SCL-90, 90-item Symptom Checklist; TDI, Thai Depression Inventory;
UAE, United Arab Emirates; UK, United Kingdom; US, United States;
Zung-SDS, ZungSelf-Rating Depression Scale; Zung-SF, Zung-SDS Short Form.
a
Studies are ordered alphabetically by country and then by year of survey.
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determination of screening instrument validity appear in
eMethods 2 in the Supplement), thoroughness of descriptive
statistics reporting, or total Newcastle-Ottawa score (P>.05
for all comparisons).
Heterogeneity Within Depression Screening Instruments
To identify potential sources of heterogeneityindependent of as-
sessment modality, heterogeneity was examined within sub-
groups of studies using common instruments when at least 6
studies were available (complete results appear in eTable4 in the
Supplement). No significant differences between cross-sectional
and longitudinal studies were observed within any instruments
when at least 3 studies were in each comparator subgroup.
Heterogeneity was partially accounted for bycountr y with
US studies yielding lower depression or depressive symptom
prevalence estimates than non-US studies among the 24 stud-
ies using the BDI and a cutoff score of 10 or greater (13.0% vs
37.5%, respectively; Q= 12.7, P< .001) and the 13 studies using
the Center for Epidemiological Studies Depression Scale
(CES-D) and a cutoff score of 16 or greater (34.4% vs 50.3%;
Q= 3.8, P= .05). However, this difference was not seen among
other instruments.
Level of training did not significantly contribute to between-
study heterogeneity among any of the examined instru-
ments. Year of baseline survey significantly contributed to
observed statistical heterogeneity among 3 instruments,
Table 2. Selected Characteristics of the 24 Studies of Suicidal Ideation
a
Source Country
Survey
Years
Year of
Training
No. of
Students Age, y
Men,
No. (%)
Instrument and Cutoff
Score or Description
b
de Melo Cavestro and Rocha,
65
2006
Brazil 2003 1-6 213 Mean (SD): 23.1 (2.3) 109 (51.2) MINI
Alexandrino-Silva et al,
34
2009 Brazil 2006-2007 1-6 336 Mean (SD): 22.4 (2.5) 105 (31) BSI >0
Chen et al,
188
2004 China 2002 2-3 892 Mean (SD): 17.5 (0.4) 0 Suicidal ideation over past
12 mo
Wanetal,
4
2012 China 2010 1-5 4063 Mean (SD): 20.5 (1.1) 1895 (46.6) Suicidal ideation over past
12 mo
Sobowale et al,
160
2014 China 2012 2-3 348 NR NR Suicidal ideation over past
2 wk (PHQ-9)
Ahmed et al,
185
2016 Egypt 2016 NR 612 Mean (SD): 21.2 (1.6) 190 (31) BSI >24
Okasha et al,
192
1981 Egypt 1978-1979 5 516 NR NR Suicidal ideation over past
12 mo
Alem et al,
186
2005 Ethiopia 2001 NR 273 NR 227 (83.2) Suicidal ideation over past
1mo
Wege et al,
174
2016 Germany 2012-2013 1 590 Mean (SD): 21.1 (3.9) 177 (29.9) Suicidal ideation over past
2 wk (PHQ-9)
Tin et al,
167
2015 Malaysia 2013 1-5 517 NR 188 (35) SBQ-R ≥7
Eskin et al,
189
2011 Multiple NR 1-6 646 Mean: 21.4 353 (54.6) Suicidal ideation over past
12 mo
Menezes et al,
191
2012 Nepal 2010 2-3 206 Mean (SD): 21 (1.7) 112 (54.4) Suicidal ideation over past
12 mo (GHQ-28)
Tyssen et al,
194
2001 Norway 1993-1994 6 522 Mean (SD): 28 (2.8) 224 (43) Suicidal ideation over past
12 mo (Paykel Inventory)
Osama et al,
5
2014 Pakistan 2013 1-5 331 Mean (SD): 20.7 (1.7) 135 (41.2) Suicidal ideation over past
12 mo (GHQ-28)
Khokher and Khan,
190
2005 Pakistan NR 1-5 217 Mean: 22.6 96 (44.2) Suicidal ideation over past
12 mo (GHQ-28)
Wallin and Runeson,
195
2003 Sweden 1998 1, 5 305 Mean: 27.4 127 (41.6) Suicidal ideation over past
12 mo
Dahlin et al,
62
2005 Sweden 2001-2002 1, 3, 6 296 Mean (range): 26.1 (18-44) 126 (39.8) Suicidal ideation over past
12 mo (Meehan Inventory)
Amiri et al,
187
2013 United Arab
Emirates
NR 1-6 115 Mean (SD): 20.7 (2.1) 47 (40.9) Suicidal ideation over past
12 mo
Thompson et al,
165
2010 US 2002-2003 3 43 NR NR Suicidal ideation over past
2 wk (PRIME-MD)
Goebert et al,
79
2009 US 2003-2004 1-4 1215 NR NR Suicidal ideation over past
2 wk (PRIME-MD)
Dyrbye et al,
73
2008 US 2006-2007 1-4 2230 NR 1159 (51.6) Suicidal ideation over past
12 mo (Meehan Inventory)
Dyrbye et al,
74
2014 US 2011-2012 1-4 4032 Median: 25 1972 (45.1) Suicidal ideation over past
12 mo (Meehan Inventory)
MacLean et al,
112
2016 US NR 1-4 385 NR NR Suicidal ideation over past
12 mo (Meehan Inventory)
Tran et al,
193
2015 Vietnam 2009 1, 3, 5 2099 Mean (range): 21.5 (18-30) 1052 (50.1) Suicidal ideation over past
12 mo
Abbreviations: BSI, Beck Scale for Suicidal Ideation; GHQ, General Health
Questionnaire; MINI, Mini International Neuropsychiatric Interview; NR, not
reported; PHQ-9, 9-item Patient Health Questionnaire;PRIME-MD, Primary
Care Evaluation of Mental Disorders; SBQ-R, Revised Suicidal Behaviors
Questionnaire; US, United States.
a
Studies are ordered alphabetically by country and then by year of survey.
b
Studies for which a specific instrument is not specified used variably worded
short form screening instruments.
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Figure 2. Meta-analysis by Scores on the Aga Khan University Anxiety and Depression Scale and the Beck Depression Inventory
0 60 10040 80
Prevalence, % (95% CI)
20
Weight, %
No.
Depressed
Total
No.Source
Aga Khan University Anxiety and Depression Scale Score ≥19
Prevalence, %
(95% CI)
0.599 142Khan et al,11 2006 69.7 (61.5-77.1)
0.6113 189Inam et al,93 2003 59.8 (52.4-66.8)
0.6114 226Inam,94 2007 50.4 (43.7-57.1)
0.6214 482Jadoon et al,97 2010 44.4 (39.9-49.0)
Aga Khan University Anxiety and Depression Scale Score >19
0.6121 182Ali et al,36 2015 66.5 (59.1-73.3)
Beck Depression Inventory Score ≥5
0.678 312Vitaliano et al,208 1988 25.0 (20.3-30.2)
Beck Depression Inventory Score ≥8
0.545 110Clark and Zeldow,199 1988 40.9 (31.6-50.7)
0.680 330Levine et al,202 2006 24.2 (19.7-29.2)
0.6101 356Mehanna and Richa,119 2006 28.4 (23.7-33.4)
Beck Depression Inventory Score ≥9
0.520 92Yusoff et al,46 2011 21.7 (13.8-31.6)
0.6126 352Paro et al,130 2010 35.8 (30.8-41.0)
Beck Depression Inventory Score ≥10
0.538 80De Sousa Lima et al,67 2010 47.5 (36.2-59.0)
0.534 84Costa et al,61 2012 40.5 (29.9-51.7)
Beck Depression Inventory Score >10
0.553 161Hirata et al,87 2007 32.9 (25.7-40.8)
Beck Depression Inventory Score ≥11
0.543 232Bassols et al,49 2014 18.5 (13.8-24.1)
0.6123 651Jurkat et al,100 2011 18.9 (16.0-22.1)
Beck Depression Inventory Score ≥12
0.522 111Leão et al,66 2011 19.8 (12.9-28.5)
Beck Depression Inventory Score ≥14
0.61751 8819Pan et al,129 2016 19.9 (19.0-20.7)
0.663 263Adamiak et al,28 2004 24.0 (18.9-29.6)
0.516 85Del-Ben et al,200 2013 18.8 (11.2-28.8)
0.521 110Hendryx et al,85 1991 19.1 (12.2-27.7)
0.542 122Kim and Roh,104 2014 34.4 (26.1-43.6)
0.568 150Gupta and Basak,82 2013 45.3 (37.2-53.7)
0.547 165Ahmed et al,30 2009 28.5 (21.7-36.0)
0.667 192Vahdat Shariatpanaahi et al,150 2007 34.9 (28.2-42.1)
0.514 200Herzog et al,86 1987 7.0 (3.9-11.5)
0.677 287Amaral et al,39 2008 26.8 (21.8-32.4)
0.6116 302Melo-Carrillo et al,120 2012 38.4 (32.9-44.2)
0.668 304Zoccolillo et al,183 1986 22.4 (17.8-27.5)
0.6145 331Marakoğlu et al,115 2006 43.8 (38.4-49.3)
0.6161 335Chan,56 1991 48.1 (42.6-53.6)
0.6285 400Kumar et al,26 2012 71.2 (66.5-75.6)
0.537 438Smith et al,157 2007 8.4 (6.0-11.5)
0.6184 481Baldassin et al,47 2008 38.3 (33.9-42.8)
0.6140 615Ristić-Ignjatović et al,139 2013 22.8 (19.5-26.3)
0.6328 628Aghakhani et al,29 2011 52.2 (48.2-56.2)
0.6200 657Serra et al,147 2015 30.4 (26.9-34.1)
0.6384 797Al-Faris et al,8 2012 48.2 (44.7-51.7)
0.6350 995Yilmaz et al,178 2014 35.2 (32.2-38.2)
0.6521 1262Seweryn et al,148 2015 41.3 (38.6-44.1)
0.61699 10
140Sun et al,162 2011 16.8 (16.0-17.5)
The vertical dashed lines indicate the pooled summary estimate (95% CI) for all
studies in Figures 2-6: 27.2% (37 933/122 356 individuals); 95%CI,
24.7%-29.9%; I
2
= 98.9%, τ
2
=0.78,P< .001. The area of each square is
proportional to the inverse variance of the estimate. Horizontal lines indicate
95% confidence intervals of the estimate. The studies in Figures 2-6 are
ordered alphabetically by screening instrument and then sorted by increasing
sample size within each instrument.
Research Original Investigation Prevalence of Depression and Suicidal Ideation Among Medical Students
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Figure 3. Meta-analysis by Scores on the First, Second, and Short Form Versions of the Beck Depression Inventory, Brief Symptom Inventory
Depression Scale, and the Center for Epidemiological Studies Depression Scale
0 60 10040 80
Prevalence, % (95% CI)
20
Weight, %
No.
Depressed
Total
No.Source
Beck Depression Inventory Score ≥15
Prevalence, %
(95% CI)
Beck Depression Inventory Score ≥16
Beck Depression Inventory Score ≥17
Beck Depression Inventory Score ≥19
Beck Depression Inventory Score ≥21
Beck Depression Inventory II Score ≥10
Beck Depression Inventory II Score ≥14
Beck Depression Inventory II Score ≥17
Beck Depression Inventory II Score ≥20
Beck Depression Inventory II Score ≥21
Beck Depression Inventory Short Form Score ≥8
Brief Symptom Inventory Depression Scale Score >0.41
Center for Epidemiological Studies Depression Scale Score ≥16
Center for Epidemiological Studies Depression Scale Score >16
Center for Epidemiological Studies Depression Scale Score ≥19
Center for Epidemiological Studies Depression Scale Score ≥80th percentile
0.595 164Ibrahim and Abdelreheem,89 2015 57.9 (50.0-65.6)
0.530 119Lupo and Strous,111 2011 25.2 (17.7-34.0)
0.6118 534Choi et al,60 2015 22.1 (18.6-25.9)
0.6117 295Aziz et al,45 2011 39.7 (34.0-45.5)
0.676 465Castaldelli-Maia et al,55 2012 16.3 (13.1-20.0)
0.515 128David and Hamid Hashmi,64 2013 11.7 (6.7-18.6)
0.524 202Mayda et al,118 2010 11.9 (7.8-17.2)
0.677 352Kaya et al,102 2007 21.9 (17.7-26.6)
0.536 354Mancevska et al,114 2008 10.2 (7.2-13.8)
0.6232 668Güleç et al,81 2005 34.7 (31.1-38.5)
0.515 95Chan,57 1992 15.8 (9.1-24.7)
0.537 336Alexandrino-Silva et al,34 2009 11.0 (7.9-14.9)
0.6359 951Borst et al,197 2015 37.7 (34.7-40.9)
0.526 44Thompson et al,165 2010 59.1 (43.2-73.7)
0.528 60Peleg-Sagy and Shahar,131 2012 46.7 (33.7-60.0)
0.516 69Mosley et al,123 1994 23.2 (13.9-34.9)
0.533 89Jeong et al,99 2010 37.1 (27.1-48.0)
0.692 192Peleg-Sagy and Shahar,205 2013 47.9 (40.7-55.2)
0.6179 455Guerrero López et al,7 2013 39.3 (34.8-44.0)
0.6135 480Smith et al,159 2011 28.1 (24.1-32.4)
0.6310 844Smith et al,158 2010 36.7 (33.5-40.1)
0.6385 973Pinzón-Amado et al,137 2013 39.6 (36.5-42.7)
0.6569 1241Shindel et al,155 2011 45.9 (43.1-48.7)
0.667 171Rosal et al,207 1997 39.2 (31.8-46.9)
0.6131 336Ludwig et al,203 2015 39.0 (33.7-44.4)
0.515 99Zeldow et al,182 1987 15.2 (8.7-23.8)
0.522 101Haglund et al,10 2009 21.8 (14.2-31.1)
0.698 279Alvi et al,38 2010 35.1 (29.5-41.0)
0.671 301Ghodasara et al,77 2011 23.6 (18.9-28.8)
0.6317 543AlFaris et al,35 2014 58.4 (54.1-62.6)
0.546 194Givens and Tjia,78 2002 23.7 (17.9-30.3)
0.649 322Tjia et al,168 2005 15.2 (11.5-19.6)
0.61093 2683Shah et al,149 2009 40.7 (38.9-42.6)
0.6257 1184Goebert et al,79 2009 21.7 (19.4-24.2)
0.61954 2925Shi et al,153 2016 66.8 (65.1-68.5)
0.61230 1738Shi et al,154 2015 70.8 (68.6-72.9)
0.521 427Chandavarkar et al,58 2007 4.9 (3.1-7.4)
0.6689 7357Roh et al,141 2009 9.4 (8.7-10.1)
The vertical dashed lines indicate the pooled summary estimate (95% CI) for all
studies in Figures 2-6: 27.2% (37 933/122 356 individuals); 95% CI, 24.7%-29.9%;
I
2
= 98.9%, τ
2
=0.78,P< .001. The area of each square is proportional to the in-
verse variance of the estimate. Horizontal lines indicate 95%conf idence intervals
of the estimate. The studies in Figures 2-6 are ordered alphabetically byscreening
instrument and then sorted by increasing sample size within each instrument.
Prevalence of Depression and Suicidal Ideation Among Medical Students Original Investigation Research
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Figure 4. Meta-analysis by Scores on the Depression Anxiety Stress Scale, Diagnostic and Statistical Manual of MentalDisorders, Fourth Edition,
Criteria A and C, Derogatis Stress Profile, Emotional State Questionnaire, General Depression Scale Short Form, General Health Questionnaire, and
the Hospital Anxiety and Depression Scale
0 60 10040 80
Prevalence, % (95% CI)
20
Weight, %
No.
Depressed
Total
No.Source
21-Item Depression Anxiety Stress Scale Score ≥10
Prevalence, %
(95% CI)
0.540 127Bore et al,52 2016 31.5 (23.5-40.3)
0.670 170Yusoff et al,210 2013 41.2 (33.7-49.0)
0.6125 358Saravanan and Wilks,145 2014 34.9 (30.0-40.1)
21-Item Depression Anxiety Stress Scale Score ≥14
0.658 194Yusoff,181 2013 29.9 (23.5-36.9)
0.524 198Carter et al,54 2014 12.1 (7.9-17.5)
0.6190 442Kulsoom and Afsar,108 2015 43.0 (38.3-47.7)
42-Item Depression Anxiety Stress Scale Score ≥10
0.527 66Rizvi et al,140 2015 40.9 (29.0-53.7)
Derogatis Stress Profile Score >50
0.6217 356Helmers et al,84 1997 61.0 (55.7-66.1)
Emotional State Questionnaire Score ≥12
0.6126 413Eller et al,184 2006 30.5 (26.1-35.2)
General Depression Scale Short Form Score >17
0.6107 419Kohls et al,105 2012 25.5 (21.4-30.0)
12-Item General Health Questionnaire Score ≥5
0.688 384Berner et al,51 2014 22.9 (18.8-27.5)
12-Item General Health Questionnaire Score >15
0.6276 527Imran et al,92 2016 52.4 (48.0-56.7)
28-Item General Health Questionnaire Score >6
0.520 138Akbari et al,31 2014 14.5 (9.1-21.5)
28-Item General Health Questionnaire Score ≥23
0.693 172Bayati et al,9 2009 54.1 (46.3-61.7)
Hospital Anxiety and Depression Scale Score ≥7
0.556 166Akvardar et al,33 2004 33.7 (26.6-41.5)
0.6154 447Akvardar et al,32 2003 34.5 (30.1-39.1)
Hospital Anxiety and Depression Scale Score ≥8
0.517 87Rab et al,138 2008 19.5 (11.8-29.4)
0.518 110Khan et al,103 2015 16.4 (10.0-24.6)
0.45 114Newbury-Birch et al,204 2001 4.4 (1.4-9.9)
0.513 136Pickard et al,135 2000 9.6 (5.2-15.8)
0.673 186Ashton and Kamali,44 1995 39.2 (32.2-46.7)
0.57 197Vaysse et al,171 2014 3.6 (1.4-7.2)
0.688 311Amir and Gillany,40 2010 28.3 (23.4-33.7)
0.648 338Bunevicius et al,53 2008 14.2 (10.7-18.4)
0.512 350Kötter et al,107 2014 3.4 (1.8-5.9)
0.6118 409Waqas et al,173 2015 28.9 (24.5-33.5)
0.6136 485Karaoğlu and Şeker,101 2011 28.0 (24.1-32.3)
0.6142 2155Quince et al,206 2012 6.6 (5.6-7.7)
0.6105 208Farahangiz et al,76 2016 50.5 (43.5-57.5)
12-Item General Health Questionnaire Score ≥4
0.557 119Aktekin et al,196 2001 47.9 (38.7-57.2)
0.563 172Guthrie et al,201 1998 36.6 (29.4-44.3)
0.6103 324James et al,98 2013 31.8 (26.8-37.2)
0.6166 396Sherina et al,152 2004 41.9 (37.0-47.0)
0.685 407Sreeramareddy et al,161 2007 20.9 (17.0-25.2)
0.6177 451Oku et al,128 2015 39.2 (34.7-43.9)
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Criteria A and C
0.540 309Dahlin et al,62 2005 12.9 (9.4-17.2)
0.557 193Baykan et al,50 2012 29.5 (23.2-36.5)
0.6181 353Iqbal et al,95 2015 51.3 (45.9-56.6)
0.6266 442Abdel Wahed and Hassan,27 2016 60.2 (55.4-64.8)
The vertical dashed lines indicate the pooled summary estimate (95% CI) for all
studies in Figures 2-6: 27.2% (37 933/122 356 individuals); 95%CI,
24.7%-29.9%; I
2
= 98.9%, τ
2
=0.78,P< .001. The area of each square is
proportional to the inverse variance of the estimate. Horizontal lines indicate
95% confidence intervals of the estimate. The studies in Figures 2-6 are
ordered alphabetically by screening instrument and then sorted by increasing
sample size within each instrument.
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Figure 5. Meta-analysis by Scores on Several Scales
0 60 10040 80
Prevalence, % (95% CI)
20
Weight, %
No.
Depressed
Total
No.Source
Hospital Anxiety and Depression Scale Score ≥11
Prevalence, %
(95% CI)
Hospital Anxiety and Depression Scale Score ≥12
Health-Related Self-Reported Scale Score ≥25
Kessler Psychological Distress Scale Score ≥20
Kutcher Adolescent Depression Scale Score ≥6
Major Depression Inventory Score >27
Minnesota Multiphasic Personality Inventory-Depression Scale Score >70
9-Item Patient Health Questionnaire Score ≥5
9-Item Patient Health Questionnaire Score ≥9
9-Item Patient Health Questionnaire Score ≥10
9-Item Patient Health Questionnaire Score >10
Primary Care Evaluation of Mental Disorders
Mini International Neuropsychiatric Interview ≥ DSM-IV criteria
0.2173Prinz et al,2 2012 1.4 (0.0-7.4)
0.44 153Voltmer et al,172 2012 2.6 (0.7-6.6)
0.666 450Ibrahim et al,90 2013 14.7 (11.5-18.3)
0.686 558Ibrahim et al,91 2013 15.4 (12.5-18.7)
0.6127 588El-Gilany et al,75 2008 21.6 (18.3-25.1)
0.556 80Saeed et al,143 2016 70.0 (58.7-79.7)
0.692 232Matheson et al,117 2016 39.7 (33.3-46.3)
0.537 408Dahlin et al,63 2011 9.1 (6.5-12.3)
0.519 213de Melo Cavestro and Rocha,65 2006 8.9 (5.5-13.6)
0.532 178Walkiewicz et al,209 2012 18.0 (12.6-24.4)
0.526 153Thompson et al,166 2016 17.0 (11.4-23.9)
0.524 174Yoon et al,179 2014 13.8 (9.0-19.8)
0.551 237Sidana et al,156 2012 21.5 (16.5-27.3)
0.543 255Samaranayake and Fernando,144 2011 16.9 (12.5-22.0)
0.688 331Vankar et al,170 2014 26.6 (21.9-31.7)
0.6117 340Naja et al,125 2016 34.4 (29.4-39.7)
0.647 348Sobowale et al,160 2014 13.5 (10.1-17.6)
0.6145 381Youssef,180 2016 38.1 (33.2-43.1)
0.672 504Schwenk et al,146 2010 14.3 (11.3-17.6)
0.672 505Wimsatt et al,175 2015 14.3 (11.3-17.6)
0.538 537Tan et al,167 2015 7.1 (5.1-9.6)
0.6270 553Honney et al,88 2010 48.8 (44.6-53.1)
0.6135 206Manaf et al,113 2016 65.5 (58.6-72.0)
0.6537 1294Lapinski et al,109 2016 41.5 (38.8-44.2)
0.512 130Wolf and Rosenstock,176 2016 9.2 (4.9-15.6)
0.57 183Gold et al,80 2015 3.8 (1.6-7.7)
0.655 336Mousa et al,124 2016 16.4 (12.6-20.8)
0.6217 364Chang et al,59 2012 59.6 (54.4-64.7)
0.533 385MacLean et al,112 2016 8.6 (6.0-11.8)
0.6294 535Thomas et al,164 2007 55.0 (50.6-59.2)
0.6296 545Dyrbye et al,72 2006 54.3 (50.0-58.6)
0.6330 870Dyrbye et al,68 2015 37.9 (34.7-41.2)
0.542 593Kongsomboon,106 2010 7.1 (5.2-9.5)
0.6173 1068Romo-Nava et al,142 2016 16.2 (14.0-18.5)
0.6285 1294Miletic et al,121 2015 22.0 (19.8-24.4)
0.679 1871Nava et al,127 2013 4.2 (3.4-5.2)
0.6100 1014Angkurawaranon et al,41 2016 9.9 (8.1-11.9)
0.6820 1691Dyrbye et al,71 2007 48.5 (46.1-50.9)
0.61037 2228Dyrbye et al,73 2008 46.5 (44.5-48.6)
0.61398 2661Dyrbye et al,69 2010 52.5 (50.6-54.4)
0.62528 4354Jackson et al,96 2016 58.1 (56.6-59.5)
0.6541 1428Dyrbye et al,70 2011 37.9 (35.4-40.5)
0.62552 4402Dyrbye et al,74 2014 58.0 (56.5-59.4)
0.661 590Wege et al,174 2016 10.3 (8.0-13.1)
0.530 477Mojs et al,122 2015 6.3 (4.3-8.9)
The vertical dashed lines indicate the pooled summary estimate (95% CI) for all
studies in Figures 2-6: 27.2% (37 933/122 356 individuals); 95%CI,
24.7%-29.9%; I
2
= 98.9%, τ
2
=0.78,P< .001. The area of each square is
proportional to the inverse variance of the estimate. Horizontal lines indicate
95% confidence intervals of the estimate. The studies in Figures 2-6 are
ordered alphabetically by screening instrument and then sorted by increasing
sample size within each instrument. DSM-IV,Diagnostic and Statistical Manual
of Mental Disorders, Fourth Edition.
Prevalence of Depression and Suicidal Ideation Among Medical Students Original Investigation Research
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although the results were inconsistent (ie, 2 analyses sug-
gested that depression was increasing with time, whereas a
third suggested it was decreasing). Age and sex were not sig-
nificantly associated with depression prevalence among any
instruments.
Analysis of Longitudinal Studies
The temporal relationship between exposure to medical
school and depressive symptoms was assessed in an analysis
of 9 longitudinal studies that measured depressive symp-
toms before and during medical school (Table 3). Because
studies used different assessment instruments, the relative
change in depressive symptoms was calculated for each
study individually (ie, follow-up prevalence divided by base-
line prevalence) and then the relative changes derived from
the individual studies were examined. Overall, the median
absolute increase in depressive symptoms was 13.5% (range,
0.6%-35.3%) following the onset of medical training.
Prevalence of Suicidal Ideation Among Medical Students
In an analysis of 24 studies, the crude summary prevalence
of suicidal ideation, variably reported as having occurred over
the past 2 weeks to the past 12 months, was 11.1% (2043/
21 002 individuals; 95% CI, 9.0%-13.7%), with significant evi-
dence of between-study heterogeneity (Q=547.1
2
= 0.32,
I
2
= 95.8%, P< .001) (Figure 10). The prevalence estimates re-
ported by the individual studies ranged from 4.9% to 35.6%.
Sensitivity analysis showed that no individual study affected
the overall pooled estimate by more than 1.9% (eTable 5 in the
Supplement).
To further characterize the range of the suicidal ideation
prevalence estimates identified, stratified meta-analyses
were performed by screening instrument and cutoff score.
Summary prevalence estimates ranged from 7.4% (69/938
individuals [95% CI, 5.9%-9.2%]; Q= 0.01, τ
2
=0,I
2
= 0%)
over the past 2 weeks for studies using the 9-item Patient
Health Questionnaire (PHQ-9) to 24.2% (208/754 individuals
Figure 6. Meta-analysis by Scores on the Patient-Reported Outcomes Measurement Information System, Quick Inventory of Depressive
Symptomatology,90-Item Symptom Checklist, Thai Depression Inventory, and the Zung Self-Rating Depression Scale
0 60 10040 80
Prevalence, % (95% CI)
20
Weight, %
No.
Depressed
Total
No.Source
Patient-Reported Outcomes Measurement Information System Score >60
Prevalence, %
(95% CI)
0.6316 3149Hardeman et al,83 2015 10.0 (9.0-11.1)
Quick Inventory of Depressive Symptomatology Score ≥9
0.6524 1000Perveen et al,133 2016 52.4 (49.3-55.5)
90-Item Symptom Checklist Score >2
0.536 1137Yang et al,6 2014 3.2 (2.2-4.4)
Thai Depression Inventory Score >35
0.519 368N Wongpakaran and T Wongpakaran,177 2010 5.2 (3.1-7.9)
Zung Self-Rating Depression Scale Score >30
0.6166 230Pillay et al,136 2016 72.2 (65.9-77.9)
Zung Self-Rating Depression Scale Score ≥40
0.6175 238Supe,3 1998 73.5 (67.4-79.0)
Zung Self-Rating Depression Scale Score >45
0.557 146Nasioudis et al,126 2015 39.0 (31.1-47.5)
Zung Self-Rating Depression Scale Score ≥50
0.528 94Basnet et al,48 2012 29.8 (20.8-40.1)
0.541 121Tang,163 2005 33.9 (25.5-43.0)
0.526 122Phillips et al,134 2006 21.3 (14.4-29.6)
0.529 166Marwat,116 2013 17.5 (12.0-24.1)
0.551 215Ali and Vankar,37 1994 23.7 (18.2-30.0)
0.542 232Camp et al,198 1994 18.1 (13.4-23.7)
0.661 262Aniebue and Onyema,42 2008 23.3 (18.3-28.9)
0.534 269Ashor,43 2012 12.6 (8.9-17.2)
0.526 487Liao et al,110 2010 5.3 (3.5-7.7)
0.6143 615Valle et al,169 2013 23.3 (20.0-26.8)
0.61881 4063Wan et al,4 2012 46.3 (44.8-47.8)
Zung Self-Rating Depression Scale Score ≥53
0.699 313Shen et al,151 2009 31.6 (26.5-37.1)
Zung Self-Rating Depression Scale Short Form Score ≥22
0.6184 590Pereyra-Elías et al,132 2010 31.2 (27.5-35.1)
The vertical dashed lines indicate the pooled summary estimate (95% CI) for all
studies in Figures 2-6: 27.2% (37 933/122 356 individuals); 95%CI,
24.7%-29.9%; I
2
= 98.9%, τ
2
=0.78,P< .001. The area of each square is
proportional to the inverse variance of the estimate. Horizontal lines indicate
95% confidence intervals of the estimate. The studies in Figures 2-6 are
ordered alphabetically by screening instrument and then sorted by increasing
sample size within each instrument.
Research Original Investigation Prevalence of Depression and Suicidal Ideation Among Medical Students
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[95% CI, 13.0%-40.5%]; Q=37.2
2
= 0.42, I
2
= 94.6%) over
the past 12 months for studies using the 28-item General
Health Questionnaire.
The median prevalence of suicidal ideation over the
past 12 months reported by 7 studies using variably worded
short-form screening instruments was 10.2% (723/8636
individuals [95% CI, 6.8%-15.0%]; Q= 176.5, τ
2
= 0.33,
I
2
= 96.6%). Among the full set of studies, no statistically
significant differences in prevalence estimates were
noted by country (United States vs other countries), conti-
Figure 7. Meta-analyses of the Prevalence of Depression or Depressive Symptoms Among Medical Students Stratified by Screening Instrument and
Cutoff Score
0 60 10040 80
Prevalence, % (95% CI)
20
No. of
Studies
No.
Depressed
Total
No.Screening Method and Cutoff Score
Prevalence, %
(95% CI)
4 1039540Aga Khan University Anxiety and Depression Scale Score ≥19
I2
=
98.9%, τ2
=
0.78, P<.001
55.9 (45.1-66.2)
5 1323523Beck Depression Inventory II Score ≥14
I2
=
97.2%, τ2
=
0.73, P<.001
29.5 (16.3-47.4)
3 796226Beck Depression Inventory Score ≥8
I2
=
81.9%, τ2
=
0.09, P
=
.004
30.2 (22.8-38.7)
2 51695Beck Depression Inventory Short Form Score ≥8
I2
=
82.6%, τ2
=
0.12, P
=
.02
19.0 (12.1-28.7)
2 444146Beck Depression Inventory Score ≥9
I2
=
84.3%, τ2
=
0.20, P
=
.01
29.0 (17.2-44.6)
24 19
1605042Beck Depression Inventory Score ≥10
I2
=
98.6%, τ2
=
0.62, P<.001
32.4 (25.8-39.7)
2 883166Beck Depression Inventory Score ≥11
I2
=
0%, τ2
=
0, P
=
.91
18.8 (16.4-21.5)
2 37485Beck Depression Inventory Score ≥12
I2
=
0%, τ2
=
0, P
=
.39
22.8 (18.8-27.3)
6 1868479Beck Depression Inventory Score ≥17
I2
=
97.1%, τ2
=
0.75, P<.001
21.7 (12.0-36.0)
13 10
2945214Center for Epidemiological Studies Depression Scale Score ≥16
I2
=
99.0%, τ2
=
0.61, P<.001
42.8 (32.7-53.6)
4 109750121-Item Depression Anxiety Stress Scale Score ≥10
I2
=
95.3%, τ2
=
0.35, P<.001
41.9 (28.5-56.6)
3 83427221-Item Depression Anxiety Stress Scale Score ≥14
I2
=
96.3%, τ2
=
0.58, P<.001
26.5 (13.0-46.6)
3 61226542-Item Depression Anxiety Stress Scale Score ≥10
I2
=
91.5%, τ2
=
0.28, P<.001
40.4 (26.5-56.0)
6 186965112-Item General Health Questionnaire Score ≥4
I2
=
91.1%, τ2
=
0.15, P<.001
35.7 (28.5-43.6)
2 38019828-Item General Health Questionnaire Score ≥23
I2
=
0%, τ2
=
0, P
=
.49
52.1 (47.1-57.1)
2 613210Hospital Anxiety and Depression Scale Score ≥7
I2
=
0%, τ2
=
0, P
=
.87
34.3 (30.6-38.1)
12 4878677Hospital Anxiety and Depression Scale Score ≥8
I2
=
97.2%, τ2
=
0.85, P<.001
13.6 (8.4-21.3)
4 1234157Hospital Anxiety and Depression Scale Score ≥11
I2
=
84.8%, τ2
=
0.24, P<.001
9.3 (5.3-15.7)
2 312148Kessler Psychological Distress Scale Score ≥20
I2
=
95.2%, τ2
=
0.76, P<.001
54.9 (26.0-80.8)
2 672 15009-Item Patient Health Questionnaire Score ≥5
I2
=
97.5%, τ2
=
0.47, P<.001
53.5 (30.5-75.1)
15 855115309-Item Patient Health Questionnaire Score ≥10
I2
=
98.0%, τ2
=
0.67, P<.001
18.3 (12.8-25.4)
14 20
11210
120Primary Care Evaluation of Mental Disorders
I2
=
98.4%, τ2
=
0.19, P<.001
37.5 (32.0-43.3)
11 66462362Zung Self-Rating Depression Scale Score ≥50
I2
=
98.0%, τ2
=
0.76, P<.001
21.3 (13.8-31.5)
Study Sample
Pooled summary estimates are ordered alphabetically by screening instrument.
The individual studies contributing to each summary estimate are reported in
Figures 2 through 6. The area of each diamond is proportional to the inverse
variance of the estimate. Horizontal extremes of the diamonds indicate 95% CIs
of the estimate.
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nent or region, level of training, baseline survey year, aver-
age age, proportion of male study participants, or total
Newcastle-Ottawa score (P> .05 for all comparisons). Within-
instrument heterogeneity was not examined because there
were not enough studies using identical screening instru-
ments (≤4 for each assessment modality), precluding mean-
ingful analysis.
Assessment of Publication Bias
Visual inspection of the funnel plot of studies reporting on
depression or depressive symptoms revealed significant
asymmetry (eFigure 2 in the Supplement). There was evi-
dence of publication bias, with smaller studies yielding more
extreme prevalence estimates (P= .001 using the Egger test).
The funnel plot of studies reporting on suicidal ideation
revealed minimal asymmetry (eFigure 3 in the Supplement),
suggesting the absence of significant publication bias (P=.49
using the Egger test).
Discussion
This systematic review and meta-analysis of 195 studies
involving 129 123 medical students in 47 countries demon-
strated that 27.2% (range, 9.3%-55.9%) of students screened
positive for depression and that 11.1% (range, 7.4%-24.2%)
reported suicidal ideation during medical school. Only
15.7% of students who screened positive for depression
reportedly sought treatment. These findings are concerning
given that the development of depression and suicidality
has been linked to an increased short-term risk of suicide as
well as a higher long-term risk of future depressive episodes
and morbidity.
211,212
The present analysis builds on recent work demonstrat-
ing a high prevalence of depression among resident physi-
cians, and the concordance between the summary preva-
lence estimates (27.2% in students vs 28.8% in residents)
suggests that depression is a problem affecting all levels of
medical training.
13,213
Taken together, these data suggest
that depressive and suicidal symptoms in medical trainees
may adversely affect the long-term health of physicians as
well as the quality of care delivered in academic medical
centers.
214-216
When interpreting these findings, it is important to
recognize that the data synthesized in this study were
almost exclusively derived from self-report inventories of
depressive symptoms that varied substantially in their
sensitivity and specificity for diagnosing major depressive
disorder (eTable 6 in the Supplement).
217
Instruments such
as the PHQ-9 have high sensitivity and specificity for diag-
nosing major depression, whereas others such as the Pri-
mary Care Evaluation of Mental Disorders (PRIME-MD) have
low specificity and should be viewed as screening tools.
Although these self-report measures of depressive symp-
toms have limitations, they are essential tools for accurately
measuring depression in medical trainees because they
Figure 8. Meta-analyses of the Prevalence of Depression or Depressive Symptoms Among Medical Students Stratified byStudy-Level Characteristics
0 60 10040 80
Prevalence, % (95% CI)
20
No. of
Studies
No.
Depressed
Total
No.
Type of Study
Prevalence, %
(95% CI)
P Value for
Difference
Study Sample
167 116
62836
632Cross-sectional (I2
=
99.0%, τ2
=
0.78, P < .001) 27.3 (24.7-30.1)
16 57281301Longitudinal (I2
=
97.5%, τ2
=
0.75, P < .001) 26.7 (19.1-36.1)
Academic Year
45 25
4624866Preclinical (I2
=
97.8%, τ2
=
0.68, P < .001) 23.7 (19.5-28.5)
108 79
96629
273Both (I2
=
99.0%, τ2
=
0.67, P < .001) 30.4 (27.2-33.9)
17 13
1722917Clinical (I2
=
96.4%, τ2
=
0.35, P < .001) 22.4 (17.6-28.2)
Continent or Region
6 1860853Africa (I2
=
97.5%, τ2
=
0.58, P < .001) 46.3 (31.7-61.6)
51 49
60213
435Asia (I2
=
99.4%, τ2
=
1.14, P < .001) 29.1 (23.4-35.6)
Country
141 86
10723
577All other countries (I2
=
98.8%, τ2
=
0.83, P < .001) 27.4 (24.5-30.6)
42 36
24914
356United States (I2
=
98.9%, τ2
=
0.53, P < .001) 26.7 (22.5-31.3)
10 39581288Eurasia (I2
=
90.4%, τ2
=
0.12, P < .001) 31.5 (26.8-36.6)
26 12
6042728Europe (I2
=
97.8%, τ2
=
0.65, P < .001) 16.9 (12.8-21.9)
20 66102414Middle East (I2
=
97.0%, τ2
=
0.49, P < .001) 35.2 (28.5-42.7)
49 40
65515
238North America (I2
=
99.0%, τ2
=
0.61, P < .001) 26.7 (22.5-31.2)
3 580107Oceania (I2
=
89.5%, τ2
=
0.31, P < .001) 19.0 (10.8-31.4)
18 64871870South America (I2
=
93.6%, τ2
=
0.22, P < .001) 26.6 (22.4-31.2)
.90
.72a
.78
<.001
The area of each diamond is proportional to the inverse variance of the estimate.
Horizontal extremes of the diamonds indicate 95% CIs of the estimate.
a
Comparison of studies reporting only on preclinical students with those
studies reporting only on clinical students.
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protect anonymity in a manner that is not possible through
formal diagnostic interviews.
218
To control for the differ-
ences in these inventories, we stratified our analyses by sur-
vey instrument and cutoff score, identifying a range of esti-
mates not captured in another evidence synthesis.
219
The prevalence of depressive symptoms among medical
students in this study was higher than that reported in the
general population.
220-222
For example, the National Insti-
tute of Mental Health study of behavioral health trends in
the United States, including 67500 nationally representa-
tive participants, found that the 12-month prevalence of a
major depressive episode was 9.3% among 18- to 25-year-
olds and 7.2% among 26- to 49-year-olds.
220
In contrast, the
BDI, CES-D, and PHQ-9 summary estimates obtained in the
present study were between 2.2 and 5.2 times higher than
these estimates. These findings suggest that depressive
symptom prevalence is substantially higher among medical
students than among individuals of similar age in the gen-
eral population.
How depression levels in medical students compare
with those in nonmedical undergraduate students and pro-
fessional students is unclear. One review concluded that
depressive symptom prevalence did not statistically differ
between medical students and nonmedical undergraduate
students.
223
However, this conclusion may be confounded
because the analysis did not control for assessment modal-
ity and did not include a comprehensive or representative
set of studies (only 12 studies and 4 studies exclusively com-
posed of medical students and nonmedical students,
respectively). Two large, representative epidemiological
studies have estimated that depressive symptom prevalence
in nonmedical students ranges from 13.8% to 21.0%, lower
than the estimates reported by many studies of medical stu-
dents in the present meta-analysis.
224,225
Some professional students, such as law students, may
not markedly differ from medical students in their suscepti-
bility to depression, although firm conclusions cannot be
drawn from the currently available data.
226,227
Together,
these findings suggest that factors responsible for depres-
sion in medical students may also be operative in other
undergraduate and professional schools. The finding in the
longitudinal analysis of an increase in depressive symptom
prevalence with the onset of medical school suggests that it
is not just that medical students (and other students) are
prone to depression, but that the school experience may be
a causal factor.
This analysis identified a pooled prevalence of suicidal ide-
ation of 11.1%. Endorsement of suicidal ideation as assessed
by the PHQ-9 or other similar instruments increases the cu-
mulative risk of a suicide attempt or completion over the next
year by 10- and 100-fold, respectively.
228
Combined with the
finding that only 15.7% of medical students who screened posi-
tive for depression sought treatment, the high prevalence of
suicidal ideation underscores the need for effective preven-
Figure 9. Meta-analyses of the Prevalence of Depression or DepressiveSymptoms Among Medical Students Stratified by Newcastle-Ottawa Scale
Components and Total Score
0 60 10040 80
Prevalence, % (95% CI)
20
No. of
Studies
No.
Depressed
Total
No.Newcastle-Ottawa Scale Components
Sample Representativeness
Prevalence, %
(95% CI)
P Value for
Difference
150 53
66313
567Less representive (I2
=
97.8%, τ2
=
0.77, P< .001) 25.4 (22.8-28.2)
33 68
69324
366More representive (I2
=
99.7%, τ2
=
0.73, P< .001) 36.3 (29.9-43.3)
Sample Size
57 76322274<200 Participants (I2
=
93.6%, τ2
=
0.62, P< .001) 27.2 (23.2-31.6)
126 114
72435
659≥200 Participants (I2
=
99.2%, τ2
=
0.79, P< .001) 27.3 (24.3-30.6)
Respondent-Nonrespondent Comparability
165 113
26034
774Less comparable (I2
=
99.0%, τ2
=
0.81, P< .001) 27.6 (24.9-30.5)
18 90963159More comparable (I2
=
97.6%, τ2
=
0.52, P< .001) 23.8 (18.1-30.6)
Ascertainment of Depression
102 71
29122
566Less valid (I2
=
99.0%, τ2
=
0.78, P< .001) 28.6 (25.2-32.3)
81 51
06515
367More valid (I2
=
98.8%, τ2
=
0.81, P< .001) 25.5 (21.9-29.5)
Descriptive Statistics Reporting
97 60
30018
595Less thorough (I2
=
99.0%, τ2
=
0.94, P< .001) 25.8 (22.2-29.7)
86 62
05619
338More thorough (I2
=
98.8%, τ2
=
0.66, P< .001) 28.8 (25.4-32.6)
Total Newcastle-Ottawa Score
138 69
78921
518<3 points (I2
=
98.7%, τ2
=
0.91, P< .001) 27.0 (23.9-30.3)
45 52
56716
415≥3 points (I2
=
99.3%, τ2
=
0.64, P< .001) 27.9 (23.4-32.9)
.002
.95
.29
.24
.75
.25
Study Sample
Full details regarding Newcastle-Ottawarisk of bias scoring are provided in
eMethods 2 in the Supplement. Component scores for all individual studies are
presented in eTable 2 in the Supplement. The area of each diamond is
proportional to the inverse variance of the estimate. Horizontal extremes of the
diamonds indicate 95% CIs of the estimate.
Prevalence of Depression and Suicidal Ideation Among Medical Students Original Investigation Research
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tive efforts and increased access to care that accommodate the
needs of medical students and the demands of their training.
Limitations
This study has important limitations. First, the data were de-
rived from studies that had different designs, screening in-
struments, and trainee demographics. The substantial hetero-
geneity among the studies remained largely unexplained by
the variables inspected. Second, many subgroup analyses re-
lied on unpaired cross-sectional data collected at different
medical schools, which may cause confounding. Third, be-
cause the studies were heterogeneous with respect to screen-
ing inventories and studentpopulations, the prevalence of ma-
jor depression could not be determined. Fourth, the analysis
relied on aggregated published data. A multicenter, prospec-
tive study using a single validated measure of depression and
suicidal ideation with structured diagnostic interviews in a ran-
dom subset of participants would provide a more accurate es-
timate of the prevalence of depression and suicidal ideation
among medical students.
Future Directions
Because of the high prevalence of depressive and suicidal symp-
tomatology in medical students, there is a need for additional
studies to identify the root causes of emotional distress in this
population. To provide more relevant information, future epi-
demiological studies should consider adopting prospective
study designs so that the same individuals can be assessed over
time, use commonly used screening instruments with valid cut-
offs for assessing depression in the community (eg, the BDI,
CES-D, or PHQ-9), screen for comorbid anxiety disorders, and
completely and accurately report their data, for example, by
closely following the Strengthening the Reporting of Observa-
tional Studies in Epidemiology guidelines.
229
Possible causes of depressive and suicidal symptomatol-
ogy in medical students likely include stress and anxiety sec-
ondary to the competitiveness of medical school.
62
Restruc-
turing medical school curricula and student evaluations
(such as using a pass-fail grading schema rather than a tiered
grading schema and fostering collaborative group learning
through a “flipped-classroom” education model) might ame-
liorate these stresses.
230,231
Future research should also
determine how strongly depression in medical school pre-
dicts depression during residency and whether interventions
that reduce depression in medical students carry over in their
effectiveness when those students transition to residency.
232
Furthermore, efforts are continually needed to reduce barri-
ers to mental health services, including addressing the
stigma of depression.
146,233
Conclusions
In this systematic review, the summary estimate of the preva-
lence of depression or depressive symptoms among medical
students was 27.2% and thatof suic idal ideation was 11.1%. Fur-
ther research is needed to identify strategies for preventingand
treating these disorders in this population.
Table 3. Secondary Analysis of 9 LongitudinalStudies Reporting Depression or Depressive Symptom Prevalence Estimates Both Before and During Medical School
Source
a
Screening
Instrument
Cutoff
Score
Follow-
up, mo
Baseline Follow-up Comparison
No.
Depressed
Sample
Size
Prevalence,
% (95% CI)
No.
Depressed
Sample
Size
Prevalence,
% (95% CI)
Absolute Increase,
% (95% CI)
Relative Increase,
Ratio (95% CI)
Walkiewicz et al,
209
2012
MMPI-D >70 12 31 178 17.4 (11.8 to 23.0) 32 178 18.0 (12.4 to 23.6) 0.6 (−7.4 to 8.5) 1.0 (0.6 to 1.8)
Quince et al,
206
2012 HADS-D ≥8 12 38 665 5.7 (3.9 to 7.5) 36 429 8.4 (5.8 to 11.0) 2.7 (−0.4 to 6.1) 1.5 (0.9 to 2.4)
Levine et al,
202
2006 21-Item BDI ≥8 20 64 376 17.0 (13.2 to 20.8) 80 330 24.2 (19.6 to 28.8) 7.2 (1.3 to 13.2) 1.4 (1.0 to 2.0)
Camp et al,
198
1994 Zung-SDS ≥50 3 14 232 6.0 (2.9 to 9.1) 42 232 18.1 (13.2 to 23.1) 12.1 (6.2 to 18.0) 3.0 (1.6 to 5.6)
Vitaliano et al,
208
1988 BDI ≥5 8 36 312 11.5 (8.0 to 15.0) 78 312 25.0 (20.2 to 29.8) 13.5 (7.4 to 19.4) 2.2 (1.4 to 3.3)
Clark and Zeldow,
199
1988
21-item BDI ≥8 14 11 116 9.5 (4.2 to 14.8) 24 88 27.3 (18.0 to 36.6) 17.8 (7.2 to 28.7) 2.9 (1.3 to 6.2)
Rosal et al,
207
1997 CES-D ≥80th
b
18 48 264 18.2 (13.6 to 22.9) 67 171 39.2 (31.9 to 46.5) 21.0 (12.3 to 29.6) 2.2 (1.4 to 3.3)
Aktekin et al,
196
2001 GHQ ≥4 12 21 119 17.6 (10.8 to 24.4) 57 119 47.9 (38.9 to 56.9) 30.3 (18.5 to 40.9) 2.7 (1.5 to 4.8)
Yusoff et al,
210
2013 DASS-21 ≥10 12 10 170 5.9 (2.4 to 9.4) 70 170 41.2 (33.8 to 48.6) 35.3 (26.8 to 43.3) 7.0 (3.5 to 14.0)
Abbreviations: BDI, Beck Depression Inventory; CES-D, Center for Epidemiological Studies Depression Scale;
DASS-21, 21-item Depression Anxiety Stress Scale; GHQ, General Health Questionnaire; HADS-D,Hospital Anxiety
and Depression Scale; MMPI-D, Minnesota Multiphasic Personality Inventory-Depression Scale; Zung-SDS, Zung
Self-Rating Depression Scale.
a
Studies are sorted by the percentage increase in depressive symptoms from baseline to the follow-up survey.
The median percentage increase among the studies was 13.5%.
b
Indicates 80
th
percentile.
Research Original Investigation Prevalence of Depression and Suicidal Ideation Among Medical Students
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ARTICLE INFORMATION
Author Affiliations: Harvard Medical School,
Boston, Massachusetts (Rotenstein, Torre, Segal,
Peluso, Mata); Harvard Business School, Boston,
Massachusetts (Rotenstein); YaleSchool of
Medicine, Yale University, New Haven, Connecticut
(Ramos); Department of Pathology, Brigham and
Women’s Hospital, Boston, Massachusetts (Torre);
Department of Medicine, Brigham and Women’s
Hospital, Boston, Massachusetts (Peluso);
Department of Psychiatry and Behavioral Sciences,
Medical University of South Carolina, Charleston
(Guille); Molecular and Behavioral Neuroscience
Institute, University of Michigan, Ann Arbor (Sen);
Department of Psychiatry, Universityof Michigan,
Ann Arbor (Sen); Division of MPE Molecular
Pathological Epidemiology, Department of
Pathology, Brigham and Women’s Hospital, Boston,
Massachusetts (Mata); Brigham Education Institute,
Boston, Massachusetts (Mata).
Author Contributions: Dr Mata had full access to
all of the data in the study and takes responsibility
Figure 10. Meta-analysis of the Prevalence of Suicidal Ideation Among Medical Students
0 60 10040 80
Prevalence, % (95% CI)
20
No.
Suicidal
Total
No.Source
Score >0 on Beck Scale for Suicidal Ideation
Prevalence, %
(95% CI) Weight, %
33645Alexandrino-Silva et al,34 2009 13.4 (9.9-17.5) 4.2
Score >24 on Beck Scale for Suicidal Ideation
61278Ahmed et al,185 2016 12.7 (10.2-15.6) 4.4
Mini International Neuropsychiatric Interview
21316de Melo Cavestro and Rocha,65 2006 7.5 (4.4-11.9) 3.8
Score ≥7 on Revised Suicidial Behaviors Questionnaire
51736Tan et al,167 2015 7.0 (4.9-9.5) 4.2
Suicidal Ideation Over Past Month
27316Alem et al,186 2005 5.9 (3.4-9.3) 3.8
Suicidal Ideation Over Past 12 mo
1158Amiri et al,187 2013 7.0 (3.1-13.2) 3.2
30540Wallin and Runeson,195 2003 13.1 (9.5-17.4) 4.2
51666Okasha et al,192 1981 12.8 (10.0-16.0) 4.3
Suicidal Ideation Over Past 12 mo (28-Item General Health Questionnaire)
20622Menezes et al,191 2012 10.7 (6.8-15.7) 3.9
21768Khokher and Khan,190 2005 31.3 (25.2-38.0) 4.3
331118Osama et al,5 2014 35.6 (30.5-41.1) 4.4
64675Eskin et al,189 2011 11.6 (9.2-14.3) 4.4
892156Chen et al,188 2004 17.5 (15.1-20.1) 4.5
2099179Tran et al,193 2015 8.5 (7.4-9.8) 4.5
4063199Wan et al,4 2012 4.9 (4.3-5.6) 4.5
8636723Summary Prevalence I2
=
96.6%, τ2
=
0.33, P< .001 10.2 (6.8-15.0) 29.6
754208Summary Prevalence I2
=
94.6%, τ2
=
0.42, P< .001 24.2 (13.0-40.5) 12.6
Suicidal Ideation Over Past 12 mo (Meehan Inventory)
29616Dahlin et al,62 2005 5.4 (3.1-8.6) 3.8
Suicidal Ideation Over Past 12 mo (Paykel Inventory)
52274Tyssen et al,194 2001 14.2 (11.3-17.5) 4.4
Suicidal Ideation Over Past 2 wk (9-Item Patient Health Questionnaire)
34826Sobowale et al,160 2014 7.5 (4.9-10.8) 4.0
59043Wege et al,174 2016 7.3 (5.3-9.7) 4.2
93869Summary Prevalence I2
=
0%, τ2
=
0, P
=
.92 7.4 (5.9-9.2) 8.3
Suicidal Ideation Over Past 2 wk (Primary Care Evaluation of Mental Disorders)
4313Thompson et al,165 2010 30.2 (17.2-46.1) 3.4
121580Goebert et al,79 2009 6.6 (5.3-8.1) 4.4
125893Summary Prevalence I2
=
96.3%, τ2
=
1.59, P< .001 14.5 (2.8-50.2) 7.8
21
.
0022043Pooled Summary Estimate I2
=
95.8%, τ2
=
0.32, P< .001 11.1 (9.0-13.7) 100.0
38545MacLean et al,112 2016 11.7 (8.7-15.3) 4.2
2230249Dyrbye et al,73 2008 11.2 (9.9-12.5) 4.5
4032375Dyrbye et al,74 2014 9.3 (8.4-10.2) 4.5
6943685Summary Prevalence I2
=
77.7%, τ2
=
0.03, P
=
.004 9.7 (8.0-11.7) 17.1
Contributing studies are stratified by screening modality and sorted by
increasing sample size. The dotted line marks the overall summary estimate for
all studies, 11.1%(2043/21 002 individuals; 95% CI, 9.0%-13.7%; Q=547.1,
τ
2
= 0.32, I
2
= 95.8%, P< .001). The area of each square is proportional
to the inverse variance of the estimate. Horizontal lines indicate 95% CIs
of the estimate.
Prevalence of Depression and Suicidal Ideation Among Medical Students Original Investigation Research
jama.com (Reprinted) JAMA December 6, 2016 Volume 316, Number 21 2231
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for the integrity of the data and the accuracy of the
analysis. Ms Rotenstein, Messrs Ramos and Segal,
and Dr Torre are equal contributors.
Concept and design: Mata.
Acquisition, analysis, or interpretation of data: All
authors.
Drafting of the manuscript: Mata.
Critical revision of the manuscript for important
intellectual content: All authors.
Statistical analysis: Mata.
Obtained funding: Guille, Sen, Mata.
Administrative, technical, or material support:
Guille, Sen, Mata.
Study supervision: Guille, Sen, Mata.
Conflict of Interest Disclosures: The authors have
completed and submitted the ICMJE Form for
Disclosure of Potential Conflicts of Interest and
none were reported.
Funding/Support: Funding was provided by the
National Institutes of Health (MSTP TG
2T32GM07205 awarded to Mr Ramos and grant
R01MH101459 awarded to Dr Sen) and the US
Department of State (Fulbright Scholarship
awarded to Dr Mata).
Role of the Funder/Sponsor:The National
Institutes of Health and the US Department of State
had no role in the design and conduct of the study;
the collection, management, analysis, or
interpretation of the data; the preparation, review,
or approval of the manuscript; or the decision to
submit the manuscript for publication.
Disclaimer: The opinions, results, and conclusions
reported in this article are those of the authors and
are independent from the National Institutes of
Health and the US Department of State.
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