Observational Study
Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Psychiatr. Jul 15, 2019; 9(4): 65-77
Published online Jul 15, 2019. doi: 10.5498/wjp.v9.i4.65
Medical student depression and its correlates across three international medical schools
Jessica A Gold, Xinran Hu, Gan Huang, Wan-Zhen Li, Yi-Fan Wu, Shan Gao, Zhe-Ning Liu, Mickey Trockel, Wan-Zhen Li, Yi-Fan Wu, Shan Gao, Zhe-Ning Liu, Robert M Rohrbaugh, Kirsten M Wilkins
Jessica A Gold, Department of Psychiatry, Washington University in St Louis, St Louis, MO 63110, United States
Xinran Hu, Robert M Rohrbaugh, Kirsten M Wilkins, Department of Psychiatry, Yale University, New Haven, CT 06511, United States
Gan Huang, Wan-Zhen Li, Yi-Fan Wu, Shan Gao, Zhe-Ning Liu, Central South University Xiangya School of Medicine, Changsha 410013, Hunan Province, China
Mickey Trockel, Department of Psychiatry, Stanford University, Stanford, CA 94305, United States
Author contributions: Gold JA, Rohrbaugh RM, and Wilkins KM contributed to study conception and design; Gold JA, Huang G, Li WZ, Wu YF, Gao S, and Li ZN contributed to data acquisition and interpretation; Trockel M and Hu X contributed to data analysis and interpretation; Gold JA, Hu X, Huang G, Trockel M, Li WZ, Wu YF, Gao S, Liu ZN, Rohrbaugh RM, and Wilkins KM contributed to editing, reviewing and final approval of the article.
Institutional review board statement: The Yale and Middle Eastern School’s Institutional Review Boards deemed this study exempt. The Ethics Committee of Xiangya approved the study.
Informed consent statement: All involved persons gave their informed consent prior to study inclusion.
Conflict-of-interest statement: The authors report no conflicts of interest related to this work.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Kirsten M Wilkins, MD, Associate Professor, Department of Psychiatry, Yale University, 300 George Street Suite 901, New Haven, CT 06511, United States. kirsten.wilkins@yale.edu
Telephone: +1-203-2601110 Fax: +1-203-9373886
Received: January 19, 2019
Peer-review started: January 22, 2019
First decision: March 15, 2019
Revised: April 26, 2019
Accepted: May 23, 2019
Article in press: May 23, 2019
Published online: July 15, 2019

Medical students have high rates of depression, anxiety, and burnout that have been found to affect their empathy, professional behaviors, and performance as a physician. While studies have examined predictors for burnout and depression in the United States (US), no study, to our knowledge, has compared depression in medical students cross-culturally, or has attempted to examine the effect of factors influencing rates including burnout, exercise, stress, unmet mental health needs, and region.


To examine rates of depression in three international cohorts of medical students, and determine variables that may explain these differences.


Convenience samples of medical students from three countries (US, China, and a Middle Eastern country whose name remains anonymous per request from the school) were surveyed in this observational study. Using the Patient Health Questionnaire-2 (PHQ-2) and a modified Maslach Burnout Inventory, depression and burnout were examined among medical students from the three cohorts (n = 473). Chi-square test and analysis of variance were used to examine differences in demographics, behavioral, and psychological variables across these three schools to identify potentially confounding descriptive characteristics. Analysis of covariance compared depression and the emotional exhaustion component of burnout identified through Principal Component Analysis across countries. Multiple linear regression was used to analyze the impact of demographic, behavioral, and psychological variables on screening positive for depression.


Medical students from the Middle Eastern country had the highest rates of positive depression screens (41.1%), defined as a PHQ-2 score of ≥ 3, followed by China (14.1 %), and then the US (3.8%). More students in the Middle Eastern school had unmet mental health needs (50.8%) than at the medical school in China (34.8%) or the school in the US (32.8%) (Pearson chi-square significance < 0.05). Thus, PHQ-2 scores were adjusted for unmet mental health needs; however, the Middle Eastern country continued to have the highest depression. Adjusting for PHQ-2 score, medical students from the US scored the highest on emotional exhaustion (a measure of burnout). Demographic variables did not significantly predict medical student depression; however, lack of exercise, unmet mental health needs, stress, and emotional exhaustion predicted nearly half of depression in these cohorts. In comparison to the US, coming from the Middle Eastern country and China predicted higher levels of depression.


Depression rates differ in three international cohorts of medical students. Measured factors contributed to some observed differences. Identifying site-specific prevention and intervention strategies in medical student mental health is warranted.

Keywords: Medical students, Wellness, Burnout, Depression, International

Core tip: Depression among medical students places them at increased risk for suicide, and impacts many aspects of professional performance. Medical students around the world share common stressors, including competitive selection processes, intense coursework, and pressure for high achievement. However, differences in depression rates are influenced, in part, by burnout, exercise, stress, unmet mental health needs, and region.