International Review of Psychiatry

ISSN: 0954-0261 (Print) 1369-1627 (Online) Journal homepage: https://www.tandfonline.com/loi/iirp20

A descriptive study of mental health and wellbeing

among medical students in Portugal

Telma Almeida, Murtaza Kadhum, Sarah Marie Farrell, Antonio Ventriglio &
Andrew Molodynski

To cite this article: Telma Almeida, Murtaza Kadhum, Sarah Marie Farrell, Antonio Ventriglio &
Andrew Molodynski (2019): A descriptive study of mental health and wellbeing among medical
students in Portugal, International Review of Psychiatry, DOI: 10.1080/09540261.2019.1675283

To link to this article: https://doi.org/10.1080/09540261.2019.1675283

Published online: 22 Oct 2019.

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INTERNATIONAL REVIEW OF PSYCHIATRY
https://doi.org/10.1080/09540261.2019.1675283

ORIGINAL RESEARCH

A descriptive study of mental health and wellbeing among medical students

in Portugal
Telma Almeidaa, Murtaza Kadhumb, Sarah Marie Farrellb, Antonio Ventriglioc and Andrew Molodynskid,e
a
Department of Psychiatry, CUF Porto Hospital, Porto, Portugal; bOxford University Clinical Academic Graduate School (OUCAGs),
University of Oxford, Oxford, UK; cDepartment of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy; dOxford
Health NHS Foundation Trust, Oxford, UK; eDepartment of Psychiatry, Oxford University, Oxford, UK

ABSTRACT KEYWORDS
In studies around the world, medical students have been identified as being at high risk for Mental ill health; wellbeing;
poor mental wellbeing, burnout and mental ill health. This can lead on to poorer physical medical students;
health, substance misuse and reduced academic performance. We surveyed Portuguese medical burnout; Portugal
students to assess burnout (using the Oldenburg Burnout Inventory, OLBI), minor psychiatric ill-
ness (General Health Questionnaire 12, GHQ12) and alcohol misuse (CAGE questionnaire). A total
of 622 medical students participated in the study. We found high levels of exhaustion (89%),
disengagement (81%) and minor psychiatric illness (91%). The CAGE questionnaire was positive
in 10% of students. Future research is required to confirm these results, assess and monitor local
and global trends and investigate interventions at both local and national level to improve the
mental wellbeing of medical students.

Introduction
Health-related university degrees such as medicine, den-
tistry and nursing have been recognised for some time
as being academically, psychologically, and emotionally
challenging (Rezaei, Karimi, & Omidpanah, 2019).
Strong evidence has emerged that these student cohorts
have an elevated risk of poor mental wellbeing, burnout
and psychiatric disease (Bhugra et al., 2019; Volpe et al.,
2019). Mental wellbeing and mental ill health have been
linked to detrimental effects on physical health (includ-
ing alcohol and drug misuse and suicidal ideation) and
reduced academic success (Dyrbye & Shanafelt, 2011).
Of particular importance, distress amongst medical stu-
dents can damage professional performance, with detri-
mental effects on empathy, ethical conduct and
professionalism (Dyrbye & Shanafelt, 2011).
To tackle the consequences of poor mental well-
being, burnout and mental ill health in medical stu-
dents and junior doctors, the medical community has
been more active recently in recognising the degree of
the problem and showing motivation to appropriately
investigate and generate solutions (BMA, 2019).
Internationally there have been various consensus
statements and recommendations published that
emphasise proactive and preventative approaches to
student wellbeing (Kemp et al., 2019).
Like other countries, studies among Portuguese
medical students have also reported high levels of
stress, risky behaviour and mental ill health such as
anxiety and depression (Roberto, 2009). A recent
study comparing medical versus non-medical students
found significantly higher levels of anxiety and
depression with concurrent negative impact on aca-
demic performance in the former (Moreira de Sousa,
Moreira, & Telles-Correia, 2018).
As part of a wider global initiative, we aimed to
perform a large descriptive study of Portuguese med-
ical students to clarify the current state of wellbeing
among them. Specifically, it aimed to Quantify and
characterise difficulties medical students face regard-
ing stressors, psychological distress, and psychiatric
morbidity using standardised reliable and validated
instruments. We also looked to identify differences
associated with year of study and identify areas of
similarity and difference cross culturally. In the pro-
cess of the survey, we hoped that students would
reflect on their wellbeing and self-care.

CONTACT Andrew Molodynski andrew.molodynski@oxfordhealth.nhs.uk Oxford Health NHS Foundation Trust, Warneford Hospital, Gypsy Lane,
Headington, Oxford OX3 7JX, UK
ß 2019 Institute of Psychiatry and Johns Hopkins University
2 T. ALMEIDA ET AL.

Methodology
Portuguese medical students were invited to complete
an anonymous online survey from January 2019 to
April 2019. The survey was distributed using the
‘Typeform’ online platform, allowing for anonymous
collection of survey data, with associated device and
IP address data and automatic collation and graphical
representation for each survey question. Data is pass-
word protected and students were not required to
provide any personal identifiers as part of the study.
Four medical schools around the country partici-
pated: Faculty of Medicine of University of Coimbra
(FMUC, Portugal), Faculty of Medicine of University
of Lisbon (FMUL, Portugal), Beira Interior Institute
(UBI, Portugal), and Abel Salazar Biomedical Sciences
Institute - University of Porto (ICBAS, Portugal).
Past students and staff were excluded from partici-
pating in the study. A covering email was developed
locally to introduce the survey, stress anonymity,
and to remind students of local support services for
mental ill health to act as a safety net for any con-
cerned students.
The survey included demographic data points
including year and medical school of study, gender,
educational level of parents and previous mental
health difficulties prior to medical school. Validated
and reliable instruments were used:
1. General Health Questionnaire (GHQ12) (El-Metwally
et al., 2018) to identify minor psychiatric illness
2. Oldenburg Burnout Inventory (OLBI) (Reis,
Xanthopoulou, & Tsaousis, 2015) to measure
burnout
3. CAGE questionnaire (Saitz, Lepore, Sullivan,
Amaro, & Samet, 1999)
Results
A total of 622 medical students participated in the study
(Table 1). Of these, 303 students (49%) were aligned to
the Faculdade de Medicina da Universidade de Lisboa
(FMUL), 194 (31%) to the Instituto de Ci^encias
Biomedicas Abel Salazar (ICBAS), 124 (20%) from the
Faculdade de Medicina da Universidade de Coimbra
(FMUC) and only one student from Faculdade de
Medicina da Universidade da Beira Interior (UBI). 109
(18%), 129 (21%), 99 (16%), 91 (15%), 93 (15%) and 95
(15%) were in year 1–6 of medical school respectively,
giving a fairly even spread across year groups. 452 stu-
dents (73%) were female, with only 167 (27%) male,
with three self-reporting as ‘other’. Educational achieve-
ments of parents was obtained from each student, with
154 (25%) indicating high school or below, 23 (4%)
indicating GCSE or equivalent, 28 (5%) indicating
A-Level or equivalent, 163 (26%) indicating undergradu-
ate and 248 (40%) indicating postgraduate education.
Among the 622 respondents, 160 (26%) reported
visiting a general practitioner, psychologist, psych-
iatrist or psychotherapist specifically for their mental
health prior to medical school (Table 2). These con-
sultations were noted to be due to feelings of sadness,
stress, anxiety, mania, eating disorders or obsessional
behaviour. 47 (8%) of the overall sample reported
being formally diagnosed with a mental health condi-
tion prior to medical school. The reported diagnoses
were: 22 (4%) depressive disorders, 15 (2%) anxiety
disorders, 7 (1%) ADHD or autism, 4 (1%) obsessive
compulsive disorder and 3 (0.2%) eating disorders.
Regarding psychotropic medication, 88 (14%) stu-
dents reported being prescribed medication for their
mental health (including depression, anxiety, psych-
osis and ADHD). Specifically, 40 (6%) had

Table 1. Socio-demographic characteristics of the medical

For the GHQ12, a score of 2 was considered as the
students (n ¼ 622).
cut-off to identify cases (Kim et al., 2013). For the
Characteristics n %
OLBI, burnout was indicated by a mean score of 2.25 Total number of participants: 622 100
for exhaustion and 2.10 for disengagement (Peterson, Gender:
Female 452 73
Demerouti, Bergstr€ om, Åsberg, & Nygren, 2008). Male 167 27
Finally, students were considered positive for prob- Other 3 <1
University of Participant:
lematic drinking if they scored 2 or more on the Faculty of Medicine of University of Coimbra, FMUC 124 20
CAGE questionnaire (Saitz et al., 1999). Faculty of Medicine of University of Lisbon, FMUL 303 49
Once data collection was completed, data was Beira Interior Institute, UBI 1 <1
Abel Salazar Biomedical Sciences Institute - University 194 31
extracted from Typeform into a customised Excel of Porto, ICBAS
(Microsoft, 2018) spreadsheet. This password-protected Year of study in medical school:
1st 109 18
spreadsheet was used to produce the results and data 2nd 129 21
analysis, if required, was performed using GraphPad 3rd 99 16
4th 91 15
Prism software. Statistical significant was inferred 5th 93 15
at p < 0.05. 6th 95 15
 INTERNATIONAL REVIEW OF PSYCHIATRY 3

Table 2. Mental health of respondents (n ¼ 622). Table 3. Summary of results obtained from the CAGE ques-
Mental health n (%) tionnaire, GHQ12 and OLBI.
Prior to medical school: – Instrument Cases (%)
Students with existing contact with healthcare 160 (26) CAGE 62 (10%)
professionals regarding mental health GHQ12 565 (91%)
Psychiatric diagnosis 47 (8) OLBI
Depressive disorders 22 (4) Disengagement 504 (81%)
Anxiety disorders 15 (2) Exhaustion 555 (89%)
ADHD or autism 7 (1)
OCD 4 (1)
Eating disorders 3 (<1) prescription medication outside of its intended use to
Psychotropics 88 (14)
Antidepressants 40 (6) feel better or uplift their mood, including multivitamins
Benzodiazepines 32 (5) (12%), methylphenidate (2%), benzodiazepines (1.5%),
Antipsychotics 5 (1)
Stimulants 4 (1) propranolol (1.1%) and modafinil (0.2%). In addition,
Whilst at medical school – 489 students (78.6%) reported using cannabis and 12
New contact with healthcare professional regarding 111 (18)
mental health (1.9%) using ecstasy.
Psychiatric diagnosis The GHQ-12 (El-Metwally et al., 2018) was used to
Anxiety disorders 94 (15)
Depressive disorders 44 (7)
assess non-psychotic ‘minor psychiatric disorders’
Eating disorders 40 (6) among medical students. The mean score of the
ADHD or autism 5 (1) whole sample was 5.77. 565 (91%) of students scored
OCD 2 (<1)
BPD 1 (<1) 2 or more and therefore flagged positive as a case.
Burnout 1 (<1) The OLBI was used to ascertain rates of burnout. 504
Psychotropic 81 (13)
Antidepressants 48 (8) (81%) flagged positive for disengagement and 555
Benzodiazepines 12 (2) (89%) for exhaustion (Table 3).
Other drugs 8 (1)
Stimulants 4 (1)

antidepressants, 32 (5%) had benzodiazepines, 5 (1%)
antipsychotics and 4 (1%) stimulants (Table 2).
In total, 94 (15%) medical students had been diag-
nosed with a mental health condition whilst at med-
ical school (Table 2). Specific diagnoses were: anxiety
disorders (n ¼ 44; 7%), depressive disorders (n ¼ 40;
6%), eating disorders (n ¼ 5; 1%), ADHD or autism
(n ¼ 2; 0.3%), OCD (n ¼ 1), BPD (n ¼ 1) and burnout
(n ¼ 1). Nearly one in five respondents (n ¼ 111; 18%)
reported currently seeing a general practitioner,
psychologist, psychiatrist or psychotherapist. 81 stu-
dents (13%) were taking medication for their mental
health. 48 (8%) were taking antidepressants, 12 (2%)
benzodiazepines, 8 (1%) other drugs, and 4 (1%)
stimulants (n ¼ 4; 0.64%).
Various stressors were identified. Of note, 446
(72%) students noted money, 77 (12%) housing, 41
(7%) studying and 293 (47%) relationships as key
stressors in their life.
The CAGE questionnaire test (Saitz et al., 1999) was
administered to identify problematic drinking. In total,
62 (10%) students were identified as being at risk of
alcohol-related health problems with 12% reporting
problems in cutting down on drinking, 8% annoyed by
being criticised because of their drinking, 18% feeling
guilty because of drinking and 2% having had a drink
first thing in the morning. In addition, 52 (8%) stu-
dents reported taking a non-prescription substance or
Discussion
Our results indicate that 8% of Portuguese medical
students were formally diagnosed with mental ill
health before starting medical school, with 15% being
diagnosed during medical school. Multiple key stres-
sors were identified by the students, with the majority
highlighting interpersonal relationships and financial
difficulties. Problem drinking, as identified through
the CAGE questionnaire, was seen in 10% of students.
Cannabis use was reported in 79% of the participants,
a very high figure compared to other countries in our
survey series. 91% of reached ‘caseness’ on the
GHQ12 questionnaire, which appears to indicate
widespread ‘mild’ mental distress in this cohort. For
burnout, disengagement was found in 81% and
exhaustion in 89% of respondents.
Previous studies in Portugal investigating mental
wellbeing and psychiatric illness in medical students,
namely anxiety and depression, revealed varied results
ranging from 6% to 21.5% (Moreira de Sousa et al.,
2018; Roberto, 2009). These results are considerably
lower than in this study, but distinct differences exist
in the instruments and cut-offs used. For example,
these studies utilised the Hospital Anxiety and
Depression Scale (HADS), which is limited towards
anxiety and depression and disregards other condi-
tions (Moreira de Sousa et al., 2018). Burnout has
previously been investigated by one study in Portugal
(Pereira et al., 2014). Through use of the Maslach
4 T. ALMEIDA ET AL.
Burnout Inventory, the authors observed high levels
of emotional exhaustion, disbelief and professional
efficacy similar to our findings. Previous studies
investigating problem drinking in Portuguese students
reveal similar results to our study, identifying 9% as
cases (Gonçalves & Carvalho, 2017).
During the late 1990s, Portugal suffered from very
high levels of alcohol and substance misuse in the
general population (Queensland Mental Health
Commission, 2018). By 2000, a new strategy was
introduced focussing on a public health approach to
controlling substance misuse, rather than criminal
justice approach (Queensland Mental Health
Commission, 2018). Cannabis remains the most com-
monly used substance in Portugal, with an average of
10% regular use across the Portuguese population
(World Health Organisation, 2009). Our results reveal
that approximately 78% of medical students have
used cannabis. Whilst regular cannabis use may be in
line with the national average, the high stress environ-
ment and academic adaptation required in medical
school combined with cannabis use may lead to detri-
mental effects on mental wellbeing.
Access to appropriate psychiatric care for Portuguese
medical students remains limited, with low numbers
seeking help due to complex reasons. Many students
may refuse help or may not recognise the importance
of seeking professional help, whilst others express finan-
cial difficulties and time constraints (Moreira de Sousa
et al., 2018). Stigma surrounding mental health remains
prominent in Portugal and extends into the medical
student population (Korszun, Dinos, Ahmed, & Bhui,
2012; Rodrigues-Silva et al., 2017; Telles-Correia, Gama
Marques, Gramaça, Sampaio, & Sampaio, 2015). This,
combined with the relatively high GHQ12 and OLBI
scores, may indicate the need for intensified support for
Portuguese medical students and awareness campaigns.
Limitations do exist within our study. The study
design is cross sectional, and though our sample was
large we do not know the response rate. However, this
study is part of a global initiative to characterise mental
wellbeing, burnout and psychiatric illness in medical
students. Results in Portugal are consistent with global
trends (Bhugra et al., 2019; Volpe et al., 2019; World
Health Organisation, 2009) and as such helps to further
characterise medical students as a unique population
requiring more support, safeguarding and interventions.
Future research is required to understand causality,
monitor trends and implement University, National
and international-level support and guidance for the
mental wellbeing of our future doctors.
Conclusion
Portuguese medical students report high levels of
burnout and mental ill health, higher than other stu-
dents. Financial and interpersonal stressors are identi-
fied as key difficulties throughout medical school.
Future research is needed to confirm and compare
these results globally, understand causality, monitor
future trends and crucially to determine evidence-
based interventions to tackle burnout and psychiatric
illness and improve mental wellbeing in medical stu-
dents. Early intervention, through university-wide
campaigns, support groups and education of medical
staff or tutors, with activities to promote psycho-
logical wellbeing and health (such as self-help, medi-
tation or mindfulness), may be crucial to safeguard
the future generations of doctors.
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