From Burnout to Broken Systems: Massive Review Maps the Web of Suicide Risk in Medical Trainees

Medical training has long carried a hidden toll, and one of its darkest manifestations is suicidality — a spectrum that ranges from fleeting thoughts of ending one’s life to concrete plans and actual attempts. A new scoping review published in BMC Psychiatry has now taken the most comprehensive look yet at why medical students, interns, residents, and fellows experience suicidal thoughts and behaviors, mapping the contributing factors across every layer of their lives. Drawing on 111 studies from 35 countries, the research team led by Reza Goujani and AliAkbar Haghdoost of Kerman University of Medical Sciences used the Social-Ecological Model, a well-established public health framework, to organize the evidence into four nested domains: individual, interpersonal, community, and societal. The result is a sweeping cartography of risk that makes one thing unmistakably clear — the crisis in medical trainee mental health is not a personal failing but a systems problem.

The scale of the underlying literature is staggering. The researchers searched four major databases — PubMed, Scopus, Web of Science, and APA PsycInfo — from their inception to July 23, 2025, and identified 11,260 records. After independent screening by two reviewers at both the title-and-abstract and full-text stages, 111 studies met the inclusion criteria. The methodological framework followed the classic approach of Arksey and O’Malley, refined with guidance from the Joanna Briggs Institute and reported according to the PRISMA-ScR checklist, the international standard for scoping reviews. Data extraction used a standardized form, and every factor reported in association with suicidality was classified into one of the four Social-Ecological Model levels. This systematic categorization allowed the team to see patterns that no single study could reveal on its own.

One of the most striking findings is how lopsided the evidence base is. The vast majority of the included studies — 80.2 percent, or 89 of the 111 — focused on medical students, while postgraduate trainees such as residents and fellows were comparatively neglected. Most studies were also cross-sectional, meaning they captured a single moment in time rather than following trainees over years. This design limitation matters enormously: cross-sectional data can reveal which factors are associated with suicidality, but it cannot establish whether a factor causes suicidal thinking, results from it, or simply coexists with it. The authors are explicit on this point, noting that the findings represent a heterogeneous evidence base and do not establish causal relationships. Still, the sheer breadth of the synthesis offers something the field has lacked — a unified map of where the risk factors cluster.

At the individual level, the picture is dominated by well-known psychiatric and psychological burdens. Depression, anxiety, burnout, psychological distress, and sleep-related problems were the most frequently reported factors, appearing in the overwhelming majority of studies. These are not surprising candidates; depression in particular is one of the strongest known correlates of suicidal ideation in any population. But the medical training environment appears to amplify each of them. Sleep deprivation is structurally built into residency through overnight call schedules, burnout is fueled by relentless workload and emotional exhaustion, and the competitive, high-stakes nature of medical education creates chronic psychological pressure. The consistency of these individual-level findings across countries and decades underscores that the trainee experience itself may be a potent generator of the internal conditions that precede suicidal thinking.

The interpersonal level reveals how relationships — or their absence — shape risk. Family dysfunction, poor social support, and harassment emerged as key factors reported across the literature. For trainees who spend long hours in hospitals and often relocate for training, social isolation is a real hazard, and the erosion of supportive networks can strip away one of the most powerful protective buffers against suicide. Harassment, whether from colleagues, supervisors, or patients, adds a corrosive layer of humiliation and threat to an already stressful environment. These findings align with decades of suicide research showing that connectedness to family, friends, and community is among the strongest protective factors, while interpersonal conflict and abuse are among the strongest risk factors. In medicine, where hierarchy is steep and reporting mistreatment can feel career-threatening, these interpersonal dynamics deserve particular scrutiny.

At the community level, the review identified academic pressure, workload, and workplace stressors as the dominant reported factors. This is the domain where the architecture of medical education itself comes into focus: examination systems, duty-hour demands, the pressure to publish, and the culture of perfectionism that pervades teaching hospitals. Notably, the authors observed a temporal shift in the literature. Community-level factors were reported in 27.6 percent of studies published between 2000 and 2015, but that figure rose to 35.4 percent in the 2016 to 2025 period. Individual-level factors remained dominant in both eras, reported in 72.4 percent and 76.8 percent of studies respectively. The gradual increase in attention to community-level drivers suggests the field is slowly widening its lens, moving beyond the individual psyche toward the environments that shape it.

The societal level, the outermost ring of the Social-Ecological Model, exposes forces that individual trainees have almost no power to change. Financial pressures, stigma surrounding mental illness, and barriers to accessing mental health services were the most commonly reported societal factors, alongside societal disruptions such as the COVID-19 pandemic. Stigma is particularly insidious in medicine: trainees fear that seeking psychiatric care or disclosing depression could jeopardize licensure, fellowship applications, or employment. Licensing questions about mental health history in many jurisdictions have long been criticized for discouraging physicians from getting help. Financial pressures compound the problem, with medical students in many countries carrying enormous educational debt while earning little or nothing during training. The pandemic added a further layer of strain, thrusting trainees into overwhelmed health systems at personal risk.

The authors are careful about what this synthesis can and cannot claim. Because the evidence relies predominantly on self-reported data, reporting bias is a real concern — trainees may underreport suicidal thoughts due to stigma or fear of professional consequences, meaning the true prevalence could be even higher than studies suggest. The heterogeneity of study designs and measurement tools across the 111 studies also limits comparability, preventing any meta-analytic pooling of effect sizes. What the review delivers instead is a framework: proof that factors associated with suicidality among medical trainees span all four Social-Ecological domains, and a demonstration that a multilevel lens is both feasible and necessary for organizing this literature. By including both undergraduate and postgraduate trainees, the review also offers a broader perspective across the entire arc of medical training than most previous syntheses.

The implications for intervention are significant. If suicidality among trainees were driven solely by individual pathology, the solution would be screening and treatment. But a multilevel map demands a multilevel response: duty-hour reform and workload management at the community level, anti-harassment policies and mentorship structures at the interpersonal level, destigmatized and confidential mental health services at the societal level, and evidence-based care for depression, anxiety, and burnout at the individual level. The authors call for future research to examine contextual and system-level factors, particularly among postgraduate trainees, using longitudinal and multilevel designs that can finally untangle cause from correlation. Until then, this review stands as both a warning and a blueprint — a demonstration that the path from medical school to suicide is paved not just by personal vulnerability, but by the systems that trainees are required to endure.

Subject of Research: Multilevel factors associated with suicidality among medical trainees

Article Title: Suicidality among medical trainees: a scoping review of multilevel associated factors using the Social-Ecological Model

Article References: Goujani, R., Nakhaee, N., Heidari, M., Rezaei-Gazki, P., Dehesh, P., Abdollahinia, Z., & Haghdoost, A. (2026). Suicidality among medical trainees: a scoping review of multilevel associated factors using the Social-Ecological Model. BMC Psychiatry. https://doi.org/10.1186/s12888-026-08711-9

Image Credits: AI Generated

DOI: 10.1186/s12888-026-08711-9

Keywords: suicidality, medical trainees, medical students, residents, Social-Ecological Model, scoping review, burnout, depression, mental health stigma, workload, harassment, COVID-19