Introduction

In 1974, Beck, Weissman, Lester and Trexler created the concept of suicide risk, which is understood as any act aimed at deliberately inflicting harm on oneself, regardless of the degree of lethality, and includes self-injurious behaviors, suicidal ideation and previous suicide attempt ¹. Currently, there are multiple scales to assess suicidal ideation, such as the Columbia-Suicide Severity Rating Scale ², the Suicide Assessment Five-Step Evaluation and Triage ³, the Beck Scale for Suicidal Ideation ⁴, among others; however, the Plutchik and Van Praag Suicide Risk Scale is a simpler instrument ⁵ since it makes a discrimination between cases in which there was or was not a suicide attempt in the past ⁶.

According to the World Health Organization, more than 700,000 people worldwide die by suicide each year. Suicide is the fourth leading cause of death among people aged 15 to 29 years and the third leading cause of death among girls aged 15 to 19 years ⁷. Physicians are one of the groups at high risk for suicide ^2,3.

Some authors place suicide as the third leading cause of death among young adults. Although suicide rates vary worldwide, the highest rates occur in developed and high-income countries compared to developing countries ⁸.

For example, in Eastern Europe, Southeast Asia and countries such as South Korea and Russia, suicide rates exceed 20 cases per 100,000 people; whereas, in North Africa, Middle East and some Latin American countries, lower rates are reported, with five cases per 100,000 people ⁹.

An increase in suicide rates has been observed in Mexico. It has been estimated that, from 2000 to 2012, the suicide rate increased by approximately 17.1 % ¹⁰. In 2017, the suicide rate in Mexico was 5.31 per 100,000 people ¹¹. In addition, the incidence of suicidal behavior in Mexico City has also increased ¹⁰.

Medical training―from undergraduate studies―leads to a high prevalence of anxiety, depression and stress, which is widely documented ^12-14. A systematic review and metaanalysis of depression among physicians in undergraduate training performed by Rotenstein et al. ¹³ found a prevalence of 27.2 %, with a range of 9.3 % to 55.9 %, which means that it is 2 to 5 times higher than in the general population. The reported prevalence of suicidal ideation was 11.1 %, with a range of 7.4 % to 24.2 % ¹³.

A Canadian study conducted by Laramée et al. in 2019 identified a high rate of suicidal ideation and burnout among Canadian family medicine residents ¹⁵.

A study carried out in Egypt ¹⁶ reported high numbers of suicidal ideation among medical students. However, in the United States ¹⁷, the suicide rate was lower in medical residents compared to the general population, and suicidal ideation might be more closely associated with depression and burnout. This situation makes us question where we stand as hospitals and schools training medical specialists.

On the other hand, one study found that approximately 300 to 400 practicing physicians died by suicide each year ¹⁸, and another showed that one out of 16 surgeons reported suicidal ideation ⁸. Other studies revealed that resident physicians had a higher risk of depressive disorders, low mood, burnout and suicidal ideation than their peers in the general population ^12,19.

A study conducted in the Netherlands showed that 12 % of resident physicians reported suicidal ideation at least once during their training and 1 % of them had these thoughts several times ¹².

A study claims that the prevalence of suicidal ideation among medical students in Latin America is 13.85 % ²⁰. For their part, Lozano-Mundo et al. ²¹ reported 14 % in a sample of resident physicians in Jalisco, Mexico, and Jiménez et al. found a suicide risk of 7.4 % in resident physicians in Mexico City ^22,29. Another research, such as that of Jordán Alfonso et al. in Paraguay, described higher rates of suicidal ideation (16.2 %) than in the general population ²³. According to 2017 data from the Instituto Nacional de Estadística y Geografía (INEGI - National Institute of Statistics and Geography) in Mexico, Sonora ranked third below Aguascalientes and Chihuahua, where higher suicide rates are concentrated in the general population ²⁴.

However, statistics on resident physicians are very scarce in this region, so the present study will discuss the prevalence of suicidal ideation in the study population.

Results

A total of 225 surveys were answered, out of which 20 were eliminated due to inadequate completion, leaving 205. The average age was 28.66 years (SD ± 2.360); with respect to sex, 71.2 % were females and 28.8 % males. As for the federal entity of origin, 49.8 % were from the state of Sonora, 17.6 % from Sinaloa, 9.8 % from Baja California and 22.9 % from other states.

The average number of first-year resident physicians was 63.4 %; second-year 22.4 %; third-year 11.2 % and fourthyear 2.9 %. Concerning the specialties, pediatrics registered 28.8 %, general surgery 13.7 %, internal medicine and gynecology 10.2 %, otorhinolaryngology 7.8 %, nephrology and traumatology 2.9 %, and radiology and ophthalmology 2.5 %.

According to the relationship status of the resident physicians (being with or without a partner), the average number of residents without a partner was 60.5 % and with a partner 39.5 %. In relation to the daily working hours, it was found that 73.2 % work more than 12 hours, while 26.8 % work 11 hours or less. Regarding the suicidal ideation established with the PSRS, an average of 76.6 % of residents had a negative test and 23.4 % a positive one.

By using Pearson’s chi-square goodness of fit test to analyze the association with some variables and the possibility of having a positive test for suicidal ideation, a significant association between specialties with p = 0.0000 and academic degrees with p = 0.003 (p ≤ 0.05) was evidenced. On the other hand, sex (p = 0.165), federal entity of origin (p = 0.320), being with or without a partner (p = 0.317), daily working hours (p = 0 .744) and physical activity (p = 0.805) did not show a significant association (Table 1).

The PSRS yielded a 23.4 % positivity of suicidal ideation in the sample of 205 resident physicians. Pearson’s chi-square goodness of fit test did not find significant differences between the sample reported by DenisRodríguez et al. ²⁰ in Latin America with a prevalence of 13.85 % and the sample of this study with p = 0.139 (p ≤ 0.05).

In order to establish if there were differences regarding suicidal ideation between the groups of resident physicians by specialty, the Kruskal-Wallis H test, which is used to evaluate more than two groups, showed a value of p = 0.000. Additionally, in order to know which group was different, Tukey’s Honest Significant Difference test revealed that the specialty of gynecology was the different one.

Discussion

Suicidal ideation includes thoughts of being the agent of one’s own death, while a suicide attempt is a selfinjurious behavior with non-fatal outcomes accompanied by implicit evidence that the person intended to die by suicide ¹⁵. In a Mexican study on causes of death, a 70 % mortality rate by suicide was found among students and health professionals, which is higher than in other professionals ³⁰. Studies conducted more than 20 years ago ^32-34 as well as more recent ones ^34,16,17 have reported higher rates of depression and anxiety, above those observed in the general population. In a 2017 meta-analysis conducted in Latin America, DenisRodriguez et al. ²⁰ noted a prevalence of 13.85 %, which is lower than that found in the sample of the present study, which accounted for 23.44 %. However, the results of this study were lower than those described by Deschamps et al. ³⁶ in the United States, with 33.3 %; higher than those found by Laramée et al. ¹⁵ in Canada, with 12.8 %; but similar to those reported by Mortier et al. ³⁶, with 23.3 %.

When performing Pearson’s chi-square goodness of fit test, no significant differences were found between the sample of this study and that reported by Denis-Rodríguez et al. ²⁰ in Latin America.

Based on the demographic characteristics, the present study showed that there was a higher proportion of female residents, different from that reported by Jiménez-López et al. ²² in a sample of 108 residents in Mexico City, but similar to that described by authors such as Laramée et al. ¹⁵ in a sample of 109 family medicine residents. As for the average age, this study found similar results to those described by Jiménez-López et al ²².

With respect to the specialties included in the sample of this study, pediatrics was the most common specialty, followed by anesthesiology; while in the study by JiménezLópez et al. ²², general surgery was the most common specialty, followed by anesthesiology.

Suicidal ideation and male or female sex did not show a significant association, nor did physical activity or daily working hours greater than 12 or less than 11 hours, which differs from the study conducted by Grasdalsmoen et al ³⁷ in Norway. However, a Japanese study found a higher risk of depression and thus a greater possibility of suicidal ideation ³⁸.

In this study, no significant association was found with regard to the relationship status (being with or without a partner); however, Kyung-Sook et al. ³⁹ point out in their study that suicide occurs more frequently in unmarried people compared to their married counterparts. The federal entity of origin did not have a significant association in the present study.

When evaluating the association with a specific specialty, the research by van der Heijden et al. ⁴⁰ found that psychiatry residents had more frequent suicidal ideation, unlike the sample of this study, where the specialty that showed a difference was gynecology. However, the sample of the present study did not include residents of the specialty of psychiatry, since both hospitals do not cover this branch of medicine.

In conclusion, according to the results of the study sample, one fifth of the resident physicians had suicidal ideation and the prevalence in this sample showed no significant difference with respect to its incidence in Latin American. In addition, an association between suicidal ideation, medical specialties and academic degree was found. Regarding the comparison of specialties, gynecology presented the highest suicidal ideation.

This study had some limitations; for example, the groups were very heterogeneous, a probabilistic selection technique was not used, and the statistical tests were nonparametric. More-homogeneous research groups are proposed to reduce biases, as well as a normal distribution to conduct more-robust statistical tests than nonparametric ones.