Introduction

Recognition of mental health problems within the medical profession has led to various efforts to study this problem and the risk factors involved in their presentation, such as long workdays at the hospital, work overload, sleep deprivation, complaints from relatives and patients, insufficient medical knowledge, informal learning, uninspiring academic environments, a high degree of competitiveness, and changes in their work and personal environment, which sometimes involves moving away from their families or places of origin (^{Prieto-Miranda, Rodríguez-Gallardo, Jiménez-Bernardino, & Guerrero-Quintero, 2013}). It has been observed that from the early stages of medical training, the presence of depression or depressive symptoms is reported in 10% to 25% of students (^{Schwenk, Davis, & Wimsatt, 2010}), while nearly half of them experience burnout and 10% suicidal ideation (^{Dyrbye et al., 2008}), with suicide being the second cause of death in this population (^{Whitcomb, 2004}; ^{Anderson, 2018}). At the same time, physicians in training experience various barriers in help seeking such as long waiting times to receive care, concern that their medical records will affect their ability to secure employment or work licenses in the future, stigma, and lack of time (^{Karp & Levine, 2018}).

The nature of medical education would seem to contribute to this disparity, since on admission, medical students score better on mental health indicators than students of a similar age (^{Brazeau et al., 2014}), yet as the medical training process advances, there is an increase in depressive symptoms (^{Mata et al., 2015}), burnout (^{Dewa, Loong, Bonato, Trojanowski, & Rea, 2017}), substance use (^{Martínez-Lanz, Medina-Mora, & Rivera, 2005}) and suicide risk, the latter being the leading cause of death in men engaged in a medical residency program, and the second leading cause in women (^{Yaghmour et al., 2017}). Specialty studies in medical residencies correspond to a period in which an increased risk of presenting with mental health problems has been observed, which has been related to long workdays and a heavy workload, increased patient care responsibilities, sleep deprivation, and workplace bullying (^{Levy, 2018}).

In Mexico, although studies have been carried out to undertake a mental health diagnosis of resident physicians, very few include different institutions (^{Prieto-Miranda et al., 2013}). ^{Jiménez-López, Arenas-Osuna, and Angeles-Garay (2015)} conducted a prospective, longitudinal study of 108 resident physicians at the Specialty Hospital, Centro Médico Nacional La Raza of the Instituto Mexicano del Seguro Social, in which a six-month follow-up found an increase in the prevalence of depression from 3.7% to 22.2%, anxiety from 38% to 56.5%, and suicide risk from 1.9% to 7.4%. It is a well-known fact that medical residents have a high risk of developing burnout syndrome, characterized by depersonalization, emotional fatigue, and a decrease in the effectiveness of their work, which is linked to depression, affecting the personal and family structure, and reflected in job quality and performance (^{Pérez Cruz, 2006}), as well as a deterioration in their quality of life (^{Prieto-Miranda et al., 2013}).

This study seeks to determine the mental health conditions and associated factors in medical residents in the Guadalajara Metropolitan Area, which can serve as the basis for proposals to improve the well-being, quality of life, prevention, and care of specialists in training.

Method

Results

Discussion and conclusion

There have been numerous efforts to study the phenomenon of mental health in medical training. A meta-analysis of 54 studies, including 17,560 resident physicians, found a depression prevalence of 28.8% (^{Mata et al., 2015}), while in its report on the lifestyle and happiness of residents, Medscape notes that 10% of the residents in the United States feel depressed daily or most days, and 33% sometimes, while 9% report having suicidal thoughts (^{Levy, 2018}). It is worth noting the relatively low proportion of people who reported depression in the survey (9.2%), especially as compared with the high percentage who reported having had “the idea of not wanting to live or taking their own lives in the past weeks” (14%). Apparently other phenomena such as burnout, anxiety symptoms, and substance use could have contributed as intervening factors (independently of depression) to the increase in the number of people with “thoughts of death.”

Depression affects people’s working lives and decreases their work effectiveness, and since they are medical personnel in training, this is an even more delicate issue, since it is associated with a high number of accidents or iatrogenesis, and deficiencies in the quality and warmth of patient care, which in turn affects the healing process (^{Velásquez-Pérez, Colin-Piana, & González-González, 2013}).

Since certain factors facilitate involvement in drug use, such as the presence of tension, stress and, anguish caused by the demands of the role played by the subject, those engaged in the medical profession and in training are particularly susceptible to substance use. In our study, the most frequently consumed substances were ethanol (88.2%), tobacco (54.1%), and cannabis (28.1%), followed by tranquilizers (9%) and methamphetamines (6%). These data contrast with a survey conducted on 192 residents of a general hospital in Mexico City, where less substance use was reported (65% consumed alcohol, 4.5% cannabis, and 3.4% amphetamines), except for the consumption of tobacco and tranquilizers (55% and 10.6%, respectively), which was higher (^{Martínez-Lanz et al., 2005}).

Regarding the correlation analysis, what is observed in terms of alcohol consumption and its association with other substances and intervening factors is relevant since no other substance correlated with as many variables. It could therefore be hypothesized that alcohol is usually a gateway drug, which leads to the use of other substances (in our study, it had a statistically significant association with all substances except methamphetamines). Even more striking are the levels of correlation between cocaine and alcohol and tranquilizers use. It is known that cocaine users tend to combine this substance with alcohol and subsequently abuse benzodiazepines (tranquilizers) following intoxication with the drug in question. However, given the extremely small sample of people who use this substance (nine people reported consuming cocaine, six of whom only mildly), these results should be taken with caution, especially because, when the non-parametric Spearman’s test was performed, no statistical significance was obtained for the correlation levels.

A risk of developing burnout was observed in 72.5% of our sample, exceeding the rates reported in similar surveys conducted in several countries, where it was reported that a third to half (36-51%) of physicians experienced professional burnout, depression, or both simultaneously, and that 19%-25% of the latter reported that their problem was so serious that it made them consider dropping out of medical school (^{Kerry, 2019}). Along these same lines, our results reflect the fact that in residents who frequently thought about quitting (21.2%), there was a greater risk of developing anxiety, insomnia, depression, and burnout symptoms. Moreover, those who reported the presence of workplace bullying (39.2%) had a higher risk of developing intense symptoms of anxiety, insomnia, and burnout, as did those with a higher number of on-call shifts, as well as over 80 HWW. These data coincide with the risk variables present in the study conducted by ^{Kerry (2019)}.

Despite the scope of the problem, there is a large gap in the search for mental health care in this population, where stigma seems to be the main factor preventing them from receiving specialized treatment, since it can raise doubts about whether seeking care would affect their stay in medical school or jeopardize their academic achievements (^{Whitcomb, 2004}). It is estimated that 64% of the physicians with burnout or depression have never received care (^{Kane, 2019}), while 68% of the residents report stigma related to mental health care seeking (^{Levy, 2018}). The reasons cited for refusing to seek care include the fact that they prefer to handle it independently, lack of time, fear of being reported to the medical leave department, shame of receiving a psychiatric diagnosis, and fear of this having repercussions on their work (^{Gold et al., 2016}). In our survey, nearly a third considered it disadvantageous for their colleagues or the authorities to know about their mental health care, while half, mainly women, did not know how to access these services. Those with anxiety and insomnia had a greater need to request care, compared to those with fewer than 80 HWW, who were less likely to have requested it. At the same time, fear of professional sanctions can lead to risky coping methods, such as excessive substance use or self-medication (^{Schwenk et al., 2010}).

The limitations of our study include the fact that it is based on self-reported data, and may contain several potential sources of bias, due to the difficulties caused by selective memory, attribution, or exaggeration, as well as the selection of residents from clinical specialties included in the study rather than surgical specialties, possibly attributable to the non-probabilistic selection of the sample.

Our study contains crucial features, such as the greater number of hours worked per week, the presence of workplace bullying in the hospital to which they are attached, and the consumption of ethanol and methamphetamine, which impact the mental health of medical residents. These findings are consistent with what has been reported in the literature and enable one to identify significant areas of intervention for the improvement of academic and work conditions, to improve training processes and reduce the risks to mental health of medical specialists in training, thereby improving the quality and safety of care for the user population.