Prevalence of mental health problems among medical students in Brazil: an updated systematic review and meta-analysis of 126 studies

²MD, PhD, Professor, Department of Life Sciences, Universidade do Estado da Bahia, Salvador, Brazil

³MD, PhD, Professor, Department of Neurosciences, Universidade Federal da Bahia, Salvador, Brazil

Date submitted: 10-June-2025

Email: Vitor Melo (vitormfmelo@gmail.com)

This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

Citation: Melo V, Balac R, Marques M, and Melo A. Prevalence of mental health problems among medical students in Brazil: an updated systematic review and meta-analysis of 126 studies. Educ Health 2025;38:411-430

Online access: www.educationforhealthjournal.org
DOI: 10.62694/efh.2025.355

Published by The Network: Towards Unity for Health

Background

Mental health problems (MHPs) are among the most prevalent health-related issues worldwide and are leading causes of disease burden. Among those most susceptible to the wide array of MHPs are university students, with medical students experiencing especially high rates.^1,2,3 Some studies suggest that the highly competitive academic environment, demanding workload, and peer pressure are contributing factors for a diminished quality of life and poor mental health in this population.⁴

Within the Brazilian context, a review from 2016 reported elevated prevalence rates of different MHPs, such as excessive daytime sleepiness (46.1%), general anxiety (32.9%), depression (30.6%), common mental disorders (31.5%), low sleep quality (51.5%), and stress (49.9%), among medical trainees in the country.⁵ Since then, a significant number of new primary studies have been published, reflecting the growing interest in this subject.

Additionally, the onset of the COVID-19 pandemic in 2020 significantly influenced the mental health landscape—globally and in Brazil. Numerous factors contributing to poor mental health outcomes were exacerbated, which influenced the frequency of various MHPs. A study conducted in 2020, assessing the prevalence of depressive and anxiety disorders in 204 countries and territories estimated that during the pandemic, the prevalence of major depressive disorder and anxiety disorders increased globally by 25% and 28%, respectively, particularly among younger individuals.⁶ In Brazil, while numerous primary studies have been published, they are fragmented and present varying results from different populations. Consequently, the current epidemiological state of MHPs among Brazilian medical students remains unknown.

While extensive primary data on mental health issues exist among medical trainees in Brazil, the COVID-19 pandemic has introduced a new epidemiological landscape. Therefore, this study aimed to conduct a systematic review of the available literature to estimate the prevalence of MHPs among medical students in Brazil via meta-analysis, and to assess the pooled prevalence of studies conducted before and after the onset of the COVID-19 pandemic in the country.

Methods

This systematic review was registered in the PROSPERO International Prospective Register of Systematic Reviews (registration number CRD42024499416) and is reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis checklist (PRISMA).

Search strategy and selection criteria

In this systematic review and meta-analysis, we searched PubMed, EMBASE, Scopus, LILACS and PsycINFO from database inception until Feb 20, 2024, to identify all relevant cross-sectional studies that reported the prevalence of MHPs (e.g., depressive or anxiety symptoms, burnout syndrome, suicidal ideation, etc.) among medical students in Brazil. There were no restrictions on language or date of publication. The search strategy for all databases used the following terms: “medical students”, “undergraduate students”, “mental health”, “depressive disorder”, depression, “mood disorders”, “bipolar, schizophrenia, stress, anxiety, burnout,” “panic disorder”, “panic attack”, “affective disorders”, “behavioral symptoms”, “suicide, suicidal”, “sleep disorders”, “sleep deprivation”, “sleep quality”, “sleep wake disorders”, “personality disorders”, “substance-related disorders”, “Brazil, Brazilian, Brasil”. In addition to these bibliographic database searches, the references of all relevant research articles were scrutinized to identify additional data sources. A complete list of search terms for MEDLINE is provided in an Appendix available upon request to Author.

Eligibility criteria

To be included in this review, primary studies had to be cross-sectional studies reporting the prevalence of one or more MHPs in a sample of medical student in Brazil, published in a peer-reviewed journal, and utilizing validated instruments translated into Brazilian Portuguese. For international multicenter studies, separate data on the Brazilian sample should be reported. We excluded studies that focused on university students without subgroup analysis of medical students; studies using questionnaires in which the primary focus was not the assessment of an MHP (e.g., quality of life questionnaires, lifestyle questionnaires); studies with samples comprising only one sex; studies published in formats that do not undergo peer review (e.g., letter to the editor); cross-sectional studies with data collection at different time periods on the same sample (e.g., at the beginning and end of the year); and studies with overlapping data from another included study (in such cases, the most comprehensive report with the largest sample size was included). If the full text was not available, the corresponding author was contacted via e-mail. If a study had overlapping data with one of the included studies but presented data on additional MHPs, only the latter was included.

Selection process

Two reviewers independently screened the titles and abstracts identified in the literature search. The full texts of potentially eligible articles were obtained to determine whether the studies met the eligibility criteria. Disagreements were resolved through discussions between the two authors until consensus was reached. A third reviewer was available for arbitration, if needed.

Data items

Two investigators independently extracted relevant information from individual studies using a preconceived and standardized data extraction form, including the first author, publication year, period of data collection (year and month range), Brazilian state and region (North, Northeast [NE], Central-West [CW], Southeast [SE] and South) where recruitment was performed, sample size, mean or median sample age, proportion of female participants, MHP assessed, instrument and cutoff score used, prevalence in the total sample, and prevalence in males and females, when available. The data collection periods of the included studies were dichotomized into pre-pandemic and post-pandemic onset. Studies were considered to have been conducted after the onset of the COVID-19 pandemic if data collection began after March 2020, when the initial physical distancing and isolation measures started in Brazil, or if it was explicitly stated in the methods section that data collection was performed entirely during the COVID-19 pandemic. Studies that began data collection before this date but completed it afterwards were labeled as “overlapping”. Any discrepancies were resolved through discussion and consensus among the authors. When relevant data were not available, we contacted the corresponding authors of the studies to request the information.

Risk of bias assessment

We assessed the methodological quality of the included studies using The Joanna Briggs Institute Critical Appraisal Checklist for studies reporting prevalence data. This checklist contains nine questions, and answers could be “yes,” “no,” “unclear,” or “not applicable.” The cutoff points were determined according to previous systematic reviews and were as follows: risk of bias (RoB) was defined as “high” when the study reached up to 49% score “yes”; “moderate” when the study reached 50% to 69% score “yes”; and “low” when the study reached more than 70% score “yes”.^7,8 Two reviewers independently assessed study quality, with disagreements resolved by consensus or arbitration by a third author. Additionally, each study was given a global score ranging from 0 to 9 based on the number of questions answered “yes”, with higher scores indicating higher quality studies.

Studies classified as having a moderate to low RoB according to these criteria were synthesized separately using the methods described below.

Synthesis methods

A meta-analysis was performed to assess the pooled prevalence of the different MHPs. We pooled the prevalence estimates from studies for each mental health issue using the DerSimonian-Laird random-effects model, and the prevalence estimates were transformed via the Freeman-Tukey double arcsine transformation. Between-study heterogeneity was assessed using the I² statistic. The results are presented in forest plots with 95% confidence intervals (95% CI). Analyses were performed using the meta package in R (version 4.0.5).

We performed a subgroup analysis to explore the role of the dichotomized data collection period (pre-pandemic onset vs. post-pandemic onset) on MHPs prevalence whenever at least eight studies were available for each period. Meta regression was used for continuous variables: “year of data collection” and “RoB score”. Statistical significance was set at p-value < 0.05. We also conducted a sensitivity analysis that included studies reporting prevalence estimates for the same MHP using the most frequently employed screening instrument and its most common cutoff (e.g., depressive symptoms assessed by the Beck Depression Inventory with a cutoff score of ≥10). Additionally, owing to Brazil’s large territorial size, analyses were also grouped by geographic macroregion.

We did not assess publication bias in this study because it only included prevalence studies. As discussed by Borenstein,⁹ the procedures to address publication bias are based on the premise that statistically significant studies are more likely to be published than those that are not; this premise does not apply to studies reporting the prevalence of a condition (e.g., depressive symptoms) in a sample. This approach aligns with other guidelines for conducting proportional meta-analyses.¹⁰

Results

Study selection

We initially identified 2,572 records through the database search. After the removal of duplicates, 2,078 records were screened by title and abstract, of which 217 full-text articles were reviewed, and 126 were included in analysis (Figure 1). The list of studies excluded at the full-text screening stage, along with reasons for exclusion, can be found in an Appendix available upon request to Author.

Study characteristics

A total of 47,513 medical students in Brazil were included in the review, with sample sizes ranging from 35 to 4,840. The mean or median age of students varied from 20 to 27.7 years (range 17 – 41), and the proportion of female participants varied from 39.1% to 80.6% across the included studies. A total of 102 studies provided information from data collected before March 2020 (labeled as pre-Covid-onset), ^11–112, 20 after the referred date (post-Covid-onset), ^113–132 and four were undetermined.^133–136 Regarding the five Brazilian territorial macro regions, 35 studies were conducted in the NE region, two from the North region, 49 from the SE region, five from the CW region, and 24 from the South region; eight were multicenter studies, and three did not report. Information on each study is available in an Appendix available upon request to Author.

RoB in studies

For the RoB assessment, 37 (29.4%) studies were classified as having a low risk of bias, 66 (52.4%) as having a moderate risk and 23 (18.2%) as having a high risk. The item with the most unsatisfactory response among the studies was question five: “Was the data analysis conducted with sufficient coverage of the identified sample?”, as only 42 (33.3%) studies received a “yes” score. The most common RoB score was five, which was assigned to 35 studies. The lowest score was two, which was received by six studies, whereas the highest score was nine, which was assigned to two studies.

Results of synthesis

In the 50 studies (n=24,072 participants) in which the prevalence of depressive symptoms was reported, the pooled estimate from the random-effects meta-analysis was 36.3% (95% CI 31.2–41.6, I²=99%) (Figure 2). Meta-analytic pooling from the 20 studies that provided values for males and females yielded a pooled prevalence of 27.9% (95% CI 20.6–35.8, I²=96%) for males and 36.8% (95% CI 28.0–46.9, I²=98%) for females. The prevalence of anxiety symptoms was reported in 29 studies (n=12414 subjects), yielding a pooled prevalence of 41.2% (95% CI 33.8–48.8, I²=99%) (Figure 3). Eight studies provided prevalence data for males (27.4% [95% CI 19.7–35.7, I²=88%]) and females (39.8% [95% CI 30.6–49.3, I²=94%]). The pooled prevalence estimates of other MHPs are displayed in Table 1.

Figure 2 Pooled prevalence of depressive symptoms among medical students in Brazil

Figure 3 Pooled prevalence of anxiety symptoms among medical students in Brazil

Table 1 Pooled prevalence of mental health problems among medical students in Brazil

For subgroup analysis based on the time of data collection, 41 pre-Covid-onset studies (n=20,084 subjects) assessed the prevalence of depressive symptoms, resulting in a pooled prevalence of 34.8% (95% CI 29.1–40.7, I²=98%), whereas the nine post-Covid-onset studies (n=3,988 subjects) reported a pooled prevalence of 43.4% (95% CI 31.0–56.3, I²=99%; test for subgroup differences p=0.22). Regarding anxiety symptoms, subgroup analysis showed that the 19 pre-Covid studies (n=8,306 subjects) yielded a pooled prevalence of 40.2% (95% CI 31.0–49.8, I²=99%), compared to 43.1% (95% CI 30.3–56.4, I²=99%; p=0.73) of the 10 post-Covid studies (n=4108 subjects). Owing to the insufficient number of post-Covid-onset studies, it was not possible to perform this subgroup analysis for other MHPs.

To further assess the impact of other moderators on the prevalence rates of MHPs, meta-analyses stratified by geographic region and RoB (moderate to low RoB studies) were conducted, and the results are displayed in Table 2, respectively. Notably, it was not possible to synthesize results for the North region for any MHP, because of an insufficient number of studies, as only two articles were identified during the literature search, each assessing a different mental health issue.

Table 2 Pooled prevalence of mental health problems among medical students in Brazil, by region.

In the meta-regression analysis, we found a significant positive association between the year of data collection and the prevalence of depressive symptoms (β-coefficient=0.01, p=0.0474) and common mental disorders (β-coefficient=0.01, p=0.0002). The year of data collection for other MHPs did not significantly account for heterogeneity in prevalence estimates. The RoB score also showed no association with the prevalence estimates of any MHP.

For the sensitivity analysis, we found that the pooled prevalence of each MHP was generally consistent when comparing studies that used the most frequently employed screening instrument and its most common cutoff value against the overall pooled prevalence in an Appendix available upon request to Author. As an exception, two questionnaires related to anxiety symptoms were tied as the most commonly used across studies (i.e., the Beck Anxiety Inventory [BAI] ≥ 11 and the General Anxiety Disorder-7 ≥ 10); studies using the BAI reported a pooled prevalence of 29.5% (95% CI 14.3–47.4) compared with the overall prevalence of 41.2% (95% CI 33.8–48.8).

Discussion

To the best of our knowledge, this is the first systematic review and meta-analysis of the prevalence of multiple MHPs among medical students in Brazil following the COVID-19 pandemic. We synthesized data from 126 studies involving 47,513 participants, providing the pooled prevalence of multiple MHPs, such as depressive symptoms (36.3%), anxiety symptoms (41.2%), burnout syndrome (21.9%), alcohol abuse (31.2%), poor sleep quality (65.6%) and others.

When studies conducted before and after the start of the COVID-19 pandemic were pooled, depression and anxiety symptoms were not significantly different in their estimated pooled prevalence among medical trainees. It is worth noting that this analysis does not assess the causal impact of the pandemic on the observed differences in prevalence. Nonetheless, there is evidence of a global rise in mental health cases during that global health emergency, particularly from longitudinal studies, which are outside the inclusion criteria for this review. One large review estimated 53.2 million new cases of major depressive disorder and 76.2 million new cases of anxiety disorders worldwide due to COVID-19, with the most notable increase among younger individuals.⁶

In contrast, a repeated cross-sectional study evaluating mental distress in a sample of medical students in Brazil before and during the pandemic reported stable results over a three-year period.¹³⁷ This stability may be attributed to the already high levels of CMD among students prior to the pandemic, possibly resulting in a “ceiling effect”, which is consistent with the already high prevalence rates of MHPs found in our review, even though crude pre/post comparisons of cross-sectional data do not assess causality. Nevertheless, a longitudinal survey of medical students in India revealed an increase in anxiety and stress levels during the pandemic, which aligns with the results from young adults in a random sample survey of the UK population in the same period.^138,139 The differences found among studies from different countries that directly assessed the causal impact of the pandemic are likely due to variations in sample characteristics, the types of MHPs assessed, study design, and how each country managed the pandemic.

Further analyses were performed to assess the impact of other moderators. Meta-analyses of studies with lower RoB yielded prevalence rates similar to those found from synthesizing all studies, suggesting that the overall estimates are robust and not substantially influenced by study quality. We also grouped samples by Brazil’s geographic macroregions. While the prevalence of some MHPs, such as depression and poor sleep quality, were consistent across regions, others like CMD and stress showed some variation. These differences may be related to other factors such as instruments used, types of institutions involved and the number of available studies in each region. This highlights the need for nationwide inquiries into medical and other undergraduate students’ mental health, using unified instruments to better understand regional differences and particularities. Notably, although the North region covers almost half of the country’s territory, we identified only two available studies during the literature search, each addressing a different outcome. As a result, meta-analysis was not possible for the region. This issue has also been identified in previous Brazilian reviews, due to the shortage of studies from this area.^5,8 Thus, future research should ensure the inclusion of samples from the North to better account for the country’s full demographic diversity.

The present analysis builds on extensive evidence showing that medical trainees often exhibit high levels of MHPs. A similar review synthesizing studies from various countries reported a prevalence of 27.2% for depression and 11.1% for suicidal ideation during medical school, similar to our results of 36.3% and 11.4% for these MHPs, respectively.¹⁴⁰ These rates are notably higher than those typically reported in the general population.¹⁴¹ For instance, a large and representative mental health survey in the metropolitan region of São Paulo found that among young adults from the general public, 9.7% of participants suffered from major depressive disorder, 19.2% from any anxiety disorder and 3.5% with alcohol abuse; lower rates than those found in our review.¹⁴²

Burnout syndrome is another well-documented concern among medical students, as confirmed by the high prevalence found in the present review. A national survey of the United States population found that burnout is more prevalent among physicians, residents, and medical students than among their peers in the general population, peaking during medical school and gradually declining with each career stage.² Similarly, a Brazilian study observed that medical students exhibited poorer psychological well-being and social relationships than their age-matched controls did.³ Factors such as increased competition, lack of time for personal activities, and insecurity about their professional future have been shown to negatively impact medical students’ mental health and quality of life, placing a substantial burden on their well-being.⁴

Furthermore, we found that the prevalence of depressive symptoms and CMD showed a positive increase according to the year of data collection. The other MHPs did not show any significant difference. The reasons for this increase remain unclear. This could be due to general societal changes, as evidence shows a rise in mental health issues and their burden over the past decades, which naturally affects medical students.¹⁴³ Alternatively, differences in data collection methods or diagnostic criteria over the years could also be contributing factors for the increase. Nonetheless, it is worth noting that a similar systematic review, which focused only on studies conducted after the pandemic outbreak, reported rising prevalence rates of depression and anxiety symptoms among medical students globally.¹⁴⁴ Therefore, despite growing evidence-based interventions for treating MHPs, these appear to continue to increase in both the general population and specific groups, such as medical trainees, and external factors, such as the pandemic, likely exacerbated these issues.¹⁴³

The rates of sleep-related disturbances were the highest among the MHPs in this review, with 65.6% of students experiencing poor sleep quality and 54.6% suffering from excessive daytime sleepiness. These findings indicate that the majority of medical students in Brazil do not enjoy adequate sleep hygiene, which itself is a contributing factor to other poor mental health outcomes. One systematic review demonstrated that poor sleep and insomnia symptoms are both associated with increased stress among undergraduate students.¹⁴⁵ Furthermore, a review of randomized controlled trials revealed that improving sleep led to a significant positive effect on mental health, including reductions in depression, anxiety, stress and psychotic symptoms.¹⁴⁶ The high prevalence of sleep disturbances reported in the present review emphasizes the opportunity to address sleep hygiene in medical education as an effective way to support students’ overall health.

In general, we observed that female students had higher prevalence rates of MHPs than males, except in the case of alcohol abuse. This trend was also observed in a previous review of Brazilian medical students, as female gender was significantly associated with higher rates of depression, anxiety, and stress, indicating a consistent pattern.⁵ Similar findings have also been reported in epidemiological studies of the general population and have persisted during the pandemic.^144,147 Underlying biological, psychological, and social factors are likely contributors to this disparity, and possible explanations have been discussed previously.¹⁴⁸ Furthermore, the higher prevalence of alcohol abuse among male students found in our review is consistent with similar reports of higher rates of substance use disorders, alcohol abuse and dependence in this group.¹⁴⁸ This could be due to different social behaviors in this population, such as the use of alcohol to cope with academic stress, and greater social acceptance of drinking among males. The university setting can also play a role in problematic substance use, as students often face peer pressure to initiate or escalate consumption, and typically gain legal access to alcohol and other substances (e.g., tobacco) during this period.

However, this issue is not limited to male students, as our review also underscored a notably high frequency of alcohol abuse among female students (27.5%). Given the consistency of these findings with the available evidence, future research should explore gender differences in greater depth to develop targeted interventions for specific demographics.

Sensitivity analysis generally found consistent results when comparing the overall prevalence of MHPs with studies that used the most frequently employed screening instrument. Still, it is important to recognize that the data synthesized in this study were mostly derived from self-report instruments, which can differ in their sensitivity and specificity, depending on their intended use. For instance, studies that used the BAI compared to those that used GAD-7 found considerably lower rates of anxiety. This variability should be acknowledged when interpreting these findings, although the overall prevalences from other MHPs remained stable. Despite their limitations, self-reporting instruments are essential for clinical research on mental health as they have the advantage of being easy to administer and, importantly, allow anonymity, which is crucial for accurately identifying MHPs.¹⁴⁰

However, our review has some limitations. First, the high heterogeneity (I² > 90%) found in most analyses indicates considerable variability between studies. Nonetheless, this is observed in the majority of proportional meta-analyses and could be attributed to differences in the year of publication, sample characteristics, and assessment tools.¹⁰ Second, the scope of this review included only cross-sectional studies, which limited our ability to infer causality and observe changes in MHPs over time. Third, some MHPs had few available studies, resulting in less robust estimates and limited generalizability for specific conditions. Fourth, the limited number of post-pandemic-onset studies constrained our ability to perform further subgroup analyses for all MHPs in this study. Fifth, we found no studies reporting the prevalence of psychotic disorders or symptoms, even though these conditions often emerge during college. This lack of data could be attributed to the fact that individuals with these conditions often leave university environments. Consequently, when a sample of university students is recruited, those with psychosis are typically underrepresented because they do not attend classes regularly. This issue likely extends to the most severe cases of the other MHPs assessed in this review. Future research should address this gap by considering alternative recruitment strategies that include individuals who have left universities due to severe mental health conditions.

In summary, our study synthesized the available evidence estimating the prevalence of various MHPs faced by medical students in Brazil. These findings have important implications for health policy and clinical practice and may prompt future research in different areas. Policymakers and healthcare providers can use this information to prioritize health resources, as the high rates reported for various MHPs underscore the urgent need to implement targeted mental health interventions and support systems in medical schools. Some studies have advocated that fostering students’ resilience through institutional policies, such as student-centered educational approaches (e.g., active learning), incentives for extracurricular activities, and accessible counseling services, along with individual strategies like adopting problem-focused coping skills, may help improve students’ mental health.^149,150 Additionally, specific strategies may be required to address the distinct mental health needs of different demographic groups. We emphasize that without addressing these issues, we risk perpetuating mental health struggles that affect not only medical students, but also the quality of care they provide as future physicians.

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