Journal Club 3/21/22: Mental Health in the International Community

Prevalence of burnout among university students in low- and middle- income countries: a systematic review and meta analysis - presented by Jonathan Kajjimu

Burnout is a form of distress that manifests with features of emotional exhaustion, depersonalization, and reduced personal/professional accomplishment. Emotional exhaustion or unsuccessful coping with stressors, is the fatigued feeling that develops as one’s emotional energies are drained. Depersonalization refers to a student’s indifference, negative or cynical attitude. Reduced personal accomplishment is a negative self-evaluation of one’s abilities which manifests itself with feelings of failure. University education is an intrinsically demanding time which puts university students at risk for burnout, coupled with other burnout risk factors such as individual/personal factors and extracurricular factors. Burnout causes significant physical, emotional, psychological, and spiritual damage to students.  

However, from this article there had been paucity of and discrepancies in data on the overall prevalence of burnout in university students from low- and middle-income countries (LMICs). Students pursuing health-related programs in mostly high-income countries (HICs) had been mostly studied previously.

In this review, 55 articles were included, with a total of 27,940 (female: 16,215, 58.0%) university students from 24 LMICs. The Maslach Burnout Inventory (MBI) was found to be the most widely used tool for measuring burnout in 43 studies (78.2%). The pooled prevalence of burnout was 12.1% (95% CI: 11.9–12.3; p = < 0.001). Pooled significant prevalence of emotional exhaustion, cynicism, and reduced personal/professional efficacy were 27.8% (95% CI 27.4–28.3), 32.6% (95% CI: 32.0– 33.1), & 29.9% (95% CI: 28.8–30.9) respectively. Burnout pooled prevalence was highest among the African region at 35.4%, followed by the Asian region at 30.2%, and the European region at 20.7%. 

Figure 1: Forest plot for the prevalence of burnout in LMICs

In this review, burnout rates found in LMICS were lower than those in HICs, which the author believed to be due to publication bias. Authors further recommended low cost interventions that were needed more in low income countries than in middle income countries for managing burnout. These included mindfulness practices, yoga exercises, and group discussions. The current COVID-19 pandemic was also highlighted as having been found to put university students at a higher risk of burnout. Consequences of burnout in students include absenteeism, drop out, reduced academic performance, depression, alcohol and drug abuse, suicide, professional impairment and dissatisfaction, increased incidence of errors and near-misses.

Discussion Questions:

  • How can medical schools focus more on mental health of medical students?
  • How can we ensure that medical students always have their wellbeing in check? 
  • Do you think medical students actually get burnt out or are they just morally injured?

Some of the great recommendations received were having wellness days, “Opt out sessions”, and free counselling sessions in medical school for openly bringing out mental health issue discussions. However, one student confidently believed it would be difficult for schools to focus on mental health of students despite other discussants’ optimism.

Med students can: Focus on reducing energy drain. Identify what you can change – and what you can’t.  Align your goals, values and beliefs. Set limits and delegate. Create new challenges that are aligned with your values. Give yourself frequent breaks. Seek support. Monitor your energy level and emotional state. Eat energy and brain foods. Pace yourself. Build problem-solving skills. Lighten the situation with humor. Having regular physical exercise. 

Medical schools can: Advocate for student autonomy i.e. ability to influence student environment and schedule control. Provide adequate support services such as counselling, secretarial, administrative, social work, and financial. Encourage collegial work environments, healthy relationships and sharing of common goals. Minimize school-home interference. Promote proper work-life balance. Ensure vacation time and limit overtime. Establish mentoring. Consider periodic sabbaticals.

Kaggwa MM, Kajjimu J, Sserunkuma J, Najjuka SM, Atim LM, Olum R, et al. (2021) Prevalence of burnout among university students in low- and middle-income countries: A systematic review and meta-analysis. PLoS ONE 16(8): e0256402. pone.0256402

Mental Health in the International Community - Presented by Alexander Gallaer

Mental illness is a topic that is still gaining awareness, acceptance, and understanding in many parts of the world. While western medicine, most notably the DSM-V, has sought to carefully categorize and define mental disease, the definition of what constitutes mental illness is still very much disputed globally. Unfortunately, many global populations may suffer from unaddressed mental health struggles as a result of these varying attitudes. Notably, post-traumatic stress disorder (PTSD), as defined by the DSM-V, is a disease that has an enormous global burden. As emergency physicians increasingly become the sole health care providers, especially in marginalized populations, it is important to have awareness of what groups may need special attention or follow up to diagnose or address underlying PTSD. Some of these groups include male military veterans (lifetime prevalence of 30.9% (1)), emergency healthcare providers (up to 15.8% (2)), and, most notably here, refugee populations (up to 62% in some Cambodian cohorts (3)). Early recognition of symptoms and swift referral of patients to mental health services as soon as symptoms are identified could alleviate long term disease burden and lead to improved outcomes (4). Because refugee populations are high risk, providers can consider routinely screening for symptoms.

Discussion Questions:

  • How would you approach treating a mental health crisis in an individual who does not believe such issues exist, or that such disease processes can affect them?
  • How can we raise awareness of PTSD in populations with traditionally low recognition of mental illness? Should we do this?


1) Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):593.

2) Bahadirli S, Sagaltici E. Post-traumatic stress disorder in healthcare workers of emergency departments during the pandemic: A cross-sectional study. Am J Emerg Med. 2021 Dec;50:251-255. doi: 10.1016/j.ajem.2021.08.027. Epub 2021 Aug 14. PMID: 34416516.

3) Marshall GN, Schell TL, Elliott MN, Berthold SM, Chun CA. Mental health of Cambodian refugees 2 decades after resettlement in the United States.JAMA. 2005;294(5):571.

4) Fanai M, Khan MAB. Acute Stress Disorder. [Updated 2021 Jul 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-

The Unique Challenges of Mental Health and Multidrug Resistant Tuberculosis- Presented by Ellen Chiang

Calculating disability adjusted life years (DALY) aims to quantify disease burden in terms of both mortality and morbidity. This calculation is an important tool in global health work and as with all tools, it has limitations. Attempts to quantify disability from mental health disorders demonstrate the constraints of the DALY. 

Our understanding and definition of what classifies a mental illness is influenced by our sociocultural context. The Diagnostic and Statistical Manual of Mental Disorders (DSM) is therefore impacted by politics and prejudice. While DALY calculations include sex and gender as weighted factors, many other social factors are not considered. Additionally, much of the medical research published in the major psychiatric journals center on Euro-American study populations, which limits the cross-cultural application of findings. 

Without full consideration of what is not captured by our quantitative measurement of choice, global health interventions can have unintended, significant consequences. The book chapter highlights this by discussing the emergence of multidrug resistant tuberculosis (MDTRB) from the implementation of the DOTS protocol in Peru, which was supported largely by the cost effectiveness paradigm. 

Global health experts should understand the limitations of the DALY when using it to identify priorities and create and evaluate interventions. Remaining aware of what falls outside of the DALY can help create more context appropriate health interventions and new measurements that factor in important social dimensions of disease burden

Discussion Questions:

  • Is it possible to create a metric for disease burden that accounts for social context?
  • When implementing a large-scale health intervention, what are some ways to maintain the flexibility needed to address unexpected challenges?


Ji, Jianlin, Arthur Kleinman, and Anne Becker. “Suicide in Contemporary China: A Review of China’s Distinctive Suicide Demographics in Their
Sociocultural Context.” Harvard Review of Psychiatry 9, no. 1 (2001): 1– 12.

Anand, Sudhir, and Kara Hanson. “Disability-Adjusted Life Years: A Critical Review.” Journal of Health Economics 16, no. 6 (1997): 685– 702.

Sen, Amartya. “Missing Women: Social Inequality Outweighs Women’s Survival Advantage in Asia and North Africa.” British Medical Journal 304, no. 6827 (1992): 587– 588.

Wrap up!

We thoroughly enjoyed the discussion sparked by these three mentees and are proud to be to present a brief summary of their work here! Please stay tuned for more article summaries and details about our upcoming meetings.  Connect with us through one of our contact options listed below if you are interested in attending!

Thank you to our authors and presenters!

Jonathan Kajjimu, MS5

Jonathan Kajjimu, MS5

Mbarara University of Science and Technology

Alexander Gallaer, MS4

University of Connecticut School of Medicine

Ellen Chiang, MS4

Ellen Chiang, MS4

UNC Chapel Hill

Jeff Downen, MD, MS

Jeff Downen, MD, MS

PGY-2 University of Florida, Jacksonville
Blog Editor

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Cite this article as: Global EM Student Leadership Program, "Journal Club 3/21/22: Mental Health in the International Community," in International Emergency Medicine Education Project, January 25, 2023,, date accessed: October 1, 2023

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