Prevalence and Determinants of Psychological Distress in Medical Students in Spain (2010–2024): A Narrative Review

Abstract

This study aims to provide a comprehensive overview of psychological distress among medical students in Spain, a growing concern given the high prevalence rates of anxiety, depression, and burnout reported across multiple medical schools and universities. To assess the scope and key characteristics of this phenomenon, a thorough literature search was conducted in the PubMed, ProQuest, and Web of Science (WoS) databases. Studies published between 2010 and 2024 in peer-reviewed scientific journals, written in English or Spanish, and specifically focused on medical students enrolled in Spanish universities were considered for inclusion. A total of 14 studies were analysed. The findings indicate that psychological distress often emerges early in medical training and tends to intensify as students progress academically. Female medical students are consistently more affected, as most of the studies reviewed indicate that they exhibit higher levels of depressive symptoms, trait anxiety, and perceived stress. Some research also suggests greater levels of burnout among female students compared to their male peers. Key contributing factors include academic overload and dissatisfaction, sleep deprivation, and the use of maladaptive coping strategies. Although awareness of the issue is increasing, available evidence suggests that institutional responses remain limited, and that only a small number of universities have implemented structured mental health programmes. Overall, the results underscore the urgent need for institutional reforms in Spanish medical education to safeguard students’ mental wellbeing. Key priorities include revising curricula, implementing structured emotional support programmes, and ensuring accessible services—requiring coordinated, long-term commitment across academic, healthcare, and policy sectors. Future research should explore longitudinal trends and the effectiveness of targeted interventions.

1. Introduction

Psychological distress among medical students has become a significant area of concern in both academic and clinical settings, attracting considerable attention from researchers worldwide due to its profound effects on students’ mental health [1,2], quality of life [3], academic performance, and professional development [4,5]. Medical students consistently report experiencing high levels of psychological distress [4,6,7,8], particularly anxiety [9] and depression [2,10,11,12,13], especially when compared to the general population [5,14,15,16] and students in other academic disciplines [11,17]. Studies conducted in various countries such as Brazil [15], the Netherlands [16], India [4,7], Canada [14], the UK [18], Colombia [19], Denmark [1], and Malaysia [8], among others, reveal similar patterns of psychological distress in medical students, highlighting the global nature of the problem and emphasising the need for targeted interventions to address the unique challenges within each cultural and academic context.

One of the most pervasive manifestations of psychological distress is burnout, which is characterised by three core components: (a) emotional exhaustion, associated with strain and commonly linked to tension, anxiety, physical fatigue, and insomnia; (b) depersonalisation, understood as a maladaptive coping mechanism whereby individuals conserve emotional energy by treating others as objects or numbers rather than as human beings; and (c) a reduced sense of personal accomplishment, reflecting diminished self-efficacy and impaired adjustment to demanding situations. These dimensions arise in response to chronic emotional and interpersonal stressors [20]. Burnout is a common issue among medical students [18,21,22], as highlighted by Castaldelli-Maia et al. [15], who reported a prevalence rate of 80%. This syndrome carries significant long-term consequences, such as reduced job satisfaction and a higher risk of professionals leaving the medical field, which may, in turn, affect the quality of patient care [21,23].

Various factors have been identified as contributing to the high levels of psychological distress and burnout in this population, with a demanding academic workload, long study hours, and a persistent fear of academic failure frequently cited as primary stressors [21,22]. Therefore, psychological distress in medical students is a reflection of academic pressures, as identified by Bartlett and Fowler [14], but it is also deeply influenced by the high level of perfectionism inherent in medical training, as medical students often feel an overwhelming pressure to meet unattainably high standards, both academically and personally in a competitive medical training environment, with students facing constant pressure to perform at the highest level. This can result in chronic emotional distress and a diminished sense of personal wellbeing [24]. Furthermore, maladaptive or ineffective coping strategies for dealing with stress, such as substance use or excessive use of social media [4,19,25], poor sleep quality [26] and consequent excessive daytime sleepiness [9,19,27], poor family functioning [19], and dissatisfaction with social activities [17], etc., all contribute to causing or exacerbating psychological distress among medical students.

The COVID-19 pandemic introduced additional stressors for medical students, interrupting their studies, altering academic routines, and generating uncertainty about both their education and future careers. These disruptions, combined with growing health-related concerns, have been linked to a noticeable decline in students’ psychological health [28]. While the high prevalence of psychological distress among medical students is undoubtedly concerning, there are strategies that may help to alleviate its effects. One important protective factor identified in the literature is psychological resilience, which has been shown to support students’ mental wellbeing [3,13,29]. Resilient students tend to cope more effectively with the emotional demands of medical training, enabling them to adapt to challenges and recover more readily from setbacks. Therefore, initiatives aimed at strengthening resilience—such as the development of effective coping mechanisms and the promotion of emotional health—are essential to help students manage the psychological pressures associated with their studies.

As for gender, higher prevalence levels of psychological distress or burnout have been found in females compared to males [15,16,22,29], although in some studies, the opposite trend has been detected [3,4]. Moreover, although psychological distress has been found in first-year medical students [7], it seems to increase in more senior students [21,22]. In fact, the consequences of psychological distress in medical students extend beyond the classroom and persist throughout their clinical years and professional careers.

Despite the increasing body of literature on psychological distress among medical students in Spain, no comprehensive reviews have been conducted to synthesise the existing evidence. Most studies are isolated, focusing on specific institutions, regions, or mental health outcomes, which limits the ability to gain a broader understanding of the national situation. The lack of a comprehensive review obstructs the identification of common trends, risks, and protective factors, as well as potential intervention targets across the country. An in-depth analysis of the available research is therefore essential to provide a clearer picture of the mental health challenges faced by Spanish medical students in recent years.

The objectives of this study are to examine the scientific literature published on psychological distress among medical students in Spain—defined as significant emotional suffering that often manifests as anxiety, depression, burnout, or other mental health concerns—and to consolidate the findings. Specifically, this review aims to: (1) assess whether Spanish medical students experience psychological distress, as observed in other populations; (2) explore the characteristics of this distress, including the types of symptoms or disorders reported and their distribution across gender and academic year; and (3) propose potential strategies for improving the early detection and prevention of mental health issues within Spanish medical education settings.

2. Methods

To provide a comprehensive understanding of psychological distress among medical students in Spain, a thorough literature search was conducted in the PubMed, ProQuest, and Web of Science (WoS) databases. The following search syntax was applied in each database, with terms required to appear in the title or abstract of the articles: (“medical students”) AND (“psychological distress”); (“medical students”) AND (“anxiety”); (“medical students”) AND (“depression”); (“medical students”) AND (“burnout”). Studies published between 2010 and 2024 in peer-reviewed scientific journals, written in English or Spanish, and conducted in Spain were considered for inclusion. The exclusion criteria were subsequently applied to remove studies that were not directly relevant to the topic or that focused on students from other health science disciplines. Ultimately, 14 studies that met the inclusion criteria were selected for evaluation. The findings are presented in Section 3.

3. Results

The studies under review confirmed the significant prevalence of psychological distress among medical students in Spain [30,31], even higher than that observed in students from other health sciences, such as Nursing or Physiotherapy [32], underscoring the widespread nature of depression, anxiety, and burnout within this population (see Table 1).

Depression symptoms were reported in 23.4% to 39.1% of medical students using the Beck Depression Inventory II [30,33,34], and 47.8% of students on average when using other assessment instruments such as the Patient Health Questionaire-9, the Brief Symptom Inventory-18, or the Goldberg Anxiety and Depression Scale [32,34,35], with these figures rising to 70.03% during the COVID pandemic [36]. Additionally, suicidal ideation was found in an average of 12.6% of medical students [30,33,34], a figure that increased to 16.84% during the COVID pandemic [36].

Trait Anxiety—a stable tendency to experience fear, worry, and anxiety across various situations—was reported in 25% to 49.1% of medical students when assessed using the State-Trait Anxiety Inventory [30,34,37]. An average prevalence of 42.3% was observed when using other instruments, such as the Brief Symptom Inventory-18 or the Goldberg Anxiety and Depression Scale [32,35]. Notably, these figures increased significantly during the COVID-19 pandemic [36,38], reaching as high as 64.5% in some studies [39]. Interestingly, Romo-Barrientos et al. [37] found that anxiety decreased with adaptation to the dissection room environment, suggesting the positive effect of habituation on academic stress management.

Lastly, Burnout was present in about four out of ten students in different studies using the Student Survey (SS) or the General Survey (GS) of the Maslach Burnout Inventory [30,40,41,42,43], and even appeared before the start of clinical courses [40]. Furthermore, medical students exhibited higher rates of emotional exhaustion (55.1%), a component of burnout, compared to students in other disciplines [32]. Atienza-Carbonell [34] also found that 40.2% of medical students experienced academic burnout using the IUBA instrument.

Table 1. Studies on psychological distress in medical students in Spain.

Authors and Publication Year	Sample	Objectives	Study Design and Instruments	Results
Serrano et al. (2023) [36]	297 undergraduate medical students from the University of Granada (72.39% female, 22.90% in fifth year, and 29.63% in sixth year).	To analyse the psychological impact of COVID-19 on medical students and the possible factors associated with this impact.	Cross-sectional study.   GAD-7, GHQ-12, BDI-II (only item 9).	The pandemic has caused an important emotional and psychological impact among medical students, increasing their levels of anxiety and depression, as well as the risk of suicide, with prevalence rates of 51.18% of anxious symptoms, 70.03% of depressive symptoms, and 16.84% of suicidal ideation.
Atienza- Carbonell et al. (2022) [34]	1265 medical students from the University of Valencia and the University of the Basque Country (74.2% female).	To determine the prevalence of mental health problems among Spanish medical students, and their association with sociodemographic factors.	Cross-sectional study.   BDI-II, PHQ-9, STAI, IUBA.	The prevalence of depressive symptoms was 37.4% (BDI-II) and 53% (PHQ-9), and suicidal ideation affected about 12%; 28.8% and 29.4% reported high levels of state and trait anxiety, respectively. Burnout prevalence was 40.2%. Female and pre-clinical students reported significantly higher symptom rates. Mental health problems correlated with lower academic performance and the number of substances consumed in the last 30 days.
Gómez-Durán et al. (2022) [38]	175 undergraduate medical students above third year and recently graduated from the International University of Catalunya (78% male; 14.5% participated in healthcare-related volunteering activities during the COVID pandemic).	To examine the symptoms and volunteering experience of medical students during the initial months of the Spanish COVID-19 pandemic.	Cross-sectional study.   GAD-7, PSS-14, PHQ-9, IES–R.	Students showed a high prevalence of perceived stress, anxiety, and depressive symptoms. Symptoms were significantly higher in medical students that did healthcare volunteering during the initial months of the COVID pandemic than in those who did not, and 32% reported a highly traumatic event during volunteering, with high scores on the IES-R in 16% of volunteers. One out of three reported currently feeling the same symptoms.
March- Amengual et al. (2022) [32]	506 health sciences and non-health sciences undergraduate students from the University of Vic–Central University of Catalonia (64.8% female and 15.4% medical students).	To investigate the prevalence of psychological symptoms and burnout reported by first-year students, and the relationship between these variables and their academic performance.	Cross-sectional study.   BSI-18, MBI-SS, and students’ grades for the first semester from academic records.	The study shows a high prevalence of psychological distress among first-year medical students, exceeding that of Nursing and Physiotherapy students, and significantly higher than in non-health sciences students. Prevalence rates include clinical levels of somatization (19.2%), depression (29.5%), anxiety (29.7%), and psychological distress (32.1%). Burnout components were also high, particularly emotional exhaustion (55.1%) and depersonalization (7.7%), surpassing health sciences students’ averages (47.1% and 7.2%, respectively).
Santabárbara et al. (2022) [39]	31 medical students in their first year at the Faculty of Health and Sports Sciences of the University of Zaragoza (77.4% female).	To report the prevalence of anxiety among Spanish medical students during the COVID-19 pandemic as well as to investigate the influence of sociodemographic characteristics on it.	Cross-sectional study.   GAD-7.	64.5% of the sample presented anxiety, being more prevalent among women and the youngest; 64.5% of the students manifested some degree of self-reported anxiety during the COVID pandemic.
Capdevila-Gaudens et al. (2021) [30]	5216 students from all 43 medical schools in Spain (76.3% female).	To analyse the prevalence of depression, anxiety, empathy and burnout among medical students.	Cross-sectional study.   BDI, MBI-SS, STAI, JSE.	The overall prevalence of depression was 41%, with 23.4% experiencing moderate to severe depression and 10% having suicidal ideation. Burnout was at 37%, significantly higher in 6th-year students than among 1st-year students. Anxiety levels (25%) exceeded the general population, with women showing higher trait anxiety. Empathy scores were high, with more women in the highest-scoring group.
Gil-Calderón et al. (2021) [42]	1073 medical students from 32 of the 42 medical schools in Spain, ranging from first-year to sixth-year students (75% female, 63% in their third to fifth year).	To analyse the influential factors that may contribute to the presence of burnout symptoms in medical students.	Cross-sectional study.   MBI-SS.	Burnout syndrome is a problem among medical students in Spain that increases with the number of years studying Medicine. Higher levels of family support for studying medicine are associated with lower burnout levels.
Gutiérrez et al. (2021) [35]	474 medical students from the Miguel Hernández University, ranging from first to sixth-year students (68.1% female).	To estimate the prevalence of anxiety and depression and the self-perceived health status of medical students and analyse its association with sociodemographic and lifestyle variables.	Cross-sectional study.   The Visual Analogue Scale of the EQ-5D, GADS.	Medical students exhibited a high prevalence of probable anxiety (54.9%) and depression (60.9%). Women and first-year students, compared to those in their fourth and fifth years, reported significantly higher levels of both variables. Additionally, 60.8% of students indicated consuming alcohol at least 2–4 times per month, while 45.9% reported using cannabis, marijuana, or hashish.
Amor et al. (2020) [40]	Two cohorts of medical students from Pompeu Fabra University and the Autonomous University of Barcelona: academic years 2017–2018 (149 students; 66.4% female) and 2018–2019 (224 students; 69.2% female).	To analyse the prevalence of burnout among medical students and its relationship with demographic and personal characteristics.	Cross-sectional cohort study.   MBI-GS.	The prevalence of burnout was notably high, with rates of 33.6% in 2018 and 38% in 2019. Among preclinical students (first to third years), burnout rates were 26.1% in 2018, increasing to 31.3% in 2019, with higher rates observed in later years. No significant gender differences were found. The 2017–2018 cohort reported high levels of emotional exhaustion, depersonalization, and low personal efficacy (65.1%, 37.6%, and 34.2%, respectively), with marked increases in the 2018–2019 cohort (68.3%, 45.1%, and 40.6%, respectively). Burnout symptoms manifested early in medical education, even prior to the initiation of clinical coursework.
Atienza- Carbonell et al. (2020) [33]	858 medical students from the University of Valencia (69.2% female).	To determine the prevalence of depressive symptoms and suicidal ideation in medical students, as well as its relationship with other variables of interest.	Cross-sectional study.   BDI-II.	Among medical students, 39.1% reported depressive symptoms in the previous two weeks, with 15.9% mild, 15.6% moderate, and 7.6% severe. Additionally, 15.8% experienced recent suicidal ideation. Women exhibited significantly higher depressive symptoms, but these symptoms were largely independent of academic year.
Oro et al. (2019) [43]	118 medical students from the University of Lleida (71.2% female; 79.7% second-year students).	To determine the levels of perceived stress, reported symptoms, and degree of burnout among medical students.	Cross-sectional study.   PSS, SCL-90-R, MBI-SS.	Medical students reported higher perceived stress than the norm, with elevated stress levels from early years, particularly among women. Scores for psychopathological symptoms were similar to those for psychosomatic patients, with 16.95% of students exceeding the global severity index score for psychiatric patients, with obsessive–compulsive symptoms being particularly prominent. Academic burnout was higher from emotional exhaustion and academic inefficacy. The three variables correlated with each other.
Romo-Barrientos et al. (2019) [37]	Students at the University of Castilla–La Mancha	To explore the anxiety levels of first-year medical students when working in the dissecting room, over a period of one year.	Descriptive study.   STAI.	Anxiety levels decreased significantly from 49.1% to 14% by the end of the first year. Female students initially had higher state anxiety than males, but by the year’s end, levels were similar. Despite students’ satisfaction with dissection practices, they caused stressful responses.
Salamero et al. (2012) [31]	420 medical students from the University of Barcelona, the Autonomous University of Barcelona, Rovira i Virgili University, and the University of Lleida, enrolled in the fourth year (75% female).	To estimate the prevalence of psychological distress, academic stress, and emotional exhaustion among medical students.	Cross-sectional study.   GHQ-12, OLBI.	The levels of emotional distress and potential risk of developing psychopathological disorders are very high in medical students and greater in women: the prevalence of students at risk of psychopathological disorders is 38% in men and 50% in women. These figures are significantly higher than those found among the student population in Catalonia (7% in men and 11% in women).
Galán et al. (2011) [41]	270 medical students from the University of Seville (70% female; 65% in their final year of preclinical training and 35% in their final year of clinical training).	To investigate the prevalence of the risk of burnout in medical students in preclinical and clinical years of training.	Cross-sectional study.   MBI-SS.	The prevalence of burnout risk doubled from the third year (14.8%) to the sixth year of training (37.5%). No significant association was found between gender and burnout subscales.

Abbreviations: GAD-7: The Generalized Anxiety Disorder-7 scale [44]; GHQ-12: The General Health Questionnaire-12 [45,46]; BDI-II: The Beck Depression Inventory II [47,48]; PHQ-9: The Patient Health Questionaire-9 [49,50]; STAI: The State and Trait Anxiety Inventory [51,52]; IUBA: The single item of academic burnout [53]; PSS-14: The Perceived Stress Scale [54]; IES-R: The Impact of Event Scale—Revised [55]; BSI-18: The Brief Symptom Inventory [56]; MBI-SS: The Maslach Burnout Inventory-Student Survey [57,58]; JSE: The Jefferson Scale of Empathy [59]; EQ-5D: The European Quality of Life-5 Dimensions [60]; GADS: The Goldberg Anxiety and Depression Scale [61]; MBI-GS: The Maslach Burnout Inventory-General Survey [62]; PSS: The Perceived Stress Scale [63]; SCL-90-R: The Symptom Checklist-90-R [64]; and OLBI: The Oldenburg Burnout Inventory [65].

Table 1. Studies on psychological distress in medical students in Spain.

Authors and Publication Year	Sample	Objectives	Study Design and Instruments	Results
Serrano et al. (2023) [36]	297 undergraduate medical students from the University of Granada (72.39% female, 22.90% in fifth year, and 29.63% in sixth year).	To analyse the psychological impact of COVID-19 on medical students and the possible factors associated with this impact.	Cross-sectional study.   GAD-7, GHQ-12, BDI-II (only item 9).	The pandemic has caused an important emotional and psychological impact among medical students, increasing their levels of anxiety and depression, as well as the risk of suicide, with prevalence rates of 51.18% of anxious symptoms, 70.03% of depressive symptoms, and 16.84% of suicidal ideation.
Atienza- Carbonell et al. (2022) [34]	1265 medical students from the University of Valencia and the University of the Basque Country (74.2% female).	To determine the prevalence of mental health problems among Spanish medical students, and their association with sociodemographic factors.	Cross-sectional study.   BDI-II, PHQ-9, STAI, IUBA.	The prevalence of depressive symptoms was 37.4% (BDI-II) and 53% (PHQ-9), and suicidal ideation affected about 12%; 28.8% and 29.4% reported high levels of state and trait anxiety, respectively. Burnout prevalence was 40.2%. Female and pre-clinical students reported significantly higher symptom rates. Mental health problems correlated with lower academic performance and the number of substances consumed in the last 30 days.
Gómez-Durán et al. (2022) [38]	175 undergraduate medical students above third year and recently graduated from the International University of Catalunya (78% male; 14.5% participated in healthcare-related volunteering activities during the COVID pandemic).	To examine the symptoms and volunteering experience of medical students during the initial months of the Spanish COVID-19 pandemic.	Cross-sectional study.   GAD-7, PSS-14, PHQ-9, IES–R.	Students showed a high prevalence of perceived stress, anxiety, and depressive symptoms. Symptoms were significantly higher in medical students that did healthcare volunteering during the initial months of the COVID pandemic than in those who did not, and 32% reported a highly traumatic event during volunteering, with high scores on the IES-R in 16% of volunteers. One out of three reported currently feeling the same symptoms.
March- Amengual et al. (2022) [32]	506 health sciences and non-health sciences undergraduate students from the University of Vic–Central University of Catalonia (64.8% female and 15.4% medical students).	To investigate the prevalence of psychological symptoms and burnout reported by first-year students, and the relationship between these variables and their academic performance.	Cross-sectional study.   BSI-18, MBI-SS, and students’ grades for the first semester from academic records.	The study shows a high prevalence of psychological distress among first-year medical students, exceeding that of Nursing and Physiotherapy students, and significantly higher than in non-health sciences students. Prevalence rates include clinical levels of somatization (19.2%), depression (29.5%), anxiety (29.7%), and psychological distress (32.1%). Burnout components were also high, particularly emotional exhaustion (55.1%) and depersonalization (7.7%), surpassing health sciences students’ averages (47.1% and 7.2%, respectively).
Santabárbara et al. (2022) [39]	31 medical students in their first year at the Faculty of Health and Sports Sciences of the University of Zaragoza (77.4% female).	To report the prevalence of anxiety among Spanish medical students during the COVID-19 pandemic as well as to investigate the influence of sociodemographic characteristics on it.	Cross-sectional study.   GAD-7.	64.5% of the sample presented anxiety, being more prevalent among women and the youngest; 64.5% of the students manifested some degree of self-reported anxiety during the COVID pandemic.
Capdevila-Gaudens et al. (2021) [30]	5216 students from all 43 medical schools in Spain (76.3% female).	To analyse the prevalence of depression, anxiety, empathy and burnout among medical students.	Cross-sectional study.   BDI, MBI-SS, STAI, JSE.	The overall prevalence of depression was 41%, with 23.4% experiencing moderate to severe depression and 10% having suicidal ideation. Burnout was at 37%, significantly higher in 6th-year students than among 1st-year students. Anxiety levels (25%) exceeded the general population, with women showing higher trait anxiety. Empathy scores were high, with more women in the highest-scoring group.
Gil-Calderón et al. (2021) [42]	1073 medical students from 32 of the 42 medical schools in Spain, ranging from first-year to sixth-year students (75% female, 63% in their third to fifth year).	To analyse the influential factors that may contribute to the presence of burnout symptoms in medical students.	Cross-sectional study.   MBI-SS.	Burnout syndrome is a problem among medical students in Spain that increases with the number of years studying Medicine. Higher levels of family support for studying medicine are associated with lower burnout levels.
Gutiérrez et al. (2021) [35]	474 medical students from the Miguel Hernández University, ranging from first to sixth-year students (68.1% female).	To estimate the prevalence of anxiety and depression and the self-perceived health status of medical students and analyse its association with sociodemographic and lifestyle variables.	Cross-sectional study.   The Visual Analogue Scale of the EQ-5D, GADS.	Medical students exhibited a high prevalence of probable anxiety (54.9%) and depression (60.9%). Women and first-year students, compared to those in their fourth and fifth years, reported significantly higher levels of both variables. Additionally, 60.8% of students indicated consuming alcohol at least 2–4 times per month, while 45.9% reported using cannabis, marijuana, or hashish.
Amor et al. (2020) [40]	Two cohorts of medical students from Pompeu Fabra University and the Autonomous University of Barcelona: academic years 2017–2018 (149 students; 66.4% female) and 2018–2019 (224 students; 69.2% female).	To analyse the prevalence of burnout among medical students and its relationship with demographic and personal characteristics.	Cross-sectional cohort study.   MBI-GS.	The prevalence of burnout was notably high, with rates of 33.6% in 2018 and 38% in 2019. Among preclinical students (first to third years), burnout rates were 26.1% in 2018, increasing to 31.3% in 2019, with higher rates observed in later years. No significant gender differences were found. The 2017–2018 cohort reported high levels of emotional exhaustion, depersonalization, and low personal efficacy (65.1%, 37.6%, and 34.2%, respectively), with marked increases in the 2018–2019 cohort (68.3%, 45.1%, and 40.6%, respectively). Burnout symptoms manifested early in medical education, even prior to the initiation of clinical coursework.
Atienza- Carbonell et al. (2020) [33]	858 medical students from the University of Valencia (69.2% female).	To determine the prevalence of depressive symptoms and suicidal ideation in medical students, as well as its relationship with other variables of interest.	Cross-sectional study.   BDI-II.	Among medical students, 39.1% reported depressive symptoms in the previous two weeks, with 15.9% mild, 15.6% moderate, and 7.6% severe. Additionally, 15.8% experienced recent suicidal ideation. Women exhibited significantly higher depressive symptoms, but these symptoms were largely independent of academic year.
Oro et al. (2019) [43]	118 medical students from the University of Lleida (71.2% female; 79.7% second-year students).	To determine the levels of perceived stress, reported symptoms, and degree of burnout among medical students.	Cross-sectional study.   PSS, SCL-90-R, MBI-SS.	Medical students reported higher perceived stress than the norm, with elevated stress levels from early years, particularly among women. Scores for psychopathological symptoms were similar to those for psychosomatic patients, with 16.95% of students exceeding the global severity index score for psychiatric patients, with obsessive–compulsive symptoms being particularly prominent. Academic burnout was higher from emotional exhaustion and academic inefficacy. The three variables correlated with each other.
Romo-Barrientos et al. (2019) [37]	Students at the University of Castilla–La Mancha	To explore the anxiety levels of first-year medical students when working in the dissecting room, over a period of one year.	Descriptive study.   STAI.	Anxiety levels decreased significantly from 49.1% to 14% by the end of the first year. Female students initially had higher state anxiety than males, but by the year’s end, levels were similar. Despite students’ satisfaction with dissection practices, they caused stressful responses.
Salamero et al. (2012) [31]	420 medical students from the University of Barcelona, the Autonomous University of Barcelona, Rovira i Virgili University, and the University of Lleida, enrolled in the fourth year (75% female).	To estimate the prevalence of psychological distress, academic stress, and emotional exhaustion among medical students.	Cross-sectional study.   GHQ-12, OLBI.	The levels of emotional distress and potential risk of developing psychopathological disorders are very high in medical students and greater in women: the prevalence of students at risk of psychopathological disorders is 38% in men and 50% in women. These figures are significantly higher than those found among the student population in Catalonia (7% in men and 11% in women).
Galán et al. (2011) [41]	270 medical students from the University of Seville (70% female; 65% in their final year of preclinical training and 35% in their final year of clinical training).	To investigate the prevalence of the risk of burnout in medical students in preclinical and clinical years of training.	Cross-sectional study.   MBI-SS.	The prevalence of burnout risk doubled from the third year (14.8%) to the sixth year of training (37.5%). No significant association was found between gender and burnout subscales.

Abbreviations: GAD-7: The Generalized Anxiety Disorder-7 scale [44]; GHQ-12: The General Health Questionnaire-12 [45,46]; BDI-II: The Beck Depression Inventory II [47,48]; PHQ-9: The Patient Health Questionaire-9 [49,50]; STAI: The State and Trait Anxiety Inventory [51,52]; IUBA: The single item of academic burnout [53]; PSS-14: The Perceived Stress Scale [54]; IES-R: The Impact of Event Scale—Revised [55]; BSI-18: The Brief Symptom Inventory [56]; MBI-SS: The Maslach Burnout Inventory-Student Survey [57,58]; JSE: The Jefferson Scale of Empathy [59]; EQ-5D: The European Quality of Life-5 Dimensions [60]; GADS: The Goldberg Anxiety and Depression Scale [61]; MBI-GS: The Maslach Burnout Inventory-General Survey [62]; PSS: The Perceived Stress Scale [63]; SCL-90-R: The Symptom Checklist-90-R [64]; and OLBI: The Oldenburg Burnout Inventory [65].

Several factors have been identified as relevant to the development of psychological distress among medical students in Spain. One of the primary contributors is academic overload and difficulty with time management [30]. Additionally, dissatisfaction with academic performance is strongly associated with elevated levels of depressive symptoms and burnout—an important consideration given that nearly half of students report that their academic results fall below expectations [33,34]. In fact, approximately 50% of students indicated that their grades were lower than anticipated given the effort invested, and expressed little or no satisfaction with their current academic performance [30]. With regard to the academic environment, negative perceptions of teaching quality and low satisfaction with institutional support services have also been shown to contribute significantly to psychological distress. These perceptions are associated with increased risk of psychopathology, emotional exhaustion, and academic disengagement [31]. Importantly, this dissatisfaction remains a significant predictor even when controlling for personality traits and recent adverse life events.

Substance use further compounds the risk of psychological distress. Approximately 20% of students report the use of psychotropic medication—mainly anxiolytics and antidepressants—with usage increasing in later years of study. Moreover, the consumption of alcohol, tobacco, cannabis, and energy drinks is positively correlated with symptoms of depression, anxiety, and burnout [30,34]. The number of substances used, both over the lifetime and in the previous 30 days, was also found to correlate significantly with indicators of psychological distress [34].

Notably, medical students report shorter sleep durations than what is typical for young adults in the general population. This pattern of sleep deprivation is also associated with the presence of mental health issues, suggesting its potential contribution to psychological distress [31].

In contrast, family support and vocational motivation have been identified as protective factors [42]. Specifically, students reporting strong familial support exhibit lower levels of emotional exhaustion and depersonalisation. Similarly, those who pursue medical studies out of vocational interest tend to experience reduced levels of burnout, particularly in the dimensions of academic efficacy and depersonalisation.

During the COVID-19 pandemic, medical students in Spain experienced a significant psychological impact. High prevalence rates of anxiety, depression, and suicidal ideation were reported [36,39], with contributing factors including heightened fear of the virus, pre-existing mental health conditions, and a prior history of suicidal ideation [36]. Anxiety symptoms were particularly common among women and younger students, highlighting the vulnerability of specific subgroups [39]. Moreover, students who volunteered in healthcare settings during the early stages of the pandemic reported elevated levels of stress, anxiety, and depression compared to non-volunteers [38]. While many found the experience meaningful, challenges such as insufficient training, lack of supervision, inadequate protective equipment, and fear of infection were frequently reported. Notably, 32% of volunteers described their participation as highly traumatic, and 16% presented symptoms consistent with post-traumatic stress.

As for gender, the levels of psychological or emotional distress and potential risk of developing psychopathological disorders are greater in women. Indeed, Salamero et al. [31] reported that 50% of female medical students were at risk of psychopathological disorders, compared to 38% of male students. Specifically, several studies indicate that female medical students in Spain exhibit higher rates of depressive symptoms [33,34,35,43], trait anxiety [30,34,35,37], and perceived stress [43]. In addition, some studies have found no gender differences in burnout symptoms [40,41], whereas others showed higher burnout levels [34] and its components, such as academic ineffectiveness [43] or exhaustion [42], in women compared to their male counterparts.

Psychological distress is evident in medical students from the early stages of their studies, even before the onset of clinical coursework [40,43], and is detectable as early as the first year [32]. Moreover, it is higher than that observed in students from other fields of study [32]. Additionally, psychological distress appears to intensify as students progress in their education; specifically, higher levels of depression and anxiety have been reported in more advanced years [35]. Several studies have also observed that burnout tends to increase progressively as students advance through medical school, with some reporting that its prevalence can double between the third and sixth years of study [30,40,41,42]. This trend suggests that sustained exposure to academic and clinical demands may significantly contribute to the development of burnout. However, not all findings are consistent. Some research has indicated that preclinical students may experience higher levels of anxiety, depression, and burnout compared to their clinical counterparts [34], while other studies have found that depression appears to be unrelated to the academic year [33]. Additionally, perceived stress levels among first-year students have been reported to be comparable to those experienced by students in later years [43].

4. Discussion

Regarding the first objective of this study, the results clearly confirm the presence of psychological distress among medical students in Spain. Several studies have reported high prevalence rates of depression [30,32,33,34,35], anxiety [30,32,34,35,37], suicidal ideation [30,33,34], and burnout [30,40,41,42], all of which increased during the COVID-19 pandemic [36,38,39]. These findings align with previous international research [1,4,6,7,8,14,15,16,18,19], indicating that psychological distress in medical students is a widespread and systemic issue that warrants institutional attention and should be regarded as a public health priority.

Addressing the second objective, the reviewed studies highlight several key contributing factors to psychological distress among medical students in Spain. One of the most significant factors is academic overload [30,32], characterised by long study hours, constant pressure to excel, and high academic expectations, factors that create a chronic stress environment [13,14,21,22] and increase the risk of emotional exhaustion and burnout [23], as well as diminished personal wellbeing [24].

In addition, dissatisfaction with the academic environment [31,34] and academic performance [30,33,34] has also been identified as a contributing factor. These findings support previous research linking psychological distress to academic satisfaction [66] and performance [67].

Sleep deprivation is another relevant factor [31,33], as poor sleep quality has repeatedly been associated with higher levels of anxiety, depression, and perceived stress among medical students, likely due to the fact that inadequate rest impairs emotional regulation and reduces students’ ability to cope with academic demands [26,68,69].

Ineffective coping strategies for managing stress, such as substance use, including alcohol, cannabis, or tranquillisers, have also been documented at rates exceeding those found among the general student population [30,31,34,35]. While substance use as a stress response is not unique to Spain, its prevalence varies by country [70,71].

Other contributing factors include high levels of perfectionism [33], which have been associated with an increased risk of suicide [72], as well as low vocational motivation and limited family support [42]. These findings highlight the potential buffering role of supportive interpersonal relationships [19] and intrinsic motivation in mitigating psychological distress among medical students.

The COVID-19 pandemic significantly exacerbated psychological distress among medical students, intensifying pre-existing stressors and introducing new challenges such as increased uncertainty, disruptions in clinical training, and social isolation [36,38,39]. Similar patterns have been reported worldwide [73,74,75,76,77,78,79], with these factors contributing to elevated levels of anxiety and depression. A review conducted by Wang et al. [80] further identified a wide range of negative influences on student mental health, including excessive screen time, academic overload, financial instability, reduced physical activity, poor sleep quality, pathological internet use, limited social support, substance use, pre-existing health conditions, low resilience, and COVID-19-like symptoms. These factors may have contributed to increased psychological distress among medical students during the pandemic. Collectively, these findings underscore the particular vulnerability of medical students during public health crises and emphasise the urgent need for resilient, well-structured institutional mental health systems.

Consistent with the previous literature, a gender-related trend has been observed, with female students exhibiting higher levels of depression [33,34,35,43], trait anxiety [30,34,35,37], academic burnout [34,42,43], and perceived stress [43]. According to Salamero et al. [31], 50% of female medical students were at risk of psychopathological disorders, compared to 38% of male students. However, some studies conducted in Spain have not identified such differences regarding burnout symptoms [40,41], echoing earlier findings [3,4]. Overall, these results align with prior research that has identified higher levels of psychological distress in females compared to males [15,16,22,29], and are consistent with broader epidemiological evidence showing higher rates of internalising disorders among women in the general population [81,82]. Gender differences in psychological distress among medical students can also be partly explained by research on psychological traits, coping strategies, and social norms. Female students tend to score lower on emotional stability [29] and more frequently adopt emotion-focused and avoidant coping styles, such as behavioural disengagement, which is associated with poorer long-term outcomes. In contrast, male students are more likely to use problem-focused strategies [83], yet are less inclined to seek emotional or instrumental support—possibly due to social norms that emphasise independence [84]. These coping patterns appear to be shaped by socially reinforced expectations regarding emotional expression and autonomy, which influence how students respond to stress in demanding academic environments. Moreover, gender differences in psychological distress are likely exacerbated by disparities in perceived competence and self-confidence. Despite performing at similar or higher levels than their male peers, female students frequently report greater anxiety, increased stress related to assessments, and lower self-confidence [85]. They are also perceived as less confident, particularly during early clinical interactions. These perceptions and internalised doubts may intensify psychological distress, suggesting that confidence-related stressors may disproportionately affect female students and further contribute to elevated levels of distress. Therefore, female medical students may face a greater psychological burden due to a combination of biological, psychological, and sociocultural factors, underscoring the need for gender-sensitive approaches to mental health promotion within medical education, as suggested by Judd et al. [86].

Aligned with existing research [7,21,22], psychological distress appears from the first year of study [32], even before the onset of clinical coursework [40,43], and tends to increase as students advance [30,35,40,41,42], likely due to growing academic and clinical demands, as the transition to clinical rotations introduces emotionally demanding patient interactions, time pressure, and performance evaluations. However, the literature shows mixed findings: while some studies report greater distress in preclinical students in Spain compared to clinical students [34], others find that psychological distress is independent of the academic year [33] or comparable between first-year students and those in later years [43].

In summary, the key risk factors identified in the present review of psychological distress among Spanish medical students include academic overload, sleep deprivation, low academic satisfaction and performance, ineffective coping strategies for managing stress, low vocational motivation, limited family support, and high levels of perfectionism. Gender differences also play a significant role, with female students consistently exhibiting higher levels of psychological distress. The COVID-19 pandemic further exacerbated these factors, amplifying both academic and emotional challenges.

As for the third objective, the revised literature highlights several potential strategies for mitigating psychological distress in medical students in Spanish universities. These include fostering open discussions about mental health and accessible guidance [30], establishing dedicated mental health services [33], enhancing students’ ability to recognise, address, and seek help for mental health issues [34], and prioritising the emotional wellbeing and quality of life of their students [32]. Promoting healthy lifestyles, the self-detection of emotional issues, and reducing academic stress are also critical [31]. In addition, specific preventive measures should be taken to address suicidal ideation [30]. Targeted prevention efforts, such as peer support, curricular changes to reduce academic stress, and psychotherapeutic interventions [34], are also recommended. Universities should consider implementing support groups, providing psychological assistance, integrating coping skills training, and offering tailored interventions for high-risk students [40,43] within the curriculum, or offered as extracurricular activities. Ultimately, without institutional reforms focused on the recommended actions for prevention, support, and early identification, psychological distress is likely to persist beyond the academic setting, potentially leading to long-term consequences for future healthcare professionals and the quality of care they provide.

In addition to the general strategies previously discussed, several innovative interventions have shown promising results in reducing psychological distress among medical students. One such approach is Compassion Cultivation Training (CCT), which has been found to significantly reduce stress, anxiety, and the emotional exhaustion component of burnout, while enhancing self-compassion and emotional regulation. Notably, some of these effects were sustained at follow-up [87]. Mindfulness-based interventions also seem to offer a good possibility to enhance medical students’ wellbeing [88]. For instance, a seven-week mindfulness training implemented in Norway led to sustained improvements in dispositional mindfulness, problem-focused coping, and overall wellbeing, even six years post intervention [89]. Shorter versions of such programmes, including Group-Based Mindfulness Cognitive Therapy in Malaysia [90] and a six-session intervention in Germany [91], also helped to reduce perceived stress and maintain mindfulness in the short to medium term. Digital interventions are likewise valuable, as they broaden access to psychological support. The Transitions programme, for example, improved mental health literacy, reduced emotional symptoms and stress, and encouraged help-seeking attitudes among first-year medical students in Finland. Moreover, it was easily integrated into the university curriculum [92]. Internet-based cognitive behavioural therapy (iCBT) platforms, such as ThinkFeelDo, have also been associated with increased use of coping strategies [93]. Overall, these findings underscore the importance of integrating emotional skills training, digital tools, and peer-based resources into medical education.

Several limitations of this review must be acknowledged. First, the concept of psychological distress presents a challenge, as the included studies assess it either as a global construct or through its individual components—such as depression, anxiety, stress, and burnout. This conceptual heterogeneity complicates the synthesis of results and limits the comparability of findings across studies. Furthermore, the use of diverse instruments to measure psychological distress hinders direct comparisons. The reviewed studies also differ considerably in sample sizes and methodological approaches, including variations in populations, sampling procedures, and outcome measures. Additionally, most of the available evidence is derived from cross-sectional designs, which restricts the ability to draw causal inferences. Finally, the scarcity of multicentre studies and the inconsistent reporting of institutional actions further limit the generalisability of some findings.

Given the information discussed previously, it is evident that longitudinal studies are needed to analyse the progression and long-term consequences of psychological distress in medical students. Furthermore, intervention-based research should be developed to evaluate the effectiveness of targeted interventions, particularly those tailored to students’ academic stage and gender, thereby strengthening the scientific foundation for educational policies.

5. Conclusions

Psychological distress is highly prevalent among Spanish medical students, with anxiety, depression, and burnout affecting a significant proportion. These symptoms are consistently reported across various studies and institutions, indicating that distress is not isolated or occasional, but rather a widespread issue that requires institutional recognition and comprehensive public health strategies. Key contributing factors include academic overload, sleep deprivation, and maladaptive coping strategies, while protective factors such as family support and emotional resilience are often underutilised.

Female students consistently report higher levels of psychological distress compared to their male counterparts. These findings align with broader international data and emphasise the need for gender-sensitive strategies within academic institutions to ensure equitable mental health support throughout medical training. Moreover, this symptomatology often manifests in the early stages of medical education and may intensify as students progress. The transition to clinical practice, increased academic responsibilities, and patient interactions contribute to escalating emotional demands, highlighting the importance of early and continuous interventions throughout the academic journey.

Although awareness of psychological distress among Spanish medical students is increasing, only a small number of universities appear to have implemented structured mental health programmes. There is an urgent need for institutional reforms aimed at prevention, emotional education, and the early identification of mental health concerns. In the absence of such measures, psychological distress may persist beyond medical school, potentially affecting both individual wellbeing and the quality of healthcare provision. To address this challenge, three key areas for intervention are proposed. First, medical curricula should be re-evaluated to ensure a better balance between academic demands and students’ mental health. Second, universities should develop comprehensive programmes from the first year onwards, focusing on emotional awareness, stress management, healthy lifestyle promotion, and resilience building. Third, mental health support services must be easily accessible, confidential, and fully integrated into university life, offering both peer-led initiatives and professional psychological care. These actions require long-term institutional commitment and coordination among academic, healthcare, and policy sectors to establish a sustainable mental health framework within medical education.