Table 1

Articles investigating the effect on Mental Health

StudyYearSample sizeStudy designSignificant findingsOxford level of evidence
USA studies
Hafferty et al5198696Cross-sectional surveyHigher levels of debt associated with greater concern about practise climate.4
Jackson et al1620164402Cross-sectional survey32.4% met criteria for alcohol abuse/dependence; 80% had burnout, alcohol abuse/dependence or depressive symptoms at time of survey.4
Marci and Roberts181998100Longitudinal surveyIncreasing debt levels positively correlated with worry and negatively correlated with comfort in a linear manner. Comfort with debt was rated from −3 (not comfortable) to +3 (very comfortable) on a Likert scale. For 1997 graduates with debt projections over US$75 000, comfort level was rated significantly lower (−1.86 vs 0.89, p<0.001).3
Rohlfing et al2220143032Cross-sectional surveyEach US$50 000 increase in medical student loan debt was associated with increased stress, mainly financial (crude OR 1.54, 95% CI 1.43 to 1.67, adjusted OR 1.55, 95% CI 1.34 to 1.81).4
Phillips et al562016132Cross-sectional qualitative studyThere were many themes on how students emotionally perceive debt including: debt symbolises lack of social investment; debt reinforces a sense of entitlement.4
Canadian studies
Kwong et al1720052994Cross-sectional surveyCompared with non-rural, rural students reported more debt at both entry to medical school and on graduation. They were also more likely to report fair-to-extreme levels of financial stress compared with non-rural (61.7% vs 55.4%, p=0.03).4
Merani et al1920107795Longitudinal surveyMore students in 2007 than 2001 expected to graduate with debt (89.7% vs 75.7%). Rose from US$14 500 to US$30 000 in Quebec but US$50 000 to US$90 000 outside Quebec (p<0.0001). Quebec students anticipated less debt and less likely to report financial stress than those outside Quebec.3
Morra et al202008549Cross-sectional surveyPerceived financial stress correlated significantly with both current debt (r=0.303) and anticipated debt (r=0.455). The anticipated debt was also able to account for an additional 11.5% of the variance in reported stress over that predicted by current debt alone.4
Kwong et al2520022994Cross-sectional surveyStudents reported that their financial situation was ‘very’ or ‘extremely’ stressful (21.4% vs 26%), opposite result was found in control groups.4
McLuckie et al272017381Cross-sectional surveyFeeling psychologically/emotionally unsupported at their university, which increased through the years of medical training, was a predictor of psychological distress and burnout. This risk was reduced in those who felt supported.4
New Zealand studies
Gill et al152001179Cross-sectional surveyWorrying about debt increased in sixth year students with levels of debt: those who never worried (14%) had debts of US$2500, those who always worried (7%) had debts of US$86 750. Frequency of worrying for all students was never (20%), rarely (10%), sometimes (34%), often (30%), always (5%).4
Perry and Wilkinson262010372Cross-sectional survey32% of students always or often worry about debt, 34% sometimes. The amount of worry was positively correlated with amount of debt.4
Scottish study
Ross et al232006352Cross-sectional survey42% reported stress about money contributed to up to one-fourth of their stress, nearly 16% stated stress about money made up >50% of their overall stress; 37.4% thought worrying about money affected their studies. Money came in as the second most common cause of stress after coursework at 78.1%.4
Australian study
Rogers et al242012755Cross-sectional surveyBarriers (including medical specialty choice, family and lifestyle conditions, male domination, hours of work), concern about debt, academic stress accounted for 12.7% of variance on well-being.4