Prevalence, causes and interventions for anxiety, depression and burnout among medical students: a scoping review

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INTRODUCTION

Mental health issues among university students have become a critical global public health concern, affecting millions worldwide. Anxiety, depression, and burnout are the most prevalent conditions, impairing academic performance, social functioning, and long-term psychological well-being [1]. Burnout, characterized by emotional exhaustion, depersonalization, and reduced personal accomplishment, is increasingly recognized as a syndrome resulting from chronic academic stress [2]. Evidence suggests high prevalence rates, with 30–50% of students experiencing anxiety, 20–40% depression, and up to 60% burnout [1–3].

These concerns are particularly pronounced among international students, a rapidly growing yet vulnerable population. They face additional challenges, including cultural adjustment, language barriers, social isolation, financial hardships, and acculturative stress, which exacerbate psychological distress [4–6]. Such stressors negatively affect academic performance and long-term well-being, including resilience, career development, and quality of life [6]. Risks are further intensified during crises, such as geopolitical instability or the COVID-19 pandemic, increasing uncertainty, fear, and social disconnection [6, 7]. In extreme contexts, including conflict zones, students report elevated trauma-related symptoms and suicidal ideation, underscoring the need for culturally sensitive support systems [4, 5].

Despite these vulnerabilities, limited research has focused on students in health-related professional programs, particularly medicine. Medical students, especially those studying abroad, face unique pressures, including intensive academic demands, clinical responsibilities, and emotional strain. Consequently, they exhibit disproportionately high rates of anxiety, depression, and burnout, with some studies reporting prevalence as high as 70%, compared to 16% among local peers [8]. The combined burden of rigorous training and cross-cultural adaptation further heightens their risk of adverse mental health outcomes. However, the existing literature has notable limitations. There is limited synthesis of prevalence data across diverse contexts, a lack of longitudinal studies, and insufficient consideration of sociocultural and systemic factors. Moreover, little is known about how macro-level influences — such as healthcare infrastructure, societal attitudes, and institutional policies — affect international students' mental health. The question of whether international students fare better or worse than their local counterparts remains unresolved, with contradictory findings across regions.

Addressing these knowledge gaps is critical, as mental health challenges among international medical students affect not only academic performance and clinical competence but also healthcare systems, patient safety, and workforce sustainability [9]. Poor mental health is associated with impaired clinical judgment, reduced empathy, and an increased risk of medical errors, directly compromising care quality [9]. Moreover, stigma and systemic barriers often limit help-seeking, exacerbating health inequities within this population [10]. Given the growing internationalization of medical education and the essential contributions of international medical students, there is an urgent need for evidence-based policies and targeted support services.

Against this background, this scoping review aims to synthesize the current evidence on the prevalence, causes, and interventions associated with anxiety, depression, and burnout among international medical students and to compare these outcomes with those observed in local student populations.

METHODS

Protocol and registration

This scoping review was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines [11].

Eligibility criteria

Studies were eligible if they met the following inclusion criteria:

• original research exploring the prevalence, causes, or interventions associated with anxiety, depression or burnout among international medical students;
• comparison between international medical students and local medical students, or between international medical students and students in non-medical programs;
• publication date from the 2000 onward;
• publication in English or Russian.

Studies were excluded if they met any of the following criteria:

• involvement of non-international students or students in non-medical educational programs, or exclusive focus on domestic medical students without specific reference to international cohorts;
• classification as opinion pieces, editorials, gray literature, or other non-peer-reviewed publications.

Data sources

A search of electronic databases (PubMed, eLIBRARY.RU and Google Scholar) was conducted in March–April 2025, covering studies published between 2000 and 2024. This timeframe captures the development of research on mental health challenges among international medical students while ensuring relevance by excluding pre-2000 studies.

Search strategy

The search used combinations of key terms related to the areas of interest, including "international medical students" AND "mental health" (see Appendix S1 in the Supplementary for the full search strategy).

Selection process

The titles and abstracts of the identified records from PubMed and Google Scholar were exported to Rayyan.ai, a free web-based application designed to facilitate the screening process for systematic and scoping reviews [12]. Articles retrieved from eLIBRARY.RU were uploaded to a separate Excel spreadsheet for two-stage screening. First, two independent reviewers (K.O. and A.Ia.) screened the titles and abstracts against the inclusion and exclusion criteria. Second, the selected studies were examined in full to confirm eligibility. Any discrepancies were resolved through discussion and adjudication by a third reviewer (V.S.). Additionally, three of the included studies were published in Russian [13–15]; these were independently translated into English by two reviewers (A.Ia. and V.S.), and the translations were compared, with any discrepancies resolved through discussion to minimize translation bias.

A standardized data extraction form was developed in an electronic spreadsheet to record the following information: authors' details, international students' home countries, ethnic background, sample size, mean age, year of study, study design, assessment methods, and primary and secondary outcomes. Data extraction was initially conducted by one reviewer (K.O.) and subsequently verified by a second reviewer (A.Ia.) to ensure accuracy and consistency. Any disagreements were resolved through discussion.

Data collection process

A narrative synthesis approach was employed to integrate and interpret data extracted from the included studies, following established methodological guidance [16]. The specific methods used included: (a) data tabulation — relevant data were systematically extracted from each study using a standardized data collection form and subsequently organized into comprehensive tables to provide an overview of the evidence landscape; (b) descriptive summaries — following data organization, descriptive summaries were generated to report ranges of prevalence, identify common causes, and characterize intervention types. Additionally, comparative analyses were conducted to examine differences in outcomes between international and local medical students across various geopolitical and cultural contexts.

Study quality and risk of bias assessment

The quality of the included studies was assessed using tools appropriate to each study design. The Newcastle-Ottawa Scale¹ was used for longitudinal cohort studies; the Jadad Scale [17] was employed for randomized controlled trials; and the Appraisal tool for Cross-Sectional Studies [18] was applied to cross-sectional studies.

RESULTS

Study selection

The original search yielded 748 articles. Following the removal of 240 duplicates, 462 articles were excluded during title and abstract screening based on the predefined inclusion and exclusion criteria. The full texts of the remaining 46 articles were assessed for eligibility, resulting in 24 studies being included in the review. The selection process is shown in Figure 1.

 

Figure 1. PRISMA flow diagram of the literature search and selection process.

Source: Otabil et al., 2026.

 

Overview of included studies

Included studies were published between 2006 and 2024, encompassing a total of 10,000 participants. Geographically, eight studies were conducted in China [7, 19–25], five in the Russian Federation [13–15, 26, 27], two in Saudi Arabia [28, 29], and one each in Lithuania [30], Bulgaria [31], Ukraine [5], Turkey [32], Germany [33], Pakistan [34], Kazakhstan [35], Israel [4] and Poland [36]. Regarding study designs, 21 studies employed a cross-sectional design, two used a prospective longitudinal cohort design [30, 33], and one was a randomized controlled trial [21]. Of the 24 retrieved studies, 17 focused exclusively on international medical students, while the remaining seven [4, 5, 22, 31–36] presented comparisons between local and international medical students. The main characteristics of included studies are presented in Appendix S2 in the Supplementary.

Prevalence of anxiety, depression and burnout among international medical students

The prevalence data on anxiety, depression and burnout among international medical students found in our study, with rates varying markedly across regions, reflect the influence of sociocultural, economic, and systemic factors such as institutional policies, curriculum structure, and mental health infrastructure. In the Czech Republic, Yamada et al. (2013) [8] reported that nearly 49% of international medical students experienced mental health challenges, indicating a particularly high mental health burden. In Kazakhstan, Ibrayeva et al. (2018) [35] observed lower but still substantial prevalence rates, with depression affecting 33.2% of international medical students and anxiety affecting 22%. These moderate levels may be partly attributable to regional differences in mental health infrastructure and cultural perceptions of mental health [34]. Comparatively lower levels of mental health challenges were reported among East Asian international medical students, particularly those from China. Xiao et al. (2024) [21] identified prevalence rates of 23.27% for anxiety and 48.52% for depression. Although mental health concerns remain substantial in China, these rates were generally lower than those observed in the Czech Republic and Kazakhstan, potentially reflecting differences in cultural norms, stigma-related reporting, and collectivist social support [19]. In contrast, exceptionally high prevalence rates of mental health challenges were observed in Egypt. Ali et al. (2024) [37] found that nearly 64% of international medical students experienced moderate to severe symptoms of anxiety, a finding likely attributable to socio-economic challenges and limited access to mental health resources [10].

In contrast to anxiety and depression, the evidence for burnout among international medical students is considerably more limited and must be interpreted with caution. Only two studies included in this review employed validated, standardized burnout instruments: AlGerafi et al. (2021) [22] used the Oldenburg Burnout Inventory [38] among international medical students in China during the COVID-19 pandemic lockdown, and Ungku Fadzil et al. (2024) [26] used the Maslach Burnout Inventory (MBI; Maslach & Leiter, 2018) [39] in a pre-pandemic study conducted in Russia. AlGerafi et al. [22] reported that nearly 100% of students exhibited high levels of exhaustion and disengagement, which was significantly associated with isolation and lockdown-related stress. Ungku Fadzil et al. [26], by contrast, found only moderate levels of burnout, characterized by emotional exhaustion and depersonalisation. A third study [5] used a non-standardized burnout questionnaire during the war in Ukraine and reported elevated burnout scores, but its findings are not directly comparable to the available literature due to the unvalidated instrument and the extreme contextual conditions.

Overall, available evidence suggests that burnout among international medical students is moderate under typical academic conditions but may increase substantially during crisis situations. Burnout frequently co-occurs with anxiety and depression, highlighting the need for further research using standardized measures.

Primary causes of anxiety, depression and burnout among international medical students

The high prevalence of anxiety, depression, and burnout among international medical students is driven by several interrelated causes, including demanding academic requirements, challenges associated with adapting to new cultural and linguistic environments, significant lifestyle adjustments, social isolation, and institutional barriers. The relative contribution of these factors varies across regions and educational contexts, as discussed below.

Firstly, numerous studies [10, 19, 28, 34] indicate that international medical students face heavy academic workloads and intense performance pressures, which significantly impact their mental health. Students described the demands of medical education as "overwhelming", emphasizing that the curriculum is considerably more rigorous than that of other non-medical programs and often exceeds their prior educational experiences [10]. Additionally, clinical training has been identified as a significant factor affecting international medical students' mental health [10, 34, 40]. International medical students studying in Italy described clinical training as "a journey filled with roses and thorns", reflecting the emotional strain associated with emotionally demanding clinical environments [40].

Secondly, several studies [4, 5, 10, 41] identify language barriers as a significant factor affecting international medical students' mental health by posing an obstacle to both academic performance [4, 5] and social integration [10, 41].

Thirdly, environmental and lifestyle challenges, such as adjustment to unfamiliar climates, local cuisine, accommodation conditions, and transportation systems, significantly affect the mental health of international medical students [10, 27, 31, 40, 41].

Fourthly, psychological and social isolation are prevalent challenges among international medical students, often leading to emotional distress, anxiety, depression, and burnout [10, 21, 34, 40, 42]. Many students report feelings of loneliness, difficulties in building social networks, experiences of cultural dissonance [34] and homesickness [10]. Seven studies [7, 19, 22, 23, 25, 28, 30] collectively highlight the substantial impact of the COVID-19 pandemic on mental health among international medical students, particularly concerning anxiety, depression, and burnout. These findings highlight the exacerbation of pre-existing mental health challenges faced by international medical students during global health crises.

Fifthly, systemic and institutional challenges which include complex visa procedures, perceived discrimination, inadequate academic and psychological support, and unmet expectations play a critical role in exacerbating international medical students' mental health problems [10, 31, 34, 36].

Distinct regional differences are evident in the experiences of international medical students. In Italy, students primarily encounter challenges related to climate adaptation and dietary adjustments [40]. Conversely, students in Russia and Bulgaria face more significant logistical difficulties, particularly concerning housing and transportation [27, 31]. In Egypt, issues such as substandard accommodation and limited internet connectivity are prominent, reflecting regional disparities in environmental factors and lifestyle-related challenges experienced by international medical students [10].

Interventions targeting anxiety, depression and burnout among international medical students

Addressing the mental health challenges faced by international medical students requires the implementation of targeted, evidence-based interventions supported by empirical data. A recent study by Xiao et al. (2024) [21] provides valuable insights into strategies that effectively reduce mental health challenges and promote social integration within this particularly vulnerable population. Xiao et al. (2024) [21] conducted a randomized controlled trial involving 89 international medical students in China. The study implemented an eight-week positive emotional writing intervention, whereby participants in the experimental group were instructed to engage in daily reflective writing focused on positive experiences, supportive interpersonal relationships, and personal strengths. This activity was administered alongside routine psychological care. The effectiveness of the intervention was assessed using validated standardized instruments administered before and after the intervention, including the Self-Rating Depression Scale, Self-Rating Anxiety Scale, and the General Well-being Schedule. The results revealed statistically significant reductions in depression and anxiety scores, accompanied by significant improvements in subjective well-being, among participants in the experimental group compared with the control group. These findings indicate that structured expressive writing interventions can yield measurable mental health benefits within a relatively short timeframe.

Comparative analysis of mental health challenges faced by international and local medical students

Compared with local students, several studies indicate that international medical students often experience elevated levels of mental health issues, including anxiety, depression, and burnout, compared with local students. Kovatz et al. (2006) [4] reported that American international medical students demonstrated higher mean scores for anxiety (1.03 on the General Health Questionnaire (GHQ-28) anxiety subscale, range 0–28) and fear (4.27 on Gal's questionnaire, range 1–7), than their Israeli local counterparts (anxiety: 0.73; fear: 3.37). In contrast, Gurnish and Ivanitska-Diachun (2025) [5] found the opposite pattern, with Ukrainian local students exhibiting more severe mean scores for stress (23 points on the Depression, Anxiety and Stress Scale (DASS)-21 stress subscale, range 0–42), anxiety (19 points on the DASS-21 anxiety subscale, range 0–42), depression (18 points on the DASS-21 depression subscale, range 0–42), and burnout (71 points on a specialized burnout questionnaire, range 28–140) than their international peers (stress: 14; anxiety: 12; depression: 10; burnout: 48). Conversely, some studies highlight the resilience and adaptive capacity of international medical students. Vatansever et al. (2021) [31] found Turkish students who were studying in Turkey had significantly higher depression scores than their international student counterparts who were studying in Bulgaria, indicating that local students can also experience substantial mental health challenges. Ruzhenkova et al. (2020) [27] reported decreasing anxiety among international medical students in Russia over time, suggesting progressive psychological adaptation to the host environment. Abdulhamed et al. (2024) [32] found comparable levels of depression and unhappiness among both local and international students in Turkey, highlighting that mental health challenges may be shared across student groups regardless of background.

Risk of bias assessment

The analysis of risk of bias across the 24 studies indicates that the majority fall within the moderate to low-risk categories, suggesting a generally acceptable level of methodological quality. Only one study [34] was rated as having a high risk of bias, highlighting the need for cautious interpretation of findings from that particular study. The results of the risk assessment are provided in Appendix S3 in the Supplementary.

DISCUSSION

The review highlights that international medical students are particularly vulnerable to mental health issues, with prevalence rates of anxiety (22–53%), depression (15–48%). These outcomes are primarily attributed to academic pressures, linguistic and cultural barriers, environmental stressors, and systemic challenges, such as visa-related difficulties and experiences of discrimination. Additionally, the COVID-19 pandemic worsened these mental health challenges through increased social isolation and disruptions to academic and clinical routines.

When comparing our findings with studies involving non-medical students, several similarities emerged. Consistent with broader student populations, this review found that international medical students often experience higher levels of mental health challenges than their local counterparts [43]. This disparity is likely driven by additional stressors associated with international status, including cultural adaptation, language barriers, and social isolation. However, some studies [27, 31] indicate that local medical students may sometimes experience comparable or even higher levels of distress, particularly in settings characterized by limited institutional support and socioeconomic strain. This suggests that international status functions as a context-dependent risk factor rather than a deterministic predictor of poor mental health outcomes.

Across both medical and non-medical student populations, mental health outcomes are shaped by a combination of academic pressures, social and cultural adaptation challenges, and structural or systemic factors. Individual characteristics, such as gender, age, and year of study, further influence outcomes [44]. In addition, cultural perceptions of mental health and stigma can affect help-seeking behaviors and reporting patterns, with lower disclosure of distress observed in East Asian student populations [19, 21]. Consequently, lower reported prevalence rates should be interpreted with caution, as they may reflect underreporting rather than genuinely lower levels of distress.

Turning to differences, some evidence suggests that non-medical students may experience higher levels of depression and anxiety than medical students [44, 45]. For instance, during the COVID-19 pandemic in China, non-medical students showed significantly higher rates of depression (29.1% vs. 17.9%) and anxiety (19.7% vs. 8.9%) than medical students. Similarly, Carrard et al. (2025) [45] found a higher prevalence of depression among non-medical students (55.19%) compared to medical students (47.59%), although these differences became less pronounced after adjusting for confounders. These findings challenge the assumption that medical students consistently represent the most psychologically vulnerable group, indicating instead that vulnerability varies by context and underlying stressors.

Overall, the evidence highlights that mental health challenges are widespread across student groups, regardless of discipline or status, although they are shaped by differing contextual factors. Accordingly, effective interventions should adopt a context-sensitive approach that addresses both shared and population-specific stressors, rather than focusing solely on student classification.

The current review exhibits a key strength in its scope, as it integrates findings from 24 studies, thereby offering a comprehensive overview that enhances understanding of this population. Despite this strength, the review also acknowledges several important limitations that are discussed below.

First, the majority of the included studies (17 of 24) relied exclusively on samples of international students, without including a comparison group of domestic peers. This limitation restricts the ability to isolate the specific impact of studying and residing in a foreign cultural context on mental health outcomes. Nevertheless, approximately one-third of the studies included a local comparison group, allowing for indirect comparative insights.

Second, study inclusion was limited to articles published in English or Russian or those with available translations. This language restriction may have resulted in the exclusion of relevant research from non-English-speaking regions, which is particularly important given the cultural diversity of international medical students worldwide.

Third, the included studies employed a range of assessment tools, such as GHQ-12, DASS, and Symptom Checklist–90 (SCL-90), which differ in their sensitivity, specificity, and the dimensions of mental health that they assess. This heterogeneity complicates the direct comparison, integration, or synthesis of findings across studies. Additionally, some studies used tools that were not adequately validated or were adapted for different cultural contexts, potentially introducing measurement bias and inaccuracies.

Fourth, although the reviewed studies span multiple countries, there is a notable concentration of research originating from China (eight studies) and the Russian Federation (five studies). The underrepresentation of studies from other countries limits the generalizability of findings.

Fifth, while the review employed PubMed, Google Scholar and eLIBRARY.RU, it did not include other major databases such as PsycInfo, Embase, Scopus, or Web of Science. This restricted search strategy might have resulted in the omission of relevant studies, particularly those published in psychology, social sciences, or regional databases not indexed in the selected platforms.

Future research may need to prioritize studies using validated, culturally adapted instruments or standardized frameworks, such as the dual continua model of mental health [46], to enhance comparability and synthesis of findings. There is a pressing need for longitudinal and controlled studies to evaluate the effectiveness of interventions like resilience training, counseling, and peer support, thereby clarifying causal relationships and long-term outcomes. Expanding research to underrepresented regions such as Africa and Latin America will improve cultural relevance and generalizability. Additionally, examining pre-admission experiences, early mental health responses, and systemic factors, such as institutional policies, curricula, and mental health infrastructure — is essential for informing targeted prevention strategies and evidence-based policymaking. From a practical perspective, institutions should implement culturally responsive mental health support systems that foster community connection and promote resilience-building initiatives. Particular attention should be given to supporting individuals during early transition phases. Policies should focus on reducing structural barriers such as complex visa procedures, perceived discrimination, and inadequate academic and psychological support, and strengthening support networks to effectively promote mental well-being across diverse populations.

CONCLUSION

In summary, international medical students appear to experience a considerable burden of depression and anxiety, driven by academic, linguistic, and cultural stressors and amplified during the COVID-19 pandemic. Evidence on burnout remains insufficient to draw firm conclusions. Given the methodological limitations of the existing literature future studies may need to employ longitudinal design and standardized measures. Meanwhile, strengthening social support networks and adopting culturally sensitive interventions may help to improve the mental well-being of international medical students.

Article history

Submitted: 23 Jul. 2025

Accepted: 22 Jul. 2026

Published Online: 15 Sep. 2026

Authors' contribution: Kingsford Otabil: conceptualization, formal analysis, writing the original draft. Vsevolod Severtsev, Anastasiia Iakuba, Tigist Hunde Shiferaw: conceptualization, formal analysis, data curation, writing the original draft. Marina Kinkulkina, Yulia Tikhonova: supervision, methodology, revision and editing of the draft. All authors made significant contributions to the research and article writing and have read and approved the final manuscript version prior to publication.

Funding: The research was carried out without additional funding.

Conflict of interest: The authors declare no conflicts of interest.

Generative AI use statement: Nothing to disclose.

Supplementary data

Supplementary material to this article can be found in the online version by doi:

Appendix S1: 10.17816/CP15727-145667

Appendix S2: 10.17816/CP15727-146316

Appendix S3: 10.17816/CP15727-146317

¹ Wells G, Shea B, O'Connell J, et al. The Newcastle-Ottawa Scale (NOS) for Assessing the Quality of Nonrandomised Studies in Meta-analyses. Ottawa Health Research Institute. 2014. URL: https://ohri.ca/en/who-we-are/core-facilities-and-platforms/ottawa-methods-centre/newcastle-ottawa-scale

About the authors

Kingsford Otabil

I.M. Sechenov First Moscow State Medical University (Sechenov University)

Author for correspondence.
Email: Kingsfordotb2@gmail.com
ORCID iD: 0009-0005-3602-2038

PhD Student

Russian Federation, Moscow

Anastasiia S. Iakuba

I.M. Sechenov First Moscow State Medical University (Sechenov University)

Email: Kingsfordotb2@gmail.com
ORCID iD: 0009-0008-7705-3166

6th-Year Student

Russian Federation, Moscow

Tigist Hunde Shiferaw

Peoples' Friendship University of Russia named after Patrice Lumumba

Email: Kingsfordotb2@gmail.com
ORCID iD: 0000-0001-5873-2683

PhD Student, Department of Psychology

Russian Federation, Moscow

Vsevolod V. Severtsev

I.M. Sechenov First Moscow State Medical University (Sechenov University)

Email: Kingsfordotb2@gmail.com
ORCID iD: 0000-0001-8712-3561
SPIN-code: 5969-2020

MD, Cand. Sci (Med.), Assistant Professor at the Department of Psychiatry and Addiction Medicine

Russian Federation, Moscow

Yulia G. Tikhonova

I.M. Sechenov First Moscow State Medical University (Sechenov University)

Email: Kingsfordotb2@gmail.com
ORCID iD: 0000-0001-6071-2796
SPIN-code: 7978-4247
Scopus Author ID: ID: 56558516000
ResearcherId: MCY-7146-2025

Dr. Sci (Med.), Professor, Department of Psychiatry and Narcology

Russian Federation, Moscow

Marina A. Kinkulkina

I.M. Sechenov First Moscow State Medical University (Sechenov University)

Email: Kingsfordotb2@gmail.com
ORCID iD: 0000-0001-8386-758X
SPIN-code: 9040-4108
Scopus Author ID: 23977940700
ResearcherId: U-8234-2017

MD, Dr. Sci (Med.), Corresponding Member of the Russian Academy of Sciences, Professor, Head of the Department of Psychiatry and Narcology

Russian Federation, Moscow

References

Supplementary files