Abstract
BACKGROUND:
Suicidal behavior is a leading mental health concern among medical students, particularly in China where postgraduates face intense academic pressure and hierarchical dependence on supervisors. The quality of the student–supervisor relationship (SSR) has been associated with psychological distress, but its contribution to suicidal behavior and the potential mediating roles of depression and insomnia remain unclear.
MATERIALS AND METHODS:
A total of 1,304 validated questionnaires designed to collect demographic information and study programs, including the Suicidal Behaviors Questionnaire-Revised (SBQ-R), the Leader-Member Exchange 7 (LMX-7), the Patient Health Questionnaire-2 (PHQ-2), and the Insomnia Severity Index-7 (ISI-7) scale were distributed to participants. The relationship between variables was explored through multiple regression analysis. A serial mediation analysis with 10,000 bootstrap simulations was conducted to explore the mediating effects of depression and insomnia on the relationship between SSR and suicidal behaviors.
RESULTS:
Among 1,304 respondents, 6.7% participants were at risk of experiencing suicidal behaviors. The proportions of depression, suicidal behaviors, and severity of insomnia were higher in the medium-to-low quality SSR group (LMX-7 score <25) compared with the high-quality SSR group. Multiple regression analysis revealed that LMX-7, PHQ-2, and ISI-7 strongly correlated with the SBQ-R. Depression and insomnia mediated 57.3% of the total effect of the SSR on the risk of suicidal behavior.
CONCLUSION:
SSR influences the risk of suicide in medical postgraduates partly by modulating depression and insomnia. Therefore, strategies for identifying students with poor SSR are needed to improve the implementation of psychological interventions and insomnia treatment to mitigate the occurrence of suicide.
Keywords: Depression, insomnia, medical, preceptorship, students, suicidal behavior, suicide prevention
Introduction
Suicide is the second leading cause of death globally among young people aged 15–29 years.[1] Each year, more than 700,000 individuals die by suicide, and many more attempt it, creating a substantial personal and societal burden.[2] Medical students are particularly vulnerable.[3,4] A systematic review and meta-analysis estimated that 27% of medical students globally experience depression and nearly 11% report suicidal ideation during training.[3] Factors such as heavy academic load, sleep deprivation, and hierarchical training structures compound this risk. This calls for the timely identification of training-related risk factors to initiate appropriate interventions.[5] Depression and insomnia are highly prevalent in medical student populations. Around 27% of Chinese medical students experience depressive symptoms.[6] Insomnia is also a pervasive issue among medical students both globally and within China. A recent meta-analysis reported a pooled prevalence of poor sleep quality at approximately 57% among medical students worldwide.[7]
Mentorship is a crucial component of medical training.[8] In China, medical postgraduates work under the guidance of a supervisor who serves as the primary mentor, role model, and career sponsor.[9] Although this framework provides appropriate guidance, there may be cases of psychological strain when the relationship between the student and supervisor is strained.[10] In our previous studies, we demonstrated a strong association between poor student-supervisor relationship (SSR) quality and increased suicidal behaviors among Chinese medical postgraduates, particularly those from families with low subjective socioeconomic status.[11] However, considering the complex, multifactorial nature of suicidal ideation, identifying associations alone does not provide the necessary foundation for formulating appropriate prevention interventions.[12] Notably, based on the Confucian values of hierarchy and respect, awareness of SSR-related risk rarely translates into individual-level relationship repair,[13] necessitating the search for more effective alternative interventions.
Studies have shown that depression and insomnia can contribute to the risk of suicide, and cannot be effectively addressed through psychological interventions.[14,15] In the Chinese medical postgraduate training, we hypothesize that the high chronic stress seen among students with poor SSR may strongly present as depressive symptoms and insomnia, in turn, increasing the risk of suicidal behavior. Therefore, uncovering the mechanisms by which depression and insomnia mediate the link between SSR and suicidal behavior is essential, as identifying modifiable pathways can help to develop prevention strategies and tailored interventions.[12,15]
Against this background, we aimed to explore the association between the student-supervisor relationship and suicidal behaviors, and clarify the mediating role of insomnia and depression on this association.
Materials and Methods
Study design and setting
This was a cross-sectional, questionnaire-based survey conducted among medical postgraduates at [blinded to reviewers] University. Data were collected online during 2022.09–2023.01 using a self-administered instrument.
Study participants and sampling
A self-administered questionnaire was distributed to postgraduate students majoring in clinical medicine, medical technology, and nursing at three prestigious medical institutions affiliated with a top medical university in China. Among the 1,316 distributed questionnaires, 1,304 were correctly filled and returned, translating to a response rate of 99.1%.
Data collection tool and technique
The questionnaire was performed through email and cellphone text messages, and completed responses were recorded by one investigator. The questionnaire (detailed in supplementary material 1) comprised demographic variables including age, gender, marital status, and educational program. We used validated scales to assess the primary variables of interest: (1) the Revised Suicidal Behavior Questionnaire (SBQ-R), (2) the Leader-Member Exchange 7 (LMX-7) questionnaire, (3) the Patient Health Questionnaire-2 (PHQ-2), and (4) the Insomnia Severity Index-7 (ISI-7) scale.
Measures
Risk of suicidal behaviors
The prevalence of suicidal ideation was determined using SBQ-R, which contains four questions designed to obtain information about the frequency and intensity of suicidal thoughts and attempts experienced by the student in the past, as well as the likelihood of future suicidal behavior. The SBQ-R scores range from 3 to 18, with high scores reflecting increased suicide risk. A score of 7 was set as the threshold for significant suicide risk for the general adult population, which classified the participants into a high-risk group (SBQ-R ≥7) or a low-risk group (SBQ-R <7).[16]
Student-supervisor relationship
The quality of the association between medical postgraduates and their supervisors was explored using the LMX-7 questionnaire. The leader-member exchange relationship is defined as the exchange relationship between a leader and a subordinate, mirroring that between a supervisor and a postgraduate student in China.[17,18] The LMX-7 questionnaire consists of seven items designed to determine the extent of mutual trust, respect, and cooperation in the supervisor–student relationship. Participants rated their agreement with each statement on a 5-point Likert scale by selecting a score of 1 (strongly disagree) or 5 (strongly agree). Typically, a score of 25 or more reflected a high-quality relationship.
Depression
The Patient Health Questionnaire-2 (PHQ-2), which is a validated ultra-brief instrument for evaluating core depressive manifestations (depressed mood and anhedonia) for the preceding 2 weeks, was applied to identify depressive symptoms.[19] On this scale, each item is scored 0–3 (total range: 0–6), with higher scores reflecting high symptom burden. A cutoff of 2 or higher yields a sensitivity of 0.92 (95% CI: 0.88–0.95) and a specificity of 0.67 (95% CI: 0.63–0.70) in predicting the risk of major depression.[20] Furthermore, a recent study comprising adolescents and young adults proposed a PHQ-2 cutoff value of 2 rather than 3.[21] In this study, we used a PHQ-2 score of 2 as the cutoff value for perceived depression.
Insomnia
Insomnia was evaluated using the ISI-7 scale, a five-point Likert scale that contains seven items, each scored on a scale ranging from 0 (no problem) to 4 (very severe problem), with total scores ranging from 0 to 28. The severity of insomnia was classified into four levels: no insomnia (0–7), subthreshold insomnia (8–14), moderate insomnia (15–21), and severe insomnia (22–28), based on the total ISI-7 score.[22]
Ethical consideration
The study was approved by the Ethics Committee of [blinded to reviewers] University. All participants provided electronic informed consent before data collection. Responses were anonymized and treated confidentially in accordance with institutional policy and the Declaration of Helsinki.
Statistical analysis method
The reliability of the questionnaire was determined based on the Cronbach’s alpha, and the bootstrap method was used to calculate its 95% confidence interval (CI). Continuous variables were expressed as the mean and standard deviations (SD) or median and interquartile ranges (IQR), depending on the normality of the data, which was evaluated using the Shapiro–Wilk test. For normally distributed variables, the Student t-test was used, whereas for non-normally distributed variables, the Wilcoxon rank-sum test was applied. Categorical variables were expressed as numbers and percentages and analyzed using the Chi-square test. The associations between variables as well as adjustment for confounders was performed using multiple linear regression models. A serial mediation analysis with 10,000 bootstrap simulations was used to determine the mediating effects of depression and insomnia between SSR and suicidal behavior. All statistical analyses were performed in R software (version 4.2.2, The R Foundation for Statistical Computing). Statistical significance α was set at 0.05.
Results
Demographic characteristics
Overall, 467 men (35.8%) and 837 women (64.2%), with a median age of 26.0 years (IQR: [24.0, 28.0]) were included in this study. Among them, 746 (57.2%) were master’s students, while 558 (42.8%) were doctoral degrees. Furthermore, 88 (6.7%) participants exhibited a high risk of suicidal behaviors.
Differences in student–supervisor relationships
Among the 1304 subjects, 846 (64.9%) showed a high-quality SSR, while 458 (35.1%) had low-quality SSR based on a cutoff score of 25 on the LMX-7 scale. The distribution of scores on the LMX-7 scale is shown in Figure 1. Notably, the Cronbach’s alpha coefficient for the LMX-7 was 0.900 (95% CI: 0.890–0.908). Further analysis revealed that the median age (P = 0.001), proportion of doctoral students (P = 0.004), proportion of male participants (P < 0.001), and proportion of married participants (P < 0.013) were significantly higher in the high-quality SSR group than in the medium-to-low quality SSR group [Table 1]. By contrast, the total scores and individual item scores on the ISI-7, PHQ-2, and SBQ-R scales were significantly higher in the medium and low-quality SSR groups relative to the high-quality SSR group (P < 0.001). Furthermore, the proportion of depression, suicidal behavior, and severity of insomnia were significantly increased in the medium-to-low quality SSR group compared with the high-quality SSR group (P < 0.001).
Figure 1.
Analysis of the distribution of scores for each item on the LMX-7 questionnaire. The percentages on the left represent responses 1 and 2, those in the middle reflect response 3, and those on the right denote responses 4 and 5
Table 1.
Comparison between low- and moderate-quality SSR and high-quality SSR groups
| Variable | Low-/Moderate-quality SSR | High-quality SSR | P | |||||||
|---|---|---|---|---|---|---|---|---|---|---|
|
| ||||||||||
| Mean (SD) | Median [IQR] | Mean (SD) | Median [IQR] | |||||||
| n | 458 | 846 | ||||||||
| Degree (%) | 0.004 | |||||||||
| Master | 287 (62.7) | 459 (54.3) | ||||||||
| Doctor | 171 (37.3) | 387 (45.7) | ||||||||
| Sex (%) | <0.001 | |||||||||
| Male | 133 (29.0) | 334 (39.5) | ||||||||
| Female | 325 (71.0) | 512 (60.5) | ||||||||
| Age | 25.9 (3.3) | 25.0 [24.0, 27.8] | 26.6 (3.8) | 26.0 [24.0, 28.0] | 0.001 | |||||
| Marriage (%) | 0.013 | |||||||||
| Yes | 64 (14.0) | 166 (19.6) | ||||||||
| No | 394 (86.0) | 680 (80.4) | ||||||||
| ISI-7 Score | 5.7 (5.0) | 4.0 [1.0, 8.0] | 3.5 (4.0) | 2.0 [1.0, 6.0] | <0.001 | |||||
| ISI 1 | 0.8 (0.9) | 1.0 [0.0, 1.0] | 0.6 (0.8) | 0.0 [0.0, 1.0] | <0.001 | |||||
| ISI 2 | 0.7 (0.9) | 0.0 [0.0, 1.0] | 0.4 (0.7) | 0.0 [0.0, 1.0] | <0.001 | |||||
| ISI 3 | 0.4 (0.8) | 0.0 [0.0, 1.0] | 0.3 (0.6) | 0.0 [0.0, 0.0] | <0.001 | |||||
| ISI 4 | 1.4 (0.9) | 1.0 [1.0, 2.0] | 1.1 (0.8) | 1.0 [1.0, 1.0] | <0.001 | |||||
| ISI 5 | 1.0 (1.0) | 1.0 [0.0, 2.0] | 0.5 (0.8) | 0.0 [0.0, 1.0] | <0.001 | |||||
| ISI 6 | 0.6 (0.8) | 0.0 [0.0, 1.0] | 0.3 (0.6) | 0.0 [0.0, 1.0] | <0.001 | |||||
| ISI 7 | 0.8 (0.9) | 1.0 [0.0, 1.0] | 0.4 (0.6) | 0.0 [0.0, 1.0] | <0.001 | |||||
| LMX-7 Score | 21.8 (2.2) | 22.0 [21.0, 23.0] | 28.6 (3.0) | 28.0 [26.0, 30.0] | <0.001 | |||||
| LMX 1 | 3.4 (0.6) | 3.0 [3.0, 4.0] | 4.4 (0.5) | 4.0 [4.0, 5.0] | <0.001 | |||||
| LMX 2 | 2.9 (0.7) | 3.0 [3.0, 3.0] | 3.9 (0.8) | 4.0 [3.0, 4.0] | <0.001 | |||||
| LMX 3 | 3.0 (0.4) | 3.0 [3.0, 3.0] | 4.1 (0.6) | 4.0 [4.0, 4.0] | <0.001 | |||||
| LMX 4 | 3.1 (0.6) | 3.0 [3.0, 3.0] | 4.2 (0.5) | 4.0 [4.0, 4.0] | <0.001 | |||||
| LMX 5 | 2.9 (0.5) | 3.0 [3.0, 3.0] | 3.9 (0.7) | 4.0 [3.0, 4.0] | <0.001 | |||||
| LMX 6 | 2.8 (0.6) | 3.0 [3.0, 3.0] | 3.8 (0.8) | 4.0 [3.0, 4.0] | <0.001 | |||||
| LMX 7 | 3.6 (0.7) | 4.0 [3.0, 4.0] | 4.4 (0.5) | 4.0 [4.0, 5.0] | <0.001 | |||||
| SBQ-R Score | 4.3 (2.2) | 3.0 [3.0, 5.0] | 3.5 (1.2) | 3.0 [3.0, 3.0] | <0.001 | |||||
| SBQ-R 1 | 1.2 (0.5) | 1.0 [1.0, 1.0] | 1.1 (0.3) | 1.0 [1.0, 1.0] | <0.001 | |||||
| SBQ-R 2 | 1.2 (0.6) | 1.0 [1.0, 1.0] | 1.0 (0.3) | 1.0 [1.0, 1.0] | <0.001 | |||||
| SBQ-R 3 | 1.1 (0.3) | 1.0 [1.0, 1.0] | 1.0 (0.2) | 1.0 [1.0, 1.0] | <0.001 | |||||
| SBQ-R 4 | 0.8 (1.3) | 0.0 [0.0, 2.0] | 0.4 (0.9) | 0.0 [0.0, 0.0] | <0.001 | |||||
| PHQ-2 Score | 1.6 (1.1) | 2.0 [1.0, 2.0] | 0.8 (1.0) | 0.0 [0.0, 2.0] | <0.001 | |||||
| PHQ 1 | 0.7 (0.6) | 1.0 [0.0, 1.0] | 0.4 (0.5) | 0.0 [0.0, 1.0] | <0.001 | |||||
| PHQ 2 | 0.8 (0.6) | 1.0 [1.0, 1.0] | 0.4 (0.5) | 0.0 [0.0, 1.0] | <0.001 | |||||
| Depression, positive | 287 (62.7) | 271 (32.0) | <0.001 | |||||||
| Insomnia (%) | <0.001 | |||||||||
| No | 321 (70.1) | 712 (84.2) | ||||||||
| Subthreshold | 110 (24.0) | 121 (14.3) | ||||||||
| Moderate | 22 (4.8) | 10 (1.2) | ||||||||
| Severe | 5 (1.1) | 3 (0.4) | ||||||||
| Suicide Behaviors, positive | 58 (12.7) | 30 (3.5) | <0.001 | |||||||
The distribution of age, PHQ-2 scores, ISI-7 scores, and SBQ-R scores among participants in the medium-to-low quality SSR group and high-quality SSR group is presented in Figure 2. The Cronbach’s alpha coefficient for the PHQ-2, ISI-7, and SBQ-R questionnaires was 0.836 (95% CI: 0.807–0.859), 0.917 (95% CI: 0.906–0.926), and 0.774 (95% CI: 0.725–0.812), respectively.
Figure 2.
Distribution of age and questionnaire scores in the low- and moderate-quality SSR groups and the high-quality SSR group. (a). Age distribution; (b). Distribution of PHQ-2 score. The gray vertical dashed line indicates a PHQ-2 score ≥ 2; (c). Distribution of ISI-7 score. The three gray dashed lines from left to right reflect ISI-7 scores > 7, >14, and > 21; (d). Distribution of SBQ-R score. The gray dashed line indicates a SBQ-R score ≥ 7
Correlation and moderation of SSR and suicide behavior
Analysis of the scatter plot of LMX-7 and SBQ-R scores in Figure 3 indicated that, among the 58 participants with low to moderate SSR and risk of suicidal behavior, 48 (82.8%) developed depression, 35 (60.3%) had clinically significant insomnia, and 30 (51.7%) had both depression and clinically significant insomnia. Moreover, these proportions were significantly higher than those reported in the general population (all P < 0.001).
Figure 3.
Scatterplot of LMX-7 and SBQ-R Scores. The vertical dashed line on the left side indicates low quality SSR (LMX-7 score ≤ 24) and the horizontal dashed line above indicates the presence of suicidal behavior risk (SBQ-R score ≥ 7). In the plot, red dots indicate participates with depressive tendencies, green dots represent those without depressive tendencies, and the size of the dots reflects the severity of insomnia
Multiple regression models [Table 2] showed that, in Model 1, which adjusted for age, gender, degree program, and marital status, there was a significant negative association between centered LMX-7 and SBQ-R scores (β = −0.102, 95% CI [−0.123, −0.081], P < 0.001). In Model 2 in which confounding factors were adjusted, PHQ-2 demonstrated a negative relationship with LMX-7 (β = −0.098, 95% CI [−0.111, −0.085], P < 0.001). Model 3 showed that the inclusion of the PHQ-2 variable did not alter the negative correlation between ISI-7 and LMX-7 (β = −0.173, 95% CI [−0.227, −0.119], P < 0.001). Model 4, which included the potential mediating variables PHQ-2 and ISI-7, revealed that the effect of LMX-7 (β = −0.044, 95% CI [−0.065, −0.022], P < 0.001), PHQ-2 (β =0.348, 95% CI [0.257, 0.439], P < 0.001), and ISI-7 (β =0.070, 95% CI [0.049, 0.092], P < 0.001) on SBQ-R scores remained significant after adjustment.
Table 2.
Multiple regression analysis
| Model 1 | Model 2 | Model 3 | Model 4 | |||||
|---|---|---|---|---|---|---|---|---|
| Outcome Variable |
SBQ-R | PHQ-2 | ISI-7 | SBQ-R | ||||
| Age | 0.004 | −0.001 | 0.019 | 0.003 | ||||
| (−0.032, 0.039) | (−0.023, 0.021) | (−0.066, 0.103) | (−0.031, 0.036) | |||||
| Sex, Female | 0.054 | 0.002 | −0.284 | 0.073 | ||||
| (−0.133, 0.241) | (−0.114, 0.119) | (−0.729, 0.160) | (−0.104, 0.249) | |||||
| Degree, Doctor | −0.218 | −0.008 | 0.02 | −0.216* | ||||
| (−0.444, 0.008) | (−0.148, 0.133) | (−0.518, 0.557) | (−0.429, −0.003) | |||||
| Marriage, NO | −0.001 | 0.073 | 0.172 | −0.047 | ||||
| (−0.296, 0.295) | (−0.111, 0.256) | (−0.531, 0.874) | (−0.326, 0.231) | |||||
| LMX-7 Score | −0.102*** | −0.098*** | −0.173*** | −0.044*** | ||||
| (−0.123, −0.081) | (−0.111, −0.085) | (−0.227, −0.119) | (−0.065, −0.022) | |||||
| PHQ-2 Score | □- | □- | 1.766*** | 0.348*** | ||||
| □- | □- | (1.558, 1.974) | (0.257, 0.439) | |||||
| ISI-7 Score | □- | □- | □- | 0.070*** | ||||
| □- | □- | □- | (0.049, 0.092) |
* P<0.05; *** P<0.001
Evaluation of the mediating effects model [Table 3] demonstrated that SSR not only had a direct effect on suicidal behavior but also exerted significant indirect effects through depression and insomnia. Notably, we identified the following three indirect paths from SSR to suicide behavior: SSR → Depression → Suicide behavior, SSR → Insomnia → Suicide behavior, and SSR → Depression → Insomnia → Suicide behavior [Table 3]. Specifically, evaluation of the mediating effects model [Figure 4] demonstrated that SSR could directly affect the risk of suicidal behavior (β = −0.044, 95% CI [−0.066, −0.022], P < 0.001) but indirectly mediate the risk through depression and insomnia (β = −0.059, 95% CI [−0.075, −0.044], P < 0.001), together accounting for 57.3% of the total effect.
Table 3.
Effect estimates for all pathways from SSR to suicide behavior
| Path | Effect estimate | 95% CI | P | |||
|---|---|---|---|---|---|---|
| Direct | −0.044 | (−0.066, −0.022) | <0.001 | |||
| Indirect | −0.059 | (−0.075, −0.044) | <0.001 | |||
| SSR → Depression → Suicide behavior | −0.034 | (−0.047, −0.023) | <0.001 | |||
| SSR → Insomnia → Suicide behavior | −0.012 | (−0.020, −0.006) | <0.001 | |||
| SSR → Depression → Insomnia → Suicide behavior | −0.012 | (−0.018, −0.007) | <0.001 | |||
| Total | −0.102 | (−0.128, −0.078) | <0.001 |
Figure 4.
Mediating effects model
Discussion
This study found that the student–supervisor relationship (SSR), depression, and insomnia may influence the risk of suicidal ideation and suicidal behavior among Chinese medical postgraduates. It was also observed that 57.3% of the total effect of SSR on suicidal behaviors was mediated by depression and insomnia.
Evidence indicates that supervisors are major players that shape the careers of postgraduates, indicating that a good relationship between students and supervisors is essential to the success of medical postgraduates.[10] Here, we used the Leader-Member Exchange (LMX-7) questionnaire to explore the emotional and resource exchange between supervisors and their students. There was a significant association between the quality of SSR and the risk of suicidal behaviors. Specifically, a high LMX-7 score, reflecting positive exchanges, correlated with lower scores on the Suicidal Behaviors Questionnaire-Revised (SBQ-R).
The data also indicated that a harmonious SSR can prevent the development of mental health issues. Notably, a negative association between LMX-7 and PHQ-2 scores (Patient Health Questionnaire-2, a measure of depression symptoms) in Model 2, revealed that a good SSR suppressed the risk of depression. Furthermore, Model 3 demonstrated that the inclusion of PHQ-2 did not alter the negative relationship between LMX-7 and insomnia (ISI-7), suggesting that SSR can independently influence the development of insomnia, regardless of the depression status. This suggests that strategies for mitigating issues associated with SSR can improve the mental health of medical postgraduates and reduce the risk of suicidal behaviors.
Notably, supervisors hold more authority and control over the relationship between supervisors and postgraduates.[13,23] At an individual level, postgraduates who feel unsupported within the SSR may struggle to address this societal factors. In this study, although most medical postgraduates reported a harmonious relationship with their supervisors, some experienced significant challenges due to inadequate support. In such cases, mediating factors that could potentially moderate the association between the SSR and suicide risk need to be identified.
Overall, this study show that SSR not only has a significant direct effect on suicidal behavior but also exerts significant indirect effects mediated by depression and insomnia. In this mediation analysis, we found that approximately 57.3% of the association between SSR and suicidal behavior was mediated by depression and insomnia. This matches the results from previous investigations which reported that both depression and insomnia can contribute to an increased risk of suicide. Several theories have highlighted the crucial role of this relationship in suicide.[24] Suicidal thoughts and behaviors are often considered as symptoms of a depressive episode.[25] Studies have also shown that sleep disturbances can affect the occurrence of suicidal behavior, with disrupted sleep linked to a 2- to 3-fold elevation in the risk of suicide.[26] A comprehensive analysis of existing literature showed that most studies (approximately 70%), reported a strong association between various sleep problems and the risk of suicidal thoughts and actions among young individuals.[27] In this study, we focused on two pathways, showing that issues related to depression and insomnia should be addressed to reduce the risk of suicidal behavior among this vulnerable population.
In the mediation analysis, we demonstrate a complex pathway by which SSR increases suicide risk. Indeed, some psychotherapeutic techniques, such as cognitive-behavioral therapy and dialectical behavior therapy, can effectively reduce the risk of suicide and improve sleep or depression symptoms.[28] This is likely due to their ability to target multiple aspects of mental health simultaneously, including mood regulation, sleep quality, and cognitive coping processes.[29,30,31]
Nevertheless, this study has several limitations. First, we adopted a cross-sectional design which limited our ability to determine causal relationships between suicidal behavior risk, SSR, depression, and insomnia. Future longitudinal studies are necessary to explore the causality of the identified relationships. Second, we recruited postgraduate students from a single medical school, which may affect the generalizability of our findings. In future, multicenter studies should be performed to verify the present results.
Limitation and recommendation
This cross-sectional design precludes causal inference and limits interpretation of the mediation pathways between SSR, insomnia, depression, and suicidal behaviors. All variables were self-reported, raising the possibility of recall and social-desirability bias and common-method variance; clinician-verified diagnoses were not obtained. Sampling from a single university restricts generalizability and nonresponse bias cannot be excluded. Future work should use longitudinal, multicenter designs to establish temporal ordering and enhance external validity, with pre-registered protocols and analysis plans. Replication across diverse cultural and institutional settings is encouraged to inform context-specific guidance.
Conclusion
In conclusion, this study demonstrates the impact of SSR on the suicidal behavior in medical postgraduate students. Based on our results, it is imperative to develop educational programs, teaching approaches and support networks to foster positive SSR. In addition, specific suicide prevention and intervention strategies should be developed to target students facing challenges in their relationships with supervisors.
Using AI
No generative AI tools were used in this manuscript.
Abbreviations
ISI-7: Insomnia Severity Index-7; LMX-7: Leader-Member Exchange 7; PHQ-2: Patient Health Questionnaire-2; SBQ-R: Suicidal Behaviors Questionnaire-Revised; SSR: student-supervisor relationship.
Conflicts of interest
There are no conflicts of interest.
Acknowledgment
We would like to sincerely thank all study participants who participated in this survey.
Funding Statement
Nil.
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