Over the past several decades, there has been an increase in the number of students enrolling in medical education, which has increased awareness of student mental health and wellbeing, as well as concerns regarding the impacts of financial stress. Financial concerns are particularly significant for first-generation college students [1]. College students faced challenging financial circumstances, which can be a source of stress and anxiety for them. As they transition from adolescence to adulthood, these students must contend with rising tuition costs that exceed the rate of general inflation, heavy debt burden, and uncertain employment prospects [2]. Students frequently report insufficient savings, high credit card debt, and insufficient income to cover expenses, payment delays, and account overdrafts [3]. According to research [4], college students are more likely to experience financial anxiety, which can negatively affect not only on their financial behavior but also on their academic performance and overall well-being. According to research [5], a significant proportion of college and university students report experiencing financial stress. According to Heckman et al., 71% of students reported feeling anxious as a direct consequence of their personal financial difficulties [5]. Another study revealed that financial concerns are among the leading sources of stress for college freshmen. Approximately 35% of students reported experiencing financial stress in the preceding year [6]. Increasingly, policymakers are concerned that rising financial pressures may be contributing to a parallel decline in student mental health. Mental health issues are expected to have increased between 2010 and 2021, peak from 2018 and 2021. During this time period, the prevalence of mental health issues among men increased from 27% to 41%, while among women it increased from 45% to 62% [7]. It appears that student mental health services are under pressure as a direct result of this trend. In addition to experiencing poor mental health, adolescent who reported inter-parental conflict also reported having suicidal ideation [8], a phenomenon that has been shown to negatively impact academic performance. A multisite study [9] found that 78% of college students who attempted suicide cited financial issues as a motivating factor in their decision. Students under significant financial stress tend to enroll in fewer classes, drop out of college at higher rates, and achieve lower academic performance [10,11].

A study showed a connection between psychological distress and the expectations imposed on children by their parents [12]. We hypothesized that suicide thoughts among pre-medical students may be influenced by their families’ expectations. The term “parental expectations” (or “parental hopes and expectations”) is used to describe the high hopes and high expectations that parents have for their children. Children’s academic outcomes are profoundly affected by their parents’ expectations for them [13], which are molded by a multifaceted evaluation of the child’s ability, past academic performance, ideals, and family circumstances [14,15]. When it comes to shaping and influencing adolescents’ academic success, parental expectations play an important role [16]. However, at times, these expectations can make it challenging for students to meet and fulfills what is anticipated of them by their parents. A previous study [17] suggested that high parental expectations may increase stress level among children about their academic performance. High parental expectations can also lead to a more controlling and overly involved relationship with children. In such scenario, students may spend more time to studying and experience greater academic pressure compared to their peers. High expectations from family members may also be a factor in exam anxiety [18]. This could be the reason, as parental expectations may make students more depressed and anxious [19].

According to the theory of ecosystems, an individual’s environment has a significant impact on their development [20]. The family is essential for the development of children because it provides an essential environment for the process of personal growth. Parental expectations will motivate parents to make more decisions that will benefit their children, thereby providing them with a stronger foundation for life. Children can learn about themselves and develop self-efficacy by observing their parents’ attitudes and actions [21]. Parents who have higher expectations for their children tend to allocate more attention to them. This dedication generally results in improved assistance [22].

Test anxiety is a sort of trait anxiety that is influenced by an individual's cognition, personality, and other qualities in the context of an examination [23,24]. Anxiety, physical symptoms, and increased arousal from both emotional and physiological sources describe this mental state. The effects of test anxiety on students’ academic performance and mental health include difficulty in the classroom (eight), lower grades (twenty-four), and an increased likelihood of anxiety and depression. Anxiety over exams can manifest itself physically through issues with one’s food, mood, and quality of sleep. Self-injury and thoughts of suicide are possible outcomes [25].

The epidemic caused by COVID-19 has had a severe impact on Pakistan’s economy as well as the country’s political stability [26]. The World Bank anticipated that Bangladesh’s economy has grown by 8.1% in 2020, while Afghanistan’s grown by 3.9% and India’s grown by 4.2%. Pakistan’s economic growth rate was projected to be 1.9%. The inflation rate in Pakistan grew from 35.4% in March to 36.4% in April 2023, compared to the previous month’s rate of 35.4%. The price of food went up by 48.1%, while the cost of transportation went up by 56.8%, and the cost of education went up by 8.5%. In addition, the rate of core inflation, which removes the effect of fluctuating commodity prices, had a large increase in April, going from 18.6% in March to 19.5% in April [27]. Due to the economic challenges, 29 suicides were reported [28], and 22% of young adolescents reported suicidal tendencies due to parental conflicts [8].

The cost of medical education in Pakistan is exorbitant, poses a significant financial burden on many households. Unfortunately, this dedication to pursuing a medical career often goes unnoticed and unheard. The pressures to meet multiple parental expectations adds complexity to the situation, making the endeavor of passing the medical entrance examination more than just an academic pursuit; it becomes an attempt to gain societal approval and validation. In 2020, a remarkable 125,000 students registered for the examination, raising a pertinent question about the country’s capacity to accommodate such a substantial number of aspiring physicians. This concern is particularly noteworthy when considering the apparent scarcity of applicants in other fields of study. Many young girls are taught that medicine is the sole respectable career for women and the only road to social acceptance. High-achieving children are expected to attend medical school; if they succeed, they are lauded; if they fail, their academic careers are considered over. Past research has revealed that 4.8% of Pakistani medical students committed suicide [29]. Research has shown that individuals under extreme financial pressure are approximately twenty times more likely to attempt suicide compared to those not facing such pressures [30]. Therefore, the purpose of the current study was to address these issues, assess whether financial stress causes suicidal ideation among pre-medical students, and examine the association between parental expectation and medical entrance test anxiety on suicidal ideation among pre-medical students.

In the conceptual model (Fig. 1), we examined the interconnectedness of financial stress, test anxiety and parental expectations, examining their combined influence on the emergence of suicidal ideation in pre-medical students, particularly in educational environment.

The current study investigated the relationships among parental expectations, test anxiety, and financial stress relate to suicide ideation. The findings indicated that parental expectation was the most significant predictor of suicidal ideation among pre-medical students within the sample of present study. The second leading cause of suicidal ideation was test anxiety, while financial stress was identified as the least common reason for suicide ideation among pre-medical students.

According to the findings of present study, test anxiety and suicide thoughts were significantly positively correlated, which is aligns with findings from earlier studies [39]. Suicidal thoughts were triggered by a various factors, including undiagnosed depression, student rivalries, the stress of preparing for multiple examination, and work-related challenges [40]. Long-term exposure to such stressors may heighten an individual’s anxiety levels [41,42]. Suicidal ideation can effect of an individual's cognition processes, which may, in return have an indirect impact on test anxiety [43]. Notably, there has been no previous research that compared suicidal thoughts with test anxiety in pre-medical students. Suicide rates among young people in Pakistan are higher than in other nations [8], and there is a significant incidence of suicidal ideation, and suicidal attempts among Pakistani students.

This study identified a positive correlation between parental expectations and suicidal ideation, a finding that is consistent with previous research [44], indicating an association between parental expectations and suicidal ideation. In addition, earlier studies [45] revealed that high parental expectations are positively associated with both test anxiety and suicidal ideation. The beta value indicated that parental expectations serve as one of the factors influencing suicidal ideation. According to the relational development system theory [46], the interplay between the environment factor and individual interaction functions dually in the process of individual personal development. This theory posits that both the external environment and the unique characteristics of an individual can independently influence and predict their developmental outcomes. The combination of these factors can also produce a joint impact on an individual development [46]. When parental expectations were high, parents tend to employ more constructive parenting techniques and fewer detrimental ones [47], which affected adolescents’ attitudes toward academics. In contrast, low parental expectations can also result in individuals not treating life and school seriously, which can lead to poor academic performance and suicidal ideation [48].

In the current study, financial stress is associated with suicidal tendencies among pre-medical students. Beyond financial difficulties, students may experience stress due to academic pressure [49], family and social separation, emotional and interpersonal relationships, personal responsibility, and employment-related stress [28]. These stresses increase the likelihood of college students developing mental health issues [49]. Previous research has emphasized the influence of financial concerns on academic progress, notably in terms of students dropping out or not finishing their education. However, empirical data suggests an association between financial issues and mental health problems has caused suicidal ideation [50]. Contrary to what may appear to be common sense, pre-medical students are frequently perceived as being more vulnerable to the dangers of financial stress, particularly given the resources required to attend and study for the medical entrance exam [51]. Thus, it is possible to minimize or disregard the association between financial hardship and suicidal ideation among pre-medical students. Our findings corroborate the hypothesis that stressful financial situations are common among college students and can have substantial negative effects on mental health and academic performance [52].

The goal of this research was to examine whether or not pre-medical students’ suicide ideation is influenced by their parents’ academic expectations, test anxiety, and financial stress. Among pre-med students, there was a statistically significant relationship between test anxiety and suicidal ideation. We also looked for links between suicide thoughts and parental expectations. Furthermore, there was an increase in suicidal ideation when financial difficulties were present.