Staying Sane: Addressing the Growing Concern of Mental Health in Medical Students

September 08, 2015

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By: Cheri Dijamco, MS4 at UT School of Medicine at San Antonio

Social Media Coordinator, Grassroots Organizing Action Committee

It is well­ known that suicide rates among physicians in the U.S. are high compared to the general population. According to the American Foundation for Suicide Prevention, approximately 300 to 400 physicians commit suicide each year, which is equivalent to roughly 1 physician suicide per day. Medical training involves many risk factors for mental illness, including role transition, decreased sleep, relocation (resulting in fewer support systems), and increased feelings of isolation. So, if the problem is well­recognized by the medical community, then where does the solution lie? In 2015, JAMA Psychiatry published the paper “Depression and Suicide Among Physician Trainees: Recommendations for a National Response”, which suggested that national organizations should address the mental health of residents and fellows by proposing strategies for comprehensive education, screening, and treatment. However, we propose that the answer to addressing these ongoing issues lies primarily in mental illness monitoring and wellness promotion earlier on during medical school.

It’s no surprise, then, to see how the cycle of stress, anxiety, and depression takes root during medical school since students frequently lack time for enough sleep, healthy eating, regular exercise, and smaller support systems. In a study published by Academic Medicine in 2009 called “Distress among matriculating medical students relative to the general population”, it was found that matriculating medical students (MMSs) began training with similar or better mental health than age­similar controls. Therefore, the high rates of distress reported in medical students and residents support concerns that the training process and environment contribute to the deterioration of mental health in developing doctors. Interventions targeting physicians, therefore, should take place early in training during the first year of medical school.

A study by Ludwig published in BMC Medical Education in 2015 demonstrated a significant increase in the proportion of students at risk for depression in their third year as compared to their first year and an increase in perceived stress. The study, which followed students at Albert Einstein College of Medicine, implemented a comprehensive program to address student wellness, including efforts to target issues specific to individual clerkships during the third year of medical school.

In 2009, Academic Medicine published a study by Goebert that concluded depression remains a significant issue for medical trainees. Depression rates were found at a higher rate among medical students versus residents as well as at a higher rate among women versus men. The highest rate of suicidal ideation was found among black/African American versus Caucasian respondents. This study highlights the importance of ongoing mental health assessment, treatment, and education for medical trainees. The pattern of unhealthy behaviors and thoughts persist into residency with 3⁄4 of residents experience burnout, leading to increased rates of medical errors and communication failures with patients.

Another article published by JAMA in 2003 called “Confronting depression and suicide in physicians: a consensus statement”, concluded that the culture of medicine assigns low priority to physician mental health despite convincing evidence of untreated mood disorders and an increased burden of suicide among physicians compared to the general population. The study cited several negative barriers to doctors seeking help including: discrimination in medical licensing, hospital privileges, and professional advancement. To encourage more physicians to seek help, we must help transform professional attitudes within the medical community and work toward changing institutional policies. As barriers are eliminated and doctors become more comfortable discussing the topic of depression and suicide with their colleagues, the medical community is more likely to identify and treat mental illnesses in patients, physicians, and medical students.

As medical students, we can help start the process by simply promoting safe spaces to discuss mental health issues on campus by promoting candid discussions and opening up to classmates about our own struggles. On KevinMD.com, one brave medical student with anxiety and depression published in a guest post: “I avoided treatment at the beginning of med school for those same reasons. Admitting to “mental illness” seemed like admitting to failure – after all, who would ever want to see a physician who had struggled with anxiety? Who would ever want to talk to a psychiatrist who had experienced depression?” To which the author adds that he actually would see those kinds of doctors, claiming that more people would probably agree with him if they realized how many physicians gained more insight by facing their own problems.

The AAMC Reporter published an article in 2013 that points to a few examples of how medical schools can take an active role in reducing students’ stress and anxiety. Given medical students’ reluctance to seek help for emotional problems, medical schools must play an active role in helping their students deal with these issues. Some have suggested changing medical school curricula to pass/fail grading, reducing the volume of material covered in classes, and lowering the number of classroom hours to reduce stress/anxiety over grades. Saint Louis University School of Medicine (SLU) has begun promoting student interests related to medicine through learning communities focused on as service, advocacy, research, global health, wellness, and medical education through non­graded elective coursework. Dr. Stuart Slavin, dean of student affairs at SLU, believes that these student groups may increase the chance for students to form meaningful relationships, which can sometimes get overshadowed in a competitive academic atmosphere. Yet another approach SLU has taken to promote student wellness is implementation of courses to teach coping methods and stress management.

Innovative programs for promoting student wellness have increased over the past few years, including implementation of extracurricular activities that focus on community ­building among students. At Vanderbilt University School of Medicine, a student­ run Wellness Committee splits the first­ year class of medical students into colleges that compete in recreational athletic, trivia, and cooking competitions throughout the year. According to Dr. Scott Rodgers, the associate dean of student affairs at Vanderbilt SOM, “You don’t want to lose your humanity by becoming a doctor. Students should participate in activities outside of medicine, maintain personal connections, and make their own physical health a priority.”

Additional research is needed to evaluate whether or not these new medical school programs have a positive influence on rates of depression and burnout in medical students over time. However, the shift in medical students’ attitudes regarding seeking help for mental health issues is a positive sign and shows significant promise for a brighter future for physician well­being. If our goal is to achieve a culture of acceptance and openness regarding mental health issues, then medical students must begin taking charge by advocating for increased educational opportunities related to self­care, improved access to mental health services on campus, and greater availability of peer support groups to deal with academic stress.

In our opinion, the opportunity to make this world a reality, where mental health is considered as important as physical health, is a huge undertaking that physicians, students and educators must tackle together with a sense of urgency and optimism.