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You're Not Alone: Mental Health Issues During Medical School

Anxiety, depression, substance abuse, suicidal ideation. As medical students, we’re versed in recognizing the signs and symptoms of various psychiatric disorders, learning to care for patients on our psychiatry clerkships. But what about when we see these same signs in symptoms not in our patients, but our peers? Or ourselves?
If you have found yourself in either situation, you are not alone. Studies have found upwards of 1 in 4 medical students meet criteria for depression when surveyed1, significantly higher than our peers who opted for different career paths. While rates of depression are fairly comparable to our peers before we start first year of medical school (some studies say a little higher, others a little lower)2, they climb over the first two years, peaking as we transition into clinical training3,4. As exams and expectations pile up, it is no great surprise that medical students also report increased levels of anxiety throughout their medical school training2.

When to seek help

How do you know when feeling stressed and overwhelmed goes beyond “normal” medical school angst and requires professional help? First, if you’re wondering about it, make the call and let a mental health professional help you determine whether you would benefit from further treatment. In addition, if you have the following signs or symptoms, please consider seeking treatment:

  • Changes in sleep habits or appetite
  • Loss of interest in things you once enjoyed
  • Lack of energy
  • Inability to concentrate
  • Increased anxiety
  • Any thoughts of suicide

Stress is a seemingly unavoidable component of the medical education process; there are just too many books to read, too many facts to learn, too many transitions to stumble through for anyone to have four years of smooth sailing. A certain level of stress is completely normal, and it’s important to be able to recognize signs in ourselves. As we have learned in medical school, stress is essentially the body’s fight-or-flight response kicking in; it’s just that running from or fighting against medical school is unlikely to help. Common signs of stress include physical symptoms such as gastrointestinal distress, muscle aches, tachycardia and dizziness; emotional symptoms like increased frustration, anxiety, and feelings of being overwhelmed; and behavioral symptoms like trouble with sleep, isolating yourself and procrastination. How we respond to that stress may help or hurt our overall mental health. Studies have found that using engaging coping strategies, such as problem solving and seeking out the support of others, may be protective against developing more serious symptoms of depression compared to those who tend to disengage, withdrawing socially and avoiding problems2.
Trying to cope with the anxiety and depression on one’s own can lead to more problems. While drugs and alcohol may temporarily alleviate those emotions, they can have long-term consequences, both personally and professionally. Although we preach alcohol in moderation to our patients, we do not always follow this ourselves. Medical students have rates of alcohol use – and misuse – comparable to our non-medical school peers5. However, while the general population tapers off in their alcohol use with age, physicians have increased alcohol problems as they get older (as do lawyers, in case you were wondering)6. Finally, medical students are more likely to consider ending their life, particularly those suffering from depression7. As with alcohol use, this is a problem that does not go away after medical school; studies have shown male physicians have about a 1.5 fold increased risk of suicide and for women, the rate is over two times higher than our non-MD counterparts, although some studies have put the numbers significantly higher8. Over 250 physicians in the United States suicide annually9. That’s the equivalent of an entire large medical school class9Every year.
Here’s the thing: not only are we, as medical students, more likely to experience mental health issues, we’re also less likely to seek help. One study found that, of medical students with depression, only one in four had sought any treatment10. Of those considering suicide, less than half sought professional help1.
Many studies have tried to figure out the reason why – you can probably guess many of them yourself. There’s the lack of time, the cost, the concerns about confidentiality, and the stigma surrounding mental health treatment, to name a few1. One medical student interviewed summed the situation up well, remarking, “I wouldn’t want it on my CV” 11.

How to seek help

The LCME requires medical schools to provide students with access to confidential mental health care by clinicians who are not directly involved in their academic career. Please contact your Dean of Student Affairs or another trusted advisor to put you in contact with these services.
The Liaison Committee on Medical Education (LCME), the governing body that accredits medical schools, recognizes the importance of not just ensuring students have access to mental health care, but also that that care is kept separate from their academic careers. Thus, in addition to requiring that all medical schools provide students with mental health services, all professionals involved in this care “must have no involvement in the academic assessment or promotion of medical students receiving those services”12.
Why seek help? No one doubts medical school is hard under the best of circumstances. Trying to perform at your highest level while dealing with crippling anxiety or stifling depression is like running a marathon on a sprained ankle. The habits we establish in medical school are likely to stick with us throughout our careers. Establishing healthy practices now can set you up for career – and life – success. Need a final reason to seek help? One study found board scores on USMLE Step I inversely correlated with levels of depression in April of students in the first and second years of medical – depression goes down, your board score goes up2.
The author would like to thank Joseph Murray, MD, and Janna Gordon-Elliott, MD, for their contributions this article.

References

1. Givens JL, Tjia J. Depressed medical students’ use of mental health services and barriers to use. Academic medicine : journal of the Association of American Medical Colleges. Sep 2002;77(9):918-921.
2. Dyrbye LN, Thomas MR, Shanafelt TD. Systematic review of depression, anxiety, and other indicators of psychological distress among U.S. and Canadian medical students. Academic medicine : journal of the Association of American Medical Colleges. Apr 2006;81(4):354-373.
3. Clark DC, Zeldow PB. VIcissitudes of depressed mood during four years of medical school. JAMA : the journal of the American Medical Association.1988;260(17):2521-2528.
4. Rosal MC, Ockene IS, Ockene JK, Barrett SV, Ma Y, Hebert JR. A longitudinal study of students’ depression at one medical school. Academic medicine : journal of the Association of American Medical Colleges. Jun 1997;72(6):542-546.
5. Mangus RS, Hawkins CE, Miller MJ. Tobacco and alcohol use among 1996 medical school graduates. JAMA : the journal of the American Medical Association. Oct 7 1998;280(13):1192-1193, 1195.
6. Flaherty JA, Richman JA. Substance use and addiction among medical students, residents, and physicians. The Psychiatric clinics of North America. Mar 1993;16(1):189-197.
7. Schwenk TL, Davis L, Wimsatt LA. DEpression, stigma, and suicidal ideation in medical students. JAMA : the journal of the American Medical Association.2010;304(11):1181-1190.
8. Schernhammer ES, Colditz GA. Suicide rates among physicians: a quantitative and gender assessment (meta-analysis). The American journal of psychiatry.Dec 2004;161(12):2295-2302.
http://emedicine.medscape.com/article/806779-overview#showall. Accessed 2/28/14.
10. Tjia J, Givens JL, Shea JA. Factors associated with undertreatment of medical student depression. Journal of American college health : J of ACH. Mar-Apr 2005;53(5):219-224.
11. Chew-Graham CA, Rogers A, Yassin N. ‘I wouldn’t want it on my CV or their records’: medical students’ experiences of help-seeking for mental health problems. Medical education. Oct 2003;37(10):873-880.
12. Functions and Structure of a Medical School: Standards for Accreditation of Medical Education Programs Leading to the M.D. Degree In: (LCME) LCoME, ed2013.

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Megan Riddle, MD PhD, is a psychiatry resident at the University of Washington. She is a graduate of the Weill Cornell/Rockefeller/Sloan-Kettering Tri...