Mental health is a topic which is discussed more openly in our society in recent decades and is, slowly, become less stigmatized. This, ironically, does not seem to be the case when it comes to the issue of mental health problems among medical students. The nature of medical school, and attitudes of medical students themselves, can set up barriers between students who need help and the programs that can help them. This article looks at the widespread nature of this problem in American and overseas medical schools, and also what can be done to help solve it.
Part One: Outlining the Problem
Before any attempt can be made to adequately address this problem, its extent and underlying causes need to be better understood.
Just How Widespread is the Issue?
C. Dijamco, writing in her piece on “Staying Sane: the Growing Concern of Mental Health in Medical Students”, published last year on the American Medical Student Association site, notes that mental health problems among medical students are likely far more widespread than is commonly realized, pointing to several studies, including:
● A 2009 study later published in the journal Academic Medicine which found that depression was a significant medical issue for medical trainees
● A 2015 BCM Medical Education study which looked at students at the Albert Einstein College of Medicine and found that there was an increased risk for depression between the first and third year of medical school.
Studies apart from the ones mentioned in Dijamco’s article point to the fact that depression, anxiety and even suicidal ideation are more common among medical students than previously realized. And it is not just a problem in American medical schools, either. In a Student BMS survey which screened 1,122 medical students for mental health and wellbeing, it was found that 30% of them have struggled with a mental health issue. Another study which looked at British medical students at Barts and London medical schools and the University of Cardiff found that 15% of medical students reported depression and 52% reported problems with anxiety. It was also found that a significant percentage of these students practiced high-risk behaviors including smoking (15%), binge drinking (25%) and illegal drugs (10%).
Medical School Culture
Dijamico goes on to note that medical school, inherently, involves a variety of risk factors that can lead to mental health deterioration, including intense pressure to perform in class and clinicals, the stressful situations students find themselves in on rotations, role transition from pre-med to medical students, sleep deprivation and relocation issues which often lead to feelings of isolation (since students are often far from home when they begin their medical training).
In addition to this, the long hours of study and clinical practice leave less time than normal for a healthy diet, exercise, sleep, leisure time and simple social support that are natural stress relievers; lack of these factors can lead to a buildup of stress and anxiety and lead to feelings of depression and even suicidal ideation. The nature of medical training itself it partly responsible for this problem, as a study in Academic Medicine shows that entering medical students appeared to have better mental health than average going into a medical program and do not begin to wrestle with these issues until after they have begun medical school.
However, it is not fair to merely blame the nature of medical school for this problem and leave it at that. There are many other factors at play here, including attitudes of medical students themselves and a reluctance to seek help for problems that might be developing during the course of medical training.
Stigmatization and Reluctance to Seek Help
Among medical students themselves, who tend to be highly competitive and perfectionistic with high expectations of themselves and their work, there remains a stigma around the issue of talking about mental health problems that they might be experiencing. There is also a widespread fear among medical students that if they do seek help for these problems, it will affects their grades, the way they are perceived by fellow students or teachers or even their ability to continue with their medical education.
Part Two: Solving the Problem
Once the problem of mental health issues among medical students is better understood, the next step of implementing programs to alleviate this problem can begin. It is important to note that this issue is beginning to be more widely acknowledged than before, and the Journal of the American Medical Association (JAMA), in their 2015 paper “Depression and Suicide Among Physician Trainees” not only acknowledged the problem but recommended that the mental health of medical students and residents be addressed and that schools implement programs for the screening, education and treatment of mental health issues among its students.
Education and Support
Most researchers agree that education and support on the part of medical schools is fundamental to alleviating the mental health issues among medical students. Researchers in Psychiatry Magazine, in their paper “Medical Student Mental Health” put it succinctly by saying, “Because of the psychological pressure inherent in this process, all medical schools should have easily accessible medical student mental health services”.
Many medical schools have stepped up to this challenge. For example, in response to the previously mentioned study on depression in 1st and 3rd year students at the Albert Einstein College of Medicine, that college implemented a program to better address student mental wellness. The 2009 Academic Medicine study cited above also suggested that in order to address this problem, colleges must create a “safe space” in which students can talk about and seek help for mental health issues. And because of the attitudes of many medical students about mental health, the school must take a very pro-active role when it comes to screening and treatment.
In general, it has been suggested that in order to promote mental/emotional wellness of their medical students, that medical schools:
● Develop comprehensive programs within the school where students can talk about and receive treatment for their mental health issues.
● Offer peer support so that medical students can help each other with these challenges
● Educate students beginning at their medical school orientation about the mental health services available and about how to seek them
● Increase staff training on pastoral care and on screening for students who may be more vulnerable to mental health issues.
Suggestions have also been made that medical schools seek to change the nature of the environment that creates these problems to begin with. These suggestions include creating a pass/fail system in class so that students will not feel pressured to vie for the top grade as well as decreasing the work volume and material covered to help also reduce stress among students.
Destigmatizing Mental Health
Again, because of the reluctance of many medical students to seek help for their mental health issues, many researchers have suggested that medical schools need to become more proactive in the way that students are screened for mental wellness to begin with and begin educating medical students from the very first year of medical school about what services are offered to medical students who are struggling emotionally or mentally. The University of Cardiff, for example, in response to the previously cited research, began a program where medical students needing mental health services were able to self-refer themselves anonymously and were furthermore able to go to people at the school who were engaged in pastoral care and not to their professors/advisers. This was done to help overcome the fear that students had of recrimination or dismissal from the program if their mental health problems were revealed and resulted in four times as many students as in the past making use of these services.
Promoting Coping Skills
Another important tool in the promotion of student wellness is implementing programs for all students which focus in on the development of coping skills to help deal with the inherent stressors of medical education. This can help not only treat mental health issues but even prevent or reduce their occurrence, especially if they take place early in a student’s medical training. The need for this is great: a study published in the Canadian Medical Education Journal, after a survey of Canadian medical students, noted that “Medical students are neither more resilient nor better equipped with coping skills than their peers in the general population. Greater emphasis on self-care among medical trainees is recommended.”
Professor L.B. Dunn, in his study on coping skills among medical students, noted that the metaphor of a “coping reservoir” is helpful when trying to understand medical students and their needs: this “reservoir” is filled with individual student’s personal temperament, experiences and coping style and that it can be replenished or depleted depending on the stressors in a student’s life and how they are handled. Programs that can help teach coping skills to medical students – especially if done early in training – could go a long way to promoting this emotional resiliency among physicians-to-be.
Targeting Vulnerable Groups
It is also important to realize that, even with the medical student population, certain subsets are more vulnerable to mental health problems than others. Gay/lesbian/bisexual/transgender students, students from ethnic minority groups, and female students appear to be more at risk for these problems, and programs that can address the specific needs of these groups could be more successful at promoting student well-being.
● A 2015 study published in Academic Medicine found that first year medical students who identified themselves as sexual minorities were at a significantly higher risk for depression, low self-esteem and anxiety issues than their heterosexual counterparts and reported more problems with harassment and more feelings of isolation.
● In a 2007 study which appeared in the Archives of Internal Medicine, a survey of 3,080 medical students from 5 medical schools across the country found that 47% reported burnout and 49% reported depression signs and symptoms, but that minority medical students were more likely to report that their race/ethnicity adversely affected their experience as medical students and were more likely to feel isolated.
● A 2006 review that was published in Academic Medicine, it was found that, after analyzing over 40 studies on mental health in medical school students that “medical school is a time of significant psychological distress” but noted in the majority of cases studied that female med students were more affected than males.
In short, the issue of mental health problems among medical students is far more widespread than many people realize and the nature of medical schools themselves combined with student fears and stigmatization of mental illness make it harder for students who are struggling with anxiety, depression, suicidal ideation and other significant issues to seek the help that they need. The good news is that more medical schools both in the United States and abroad are recognizing this problem and taking steps to help combat it, mostly through the implantation of programs that make mental healthcare easily accessible to struggling students so that they can overcome their challenges and continue their studies.
However, more needs to be done to educate both medical school faculties and students on learning to screen for common mental health problems and to destigmatize mental health issues so that students will not be afraid to seek treatment. Programs that are accessible and that also target vulnerable groups such as minorities, women, and LGBT students will also likely prove to be effective. In a profession already suffering from shortages worldwide – a situation which is predicted to only get worse in coming decades – the issue of getting students successfully through their training is important not only to the medical community but to the community at large.
About the Author
Brian Wu graduated from the University of Maryland with a Bachelor’s of Science in Physiology and Neurobiology. He is currently an MD candidate at the Keck School of Medicine (University of Southern California). He also holds a PhD in integrative biology and disease for his research in exercise physiology and rehabilitation. He is applying to psychiatry and is interested in doing a child psychiatry fellowship.
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