Friday, July 15, 2016

Singapore - The Untreated Epidemic Of Medical Student Depression

According to a new meta-analysis spanning four decades of research, 28 percent of medical students are depressed and 5.8 percent have considered suicide. Researchers from Singapore analyzed 77 studies, examining nearly 63,000 medical students across the globe. Distress in medical students is not just a first world problem. The percentage of students with depression or depressive symptoms ranged from 20 percent in Europe to 31.8 percent in the Middle East. Medical students in North America had the second highest prevalence at 30.3 percent. Still, there were no statistically significant differences in depression by region, sex, or even between medical students and non-medical students.

As one of the authors of a study included in the meta-analysis, it is clear to me that the numbers do not capture the stress students face. During medical school, I traveled to Mainland China to conduct a study on depression and suicidal thoughts in medical students. I was shocked while speaking with Chinese medical school students who were dealing with stressors we rarely encounter in the United States. One student said that medicine was not his first career choice, but his university entrance exam score was not high enough to place into computer science. Also, students feared for their safety because of increasing patient violence towards health care professionals.

External stressors alone may not be the culprit. Physicians are more likely to be obsessive and perfectionists, which may make them more emotionally reactive to failure. In addition, adolescence and early adulthood are the peak years of depression in the general population. Add the stresses of medical school to this vulnerable period of life, and the prevalence of depression is not surprising.

Depression is chronic and recurrent. It is associated with burnout and substance abuse. Indeed, a recent meta-analysis of 54 studies found 28.8 percent of resident physicians—doctors who recently graduated medical school—are depressed. Given the findings from medical students, it is likely that the residency experience is not the beginning of depression and suicidal thoughts, but a continuation from medical school.

A Safety Concern

Although a few studies found levels of depression between medical students and non-medical students to be similar, there is one big difference. After graduation, former medical students become primary caretakers for others, while most non-medical students do not. Depressed doctors may put patients at risk. To put this in perspective, imagine being an airplane passenger. You are preparing for takeoff, and the safety announcement comes on saying the following:

There is a nearly one in three chance that your airplane pilot is depressed. Also, around 6 percent of pilots think about ending their lives, and we do not have good documentation of those who commit suicide. Only about 13 percent of pilots seek formal mental health services. But rest assured the Airline recently started a yoga program for pilots.

Passengers would call these safety measures absurd and may not even take the flight. The Federal Aviation Administration would likely open an investigation.

Unfortunately, this analogy reflects the current state of medical education. Despite personal distress resulting from depression and having the responsibility of patients’ lives in their hands, few medical students and residents receive the help they need. Sadly, we lose 400 doctors—the equivalent of number of seats in a jumbo jet—to suicide every year. We can no longer ignore the mental distress of medical students.

How To Reduce Medical Student Stress

There are immediate steps medical school leadership and accreditation bodies can take to improve the mental health of medical students. First, school administrators can improve the learning environment by making grading pass-fail. Pass-fail curriculum during preclinical years is the trend in the United States, but not overseas.

A pass-fail system adds two key benefits. First it makes students less competitive and more collaborative. Competition and the social isolation that comes with it breeds stress. A review found that pass-fail grading decreased stress without a significant compromise in academic performance. Second, it helps foster a better work-life balance. Students have more flexibility to determine how and when they want to study and attend to their personal needs.

Second, mental health services need to be more prominent. Stress reduction programs are effective for medical students. Mental health screening should be the default at the beginning of medical school. Students would have to opt-out. While some may perceive this approach as intrusive, medical students get similarly tested for tuberculosis and Hepatitis B as a patient safety measure. Depression is also a safety issue for patients and is a lot more prevalent than tuberculosis and Hepatitis B in United States medical students. In addition, default screening ideally would normalize the experience and demystify mental health care and thereby circumvent the common barriers to care including stigma, embarrassment, and fear of lack of confidentiality.

If mental health treatment is needed, care should be easily accessible to accommodate the hectic schedule of medical students. An open-door policy where students can drop in as needed would be best. The cost of mental health services should be free of charge. To provide this service to students, schools can hire a mental health provider part-time or per-diem, or contract with providers in the community. Medical schools that are part of universities often have counseling services available to students. Alternatively, there are free internet-based programs such as MoodGYM that are widely available and can be used in private settings. MoodGYM was effective in preventing suicide ideation in medical internship, arguably the most stressful year of medical training.

Medical school is supposed to be a time of personal and professional development. We have enough data to show that depression is rampant in medical students. Now we need to take the steps to foster well-being. We owe it to our colleagues and our patients.

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