New study on depression amongst Medical Students

[pseud0]

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https://wire.ama-assn.org/education/1-4-med-students-around-world-shows-depression-signs
http://jamanetwork.com/journals/jama/article-abstract/2589340

What do you guys make of this?

27% of Medical Students around the world are depressed, 1 in 10 are suicidal.

How should we go about combating this moving forward?

 

[ChymeofPassion]

https://wire.ama-assn.org/education/1-4-med-students-around-world-shows-depression-signs
http://jamanetwork.com/journals/jama/article-abstract/2589340

What do you guys make of this?

27% of Medical Students around the world are depressed, 1 in 10 are suicidal.

How should we go about combating this moving forward?

Screen for applicants with a history of depression or qualities resembling it.

 

[Hospitalized]

Screen for applicants with a history of depression or qualities resembling it.

lmao

 

[protego]

Implement support systems, easy to access resources, reduce stigma regarding perceived weakness surrounding mental illness.. I think there's so much to be said for making it okay to not be okay.


Sent from my iPhone using SDN mobile

 

[LizzyM]

First: the authors acknowledge that the self-reported inventories may not be very good. This data may not be accurate.
Second: before suggesting changes to curriculum and so forth, I'd like to know more about the risk factors associated with development of depression. Is depression earlier in life a risk factor? Is age a risk factor? Are students with a record of high achievement (or relatively low acheivement) at greater risk? Are their other markers or predictors?

Can we/should we select for low risk students?

We should do some experiments and determine if certain suggested"fixes" are effective and base changes in medical education on evidence, not assumptions.

 

[ChymeofPassion]

lmao

😀

 

[sdhere1234]

Screen for applicants with a history of depression or qualities resembling it.

This is literally the dumbest thing I've ever read on sdn. And that's saying a lot coming from all the threads on this forum.

 

[spartan25]

Implement pass/fail (with NO internal rankings) for preclinical years. I'm only aware of a few schools that currently do this, and I have to say it does wonders for the mental health of the M1s and M2s

 

[Holmwood]

1) Just because medical students aren't suicidal during medical education, doesn't mean they won't be suicidal later in their career. I also find that those who have had significant experience coping with suicidal ideation or depression can be valuable allies. So excluding them from the profession seems counterproductive.

2) Seeking help through mental health services is also a personal choice that, frankly, most people are uncomfortable doing in the first place (even when they are at rock bottom). I would argue that medical professionals are even more inclined to not seek help for mental health issues simply because of the privileged nature of their profession.

We need a resource for mental health intervention that can work with the culture of mental health stigma among medical professionals (because it's likely not going to go away, even with significant screening and curricular changes....).

I think the important question is, "how can we motivate a doctor to seek help for his/her deepest mental health issues if he/she is afraid to talk about it with the very people who can help?"

I believe the solution lies in technology, but I'd be curious to see other suggestions here.

 

[ChymeofPassion]

This is literally the dumbest thing I've ever read on sdn. And that's saying a lot coming from all the threads on this forum.

:troll::troll::troll::troll::troll::troll::troll::troll::troll:

 

[sliceofbread136]

Implement pass/fail (with NO internal rankings) for preclinical years. I'm only aware of a few schools that currently do this, and I have to say it does wonders for the mental health of the M1s and M2s

I actually don't think that is a good thing. Your class rank and AOA status would then be entirely on clinical grades which can be significantly more stressful to ensure higher grades and is often times very frustratingly out of your control.

I think the real answer lies in removing the stigma to mental health problems that exist in medicine

 

[wb100]

First: the authors acknowledge that the self-reported inventories may not be very good. This data may not be accurate.
Second: before suggesting changes to curriculum and so forth, I'd like to know more about the risk factors associated with development of depression. Is depression earlier in life a risk factor? Is age a risk factor? Are students with a record of high achievement (or relatively low acheivement) at greater risk? Are their other markers or predictors?

Can we/should we select for low risk students?

We should do some experiments and determine if certain suggested"fixes" are effective and base changes in medical education on evidence, not assumptions.

I always wonder if relocation is a big factor. Most students end up moving away (sometimes across the country) in order to go to medical school.

 

[sullen-burger]

:troll::troll::troll::troll::troll::troll::troll::troll::troll:

Triggered. I appreciate the Internet trolling, really I do.

But seriously. If part of the answer is removing the stigma around mental health, then part of the solution is removing posts like yours from the conversation, as they serve zero purpose.


Notice I said "like yours," and not simply "yours."

 

[Sardinia]

That AMA wire article was complete schlock.

 

[Lucca]

First: the authors acknowledge that the self-reported inventories may not be very good. This data may not be accurate.
Second: before suggesting changes to curriculum and so forth, I'd like to know more about the risk factors associated with development of depression. Is depression earlier in life a risk factor? Is age a risk factor? Are students with a record of high achievement (or relatively low acheivement) at greater risk? Are their other markers or predictors?

Can we/should we select for low risk students?

We should do some experiments and determine if certain suggested"fixes" are effective and base changes in medical education on evidence, not assumptions.

This particular study aside, I think a literature review would reveal that there is a great deal of evidence to substantiate the claim that medical students and health professionals in general are at a higher risk for both social and emotional pathologies and suicide. I don't think it is ludicrous to say it might have something to do with working conditions or the educational and professional environment. After all, the alternative hypothesis, that higher risk for suicide and mental health problems covaries with the population bound for the profession anyway, seems less likely when compared to other professions full of high achievers, medicine is a stand out in its mental health track record. That being said, you are right that we cannot rule it out and it is worth considering what implications that may have.

http://m.occmed.oxfordjournals.org/content/61/3/163.short. <- suggesting occupational hazards in medicine such as hours worked and efforts to reward ratio (defined by them) could have an effect on mental health of medical professionals.

https://www.ncbi.nlm.nih.gov/m/pubmed/2944933/ <- older article claiming that not only is depression more prevalent among medical students but that there is more likely a positive bias in the selection of students more likely to develop depression

2002 study looking at prevalence of depressions amongst UCSF students (from a 1994 survey) also found about 24% suffered from depression and primarily focuses on the barriers to access of mental health care resources for those medical students. The reason for the question being asked is that only 22% of students reporting mental health issues received care for their problems.
https://www.ncbi.nlm.nih.gov/m/pubmed/12228091/

Consensus statement in JAMA from 2003 regarding reversing this trend, especially the increased burden of suicide among physicians.
https://www.ncbi.nlm.nih.gov/m/pubmed/12813122/

I don't have time to keep digging through my old bookmarks (I've done a lot of writing on this subject for the University) but I also know that suicides are more likely among physicians and that their suicide attempts are more likely to be successful than those in the general population (knowledge of human body, toxicology and pharmacology, etc).

 

[Holmwood]

This particular study aside, I think a literature review would reveal that there is a great deal of evidence to substantiate the claim that medical students and health professionals in general are at a higher risk for both social and emotional pathologies and suicide. I don't think it is ludicrous to say it might have something to do with working conditions or the educational and professional environment. After all, the alternative hypothesis, that higher risk for suicide and mental health problems covaries with the population bound for the profession anyway, seems less likely when compared to other professions full of high achievers, medicine is a stand out in its mental health track record. That being said, you are right that we cannot rule it out and it is worth considering what implications that may have.

http://m.occmed.oxfordjournals.org/content/61/3/163.short. <- suggesting occupational hazards in medicine such as hours worked and efforts to reward ratio (defined by them) could have an effect on mental health of medical professionals.

https://www.ncbi.nlm.nih.gov/m/pubmed/2944933/ <- older article claiming that not only is depression more prevalent among medical students but that there is more likely a positive bias in the selection of students more likely to develop depression

2002 study looking at prevalence of depressions amongst UCSF students (from a 1994 survey) also found about 24% suffered from depression and primarily focuses on the barriers to access of mental health care resources for those medical students. The reason for the question being asked is that only 22% of students reporting mental health issues received care for their problems.
https://www.ncbi.nlm.nih.gov/m/pubmed/12228091/

Consensus statement in JAMA from 2003 regarding reversing this trend, especially the increased burden of suicide among physicians.
https://www.ncbi.nlm.nih.gov/m/pubmed/12813122/

I don't have time to keep digging through my old bookmarks (I've done a lot of writing on this subject for the University) but I also know that suicides are more likely among physicians and that their suicide attempts are more likely to be successful than those in the general population (knowledge of human body, toxicology and pharmacology, etc).

And the question I was interested in when I see these kinds of studies is, why is it that students are comfortable reporting mental health issues for this survey and not to the folks who could be helping them?

Your thoughts?

 

[Lucca]

And the question I was interested in when I see these kinds of studies is, why is it that students are comfortable reporting mental health issues for this survey and not to the folks who could be helping them?

Your thoughts?

Well contributing to research anonymously is different than involving one's self in treatment. Not only in terms of time commitment, but it could be a lot more public than you would be comfortable. There may also be concerns that if anyone in the future finds out that it would reflect negatively on them socially or professionally. If one does make the commitment to get help, is the educational structure set up to give them the time and space in order to do so? Can an administration work with a student without treating them like a burden? These are case by case questions. The literature on barriers to care access for health professionals could answer your question better than I can I am by no means an expert, only a very interested observer

 

[efle]

I'd love to see a comparison of medical school mental health to the highly competitive PhD programs, law programs, etc. IIRC being highly intelligent and the stress of constant overwork are both huge risk factors and I have to wonder if we would see med school specifically coming out higher.

 

[BrownEMS]

https://wire.ama-assn.org/education/1-4-med-students-around-world-shows-depression-signs
http://jamanetwork.com/journals/jama/article-abstract/2589340

What do you guys make of this?

27% of Medical Students around the world are depressed, 1 in 10 are suicidal.

How should we go about combating this moving forward?

I'm always skeptical when it comes to self-reported measures, however, I don't find increased depression in med students surprising for these reasons:

1.) Medical schools select the highest achievers. These are people who are looking for the most self-improvement and positive reinforcement of the work they do. In undergrad, there were probably several peers who were below them in academic achievement. The transition into medical school can have less positive reinforcement as now almost everyone is at your level, and you longer get that sense of achievement or notability. You no longer stand out, in fact you may perform lower than other students.
2.) Low sleep, stress--> Increase likelihood of depression
3.) Separation from family-->increase stress


I don't think that it is the curriculum that causes depression, however, I think self selection of people who are more likely to be depressed along with the social factors associated with medical education are contributory. There definitely needs to be studies that evaluate this. The ones mentioned in this thread are not convincing.

 

[BrownEMS]

I'd love to see a comparison of medical school mental health to the highly competitive PhD programs, law programs, etc. IIRC being highly intelligent and the stress of constant overwork are both huge risk factors and I have to wonder if we would see med school specifically coming out higher.

Or PA schools.

 

[piii]

I actually don't think that is a good thing. Your class rank and AOA status would then be entirely on clinical grades which can be significantly more stressful to ensure higher grades and is often times very frustratingly out of your control.

I think the real answer lies in removing the stigma to mental health problems that exist in medicine

Class rank and AOA are only 11th and 17th in importance for interviews, and 14th and 24th in importance for ranking applicants. Preclinical grades aren't even listed as important. My school is P/F no rank for preclinical, and AOA is made from step, preclinical grades, and extracurricular factors. Our students match very well, and have a great reputation, and are overall very happy.

You're very misinformed.

http://www.nrmp.org/wp-content/uploads/2014/09/PD-Survey-Report-2014.pdf

 

[JB50]

I think it's more related to who's entering medical school. At the base of it, we are all pretty much the same pedigree with different personalities. Those that can't cope with imperfections or need to be the best will always be miserable/unhappy. This will never change.

This forum is a great example... Take 10 minutes and read through the pre-med forum and you know why lol. You can't just tell this population "you are all the best."

We know better.

 

[efle]

Class rank and AOA are only 11th and 17th in importance for interviews, and 14th and 24th in importance for ranking applicants. Preclinical grades aren't even listed as important. My school is P/F no rank for preclinical, and AOA is made from step, preclinical grades, and extracurricular factors. Our students match very well, and have a great reputation, and are overall very happy.

You're very misinformed.

http://www.nrmp.org/wp-content/uploads/2014/09/PD-Survey-Report-2014.pdf

Did you read further into the document past the overall dataset? For selective specialties (particularly surgical for some reason) AOA often jumps way up to 75-80%+ listing as important, even above things like clerkship grades or Dean's letter in some cases. If someone was very interested in surgery I could see clinical-only AOA being a reasonable concern since it is so widely complained about as subjective. Doesn't make sense to get all condescending with such general data that doesn't apply to everyone.

 

[sliceofbread136]

Class rank and AOA are only 11th and 17th in importance for interviews, and 14th and 24th in importance for ranking applicants. Preclinical grades aren't even listed as important. My school is P/F no rank for preclinical, and AOA is made from step, preclinical grades, and extracurricular factors. Our students match very well, and have a great reputation, and are overall very happy.

You're very misinformed.

http://www.nrmp.org/wp-content/uploads/2014/09/PD-Survey-Report-2014.pdf

Misinformed about what? My own opinion? I would hate your schools ranking system.

 

[Holmwood]

Sometimes, suicidal ideations and depressive thoughts can happen to the "best" of us. Romantic troubles, isolation, fights over social media... Someone who's worked in a high stress environment making decisive decision day-to-day are not necessaily immune to soul-crushing heartbreaks, for instance.

It is also likely that we will all contemplate the purpose of our life or show signs of feeling down at several point in our life. Self reporting is very different from a clinical diagnosis, however. And I'd be curious to ask the medical students in the survey, " Are you afraid to seek help despite feeling like you need help, or are you not seeking help because you feel you can handle it on your own?"

Maybe the goal souldn't be to reduce rates of depression and suicidal thoughts in students, but rather to ensure that they know how to cope with it in a healthy manner. Would be interesting to have medical students discuss how they've dealt with getting dumped, lol.

Other questions I had:
1) Are med students more likely to be honest with the way they feel given the nature of their profession relative to the general population?

2) Are med students more likely to forego treatment in general (not just for mental health) given their predisposition OR financial circumstances?

2) Are increased rates of suicidal thoughts and depression something to do with other factors such as the age and SES of students? Any studies on student debt?

I lost my article access, so I can't look for studies myself. 🙁

 

[spartan25]

I'm always skeptical when it comes to self-reported measures, however, I don't find increased depression in med students surprising for these reasons:

1.) Medical schools select the highest achievers. These are people who are looking for the most self-improvement and positive reinforcement of the work they do. In undergrad, there were probably several peers who were below them in academic achievement. The transition into medical school can have less positive reinforcement as now almost everyone is at your level, and you longer get that sense of achievement or notability. You no longer stand out, in fact you may perform lower than other students.
2.) Low sleep, stress--> Increase likelihood of depression
3.) Separation from family-->increase stress


I don't think that it is the curriculum that causes depression, however, I think self selection of people who are more likely to be depressed along with the social factors associated with medical education are contributory. There definitely needs to be studies that evaluate this. The ones mentioned in this thread are not convincing.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4885556/pdf/acm-89-573.pdf

Here's one study from one school that looks at depression/anxiety scores before and after implementation of a pass/fail curriculum for M1 and M2 years.

Their conclusion is that curriculum changes do in fact have an impact on student mental health.

 

[Papa Oso]

Maybe Medical School is just a very stressful experience which then leads to having a higher chance of being depressed/suicidal? Like having PTSD from going to War?
Kind of extreme but the point holds. Maybe Med Schools should try to screen for students who have shown to have resiliency?

 

[kerenza]

.

 

[Member12345674]

Pretty important to note that "medical students" in this study refers to students in PGY 1-4 aka RESIDENTS. Also, it is difficult to say anything about US education when the researchers compile information from 41 countries.

Your statement is incorrect. The article that was published on Tuesday does not include any residents; rather, it only synthesizes data collected from undergraduate medical students, i.e., MS1-MS4 students in the United States, and MS1-MS6 students abroad (where students go directly from high school to medical school). The citation for the article (emphasis added) is as follows:

Rotenstein LS, Ramos MA, Torre M, Segal JB, Peluso MJ, Guille C, Sen S, Mata DA.
Prevalence of Depression, Depressive Symptoms, and Suicidal Ideation Among Medical Students: A Systematic Review and Meta-Analysis
JAMA. 2016 Dec 6;316(21):2214-2236. doi: 10.1001/jama.2016.17324.
http://jamanetwork.com/journals/jama/article-abstract/2589340

You might be confusing this article with another systematic review and meta-analysis published in 2015, which indeed focused on depressive symptom prevalence in resident physicians (i.e., PGY1-PGY7). That article found a similar prevalence of depressive symptomatology. The citation for that article is as follows:

Mata DA, Ramos MA, Bansal N, Khan R, Guille C, Di Angelantonio E, Sen S.
Prevalence of Depression and Depressive Symptoms Among Resident Physicians: A Systematic Review and Meta-analysis.
JAMA. 2015 Dec 8;314(22):2373-83. doi: 10.1001/jama.2015.15845.
http://jamanetwork.com/journals/jama/fullarticle/2474424

I would recommend that everyone actually read the text of both articles before commenting further. One of the messages driven home by both is that there is likely no one "true prevalence" of depressive symptoms; rather, the authors have striven to provide a range of prevalence estimates, and also discuss contributing factors and possible solutions.

 

[Member12345674]

I'm always skeptical when it comes to self-reported measures.

There is no reason to be skeptical of well-designed, validated self-report measures. As has been alluded to, accurate measurement of depressive symptoms in medical trainees requires anonymity:

Levine RE, Breitkopf CR, Sierles FS, Camp G.
Complications associated with surveying medical student depression: The importance of anonymity.
Academic Psychiatry. 2003; 27:12–18.
http://link.springer.com/article/10.1176/appi.ap.27.1.12

Furthermore, high quality, well-validated survey instruments have high sensitivities and specificities for accurately diagnosing major depressive disorder.

Kroenke K, Spitzer RL, Williams JB.
The PHQ-9: Validity of a brief depression severity measure.
J Gen Intern Med. 2001; 16:606–613.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1495268/

The authors of both JAMA studies (i.e., this year's study on medical students and last year's study on resident physicians) provide tables of the sensitivities and specificities of the instruments synthesized in their analyses so that readers can judge for themselves which pooled estimates are the most reliable for diagnosing MDD. As you can see, well-validated instruments combined with proper cutoffs yield excellent results (e.g., the PHQ-9 with cutoff of >=10, the CES-D with cutoff >=16). Other instruments (e.g., the PRIME-MD) are really only useful for screening patients and prevalence estimates obtained with them do not accurately reflect actual MDD prevalence, but rather only "depressive symptom" prevalence.

From an epidemiological standpoint, virtually all studies of depression are conducted using surveys, for a few reasons. (1) In-person interviews do not scale. It would be impossible to conduct 129,000 in-person interviews with medical students, for example. (2) Standardized surveys, which probe the exact same set of symptoms as would a psychiatrist following the DSM-V, do not vary from one participant to the next (i.e., there is no variability introduced by the interviewer-interviewee relationship). This reduces confounding. (3) The surveys produce objective, quantifiable data (i.e., a depressive-symptom score), allowing more refined statistical analyses (i.e., regression modeling) to be performed.

 

[Member12345674]

Screen for applicants with a history of depression or qualities resembling it.

Aside from this being a very disturbing suggestion coming from someone who wants to be a physician (should we also exclude applicants with histories of diabetes because they might have a heart attack mid-career? or those on corticosteroids for asthma because they might become sick when exposed to patients on the wards? or those who still have their appendices, as they might develop appendicitis while in class one day?), even if it were a viable suggestion, it's likely wrong. There is work to suggest that future medical students (i.e., premedical students about to graduate from college) actually have better mental health than their non-premedical peers. This really gets to the point that it is not the individual student who is the "problem" - it's the medical school / residency environment that leads to increased depression risk. Check out the following paper for more details.

Brazeau CM, Shanafelt T, Durning SJ, et al.
Distress among matriculating medical students relative to the general population.
Academic medicine : journal of the Association of American Medical Colleges.
2014;89(11):1520-1525.
https://www.ncbi.nlm.nih.gov/pubmed/25250752

And anyway, people need to remember that major depressive disorder is a highly treatable disease, just like bacterial cellulitis, diabetes, or a fracture. If you had cellulitis, you would get better after appropriate wound care and antibiotic administration. If you had type II diabetes, you would get better with appropriate lifestyle changes and insulin-sensitizer administration. If you had a fracture, you would get better with orthopedic surgery and NSAIDS. Depression is an illness like any other, and antidepressant medication administration and cognitive-behavioral therapy are equally effective in treating it. People need to wake up and realize that the brain is an organ like any other, so why should we treat it differently?

 

[Lannister]

Maybe Med Schools should try to screen for students who have shown to have resiliency?

It seems like they already do. A lot of interview questions have to do with your ability to overcome stressful situations and how you deal with anxiety/uncertainty/not getting your way.

 

[TaroBubbleTea]

It seems like they already do. A lot of interview questions have to do with your ability to overcome stressful situations and how you deal with anxiety/uncertainty/not getting your way.

To be honest, that's not really reassuring. It's so easy to fake like you have it together for a 1 hour conversation.

Heck, I do that on a daily basis

 

[Mad Jack]

Make sure you want it before you go for it


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Wanting something bad enough doesn't make mental health issues go away.

 

[Lannister]

To be honest, that's not really reassuring. It's so easy to fake like you have it together for a 1 hour conversation.

Heck, I do that on a daily basis

Oh absolutely 😛 but at the same time, it's also kind of easy to tell when an interviewee is faking it. For example, when they say they grew as a person as a result of some experience but then can't give any specific examples of how they changed. I'm sure some people are good actors but I think most are too nervous to just completely make stuff up.

Edit: disclaimer, my school does MMI so our conversations are only 6 minutes, not an hour. Not sure if that makes it easier or harder to fake it.


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