Acad Psychiatry DOI 10.1007/s40596-015-0301-5
IN BRIEF REPORT
The Impact of Medical School on Student Mental Health Lisa MacLean & Jason Booza & Richard Balon
Received: 12 June 2014 / Accepted: 27 January 2015 # Academic Psychiatry 2015
The pace of medical school is extremely rigorous. Students commonly report high stress due to feelings of lack of control, problems without solutions, and exposure to death and dying for the first time. Medical student’s tendency to be a perfectionist and their struggle to re-identify as patients only add to this stress. Stress has negative physiological and psychological effects on individuals which could result in poor mental health, substance use, and the need to develop healthy coping strategies. Poor mental health can also lead to other negative outcomes including medical school dropout [1] and suicidal ideation and burnout [2]. Previous studies show that students begin medical school with similar rates of depression as their non-medical peers [3, 4]. However, various studies suggest that the mental health of students worsens throughout medical school [3, 5]. Other studies have reflected on factors which impact student success, such as the use of alcohol and illicit substances [6]. A study from Webb et al. revealed that university students experiment with illicit drugs and that medical students do not differ markedly from other student groups despite their knowledge of the potential hazards of illicit drugs [7]. Additionally, the culture of medicine has created expectations of physicians to always put patients first and ignore their own needs. As a result, it may be difficult for physicians to accept help. The impact of depression and anxiety, as well as marijuana and cocaine use, needs to be understood so students, who experience difficulty, seek help. Additionally, this could assist in the integration of preventive health programs to help medical stu-
L. MacLean (*) : J. Booza : R. Balon Wayne State University, Detroit, MI, USA e-mail: [email protected]
dents remain mentally healthy and prevent the long-term consequences of mental illness and substance use. The purpose of this study is to understand the current rates of depression, anxiety, use of marijuana and cocaine, and help-seeking behavior in medical students.
Method A cross-sectional study was designed at a large public single campus urban medical school. Approval was obtained from the University IRB. A 47-item survey was used to identify the current frequency of mental health symptoms, marijuana and cocaine use, and help-seeking behavior in medical students. The survey was composed of questions from several validated instruments including: (1) the PHQ4 [8], which screened for depression and anxiety; (2) three suicide questions from the inventory developed by Meehan [9]; and (3) six questions taken from the National Survey on Drug Use and Health [11] which screened for past and current marijuana and cocaine use. Additional questions were added to assess student’s perception of their health, stress level, and help-seeking behaviors. The survey was sent to n=1169 students via e-mail, inviting them to participate in the study. Informed consent was embedded in the e-mail, and students were instructed that completing the survey implied consent. Three e-mail reminders were sent over a 3-week period. Participation was voluntary, and all responses were anonymous. Students who completed the survey were offered an opportunity to participate in a draw for one of five $100 gift cards. For safety reasons, all students received information about mental health referrals upon completion of the survey.
Acad Psychiatry
Results Of the n=1169 medical students, n=385 (33 %) completed the survey. Using the PHQ-4, 8.6 % (n=33) of students reported depression, and 25.7 % (n=99) anxiety. Only 34 % of those reporting depression and/or anxiety in the last year sought counseling. Additionally, of those responding, 82 % (n=318) reported an increase in stress, 11.7 % (n=45) reported suicidal thoughts in the last year, and 29.9 % (n=115) admitted suicidal ideation at some point in their life, with 1.8 % (n=7) having made a suicide attempt. Use of marijuana within the past year for this same population was 18.2 % (n=70) and for cocaine was 1.1 % (n=4).
Discussion The intense academic demands that medical students face contribute to students’ risk for stress. In our sample, 82 % (n=315) of students felt an increase in stress in the last year. Students spend many hours in lectures, labs, studying, and less time in health-promoting activities like exercise and eating healthy. Some students will experience increased depression, anxiety, interpersonal difficulties, and suicidal thoughts. Nine percent of our students reported depression, as compared to the 14 % in the study by Schwenk et al. [12]. Schwenk’s use of the PHQ-9 may have resulted in greater sensitivity for the detection of depression versus the PHQ-2 used in this study. Outcomes from our study also showed that 25 % of the respondents reported moderate to severe anxiety. There is limited data looking at anxiety in medical students. A study done by Eisenberg et al. [13], using the PHQ, indicated that only 3.8 % of graduate students reported any anxiety. The higher rates of anxiety in our population could be related to the rigor and pressures unique to medical education. The rate of suicidal ideation in the 11.7 % of students was similar to the study by Dyrbye, which reported an 11 % rate of suicidal ideation [2]. Unfortunately, as students experience depression, anxiety, and suicidality, their ability to cope can diminish, which, in turn, can impact a student’s self-care. Studies also show that medical students have a significant change in health habits in the course of their studies [5] and have difficulty facing health issues and finding appropriate help [11]. In this study, only 33 % (n=37) students who endorsed either symptoms of moderate to severe depression or anxiety actually sought help. Persistent stress and emotional exhaustion could lead medical students to self-medicate with caffeine, alcohol, and other illicit substances like marijuana and cocaine. Approximately 18 % (n= 69) of students reported using marijuana and 1.1 % (n=4) using cocaine in the last year. According to the 2012 National Survey on Drug Use and Health, the prevalence of marijuana use for people aged 26–34 is 18.2 % and for cocaine is 3.1 % [10]. This indicates that medical students do not appear to be using any
more or less marijuana than the general population but may use less cocaine. Any use of marijuana and cocaine in medical students is concerning because medical students are trained in understanding the health risks of substance abuse and the potential impact on themselves and their future patients. Our study has several limitations. First, the response rate was slightly lower than expected, even though we did receive an n= 385 students. We postulate that distressed medical students may be less motivated to fill out a survey or less likely to report substance abuse or mental health issues. Additionally, many students may fear the lack of confidentiality when reporting substance use and psychiatric disorders. Finally, the participants all originated from the same institution, thus impacting external validity. However, the results do build on the current literature and allows for study replication. These results show a high level of stress and increased anxiety in medical students which need to be addressed. The Liaison Committee for Medical Education (LCME) requires that medical schools address the health and wellness of its students. As a result, medical schools must develop programs that promote specific wellness activities focused on the health of the students’ mind and body, help-seeking behaviors, and the use of healthycoping strategies. Potential supportive measures could include more education on the use of drugs for self-medication and managing stress and anxiety, physical activity programs, and programs teaching students the basics of preparing healthy food. An integrated lifestyle curriculum embedded in the medical program which addresses the physical and emotional aspects of a person could deliver all these components. More education research is needed to explore the efficacy of these programs in determining “best practices” toward improving the health of medical students and creating a culture in which seeking help is not only recommended but also expected. Implications For Educators • The stress of medical school may increase the onset of anxiety in medical students. • Medical students who report moderate/severe depression and/or anxiety do not consistently seek counseling. • Medical schools need to take an active approach to promoting wellness strategies and eliminating unhealthy behaviors and, finally, to determine whether or not implementation of these strategies will result in student wellness. Disclosures On behalf of all authors, the corresponding author states that there is no conflict of interest.
References 1. Dyrbye LN, Thomas MR, Power DV, et al. Burnout and serious thoughts of dropping out of medical school: a multi-institutional study. Acad Med. 2010;85(1):94–102.
Acad Psychiatry 2. Dyrbye LN, Thomas MR, Massie FS, et al. Burnout and suicidal ideation among US medical students. Ann Intern Med. 2008;149: 334–41. 3. Rosal MC, Ockene IS, Ockene JK, et al. A longitudinal study of students' depression at one medical school. Acad Med. 1997;72: 542–6. 4. Carson AJ, Dias S, Johnston A, et al. Mental health in medical students: a case control study using the 60 item General Health Questionnaire. Scott Med J. 2000;45:115–6. 5. Ball S, Bax A. Self-care in medical education: effectiveness of health habits interventions for first year medical students. Acad Med. 2002;77:911–7. 6. Newbury-Birch D, White M, Kamali F. Factors influencing alcohol and illicit drug use amongst medical students. Drug Alcohol Depend. 2000;59:125–30. 7. Webb E, Ashton CH, Kelly P, Kamali F. An update on British medical student’s lifestyles. Med Educ. 1998;32: 325–31.
8. Kroenke K, Spitzer RL, Williams JBW, Löwe B. An ultra-brief screening scale for anxiety and depression: the PHQ-4. Psychosomatics. 2009;50:613–21. 9. Meehan PJ, Lamb JA, Saltzman LE, O'Carroll PW. Attempted suicide among young adults: progress toward a meaningful estimate of prevalence. Am J Psychiatry. 1992;149:41–4. PMID: 1728183. 10. SAMHA - Substance Abuse and Mental Health Services Administration. NSDUH. 2012. [cited Sept 2014] http://www. samhsa.gov/data/NSDUH/2012SummNatFindDetTables/DetTabs/ NSDUH-DetTabsSect1peTabs1to46-2012.htm#Tab1.7B 11. Brimstone R, Thistlethwaite JE, Quirk F. Behavior of medical students in seeking mental and physical health care: exploration and comparison with psychology students. Med Educ. 2007;41(1):74–83. 12. Schwenk TL, Davis L, Wimsatt LA. Depression, stigma, and suicidal ideation in medical students. JAMA. 2010;304(11):1181–90. 13. Eisenberg D, Gollust SE, Golberstein E, Hefner JL. Prevalence and correlates of depression, anxiety, and suicidality among university students. Am J Orthopsychiatry. 2007;77:534–42.
IN BRIEF REPORT
The Impact of Medical School on Student Mental Health Lisa MacLean & Jason Booza & Richard Balon
Received: 12 June 2014 / Accepted: 27 January 2015 # Academic Psychiatry 2015
The pace of medical school is extremely rigorous. Students commonly report high stress due to feelings of lack of control, problems without solutions, and exposure to death and dying for the first time. Medical student’s tendency to be a perfectionist and their struggle to re-identify as patients only add to this stress. Stress has negative physiological and psychological effects on individuals which could result in poor mental health, substance use, and the need to develop healthy coping strategies. Poor mental health can also lead to other negative outcomes including medical school dropout [1] and suicidal ideation and burnout [2]. Previous studies show that students begin medical school with similar rates of depression as their non-medical peers [3, 4]. However, various studies suggest that the mental health of students worsens throughout medical school [3, 5]. Other studies have reflected on factors which impact student success, such as the use of alcohol and illicit substances [6]. A study from Webb et al. revealed that university students experiment with illicit drugs and that medical students do not differ markedly from other student groups despite their knowledge of the potential hazards of illicit drugs [7]. Additionally, the culture of medicine has created expectations of physicians to always put patients first and ignore their own needs. As a result, it may be difficult for physicians to accept help. The impact of depression and anxiety, as well as marijuana and cocaine use, needs to be understood so students, who experience difficulty, seek help. Additionally, this could assist in the integration of preventive health programs to help medical stu-
L. MacLean (*) : J. Booza : R. Balon Wayne State University, Detroit, MI, USA e-mail: [email protected]
dents remain mentally healthy and prevent the long-term consequences of mental illness and substance use. The purpose of this study is to understand the current rates of depression, anxiety, use of marijuana and cocaine, and help-seeking behavior in medical students.
Method A cross-sectional study was designed at a large public single campus urban medical school. Approval was obtained from the University IRB. A 47-item survey was used to identify the current frequency of mental health symptoms, marijuana and cocaine use, and help-seeking behavior in medical students. The survey was composed of questions from several validated instruments including: (1) the PHQ4 [8], which screened for depression and anxiety; (2) three suicide questions from the inventory developed by Meehan [9]; and (3) six questions taken from the National Survey on Drug Use and Health [11] which screened for past and current marijuana and cocaine use. Additional questions were added to assess student’s perception of their health, stress level, and help-seeking behaviors. The survey was sent to n=1169 students via e-mail, inviting them to participate in the study. Informed consent was embedded in the e-mail, and students were instructed that completing the survey implied consent. Three e-mail reminders were sent over a 3-week period. Participation was voluntary, and all responses were anonymous. Students who completed the survey were offered an opportunity to participate in a draw for one of five $100 gift cards. For safety reasons, all students received information about mental health referrals upon completion of the survey.
Acad Psychiatry
Results Of the n=1169 medical students, n=385 (33 %) completed the survey. Using the PHQ-4, 8.6 % (n=33) of students reported depression, and 25.7 % (n=99) anxiety. Only 34 % of those reporting depression and/or anxiety in the last year sought counseling. Additionally, of those responding, 82 % (n=318) reported an increase in stress, 11.7 % (n=45) reported suicidal thoughts in the last year, and 29.9 % (n=115) admitted suicidal ideation at some point in their life, with 1.8 % (n=7) having made a suicide attempt. Use of marijuana within the past year for this same population was 18.2 % (n=70) and for cocaine was 1.1 % (n=4).
Discussion The intense academic demands that medical students face contribute to students’ risk for stress. In our sample, 82 % (n=315) of students felt an increase in stress in the last year. Students spend many hours in lectures, labs, studying, and less time in health-promoting activities like exercise and eating healthy. Some students will experience increased depression, anxiety, interpersonal difficulties, and suicidal thoughts. Nine percent of our students reported depression, as compared to the 14 % in the study by Schwenk et al. [12]. Schwenk’s use of the PHQ-9 may have resulted in greater sensitivity for the detection of depression versus the PHQ-2 used in this study. Outcomes from our study also showed that 25 % of the respondents reported moderate to severe anxiety. There is limited data looking at anxiety in medical students. A study done by Eisenberg et al. [13], using the PHQ, indicated that only 3.8 % of graduate students reported any anxiety. The higher rates of anxiety in our population could be related to the rigor and pressures unique to medical education. The rate of suicidal ideation in the 11.7 % of students was similar to the study by Dyrbye, which reported an 11 % rate of suicidal ideation [2]. Unfortunately, as students experience depression, anxiety, and suicidality, their ability to cope can diminish, which, in turn, can impact a student’s self-care. Studies also show that medical students have a significant change in health habits in the course of their studies [5] and have difficulty facing health issues and finding appropriate help [11]. In this study, only 33 % (n=37) students who endorsed either symptoms of moderate to severe depression or anxiety actually sought help. Persistent stress and emotional exhaustion could lead medical students to self-medicate with caffeine, alcohol, and other illicit substances like marijuana and cocaine. Approximately 18 % (n= 69) of students reported using marijuana and 1.1 % (n=4) using cocaine in the last year. According to the 2012 National Survey on Drug Use and Health, the prevalence of marijuana use for people aged 26–34 is 18.2 % and for cocaine is 3.1 % [10]. This indicates that medical students do not appear to be using any
more or less marijuana than the general population but may use less cocaine. Any use of marijuana and cocaine in medical students is concerning because medical students are trained in understanding the health risks of substance abuse and the potential impact on themselves and their future patients. Our study has several limitations. First, the response rate was slightly lower than expected, even though we did receive an n= 385 students. We postulate that distressed medical students may be less motivated to fill out a survey or less likely to report substance abuse or mental health issues. Additionally, many students may fear the lack of confidentiality when reporting substance use and psychiatric disorders. Finally, the participants all originated from the same institution, thus impacting external validity. However, the results do build on the current literature and allows for study replication. These results show a high level of stress and increased anxiety in medical students which need to be addressed. The Liaison Committee for Medical Education (LCME) requires that medical schools address the health and wellness of its students. As a result, medical schools must develop programs that promote specific wellness activities focused on the health of the students’ mind and body, help-seeking behaviors, and the use of healthycoping strategies. Potential supportive measures could include more education on the use of drugs for self-medication and managing stress and anxiety, physical activity programs, and programs teaching students the basics of preparing healthy food. An integrated lifestyle curriculum embedded in the medical program which addresses the physical and emotional aspects of a person could deliver all these components. More education research is needed to explore the efficacy of these programs in determining “best practices” toward improving the health of medical students and creating a culture in which seeking help is not only recommended but also expected. Implications For Educators • The stress of medical school may increase the onset of anxiety in medical students. • Medical students who report moderate/severe depression and/or anxiety do not consistently seek counseling. • Medical schools need to take an active approach to promoting wellness strategies and eliminating unhealthy behaviors and, finally, to determine whether or not implementation of these strategies will result in student wellness. Disclosures On behalf of all authors, the corresponding author states that there is no conflict of interest.
References 1. Dyrbye LN, Thomas MR, Power DV, et al. Burnout and serious thoughts of dropping out of medical school: a multi-institutional study. Acad Med. 2010;85(1):94–102.
Acad Psychiatry 2. Dyrbye LN, Thomas MR, Massie FS, et al. Burnout and suicidal ideation among US medical students. Ann Intern Med. 2008;149: 334–41. 3. Rosal MC, Ockene IS, Ockene JK, et al. A longitudinal study of students' depression at one medical school. Acad Med. 1997;72: 542–6. 4. Carson AJ, Dias S, Johnston A, et al. Mental health in medical students: a case control study using the 60 item General Health Questionnaire. Scott Med J. 2000;45:115–6. 5. Ball S, Bax A. Self-care in medical education: effectiveness of health habits interventions for first year medical students. Acad Med. 2002;77:911–7. 6. Newbury-Birch D, White M, Kamali F. Factors influencing alcohol and illicit drug use amongst medical students. Drug Alcohol Depend. 2000;59:125–30. 7. Webb E, Ashton CH, Kelly P, Kamali F. An update on British medical student’s lifestyles. Med Educ. 1998;32: 325–31.
8. Kroenke K, Spitzer RL, Williams JBW, Löwe B. An ultra-brief screening scale for anxiety and depression: the PHQ-4. Psychosomatics. 2009;50:613–21. 9. Meehan PJ, Lamb JA, Saltzman LE, O'Carroll PW. Attempted suicide among young adults: progress toward a meaningful estimate of prevalence. Am J Psychiatry. 1992;149:41–4. PMID: 1728183. 10. SAMHA - Substance Abuse and Mental Health Services Administration. NSDUH. 2012. [cited Sept 2014] http://www. samhsa.gov/data/NSDUH/2012SummNatFindDetTables/DetTabs/ NSDUH-DetTabsSect1peTabs1to46-2012.htm#Tab1.7B 11. Brimstone R, Thistlethwaite JE, Quirk F. Behavior of medical students in seeking mental and physical health care: exploration and comparison with psychology students. Med Educ. 2007;41(1):74–83. 12. Schwenk TL, Davis L, Wimsatt LA. Depression, stigma, and suicidal ideation in medical students. JAMA. 2010;304(11):1181–90. 13. Eisenberg D, Gollust SE, Golberstein E, Hefner JL. Prevalence and correlates of depression, anxiety, and suicidality among university students. Am J Orthopsychiatry. 2007;77:534–42.
