Curbing Depression in Medical Students

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There is a strong link between depression and burnout in physicians and quality of care, with increases in medical errors and declines in empathy and altruistic behavior.
There is a strong link between depression and burnout in physicians and quality of care, with increases in medical errors and declines in empathy and altruistic behavior.

It is time to take a more critical look at the culture of medical training, and new steps are needed to assess and monitor student well-being, according to Stuart Slavin, MD, associate dean for curriculum and professor of pediatrics at Saint Louis University School of Medicine in Missouri. 

In a recent issue of JAMA that focused on medical education, Dr Slavin published an editorial in which he contends the well-being of medical students must be viewed as an environmental health issue.1

“I worry that we are sowing the seeds for poor mental health of physicians by creating such adverse educational environments in medical school,” said Dr Slavin. “Ultimately, it is about culture. Efforts need to be made at all levels of medical education and training to create more supportive and nurturing educational settings.”

He also noted that medical schools need to address the newly recognized mental health crisis among medical students.

In a new systematic review, scientists searched EMBASE, ERIC, MEDLINE, and other sources for studies on the prevalence of depression, depressive symptoms, or suicidal ideation in medical students. The studies were published before September 17, 2016, in the peer-reviewed literature.

The review included 167 cross-sectional studies including 116,628 participants and 16 longitudinal studies involving 5728 participants from 43 countries. Overall pooled crude prevalence of depression or depressive symptoms was 27.2%.2 In the longitudinal studies assessing depressive symptoms before and during medical school, the researchers found that the median absolute increase in symptoms was 13.5%,2 and the percentage of medical students with positive screening assessments for depression and seeking psychiatric treatment was 15.7%.2 

“The surprising finding was that depression in particular is 2- to 5-times higher in medical students compared with similarly aged individuals in the general population,” said study co-author Douglas Mata, MD, MPH, resident physician at Brigham & Women's Hospital and a clinical fellow at Harvard Medical School in Boston, Massachusetts. It is important to look at all the available data on this topic in order to know the true prevalence, he explained, noting that these findings should help motivate policymakers and individuals in hospital administration because now they have actionable data.

He said that if they are in a good state of mind, students and residents can learn better. The current depression levels found in this review are abnormal, and that is due to system-wide issues. 

“Depression is endemic in medical students,” Dr Matta told Endocrinology Advisor. “There are a multitude of steps we need to take.” 

What Changes Are Needed?

Researchers have also been studying what undergraduate medical education learning environment interventions may be associated with improved emotional well-being among medical students. They found it may be time for program reforms when it comes to mental health programs, wellness programs, and mentoring programs. Data also appear to support a preclinical pass/fail grading system.3

“The main changes needed in medical education are primarily structural with pass/fail grading and reduction in class time and amount of information being taught,” said Dr Slavin.

He noted that there is a strong link between depression and burnout in physicians and quality of care, with increases in medical errors and declines in empathy and altruistic behavior.  

“My personal feeling is that we should be routinely, and perhaps annually, anonymously or confidentially assess students, residents, and physicians for depression and burnout. I feel like action will only occur when we are willing to measure and track mental health outcomes of our students and employees in the healthcare setting,” Dr Slavin told Endocrinology Advisor.

Addressing Issues of Disabilities

Researchers recently assessed the prevalence of all disabilities and the accommodations in use at allopathic medical schools in the United States. They sent an electronic, web-based survey between December 2014 and February 2016 to 145 institutions. Among the 133 schools deemed eligible, 91 completed the survey (68.4%).4 The respondents identified 1547 students with disabilities (43.3% men) and represented 2.7% of the total enrollment.4 The survey found that 97.7% received accommodations.4 The most common disabilities were attention-deficit/hyperactivity disorder (ADHD; 33.7%), learning disabilities (21.5%), and psychological disabilities (20.0%).4

“So many individuals with disabilities are being dissuaded from medicine and incorrectly counseled that accommodations are not available in medical school or in the clinical years. We wanted to highlight just how many students with disabilities are in medical school. It was also critical to try to capture the entire spectrum of disability as previous studies only included subsets of disability like sensory or physical disabilities,” said study author Lisa Meeks, PhD, director of Medical Student Disability Services and assistant professor of medicine at the University of California, San Francisco. 

Physicians with disabilities add a rich dimension to their care of patients, according to Dr Meeks. She said physicians with disabilities have the potential to increase patient compliance and satisfaction through patient-physician concordance, similar to the effects shown with other marginalized populations. One in five Americans has a disability, so it is certain that future physicians will care for people with disabilities. However, she said providers with disabilities remain an underrepresented minority in the healthcare workforce, with the numbers being disproportionate (2.7%) to the magnitude of disabled people in the general population (20%).

“Medical schools around the country would benefit from learning more about how to support students with disabilities in keeping with the spirit of the Americans with Disabilities Act,” Dr Meeks told Endocrinology Advisor. “I think now that we know the prevalence, we need to work toward standardizing the process by which they receive accommodations.”

She said students at any allopathic or osteopathic program should expect the same objective, confidential, and supportive analysis of their accommodation needs by a qualified disability provider who does not play an evaluative role in their education.

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References

  1. Slavin SJ. Medical student mental health culture, environment, and the need for change. JAMA. 2016;316(21):2195-2196.
  2. Rotenstein LS, Ramos MA, Torre M, et al. Prevalence of depression, depressive symptoms, and suicidal ideation among medical students: a systematic review and meta-analysis. JAMA. 2016;316(21):2214-2236.
  3. Wasson LT, Cusmano A, Meli, L, et al. Association between learning environment interventions and medical student well-being: a systematic review. JAMA.  2016;316(21):2237-2252.
  4. Meeks LM, Herzer KR. Prevalence of self-disclosed disability among medical students in US allopathic medical schools. JAMA. 2016; 316(21):2271-2272. 
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