A New Approach to Medical School Mental Illness
The mental health of medical students is a subject which has received copious attention in the past three decades. The perspective is usually bleak. As is the case for mental health in general, the focus has been on the negative aspects of students’ psychological health on vulnerability, or risk, rather than resilience. Indeed, trainee physicians appear to be uniquely vulnerable, with rates of depression among medical students as high as three times that of the rest of the population. Shockingly, almost a quarter of medical students in the United States suffer from some form of mental illness. The reasons for this increased vulnerability are numerous – among them the sleep deprivation and stress that many within this field consider par for the course. While the consequences of mental illness amongst future physicians, including worse patient care and more medical errors, are disturbing, this population has especially low rates of help-seeking – which is even more worrying. As such, it is imperative that medical schools emphasize the development of positive mental health early during training. A number of institutions have already instigated programs to do just that – with significant success. Mindfulness is part of the curriculum at Monash University in Australia, while at Jefferson Medical College in the U.S., stress reduction electives are offered to incoming first year students, with an introduction to mindfulness available for all medical students. Furthermore, medical students are still being followed up at Friedrich-Alexander University in Germany after trialling new relaxation skills courses with early success.
Mental Illness among Medical Students
As I’ve alluded to above, rates of depression and other mental illnesses appear to be significantly increased in medical students. Trainee physicians have much higher levels of distress, anxiety and depression than the population in general. Not only are medical students more depressed, they are also at a higher risk of suicide: the proportion of depressed medical students who experience suicidal thoughts is much higher even than that of people with severe depression. Medical students also score higher than population norms on general psychological distress tests. It is often said that those who pursue a career in the medical field are inherently more susceptible to mental illness, given the high entry requirements, which means they need to be high achieving and academically inclined. Some have even suggested that doctors’ personality traits increase their vulnerability. Physicians tend to be more obsessional, experience more doubt and have an out-of-proportion sense of personal responsibility. This so-called “compulsive triad”, while undoubtedly lending itself to conscientious patient care, could make medical students more likely to suffer from high levels of stress, increasing their risk of mental illness. This debate between social selection and social causation remains controversial but in any case, it seems likely that medical education contributes significantly to psychological distress.
Under-treatment of Mental Illness and its Consequences
Alongside the high levels of mental illness in trainee doctors, are parallel levels of under treatment. There are a number of reasons for this. The most common reason is a perceived lack of time, followed by a lack of confidentiality, a fear of not being understood, as well as apprehension regarding the stigma surrounding mental illness. Students also express concern that seeking psychiatric help may tarnish their academic records. Indeed, medical students appear to have poor attitudes towards their own general health, with only approximately a third seeking regular healthcare. We cannot forget that medical students are mere years away from becoming practising physicians, and consequently their health (or lack of) has a direct impact on patient safety. It is well known that doctors with poor mental health are more likely to commit medical errors and provide a lower standard of patient care. On the other hand, stable, resilient and healthy physicians are better able to provide their patients with better care, comfort and hope. Physicians who take good care of their own health are also more likely to discuss health promotion with their patients. Essentially, doctors who invest time and energy in their own well-being are better equipped to take responsibility for the well-being of others.
Changing the Focus from Risk to Resilience
Given the serious issue with medical students experiencing psychiatric distress for which they may not seek treatment, there is a serious need to approach the problem from a different angle. Many suggest adjusting the focus from treatment to prevention; from vulnerability and risk to resilience. While it would be erroneous to suggest that depression (or indeed any mental illness) can be completely prevented by improving coping skills, coping strategies are undoubtedly a modifiable risk factor for depression. Indeed, psychoeducational “resilience” interventions may increase the ability of students to cope and also reduce the symptoms of mental illness. Some have gone as far as to suggest that interventions providing medical students with coping skills early during training is a matter of both patient and physician safety: “In a university medical degree course in which students are taught about managing the health of others, there is an imperative to provide them with effective, evidence-based ways to manage their own stress.” wrote the authors of a key study on the effectiveness of mindfulness practice for medical students. Arming medical students with the skills to safe-guard their own mental wellbeing throughout medical training and beyond is important not only in terms of improving physician mental health but also in terms of improving professionalism, physician fulfilment and patient care. There is a growing consensus that student doctors who take part in stress-management programs experience benefits that range from decreased depression and anxiety and enhanced empathy to improved immunologic function. In a population who are clearly more susceptible to developing psychiatric illness, we need to attempt to modify the risk where possible. Intervening before illness occurs and cultivating resilience in medical students has benefits not only for the students themselves but also for their future patients.
The First Steps in the Right Direction
Although there is much work to do in terms of investigating the impact of resilience interventions on medical student mental health, so far there have been some promising steps in the right direction. The majority of programmes instigated to improve medical student resilience are based around mindfulness practice. Importantly, there is robust evidence implicating mindfulness as a means to improve anxiety and mood, with studies already showing reduced overall psychological distress and depressive symptoms in medical students who participate in mindfulness-based stress reduction (MBSR) courses. Generally, students are taught evidence-based methods of stress reduction, an important coping skill, and one that will hopefully serve them well when facing the challenges of medical education. Despite the disparate methods of teaching and program organisation, MBSR courses for medical students seem to be effective. These courses, ranging from 4 to 10 weeks, reduce student depression and anxiety while increasing positive mood states and empathy. They also reduce stress and negative emotions in general, and enhance mindfulness and self-compassion.
One of the first institutions to introduce an MBSR course of this kind was Jefferson Medical College in the U.S., with their first trial running from 1996 to 2000. As well as being taught about different mindfulness practices, like walking meditation and Hatha yoga, students were expected to participate in 20 minutes of meditation per day, 6 days a week. The course was taken up so enthusiastically by students (98% said they would recommend it not only to other medical students but to patients) and had such positive results (a 38% decrease in total mood disturbance, as opposed to an 18% increase in the control group, measured by the Profile of Mood States inventory), that the university has continued to offer it for the last 16 years. More recently, Monash University in Australia has become the first medical school to integrate mindfulness into the core curriculum. Students are given 8 lectures covering topics such as mind-body medicine and behaviour change strategies, while also taking part in 6 tutorials, which focus on MBSR and cognitive behavioural therapy (CBT). The program focusses on experiential learning, with students completing homework assignments that introduce mindfulness exercises into their daily lives, as well as completing a journal, on which they receive weekly feedback. Unlike other courses, the material taught at Monash is integrated into written exams and an end-of year OSCE station, and all students are required to complete the course. By the end of the course, the majority (90.5%) reported incorporating mindfulness practice into their lives. These students had improved wellbeing overall, and had statistically significant improvements on depression scales, as well as on scales of general psychological distress. While these results aren’t conclusive in and of themselves, they are hopeful, especially given that the data was measured in the pre-exam period- a timeframe which has previously been associated with decreased well-being in medical students- and that self selection bias was not a factor.
Mindfulness is not the only form of wellness intervention that may be used. Medical students at Friedrich-Alexander University in Germany, who attended a relaxation skills course focusing on progressive muscle relaxation (PMR) and autogenic training (AT) – a technique involving the use of visualisations to induce relaxation – seemed to be less affected by burnout as well as anxiety. While the students showed statistically significant reductions in trait anxiety, cognitive burnout and emotional burnout, similar reductions in depressive scores were not significant. The semester long course, which involved weekly tutorials as well as twice daily practice sessions, was taken up enthusiastically by students and has been rolled out in subsequent semesters. Currently, all 42 participants in the study are being followed up, with the intention of discovering whether these “afterglow” effects will be maintained as the students continue with their medical training. There is growing evidence that simple, implementable stress-reduction interventions may be effective in making medical students more resilient, and, in the process, decreasing their rates of mental illness. The imperative now is to build on the work that has been done- to investigate the most effective method and timeframe for resilience intervention- in order to create a programme that is standardized, effective and easily implementable. Only then will it be possible to offer what is clearly necessary support to the majority of medical students, and not just the fortunate minority.
In conclusion, medical school is a time of great upheaval and stress, during which many students encounter issues with their mental health. In addition, too few are inclined to seek help. To combat this problem, many experts suggest a change in focus to building positive mental health and resilience earlier in training. Studies in this field have generated strong results so far which are indicative of the potential efficacy of these type of programs. They highlight the importance of an early focus on positive mental health, as opposed to waiting for symptoms to emerge before confronting it – a strategy which could alter the grim narrative of mental health in medical school. Above all, these studies represent an imperative to expand on the work that has already been done: these programs all work – but which work best? And how can we standardise this practice. Should such courses be mandatory or optional? When, during medical school, should they be provided? These questions, and more, will need to be answered before we see real change.