September 16, 2010 — Depressed medical students have a higher prevalence of stigmatized attitudes than their nondepressed counterparts, a new cross-sectional study suggests.
In fact, 56% of those with moderate to severe depression said that their fellow medical students would respect them less, and more than 83% worried that faculty members would question whether they could handle their responsibilities.
The survey also found that although the depressed medical students had higher rates of suicidal ideation compared with the nondepressed students, those in their third and fourth years of school were more likely to report it than first- and second-year students.
"It was somewhat worrisome and concerning to see that students with high depression scores experienced really quite a wide range of stigma, and that it came from many directions. Perhaps most unsettling was that it came from their fellow students, faculty members, and counselors," lead author Thomas L. Schwenk, MD, professor and chair of the Department of Family Medicine at the University of Michigan, Ann Arbor, told Medscape Medical News.
"Now, we don't have any way of knowing: Is this real or is it perception?" added Dr. Schwenk. "But of course it doesn't really matter so much because for them, perception is real. Feeling that this stigma comes from so many different places makes it difficult to know where to go to safely disclose and safely seek care."
The study authors note that overall, "medical students experience depression, burnout, and mental illness at a higher rate than the general population, with mental health deteriorating over the course of medical training."
However, they are also less likely to seek appropriate treatment. "Students may worry that revealing their depression will make them less competitive for residency training positions or compromise their education, and physicians may be reluctant to disclose their diagnosis on licensure and medical staff applications," the investigators write.
"We just think that caring for oneself and for each other should be part of the attributes of an outstanding physician and being receptive to treatment of mental illness and to the needs of colleagues should become part of the construct of professionalism," added Dr. Schwenk.
The study appears in the September 15 issue of the Journal of the American Medical Association, a theme issue on medical education.
High Prevalence of Stigma
For the study, the investigators evaluated data from all 769 students enrolled at the University of Michigan Medical School. The Web-based Patient Health Questionnaire survey was completed by 505 (65.7%) of the students (58.4% women) between September and November 2009, and all identities were kept confidential.
Because of the anonymity of the participants, no follow-ups were conducted or referrals to mental health resources offered. However, existing medical school resources were described throughout the survey process.
Results showed that the overall prevalence of moderate to severe depression in the students was 14.3% (95% confidence interval [CI], 11.3% - 17.3%).
Of these, female students were found to be twice as likely as male students to have moderate to severe depression (18% vs 9%, respectively; 95% CI for difference, −14.8% to −3.1%; P = .001). There was no significant difference in depression found between the first- and second-year students (13.4%) and the third- and fourth-year students (15.4%).
Suicidal ideation at some point during medical school was reported by 4.4% of the overall students. However, it was more likely to be reported by third- and fourth-year students than by first- and second-year students (7.9% vs 1.4%; P = .001).
There was no significant difference in suicidal ideation found between the women and the men (5.1% vs 3.3%, respectively).
When looking at the stigma questions, students with moderate to severe depression agreed more frequently with the statement "If I were depressed, fellow medical students would respect my opinions less" than did those without depression (56.0% vs 23.7%; P < .001). They also agreed more frequently that fellow students and faculty members would view them as being unable to handle their school responsibilities (83.1% vs 55.1%; P < .001).
"Students with higher depression scores also felt more strongly than did those with no to minimal depression that telling a counselor would be risky (53.3% vs 16.7%) and that asking for help would mean the student's coping skills were inadequate (61.7% vs 33.5%)," report the study authors.
Men agreed more often than women that others would not want to work with a depressed medical student (49% vs 29.4%; P < .001) and that they could endanger patients (36.3% vs 20.1%; P = .002).
Finally, first- and second-year students agreed more frequently than did third- and fourth-year students that seeking help for depression would make them feel less intelligent (34.1% vs 22.9%; P < .01) and that "depressed medical students would provide inferior patient care" (79.3% vs 66.9%; P = .007).
"The male vs female and first-year vs third- and fourth-year student data are important and certainly provocative, but we did not explore them in great detail in terms of other factors," said Dr. Schwenk. "If you take the data at face value, however, it suggests that men are somewhat more critical of students who are depressed than women are. That's somewhat worrisome, given the fact that women experience depression at a higher rate."
Overall, the study's results "suggest that new approaches may be needed to reduce the stigma of depression and to enhance its prevention, detection, and treatment," summarize the authors.
Dr. Schwenk reported that his team hopes to expand this study and to "reach out to other schools" with the survey. "Clearly, one school does not constitute an adequate sample." Also, "in short order," they hope to design some intervention programs to be used in a medical school environment.
Deconstruct Stigmatized Attitudes
This study "serves as a reminder of how difficult it is to be a medical student. The initial encounters with severe illness and the extremes of life are poignant and profoundly affecting," writes Laura Weiss Roberts, MD, from the Department of Psychiatry and Behavioral Sciences at Stanford University, California, in an accompanying editorial.
Dr. Roberts, who was not involved with this study, writes that the study showed some encouraging results. "Third- and fourth-year students expressed less stigmatized views of depression in peers. These data suggest that the iterative experiences of medical training may inspire more accurate and empathic understanding of the illness experience, whether in a patient or a colleague."
She notes that the findings also "issue a clear invitation to intervene" with depressed and at-risk students. "Whether the stigma perceived by depressed medical students is a sign of illness...or an accurate 'read' of the culture of medicine, it is important to deconstruct stigmatized attitudes toward mental illness.
"Such efforts will be seen as superficial unless secure, affordable, and confidential pathways to mental healthcare, preferably outside of their usual training settings, are created for physicians in training across all levels," she adds.
Dr. Roberts writes that "few funds" are currently dedicated to medical education research, although it is a critically important area to explore.
"The future of medicine rests on the shoulders of today's medical students, and the care with which medical school administrators and faculty attend to their learning and well-being may bring good to them, as well as to the patients of tomorrow," she concludes.
This study was supported by the Department of Family Medicine at the University of Michigan. The study authors have disclosed no relevant financial relationships. Dr. Roberts reported receiving research funding from the National Institutes of Health, the US Department of Energy, and the Medical College of Wisconsin, and being the owner of Terra Nova Learning Systems.
JAMA. September 2010; 304:1181-1190.
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