Givens, Jane L. MD; Tjia, Jennifer MD
Medical students have rates of depression and suicide that are higher than those of the general population.1,2,3,4,5,6 Previous work shows that students enter medical school with their lowest rates of depression and peak in depressive symptoms at the end of their second year of school.2 Although counseling is known to be an effective treatment for depression, depressed medical students have low rates of using mental health counseling services and may not have access to such services at all.7 One study found that only 40% of depressed medical students used available mental health services.3 Undertreatment of depression can have significant immediate and delayed consequences because depression is a recurrent disease for many who suffer from it.
Reasons for undertreating depression identified in the literature are derived largely from data about the general population. These reasons include underdiagnosis, limited access to treatment, stigmatizing mental health, and lack of health insurance.8 Previous studies of medical students report confidentiality as a major concern regarding use of mental health services.7,9 There are, however, few data about treating depression among medical students, and the modifiable factors that may hinder use of treatment options.
The goal of this study was to measure depressed medical students' use of mental health services and to assess barriers to use. Apart from demonstrating areas for improvements by student services in medical schools, these data may inform the discussion about access to mental health services and future directions for research.
In spring of 1994, we conducted a cross-sectional, population-based survey of first- and second-year medical students in the School of Medicine at the University of California, San Francisco (UCSF), a state-sponsored medical school. Our target population was the 280 students of the first- and second-year classes of the medical school. We distributed in class a one-time, anonymously self-reported questionnaire. A total of 209 students (98% of the first-year class and 51% of the second-year class) were in attendance and received the questionnaire. To protect confidentiality, non-attendees were not specifically identified and, therefore, could not be sampled at a later date. Repeated anonymous sampling was avoided to prevent duplicate sampling of individual participants.
We constructed our questionnaire to identify the medical students' severity of depression, use of mental health services, perceived barriers to use, and demographic data. Specifically, we used a standardized measure of depression symptoms, the 13-item Beck Depression Inventory (BDI).10 This self-reported instrument correlates well with clinicians' ratings of depression, depression diagnosed by criteria of the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III), and other tests of depression, including the Center for Epidemiological Studies-Depression (CES-D) scale, Depression Adjective Check Lists (DACL), and the Minnesota Multiphasic Personality Inventory (MMPI).11,12
Additional items on the questionnaire elicited current use of both university-based and non-university mental health services. We also asked participants to identify barriers to their use of mental health services from a checklist constructed from a separate survey of a convenience sample of similar students. Respondents could choose as many barriers as applied and could also provide other responses not on the list. The entire questionnaire was pretested on a convenience sample of 36 preclinical medical students drawn from a population separate from the target students.
For the purpose of dichotomous analysis, we defined depression as a BDI score of 8 or higher, a score designated by the BDI to correlate with moderate or severe depressive symptoms (0–4 is none to minimal depression, 5–7 is mild depression, 8–15 is moderate depression, and 16 or higher is severe depression).10 We calculated descriptive statistics for the point-prevalence of depression, suicidal ideation, and use of mental health services, and used descriptive methods to analyze the barriers to using mental health services.
This study was reviewed and approved by the Human Subjects Committee at the University of California, Berkeley.
Of the 280 students in the target population, 209 were in attendance when we distributed the questionnaire. A total of 194 of the 209 students (93%) returned the questionnaires. The second-year class, however, was undersampled; only 51% of 140 second-year students were in attendance on the day we distributed of the questionnaire. Nevertheless, the demographics of the respondents were representative of the overall class of second-year medical students. The demographics of all respondents (first- and second-year students) were: 57% women, 75% under age 25, 52% Caucasian, 22% Asian American, and 21% underrepresented minorities.
Of the 194 students who responded, 46 (24%) had BDI scores of 8 or higher, indicating the presence of moderate to severe depressive symptoms. Only ten (22%) of the 46 depressed students had used mental health services. Of these, half had used university-based services, while the other half had used services not affiliated with the university.
Table 1 shows the frequencies of the 46 medical students' reported barriers to using mental health services. The most commonly cited barrier was lack of time, reported by almost half of the depressed students who were not using mental health services. More than one third of the depressed students cited lack of confidentiality as a reason for not seeking treatment. In addition, close to a third of the depressed students also cited the stigma of mental illness and cost as reasons for not seeking treatment.
In the free-response section of the questionnaire, the students noted several other barriers, including lack of faith in mental health services, a feeling that stress is normal in medical school, a concern with the limited number (ten) of sessions offered by the counseling services at UCSF, and the belief that the counseling service staff tended to recommend pharmacotherapy without sufficient psychotherapy.
Since non-depressed students may become depressed at some time in the future, we were also interested to see whether non-depressed students perceived similar barriers to using mental health services. To see whether depressed and non-depressed students cited different barriers, we compared the frequencies of barriers reported by the two groups. Although most of the barriers cited by the non-depressed students were the same in level of importance, the depressed students were much more concerned about “lack of confidentiality” than were the non-depressed students.
We also examined suicidal students' rate of using counseling services, since these students are most in need of mental health treatment. Of the 46 depressed students, 12 (26%) had contemplated suicide during their medical school training; only five of the 12 (42%) were receiving treatment for their depression. Suicidal students were 2.8 times more likely than were the other depressed students to report a “fear of unwanted intervention” as a major barrier for seeking treatment.
Twenty-four percent of the first- and second-year students in our survey were depressed by BDI measurement. Only 22% of the depressed students reported using mental health services. This percentage, though similar to treatment rates in the general community,8 is much lower than that found in another study of depressed medical students, which reported a 40% rate of use.3 This difference is difficult to explain, but may represent differences in local cultural attitudes toward mental health services or institutional differences.
To our knowledge, ours is the first study to examine depressed medical students' reported barriers to the use of mental health services, and we document numerous obstacles to treatment. Obstacles reported by more than one third of the students included lack of time, lack of confidentiality, concern that “no one will understand my problems,” the stigma of mental health care, and feeling that “my problems are not important” (see Table 1). Previous work in this area shows that academic jeopardy is an important consideration for medical students seeking care for depressive symptoms.9 Students may be correct in their perception that using mental health services is stigmatizing; it has been reported that students who receive psychological counseling are less likely to secure residency positions.15
When categorized according to the National Depressive and Manic Depressive Association's three main domains for obstacles to treatment8 (patient-based barriers, system-based barriers, and provider-based barriers), system-based barriers were cited most often (see Table 2). An earlier study of student representatives from medical schools across the United States reported a need for greater confidentiality regarding mental health records and also documented that students desired more information regarding mental health services, as well as more preventive services.16
Of the 24% of medical students in our study who were depressed according to BDI measurement, 26% reported suicidal ideation. This percentage is higher than the published prevalence of 15% suicidal ideation for severely depressed patients13 and supports previously published data that indicate medical students have higher rates of depression and suicide than the general population. Although physicians are known to have higher rates of suicide than the general population, our study is the only one we are aware of that reports undertreatment of suicidal medical students—only five of the 12 suicidal students (42%) were receiving treatment. The only other comparable data are from a study of university students that reported about 50% of their suicidally depressed students were using counseling.14
One limitation of our study is that we did not investigate the prevalence of pharmacotherapy, and this may account for a possible overestimation of under-treatment. Use of counseling services, however, may be a fair marker of treatment, since counseling usually accompanies drug therapy. Another limitation of our study is its limited scope; we surveyed students from one school at one point in time. Previously published longitudinal studies reported fluctuating levels of depression, depending on level of training and time of year. One study found a peak prevalence of depression among medical students at the end of the second year of medical school. The level of depression found in our study, however, is comparable to other reported levels and may, in fact, underestimate the level of depression, since we undersampled the second-year students.
The instrument we used in this study, the BDI, measures depressive symptoms and tends to overestimate true depression. Nevertheless, the BDI is a well-validated instrument and has been used in most of the previously published studies of medical students' depression. In addition, for our estimates we relied on the medical students to self-report their use of mental health services. Because of doctor—patient confidentiality, we could not obtain objective measures for use of counseling services for verification.
Depressive symptoms are prevalent among medical students, but few depressed students are using mental health services. Significant barriers to seeking treatment include lack of confidentiality, the stigma of mental health care, and fear of documentation.
We believe that medical schools can address some of these concerns by ensuring that counseling services are confidential, available to all students, easily accessible, and well advertised. Our data also suggest that the point of contact should be separate from the academic affairs and dean's offices and that long-term counseling should be available if necessary.
Adequate treatment of medical students' depression will have important effects on the students themselves, their lives as physicians, and their future patients. Early detection and treatment of depression may help prevent the unnecessary deaths of medical students and prevent the impairment of future physicians.
1. Epstein L, Thomas C, Shaffer J, Perlin S. Clinical prediction of physician suicide based on medical student data. J Nerv Ment Dis. 1973;156:19–29.
2. Clark D, Zeldow P. Vicissitudes of depressed mood during four years of medical school. JAMA. 1988;260:2521–8.
3. Zoccolillo M, Murphy G, Wetzel R. Depression among medical students. J Affective Disorders. 1989;11:91–6.
4. Milagros RC, Ockene IS, Ockene JK, Barrett SV, Ma Y, Herbert JR. A longitudinal study of students' depression at one medical school. Acad Med. 1997;72:542–6.
5. Vitaliano P, Maiuo R, Russo J, Mitchell E, Carr J, Van Citters R. A biopsychosocial model of medical student distress. J Behav Med. 1988;11:311–31.
6. Mosley TH, Perrin SG, Neral SM, Dubbert PM, Grothues CA, Pinto BM. Stress, coping and well-being among third-year medical students. Acad Med. 1994;69:765–7.
7. Seigle RD, Schuckit MA, Plumb D. Availability of personal counseling in medical schools. J Med Educ. 1983;58:542–6.
8. Hirshfeld RMA, Keller MB, Panico S, et al. The National Depressive and Manic-depressive Association consensus statement on the undertreatment of depression. JAMA. 1997;277:333–40.
9. Roberts LW, Hardee JT, Franchini G, Stidley C, Siegler M. Medical students as patients: a pilot study of their health care needs, practices and concerns. Acad Med. 1996;71:1225–32.
10. Beck A, Beck R. Screening depressed patients in family practice, a rapid technique. Postgrad Med. 1972;52:81–5.
11. Stehouwer RS. Beck Depression Inventory. In: Keyser SJ. Test Critiques. Kansas City, MO: Westport Publishers, 1985:83–7.
12. Zich JM, Attkisson CC, Greenfield TK. Screening for depression in primary care clinics, The CED-D and the BDI. Int J Psychiatr Med. 1990;20:259–77.
13. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: APA, 1994.
14. Schweitzer R, Klayich M, McLean J. Suicidal ideation and behaviours among university students in Australia. Aust NZ J Psychiatr. 1995;29:473–9.
15. Oppenheimer K, Miller M, Forney P. Effect of history of psychological counseling on selection of applicants for residencies. J Med Educ. 1987;62:504–8.
16. Plaut MS, Maxwell SA, Seng L, O'Brien JJ, Fairclough GF. Mental health services for medical students: perceptions of students, student affairs deans, and mental health providers. Acad Med. 1993;68:360–5.