Letters to the Editor
Dr. Hubbeling highlights the need to make a distinction between depressive diagnoses and their symptoms. The Center for Epidemiologic Studies Depression Scale (CES-D), which she discusses, is an excellent screening measure, assessing depressive symptoms developed in nonclinical populations. While it has been shown to predict major depression and dysthymic disorder, it is not a diagnostic measure. In our medical trainee project, we also administered the Primary Care Evaluation of Mental Disorders (PRIME-MD), a tool based on DSM-IV criteria. We found that 2.8% of medical students and 3.5% of residents met DSM-IV criteria for major depression (data unpublished), substantially fewer than identified as “probable depression” using the CES-D. Because the DSM-IV criteria (as Dr. Hubbeling points out) cast an overly wide net for diagnosing depression, we are all the more encouraged by the PRIME-MD finding, even though the PRIME-MD cannot substitute for a clinical interview. But no matter which screening measure is used, and even though not everyone reporting high levels of symptoms has a diagnosable depressive disorder, those individuals who do report high levels are suffering and may benefit from intervention. Given the symptom rates among medical trainees, we feel it is important to regularly screen for depression and to make mental health resources available.
Drs. Dyrbye and Shanafelt also make good points about the need to identify suicidal ideation and to be aware of burnout among medical trainees. Collectively, this emphasizes the importance of students' maintaining their health and well-being in medical school. At our program, these are key domains of the educational program. Our medical student graduates must adopt strategies to cope with the risks, stresses, and forms of impairment encountered in medical training. There are also environmental factors that can improve well-being such as work hours, rotation schedules, and consistency between modeled behavior and trainee expectations.
The roots of suicide are multifaceted. Depression is only one potential contributing factor. Physical, emotional, and financial stress; anxiety; burnout; relationship difficulties and the inability to balance personal and professional life; inability to meet patient expectations or deal with patient suffering and death; poor coping skills; and substance misuse are just some of the experiences that may play a stressing role in the lives of medical trainees. We encourage programs to take a comprehensive approach to fostering and promoting well-being among their medical trainees.
Deborah Goebert, DrPH
Associate professor and associate director of research, Department of Psychiatry, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii; (firstname.lastname@example.org).
Junji Takeshita, MD
Associate professor and associate chair of clinical services, Department of Psychiatry, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii.