Depressive symptoms and suicidal ideation in medical students continue to be common, and these negatively impact personal and professional life, potentially leading to substance abuse, resignation from medical school, and, in extreme cases, suicide.1 The common stressors for medical students—almost pathognomonic of a highly charged academic environment—include pressures to perform well academically, occasionally difficult relationships with faculty, patient and clinic responsibilities, personal life issues, and struggles to develop a professional identity.2 In recent multisite studies, 22% to 49% of medical students reported depressive symptoms; the highest rates were among women and minorities.3,4 Furthermore, one of these recent studies reports suicidal ideation in 7% of medical students.4 Tragically, suicidal ideation and depressive symptoms can lead to attempted and completed physician suicides.5 Surprisingly, few published articles report either interventions for, or outcomes of, improving mental health in medical students.6 Research suggests that medical students are interested in addressing these issues; for example, an anonymous online mental health forum for medical students received 100 postings and over 1,000 hits during a 10-day trial.7 Similarly, a voluntary stress management program at another medical school has had a mean participation rate of 94% for 16 years.8 Despite some successes such as these, stigma surrounding mental health continues to be a barrier to treatment.6 Even after medical students take exams on the appropriate use of empirically supported depression diagnoses and treatments, they are unlikely to apply this knowledge to their own mental health.9
We measured depressive symptoms in third-year medical students (class of 2003) at John A. Burns School of Medicine (JABSOM) and found alarmingly high rates of reported depressive symptoms and suicidal ideation. In response, we instituted a treatment intervention comprising individual counseling, faculty education, and a specialized curriculum that includes lectures and a student handbook. We followed this intervention with postimplementation depression assessments, which were part of a larger multisite assessment,4 of the following third-year class (class of 2004). We initiated the multisite study, which included five additional Association of American Medical Colleges–affiliated schools, in part, to allow us to examine whether the high rates of depression and suicide ideation among third-year students at JABSOM were a reflection of national trends, particularly at minority-serving institutions.
In April 2002, we asked the third-year medical students (class of 2003) from the University of Hawaii JABSOM to complete the 20-question Center for Epidemiologic Studies Depression Scale (CES-D)10 and to answer a single question about suicidal ideation. The question derived from the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire (PRIME-MD).11 The response to the suicidal ideation query on this initial pilot (see Results) emphasized the need for intervention (see Program Changes) and led to our replication of the study. Thus, in the spring of 2003, we repeated the student study, administering the same two instruments, with the next class of third-year medical students (class of 2004).
Both years, we administered the anonymous surveys during colloquia, a mandatory monthly meeting for third-year medical students. We asked the students to sit apart, consistent with usual test-taking arrangements. Cover letters described the project, solicited participation, and provided students with a means to shield their answers for added privacy (the cover sheet also contained contact information should the student want to seek immediate psychiatric counseling). After completing the forms, participants placed them in a box and received a snack in appreciation for returning the survey. The colloquia facilitator sent the sealed envelopes containing the forms to the primary investigator (D.T.).
The institutional review board (IRB) at the University of Hawaii approved both the initial and follow-up study. Given the anonymous nature of the study, the IRB did not require documentation of informed consent.
Previous studies have demonstrated the validity and reliability of the CES-D in both nonclinical samples and multiethnic groups, making it appropriate for screening for depressive symptoms (the CES-D does not measure clinical depression). We applied standard CES-D cutoff scores: no depression (CES-D <16), mild to moderate depression (CES-D between 16 and 21, inclusive), and probable major depression (CES-D >21). The suicidal ideation question derived from PRIME-MD asked students to rate the frequency of “Thoughts that you would be better off dead or of hurting yourself in some way” over the past week on a 4-point scale from 0 to 3. We scored the suicidal ideation answer as a dichotomous variable—either 0 (not at all) or 1–3 (several days to nearly every day).
We analyzed the data using Statistical Package for the Social Sciences, Version 18 (Chicago, Illinois).
Givens and Tjia12 identified barriers that keep students from obtaining mental health treatment including lack of time, fear of compromised confidentiality, stigma, cost, fear of documentation on academic record, and fear of unwanted intervention. We felt that we could reduce some of these barriers by reducing stigma through increasing faculty and student awareness and education, offering full confidentiality, and providing services at no or greatly reduced cost.
In 2002, we presented the initial findings (of our 2002 survey; see Results) at a faculty meeting, and we reviewed the symptoms of depression with faculty. Each year since, we have continued to review these basic tenets with the faculty, and we encourage faculty to maintain a low threshold for asking students about depression. This yearly mandatory faculty meeting occurs at the beginning of the new school year during first-year orientation. In addition to a 30-minute primarily didactic presentation, faculty have an opportunity to ask questions and receive individual coaching. The presentation includes both a general review of medical student risk factors (e.g., sleep deprivation, isolation, difficult academic workload) and a discussion of—as enumerated in the student well-being handbook—depressive symptoms (e.g., not smiled in a few days, less motivated, changed appetite and/or sleep). Additionally, psychiatry faculty present different scenarios that medical school faculty may encounter and offer suggestions for appropriate responses. Faculty education includes suggestions and even coaching on how to talk one-on-one with a student expressing symptoms of depression; for example, faculty learn to acknowledge the depression and give the student permission to feel depressed. A faculty member might say, “It must be difficult for you, but I'm here to support you.“ We also iterate to faculty that they have the option of notifying the dean of student affairs, who may then contact the student, and we emphasize the importance of maintaining an atmosphere in which students feel comfortable sharing their concerns with faculty.
Faculty again informally discuss student depression when they review the results from the Graduating Student Questionnaire at the completion of the academic year.
Medical student counseling.
We enhanced two resources for individual therapy for students: university and private practice counselors. Faculty from the JABSOM Department of Psychiatry coordinated treatment. Psychologists, psychiatrists, and master-level counselors staff the University Counseling Center, the services of which are confidential and free of charge (usually limited to 12 sessions). In addition, the Office of Student Affairs maintains a referral list of community psychiatrists not affiliated with JABSOM and not involved in teaching or assessing students who have agreed to see medical students at the rate of $25.00 per session without supplemental funding.
Medical student education.
Directly after we reported the results of the first (2002) survey, the Office of Student Affairs wrote a student well-being handbook. We distributed the handbook to all upperclassmen as well as to first- and second-year students. Each chapter focused on 1 of 24 topics (each a common stressor for medical students) and included a self-assessment, a list of coping strategies, contacts for questions/concerns, and advice from upperclassmen. The topics ranged from dealing with relationship stressors, maintaining a life outside of school, and recognizing depression, to dealing with stress and test anxiety, maintaining physical health, and managing financial stressors. In addition to providing students with the wellness handbook, we added an hourlong, primarily didactic discussion of the risks of depression to orientation (during the first year) and to the beginning of the third year—both critical times that, according to research, are particularly challenging for medical students.13 During both of those sessions, the director of student affairs, who leads the discussions, encourages students to seek counsel for any symptoms of concern either from the director of student affairs him/herself or from another source (e.g., the clerkship director, the counseling center on campus, or a primary care physician). The director of student affairs also invites the first-year students to participate in a program called “Healer's Art”; the JABSOM program follows the outline of the national program, including large- and small-group discussion of the following topics: Discovering and Nurturing Your Wholeness, Sharing Grief and Honoring Loss, Allowing Awe in Medicine, and The Care of the Soul.14 This course allows students to explore ways to find and maintain joy and meaning in their careers. Attendance has steadily increased at the medical school and now includes one-third of the first-year class each year.
Of 58 third-year students in the preimplementation group (the class of 2003), 44 returned surveys for a 75.9% response rate. The response rate for the postimplementation group (the class of 2004) was 93.5% (58 out of 62 third-year students). In the preimplementation group, 43 students (97.8% of 44) responded to the suicidal ideation item, and in the postimplementation group, only 33 students (56.8% of 58) responded.
The initial scores on both the CES-D and the suicide ideation query were concerning. Three out of five students (n = 26; 59.1%) reported symptoms of mild to probable depression, and nearly one in three students (n = 13; 30.2%) reported suicidal ideation (Table 1). To address the problem highlighted by these alarming results, JABSOM decided to implement the three-pronged approach, involving faculty, students, and the counseling service outlined above.
After one year of exposure to the newly implemented approach (i.e., a discussion at the beginning of the school year, heightened faculty awareness, and receipt of the well-being handbook), the rates of depressive symptoms and suicidal ideation in the next third-year class (class of 2004) were markedly lower. Only one in four students (n = 14; 24.1%) described symptoms of mild or probable depression, representing a significant decrease from the previous year (χ2 = 12.84, df = 2, P < .01). Only one student (3%) reported suicidal ideation, representing a 10-fold decrease (χ2 = 13.05, df = 1, P < .001).
We do not have any data regarding the number of students who received counseling because such data are confidential. We are not aware of any suicide attempts at the medical school since the implementation of the study in 2002.
This study showed that a straightforward yet comprehensive program could successfully effect a significant and marked decrease in reported depressive symptoms and suicidal ideation. Given the simplicity of the intervention, such dramatic results (a 10-fold drop in suicidal ideation and a 35% drop in depressive symptoms) are surprising; nonetheless, these were indeed our findings.
Since the original study in 2002, we have made minor additions to the handbook, providing new sections on topics such as “being a husband or wife in medical school” and “issues related to gay and lesbian students”; however, the basic tenets remain. A new, additional lecture series concerning mental wellness, begun in 2007, is now an important aspect of the curriculum, and understanding personal health and well-being has, since 2003, been one of seven key objectives for graduation.
While the overall rate of depression and suicidal ideation for third-year students reported in the 2003 multisite study was higher than that noted in the initial 2002 assessment of JABSOM students, there were significant differences by site: The 2003 results from JABSOM were within the range of reporting for third-year students among all sites,4 and JABSOM's 2003 rates were significantly lower than those from the previous year (2002).4 Additionally, the scores noted in the 2003 multisite study reported overall means and not the means of individual sites; the discrepancy between the 2003 overall rates and JABSOM's 2002 rates is likely due to intersite variability.
Although counseling has always been available to the medical students at JABSOM, either through the university service or in the form of faculty encouraging students to see a private physician or an assigned psychiatric faculty member who would be the liaison for services, this project marked the school's first comprehensive plan. Both faculty and students received education for improving their recognition of depression. We theorize that improved recognition of depression accounted for the decrease in reported symptoms post intervention. We suspect that awareness leads to treatment, which in turn leads to decreased symptoms and fewer incidences of suicidal ideation.
Our study had some weaknesses. Because of marked differences pre- and post implementation, the question of differences between the two classes of medical students arose. Overall, we marked no notable differences between the preimplementation class (class of 2003) and the postimplementation class (class of 2004) either nationally or at JABSOM. Because JABSOM is the only medical school in the state, 90% of its students are consistently from Hawaii. Further, the average age of first-year students nationwide and in Hawaii is 24 years. No changes in the curriculum (other than those described) or course load between the two study years could have improved medical student mental health. Our study also had a unique strength: It focused specifically on third-year medical students. Most studies include medical students from all four years of medical school, but some research shows that rates of anxiety, attentional disorders, and depression peak in the third year and then drop during year four.13
The faculty met with this original study cohort (class of 2003) to discuss their scores and to provide information on accessing confidential treatment shortly after these students completed the survey but before they began their fourth year. Repeating the CES-D with this original cohort would have been ideal; however, so few fourth-year students completed the survey the following year (many were completing off-site and off-island rotations) that using the survey results was not possible. We believe the similarly low response rate among fourth-year medical students in our 2003 multisite study was also a result of fourth-year students completing off-site rotations. Furthermore, as mentioned, research shows that the rates of depression levels and suicidal ideation are lowest among fourth-year medical students and interns, so we would not have been able to discern whether any decreases in rates of depression or suicidal ideation were a result of a natural buoyancy from year 3 to year 413 rather than our intervention. An important future study would be to have a longitudinal investigation looking at the same cohort of medical students during training. We are hoping to do a follow-up study on this original cohort of students (class of 2003) as they are currently completing residency training and starting practice.
Another weakness was the unexplained drop in response rates to the suicidal ideation question in the postimplementation group. Conjecturing whether or not the individuals who did not respond would have endorsed suicidal ideation if they had recorded an answer is impossible; however, lower scores on the CES-D in the posttreatment group might imply otherwise as scores above 16 and endorsement of depressive symptoms are more likely to be associated with suicidal ideation.15,16
Although we were not able to track the number of students treated by the counseling center pre- and post-program implementation, the medical school faculty did anecdotally report that they referred more students. These increased referrals were in large part due to a heightened awareness by the faculty. Referrals, student education, and faculty education are all possible factors that may have contributed to the lower rates of postimplementation depression. However it is possible that the improvement reflects regression to the mean, which is more common in naturalistic studies than in randomized controlled trials. Also, there is the possibility that some students might have been even more hesitant to report depressive symptoms once the intervention was in place. We did take additional measures to ensure anonymity with the survey: Students sat at intervals and had a cover sheet which they could use to place over the surveys so that they could complete and submit these without fear that their classmates or faculty would see their answers.
Despite documented concerns over privacy issues,17,18 fear of lost privacy did not manifest as a major barrier to seeking treatment. Specifically, we anticipated that students would not want evidence of psychiatric treatment listed on their health records, but they did not seem to worry about recorded psychiatric treatment: The director of student affairs in 2003, Dr. Sakai, and the current director, Dr. Antonelli, noted that no student expressed such a concern (personal communication, February 23, 2010).
In conclusion, the development of multipronged programs designed to support the emotional health of medical students is an effective and important addition to medical school curricula. Such an intervention led to a culture change at JABSOM regarding student mental health. Before the intervention, the faculty had not emphasized the importance of student wellness. Faculty eagerly agreed to the initial meetings based on the startling findings of the first set of surveys. Faculty were very supportive once they became aware of the issue, and they discussed the issues of depression and suicidal ideation that they remembered from their own medical school and residency experiences. These memories of their own experiences and the stories of their colleagues' experiences clearly increased their willingness to participate in developing and implementing the new student wellness plan.
The main challenge, not due to any specific roadblock, is continually keeping mental health at the forefront of the medical school program. The yearly discussion is helpful, and the data from this study have acted as an impetus for new programs. Most recently, the JABSOM Office of Student Affairs, in collaboration with the University Counseling Center and the Developmental Center, hired a counselor who will be on-site at the medical school. We hope that the presence of this counselor will be another resource for medical students, further reducing their inhibitions about approaching faculty with their mental health concerns and encouraging them to make mental wellness a priority for the rest of their lives.
The authors would like to thank Dr. M. Antonelli, Dr. A. Guerrero, Dr. R. Kasuya, and Dr. D. Sakai at the University of Hawaii John A. Burns School of Medicine (Honolulu, Hawaii). They were instrumental in working with the authors to implement the interventions.
The Queen Emma Research Fund at the Queen's Medical Center supported this project.
The internal review boards at the University of Hawaii and the Queen's Medical Center approved this study.
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