F.I., 31, is in her final year at the University of California, San Diego School of Medicine. She’s studying to be an emergency department doctor, and come March 17, or “Match Day,” she and thousands of other medical students across America will find out if they got matched to a hospital residency program after graduation.
F.I. has something else in common with many of her medical school colleagues: She’s struggled with depression and suicidal thoughts. These are issues she’s dealt with since she was 10 years old, but F.I., who asked that we use her initials due to concerns about mental health stigma in her field, said her symptoms got worse when she was applying to medical school.
When F.I. got into a top-20 medical school, she thought her problems were over. But soon, the relentless competition and insecurities about not being smart or prepared enough re-triggered her old depression symptoms.
“I still remember the day I got the acceptance letter,” said F.I. “I was really shocked and I was incredibly happy, and I thought all those feelings of inadequacy would be gone.”
“But then after I started, they all returned, and it’s never-ending,” she continued. “Then you have to apply for residency, and it’s like the same thing all over again.”
F.I. isn’t alone in her struggle, and American medical students aren’t unique in their unusually high rates of depression and suicidal thoughts. A large-scale analysis of 195 studies involving over 120,000 students in 47 countries found that 27 percent of medical students experience depression or depression symptoms, with more than 1 in 10 reporting suicidal thoughts. To put that in perspective, this means that medical students are five times more likely than the general population to have depression.
The study, published this month in the Journal of the American Medical Association, found that, on average, students experienced a 13 percent increase in depression symptoms when they started medical school. Students in both the beginning and later years of their programs were equally at risk, and medical residents, too, face comparably high rates of depression.
How Medical School Raises The Risk For Depression
The study doesn’t delve into why medical students would have elevated depression rates and suicidal ideation. But there are a few possibilities, says Dr. Douglas Mata, a pathology resident at Brigham and Women’s Hospital and clinical fellow at Harvard Medical School who was the study’s senior corresponding editor.
“There are times when she said, like, ‘Some things you say are stupid,’ or ‘You should have already known that' ... She just really thought I was bad, and she made sure I knew it.”- F.I., student at the University of California, San Diego School of Medicine
Medical school is notorious for its long hours, demanding course loads, competitive atmosphere and high rates of stress and burnout. While it’s well-known that this pressure-cooker environment can take a toll on students’ mental health, new research suggests that depression among medical students may be even more widespread than is usually acknowledged.
Lack of sleep is a known risk factor for depression, and students’ chronic sleep deprivation from studying and working overnight shifts at hospitals could increase depression rates, Mata said. Plus, the amount of financial debt that students take on in order to graduate could make them feel mentally and emotionally trapped. Medical students who graduated with debt in 2014 owed an average of $180,000, according to the Association of American Medical Colleges.
“Sometimes people feel trapped by that, because in addition to not having enough money to do everyday things, if, God forbid, you decide that maybe you made the wrong decision and that medicine is not actually what you want to do, you’re pretty much locked in just for monetary reasons,” said Mata. “You really don’t have a choice of quitting and starting anew if you’ve gotten yourself into that much debt.”
F.I. is confident that she wants to become a doctor, but she does identify strongly with all the other risk factors Mata outlined. Her worst bouts of depression occurred during her pediatrics rotation, when she had to work a 30-hour shift every five days, and during a surgery rotation, when she felt her attending supervisor conveyed daily that she didn’t belong in the rotation, in the hospital or even in medical school.
“There are times when she said, like, ‘Some things you say are stupid,’ or ‘You should have already known that,’” F.I. recalled. “She just really thought I was bad, and she made sure I knew it.”
Finally, while she receives financial aid to go to school, the money doesn’t cover F.I.’s everyday expenses like groceries and bills. She is in debt, and to make extra money, she recently started driving for Uber and Lyft whenever her busy schedule allows.
What Schools Are Doing To Protect Their Students
To cope with the pressure on multiple fronts, F.I. took advantage of her school’s free counselors. She found help from professionals she liked and trusted, calling it “one of the best experiences” she’s ever had in her life. But when a friend and fellow medical school student committed suicide in 2015, she found herself fantasizing about death as a type of freedom or escape. That’s when F.I. realized she needed to start seeing a psychiatrist, who then went on to prescribe her antidepressant medication.
Too many students like F.I., as well as full-fledged doctors, are struggling with med school and hospital life. An estimated 300 to 400 doctors commit suicide every year, and the medical profession is scrambling to come to terms with how to change so it can protect physicians from this risk.
F.I. feels she is now getting the help she needs. While she still struggles with depression symptoms, she’s looking forward to Match Day and enjoys spending time with her patients.
Some schools provide mental health services through their psychiatry departments and others offer free counseling for students, but these programs assume that students will seek help, and they may not be enough to address the structural features of medical school that increase depression. For instance, Mata’s meta-analysis found that only 16 percent of the students who screened positive for depression sought treatment.
Examples of institutional change, on the other hand, include Saint Louis University School of Medicine’s recent decision to adopt a pass/fail system and reduce class time by 10 percent, which resulted in improved academic performance and fewer students reporting symptoms of anxiety and depression.
While Mata says that it’s a good sign more medical schools are taking the mental health and well-being of their students seriously and offering services like free counseling, yoga or mindfulness meditation, institutions need to take a more structural approach to change.
“Both of these things put the onus on the student, and I don’t think get to the root causes of depression, which are more system-based issues,” he said. “There are a couple of big changes that can be made.”
The Culture Around Mental Health Needs To Change
There are certain deeply ingrained aspects of medicine culture that make it difficult to fix this problem, Dr. Stuart Slavin argues in an editorial also published in JAMA.
“If you meet criteria for major depressive disorder, you shouldn’t stay home, dig your heels in and try to tackle it on your own.”- Dr. Douglas Mata
“The first is the belief by some that medicine is a demanding profession and, therefore, medical school should also be extremely rigorous and demanding. If students are not ‘strong’ enough to handle the stress, then they should probably seek another profession,” wrote Slavin, who is the associate dean for curriculum and a pediatrics professor at Saint Louis University School of Medicine. “A second aspect of medical culture is that mental problems ordinarily have not been taken as seriously as physical problems.”
Mental illness stigma is particularly rampant in the medical community, Slavin suggests, and likely prevents students from seeking help.
Mata hopes that his study and similar research serve as a wake-up call for both medical schools and medical students. Just as a person with an infection would go to a doctor for antibiotics, or a person with diabetes would take a pill or insulin, people with depression should seek medical treatment, he concluded.
“If you meet criteria for major depressive disorder, you shouldn’t stay home, dig your heels in and try to tackle it on your own,” Mata said. “You should go see somebody, because both medication and therapy are equally effective, and it’s not a sign of weakness for people to get treated for their illness. It’s an illness just like any other.”