Depression Med School

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NEW ENGLAND JOURNAL

MEDICINE

n engl j med

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it was a big problem,” he said.“People were feeling isolated.”So Kansagra came up with an in-novative way to provide emotionalsupport to depressed students while shielding their identities.With the help of Caroline Haynes,Duke’s associate dean for medicaleducation, he arranged an onlineforum to give students a safe placeto talk and to help them “realizethey aren’t alone and that thereare a lot of resources available.”Students posted messages anony-mously. Although the postings were reviewed by a psychiatrist inDuke’s student counseling service,the administration was not privy to the forum, which received morethan 100 postings and more than1000 hits during its planned 10-day existence in April 2005.According to Kansagra, “peo-ple had a lot to say about fight-ing with depression and [feeling]that medicine in general seesmental illness as a weakness andnot an actual disease. People felt the need to hide it . . . because weare taught that we are the healersand not the ones with problems.”The pilot project led to open dis-cussions about mental health, andin the subsequent week, Haynes,a psychiatrist, made two referralsfor depression counseling. “This was a fabulous first step,” shesaid. “People felt that their con-cerns were normalized and vali-dated. . . . It started a conversa-tion that many people are hesitant to start.”Medical students are moreprone to depression than theirnonmedical peers. Researchersrecently surveyed first- and sec-ond-year medical students at theUniversity of California, San Fran-cisco (UCSF), and found that about one fourth were depressed.

Others have suggested that al-though the rate of depressionamong students entering medicalschool is similar to that amongother people of similar ages, theprevalence increases dispropor-tionately over the course of medi-cal school.

Laurie Raymond, apsychiatrist and the director of the Office of Advising Resourcesat Harvard Medical School in Bos-ton, said that she met individu-ally with 208 medical students — about one quarter of the student body — between July 2003 and July 2005. Thirty-one students(15 percent) presented with self-described depression — 20 of them with transient, “reactive”depressed mood that improved with supportive counseling ortherapy and 11 who had a history of major depression. The majority (130 students) consulted Raymondbecause of concern about aca-

White Coat, Mood Indigo — Depression in Medical School

Julie M. Rosenthal and Susan Okie, M.D.

s the head of student government at Duke Uni- versity School of Medicine in Durham, NorthCarolina, Sujay Kansagra had witnessed several of his fellow students dealing with depression. “I knew

september 15, 2005

Perspective

PERSPECTIVE

n engl j med

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demic performance, but major de-pression was diagnosed in 25 of them. A fourth-year medical stu-dent at Harvard estimated that three quarters of her close friendsin medical school have taken psy-chiatric medications at some point during the four years.Depression not only affectsstudents’ lives but may also haverepercussions for patient care inthe long run. Jennifer Tjia, an in-structor in internal medicine at the University of PennsylvaniaSchool of Medicine in Philadel-phia, believes that many practic-ing physicians are afraid of beingtreated for depression and there-by revealing that they have thecondition. But “if people don’t know how to treat their own de-pression, it has a negative im-pact on how they treat patients,”Tjia said.Why does being a medicalstudent increase the risk of de-pression? Raymond believes that students’ coping strategies andpersonal health deteriorate asthey progress through medicalschool. Students “see themselvesgoing into a very narrow tunnel,”she said. “A lot of the depression we see halfway through the [first] year — it’s a reaction to havingconstricted themselves down tostudying these subjects in a very intense way. It’s pretty unidimen-sional.”Symptoms of depression inmedical students can be difficult to distinguish from the effects of the stress inherent in student life.Students often dismiss their feel-ings of despondency as a normalemotional response to medicalschool, where they live from test to test and don’t take time forthemselves.“It’s hard to ask about depres-sion in medical students, because you ask about sleep, and all med-ical students aren’t sleeping,” ex-plained Angela Nuzzarello, a psy-chiatrist and dean of students at Northwestern University’s Fein-berg School of Medicine in Chi-cago. “They are overwhelmed,they are working hard, and they aren’t having fun socially. . . .Of course they are fatigued.”The emotional and academicchallenges involved in becominga physician wear on students.Their initial encounters with ill-ness and death may unmask psy-chological vulnerabilities. Suchencounters often resonate withunresolved episodes of loss ortrauma in the student’s past orcome as a shock to those whohave had little experience withdeath. The treatment of death asa part of the daily routine may ap-pear cold and calculating to stu-dents, who may fear becomingemotionally detached. Some be-come overwhelmed by the emo-tional toll of caring for others.For students who have beenlifelong achievers, getting a me-

white coat, mood indigo — depression in medical school

M a l e F e m a l e W h i t e A s i a n H i s p a n i c B l a c k O t h e r F i r s t S e c o n d T h i r d F o u r t h H e t e r o s e x u a l H o m o s e x u a l o r b i s e x u a l Y e s N o

100908070605040302010

P e r c e n t a g e o f M e d i c a l S t u d e n t s

SexRace orEthnic GroupMedical SchoolYearSexualOrientationHistory of Depression

Students whoreceived treatmentStudents who did notreceive treatmentStudents who wereclassified as depressedStudents who were notclassified as depressed1751476208622917807475933129242980100908070605040302010

P e r c e n t a g e o f D e p r e s s e d M e d i c a l S t u d e n t s

O v e r a l l M i l d - t o - M o d e r a t e D e p r e s s i o n S e v e r e D e p r e s s i o n S u i c i d a l I d e a t i o n N o S u i c i d a l I d e a t i o n

494271039

Rates of Depression among Medical Students (Panel A) and Treatment of Depressed Medical Students (Panel B).

Data in Panel A are for 322 medical students who responded to a questionnaire; data in Panel B are for the 49 medical students whose responsesto the questionnaire indicated that they were depressed. Treatment consisted of counseling, antidepressants, or both. Total numbers (given in thebars) reflect the numbers of students who replied to the relevant question. Data are from Tjia et al.

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diocre grade on an exam often isshocking. As a fourth-year student at Vanderbilt University School of Medicine in Nashville put it, “Thetransition from college to medi-cal school [is] definitely an eye-opener . . . especially if your ac-ademic performance isn’t up topar. If you get C’s on your first set of tests, I can see that it wouldbe easy to get depressed.” At theend of his second year, this stu-dent lost 15 or 20 pounds. “Ret-rospectively, I can say I was clini-cally depressed,” he said, “but at the time it was just one of thoserough things.” He never sought treatment, he added, because “asa medical student, you are sup-posed to just deal with it.”It is unclear whether there hasbeen a recent increase in depres-sion among medical students or whether greater awareness of mental health issues has simply led to increased recognition of the phenomenon. Nanette Gar-trell is an associate clinical pro-fessor of psychiatry at UCSF whohas treated many medical stu-dents and physicians for depres-sion during 25 years of privatepractice. She said that in recent years, “[we] are seeing more stu-dents, because we have somemore efficient pharmaceuticaltreatments.” Students know that selective serotonin-reuptake in-hibitors (SSRIs) can make themfeel better much more quickly than psychotherapy or older class-es of antidepressants could. Gar-trell added that virtually all thedepressed physicians she seeshave self-medicated with an SSRIbefore consulting her.In addition, both Haynes andRaymond noted that many morestudents than in past decades areentering college or medical school with previous diagnoses and treat-ment for mental illness. WhenBlue Cross asked Duke for a pre-mium increase in their student health insurance policy recently,Haynes and others reviewed thepolicy for the university as a whole. They found that three of the top five medications that theplan was covering were new anti-depressants.Students may become de-pressed at any point in medicalschool, but Gartrell has foundthat the period of greatest dis-tress occurs during the third andfourth years, when students rotatethrough the hospitals and clinics.“In the clinical years, there’s just far greater commitment of time,plus as match pressure begins toemerge, it’s an extremely stress-ful time for a lot of people,” shesaid. Students are often separat-ed from friends and classmatesand must work with a constantly changing set of residents andattending physicians, which con-tributes to their sense of isola-tion. Gartrell said that many of the female students she sees are worried that the mounting de-mands of training and clinicalpractice will not allow them timeto find a partner, marry, and havechildren. Haynes noted that theincrease in sleep deprivation dur-ing rotations may also exposemood disorders.The Harvard medical student mentioned above recalls that hermood took a downturn duringher third year. The pressures of school were building, and medi-cine was not turning out to be what she had expected. She be-gan to think, “Man, this life isn’t exactly what I imagined it wouldbe, and now I’m stuck and haveall these debts. I don’t like what I’m seeing in the hospital; that’snot how I want to practice medi-cine.” She found herself disillu-sioned by the long hours, thecompetition among students anddoctors, and the lack of time forreally caring about, and not just for, patients.As they begin to treat sick pa-tients, depressed medical studentsusually become even more reluc-tant to admit that they are not well themselves. Northwestern’sNuzzarello said that “even thoughthey know about depression, [stu-dents] don’t recognize it often inthemselves. . . . That’s part of the psychology and the denial: if I’m going to be a doctor, I’ve got to be well.”One medical student who took antidepressants told friends that she felt guilty about needing them.Such guilt is common among de-pressed medical students, since,according to Penn’s Tjia, the stig-ma associated with treatment isstrong. “One of the problems stu-dents have in getting help . . . isa tremendous fear that it will go

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