Sujay Kansagra, MD'06, helped to launch an online forum in 2005 for Duke medical students to share health concerns.

by Jim Rogalski

The intro hits like a hard slap to the face: “Depression among medical students is a serious problem.”

That's how authors of an article published in the journal Academic Psychiatry introduced a piece about higher rates of depression and suicide among medical students nationally when compared to other student bodies and the general population.

“I think everyone is concerned,” says Caroline Haynes, MD'79, PhD'83, HS'84-86,'87-'89, an assistant clinical professor with the Duke Department of Psychiatry and Behavioral Sciences and associate dean for medical education. “At many national meetings there are sessions on how to recognize psychiatric difficulties in students.”

At Duke, efforts have been ratcheted up to educate medical students about warning signs in themselves and their classmates, and to stress the importance of seeking help—something medical students nationwide traditionally are reluctant to do out of fear that a mood disorder diagnosis may somehow crimp their residency or career options.

Medical students at Duke, though, seem a bit more willing to talk about their psychological health concerns.

“As physicians and medical students, there is often an unrealistic expectation that we should be completely healthy, both physically and mentally.” - Sujay Kansagra, MD'06

Haynes and colleagues anonymously polled last year's second-year class after their clerkships were over, and found that “the majority of the class said they became seriously depressed or demoralized during the year.”

Only one-sixth of respondents, however, endorsed the statement “my psychological health during this year suffered extremely.” The majority, she says, indicated their psychological health concerns were intermittent and they expected to fully recover.

In early 2005 student Sujay Kansagra , MD '06, was so concerned about what he saw as a high rate of depression in his classmates that he partnered with Haynes to launch a 10-day online forum where Duke medical students posted anonymous comments and questions about what they were dealing with emotionally. Duke administrators were not privy to the forum, but postings were reviewed by a psychiatrist at Counseling and Psychological Services (CAPS) who offered direction for seeking help.

Free Physician "Life Support" Material Available. Click here.

“It was a safe place for students to get together and chat,” Kansagra says, “and a way to show them what resources are available. We didn't want this to be a forum where people get psychiatric advice. It was to show medical students that they were not alone in dealing with depression and anxiety, and that it's O.K. to seek help.”

There were more than 100 different posts to the forum, which received more than 1,000 visits during its 10-day run. Haynes says she referred two students for counseling who came to her after the forum was open. “They felt more comfortable seeking advice and help as a result of encouragement from their peers through the forum,” she says.

Most importantly, the forum brought the issue of medical student depression out of the shadows and proved enlightening for all involved. It was a springboard for Duke to boost efforts to educate medical students about depression, and emphasize that confidential help is available.

“As physicians and medical students, there is often an unrealistic expectation that we should be completely healthy, both physically and mentally,” Kansagra says. “So unfortunately, someone suffering from depression may consider this a weakness. It is important to realize that people in medicine are not immune to these issues.”

By the Numbers

Roughly 12 percent of the national medical school population suffers from “serious”depression in which treatment should be sought, studies conclude, compared to roughly 4 percent of the general population.

The problem with not addressing the condition is that some students carry their untreated depression into their professional lives, which is partially responsible for the higher rates of physician suicides when compared to the general population.

For physicians, suicide is higher for females than for males, according to a 2003 article in the Journal of the American Medical Association.

In the last 10 years there have been two medical student suicides at Duke. As Kathy Hollingsworth, director of CAPS points out, suicide is not always linked to depression.

“It's important to remember that only a small percentage of depressed individuals ultimately commit suicide,” she says.

Haynes says accurate numbers for medical students are difficult to get because this group of hard-working high achievers are reluctant to acknowledge to themselves or to others that they are suffering from depression.

“I've seen recent estimates that perhaps 25 percent of college students become depressed while in college and the rates of antidepressant medications among college students is very high,” she says.

Last year a total of 70 Duke medical students—or 15.4 percent of the medical student body—sought counseling at CAPS for stress, depression, and other concerns.

“Students will come in and acknowledge having anxiety about something,” says Hollingsworth, “school work, grades, relationship problems, or clinical performance. But what they really are talking about is fearing for their future. They may feel that everything they have worked for their entire life is going down the tubes.”

The Causes

The two periods in medical school that are most likely to spur an onset of depression, according to studies and observers, are the first year and the clinical year, which at Duke is the second year.

First-year students may have come from the top of their class in undergraduate school and suddenly find themselves in a sea of equally or even more talented peers in a highly competitive environment.

“Suddenly they are just a banana in a bunch of bananas and the workload is very intense,” Kansagra says. To some it feels like going into a whole new world. They are extremely busy and their social lives can fall to the wayside. “It is not unusual for students to spend a great deal of their time worrying about grades and doing well,” he says.

Hollingsworth says medical schools in general possess a variation of the “boot camp mentality” in which there is a lot of emphasis on performance and a fear of showing vulnerability.

“Think about it,” she says, “They've always been at the top of their class and then suddenly someone has to be average and none of the medical students are accustomed to being average in any sense of the word.”

In any population, Haynes says, prolonged stress and sleep deprivation can be provocative for people who are susceptible to becoming depressed, “and medical students certainly are stressed and probably more sleep-deprived than many of their peers.”

With added pressure to succeed coming from family and former teachers who have a vested interest in the student's talents, Hollingsworth says, the stakes go up. Add to the mix a personal loss such as the death of someone close, a broken relationship, or alcohol—which Hollingsworth says is common among medical students as a “quick fix” for emotional struggles—and a student can spiral out of control. The tricky part for counselors, faculty, and staff, she says, is that medical students “are so smart and competitive they know how to perform. It's not until they confide in you that you learn (some) are walking away from social interactions and feeling like failures.”

For some students the clinical year can be an emotional roller coaster filled with doubt. Some students will discover that medicine is not what they thought it would be and will find themselves feeling lost. Haynes says others will have their basic optimism or even spiritual beliefs challenged in the face of witnessing the suffering and misfortune of their patients. Long hours, lack of sleep, and lack of positive feedback can conspire to bring on despondency and feelings of failure.

“While on the wards, feelings of inadequacy as a medical student are not uncommon,” Kansagra says. “And you can feel isolated from your peers.”

Barriers To Help

Fear of being stigmatized or somehow denied career advancement if they admit to having any sort of mood disorder is a major problem and the primary reason more students don't seek help, according to Haynes.

“We attract a group of extremely successful, high-achieving people,” she says. “They have received the message in this culture that you must groom yourself for years to get the right opportunity, and they are not about to trust that if they divulge a problem or what they consider a weakness in this intensely competitive environment, it might not harm their chances of some future opportunity.”

Some medical students have an idealized image of the profession and self, seeing themselves as helpers, not those in need of help, Hollingsworth says. For many it is hard to admit that they have a problem. Some of those who do admit to needing help are not sure where to go, she adds.

“They are embarrassed or concerned about confidentiality. They may not accept medications because they don't want it on their insurance record” for fear that a licensing board down the road may reject them.

That fear is unfounded, Haynes says.

“While it may be uncomfortable to disclose, people don't lose or not get jobs because of well-treated health concerns of any kind. In fact, that sort of discrimination is now illegal.”

Haynes stresses to students that their success as a healer greatly depends on their ability to keep themselves physically, mentally, and emotionally in shape, and Duke has an action plan in place to help students do just that.

How is Duke SOM Helping?

At new student orientation, Haynes and Hollingsworth address the students with a poignant two-pronged message. Haynes tells them the very nature of medical school makes them vulnerable to stress, which can lead to a variety of illnesses including depression, anxiety, substance abuse, eating disorders or Post Traumatic Stress Disorder. If they choose not to seek help it is likely their academic, personal, and professional lives will suffer.

Hollingsworth's message is equally direct: All therapy at CAPS is confidential, and help is available 24 hours a day.

“We encourage students to talk to their advisory deans or other faculty members if they are troubled, feel mistreated, or have lost their sense of purpose in being in medical school.” - Caroline Haynes, MD'79, PhD'83, HS'84-'86, '87-'89

In a letter to students last year, Haynes wrote that “there is an absolute firewall between CAPS and the school…and records never appear anywhere except at CAPS.”

They also educate students on how to recognize warning signs of stress and depression in themselves as well as in their classmates, and how to get help for a friend.

“It boils down,” Hollingsworth says, “to being able to transcend the social prohibition and say out loud, ‘you don't look right. Are you OK? '”

Ultimately, the duo tells the class, students will be evaluated on their performanceso staying in good health by eating well, getting exercise and adequate sleep, and spending time with friends in positive social settings, will help them to succeed in class, in the clinics, and in their personal lives.

Haynes wrote in the letter to students last year that “well-treated mental health issues are not going to stop you from getting a license, but not taking care of them and having behavioral problems related to them can.”

Each Duke medical student is assigned to an advisory dean who follows them throughout medical school. First-year students meet with their advisor weekly in small group lunch meetings, and then monthly during their second year.

“We encourage students to talk to their advisory deans or other faculty members ifthey are troubled, feel mistreated, or have lost their sense of purpose in being in medical school,” Haynes says.

The advisory dean program was started in 1987 by then Dean of Medical Education Doyle Graham, MD'66, PhD'71, who said his own medical school experience lacked adequate emotional support from within the institution. He became dean of medical education in 1987 and immediately established the program.

“My major feeling was that if you're going to be in a profession where you give and give and give you can't be constantly drained unless you regularly fill up,” he says. “My strong belief was that if the medical school could provide emotional support it would be stacking the deck in favor of people holding on to the values that attracted them to medicine in the first place.”

But since the advisory dean is the one who will write the eventual Medical Student Performance Evaluation in the fourth year, Haynes says some students are eluctant to disclose problems. “It's hard for them to divulge any problem when they feel they are being evaluated all the time,” Haynes says.

Still, just meeting regularly with the advisory deans or with small group faculty in labs or the Practice Course allows the deans to identify possible emotional or physical changes in the student such as a slide in academic performance, mood, or motivation, or significant weight gain or loss. When a student does confide a problem to their faculty or advisor, the dean serves as an advocate to ensure the student has time to seek help and that missed work can be made up later.

Another way Duke is reaching out to students is by adding a “resilience curriculum”as part of the dean's lunch meetings beginning this year. It will emphasize positive coping strategies for various stresses and positive self-development. An example will be a session titled “Managing Your Mood in the Face of Medical School Stress.”

Duke also has developed explicit policies on the appropriate treatment of students and a duty hours policy, which include an 80-hour maximum work week and a mandatory full day off per week.

Haynes and Hollingsworth also are reaching out to faculty and staff about recognizing the warning signs in students. Anything schools can do to encourage time to reflect and have genuine conversations with other students and faculty in and out of the classroom will make a huge difference, Hollingsworth says.

“Developing networks of support and educating faculty and staff is one of the best strategies to ensuring students receive timely interventions. In our discussions with faculty and staff we emphasize our availability for consultation to anyone who is concerned about a student.”

Says Kansagra, who is doing a pediatrics residency at UNC Hospitals and will returnto Duke in 2008 for a residency in pediatric neurology, “Hopefully we can get to the point in medicine where people don't think of this as a weakness.”