World Mental Health Day 2018, but how aware are medical students?

The 10th of October marks the World Federation of Mental Health’s 22nd mental health awareness day. This day was created with a three-pronged approach in mind – highlighting the prevalence of mental illness amongst us, removing the stigma associated with mental illness and celebrating the recovery of those who were once victims of mental illness.¹ Depression is the second most common cause of disability worldwide, creating an increasing socio-economic burden.² With more emphasis being placed on mental health screening, it is no surprise that the prevalence will only increase with time. Indeed, it is currently estimated that one in six people in the past week have experienced a common mental health problem.³ These are just numbers that do not consider the number of individuals who have yet to come forth due to fear of stigmatization. Medical professionals without a doubt have a higher chance of developing mental illness due to a myriad of factors such as chronic stress, large workloads and compassion fatigue. Interestingly, there is a growing body of evidence in the past 5 years suggesting that physician burnout may have its origins in medical school.⁴ With national statistics showing more than 400 doctors in the UK taking their own lives between 2011 and 2015,⁵ perhaps one should look toward the root of the problem – medical education. Many questions remain but importantly, how are the medical students coping? How do medical students feel about mental illness?

Mental health amongst medical students has been increasingly discussed in recent years. While not considered a mental illness, burnout can be considered a mental health issue. Recent studies suggest that students commonly suffer from burnout. One systematic review reported data from nine studies examining US medical students, with burnout prevalence ranging between 45% and 71%. Furthermore, symptoms of depression and suicidal ideologies were more rampant during medical school as compared to practicing physicians.⁴ The use of dysfunctional coping strategies, such as the use of alcohol and illicit drugs, has been significantly reported amongst UK and US medical students as well, along with high depression scores.^6,7 This suggests that medical students have low levels of help-seeking when it comes to personal psychiatric problems, often only when a crisis arises. One reason for this is the fear of stigmatization. In an American study, it was found that depressed medical students more frequently endorsed several depression stigma attitudes than nondepressed students. This meant that compared with students with low self-identified depression, students with high depression scores more frequently agreed that the opinions of depressed medical students would be less respected, that the coping skills of depressed medical students would be viewed as less adequate, that they would be viewed as less able to handle their responsibilities by faculty members and that telling a counselor about depression would be risky. This is dangerous as it reflects how inaccurately distorted perceptions are amongst depressed students. Furthermore, students with high scores would be less likely to seek treatment if depressed than would students with low scores. These feelings were echoed by their UK counterparts where avoidance of appropriate help-seeking behavior is observed to start early in medical school for it is seen as a form of weakness.⁸ This distortion in perception is evident amongst doctors as well. In a survey of 6,000 American physicians, a whopping 40% of them revealed that they would be reluctant to seek treatment for mental health problems in fear of facing problems with obtaining their medical licensure.⁹ This is due to one-third of states having a mental health section on their medical licensure application questions. It is rather unexpected to see the medical community reinforce this stigma by their own attitudes, creating a vicious cycle by deterring doctors seeking treatment for themselves.

Underlying this problem of stigma amongst medical students is another issue – indifference. It is perhaps ironic that despite being future health care professionals, medical students might be lacking empathy toward individuals with mental illness. Depersonalization and emotional exhaustion are core symptoms of burnout and thus could potentially explain the progressive lack of empathy as doctors progress through their training. However, this does not seem to be the case. A study of 760 UK medical students examining their attitudes to mental illness, as compared with attitudes toward other medical illness, showed that students showed the highest regard for patients with pneumonia as compared to other conditions such as abdominal pain and mental illness. What was shocking was that these attitudes were worse in the more experienced senior medical students.¹⁰ Another qualitative study in China, although with a small sample size, recorded the attitudes of fresh medical graduates at a local university.¹¹ They showed that of 241 coded responses concerning negative attitudes toward mental illness, 51% reflected fear of violent behavior and 23% reflected shame from interpersonal associations. From these studies, we can see that there are differing attitudes when comparing mental illness to other types of pathologies. It is easy to develop empathy towards patients with visible pathologies within a hospital, but if you replace what we can see with an invisible illness, do we still feel the same for these individuals?

Such low levels of social acceptance of individuals with mental illness should not be expected from future doctors. Current research on interventions to fight mental health stigma has been equivocal. Interventions that involve social contact are more effective in reducing stigmatizing attitudes than brief education sessions but only for the short term. There is yet concrete evidence for the medium-long term. Perhaps future studies should look to further understand the attitudes of medical students or even before they enter university. By tackling the root of the problem, we can then shape initiatives that promote psychiatric education, combat stereotypes and promote more positive attitudes amongst our future doctors. Hence, I ask all clinicians and medical educators, on this Mental Health Awareness Day, when you see your medical students under your charge, do not follow through with the mental health curriculum by showing plain statistics and clinical signs. Rather, take it to the next level by placing an emphasis on empathy toward individuals with mental illness. Perhaps medical students can learn to empathize more by emulating their role models. As for the medical students, I implore you to look inward before you speak to a patient with mental illness – Would you treat the patient any differently if the patient was family? Would you still take the same elaborate history as with a complex cardiovascular pathology? Would you offer the same amount of compassion as with a patient with terminal stage breast cancer?