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FORUM Behind the White Coat: Depression in Medical School Alisa Land Photo by Graham Ramsay As my class approaches graduation this spring, I am reminded that some students with whom I started this journey will not be here for the final chapter as we begin our careers in medicine. Some will not graduate because they discovered along the way that this was not their chosen path. Others, however, have left our midst in more permanent ways. I cannot forget one of my classmates, a gentle and compassionate woman, who will not graduate because she took her own life during our first year of medical school. Her death must give each of us pause. I ask myself what might have been different for her and all of us that we might have been protected from the fatigue, sadness, and even despair that affects our profession perhaps more than we dare to admit. The Worst of Times One might argue that the plight of medical students reflects the broader struggles of our society. The WHO recently reported that in the last 45 years suicide rates have increased by 60 percent worldwide. Suicide is now the third leading cause of death among those of both sexes ages 15 to 44. Yet research suggests that physicians are actually at a higher risk for depression, anxiety, substance abuse, and suicide than the general population. The question remains as to what can be done to address the mental health needs of medical students and residents to ensure that they will be ready to assume their role as the doctors of the future. --Alisa Land This vulnerability becomes noticeable in the early years of medical training. In one study comparing medical students with graduate students in other disciplines, the medical students showed significantly higher clinical levels of depression and anxiety than the control group. Medical students reported having less sleep, less time for recreation and personal care, and less time with family and friends than any other group. As we students turn from the more purely academic first two years to the clinical years, another challenge awaits us on the wards. There are moments of connection with our patients, of understanding as we begin to internalize the clinical presentation of disease, and perhaps best of all, there are times when we are able to finally be the "doctor" for our patients. It is perhaps our optimism and anticipation of these glorious moments that make the harsher times more difficult to bear. Several studies have been done on the treatment of medical students on clinical rotations to evaluate the prevalence of abusive experiences during training. In one longitudinal study in the Journal of the American Medical Association, 72 percent of students reported at least one such experience including verbal abuse, gender discrimination, exclusion from informal settings, and unwanted sexual advances. Of those who felt negatively affected, however, only 31 percent reported the episodes, generally due to fear of retaliation and the belief that reporting was pointless. The most common consequences of these events included a poor learning environment, lack of confidence, and feelings of anger, humiliation, anxiety, and depression. Life Support In my conversations with other medical students, I have been comforted by a sense that I am not alone in my experience of the challenges of medical training. I know that many shared my burden of wanting to learn while feeling unable to retain all that I had been taught and read. We spoke in hushed corners about our loved ones who seemed so far away and wondered when our next visit home would be. We exchanged war stories of being pimped in rounds to our shame or being asked to present a complicated patient after 24 hours without sleep to a crowded room of residents and attendings. Though I wasn't alone, I often felt isolated in a culture where vulnerability is often equated with weakness. I think we have all felt the pressure to act as though we have it together, whatever the truth may be behind the white coat. I have spoken to several students who entered the fourth year feeling adrift and discouraged, wondering whether they really wanted to continue in medicine. One told me she had felt "totally destroyed" by the end of third year and decided to take a year off to recover her sense of why she had entered the profession. Others have told me that their self-esteem has been deeply wounded, that overall they felt better about themselves before coming to medical school than they do now. The question remains as to what can be done to address the mental health needs of medical students and residents to ensure that they will be ready to assume their role as the doctors of the future. Though U.S. doctors have made progress in their own health in terms of cardiovascular risk reduction and cancer prevention, we remain a profession as much if not more at risk of depression, anxiety, substance abuse, and suicide than in the past. I believe reform efforts should include not only early identification and effective services for those in need, but also a more supportive model of training that facilitates a positive experience of learning in the hospital. The demands of medical training often stress the trainee's natural support system and isolate him or her from family, friends, and needed meaningful activities outside of work--thus putting the trainee at high risk for negative mental health outcomes. It is imperative that we find a better balance between time spent in the hospital and out of it if we are to take seriously this vital area of our own health and be ready to care for the health of our patients. --Alisa Land, a fourth-year medical student at HMS