When he attended medical school in Texas, Dr. Douglas Mata saw the problem all around him. Many students either knew a classmate who was depressed or had been there personally. Often, they did not seek help, and he was aware of three students who committed suicide.
This experience in part prompted Mata to coauthor the largest analysis yet on the prevalence of depression in medical school, showing that it afflicts 27 percent of students. Eleven percent of students were found to have suicidal thoughts.
The paper, published online Tuesday in the Journal of the American Medical Association , provided evidence to support what long has been suspected — that future doctors suffer depression, or depressive symptoms, at higher rates than the general population.
Mata, who is now a resident at Brigham and Women’s Hospital in Boston, and his coauthors analyzed nearly 200 smaller studies from 47 countries to calculate overall rates — highlighting that depression in medical school is a “global problem of significant proportion,’’ wrote Dr. Stuart Slavin of Saint Louis University School of Medicine in an accompanying editorial.
Despite the prevalence of depression, the researchers, which included students from Harvard and Yale medical schools, found that only about 16 percent of students testing positive for depression sought treatment.
“There is still a lot of stigma,’’ Mata said.
Students fear that if their problems become known, supervisors will label them incompetent or weak, or they worry they won’t be granted a medical license, he said. Many state applications ask about mental health history.
Marco Ramos, a medical and doctoral student at Yale, said, “There is this tendency in medical culture to see psychological issues as not real health issues.’’ Rather than suffering from depression, he said, students with mental health diagnoses are often described as “struggling.”
“It is an issue with them. They are failing to perform the way they need to perform. It makes you not want to talk about it. We don’t want to be seen as struggling,’’ said Ramos, a coauthor on the study.
The research comes at a time of growing focus on physician depression and burnout and the negative impact on doctors as well as their patients. It also builds on a similar analysis published a year ago in the Journal of the American Medical Association by Mata and his colleagues finding that 29 percent of residents, or physicians in training, experience depression or depressive symptoms. The medical students screened positive on questionnaires for depression, but only a psychiatrist can make a definitive diagnosis, Mata said. He said about 9 percent of young adults overall screen positive for depression.
The study did not focus on why the disorder appears to be more common among medical students — especially because as a group, some research suggests, they have good mental health before entering medical school.
But it’s clearly a pressure-cooker. “Even to get into medical school in the first place, you have to be on track from high school and jumping through all these hoops,’’ Mata said. “Once you’re there, the workload is so high it’s like drinking from a fire hose. Many people can’t adapt to that.’’
Along with the crushing workload, students are constantly ranked against their competitive high-performing classmates, Ramos said. “You are beating yourself up when you’re not the best, in addition to working so hard,’’ he said.
There is little time for exercise, socializing with family and friends, or even buying groceries. In the third year, most students leave the classroom and begin clinical rotations in hospitals, where many have their first encounters with very sick and dying patients. During the clinical years of medical school and residency, the infamously long work hours can make individuals less able to cope with this stress.
Some evidence exists that students in law and business schools also may have high depression rates, but more research is needed, Mata said.
In his editorial, Slavin said schools have failed to address the problem, in part because of a stubborn but misguided belief that the rigors of medical education and training weed out those too weak to handle the stress of the profession and lead to a better educated workforce. Interventions in recent years, he said, have relied too heavily on encouraging students to eat well, exercise, do yoga, meditate, and participate in narrative medicine activities.
“These approaches may allow educators to feel comforted by their efforts but also may distract educators from recognizing that the learning environment is at the core of the problem, and more must be done to improve it,’’ he said.
Mata agreed these approaches are a “Band-Aid’’ and hoped the new research will spark more systemic solutions. This could include reducing students’ workload and moving to a pass or fail system for courses, as some schools have done, abolishing letter grades.
Ramos said he is working with Yale students to bring mental health services onto the medical school campus. Historically, they have been housed elsewhere, so students can seek treatment more privately, but Ramos said the distant location reinforces stigma.
Lisa Rotenstein, a fourth-year medical student at Harvard who also worked on the study, said mentors sometimes write a student’s evaluations, which can discourage students from confiding in the physicians they know the best. She said Harvard has taken steps to help, among them, having someone other than a student’s advisers write the “dean’s letter’’ required for admission to residency programs.
“I can tell you people are struggling with this. It is an issue,’’ she said.
Mata attended Baylor College of Medicine in Houston, graduating in 2014. He said he needs a full-night’s sleep, and with “all the sleeplessness, I definitely went through periods I felt burned out and depressed,’’ he said. The first time, he dug in his heels and got through it. The next time, he took advantage of counseling resources at school, which he described as extremely helpful. “You feel like you are actually taking control and doing something about it.’’