From Medscape.com How Medical Schools Can Meet Mental Health Needs of Students - Medscape - Oct 03, 2018.
By Roxanne Nelson BSN, RN
Last May, a fourth-year medical student at New York University School of Medicine and a psychiatry resident at New York University Langone Health, died by suicide within 5 days of each other. The news of their deaths sparked media coverage and drew renewed attention to the high rate of suicide among medical professionals.
A new perspective paper published online September 27 in the New England Journal of Medicine (NEJM) says medical schools must step up to the plate to meet the mental healthcare needs of their students. In their article, the authors also describe the model that has been implemented at their institution, which attempts to circumvent some of the barriers that medical students face in accessing care.
Medical students have higher rates of depression, suicidal ideation, and burnout compared with the general population, as well as greater concerns about the stigma of mental illness, write Jordan F. Karp, MD, and Arthur S. Levine, MD, both from the University of Pittsburgh School of Medicine, Pennsylvania, in the NEJM article.
Alarming Numbers of Students Depressed, Suicidal
The statistics are alarming: About half of all medical students experience burnout, and 10% have reported experiencing suicidal ideation, note the authors.
These figures are similar to those reported in a large Medscape survey of residents. About 10% stated that they feel depressed always or most of the time, which is higher than the 6.7% seen in the general population, according to the National Institute of Mental Health. And 9% of respondents said they have considered suicide compared with 3.9% of the general population aged 26 to 49 years reported by the Substance Abuse and Mental Health Services Administration.
Overall, US physicians have the highest suicide rate of any profession, with one completed suicide every day. In addition, the number of physician suicides is more than twice that of the general population.
"We have long been aware of how many healthcare professionals struggle with burnout," commented Darrell G. Kirch, MD, president and chief executive officer of the Association of American Medical Colleges, "And how many slip into anxiety and depression."
He told Medscape Medical News that many healthcare professionals are reluctant to seek treatment, even though these mental health conditions are largely treatable. "We are the people who give care, and we may not acknowledge when we need care," Kirch said. "But now we are acknowledging that this problem exists, and we were in denial about the toll it was taking on people working in healthcare."
"But now we are coming together to recognize the problem and focus on solutions and interventions," he pointed out, "Some of which are discussed by the NEJM article authors. Medical schools are a great point to start to work on these issues."
Medical students are very motivated, bright, and resilient. "But they can burn out very quickly, and many will experience true anxiety and depression," Kirch added.
Challenges to Care
The 1992 Association of American Medical Colleges Recommendations Regarding Health Services for Medical Students "remains relevant and includes sensible guidance" related to mental health issues, note Karp and Levine. These recommendations include providing all students with access to confidential counseling by mental health professionals and establishing confidentiality policies, as well as creating clear policies about administratively mandated evaluation and treatment.
But these recommendations may not be optimally implemented by the school because of a lack of resources.
A number of challenges also face students and can present formidable barriers. These include long wait times for counseling centers, financial concerns (lack of adequate insurance, high copays or insurance type not accepted by providers), and concerns about future employability and licensure.
Students who are still covered by their parents' health insurance plans may not want their families to know they are receiving mental health treatment, the authors point out, and hectic schedules and lack of time also present barriers to care.
The authors write they "believe the time has come to move beyond simply measuring depression, burnout, and suicidal ideation among medical students to discussing practical approaches to implementing school-based solutions." At the University of Pittsburgh School of Medicine, an aggressive and proactive approach has been taken to ease the transition into medical school, reduce stress, and importantly, address the main challenges that students having mental health issues commonly contend with: access, privacy, and stigma.
They have created a dedicated medical student mental healthcare team, and it is financially supported by the medical school to provide care for the 560 medical students and 360 graduate students. Karp, the coauthor of this paper, is one of the codirectors of the program.
Medical students learn about the existence of this program during their orientation to school, and teaching faculty members and advisory deans are educated about the team annually. Wait time is no longer than 5 days after a student contacts the team, and to accommodate erratic and busy schedules, evening, weekend, and online video appointments are provided, along with secure email communications.
"All mental health care is provided to students at no cost, and insurance is never billed, which minimizes students' concerns about stigma and future insurability," they emphasize. And to reduce concerns about confidentiality, all "[t]reatment notes are stored in the firewall-protected electronic medical record of the university counseling center, which is separate from the university hospital's electronic medical record."
The program also ensures that a psychiatrist will be available to evaluate students who take a voluntary or mandated leave of absence and to give them psychiatric clearance when they return from medical leave and reenter medical school.
Another component of the program is the Student Health Advocacy Resource Program, which is a confidential peer counseling referral and advocacy service that is sponsored by the university's office of student affairs. The Student Health Advocacy Resource Program is organized by medical students and supervised by faculty members from the departments of Medicine and Psychiatry.
Students are making use of these services, the authors write. During the 2016 to 2017 academic year, the psychologist was consulted by 16% of students, for a total of 850 visits, with 150 students seen. Two thirds of students underwent short-term psychotherapy (one to six sessions), whereas 31 had longer-term therapy. In addition, about 20% of students who self-referred to the mental healthcare team did so because they were having problems with concentration and academic performance.
Finally, the authors point to other schoolwide initiatives that can help improve mental health and reduce stress among students, such as the Faculty and Students Together program, which assists in making the transition into medical school.
"Other medical schools must make the same financial investment and commitment that we have made to achieve a similar result," Levine told Medscape Medical News.
Addressing the Root Causes
Various strategies and interventions aimed at improving mental healthcare are also being implemented at various medical schools. These include appointing faculty "wellness advisors," sponsoring wellness initiatives to promote self-care, and bringing university counseling center staff on site for regular clinics.
The University of California, San Diego, as an example, has implemented the Healer Education Assessment and Referral program, which is designed to educate medical and pharmacy students, house staff, faculty, trainees, and hospital staff about burnout, depression, and suicide. It provides confidential, online assessment of stress, depression, and other related issues.
If a mental health issue is identified, personalized referrals are made to local mental health clinicians and other community resources. An estimated 320 mental health referrals were made from May 2009 through June 2017, with most of the individuals reporting that they probably would not have sought help if it were not for Healer Education Assessment and Referral.
"Our program is known to and available to medical students, residents, faculty, and professional staff, and is readily available to all," said Sidney Zisook, MD, a professor of psychiatry at UC San Diego Medical Center. "Students also have access to student health and counseling services and our college mental health program, which has helped them overcome many of the obstacles to care."
However, although these interventions are needed to ensure that medical students have access to confidential and appropriate mental healthcare, Srijan Sen, MD, PhD, Frances and Kenneth Eisenberg Professor of Depression and Neurosciences, University of Michigan, Ann Arbor, feels that this a more system-level problem than an individual one.
"A lot of effort is put into treatment after people start having symptoms," he said. "We need to put more resources into prevention and address the culture of medicine to make changes."
There seem to be some elements in the training environment that increase depression, and thus a need to "fundamentally redefine medical education" so that healthy work-life balance is possible, explained Sen, who is also the principal investigator of the Intern Health Study, a longitudinal study of depression among interns nationwide.
Finding that balance is not easy, but steps like reducing the number of hours medical students and residents work would be a start, he said. "There's also a big gender gap, and that's driven by work/family conflict."
Work-family conflict predisposes people of both sexes to depression, but women are twice as likely to experience depression as men. "So we can implement strategies that can help with that, like better maternity leave, access to low-cost daycare, and daycare that is open and available at times that will work for this population, and increased flexibility and autonomy in work schedules," he said.
The way that medicine is practiced has also changed, Sen pointed out. "More time spent with a computer rather than the patient seems to also correlate with a greater emergence with mental illness," he said.
"Half of first year residents will get depressed," he said. "We need to change the training environment and take the needs of the medical students and residents into account when we design these programs."
Karp and Levine have disclosed no relevant financial relationships. Sen has disclosed no relevant financial relationships.
N Engl J Med. Published online September 27, 2018. Extract