When investigating depression and anxiety in undergraduate medical students timing of assessment is an important factor - a multicentre cross-sectional study

The experiences of students with mental health difficulties at medical school: a qualitative interview study

BACKGROUND

High rates of burnout, anxiety, and depression in medical students are widespread, yet we have limited knowledge of the medical school experiences of students with mental health issues. The aim of the study is to understand the impact of mental health issues on students' experience and training at medical school by adopting a qualitative approach.

METHODS

Qualitative study using in-depth semi-structured interviews with 20 students with mental health issues from eight UK medical schools of varying size and location. Students were purposefully sampled to gain variety in the type of mental health issue experienced and demographic characteristics. Reflexive thematic analysis was employed using NVivo software.

RESULTS

Three themes were identified. 1) Culture of medicine: medical culture contributed to causing mental ill-health through study demands, competitiveness with peers, a 'suck it up' mentality where the expectation is that medical school is tough and medical students must push through, and stigma towards mental ill-health. 2) Help-seeking: students feared others discovering their difficulties and thus initially tried to cope alone, hiding symptoms until they were severe. There were multiple barriers to help-seeking including stigma and fear of damage to their career. 3) Impact on academic life: mental health issues had a detrimental impact on academic commitments, with students' unable to keep up with their studies and some needing to take time out from medical school.

CONCLUSION

This study provides insight into how medical culture contributes both to the cause of mental health difficulties and the reluctance of medical students to seek help. Mental health issues had a considerable negative impact on medical students' ability to learn and progress through their degree. Addressing the medical culture factors that contribute to the cause of mental health issues and the barriers to help-seeking must be a priority to ensure a healthier medical workforce.

Measuring wellbeing: A scoping review of metrics and studies measuring medical student wellbeing across multiple timepoints

PURPOSE

Studies have demonstrated poor mental health in medical students. However, there is wide variation in study design and metric use, impairing comparability. The authors aimed to examine the metrics and methods used to measure medical student wellbeing across multiple timepoints and identify where guidance is necessary.

METHODS

Five databases were searched between May and June 2021 for studies using survey-based metrics among medical students at multiple timepoints. Screening and data extraction were done independently by two reviewers. Data regarding the manuscript, methodology, and metrics were analyzed.

RESULTS

221 studies were included, with 109 observational and 112 interventional studies. There were limited studies (15.4%) focused on clinical students. Stress management interventions were the most common (40.2%). Few (3.57%) interventional studies followed participants longer than 12 months, and 38.4% had no control group. There were 140 unique metrics measuring 13 constructs. 52.1% of metrics were used only once.

CONCLUSIONS

Unique guidance is needed to address gaps in study design as well as unique challenges surrounding medical student wellbeing surveys. Metric use is highly variable and future research is necessary to identify metrics specifically validated in medical student samples that reflect the diversity of today's students.

A Pilot Study of Symptoms of Major Depressive Disorder in Medical Students at an Osteopathic Medical School Before and After High-Stakes Examinations

Background

Given the high prevalence of symptoms of major depressive disorder (MDD) in medical students, identifying factors that impact the development of such symptoms is important. Previous data suggest that medical students can experience symptoms of MDD after medical school exams. It is not known if medical students experience more symptoms of MDD directly before or after exams. The aim of the current study is to determine the prevalence of symptoms of MDD in first- and second-year medical students directly before and after high-stakes medical school examinations.

Methods

Two anonymous surveys were sent via REDCap to first- and second-year medical students at the University of New England College of Osteopathic Medicine. A pre-exam survey on the day of the exam asking about the past three days' MDD symptoms, and a post-exam survey sent three days after the exam asking about MDD symptoms experienced after the exam was sent out to a total of 391 students with a response rate of 23%.

Results

First- and second-year medical students regardless of gender experienced symptoms of MDD at higher rates before exams than afterwards. Female students experienced symptoms of MDD (as defined by the DSM-5) including sadness, sleep disturbances, and feelings of guilt or worthlessness at a greater rate compared to males before exams. After exams, females were more likely to experience sleep disturbances and decreased energy. Second-year male students were the least likely to experience symptoms of MDD.

Conclusion

First- and second-year medical students can experience symptoms of MDD surrounding exams. This study highlights the emotional burden that students may carry near exams. It underscores the importance of further research on this topic to evaluate the effect exams have on the mental health of medical students during their training.

Mental health help-seeking among Brazilian medical students: Who suffers unassisted?

INTRODUCTION

Several barriers for mental health help-seeking were identified among medical students, including minimizing mental illness. Studies examining aspects particular to those who perceive psychological impairment but do not access treatment are necessary for planning interventions.

AIMS

To identify help-seeking barriers based on the students' perception about their need for treatment and psychiatric symptoms. Methods: Cross-sectional study assessing 436 Brazilian medical students (833 attending the medical school = 52.3% response rate). Data collection covered sociodemographic data, mental health, academic environment, and Beck Inventories of Depression (BDI) and Anxiety (BAI). Non-parametric tests and hierarchical logistic regression were used to compare students undergoing treatment, those willing to access treatment, and the ones reporting no need for treatment.

RESULTS

Among the 382 students who completed the survey (87.6% completion rate), 38.5% (n = 147) were in treatment, and 33% (n = 126) were in need. Moderate to severe risk of alcohol abuse was observed in 45.9% (n = 50) of students reporting no need for treatment. Regression models suggested that perceiving need for treatment - whether already undergoing it or not - was associated with the severity of depressive symptoms (OR 1.14 [95% CI 1.07-1.21]), female assigned sex (OR 2.18 [95% CI 1.23-3.88]), LGBTQ+ (OR 2.47 [95% CI 1.09-5.60]) and reporting good relationship with the family (OR 0.26 [95% CI 0.08-0.83]). Models comparing students in treatment and those in need, pointed that the factors associated with lacking mental health care were age (OR 0.90 [95% CI 0.82-0.99]), perception of a heavy workload (OR 2.43 [95% CI 1.35-4.38]) and good relationship with colleagues (OR 3.51 [95% CI 1.81-6.81]).

DISCUSSION

Social variables and the severity of depressive symptoms are positively associated with perceived need for treatment. Age and academic environment factors were related to help-seeking behavior among students with appropriate self-awareness. We discuss these findings' implications for planning interventions.

Impact of Providing Peer Support on Medical Students’ Empathy, Self-Efficacy, and Mental Health Stigma

Background: Peer-support programs in medical school can buffer feelings of inadequacy, anxiety, social isolation, and burnout, drawing upon the benefits of near-peer-support resources. This study examined the effects of providing support to students in a medical school peer-support program. Methods: Using a pre-post, quasi-experimental study design, the investigators surveyed medical students who were peer supporters in their second through fourth years of medical school with four measures assessing (1) empathy, (2) self-efficacy, (3) mental health stigma, and (4) likelihood to assist peers with mental health problems to examine if serving as a volunteer peer supporter had any effect. Participants included 38 medical students that were actively enrolled peer supporters during the 2020–2021 year at a United States allopathic medical school. Results: Medical students who participated as peer supporters were found to have higher ratings of empathy scores (Z = −1.964, p = 0.050, r = 0.34) and self-efficacy scores (Z = −2.060, p = 0.039, r = 0.35) after participation in the program. No significant changes were noted for mental health stigma or likelihood to assist peers with mental health problems. Discussion: Peer-support programs present a low-cost, sustainable modality to promote wellbeing in medical students. There is a growing body of literature documenting the benefits of peer-support services. This brief, novel study examined the effects of providing peer support on the peer supporters and found higher self-reported ratings of empathy and self-efficacy after participation. These findings underscore peer-support programs as a valuable wellness resource not only for medical students who use the services but for those who provide them as well.

Symptoms of depression and anxiety in Indonesian medical students: association with coping strategy and resilience

BACKGROUND

Depression and anxiety are prevalent mental health issues among medical students due to the various challenges during medical education. These issues affect not only their quality of life, but also their academic and professional development. Coping strategy and resilience are two factors that may influence students' mental health outcomes. Data of medical student mental health in Indonesia is scarce, hampering efforts to systematically address the problem. Hence, this study aims to estimate the prevalence of depressive and anxiety symptoms in Indonesian medical students, and their association with coping strategy and resilience.

METHODS

Undergraduate medical students from each year of study (Preclinical Year 1 to 4, Clinical Year 1 and 2) in the Faculty of Medicine Universitas Indonesia were randomly selected to participate in this cross-sectional study. The study questionnaire included sociodemographic characteristics, Depression Anxiety Stress Scale (DASS) to measure symptoms of depression and anxiety, Brief COPE to measure coping strategy, and Connor-Davidson Resilience Scale (CD-RISC) to measure resilience. Scores of depression and anxiety symptoms were analyzed by comparing them between different sociodemographic groups and by measuring their correlation with coping strategies and resilience. Multiple regression analyses were conducted to identify predictors of depression and anxiety symptoms.

RESULTS

Among 532 respondents, 22.2% reported symptoms of depression and 48,1% reported anxiety, including 3.0% and 8.1% with extremely severe depression and anxiety, respectively. Students not living with immediate family had higher depression score; female students and those in Preclinical Year 1 and Clinical Year 1 showed higher anxiety scores. Dysfunctional coping strategies and lower resilience are predictors of higher depression and anxiety symptoms.

CONCLUSIONS

Students show different levels of depressive and anxiety symptoms, signifying different levels of mental health support needs from universal mental health promotion to psychiatric treatment. Prevention programs can be targeted towards students with risk factors, such as not living with immediate family, undergoing first year of preclinical studies or clinical rotations, coping with dysfunctional strategies, and having low resilience. Additionally, medical educators must be aware of other, non-student factors that may impact student mental health, such as curriculum design and learning experience.

Gender Disparities in Symptoms of Depression After Medical School Exams and Student Coping Strategies for Postexam Depression Symptoms

CONTEXT

Little research exists to determine if medical students experience symptoms of depression after examinations and if symptoms vary by gender.

OBJECTIVES

Determine if is there a difference between male and female medical students in the number of symptoms of major depressive disorder (MDD) experienced after exams, as well as which coping strategies are used by students to alleviate depression symptoms.

METHODS

An anonymous and secure survey was sent via university email to first, second, and third-year medical students after exams for 2 consecutive exam periods. Surveys that were not fully completed were excluded from the analysis.

RESULTS

A total of 162 out of 550 students completed the survey for a response rate of 30%. Overall, a greater proportion of female students experienced more symptoms of depression compared to males. This was statistically significant for the Diagnostic and Statistical Manual of Mental Disorders 5th Edition symptoms of MDD: depressed mood, anhedonia, changes in sleep, fatigue, and difficulty with concentration after exams compared to their male counterparts. Male first-year medical students experienced higher rates of depression compared to their third-year counterparts. Most students exhibited coping strategies that helped them feel less depressed. The 3 most common coping strategies reported were: reaching out to social support networks, physical activity/exercise, and engaging in hobbies.

CONCLUSIONS

Both gender and year in a medical school play a role in the number of symptoms of depression experienced after medical school exams. Recognizing that examinations can be a trigger of depressive symptoms in medical students, particularly female and first-year students, has important implications on student mental health. Helping students recognize these symptoms and employ healthy coping strategies may further help alleviate these symptoms. Long-term consequences of experiencing symptoms of depression after recurrent exams in medical school are unknown and require further research.

Changing Student Perception of an Online Integrated Structured Clinical Examination During the COVID-19 Pandemic

BACKGROUND

The COVID-19 pandemic has created a hiatus in in-person clinical assessments due to safety and logistical concerns. We aimed to evaluate student perception and utility of an online Integrated Structured Clinical Examinations (ISCEs) during the pandemic.

METHODS

Final-year medical students from a single institution were offered an online mock ISCE through a student-to-student ("near-peer") teaching-programme. A questionnaire-based cross-sectional study was conducted pre- and post-online mock ISCE.

RESULTS

Sixty-four students completed the study. Pre- and post-data showed an increase in confidence (p<0.0001), less worry regarding the online format (p<0.0001) and less anxiety about excelling in ISCEs (p<0.001). Students felt that having done the mock, an online format would more positively affect their overall performance (p=0.007).

CONCLUSION

This study demonstrates a positive change in student perception and confidence in online ISCEs. Online ISCEs are thus feasible, though sole reliance on this format may provide an incomplete assessment of student's overall clinical competency.

Endocannabinoids, cannabinoids and the regulation of anxiety

Cannabis has been used for hundreds of years, with its ability to dampen feelings of anxiety often reported as a primary reason for use. Only recently has the specific role cannabinoids play in anxiety been thoroughly investigated. Here we discuss the body of evidence describing how endocannabinoids and exogenous cannabinoids are capable of regulating the generation and termination of anxiety states. Disruption of the endogenous cannabinoid (eCB) system following genetic manipulation, pharmacological intervention or stress exposure reliably leads to the generation of an anxiety state. On the other hand, upregulation of eCB signaling is capable of alleviating anxiety-like behaviors in multiple paradigms. When considering exogenous cannabinoid administration, cannabinoid receptor 1 (CB1) agonists have a biphasic, dose-dependent effect on anxiety such that low doses are anxiolytic while high doses are anxiogenic, a phenomenon that is evident in both rodent models and humans. Translational studies investigating a loss of function mutation in the gene for fatty acid amide hydrolase, the enzyme responsible for metabolizing AEA, have also shown that AEA signaling regulates anxiety in humans. Taken together, evidence reviewed here has outlined a convincing argument for cannabinoids being powerful regulators of both the manifestation and amelioration of anxiety symptoms, and highlights the therapeutic potential of targeting the eCB system for the development of novel classes of anxiolytics. This article is part of the special issue on 'Cannabinoids'.

The Psychological Impact Analysis of Novel COVID-19 Pandemic in Health Sciences Students: A Global Survey

OBJECTIVE

 To evaluate the anxiety and depression amid novel coronavirus disease-19 (COVID-19) pandemic in health sciences students around the globe.

MATERIALS AND METHODS

 This cross-sectional observational study comprised 523 health science students. A well-structured online questionnaire consisting of closed-ended questions based on student's general information, Patient Heath Questionnaire (PHQ)-9 and Generalized Anxiety Disorder (GAD)-7 scales were used to assess the psychological impact of COVID-19.

STATISTICAL ANALYSIS

 SPSS-25 was used to analyze the outcome of this study. Multiple linear regression analysis test was used to assess variables which had impact on PHQ-9 and GAD-7 scores among the participants. A p-value of ≤ 0.05 was considered as statistically significant.

RESULTS

 Among the 523 participants, 365 (69.55%) students were from developing countries and 158 (30.21%) from developed countries; 424 (81.1%) students were tested negative for COVID-19 and 99 (18.9%) had suffered from severe acute respiratory syndrome coronavirus 2 infection during pandemic. The mean GAD-7 and PHQ-9 scores were 7.16 ± 5.755 and 7.30 ± 6.166, respectively. Significant impact on anxiety levels was associated with age, gender, education status, and COVID-19 positive patient, while depression was not significantly associated with gender, COVID-19, and its reported symptoms in participants.

CONCLUSION

 As the world is trying to contain the health effects of COVID-19, the psychological effects might take a longer time to be addressed. Our study highlights the dire need to identify mental well-being of health science students as this may have a direct impact on their professional commitments and future responsibilities.