Open Your Eyes - Depression in Medical Students
by Anna Taylor

Tags: multimedia - film - wounded_healer - depression - consultations - comp1 - student mental health -

I decided to write about depression in medical students because I believe that depression is misunderstood. Depression is the commonest mental health problem, and can be co-morbid with anxiety, eating disorders, chronic physical health problems and drug or alcohol misuse. One in four1 people suffer from mental illness at some point in their lives, and greater awareness and understanding of depression by doctors will enable doctors to provide better care for their patients.

Research in the UK indicates that the prevalence of depression and alcohol-related problems is higher among medical students and doctors compared to the general population2, possibly due to the stresses associated with the education, training, responsibilities, pressures and professional sacrifices required to become and practice as a doctor3. Thus, it is important to educate medical students, as prospective doctors, about the causes and symptoms of depression and anxiety, as well as give information about the various options for treatment, so that they can be more aware of themselves and colleagues, and patients throughout all specialties. The NICE guideline4 for depression summarises the evidence-base for depression management and outline treatment options such as cognitive behavioural therapy (CBT), mindfulness-based cognitive therapy, counselling or interpersonal therapy (IPT). Anti-depressant medication such as SSRIs (selective seratonin-reuptake inhibitors) may be used for moderate or severe depression, often in conjunction with a psychological intervention such as CBT or IPT.

Many colleagues I have spoken to are not aware of the alternatives to anti-depressants or, if they are aware of them, believe that they are not effective. This may be another reason why students do not self-report symptoms of anxiety or depression as they may dislike the idea of being seen to be dependent on medication. This was certainly a factor in my own delay in help-seeking, but I found mindfulness-based cognitive therapy to be beneficial, and I feel that the practices can be used in any stressful situations to help students and doctors keep calm, look after themselves and thus provide the best quality of care possible.

I believe that amongst my friends and year group there are many misconceptions about depression, including the notion that sufferers are weak in some way, and in my own experience this can lead to feelings of shame and embarrassment. Medical students commonly fear that reporting symptoms of depression will affect their future prospects as doctors and that they ‘wouldn’t want it on my CV or their records’2. This negative thinking about depression only serves to propagate the stigma that already surrounds mental illnesses such as depression and may affect the relationship the student has with any depressed patients further on in their career. The stigma and shame surrounding a diagnosis of depression can prevent students and doctors seeking help and may lead to them struggling with their illness for a long period of time and may severely affect their work and relationships. In her memoir An Unquiet Mind: A Memoir of Moods and Madness, Dr Kay Redfield Jamison describes her initial help-seeking experience for depression in this way5:

‘...I felt totally unable to ask anyone for help... Finally, however, after hearing a lecture about depression in my abnormal psychology course, I went to the student health service with the intention of asking to see a psychiatrist. I got as far as the stairwell outside the clinic but was only able to sit there, paralysed with fear and shame, unable to go in and unable to leave. I must have sat there, head in my hands, sobbing, for more than an hour. Then I left and never went back.’

Although her experience occurred more than forty years ago, it is not dissimilar to my own and others’ help-seeking experience now, which suggests that, despite an increased medical knowledge of illnesses and treatments, there is still a huge stigma surrounding mental illnesses. This stigma may be due to the fact that students get most of their information on depression and other mental illnesses from the media, which is often inaccurate. It can either trivialise or dismiss symptoms, write them as a background to another, more active, problem such as alcohol misuse, or write them as being ‘triggered’ by a life event such as a death in the family, which is not always the case. Characters may also be consigned to the secondary plot or background of the film due to the fact that depression can make a withdrawn and passive character, which is hard to create a story around. As such, there are very few accurate portrayals or descriptions of depression that could improve students’ understanding or awareness of the condition. As a result of this, students will not have any real understanding of depression unless they know someone who has suffered from depression, have suffered from depression themselves, or have educated themselves in their own time. Therefore, students may not recognise the development of depression or anxiety in themselves or their peers, or know the ways in which it can be treated. This is especially problematic given the fact that although we have academic mentors, we do not have pastoral tutors like the vast majority of non-medical students and as such students may feel quite anonymous in the medical school and therefore may feel uncomfortable approaching the Student Advisor or Student Health Service.

Better education and awareness about depression early in the university course can assist medical students and doctors to improve their emotional intelligence (EQ) and enable them to feel that they can recognise and manage their emotions, share them openly and ask for help if they feel that they need it, as advised by Smith6. The pressure to deny emotions can have a serious effect on health, and doctors who belong to Balint7 groups also reported being better able to listen to patients when more in touch with their own emotions. Self-care is essential in helping to create resilient doctors, and better self-care can be encouraged by talking openly and honestly about depression from the very beginning of a student’s career. As a result of this, medical students and doctors can understand the best ways to care for themselves and manage their emotions, whether it is through reading, music, yoga, exercise etc. The better doctors are able to take care of themselves and the more informed they are about how common depression is, the better they are able to care for their patients and destigmatise the diagnosis of depression, which will improve the doctor-patient relationship and make care more effective. It is also important to be aware of depression and anxiety should it develop in a colleague. The GMC’s Duties of a Doctor8 states that a doctor must report a colleague if he or she feels them to be unfit to work due to a mental health problem, but this outcome may be avoided, and colleagues supported early on, if doctors have a better understanding and awareness of depression and the ways it can be successfully treated, as well as information about self-care and its benefits.

Creative Piece

I was inspired by my own and others’ experiences to create a short film about a medical student (acted by me) suffering from depression, which I see as a more realistic portrayal than what is commonly shown in the media. With my film I seek to address the concerns that students have about reporting symptoms and to look at the experience of suffering from depression in a more accurate way than the media’s impressions of it. It shows a student’s experience during depression and her help-seeking. I decided to show the student choosing a treatment method that did not involve SSRIs as a way of showing the effectiveness of other treatments. I titled the film ‘Open Your Eyes’ for several reasons. Firstly, it reflects the student’s personal journey during the film, which is a reflection of my own experience - a battle to get up in the mornings and to open my eyes to the beauty of the world and the small things like cooking that I had lost sight of. Secondly, it is my personal intention to open the eyes of my fellow medical students that one in four of the people in the year (and one in four of the patients they encounter) may be suffering from a mental health problem1 such as anxiety, depression, eating disorder etc, and become more aware of the symptoms of anxiety and depression, which would hopefully enable them to recognise the development of similar symptoms in themselves or friends if it were to occur. Lastly, my film is my personal contribution to the Time To Change campaign9 which seeks to educate people about mental health issues and break down the barriers of stigma and embarrassment, which would enable and empower patients who suspect they may have a mental illness to feel more comfortable seeking help, without fear of being judged.

My own experience with depression led me to choose this topic. I feel strongly that medical students need to be made aware of the fact that suffering from depression does not make a person weak and that it will not affect their future career as a doctor if they are able to combat it successfully. I know that if I had been made aware of this I would not have delayed my help seeking for so long and would have felt more comfortable approaching the Student Advisor and my GP. I found that writing the script for my film was cathartic and I learned a great deal about myself during the process of writing and shooting the film. Since it was based on my own experience it was challenging to remember the emotions and thoughts I had had during my depression, but I feel that both having beaten depression and the process of making the film has made me a much stronger person, and far more knowledgeable about this common problem. I believe that this has also increased my EQ and will enable me to empathise well with my colleagues and future patients, as well as successfully deal with any strong emotions that may arise. Discussing my project with fellow students was somewhat difficult as I was nervous about how they would react and whether they would be dismissive or unsupportive of my experiences, but as a general rule they have been interested and supportive of my project and asked me questions about my experience with CBT. I came to realise that suffering with depression is nothing to be ashamed of and what matters is that I was able to combat it and become a stronger person. I believe that my own EQ was also improved during my course in mindfulness and I feel that this practice should be encouraged among medical students. It has been beneficial in helping me understand and manage my own emotions and stress better. This will be particularly useful when I reach the clinical years and will be under a lot more pressure.I feel that other students would also benefit from the mindfulness course in improving their EQ, which, as well as being useful for managing their own emotions, will also improve their relationships with both colleagues and patients as they will be able to set a supportive tone for discussions and consultations, enabling the other person to feel able to freely talk about their own feelings without fear of judgement or reprisal. As a result of this, the doctor is able to hear the patient’s full story, including any psychological distress, which is vital for effective care.

It is my understanding that the only formal teaching on depression and anxiety that medical students at the University of Bristol receive is during the Psychiatry unit during Year 3, and this teaching only relates to mental health problems in patients. As most patients with mental health problems are managed in primary care, there is an opportunity to discuss depression and anxiety during the general practice attachment, but this will depend on the GP tutor and on the patients encountered. There is a lecture titled ‘Mental Health Awareness’ that occurs during Freshers Week, but this only addresses drug and alcohol-related problems and a small amount of information on eating disorders. The glaring omission of depression and anxiety, linked with misconceptions students glean from the media, can create the impression among students that depression and anxiety are unimportant and something to be ashamed of; as such, if a student develops mental health problems over the course of their time in university or even later on in their career they would be far less inclined to report their symptoms and seek help. I believe that it is also critical to make the alternatives to SSRIs (such as CBT, mindfulness or counselling) more widely known so that students and doctors do not believe that the only effective treatment of depression and anxiety is to take medication. Greater awareness may be achieved by a member of the Student Health Service team giving a short lecture about depression, its symptoms and the ways to treat it, as well as information about self-care and how best to do so. I feel that there should also be easy-to-access contact details for groups such as the Samaritans or the University Nightline in the Student Advisor section of BlackBoard or on the Student Health Service website.

I feel strongly that a greater knowledge and understanding of depression can only be beneficial to patients and doctors alike, as it will decrease the stigma that currently surrounds depression, which I believe is a major barrier to help-seeking. In addition, a better knowledge of non-medication treatments will improve self-reporting of symptoms of depression and anxiety, as well as decrease any misconceptions people have about CBT, particularly the notion that it is ineffective compared to SSRIs.

I firmly believe that if we were taught how to recognise depression, both in ourselves and colleagues, early on in our medical school careers, and given information on the multiple options for treatment rather than a sole focus on medication, this would help to prevent stigma and would benefit ourselves and our future patients as we would have a higher EQ, which would enable us to empathise better with patients and have a richer understanding of their experiences. As well as this, an improved knowledge and understanding of depression and anxiety may also decrease the prevalence among doctors and medical students, as, without a fear of stigma and a negative impact upon their career, people may be more inclined to admit they need help early and know more about the ways in which they can tackle their illness to prevent their problems worsening. After all, it is only when we ourselves are healthy, both physically and emotionally, that we can begin to treat others and help them to achieve good health.

(Note: All students I spoke to fully consented to my use of their contributions in this assignment.)

Anna Taylor, Whole Person Care, Year One, 2012

References

  1. Royal College of Psychiatrists. 1 in 4. [Online] Available from: http://www.youtube.com/watch?v=RZowYsQApbY [Accessed 18th March 2012]
  2. Chew-Graham CA, Rogers A and Yassin N. ‘I wouldn’t want it on my CV or their records’: medical students’ experiences of help-seeking for mental health problems. Medical Education 2003;37:873-880
  3. Boisaubin, Eugene V., and Ruth E. Levine. ‘Identifying and assisting the impaired physician. American Journal of Medical Sciences 322 (2001): 31-36
  4. NICE. Depression: The treatment and management of depression in adults. [Online] Available from http://www.nice.org.uk/nicemedia/pdf/CG90NICEguideline.pdf [Accessed 18th March 2012]
  5. Redfield Jamison K. An Unquiet Mind: A Memoir of Moods and Madness. Picador, UK: 1995
  6. Smith R. All Doctors Are Problem Doctors. BMJ 1997; 314:841
  7. Clyde M. Balint, Norell J, eds. Six minutes for the patient. London: Tavistock, 1973
  8. GMC UK. Good Medical Practice: Conduct and performance of colleagues. [Online] Available from http://www.gmcuk. org/guidance/goodmedicalpractice/workingwithcolleaguesconductand_performance.a sp [Accessed 18th March 2012]
  9. Time To Change. Let’s end mental health discrimination. [Online] Available from http://time-tochange. org.uk/ [Accessed 18th March 2012]