Thursday, September 6, 2018

The Cruelty of Depression

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Author: Becky Lee, MS4
University of Maryland School of Medicine
AAEM RSA Wellness Committee

In the middle of a hot August day, excited chatter echoed inside the dome of the columned, 200-year-old medical school building. It was our first day of medical school, and my classmates and I were eager to get started on our long-held dreams of becoming doctors. The next few days of orientation were a blur of information and optimism, all leading up to the first day of anatomy lab, where we paused in solemn silence to thank the donors and their families. I let this feeling sink in – the feeling that I was exactly where I was supposed to be. I had no idea that the next few months would be my darkest days of medical school. By the time winter break loomed around the corner, I couldn’t sleep, I no longer felt like eating, and I stopped talking to my friends and family. I stopped running and reading. In fact, I stopped going outside altogether. I spent most of my time in bed, staring at the ceiling, wondering if things would ever get better, and questioning how I ended up here. Sometimes, the thought occurred to me that I wouldn’t mind if I didn’t wake up the next day.

When I think back and try to understand how I became so depressed, I imagine a video montage: me, a bright-eyed medical student, coming home that first day, eyes already scanning the fresh new pages of Netter’s. I was motivated to learn every coiling arterial branch and delicate layer of muscle. As the days progress, the film drains a bit of its color frame by frame. The novelty of medical school begins to fade and the stress from the sheer workload and social isolation begins to pervade my normally buoyant demeanor.

By the end of fall, everything became dreary and gray. The oppressive feelings of apathy, dread, and fatigue were relieved only by punctuated moments of the shame and anxiety that I was struggling so much. I frequently thought, “My application must have slipped through the cracks. I must have been admitted by mistake.” I often woke up in the middle of the night, dreading the inevitable torrent of new information that would greet me in the morning. I could barely hold it together during anatomy lab, my friendly, uncertain smile beguiling the fact that I was scared to death. I hoped my new classmates would not notice my distress because a simple, “Are you okay?” would have been enough to topple my fa├žade, leaving me in a puddle of tears. Each day of anatomy lab went like this and ended with me sitting in front of my anatomy textbook, no longer a symbol of liberating possibility, but instead a heavy weight that I now carried at all times on my shoulders, my chest, and in my nightmares.

There was no dramatic moment of insight. Everything happened gradually, including my eventual acceptance that I was deeply unhappy. I knew the school had counseling services, but I was afraid that an appointment would confirm that I didn’t have what it takes to make it through medical school. At the same time, I was beginning to become familiar with a sense of dread that this was it: this numbness, fear, and shame would be my life for the rest of medical training. That was not okay. I needed help. I dialed and pressed call. When I sat across from the school psychiatrist at the counseling center a few days later, I admitted, “It’s been horrible.” My tense shoulders melted for the first time in many months when she looked at me warmly and gave me hope: “You’re not alone,” she said, “lots of students come to see me every year.” She referred me to the medical school’s psychiatry resident clinic, where I began to work with a compassionate psychiatrist-in-training, who helped support me to get me back on my feet. Oftentimes, a few words of validation from someone who had been through medical school herself were often powerful enough to completely relieve my worries. After starting a selective-serotonin uptake inhibitor (SSRI) and undergoing cognitive behavioral therapy (CBT), I gradually began to feel like myself again. Nowadays, I make sure to take time to enjoy feeling like I am on solid ground because it has not been long since I felt like I was drowning.

I can now look back and see that I was needlessly suffering alone. As lonely as I felt, depression is a common issue in medical students. In 2016, The Journal of the American Medical Association (JAMA) published a meta-analysis that demonstrated a prevalence of 27.2% of depression or depressive symptoms and 11.1% of suicidal ideation in medical students.[1] These numbers are no surprise to me. I’ve had numerous conversations with my classmates, where we realized there were times where we would have easily qualified for SIGECAPS, especially during the study period for Step 1. These shared realizations are always followed by an uneasy pause because we are never sure whether we should broach this heavy topic. I was one of the countless medical trainees who suffer silently with their depression, but I am not anymore. Depression in medical students has been a long-standing problem in medical education that demands systemic changes. The prevalence of depressive mood in medical students was described in JAMA as early as 1988.[2] What kind of policy changes have medical schools implemented to address this issue so ingrained in our education? One strategy has been switching to a pass/fail curriculum, which has been shown to decrease stress and improve wellbeing, at least in the short term.[3]

Unfortunately, there is limited research to guide medical schools on how to help their students. Research in the interventions that effectively improve mental health in medical students is essential to producing wide-spread change. We need a two-pronged approach that involves both policy changes and individual efforts to deconstruct stigma against mental illness. The conversations we have about mental illness matter. Even with access to mental health services, depressed medical students are undertreated and have cited concerns about stigma.[4] When I realized that my start to medical training, as isolating as it was, was a common experience, I was more comfortable being open about it. I posted my story and the resources that my school offered on our class Facebook group. Since then, several my colleagues have reached out to tell me about their similar struggles. Each time that I made myself vulnerable by sharing, I continually realized that many of my classmates and I were each taking on the heavy burden of medical school by ourselves. The cruelty of depression is that it convinces us that we are on this journey alone, but the truth is, many of us are traveling the same path. By speaking openly about this common experience, we can mold our medical culture to emphasize acceptance, resilience, and recovery.

The issue of depression and suicide in students, residents, and physicians is an area of concern that is central to the Wellness Committee at AAEM/RSA. Emergency medicine providers continue to face challenges with mental health; a 2018 Medscape survey found that 48% of emergency medicine physicians responded that they were “burned out, depressed, or both.”[5] The same survey revealed alarming rates of burnout reaching many other areas of medicine. AAEM/RSA strives to alleviate these manifestations of stress by addressing wellness at the medical student and resident level. We can promote wellness by accepting that though medicine is certainly a career held to high standards, at the end of the day, we are all human. We need to eat and sleep well, exercise, and maintain meaningful connections, just like we encourage our patients to do. And just as we are vulnerable to physical ailments, we are also susceptible to strains on our mental health, manifesting as anxiety, depression, or even suicidal thoughts. The demands in medicine will always be present, but we can change the way we take care of each other and ourselves.

References:

1. Roteinstein LS, Ramos MA, Torre M. Prevalence of depression, depressive symptoms, and suicidal ideation among medical students. JAMA. 2016;316(21):2214.

2. Clark DC. Vicissitudes of depressed mood during four years of medical school. JAMA. 1988;260(17):2521-8. doi:10.1001/jama.260.17.2521.

3. Spring L, Robillard D, Gehlbach L, Simas TAM. Impact of pass/fail grading on medical students’ well-being and academic outcomes. Med Educ. 2011;45(9):867-77.

4. Tjia J, Givens JL, Shea JA. Factors associated with undertreatment of medical student depression. J Am Coll Health. 2005;53(5):219-224. doi:10.3200/jach.53.5.219-224.

5. Grisham S. Medscape emergency medicine physician lifestyle report 2018: personal happiness vs. work burnout. Medscape. https://medscape.com/slideshow/2018-lifestyle- emergency-medicine-60092234#. Published January 24, 2018. Accessed August 5, 208.

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