Academic Psychiatry 27:19-20, March 2003
© 2003 Academic Psychiatry
On the Importance of Anonymity in Surveying Medical Student Depression
Michael Myers, M.D.
Dr. Myers is Clinical Professor in the Department of Psychiatry, University of British Columbia, and St. Paul's Hospital, 1081 Burrard Street, Vancouver, BC, Canada V6Z 1Y6. E-mail: myers{at}telus.net
Key Words: Medical Students • Survey Methods • Confidentiality
Dr. Levine and colleagues' study of depression in medical students at one medical school (1) has identified several issues: that it is hard to obtain accurate measures of depression in medical students at various points in their training by using an anonymous questionnaire; that students do not trust reassurances about anonymity and confidentiality of their responses; that identifying symptomatic medical students, especially students with suicidal ideation, creates ethical dilemmas for both the researchers and the subjects; that it is challenging to replicate earlier research that has illustrated lower rates of depression in a curriculum that is problem based rather than traditional; and that in future studies, giving students a role in research by having them choose their own personal identification numbers may enhance the validity of their answers.
The authors have postulated several possible reasons for low response rates and dishonest responses on self-report depression questionnaires: invasion of privacy; fallout from any perceived "weakness" associated with mental symptoms (effects on academic standing and progression and competition for residency positions); ethical angst about participating or not participating in the research; stigma of mental illness; worry about obtaining health or disability insurance upon graduation; and perceived "double agent" roles of researchers who are also their teachers and program directors. I would like to expand on a few of these and introduce other potential factors.
As a specialist in medical student and physician health, I have been given a privileged opportunity to appreciate the complexities of our trainees' lives. What follows are some insights that I have gained from my medical student patients. These insights help to explain students' attitudes toward and responses to well-intentioned attempts to study their mental health and well-being—and why some questionnaires are immediately tossed into the recycling bin, why some are only partially completed, and why some are falsified.
Today's medical students are far from monolithic. At my medical school orientation week, when I look out at the class I see a cultural mosaic, an arresting sea of diverse faces. Each one brings a unique vision to the study and practice of medicine. Most have lots of energy, passion, sense of responsibility, and self-discipline. But we medical educators also are aware that an unknown percentage of our students have already been diagnosed with and treated for depression prior to acceptance to medical school. Another cluster have first-degree biological relatives with substance abuse problems and/or mental illness—especially mood disorders. Indeed, these family-of-origin facts have often been instrumental, at least partially, in the student's quest to become a physician.
Many if not most of us in medicine are wounded healers. We have survived poverty, hunger, war, forced migration, torture, family heartache, alcoholism, divorce, suicide deaths of loved ones, physical, emotional, or sexual abuse, racial and ethnic discrimination, religious persecution, gay-bashing, life-threatening disease, and other traumas and losses too numerous to count. These "sticks and stones" and scars of battle generally strengthen us, enable us to do better work, and make our empathy for patients palpable. But these same psychosocial dynamics, coupled with genetic loading, can make medical students and physicians very vulnerable to depression and other psychiatric illnesses; subclinically, they make them fearful, wary, and very private about personal matters.
And there is more. Today's medical students have lots of anxiety about money—student loans or debts to their parents. Some are living with worry and role conflict about a family member with a severe, life-threatening illness. Some lose a loved one by death and don't really get a chance to grieve properly. Many medical students are adult children of divorce. In fact, at no time in the history of medical education have we had so many women and men studying medicine whose parents have divorced, some more than once. There may be residual hurt and conflict that cause anxiety and insecurity in their own love relationships and marriages. Some medical students are sons and daughters of IMG (international medical graduate) physicians; not only do they feel pressure to do well scholastically, but some feel guilty about their symptoms (including thoughts of suicide!) or feel ashamed of "not coping well" given what their parents have gone through to "make it" in North America.
I agree with the authors about the effect of stigma on research into depression in medical students. I would go further: stigma associated with mental illness is pervasive in the house of medicine. One type, enacted stigma, refers to actual discrimination against or unacceptability of psychiatric illness in the profession. There is less of this kind of stigma in our medical schools than there once was, but we still have some way to go. Despite our efforts at orientation with medical students, they witness very quickly in lectures, seminars, and at the bedside subtle and not so subtle cracks about the mentally ill, including whispers and asides about attending physicians and classmates who fall prey. Another type is felt stigma. This refers to the fear of such discrimination. This fear rests within the student himself or herself. Both types of stigma threaten self-esteem, security, identity, and life chances. Felt stigma leads to nondisclosure and concealment, and ultimately it proves more disruptive of the student's life.
Stigma reinforces denial and minimization of symptoms. Who wants to accept (or grasp the magnitude of the realization) that their weight loss, insomnia, fatigue, or inability to study might be due to depression? Hence, medical students hesitate to go for help early, and their morbidity is enhanced. We know that stigma kills; witness the number of individuals who die by suicide each year who have succumbed to a treatable illness—an illness that was undiagnosed, untreated, or undertreated.
Yes, we need to continue studying medical students (especially for purposes of primary and secondary prevention), but we also need to make certain that we have good care available for them—care that is humane, affordable, immediately available in a crisis, comprehensive, state-of-the-art, culturally competent, and surrounded by the highest safeguards for confidentiality. And as their role models, we need to fight internalized stigma within ourselves, lead a balanced life, and be judiciously open about our own personal psychiatric treatment.
REFERENCES
- Levine RE, Breitkopf CR, Sierles FS, et al: Complications associated with surveying medical student depression: the importance of anonymity. Acad Psychiatry 2003; 27:12-18[Abstract/Free Full Text]
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M. F. Myers
Physician Impairment: Is It Relevant To Academic Psychiatry?
Acad Psychiatry,
February 1, 2008;
32(1):
39 - 43.
[Abstract]
[Full Text]
[PDF]
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