Medical students and suicide
Many medical students struggle with large debts and high academic standards. How can students’ wellbeing and the culture of medical school be improved?
During his second year of study, Tom (a pseudonym) regularly thought about killing himself and the freedom that this would bring. But the fourth year, UK based, medical student says he remained determined not to do it.
Tom represents the one in 10 medical students who experience suicidal thoughts, according to a systematic review and meta-analysis of the prevalence of depression, depressive symptoms, and suicidal ideation among medical students published by the Journal of the American Medical Association (JAMA) at the end of 2016, which reviewed over 200 studies in 43 countries.
Tom hit rock bottom with ongoing depression in his second year and faced problems professionally because of his “lack of enthusiasm” in clinical skills teaching sessions. He also became aware that psychological issues, stemming from his childhood with a violent alcoholic father, were starting to surface.
“I thought about death daily, but luckily my innate stubbornness not to give in, and a promise I made to myself of never doing it, took precedence,” says Tom, who was among students to respond to a survey about medical student health conducted by Student BMJ in 2015.
He says he did not receive adequate support from his university, but a network of friends and family, and the right combination of drugs from his GP, helped him to recover.
How common is suicide in the medical student population?
The research published in JAMA found that 27.2% of the 122 356 medical student participants reported depressive symptoms—higher than the general population. Around 11% of the participants reported suicide ideation.
A Student BMJ survey of 1122 medical students, published in 2015, also found a high rate of suicide ideation (15%). A total of 30% of students said that they had received treatment for a mental health condition while at medical school.
Medical student suicides continue to be in the news. In 2017, there was an inquest into the death of a Southampton University student who took an overdose. Meanwhile, media in India have this year reported three suicides in one state in the space of four months.
Douglas Mata, lead researcher of the JAMA paper and clinical fellow in pathology at Brigham and Women’s Hospital, Boston, USA, says, “A lot of people who have suicidal ideation are not actually going to go through with attempting to commit suicide. But nonetheless it increases your risk of attempt or completion [over the next year] by 10 fold or 100 fold respectively; so it’s an alarming statistic.”
Why are medical students susceptible to mental illness?
Mata has examined data on depression among medical students worldwide since the early 1970s. “It’s not getting worse, but it’s not getting better either,” Mata says.
His research has shown that before starting medical school, students have better mental health than their would-be teacher or business peers. But this changes when medical students get to university. He lists the contributing factors as stress, sleep deprivation, academic rigour, exposure to traumatic clinical situations, debt, and moving away from loved ones.
Alys Cole-King, consultant liaison psychiatrist in north Wales and clinical director of Connecting with People, an organisation that provides training and resources for the prevention of suicide, says, “Most medical students will be perfectionists. They can have more stigma—not less—about disclosing mental health issues.” She also says that debt is a huge stress factor for medical students, who often have longer and more expensive courses than students in other disciplines.
One medical student from Lancaster University, who attempted suicide with a drug overdose, has spoken to Student BMJ. The student claims it was the culmination of a series of events, including immense pressure and suspension from a hospital placement after recreational drug use. “This sent me into a spiral that I found it hard to pull out from,” says the student, who is now well after successful treatment by their GP.
Kate Simpson, a third year medical student at Liverpool University, has a history of disordered eating, depression, and anxiety. Kate’s health took a downturn during her first year at university as she struggled with the demands of the course and the feeling that she was underperforming.
When a consultant told her that she would “never become a doctor” during a ward round on her first clinical placement, Kate had only just started to see a counsellor.
“That was the first time I had considered suicide. It lingered in my mind for several months, and [during] the weeks where I was timetabled in hospital rather than in lectures; those feelings were overwhelming,” she says.
Simpson, who writes a blog about her experiences, praises Liverpool University’s Psychological Support Service for Student Practitioners, which supported her recovery.
This unique, university funded service is dedicated to health science students, says its senior clinical psychologist, Linda Steadman.
The service supports 12 to 16 students each week, most of whom are medical students, providing individual 1.5 hour consultations including a range of psychotherapies.
“Demand has increased over the years, and we actually see that as a positive development [because awareness has increased] and the GMC [General Medical Council] has commended it as a model of good practice,” says Steadman.
University College London (UCL) is aiming to increase access to support for medical students alongside the existing evening counselling appointments available for those on placements.
Students can also self-refer for group or individual sessions of cognitive behavioural therapy and psychodynamic therapy through the counselling service.
UCL director of student support and wellbeing Denise Long says, “We want to show students that there are lots of different ways to access support. It does not have to be face to face.”
There are also a number of medic-specific confidential services outside of universities including the BMA’s 24 hour, year round counselling service, which is available to both non-members and members.
BMA medical students committee welfare lead Twishaa Sheth says,
“It is crucial that students feel able to speak up [about mental health issues] because the support systems are there if we speak out.”
The GMC and Medical Schools Council have produced guidance to help medical schools support students with mental health conditions, and help schools to establish their own policies.
The guidance covers prevention—such as promoting wellbeing and fostering an open environment where mental health conditions can be discussed without stigma; identification; referral; and ongoing management and support.
Colin Melville, GMC director of education and standards, says, “I would encourage any medical student who thinks they may have a health related concern to be proactive and to approach the relevant staff within their medical school. The school can provide timely advice, offer support, or refer them for independent medical advice.”
Melville also adds that medical students have found its mental health myth busters guide useful. This guide covers the common misconceptions medical students have about mental health and how it impacts on issues relating to fitness to practise.
What support works?
Unfortunately, there is not a simple solution. Mata outlines three available approaches: reactive—having counsellors available if needed; proactive—having events to promote wellbeing; and systemic—attempting to change the prevailing culture.
Some students are actively seeking to change the culture around mental health issues by creating a more open environment for the discussion of mental health concerns.
Aisling O’Sullivan and Jerry Su, third year students at UCL, ran an event for medical students earlier this year called “What do you think?” This aimed to combat the stigma surrounding mental health and improve understanding of different mental health conditions. The day, funded by the university, included discussions on eating disorders and suicide, performances, and classes in mindfulness, meditation, yoga, and creative writing.
Subodh Dave, a clinical teaching fellow and consultant psychiatrist at the Royal Derby Hospital, UK, says that students often disclose a mental health issue whilst on placement. He argues that better links could be made between placement providers and universities to support such students.
Dave, who is also associate dean at the Royal College of Psychiatrists, says that medical students should be given talks in year one about the risk of mental ill health and where they can access support. He adds that educational supervisors need more time and training to support these students.
Meanwhile, some universities have sought to change their culture by altering their curriculum.
St Louis University School of Medicine, Missouri, USA, showed some improvement in students’ mental health by reducing class hours and introducing a pass or fail grading system, longer term electives, and sessions such as mindfulness.
Steadman says she is keen to establish self-care—mental health awareness training—within the professional skills part of the medical school curriculum in Liverpool.
Cole-King agrees on the importance of this. She sums it up by saying that just as students need to ease the pressures of exams by preparing in advance, they need to put time into promoting wellbeing and emotional resilience.
“Professional athletes know that pushing themselves at 100% of their capacity 100% of the time results in little or no long term performance gain and will probably shorten their career. So they build ‘recharge time’ into their training routines. We could all benefit from the same approach when developing and maintaining emotional wellbeing and resilience,” she says.
Sources of support
The BMA Counselling Service is a 24 hour confidential support line for doctors and medical students with immediate access to trained counsellors—Telephone: 08459 200169. www.bma.org.uk/advice/work-life-support/your-wellbeing .
The Samaritans offer a 24 hour service for anyone who wants to talk through their difficulties in confidence. You don’t have to feel suicidal to get help—www.samaritans.org/ or telephone: 08457 90 90 90.
The Doctors Support Network is a charity set up by doctors with experience of mental health problems to support others in the same situation. It has an online support forum for student members and points to some useful resources—www.dsn.org.uk.
Competing interests: None declared.
Provenance and peer review: Commissioned; not externally peer reviewed.
- Rotenstein LS, Ramos MA, Torre M, et al. Prevalence of depression, depressive symptoms, and suicidal ideation among medical students. JAMA 2016;316:2214-36.
- Student BMJ. Medical students with mental health problems do not feel adequately supported. 2015. www.bmj.com/company/wp-content/uploads/2014/07/student-bmj-survey.pdf
- Irving N, Jones S. Medical student, 20, killed herself by overdosing on diet pills bought online. Mirror 2017; 26 January. www.mirror.co.uk/news/uk-news/medical-student-20-killed-herself-9695536 .
- Dwivedi S. Stress driving aspiring docs towards suicide. Ahmedabad Mirror 2017;10 February. http://ahmedabadmirror.indiatimes.com/ahmedabad/education/stress-driving-aspiring-docs-towards-suicide/articleshow/57088336.cms .
- Connecting with People. About Us. 2017. www.connectingwithpeople.org/about.
- The Medic Journal. Just Average. 2017. www.themedicjournal.com .
- University College London. Student Psychological Services. 2017. www.ucl.ac.uk/student-psychological-services/index_home .
- British Medical Association. BMA Counselling and Doctor Advisor service. 2017. www.bma.org.uk/advice/work-life-support/your-wellbeing/bma-counselling-and-doctor-advisor-service .
- General Medical Council. Supporting medical students with mental health conditions. 2017. www.gmc-uk.org/education/undergraduate/23289.asp .
- General Medical Council. Myth busters. 2017. www.gmc-uk.org/education/undergraduate/26588.asp .
- University College London. UCL Medical students mastermind What Do You Think?: a mental health awareness day to change your perspective on mental illness. 2017. www.ucl.ac.uk/news/students/012017/012017-180117-what-do-you-think-mental-health-awareness-day .
- Slavin SJ, Schindler DL, Chibnall JT. Medical student mental health 3.0: improving student wellness through curricular changes. Acad Med 2014;89:573-7.
- General Medical Council. Doctors under pressure need resilience, not mental toughness. 2017. https://gmcuk.wordpress.com/2015/07/15/doctors-under-pressure-need-resilience-not-mental-toughness/ .