The mental health and wellbeing of medical students-A case study reflection

Depression is one of the most commonly diagnosed mental disorders among adults. Our understanding of the course and nature of depression has changed signifi cantly in the last 15 years. Depression was previously seen as an acute and selflimiting illness, but is now recognised as a chronic, lifelong illness. The prevalence of depression is of concern, leading to signifi cant patient morbidity, increased mortality and substantial costs to both health and social care [1]. This case report, follows a series of on line interviews with Joanna (an alias for confi dentiality purposes), a 53 year old, university educated, part time accountant, highlighting a number of areas I found thought provoking and the associated refl ective mental health and wellbeing of medical students in general.

of those who recover from a fi rst episode of depression have one or more additional episodes in their lifetime, and approximately 80% of those with a history of two episodes having another recurrence [2]. Once a fi rst episode has occurred, recurrent episodes will usually begin within fi ve years of the initial episode, with fi ve to nine separate depressive episodes in their lifetime [3,4].This correlates positively with Joanna, who has already had four episodes. Joanna revealed that she attempted to take her own life last year, which took me by complete surprise, and it was something that I was not prepared for at all. This correlates with published research. A recent systematic review which included 28 publications, found that factors that signifi cantly increase the risk of suicide, include: male gender (OR=1.76, 95% CI=1.08-2.86), family history of psychiatric disorder (OR=1.41, 95% CI=1.00-1.97), previous attempted suicide (OR=4.84, 95% CI=3.26-7.20), more severe depression (OR=2.20, 95% CI=1.05-4.60), hopelessness (OR=2.20, 95% CI=1.49-3.23) and comorbid disorders, including anxiety (OR=1.59, 95% CI=1.03-2.45) and misuse of alcohol and drugs (OR=2.17, 95% CI=1.77-2.66) [5].
We often read in the media about doctors taking their own life, which provoked me to refl ect and research. A recent systematic review which included 167 cross-sectional studies [n= 116 628] and 16 longitudinal studies [n= 5728] from 43 countries showed that the overall pooled crude prevalence of depression or depressive symptoms in medical students was 27.2% (37 933/122 356 individuals; 95% CI, 24.7% to 29.9%, I2 = 98.9%). In the 9 longitudinal studies that assessed depressive symptoms before and during medical school [n = 2432], the median absolute increase in symptoms was 13.5% (range, 0.6% to 35.3%). The percentage of medical students screening positive for depression who sought psychiatric treatment was only 15.7% (110/954 individuals; 95% CI, 10.2% to 23.4%, I2 = 70.1%). Suicidal ideation prevalence data were extracted from 24 cross-sectional studies (n = 21 002] from 15 countries and the overall pooled crude prevalence of suicidal ideation was 11.1% (2043/21 002 individuals; 95% CI, 9.0% -13.7%, I2 = 95.8%) [6]. A survey of more than 4,300 doctors and medical students in the UK, showed more than a quarter (27%) of respondents reported being diagnosed with a mental health condition at some point, and 40% of respondents reported currently suffering from a broader range of psychological and emotional conditions [7].
At the British Medical Association's (BMA) annual representative meeting in Brighton, UK (2019), members passed a motion calling for more research into the types of mental health issues experienced by medical students and to improve services available to them. The motion further asks that mental health awareness and promotion of self-care practices are made a core part of the curriculum, and that student health services should provide extended opening hours for those studying medicine, who are often unable to comply with a 9-to-5 timetable.

Are symptoms of anxiety related to depressive symptoms and is this common in medical students ?
Most people think of symptoms of depression related to continuous low mood or sadness, feeling hopeless and helpless, having low self-esteem, feeling tearful, guilt-ridden, irritable and intolerant of others , having no motivation or interest in things, fi nding it diffi cult to make decisions , not getting any enjoyment out of life, feeling anxious or worried, having suicidal thoughts or thoughts of harming yourself [8]. Although Joanna described many of the traits above, she also described what she called her sixth sense, almost like an 'aura' and recognised the 'impending sense of doom'. She described this as symptoms of worry and anxiety, feeling anxious about her work as an accountant, 'how she would cope, how this affected her mental health', constant ruminations. She recognised this as being a consistent factor throughout her relapses, demonstrating a thorough understanding of oneself. She described how she will be aware of imminent relapse, complicated by feelings of complete isolation and unable to initiate self-management steps to pivot herself out of a severe depressive episode. She had previously worked full time for a reputable accountancy fi rm but had now resigned herself to part-time, self-employment.
Research studies have consistently documented extensive comorbidity between anxiety and depression [9]. Major depressive disorders co-occur substantially with anxiety disorder, at much higher rates than with other diagnostic categories, such as substance use disorder or impulse-control [10,11]. Moreover, anxiety co-occurring with depression has been shown to have negative implications beyond the impact of each individual disorder, including poorer prognosis, academic diffi culties, suicide risk, lower quality of life, and worse treatment outcomes [12,13].

Are there any intervention to support anxiety for medical students ?
There are a number of self-help interventions that have been shown to help reduce general anxiety symptoms, which include regular exercise, breathing techniques to help you learn to relax, avoiding stimulants (alcohol, smoking caffeine), joining support groups and more specialist online Cognitive Behavioural Therapy (CBT) [17]. When I discussed these with Joanna, she talked about a series of simple breathing exercises that she had been taught to help her, allowing her to focus on being present in that moment, which she found particularly helpful, and suggested this might be helpful for medical students too. Mindfulness, the process by which one attends to present-moment sensations, thoughts, emotions and experiences in a non-judgmental manner [18]

Summary
In conclusion, meeting Joanna has been an invaluable experience, allowing me to refl ect on how her symptoms relate to the mental health and wellbeing of medical students.
There is a high prevalence of anxiety and depression amongst medical students and in those with anxiety symptoms alone, the risk of developing other mental health symptoms longterm is high. Medical student mental health and wellbeing has been recognised by the BMA and proposal to include mental health awareness and promotion of self-care practices as part of the core curriculum, and that student health services should provide extended opening hours for those studying medicine, who are often unable to comply with a 9-to-5 timetable. Most of all however, there are many simple elf help interventions that can help to reduce general anxiety symptoms. Medical students should be more encouraged to take part in university societies, and extracurricular activities.