Wellness and Medical School: Aspiration-or Pipe Dream?
Over the past 10 years, a growing literature has documented the significantly increased rates of stress, burnout, depression, and suicidal ideation in medical students.
[[{"type":"media","view_mode":"media_crop","fid":"40452","attributes":{"alt":"© PATHDOC/SHUTTERSTOCK.COM","class":"media-image media-image-right","id":"media_crop_9197267880249","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4147","media_crop_rotate":"0","media_crop_scale_h":"138","media_crop_scale_w":"150","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":" ","typeof":"foaf:Image"}}]]One can scarcely open a newspaper these days without seeing yet another article addressing critical issues in college mental health. The articles focus on very real and important topics: a significant upsurge in students’ stress levels; increased rates of depression and anxiety in college students; campus mental health programs struggling to meet the increased demand for services in the face of limited resources; and, of course, a number of highly publicized suicides of college students on campuses across the US.
For practitioners not directly involved in college mental health, this crisis may have gone unnoticed. According to the American College Health Association annual survey from 2014, 14% of college students were treated for anxiety disorders and 12% received a diagnosis of depression during the past year.1 The numbers are staggering-1 of 4 students on campuses has received a diagnosis or is being treated for a significant psychiatric disorder. On this survey, half of college students reported that they have been stressed to the point where they could not function during the past year. The increased severity of clinical problems students experience and the acceleration in the number of students needing clinical care is unprecedented.
Not all bad news
Some of these trends may be good. The number of students who are entering college with established psychiatric diagnoses and the need for ongoing treatment has increased significantly. This trend may represent successful earlier identification of their conditions and successful treatment outcomes that have allowed them to go to college when they may not have been able to before. The increased demand for services may also show that these young people are more open and vocal about their needs. It seems that they are less affected by stigma, which is very positive.
Increased levels of distress
The increased levels of stress and anxiety have raised questions about the underlying vulnerability of this generation: are they less equipped to handle the transition to life at college? are they less adaptable, less resilient? or, are the environmental stressors more toxic? This is an area ripe for research.
This trend of increased need for services and increased levels of distress is also true in graduate-and especially medical-schools. Over the past 10 years, a growing literature has documented the significantly increased rates of stress, burnout, depression, and suicidal ideation in medical students. In response to these concerns, the American Association of Medical Colleges has encouraged individual medical schools to develop programs to maximize student wellness and encourage help-seeking behaviors.
When I decided to return to my medical school alma mater and direct our campus mental health program 5 years ago, it became clear to me that establishing a strong mental health treatment program would be very important. But more was needed.
In surveying what a wide variety of campus mental health programs do for treatment, outreach, and suicide prevention, we decided to implement evidence-based approaches not only for treatment but also for screening and suicide prevention. Being able to reach students who are in distress but who are not seeking treatment was a priority, as was creating programs to enhance student resilience, promote wellness, and create a campus culture of caring.
Wellness and mental health screenings became an important intervention to reach students in distress sooner and encourage awareness and help-seeking behaviors. The overall strategy was built on a systems approach to promote campus-wide mental health and wellness. This systems approach addresses the multiple levels of influence on a student’s mental health, from the individual micro level, to the social, organizational, and institutional levels that include policy, programs and, more broadly, campus culture.2[PDF]
The University of Texas Southwestern Medical Center includes a medical school, a graduate school for biomedical sciences, and a graduate school for health professions. We are a campus of graduate students, with many unique mental health resources as well as unique challenges that differ from those of undergraduate mental health programs.
Our student population is different. They all have undergraduate degrees and have passed significant hurdles to be accepted to and matriculate in a highly selective professional school. The assumption is that they have successfully passed over a variety of cognitive, emotional, and developmental hurdles to be accomplished and successful applicants.
What we find, however, is that there is wide variability in where students find themselves along the trajectory of maturation of “emerging adulthood.” This variability in maturation accounts for a great deal of success in adapting to the heightened academic, social, and psychological challenges of medical school. The highly demanding nature of the learning environment and the competitive and perfectionistic nature of the students create a backdrop ripe with stress.
Medical school culture, with its “hidden curriculum,” often includes strong messages to “suck it up and soldier on.” Medical schools often do not provide structures or experiences that encourage students to pay attention to their emotional responses when exposed to high levels of illness, suffering, and death in patients.
The systems approach
The first goal in shifting to a campus-wide focus on mental health was to strengthen and increase resources for treatment. We rebranded our student mental health program as Student Wellness and Counseling, to emphasize our focus on wellness and to de-stigmatize help-seeking. By creating mental health treatment programs that are accessible and valued, help-seeking on campus is increased. We tripled the number of patients seen over the first 3 years. And, we hired clinical psychologists trained in evidence-based treatments, such as cognitive-behavioral therapy, for anxiety and depression (the two most frequent conditions on campus). Creating a developmentally oriented, integrated, interdisciplinary treatment team takes a lot of work, but it has improved patient satisfaction and clinical outcomes.
To reach students who were not coming in to see us and to increase awareness of mental health generally, we began a screening program using wellness surveys. Incoming students are screened in their first weeks using an evidence-based wellness assessment. This process educates students about the dimensions of wellness, how school and stress can result in study-life imbalance, and how to respond proactively in rebalancing their “wellness wheel.”
Wellness assessments were also implemented into the curriculum during the weekly small-group sessions with mentors, “Academic Colleges.” Academic Colleges at UT Southwestern are small learning communities that bring together gifted faculty members and small groups of medical students who meet weekly. During these sessions, students perform a self-assessment of their wellness, along a dimensional measure. The small-group format provides the opportunity for medical students to discuss self-care, how to check in with themselves and their peers, and how to be proactive in response to distress.
In addition to focusing on individual student wellness, the students have helped create a wellness program that reaches out to the entire student body and provides “wellness opportunities.” The student-run wellness program offers a Wellness Week twice a year. This program has daily campus activities centered on one aspect of wellness for each day of Wellness Week.
One of the most valued and effective wellness programs we offer is mindfulness meditation classes. Extended into treatment modules for depression and anxiety, mindfulness meditation has a robust evidence base that supports its use in enhancing resilience and decreasing and preventing burnout. Our mindful-ness class is led by a faculty clinical psychologist who is also a teacher and psychotherapist in the community, with extensive experience in meditation.
For campus mental health, it is important not to be confined to your therapy office, but to get out and reach the students where they are-physically and virtually. Outreach, education, and visibility help raise the profile of campus services and normalize our presence as just one more part of student services and activities. Creating strong partnerships across campus with staff most closely involved with students is critical.
Gatekeeper intervention is perhaps the most broadly used suicide prevention technique on college campuses. Gatekeeper training for suicide prevention is based on a social science model that predicts that people are actually unlikely to help others in certain situations.3 Through funds provided by the UT System Board of Regents specifically for reduction of harm on campuses and a gift from a medical school alumnus who experienced suicide in his family, we offer mental health gatekeeper training through an online interactive training tool, Kognito. The program is designed to teach students how to recognize signs of psychological distress in a fellow student. Through role-play conversations, mental health gatekeepers practice how to approach students who may be at risk, discuss their concerns, and connect the student with resources. Kognito also has a training module for campus faculty and staff on how to recognize and respond to students in distress.
We are currently implementing the in-person format of the QPR (question, persuade, refer) Gatekeeper Training for Suicide Prevention.4 QPR mirrors CPR as a lifesaving intervention that can be taught briefly and can save lives. QPR training provides students with skills to respond to a peer in distress through interactive scenarios practiced with fellow students and supervised by trainers. With an extensive evidence base, the program is widely used on hundreds of college campuses across the US. Together with materials on medical student depression and suicide from the American Foundation for Suicide Prevention, we believe these experiences have significantly improved awareness and insight into medical student distress that will open doors to students engaging in treatment.
Conclusion
Gatekeeper training provides medical students with important skills in recognizing and responding to fellow students in distress. This training heightens their awareness of the risks and prevalence of burnout, depression, and suicidal ideation in friends and colleagues, but most importantly, in themselves. Talking openly about medical student and physician depression and suicide de-stigmatizes these topics and encourages help-seeking behaviors. It raises awareness of the mental health issues that affect all of us.
Our focus remains on developing wellness for individuals and the community. Strengthening, practicing, and growing resilience is the key in promoting wellness.5 We would be interested in hearing from others on programs they are using to promote medical student wellness!
Disclosures:
Dr Wiles is the Drs Anne and George Race Professor of Student Psychiatry and Director of Student Wellness and Counseling at the University of Texas Southwestern Medical Center in Dallas. Dr Wiles can be reached at Preston.Wiles@UTSouthwestern.edu. He reports no conflicts of interest concerning the subject matter of this article.
References:
1. American College Health Association. American College Health Association-National College Health Assessment II: Reference Group Executive Summary, Spring 2014. Hanover, MD: American College Health Association; 2014.
2. A Guide to Campus Mental Health Action Planning. Jed Foundation. http://www.jedfoundation.org/CampusMHAP_Web_final.pdf. Accessed July 2, 2015.
3. At-Risk on Campus. Kognito. https://www.kognito.com/products/highered. Accessed July 2, 2015.
4. Quinnett P. QPR Gatekeeper Training for Suicide Prevention: the model, rationale, and theory. QPR Institute. http://www.qprinstitute.com. Accessed July 2, 2015.
5. Southwick SM, Vythilingam M, Charney DS. The psychobiology of depression and resilience to stress: implications for prevention and treatment. Annu Rev Clin Psychol. 2005;1:255-291.
