Stigma and mental health challenges in medical students

Abstract

Despite the perception that medical students and doctors should be ‘invincible’, mental health challenges are common in this population. Medical students and doctors have low levels of help seeking for their own psychiatric problems often only presenting to mental health services once a crisis arises. Fear of exposure to stigmatisation is a crucial factor contributing to symptom concealment and is a barrier to accessing mental health services. Autobiographical narratives of the ‘Wounded Healer’ are gaining popularity among medical students and doctors with mental health challenges both as an effective form of adjunctive therapy and as a means to campaign against stigma. Indeed, the results of a randomised controlled trial to assess the efficacy of Coming Out Proud with mental illness revealed immediate positive effects on stigma stress-related variables. We provide an autobiographical narrative from a medical student who has first-hand experience with mental health challenges.

Background

Introduction

A stigma was a scar on the skin of ancient Greek criminals.¹ It was a sign to all that these people were unsafe, unclean and wanted. Stigma still persists today in the attitudes towards those who have a mental illness.² Nowhere is this more apparent than in the medical profession. In this article, we explore the issue of stigma. We provide a brief overview on the prevalence of mental illness in medical students and doctors. We describe the negative consequences that stigmatising attitudes and behaviours can have on this population.³ We then discuss the merits of autobiographical narratives of those who have mental health challenges.

Stigma: contemporary definition

Although the term stigma has ancient origins, it was only in the 20th century that the term was introduced into the psychological and sociological literature. The Canadian sociologist Erving Goffman described stigma as an attribute considered to be undesirable and unpleasant by society and which differentiates the stigmatised person from other members of the community that he or she should belong to.^{4 5}

Link and Phelan⁶ have further developed the definition of stigma by referring to ‘the co-occurrence of its components’ including stereotyping, prejudice and attitude. Stereotypes are widely held beliefs concerning the habits, behaviours and characteristics that are attributed to people with mental illness. Prejudice is the automatic emotional response to the stereotype and attitude is the affective response that leads to the behaviour adopted to preserve and protect (those who are stigmatising) from the possible consequences that might ensue from the stereotype.⁷

The mental health of doctors

Despite the perception that doctors should be ‘invincible’,⁸ mental illness is common in this population. In Canada, for example, a study using an objective measure of emotional exhaustion revealed that 80% of doctors were suffering from burnout.⁹ Suicide rates are also high with 400 doctors lost to this cause of death every year in the USA alone.¹⁰ We were tragically reminded of the issue of suicide among doctors in the UK when, in October 2000, Daksha Emson, a brilliant trainee psychiatrist with bipolar affective disorder, killed herself and her daughter. An independent inquiry concluded that Dr Emson was the victim of stigma in the NHS and consequently called for a wider understanding of mental illness to try to end the secrecy and taboo associated with it.¹¹

Medical student mental health

The General Medical Council (GMC) stated that medical schools report that one of the most complex situations they face is when a student is struggling with the course due to a mental health condition.¹² The mental health of medical students has been widely discussed over recent years. In a 4-year longitudinal study,¹³ at least 12% of a class of American medical students scored above the threshold number of symptoms on the Beck Depression Inventory. The use of cannabis and illicit drugs is also reported to be on the increase: UK studies in Leeds¹⁴ and Newcastle-upon-Tyne¹⁵ have demonstrated high levels of alcohol consumption and illicit drug use and high anxiety and depression scores.

Doctors and medical students have low levels of help seeking for their own psychiatric problems often only presenting to mental healthcare services once a crisis arises. One reason for this is symptom concealment owing to fears of exposure to stigmatisation.¹⁶

Stigma in medical students

The results of a recent study identified stigma as an explicit barrier to the use of mental health services by 30% of first-year and second-year medical students experiencing depression.¹⁷ In another study conducted in the USA, depressed medical students more frequently endorsed several depression stigma attitudes than non-depressed students. Compared with students with low self-identified depression, students with high scores more frequently agreed that the opinions of depressed medical students would be less respected, that they would be viewed as less able to handle their responsibilities by faculty members, and that telling a counsellor about depression would be risky. Students with high scores would also be less likely to seek treatment if depressed than would students with low scores.¹⁸

These findings may reflect a medical school environment in which depressed students are stigmatised because of their disease rather than on the basis of performance.¹⁸

Mental illness in doctors and ‘self-stigmatisation’

Self-stigma describes the phenomenon whereby people adopt and internalise external social stigma and experience loss of self-esteem and self-efficacy.^19–21 A British study utilising in-depth semistructured interviews revealed that self-stigmatising views, which possibly emerge from the belief that ‘doctors are invincible’, represent a major obstacle to doctors returning to work.³ It has been suggested that doctors stigmatise mental illness more than the public²² and that this may be a contributory factor towards self-stigmatisation. These issues have been recognised as factors in delaying or preventing a doctor seeking medical attention.²³

The ramifications that stigma from healthcare professionals can have on mental health service users

The 2008 Stigma Shout survey of almost 4000 people using mental health services and carers revealed that healthcare professionals are a common source of discrimination reported by people with mental illness.²⁴

Stigmatising views from healthcare professionals can have negative effects on those who suffer with mental health challenges. For example, people with mental illness have lower rates of coronary revascularisation,²⁵ hospital admission for diabetes²⁶ and basic assessments such as blood pressure measurement²⁷ compared with people without a mental illness. These inequalities can actually result in people with mental illness dying prematurely.^28–30

The Wounded Healer

Carl Jung used the term the ‘Wounded Healer’ as an archetypal dynamic to describe a phenomenon that may take place in the relationship between the analyst and analysand.³¹ The ‘Wounded Healer’ remains a powerful archetype in the healing arts. Jung discovered this archetype in relation to himself; for Jung, “…it is his own hurt that gives a measure of his power to heal…”³²

The health humanities

There is a growing perception that science alone provides overall, insufficient foundation for the holistic understanding of the interaction between health, illness and disease.³³ The health humanities has emerged as a distinct entity in attempts to ameliorate the limitations in the provision of healthcare. The health humanities can be described as the application of literature and art (in general) to medicine.³⁴

Autobiographical narrative

It is with the immediacy and authenticity of the first person narrative that the mental illness memoir creates a vivid account of human existence in the ‘Kingdom of the Sick’.³⁵ Reading autobiographical narratives of psychopathology sufferers can ‘augment’ and ‘embellish’ service providers’ and the general public's humanity by offering precious qualitative insights into minds afflicted with mental illness.³⁶

Autobiographical narratives of the Wounded Healer are gaining popularity among doctors with mental health challenges both as an effective form of adjunctive therapy and as a means to campaign against stigma.³⁶

Autobiographical narratives are not just the preserve of doctors, however. In an anonymous article published in Student BMJ, entitled ‘Suicide in medical students’, the author, a parasuicidal medical student, poignantly and evocatively describes his feelings and thoughts towards his personal experiences with low mood and alcohol dependence and how these factors precipitated a suicidal attempt. The author contends that, “… it is only through increasing the extent to which we make it more acceptable to share our experiences with difficulties with low mood that the number of suicides among medics will fall…”³⁷

We provide an autobiographical narrative from a medical student with first-hand experience of mental health challenges.

Case presentation

Disclaimer

It is absolutely imperative to realise that those of you experiencing mental distress in any of its many forms must engage with the appropriate mental healthcare services. You are not the best person to plan your assessment, treatment and referral. You must attend follow-up sessions with the relevant healthcare professionals so as to ensure that you are responding well to therapy and that your occupational, educational and social functioning is not impaired. With the right support, many people who have experienced mental illness have recovered and achieved their goals.

Background

Born in Sheffield in 1992, I had a typical British childhood complete with a loving family. I recall having a deep appreciation and enthusiasm for my education and this, coupled with the unwavering support that I received from my family, stood me in good stead for my preparation to get into medical school. Other than traits of perfectionism with regard to my school grades, and a slight disinterest in socialising, there were no classic predisposing factors of mental illness. My family members were and are all very supportive in every way possible. As many therapists would later seem disappointed to discover, there was no history of abuse or any trauma, other than the usual bullying that high achievers often find themselves up against at primary school and that I soon learnt to ignore.

In 2008, however, I noticed that my life started to transform, initially in subtle ways. Something was creeping up on me, warping my ability to think lucidly. This ‘something’ was forcing me to stay in bed and was impairing my academic functioning; I no longer seemed to be able to focus and complete the important assignments that I would ordinarily be so motivated to do. It was not long before this elusive ‘something’ transformed into an uncontrollable depression. The scars on my body started to tell the ineffable story of my struggles more than I could ever articulate in words. I developed the textbook symptoms: insomnia, reduced appetite, an inability to concentration, irritability, anhedonia and a complete lack of interest in anything that life offered me. Initially I was tearful most of the day—a symptom that I would soon come to miss, as my emotions became completely flat and I seemingly entered a state of nothingness. Despite this, I still managed to complete my GCSEs, achieving straight A/A*s.

Psychosis was soon to join forces with the depression in an unrelenting crusade to crush me. I would spend weeks concealed under my duvet, neglecting my personal hygiene and refusing to eat, drink and take medication. This was followed by a full blown paranoid psychotic episode. I was subsequently admitted into a psychiatric ward and I had to drop out of my A level course. This was to be the first of three admissions in the same year. Just when I thought we were making progress once the psychosis was under control, the depression took hold of the reins and I was at the behest of this cruel disorder of affect. In extremis, I developed suicidal ideation. I was no longer able to resist these thoughts that would permeate my severely depressed mind. I attempted to take my life with my own hand and it so nearly worked. This led to subsequent inpatient admissions, one of which to a hospital over 70 miles away from my family.

Recovery

Today, I still experience mild episodes of low mood and anxiety. The medication that I was initiated on, however, has stabilised me. Pharmacotherapy along with developing an insight that allows me to recognise when I need extra support has enabled me to function once again. Ever since my recovery, I have developed a determination to one day use my experiences positively in my attempt to prevent people from ever having to experience the despair that mental illness can cause and to also try and support those who have already succumbed to psychopathology in any of its many forms.

My interest in medicine was the crucial factor that saved me from myself, and this itself fuelled my passion for it. I enrolled on an A level course at my local college and gained straight A grades, despite recurring periods of illness throughout. I am now in my first year at Sheffield Medical School, and well on my way to realising my dream of being a doctor and helping to tackle the stigmatising beliefs that people with mental illness cannot lead a successful medical career.

Stigma

I have not been exempt from the negative reactions that individuals with mental health difficulties are all too often subjected to. These range from the general misunderstanding of my illness to the more ignorant, hurtful beliefs; from the misconception that depression is the same as sadness to the idea that my history of mental illness (particularly psychosis) means that I am a risk to others (I can explicitly say that I have never, no matter how unwell, ever considered or acted on purposely harming anyone in any way).

It is difficult to know how much of the isolation that I found myself in was due to the depression. It is likely that a large proportion of it was ‘my own choice’. It did not take long, though, until friends stopped trying to break through the wall that I was building around myself. In some cases, they helped to lay the bricks. My phone became much quieter as my thoughts got louder.

What struck me the most, though, is that this stigma is still extremely prevalent among healthcare professionals. Attending the emergency department the few times that I had to was scary not because of my illness itself, but because of the reactions of the receptionists, nurses and doctors to it. On the rare occasion that I was asked how I was feeling, it became uncomfortable if I told the truth. Yet, on many occasions, a 10 min conversation with a psychiatrist or a general practitioner has done more for my health than any medication could (although I do not dismiss how effective medication has been).

Yet, I find myself having to question why people are so reluctant to talk about mental health. Why are psychiatric wards so devoid of get well soon cards and visitors? What makes talking about schizophrenia, bipolar disorder and depression so much more frightening than talking about cancer, diabetes or hypertension? What can we do to change this?

The Wounded Healer and the future…

My experiences of mental illness have, without a doubt, increased my ability to empathise with patients and act with sincere compassion. Not only do I have a sense of how it feels to be in a similar position, but I have the drive to ensure that I do my absolute best in making the individual's situation better, whether that is a life-saving treatment or simply a reassuring smile. Despite this, the potential of my health difficulties being a setback in my career has plagued me since the initial stages of my recovery.

Dr Hankir's ‘The Wounded Healer’ talk and BMJ publication of the same title provided me with some form of perspective and showed me that mental illness does not prevent you from achieving great personal and professional goals. His enthusiastic delivery added to the inspirational journey that Dr Hankir shared with us. It was refreshing to hear a doctor speak so openly about their own challenges with mental illness, and encouraging this openness and acceptance among others. I came away from this talk and from reading his article even more convinced of my existing belief that talking about mental health and sharing experiences is the best way of confronting the stigma surrounding mental illness. The impact was so powerful that I decided that it was time to share my own story in this article. I was unsure about whether I should go ahead with it at first—what if my future employers/colleagues/patients read it and use it against me somehow? However, I realised that these doubts only highlighted how necessary it is to take action. I should not be concerned that my medical history will be used as a weapon by others. I will be a good doctor not despite my experiences but because of them.

If more people can realise that doctors and medical students, like other human beings, struggle from time-to-time with our mental health but can still go on to have a successful career, maybe more doctors will feel comfortable seeking help for themselves, or be more understanding of colleagues and patients who need support. Talks and publications like Dr Hankir's should be a compulsory component of any medical education, to help the next generation of health professionals achieve a parity of esteem between physical and mental health.

Treatment

The patient was initiated on citalopram and mirtazapine and continues to comply with this treatment, which is effectively controlling the symptoms of depressive illness.

Discussion

Stigma and recovery from mental illness

A ‘physician bias’ has been reported in the literature whereby healthcare practitioners, especially psychiatrists, tend to have more negative views, for instance, about the recovery of people with mental illness compared with the general public. This may be because physicians reflect on their own clinical experience where they are more likely to see individuals with severe problems when they are most acutely unwell or mainly during periods of relapse.^{38 39}

We, the authors, feel that this autobiographical narrative and others clearly illustrates that, with the correct treatment and support, those who experience mental illness can recover and go on to become high achievers. Dr Hankir published his own autobiographical narrative in BMJ Case Reports in which he describes his personal experiences with profound oscillations in his mood and how this affected his cognition, behaviour and social and occupational functioning as well as his modus operandi.³⁷ Almost a year later, Dr Hankir went on to receive the 2013 Royal College of Psychiatrists Foundation Doctor of the Year Award thus reinforcing the message in his previous publication, namely that doctors who experience mental distress can recover and go on to realise their dreams.

We hypothesise that if more healthcare professionals were aware of this fact, this would then lead to a change in the negative views towards those who have mental health challenges and their recovery. More research into this area is required utilising validated questionnaires that can measure changes in stigmatising views.

The benefits of experiencing mental illness

As enumerated above, mental illness is the cause of large-scale morbidity and mortality. However, healthcare professionals who have experienced psychopathology describe, much in the same way that the patient has in her own autobiographical narrative, that these experiences have actually made them more empathetic towards mental healthcare service users.

Dr Clare Polkinghorn, for example, in her 2012 Morris Markowe award winning article entitled, ‘Doctors go mad too’, stated that, “…As a psychiatrist, I had hoped that I was pretty good at empathising with my patients…However, the last nine months of my life has taught me more about mental illness than years of clinics, ward-rounds and home visits or reading psychiatric literature…I was diagnosed with a depressive illness, detained under the Mental Health Act and spent 6 weeks in an NHS psychiatric hospital…”⁴⁰ Dr Polkinghorn, in the epigram of her exposition, quotes Atticus Finch from Harper Lee's To Kill a Mocking Bird: “In order to understand someone you have to slip into their shoes and walk around in them…”⁴¹ It seems that the author is suggesting that healthcare professionals who have first-hand experience of mental health challenges are able to better understand what it is like for mental healthcare service users. This understanding can facilitate empathy, which in turn can enable ‘healing’ to take place.

If other healthcare professionals who have not experienced psychopathology were more aware that having a mental illness may not necessarily be a disadvantage (but on the contrary may actually be advantageous as illustrated in this case report and others), this might lead to a change in attitudes.

The efficacy of Coming Out Proud on reducing self-stigma

Many people with mental illness have to choose between secrecy and disclosure in different settings. Coming Out Proud (COP) is a 3-week peer-led group intervention that offers support in making this difficult decision in order to reduce stigma’s negative impact.⁴¹

A group of researchers conducted a randomised controlled trial to assess COP’s efficacy to reduce negative stigma-related outcomes. The results revealed no effect of COP on self-stigma or empowerment, but immediate positive effects on stigma stress, disclosure-related distress, secrecy and perceived benefits of disclosure, which may thus alleviate stigma’s negative impact.⁴¹

Both Dr Hankir and the patient, although they have not objectively measured stigma-related outcomes, report that talking candidly about their personal experiences with mental health challenges can be subjectively liberating and even cathartic, particularly in a setting in which there are other healthcare professionals who have had similar experiences, since they are able to derive solace from shared experience.

Conclusion

Stigma and discrimination are pervasive phenomena that exert a negative influence, through a multitude of ways, on the lives of many individuals affected by mental illness. Antistigma work targeting specific groups, such as healthcare staff, or strategies that empower individuals facing discrimination, are likely to play a key role in reducing the impact of stigma. Interventions building on the principle of contact frequently show promise at reducing the stigma associated with mental health challenges and we need to continue to incorporate personal stories and narratives into interventions in order to build awareness at local and national levels.

Learning points.

• Despite the perception that medical students and doctors should be ‘invincible’, mental health challenges are common in this population.

• Medical students and doctors have low levels of help seeking for their own psychiatric problems, often only presenting to mental health services once a crisis arises.

• Self-stigma—the phenomenon whereby people adopt and internalise external social stigma and experience loss of self-esteem and self-efficacy—has been recognised as a factor in delaying or preventing doctors from seeking medical attention.

• Fear of exposure to stigmatisation from the public and healthcare professionals is a crucial factor contributing to secrecy and symptom concealment and is a barrier to accessing mental health services.

• A randomised controlled trial on the efficacy of Coming Out Proud with mental illness has revealed immediate positive effects on stigma stress-related variables. Such interventions have shown promise in reducing the stigma associated with mental health challenges and we need to continue to incorporate personal stories and narratives into interventions in order to build awareness at local and national levels.