By Alexandra J Brown, Temple University School of Podiatric Medicine, Class of 2022
It is probably no surprise to readers that many studies suggest medical students experience higher levels of anxiety, depression, and perceived stress as compared to their age-matched non-medical student peers (1). How prevalent are these mental health problems during medical training? A 2016 systematic review and meta-analysis evaluated 195 studies and reported a 27.2% rate of positive symptoms of depression, with 11.1% of participants demonstrating suicidal ideations (2). Longitudinal analyses demonstrate that medical students never reach their pre-matriculation baseline levels of physical, emotional, and overall health, with the lowest point occurring at the end of the first year of studies (3). Although relatively recent, some studies support the hypothesis that the pandemic is further negatively affecting medical students (and the general population’s) mental health, significantly affecting anxiety and stress levels (4). These statistics are tragic – what can we do about it?
Ironically, I experienced a ton of anxiety when trying to write this article. Having personally struggled with anxiety disorder and depressive episodes, it is incredibly important to me to present an accurate, helpful article. During the early months of the pandemic, I started dedicating many hours to investigating research-based methods to improve mental health. Although most is advice we’re already familiar with (e.g. sleep at least 7 hours per night, exercise 30 minutes at least 3 times per week), I only started incorporating these practices after understanding the research behind it. Part of my anxiety about this article was an unrealistic goal of sharing all the information available. Although I couldn’t distill a comprehensive review, I have collected a series of resources to share, as well as the learnings that were most impactful for me in this journey. Before I jump into the advice portion, it’s helpful to acknowledge why medical students do not readily disclose their mental health problems, as well as how helpful it is for mentors to share their own struggles with students.
There are many unseen barriers to students seeking mental health support during medical school.
There are many unseen barriers to students seeking mental health support during medical school. Students worry about perceived stigma, confidentiality, unwanted interventions, time, and cost factors (5). Understandably, students are often reluctant to disclose their struggles because, despite many efforts, mental health remains highly stigmatized. Of note, research suggests that physician mentors discussing their vulnerabilities (e.g. failures, personal psychopathology) openly with medical students may lessen the students’ stigma of mental health and increase their likelihood to disclose personal mental health needs (5). Conscious efforts on the part of physicians, administrators, and student peers to reduce the stigmatization will ultimately help develop healthier healthcare providers. This is why I openly discuss my mental health experience. Although I am not a physician, I am an upperclassman. My hope is that sharing these experiences helps at least one student feel less alone.
Now for the advice, as promised:
Meditation and Self-Compassion
The most interesting thing I read about meditation is why it helps make you happier. There is evidence that the mind wanders, due to what is called the brain’s “default network.” Studies suggest that mind-wandering is not only prevalent with estimates that we mind-wander nearly 46.9% of the time, but also that the mind-wandering actually causes you to be less happy (6, 7). Research shows positive effects associated with meditation, including decreased mind-wandering, increased concentration both during and after the meditation, more positive moods, and increased feeling of social connection (6). In short, meditation may help you increase happiness.
Self-compassion is more important than ever in a year like 2020; as we move into 2021, it is a worthy New Year’s resolution for all. “There’s a lot of evidence that self-compassion has enormous benefits and that it is trainable through meditation,” says Dan Harris, cofounder of Ten Percent Happier. Being understanding and kind to yourself and allowing yourself grace when you experience hardship, failure, or feelings of inadequacy is critical to your mental well-being. So much of our lives, social connectedness, studies, and daily stressors have been significantly impacted by the COVID pandemic. It is imperative that we practice self-compassion. In medical school, we are often overly self-critical and/or self-doubting. It is detrimental to our mental health to compare our current situation to the upper-year students before us. We need to recognize the many effects the pandemic is having and allow ourselves to be comfortable with our best efforts by not holding ourselves to the standards of success that were defined pre-pandemic.
Kindness and Happiness
In addition to being kind and understanding towards yourself, research supports the concept of “random acts of kindness” for others and the subsequent effects on happiness. A fascinating study by Lyubomirsky et al. suggested performing intentional acts of kindness not only increases mood temporarily, but it also results in long-lasting well-being (8). Additionally, people committing acts of kindness are more likely to feel efficacious, confident, and optimistic about their ability to help (8). Acts of kindness may include talking to a stranger, donating blood, treating a friend to coffee, writing a thank you note to someone you have been meaning to thank.
Something very small that has helped my well-being is offering to help strangers who appear lost. Every so often, someone is not interested in help with directions and will simply say, “No.” The vast majority of the time, though, the stranger is genuinely appreciative for the help. Not only does it make me feel useful, boost my mood, and help me feel more socially connected, but it makes the city seem more friendly. There is a great deal of evidence suggesting that, although we may think we prefer solitude, being social and having strong social ties are what actually make people happier (9). Talking to strangers might sound scary or you might think the other person would be annoyed (and they might be – definitely respect boundaries!), but research supports that starting these conversations more often makes both parties happier than they were prior to the exchange (10). Doing something as simple as giving directions helps the individual get to their destination, we both get a temporary mood boost, and it improves my overall well-being.
being social and having strong social ties are what actually make people happier
Intentionally practicing gratitude has significantly improved my mood and perspective on my life. Gratitude can be defined as a, “positive emotional state in which one recognizes and appreciates what one has received in life” (11). Reflecting on what or whom you are grateful for in life has been shown to increase happiness, supported by a study evaluating several happiness interventions (12).
Gratitude can be practiced with daily journaling, such as taking a few minutes every night to jot down 5 things for which you are grateful. Practicing gratitude can also look like writing a “thank you” letter to someone you feel you haven’t properly thanked and visiting them to read the letter to them. A study evaluating happiness interventions found that these gratitude visits can cause large positive changes in happiness that last for a whole month (12)! Anecdotally, gratitude visits have the most significant effect for me. When I remember to complete my gratitude journaling exercise, I start the next day feeling better than baseline.
An important thing to remember when incorporating these practices: happiness takes work. Sonja Lyubomirsky, psychologist and author of The How of Happiness, says, “Even though we know what will make us really happy, we still don’t do it as much as we should…I have to put it in my to-do list to make sure I create time…It’s a deliberate act.” Although it takes practice and a conscious effort to incorporate these practices, it is worth every bit of work to be incrementally happier.
By Alexandra J Brown
Temple University School of Podiatric Medicine, Class of 2022
1. Dyrbye LNT, Matthew R; Shanafelt, Tait D; . Systematic Review of Depression, Anxiety, and Other Indicators of Psychological Distress Among U.S. and Canadian Medical Students. Academic Medicine. 2006;81(4):354-373.
2. Rotenstein LS, Ramos MA, Torre M, Segal JB, Peluso MJ, Guille C, Sen S, Mata DA. Prevalence of Depression, Depressive Symptoms, and Suicidal Ideation Among Medical Students: A Systematic Review and Meta-Analysis. JAMA. 2016 Dec 6;316(21):2214-2236. Epub 2016/12/07. doi:10.1001/jama.2016.17324. Cited in: Pubmed; PMID 27923088.
3. McKerrow I, Carney PA, Caretta-Weyer H, Furnari M, Miller Juve A. Trends in medical students’ stress, physical, and emotional health throughout training. Med Educ Online. 2020 Dec;25(1):1709278. Epub 2020/01/07. doi:10.1080/10872981.2019.1709278. Cited in: Pubmed; PMID 31902315.
4. Saraswathi I, Saikarthik J, Senthil Kumar K, Madhan Srinivasan K, Ardhanaari M, Gunapriya R. Impact of COVID-19 outbreak on the mental health status of undergraduate medical students in a COVID-19 treating medical college: a prospective longitudinal study. PeerJ. 2020;8:e10164. Epub 2020/10/23. doi:10.7717/peerj.10164. Cited in: Pubmed; PMID 33088628.
5. Fletcher I, Castle M, Scarpa A, Myers O, Lawrence E. An exploration of medical student attitudes towards disclosure of mental illness. Med Educ Online. 2020 Dec;25(1):1727713. Epub 2020/02/15. doi:10.1080/10872981.2020.1727713. Cited in: Pubmed; PMID 32054420.
6. Brewer JA, Worhunsky PD, Gray JR, Tang YY, Weber J, Kober H. Meditation experience is associated with differences in default mode network activity and connectivity. Proc Natl Acad Sci U S A. 2011 Dec 13;108(50):20254-9. Epub 2011/11/25. doi:10.1073/pnas.1112029108. Cited in: Pubmed; PMID 22114193.
7. Killingsworth MA, Gilbert DT. A wandering mind is an unhappy mind. Science. 2010 Nov 12;330(6006):932. Epub 2010/11/13. doi:10.1126/science.1192439. Cited in: Pubmed; PMID 21071660.
8. Lyubomirsky S, Sheldon KM, Schkade D. Pursuing Happiness: The Architecture of Sustainable Change. Review of General Psychology. 2005;9(2):111-131. doi:10.1037/1089-2618.104.22.168.
9. Diener ES, Martin E.P. Very Happy People. Psychological Science. 2002;13(1):81-84.
10. Epley N, Schroeder J. Mistakenly seeking solitude. J Exp Psychol Gen. 2014 Oct;143(5):1980-99. Epub 2014/07/16. doi:10.1037/a0037323. Cited in: Pubmed; PMID 25019381.
11. Santos L. The Science of Wellbeing. Yale: Coursera.org; 2020. Available from: https://www.coursera.org/learn/the-science-of-well-being – about.
12. Seligman ME, Steen TA, Park N, Peterson C. Positive psychology progress: empirical validation of interventions. Am Psychol. 2005 Jul-Aug;60(5):410-21. Epub 2005/07/28. doi:10.1037/0003-066X.60.5.410. Cited in: Pubmed; PMID 16045394.