Depression: A Med Student's Hidden Struggle

Megan Brooks

May 30, 2017

A medical student vividly describes her struggle with depression and the stigma of mental illness in the medical field in an anonymous essay published May 16 in Annals of Internal Medicine.

The author, "Cassandra," starts by painting a haunting picture.

"I write this because I am a fourth-year medical student typing on a small laptop in my closet in the dark. Because I am sitting on the floor with my back against the wall. Because to my left lies a pile of unsorted clothes and underneath a silver knife.

"Because in my senior year of college, I sat on the corner of my bed – on my bed, because back then my closet was overfull of skeletons and nightmares seeped in under door cracks and through the walls and there was nowhere left to hide from my darkness anymore – and that blade seemed like it would be kinder than the psychologist who diagnosed me with depression and laughed when I told her I was afraid to check my email."

Cassandra continues: "I write this because I cannot ask for help. Because first I was a pre-med student and now a medical student and soon I will be applying for a residency program and then I hopefully will become a practicing physician. This is why I cannot ask for help."

"Irreparably Broken"

In an accompanying editorial, Michael LaCombe, MD, associate editor of Annals of Internal Medicine, said Cassandra's article is a major departure from the journal's usual content.

"I am blessed with two editors at the journal where the student submitted this essay to go all-in with it, asked me to write the editorial, and consented to the anonymity of the author, which we very, very rarely do," Dr LaCombe told Medscape Medical News.

Studies have shown that medical students are at higher risk for depression and suicidal ideation than the general population and are less likely to receive appropriate treatment despite working in healthcare settings. Medical students also report that stigma against mental illness is a barrier to seeking treatment.

Cassandra has seen evidence of this stigma in the medical profession firsthand and shares several stories in her essay. She writes of the resident who whispers "psych consult" as if mental illness were something "too filthy to hold the words in your mouth too long. My resident says it's too bad we can't really fix the problem. As if mental illness left a person irreparably broken."

On the wards, diagnoses related to mental illness are often discussed "only in rushed whispers tacked onto the ends of differentials, as if physicians were afraid of touching something dirty," she writes. Regarding one patient's discharge, a resident explains, " 'He's not sick. He just has depression.' As if an illness in the mind were anything less than real."

"[O]n my psychiatry rotation," writes Cassandra, "another medical student pointed out a depressed young man admitted for a failed suicide attempt and told me that this admission is completely pointless because that patient is already just death, walking.... I write this because I have seen a psychologist's eyes looking at me as if I were dead already. I write this because this is why sometimes I wish to ask for help in medical school and know I cannot ask, cannot admit what I set down here in black ink on cold, pale paper.

"I write this because we would never look at a patient with cancer and say that person is already dead, but the actions of some health care professionals imply this about our patients and colleagues struggling with mental illness," she adds.

"I write this," she concludes, "because I hope for a future in which a medical student fighting mental illness will be seen as someone strong and not as someone dying. I write this because I dream of a future in which I will not have to be afraid to write this."

Teaching by Terror

In his editorial, Dr LaCombe writes about visiting residency programs and holding group sessions with residents on "forbidden topics." In these closed-door sessions, "absolute confidentiality" is pledged on both sides, and no faculty or administrative personnel are permitted to attend, including the chief resident.

"As the trust builds in the room, they bring up the ever-present poor attending who has been allowed to hang around and teach them for want of any more profitable pursuit and of whom they would dearly love to be rid of. Sexual harassment surfaces, as does the problem of the harsh, hostile, arrogant attending who subscribes to the House philosophy of teaching-by-terror," writes Dr LaCombe.

"Yet, although it is common among them, the subject of depression, much less thoughts of suicide, is not broached. It would make them seem weak, less intelligent, a danger to patients, not fit for further training," he notes.

"More papers like Cassandra's need to be published," Dr LaCombe writes, adding, "it is our responsibility as teaching attendings to care as much for our students as we do our own children."

"Lifesaving" Article

In an interview with Medscape Medical News, Michael Myers, MD, professor of clinical psychiatry and vice-chair of education, SUNY Downstate Medical Center in New York City, praised the author for writing the essay and the journal for publishing it.

"In many respects, I feel we have come a long way. In contrast to Cassandra'a piece, we do read more and more first-person accounts of students or residents or practicing physicians who have made the decision to go public with their mental health issues," said Dr Myers.

"Whenever I read a piece at all where the individual has come out of the closet, so to speak, I always send them an email or card to thank them for their gift.

"It's such a courageous statement, and not only is it healthy for the person who has written the piece, but it also helps those physicians who are struggling privately to go and get help themselves. Stories like this actually save lives. This is the kind of stuff I would like more and more residents to read," said Dr Myers.

Ann Intern Med. 2017;166:754-756. Abstract, Editorial

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