Medical students keep quiet about depression because of fear of stigma

Not only are a considerable proportion of medical students depressed, those who are believe they’ll lose the respect of their peers and their tutors if they speak out, according to new research in published in Journal of the American Medical Association.

The study of 505 medical students in Michigan found that more than one in 10 (14.3%) of them were depressed, almost three times as many as in the general population of the United States (prevalence 5.4%).

More than half of those who were depressed felt that telling a counselor would be risky and that fellow medical students would respect their opinions less if they knew (53.3% and 56.0%, respectively), whereas far fewer of their non-depressed peers held these views (16.7% and 23.7%).

The authors of this research invited all 769 medical students enrolled at the University of Michigan Medical School in September-November 2009 to do an anonymous internet survey on depression and their attitudes to the disease.

Women were more likely than men to have moderate to severe depression (18.0% vs 9.0%), and students who were depressed were nearly eight times more likely to have considered leaving medical school than had those with minimal depression (43.1% vs 5.6%). As many as 68% of those with depression had seriously considered committing suicide, although the overall number of students with “suicidal ideation” was small (22/505 (4.4%)).

Medical school is mentally and academically demanding, so it’s not surprising that rates of depression, burnout, and suicide are higher in medical students than in the general population. Yet despite no doubt being familiar with mental health issues given their training, medical students with depression are notoriously bad at seeking treatment. In this study, for example, approximately 70-80% of students with moderate to severe depression had not received a diagnosis or treatment for depression.

As well as worrying about what their tutors and peers thought of them, medical students with moderate to severe depression were more likely than those not depressed to think that asking for help would mean their coping skills were inadequate (61.7% vs 33.5%). They also felt that others would consider them unable to handle their medical school responsibilities (83.1% vs 55.1%).

It wasn’t just the students who were depressed who believed stigmas associated with the disease: those without depression were more likely to think that depressed medical students would be a danger to patients (25.7% vs 13.6%).

The fact that so many medical students seem to hold negative views of depression is rather worrying, not least because one study found that 30% of first year and second year medical students with depression cited stigma as a barrier to seeking treatment. It does seem counter-intuitive that this group exposed to health messages pretty much non-stop thanks to their course of study seems to sign up to negative stigmas surrounding depression.

The authors suggest that rather than the emphasis on academic excellence and professionalism scaring medical students out of reporting depression, medical education programmes could be tweaked so that students perceive looking after the mental health of themselves and their peers as a key aspect of being an outstanding doctor.
Schwenk T, Davis L, & Wimsatt L (2010) Depression, Stigma, and Suicidal Ideation in Medical Students. JAMA: The Journal of the American Medical Association 304 (11): 1181-1190. DOI: 10.1001/jama.2010.1300

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Talking therapies for depression are overrated thanks to publication bias

DepressionAn analysis of studies into counseling therapies for depression – such as cognitive-behavioural therapy – has found that the effect of such approaches has been overestimated because studies that show a strong effect of the treatments are getting published over studies with more modest results.

In 117 studies, “talking therapies” had an average effect of 0.67 on symptoms of depression, with zero being “no effect,” whereas once publication bias was taken into account this effect dropped to 0.42.

Publication bias is “the tendency for increased publication rates among studies that show a statistically significant effect of treatment.” Think about it – patients, researchers and editors are going to be more interested in studies showing that a treatment has a considerable effect on a condition than those showing that the treatment has only a negligible effect. As a result, those studies showing a strong effect either way – that a treatment is really good or really useless – are more likely to get published and the effect of a therapy gets overestimated.

Publication bias is known to affect studies on the effects of antidepressant medications: trials showing that a drug works are more likely to get published than those showing that it doesn’t work. This is due in no small part to the pharmaceutical companies that fund drug research wanting to promote the most positive outcome possible for the medications that they sell.

Now a new analysis by Cuijpers et al. has found a similar effect among studies about psychotherapy for depression – only the most dramatic findings are getting out there and as such the effects of “talking therapies” are being “talked up.”

The authors looked at published studies on psychological treatments for depression – either approaches where verbal communication between a therapist and a client was the core element or in which a patient independently worked through a treatment book with some kind of personal support from a therapist.

They found a total of 117 studies that compared 175 treatment conditions with a control condition. When they calculated the effect of treatment in each study and analysed all these numbers together, the mean treatment effect for psychotherapy compared with control was 0.67, with zero being “no effect.”

The authors then undertook several types of statistical tests to determine whether the studies in their analysis were subject to publication bias.

The mean effect dropped to 0.42 once all the data had been adjusted for publication bias, and the various tests all pointed strongly to bias. The authors point out that effect sizes of 0.80 can be assumed to be large, effect sizes of 0.50 are moderate, and effect sizes of 0.20 are small.

Interestingly, no indication of publication bias was found for studies examining interpersonal psychotherapy, which targets how the patient interacts with other people, or for studies examining psychotherapy for women with postpartum depression.

The authors then looked specifically at the much vaunted approach cognitive-behavioural therapy, where therapist focuses on the impact a patient’s present dysfunctional thoughts have on current behaviour and future functioning. The overall effect size of the 89 comparisons between cognitive-behavioural therapy and a control condition was 0.69, but this value was reduced to 0.49 after adjustment for publication bias.

The authors conclude that research on psychotherapy for adult depression does not seem to be any freer from publication bias than research on medication treatment. As they say, “Pharmaceutical companies have clear financial reasons to inflate research findings, and psychological investigators have both personal and professional reasons for doing the same.”

The implications for this analysis are pretty messy – the research suggests that one of the two most important treatments for adult depression is not as effective as assumed, bad news given that “talking therapies” are generally thought to work better than pharmaceutical approaches, the other top therapy.
Cuijpers P at el. (2010) Efficacy of cognitive-behavioural therapy and other psychological treatments for adult depression: meta-analytic study of publication bias. The British Journal of Psychiatry 196 (3): 173-178. DOI: 10.1192/bjp.bp.109.066001

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When is a side effect not a side effect? With antidepressants and functional gastrointestinal disorders

ibsNew research has shown that the side effects of tricyclic antidepressants reported by patients with functional gastrointestinal disorders (FGDs) such as irritable bowel syndrome (IBS) often aren’t actually real side effects of the drugs.  Instead, most of the symptoms experienced by the women in the study were present before they started taking the medication, suggesting that the patients receiving antidepressants were simply over-reporting symptoms rather than experiencing side effects.

Interestingly, the authors of this study note that patients with a higher level of psychological distress were more likely to report symptoms than were less anxious patients.  It is possible, therefore, that the ‘side effects’ among such patients were a result of their underlying stress and anxiety and not the antidepressants they were taking.

FGDs comprise gastrointestinal symptoms such as cramps but no clear pathology or anatomical problem.  Instead, the primary abnormality is an altered physiological function (ie a change in the way the body works) rather than an identifiable structural or biochemical cause.  FGDs do have a strong psychological component though, and are often triggered or exacerbated by stress. As such, antidepressants have proved effective in treating patients with FGDs; however, such drugs often have unpleasant side effects.

The authors of this study enrolled 245 women with FGDs: irritable bowel syndrome, painful constipation, functional abdominal pain, or unspecified functional bowel disorder. All patients filled in a questionnaire about their various symptoms at the start of the study, then 57 individuals were randomly assigned to receive the tricyclic antidepressant desipramine for 12 weeks and 36 were assigned a placebo for the same period of time.

At 2 weeks, both groups were reporting the same levels feeling tired in the morning, having trouble sleeping, nausea, blurred vision, headaches, and decreased appetite as they had experienced at the beginning of the study, indicating that these signs were not side effects of the tricyclic antidepressant.  On the other hand, dry mouth, lightheadedness, dizziness, flushing and jitters or tremors at week 2 were more common among the patients on desipramine than among those on placebo, suggesting that these particular symptoms may be related to the known anticholinergic effects of the medication.  By 12 weeks, there was no difference between the two groups in the side effects reported.

Patients with a high score on the SCL-90 GSI test, a measure of psychological distress, reported more symptoms than did patients with lower scores.  The authors thus state that the more symptoms a patient reports, the less likely it is that the symptoms are related to the medication.

I think this study has some interesting implications.  Given that antidepressants by design are often used in anxious individuals, it seems possible that in many cases the side effects reported with this class of drugs might be due to patients reporting every single symptom they experience, however slight.  Given this likelihood of over-reporting, and also the fact that the anxiety itself can cause symptoms, perhaps the side effects of tricyclic depressants are less common than we think, and these drugs might be safe to use in a broader spectrum of patients than is currently treated.


Thiwan S et al. (2009) Not All Side Effects Associated With Tricyclic Antidepressant Therapy Are True Side Effects. Clinical Gastroenterology and Hepatology 7 (4): 446-451 DOI: 10.1016/j.cgh.2008.11.014

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Financial altruism leads to depression

Lending moneyDo you give cash to people who aren’t your direct family or close friends, including people on the street begging for money? A new study in PLoS One suggests that such charitable behaviour will eventually lead to major depression.

Author Takeo Fujiwara found that financial altruism towards someone other than a family member or close friend was significantly associated with the onset of major depression two or three years later. Study participants who provided $10 a month or more to someone outside their close personal group were 2.6 times more likely to develop major depression than less generous individuals.

On the other hand, neither unpaid assistance – for example, helping someone other than family members or close friends with transportation or childcare – nor emotional support – comforting, listening to problems, or giving advice to anyone outside of your close personal circle – was associated with major depression.  In fact, providing unpaid assistance was nonsignificantly associated with protection against depression.

The author suggests that when people give money to others, they expect some sort of ethereal reward – such as reputation or status – in return for exhibiting good behaviours. People providing emotional support immediately and directly receive emotional reward, like a sense of meaning or purpose. This disparity in compensation for altruistic behaviour might explain why those providing emotional support did not develop of MD whereas those providing financial support did.

“The differential effect on major depression between unpaid assistance [and financial support] might be due to the difference of focus, whether outside the self or not”, says Dr Fujiwara. “[P]eople might join a volunteer activity from an achievement-oriented egocentricity, rather than focusing outside the self.”

In addition, people who give money to others might feel overstretched, as financial resources are harder to come by than emotional ones, and guilty when they don’t give, both of which might contribute to major depression.

A previous study, however, has shown that providing financial support to children or grand children protects against the later onset of major depression.  Better focus your financial generosity your close friends and family then.

Takeo Fujiwara (2009) Is Altruistic Behavior Associated with Major Depression Onset? PLoS ONE 4 (2) DOI: 10.1371/journal.pone.0004557

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