|Year : 2019 | Volume
| Issue : 2 | Page : 120-125
Rethinking medical school curriculum: An exploratory study of medical student mental health in a nontraditional program
Lindsey N Teal1, Krucial K Styslinger1, Steven H Kelder2, Freya Spielberg2
1 The University of Texas at Austin Dell Medical School, Austin, Texas, USA
2 School of Public Health, University of Texas Health Science Center at Houston (UTHealth), Austin, Texas, USA
|Date of Web Publication||22-Jul-2020|
Lindsey N Teal
4646 Mueller Blvd. Apt 1063, Austin, Texas 78723
Source of Support: None, Conflict of Interest: None
Context: Medical student mental health has been studied extensively, yet little is known about students in nontraditional medical school programs. Aims: The goal of this study was to assess the frequency of symptoms of mental illness in the first, second, and third class at a new, nontraditional medical school. Settings and Design: An exploratory self-reported study was conducted in students enrolled at recently opened University of Texas at Austin Dell Medical School (n = 147) in April 2019. Methods: The Patient Health Questionnaire-9 was selected as the outcome measure for the study which includes subscales for depression, thoughts of suicidal ideation or self-harm, anxiety, and posttraumatic stress disorder (PTSD). Qualitative interview data were collected to better understand perceived barriers to engaging with university mental health services. Statistical Analysis Used: Descriptive statistics was used for the univariate analysis with Chi-square, and logistic regression models were used for the bivariate analysis. Results: One hundred and twenty of the 187 students responded to the survey, and the response rate was 81.6%. Overall, 16 (13.3%) of medical students were screened positive for depression, 14 (11.7%) for anxiety, and 4 (3.4%) for PTSD. There were 7 (5.8%) of students who reported suicidal ideation or thoughts of self-harm. The second year students reported higher rates of mental health illnesses when compared to other classes. Common barriers to using mental health services were lack of time (n = 52, 63.4%) and stigma (n = 13, 15.9%). The response rate for the quantitative and qualitative data was 120 (81.6%) and 82 (68.3%), respectively. Conclusions: Attending a nontraditional medical school program may contribute to a low prevalence of anxiety (11.7%). Since the 2nd year clinical medical students had the highest rates of mental illness and reported lack of time as the largest barrier, interventions should focus on providing flexible timing of mental health services.
Keywords: Anxiety, depression, depressive disorder, graduate medical education, medical students, mental health, posttraumatic, stress disorders, suicidal ideation
|How to cite this article:|
Teal LN, Styslinger KK, Kelder SH, Spielberg F. Rethinking medical school curriculum: An exploratory study of medical student mental health in a nontraditional program. J Mental Health Hum Behav 2019;24:120-5
|How to cite this URL:|
Teal LN, Styslinger KK, Kelder SH, Spielberg F. Rethinking medical school curriculum: An exploratory study of medical student mental health in a nontraditional program. J Mental Health Hum Behav [serial online] 2019 [cited 2022 Oct 7];24:120-5. Available from: https://www.jmhhb.org/text.asp?2019/24/2/120/290515
| Introduction|| |
The mental health of medical students has been studied extensively over the past few decades. Mental illnesses among medical students are six (depression) to ten (anxiety) times that of the U.S. adult population, possibly due to the increased stress and work environments., Some studies show the rates of depression increase threefold from the 1st to 2nd year of medical school.,
Medical students at this school rotate through trauma services, treat patients in critical care centers, and participate in running codes. Previous studies have found that physicians and residents participating in these types of environments experience elevated rates of posttraumatic stress disorder (PTSD)., However, to our knowledge, there have not been any studies done on the effects of these environments and the development of PTSD in medical students.
Entering a nontraditional medical school program could have positive or negative impacts on the health and well-being of students. A great deal of trial and error with curriculum modifications and unknown academic terrain are elicited in nontraditional programs, which could potentially lead to heightened stress. Dell Medical School uses what is considered a nontraditional program. Specifically, the preclinical studies were shortened into 1 year (as opposed to two), and the students began clinical clerkships at the beginning of their 2nd year. It is possible that condensing the knowledge from 2 years to 1 and entering clinical clerkships in year 2 instead of year 3 could create stressful conditions that trigger mental illness. On the other hand, students spend more time in areas they are passionate about, which may buffer the effects of increased stress. Finally, Dell Medical School requires 3rd year students to take a “growth year,” which entails spending the year conducting research or enrolling in a second degree program (i.e., MBA or MPH), which could also have a differential influence on their mental health.
Despite the numerous studies on mental health illnesses and risk factors in medical students, to our knowledge, the effect of nontraditional medical school training on mental health outcomes has not been reported., The goal of our study was to assess the frequency of symptoms of mental illness in the first, second, and third class at a new, nontraditional medical school, using standardized mental health screening tools.
| Methods|| |
In April 2019, we conducted an exploratory survey of the first three classes (1st, 2nd, and 3rd year) at the newly opened UT Dell Medical school. The research was approved by the University of Texas Health Science Center at Houston Ethical and Institutional Review Board. Students were recruited via their UT e-mail address and the depression, anxiety, and PTSD questionnaires, and consent disclaimers were administered through the online REDCap data collection and management system. All students enrolled in the medical school were selected to participate. The questionnaires were anonymous and gave the students their calculated scores in real time with a message indicating resources to contact if the score indicated positive on any the three mental health scales. If students reported affirmative to self-harm in the last 2 weeks, a system-generated message with provider contact information advised them to seek urgent assistance.
The independent exposure variable was student class year ( first, second, and third) and attending the nontraditional Dell Medical School program. Since this is a new school, there are currently not any 4th year students. The dependent outcome variables were depression, anxiety, and PTSD.
We measured depression using the Patient Health Questionnaire-9 (PHQ-9). It has nine questions that score each of the DSM-4 criteria on a Likert scale from “0” (not at all) to “3” (nearly every day). A score of >5 was used as the threshold to suggest seeking care in the questionnaire. A score of >10 of 27 was considered positive for moderate-to-severe depression (sensitivity: 88% and specificity: 88%). The ninth question in this screen determines suicidal ideation in the past 2 weeks. Any response other than “0” (not at all) was considered positive for self-harm or suicidal ideation.
We measured anxiety using the General Anxiety Disorder-7 (GAD-7), a 7-item questionnaire that is made constructed by some of the DSM-4 criteria for anxiety. The seven questions are scored on a Likert scale from “0” (not at all) to “3” (nearly every day). A score of >5 was used as the threshold to suggest seeking care in the questionnaire. A score of >10 out of 21 was considered positive (sensitivity: 89% and specificity: 82%).
We measured PTSD using the Primary Care PTSD Screen for DSM-5, a 5-item screen constructed by DSM-5 criteria for PTSD. The 5-item screen is scored on a binary yes/no scale. An answer of “yes” to >3 of the 5 questions was considered positive (sensitivity: 93% and specificity 80%).
We incorporated the three screening tools in the questionnaire to assess the exposures and outcomes, in addition to a free-response question regarding barriers to the use of mental health services. To assess barriers, the question “what, if any, has been the biggest barrier to seeking out mental health services during your time in medical school?”
All reported analyses were conducted in Stata version 14.0 (Stata Corp., College Station, TX, USA). Descriptive statistics (mean and proportions) was used to determine the proportion of responses to independent exposure and dependent outcome variables, as well as the mean scores for each dependent outcome variable. Chi-square tests and logistic regression models were used to analyze mental illnesses across class years. A two-sample t-test was used to compare the means between the class years for the severity of depression and anxiety. The level of statistical significance was 5% (P < 0.05) for all analyses.
Regarding the free-response question, the data were analyzed using inductive thematic content analysis. The research team read through the responses, developed a thematic coding structure, and then applied the codes to the open-ended questions.
| Results|| |
The overall response rate was 120/147 (81.6%) and this varied slightly by class year: 40/50 (80.0%) for the 1st year students, 39/47 (83.0%) for the 2nd year, and 41/50 (82.0%) for the 3rd year. [Table 1] reports the univariate statistics of the three scales with 23 (19.2%) respondents who were screened positive for at least one of the three mental health illnesses, 12 (10.0%) screening positive for only one mental illness, 9 (7.5%) for two, and 2 (1.7%) screening positive for all three. The odds of screening positive for more than one was higher among 2nd year students when compared to the 1st and 3rd years (odds ratio [OR] = 6.7; 95% confidence interval [CI] 1.7–27.0; P < 0.01).
|Table 1: Number of medical students who were screened positive for depression, anxiety, and posttraumatic stress disorder by medical school year|
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Depression and self-harm
Overall, 16 students (13.3%) failed the depression screen, scoring high enough to warrant follow-up for possible depression. Of these, 5 (12.5%) were 1st year students, 9 (23.1%) were 2nd years, and 2 (4.9%) were 3rd years. The odds of screening positive for depression was higher among the 2nd year students when compared to 1st and 3rd years (OR = 3.2, 95% CI 1.1–9.3, P < 0.05). Regarding depression severity, 69 (57.5%) had no depression symptoms, 35 (29.2%) were in the mild range, 14 (11.7%) moderate, 2 (1.7%) were moderately severe, and none were severe [Table 2]. When stratifying depression severity by the class year, the mean score on the PHQ-9 was 4.9 (3.5) in the 1st years, 5.8 (3.7) in the 2nd years, and 3.5 (3.9) in the 3rd years. The depression severity mean in the 2nd years was significantly higher than in the 3rd years (t: −2.7; 95% CI − 4.0–−0.6; P < 0.01).
|Table 2: Severity of depression and anxiety among all medical school students|
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In addition, overall 7 (5.8%) of students reported self-harm or suicidal ideation, with small nonsignificant variations by class: 4 (10.0%) in the 1st year, 2 (5.1%) in the 2nd year, and 1 (2.4%) in 3rd year.
Overall, 14 students (11.7%) met the criteria for anxiety, with 2 (5.0%) 1st years, 9 (23.1%) 2nd years, and 3 (7.3%) 3rd years. The odds of screening positive for the anxiety was higher among the 2nd year students when compared to the 1st and 3rd years (OR = 4.6, 95% CI 1.4–14.7, P < 0.05).
Regarding the severity of anxiety, 79 (65.8%) had no anxiety symptoms, 27 (22.5%) were in the mild range, 12 (10.0%) were moderate, and 2 (1.7%) were severe. This is depicted in [Table 2]. When stratifying anxiety severity by class year, the mean score on the GAD-7 was 3.5 (3.0) in the 1st years, 5.6 (4.3) in the 2nd years, and 3.0 (3.3) in the 3rd years. The anxiety severity mean in the 2nd years was significantly higher than the mean in the 3rd years (t: −3.0; 95% CI − 4.3–−0.9; P < 0.01) and 1st years (t: −2.5; 95% CI − 3.7–−0.4; P < 0.05).
Posttraumatic stress disorder
Overall, 4 students (3.4%) met the criteria for PTSD, with 1 (2.5%) 1st year, 3 (7.9%) 2nd years, and 0 (0.0%) of 3rd years. There was no significant difference in the 2nd year compared to the 1st and 3rd year students (OR = 6.9; 95% CI 0.7–68.2; P = 0.1).
Eighty-two (68.9%) students responded to the question regarding barriers to seeking mental health services. The findings of perceived barriers are described in relation to the five main themes identified: (1) time, (2) stigma, (3) knowledge of services, (4) availability of services, and (5) cost. Of these, 52 (63.4%) stated that finding the time to attend these services was the largest barrier, followed by stigma, knowledge of services, availability of services, and cost (n = 13, 15.9%; n = 11, 13.4%; n = 7, 8.5%; and n = 4, 4.9%, respectively). Time was indicated as a major barrier for seeking services in 15 (65.2%) 1st year students, 22 (81.5%) 2nd year students, and 15 (51.7%) 3rd year students. Stigma was a major barrier for 2 (8.7%) 1st year students, 6 (22.2%) 2nd year students, and 5 (17.2%) 3rd year students. Knowledge of services was a major barrier for seeking services in 3 (13.0%) 1st year students, 0 (0.0%) 2nd year students, and 8 (27.6%) 3rd year students. Furthermore, 2 (50%) of those who reported cost, 5 (38.5%) of those who reported stigma, and 14 (26.9%) of those who reported time as a barrier to seeking services met the criteria for 1 or more mental illnesses.
| Discussion|| |
Mental health illnesses in medical students continue to be a problem faced by medical students in the United States. Many medical schools across the nation are attempting to tackle this issue and are looking for the new solutions to this problem.
Depression and self-harm
Second-year clinical medical students had a depression prevalence of roughly two to four times that of 3rd and 1st years, respectively. The severity of depression in the 2nd year students was also greater, as the mean PHQ-9 score was 1–2 points higher than the 1st and 3rd years, respectively. Other studies have also found an increased prevalence of depression (1.5 times higher) from preclinical to clinical years.,
The overall prevalence of depression among the UT Dell Medical School nontraditional students varied little from the traditional programs reported by a similar study using the same questionnaire and PHQ-9 cutoff (13.3% vs. 14.3%). However, reported depression in the 3rd year Dell medical students was nearly one-third the rate reported by the traditional medical schools students cite (7.3% vs. 21.7%). This could be due to the “growth year” given to the 3rd year medical students at this program, compared to the traditional 3rd year students in clinical rotations. Even in comparing the rates of depression of 2nd year clinical students from the nontraditional program to the 3rd year clinical students from traditional programs, the prevalence was not significantly different. This implies that this nontraditional medical school program affords 1 year of significantly less depression in students than the traditional routes. Perhaps, the freedom of working on degrees/research in the areas of particular interest and increased flexibility of schedule during this 3rd year contributed to the decreased prevalence of depression.
First-year students had higher rates of suicidal ideation/self-harm, but the numbers across the classes were small (n = 7). Other studies investigating suicidal ideation and self-harm in medical school have found various trends in suicidal ideation among class years.
The prevalence of anxiety in the 2nd years was three to five times that of the 3rd and 1st years, respectively. The severity of anxiety in the 2nd year students was also greater, as the mean GAD-7 score was 2–2.5 points higher than the 1st and 3rd years, respectively. Other studies have also found an increase in anxiety as students enter their clinical year. Anxiety has been found to increase in medical students as examinations near, and the 2nd year medical students have clerkship examinations every 8-week period during the 2nd year and one important board examination at the end of 2nd year, roughly 3 months after this survey was administered.
The prevalence of anxiety at Dell Medical School was lower compared to traditional programs (11.7 vs. 20.3). The comparison study did not provide breakdowns by year; thus, the prevalence of anxiety across class years between programs could not be compared. This nontraditional medical school promotes student wellness through its emphasis on mindfulness., In addition, arts and humanities courses are integrated into the curriculum to help build resiliency, which has been postulated to lower anxiety levels in students.,, Finally, the school also has a pass/fail grading system in preclinical years, which can reduce stress levels while promoting collaborative work with peers. It is possible that the combination of these, along with the shortened preclinical curriculum and “growth year” during the 3rd year, has contributed to lower anxiety levels.
Posttraumatic stress disorder
The prevalence of PTSD in the 2nd years in this study was three to eight times higher than 1st and 3rd years, respectively. Health-care providers working in critical care centers and participating in resuscitation events have a PTSD prevalence of 24% and 28%, respectively., These students are in their clinical year and may be exposed to these environments, which could contribute to the increased levels of PTSD.
There were not any national studies on the rates of PTSD in medical students that matched the screening survey used in this study. However, the prevalence of PTSD at 3.4% is slightly below the 1-year prevalence rates of 3.5%–6.8% found in other studies in the US adult population.,,
The major barriers to accessing mental health services were time, stigma, knowledge of services, availability of services, and cost. These barriers are similar to what previous studies have found, with the exception of confidentiality, which was not found in the Dell study.,, Time was the most prominent barrier, especially in the 2nd year clinical students. This is likely because the clinical schedule encompasses most of the average workday and students had assignments and tests at the same time, leaving little time to access services regularly. Other studies have reported clinical students sleep less than preclinical students, indicating less time available for self-care., One might expect that the barrier of time may be significantly less for the students in the 1st and 3rd years of medical school, as these students had more flexible schedules. However, over 60% of 1st year and half of the 3rd years still reported time as their most significant barrier to accessing services. This could potentially be due to increased assignments/research that are not necessarily scheduled classes.
The second most common barrier to using mental health services was perceived stigma and/or fear of reporting being treated for mental illness. Over one-third of the students who reported stigma as a barrier were screened positive for at least 1 mental illness. Similar results were found in a study done in medical students at the University of Michigan, with most student's reporting they would be embarrassed if their classmates knew they were depressed. An interesting finding was that this barrier seemed to be higher for the 2nd and 3rd year students. A possible reason is due to the increased exposure to these stigmas on entering the clinical setting, which is congruent with other studies that have found stigma toward mental health among health professionals., Depression can be seen as a weakness, as it is perceived to impact a student's educational experience and chances of future employment., This perceived impact often discourages health-care professionals from discussing their mental illness and seeking help., This stigma permeates into patient care, as patients cite health-care professionals as a source of discrimination.
Other common barriers to seeking mental health services were knowledge of services, availability of services, and cost. We were surprised to find that this barrier was higher for the 3rd years than the 1st or 2nd years, as other studies have found that knowledge of services became less of a barrier to seeking services as students progressed in medical school. It is possible that the orientation to these services differed among class years or that services have been made more transparent over time. Availability of services and cost were reported in <10% and 5% of students, respectively. These findings, when analyzed with previously mentioned barriers, may indicate that even though there are affordable services available, time to attend those services and stigma associated with mental health illnesses still prevent students from seeking treatment.
Our study had several limitations. First, the data were collected from a single institution with a small number of students, thus limiting the generalizability of these results. However, the prevalence of mental illnesses was similar to those in other studies. Second, since this was a cross-sectional study, causality cannot be attributed. As this was an exploratory study, correction for multiple comparisons was not carried out. In addition, students may have entered medical school with these mental illnesses. This could also account for the different rates between the classes. Another limitation is that the study included a self-selected sample. This could have introduced a self-selection bias based on those who participated, leading to a nonrepresentative sample of the overall medical student population.
Future interventions should focus on reducing the various barriers that exist to using mental health services. The first and most common barrier, time, can be addressed by allotting students a certain amount of protected time each week to focus on their mental health. Students would then have designated time off during their clinical rotations to make therapy appointments during business hours. Telemedicine could also be implemented to help with the busy work schedule of medical students, allowing for more flexible scheduling at the location of the student's choice. Appointments could be during a lunch break at the hospital or at home during the evening. One study that offered on-site and after-hour telephone wellness counseling services to residents found that many still noted lack of time as the largest barrier to accessing services. Many stated that they could not leave their clinical duties to access services, further stressing the need of protected time off for these services.
To reduce stigma, interventions that emphasize the importance of mental health care in medical students and other health-care professionals could be implemented. Educational programs aimed to increase mental health awareness and empathy have been shown to decrease stigma in medical students., Similar programs targeted toward health-care providers have been shown to increase stigma awareness and lower prejudice levels to better care for patients with mental illnesses. Other programs have focused on coping strategies for those who face the negative impacts of the stigma associated with mental illnesses.
| Conclusions|| |
Our study found that this nontraditional medical school program had decreased overall rates of anxiety and decreased rates of depression in 3rd year medical students when compared to similar medical education studies. Factors that may contribute are shortened preclinical time, a 3rd year “growth year,” the early emphasis on mental health and wellness, and integration of medical humanities into the curriculum. Students in their clinical years have higher rates of all mental illnesses, and lack of time is their greatest barrier to using mental health services. Early and regular screening of medical students for mental illnesses should be implemented, as well as offering the flexibility of timing for mental health services provided.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Rotenstein LS, Ramos MA, Torre M, Segal JB, Peluso MJ, Guille C, et al.
Prevalence of depression, depressive symptoms, and suicidal ideation among medical students: A systematic review and meta-analysis. JAMA 2016;316:2214-36.
Mousa OY, Dhamoon MS, Lander S, Dhamoon AS. The MD blues: Under-recognized depression and anxiety in medical trainees. PLoS One 2016;11:e0156554.
Clark DC, Zeldow PB. Vicissitudes of depressed mood during four years of medical school. JAMA 1988;260:2521-8.
Rosal MC, Ockene IS, Ockene JK, Barrett SV, Ma Y, Hebert JR. A longitudinal study of students' depression at one medical school. Acad Med 1997;72:542-6.
Mealer ML, Shelton A, Berg B, Rothbaum B, Moss M. Increased prevalence of post-traumatic stress disorder symptoms in critical care nurses. Am J Respir Crit Care Med 2007;175:693-7.
Kolehmainen C, Stahr A, Kaatz A, Brennan M, Vogelman B, Cook J, et al
. Post-code PTSD symptoms in internal medicine residents who participate in cardiopulmonary resuscitation events: A mixed methods study. J Grad Med Educ 2015;7:475-9.
Moir F, Yielder J, Sanson J, Chen Y. Depression in medical students: Current insights. Adv Med Educ Pract 2018;9:323-33.
Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap) – A metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009;42:377-81.
Kroenke K, Spitzer RL, Williams JB. The PHQ-9: Validity of a brief depression severity measure. J Gen Intern Med 2001;16:606-13.
Spitzer RL, Kroenke K, Williams JB, Löwe B. A brief measure for assessing generalized anxiety disorder: The GAD-7. Arch Intern Med 2006;166:1092-7.
Prins A, Bovin MJ, Smolenski DJ, Marx BP, Kimerling R, Jenkins-Guarnieri MA, et al
. The primary care PTSD screen for DSM-5 (PC-PTSD-5): Development and evaluation within a veteran primary care sample. J Gen Intern Med 2016;31:1206-11.
Schwenk TL, Davis L, Wimsatt LA. Depression, stigma, and suicidal ideation in medical students. JAMA 2010;304:1181-90.
Compton MT, Carrera J, Frank E. Stress and depressive symptoms/dysphoria among US medical students: Results from a large, nationally representative survey. J Nerv Ment Dis 2008;196:891-7.
Virtanen M, Ferrie JE, Singh-Manoux A, Shipley MJ, Stansfeld SA, Marmot MG, et al
. Long working hours and symptoms of anxiety and depression: A 5-year follow-up of the Whitehall II study. Psychol Med 2011;41:2485-94.
Coentre R, Góis C. Suicidal ideation in medical students: Recent insights. Adv Med Educ Pract 2018;9:873-80.
Chandavarkar U, Azzam A, Mathews CA. Anxiety symptoms and perceived performance in medical students. Depress Anxiety 2007;24:103-11.
Kulsoom B, Afsar NA. Stress, anxiety, and depression among medical students in a multiethnic setting. Neuropsychiatr Dis Treat 2015;11:1713-22.
Slavin SJ, Schindler DL, Chibnall JT. Medical student mental health 3.0: Improving student wellness through curricular changes. Acad Med 2014;89:573-7.
Hofmann SG, Sawyer AT, Witt AA, Oh D. The effect of mindfulness-based therapy on anxiety and depression: A meta-analytic review. J Consult Clin Psychol 2010;78:169-83.
Stuckey HL, Nobel J. The connection between art, healing, and public health: A review of current literature. Am J Public Health 2010;100:254-63.
Charney DS. The psychobiology of resilience and vulnerability to anxiety disorders: Implications for prevention and treatment. Dialogues Clin Neurosci 2003;5:207-21.
Walsh SM, Martin SC, Schmidt LA. Testing the efficacy of a creative-arts intervention with family caregivers of patients with cancer. J Nurs Scholarsh 2004;36:214-9.
Rohe DE, Barrier PA, Clark MM, Cook DA, Vickers KS, Decker PA. The benefits of pass-fail grading on stress, mood, and group cohesion in medical students. Mayo Clin Proc 2006;81:1443-8.
Goldstein RB, Smith SM, Chou SP, Saha TD, Jung J, Zhang H, et al
. The epidemiology of DSM-5 posttraumatic stress disorder in the United States: Results from the national epidemiologic survey on alcohol and related conditions-III. Soc Psychiatry Psychiatr Epidemiol 2016;51:1137-48.
Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005;62:617-27.
Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005;62:593-602.
Givens JL, Tjia J. Depressed medical students' use of mental health services and barriers to use. Acad Med 2002;77:918-21.
Guille C, Speller H, Laff R, Epperson CN, Sen S. Utilization and barriers to mental health services among depressed medical interns: A prospective multisite study. J Grad Med Educ 2010;2:210-4.
Menon V, Sarkar S, Kumar S. A cross-sectional analysis of barriers to health-care seeking among medical students across training period. J Ment Health Hum Behav 2017;22:97-103.
Azad MC, Fraser K, Rumana N, Abdullah AF, Shahana N, Hanly PJ, et al
. Sleep disturbances among medical students: A global perspective. J Clin Sleep Med 2015;11:69-74.
Alsaggaf MA, Wali SO, Merdad RA, Merdad LA. Sleep quantity, quality, and insomnia symptoms of medical students during clinical years. Relationship with stress and academic performance. Saudi Med J 2016;37:173-82.
Wimsatt LA, Schwenk TL, Sen A. Predictors of depression stigma in medical students: Potential targets for prevention and education. Am J Prev Med 2015;49:703-14.
Schulze B. Stigma and mental health professionals: A review of the evidence on an intricate relationship. Int Rev Psychiatry 2007;19:137-55.
Nordt C, Rössler W, Lauber C. Attitudes of mental health professionals toward people with schizophrenia and major depression. Schizophr Bull 2006;32:709-14.
Chew-Graham CA, Rogers A, Yassin N. 'I wouldn't want it on my CV or their records': Medical students' experiences of help-seeking for mental health problems. Med Educ 2003;37:873-80.
Roberts LW, Warner TD, Lyketsos C, Frank E, Ganzini L, Carter D, et al.
Perceptions of academic vulnerability associated with personal illness: A study of 1,027 students at nine medical schools. Collaborative research group on medical student health. Compr Psychiatry 2001;42:1-5.
Adams EF, Lee AJ, Pritchard CW, White RJ. What stops us from healing the healers: A survey of help-seeking behaviour, stigmatisation and depression within the medical profession. Int J Soc Psychiatry 2010;56:359-70.
Wallace JE. Mental health and stigma in the medical profession. Health (London) 2012;16:3-18.
Hamilton S, Pinfold V, Cotney J, Couperthwaite L, Matthews J, Barret K, et al.
Qualitative analysis of mental health service users' reported experiences of discrimination. Acta Psychiatr Scand 2016;134 Suppl 446:14-22.
Ey S, Moffit M, Kinzie JM, Choi D, Girard DE. “If you build it, they will come”: Attitudes of medical residents and fellows about seeking services in a resident wellness program. J Grad Med Educ 2013;5:486-92.
Friedrich B, Evans-Lacko S, London J, Rhydderch D, Henderson C, Thornicroft G, et al.
Anti-stigma training for medical students: The education not discrimination project. Br J Psychiatry Suppl 2013;55:s89-94.
Aggarwal AK, Thompson M, Falik R, Shaw A, O'Sullivan P, Lowenstein DH. Mental illness among us: a new curriculum to reduce mental illness stigma among medical students. Acad Psychiatry 2013;37:385-91.
Michaels PJ, Corrigan PW, Buchholz B, Brown J, Arthur T, Netter C, et al
. Changing stigma through a consumer-based stigma reduction program. Community Ment Health J 2014;50:395-401.
Rüsch N, Abbruzzese E, Hagedorn E, Hartenhauer D, Kaufmann I, Curschellas J, et al
. Efficacy of coming out proud to reduce stigma's impact among people with mental illness: pilot randomised controlled trial. Br J Psychiatry 2014;204:391-7.
[Table 1], [Table 2]