Future doctors : mental distress during medical education : cross-sectional and longitudinal studies

Medical education is long and stressful and medical students may suffer from mental distress. The aims of this dissertation are threefold; to investigate levels of distress in medical students at one Swedish medical school, to examine gender differences in such distress and to study individual and environmental determinants of distress. Major outcome measures were self-rated depression, burnout and interviewer-rated psychiatric morbidity. The thesis consists of two cross-sectional (I, II) and two longitudinal (III, IV) studies of medical students at Karolinska Institutet, examined by questionnaires (all) and interviews (III). A study stress inventory (HESI) is also introduced.

Study I showed that women students were more often depressed and reported higher levels on several aspects of study stress than men did. Medical students were also more often depressed than general population controls. Study stress factors Worries about future endurance/capacity, Workload, Low commitment and Insufficient feedback were associated with depression. Suicidal ideation and reported suicide attempts were not more common than usually reported in this age group. In Study II, an association was found between performance-based self-esteem and each of the two burnout dimensions exhaustion and disengagement. Exhaustion among medical students was also found to be associated with poorer self-rated health. Study III followed one cohort from 1st to 3rd year of medical school. A cluster analysis identified students with high/low burnout at 3rd year.

High burnout was predicted by impulsivity personality trait and associated with concurrent workload (HESI). This cohort, affected by restrictions of the student financial aid system, had increased levels of financial concerns, which were also associated with high burnout. By interviews at 3rd year, 27% were assessed as having a psychiatric condition. This was predicted by depressive symptoms at first year. A history of depression was reported by 42%. Study IV followed two cohorts from their final year of medical school into their first postgraduate year and examined determinants of exhaustion in the postgraduates. Women students were more exhausted at both points of observation and also increased their scores. Exhaustion before graduation and Worries about future endurance/capacity (HESI) predicted exhaustion in the junior physicians. Concurrent job strain had a positive association with exhaustion whereas a good climate for learning in the clinic had a negative impact. The gender effect was mediated by worries about the future, which was more pronounced in women.

Mental distress was common among medical students, especially women, but mild to moderate forms predominated. Individual and environmental factors contributed to distress.

List of scientific papers

I. Dahlin M, Joneborg N, Runeson B (2005). Stress and depression among medical students: a cross-sectional study. Med Educ. 39(6): 594-604.
https://doi.org/10.1111/j.1365-2929.2005.02176.x

II. Dahlin M, Joneborg N, Runeson B (2006). Performance-based self-esteem and burnout in a cross-sectional study of medical students. Medical Teacher. [Accepted]
https://doi.org/10.1080/01421590601175309

III. Dahlin ME, Runeson B (2007). Burnout and psychiatric morbidity among medical students entering clinical training: a three year prospective questionnaire and interview-based study. BMC Med Educ. 7: 6.
https://doi.org/10.1186/1472-6920-7-6

IV. Fjell J, Dahlin M, Runeson B (2007). Exhaustion among physicians during the first postgraduate year - a prospective study on dispositional and organisational determinants. [Submitted]