Why do medical students kill themselves?

“I can’t do this anymore,” Mary* said to me after morning rounds.

As third-year medical students, this could have been in reference to a number of things: 5 a.m. rounds, practice sutures, 14-hour days, the list goes on. Though I later learned Mary was simply referring to living.

An article recently published by JAMA showed depression or depressive symptoms among medical students was as high as 27.2 percent and that of suicidal ideation was 11.1 percent. This is in stark contrast to similar age groups of the general population, where the prevalence has been shown to be 9.6 percent and 3.7 percent respectively.

Why is it that depression and suicidal ideation are so prevalent in this student population? One would think a group of this caliber of intelligence, made up some of the most strong-minded and strong-willed individuals, would be in some way protected from mental illness? But, perhaps, that is exactly where our logic is misguided. And, perhaps, that is where we begin to fail this group of gifted individuals.

A number of institutions have implemented practices to prevent, alleviate and save students that may be struggling. Schools such as UCSF, UCLA, and Stanford have similar programs of mental health check-in sessions to assess for struggling students in their third and fourth years. St. Louis University has applied surveys for anxiety and depression and were able to improve student mental health with curricular changes. By the end of the first year of implementation, students reported significantly lower rates of depression and anxiety and to top it off, first-year board exams average increased from 222 to 229.

While these interventions are necessary, there are still certain aspects of medical school that are not yet addressed and which may cause the numbers we are now seeing.

Loss of individuality

Upon matriculating to medical school, the student has realized their entire life’s dream up to that point, reaching an all-time high. They were likely highly unique amongst their peers and stood above and beyond to reach this point. However once starting school, this high is abruptly short-lived. They are now joined by about a hundred individuals as talented, as intelligent, as driven as them. They become devoid of the individuality that once gave so much meaning; they no longer stand out like they may have once — leading to identity loss and possibly deindividuation.

Loss of belonging

Depression can further creep in through the loss of belonging, classically manifesting as isolation and feelings of hopelessness. Many medical students leave family and friends upon matriculation. While it’s natural to miss loved ones, the culture of school praises students for how much they sacrifice in order to study or work longer hours. Students become lost in a sea of grades, evaluations and, ultimately, lose a sense of purpose. They lose what it felt like to want to become a doctor and focus instead on the looming Step 1 exam or what research needs to be performed or organizations to join, so they may “match successfully.” Even during the frantic research and numerous student org sign-ups — many are still unsure of what specialty to go in to, particularly in the first three years of medical school, which only further drives isolation and the loss of belonging, meaning and purpose.

Shame

For some, pressure from academia can cause resentment for their studies. This can cultivate shame for developing such emotions and having no appropriate outlet to discuss or comprehend what they are experiencing. They made it here-amongst rare 2.5 percent that are accepted to medical school- how could they not feel anything but joy and gratification? Instead of classifying the symptoms as depression, anxiety, burnout, etc., the student thinks to themselves, “I just need to work harder.”

Failure

This is likely the most harmful inciter of depression amongst medical students. While it is common for a student to fail an exam without serious repercussions, this can challenge a student’s identity. They likely did everything they were told: prepared intensely, sacrificed sleep, limited social interactions and family time, and yet still failed. How can they reconcile? How can they admit this failure to classmates, loved ones, mentors? This can incite all the factors mentioned above — shame, loss of belonging and loss of individuality.

Depression is not weakness, but “being strong” may be slowly killing medical students. It is dangerous and presumptuous to assume an individual is “doing fine” because they continue to show up to class, are a leader of a student org or are scoring well on exams. Even though we may be dedicating our life to the betterment of others — we too can fall ill. Yet, we suffer by denying that reality.

More than establishing interventions, we must promote conversation about the mentioned deadly factors that can lead a person to depression and ultimately their death. Mary entrusted me with her experience with depression and thoughts of suicide, and we were lucky to have time to intervene. Only when we will be able to constantly leave the doors open for safe and confidential conversation may we drive the profession to demystify the stigma.

Physician culture generally takes pride in being objective, analytical and detached. Upon donning the white coat, a transformation occurs — the physician is no longer a person with a family, financial problems, illness or stressors. It can be very easy for medical students, already making their way through a challenging four years, to see that as something to idealize. But we must constantly remind each other that we are just as in need of mental health checks as our patients, if not more. We must change the culture of glorifying sacrifice of physical and mental health and spend more efforts in building resilience in our medical students not only for them but also for the patients they will one day serve.