Purpose To descriptively assess medical students’ concerns for their mental and emotional state, perceived need to conceal mental problems, perceived level of support at university, knowledge and use of student support services, and experience of stresses of daily life.
Study design From March to September 2011, medical students at an Australian university were invited to complete an anonymous online survey.
Results 475 responses were received. Students rated study and examinations (48.9%), financial concerns (38.1%), isolation (19.4%) and relationship concerns (19.2%) as very or extremely stressful issues. Knowledge of available support services was high, with 90.8% indicating they were aware of the university's medical centre. Treatment rates were modest (31.7%). Students’ concerns about their mental state were generally low, but one in five strongly felt they needed to conceal their emotional problems.
Conclusions Despite widespread awareness of appropriate support services, a large proportion of students felt they needed to conceal mental and emotional problems. Overall treatment rates for students who were greatly concerned about their mental and emotional state appeared modest, and, although comparable with those of similarly aged community populations, may reflect undertreatment. It would be appropriate for universities to address stressors identified by students. Strategies for encouraging distressed students to obtain appropriate assessment and treatment should also be explored. Those students who do seek healthcare are most likely to see a primary care physician, suggesting an important screening role for these health professionals.
- MENTAL HEALTH
- MEDICAL EDUCATION & TRAINING
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Mental distress and mental health problems have substantial and negative impacts on tertiary students’ academic performance. Globally, the prevalence of mental health problems and distress is high in tertiary students, similar to or greater than that of the general population in each country.1–5 Hence, it is likely that students presenting to physicians for any reason may also be experiencing emotional problems.
Previous research into student mental health has focused on demographic risk factors and previous histories of mental illness and used validated tools to screen for mental distress, mental illness and other quality of life and health parameters.1 ,5–8 Relatively little research has examined how students view or weight the impact of various life stressors. Also, much of the published research has been undertaken in the USA and little work has been conducted in Australia, including into treatment rates of mental illness among university students. Funding arrangements for tertiary students differ across countries.8 Thus, differences in affordability of health services and student financial provisions imply results from the USA cannot necessarily be extrapolated to the Australian context. There has also been little prior research into the effects of living circumstances on students’ mental health.3 ,8 Australian students, living in a different sociocultural and economic environment, may have different mental and emotional concerns and priorities, and data is required so that clinicians can provide effective and relevant treatment.
This study is part of a larger study (box 1) investigating mental distress in Australian medical students. The current study explores Australian medical students’ concerns regarding mental and emotional issues and current treatment rates. It investigates perceived need to conceal mental and emotional issues, how supported students feel at university, and awareness of university support services. This study also aims to index medical students’ perceptions of how stressful they find lifestyle issues.
▸ The overall study investigated sources of mental distress in students enrolled at Sydney Medical School and included: Kessler-10 scores for mental distress; use of alcohol and other recreational drugs; thoughts of dropping out of their studies; and the types of services students would like the university to provide. Socioeconomic factors included accommodation type (family home, own residence or renting); number of people living at the same residence; travelling time to site of study; paid work; and type of financial support during studies. Demographic data included: age; gender; year of enrolment; type of student (domestic/international); study pace (full time/part time); and dependant children. These results will be presented elsewhere.9
Data were collected by anonymous online survey from March to September 2011. Electronic bulletins containing the link to the survey were sent to all students enrolled at Sydney Medical School on six occasions over the 6 months.
Sydney Medical School (SMS)
▸ The medical programme at the University of Sydney is a 4 year graduate entry course; students will have completed at least one undergraduate degree before enrolment. Selection for entry into SMS at the time of the study was based on the student's score in a national entry examination, and a series of short structured interviews. During the final 2 years of the course, students are based at hospitals, and may have to commute up to 60 km depending on where they live. Students who are permanent Australian residents have access to government-funded (Medicare) subsidies to consult physicians and non-medical providers of psychological services. All students are eligible to use the free on-campus counselling services and other student services.
Students were asked about their mental and emotional states, knowledge of support services, and how stressful they found certain lifestyle issues:
How concerned are you about your mental or emotional state? (Not at all/A little/Somewhat/A lot/A great deal).
Are you currently receiving treatment for a mental or emotional problem? (Yes/No).
If no, have you considered seeking treatment for a mental or emotional problem? (Yes/No).
Did you ever feel you had to conceal mental or emotional problems while at university? (Never/A little/Somewhat/A lot/Always).
While at university how supported do you feel, mentally and/or emotionally? (Not at all/A little/Somewhat/A lot/A great deal).
Before today, which of the following university services were you aware of?
Have you ever sought treatment for mental or emotional reasons while at university (eg, stress, problems sleeping, depression, etc)? (Yes/No).
If yes, please tick which services you have used;
How stressful do you find the following issues in your life? (Rating table: financial, relationship, study and examination, isolation, accommodation and living arrangements, travelling and commuting, family) (Not at all/A little/Somewhat/Very/Extremely).
The questions were adapted from a number of sources5 ,11 ,12 and refined by the investigators (GW, LL, GSM). The resulting emphasis on financial, accommodation and transport issues was felt to be representative of important issues in the Australian context.
Data were analysed using IBM SPSS Statistics (V.19 and V.20, 2010 and 2011: Armonk, New York, USA). Responses to each question were tallied under the options and categories from which students could select. Proportions for the various categories were compared descriptively to determine students’ perceptions.
This study was given approval by the University of Sydney Human Research Ethics Committee. Participation in the study was voluntary and answering the survey was taken as an indication of consent to participate. At the end of the survey, students had the opportunity to participate in a lucky draw to win one of 50 cinema tickets, as compensation for the time spent completing the survey.
Five hundred and twenty-four students responded to the survey, with 475 completing the subjective rating table ‘How stressful do you find the following issues in your life’. This yielded a response rate of 40.7%. Table 1 shows how students rated their concern regarding their mental state, their need to conceal their mental state, and how supported they felt at university. The mean age of the students who responded to the rating table was 25.5 years, SD 3.8 (220 male, 254 female, 1 no answer); 81 were international students.
Student concerns regarding mental or emotional state and the number currently receiving treatment
More than 60% of respondents reported that they were not at all or a little concerned about their mental or emotional state, while 14% were concerned a lot or a great deal. Fifty-seven (11.9%) reported they were currently receiving treatment for a mental/emotional problem; 23 (35%) of those who said they were concerned a lot or a great deal about their mental or emotional state were currently receiving treatment. Of the 421 who had not received treatment, 31.1% had considered seeking treatment.
Need to conceal mental state and perceived support
Nearly a third of respondents said they never felt they had to conceal a mental or emotional problem, while a fifth reported they felt a lot of need or always had to conceal a mental or emotional problem. More than half of the respondents felt not at all or a little supported at university, mentally and emotionally, while 17.0% felt the university supported them a lot or a great deal.
Awareness of support services and rates of use
The best known of the university's support services were the Medical Centre, the University Counselling Service and the Financial Assistance Office (table 2).
Nearly a third of respondents (151 out of 477) had ever sought treatment for mental or emotional reasons while at university. Of these, the most common services used were the university counselling services, private psychologists and General Practitioners (GPs) (table 3).
Student perceptions of how stressful they found life issues
Table 4 shows students’ rankings of how stressful they found financial, relationship, study and examination, isolation, accommodation and living arrangements, travelling and commuting and family issues.
Rates of treatment-seeking in our study are comparable with population rates, where less than a quarter of individuals 16–34 years who met criteria for a mental disorder sought treatment which might have benefited them.13 Midtgaard et al found 31% of Norwegian medical students had mental health problems in their first 3 years of medical school which required treatment, yet 54% of these did not seek help.7 An Australian study by Leahy et al6 found 44% of medical students were psychologically distressed, yet only 10% had ever been diagnosed or treated for mental health problems, so it may be that mental health literacy has improved, and that medical students may now be more likely to seek treatment. While high levels of concern about mental and emotional symptoms do not necessarily equate to having a disorder, it is likely that a proportion of such individuals would meet criteria for a mental disorder and benefit from treatment. Hence, efforts to encourage distressed students to seek professional assessment should be promoted.
One in five students strongly felt the need to conceal mental or emotional problems. This concurs with Martin's study of 54 Australian students who had experienced mental health difficulties in which 34 (63%) had not disclosed their mental health conditions to university staff.14 Reasons given included feeling there was no need to, concerns they would not be believed or that staff would feel they were seeking privileges, fears of being discriminated against, judged or stigmatised, concerns of privacy and confidentiality being breached, embarrassment and previous negative experiences. Further, medical students in the UK associated mental illness with stigma, with stigma being a barrier to their seeking treatment.15 Stigma as a barrier to students seeking help has also been raised in the popular media.16 Given that issues of privacy, stigma and perceived level of confidentiality may be of concern to students, affordable options for care on-campus and off-campus may be important. The role of screening also becomes important.
The primary care physician or GP is the health practitioner most commonly approached by students. Stallman and Shochet's Australian study also found GPs were the service most frequently consulted by distressed students.17 Research clearly shows many emotionally troubled persons do not volunteer psychological symptoms to their GP, but rather present with a physical complaint.18 ,19 Thus, students may attend GPs for physical reasons such as minor illness, contraceptive advice or sporting injuries, but have concurrent mental or emotional problems. Given the apparently high prevalence of psychological distress among medical students, it is important for clinicians, who may be students’ first port of call, to screen for psychological distress. Our results draw attention to student concerns about revealing their symptoms, so clinicians should be appropriately reassuring about privacy and confidentiality. Encouraging high levels of self-care in future colleagues is an important priority.
There is a high level of awareness of services, particularly for counselling, financial and medical centre services. In contrast, in the USA, lack of awareness of services and the cost of treatment are barriers, even if the costs are only ‘perceived’ costs, since students in the USA have access to free mental health services on campus.20 ,21 In Australia, GPs can be accessed through the university's medical centres free of charge for domestic students but the financial cost of treatment by private psychologists—which were popular with this study's participants—may be a concern.
The most stressful life issue reported by medical students was study and examination, with nearly half saying they found it very or extremely stressful. Several other aspects of daily life were reported as being very or extremely stressful: two-thirds cited financial concerns, two-fifths cited isolation and two-fifths cited relationship issues. This agrees with Marshall et al's22 findings in Doctor of Pharmacy students, who most frequently reported family and relationships, examinations and assignments, and financial concerns as stress triggers. Perceived stress and the perceived burdens of isolation, relationships and study load significantly and positively correlated with levels of depressive symptoms in European university students, the correlation coefficients ranging from 0.28 to 0.70.5 Other studies also show living alone being associated with significantly higher levels of distress in students,3 ,8 which is congruous with isolation as an important stressor.
The finding of high levels of stress associated with studying is supported by other studies in medical students.23 ,24 However, stress may also be perceived as a ‘normal’ aspect of being a university student20 and while nearly half of our study sample found studying very or extremely stressful and an additional 35% found it somewhat stressful, it is interesting to note that more than half of the respondents reported they had little or no concern about their mental state.
Recently, the Australian media has reported the pressures tertiary students face, including the lack of affordable accommodation leading to long commute times, students sleeping in university buildings, undertaking paid employment at the cost of study time, the high rates of mental distress in students facing financial stress, and the lack of mental health support at university.16 ,25 Only a few previous studies have investigated financial concerns and psychopathology in tertiary students. In Australian students and non-students, having financial problems was associated with significantly greater risk of moderate and high distress.26 Morra et al27 found a positive relationship between perceived financial stress and current and anticipated debt in Canadian medical students, but did not investigate the impact of financial stress on health. An older UK study found worse mental health was significantly predicted by longer working hours and difficulty paying bills.28 Poor financial status is also associated with poor academic performance in Iranian medical students.29 Khawaja and Dempsey reported many students are moderately to severely stressed when managing financial matters and they often report financial strain30 and Stallman found 85% of students surveyed reported being under financial stress and these students were twice as likely to screen positive for mental illnesses than students with no financial stress.3 More than a third of our study sample reported financial issues as very or extremely stressful and a further quarter stated this was somewhat stressful. This also corroborates with student reasons for considering dropping out of medical school.9 Financial costs of mental health services can also be a burden for students requiring treatment,14 especially international students who are not eligible for Medicare subsidies in Australia. Access to treatment, given the intensiveness of study contact hours, may also be an issue.
We had expected accommodation concerns to be a stressful issue for many students, particularly as 62% of our respondents rented accommodation and renting contributes to financial pressures.9 However, only a small proportion of our study sample (13.5%) found accommodation to be very or extremely stressful, with a quarter finding it somewhat stressful. Similarly, only a small proportion found commuting to be very or extremely stressful (13.1%) and a fifth somewhat stressful, despite 78.2% of our sample having to travel to their place of study. It suggests that while the proportion of respondents who found commuting and accommodation to be highly stressful was small, these factors could have enormous impact on these specific students’ distress levels. Alternatively, our results perhaps indicate that accommodation and commuting, while causing students distress,9 are not viewed as being of substantial concern by the students themselves.
Limitations of this study include its cross-sectional and voluntary nature, and that our response rate (40.7%) was low. This may have biased our study sample towards students with a particular interest in mental and emotional issues and who were also well enough to participate. Students who were either severely ill, or who were well and therefore disinterested in the topic, may have been less likely to take part. Thus, our results may over-represent the slightly to moderately distressed student. Further, our results can only be generalised to Australian medical students and may not be relevant to students from other faculties or in universities in other countries that have different student sociodemographic profiles. Future research should investigate mental concerns, awareness and use of support services and life stressor profiles, including physical health concerns, in students from other disciplines and in other countries. Effective intervention strategies which clinicians can deliver to this group should also be examined, as should the management of stigma when students seek treatment.
A small but significant proportion of medical students report high levels of concern for their mental and emotional states. Only a third admitted to receiving treatment, and a perceived need to conceal psychological symptoms appears to be an important barrier to seeking help. Clinicians who provide medical care to medical students should be aware of the prevalence of hidden distress and screen for it in a way that is sensitive to student fears of disclosure and that emphasises the importance of self-care in the medical profession. The four most frequently endorsed sources of stress were study and examinations, financial difficulties, social isolation and relationship concerns. Awareness of common sources of stress may assist in screening and referring for appropriate support. Universities also have a role to play, directing resources to these areas identified by students as important sources of stress. Improving the format of the course curriculum, workshops and strategies to assist students with study efficiency as well as their sense of isolation or relationship issues, and financial assistance should be considered. The medical curriculum should include topics such as the importance of personal self-care, and research into the effectiveness of such teaching should be undertaken. Future research should examine ways to reduce perceived stigma, promote students seeking assessment of psychological problems and reduce sources of stress. Medical student distress is an important issue because these are the physicians of the future: safe practice and longevity in the profession depend on being able to monitor individual mental and physical health and seek appropriate treatment.
Approximately 14% of medical students responding to the survey reported high levels of concern about their mental or emotional state.
Students reported a high level of awareness of support services, compared with tertiary students in other countries.
Students with high levels of mental distress perceived a need to conceal their problems.
Only about a third of emotionally troubled students admitted to receiving treatment. Given the demands of their future employment, this is of concern and should be addressed.
Australian medical students most frequently endorsed study and examinations, financial concerns, isolation and relationship issues as highly stressful life issues.
Current research questions
How concerned are students about their physical health?
What interventions would be most effective in reducing levels of stress from life issues?
What strategies would be effective in ensuring more troubled students seek and obtain psychiatric assessment and appropriate treatment?
Stallman HM. Psychological distress in university students: A comparison with general population data. Aust Psychol 2010;45:249–57.
Leahy CM, Peterson RF, Wilson IG, et al. Distress levels and self-reported treatment rates for medicine, law, psychology and mechanical engineering tertiary students: cross-sectional study. Aust N Z J Psychiatry 2010;44:608–15.
Soh N, Ma C, Lampe L, et al. Depression, financial problems and other reasons for suspending medical studies, and requested support services: findings from a qualitative study. Australas Psychiatry 2012;20:518–23.
We thank the Office of Medical Education and Postgraduate Board of Studies for facilitating the distribution of the survey, and the students themselves for taking part.
Funding Discipline of Psychiatry, University of Sydney, Australia.
Competing interests None.
Ethics approval University of Sydney Human Research Ethics Committee.
Provenance and peer review Not commissioned; externally peer reviewed.
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