Journal of Affective Disorders, 11 (1986) 91-96 91

Elsevier

JAD 00391

Depression among Medical Students

Mark Zoccolillo, George E. Murphy and Richard D. Wetzel

Department of Psychiatry, Washington University School of Medicine, 4940 Audubon Auenue, St. Louis, MO 63110 (U.S.A.)
(Received 5 June, 1986)
(Accepted 19 June, 1986)

Summary

304 first- and second-year medical students were prospectively assessed for depression with a monthly
Beck Depression Inventory (BDI). Students scoring above nine on the BDI and a control group were then
interviewed with the NIMH Diagnostic Interview Schedule. The incidence of major depression or probable
major depression by DSM-III criteria during the first two years of medical school was 12%. The lifetime
prevalence was 15%, three times greater than the rate in the general population. An episode of depression
prior to medical school was much more common among the depressed students (69 vs. 8%, P < 0.001) as
was a family history of treated depression (46 vs. 21%, P < 0.025). The elevated rate of depression during
medical school does not appear to be a result of the medical school experience alone. Rather, it suggests a
positive bias of unknown nature in the selection of students predisposed to depression.

Key words: Depression - Prevalence - Medical students

Introduction genie? Does the medical profession select for those

at risk for depression?
Members of the medical profession appear to We have found only one published systematic
be at increased risk for major depression. Two study of depression in medical students (Pitts et
studies have found an extremely high incidence of al. 1961). A random sample of 40 sophomore
depression during internship (27 and 30%) (Valko medical students were given a standard interview.
and Clayton 1975; Clark et al. 1984). Clayton et Two of 40 students had become depressed during
al. (1980) found that 39% of women physicians medical school and a third student had suffered a
(mean age 46.5 years), had had episodes of major manic episode. Both studies of depression during
depression in contrast to the lifetime prevalence of internship (Valko and Clayton 1975; Clark et al.
major depression in the general female population, 1984) found high reported rates of depression
between 4.9 and 8.7% (Robins et al. 1984). All before internship (23 and 40%).
three studies cited above found a family history of
depression to be increased among physicians who Method
became depressed. Is medical education depresso-
All first- and second-year students in the
Reprint requests to Dr. Murphy. Washington University School of Medicine during

0165-0327/86/$03.50 0 1986 Elsevier Science Publishers B.V. (Biomedical Division)

92

the academic years 198221983 and 198331984 1983-1984 (to ensure a base of adequate size).
were invited at the beginning of the academic year Female students comprised 24% of all students
to participate in the study. Those electing to do so and 21% of those participating. Control students
signed a consent form approved by the Human were interviewed during their third and fourth
Studies Committee. Complete confidentiality re- years, after the incidence study was completed, to
garding responses and diagnoses was assured and determine whether it was likely that a substantial
maintained. The sample was composed of three number of cases had been missed by our case-
cohorts: first-year students during 198221983 and finding method as well as to see if additional
second-year students 1983-1984 (together forming psychopathology not targeted by the BDI was
one cohort), second-year students 1982-1983, and present in the group.
first-year students 1983-1984. Data analysis was done by computer using
In order to identify and date the onset of Statistical Analysis System (SAS Institute 1982)
depression, students were asked to return a self-re- software. Two-by-two tables were analyzed by
port Beck Depression Inventory (BDI) (Beck et al. chi-square for statistical significance.
1961) approximately every four weeks during the
academic year. Students scoring above nine on Results
any occasion, were interviewed by the first author,
using the NIMH Diagnostic Interview Schedule Of 384 eligible students, 304 (79%) agreed to
(DIS) (Robins et al. 1981). The BDI was chosen participate and returned at least one BDI. All
because it can be self-administered, is easily scored, students who declined to participate in one cohort
is highly sensitive (Nielsen and Williams 1980) (n = 24) were contacted by telephone. Two spon-
and correlates well with other measures of depres- taneously volunteered that they had been de-
sion. The DIS was selected because it gives both pressed. A third non-participant left school be-
current and lifetime diagnoses that can be com- cause of mental illness.
pared directly to recent general population studies Dropouts were defined as students who failed
using the same instrument, and it can be scored by to return three or more BDIs in a row. Students
the same algorithm used in those studies. The would often fail to return an occasional BDI but
diagnostic criteria used were those of DSM-III those who failed to return three or more in a row
(American Psychiatric Association 1980). While usually did not resume participation in the study.
the main disorder of interest was major depres- Forty-five students (15%) dropped out, but 11 of
sion, other diagnoses assessed include bereave- these students were interviewed, either as de-
ment, dysthymic disorder, bipolar II disorder, pressed with BDI > 9 prior to dropout, or later, as
mania, schizophrenia, alcohol abuse and depen- controls.
dence, other substance abuse, antisocial personal- Sixty-eight students (22%) scored above nine on
ity disorder, somatization disorder, panic disorder, the BDI during the study. Of these, 63 (93%) were
phobic disorder, anorexia nervosa, and obsessive- interviewed and five refused to be inter.viewed. Of
compulsive disorder. 34 male controls randomly chosen, 27 (79%) were
Family history of psychiatric illness and past interviewed. One student was not interviewed be-
history of psychiatric treatment were also sys- cause he had left school for academic reasons, one
tematically assessed. A family history of depres- student transferred to another school, two de-
sion was considered positive if a first-degree family clined to be interviewed, and three did not return
member (parent or sibling) had sought care for calls or letters. Twenty-two of 23 females were
depression. interviewed; one was out of town for several
A control group was drawn from among stu- months and was missed on that account. There-
dents participating in the study who never scored fore, a total of 112 students were interviewed (63
above nine on the BDI. The control group con- students with a BDI score greater than nine and
sisted of randomly selected males from the sec- 49 controls). The mean age of the interviewed
ond-year class of 1982-1983 and all of the females students, including those interviewed during their
of the second-year classes of 1982-1983 and third and fourth years, was 24.6 years.
 93

Rates of depression school, a statistically significant difference (x2 =

Major depression was diagnosed by DSM-III 4.19; P < 0.05).
(American Psychiatric Association 1980) criteria Ten of the students who had been depressed at
and must have been severe enough to cause the some time met criteria for another lifetime psychi-
student to seek care or to interfere with life or atric diagnosis. Three met criteria for phobic dis-
activities, as judged by the student. The term order, two for alcohol abuse, two for antisocial
depression, as used here, includes major depression personality disorder, one for obsessive compulsive
(n = 23) and probable major depression (sustained disorder, anorexia nervosa and a phobic disorder
depressed mood plus three depressive symptoms (all coexistent with major depression), one for
instead of the required four, and/or did not seek marijuana dependence, and one for bipolar dis-
care or judge the depression as interfering with life order. None of the students met criteria for bi-
or activities: n = 12). Thirty-five students had been polar II disorder. Of those students who were not
depressed, 26 during the first two years of medical depressed during the period under study and who
school (Table 1). were interviewed as controls, three met criteria for
Only twenty-three of 63 students with BDI alcohol abuse, two for marijuana dependence, one
scores greater than nine were found positive for for amphetamine abuse, and one for bereavement.
major depression using the DIS and DSM-III None of the students given a substance abuse
criteria. The average BDI score of students meet- diagnosis admitted to abusing these substances
ing these criteria for depression or probable de- since entering medical school.
pression was 13.8 + 6, with a range of 10-29. The lifetime prevalence of major depression
Fifty-two percent of the elevated scores were less (not including probable cases) through the second
than 16. As no control student reported having a year of medical school, using the same interview,
depression during the period of study, it is likely scoring, and criteria as used in the Epidemiologic
that a BDI cutoff score of nine identified all of the Catchment Area (ECA) study (Robins et al. 1984)
students with major depression. was calculated for men using the second-year class
The two-year prevalence of depression in the of 1982-1983 and the controls from that class and
cohort followed for two years (first-year 1982-1983 for women using the second-year classes of
and second-year 1983-1984) was 11 of 91 students 1982-1983 and 1983-1984 and the controls from
(12%). The one-year prevalence for the first-year those classes. Six of 40 women (15%) and 13 of 88
class of 1983 was 8/124 or 6% and for the men (15%) were estimated to have had a major
second-year class of 1982, 7/87 or 8%. Ten of 64 depression during their lifetime. The lifetime prev-
women (16%) and 16 of 240 men (7%) were de- alence for major depression in the 18- to 24-year-
pressed during the first two years of medical old cohort in St. Louis from the ECA study is 7%
for women and 1.1% for men (n = 471) (Robins,
L.N., personal communication). The rate of major
TABLE 1 depression in medical students is significantly
LIFETIME AND MEDICAL SCHOOL OCCURENCE OF
higher, P < 0.001.
MAJOR DEPRESSIVE DISORDER AMONG MEDICAL A history of depression before medical school
STUDENTS was much more common among those students
who became depressed during medical school than
Rates of depression n among those who did not (Table 2). The ap-
Ever had major depression proximate relative risk (Everitt 1977) of becoming
or probable major depression 35 depressed during medical school is 25 for students
Ever had a major depression 23 with a prior history of depression compared to
students without such a history. An alternative
Ever had probable major depression only 12
way of expressing this risk is that students without
Developed major depression or probable major such a history of prior depression had only 4% the
depression during first two years
risk of students with such a history of becoming
of medical school 26
depressed in medical school, with a 95% confi-
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TABLE 2
PRIOR PERSONAL HISTORY AND FAMILY HISTORY OF DEPRESSION AMONG THOSE DEPRESSED DURING
MEDICAL SCHOOL

History Depressed Not depressed P

” = 26 (W) n = 86 ($)
Positive history of depression
before medical school 18 (69) 7 (8) < 0.001

Positive family history of

depression 12 (46) 18 (21) < 0.025

Either or both 23 (88) 23 (27) < 0.001

dence interval of l-12%. Of the 23 students who not known in most instances. However, two stu-
qualified for a diagnosis of major depression, 15, dents were known to have left medical school
or 65% had been depressed before medical school. permanently because they could no longer func-
Multiplying 0.65 and the estimated lifetime preva- tion due to depression. A third student was psy-
lence rate of 15% gives a lifetime prevalence rate chiatrically hospitalized during the school year
of major depression prior to medical school of with a manic episode but was not in academic
lo%, which is twice that of the general population difficulty.
rate found in the ECA study.
A family history of depression was significantly Discussion
more common among those students who became
depressed than among those who did not (Table Two methodologic issues need to be addressed.
2). Only two students had a family history of The first is that of the limitations on interpreta-
mania; neither had become depressed or manic. tion of the data posed by the sampling method.
Eighty-eight percent of the students who became Cooperation was voluntary and one-fifth of the
depressed during the first two years of medical class members did not participate. What is the
school had either an episode of depression before likelihood of bias? Did we succeed in attracting to
medical school, a positive family history of de- the study a disproportionate number of students
pression, or both, compared to 27% of those who concerned about their mental health? At least two
did not become depressed (P < 0.001). The aver- students refused to participate because they were,
age age of onset of the first depressive episode was or had been, depressed and another withdrew
19.5 k 4.7 years, with a range of 6-27 years. from school for mental health reasons. Thus, at
There was no distinguishable temporal pattern least some students with depression did not par-
to the onset of depression during medical school. ticipate. Further, several students ceased to par-
Second-year students had examinations at regular ticipate after they were identified as depressed. It
intervals and there was no obvious increase in is not possible to examine those who do not wish
depression in relation to examination periods. to cooperate. The known rate of depression in one
Of students identified as depressed, 40% had non-participant group is two out of 24, 8%.
sought treatment, 43% did not seek treatment, and The second issue is, can the lifetime prevalence
17% delayed seeking treatment for a month or rate for depression in medical students, which we
more. While not systematically assessed, two main estimated to be 15%, properly be compared to the
reasons given for not seeking treatment were the general population rate for 18- to 24-year-olds
perception that being depressed was a normal part found in the ECA study? Our case-finding was
of medical school and that obtaining treatment much more intensive, while the ECA subjects were
would take up too much time. Unless the student’s interviewed once. However, the previous studies
BDI score remained elevated, he or she was not cited (Pitts et al. 1961; Valko and Clayton 1975;
re-interviewed, so the outcome of the depression is Clark et al. 1984) used a single interview and also
 95

found rates similar to ours, suggesting that our arduous pursuit of high academic performance
method of intensive case-finding did not raise the and of acceptance into and completion of medical
rate of depression. We also used the same inter- school. One does not need to look far to descry its
view and scoring algorithms used in the ECA presence among one’s colleagues (or even oneself).
study, but the interview in the ECA study used lay It seems unlikely that medical schools know-
interviewers, which may underestimate the num- ingly select specifically for a depressive diathesis.
ber of cases compared to a physician interviewer Nor does it seem likely that a tendency to depres-
(Helzer et al. 1985). The magnitude of this under- sion would orient persons specifically toward a
estimate is much lower than the three-fold in- medical career. To be sure, prior helpful contact
crease in lifetime prevalence for major depression with a physician can provide a role model and
in medical students. We believe that the compari- may even crystallize a career decision. However, in
son between our findings and the ECA data is the present instance, only a minority of our de-
valid. pressed students had had prior medical treatment
If we accept these high rates as substantially for their depression. It seems to us more likely
valid, what is the explanation? The depressed that the obsessional traits that help many aspirants
medical students’ response might be ‘medical to successfully negotiate pre-medical education
school’. Yet we find that two-thirds of these de- carry with them an added vulnerability to depres-
pressed students had had an earlier episode and sion. A different study than this one is needed to
nearly half had a positive family history of depres- test that hypothesis.
sion. More. than four-fifths had one, the other, or The second author of this paper, in the course
both risk factors. This is not to suggest that medical of five years of psychiatric care to the medical
school is not a stressor. The medical school en- student body, was impressed by the attitude of
vironment may contribute to depression but it is some students to the learning process. Despite
in addition to the major effect of a previous obvious successes, these students readily antic-
history of depression and a family history of de- ipated failure at new endeavors. They seemed to
pression. It appears to act on the recognizably lack confidence that their past performance was
vulnerable - those with a prior history or a stably indicative of their abilities or reliably pre-
family history of depression. We must try to dictive of their future performance. They received
account for the presence of so many vulnerable reassurance from superior performance ratings,
persons in the medical school class. but not confidence.
Current studies do not support higher socio- The selection of medical students relies heavily
economic status (Boyd and Weissman 1982) or on past evidence of superior academic perfor-
intelligence as factors associated with depression. mance. Inevitably, adept learners are selected. It
Terman followed up 1528 high IQ students (aver- may be that an irrational fear of failure both
age IQ 151),from an average age of 11 to age 44 ensures academic success in some and leads to
(Helzer et al. 1985). There was no excess of depression at even the hint of failure. Alterna-
hospitalizations for mental problems, and only a tively, an irrational fear of failure may be a sub-
very slight excess of suicides in the women, but clinical manifestation of depression, but one which
not in the men. The follow-up looked only at also leads to academic success by way of intense
hospitalizations and suicide, and thus may not effort.
reflect the true rate of major depression. Studies In summary, we found depression to be at least
of college students (Rimmer et al. 1978) and wom- three times more common among medical stu-
en Ph.D.s (Clayton et al. 1980) also find high rates dents than in the general population. This is a
of depression, so it may be that efforts toward significant student health problem which requires
educational achievement are implicated. aggressive case-finding by student health services
Hirschfeld and Klerman (1979) report that de- to provide necessary treatment and prevent poten-
pressive patients demonstrate ‘more neuroticism, tially devastating consequences. The increased rate
introversion and obsessionality than [ . . . ] normal of depression among medical students appears to
individuals’. Obsessionality is advantageous in the be largely due to an unwitting selection of predis-
96

posed students. The factors associated with de- Everitt, B.S. The Analysis of Contingency Tables, Chapman
pression which predispose students to enter medi- and Hall, London, 1977, pp. 32-34.
Helzer, J.E., Robins, L.N., McEvoy, L.T., Spitmagel, E.C.,
cal school remain unknown. From a practical point
Stoltzman, R.K.. Farmer, A. and Brockington, I.F., A
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Nielsen, III, A.C. and Williams, T.A., Depression in ambula-
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