Supporting future doctors: Mental health help-seeking behaviour in medical students at the University of Witwatersrand, Johannesburg, South Africa

Abstract

Studies have shown that medical students may have higher rates of mental distress than the general population. Serious consequences thereof include academic failure, substance use and suicide attempts. In the wake of recent media reports of suicide in university students, mental health help-seeking behaviours and associated barriers to help-seeking in clinical year medical students at the University of Witwatersrand were examined. It was found that although formal mental healthcare was viewed favourably, medical students most often sought assistance from family members or friends rather than trained mental health professionals. The most commonly reported barriers to seeking mental healthcare were lack of time (primarily due to academic obligations) and fears of stigma and discrimination from colleagues and superiors. The need for support structures to be more easily accessible to medical students is highlighted by these findings, as well as the importance of lecturers and university staff being more familiar with the mental health screening of medical students.

Main article text

Introduction

Medical school can bring about difficult experiences for medical students, which can contribute to poor academic performance, reduced empathy towards patients, burnout and feelings of depression or anxiety.(1) An Ethiopian study showed that rates of mental distress, depression and anxiety were higher in medical students than in the general population.(2) A study from University of Cape Town found that the risk of developing a depressive disorder in the pre-clinical years of study was more significant than in the later years of study.(3) Medical students are affected by high workload, academic pressure, sleep deprivation, lack of breaks, proper time management and financial stress.(2,3) Additionally, being confronted with patients who are dying may be another difficulty.(2)

A meta-analysis of 165 cross-sectional and 16 longitudinal studies from 43 countries found that the overall rate of depression in medical students was 27.2%, while the rate of suicidal ideation was 11.1%.(4) Despite being at greater risk, medical students do not regularly seek appropriate help for mental health disorders.(4) Instead, they utilise various self-care habits (constructive or maladaptive) or seek assistance from other less formalised or well-trained avenues.(1). Substance use may be employed as a coping mechanism, leading to possible dependence and addiction.(5)

Factors discouraging help-seeking include stigma, embarrassment, preference to handle problems alone or to talk to friends and family, concerns about confidentiality, and a fear of discrimination affecting career opportunities and social status.(6–8)

Materials and Methods

A cross-sectional study was conducted at the University of the Witwatersrand (Wits) Medical School campus in Johannesburg, South Africa. The study population consisted of all clinical year medical students (i.e. Graduate Entry Medical Programme [GEMP] 1, 2, 3 and 4 students), which numbered 1401 students in total.

We sent all eligible participants a link to an online questionnaire using the university's internal student email database. The questionnaire included demographic details and the following screening tools: the Actual Help Seeking Questionnaire (AHSQ),(9) the General Help Seeking Questionnaire (GHSQ)(10) and the Barriers to Seeking Mental Health Counselling (BMHC).(11) The AHSQ and GHSQ pose similar questions but measure future help-seeking behaviour and past help-seeking behaviour, respectively. The questionnaire also asked participants if they used substances as a means to cope with mental/psychological distress and what substances they used, if any. The questionnaire assessed past and future help-seeking behaviour, barriers to help-seeking, and some commonly reported barriers in medical students.

Data were analysed using descriptive statistics with frequencies and percentages. Ethical clearance for the study was obtained from the Wits Human Research Ethics Committee.

Results

A total of 191 responses were received, reflecting 14% of the total student population and 64% of the calculated sample size. Figure 1 illustrates the demographic characteristics of the respondents. The majority were female (n = 136, 71.2%) and between the ages of 21 and 25 (n = 150, 78.5%). Most spoke English at home (n = 135, 70.7%), and about half of the students were Christian (n = 97, 50.8%).

Figure 1:

Demographic details of study participants

Help-Seeking Behaviour

Figure 2 illustrates responses to the AHSQ. Although formal mental health resources were viewed favourably in the study population, more than half of the respondents reported that they would most likely approach their close friends (n = 154, 80.6%) or mothers (n = 109, 57.1%) for help if they were experiencing emotional distress. Only 11% (n = 21) reported that they would seek help from a mental health professional.

Figure 2:

Responses to the AHSQ

Of the respondents who had previously sought formal mental health assistance, most reported having seen a psychologist rather than other mental health professionals, such as a psychiatrist. Females were more likely to have reported formal intervention and were also more likely to have engaged in longer-term interventions.

Barriers to Help-Seeking

The most common barriers to help-seeking were academic and work-related obligations (particularly in GEMP 3 and GEMP 4 students), not having the time to seek out counselling/assistance, and believing that public knowledge of mental health distress would affect treatment from colleagues and superiors. (Figure 3) Respondents were less concerned about judgement from family members or friends or how cultural perceptions of mental illness may affect people's view of them.

Figure 3:

Responses to the BMHC

Substance Use

Figure 4 illustrates the prevalence of substance use as a coping mechanism in respondents. Less than 20% (n = 35) of students reported using substances as a coping mechanism. More female students (n = 8; 32%) reported using alcohol to cope, while more male students reported using nicotine (22%, n = 2) and illicit drugs (22%, n = 2), although the actual numbers were small. Females were also more likely to use psychiatric medication (40%, n = 10 in females compared to 33%, n = 3 in males). A more significant proportion of GEMP 4 students, i.e. final-year students, reported using psychiatric medication, although the actual numbers (n = 2) were relatively small.

Figure 4:

Prevalence of substance use by gender and year of study

Discussion

In keeping with other reports, this study found that respondents appeared to favour seeking mental health support, when needed, from informal sources. This finding could reflect better social support systems among those who responded. Still, it is also a concern as severe mental health symptoms in students may go unrecognised by the absence of formal assessment. The World Health Organisation recognises informal community care as a critical source of mental health support in their ‘Model of Optimal Mental Health Care’.(12) However, formal sources of mental healthcare are still necessary for individuals with clinically significant symptoms, as well as to initiate and monitor effective treatment.

A notable finding of this study is that students in more advanced years of study reported lower levels of help-seeking. However, other reports in this field did not find much difference in the prevalence of mental health symptoms in earlier (pre-clinical) versus later (clinical) years of study.(3,4) Our findings could be a play of chance as our study sample was small.

Of interest in this study is that respondents were not very likely to use substances as a coping mechanism, which is not in concert with other studies, especially considering the high rates of substance abuse in South Africa. Substance use by the participants may have been under-reported in the survey. The reported prevalence of alcohol use is comparable with other studies reporting alcohol consumption rates of 17% to 34% in medical students.(13) Alcohol is a dysfunctional coping mechanism, and it has been associated with a decreased rate of seeking professional, effective and safe assistance.(14) Mitigating the risks of maladaptive substance use in medical students should be seen as a priority and should preferably include psychoeducation on the dangers of substance use as well as information on easily accessible avenues of assistance for mental health concerns

Limitations

The study had a lower than expected response rate, resulting in a smaller sample size than expected, as well as sampling error and non-response error associated with this form of study. Also, most respondents were White, female, and English-speaking, which is not reflective of the overall profile of medical students at the university.

Conclusion

Following recent student suicides at the University of Witwatersrand, Samuels (15) has highlighted the need for more attention to the issue of student mental health. The most common barriers to help-seeking relate to the university and academic environment. The lack of time is associated with overwhelming academic pressure and stigma from colleagues and superiors. We recommend that the university create more awareness about mental health, educate the students regarding the various modalities of assistance that the university offers and for lecturers and university personnel to become more familiar with screening and referral of at-risk students and foster non-judgmental attitudes to reduce stigma around mental illness.

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