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Original Article

Survey of the Prevalence of Burnout,


Stress, Depression, and the Use of Supports
by Medical Students at One School

Elaine Chang, M.D.


Florence Eddins-Folensbee, M.D.
John Coverdale, M.D., M.Ed., FRANZCP

Objective: The authors determined the prevalence of stress, de-


pression, and burnout in medical students and the resources used
by students in one school to alleviate psychological distress.
M edical students mental health is a topic of great
interest, given that several multi-institutional studies
have revealed that they have a substantially lower mental
quality of life than similar-age individuals in the general
Methods: A survey was administered to 526 students in the rst
population (13). These are issues that have implications
3 years of medical school (336 responders; response rate: 70%)
for medical student professionalism (4), dropout rates (5),
at one institution, using a modied Maslach Burnout Inventory
Human Services Survey (MBI-HSS), the two-question PRIME- and the health of future physicians (6). Medical school
MD depression screening survey, the Perceived Medical School pressures, including overwhelming amounts of material
Stress Scale, along with questions on demographics and helpful to learn in short periods of time, unclear expectations,
programs to cope with stress. and nancial stressors (7), contribute to excessive work
demands. Burnout, stress, and depression are three possi-
Results: The percentage of respondents scoring in the High ble adverse consequences of these stressors.
Burnout range was approximately 55% for all three subscales. Burnout is a pathological syndrome with three dimen-
Depressive symptoms were reported by 60% of respondents. The sions: emotional exhaustion, depersonalization, and loss
most helpful coping mechanisms reported were social support
of sense of personal achievement (8). Burnout and depres-
from peers and faculty, counseling services, and extracurricu-
sion are also associated with suicidal behaviors among
lar activities.
medical students (9). Only in the past 6 years has the eval-
Conclusions: The prevalences of burnout, depression, and stress uation of burnout among medical students become of
were higher in this sample of rst- through third-year medical interest to the medical community (3). We found nine re-
students when compared with other medical student groups cently published studies evaluating burnout (1, 2, 4, 5, 9
previously studied. Important limitations of this research included 13), only ve of which measured stress, burnout, and
the fact that it was cross-sectional in design and that the PRIME- depression simultaneously among United States medical
MD tool is simply a screening tool and does not diagnose major students (1, 4, 5, 9, 13). These ve studies were limited to
depression. Medical educators, deans, and administrators should
the same seven medical schools. Moreover, only one study
appreciate the possibility of higher levels of psychological distress
of burnout investigated resources or coping mechanisms
among their own students than those previously reported.
used by students (10).
In our medical school, two medical student suicides
Academic Psychiatry 2012; 36:177182
within an 11-month span heightened concerns about the
emotional well-being of our students. Also, our institution
Received April 21, 2011; revised September 12, November 2, December 7,
2011; accepted December 13, 2011. From Elaine Chang, Dept. of Medi- is relatively unique in that it teaches the basic sciences within
cine, Baylor College of Medicine; Florence Eddins-Folensbee, Dept. of 1.5 years, rather than 2 years, and this practice may result in
Psychiatry, The University of Texas School of Medicine at San Antonio; different patterns of psychological morbidity throughout
John H. Coverdale, Dept. of Psychiatry, Baylor College of Medicine. Send
correspondence to Dr. Chang; e-mail: elainec@bcm.edu the medical student career. Our objective in this study,
Copyright 2012 Academic Psychiatry therefore, was to investigate the prevalences of stress,

Academic Psychiatry, 36:3, May-June 2012 http://ap.psychiatryonline.org 177


PREVALENCE OF BURNOUT, STRESS, AND DEPRESSION

depression, and burnout at this school in the rst-, second-, to Strongly Agree) with a statement about medical school
and third-year classes, as well as the resources used by stress. Previous research has provided validation information
students to alleviate psychological distress. and documented the reliability of the scale at 0.83 (7).
Reliability in our data was 0.87. Finally, we asked one
Method open-ended question: What (medical school) program(s)
have helped you cope with stress, anxiety, or burnout?
Measures Please explain.
The online survey included three scales designed to
assess burnout, depression, and stress; one open-ended
Procedures
question on institutional programs that had helped them
Approval for the study was obtained from the schools
cope; and questions on demographic background.
Institutional Review Board. All 526 rst- (MS1s), second-
We utilized the Maslach Burnout Inventory, a 22-item
(MS2s), and third-year (MS3s) students were e-mailed
instrument that is the gold standard, and most frequently
three times to ask for their participation in the online
used measure of burnout in the medical literature (9), to
survey. Fourth-year students were invited to participate as
assess burnout. Each item asks participants to indicate how
well, but results from this cohort were not included in this
often they have certain work-related feelings. The questions
study because of low participation rates. The e-mail included
were adapted with permission from the publisher to address
a description of the compensation, which was a $5 reward
attitudes toward medical school (rather than work). Three
to be added to class funds for each student who participated.
subscales evaluate three domains of burnout: emotional
The survey was open from March 14 until April 2, 2010.
exhaustion (a sense of overwhelming work demands that
Participation was elective, and responses were anonymous.
deplete emotional resources and the ability to help people),
Information about help available for concerns relating to the
depersonalization (negative, cynical feelings toward patients
survey was provided in the e-mail.
or colleagues), and lack of personal achievement (a sense of
inefcacy and low personal accomplishment) (10). It has
been validated among human-service workers (14, 15) Analysis
and used extensively in studies of medical students (1, 2, 4, For data from the three scales, both descriptive (mean,
5, 913). Although the original burnout scale utilized median, standard deviation [SD], percent), and inferential
a 7-point Likert scale (06; never to every day) for statistics were used. To determine differences among classes
response options to each item, we inadvertently excluded for burnout and stress, we used analysis-of-variance tests with
the never option in the response options for each item. eta-squared (h2) for effect-size estimation. To determine
This converted the scaling for each item to a 6-point scale differences in classes for depression, we used chi-square tests
(a few times a year or less to every day). Reliability of (x2, with Cramers V [w] for effect-size estimation. We used
the scale among our sample was 0.90, with reliabilities for SPSS Version 18.0 to conduct our analyses, with alpha (a) set
each subscale at 0.90, 0.76, and 0.78 (for emotional ex- at 0.05. We adjusted for the inadvertent truncation of the
haustion, depersonalization, and personal achievement, burnout scale by converting responses of 1 (a few times
respectively). a year or less) to 0 (never) for the emotional exhaustion
We used the two-item Primary Care Evaluation of Men- and depersonalization subscales, while keeping the personal
tal Disorders (16), a screening tool that performs as well as achievement subscale a 6-item scale. Responses greater than 1
longer instruments (17) for assessing potential depression. were not converted. This change underestimated the prevalence
Respondents screen positive for possible depression if they of burnout, as burnout is calculated on the basis of cumulative
answer positively to either During the past month, have scores.
you often been bothered by feeling down, depressed, or To analyze qualitative data from the open-ended question,
hopeless? or During the past month, have you often been two team members (TH and FE) used the constant-
bothered by little interest or pleasure in doing things? This comparison method (18) to review a random subset of 40
instrument has a sensitivity of 86%96% and a specicity responses to develop a coding scheme of 15 possible coping
of 57%75% for major depressive disorder (16, 17). approaches. Two other team members (EC and JC) indepen-
We selected the Perceived Medical School Stress Scale dently coded the responses. Because responses were multi-
(7) to assess stress. Each of the 13 items assessed students faceted (with multiple approaches to coping identied in one
agreement (on a 5-point Likert scale, from Strongly Disagree response), coders could assign up to four themes for each

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CHANG ET AL.

response. Initial inter-coder reliability was measured, with (35.4%) regarded nothing offered by the institution as
kappa (k) at 0.84. Coders resolved disagreements, establish- helpful or had not used school resources. Of the 133 students
ing consensus for each response through discussion. who reported something that helped them cope, 99 of these
found at least one institutional program helpful. Among
Results these 99, 38 students reported other students and student-
oriented programs as helpful, with the PRN program,
A total of 336 students in the rst 3 years of medical school a student-led, peers-as-resource networking program, cited
returned the survey (69.3% response rate). This comprised by most; 28 students regarded faculty and mentors as
150 MS1s (response rate: 82.0%), 118 MS2s (68.2%), and helpful in coping, whereas 25 found structured events
98 MS3s (57.7%); 56% were women. Almost half (45.4%) such as courses and student-affairs activities helpful, and
reported their race or ethnicity as Caucasian, 33.1% as 28 found counseling helpful. Of the 32 who cited non-
Asian, 10.9% as Hispanic, and 4.1% as African American. institutional coping approaches, responses included religious
The demographic characteristics of our sample were consis- organization or practice, family and friends, extracurricular
tent with the demographic characteristics of our full student activities such as volunteering and exercise, and time away
body. from coursework.
The percentage of students reporting high levels of
emotional exhaustion, depersonalization, and low personal Discussion
achievement were 51.7%, 44.0%, and 52.0%, respectively,
with varying percentages of students in each class (see The prevalences of burnout, depression, and stress were
Table 1). Analysis of variance revealed signicant differences higher in this sample of rst- through third-year medical
between MS1s, MS2s, and MS3s for depersonalization and students, as compared with other medical-student groups (1, 2,
personal achievement, but not for emotional exhaustion. 4, 5, 7, 913). Approximately 50% of students met criteria
Post-hoc analyses revealed that MS1s reported signicantly for high burnout in each of the three domains. In contrast,
less depersonalization than MS2s or MS3s, although MS2s approximately 30%40% of students met criteria for high
and MS3s were not different from each other. MS1s also burnout in each of the three domains in a seven-institution
reported signicantly less personal achievement than study (9). These ndings indicate that previous studies
MS2s, although there was no difference between MS3s and may not have captured the entire range of experiences of
either MS1s or MS2s. About 60% of students (59.6%) were burnout across medical schools. Administrators, deans and
symptom-screen positive for depression, with no signi- medical educators should therefore appreciate this possibility
cant differences between classes. Conversely, there was of higher levels of burnout within their own medical student
a signicant difference between the classes in perception of groups.
medical school stress, with MS1s reporting less stress than Similarly, the prevalence of depression and stress, even
either MS2s or MS3s. However, all effect sizes for all of when using the same measurement tools, were also higher than
these differences were small. those previously reported (1, 2, 4, 5, 7, 913); 60% of stu-
Of the 13 items in the Perceived Medical School dents answered afrmatively to either of the two depression
Stress Scale, 5 stressors received responses of Agree or screening questions, whereas 47% of students in the earlier
Strongly Agree from the majority of students: Decisions multisite study answered afrmatively to either of these two
regarding electives and clerkships are made on the basis of questions (9). One earlier study also found a lower level of
information obtained from fellow students and not from the stress than that which was reported here (7). Earlier studies
faculty. (72%); I am concerned that I will be unable to have found lower rates of burnout among minorities, as com-
master the entire pool of medical knowledge. (70%); pared with non-minorities, and no differences in depression by
Personal nances are a source of concern to me. race/ethnicity. Minorities who experience discrimination or
(61%);Medical training controls my life and leaves too adverse experiences involving race, however, have higher
little time for other activities. (57%);I am concerned that I rates of burnout (1). Mixed ndings are reported in compar-
will not be able to endure the long hours and responsibilities isons of depressive symptoms between genders, with at least
associated with clinical training and practice. (51%). half of studies reporting no difference (1925). Longitudinal
A total of 189 students (56.3%) responded to the open- studies consistently show higher rates of depression and sui-
ended question concerning which school programs helped cidal ideation in second-, third-, and fourth-year students than
students cope with stress, anxiety, or burnout. About one-third in rst-year students (9, 25, 26).

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180
TABLE 1. Percentages of Medical Students Experiencing Burnout,a Stress,b and Depression,c and Mean Scores Among Class Cohorts

Students
Measures MS1 MS2 MS3 All Students p
Maslach Burnout Inventory
Emotional Exhaustion
N 143 113 96 352
% With High Burnout 53.8% 51.3% 49.0% 51.7%
Mean (SD) 26.6 (9.8) 25.9 (11.1) 27.0 (10.6) 26.5 (10.4) NS
Depersonalization
N 140 113 95 348
% With High Burnout 34.3% 46.0% 55.8% 44.0%
Mean (SD) 7.2 (5.7) 9.5 (5.4) 10.8 (6.0) 9.0 (5.9) ,0.001d
Personal Achievement

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PREVALENCE OF BURNOUT, STRESS, AND DEPRESSION

N 139 113 96 348


% With High Burnout 57.6% 45.1% 52.1% 52.0%
Mean (SD) 30.9 (7.0) 33.5 (6.6) 32.9 (6.7) 32.3 (6.8) ,0.01e
Prime-MD
N 149 149 118 97 364
% Met Criteria 99 (66.4%) 99 (66.4%) 65 (55.1%) 53 (54.6) 217 (59.6%)
Medical School Stress Scale
N 149 149 118 98 365
Mean (SD) 38.4 (9.5) 41.5 (9.5) 42.4 (8.7) 40.5 (9.4)

MS1, MS2, MS3: First-, second-, and third-year medical students, respectively; SD: standard deviation.
a
Maslach Burnout Inventory, utilized Medicine norms (which included 1,104 physicians and nurses) to determine High Burnout; for Emotional Exhaustion, high burnout is dened as 27 on a
054 scale; for Depersonalization, as 10 on a 030 scale; for Personal Achievement, high burnout is 33 on a 048 scale.
b
Medical School Stress Scale; total score created by summing 13 items on 04 scale
c
Prime-MD (two-item) measure; endorsement of either of the two questions is considered a symptom-screen positive test result.
d
Post-hoc analyses show differences between MS1s and MS2s, MS1s and MS3s, but not MS2s and MS3s.
e
Post-hoc analyses show differences between MS1s and MS2s only.

Academic Psychiatry, 36:3, May-June 2012


CHANG ET AL.

This study did not compare burnout and depression rst 3 years of medical school, and there may be a response
among race/ethnicity or between gender groups, but analyzed bias due to the lack of fourth-year participation and the 30%
results by class because of the relatively unique 1.5-year of students who did not respond, and the ndings may not be
curriculum. We had wondered whether burnout and de- generalizable from this one school. Another limitation is the
pression levels would be lower among students in the clini- lack of baseline data obtained on mental health measures for
cal years because of a more exible schedule during this time these students before their entry into this medical school. This
as compared with other schools. Although our results cannot limits our ability to evaluate for differences in vulnerability to
be compared directly with those of other schools, and timing burnout, depression, and stress present in typical accepted
during the school year and closeness to stressful academic or applicants, which may be higher in our institution, based on
personal events can be a factor in the varying results between our criteria for acceptance. Finally, the PRIME-MD tool has
studies, it has been suggested that mental health worsens as limited specicity, and even for those correctly identied as
students progress through medical school (9, 25, 26). In our depressed, it does not indicate the severity of depression.
study, however, there was no signicant difference in the The PRIME-MD is limited to use as a screening tool that
level of depression among class years. detects those at risk for major depression.
The rst-, second-, and third-year medical students In conclusion, our ndings underscore those of earlier
surveyed identied several factors that were benecial in surveys by emphasizing the importance of vigilance for
improving wellness and relieving stress. Students identied burnout, stress, and depression in medical students. The
support from faculty, peers, and relationships outside of high rates of burnout, stress, and depression found here
medical school as helpful. Counseling services and extra- suggest that further study into this area is indicated. In par-
curricular activities were also perceived to be helpful. ticular, longitudinal studies to delineate the relationship be-
Respondents valued the sense of personal achievement tween these variables and efcacy studies are needed to
gained from extracurricular activities, and this may be determine the potential benets of wellness programs. Multi-
especially important in the preclinical years of medical site studies measuring levels of psychological distress at
school. Previous studies have noted that medical students schools with shorter preclinical curricula, as compared with
develop a sense of personal accomplishment as they prog- longer ones, would also be helpful. A medical school culture
ress through medical school, which appears to counterbal- that fosters resiliency through peer-support, mentorship, ex-
ance the burnout resulting from emotional exhaustion and tracurricular activities, and teaching self-care from the start of
depersonalization (10). Also, because emotional exhaustion the rst year may be benecial in improving the mental health
was highest among the rst-year students, intervention of students. More work needs to be done in identifying, pre-
programs may be of most benet if initiated in the rst year. venting, and reducing the rate of these psychologically dis-
Although this institution had been involved in activities tressing symptoms in medical students.
identied by the literature and described above to promote
student health and well-being, recent student suicides at this We acknowledge Cayla Teal, Ph.D., and Britta Thompson,
school prompted the medical college administration to initiate Ph.D., for their contributions in study design, statistical analysis,
and editing, as well as Toi Harris, M.D., for her contribution in
formal work groups comprising faculty and students in order
study design, coding, and editing.
to identify additional areas of student well-being in need of
improvement. The time interval between the most recent References
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