Comparison of Suicidal Ideation and Depressive Symptoms Between Medical and Pharmacy Students

DISCUSSION

The prevalence of depression and suicidal thoughts that have been previously reported among medical students are alarming^4,14 and are higher than the reported annual prevalence of 4% for suicidal ideation in adults in the United States.⁵ This is the first report that compares depression, suicidal ideation, and other risk factors between pharmacy and medical students over an 11-year period. Mean PHQ-9 scores from this study suggest that pharmacy students are more depressed than medical students. In a study by Fischbein and colleagues, 18% of pharmacy and medical students met clinical cutoffs for depression,⁶ which were less than rates found in this study of 24.3% and 35.1% of medical and pharmacy students, respectively, who met criteria for moderate to severe depression. While not significantly different, current data also suggest trends toward higher suicide risk (especially with respect to suicide planning and behavior) among pharmacy students compared to medical students. Previous studies have shown that nonsuicidal self-injury (NSSI) is associated with a 3.46-fold increased risk of suicidal attempts later on in the life of a student.¹⁵ Another study showed that NSSI may suggest higher risk of suicide attempt in adolescents and college students not reporting suicidal ideation compared to those endorsing suicidal ideation in the past year.¹⁶ The current ISP does not directly query NSSI but instead asks about past attempts and self-injurious behavior. It is unknown whether the self-injurious behavior occurred recently or in a distant past based upon the cross-sectional nature of the ISP administrations examined in this study. Kieckens and colleagues found that recent NSSI was associated with a dose-response relationship with the number of mental disorders and suicidal thoughts and behaviors in a 12-month period.¹⁷ In Germany, a lifetime prevalence of NSSI was estimated to be 14.3% for NSSI and 1.5% for suicide attempt among medical students.¹⁸

Data surrounding the prevalence of depression and suicidal ideation among pharmacy students are limited, although they are emerging. In 2017, the American Association of Colleges of Pharmacy (AACP), representing all schools/colleges of pharmacy in the United States and Canada, issued a policy statement stating that “AACP encourages schools and colleges of pharmacy to proactively promote overall wellness and stress management techniques to students, faculty, and staff.”¹⁹ The AACP convened two national conferences (Strategies to Promote a Culture of Well-being among Students and Faculty) to draw attention to the issue of student well-being, burnout, depression, and suicidality at schools/colleges of pharmacy across the Academy.²⁰ Pharmacy institutions and academics gathered to brainstorm ways to mitigate the growing and disturbing trends in student suicide and referrals to counseling/psychiatric care. Suicide generally is caused by the convergence of multiple risk factors, the most common being untreated or inadequately managed mental health conditions.²¹ At this public university, the schools of medicine and pharmacy employ a variety of strategies and resources to enhance student well-being, such as improved access to psychiatric care,²² drop-in counseling services and wellness symposia, and annual screenings. At the school of pharmacy, quality of life surveys are also administered each year for all students, and a faculty guide has been developed for students in distress as a resource. While mental health resources are important, this current study suggests that pressures within the program to maintain work-life balance may also be contributors for student well-being.

Pharmacy students also reported higher levels of anhedonia, impaired sleep, and decreased concentration compared to medical students. It should also be noted that more than 60% of medical and pharmacy students endorsed feeling tired or having little energy. Levey²³ reported that tiredness and lack of energy are both risk factors for depression and suicide ideation in medical residents. More pharmacy students reported fatigue compared to medical students, which could be explained by the fact that most pharmacy students at this institution are employed during pharmacy school. Employment is encouraged for pharmacy students so that they obtain hands-on skills and preparation for careers, especially if they do not pursue postgraduate training (that is not currently required for pharmacists). More pharmacy students also endorsed feeling nervous, feeling easily annoyed or irritable, and feeling that life is too stressful compared to medical students. There has been a change in the pharmacy workforce that may generate nervousness and high stress. Issues such as insufficient number of residency positions compared to the number of applicants,²⁴ lack of job growth,²⁵ and shortage of jobs along with decreased salary in some sectors²⁶ have all led to uncertainties in the pharmacy profession. A recent National Pharmacist Workforce Study in 2019 showed that more pharmacists rated their workload as high or excessively high compared to previous years, especially in the retail pharmacy setting, and that students had higher debt at the time of graduation.²⁷

In a study of various health professions, stress has been directly linked to depression and suicidal ideation²³ and is detrimental to physical and mental health, which can lead to poor performance and lowered self-esteem and self-value.^28,29 Among medical students, chronic stress and anxiety negatively affected mental health and were associated with suicidal ideation.³⁰

For medical students, the high rate of response for academic difficulties is consistent with previously reported risk factors for suicidal ideation, which include poor performance, difficulty coping with long study hours, and emotional distress brought on from failure in examinations.³¹ In addition, stressors for medical students are commonly found to be heavy course loads, pressures of family and society to be academically flawless, and difficulty accepting lower grades or academic standings from undergraduate years.³² To our knowledge, risk factors correlating with depression and/or suicidality among pharmacy students have yet to be described.

In the qualitative data, for both pharmacy and medical students, themes about relationship and physical/mental health and substance abuse were common between the two professional student groups.^33,34 Relationship issues are not surprising considering the age of the students (mid-20s) who are at prime ages of building relationships with partners or adjusting to relationship issues with the rigors of pharmacy or medical school academic life. Per recent review, incorporating peer and faculty-led support to build a well-being curriculum are needed to prevent and manage distress and depression that students and practitioners may develop.³⁵

About a fifth of both medical and pharmacy students reported drinking alcohol more than usual, and more than a third of students reported eating-related behaviors that could be concerning. Increased alcohol consumption among medical students has been previously reported.³⁶ These results emphasize the need for student health services to be available at all pharmacy and medical schools. The combined risk of academic rigors along with transition difficulties (ie, geographical, social structure, housing) associated with health professions school students cannot be ignored, especially given that the emergence of depression, anxiety disorders, and other physical ailments often occur during the years between the 20s and 30s.³⁷ Substance use has been shown to be a risk factor for burnout and suicidality among health professions students.³⁸ Self-medication for anxiety, sleep disorders, and other symptoms that are untreated have been shown to increase the risk of suicide among physicians.³⁹

The majority of pharmacy student respondents were female, which is representative of pharmacy students nationwide, with a national percentage of 63% female.⁴⁰ During 2014 to 2019, approximately 50% of enrolled medical students were female.⁴¹ Of the pharmacy students, Asian or Pacific Islander and White students were the majority in the study, while nationally, Asian students make up only 28% of students (Table 1).⁴⁰ Most of the medical students in this sample were White or Asian/Pacific Islander students, which somewhat resembles the demographic makeup of medical students across the country. According to the Association of American Medical Colleges, medical students comprise 54% White and 21% Asian students.⁴¹ In this study sample, Asian and female students were overrepresented in both pharmacy and medical schools. The average ages for both pharmacy and medical students were similar but significantly different. The average ages are consistent with the profile of medical and pharmacy students across the country.^40,41 While studies have not conclusively linked race/ethnicity with rates of burnout among medical and pharmacy students, studies have found that minority medical students experience discrimination, prejudice, and isolation, which may result in burnout.¹⁴

The study was limited by the relatively low response rates for both cohorts. Therefore, the prevalence rates found in this sample might be over- or underrepresentations of the actual rates in the target population if we consider the possibility that more depressed students chose to complete the survey or that fewer depressed students filled it out for fear of stigma or lack of motivation. Shea and colleagues surveyed University of Pennsylvania medical students and found that only one-fourth of those who were depressed had sought treatment. In addition to stigma and fear of disclosure, students cited reasons such as lack of time and cost.²⁹ Our study was also limited to the students attending the School of Medicine and School of Pharmacy at one public university, so generalizability to all medical and pharmacy students is limited. In addition, our questionnaire was purely voluntary, so we faced sampling bias in which students with suicidal ideation could opt out of responding to the survey. The study was also cross-sectional in nature; therefore, students’ report of suicidal ideation could have changed after they responded to the survey. It should be noted, however, that the data presented here represent 11 years of survey administration.