Complications Associated With Surveying Medical Student Depression

Depression among medical students is a serious problem. There is considerable evidence that rates of depression and suicide are higher in medical students than in students involved in other graduate studies and that these rates continue to remain elevated when these students become physicians . A recent review reported higher rates of suicide in physicians compared with rates in both the general population and other professionals. Several studies have also documented high rates of depression in medical students compared with the general population. For instance, Clark and Zedlow reported that at least 12% of medical students evidenced significant symptoms of depression on the Beck Depression Inventory (BDI) at three measuring points during their first three years compared with a rate of 3% to 4% observed among the general population . Similarly, Zoccolillo et al. using clinical interviews of students, found a 12% prevalence of major depression in the first two years of medical school. Camp et al. , gathering self-assessments of depressed mood on the Zung inventory, reported scores associated with mild to moderate depression in 20% of medical students in a traditional curriculum compared with 10% of students in a problem-based curriculum. Wolf et al. reported significant depression based on BDI scores in 18% of a medical school class at the end of their first year.

In 1998 we began research that focused on comparing depressed mood in medical students from different curricula (traditional, hybrid, and problem based) at the University of Texas Medical Branch in Galveston. Previous studies have demonstrated lower rates of depression and higher rates of emotional and intellectual satisfaction in a problem-based curriculum compared with a traditional curriculum. Our own problem-based curriculum subjectively appeared to provide greater social support from peers and faculty and a less competitive and more caring environment. In order to objectively assess these observations, we decided to test the hypothesis that rates of depression might be lower in our problem-based or hybrid curriculum compared with the rates in our outgoing traditional curriculum. The BDI was administered with a number of other measures upon matriculation, at the end of year 1, at the end of year 2, and during year 4. The students were given a separate consent form attached to the BDI. This document informed students that if they acknowledged suicidal ideation or scored in a clinically significant range, they would be contacted by the Dean of Students.

The initial administration of the BDI to the Class of 2001, at the end of the first year, yielded a lower than expected rate of abnormal scores. Only 2% to 3% of students scored 14 or higher, in contrast to 12% to 25% of students in published research in which the BDI had been administered at similar intervals . In response to this discrepancy, we modified the consent form. Specifically, we removed the name of the Dean of Students, although we continued to inform students that they would be contacted "to provide guidance regarding appropriate services" if they had significantly elevated scores.

Our consent form modification had little effect. Arguments arose in our research group between those who felt we had an obligation to act if we identified a depressed student and others who believed that telling the students that they would be contacted was interfering with the collection of valid data. We modified our consent form further, emphasizing that scores would not be a part of a student's academic record. Again, little difference was found in the students' low scores on the BDI. Because of our doubts over the results, we did not submit these data for publication.

The purpose of this follow-up study was to gain an understanding of the nature of the unexpectedly low observed scores and to evaluate the hypothesis that student responses were adversely influenced by concerns over anonymity and potential negative repercussions associated with a high score on the BDI. Specifically, this research was designed to discern students' concerns about the BDI administration, determine whether students intentionally distorted their responses, and identify the reasons for dishonesty among those who reported distortion.