Scoping review of barriers to mental health service utilization among medical students and residents

²MD, Department of Psychiatry, All India Institute of Medical Sciences, Bhopal, India

Date submitted: 22-Feb-2024

Email: Snehil Gupta (snehil.psy@aiimsbhopal.edu.in)

This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

Citation: Singh Brar S, Sai Maddipatla A, Gupta S. Scoping review of barriers to mental health service utilization among medical students and residents. Educ Health 2024;37:164-177.

Online access: www.educationforhealthjournal.org
DOI: 10.62694/efh.2024.16

Published by The Network: Towards Unity for Health

Background

Medical students and residents have elevated psychological distress, depression, and suicide rates compared to the general population.^1–7 Their academic journey in medicine involves significant burnout, mistreatment, competitiveness, a pressure to excel in career or performance pressure, alongside a fear of uncertainty or low optimism about the future.^8–10 Preconceived notions and cultural factors, concerns about financial stability as future doctors, the high-intensity workload, the difficulty of their studies due to the necessity of memorization, and the extensive workload all play a role in shaping their health and coping mechanisms.

Burnout among residents is prevalent, with 27–76% residents experiencing this at some point of their training. The longer years of study required in medicine, time-demanding nature of the field, structure of the hospital hierarchy, challenging job situations and interpersonal relationships likely contribute to higher rates of depression among medical students and residents.^8,11

Studies have correlated undiagnosed and untreated depression in medical students and residents with cognitive dysfunction, diminished quality of life, an elevated risk of errors in patient treatment, and suboptimal patient care.^12–17 Despite the substantial mental health challenges faced by medical students and residents, the utilization of mental health services remains dismal, with rates ranging from 12–40%.^3,18–20

Attitudinal and structural barriers impede medical students’ and residents’ access to professional mental healthcare. These barriers include stigmas, time constraints, confidentiality concerns, underdiagnosis, and limited treatment access.^3,18–20 The available literature on barriers to mental health service utilization among medical students and residents is scattered and predominantly originates from developed nations. A comprehensive review, including research from developing nations, is still lacking. Therefore, the current research work aims to review the major barriers to seeking mental health treatment among undergraduate medical students and resident doctors, and explores measures to mitigate these barriers.

Methodology

The current scoping review was conducted by two medical students (AS, SB), and one psychiatry faculty (SG) who is actively involved in psychiatry teaching, treatment and training. In the present work we followed Arksey and O’Malley’s framework for scoping reviews.²² The review was conducted in 5 steps: 1) identifying the research question; 2) identification of relevant studies; 3) study selection; 4) data charting; and 5) summarizing and reporting the results.

Research Question

The review was guided by the question: What are the barriers in seeking mental health support/treatment for undergraduate medical students and resident doctors with mental health conditions? We also explored measures to overcome the prevailing treatment-seeking-related obstacles.

Data Sources, Search Strategy and Eligibility Criteria

To look for relevant studies, advanced search was conducted on PubMed, Web of Science and Scopus databases from inception till 30^th April 2023. A bibliographic search was also performed to identify the relevant papers.

Search terms used for the undertaking of a database exploration pertained to ‘Medical Students’; ‘Mental Health’; and ‘Mental Health Services’. The related terms for the above topics were combined through the Boolean operator ‘AND’ to obtain the relevant records. Figure 1 shows the PRISMA flowchart and search strategy for the study.

Figure 1 PRISMA flow diagram including searches of databases, registers and other sources

Original articles published in English dealing with the barriers in seeking mental health treatment/care by the above populations, or providing significant findings in the above subject matter, were considered for inclusion. Studies that did not include medical students or did not evaluate barriers to seeking treatment, and non-original papers were excluded from the current review.

RESULT

Study Selection

The search yielded 126 records, out of which 18 were duplications, which were subsequently removed. The two (SB & AS) authors independently screened the rest of the articles on Rayyan (software). Articles to be included for full-text screening were agreed upon; this was also cross-checked by an independent reviewer (SG).

Out of the 108 non-duplicate studies, 12 were included (eight from the database searches and four by cross-referencing). PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines,²³ as described by Peter et al.,²⁴ were followed for the screening process. Supplementary Table 1 summarizes all the studies included in the review. Figure 1 shows the PRISMA Diagram for our scoping review.

Major Findings

The critical findings of this scoping review were grouped into five themes: (1) stigmatization; (2) attitudinal barriers; (3) confidentiality; (4) time constraints; and (5) other barriers (lack of access to services, knowledge about the mental illness or treatment). We deliberately did not attempt to dissect our review’s findings separately for medical students and residents, including identifying measures to overcome the barriers to seeking help, as in various medical schools’ mental health services (including student wellness center, student deanery, services through Psychiatry department) are the same for both populations. Therefore, we intended to highlight the common factors affecting help-seeking among them and provide a common solution for both of these groups so that such solutions are realistic and can be implemented in different medical colleges/varsities.

Stigmatization

The majority of studies assessing barriers to mental health treatment among medical students and residents found stigmatization as one of the most significant barriers to seeking help from mental health professionals. Kasam et al., additionally, reported that stigma was strongly associated with other barriers to mental health treatment, such as confidentiality concerns, lack of time, and attitudinal barriers.²⁷

Chew-Graham et al., found that shame and embarrassment attached with seeking professional help were substantial barriers to seeking mental health services among medical students.²⁸ They also observed that students considered reaching out for help as a sign of personal weakness which could lead to social ostracism, a finding supported in another study by Menon et al.²⁶ Ey et al. also found that a majority of medical students were concerned about the social implications of receiving mental health treatment.²⁵

Grover et al. and Gulle et al. also observed that a considerable proportion of senior and junior residents identified stigma as a significant barrier to accessing mental health care. They were concerned about potential judgment from others if they were to seek mental health treatment.^19,33 Likewise, Sydney et al. found that stigma was the second biggest barrier (for 27% participants) to participating in a resident wellness program.²⁰

Attitudinal Barriers

Attitudinal factors for medical students and residents were also cited as crucial barriers in the utilization of mental health services. Chew-Graham et al. and Kasam et al., reported that a majority of undergraduate medical students prefer solving problems independently or seeking help and support from their family and friends rather than a professional mental health service.^27–28 A study by Brimstone et al., additionally, found that some medical students also believed that they were merely over-identifying with disorders that they had read about and were confident in their ability to self-diagnose.³⁵ Givens et al., underlined that some students believed that their problems were insignificant and that no one would understand them.²⁹

Winter et al. investigated medical students’ perceptions of mental health problems and the potential consequences of disclosing such issues.³⁴ They found that students believed disclosure could lead to disciplinary action—and even expulsion from college. The lack of transparency and trust in the medical school system exacerbating these concerns led many students to believe that campus mental health support systems were used to screen out students deemed unfit to become doctors, particularly those facing mental health issues. These beliefs were reinforced by the habit of concealing emotions and attending college regularly despite illness, serving as a reinforcing mechanism, notions of toughness and the perceived weakness associated with mental health problems.^25,26,28,29

Confidentiality

Confidentiality concerns were highlighted as another crucial barrier in the utilization of mental health services by medical student and residents. Menon et al. and Kasam et al., reported that among medical students concern about confidentiality was the main barrier to seeking mental healthcare (61.2%).^26,27 Similarly, Grover et al., Sydney et al. and Guille et al., found that 36.3%, 21% and 57.3% of residents, respectively, avoided seeking mental health treatment due to confidentiality concerns.^19,20,33

Brimstone et al. conducted a study in Australia involving medical and psychology students and found that knowing the university counsellor or General Practitioners or having a potential of future dealing with the counsellor was a major barrier to seeking help. ³⁵ This finding was supported by a study by Chew-Graham et al.²⁸ Similarly, research conducted by Givens et al. found that more than one-third of the distressed students did not seek treatment due to a fear of lack of confidentiality.²⁹

Time Constraints

Time constraints emerged as another significant barrier to seeking mental health treatment among medical students and residents. Grover et al., Sydney et al. and Guille et al. found that 43%–91.5% of residents were discouraged from accessing mental health care due to a lack of personal time.^19,20,33 Menon et al. and Givens et al. similarly found that almost half of medical students were not able to utilize mental health services due to lack of time.^26,29

Other Barriers

Menon et al., Ey et al. and Guille et al. found that medical students were apprehensive about the effectiveness of counselling.²⁰, ²⁶ Brimstone et al. and Chew-Graham et al. reported that medical students had limited knowledge of both in-campus and off-campus mental health care services.^28,35 Tyssen et al. noted that students with lower perceived levels of mental health problems were less likely to approach mental health services.³⁶

Possible Strategies to Overcome Barriers

Sofka et al. found that the provision of a free day from work contributed to the 93% utilization rate of the mental health wellness program in their study.³² The screening appointment being arranged by the program administrator and being built into the residents’ schedules also helped tackle time constraints and reduced the feelings of shame associated with mental health service utilization. They also found that residents who attended the program were far more likely to go back if they needed any assistance with depression, burnout, anxiety, and other mental health problems. Additionally, Brimstone et al. and Chew-Graham et al., found that medical students had lower barriers to non-campus health centers as compared to campus health centers for seeking treatment of their mental health problems because of better-perceived confidentiality. ^28,35

Discussion

To the best of our knowledge, the current review represents pioneering work in highlighting and discussing the critical issues surrounding the key barriers to seeking mental health care for medical students and residents.

The stigma related to mental illness and its treatment was identified as one of the most widely and frequently reported barriers in our review. ^{20,27–29,33} Despite their awareness of mental health problems, medical students and residents often had preconceived notions about the social implications of seeking help for their mental health issues. They were concerned about what others would think of them if they found out about their mental health issues and often linked help-seeking behavior with ostracism from society/medical community, feelings of shame, embarrassment, weakness, and being a failure.^20,27,28

Medical students often have a notion that physicians should be resilient, self-sufficient, and handle stressful challenges on their own and this belief ‘self-stigmatizes’ help-seeking behavior. This assertion is supported by a study that found that students with higher levels of ‘social perfectionism’ reported a greater barrier in help-seeking and were at greater risk of psychological maladjustment.²⁵

The stigmatization of mental health was also closely associated with other barriers, such as attitudinal (self-diagnosis, informal help, etc.) and instrumental barriers (lack of knowledge, lack of time, etc.) to help-seeking behavior.²⁷ Kasam et al. hypothesized that stigmatization encouraged medical students and residents to solve their mental health problems independently and further promote their concerns about confidentiality. The association of stigmatization with other barriers to help-seeking behavior and social perfectionism need to be further evaluated to establish causal relationships and draw firm conclusions.

The implementation of universal mental health screening as a part of routine health check-ups on psychological well-being could also be a viable approach to reducing stigmatization. Sofka et al conducted an interventional study in which residents at an institute were registered for a wellness program with an opt-out option.³² These programs can normalize help-seeking behavior, promote positive mental health, and identify mental health problems early, thereby improving mental health outcomes of medical students and residents. Concerns about confidentiality were also identified as one of the key barriers to help-seeking behavior related to mental health. Medical students and residents, who work closely with faculty members, had concerns about potential interactions with their treating physician in a professional setting. They felt that a breach of confidentiality would negatively affect their teacher’s/ faculty’s attitude towards them, future career prospects, and relationships with peers and family members.

The concerns of breach of confidentiality and stigma towards mental health problems coupled with a perceived lack of transparency regarding medical school processes fostered distrust towards on-campus mental health support systems.²⁶ Menon et al. noted that medical students believed that these mental health screening and support programs were designed to filter out students who were not fit to be physicians, however, these results were mixed and inconsistent in other studies.^27,34 The viewpoint of medical students and residents on the on-campus mental health support system needs to be further investigated.

The establishment of off-campus mental health services, along with measures such as separating the medical records of students from administrative records and restricting access to medical records to only the treating professional, could reduce confidentiality concerns and boost utilization of mental healthcare services among medical student and residents.^28,32,35 Although these steps warrant institutional-level strategies, they create an opportunity for institutes to collaborate with local mental health services to enhance mental health service utilization. The results in terms of service utilization, mental health outcomes, and acceptability of the services of such strategic measures can be systematically researched for their feasibility and effectiveness.

Medical students and residents also struggled with accurately gauging the severity of their mental health problem and the level of care required. The participants often dismissed their problems as trivial, overestimated the level of distress considered “normal”, and felt that they over-identified with medical conditions.^29,35 The students’ preconceptions that physicians should be able to independently endure highly stressful or challenging environments may have contributed to these assumptions.

We also noted a greater reliance of study participants on self-diagnosis and a preference for informal help from colleagues and family over professional help.^{19,26–28,35} This perspective towards existing professional mental health services may arise from the observable pre-existing attitudes of their mentors regarding self-diagnosis; uncertainties surrounding the effectiveness of mental health services; and fears of unwanted interventions.

A systemic intervention could promote an adaptive perception of mental health issues, including service utilization, normalizing having mental health problems and availing services for both medical students and their mentors. These campaigns can also establish more realistic goals for medical students and residents and help them overcome their misconceptions related to social perfectionism. The adoption of evidence-based practices for treatment and dissemination of information about the functioning of student welfare programs could decrease misconceptions regarding treatment and reduce the stigmatization of help-seeking behavior.²⁰

Another critical factor affecting mental health service (non)-utilization is the lack of available time for the students and residents. They often face a significant time constraint due to the demanding nature of their training which is often tightly packed with rigorous coursework, clinical rotations, studying for exams, patient care and academic pursuits. This scarcity of time can lead to high levels of stress, burnout, and a compromised work-life balance, leaving little opportunity to prioritize personal wellbeing—especially for residents. The accommodation of welfare programs into demanding schedules, or part of the curriculum, could increase the utilization of these services.³²

The digital delivery of mental health services can also provide a promising solution for addressing time constraints, confidentiality concerns, and the reliable evaluation of the mental health of medical students and residents. These services could offer convenient and flexible options for support, allowing students to seek help at their own pace and to their own schedule. They could also raise awareness about mental health problems and provide coping strategies for managing subclinical conditions, as well as information regarding available welfare services on campus, or in the vicinity, for more serious mental health issues.

Some of the established models worldwide include apps such as DBT Coach, the American Foundation for Suicide Prevention Individual Screening Protocol, student wellness centers, and the Tele-Mental Health Assistance and Networking Across State (tele-MANAS) facility (launched by the government of India in 2022).³⁷ The feasibility and effectiveness of these platforms in terms of utilization, confidentiality, outcomes, and acceptability can be systematically studied.

The studies under consideration also highlighted additional barriers to help-seeking behavior, such as a lack of knowledge about available services, limited access to services, and concerns about the cost of these services. While these barriers are also present for individuals of a comparable age group in the general community, medical students and residents perceive confidentiality concerns, time constraints, and stigmatization as even greater obstacles. The establishment of affordable, flexible, convenient, and easily accessible counselling services—tailored to the specific needs of medical students, is essential for addressing these concerns.

The information on available mental health services, including counselling and online services, could be provided to students as part of their mental health education at the onset of their professional courses. This information can be refreshed at the start of each semester, cultural festivals, sports meets, educational workshops, club activities, etc. The feedback from students must be solicited to have a service-users’ perspective and to gain greater insight on the areas surrounding accessibility, affordability, and quality of care. This feedback could be utilized to identify gaps in mental health curriculum/training and improve the accessibility and availability of mental healthcare services.

We recommend further research on various interventions to assess their feasibility in increasing mental health service utilization among medical students and residents. Additionally, we suggest investigation of the barriers to help-seeking in resource-limited settings. These countries have significantly different socio-economic structures, resulting in unique challenges and requirements for this population.

Conclusion

This scoping review identifies several critical barriers that prevent medical students and residents from seeking help for mental health problems. The prominent barriers included the stigma surrounding mental health along with concerns about confidentiality, lack of time, attitudinal barriers, and other minor obstacles were lack of knowledge and access to services. Implementing mental health campaigns, universal mental health screening in the institute, service provision in collaboration with local mental health professionals, (including counselling centers and internet-based services) utilizing mental healthcare apps, and improving mental health education are some steps that could be taken to overcome these barriers.

Recognizing the unique challenges faced by medical students and offering flexible and accessible mental health services, both in-person and digitally, can help overcome these barriers and promote help-seeking behavior. Greater research in this area is required, particularly those studies including robust methodology, such as controlled-study design, feasibility assessment, and long-term outcomes.

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Student Contribution