Admitting you have a mental health problem can be traumatic for medical students. Despite these problems being common, stigma is still attached, which is why the medical student coauthor wants to remain anonymous. She and Laura Bennett give some practical advice about coping and seeking help

Mental illness does not discriminate--it can affect anyone at any time. For doctors and medical students, prevalence is actually greater than among the general population.^1-4 Up to 36% of doctors working in the NHS have symptoms of minor psychiatric disorder.1 Less research has been done for medical students, but one study in the 1980s found that 31.2% of second year UK clinical students were emotionally disturbed compared with 9.7% of unemployed young people,3 and this prevalence is confirmed by more recent research.4 Imagining, however, that "this will never happen to me" is all too easy. It might.

First and foremost the ill person is a person. They may be in distress or have unusual circumstances, but their main wish is probably to be honest about their illness and to be able to continue to function as much as they are able.

How do you know if its you?

If someone tells you are unwell, then you probably are. Many of us are unaware of how we feel. We may feel constantly tired, feel below par, sleep badly, or just be plain grumpy and assume it is just part of being a medical student or doctor. If you constantly feel unwell or just not quite right then there is a problem. Talk to someone about how you feel or check your own mental health with Hamilton's depression rating scale or the general health questionnaire (www.dsn.org.uk).

So what do I do next?

Admit it

Admitting that you have a problem and need help is a huge achievement. Many doctors and medical students currently work with different health needs, so this is the start of a new approach not the end of your career.

Talk

Talk to someone--your partner or a friend. You may find their perspective on the situation helpful. Look for the cause of your problems--work, home, or relationship. Find ways to sort them out before they become overwhelming. Your family and friends will be able to give you some support.

Often even people who are close to you will have no idea how you are feeling or what problems you are experiencing. If you do not share this with them they cannot help. Friends worth having will stand by you and support you. They might be able to offer practical help to reduce your stress.

Sometimes it helps to talk to someone outside your circle of friends and family. Consider talking to a doctor, who may be more aware of work related issues, through the Doctors' Support Line, the Doctors' Support Network, or a counsellor from the BMA Counselling Line. Maybe a more generic organisation such as Nightline or the Samaritans could help. You could also speak to someone face to face at your university's student counselling service, which is free and confidential.

Do you know how ill you are?

Sometimes it is difficult to assess our own situation. Talking to people can help provide a useful yardstick. It is easy to carry on coping, and end up feeling constantly tired and unwell. With many mental and physical illnesses, we tend to overestimate our ability to manage. Feeling too tired to meet friends or go to a party may be just tiredness but could be mild depression. Not enjoying your day may mean you have had a bad day, but a few bad days may indicate depression.

Get help

Do this as soon as you can. Talk to people who have experience of mental health. Taking that first step of going to see your general practitioner or admitting to anyone that you are unwell is huge. You will feel awful the first time, but getting help is so important. You are not a fraud nor are you wasting time. No one should be expected to be superhuman; you are struggling and are taking responsible appropriate action to get help and to prevent the situation deteriorating.

If you find visiting your general practitioner difficult, take someone with you. They will also stop you "doing a runner" from the waiting room and they will ensure that you talk to your doctor about your problem

You may also find it helpful to speak to other specialist university services, who can help you in other areas of your life. The welfare service of the National Union of Students is often a good place for advice independent of your faculty. Welfare officers are often experienced in dealing with students' needs and can provide practical advice and support on housing, finance, child care, and health issues. They will also be able to point you in the direction of other more specialised sources of help.

Your illness may affect your academic work. Whether you decide to disclose this and ask for help and support or modifications to the course, like flexible deadlines, is up to you. Remember that if you do decide to struggle on without disclosure, then the faculty cannot help you or take your illness into account when assessing you. Choose who you talk to carefully as academic staff have different levels of training in pastoral issues--medical schools tend to have staff responsible for student welfare.

But it might be better to avoid telling people who manage you directly. For example, talking to the clinical dean is probably better than talking to a consultant who is going to assess you. The dean would also have the power to make adjustments to your course if you needed them.

VERONIQUE BOISSECQ/PHOTONICA

Treatment options

Your general practitioner might consider medical treatment, counselling, or involving tertiary level psychiatric care. As a medical student, you have as much right to a full explanation as any other patient and to be involved in treatment decisions with the team responsible for your health. The treatment team should also remember that you are their patient and they are responsible for your treatment. If you feel uncomfortable at having to make too many decisions, too few, or that your concerns are being dismissed too easily as medical students' disease or hypochondria, then say so. If you cannot tell the person directly use a mediator or write things down.

Rights and responsibilities

Your university is also legally bound to help you. All universities owe their students a duty of care whereby they ensure that any claims in documentation are clear and precise, ensure appropriate training of support staff and implement clear support and referral procedures for students.⁵

Mental health is also covered by the Disability Discrimination Act. This requires institutions to make "reasonable adjustments" so disabled students are not "substantially disadvantaged."⁶ You can obtain more information on this by contacting Skill.

Who to tell?

This is a difficult decision. Gauging how people will react, particularly those who you do not know well, can be hard. My advice would be to go with your gut instinct: only tell those people you feel safe telling.

Confidentiality

Medical students have the same rights to confidentiality as all other patients. If you are still worried, you do not have to register with your university medical centre and you can ask for out of area referrals to secondary care. Local services should be able to make some adaptations for you so that you avoid meeting other medical students on teaching attachments as a patient.

Looking towards the future

If you have an ongoing health problem or concern then talking to your occupational health department towards the end of your course may be a good idea. The department does not officially provide a service for students at most universities but may be happy to advise you on health issues and working after you qualify.

If things get really bad

Telling somebody, if you can, will help to make your problems seem less insurmountable and may point out things that you had not thought of. Medicine can be a difficult course at the best of times and can be difficult to adapt to the needs of students due to its pressurised nature. At times you may feel that everyone is against you and that you will never manage to work with the support you need. You can feel very alone. Sometimes you may want to sit and cry or scream, hoping that someone will bring you the instruction book.

Consider your options. You may want to take time out, a few months or a year, to concentrate on your own wellbeing and reassess things in a more objective light. Your medical faculty will be able to advise you on this. Bear in mind that you usually need to complete the degree course within seven years.

Whatever you decide to do you have not failed, you are making the best decision you can at that time with the resources you have available. If you need to take time out then you are looking after you.

Work-life balance

Life is to be enjoyed. The more ways you have to enjoy yourself the happier you will be. Timetable something for you in your week. You may want to start playing the violin or go swimming or simply take time out to relax. Whatever you choose make sure that you stick to it. People will usually respect your decision to take responsibility for your own needs.⁷

And finally

Acknowledge your difficulties and get help and support to deal with them. Make a plan but do not blame yourself if things go astray. Remember that you are not alone. Keep talking, keep well, and keep safe.

Further information

Support lines

Doctors' Support Line--staffed by trained volunteer doctors; confidential and anonymous service to talk about work and personal concerns (tel 08 707 650 001; www.doctorsupport.org)

Nightline--student welfare telephone helpline run by students; Nightline is specific to each university (www.nightline.niss.ac.uk)

BMA Counselling Service--24 hour support with immediate access to trained counsellors (tel 08 459 200 169)

Samaritans--tel 08 457 90 90 90; www.samaritans.org.uk; email jo@samaritans.org

University Services

NUS Welfare Service--www.nus.org.uk

Student Counselling Services-- www.studentcounselling.org

Peer support

Doctors' Support Network--friendly relaxed network for doctors who have or have had problems with their mental health; meetings, newsletter, and email forum (tel 08 703 210 642; www.dsn.org.uk; email lizzie@dsn.org.uk; for Wales and the south west contact janet@dsn.org.uk)

BMJ Careers Chronic Illness and Discrimination Matching Schemes--provides doctors who have a chronic illness or disability or who have been discriminated against to receive informal support and careers advice from another doctor (www.bmjcareers.com/discrimination
www.bmjcareers.com/chill)

British Doctors' and Dentists' Group--For people recovering from alcohol and chemical dependency providing admission where indicated; monthly group meetings (tel 01 252 317 976 or 020 7487 4445)

Treatment

Sick Doctors Trust Confidential--service providing early intervention in chemical dependency; training in its recognition; organise admission when indicated; help in re-employment when required; support for family (tel 01 252 345 163; www.sick-doctors-trust.co.uk)

Disability

Skill (National Bureau for Students with Disabilities)--tel 020 7657 2337; www.skill.org.uk