Silent Screams: Aspiring Doctors Suffer Depression Quietly as Stigma Rules the Roost

Many decades ago, a renowned psychiatrist named Carl Jung had famously referred to doctors as “the wounded healer.” Education Post’s Rohit Wadhwaney digs deeper to understand why the risk of suicide among medical students and physicians is more than double that of the general population.

Govind Mane, a third-year MBBS student of Mumbai’s King Edward Memorial Hospital, committed suicide at his Sangli home on August 25, 2022. The son of a well-known pathologist, Mane had topped the National Eligibility cum Entrance Test (NEET) in 2019.

Pradipta Das, a fifth-year student at the Calcutta National Medical College, was found hanging from the ceiling fan of her hostel room on August 2, 2022. Police concluded the 23-year-old resident of West Bengal’s Sodepur killed herself.

Tejashree, a 23-year-old student of Karnataka’s Koppal Institute of Medical Sciences (KIMS), jumped from a moving train near her college on July 2, 2022. The daughter of Bellari’s known litterateur Vinoda Karnam, she breathed her last the following day.

Hardik Rayiani’s dead body was found in a pond in Ahmedabad on March 10, 2022, just a day after he secured admission in a postgraduate stream at the BJ Medical College. Police said the 25-year-old Surat resident committed suicide—the third such drastic step taken by a medical student in Gujarat in three days.

These are just a few of the dozens of suicide cases among medical students registered across India this year. In all these cases, the states are different, the colleges are different, and the methods are different. But all of them have one thing in common—a suffering from depression.

Rough and extremely conservative estimates suggest that some 500 medical students in India have taken their own lives in the last decade. Actual figures are unavailable because, despite having the world’s largest medical education consortium, India — unlike most of the developed nations—does not have a comprehensive and nationally representative data on suicide deaths among medical students. So, statistics are largely dependent on the compilation of newspaper reports of individual cases.

By no means is this a new phenomenon, says Soumitra Pathare, director of Pune’s Centre for Mental Health Law and Policy.

“When I went to medical school in Mumbai in the 1980s, each batch would graduate with one or two student suicides during the five-year course. Very exceptional batches, maybe one in five or six batches, would have no suicides,” he says.

But now, there are one or two suicides each year in most medical colleges in India, a “very high rate compared to the general population,” Pathare says.

Some case studies

Shruti Desai (name changed), 26, a gynecology student at AIIMS Delhi, admits she had suicidal tendencies during her initial years as an MBBS student. She was suffering from “severe depression.”

“I never actually attempted suicide, but I was having thoughts. I was in mental agony,” she says.

A bright student from a well-to-do family of doctors, and pursuing medicine at one of India’s top institutes, it would seem unimaginable that Desai was once clinically depressed to the extent that she wanted to live no longer.

“Depression is an illness, like cancer. It doesn’t discriminate between the rich and poor, the educated or uneducated, upper caste or lower caste. It can affect anyone,” Desai says.

Reasons for Desai’s mental condition were not one but several. “Study workload, long hours, lack of sleep, lack of appreciation, lack of friends to talk to because of lack of time to talk to them, the pressure of failing after coming this far. There are a multitude of reasons,” she says.

Desai suffered in silence for a year, until she confided in her progressive parents, who told her to seek immediate help. It took her two years of psychiatric therapy to feel better. “I should have told my parents about my mental state at the time long before I actually did. I underestimated their understanding and support,” she says.

But not everyone is lucky enough to have a robust support system like Desai’s.

S. Manohar (name changed), a first-year MBBS student of the Coimbatore Medical College Hospital, is sure he is suffering from depression. But apart from a couple of batch mates, the 20-year-old has told no one about it.

He initially refused to speak to Education Post, but after his two friends convinced him to open up, he agreed to an interview via the Telegram app.

“My parents will never understand. They will think I am making excuses to leave medical college,” says Manohar, whose father is a “government official at a lower post” and mother a housewife.

Manohar’s friends say he was an “extremely jovial guy” when he entered college a year back. But six months down, they started sensing a change in him. “He gradually stopped talking, stopped laughing and would suddenly burst out crying during regular conversations,” one of Manohar’s batchmates says. “It pains us to see him in this condition.”

Manohar fears his current medical condition will worsen and he’ll end up like a 25-year-old Doctorate of Medicine from the same college who recently killed himself because of depression

Still, he is afraid to seek professional medical help. “Everyone will think I am mad.”

It’s common knowledge that there is a stigma, illogical as it may be, attached to seeing a psychiatrist for help in India—a reason names of our case studies have been changed. But we’ll get to that in the later part of this story.

All these promising medical students took their own lives due to depression

Look at these stats

More than 40% of medical students in India suffer from depression, believed to be the “commonest occupational hazard of a career in medicine,” according to the Indian Journal of Social Psychiatry.

The “meta-analysis based on original research articles that have used screening tools revealed a significant burden of depression among medical students of India,” it said.

As part of one such research, a total of 3,170 females and 3,189 male medical students were tested. Among them, 3,003, or 42.6%, were found to be depressed.

In March 2018, six doctors in AIIMS Delhi checked into the psychiatric ward for treatment, prompting the Indian Medical Association (IMA) to admit for the first time on record that suicide among physicians is a “public health crisis” that needs to be “tackled before it’s too late.”

What followed was a study by Chandigarh’s Postgraduate Institute of Medical Education and Research, which concluded that 30% of the 445 doctors tested were depressed and about 17% had thought about ending their lives.

A mind-boggling 80% of doctors, especially in the earlier stages of their academics and career, “face the risk of burnout,” per the Indian Journal of Psychiatry

Another study among clinicians in India finds that 45% of respondents were emotionally exhausted and 87% of the doctors scored low on “personal accomplishments.”

A research paper that studied 358 suicide deaths in India—125 medical students, 105 residents, and 128 physicians—between 2010 and 2019 reveals that seven out of 10 suicides happened before the age of 30, with the maximum number of such deaths concentrated in South India, except the state of Kerala.

Academic stress among medical students (45.2%) and marital discord among physicians (26.7%) were the most noticeable reasons for suicide. Mental health problems, at 24%, was the next most common reason for suicide among medical students, followed by harassment—20.5%.

The study goes on to reveal that 26% of the 358 suicides had exhibited warning signs and only 13% had ever sought psychiatric help before ending their lives.

And decades ago, a world-renowned Swiss psychiatrist and psychoanalyst, Carl Jung (1875-1961), had famously referred to doctors as “the wounded healer.”

Not so NEET

It all begins with an exam-the dreaded and decorated National Eligibility cum Entrance Test (NEET), formerly called the All India Pre-Medical Test.

More than 15 lakh hopefuls—18 lakh in 2022—appear for this test each year, competing for just under 92,000 MBBS seats in 612 Indian medical colleges.

It is the only national-level entrance exam for admission to all medical courses, with everyone trying to beat the odds in doing well enough in this test to secure a subsidized seat in a government-run medical university.

The cost of an MBBS course from a public institute is anywhere between Rs. 8,000 and Rs. 35,000 per annum, while the same course from a private university is between Rs. 2 lakh and a staggering Rs. 24 lakh each year.

For the record, there are 322 government medical colleges in India with just over 48,000 MBBS seats each year.

“Due to the low number of seats, and steep competition among lakhs of students who write the NEET each year, there is obviously some stress,” says Dr. Dharmendra Singh, a Delhi psychiatrist who practices in the city’s Batra Hospital.

“Not everyone can afford to pay the exorbitant fees that private medical colleges demand, so almost everyone is competing for the few seats available in government colleges. Many who clear the exam, but not well enough to secure a public college seat and can’t afford tuition at a private college, feel let down—that they worked so hard, cleared the exam, but can’t pay for their MBBS,” explains Dr. Singh, adding that a lot of cases of depression stem from here.

And it does not end here for students who do manage to secure, and pay for, the few thousand available MBBS seats.

Enter medical college

Students who were once school toppers and full of pride that they cleared the highly competitive NEET, come in for a rude shock once they enter medical college.

“Medical students, be it undergraduate or postgraduate, figure at the bottom of a very extensive hierarchal system in our medical community,” says Dr. Singh. “As soon as they set foot inside the campus, a realization dawns upon them—they are nobodies. Everyone around them is a topper. No one gives a damn about them. It can be very upsetting.”

Leave aside a little bit of ragging that might be happening, juniors “aren’t allowed to look a senior in the eye” let alone talk to them, he says.

“Therefore, junior students’ problems, be it personal or professional, are often sidelined. They are expected to overcompensate and meet unrealistic expectations. This, with time, builds up stress and anxiety in them. And if not addressed timely, it progresses to depression,” Dr. Singh warns.

He says colleges should do their bit to “ensure good harmony between juniors, seniors and the faculty so it can create a positive environment, in which students feel a sense of support and are able to approach seniors for any problems they might be facing.”

And casteism, a deep-rooted problem across India for centuries, takes a whole new shape in medical colleges.

Behind white coats

It’s not just the students, but also some medical professors who seem to still believe that Scheduled Castes and Scheduled Tribes form the lowest rungs of society

“Adham jaati mein shiksha paye, bhayahu yatha ahi dudh pilaye (educating a lower-caste person is like feeding milk to a snake)”—this was a saying Dr. Surya Bali heard “several times a day from a senior professor” during his MBBS at Allahabad’s Moti Lal Nehru Medical College.

Bali, now an additional professor at AIIMS Bhopal, belongs to a Scheduled Tribe from a small village in Uttar Pradesh’s Jaunpur district.

“Every day was like hell. The upper caste students used to ignore me, and when I befriended lower caste students, they would accuse me of being casteist. I survived five years in total isolation,” Bali tells The Wire.

A study titled “The Steady Drumbeat of Institutional Casteism” sheds light on how marginalized medical students are discriminated against from the beginning of their admission process to their daily interactions in hostels and classes.

They are assigned menial roles during the course of study, and often purposefully ignored for academic and employment prospects, the study reveals.

A report by a government-appointed committee to look into allegations of harassment of SC/ST students at AIIMS Delhi found that an eye-opening 85% of Adivasi and Dalit students felt that internal examiners had discriminated against them when awarding grades.

“The first sentence I heard from a senior professor after joining (medical college) was, ‘You people are lucky, you don’t even have to study.’ That statement ignored the fact that I had qualified in the general category. I could have got a seat in radio diagnosis, which is considered the topmost branch,” Senior Resident, Ophthalmology, at AIIMS Delhi tells FirstPost.

At this point comes to mind, the highly publicized suicide of 26-year-old Payal Tadvi, a second-year resident gynecologist pursuing her master’s degree at Mumbai’s BYL Nair Hospital. She hanged herself in May 2019, leaving behind a suicide note that blamed three senior doctors for harassing her about her caste. She belonged to the scheduled Muslim Tadvi Bhil tribe of Maharashtra.

According to the subsequent police chargesheet, Tadvi experienced humiliation at the hands of her colleagues due to her social status. Witness statements also described instances in which her seniors prevented her from accessing important jobs or entering the operation theater.

Stigma of unawareness

The issue of depression, or suicide, in the medical fraternity is not limited to India. Globally, the risk of suicide among medical students and doctors is considered 2.5 times higher than the general population, according to a study. Frequently cited papers claim that some 300 to 400 doctors commit suicide in the US every year, more than double that of the general population.

The figures of suicides among doctors in India may well be much higher than what meets the eye, says Dr. Singh.

“Depression and other psychiatric disorders have lasted since humanity has existed the world over. It’s not a new phenomenon, and it’s not limited to any one country. Only, these problems have been accepted at different times in different countries as per their literacy,” Dr. Singh says.

The only difference India and other countries is that in the developed world the “acceptance of psychiatric disorders is more,” so those suffering from depression “are vocal about it and appreciated for it.”

“In India, even today, you tell someone you’re are undergoing psychiatric therapy, most people will relate that with paagalpan (madness). It’s because there is a serious lack of awareness. And it is this lack of awareness that has given birth to the stigma attached to seeking psychiatric help,” he says.

Dr. Singh gives an example of the time he was studying psychiatry. “Some professors and my collegemates in other departments, all very highly educated folks, referred to the psychiatry department as a paagalkhaana (madhouse). In fact, they would coax me every day to switch courses, wondering why I was being crazy enough to study psychiatry.”

It is this stigma that prevents youngsters suffering from depression or other mental illnesses from seeking professional help, eventually worsening their condition and leading them to take drastic steps, says Dr. Singh.

And with most Indians refusing to accept mental disorders as an ailment like any other physical illness, they fall back on their trusted line of defense—non-medical science that is devoid of logic.

A psychiatrist, who did not wish to be named, told the story of one of his patients, whose relatives refused to accept his schizophrenia diagnosis and took him instead to a baba to remove a supposed ghost from inside of him.

“This baba put a naphthalene ball in my patient’s palm and set it on fire, asking him to squeeze the burning naphthalene ball. Nothing happened, except his hand got burned.”

The solution?

First and foremost, education begins at home, says Dr. Singh. “Parents need to stop being judgemental about their children and passing unneeded remarks about their skills. Rather, they need to understand the existence of psychiatric disorders and support the child if he or she is under stress or depression.”

There is an urgent need to organize more mental health awareness programs in all educational institutes, not just medical colleges, he says.

Earlier this month, the National Medical Commission directed medical colleges to take care of their students’ mental wellbeing by addressing their grievances of long working hours, no weekly offs and non-sanctioning of leaves to name a few.

The commission further directed the institutes to ensure availability of counselling sessions for students who show symptoms of stress or anxiety.

Seconding this, Dr. Singh asks: “Why can’t there be regular screening of students’ mental health problems just like they are screened for other medical illnesses?”

And last but not the least, he says, “The psychiatry curriculum needs to be reinforced more sincerely in MBBS in order to change the perception of doctors of other departments and increase understanding among them about the seriousness of this branch of medicine.”