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Dr. Meeks and colleagues  report a sizeable gap between the prevalence of depression (25-30%) among medical students and the prevalence of depression disclosed as a disability (0.3%). The implications are clear—this is a problem of medical schools “fail[ing] to identify” medical students amongst their ranks with depression and other psychological disabilities, and “[f]ailure to identify, support, and address psychological disabilities may have wide-ranging implications.”
 Though the paper acknowledges that “[n]ot all students who screen positive for or are diagnosed with a psychological disability require accommodation,”  it ultimately concludes that not "support[ing] and address[ing]" these students’ psychological disabilities “may have wide-ranging implications.”  In short, they are accidents waiting to happen.
Dire predictions about the prognoses of medical students with psychological disabilities who aren’t “identif[ied], support[ed], and address[ed]” is not supported by empirical evidence. In fact, most studies measuring trainee and physician clinical performance objectively have found no statistically significant associations between psychological disabilities (e.g., depression) and poor performance [2, 3].
I have no doubt the authors have the best of intentions but I find the labeling of medical students with psychological disabilities as safety risks to be problematic. There is also a long-standing and increasing concern within the civil and disability rights community about school safety and surveillance policies that disproportionately target students with disabilities and students of color based on data with no predictive ability. [5, 6]
 Meeks LM, Plegue M, Case B, Swenor BK, Sen S. Assessment of disclosure of psychological disability among US medical students. JAMA Netw Open. 2020;3(7):e2011165. doi:10.1001/jamanetworkopen.2020.11165
 Lawson ND. Burnout is not associated with increased medical errors. Mayo Clin Proc. 2018;93(11):1683. doi:10.1016/j.mayocp.2018.08.015
 Lawson ND. Wellness and work: mixed messages in residency training. J Gen Intern Med. 2020;35(2):594. doi:10.1007/s11606-019-05018-2
 Lawson ND. It is time to stop linking burnout, depression, and medical errors. Acad Med. 2020;95(1):11. doi:10.1097/ACM.0000000000003030
 Strauss V. Civil rights, disabilities groups urge Florida to stop building student database they call 'massive surveillance effort.’ Washington Post. July 10, 2019. Accessed July 28, 2020
Meeks LM, Plegue M, Case B, Swenor BK, Sen S. Assessment of Disclosure of Psychological Disability Among US Medical Students. JAMA Netw Open. 2020;3(7):e2011165. doi:10.1001/jamanetworkopen.2020.11165
According to a 2019 study,1 medical student disclosure of disability increased by 69% from 2016 to 2019. In a comparison of data from schools that responded both years, the largest gain was in psychological disability. To better understand whether a meaningful proportion of students with mental health diagnoses disclose their disability, we assessed the proportion of MD students reporting psychological disabilities and examined subcategories of psychological disability.
This survey study was conducted between September 2018 and March 2019. A survey assessing the number of students reporting disabilities was sent to 140 fully accredited US allopathic medical schools’ disability offices or the school’s primary contact for disability disclosure. The study followed the American Association for Public Opinion Research (AAPOR) reporting guideline. Given the deidentified nature of the data, the University of Michigan Medical School institutional review board considered the study exempt. Aggregate data were used to estimate the proportion of medical students reporting a psychological disability and the prevalence of subcategories of psychological disability. Descriptive analyses were conducted in R version 3.5.1 (R Project for Statistical Computing). No prespecified level of statistical significance was set.
Of the 140 schools surveyed, 89 (63.6%) responded with overall categorical data for registered students with disability.1 Characteristics of responding schools are outlined in Table 1. Seventy-four medical schools (52.8%) provided data on primary psychological diagnosis (eg, depression, anxiety, bipolar disorder). Responding schools represented 46 635 MD students with 2189 (4.7%; 95% CI, 4.5%-4.9%) registering as having a disability. Overall, 675 MD students reported at least 1 psychological disability, which accounted for 30.8% ( 95% CI, 28.9%-32.8%) of all individuals who reported any disability and 1.4% of all students in the sample. The most frequently reported diagnoses were anxiety and depression (17.3% [379 students] and 5.8% [128 students] of all reported disabilities, respectively). MD students with a primary diagnosis of anxiety accounted for 0.8% (95% CI, 0.7%-0.9%) of the overall student population, and students with a primary diagnosis of depression accounted for 0.3% (95% CI, 0.2%-0.3%) of the total population (Table 2).
Research indicates that 30.8% of reported disabilities among MD students are psychological,1 representing an 11.9% increase in psychological disabilities during the past 3 years. While recent meta-analyses suggest that 25% to 30% of all MD students meet the criteria for depression,2,3 our survey estimates that only 0.3% of students disclose depression as a disability. Therefore, the proportion of disclosures is considerably lower than the expected prevalence of psychological disability among MD students, indicating a gap in mental health support–seeking among students.
Multiple factors may be driving the lower percentage of students disclosing psychological disabilities, including: (1) lack of engagement between MD students and mental health services, reducing opportunities for referral; (2) lack of stakeholder awareness that mental health diagnosis may be eligible for accommodation under the Americans with Disabilities Act4; (3) lack of accommodation of psychological disability in favor of placing students on a leave of absence; (4) stigma surrounding psychological disabilities4,5; (5) timing of diagnosis (ie, before or during medical school); (6) access to and cost of an evaluation; and (7) concerns regarding mandatory disclosure requirements on state board licensing.6
Limitations of this study include the exclusion of osteopathic schools in the reporting of disability, which affects the generalizability of our results to all medical students. Additionally, our survey only captured students who required accommodation. Not all students who screen positive for or are diagnosed with a psychological disability required accommodation.
While our data indicate a substantial percentage increase in disclosure of psychological disability, the number of students who disclosed psychological disabilities remained small. This suggests that many students who may benefit from accommodation are going without this support. Failure to identify, support, and address psychological disabilities may have wide-ranging implications for students. Therefore, a comprehensive commitment to the mental health of medical students must in part include recognizing psychological disability, removing barriers to disclosure, and ensuring appropriate support through accommodation.
Accepted for Publication: May 11, 2020.
Published: July 23, 2020. doi:10.1001/jamanetworkopen.2020.11165
Correction: This article was corrected on September 24, 2020, to correct a misspelling in an author’s name. The spelling of Dr Sen’s first name has been corrected.
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Meeks LM et al. JAMA Network Open.
Corresponding Author: Lisa M. Meeks, PhD, Department of Family Medicine, The University of Michigan, 1018 Fuller St, Ann Arbor, MI 48104-1213 (firstname.lastname@example.org).
Author Contributions: Dr Meeks had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Meeks, Swenor.
Acquisition, analysis, or interpretation of data: Meeks, Plegue, Case, Sen.
Drafting of the manuscript: Meeks, Plegue, Case, Swenor.
Critical revision of the manuscript for important intellectual content: Meeks, Plegue, Swenor, Sen.
Statistical analysis: Meeks, Plegue.
Administrative, technical, or material support: Case, Swenor.
Supervision: Meeks, Sen.
Conflict of Interest Disclosures: None reported.