An Evolutionary Model of Depression and Anxiety in Medical Students by Jaleh Shahin A thesis submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy in Counselling Psychology Department of Educational Psychology University of Alberta ©Jaleh Shahin, 2015 AN EVOLUTIONARY EXPLORATION OF MEDICAL STUDENT DISTRESS ii Abstract The quality of the healthcare system partly depends on the health and wellness of its individual members. Physicians play a critical role in any healthcare system and make up one of its largest memberships. Physician wellness has been linked to a high quality of patient care, empathy, and lower rates of medical errors. Therefore, physician wellness and mental health should be considered an important public health issue with significant implications for patients and healthcare systems. Psychological distress in physicians typically begins early on during medical school. Several studies have explored various contributing factors to medical student distress. These include a culture of mistreatment and cynicism, taxing workload, viewing self as inferior in skills and abilities compared to peers (also known as imposter syndrome), and personality traits such as perfectionism, competitiveness, workaholism, and Type A personality. Despite the recent literature emphasizing the importance of addressing medical student distress, a cohesive, empirically supported, and comprehensive model of medical student distress has been lacking. In order to adequately and effectively address medical student distress, an empirically supported model of medical student distress is needed that will enhance our understanding of the specific causes of distress in the culture of medical training. This model can then lead to testable hypotheses and it can form the theoretical foundation for evidence-based intervention and prevention recommendations. This dissertation is divided into three papers. Initially, it aims to introduce a new model of medical student distress based on empirically supported evolutionary theories of psychopathology. The second paper will test the hypotheses arising from the new proposed model. Finally, the AN EVOLUTIONARY EXPLORATION OF MEDICAL STUDENT DISTRESS iii third paper will offer practical and empirically supported prevention and intervention strategies based on the result of the second paper. AN EVOLUTIONARY EXPLORATION OF MEDICAL STUDENT DISTRESS iv Preface This thesis is an original work by Jaleh Shahin. The research project, of which this thesis is a part, received research ethics approval from the University of Alberta Ethics Board, Project Name “Impact of relationships and the social environment on medical student wellbeing”, No. Pro00040200, September 20, 2013. AN EVOLUTIONARY EXPLORATION OF MEDICAL STUDENT DISTRESS v Acknowledgement The undertaking of this doctoral dissertation has been an exciting yet challenging process. Without the tremendous support and guidance of my committee members, conclusion of this project would not have been possible. As such, I would like to express my sincere gratitude to Dr. William Whelton, Dr. Melanie Lewis, Dr. Andrew Greenshaw, Dr. Derek Truscott, Dr. Dianne Maier, and Dr. Erica Frank. Also, I would like to thank my family and friends who cheered me on and encouraged me to persist through obstacles and challenges. Finally, I would like to express my deepest gratitude to my clients who generously shared their stories and were my greatest inspiration in completing this research project. AN EVOLUTIONARY EXPLORATION OF MEDICAL STUDENT DISTRESS vi Table of Contents Abstract ............................................................................................................................... ii Preface ................................................................................................................................ iv Acknowledgement ............................................................................................................... v Table of Contents ............................................................................................................... vi INTRODUCTION ............................................................................................................... 1 Format of the Research Project ........................................................................................ 6 References ........................................................................................................................... 7 PAPER 1: Survival of the Fittest in Medical Schools: A New Model for Understanding and Treating Depression and Anxiety in Medical Training ................................................................... 12 Abstract ............................................................................................................................. 13 Introduction ....................................................................................................................... 15 Evolutionary Theories of Psychopathology ................................................................... 17 Theoretical framework ...................................................................................................... 26 The Hypothesis .................................................................................................................. 27 Preliminary Evaluation of the New Model ........................................................................ 29 Student mistreatment ..................................................................................................... 29 Discussion and Future Directions ...................................................................................... 31 References ......................................................................................................................... 34 PAPER 2: Personal and Environmental Risk Factors and Protective Factors for Depression and Anxiety in Medical Students ............................................................................................. 42 AN EVOLUTIONARY EXPLORATION OF MEDICAL STUDENT DISTRESS vii Abstract ............................................................................................................................. 43 Introduction ....................................................................................................................... 45 Medical Student Distress ............................................................................................... 46 Evolutionary Models of Psychopathology ..................................................................... 47 Rationale for the Present Study ......................................................................................... 52 Methods ............................................................................................................................. 54 Participants .................................................................................................................... 54 Measures ........................................................................................................................ 55 Procedure ....................................................................................................................... 61 Results ............................................................................................................................... 62 Descriptive Statistics ..................................................................................................... 62 Statistical Assumptions .................................................................................................. 66 Gender Differences ........................................................................................................ 67 Relationships Among Variables .................................................................................... 67 Hypothesis One: Predicting Depression ........................................................................ 66 Mistreatment as a Moderator in Predicting Depression ................................................ 72 Hypothesis Two: Predicting Anxiety ............................................................................. 72 Mistreatment as a Moderator in Predicting Anxiety...................................................... 74 Discussion ......................................................................................................................... 76 Future Directions and Limitations of the Study ................................................................ 81 References ......................................................................................................................... 83 PAPER 3: Strengthening Undergraduate Medical Education: A Mental Health Strategy ................. 93 AN EVOLUTIONARY EXPLORATION OF MEDICAL STUDENT DISTRESS viii Literature Review .............................................................................................................. 97 Canadian Medical Education ......................................................................................... 97 Barriers to Seeking Help ................................................................................................ 98 Resilience ..................................................................................................................... 101 Mistreatment ...............................................................................................................