Barriers faced by medical students in seeking mental healthcare: A scoping review

Background: Medical students commonly exhibit mental health issues. Despite the availability of professionals on medical campuses, seeking help continues to be a challenge for some students. Our review aimed to identify the barriers medical students face when seeking professional mental healthcare. Methods: A Medical Subject Headings (MeSH) search was created for articles using PubMed, Embase, and PsychINFO databases to identify articles specifically about medical students and their barriers to professional mental healthcare. Inclusion criteria included articles in which barriers to mental healthcare were either the primary variable or one of multiple study results. No date limits were imposed. Reviews, pilot projects, or articles that did not address barriers to mental healthcare faced by medical students or focused on veterinary or dental students were excluded. A total of 454 articles were identified and screened by title/abstract and then full text. Data were extracted from 33 articles using an independent framework. Barriers identified were compiled and reported. Results: From a total of 33 articles, the most identified barriers were fear of negative effect on residency/career opportunities, fear of confidentiality breach, stigma and fear of shaming from peers, lack of perceived seriousness/normalization of symptoms, lack of time, and fear of documentation on academic record. Students also preferred to seek care outside of their institution from fear of their provider being an academic preceptor. Conclusions: Many of the barriers to mental healthcare faced by medical students relate to a fear of academic and career reprisal, and fear of confidentiality breach. It appears that despite recent efforts to decrease stigma surrounding mental illness, many medical students struggle to seek appropriate support. Access to mental healthcare can be improved by increasing transparency regarding what information will be displayed on academic records, dispelling common myths about mental healthcare, and increasing awareness about resources available for medical students.


Introduction
Physician burnout is a serious issue amongst medical professionals and has been demonstrated to start early, with 44.2% of global medical students showing signs of burnout prior to starting residency [1][2][3][4][5][6] . These observations have caused many medical programs to take action through the creation of wellness programs and counselling services, designed to address and curb some of the causes of burnout during medical school 7-10 .
Despite the alarming levels of mental health issues and burnout exhibited by medical students during their studies, stigma exists both in reporting mental health concerns and in seeking professional help 11,12 . This is exemplified in a study by Givens et al., which showed that only 22% of depressed medical students used mental health counselling services 13 .
Many barriers to self-reporting have been hypothesized, with the most studied being the question of anonymity. The highly competitive nature of medical school compels many students to hide any perceived weakness in the eyes of their superiors or peers, and the stigma of mental illness remains pervasive in the field of medicine 11,14-16 . Given the importance of this issue, there is a body of literature discussing various barriers that medical students may have when trying to seek mental healthcare. However, at the time of our literature search there is no review article that summarizes and discusses these barriers.
A scoping review of the literature was completed with the goal of compiling and showcasing the available research on barriers to medical students seeking mental healthcare. With this information, institutions can hopefully improve their wellness programs and student outreach initiatives to address these perceived obstacles and encourage medical students to seek mental healthcare.

Methods
This scoping review is reported in line with the PRISMA-ScR guidelines 17 .

Stage 1-Research question
As there was no review available on the barriers to mental healthcare faced by medical students, our goal was to conduct a scoping review to showcase the available research, describe recommendations, and identify potential for future research 18 . Thus, we developed a broad research question "What are the barriers faced by medical students to seeking professional mental healthcare?". We defined professional mental healthcare as that which is sought from a counsellor, therapist, or physician, as opposed to self-care and peer support. Although self-care and peer support can be effective in improving mental health, they may not have the same barriers and stigma as professional care. Our sub-questions included:  Table 2 and Table 3. We did not impose publication year or country limits on our searches in order to assess for geographic variations in identified barriers. Our review included primary articles where barriers to mental healthcare were either the primary investigated variable or one of multiple study results. We excluded relevant review articles, however, did include primary studies from their references if they were not included in our original search.

Stage 3 -Literature selection
Our literature search yielded 438 articles, and an additional 16 articles were extracted from literature reviews that were not yielded by the initial search. The resultant total of 454 articles were reviewed for title and abstract screening. Through title and abstract screening, we excluded 389 articles that were either duplicates, pilot projects, reviews, did not address barriers to mental healthcare faced by medical students, or focused on veterinary or dental students. A full-text screening performed on the remaining 65 articles excluded studies focusing on non-professional or self-care. A total of 33 articles passed the screening process and were included in our final review [ Figure 1].
Stage 4-Charting data Data extraction was manually performed and documented using Microsoft Excel (Microsoft Excel, RRID:SCR_016137). Our data of interest were the barriers medical students faced in seeking mental healthcare noted in each article. Exact wording from each article was used when describing barriers. Data were extracted by all authors with oversight by lead author M.B.

Stage 5-Summarizing and reporting
Data extracted from studies were organized to answer the research question and sub-questions.
We listed barriers from all articles and compiled them within two broader categories: systemic barriers and individual barriers. Systemic barriers included "policies, procedures, or practices that unfairly discriminate and can prevent individuals from participating fully in a situation" 19 . Individual barriers were not directly linked to institutional practices and were dictated by a person's life experiences, emotions, and prior knowledge. Papers were assigned to barrier categories based on which barriers were identified in the study results. Studies were also categorized by geographic location, including Asia, South America, Australia, Europe, and North America. Article suggestions for addressing the barriers to medical student mental healthcare  were recorded and combined to formulate an overall recommendation most applicable in North America, as this is the context of our institution.

Results
A total of 454 articles were found through our search and 33 articles were included in the data extraction portion of our study 13,20-51 . Geographically, we accepted papers from all regions [ Figure 2]; most articles were studies conducted in North America (n=15, 46% total), with other regions including Europe (n=6, 18%), Asia (n=6, 18%), Australia (n=5, 15%), and South America (n=1, 3%). Barriers to seeking mental healthcare that were identified in the studies were divided into one of two categories: systemic barriers or individual barriers to mental healthcare.

Systemic barriers
A total of nine systemic barrier types were identified and are outlined in Table 4.
The most commonly reported systemic barriers were cost (five articles) and involvement of treating practitioner with   medical education (five articles). Amongst those that reported cost, one was from North America, two from Australia, one from Asia, and one from Europe. Fear of being treated by a future preceptor was reported in two articles from North America, two from Australia, and one from Europe. The systemic barriers that were reported least commonly were lack of available resources (one article), mandatory reporting laws (one article), and limitation in number of sessions offered (one article)

Individual barriers
All 33 articles included in our review mentioned at least one individual barrier to mental healthcare faced by medical students. There were 21 individual barriers identified, outlined in Table 5.
The most reported individual barrier was "Fears of decreased opportunities for residency and career", which was cited in 10 out of 33 papers. Other commonly noted barriers were personal stigma against seeking care, fear of non-confidentiality, and fear of discrimination (general population and peers). Globally, there were differing trends in barriers, papers from North America and Europe most commonly noted a fear of decreased opportunities for residency and career, while papers from Asia most commonly noted concerns about effectiveness/

Articles from South America
Personal stigma against seeking care 9 4 3 2 0 0 Fear of non-confidentiality

Discussion
The present review aims to identify the barriers that medical students face when seeking professional mental healthcare.
Our study found that medical students face several systemic and individual barriers to mental healthcare. When assessing systemic barriers, cost and affiliation of mental health practitioners with the university or involvement of practitioner in medical training were commonly noted. Prevalent individual barriers included stigma, fear of non-confidentiality, fear of impact on academic record, fear of decreased career opportunities and discrimination. We provide several recommendations on how to mitigate these issues and improve medical students' access to the mental health support they need.

Systemic barriers
Our study found that cost was one of the most prevalent systemic barriers to seeking mental healthcare in medical students. With high tuition fees in addition to extra-curricular and personal expenses, medical students may defer mental health services due to economic reasons alone. Although cost seemed to be a common concern for North American, European and Australian medical students, it is unlikely that this is applicable to a Canadian context, as most medical schools provide mental healthcare to their students through free university counselling services. Nevertheless, Canadian students who seek counselling elsewhere may require third party financial coverage. In addition, it is uncertain whether other factors such as the students' socioeconomic status and financial independence play a role in the likelihood of medical students seeking mental health support.
Other prevalent systemic barriers include conflict of interest with mental healthcare providers or the practitioner's affiliation with the university. The power imbalances amongst medical students and faculty members may have prevented students from sharing their concerns with these individuals due to fear of non-confidentiality. Students were perhaps afraid of their preceptors and/or mental health practitioners revealing the students' mental health status to future residency programs or concerned about making a negative impression.
In some cases, students may have individualized needs that the university does not specialize in, as described by the individual barrier of "fear of treatment not being appropriate" and the systemic barrier of "access issues". For instance, an indigenous student undergoing mental health problems may benefit from a counselor who specializes in indigenous health, which may not be offered by the university. Students from certain sociocultural groups may feel underrepresented and may not be able to confide in counsellors who do not understand the cultural background or the experience dealing with these specific issues.
While a university affiliated mental healthcare service can be a very positive thing and can significantly improve access to mental healthcare for students, we must be conscious of the barriers to care that it inherently introduces. The solution is not to transfer university affiliated mental health resources to external ones, but to acknowledge the barriers and fears they may introduce for students and work to address and alleviate those concerns.

Individual barriers
Our scoping review identified multiple individual barriers. The most commonly reported barrier was fears of decreased opportunities for residency and career with nearly 30% of articles mentioning this barrier. This fear is related to other similar individual barriers such as those of non-confidentiality and self-stigmatization, which were the second most noted barriers in our review.
Despite our best efforts, mental illness remains a heavily stigmatized topic. Medical school is challenging with high expectations and many students grapple with imposter syndrome 52 . Experiencing a mental illness along with imposter syndrome may further heighten feelings of inadequacy and isolation, thus perpetuating self-stigmatization.
Fear of non-confidentiality also proved to be a significant concern for medical students struggling with mental illness. While confidentiality in counselling is dictated by privacy laws, the college of psychotherapists, and the Committee on Accreditation of Canadian Medical Schools (CACMS), students may still be concerned as to whether confidentiality can be maintained without knowledge of these policies. Fear of non-confidentiality goes hand in hand with the fear of reduced residency opportunities, as students may be concerned that their mental health will be reported either to licensing bodies or through the application process.
Medical student barriers to care are heavily associated with their career anxieties. For many students, residency applications and mandatory health reporting are not well understood. For students struggling with their mental health earlier in their education, it is not unreasonable to believe they may avoid seeking mental healthcare out of the fear of the unknown.
Overall, our recommendations for improved care are as follows:

Counselling services led by non-physicians
Affiliation of treating practitioners with the student's university and fear of being treated by future preceptors and supervisors were common barriers to seeking mental health services by medical students. Hosting counselling sessions led by non-physicians may relieve the concern many students have about their current or future preceptors being within their circle of care.

Transparency in residency application process
Medical students are often concerned that their mental health status will be disclosed and impact their future residency application. Adopting a transparent residency application process, in which students can have access to all of the information that will be disclosed on their academic record, can give students a sense of control over their application. This may mitigate the hesitancy some students may experience when sharing their personal concerns with their university's counselling team.

Encourage faculty and residents to build non-judgmental and accommodating work environment
Encouraging a supportive environment that facilitates academic accommodations and accepts these requests in a non-judgmental manner can relieve the competition and perceived judgement faced by students.

Ensure strict confidentiality
Fear of non-confidentiality is one of the most prevalent barriers faced by medical students when seeking mental healthcare. It is essential to outline a strict and clear policy for maintaining confidentiality. Moreover, it is recommended to outline this policy at the start of every counselling session and to discuss concerns regarding confidentiality as they arise. In addition, medical students' mental health concerns should remain within a pre-defined circle of care and should not be extended beyond this team.

Provide non-university affiliated mental health resources
Despite the above measures, some students may prefer to seek support beyond their medical school due to a variety of reasons. For instance, students may have pre-existing therapeutic alliance with a non-university affiliated counsellor, or a non-university affiliated counsellor may be more accessible and/or may specialize in the specific type of support the student is seeking. Hence, it is essential to make alternate options available to students to best fit their needs.

Normalize seeking mental healthcare to reduce stigma
In order to reduce stigma, mental healthcare should be made available to medical students as soon as they enter medical school. Moreover, conversations regarding stress-management strategies and addressing stigma towards mental health should be introduced early within the medical school orientation period.

Limitations
There are limitations to our study and recommendations. Regarding the design, all studies included in the scoping review were found through internet searches. It is possible that some studies, especially those published in earlier years may not have a corresponding online version.
We also chose to avoid pilot projects, opinion pieces, reviews, and textbook publications; instead focusing only on primary literature. While this decision was made to improve the validity of our data, other forms of literature may have yielded additional barriers or recommendations for change.
Additionally, we limited our search to papers published in English only, but did not use geographical barriers; thus, it is possible that papers published in a different language, from a non-Western institution could have been missed in our search.
Finally, the recommendations made in our research paper are applicable primarily to a Western setting. While mental health challenges are pervasive for medical students around the world, other regions may have heightened stigma or increased healthcare service limitations. Thus, these recommendations must be implemented with appropriate cultural competence.

Conclusions
In conclusion, while medical students often struggle with their mental health, they face significant barriers to seeking and receiving appropriate mental healthcare. Through our scoping review, we identified multiple systemic and individual barriers, with the most common systemic barriers being affiliation of counsellor with medical school, cost, and access; and the most common individual barriers being stigma, fear of non-confidentiality, fear of impact on academic record, and fear of decreased career opportunities and discrimination. Our overall recommendations included improving the transparency in the residency application process early on in medical education, ensuring strict confidentiality and student education of confidentiality laws, providing access to non-university affiliated counselling services, and working to create a positive environment without mental health stigma. We hope our review may be useful for improving medical school counseling services. Future research may focus on describing cultural differences in mental health seeking behaviors, as well as determining the success of implementing recommendations proposed in our review.

Data availability
Underlying data All data underlying the results are available as part of the article and no additional source data are required. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.