Over the course of Elisabeth Poorman’s first year of medical residency, she went from crying occasionally to tearing up every single day.

"I couldn’t sleep even when I had time off," she said of the rapid decline in her mental health in 2013. "I didn’t really have any motivation to do anything when I wasn’t at work." She’d leave the clinic at Cambridge Health Alliance in Massachusetts feeling overwhelmed and sad. Then she’d go home and sob.

Her depression worsened before it got better. A year into her residency, Poorman decided to turn to a psychiatrist for help. Within a few months of treatment, her depression began to ease. Looking back now, she’s clear on the root of her blues: "Fundamentally, medical schools and residency cause mental health disorders," she said. "They cause depression."

A growing body of evidence suggests Poorman may be onto something: The way we train doctors may endanger their mental health. In a new systematic review and meta-analysis in JAMA that draws from 195 studies on depression among medical students, researchers found that 27 percent experienced depression or depressive symptoms, about three times higher than the general population.

Across studies, the researchers also found that 11 percent of medical students reported contemplating suicide.

This isn’t the first analysis to find higher-than-average mental health issues among physicians in training. In 2015, another JAMA systematic review and meta-analysis on depression among medical residents found that 29 percent experienced depression — about the same proportion as medical students.

Taken together, the research shows that about one in three residents or medical students are clinically depressed at some point during their training.

Things don’t necessarily improve after residents get licensed. Doctors have higher rates of suicide on average. "The suicide rate among male physicians is 1.41 times higher than the general male population. And among female physicians, the relative risk is even more pronounced — 2.27 times greater than the general female population," according to the American Foundation of Suicide Prevention. (There’s no comprehensive data on how many medical students or residents take their own lives every year, but bleak anecdotes abound.)

The researcher behind the systematic reviews, Douglas Mata, agreed that the problem is bigger than individual doctors. "That the symptoms are so widespread," he said, "is indicative of systematic systemic problems, factors in the environment of medical school that are causing these issues."

Medical trainees describe a pressure-cooker environment

Here’s the tricky part: Researchers aren’t exactly sure why medical personnel seem to suffer more with mental health problems. When I asked Mata, a resident physician in pathology at Brigham and Women’s and fellow at Harvard Medical School, he listed off a raft of potential causes. Most were related to extreme stress and the lack of sleep that comes with medical school and overnight shifts during residency.

"To get into medical school requires you to make a lot of sacrifices," he said. "In the clinics, you switch from one rotation to another and you’re in situations you don’t know what you’re doing. There’s a lack of time just for self-care activities — going to buy groceries, seeing family members."

By all accounts, the pressures are brutal. For the most recent round of medical school applications, less than half (about 42 percent) of those who applied got accepted. Once in medical school, there’s the stress of having to learn a lot of material in a very short time. "In our anatomy class, my classmates and I had to dissect and learn the entire human body in a matter of weeks," Nathaniel Morris, a Stanford psychiatry resident, wrote in an essay for the Washington Post.

Then there are the joys and sorrows — and burdens — that come with taking others’ lives into your own hands when you’re only still learning. "Rather than receiving support in these situations, these students often suffer humiliation from senior clinicians," Morris added. "This hierarchy engenders a culture of bullying toward medical trainees. More than 80 percent of medical students report mistreatment from supervisors."

Before medical school is over, students begin applying for their residency. And that can also be a fraught process. In a blog post, Poorman wrote, "We have little control over where we end up when applying for residency programs, and we may move across the country and lose our social support system. Then we have to work 80 hours a week and have no time to develop a new one."

Some of the unique cultural aspects of medicine exacerbate these stressors. Stuart J. Slavin, an associate dean at St. Louis University, described some of them in an accompanying JAMA editorial: "The first is the belief by some that medicine is a demanding profession and, therefore, medical school should also be extremely rigorous and demanding," he wrote. "If students are not ‘strong’ enough to handle the stress, then they should probably seek another profession."

With all these superhuman expectations, it’s not surprising many trainees struggle with their mental health.

The medical profession needs to help doctors by changing the system

To ease these pressures, some medical schools have introduced meditation and yoga classes. But Mata doesn’t think that goes far enough. "This puts the onus on the student," he said. "[It’s] not addressing the underlying environmental problems causing [mental health issues] in the first place."

Indeed, in the latest issue of JAMA, a second systematic review examined the evidence on similar interventions — like mind-body programs in medical school — designed to boost well-being. And the authors found little evidence that these programs helped (but also acknowledged that the quality of evidence was pretty poor and that more research is needed).

Mata pointed to medical schools — such as St. Louis, Harvard, and Baylor — that have been taking more systemic approaches. Over the past several years, for example, St. Louis has switched to a pass/fail grading system, reduced the required curricular time by 10 percent, and began tracking depression and anxiety in its medical students. After implementing these changes, the school surveyed the students and found academic performance improved, and that they were less likely to report symptoms of depression and anxiety. (Other medical schools are trying the pass/fail system, too.)

Simply offering more widespread and easily accessible mental health services for physicians and trainees — and not punishing them for seeking help — may help, too.

According to Mata’s review of depression among medical schools, of the students who screened positive for depression, only 16 percent sought psychiatric treatment. Some find accessing treatment challenging, he said. Others may avoid speaking to someone out of fear for their future job prospects — most state licensing boards ask if physicians have ever been treated for a mental health disorder, regardless of whether their disorder causes some kind of impairment.

In Poorman’s case, she was sent to a psychiatrist in the office right next to the director of her medical program. She said she’d go to the clinic for help on her day off, but was afraid of being caught getting treatment.

"Medical training creates mental health disorders, then makes it impossible for many trainees to get help," she said. Given that doctors are supposed to be caring for others, the medical community needs to resolve this paradox.