Doctoral Programs in the Health Sciences: Mental Health Concerns Surround “High Stakes” Comprehensive Examinations

Paul J. Flaer, DDS, EdD, MPH
Florida Institute for Advanced Dental Education


This article focuses on the need for the coupling of psychological services, counseling, and mentoring with comprehensive (qualifying) examinations in college and university Ph.D. programs in the health sciences. The conduct of the doctoral program and control of the nature of the comprehensive exam is at the departmental level of the academic institution. The comprehensive exam may vary from hours of testing to a simple presentation. The article reveals the elevated psychological stress (anxiety, depression, or exacerbation of existing mental disorders) and limited pedagogical value of the “high-stakes” comprehensive examination. In addition, this piece sheds some light on what can be a dark area of graduate academics coupled with an impetus for programmatic reform. As traditional procedures in doctoral programs, these examinations may constitute barriers to learning rather than useful evaluative mechanisms. The use of such archaic pedagogical instruments of doctoral evaluation as comprehensive examinations appears not to be a fair method of academic evaluation.
Keywords: Ph.D. Programs; Comprehensive Examinations; Mental Health; Counseling


In health science Ph.D. programs of many colleges and universities, comprehensive or qualifying examinations are required as mid-program evaluations. The goal of this unique intellectual exercise and the inherent rigors of doctoral programs are preparation for the challenges of future academic life beyond graduation. Passing these evaluations allows progress to the “advancement to candidacy,” i.e., the doctoral student becomes eligible to defend her or his dissertation. The high-stakes, all-or-nothing nature of the comprehensive examination stands alone as a powerful, sometimes threatening stimulus and psychological hurdle. On the other hand, the examination may reflect positively on the doctoral student’s ability to cope with emotional issues arising in the evaluative process (i.e., preparing for the examination, taking the examination, or repeating the examination). Defending the dissertation covers material familiar to the doctoral student, whereas the comprehensive exam covers everything in the discipline. These instruments contradict their pedagogical purposes (i.e., mid-program evaluation) in the curriculum of most doctoral programs.

This article about mental health issues associated with the comprehensive examination sheds some light on this dark area of academia. The author recommends that mentoring and counseling are made available to those doctoral students faced with this often inflexible impasse to the completion of their doctoral programs.

Review of the Literature

The surge in mental health needs on campus increasingly affects doctoral students and their academic performance, especially as concerns the required comprehensive examinations (Campus Health Services, 2012). Factors that surround taking the comprehensive examination by doctoral students may lead to the development of anxiety, hopelessness, or depression (Williams, Galanter, Dermatis, & Schwartz, 2008). Due to the interference of these emotional factors, the evaluative success of the comprehensive examination may not be an accurate gauge of the student’s academic competence. Awareness of mental health issues and the need for prevention and treatment are necessary parameters in curbing the psychological crises and sequelae that surround this evaluative process (American Psychiatric Association, 2000).

In recent decades the morbidity of mental health-related problems has surged on college campuses, with the concomitant need for interceptive and treatment programs (Jones, 1991). Some psychological and social issues that contribute to mental health problems on campus include the following:

  • Poor study habits.
  • Poor academic performance.
  • Negative social interactions.
  • Substance abuse.
  • Difficulty managing finances.
  • Problems in adjusting to the college environment (Ellen, 2000).

Counseling, advising, and mentoring create support and promote help-seeking behaviors and overall stress reduction (Kitzrow, 2003). Mentoring of doctoral students by Ph.D.-educated professors has shown some success in stress reduction and in the prevention of negative mental health consequences (Harvard College, 2011; University of Michigan, 2012). According to Johnston (2013):

“Although there is a connection between mentors and advisors, not all mentors are advisors and not all advisors are mentors.”

As defined by Zelditch (1990), mentors hold many roles in doctoral programs including tutors, academics, and scholars.

Depending on the doctoral program, the highly political and subjective nature of doctoral programs produces many unnecessary stressors and frustrations (Clemmons, 2004; Silber, 1999). Political power surrounds the comprehensive exams as students deal with each “friend or foe” in the committee that is providing the exam. Political conflicts surrounding doctoral programs result in the loss of many educated, highly-trained minds that are imperative providers of knowledge for the progress of our society and culture. Indeed, it is arguable that comprehensive examinations as evaluative instruments both inhibit learning and impede the overall process of education in the graduate school.

Even to the best doctoral students, i.e., the ones with excellent grades and the most potential, comprehensive examinations may present a hurdle that could delay graduation or even derail their academic careers (Cohen, 2002). The time spent preparing for the comprehensive examination, especially between repeated examination attempts, may be extremely stressful for the doctoral student. Some students may “cram” so hard for comprehensive examination that they harm themselves physically and mentally. In the past, there was little or no consideration of the need for counseling or mental health services for graduate students due to their assumed maturity and advanced educational status. Students undergoing mental health treatment usually kept it to themselves. Unfortunately, the stigma of having a mental illness might find its way to the ear of the faculty or administration who could subsequently perceive these students as personal threats or a harmful presence in the department. Self-report surveys (that are generated by focus groups of graduate students) can reveal the incidence of mental health problems among doctoral students facing comprehensive examinations. Based upon the survey results, interceptive and preventive actions can be taken such as allowing the examination to be conducted in a low stress environment such as at university disability services.


The period immediately before and after the comprehensive examination holds the greatest propensity for the highest anxiety level and susceptibility to depression. Centering on students’ well-being, doctoral programs should include a required course on mental health (i.e., covering coping methods for anxiety and fighting depression). A mandatory policy of referral for counseling should be instituted at the departmental level—removing the possible “mental health” stigma from individuals in counseling. Counselors have several options to proceed after assessment, including referral for mentoring, continued counseling, psychotherapy (i.e., “talk therapy”), or pharmacotherapy. Due to the tendency for treatment to include pharmacotherapy, access to pharmacy services and insurance coverage for prescription medication should also be mandatory.

Formats for treatment consist optimally of sessions with collaborating counselors, social workers, psychologists, or psychiatrists. Providing the student with a customized treatment plan provides “tailored” treatment modalities that promote effectiveness and comply with ethical concerns (Groth-Marnat, 2003). However, in today’s economy, group therapy meetings may be the only practical solution for treatment of the greatest number of students with often inadequate numbers of staff therapists.

The comprehensive examination, gateway to achieving one’s doctorate, may seem to the student like a formidable, mentally stressful, and almost insurmountable obstacle to graduation for a number of reasons:

  1. Most doctoral students have matriculated without any prior counseling about available employment paths upon graduation–some students even go to graduate school as an option to delay fulltime work and employment.
  2. Doctoral programs in departments and among different colleges often have differing policies toward using comprehensive examinations as evaluative mechanisms (e.g., the weight of the comprehensive examination in the curriculum).
  3. A potentially severely harmful emotional scenario for a student taking the comprehensive examination may unfold. The student may become over-stressed about the prospect of taking the examination, be emotionally unable to even take the examination, and subsequently become clinically depressed with often irreversible damage made to her or his health, career, family, or friendships.
  4. The comprehensive examination may be generally perceived as a “subjective affair” by different professors, even within the same department. They may have widely different attitudes toward comprehensive examinations, i.e., some ignore the results and some pass every student, while others treat the test-takers with various degrees of animosity.
  5. Failure in the comprehensive examination is a tragic loss to the doctoral student, who may have already invested years in their program.
  6. Comprehensive examinations may serve the faculty and administration as a vehicle for ridding the department of vocal or controversial graduate students.

The graduate student usually seeks her or his first encounter with mental health concerns at the student health services, usually located on campus (Porter, 2011). In the judgment of the physician, if a treatable outpatient mental health diagnosis is present (i.e., the diagnosis does not require hospitalization), the student is usually scheduled for follow-up or referred to a therapist (Williams et al., 2008).

Substance abuse, especially alcohol, amphetamines, and cocaine, among college students may interact with pharmacological treatment or mask emotional problems (SAMHSA, 2009). Management of anxiety, depression, and other psychogenic conditions often includes pharmacologic means. Danger of addiction and even overdose developing from combining substances and medication employed in pharmacotherapy poses a real problem to the therapist. The majority of psychotherapeutic medications cause side effects including sedation and dry mouth that can be difficult problems when trying to study and go to classes. Descriptions of treatment with psychogenic medications are provided in a detailed manner elsewhere in the medical literature—please refer to the DSM-V (American Psychiatric Association, 2013) or the Merck Manual (Porter, 2011). To counter the results of substance abuse and mental health problems on campus, the federal government has funded substantial grants for prevention and treatment (e.g., SAMHSA, 2009).

A genetically-based pre-existing mental condition, such as bipolar disorder or schizophrenia, may be triggered by the elevated stress level associated with the comprehensive examination. Mental health problems in graduate school are neither easily observed nor studied due to several factors, including the existence of stigma, the tendency of the afflicted to isolate themselves, and a highly intellectual student population often capable of hiding such afflictions. Efforts to prevent mental problems or provide necessary follow-up treatment can often be thwarted in this hard-to-reach population of graduate students.


Most doctoral students have matriculated without any prior counseling about available employment paths upon graduation–some students even go to graduate school as an option to delay fulltime work and employment. In some Ph.D. programs in the health sciences, a major hurdle to graduation is the comprehensive exam. Studying for and taking the “high-stakes” comprehensive exams would be difficult under any circumstances. However, even a professor would have difficultly proving their full knowledge of a discipline in a set of essays with a time limit of several hours.

What factors in the overall makeup of doctoral programs make evaluation by comprehensive examination so controversial? The answer to this question includes the following factors:

  • An incompatible relationship between the students and their departmental advisors or committee members could delay or derail the passing of the comprehensive examination.
  • Mentoring and advisement in the graduate school has suffered widely due to low availability of qualified faculty to make up doctoral committees (i.e., low faculty/student ratios in academic departments).
  • Departmental policies differ, but after two or sometimes three failures of comprehensive examinations, the student is summarily dismissed from the doctoral program. Failure in the comprehensive examinations is a tragic loss to doctoral students, who may have already invested years in their programs.

A policy to help prevent an untoward outcome from comprehensive examinations is to modify or eliminate their elevated place in the doctoral curriculum. This change could be accomplished by laying the groundwork for the examination from “day one” in the doctoral program and subsequent preparation for the examination in concert with required coursework (University of Memphis, 2014). Alternatively, in another approach, the comprehensive examination can be reformatted into a series of “take-home” essays based on current coursework. These practices spread out the studying for comprehensive examinations over the years of matriculation before “advancement to candidacy” and effectively lower the associated stress level. Indeed, many doctoral programs have eliminated comprehensive examinations from their curriculum altogether.

As traditional elements of doctoral programs, comprehensive examinations constitute barriers to learning rather than useful evaluative mechanisms. Comprehensives are “high-stakes” examinations and by their all-or-nothing nature are very stressful for the doctoral student. This increased level of stress could be the etiology of mental problems or exacerbate existing ones. The use of archaic pedagogical instruments of doctoral evaluation such as comprehensive examinations appear not only to be an unfair method of academic evaluation but additionally a means of damage to the health of students.


American Psychiatric Association (2000).Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV-TR). Arlington, VA: American Psychiatric Publishing.

Campus Health Services (2012). University of North Carolina, Chapel Hill. For faculty: suicidal student scenario. Retrieved from /caps/how-support-student faculty-suicidal-student-scenario.html.

Clemmons, S. (2004). Tips on graduate school politics: Politics & observations (Part I). Retrieved from magazine/previous_issues/ articles/2004_01_30/noDOI.17597834208847136571.

Cohen, D.B. (2002). Surviving the Ph.D.: Hints for Navigating the Sometimes Stormy Seas of Graduate Education in Political Science. PS 35, 585-588.

Deroma, V., Leach, J., Leverett J., & Patrick, J. (2009). The relationship between depression and college academic performance. Available from ERIC Document Reproduction Service. (ERIC No. EJ 872247).

Ellen, E.F. (2002). Suicide prevention on campus. Psych Times 29(10), 13-17.

Groth-Marnat, G. (2003). Handbook of Psychological Assessment (4th ed.). Chapter 14, 587-603. Hoboken NJ: Wiley.

Harvard College (2011). For Ph.D. students, a variety of mental health resources. Retrieved from

Johnston, J. (2013). Vanderbilt University: Mentoring graduate students. Retrieved from

Jones, J.W. (1991). Suicidality among college and university students: Contributing factors and preventive response. Available from ERIC Document Reproduction Service. (ERIC No.   ED333249).

Kitzrow, M.A. (2003). The mental health needs of today’s college students: Challenges and recommendations. JSARP 41,1, 167–181, doi: 10.2202/1949-6605.1310.

Porter, R.S. (2011). Merck Manual of Diagnosis and Therapy (19th edition). Whitehouse Station NJ: Merck.

SAMHSA (2009). Substance Abuse Mental Health Services Administration/Department of Health and Human Services: Washington D.C. Suicide prevention on campus. Keeping students connected. SAMHSA News 17(3), 1-5.

Silber, E. (1999). Helping students adapt to graduate school: Making the grade. Philadelphia:Group for the Advancement of Psychiatry.

University of Memphis (2014). Comprehensive examination in the Ph.D. program. Retrieved from

University of Michigan (2012). How to mentor graduate students: A guide for faculty. Rackham Graduate School, The Regents of the University of Michigan. Retrieved from href=””>

Williams, C.B., Galanter, M., Dermatis, H., & Schwartz, V. (2008). The importance of hopelessness among university students seeking psychiatric counseling. Psychiatr. Q. 79, 4, 311-319.

Zelditch, M. (1990). Mentor roles. Proceedings of the 32nd Annual Meeting of the Western Association of Graduate Schools, Tempe, Arizona, 16-18 March, 1990, p.11.