Doctors and their Depression

I have talked before about what depression is and how it gets diagnosed.  So why is it important to talk about depression specifically in doctors?  Depression and suicide have become something of an epidemic in the medical profession.  The medical establishment has been slow to react, and only recently has mental health care become more of a focus in training.  I don’t ever remember a superior asking about my mental health or if I was handling things well.  Even as a fellow, which was only 5 years ago, nobody seemed to notice my struggle with depression.  Nobody even talked about the possibility that we might experience depression.  

And this is not a new issue.  As early as 2003, the American Foundation for Suicide Prevention issued a statement saying “The culture of medicine accords low priority to physician mental health despite evidence of untreated mood disorders and an increased burden of suicide. Barriers to physicians’ seeking help are often punitive, including discrimination in medical licensing, hospital privileges, and professional advancement.”(1) All of these things are still issues today, and it often feels like little progress has been made.

The NIMH reports that at least 17.3 million adults in the U.S. had an episode of major depression at some point after the age of 18, which is about 7.1% of all U.S. adults.(2)  But what about if you are a doctor?  Are these numbers higher or lower?  It’s actually hard to find data on this, but the most commonly cited statistics are around 13% in male physicians and 20% in female physicians.(3)  So higher.  By quite a bit.  And it’s even worse for those in training.

It has been shown that at the beginning of medical school, students have the same rate of depression and suicide as the general population.  But over time, their depression scores increase significantly.(4)  Studies have found that 20-40% of medical residents are depressed, with symptoms worsening over time.(5)  It seems that there is something inherent in the medical training itself that increases the risk of depression and suicide.  The NIMH says that “major life changes, trauma or stress” are risk factors for depression, and medical training could be categorized as all of these.  The long hours, lack of sleep, pressure to never make a mistake and constant fear of harming someone create a chronic state of stress that is equivalent to a major trauma.

Physician burnout is another major risk factor for depression and is also considered an epidemic in the medical community.(6)  It is characterized by a triad of symptoms that include: emotional exhaustion, depersonalization, and feelings of decreased personal achievement.(7) This can lead to lack of empathy towards patients or feelings of negativity about patients.  Rates of burnout in resident physicians have been estimated as high as 75%.(5) Many factors contribute to this, but some of the biggest are intense workload, decreased efficiency at work due to implementation of electronic charting and systems, and loss of physician autonomy in the workplace.(8)

In the United States, we lose a doctor to suicide every day.  This is more than 400 of our colleagues lost per year.  That makes our profession one of the highest risks for suicide among all careers.  It was hard for me to find recent data on this, but some older studies show that male physicians have suicide rates up to 40% higher than the general population.  For female physicians, suicide rates are 130% higher than the general population.(9,10)  Part of this has to do with means – physicians typically have expert knowledge in the human body and access to toxic substances.  But it also has to do with physicians having a high rate of untreated mental illness.

Despite rates of depression and suicide being higher in physicians, they are actually less likely to seek help for their symptoms.  There are many factors that go into this, but a major component is fear of what their colleagues will say of think of them.  Doctors are taught indirectly during training that we have to be all-knowing and never make mistakes.  We cannot show weakness and must always perform at our best.  This pervasive mindset makes it especially difficult for younger physicians to ask for help from their supervisors.  There is a stigma surrounding mental health even when you work in the health care system, possibly even more so.

For those doctors that want to seek help, it may be difficult for them to find someone to treat them that is covered by their insurance but is not a colleague.  It also takes time to get help for mental health issues, time that many residents and physicians do not feel that they have.  Taking time out for their mental health means that someone else has to pick up the “slack”.  Physicians may fear recrimination from their own coworkers, many of whom are also overworked and tired.

There is also the real fear that the facility they work at will refuse to cover their malpractice insurance or maintain their hospital privileges if they admit to mental health struggles.  State licensing boards may require disclosure about mental health conditions on licensing applications as well.  I have been licensed in multiple states throughout my training, and nearly all of them asked some kind of question about mental health disorders that “cause impairment”.  But what does impairment mean?  And what happens if I answer yes?  This usually triggers a board review of your application where you are required to submit your actual medical records documenting your care.

For me, the big question is how do we change all this?  How can we possibly reverse decades of ingrained medical doctrine and start training our physicians in a way that actually supports their mental health?  How do we stop the epidemic of depression and suicide among our nation’s healers?  We need to start encouraging doctors to seek the help they need and provide compassion to our colleagues when they need it most.  We need to make our own self-care a priority, starting in medical school and continuing through training.  We need to start changing the culture of medicine itself and start recognizing that doctors are human beings too.  

1. Center C, Davis M, Detre T, Ford DE, Hansbrough W, Hendin H, Laszlo J, Litts DA, Mann J, Mansky PA, Michels R, Miles SH, Proujansky R, Reynolds CF 3rd, Silverman MM. Confronting depression and suicide in physicians: a consensus statement. JAMA. 2003 Jun 18;289(23):3161-6. doi: 10.1001/jama.289.23.3161. PMID: 12813122.
2. National Institute of Mental Health.  Prevalence of Major Depressive Episode Among Adults.  https://www.nimh.nih.gov/health/statistics/major-depression.shtml
3. Kalmoe MC, Chapman MB, Gold JA, Giedinghagen AM. Physician Suicide: A Call to Action. Missouri Medicine. 2019;116(3):211-216.
4. Brazeau CMLR, Shanafelt T, Durning SJ, Massie FS, Eacker A, Moutier C, Satele DV, Sloan JA, Dyrbye LN. Distress Among Matriculating Medical Students Relative to the General Population. Acad Med. 2014;89(11):1520–1525.
5. Mata DA, Ramos MA, Bansal N, Khan R, Guille C, Di Angelantonio E, Sen S. Prevalence of Depression and Depressive Symptoms Among Resident Physicians: A Systematic Review and Meta-analysis. JAMA. 2015 Dec 8;314(22):2373-83. doi: 10.1001/jama.2015.15845. PMID: 26647259; PMCID: PMC4866499.
6. Wurm W, Vogel K, Holl A, Ebner C, Bayer D, Mörkl S, Szilagyi IS, Hotter E, Kapfhammer HP, Hofmann P. Depression-Burnout Overlap in Physicians. PLoS One. 2016 Mar 1;11(3):e0149913.
7. West CP, Dyrbye LN, Shanafelt TD. Physician burnout: contributors, consequences and solutions. J Intern Med. 2018 Jun;283(6):516-529.
8. American Foundation for Suicide Prevention. Facts About Mental Health and Suicide Among Physicians. https://www.datocms-assets.com/12810/1578319045-physician-mental-health-suicide-one-pager.pdf
9. Schernhammer ES. Taking Their Own Lives – The High Rate of Physician Suicide. N Eng Journal Medicine. 2005;352(24):2473–2476.
10. Dutheil F, Aubert C, Pereira B, Dambrun M, Moustafa F, Mermillod M, Baker JS, Trousselard M, Lesage FX, Navel V. Suicide among physicians and health-care workers: A systematic review and meta-analysis. PLoS One. 2019 Dec 12;14(12):e0226361.