Aaron E. Carroll via www.nytimes.com
In my first year of training as a doctor, I knew something was wrong with me. I had trouble sleeping. I had difficulty feeling joy. I was prone to crying at inopportune times. Even worse, I had trouble connecting with patients. I felt as if I couldn’t please anyone, and I felt susceptible to feelings of despair and panic.
I’m a physician, and, if I do say so myself, a very well-trained one. Yet it took an “intern support group” and the social worker who ran it, close friends and my fiancée (now my wife) to convince me that I might need help. Even if I couldn’t acknowledge it, they could see I was suffering from depression.
I wasn’t alone.
Last month, a study in the Journal of the American Medical Association reviewed all of the literature on depression and depressive symptoms in resident physicians — those are doctors still being trained. They found more than 50 studies on the subject. Research shows that almost 30 percent of resident physicians have either symptoms or a diagnosis of depression.
The numbers, and how they compare with other professions, are almost beside the point. Physicians are in a position of needing to care for others continuously. That strain, coupled with difficulties in helping themselves, leaves both patients and physicians at risk. The studies that followed doctors over the course of their residencies found that the rate of depression symptoms increased more than 15 percent within a year of the beginning of training.
What makes this all worse is that medicine is a profession in which admitting a problem carries a stigma that can have more impact than in others. A study published in 2008 surveyed physicians in Michigan, asking them about their work experiences and if they had depressive symptoms. More than 11 percent reported moderate to severe depression. About a quarter of them reported knowing a doctor whose professional standing had been hurt by being depressed.
Physicians with moderate to severe depression had a decrease in work productivity and job satisfaction. They were also two to three times more likely to say that they were worried about, or had difficulty getting, mental health care. Although the Americans With Disabilities Act, passed in 1990, prohibits employers from asking broad questions about illnesses when people apply for jobs, state medical licensing boards still ask specific questions about mental health.
Because of this, physicians are much more likely to avoid treatment. They’re also more likely to self-medicate.
Sometimes that medication is appropriate, as with anti-depressants. Often, it is not. A 2012 study in JAMA Surgery found that more than 15 percent of the members of the American College of Surgeons had a score on a screening test consistent with alcohol abuse or dependence. Among female surgeons, the prevalence was more than 25 percent. Those who were depressed were significantly more likely to abuse or be dependent on alcohol.
Doctors have much easier access to drugs than most other people do. Because of this, they are more likely to misuse prescription drugs than the general population. Anesthesiologists have access to more drugs than other physicians, and their problems are even more common. A 2005 study of anesthesia residency training programs found that 80 percent of them reported experiences with impaired residents, and almost 20 percent had experiences with at least one abuse-related death of a doctor in training.
Unfortunately, depression and substance abuse can lead to further problems, including suicide. More than 6 percent of surgeons reported suicidal thoughts in the last year. Yet only one quarter of them sought any kind of help. Most who didn’t seek help feared that doing so would affect their ability to obtain a license — even though they were also worried about killing themselves.
The problem is even worse among medical trainees. About 6 percent of them reported thinking about suicide in just the previous two weeks. Those with a history of depression were almost four times as likely to report recent suicidal thoughts as those without.
It is estimated that about 400 physicians commit suicide each year. That’s about three times as many doctors as were in my medical school class at the University of Pennsylvania. Meta-analyses estimate that the rate of suicide among male physicians is 140 percent that of the general population. Among female physicians it is almost 230 percent.
What makes this important to discuss is not the prevalence of depression in physicians and trainees, although it’s clearly very high. It’s not whether physicians have the highest suicide rate of any profession, although many people argue that they do. The critical issue here is that too many physicians, especially trainees, suffer in silence, afraid to ask for help for fear that they will be punished professionally, and probably, personally.
I have always been very open about my time in residency, and how depression somewhat robbed me of a few years of my life. When I look back, I think the constant pressure to help others, coupled with frequent feelings of helplessness, weighed on me. A lack of sleep and being away from family and friends left me vulnerable. Seeing children I bonded with, and cared for deeply, suffer and die was often more than I could bear. I think some part of me, whether it be physical or behavioral, is also predisposed to depression.
But I’m lucky. Thanks to the support of those who love me, as well as two excellent therapists, I am no longer depressed. I remain vigilant, however, against a recurrence. It’s important for me, and for all physicians, to stay on top of their mental health and not wait for a crisis to act. I’ve also felt fortunate to be in a specialty (pediatrics) and a focus (research) where I don’t fear being ostracized if anyone “found out.”
Many colleagues still recoil when I talk openly about therapy, or how I plan to go to a therapist for the rest of my life. I’m sure they will find this column disconcerting as well. But we can’t avoid talking about this. Too many are suffering, and if they can’t get help from others, they may try — and fail — to help themselves. Suicide is always a tragedy; a physician’s suicide is a travesty.