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Dr. G, a second-year surgical resident, becomes depressed when his girlfriend abruptly ends their relationship. His phone calls and e-mails seeking an explanation go unanswered. Having long struggled with his self-esteem, Dr. G interprets this rejection as confirmation of his self-criticism.
Because of his work schedule, Dr. G feels that there is no way to see a therapist or psychiatrist and believes that asking for time off to do so would adversely affect his evaluations. He feels too embarrassed and “weak” to disclose his breakup and depression to his colleagues and attending physicians and senses that fellow residents would resent having to “carry his load.” Dr. G has spent the past 2 years moonlighting at the local emergency room and thinks it would be humiliating to go there for psychiatric help. His work performance and attendance decline until eventually his residency director forces him to take a medical leave of absence.
Dr. G feels that his pain will never end. He writes goodbye letters to his family, makes arrangements for his possessions and funeral, and hangs himself from the balcony outside his apartment.
Although the rate of depression among physicians is comparable to that of the general population, physicians’ risk of suicide is markedly higher.1 Depression and other mood disorders may be under-recognized and inadequately treated in physicians because physicians might:
- be reluctant to seek treatment
- attempt to diagnose and treat themselves
- seek and receive “VIP treatment” from other health care providers.
This article examines physicians’ risk for depression and suicide, licensing concerns and other barriers to effective treatment, and what can be done to overcome such obstacles.
Not immune to depression
Rates of depression are higher in medical students and residents (15% to 30%) than in the general population.2-4 A longitudinal study of medical students at the University of California, San Francisco showed that students’ rates of depression when they enter medical school are similar to those of the general population, but students’ depression scores rise over time; approximately one-fourth of first- and second-year students were depressed.3 Fahrenkopf et al5 reported that 20% of 123 pediatric residents at 3 U.S. children’s hospitals were depressed. These depressed residents made 6.2 times more medication errors than did their non-depressed peers.5 For more information on physicians-in-training, see “Treating depression in medical residents“.
After completing residency, the risk of depression persists. The lifetime prevalence of depression among physicians is 13% in men and 20% in women6; these rates are comparable to those of the general population. Firth-Cozens7 found a range of factors that predict depression among general practitioners; relationships with senior doctors and patients were the main stressors (Table 1).7 Although these stressors increase depression risk, Vaillant et al8 showed that they did not increase suicide risk in physicians who did not have underlying psychological difficulties when they entered college. Certain personality traits common among physicians, such as self-criticism and perfectionism, may increase risk for depression and substance abuse.8
A depressed physician might enter a downward spiral. Feelings of hopelessness and worthlessness frequently lead to declining professional performance. Professional and personal relationships are strained as internal dysphoria manifests as irritability and anger. Spouses and partners can feel overwhelmed and bewildered by changes in the depressed person’s behavior, which may lead to separation or divorce. Patient care and the physician’s professional standing can be endangered. Signs that suggest a physician may be suffering from depression or another mental illness appear in Table 2.9
Predictors of depression in physicians
|Difficult relationships with senior doctors, staff, and/or patients|
|Lack of sleep|
|Dealing with death|
|Source: Reference 7|
Manifestations of mental illness in physicians
|Severe irritability and anger, resulting in interpersonal conflict|
|Marked vacillations in energy, creativity, enthusiasm, confidence, and productivity|
|Erratic behavior at the office or hospital (ie, performing rounds at 3 am or not showing up until noon)|
|Inappropriate boundaries with patients, staff, or peers|
|Isolation and withdrawal|
|Increased errors in or inattention to chart work and patient calls|
|Personality change, mood swings|
|Impulsivity or irrationality in decision making or action|
|Inappropriate dress, change in hygiene|
|Sexually inappropriate comments or behavior|
|Diminished or heightened need for sleep|
|Frequent job changes and/or moves|
|Inconsistency in performance, absenteeism|
|Source: Adapted from reference 9|
Increased suicide risk
A review of 14 studies found that the relative risk of suicide in physicians compared with the general population is between 1.1 and 3.4 for men and 2.5 to 5.7 for women.1 A retrospective study of English and Welsh doctors showed elevated suicide rates in female but not male physicians compared with the general population.10 There are no recent studies of suicide rates among U.S. physicians. A 1984-1995 study showed that white male physicians have a higher risk for suicide than other white male professionals.11 A survey of 4,500 women physicians found that female doctors are less likely to attempt suicide than the general female population6; however, their attempts more often are lethal, perhaps because they have greater knowledge of toxicology and access to lethal drugs.12