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A physician who is also long-term patient living with depression discusses a pervasive problem in the house of medicine.
Earlier this year, the world learned of a tragic casualty of the COVID-19 pandemic—Emergency Department physician Lorna M. Breen, MD, New York-Presbyterian Allen Hospital in Manhattan, lost her life to suicide. Dr Breen was a highly educated, talented, and successful woman working in a clinical health care setting. Although there was no known history of depression or mental illness, she nonetheless experienced great personal pain and suffering. My heart goes out to her family, loved ones, and colleagues.
Dr Breen’s story strikes a familiar chord with me as a physician who is also long-term patientliving with depression. It highlights a pervasive problem in the house of medicine: far too many health care professionals fear mental health services.
As a trainee, and again later in practice, I found myself in deep despair, with both physical and emotional pain. I was unable to work or participate in and enjoy life. Yet, like too many physicians, I was hesitant to seek professional mental health care for fear of stigma and the potential negative impact it would have on my career. Although I did not know it at the time, I was not alone. Nearly 40% of physicians report reluctance to seek medical care for a mental health condition due to fear of repercussions to their medical licensure.1 Alarmingly, even before COVID-19, burnout and depression was found to be more common in physicians than in the general population, affecting 28.8% of resident physicians in training,2 13% of male physicians, 20% of female physicians, and approximately 15% to 30% of medical students.3 Suicide rates are also higher in these groups.4 The emotional health toll of the pandemic is likely to exacerbate these issues, and could continue to be felt for many months and years.
It is helpful to understand what contributes to physician burnout and depression. In part, it is the nature of the profession: long hours; being on-call; making difficult life-and-death decisions for other people; licensure and hospital appointment issues; litigation-related concerns; concern about risk for errors due to inexperience as a trainee; and dealing with death and dying. COVID-19 brought another layer of complexity to these concerns, including the constant fear and anxiety about getting sick or infecting our families, friends, and colleagues with coronavirus; the stress and uncertainty surrounding a novel virus and not knowing who might be infectious; working in a hazardous environment without adequate protective personal equipment; caring for high risk patients despite limited technology and equipment to serve their critical care needs; financial losses; and changes in the quality of life.
Before we can respond to the challenge of untreated or partially treated mental illness in health care providers, we must consider the barriers to seeking care that exist for physicians, nurses, and other health care personnel. Some of these challenges are systemic, created by the culture of medicine; and some of them are internally derived, based on realistic fears. Stigma is also a great concern and is a major barrier to seeking mental health care for all patients, including physicians.5
Many physicians tend to beespecially competitive, driven, selfless, and devoted to others, which can get in the way of our own self-care. The culture of medicine often discourages admission of health vulnerabilities and fosters a “toughing it out” attitude rather a help-seeking one. Physicians find it difficult to ask for help of any kind; there is a myth of invulnerability and a tradition of self-sufficiency. Some even fail to recognize mood disorder symptoms in themselves. Many find it difficult to admit that their coping skills are inadequate, and they perceive such as a failure. Having mental illness often leads to a feeling of shame and guilt in providers who have come to believe “I can do it by myself.”
Similarly, physicians are used to being in control of complex situations—something patients seek in their health care providers. However, any situation that decreases our ability to control our environment, workplace, or employment conditions (such as what has happened with COVID-19) may lead to depression and suicide.
There is also a perceived obligation in health care providers to be the picture of health; after all, if we cannot keep ourselves healthy, how are we expected to help others? As a physician seeking help for depression, I had to fight these feelings. I needed to embrace the role of patient and allow myself to be “cared for.” I had to learn to trust and defer to others. I had to learn that seeking help is not a sign of weakness; this was a major step for me as it is for many.
Added to this are concerns about confidentiality as well as personal and professional privacy. Physicians have found that admitting to a mental illness in medicine can be a punitive experience.6 During medical training, there are instances of harassment and belittlement from professors, higher level trainees, and some nurses. There are known instances of discrimination in medical licensing, difficulty retaining hospital privileges, and interruptions in professional advancement.7 Thus, many physicians are afraid that seeking mental health services will result in a negative effect on their career and, licensure.8 Many are concerned that depression or another mental illness diagnosis might infer that they are unable to provide quality care; they worry about a loss of reputation and respect in their community. In turn, this becomes a concern for their livelihood and the financial stability of their families.
Unfortunately, untreated or inadequately treated mental illness poses a greater risk not only to the physician who hasmental illness but also their patients. Thus, it is imperative that physicians, nurses, respiratory therapists, and other health care workers—including and especially those on the COVID-19 frontlines—feel that they can get the help they need free of shame, guilt, stigma, or negative professional repercussions. They will also need time and support to heal.
We must improve the way society and the medical profession regard depression and other mental illnesses. We need to inspire new thinking and a change in attitude in a variety of professional and private settings. To inspire such, here are several steps we can take to make a positive impact. Addressing these issues will do a lot to decrease stigma and encourage mental health treatment in all.
1. Understand that stigma is based on misinformation, fear, and arrogance.Continued education about depression and other mental illnesses as well as effective treatment options is key.
2. Policy change is needed on an institutional level. Our institutions need to openly discuss depression as a treatable biologic illness and offer time and resources for treatment. When this message comes from the top, others are more likely to accept it.
3. Building on these educational efforts and policy changes, a cultural shift in the way mental illness is regarded needs to occur. This is most effective when it trickles down from the top in our organizations, schools, communities, and other social structures. Creating an environment that encourages openness and wellness is the minimum prerequisite.
Psychoeducation and policy improvements are not enough to accomplish change. It is essential that those who have lived experience share their stories. When medical colleagues who have successfully received help for depression, suicidality, and other mental illness share their experiences, more of us in need of psychiatric treatment will feel comfortable to get appropriate care.
About the author
Dr Noonan is a physician consultant and Certified Peer Specialist in the Department of Psychiatry at McLean Hospital and the Massachusetts General Hospital. She is the author of four books and a blog on managing depression, most recently Helping Others With Depression: Words to Say, Things to Do (December 2020). Dr Noonan offers peer counseling to fellow patients, including physicians and other professionals, and can be confidentially reached through her website at https://susannoonanmd.com.
1. Dyrbe LN, West CP, Sinsky CA, et al. Medical Licensure questions and physician reluctance to seek care for mental health conditions. Mayo Clin Proc. 2017:92(10);1486-1493.
2. Mata DA, Ramos MA, Bansal N, et al. Prevalence of depression and depressive symptoms among resident physicians: A systematic review and meta-analysis. JAMA. 2015:314(22);2373-2383.
3. Center C, Davis M, Detre T, et al. Confronting depression and suicide in physicians: A consensus statement. JAMA. 2003:289(23);3161-3166.
4. Schernhammer ES, Colditz GA. Suicide rates among physicians: A quantitative and gender assessment (meta-analysis). Am J Psychiatry. 2004:61;2295-2302.
5. Schwenk TL, Davis L, Wimsatt LA. Depression, stigma, and suicidal ideation in medical students. JAMA. 2010:304(11);1181-1190.
6. Center C, Davis M, Detre T, et al. Confronting depression and suicide in physicians: A consensus statement. JAMA. 2003:289(23);3161-3166.
7.Center C, Davis M, Detre T, et al. Confronting depression and suicide in physicians: A consensus statement. JAMA. 2003:289(23);3161-3166.
8.Dyrbe LN, West CP, Sinsky CA, et al. Medical Licensure questions and physician reluctance to seek care for mental health conditions. Mayo Clin Proc. 2017:92(10);1486-1493.