Megan L. Copley, DO, says the stress of her intern year was the catalyst for her depression. This was in 2010, the year before new restrictions were put on resident work hours. Dr. Copley worked 30-hour shifts at the hospital and slept four to five hours at a time.
When she had free time, Dr. Copley tried to relax by taking walks, hiking and cross-stitching. Then something changed. She gradually noticed that her favorite hobbies no longer brought her pleasure.
“I felt like I just didn’t care anymore about the things that I used to as far as interests or being around people or being around my family,” says Dr. Copley, who is now finishing her final year of an internal medicine residency in Norton, Va.
Dr. Copley realized she needed help, but had reservations about speaking with her family physician, who also happened to be her attending.
“I didn’t want him to think differently of me or think I was overreacting,” Dr. Copley says.
Eventually, Dr. Copley decided the pros of seeking help outweighed the cons. She discovered that her worries were unfounded. Her attending was very receptive to her concerns, she says, and he treated her for depression. She says medication, along with the easing of her hours, helped.
“I started noticing a difference in my mood in a couple of months,” she says. “And when my intern year stopped, that helped a whole lot too. I was working fewer hours, and I wasn’t on call as much.”
As a physician who has struggled with a mental illness, Dr. Copley isn’t alone. And like her, many physicians are reluctant to seek help. But a lot of them never overcome the personal and professional barriers to treatment that they face.
Fears of stigma, confidentiality breaches and professional repercussions are common reasons physicians don’t obtain treatment for depression and mental illness, according to a recent General Hospital Psychiatry study.
Physicians commit suicide at a higher rate than the general public, and medical students are more likely to struggle with depression than their peers, studies suggest. The misgivings physicians and medical students often have about getting help stem from their role as healers.
“As physicians, we’re trained to block out our own personal emotional issues and focus on our patients, our patients’ families and others,” says psychiatrist Daniel E. Wolf, DO, who practices in Seattle. “And a lot of doctors are not going to talk about things that they think others may view as weak or vulnerable because they think, ‘We’re the doctors and we’re supposed to fix people, not need help ourselves.’ “
Nearly half of respondents to a 2005 survey of British physicians said they had an episode of depression at some point, according to the International Journal of Social Psychiatry. In addition, 7% of respondents said they self-prescribed antidepressants, citing confidentiality worries and a desire to handle the illness themselves.
Psychiatrist Blake Casher, DO, says confidentiality is a common fear.
“A lot of physicians may not seek help because they are afraid that it’s going to go on their record somehow and it will come back and hurt them, whether it’s with their license or with their hospital or another affiliation they have,” says Dr. Casher, an associate clinical professor of psychiatry at the Michigan State University College of Osteopathic Medicine in East Lansing.
Dr. Casher has let his physician patients enter through his office’s back door so patients and acquaintances wouldn’t see them in the waiting room. He notes that mental illness still carries a stigma that physical illness doesn’t.
“People may feel that somebody who’s had a history of depression is unstable,” he says. “It’s not that different, medically, from somebody who has a heart condition. But people don’t look askance at someone with a heart condition.”
Beyond general concerns about reputation, many physicians also harbor fears that seeking help could have far-reaching professional consequences.
Checking the ‘Yes’ box
State medical boards have a history of asking license applicants whether they have had a mental health problem. Physicians worried that seeking help could result in license problems, says Warren Pendergast, MD, the president of the Federation of Physician Health Programs, a nonprofit that provides resources to the state programs that help and advocate on behalf of physicians with psychiatric and substance-abuse problems. However, a physician who reveals his or her history of treatment for mental illness will not necessarily encounter license problems, Dr. Pendergast says.
Moreoever, state medical boards are evolving how they fulfill their obligation to protect the public from unfit physicians while respecting physicians’ wishes for confidential mental health treatment. Some states have even removed questions about physicians’ mental conditions.
“It’s better than it used to be,” Dr. Pendergast says. “More states are encouraging physicians to get help and not asking them this question. The states are encouraging physicians to get help through their own doctors or through physician health programs.”
Seattle’s Dr. Wolf notes that the Washington State Medical Board once asked physicians applying for an initial medical license if they ever had a drug, alcohol or mental health problem. But the medical director of the state physician health program lobbied to have the language changed. By the mid-1990s, the two organizations agreed on new language, and applicants were instead asked if they have ever had a drug, alcohol or mental health problem that is not already known to the physicians health program. The reworded question allowed physicians to seek help anonymously.
“[The medical director] got that changed specifically so that people in his program—at any time we had 100, 200 physicians in there, and now there’s more—would not be penalized for being in recovery,” he says.
Today, the language is even less specific. Applicants for allopathic and osteopathic physician licenses in Washington are simply asked to disclose if they have any medical conditions that limit their ability to practice medicine.
The extent of mental health questioning on physician license applications in other states varies widely. A 2009 study found that more than two-thirds of allopathic state physician license applications had questions pertaining to mental health or substance use that were possibly or most likely impermissible under the Americans with Disabilities Act.
Compounding physicians’ sense of vulnerability, license applications are public record in some states.
But states need to know their licensed physicians are fit for their duties, Humayun Chaudhry, DO, the president and CEO of the Federation of State Medical Boards of the United States, wrote in an email.
“Medical boards have the pre-eminent duty to protect the public, which includes licensing only individuals who are fully qualified to practice medicine,” Dr. Chaudhry wrote. “Boards must have sufficient information with which to make a good decision about granting a doctor a license to practice medicine. The answers to these questions are necessary for boards to make a thorough evaluation of a candidate.”
Among states with the most practicing DOs, Michigan, New York and Pennsylvania have license applications that do not include questions about physical or mental health beyond those about substance abuse, while California, Florida, Ohio and Texas have applications that do.
One of those states, Ohio, is currently considering modifying its questions on mental health, says Sallie Debolt, the state medical board’s general counsel. The questions protect the public, carrying out the board’s mission, she says.
“The Ohio Revised Code gives the board the authority to take action if a physician has a mental or physical illness that makes him or her unable to practice according to acceptable standards of care,” Debolt says. She notes that cases in which the state board does take action based on a physician’s mental illness are rare, and that physicians shouldn’t assume that answering yes will result in license problems.
Licensing fears aside, the driven, independent nature of many physicians, which sustained them through training and into their everyday practice, can also work against them when they’re depressed.
“A lot of us are type A personalities. We’re the type of personality that thinks, ‘I can handle this, I can get through this myself,’ ” says the AOA’s 2001-02 president, James E. Zini, DO, a family physician in Mountain View, Ark. “But if you truly are depressed and suicidal, you do need help.”
Sometimes, a tragic consequence of not seeking help is suicide. Up to 400 U.S. physicians end their own lives every year, according to Medscape. The American Foundation for Suicide Prevention (AFSP) launched a suicide prevention program specifically for physicians in 2008, the organization’s only occupation-based program.
Current and reliable data on physician suicide are not readily available. A 2004 aggregate study from The American Journal of Psychiatry found that the suicide completion rate of male physicians is 1.4 times higher than the general population’s while female physicians commit suicide at 2.3 times the rate of the general public.
A recent study published in General Hospital Psychiatry found that a job problem was substantially more likely to contribute to physician suicides than nonphysician suicides. Because physicians’ identities often center around their careers, professional setbacks may be more devastating to them than they are to people whose identities are less tied to their jobs, the study’s authors suggest.
Some physicians speculate that the changing nature of medicine may have something to do with physician depression and suicide. Today’s medical environment is more stressful than the one physicians practiced in 35 years ago, Dr. Casher notes.
“Doctors are finishing medical school with huge debts,” he says. “And you’re not your own boss. Most physicians are working for hospitals or for HMOs. It’s very hard to maintain a practice anymore and have that independence. Physicians tend to prefer autonomy. They really don’t like taking orders from somebody telling them how to practice.”
External factors are slowly eroding the control many physicians have over their work, Dr. Zini notes.
“So many pressures outside of the doctor-patient relationship affect my ability to practice the art of osteopathic medicine,” he says. “Government interference. Poverty. Patients’ ability to help themselves. Doctors are becoming more and more responsible for outcomes in all these new models of treatment. These are all pressures that play a role in the health of the physician.”
Have physician depression and suicide rates changed much in the past several decades? It’s hard to say. Reliable statistics showing physician depression and suicide rates over time are not available, says Paula Clayton, MD, the AFSP’s medical director.
Depression and medical school
Different pressures test the mental health of medical students: living up to expectations, jam-packed schedules, tests, homework. Brian Denny, OMS II, whose name has been changed for privacy, has experienced depression and suicidal thoughts since he was a teenager. In high school, he learned ways of coping with his occasional depression that worked most of the time. But the stress of medical school brought his symptoms back full force.
“There would be stretches of time when I was withdrawn from people and I wasn’t really able to concentrate on my studies,” Denny says. “And the week before exams I was just really withdrawn. It got to the point where it was affecting my grades, so I had to talk to my adviser and my friends.”
Eventually, Denny worked with his school’s education specialist, who helped him change his study habits, which led to reduced stress. He says the school’s faculty has been extremely supportive.
“When my grades did slip, there was always my faculty adviser or another faculty member keeping track of students’ progress, and someone would talk to me about what’s going on to make sure I was OK,” he says. “That helped me a lot, just having someone come check on me every once in a while.”
Medical students’ concerns about mental illness are similar to those of physicians: They worry that asking for help may impact their reputation or standing. But Denny says he doesn’t feel like there’s a stigma to seeking help where he attends school. In fact, he has a few friends there who also struggle with mental illness.
“Everyone here is going through the same process, and they know the stress is there,” he says. “So nobody is going to make fun of you for getting the help you need.”
The depression rate in medical students is more than double that of the general population, Inside Higher Ed reported in 2009. And mental health worsens as students progress through medical school, according to survey results published in JAMA in 2009. The survey found that third- and fourth-year respondents were significantly more likely to report suicidal ideation than their first- and second-year counterparts.
Recognizing the importance of medical students’ mental health, the AOA House of Delegates passed a resolution in 2011 recommending increased awareness of depression among medical students and that those affected be provided with treatment options.
In the past few years, Bridget E. McIlwee, OMS IV, says she believes the issue has gained prominence at medical schools.
“There have been more studies and articles coming out, even in the mainstream media, pertaining to medical student depression,” says McIlwee, who graduates this month from the Midwestern University/Chicago College of Osteopathic Medicine in Downers Grove, Ill. “I think awareness of the subject is increasing, though a little bit more slowly than most people would probably prefer.”
The same year that the AOA House passed the resolution, the AOA’s Commission on Osteopathic College Accreditation independently revised its accreditation standards for medical student health care, stipulating that students of osteopathic medical colleges must be provided with confidential physical health services and 24/7 access to confidential behavioral health care services.
With these resources available to students, will they use them? McIlwee says she knows students use MWU/CCOM’s counseling center, but that others may still be reluctant.
“Even if they’ve learned about the chemical imbalances that are responsible for depression and anxiety, due to medical students’ general tendency to be perfectionists, these illnesses are still seen as weaknesses,” she says. “And this may play a big role in why students don’t seek out counseling at their schools.”
What needs to change?
Physicians say the medical profession as a whole—including regulators, educators, students and physicians themselves—needs to be more accepting of mental illness.
“The physician needs to feel like he or she can get some help and not worry about repercussions,” Dr. Casher says. “I’ve seen some physicians who will pay out of pocket so there’s no record of it, but most physicians are not likely to do that. If they could somehow be made to believe that getting help is not going to hurt them professionally, that would make a big difference.”
Dr. Pendergast agrees, noting that physicians will also self-treat rather than get help, which he says is never a good idea.
“There needs to be a change in the medical culture to make it more acceptable and appropriate to get help, rather than denying the problem,” he says. Although some have stopped, state medical boards and other credentialing bodies should not ask questions about mental health on their applications, he adds.
Physicians can help each other by reaching out to colleagues who seem depressed or aren’t acting like themselves, says Dr. Zini.
“If we see depression in our colleagues—those we have a close personal relationship with and therefore a trust relationship with—we should speak out,” he says.
For physicians who recognize depression in themselves, Dr. Zini advises them to get help as soon as possible—and to recognize that they’re not alone.
“Depression is more prevalent than most people understand,” he says. “I have treated fellow physicians. And anybody who tells you that he or she hasn’t had some depression is not being realistic. We all will have some. I have not ever felt that I was suicidal, but I’ve had colleagues who did, and they received help and are functioning well now.”
The same goes for medical students, says McIlwee, who cites the higher rate of depression among medical students when compared to their age-matched counterparts.
“There are a large number of medical students who have the same issues and the same feelings, and there are plenty of resources out there to help them,” she says.
To physicians who harbor worries about licensure, Dr. Pendergast says not getting help can cause more damage. Untreated depression is a greater risk to a physician’s license than disclosing mental illness to a state medical board, he says, because it will negatively affect the physician’s personal life and, very often, work life as well.
Most physicians, says psychiatrist David A. Baron, DO, would not hesitate to treat or refer a patient who is feeling depressed and that life isn’t worth living—and they should remember this when they think of themselves.
“Physicians need to say that we’re not supermen or superwomen,” says Dr. Baron, who is the vice chair of psychiatry at Keck Hospital of USC in Los Angeles. “And if we’re feeling the same symptoms, we owe it to ourselves and to our patients to go and get professional consultation.”