emDocs Wellness: Part I – Physician Depression and Suicidality

Author: Jennifer Robertson, MD, MSEd (Assistant Professor of EM, Emory University) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital) and Brit Long, MD (@long_brit)

As physicians, we frequently care for patients with depression and suicidal ideations. On occasion, we may also have to treat patients who have actively attempted suicide via methods such as medication overdose or self-inflicted gunshot wounds. However, physicians are also not immune to depression and suicide. While the estimated lifetime prevalence of depression in physicians has been found to be approximately the same as the general population (1, 2), the actual number is likely higher due to underreporting (3). On the other hand, estimated suicide rates have been found to be higher in physicians versus the overall population. Suicide rates are estimated to be 40 percent higher male physicians and 130 percent higher in female physicians than the general population (4,5). Moreover, in a study of United States (US) male physician deaths between 1984 and 1995, suicide was found to comprise a much larger proportion of deaths in the physicians versus other professionals (6). There are hypothesized reasons as to why suicide and perhaps, depression, are more prevalent in physicians. In Part I of this topic, the reasons, risk factors, and warning signs of depression in physicians will be discussed.

Major Depressive Disorder: Review

As a review, the diagnosis of major depressive disorder is based on the DSM Criteria (7). In a two-week period, five or more of the following symptoms must be present and at least one must be a depressed mood or loss of pleasure at least most of each day and every day:

  • Significant unintentional weight loss or gain and/or decrease or increase in appetite nearly everyday
  • Insomnia or hypersomnia nearly everyday
  • Psychomotor agitation or retardation almost everyday
  • Fatigue or loss of energy virtually every day
  • Feelings of worthlessness or inappropriate guilt
  • Diminished ability to concentrate
  • Recurrent thoughts of death or suicidal ideation

These symptoms should cause impairment in social, occupational, or other important areas of function. Finally, the symptoms should not be attributable to the effects of a substance or another medical condition (7). Individuals can also have symptoms of depression without meeting the full DSM criteria and may also have gradations of depression.

Depression is obviously a risk factor for suicide. However, worldwide, it also a leading cause of overall disability (8). Depression has been linked with disruptive behavior, substance abuse, medical errors, worse physical health including coronary artery disease, and decreased work productivity (2, 9, 10-14). Thus, a physician with untreated depression may not be able to fully care for patients as well as a physician without depression or one who is adequately treated. This is a problem, however because many physicians under-report their condition and/or do not receive adequate treatment. There are suggested reasons as to why this is including social stigma and licensing concerns (3).  A subsequent emDocs article (Part 2 of Physician Depression and Suicidality) will discuss these suggested reasons for under-reporting and lack of adequate treatment. Part 2 will also discuss potential ways to mitigate depression and suicidality in physicians.

Risk Factors for Depression and Suicidality in Physicians

The prevalence of depression seems to increase in individuals as they enter medical school and graduate to residency (3, 15, 16, 17). While rates of depression in first year medical students are initially similar to other age-matched non-medical students, they increase disproportionally over the course of medical school (16). Residency training does not seem to improve the situation, as studies have found persistently high rates of depression and other mood disorders, especially in female residents (10, 15, 18).  Finally, while attending physicians seem to be somewhat less afflicted, the risk of depression and suicidal tendencies do persist (3, 19).

There are hypothesized reasons as to why depression may develop during and through medical training. If these reasons can be recognized and addressed, then perhaps medical schools and residencies can mitigate the development of depression among medical trainees.

The following are suggested risk factors for depression and suicidality in physicians: (5, 20-23)

  • Dealing with death
  • Litigation fears
  • Dealing with difficult patients
  • Making mistakes
  • Isolation, loneliness and lack of social support
  • 24-hour responsibility
  • Self-criticism
  • Work overload
  • Burnout

Other risk factors, commonly associated with depression, may also be seen in physicians: (5, 20, 21, 24, 25, 26)

  • Being single and/or childless
  • Female gender
  • Personality traits (neuroticism, introversion, perfectionism)
  • Family history of mental illness
  • Personal life stresses and major life events

Of course, not all individuals with depression commit suicide, but mental disorders, along with substance abuse, are the two most significant risk factors (2). If both are present, then the risk increases substantially. However, not all people with both substance abuse and depression die by suicide either. Thus, it is thought that other predisposing events and risk factors, such as those noted above, may augment a person’s disease and contribute to attempted or completed suicide (2). Medical training may be one of these risk factors, as it self-selects for those with perfectionism and also can lead to isolation and situations where physicians lack social support. Lack of sleep, guilt from perceived medical mistakes, and burnout are also potential consequences of medical training and may exacerbate a physician’s underlying depression and/or substance abuse.

Of note, burnout deserves a quick mention. It is different than depression, as it is not recognized as a mental illness (23, 27, 28). Burnout is considered to be a syndrome where “emotional depletion and maladaptive detachment develop in response to prolonged occupational stress” (9, 29).  While it is not thought of as a mental illness, burnout may be closely related to depression and suicidal tendencies (23, 28, 30). In addition, those with burnout may have similar personality characteristics as those with depression. A study by McCranie and Brandsma prospectively evaluated personality characteristics of 440 physicians over a period of 25 years.  Using the Minnesota Multiphasic Personality Inventory (MMPI), the authors found that those physicians with higher burnout scores also showed higher levels of low self-esteem, feelings of inadequacy, neuroticism, obsessive worry, social anxiety, and withdrawal from others (31). Thus, many of these personality traits overlap with depression risk factors and the authors did, indeed, also find that those with burnout also tended to have dysphoric moods (31). A more recent study by Bianchi et al also examined the symptomatology between 46 workers with established burnout, 46 workers with MDD, and 453 workers without burnout (28). Overall, the individuals with burnout and MDD reported similar symptoms of depression at comparable levels. The similarities between burnout and MDD were further verified for eight out of nine MDD diagnostic criteria according to the DSM-IV. Thus, the authors conclude that, perhaps, the symptoms of depression and burnout may be one and the same (28).

While burnout is not technically considered a mental illness, it may be an important risk factor for depression and suicide. Thus, as a result, hospitals and training programs may want to consider addressing burnout for potentially preventing depression and suicide in physicians. Future emDocs articles will further address burnout and its potential solutions. As a review, one can also refer to the wellness article 2 at http://www.emdocs.net/emdocs-wellness-physician-burnout/

Warning signs of Depression and Suicidality in Physicians (3, 32)

While not exclusive, the following are potential warning signs for depression and suicidality that may be seen physicians. Of note, they are also commonly seen in depressed patients in the general population:

  • Increased irritability and anger
  • Decreased professional or work performance
  • Isolation or withdrawal
  • Strained professional and personal relationships
  • Engaging in reckless or risky activities
  • Increasing alcohol use
  • Dramatic changes in mood

Any of the above signs may be worrisome, and any friend or colleague of a physician with these warning signs should consider addressing his or her concerns.

Part I Conclusions:

Depression and suicidality are certainly not exclusive to patients. Physicians are not immune to these issues, and in fact, may even be more at risk. Suicide rates are higher in physicians and depression rates may be under-reported. Physicians tend to have several risk factors for depression and suicidality, including personality traits, overwork, burnout, fear of making mistakes, and litigation concerns. Warning signs are similar in all individuals with depression and suicidality, but because depression and suicidality may be under-reported and under-recognized in physicians, anyone who sees these signs in a physician should not ignore them. Part 2 of this section will address possible reasons why depression and suicidality is under-reported and under-recognized in physicians. It will also address potential preventative measures and treatments.

 

References/Further Reading

  1. Frank E, Dingle AD. Self-reported depression and suicide attempts among US women physicians. American Journal of Psychiatry 1999;156(12):1887-94.
  2. Center C, Davis M, Detre T, Ford DE, Hansbrough W, Hendin H, Laszlo J, Litts DA, Mann J, Mansky PA, Michels R. Confronting depression and suicide in physicians: a consensus statement. JAMA 2003; 289(23):3161-6.
  3. Bright RP, Krahn L. Depression and suicide among physicians. Current Psychiatry 2011; 10(4):16-7.
  4. Gold KJ, Sen A, Schwenk TL. Details on suicide among US physicians: data from the National Violent Death Reporting System. General hospital psychiatry 2013;35(1):45-9.
  5. Schernhammer ES, Colditz GA. Suicide rates among physicians: a quantitative and gender assessment (meta-analysis). American Journal of Psychiatry 2004;161(12):2295-302.
  6. Frank E, Biola H, Burnett CA. Mortality rates and causes among US physicians. American journal of preventive medicine 2000;19(3):155-9.
  7. American Psychiatric Association. Diagnostic and statistical manual of mental disorders(5th ed) 2013; Arlington, VA: American Psychiatric Association.
  8. Friedrich MJ. Depression Is the Leading Cause of Disability Around the World. JAMA 2017;317(15):1517.
  9. Fahrenkopf AM, Sectish TC, Barger LK, Sharek PJ, Lewin D, Chiang VW, Edwards S, Wiedermann BL, Landrigan CP. Rates of medication errors among depressed and burnt out residents: prospective cohort study. BMJ 2008;336(7642):488-91.
  10. 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;314(22):2373-83.
  11. Brown SD, Goske MJ, Johnson CM. Beyond substance abuse: stress, burnout, and depression as causes of physician impairment and disruptive behavior. Journal of the American College of Radiology 2009;6(7):479-85.
  12. Oreskovich MR, Kaups KL, Balch CM, Hanks JB, Satele D, Sloan J, Meredith C, Buhl A, Dyrbye LN, Shanafelt TD. Prevalence of alcohol use disorders among American surgeons. Archives of Surgery. 2012;147(2):168-74.
  13. Ford DE, Mead LA, Chang PP, Cooper-Patrick L, Wang NY, Klag MJ. Depression is a risk factor for coronary artery disease in men: the precursors study. Archives of Internal Medicine 1998;158(13):1422-6.
  14. Simon GE, Barber C, Birnbaum HG, Frank RG, Greenberg PE, Rose RM, Wang PS, Kessler RC. Depression and work productivity: the comparative costs of treatment versus nontreatment. Journal of Occupational and Environmental Medicine 2001;43(1):2-9.
  15. Sen S, Kranzler HR, Krystal JH, Speller H, Chan G, Gelernter J, Guille C. A prospective cohort study investigating factors associated with depression during medical internship. Archives of general psychiatry 2010;67(6):557-65.
  16. Rosal MC, Ockene IS, Ockene JK, Barrett SV, Ma Y, Hebert JR. A longitudinal study of students’ depression at one medical school. Academic Medicine 1997;72(6):542-6.
  17. Dyrbye LN, Thomas MR, Shanafelt TD. Systematic review of depression, anxiety, and other indicators of psychological distress among US and Canadian medical students. Academic Medicine 2006;81(4):354-73.
  18. Goebert D, Thompson D, Takeshita J, Beach C, Bryson P, Ephgrave K, Kent A, Kunkel M, Schechter J, Tate J. Depressive symptoms in medical students and residents: a multischool study. Academic Medicine 2009;84(2):236-41.
  19. Dyrbye LN, West CP, Satele D, Boone S, Tan L, Sloan J, Shanafelt TD. Burnout among US medical students, residents, and early career physicians relative to the general US population. Academic Medicine 2014;89(3):443-51.
  20. Firth-Cozens J. Individual and organizational predictors of depression in general practitioners. British Journal of General Practice 1998;48(435):1647-51.
  21. Christensen JF, Levinson W, Dunn PM. The heart of darkness: the impact of perceived mistakes on physicians. Journal of General Internal Medicine 1992; 7:424-31.
  22. Goldman ML, Shah RN, Bernstein CA. Depression and suicide among physician trainees: recommendations for a national response. JAMA psychiatry 2015;72(5):411-2.
  23. Ahola K, Honkonen T, Kivimäki M, Virtanen M, Isometsä E, Aromaa A, Lönnqvist J. Contribution of burnout to the association between job strain and depression: the health 2000 study. Journal of occupational and environmental medicine. 2006;48(10):1023-30.
  24. Maier W, Lichtermann D, Minges J, Heun R. Personality traits in subjects at risk for unipolar major depression: a family study perspective. Journal of Affective Disorders 1992 Mar 31;24(3):153-63.
  25. Hewitt PL, Flett GL, Ediger E. Perfectionism and depression: Longitudinal assessment of a specific vulnerability hypothesis. Journal of Abnormal Psychology 1996;105(2):276.
  26. Monroe SM, Slavich GM, Gotlib IH. Life stress and family history for depression: The moderating role of past depressive episodes. Journal of psychiatric research. 2014;49:90-5.
  27. Linzer M, Konrad TR, Douglas J, McMurray JE, Pathman DE, Williams ES, Schwartz MD, Gerrity M, Scheckler W, Bigby J, Rhodes E. Managed care, time pressure, and physician job satisfaction: results from the physician worklife study. Journal of general internal medicine 2000;15(7):441-50.
  28. Bianchi R, Boffy C, Hingray C, Truchot D, Laurent E. Comparative symptomatology of burnout and depression. Journal of Health Psychology 2013;18(6):782-7.
  29. Thomas NK. Resident burnout. JAMA 2004 Dec 15;292(23):2880-9.
  30. Van der Heijden F, Dillingh G, Bakker A, Prins J. Suicidal thoughts among medical residents with burnout. Archives of Suicide Research 2008;12(4):344-6.
  31. McCranie EW, Brandsma JM. Personality antecedents of burnout among middle-aged physicians. Behavioral Medicine 1988;14(1):30-6.
  32. Rudd MD, Berman AL, Joiner Jr TE, Nock MK, Silverman MM, Mandrusiak M, Van Orden K, Witte T. Warning signs for suicide: Theory, research, and clinical applications. Suicide and Life-Threatening Behavior 2006;36(3):255-62.

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