emDocs Wellness: Part I – Physician Depression and Suicidality
- May 3rd, 2017
- Jennifer Robertson
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
- Work overload
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.
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