One study puts the toll at 300 US physician lives lost to suicide each year. Another study puts the figure closer to 400. Regardless of the precise total, one doctor lost to suicide is one too many. With the ever-increasing stresses of practicing modern medicine, is the medical community doing enough about physician mental health?
May marks Mental Health Month, and while healthcare consumers are often the focus of awareness campaigns, doctors are equally deserving of efforts to combat the stigma associated with mental illness and promote overall mental health. Researchers have indicated that, for too long, the mental health of American physicians has been overlooked.
“I think that awareness regarding physician mental health is better, but there is still a long way to go in terms of creating a sense of safety for physicians and medical trainees to ask for help or self-report when they’re struggling,” said Clif Knight, MD, senior vice president for education, American Academy of Family Physicians, in an exclusive interview with MDLinx. “It takes a combined effort from state medical boards, medical schools, residency programs, and hospitals.”
The B word
It’s impossible to discuss the mental health of doctors without broaching the topic of burnout. On the whole, the American healthcare system appears to be doing better at managing physician burnout. Earlier this year, researchers of a study published in Mayo Clinic Proceedings evaluated changes in reported burnout levels between 2011 and 2017. They concluded that burnout levels improved between 2014 and 2017, with overall burnout landing close to where it was in 2011.
That’s encouraging, but it doesn’t tell the complete story, according to a systematic review of evidence published in JAMA. An accurate understanding of the nature of physician burnout—and consequently, physician mental health—boils down to a question of semantics.
What, precisely, is burnout? And how are we asking physicians to describe it? Across studies in the JAMA review, the investigators noted inconsistent definitions of burnout, a lack of standardized burnout assessments, and varying quality of studies. If we want to truly understand burnout, we need a consensus definition and a standard way of measuring it, according to the authors.
Understanding the mental health problem
But a better understanding of physician burnout is only the beginning of rectifying the state of physician mental health. Depression among doctors and doctors-in-training is the other half of the problem.
Based on a recent MDLinx survey, which queried more than 800 US physicians, American doctors are struggling to deal with their own chronic conditions—including mental health. What’s more, many of these physicians even attributed their crumbling health conditions to work-related stress. A total of 15.6% of respondents said that they have clinical depression, which was almost double the national average of 8.1%.
One physician with clinical depression offered the following insight:
“I think physicians are held to standards which are not human, so we battle to be superhuman, to avoid litigation, keep employment, and pay off loans,” said a radiologist with clinical depression and inflammatory bowel disease.
A baseline level of awareness among doctors with mental illness might be a start. However, researchers have shown that, despite their knowledge, doctors don’t appear to be obtaining the mental health care or medications that they need.
According to a study published in General Hospital Psychiatry, physicians who have clinical depression might not be taking antidepressants. The study authors reviewed post-mortem toxicology reports from the National Violent Death Reporting System and found that doctors who died by suicide were more likely than non-doctors to have taken antipsychotics, benzodiazepines, and barbiturates, but not antidepressants or antipsychotics.
“Inadequate treatment and increased problems related to job stress may be potentially-modifiable risk factors to reduce suicidal death among physicians,” the study authors concluded.
The next generation of doctors
Depression and suicide aren’t confined to the ranks of practicing doctors. It appears that the issue might have its roots in the physician training process.
In another systematic review and meta-analysis published in JAMA, researchers examined studies involving resident physicians that were conducted from 1963 to 2015 in order to better understand the problem. By evaluating data from 17,560 residents, the investigators concluded that 28.8% of residents had experienced depression or depressive symptoms. They also noted that estimates of depression ranged from 20.9% to 43.2%, depending on how residents were assessed.
“Further research is needed to identify effective strategies for preventing and treating depression among physicians in training,” the researchers concluded.
These results are particularly troubling when considering the vulnerability of this population. The CDC cites suicide as the second leading cause of death for people between the ages of 25 and 34 (7,948 in 2017), behind unintentional injury (25,669).
What to do about physician mental health?
Stigma appears to be one of the leading barriers to mental health care for physicians across the United States. Many fear that treatment for mental illness could jeopardize their careers or their licenses to practice.
In a special report published in the Archives of Surgery, experts queried 7,905 surgeons about recent suicidal ideation. More than 6% (501) indicated they had considered suicide during the previous 12 months. Of these, just 130 sought help, while 301 said that they feared how psychiatric care might affect their license.
The American Medical Association (AMA) has since taken action, having adopted a new policy to improve physician access to mental health care as of 2018. The policy encourages state medical licensing boards to require doctors to disclose mental health conditions that could negatively affect their practices. The AMA has also created its Steps Forward program, which offers self-care education materials for physicians.
As Mental Health Month draws to a close, suicide prevention and mental health awareness will drift out of the minds of healthcare consumers and physicians alike. But the work of transforming medicine into a healthier, more sustainable career for physicians themselves will remain.
A family medicine physician with clinical depression who responded to the MDLinx survey illustrated this issue well: “The extra workload and stress make it that much more difficult to make the lifestyle changes that we encourage our patients to make.”
According to Dr. Knight, one of the first things that needs to change is physician culture.
“Physician culture has traditionally valued self-sacrifice above self-care,” Dr. Knight said. “Part of that is recognizing that physicians are humans and that physicians experience the same human emotions and mental health issues that other folks do.”