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When Aaron was an intern, or a first-year doctor in training, he knew something was wrong with him. He had trouble sleeping. He had difficulty feeling joy. He was prone to crying at inopportune times. Even worse, he had trouble connecting with patients. He felt like he couldn't please anyone, and he found himself susceptible to feelings of despair and panic.

He wasn't alone. That's the topic of this week's Healthcare Triage.


This was adapted from a column Aaron wrote at The Upshot. Links to further reading and references can be found there: http://www.nytimes.com/2016/01/12/upshot/silence-is-the-enemy-for-doctors-who-have-depression.html

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When I was an intern or a first-year doctor in training, I knew something was wrong with me.  I had trouble sleeping.  I had difficulty feeling joy.  I was prone to crying at inopportune times.  Even worse, I had trouble connecting with patients.  I felt like I couldn't please anyone and I found myself susceptible to feelings of despair and panic.

I'm a physician and if I do say so myself, a very well trained one, yet it took an intern support group, the social worker that ran it, close friends, and my then-fiance and now wife, to convince me that I might need help.  Even if I couldn't acknowledge it, they could see I was suffering from depression.  

I wasn't alone.  That's the topic of this week's Healthcare Triage.

(Intro)

Last month, a study in JAMA reviewed all of the literature on depression and depressive symptoms in resident physicians.  They found more than 50 studies on the subject.  Research shows that almost 30% of resident physicians suffer from either symptoms or a diagnosis of depression.  The numbers and how they compare to other professions are almost beside the point.  Physicians are in a unique position of needing to care for others continuously.  That strain, coupled with an inability to help themselves, leaves both patients and doctors at risk.

Longitudinal studies, or those that follow residents over the course of their training, found that the rate of depressive issues in residents increased more than 15% within a year of beginning training.  Worse, physicians exist in a profession where admitting a problem carries with it a stigma that's more impactful than in some others.  A study published in 2008 surveyed physicians in Michigan, asking them about their work experiences as well as their depressive symptoms.  More than 11% reported moderate to severe depression scores.  About a quarter of them reported knowing a doctor whose professional standing had been hurt by being depressed.  Physicians with moderate to severe depression had a decrease in work productivity and job satisfaction.  They were also two to three times more likely to say that they were worried about or had difficulty getting mental health care.

While the Americans with Disabilities Act, passed in 1990 prohibits employers from asking broad questions about illnesses when people apply for jobs, state medical licensing boards still ask specific questions about mental health.  Because of this, physicians are much more likely to avoid treatment.  They're also more likely to self-medicate. 

Sometimes that medication is potentially appropriate, as with antidepressants.  Often, it is not.  A 2012 study in JAMA Surgery found that more than 15% of the members of the American College of Surgeons had a score on a screening test consistent with alcohol abuse or dependence.  Among female surgeons, the prevalence was more than 25%.  Those who were depressed were significantly more likely to abuse or be dependent on alcohol.

Doctors have much easier access to drugs than others as well.  Because of this, they are more likely to misuse prescription drugs than the general population.  Anesthesiologists have access to even more drugs than other physicians, and their problems are even more common.

A 2005 study of anesthesia residency training programs found that 80% of them reported experiences with impaired residents and almost 20% had experiences with at least one abuse-related death of a doctor in training.

Unfortunately, depression and substance abuse can lead to further problems, including suicide.  More than 6% of surgeons reported suicidal ideation in the last year, yet only 1/4 of them sought any kind of mental health treatment.  Most who did not feared that doing so would affect their ability to obtain a license, even though they were worried about killing themselves.

The problem is even worse among medical trainees.  About 6% of them reported thinking about suicide in the last two weeks.  Those with a history of depression were almost four times as likely to report recent suicidal thoughts as those without.  Too many doctors act on suicidal impulses as well.  It's estimated that about 400 physicians commit suicide each year.  That's about three times as many doctors as were in my medical school class at the University of Pennsylvania.  

Meta-analyses estimate that the rate of suicide among male physicians is 140% that of the general population.  Among female physicians, it's almost 230%.  What makes this important to discuss is not the prevalence of depression in physicians and trainees, although it's clearly too high.  It's not whether physicians have the highest suicide rate of any profession, although many people argue that they do.  The critical issue here is that too many physicians, especially trainees, suffer in silence, afraid to ask for help for fear that they will be punished professionally, if not personally.

I've always been very open about my time in residency and how depression somewhat robbed me of a few years of my life.  When I look back, I think that the constant pressure to help others, coupled with frequent feelings of helplessness weighed on me.  A lack of sleep and being away from family and friends left me vulnerable.  Seeing children I bonded with and cared for deeply suffer and die was often more than I could bear, and I think some part of me, whether it be physical or behavioral, is also pre-disposed to anxiety and depression.

But I'm lucky.  Thanks to the support of those who love me, as well as two excellent therapists, I'm no longer depressed.  I remain vigilant, however, against a recurrence.  It's important for me and for all physicians to stay on top of their mental health and not wait for a crisis to act.  I've also felt fortunate to be in a specialty, pediatrics, and a focus, research, where I didn't fear being found out.  Many colleagues still recoil when I talk openly about their therapy or how I plan to go for the rest of my life.  I'm sure they'll find this episode concerning as well, but we can't not talk about this.  Too many of us are suffering, and if they can't get help from others, they may try and fail to help themselves.  Suicide is always a tragedy.  A physician committing suicide is a travesty.

Healthcare Triage is supported in part by viewers like you through patreon.com, a service that allows you to support the show through a monthly donation. Your support makes this show bigger and better. We'd especially like to thank our research associate Joe Sevits, give a special shout-out to Jonathon Dunn, and thank our surgeon admiral, Sam. Thanks Joe and Jon!  Thanks Sam! More information can be found at patreon.com/healthcaretriage.