Brought to you by the students of the University of Cincinnati College of Medicine
By Joe Deters
As most everyone knows, medical training, from medical school to residency to working as a medical professional, is time consuming and very demanding in regards to one’s physical and emotional life. But, perhaps the training is just too consuming. “As early as 1858, physicians in England observed that a higher suicide rate exists among physicians than the general population” (Center et al., 2003). Suicidal ideation is something inherently linked with depression—a mood disorder that also seems to be elevated among the medical student and resident populations. “Depression is common in young adults, but it is neither a normal part of aging nor a normal part of the medical training process” (Tija, Givens, and Shea, 2005). The issue is a pressing one considering that the effects of depression and suicidal ideation could have a negative impact on these physicians’ practice and put patients and the physicians themselves at risk. This paper is focused on identifying the prevalence of depression and suicidal ideation in those preparing to enter the medical profession, including what characteristics seem to contribute to these numbers and factors associated with each.
One of the best ways to consider how widespread depression is among medical students and residents is to compare them to the general population and population of college students from which these medical students came. Zivin, Eisenberg, Gollust, and Golberstein (2009) found that in undergraduate college students, the levels of depression ranged from 13%-15% while the prevalence range for depression among the general population and graduate (non-medical) students was found to be 8%-15% (Goebert et al., 2009), In comparisson,12% of medical students and residents suffer from major depression, and an additional 9.2% report mild to moderate levels of depression, with medical students reporting higher levels of depression than residents. Even compared to the high levels of depression in the general population, medical students and residents have an elevated level of depression in some form or another. “Although the rate of depression among students entering medical school is similar to that among other people of similar ages, the prevalence increases disproportionately over the course of medical school” (Rosethal and Okie, 2005). Women have an elevated level of depression in the general public, and this trend holds when studying medical students and residents (Goebert, 2009).
On top of depression, suicidal ideation is something that has come to the forefront of research due to its link to depression and the high levels of physicians reporting some form of it. In one study, Compton, Carrera, and Frank (2008) found that 9% of fourth year medical students reported affirmatively to the question, “during the past 12 months, have you had thoughts of taking your own life, even if you would not really do it?” Goebert (2009) found a suicidal ideation in 9.4% of medical students and residents who were asked “how often they were bothered by thoughts that they would be better of dead or hurting themselves in some way in the last two weeks.” In this same study, the highest rate of suicidal ideation was found among African American trainees and the lowest among Caucasian trainees. On top of this, the problem does not seem to end with residency; Schernhammer (2005) reports that the suicide rate among male physicians is 40% higher than the general male population, and 130% higher than the general female population in female physicians.
There are many factors associated with this elevated level of depression. Goebert (2009) found that those self-reporting depressive symptoms slept less than those medical students and residents that reported no depressive symptoms. Also, Rosenthal (2005) suggests a number of reasons for the widespread depression in medical students. First, exposure to illness and death may resonate with the trainees and some unresolved conflict they have with loss or their own trauma. Second, the academic demands of medical school are great and most students aren’t used to being anything but at the top of their class. Financial burden may also play a role. Plus, Rosenthal suggests women having a higher rate of depression in medical training can be attributed to the worries of balancing their profession with raising a family and having children. Female doctors can also be the targets of sexual harassment, leading to depression (Schernhammer, 2005).
Medical students showing a higher level of depression than residents can be attributed to many factors. The first reason being that there is no hourly limit on the amount of work a medical student can perform. “Medical school has a greater number of hurdles such as board examinations, applications to residency, and the match process” (Goebert, 2009). A study conducted by Grotmol et al. (2010) that followed Norwegian physicians over a 10-year period found that poor general self-esteem was significantly associated with severe depressive symptoms. Beyond that, the study confirmed that neuroticism and self-criticism were predictors for depression in physicians.
Suicidal ideation, suicide rates, and suicidal behavior are complex areas of study in the field of psychology and the explanations for high physician rates of suicide and suicidal ideation vary. As reported before with depression, personal debt is positively correlated with suicidal ideation in medical students and U. S. medical students have “lower mental quality-of-life scores for age comparable groups for the general U.S. population” (Dyrbye et al., 2008). Besides these findings, the main object of the Dyrbye et al. study was to examine the relationship between burnout and suicidal ideation in medical students. In the study, burnout was defined as high emotional exhaustion, high depersonalization, and low sense of personal accomplishment. It was found that students who exhibit burnout were 2 to 3 times more likely to report suicidal ideation. Also, suicidal ideation was found to increase with the severity of burnout, independent of depressive symptoms. These findings become very important in searching for a way to prevent suicidal tendencies in medical trainees.
Other factors contributing to suicidal ideation in physicians have been identified as well. Cornette et al. (2009) suggest that high suicide rates correspond to both having access to a means by which to commit suicide and becoming habituated to pain and death. The article cites the fact that training in the medical profession habituates students with suffering and may cause them to become emotionally detached from injury and death—putting them at risk for suicidal behavior. “Drug abuse… [is] often associated with the suicides of physicians;” with “drug abuse being particularly prevalent among psychiatrist, anesthesiologists, and emergency physicians.” (Schernhammer, 2005) This makes sense since Cornette (2009) cites multiple studies that report higher suicide rates among physiatrists and anesthesiologists. A final factor that puts physicians at risk is that when physicians attempt to commit suicide they are much more likely to succeed than the general population (Cornette, 2009; Schernhammer, 2005). This can be explained by their relatively easy access to lethal drugs and medical knowledge.
Depression and depressive symptoms can be linked to a number of negative effects on a medical professional’s practice and wellbeing. Physician depression has been linked to a deficit in episodic memory (Pitkanen, Hurn, and Kopelman, 2008). The cognitive effects of depression include “poor decision making and planning, memory and concentration problems, inattention, irritability, interpersonal difficulties and in general slowing down” (Pitkanen et al., 2008). These deficits can then have a huge impact on the way that a physician practices medicine. Zuger (2004) cited studies in which physician dissatisfaction resulted in poor clinical management, unsatisfied and noncompliant patients, and a rapid physician turnover, all of which could lead to poor medical care. Beyond this, a study conducted in 2008 by Schwenk, Gorenflo, and Leja showed that physicians who were depressed believed that their depression negatively affected their professional duties. Also, physicians with severe depression were 2 to 3 times more likely to say that their depression affected their work than those with mild or moderate depression. As one can see, the treatment of depression in physicians should be of paramount importance in the medical profession, but there are significant barriers to treatment.
Numerous factors will prevent a physician or medical trainee from getting treatment for their depression. In general, there is an idea in the medical profession that doctors are infallible beings, a stereotype re-enforced by the strict punishments resulting from malpractice suits against physicians who make mistakes. Tija, Givens, and Shea (2005) found some startling results in their study of the treatment of depressive symptoms in medical students: Only 26.5% of the depressed students sought some form of treatment for their depression (therapy or antidepressants). They found that having a previous diagnosis of depression was associated with seeking treatment, probably because these students were more familiar with what depression looked like, and were more comfortable with their depression. Also, they cite the main reasons for avoiding treatment as a lack of time, an inadequate number of provided counseling sessions by universities , the stigma of using mental health services, a fear of a negative impact on their future, and a fear of having a diagnosis reported on their medical record. As it turns out, these concerns may not be unfounded. One study found that directors of residency programs said they would be less likely ask a hypothetical applicant to interview if they had a history of psychological counseling (Rosenthal, 2005). In Schwenk (2008), 24% of the physicians said that they had personally known physicians whose professional standing had been harmed because of their depression. This same study showed that doctors who had more severe cases of depression were 2 to 3 times more likely to avoid treatment due to concerns over adverse effects on professional status or licensing. The study reports that this effect is amplified in physicians in smaller communities, maybe because they feel more at risk of scrutiny from hospital staff and licensing boards. Some methods that physicians will use to deal with their depression in order to avoid stigmatization include self-medicating with antidepressants, forgoing treatment altogether, getting treatment in a secret and often unorganized manner, or even leaving the medical profession so as to not have to deal with stigmatization (Schwenk, 2008). Also, it may be reasonable to hide mental health issues considering state licensing boards ask about significant medical history, which includes mental illness. (Rosenthal, 2005)
There is obviously a problem on many levels for medical professionals and trainees in the realm of mental health. Fortunately, since 2005 widespread mental health programs have been available for physicians across the country (Rakatansky, 2005). Many of these programs originally were aimed to help physicians with substance abuse, but have since transformed to meet the growing need of the depressed physician population (Rakatansky, 2005). One argument can be made, however, that these help groups are just treating the symptoms of a problem and not actively seeking out a solution. Hassed, de Lisle, Sullivan, and Pier (2009) outline a mindfulness-based stress management program implemented at Monash University in Australia and the effects that it had on the students there. During the study, time was set aside in the curriculum of medical students for training on mindfulness and stress reduction, which included training on maintaining a healthy lifestyle, enhancing physical health, developing a supportive environment, nutrition instruction, and promoting spirituality. After 6 weeks, it was shown that this training decreased depression and anxiety scores in students by 13% and 8%, respectively. These programs were found to improve student wellbeing, even in periods before examinations. Finally, the study outlines “resilience, balance, peer-support, self-care, and knowing when to seek help” as “core competencies for modern medical graduates” (Hassed, 2009).
These programs might be just what medical students need. Dyrbye (2008) revealed an interesting finding concerning burnout: 26% of students who were burned out in the beginning of the study managed to recover in one year, indicating that burnout is a reversible phenomenon. Since burnout was associated with higher suicidal ideation this finding is crucial in showing that it isn’t too late to help those students and residents who are suffering from burnout before something drastic happens. Along with mindfulness-based stress management programs Dyrbye (2008) also suggests that medical schools put into place a system to identify students who are currently or at risk of becoming suicidal as a precaution. Zuger (2004) also makes the suggestion that medical educators should teach and then encourage a more reasonable picture of what the medical career will entail, eliminating misconceptions which can lead to discontent.
In addition to better preparing students, the root causes of mental health problems can be combatted by changing attitudes towards mental health. In and out of medical school, “destigmatization is critical to helping physicians feel comfortable in seeking appropriate and effective mental health care and to not fear being victims of inappropriate sanctions on medical staff privileges and state licensure” (Schwenk, 2008). Sometimes it is hard to maintain doctor-patient confidentiality when the patients are physicians themselves, and this should also remain a top priority (Center, 2003). Beyond that, Center (2003) agrees that state licensure boards should be considering that “impairment cannot be inferred from diagnosis alone,” and that “such policies are overly invasive and counterproductive because they deter physicians from seeking help.” Center (2003) also suggests that physicians get training on and become more receptive to depressive symptoms and suicidal ideation within themselves and get help immediately if these feelings begin to emerge. Finally, medical institutions should be doing their best to try and minimize the effect that a depression diagnosis or any treatment, past or present, for a mental health disorder has on how they treat physicians.
There were numerous studies cited throughout the duration of this article and many of the findings need to be taken with a grain of salt. Many of these studies were conducted using particularly small sample sizes; which can sometimes yield results that do not necessarily hold across an entire population. Included in these were some articles based on suicidal theory, which were more speculative than experimental in their approach to identifying which factors influence depression, suicidal ideation, or barriers to treatment. On top of this, the experimental articles generally relied on self-report measures to determine factors like depression, suicidal ideation, burnout, and general self-esteem. These self-report measures are subject to reporter bias and can be altered by the responder to not accurately reflect what is being tested for. Along those lines, some of the studies only used one item on their questionnaire to determine suicidal ideation when perhaps more items would be beneficial in identifying a more accurate number of physicians and medical trainees are risk.
Depression and suicidal ideation are at elevated levels in the medical profession compared to the general population or to those in other professional fields. Depression is seen in higher levels among medical students than residents, suicidality is high among fourth year medical students, and in physicians the rates of suicide relative to those of the general public are staggering. Factors that contribute to depression in medical professionals and trainees are amount of sleep, financial burden, sexual harassment, workload, and self-esteem. Factors that contribute to suicidal ideation include debt level, mental quality of life, burnout, access to a means to commit suicide, apathy, and drug abuse. Depression can lead to a number of negative cognitive and interpersonal effects that can negatively impact a physician’s ability to practice. On top of this, there are a number of barriers to treatment for depression, which include a lack of time and stigmatization by other medical professionals and licensing boards. Recently, programs that focus on treatment of physicians’ issues and teaching mindfulness and stress reduction have helped to combat the high levels of depression among those in the medical profession. Finally, there were numerous suggestions made for the enhancement of the treatment of depression in physicians and medical trainees. However, though these suggestions have been made, some concrete actions still need to be taken. Thought needs to be put into considering that medical students may be putting in too many hours since there is no way to monitor the amount of hours that they work a week, unlike residents. State licensing boards need to examine how their policies may negatively influence the behavior of physicians and may actually cause them to harm themselves. It was also mentioned in multiple studies that a system should be put into place to recognize those at risk for suicide and that intervention steps should be taken. While this is a great idea in theory, it is hard to think of a concrete way that this could be implemented. These are just examples of ways in which we can begin to alleviate the problems of doctors and physicians in training who are experiencing a legitimate illness and cannot get the proper treatment—something that should be addressed and fixed as soon as possible.
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Analyzing rates of depression and suicidal ideation in the medical profession
Copyright © 2012 Mentis
About the Author:
Joe Deters is a second-year medical student