Why ‘Physician Heal Thyself’ Does Not Work

August is a very quiet month in psychiatry, and that is true in academic centers as well. Much of the faculty is away. Residents have settled into their routine, the terror of those first weeks subsided. The August of 2014 had not been much different.

It was late on a Monday afternoon, and I was wrapping up the day, once again not accomplishing as much as I had hoped when the day started. My cell phone rang, and I heard the voice of the director for House Staff Mental Health at our hospital. Another referral, I thought to myself.

I was wrong.

I knew it was serious when she asked me to sit down. “One of the interns just died. We are not sure if it was an accident. He fell from a rooftop.”

At that time, I did not know that this wonderful, brilliant young man was the roommate of one of my interns and a medical school classmate of another. The notion of how close this was to home was only exacerbated by my understanding that “there but for the grace of God…”: my own interns, in that same crop of newly minted physicians; my own sons, one having just taken the MCATs….

It had not been five days when news of yet another death at our hospital arrived, grimly delivered by the same director for House Staff Mental Health. Harrowing, devastating.

After that first Monday, those of us with expertise in suicide, physician mental health, or both deployed ourselves to meet with anyone who wanted to talk. Program directors, chief residents, chairs, resident groups.

My feelings all came flooding back when I received a call from a reporter with questions about physician suicide in the wake of yet another apparent suicide of a medical student in New York.

Such unnecessary losses are heartbreaking, but hardly surprising. Physicians have a higher suicide rate than that of the general population. In fact, the rate for male physicians is 70 percent higher than that of males of other professions. For female physicians, the rate is fourfold. Suicide is the second cause of death for physicians aged 24 to 35 years, just below accidents. In fact, every year, the equivalent of one medical school class dies by suicide (about 150 physicians per year).

But why? Why should those in the healing profession, usually with outstanding access to care, be at such heightened risk? We don’t know the answer for sure, but there are some facts that might explain it, at least in part.

For one, stigma is alive and well among physicians. Some of it was institutionalized by state departments of health with applications for licensure that asked physicians whether they had ever had a psychiatric condition—mind you, not whether they had one currently, or whether it affected their current functioning: ever. Fortunately, through advocacy and education, most of these types of questions have been eliminated. However, that is not the only cause of stigma. There is still much secrecy about mental health and concerns about its effects on career prospects. Do note that this occurs in a very worrisome context: physicians often do not have regular doctor’s appointments, obviating opportunities for screening.

Yet, psychiatric conditions and suicidal ideation are far from rare in physicians. In surveys of students, house staff, and faculty, 10 to 12 percent reported suicidal ideation, but only 25 percent of those endorsing current suicidal thoughts were taking antidepressant medication, and only 16 percent were receiving psychotherapy. The treatment gap is staggering.

Depression and alcohol misuse increase the risk for acting on suicidal thoughts, and data suggest that physicians are just as likely as the general population to meet criteria for depression. However, trainees may be at greater risk than their general counterparts. In a study of medical residents, the proportion of respondents meeting PHQ-9 criteria for depression increased from 4 percent before internship to just over 25 percent during internship, a sixfold jump.

As well, alcohol misuse is a common response to unmanageable stress, and a survey study showed that 20 percent of medical students, trainees, and faculty reported “drinking too much,” which was associated with suicidal ideation, suicide attempts, and severe depression.

A critical question is why no one detects the suffering of these physicians. After all, they are surrounded by other health care professionals who should be able to see what is happening. However, most physicians have enormous personal strength, both emotional and intellectual “reserves.” Accordingly, they often are able to compensate for the presence of psychiatric symptoms, which both makes it difficult to identify them so they can receive assistance and leads them to feel more isolated, since no one knows how they really feel.

The remedy then is self-identification. Many medical schools are now proactive in letting students know that they have access to care and encouraging them to seek help if they are feeling overwhelmed or distressed. That should promote a lifelong attitude of self-care. Other schools offer online wellness questionnaires that allow students who meet “caseness” criteria for depression or other conditions to be contacted by counselors to try to engage them in care.

But what about all of the physicians who are already out in the workforce? How can they be reached? One action that we plan to explore is to partner with the AMA or other medical organizations to remind physicians about the signs and symptoms of depression or alcohol misuse and reinforce the notion that treatments can and do work. ■