Doctors and Depression

shutterstock_233416459Physician depression is frequently a topic of discussion on SERMO.  One doctor started a conversation about doctors and depression in our depression hub.

Physician depression and grief is not uncommon, and it is recognized as an issue that should be addressed with kindness and empathy by the medical community.  I was speaking to a neighbor whose husband died 5 years ago of pancreatic cancer (diagnosed one month before his death).  My neighbor told me that she was initially in denial, went through some stages of grief, and then experienced a severe major depression. “The darkest dark I could imagine – I had no idea there was a way out.”   She was treated with an anti-depressant and was back to normal life – a new life she said, but she felt human and resumed normal activities.  She had tears in her eyes as she told me of a friend, a physician who lost a spouse a year later, and did not receive treatment for depression.  Her friend was stigmatized as a failure and “depressed physician,” and attempted suicide.  That friend has opted to leave medicine rather than face the stigma and scorn of her colleagues.  My neighbor asked, “Why, when everyone knows that lots of doctors are depressed and there is such a high suicide rate in the profession, don’t doctors help each other.”

These past few weeks, SERMO has seen several posts on physician depression and grief.  A variety of concerns have been raised as to how to avoid stigma or when to report.  What are our duties to our colleagues as physicians?  And, last but most important, how do we seek treatment and care for ourselves when needed without facing scorn, stigma, or PHP  monitoring and deep perusal of psychiatric records.

I wrote about depressed physicians and their solitary road on a prior Depression HUB post (https://app.sermo.com/posts/posts/275680 ) and have agreed to revisit that topic.  This time I am including grief, because grief can result in depression.   In addition to grief, this is a time that seasons are changing, a time when SAD can descend.  I will revisit the topic of Seasonal Affective Disorder in my next HUB post.  I would like to state firmly, that the use of light boxes is not stigma, nor is the use of any anti-depressant medication.  Whether a physician on Sermo or elsewhere takes an SSRI, an SNRI, a Tricyclic, an MAOI, or other anti-depressant, these medications are crucial to health (as much so as antibiotics to infection or blood pressure meds for HTN).  They ARE NOT mind altering substances.   By recognizing this, we can work to decrease the stigma and help our colleagues.  Depression isn’t easy, nor something people can will away.

Abraham Lincoln said when depressed, “I am now th most miserable man living. If what I feel were equally distributed to the whole human family, there would not be one cheerful face on the earth. Whether I shall ever be better I cannot tell; I awfully forebode I shall not. To remain as I am is impossible; I must die or be better, it appears to me.” As physicians, we must recognize that our colleagues feel this way when depressed, but with appropriate treatment they can return to normal function.  If we can accept a depressed president, surely we can accept depressed physicians.

Recognition of physician depression dates to the 1960s. A 1977 article even tackled the role of organized medicine in assisting depressed physicians and helping to prevent suicide (1).  As decades have past, articles have addressed the need for physicians to help depressed colleagues, but little has been accomplished during this 50+ years. It is 2015, and these questions are STILL being asked, with limited answers.  WHAT CAN WE DO?

Middleton wrote about grieving a physician suicide.  She shared her grief over the suicide of a colleague.  “Today I learned that you died, and nothing will ever be the same again. I refused to believe the words I heard, that you committed suicide. Only terribly depressed people kill themselves. You weren’t terribly depressed … but then I learned that, yes, secretly you had been. How could I not know, not realize. (2)”   She notes that “Physicians are as vulnerable to depression as is the general population, but they seek care at lower rates and commit suicide at higher rates. Fears regarding loss of professional stature and respect often prevent depressed physicians from accessing needed mental health services. As a profession, physicians must strengthen existing resources for impaired colleagues and work collaboratively to destigmaize treatment for mental illnesses.”

“hat a professional caregiver can fall ill and not receive adequate care and support, despite being surrounded by other caregivers, begs for a thoughtful assessment to determine why it happens at all. (3)”   The Tennessee PHP attempted to answer the question of what causes physicians to attempt suicide, by reviewing 141 Tennessee physicians (2001 –2009). Seven (4.9%) of these physicians subsequently attempted suicide: five died.  Depression (43%) was the most common historical diagnosis.  They found no personality differences, but did note the role of social isolation.  The failure to avert physician suicidal behavior seems due to the shame and stigma surrounding mental health issues, which prevent seeking help. (4)”

Physicians are not invincible.  “The stresses of professional practice can exact a great toll, however, and self-neglect can lead to tragic consequences. In some areas, particularly suicide rates, physicians have increased vulnerability, and in other areas problems may be unrecognized (depression, substance abuse, marital problems, and other stress-related concerns). Female physicians show some particular areas of risk. (5)”

The role of grief:  DSM-5 REMOVED THE BEREAVEMENT EXCLUSION FROM THE DIAGNOSIS OF MAJOR DEPRESSION.  Those grieving patients who meet the full symptom/duration/severity criteria for major depression within the first few weeks after bereavement should NOT BE EXCLUDED from the Dx of Major Depressive Disorder (MDD).  The DSM-5 recognizes that bereavement does not “immunize” the grieving person from MDD, and is in fact a frequent precipitant of MDD.  Grieving physicians experience depression, and they need time to grieve.   A 2002 study gathered prospective data on 205 individuals several years prior to the death of their spouse and at 6- and 18-months post-loss.  Bereaved participants could be categorized into these five patterns: common grief; chronic grief; resilience; chronic depression; depression-improvement. (6)

Sometimes major depression seems to occur out of the blue, with no warning; sometimes its onset is gradual and almost unnoticeable; and sometimes it seems to be brought on, or intensified, by stressful life events, such as the death of a loved one. When that happens, a reverberating cycle sets in: The depression increases the stress, intensifies the grief, and may even interfere with grief’s resolution, setting the stage for a condition we call complicated grief/depresion.

I am adding 2 clips on grief.  The first is a short interview of a woman I have known for 25 years.  She has experienced her grief, and shares with others.  I remember a trainee who was not allowed one day off when his wife died.  Shirley (the woman speaking here) was angered that the medical community could not provide more support.  http://www.king5.com/videos/entertainment/television/programs/new-day-northwest/2015/11/05/a-mothers-mission-to-help-others-heal-from-heartbreak/75228712/

The other clip is a song by Eric Clapton.  I am giving credit where it is do.  This link was sent to me by MovieDoc who knew I was working on this piece. https://www.youtube.com/watch?v=AscPOozwYA8&app=desktop

Sermo docs.  Let’s do what we can to support colleagues, to not judge, and to reognize that medications can save lives.  Thank you.

BILIOGRAPHY

  1. Sargent, et al. Preventing physician suicide. The role of family, colleagues, and organized medicine.   1977 Jan 10;237(2):143-5. http://www.ncbi.nlm.nih.gov/pubmed/576152/
  2. Today I’m Grieving a Physician Suicide.  Annals of Family Medicine.  2008 May; 6(3): 267–269.
  3. Legha RK. A History of Physician Suicide in America.J Med Humanit. 2012;33:219–244.
  4. Jannelli, et al. SUICIDAL BEHAVIOR AMONG PHYSICIANS REFERRED FOR FITNESS-FOR-DUTY EVALUATION.  Gen Hosp Psychiatry.  Nov-Dec.  36 (6). 732-736.
  5. Miller and McGowen. The painful truth: physicians are not invincible.  South Med J. 2000 Oct;93(10):966-73.
  6. Bonanno, et al. Resilience to Loss and Chronic Grief:  A Prospective Study From Pre-loss to 18-Months Post-loss.  Journal of Personality and Social Psychology, 2002, Vol. 83, No. 5, 1150–1164

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