February 20, 2020
Stacy San Diego, MD
Millennials are lucky to be born in a generation when mental health is widely talked about, when it is considered not to be a taboo, and when toughening it out is no longer the best advice to give. Several studies though have reported soaring rates of depression among millennials.
Physicians are at greatest risk for developing depression and committing suicide compared to any other profession. With our country having an upright population pyramid, the perceived danger is the increasing rates of depression and suicide among young doctors. Compared with other medical specialists, anesthesiologists and psychiatrists are more likely to develop depression and commit suicide.
There is higher prevalence of depression and suicide among physicians compared to the general population despite the fact that physicians have the most information regarding overall health. What factors then could have led to this phenomenon?
Prevalence and Causes of Depression and Suicide among Doctors
Factors such as long working hours, hospital culture, personal and professional relationships, and self-criticism are making physicians at risk of depression and suicide. Many of these factors such as the long hours of work and studying, high level of responsibility, and hospital culture are accepted realities but when relationships and personal traits such as immense self-criticism and perfectionism are added, the result can be catastrophic.
A recent meta-analysis showed that depression affects approximately one-third of medical students worldwide. Research suggests that mental health deteriorates during medical school and continues to decline when trainees enter the workforce.
According to a series of recent meta-analyses in Australia, the estimated prevalence of depression is 27% in medical students, 29% in resident physicians, and up to 60% in practicing doctors. Additionally, medical students, younger doctors, and females reported higher rates of psychological distress and mental health problems.
A survey found that 32% of medical students and 25% of doctors reported a lifetime history of suicidal thoughts, and 19% of medical students and 10% of doctors reported experiencing these thoughts within the past year. Four percent of medical students and 2% of doctors had made a suicide attempt at some point in their lifetime.
Access to and familiarity with lethal means of suicide has been cited as one of the key contributing factors to the increased risk observed in medical practitioners. Research has consistently found that self-poisoning is the most common suicide method used by doctors and is used at significantly higher rates than in the general population.
In a review published in the Current Psychiatry Journal, rates of depression are also higher in medical students and residents (15% to 30%) in the US compared to the general population. It also increased as they go further in their training. After completing residency, the risk of depression persists.
The lifetime prevalence of depression among physicians is 13% in men and 20% in women. A review of 14 studies found that the relative risk of suicide in physicians compared with the general population is between 1.1 and 3.4 for men and 2.5 to 5.7 for women.
A retrospective study of English and Welsh doctors showed elevated suicide rates in female but not male physicians compared with the general population. In a review published in the Journal of the American Medical Association, 54 studies involving 17,560 physicians in training demonstrated a 28.8 % prevalence of depression or depressive symptoms.
In China, a cross sectional study has pointed out that aside from the risk factors mentioned above, the doctor - patient relationship is particularly stressful. This can happen when a patient becomes belligerent and disrespectful and the physician would feel often times powerless and humiliated.
Among the 2,641 physicians recruited, an estimated 25.67% of physicians had anxiety symptoms, 28.13% had depressive symptoms, and 19.01% had both anxiety and depressive symptoms. More than 10% of the participants often experienced workplace violence and 63.17% sometimes encountered it.
Barriers to Treatment
Despite their understanding and awareness of depression and suicide, medical practitioners may be reluctant or unwilling to seek help for their own mental health issues. In Australia, less than 16% of medical students who screened positively for depression sought psychiatric treatment.
A survey found that 56% of medical students and 64% of doctors who had ever felt seriously depressed had sought treatment with significantly more females seeking treatment than males. However, only 19% of medical students and 28% of doctors respectively reported feeling comfortable seeking help for a mental health.
The reasons behind non-consultation with mental health professional are fear of social stigma, confidentiality issues, and costs. Physicians suffering from mental health disorders are the toughest ones to reach because they have the tendency to self-medicate and they are knowledgeable about the answers to evaluation that can deter a correct diagnosis or avoid hospitalization. When a physician comes to a colleague for help with a mental health issue, both parties might underestimate the severity of the crisis.
Prevention, Intervention, and Recommendation
Globally, more than 300 million people are living with depression, the leading cause of ill health and disability. According to the World Health Organization (WHO) in 2017, more than 100 million people suffer from mental disorders in the Western Pacific region. In the Philippines, depressive disorders account for 5.73% of mental disorders in the region.
The prevalence of depression and suicide among Filipino doctors and medical students is currently unknown. With more medical students enrolling every year and more doctors passing the boards, the medical community could be entering a dangerous period.
Depression and suicide is preventable. Prevention starts at home and nurturing generations to be resilient is already a solution to a potential problem. Protective factors that lower the risk of completed suicide include effective treatment, social and family support, coping skills, religious faith, and restricted access to lethal means.
There is a paucity of research regarding specific interventions designed to improve mental health and well-being among medical practitioners. In Australia, several steps have been taken to tackle the high rates of mental health problems and suicide in medical practitioners.
The Australian Medical Association’s National Code of Practice Hours of Work, Shift work and Rostering for Hospital Doctors’ responds to ongoing concerns about working hours and safe practice. The code has been instrumental in changing attitudes to the ethics of safe hours and is believed to have led to a decline in the proportion of doctors at high risk of fatigue.
Given the intensity of medical training, it is important to consider additional factors that could influence student learning and well-being. Motivation is an important factor to help medical students and residents maintain a healthy balance between study demand and personal well-being.
The clinical environment should also be improved. Bullying and harassment have been so common that it became a well-accepted culture. Doctors have become accustomed to it that going through series of humiliation and harassment was considered a rite of passage.
The journey to becoming a doctor is no walk in the park. It is the survival of the fittest. Not everyone who dreams to become a doctor is cut out to be one. It takes intelligence but also resilience. Intelligence can be part nature and part nurture but resilience is taught and acquired.
One should look into the factors causing more distressed doctors than motivated ones. Perhaps it is time to change the hierarchical culture of medicine. Instead of competition and shaming, medical doctors should look after and help each other through constructive criticism and peer evaluations that foster camaraderie.
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Journal of the American Medical Association (December 8, 2015) 314(22):2373-2383
3. Y. Gong, T. Han, W. Chen et al “Prevalence of Anxiety and Depressive Symptoms and Related Risk Factors among Physicians in China: A Cross-Sectional Study”
PLOS ONE (July 22, 2014)
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