AAMC Reporter: December 2008

Physicians, Medical Students Struggle with Mental Illness and Suicide

When neurologist Alice Flaherty, M.D., Ph.D., lost her twin babies during childbirth, she was burdened with a deep sadness. But not too long after the tragedy, her grief began to give way to manic episodes, in which she experienced bursts of creativity so strong she felt compelled to scribble down ideas for fear they would otherwise slip away. Eventually, her chair at Massachusetts General Hospital (MGH) began to notice her agitated behavior and urged her to seek treatment.

Flaherty's circumstances may be especially traumatic, but she is certainly not the only physician to struggle with mental illness. In fact, studies show that physicians are more likely to battle depression and even commit suicide than the public at large. One study from the American Foundation for Suicide Prevention (AFSP) found that 39 percent of female doctors experienced depression at some point, compared to 30 percent of women with doctorate degrees. Most studies on male physicians do not show higher depression rates than men in other professions, although other data show that both men and women doctors are more likely to take their own life compared with their counterparts in the general population. In the United States, the physician profession has the highest suicide rate of any occupation, according to AFSP Medical Director Paula Clayton, M.D. Male physicians have a 70 percent higher suicide rate than males in other professions, and women doctors have as much as a 400 percent higher rate compared with females in different careers, AFSP data report. AFSP statistics also show that between about 300 and 400 doctors end their lives each year.

"This is the equivalent of two or three graduating medical school classes," Clayton said. "Each suicide is the loss of a caring physician who will treat patients well. We certainly don't have enough physicians in this country. Every death is a terrible loss to the community."

Doctors' looming suicide rates may stem from a higher propensity for depression. Personality traits like compassion, sensitivity, and empathy may lead people into medicine but also make them more susceptible to mental illness, Clayton said. Interestingly, the AFSP finds no evidence that physicians' workload contributes to depression.

Doctors are knowledgeable and have easier access to toxic drugs, making the so-called "attempt-to-completion" suicide ratio higher than the general population, according to Clayton. But the real factor contributing to the doctors' high risk of suicide is that doctors often refuse to acknowledge their illness or seek treatment for it.

Why are physicians so afraid of getting help?

"The history of the culture of medicine has not embraced the idea that acknowledging vulnerabilities is acceptable," said Christine Moutier, M.D., associate professor of psychiatry at the University of California, San Diego (UCSD) School of Medicine and co-president of the San Diego AFSP chapter. "There is a fear that, if somebody admits to a weakness, there will be an impact on their ability to safely practice medicine. But the real threat to public health and safety is when physicians become impaired by illness or depression, not if they seek treatment for it."

Some physician reluctance may be culturally ingrained, but doctors also have practical reasons for keeping their mental illness quiet, Clayton said. Data show that among 35 states responding to an AFSP survey, 37 percent said that they can sanction a physician if he or she reports a psychiatric condition on their license application.

Furthermore, doctors worry that their patients will stop seeing them, other physicians will not send them referrals, and their superiors will not promote them if their psychiatric condition is publicly known. Some malpractice insurance companies may raise their premiums, Clayton said.

Until very recently, doctors in Arkansas had to report mental or physical illnesses to licensing officials. It was unclear how the state was using this information.

"People didn't want to lie, but they didn't want to lose their license either," said G. Richard Smith, M.D., the psychiatry department chair at the University of Arkansas for Medical Sciences College of Medicine. "Admitting to an illness and seeking treatment was inadvertently but actively discouraged by this policy."

But as Arkansas was losing several physicians to suicide, the medical community realized change was necessary, and eventually amended the law so that doctors reported an illness or disease—mental or otherwise— only if it would affect their provision of care.

"Once physicians know that their mental illness won't be asked about, it reduces one big barrier to their seeking treatment," Smith said.

Stepping forward and getting help is instrumental, as Flaherty realized. Because of her chair's encouragement, Flaherty began seeing a psychiatrist who diagnosed her with bipolar disorder. After taking medications and undergoing talk therapy, the process of discussing a mental health condition with a health care professional, Flaherty has not had a mood episode for several years. Contrary to some other physicians' fears, Flaherty's career did not spiral downward after she admitted to psychiatric problems.

"Many doctors are worried that because of the stigma attached to mental illness, they'll lose their job if they seek help," Flaherty said. "I have had zero problems with discrimination, either from patients or colleagues. Physicians are actually more frightened of mental illness than the general public is, maybe because all we see are the patients who do poorly. We don't see the people who function well in the community."

Her colleagues, who are all aware of her diagnosis, are supportive.

"Now people in my department come up to me and admit they, too, have mental illness," Flaherty said.

Depression and suicide prevention advocates are hoping for more cases like Flaherty's. Public awareness to reduce the stigma attached to mental illness, Clayton said, is an important ingredient. To this degree, the AFSP released a film called "Struggling in Silence: Physician Depression and Suicide," a one-hour documentary featuring interviews with doctors who have battled depression and people who have lost a physician family member to suicide. A Web site, www.doctorswithdepression.org, launched in advance of the movie release, provides more information about suicide risk factors and community resources.

"These tools can help physicians recognize depression both within themselves and in their patients," Clayton said. "With this information, they can offer their patients better treatment."

Medical Students Also Affected

The medical community has begun reaching out to medical students to ensure that tomorrow's doctors understand the severity of mental illness and know where to get help. Recent data show that medical students, like their physician counterparts, may be at high risk for suicide: A 2008 Annals of Internal Medicine article showed that nearly half of students participating in a survey experienced burnout, and 11 percent had suicidal thoughts.

"Eleven percent is higher than what we expected from that cohort," said Liselotte Dyrbye, M.D, the study's coauthor and an internal medicine faculty member at the Mayo Clinic. "We're not sure why this is, but we speculate that students' excessive workload and the conflict between the professional curriculum and the hidden curriculum may contribute."

Laura Kenkel, a fourth-year medical student at Ohio State University College of Medicine, said her depressive symptoms were initially triggered by academic stress.

"The amount of information you encounter in the first years of medical school is enormous," Kenkel said. "People who had a 3.8 GPA in college, and who may have had no trouble keeping up previously, realize it's not the same in medical school."

Kenkel was scared to come forward at first.

"If the medical school knew I had this depression, I thought they'd think I was a sub-par student and that I wasn't qualified to become a doctor," she said. "I worried about their perception of me."

Kenkel eventually sought treatment, where she was able to get gain control over her depression and anxiety. An aspiring psychiatrist, she even started a peer support group where about five Ohio State medical students convene to discuss their own experiences.

"This gives me the confidence to know I am not the only one out there with these issues—it's not that everyone else is excelling and I alone am underachieving," Kenkel said.

Some medical schools are developing programs that make it easier for medical students and faculty to privately seek out and receive treatment for mental illness. UCSD will soon launch a Web-based screening tool, through which students and physicians can fill out a confidential mental health survey online, and a live therapist responds if the participant shows warning signs of depression or suicide risk factors, said Moutier. The school is revamping its wellness program to include more educational information and seminars about depression and access to de-stressing activities such as yoga. Grand rounds will include topics of physician depression and suicide.

Making suicide awareness and outreach a longitudinal goal, Moutier said, is critical for making headway on this serious problem.

"Absorbing the culture of medicine and finding ways to deal with stress start in medical school," Moutier said. "But we wanted to include residents and faculty too, because if you're not consistent about teaching this, it all goes to pot. People pick up on the hidden curriculum that admitting weakness is wrong."

—By Elissa Fuchs