The facts about mental health and suicide in the academic medicine community are sobering. Physicians and trainees have higher rates of burnout, depressive symptoms, and suicide risk than the general population. A 2015 meta-analysis of 17,500 residents over 50 years estimated that 28.8 percent of resident physicians experienced significant depressive symptoms. Another prospective intern cohort study found that 24 percent of interns developed suicidal thoughts within three months of starting their internships. Yet ironically, doctors are less likely than other members of the public to seek mental health treatment.
“Tolerating the culture of silence was no longer an option. We realized it was up to us to fight the rising tide of suicide among our own.”
I became interested in the subject of physician suicide as a psychiatry resident at the University of California, San Diego, School of Medicine (UCSD), when a fourth-year medical student I knew took his life. I was shocked. How could his internal suffering or turmoil have gone unnoticed?
As I progressed in my own career, eventually becoming a professor of psychiatry and assistant dean for student affairs and medical education, I increasingly noticed that mental health and the concept of self-care as a vital component of being a good physician weren’t truly integrated. Speaking up about psychosocial realities in our patients, let alone in ourselves, wasn’t always a welcome part of the lexicon.
Why do physicians have high rates of distress?
Physicians have traditionally lived within a culture of silence when it comes to mental health. Loathe to draw attention to self-perceived weakness, we commonly cloak experiences of anxiety, worry, or shame and carry out our mission. We rationalize significant distress as part of our identity as physicians. While a certain amount of bucking up and forging through is adaptive, this coping strategy can go too far, ignoring serious deterioration of mental health.
There are multiple barriers that keep physicians and trainees from accessing mental health care—confidentiality concerns, time constraints, or uncertainty about whether treatment would improve things. Some physicians have often unfounded or outdated worries about the potential for negative ramifications on one’s reputation, licensure, or hospital privileging. Lastly, like many high-functioning, driven professionals, we often have a blind spot that keeps us from clearly recognizing the seriousness of mental health changes in ourselves.
Not seeking help when we become overwhelmed can lead to disillusionment with our work, burnout, and serious conditions, including major depression, anxiety disorders, and substance use problems. Another potential downstream consequence is self-medicating. A 2013 postmortem study of data from the Centers for Disease Control and Prevention National Violent Death Reporting System revealed that physicians who died by suicide have 20–40 times the rate of benzodiazepines, barbiturates, and antipsychotic medications in their systems than nonphysicians, which points to self-treatment. Not getting the help we may need can also lead to disrupted personal relationships, a higher likelihood of medical error in practice, and an increased risk for suicide.
Over a period of 15 years at UCSD, we lost more than 10 physicians and trainees to suicide. As happens for many communities, we reached a tipping point when a prominent and very revered faculty physician took his life. Collectively, we realized that tolerating the culture of silence was no longer an option.
Putting the focus on mental health: How UCSD stepped up
With support from both medical school and hospital leadership, we formed a multidepartmental team at UCSD to tackle suicide prevention. We modeled our efforts, in part, on the evidence-based strategy of a U.S. Air Force program that achieved an astonishing 33 percent reduction in suicides between 1996 and 2002. Air Force leadership addressed the importance of recognizing changes in mental health, and policy changes protected the privacy and professional reputations of those referred for help. The Air Force program taught members how to intervene at the first signs of distress, possibly long before an imminent risk of suicide, and to recognize more acute warning signs of suicide risk.
We adopted a similar approach at UCSD, highlighting stigma reduction as a central tenet in our educational efforts, along with policy changes that promote a safe, supportive culture and encourage rather than penalize seeking help. Our goal was to create a safety net for recognizing suicide risk and preventing suicides. We instituted the Interactive Screening Program, a confidential web-based tool created by the American Foundation for Suicide Prevention. The tool enables individuals to take a brief stress and depression questionnaire anonymously, and then, also confidentially, talk with a counselor online, by phone, or face to face.
Our efforts at UCSD had great success and are still going strong. More than seven years later, 180 physicians and trainees at UCSD have accepted referrals for mental health care, with the majority saying they would not have done so on their own.
Achieving this culture of safety takes a concerted effort from the top down, as well as a willingness to be attuned to ourselves and one another, to ask for help when we need it, and to proactively identify those same needs in our colleagues and trainees. It is critical that we speak out and model a view of mental health that gives it the same legitimacy and value as physical health.
Addressing our own physical and mental health needs allows us to remain highly competent and resilient. By shifting the lens to focus on mental health, we will reap positive outcomes—from lowered rates of angst, desperation, burnout, and suicide to enhancements in well-being and clarity of mind. We can experience a greater sense of meaning and connection to our work, our patients, and one another. The outcome will be stronger, healthier physicians, better able to serve the needs of those we treat.