Doctors get sad, like anyone else. So how do doctors cope when sad days turn into weeks, even months? Are there unique factors that lead to physician depression? Are doctors different from the general population in the way in which they respond to depression? What treatments do doctors seek or avoid?
Here's what many depressed doctors do: Nothing. Or they try things that don't help.
I recently interviewed 200 physicians who have experienced depression during their careers, and I asked what treatment they pursued. Results are as follows: 33% chose professional help, 27% self-care, 14% self-destructive behaviors, 10% nothing, 6% changed jobs, 5% self-prescribed medication, 4% other, 1% pray.
Most physicians tried multiple treatments. Sadly, the majority of doctors I spoke with did nothing for months to years until they finally decided to take action—sometimes self-harm. Professional help was not generally first-line therapy. This article presents a qualitative summary of my findings and related physician commentary.
I've been running a physician suicide hotline since 2012 and have had the opportunity to help hundreds of depressed and suicidal doctors. Physicians certainly face unique circumstances during their careers that lead to depression, such as bullying, hazing, sleep deprivation, and medical board investigations—plus the repeated near-daily exposure to suffering and death.
However, doctors also experience depression for the same reasons the general public does: for example, a failing marriage or the death of a loved one. Yet even in these cases, being a physician may make common depression risk factors even riskier.
Common Risk Factors for Depression
A failing marriage. A relationship on the rocks is destabilizing for anyone, yet physicians are more likely to lose marriages to spousal neglect. Doctors don't have predictable 40-hour work weeks. They're not often home by dinner. With erratic schedules requiring weekend and evening call, physicians routinely miss family events, kids' activities, and holidays. Even after the workday is over, many doctors need hours to decompress and may rely on their partner for emotional support—at the risk of depleting rather than strengthening their primary intimate relationship. Being a physician is a marital stressor.
Social isolation. Loneliness may lead to depression in anyone, and physicians are at high risk for social isolation. Frequent moves during training and working 80+ hour work weeks leave little time for friends or family. Even when not working, doctors are talking about medicine, thinking about patients, studying for board exams, or gathering continuing medical education credits. Introverted, studious, and highly intelligent existential thinkers by nature, doctors may find it more difficult to develop friendships than the general population.
Being a physician is an independent risk factor for social isolation. Sue summarizes her predicament: "I see the loving couples at church, and accept that there will be no Prince Charming for me. There will be no one to care for me when the breast cancer comes. There is no savings, no retirement. As I do house calls and care for the dying, I know that there will be no such loving doctor for me."
Death of a spouse. Physicians are uniquely affected by the loss of a life partner, because they have had less time to develop a support system than the general population. The death of a spouse can be a particularly devastating event for male physicians, who appear to be at higher risk for depression because they often rely on their marital partners for emotional support and are more challenged to ask for help or be vulnerable with friends or colleagues compared with female physicians.
Financial distress. Although doctors have greater earning capacity than the general population, they often save less and spend more on student loans, cars, and homes, owing to family and cultural expectations. Many physicians are financially preyed upon by unethical employers, other professionals, even friends and family who believe that "all doctors are wealthy." Physicians can also make poor financial decisions, further exacerbating their inability to build a nest egg until much later in life than most. Some still have student loan debt into their 50s or 60s and have saved little for retirement.
Childhood trauma. Early sexual, emotional, and physical abuse increase the risk for depression for all. Some physicians have shared that these very childhood wounds led to their desire to attend medical school so that they could help others. Entering medicine as a "wounded healer" and submitting to a culture of self-neglect during training and beyond (without easy access to nonpunitive mental healthcare) further destabilizes these at-risk physicians.
Family history of depression. Both nonphysicians and physicians whose parents suffer from depression are at increased risk of developing depression. Yet nowhere in the application process for medical school is it made clear to these prospective students and their families that they will be at increased risk for depression (and suicide) from medical education itself. Up to 43.2% of resident physicians have depression or depressive symptoms. Informed consent must be uniformly required to alert these individuals of the added mental health risks of a medical education before they apply for medical school.
Retirement. A major life event, such as retirement, can lead to depression in many people—yet when one's identity is wrapped so tightly around a career, as it is for a doctor, the depression may be far worse. As noted above, some doctors may not have saved enough money to retire comfortably, and others have not developed a personal life after devoting so much of their career to caring for others.
What Do Depressed Doctors Do?
So what do doctors do when they're depressed? Do they just go to the doctor? Most don't.
Many doctors do nothing. Medical training teaches us to "suck it up," so help-seeking is not a well-honed skill among doctors. Many lack self-awareness that they are suffering from depression. Because the majority of doctors are overworked, exhausted, and discontent, they don't necessarily see themselves as outliers. They've normalized their misery and pretend that it's not as bad as it seems. Distraction, avoidance, and denial are popular tactics among depressed doctors. I believe that most physicians do not seek the appropriate care that they would recommend for their own depressed patients. "I think your assessment is, unfortunately, fairly accurate. And I'm a psychiatrist," confirms Dr Shannon Sniff.
Self-distraction. As a physician who has been depressed, I chose to ignore my own condition by obsessing about my patients' terrible lives—plus I got paid for it! This is the most popular (and incentivized) method of physician self-distraction: workaholism. Even "after work," physicians distract themselves with endless charting, mindless computer games, Facebook (including doctor groups), binge-watching Netflix, or escaping into novels and mysteries. Younger doctors may go out partying with friends.
Self-soothing. Cooking and overeating may transiently ease depressive symptoms. Dark chocolate is favored, followed by other sugary snacks, such as donuts and pastries at nurses' stations and clinic break rooms. Earlier in my career, I recall drug reps covering my desk in Reese's peanut butter cups that I would use as mini-antidepressants while charting. Of course, self-soothing with food can turn into self-destructive weight gain.
Self-care. A surgeon once told me, "If you're depressed, you just need a deep rest." Some docs are chronically sleep-deprived, so sleeping in or relaxing on vacation is their go-to self-care strategy. Obsessive exercise is also extremely popular among doctors. Beware: CrossFit, running marathons, or powerlifting, although great for depression, may turn into an addiction and lead to injury.
Others read self-help books, pray, meditate, do yoga, sing, dance, listen to music, or play with kids/pets. Some docs keep a stash of thank-you cards from patients that they read when depressed. Remembering grateful patients is a form of self-affirmation that rebuilds confidence and self-esteem.
Self-care may include leaving full-time employment, or quitting medicine altogether. One doctor writes, "What did I do? I left my job! Haha." Another shares, "I have tried self-care, but was so unsuccessful that it hardly counts as an action. Ended up being more of an aspiration, and the daily failure at it led to self-destructive behaviors and thoughts."
Hobbies. I've been told, "There's a fine line between a hobby and a mental illness." Many physicians throw themselves into obsessive crafting to treat depression. As my marriage was failing, I created the most beautiful mosaic mural in my bathroom (that I lost in my divorce). Many female physicians seem to favor knitting. Ann Secord, a pathologist, shares, "I knit. A lot. I should have remembered how much I loved to knit when I was at my most depressed, back in my Navy days. Lately I've started playing ukulele. Like every day. I think it's impossible to be depressed and play ukulele." Retail therapy is a popular all-American hobby as well.
Emotional release. Physicians have disclosed crying under their desks between patients, closet crying, and crying themselves to sleep in the call room. A male physician actually sent me a photograph of himself sobbing on the bathroom floor. Other physicians admit to breaking things. Dr Michele Parker shares, "I used to go to Six Flags for roller coaster therapy and scream. Crazy."
Self-prescribing. Whereas some docs write their own prescriptions, others steal drug samples from their office or buy them on the Internet so that there's no record. Caroline shares, "I have abused my son's Adderall to try to be more efficient and survive on little sleep, and I self-prescribe Cymbalta."
Seeking Support Among Peers
Although many doctors talk to family and friends, the most common form of professional support is complaining among peers online and at work. "My friends and I would take online PHQ-9 [Patient Health Questionnaire] tests that showed we were severely depressed, and we would laugh and go back to work," states Dr Shola Shade Ezeokoli.
Some depressed physicians actually seek appropriate care with their primary physician, psychiatrist, or therapist. To keep appointments off of their official medical record, some use fake names, pay cash, and pursue treatment out of town to prevent medical board investigations and avoid local colleagues (because of confidentiality concerns). Selective serotonin reuptake inhibitors (SSRIs) appear to be the most popular prescribed medication for physician depression.
"During one part of my internship," shares Dr Joel Cooper, "I found out that at least 75% of my fellow residents were on SSRIs or other antidepressants just to get through it, because it was so horrible. Depression, or a constantly depressed state, is more or less the norm in medical school and throughout one's residency. It's truly a wonder that more doctors don't die by suicide as they go through this lengthy, rigorous, and often heartless process."
One reason doctors go underground for treatment is to avoid being referred to a physician health program (PHP). "My medical director suggested I self-refer to the PHP here," Adam says, "so I called (and didn't give my name) and was shocked by how unhelpful they were. They described the process, which would delay returning to work. I'd be forced to comply with years of monitoring and pay for multiple evaluations and random drug screens. (Even though I don't have a substance problem.) I may be mentally ill, but I'm not crazy! It seemed punitive and geared toward addicted docs, with nothing to offer everybody else."
Owing to the punitive nature of physician treatment programs, such as PHPs, and the prevalence of intrusive mental health questions on physician licensing, hospital privilege, and insurance credentialing applications, many doctors avoid seeking needed care.
Physician self-harm can take the form of self-destructive thinking patterns, addictions, and even suicide. Drinking after work is popular among depressed physicians and can quickly escalate into a dangerous routine. A doctor named Paula stated:
Recently I recognized the signs and it startled me—if one glass of wine calms the entangled fallout at the end of a day of difficult patients, families and unrealistic expectations around life expectancy, disease outcome, and cultural entitlement, then two does it better! Beginning to anticipate that 'glass-of-friend' awaiting me at the end of a 'document-this-right-or-get-prosecuted' day, I abruptly set it all aside for hot tea and orange juice. Honestly, it freaked me out how easily it happened that alcohol soothed and asked no questions—and how smoothly I justified it. If you don't think it can happen to you...
Self-harm behaviors may also include having affairs, keeping scalpels on hand, stockpiling pills, or buying a gun. Some docs stop looking both ways before crossing the street in what can be termed an "accidentally on purpose" suicide attempt. Those who fail self-harm as their primary treatment strategy for depression may eventually turn to self-care and then seek professional help with a physician.
Others maintain suicide back-up plans for comfort. "I have been actively suicidal over the past 7 years more times than I can count," claims a doctor called Mike. "In a strange way, it has become one of the few comforting constant areas/states where I feel I exert some degree of control and autonomy. What I think I experience when it comes to my profession goes beyond 'clinical depression.' It's the depletion of one's humanity."
Sadly, many doctors continue to suffer with untreated or poorly treated depression, owing to fear of seeking treatment in a medical environment that stigmatizes and punishes physicians with mental health issues. In fact, many physicians experience occupationally induced depression, and those who have non–career-related risk factors for depression seem more likely to suffer from depression than the general population, owing to the tremendous self-sacrifice required of our doctors.
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Wible P. Physician Suicide Letters—Answered . Pamela L. Wible, MD; 2016:103.