Are depression & suicide ignored when they strike emergency physicians?
Introduction to survey printed December 2005
I Have learned that there have been a number of litigation-related suicides by EPs over the past several years, and it is very likely that the phenomenon is vastly under reported. No data is available about EP suicides in other contexts.
It is deplorable that the U.S. loses, on average, the equivalent of an entire medical school class each year to suicide. Almost always, suicidality is the result of untreated or inadequately treated depression. Compared with other professionals, the proportionate mortality ratio for white male physicians is higher for suicide than for all other leading causes of death. All published studies to date indicate that women physicians may be at even greater risk.
Physicians are demonstrably poor at recognizing depression in patients, let alone in ourselves. Furthermore, physicians are notoriously reluctant to seek treatment for any personal illness. Experiences at the ACEP Wellness Booth have suggested that as many as 40% of participants have no other identifiable source of healthcare. And although everyone knows that “a doctor who treats himself has a fool for a patient!”, we also know that most of us do it anyway. Especially when the consequences of seeking treatment might subject us to shaming, or worse.
The following article summarizes the results of the survey conducted in conjunction with the above article.
Feature article printed March 2006
Survey Says: Many EPs Suffer in Silence
The eye-opening results from EPM’s physician depression survey are in
“I have had the pistol in my mouth and would have pulled the trigger, save for leaving my child without a parent.” Thus began one response to EPM’s December article and survey “Silent Treatment.” The respondent continued: “Does anyone honestly think that anyone in our position would report this type of thought to any board? Go under the microscope? Lose our ability to provide for our families? For as much hype as is given to diagnosis and treatment of depression, state boards and everyone else hold their physicians to a different standard. If I were a plumber or musician, I would just go see my psychiatrist, take medication, and go on with my life, better off for having done so. We are held to an impossible double standard.”
This desperation was echoed in countless other anonymous responses, each reinforcing the need to understand physician depression better and do away with stereotypes that might hinder treatment. Here now are our findings, and the many voices that cry for understanding.
We knew before this study that depression is at least as common in the medical profession as in the general population (estimated at 12 and 18% for males and females respectively). It is even more common in medical students and residents, 15 to 30% of whom screen positive for depressive symptoms. In both populations, the numbers are probably even higher due to under-reporting. In our EPM survey, 73% of 108 respondents had experienced symptoms that they felt might have been depression.
Suicide, on the other hand, is far more prevalent among physicians than the public, with the most reliable estimates ranging from 1.41% to 2.27% times the rate in the general population. More alarming is that, after accidents, suicide is the most common cause of death among medical students. Although female physicians attempt suicide far less often than counterparts in the general population, our success rates equal those of male physicians, and thus far exceed that of the general population. Furthermore, it is reasonable to assume that under-reporting of suicide as the cause of death by sympathetic colleagues might well skew these statistics.
Research suggests that male US physicians have a 70% increase in mortality from suicide or self-injury compared with other professionals. Our survey revealed that 48% of respondents who said they’d been depressed had considered harming themselves in the midst of this condition. “My wife was afraid to come home because she didn’t know if she’d find me alive,” wrote one.
Sadly, though physicians have a lower mortality risk from cancer and heart disease relative to the general population, presumably relating to self-care and early diagnosis, we have a significantly higher risk of dying from suicide. In addition, it is a little known fact that depression is a leading risk factor for myocardial infarction in male physicians. EPs seem to have heeded their own advice about avoiding smoking and other common risk factors, but by avoiding treatment for depression, we fail to address a significant risk of both morbidity and mortality that disproportionately affects us.
Some of our reluctance is self-imposed. Physicians feel an obligation to appear healthy, perhaps as evidence of our ability to heal others. Of course, even when healthy, physicians are notoriously unable to recognize symptoms of depression in patients, so it stands to reason we would not recognize it in ourselves when clear thinking is difficult or impossible. “It’s hard to describe, but deep depression’s like a suffocating blanket that’s fallen over you, pressing you to the ground unrelentingly,” wrote one respondent. “Just the mental effort of trying to get up is more than you can bear.”
Some reticence is imposed by colleagues who may be well-intentioned, emotionally distanced, and/or feeling vulnerable themselves. In our survey, 41% of self-diagnosed physicians did not seek treatment. Although 67% of respondents felt they had known a colleague to be depressed, and 43% had known a medical colleague who completed suicide, only half had mentioned their concerns to such a colleague. Volunteering assistance may feel like an affront to a colleague’s self sufficiency. So we do nothing, hear nothing, say nothing to avoid unnecessary burdens on them or ourselves. Even after we lose a colleague, we are often afraid to broach the subject.
“We had an ophthalmologist on staff die in the garage of CO poisoning this year,” wrote one reader. “It was called ‘accidental’ so his kids would get insurance money. The odd thing I noticed was the lack of reaction from the staff, like he never existed.”
Wrote another respondent, “Every article you read about a physician suicide contains a quote from some close contact, occasionally a spouse: ‘I never had any idea s/he was suffering’.”
When we ourselves feel depressed and less than adequate, it is difficult to ask for help, and regrettably, sometimes even more difficult to obtain it. Those who do reach out may find limited understanding or sympathy from colleagues. Said one respondent, “I was at the Mayo Clinic for a physical. The physician there listened to my discussion of my symptoms and said ‘You shouldn’t be depressed. You’re young and have so much to live for.’ And that was that. My OB/GYN referred me to a marriage counselor (a nurse I knew from previous work at that hospital) rather than offering medical treatment for what I perceived to be serious symptoms of depression. I am ashamed for my peers and hopeless about finding any reasonable care locally.”
It is widely acknowledged that physicians are uncomfortable treating fellow physicians, and this is nowhere more apparent than in the realm of mental health. When physicians do treat other physicians, the “VIP syndrome” can put up a smoke screen. Well-intentioned but superficial or inadequate treatment based on collegiality and concerns about confidentiality can significantly detract from the effectiveness of therapy. Mental health experts who have studied this phenomenon stress that immediate treatment, and often, highly confidential hospitalization of suicidal physicians can be lifesaving in our especially vulnerable population. Yet this very specter is often the major impediment to a physician’s reaching out in time of crisis.
“I had decided that my only way out was to take a prescription of Halcion and a bottle of wine and head out into the woods. During this time I was getting counseling as well as seeing a psychiatrist, both of whom tried to convince me to accept admission to a psychiatric unit, which is what I needed. I refused only because of that little box that is on all the state license applications and every hospital privileges questionnaire that asks if I’ve ever suffered from a mental illness that required hospitalization, and feeling that I would be ‘branded’. Only lately have I found a combination of medications that have faded the thoughts of taking that walk in the woods.”
It is not only the fear of temporary withdrawal from practice that hampers effective treatment-seeking by physicians. The very real concern about broad and longer term ramifications is reflected by our findings. In our survey, 85% of respondents who had experienced depression did not report this to licensing authorities, employers, or credentialing agencies. The 41% who did not seek treatment for depressive symptoms, cited similar grounds.
“Fear of reporting requirements and the recommendation of a consulting professional led me to not report depression to my state board. A colleague who developed depression following an MVA fatal to his wife and child answered yes to a query on his license renewal, and had to jump through numerous hoops to prove his fitness to continue medical practice. Hardly encourages acknowledgment or treatment for depression,” opined one reader, speaking for many.
There is wide variation in the types of questions asked by such agencies, as well as the use made of the responses. Although licensure boards for the most part now ask about impaired performance rather than diagnosis or treatment, the time frame in question can be overly broad. (i.e., “have you EVER suffered from…” rather than “are you currently experiencing impairment?”). Aside from licensure, many hiring authorities ask inappropriate questions regarding psychiatric diagnoses, and there is confusion regarding the effect of Americans with Disability Act protection where patient care may be at issue.
“I attempted to go off medications for one month and was quite suicidal. Most days en route to work I would seriously contemplate running off the road and killing myself. I told myself it would get better. I started back on meds, but I never report depression or my meds when I have to give a medical history which may be shared via computer record. I have been turned down for liability insurance because I’m on low dose Wellbutrin.”
Discrimination in insurance coverage is a common but little publicized problem for physicians suffering from mental illness. Health, disability, and liability insurance may be denied. For insurers, it seems, “physician heal thyself!” is a standard prescription.
We touched briefly on the phenomenon of seasonal affective disorder, SAD. In our survey, 55% of respondents who had been depressed or had symptoms which might be depressive in nature, reported that the feelings occurred predominantly during the winter. Predictably, 75% of respondents worked in an environment without windows (I have never worked in, or even seen an ED which had windows!). Here is an area possibly worthy of investigation and consideration in ED design.
An area of great concern to me is the relation between depression/suicide and litigation stress. Said one respondent “I have planned suicide and murders after I was sued for medical malpractice. The dark anger rises from fatigue born of the demanding, the dying, the inconsolable, who return your sacrifice with a lawsuit. The claims that, ‘It’s not personal,’ dehumanizes us into ‘targets of opportunity’.”
When one EP in Texas committed suicide, he left behind a note that read, “I hope that my death will shed light on the problem of dishonest expert testimony.” This affected me profoundly. Other physicians have completed suicide upon first receipt of outrageous malpractice claims, after erroneous judgments, while experiencing employment discrimination relating to settlements, and/or upon the realization that they are unable to work due to discrimination by liability insurers. The association between malpractice litigation and physician depression or suicide is particularly disturbing, because so often the motivating factor in litigation is to obtain or preserve wealth, a goal that is so foreign to an idealistic physician who places a higher value on the maintenance of health and preservation of life.
This article only scratches the surface of EP depression and suicide, but we hope by sharing this knowledge we might stimulate your concern and interest in a tragic and lethal condition that has the potential to affect any one of us. It deprives us of approximately 250 colleagues every year. This is a travesty.
Depression among physicians, like substance abuse, is not only more common than in the general public, but also almost invariably more readily treatable. Every day new and effective treatments and combinations are emerging, and often all that is needed is the persistence to find a qualified provider and together to discover the right balance of therapy. What is urgently needed beyond our own understanding of this disease and its disproportionate toll on our profession, is change in the system. We all need to be more open and receptive to the diagnosis, and we need to feel free to seek treatment without fear of repercussion.
Here is a most hopeful response from one reader who has conquered his fear:
“I still have depression and always will, but I talk about it openly (my wife now often notes it coming one before I do), know that I will get better when I get the meds going again and feel lucky that I never went through with the suicide plans. I was so close many times. I have learned that getting it into the open helps me and helps others to understand me and hopefully takes the stigma away from those that would consider you not a good physician because of it. That is ridiculous. At times it would probably be better that you are not working. It is like having the flu. You are not at your best then either.”
May his honesty and acceptance of this all-too-common diagnosis be an example of how we as physicians can control our destinies if we but admit that the power to do so is ours. Please accept and extend this power to anyone you know who might be suffering, including yourself.