Do physicians genuinely understand and acknowledge depression?

SIG-E-CAPS (Sleep, Interest, Guilt, Energy, Concentration, Appetite, Psychomotor agitation, Suicide) is the most infamous mnemonic for depression. It is taught in just about every medical school; if not, there are other mnemonics used. Depression is trained in all levels of training and tested on every level of boards. Depression is also taught in rotations, especially when dealing with the elderly and children, and even now, being recognized for different races, religions, sexual orientations, etc. However, studies show doctors are poor at detecting depression and rarely express their personal history and struggles with depression. 

Depression is not a new phenomenon among physicians; for over 150 years, physician mental health has been examined but not truly researched and investigated. Currently, it is becoming more recognized, and there has been an increased push to acknowledge how devastating it is and the need for proper and effective changes. According to a Medscape study conducted in 2018, depression is more prevalent within the physician community, affecting an estimated 12% of males and up to 19.5% of females physicians. Yet, only about 15% of physicians report symptoms of depression. 

Predictors of Depression in Physicians1

  • Difficult relationships with senior doctors, staff, and/or patients
  • Lack of sleep
  • Dealing with death
  • Making mistakes
  • Loneliness
  • 24-hour responsibility
  • Self-criticism

Depression is even more prevalent in medical students and residents, having higher rates than the general population, with 15-30% of them screening positive for depressive symptoms. After completing residency, the risk of depression persists. The lifetime prevalence of depression among physicians is 13% in men and 20% in women; these rates are comparable to those of the general population.

Depression in Medical Trainees2

  • Long hours
  • Learning to deal with death and dying
  • Frequent shifts in the workplace
  • Estrangement from supportive networks
  • Translocations to secure further training or job advancement
  • Harassment and belittlement by professors, higher-level trainees, and even nurses
  • Having to make difficult decisions while being at risk for errors due to inexperience

Due to the lack of transparency, fear of legal liability, being seen as incompetent, cultural, and professional stigmas, and the illusion of perfection, physician reporting is also underreported. Furthermore, medical institutions incorrectly report mental health data, if at all. Concrete research has not been truly established to shed light on the cause and effect of mental health amongst physicians. 

Factors Affecting Diagnosis and Treatment of Depression in Physicians1

  • Physicians are poor at recognizing depression in patients, coworkers, loved ones, and themselves. 
  • Early symptoms are physical, and physicians are unable to identify the root cause or misdiagnose themselves. 
  • Failure to diagnose and treat themselves leaves physicians feeling incompetent and as failures. 
  • Self-reporting underestimates the prevalence due to stigmas culturally, personally, and professionally.
  • Physicians are reluctant to receive medical care for themselves, let alone mental health services. 
  • Physicians do not have a regular and constant source of medical care. 
  • Stress surrounding medical licensure when diagnosed or treated for mental illness
  • Regulatory, taxing, and expensive intervention when diagnosed with mental illness. 
  • Physicians find it challenging to ask for help and suffer from a sense of perfectionism. 
  • Difficulty to access and achieve adequate and sufficient mental health services 
  • Reaching out to another physician about their health can affect co-worker relationships. 
  • Symptoms being summed up as stress or as being overworked by loved ones 
  • Depressed physicians who seek care may find that they receive only limited understanding or sympathy from colleagues.
  • Lack of time due to unpredictable and inundated scheduling
  • Cost-effective treatments.
  • Trouble finding a local provider who they trust and is not a colleague.
  • There is no specialized training for a physician’s physician to recognize and treat mental illnesses. 
  • Physicians consider sharing their experiences with mental illness risky and painful.
  • Fear of illness(s) being documented on their academic record and licensure
  • Litigation-related stress and reporting all malpractice settlements to the National Practitioner Data Bank can precipitate depression.

Seeking care and treatment becomes further daunting since physicians do not always recognize depression in themselves or their colleagues. Physicians are also known to make the worst patients and, oftentimes are reluctant to give up control or decide their care regimen and feel they should be given special treatment, causing constraints within the doctor-patient relationship. Physicians are also often reluctant to seek treatment for mental health issues, leading to feelings of isolation and hopelessness. Consequently, with the lack of professional psychiatric management, physicians take it upon themselves to professionally self manage and medicate or use alcohol or illicit drugs to try to alleviate symptoms. 

Mental Health and Work Balance

Risks of Caring for Physicians as Patients

  • Caregivers, family, and the patient may deny the possibility of alcohol or substance abuse. 
  • Caregivers may avoid or poorly handle discussions of death and ‘do not resuscitate’ orders. 
  • The patient may suffer from emotional isolation when protected from the standard hospital culture. 
  • The patient’s feelings of shame and fear in the sick role can go uncomforted. 
  • Caregivers may overlook neuropsychiatric symptoms because they do not wish to ‘insult’ the patient. 
  • Staff may neglect or poorly handle the patient’s toileting and hygiene.
  • Ordinary clinical routine may be short-circuited. 
  • Caregivers may avoid discussing issues related to the patient’s sexuality.

The prevalence of depression is problematic when unacknowledged and untreated, leaving physicians and the communities they serve in detriment. Furthermore, a diagnosis of mental illness is not distinct from mental impairment, creating worsening stigmas, lack of or inefficient treatment, and unfair policies. Depression affects physicians in their personal and professional lives and causes domino effects that are not always overt. 

Manifestations of Mental Illness in Physicians2

  • Severe irritability and anger, resulting in interpersonal conflict
  • Marked vacillations in energy, creativity, enthusiasm, confidence, and productivity
  • Erratic behavior at the office or hospital (i.e., performing rounds at 3 am or not showing up until noon)
  • Inappropriate boundaries with patients, staff, or peers
  • Isolation and withdrawal
  • Increased errors in or inattention to chart work and patient calls
  • Personality change, mood swings
  • Impulsivity or irrationality in decision making or action
  • Inappropriate dress, change in hygiene
  • Sexually inappropriate comments or behavior
  • Diminished or heightened need for sleep
  • Frequent job changes and/or moves
  • Inconsistency in performance, absenteeism

Mental health has come a long way in being acknowledged, accepted, and researched. 

However, mental health has a long way to go when targeting our healers, specifically our women doctors. The debilitating and vast effects of mental health cause a disproportionate and needless toll on the medical profession, starting from the inception of training.1 Also, there is an urgent need to change the attitudes of those in health care, mainly the regulatory systems, as well as the views of the general public toward mental illness. Such changes might encourage physicians to be more receptive to a diagnosis of depression and enable them to feel free to seek treatment without the fear of repercussion.

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