The articles by Goebert et al1 and Dunn et al2 in this issue of Academic Medicine are sober reminders of the high rates of depression among U.S. medical students and residents. The authors also remind us of the barriers to appropriate care-seeking. We suggest that these papers constitute a clarion call to action on the part of leadership in the nation’s schools of medicine and academic health centers (AHCs). In this commentary we pinpoint critical actions to confront depression in the next generation of the nation’s physicians.
The data from Goebert et al1 constitute the largest database available on the point prevalence of clinically significant depressive symptoms in medical students and residents. (The high response rate in the survey is also very impressive.) No fewer than one in five trainees at any one point in time acknowledge clinically significant levels of depression, and 1 in 16 report suicidal ideation. These rates are substantially higher than in the general population. Although the authors do not comment on the high rate of personal histories of depression and of positive family history, this information is useful in thinking about who among our trainees is most vulnerable. Moreover, when viewed from a longitudinal or developmental perspective, these figures represent only the tip of the iceberg.
In this context, it should be understood that depression is typically not a brief episodic illness, like pneumonia, but rather can become a recurring and even chronic condition, more like hypertension or diabetes, but never silent as these maladies often are.
Depression has many complications of particular salience to medical students, residents, and their families. In addition to a relapsing, chronic course (if left untreated), and the complication of alcohol abuse or dependence, depression begets and amplifies cognitive disabilities, thereby interfering with learning. It is, literally, toxic to the brain.
Depression begets or exacerbates interpersonal difficulties, making it difficult for medical trainees to function effectively as members of learning collaboratives and caregiving teams and to find the emotional support needed to cope with the enormous demands of becoming a physician.
Depression undermines the ability or motivation to seek medical care for other coexisting conditions and to comply with treatment.
Finally, depression can be a precursor to suicide. Tragically, the rate of suicide is several-fold greater among medical students, residents, and physicians than in the general population (especially among women physicians). Hence, the proportionate mortality ratio for suicide is greater among trainees and physicians. Although as a profession we have made strides in caring for ourselves—for instance, we have largely stopped smoking (with the result that smoking-related causes of illness and mortality among physicians have fallen significantly)—we still fail to recognize depression in ourselves and our colleagues. The result is that suicide remains a far greater source of mortality among physicians than in other groups.3
These conditions naturally lead us to ask, what are the barriers to depression recognition and treatment among medical trainees? In addition to inadequate education early during training about depression, Dunn and colleagues2 remind us of the importance of stigma (both internal to the student and external, existing within the culture of medicine) as a barrier to seeking help for depression. Other documented barriers include unwillingness on the part of students to take time for treatment, limited financial resources to pay for care, concerns over confidentiality, and fears of adverse sanctions in residency application, medical licensability, and clinical referrals.
Each of these barriers can be circumvented. Considering the enormous cost of unrecognized and untreated depression in medical students and residents, not to take action to remove them is egregious. Some schools have taken a top-down approach to mitigating stigma, with leadership promoting education about depression and encouraging the view that students owe it to themselves to take care of themselves—otherwise, their ability to care effectively for sick patients may be and often is compromised. The U.S. Air Force also showed how top-down leadership encouraging appropriate mental health services is associated with reductions in suicide among its personnel.4
In addition, some medical schools have now created Web sites that allow students to screen themselves anonymously for depression and to correspond with counselors who encourage them to come in for evaluation, to further educate themselves about this treatable illness, and to self-refer to confidential counseling services. Treatment for depression, which is now highly effective, need not take much time: there are effective, short-term, depression-specific psychotherapies that may be combined with the use of antidepressant medication to bring about recovery.
Some schools and (AHCs) now provide mental health services at no charge, including counseling with psychiatric backup as needed, thus removing financial barriers. Furthermore, medical student and resident mental health services can be located off campus to help ensure confidentiality, and it is a matter of federal law (HIPAA) that privileged health information may not be divulged without the permission of the care recipient.
If trainees are encouraged to take the time to seek care by the leadership of their schools, provided financial help to do so, and reassured of confidentiality, these simple, actionable steps can and do go far in reducing the burden of untreated depression on the nation’s physicians.
In 2003, the American Foundation for Suicide Prevention (AFSP)3 published a series of recommendations for dealing with the problems posed by depression in the nation’s medical students, residents, and physicians. As an outgrowth of that consensus statement, the AFSP (in collaboration with State of the Art.com) created an educational documentary (Struggling in Silence: Physician Depression and Suicide) about the need to confront depression in medical students and physicians. The film was broadcast nationally on 234 public television stations during the spring of 2008, and on half of these stations it was shown during primetime hours. It is available through the foundation’s Web site (www.afsp.org)5 and at (www.doctorswithdepression.org).6 We focused the film on colleagues who had been successfully treated, but we also presented vignettes of doctors who had taken their own lives, illustrating the toll this takes on surviving patients, family members, and colleagues. We believe that the film and the AFSP Web site which accompanied it provide a useful educational tool for medical schools and AHCs, for medical students, residents, faculty, and practicing physicians.
Two years ago, we addressed the Federation of State Medical Licensing Boards at its annual meeting. (Fortunately, a number of state licensing boards have begun the process of changing medical license questions, to ask only about disability rather than diagnosis or treatment of physical or mental illness.) When the audience of nearly 500 participants was asked how many had known a colleague who had taken his or her own life, every hand in the room went up. When we suggested that it was time to extend to our fellow physicians the same compassion and help we provide our patients, there was a standing ovation. The time is right for strong leadership to change the culture of medicine.
We know what to do. Do we have the will to act?
1 Goebert D, Thompson D, Takeshita J, et al. Depressive symptoms in medical students and residents: A multischool study. Acad Med. 2009;84:236–241.
2 Dunn LB, Harmond KAG, Roberts LW. Delaying care, avoiding stigma: Residents’ attitudes toward obtaining personal health care. Acad Med. 2009;84:242–250.
3 Center C, Davis M, Detre T, et al. Confronting depression and suicide in physicians: A consensus statement. JAMA. 2003;289:3161–3166.
4 Goldsmith SK, Pellmar TC, Kleinman AM, Bunney WE, ed. Reducing Suicide: A National Imperative. Washington, DC: National Academies Press; 2002.
5 American Foundation for Suicide Prevention Web site. Available at: (www.afsp.org
). Accessed October 21, 2008.
6 Struggling in Silence: Physician Depression and Suicide. Available at: (www.doctorswithdepression.org
). Accessed October 21, 2008.