Depression and Anxiety
Mamta Gautam, MD, FRCP(C)
Mood and anxiety disorders are the two most common types of psychiatric conditions experienced by physicians. In addition, physicians can develop adjustment disorders with depressed and/or anxious mood. This chapter will focus predominantly on mood disorders. Anxiety will be discussed as a feeling state that may be part of a mood disorder. In addition, some of the same psychological factors that promote depression may also contribute to anxiety.
Depression occurs commonly in the general population. Being a physician does not provide any specific immunity against depression. In fact, it may likely make one more vulnerable to depression. Recent data suggest that up to 17% of the population will develop a depressive episode at some point in their lives. The prevalence of depression in physicians is not clearly defined. There are several studies in the literature. However, some of them address psychiatric illness overall and not just depression; some are outdated, having been carried out in the 1960s and 1970s; others lack appropriate control groups, have a small sample size, or have inherent bias. In general, these suggest that physicians have rates of depressive disorders at or somewhat above the general population rates; trainees are especially at risk. It is especially important to be aware that, among women physicians, the lifetime risk of some depressive and anxiety disorders is substantially higher, just as it is for women in the general population.
Depression in physicians may often go unreported. Physicians do not admit to these problems and often do not seek help. Others ask their psychiatric colleagues for informal advice in the "hallway consultation" and so go unrecorded. Many other physicians self-treat. In one study of psychiatric problems in women physicians, 20% of the depressed women physicians disclosed that they had self-prescribed antidepressant medication. I recently reviewed the 100 most recent outpatient charts in my clinical practice and found that 78% of the physician patients had already started themselves on an antidepressant medication before being seen by me, on their own initiative, without the advice or knowledge of their family physician. As one said, "I've watched many of my own patients struggle with depression, and then improve so dramatically with medication. It looked so easy, so seductive. I wanted to feel better, too. The SSRIs are great- effective, few side effects... and just sitting there in the sample cupboard, waiting for me. "
There is a serious risk of suicide if depression is not treated. One in seven patients with recurrent severe depression commit suicide. Fifty to sixty percent of those who complete suicide suffered from a mood disorder. The high suicide rate among physician patients is alarming. Studies suggest that the rate of suicide in physicians is 1.5 times greater than the rate for the general population for males and three times greater than the general population for females. Chapter 7 provides more information about suicide in physicians.
Depression and Anxiety
Depression and anxiety commonly present together in clinical practice. From 60% to 90% of depressed patients have one or more associated symptoms of anxiety, such as worrying, somatic or psychic anxiety, phobias, or obsessive-compulsive features. Anxiety symptoms can be severe and disabling. One patient described her feeling state: “My hands shake as the nurse asks me to see the next patient. I feel almost paralyzed. I don't think I will be of any help. What if I don't know what to do for the patient? What if I miss something? What if I go blank? I read the presenting complaint over and over again and can't seem to get up to go to the patient. I can't stop ruminating about missing something big. I just want to lie down and not have to get up.”
There is considerable overlap between anxiety and depressive symptoms. Anxiety can also show up as agitation, insomnia, weight loss, or somatic complaints. Mood and anxiety disorders may share some pathophysiology, since many therapies are effective for both. With our growing recognition that depression complicates all anxiety disorders, and that anxiety complicates all depression, selective serotonin reuptake inhibitors (SSRIS) are becoming the standard first-line treatment for such patients. The symptoms resolve progressively with continued therapy. Anxiety is resolved earliest, often in the first week, followed by improvement of intellectual impairment and somatic complaints. Improvement of depressed mood, fears, and insomnia may not occur until the third or fourth week of treatment.
The presentation of coexisting anxiety and depressive symptoms usually suggests greater severity of illness and chronicity, and a poorer response to therapies. Some of the same risk factors are seen for both mood and anxiety disorders (family history, certain personality traits, etc).
The risk factors that predispose physicians to depression are many and varied. Risk factors for major depression in the general population include:
· Gender - major depression is twice as likely in women
· Age - peak age at onset is 20 to 40 years
· Family history - the risk is 1.5 to three times higher with positive family history
· Marital status - separated and divorced people have higher rates; married males have lower rates than unmarried males; married females have higher rates than unmarried females
· Negative life events - these often play a role, especially in earlier episodes of recurrent depressive illness
Biological Risk Factors
Biological factors that make physicians more vulnerable to mood disturbances include the following.
· Lack of sleep -This is the number 1 complaint among physicians. They work long hours on end and have frequent nights on call. They average two to four hours of sleep during a night of call; experts agree that we need at least eight to 10 hours of sleep each night. This limits their ability to cope in situations with high demands and high levels of stress.
· Poor eating babits - Too often, the physician is unable to eat regular, well-balanced meals. Meals are skipped or quickly put together. Fast foods from hospital cafeterias, coffee shops, or vending machines are consumed. During long, busy nights on call, extra meals or caffeine are used to help stay awake.
· Poor level of fitness - Busy physicians have little time for fitness for themselves. There is always something or someone more urgent, and they promise to take time for themselves later. Later, they are exhausted and cannot get started once they stop, or anticipate another long day ahead, and decide to rest instead.
· Positive family history of psycbiatric illness - Some physicians are genetically predisposed to psychiatric illness. A positive family history of mental illness is strongly correlated with psychiatric illness in the physician.
· Pbysical illness - Depression is very common in physicians with physical illnesses, either severe, sudden, or chronic illnesses.
Physicians tend to share common personality traits, which lead to similar issues and struggles (see Chapter 4). The following traits are the ones most frequently associated with depression in physicians.
· Need for perfection - Some physicians want to be perfect and do all that they can. They are conscientious, attend to all possible details, and do their utmost to meet their responsibilities. Thus, they cannot delegate and find it hard to slow down, relax, or do less than what they see as the right thing to do.
Case Vignette. An internist asks for help because he has a lot of difficulty supervising interns and residents at his clinic. After they have seen a patient, and completed an exhaustive history and physical examination, they review the case with him. He has to return to the patient and redo the entire assessment, because he needs to reassure himself that nothing has been missed. His clinics are very lengthy, the nurses and residents complain, and his family is upset because he never gets home before his children are in bed at night.
· Marked sense of responsibility - Physicians tend to be very responsible people, take their duties seriously, and often feel a sense of responsibility for things that are not under their control. They try to solve problems and feel guilty when they cannot fix everything.
Case Vignette. A family physician completes a very busy day. Later in the evening, she calls all the patients whom she has seen that day, to make sure they have completed the blood tests she ordered and filled prescriptions she wrote for them, or ask if they have any questions about a medical procedure they have booked for the next day.
· Need for control - Physicians generally like to be in control, of themselves and of their environment. They become anxious if they feel out of control, and struggle to stay in control. They try to take control in all situations, even if it is not necessary or appropriate. Sometimes, this is open and aggressive. Yet, it is equally controlling if done in a passive manner, sacrificing their needs for others, unconsciously attempting to control that others approve of them.
· Need for approval and discomfort with approval received - Physicians typically need to please people and want to be liked. In trying to please everyone, they may end up feeling that they have really pleased no one. When they get approval or praise, they dismiss or minimize it because they feel uncomfortable with it.
· Chronic self-doubts - Some physicians doubt themselves and at times lack self-confidence. These physicians fear that they are "just faking it" and that, any day, their cover will be blown, that people will realize just how little they know. They feel that they have been lucky so far, and managed to get away with it, but could be easily found out.
· Ability to delay gratification indefinitely - Physicians are often experts in delaying gratification. They put off earning real salaries like their friends from college to go to medical school. They kept promising to do something once they got into medical school, then once the exams were over, then once they finished call, then once they got into the residency, and so on. Eventually they feel that they worked so hard and deserve things and want the best immediately. They can then overextend themselves financially and feel further stressed.
Case Vignette. One young physician worked hard to set up his practice and was proud of its success. Shortly after he moved his family into a big house, he decided to buy the lakeside cottage of his dreams. He became increasingly frustrated and resentful when he had to work so hard to keep up with the payments that he could not take time off work to go to the cottage and enjoy it.
It is important to realize that these traits are not inherently a problem. In fact, they are generally major factors in the success of the physician, serving a very adaptive role. Yet they can easily become risk factors for depression or anxiety, if too extreme or if used too rigidly. Unconscious and experiential factors are felt to contribute to the high rates of depression within the medical profession. Some authors have proposed that, for a subset of doctors, choosing to study medicine is a response to a need to compensate for emotional neglect or parental impotence in childhood. This may have resulted in lower self-esteem and contributed to emotional distress and illness.
Physicians are subject to a number of special demands.
· Patients - Each physician deals with a small but definite group of patients who can be demanding , dissatisfied, and unappreciative, and dealing with this group is emotionally draining.
· Scrutiny - Many people, from colleagues and other health care workers to licensing boards and governmental agencies, are looking over the physician's shoulder and judging his/her performance.
· Occupational hazards - There is a serious risk of contracting illness and disease, such as AIDS, hepatitis, or tuberculosis; of being victimized by workplace violence or by sexual harassment, or of managing despite sleep deprivation.
· The business of medicine - Physicians are rarely taught business skills in their training, so it is common for them to feel stress in carrying out the business activities of a practice.
· Maintenance of competence - Physicians need to keep up with new information and knowledge by attending meetings and managing a large number of journals and books.
· Organizational changes in health care - Recent changes in the health care system have led to reductions and redistribution of funds, hospital closures and restructuring, forced retirement, loss of geographic flexibility, and loss of autonomy and independence.
· Issues specific to women - Women physicians have minority status and thus face discrimination and scapegoating; not being invited to or being ignored at meetings; not being listened to or taken seriously; being depreciated for their family commitments; having their academic contributions devalued or dismissed; and having few mentors and role models.
Major affective disorders are characterized by one or more episodes of major illness involving a prominent and persistent disturbance of mood. Once a diagnosis of depression has been made, it is important to differentiate between unipolar major depression and bipolar (manic-depressive) disease. Unipolar disease is 10 times more common than bipolar illness. In bipolar illness, the patient is prone to hypomanic or manic episodes in addition to depression. This is an important distinction, since these patients are at risk for developing a manic episode in response to their treatment for an episode of depression. This will require concomitant treatment with mood stabilizers.
In a manic episode, the essential feature is an elevated or irritable mood, with symptoms such as hyperactivity, excessive activity with little use of judgment, pressured speech, inflated self-esteem, flight of ideas, distractibility, and decreased need for sleep. The manic patient with the obvious symptoms of psychosis or dysfunction is easily diagnosed. The patient with hypomania may be more difficult to identify. One must always ask about such symptoms in a patient presenting for the first time with depression. A positive family history is very helpful, as bipolar illness has one of the strongest familial patterns of any psychiatric illness.
The essential feature of a depressed episode is a depressive mood or pervasive loss of interest or pleasure, associated with symptoms of sleep and appetite disturbance, change in weight, psychomotor agitation or retardation, decreased energy, feelings of guilt and worthlessness, and thoughts of suicide.
Among physicians, there are five early danger signs of so-called burnout, which may be a precursor to a depressive episode. These are:
· An increase in physical problems and illnesses
· More problems with relationships
· An increase in negative thoughts and feelings
· A significant increase in unhealthy habits, such as overeating, not exercising, smoking, increased alcohol intake, or lateness at work
· Fatigue or exhaustion
Barriers to Accessing Care
Physicians generally use intellectual defenses to protect themselves from painful emotions. These defenses can be a major cause of delay in seeking help. Physicians often seek help only during a personal or professional crisis, such as the death of a patient, a malpractice suit, family breakup, or acknowledgment of an addiction. Below are some of the defenses that can serve as a barrier to receiving care.
1 . Denial - Physicians deny that any problem exists. ("There is nothing wrong with me. Patients get sick, not me.")
2. Minimization - Physicians convince themselves that the problem is much smaller or less distressing than it really is. ("OK, I have a problem, but it can't be that bad. I still manage well at work.")
3. Rationalization - Physicians find an excuse or a reason to explain away the problem. ("OK, I do have a problem, but it's only because I haven't had a vacation for a couple of years. Once I get a break, I'll be fine.")
4. Reaction formation - Physicians try to give their patients and other people around them all the attention and care they would have liked to receive.
5. Displacement and sublimation - Sometimes, physicians work harder when they feel dissatisfied with their life or feel overwhelmed by demands. They resort to what has always helped them to feel better about themselves, their work, and what also helps to distract them from the upsetting issues. This works because they just do more of something they like, feel more productive, and achieve more, and because it is socially acceptable and even admired to work harder.
Significant advances have been made in the understanding of depression and approaches to treatment. For mild to moderate, nonbipolar, nonpsychotic major depression (far and away the most common variety seen), pharmacotherapy and several specific forms of psychotherapy have proved to be equally effective. There is no a priori reason to select a particular treatment course for physician patients; rather, it is preferable to allow the patient his/her choice of specific treatment option after the advantages and disadvantages of each are explained carefully. Since major depression is often a recurrent illness, a history of a good response to a previous treatment (in the patient or even a family member) might steer treatment selection toward that particular treatment.
There are several distinct classes of antidepressant medication, all with good efficacy and many with fairly minimal side effects. Physicians may be particularly desirous of avoiding certain side effects (eg, cognitive impairment or tremor), and this may determine initial drug choice. A patient who has not responded to a particular drug may still improve on another drug from a different class or even from the same class. Light therapy (phototherapy) may be a somatic yet nondrug option for physicians with a seasonal pattern to their depressions, especially if there are particular concerns about medication side effects or privacy (ie, pharmacists or others knowing about prescriptions).
Interpersonal and behavioral-cognitive psychotherapy are two specific forms of psychotherapy that are generally time-limited, practical, and focused on current difficulties, aspects that may make them especially appealing to some physicians. Some physicians express a fear of or distaste for engaging in open-ended psychotherapy or of having their early lives explored. If an intimate relationship is a major stressor for the depression, or it is sinking under the weight of a depression, couples therapy may be warranted. In general, the beneficial effects of medication are seen somewhat earlier than those of psychotherapy, although psychotherapy is eventually as effective and carries a far lower side effect burden. There is some controversy in the field about whether psychotherapy affords any protection against future depressive episodes; medication certainly does not appear to. Many experts in mood disorders recommend a combined approach to treatment incorporating both pharmacotherapy and psychotherapy.
Sixty to seventy percent of patients with depression will respond to initial treatment with monodrug therapy (usually after four to eight weeks of treatment) or to a completed course of psychotherapy (usually 12 to 20 sessions or about 12 weeks). Of the 30% who do not respond to initial treatment, the majority will improve on an alternative approach, and upward of 90% will eventually recover fully. Thus, the prognosis of major depression is among the best of any medical illness of similar severity.
Special Considerations in Treating the Physician Patient
Treating a physician patient can present certain challenges. Physicians are different in some ways from other patients, yet they are not so different in many others. This is a unique therapeutic situation, in which the patient is often as well trained as the treating physician, and it can be intimidating because he/she does not present himself/herself as the usual lay patient. It is hard for physicians to be patients. Many physicians deny problems and have difficulty initiating treatment. This leads to delayed seeking of treatment, and the problem is then often more serious. The insecurities of physicians may make them fear judgment, fear exposure, and feel a sense of guilt and personal failure. In their struggle for control, physicians may try to direct their own treatment. Some physicians self-diagnose, self-medicate, and self-refer. They can be reluctant to follow advice. Some of them refuse to accept that they are ill or to adopt the sick role, and studies show that 10% to 25% of physician patients leave hospital prematurely. They also discontinue medications prematurely and are less compliant with follow-up treatment.
The treating physician can have several reactions to having a physician as a patient. This may provoke insecurities for the treating physician, who may feel inferior and incompetent and doubt his/her abilities. The patient is seen as special and can get poorer care, such as fewer family interviews or a shorter hospital stay. The patient may be mistakenly assumed to know more than he/she does about psychiatric care, and so inadequate information is given. Sometimes the opposite reaction ensues, with the treating physician feeling superior and wanting to compete with the patient. In other situations, there is a strong identification with the patient; the problem hits close to home, and the therapist may feet threatened and deny or avoid the problem, or minimize the illness. Sometimes the treating physician likes the patient and inappropriately wants to be his or her friend.
Below are some specific suggestions for dealing with the physician patient.
· Respond quickly to requests for help. Most physicians have already waited too long before they ask for help.
· Encourage and help them to obtain a family physician. They may need a complete medical evaluation, and they often have too few supports and resources.
· Ensure confidentiality. Reassure the patient of this to help settle fears. Clarify what is required under mandatory reporting; all else is confidential.
· Be empathetic, and acknowledge their courage and strength in seeking help.
· Discuss who is in control - treatment should be a collaborative effort. Take charge, make decisions, and ask direct questions when appropriate, but don't undercut patient autonomy and self-esteem by doing so. At the same time, allow the patient to be "just a patient" and not feel like he/she has to be his/her own doctor too.
· Treat like any other intelligent patient. Special treatment is usually pooere treatment.
· Anticipate the patient's defense mechanisms, and do not allow them.
· If hospitalization is required, ensure that the patient stays in the hospital for the complete treatment course, monitor closely to ensure medication is being taken as prescribed, and follow up after discharge.
· Identify and understand your own reaction to the patient. Be confident and set and maintain appropriate boundaries.
· Avoid sharing of more personal information than you would with other patients (in other words, generally not too much).
· Recognize that what you hear will have an impact on you, and learn to expect and deal with this. Learn to disengage from their pain.
· Care for yourself - take vacations, use social supports, consult with colleagues. Be a good role model for your physician patient.
Since physicians are very reluctant to seek help for themselves, it is crucial for colleagues to recognize the signs and symptoms of depression. A conscious change in the culture of medicine is crucial, to foster an environment in which stress is recognized as normal and is openly addressed, and help is offered without judgment.
From the start, this needs to be addressed in medical school. A careful selection process will help to choose well-rounded, emotionally healthy individuals who are better suited to the demands of medicine. Students can be taught about the stresses inherent in medicine, depression, substance abuse, and the problems of overworking. They can be taught self-awareness, the need to care for themselves, to seek support, and to watch out for each other. The importance of a balanced life outside of medicine can be emphasized. In particular, students need to know of the increased vulnerability of women in medicine to depression. These messages need to be continued regularly throughout training and afterward through continuing medical education. Practicing physicians always benefit from the reminder to lead balanced lives.
Physicians must be encouraged to watch out for their colleagues. They can look for warning signs and learn to be comfortable in reaching out to help. It is especially important to be vigilant of colleagues who are vulnerable because of history of depression, who have had life stresses such as marital problems or onset of physical illness, or who are more erratic or withdrawn at work. Physicians need to learn to be more comfortable in reaching out to a colleague about whom they have concerns and assisting him/her to seek help. Covering up for a colleague does not help that colleague.
Depression, even in physicians, is a very treatable illness. Physicians do well when treated, provided that they are persuaded to complete the course of treatment and are supported in follow-up.
The Handbook of Physician Health. American Medical Association, 2000. Chapter 6, pp 80-94.
Clayton Pj, Marten S, Davis MA, et al. Mood disorder in women professionals.AffectDisord. 1980;2:37-46.
Hsu K, Marshall J. Prevalence of depression and distress in a large sample of Canadian residents, interns, and fellows. Am J Psychiatry. 1987; 144: 1561-1566.
Pitts FN Jr, Winokur G, Steward MA. Psychiatric syndromes, anxiety symptoms and response to stress in medical students. Am J Psychiatry. 196 1; 1 18:333-340.
Pond DA. Doctors mental health and mental disturbance in doctors. NZMedj. 1969;69:131-135.
Raskins M. Psychiatric crises of medical students and the implications for subsequent adjustment. j Med Educ. 1972;47:2 1 0.
Welner A, Marten S, Wochnick E, et al. Psychiatric disorders among professional women. Arch Gen Psychiatry. 1979;36:169-173.
Special Considerations for the Physician Patient
Gold N. The doctor, his illness and the patient. Aust N Z J Psychiatry, 1972;6:209.
Jones RE. A study of IO 0 physician psychiatric inpatients. Am J Psychiatry. 1977; 1 34:1119.
Remick RA. Refractory depressive illness in physicians. B C Medj 1998;40:153-155.
Waring EM. Psychiatric illness in physicians: a review. Comp Psychiatry. 1974;15:519-530.
Shortt SED. Psychiatric illness in physicians. Can MedAssocj 1979;121:283-288.
Wise TN. Depression and fatigue in the primary care physician. Primary Care. 1991;18:451-464.