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Clinical depression: more than just residency blues

Getting past old stigmas is the key to recognizing symptoms—and helping vulnerable residents

From the December 2000 ACP-ASIM Observer, copyright © 2000 by the American College of Physicians-American Society of Internal Medicine.

By Christine Kuehn Kelly

Steps residents can take to recognize and get help with depression

It wasn't the first time that the resident had overreacted to a suggestion from an attending. Other residents had been on the receiving end of her erratic outbursts. Even when she wasn't angry, she seemed to have lost her enthusiasm for internal medicine. Her performance had deteriorated to the point that faculty members were questioning her choice of residency.

Rather than suggest that the resident find another specialty, the program director persuaded her to see a hospital psychiatrist. She was diagnosed with depression and immediately began treatment.

While the scenario is hypothetical, educators and psychiatrists alike say that it shows that residents who suffer from depression often need help. "When we see a change in behavior, one of the first things we suspect is depression," said Virginia Collier, FACP, internal medicine program director at Christiana Care Health Systems in Newark, Del., and the College's Governor for the Delaware Chapter. If depression is diagnosed, she said, a short intervention can make a dramatic difference.

The stress of residency can lead to periods of feeling blue, but experts say that depression in residents is often a much more serious problem. Studies have shown a higher lifetime prevalence of depression in those who go through medical training, perhaps as high as 30%. (Among the general population, by contrast, 20% of women and 10% of men experience depression.) And nothing is more important, they say, than early recognition and treatment.

Causes of resident depression

Several factors are believed to account for depression in housestaff. For those with a propensity to depression, the first episode typically occurs when they are in their 20s—the same age when most physicians go through residency.

In addition, people who have had family experience with physical and mental illness often select medicine as a career so they can help others, said Ruth Levine, MD, a psychiatrist at the University of Texas Medical Branch in Galveston. When residents from these backgrounds discover how powerless physicians can be in some instances, however, she said their predisposition to depression may intensify.

Genetic factors may also be at play. Researchers have found a higher risk of depression in people whose family members have suffered from the disease.

"Furthermore, there is a universal stress associated with residency that will never change," said Dr. Levine. Although working conditions for housestaff may be improving, residents will always be confronted with life and death issues, acutely ill patients, long hours, learning and applying huge quantities of technical material, managed care hassles and emotional upheaval. "Being a doctor will always mean working with people at a painful point in their lives," she said.

Add to those stresses the financial strain of shouldering huge student loans while living on a modest income. "Residents are sacrificing so much, yet the financial and even the 'people rewards' are diminished," said Richard Sherman, PhD, a clinical consulting psychologist at the University of California, Los Angeles. "This triggers anger, frustration and resentment. One classic definition of depression is anger turned in on oneself."

Other factors particular to internal medicine may also lead to depression. Gregory A. Hood, FACP, a general internist at Southern California Permanente Medical Group in La Mesa, Calif., said he believes that part of what drives internists is a tendency toward obsessive compulsiveness.

Dr. Hood, who served as chief internal medicine resident at Scripps Mercy Hospital in San Diego before entering practice, said that a certain level of compulsiveness helps internists find the broadest differential diagnosis possible. "But the flip side of this is an oversensitivity to criticism," he said, "and residents endure some of the most intense criticism possible."

In addition, residents often tie their self worth to the consequences of diagnosis and treatment plans. This helps housestaff feel good when patients do well. When patients don't improve, despite a resident's best efforts, the effect can be devastating.

Getting past the stigma

Because depression is a type of mental illness, much of society still considers it shameful. Dr. Levine, for example, recalled one hospital administrator who asked her to not give a talk about depression in doctors. The administrator worried that housestaff might think their own mental health was being questioned. "The stigma is still alive," Dr. Levine said.

The demands of residency make many residents want to show that they are invulnerable and can tolerate pain without emotion. Housestaff also fear that being diagnosed with depression will impact their ability to provide care or hurt their professional reputation—and their future in medicine.

"Unfortunately, this makes residents more vulnerable to mild or more severe depression," said William Pollack, MD, a psychiatrist who is an assistant clinical professor at Harvard Medical School.

There is evidence that men in particular still tend to view depression as a sign of weakness. Dr. Pollack cited one study in which male internists underdiagnosed depression in male patients by 67% but overdiagnosed the condition in female patients by 3%. The study found that even when male patients brought up depression, male internists didn't expand on the discussion. "They explained that they didn't want to embarrass or shame their patients," Dr. Pollack said.

Watching out for your peers

While depression may be hard to spot among housestaff, experts say that physicians have a responsibility to look out for the disease in their peers and to learn how to identify and understand depression in their colleagues. Because impaired residents are unlikely to identify themselves, experts say, program directors, chief residents and other housestaff need to heighten their sensitivities.

Unfortunately, even when residents and training program staff are on the lookout for depression among residents, Dr. Levine said, it can be difficult to judge the seriousness of a resident's depressive symptoms. Normally, clinicians gauge depression by the level of impairment and the presence of somatic symptoms. With residents, however, it's difficult to read somatic symptoms because their lifestyles are characterized by chronic lack of sleep, exercise and a proper diet—all of which can cause low energy and sleep disturbances.

To pinpoint depression in residents, experts say, look for problems with concentrating, thinking or learning. Residents may fall behind in charting or work less efficiently in rounds. They may also rely on substances like alcohol to relax or get to sleep, and their personal appearance may suffer.

The worst-case scenario occurs when depressed residents become so impaired that patients are harmed by persistent misdiagnosis and treatment errors. These residents can have their licenses suspended or--in extreme cases of misconduct—revoked.

Impaired physicians who demonstrate that they are receiving treatment may have their license suspended and not revoked, according to Joseph Caldwell, JD, a West Virginia attorney who represents physicians. Licenses are typically reinstated after the resident has gone through medical compliance, periodic evaluations by a mental health professional and supervision by a sponsoring physician.

For doctors who are diagnosed with depression early in the condition, Dr. Levine said, such repercussions are rare. "Among all the physicians I've treated, none has ever had a license taken away," she explained. "The people who seek treatment get the help they need. Their prognosis is good; they have a lot going for them." More than 80% of all people with clinical depression who receive proper treatment significantly improve their lives, she added.

What can a resident who seeks help with depression expect? A thorough assessment by a mental health professional typically involves looking at factors such as a family history of depression. Pharmaceutical treatment may require several trials before the right medication and dosages are identified. "Since this can impair capacity, a resident needs to be responsible when engaging in a trial," said Dr. Pollack. Housestaff may need to be reassigned, switch rotations or take a leave of absence.

Finally, understanding depression in your colleagues can help you succeed in your clinical practice. "Many patients who see internists have an underlying emotional disorder that brings them to the doctor's office," said Dr. Pollack. "If you have gained empathetic understanding of depression, you will be able to better help them." And if the depression is your own, or that of a colleague, you need to know that getting help is a sign of strength and courage.

Christine Kuehn Kelly is a Philadelphia-based freelance writer specializing in health care.


Steps residents can take to recognize and get help with depression

Most depressed residents don't develop clinical depression but instead experience a transient depressed mood. Milder depression is characterized as a depressive disorder, mild dysphoria or an adjustment reaction.

How do you know when your depression is not transient? First, your feelings of depression won't result from an event such as a death in the family. Second, the depression is long-lasting. If three to four weeks have gone by and you are still depressed, it's time to talk to a mental health professional. You may be told to check back in a few weeks--or that immediate treatment is in order.

Mental health professionals say that residents dealing with depression should remember the following points:

  • Don't self-diagnose. Physicians have a habit of ignoring their own impairments and not seeking proper help, experts say. Self-medicating or getting a colleague to prescribe antidepressants is not an adequate treatment.
  • Get help from your residency program. Most training programs have a confidential, free counseling center for students and housestaff. Residency programs are doing a better job at being available and approachable when a resident is in distress, said Gregory A. Hood, FACP, a general internist at Southern California Permanente Medical Group in La Mesa, Calif.
  • Find a clinician you can trust. A psychiatrist or psychologist must earn your trust by being respectful and addressing your specific issues. William Pollack, MD, a psychiatrist who is an assistant clinical professor at Harvard Medical School, explained that good mental health care professionals will be open about their own emotional issues without burdening you. "He or she should be down-to-earth and direct," Dr. Pollack said. "Don't go to someone who turns you off."
  • Get help outside your institution. Residency programs often have arrangements with nearby institutions. Seeing someone outside your program will help you maintain your privacy.
  • Learn coping skills. Deal with stress by using coping mechanisms. It may be difficult, but you need to get enough rest, exercise and social support.

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