My response to a colleague who says, “I am depressed,” is critical for many reasons. As doctors have tough masks, it has been difficult for my colleague to disclose this. Due to mental illness stigma in the medical profession, this doctor may have been suffering quietly for some time and could be at risk, perhaps self-medicating with antidepressants, benzodiazepines or alcohol.
When I am the treating doctor of another doctor, listening is my most powerful skill because the presenting problem is usually not the main reason for the consultation. Often a doctor-patient will cry when I ask them how they feel because no one usually asks them this question or takes time to listen to the answer. It is a relief for doctors to disclose their stories of grief, trauma, frustration, and injustice.
When I take a history, I keep this framework in mind to ensure I have covered all aspects of a comprehensive mental health assessment.
1. Address common risk factors
Doctors have the same risk factors for mental illness as the general population. Unsurprisingly, doctor patients may have chronic illness or pain, negative life experiences and relationships, fractured family structures, family histories of mental illness, alcohol and substance misuse, violence, suicide, and child abuse. These histories can be triggered repetitively when doctors are caring for their own patients with these common problems.
Also, we often have a perfectionist, self-critical, hyper-vigilant and task-oriented personality styles that make us great doctors but put us at risk of failing our impossible expectations. When doctors become aware that their personality strengths can also be vulnerabilities, they allow themselves to set healthy boundaries and become even stronger than before.
Patients need doctors who are caring, dedicated and healthy — not selfless.
2. Recognize a mixed pattern of atypical symptoms
Doctor patients may present with a mixed pattern of atypical symptoms related to depressive disorder, anxiety disorder and post-traumatic stress disorder due to acute and chronic exposure to patient trauma, violence, abuse, and death, including suicide.
Atypical symptoms include uncharacteristic irritability or anger, difficulty concentrating or making decisions because of excessive worry, lack of empathy, social withdrawal and/or fatigue or low energy due to insomnia.
3. Ask the hard questions
It is important to cover the other aspects of a comprehensive mental health history in detail — past history, family history, past/current medication, developmental history, education, work history, social history, suicide risk, past, and current suicidal thinking.
As suicide is more common among doctors than in the general population, doctors are frequently traumatized by a colleague’s death and then placed at risk of suicide themselves. It’s not easy to ask my doctor patients this question: “Many people who are under extreme pressure feel like harming themselves. Have you ever felt this way?” Doctors have easy access to means, and ongoing suicide risk assessment is critical.
4. Overcome the special pitfalls of management
It’s easy to fall into the trap of providing brief telephone follow-up or repeat prescriptions for doctor patients too busy to attend in person. Ongoing face-to-face care is required to prevent a relapse of mental health problems in any patient.
Doctors are trained to “overthink” and have well developed negative mental filters and negative cognitive biases. Being risk-averse is part of being a good doctor. It is not easy to overcome these inherent traits by challenging negative thinking with the usual cognitive behavioral therapy techniques. Structured formal mindfulness-based cognitive behavioral therapy is an effective treatment for depression in these situations. Antidepressant medication may also be required.
Although doctors tend to take very little sick leave, many medical workplaces fail to support doctors when they request a lower patient load or time off work. Sometimes, my doctor patients require my support to take sick leave because of their fears for their career if they disclose mental health problems to their employer. Unfortunately, these fears about discrimination are often justified.
A doctor with a gynecological/urological or gastrointestinal problem is not required to divulge their symptoms to their employer, although these temporary symptoms may prevent them from working. Similarly, no employer has the right to ask about a doctor’s mental health symptoms. Doctors who have insight seek help and comply with treatment for any physical or psychological condition, continue to provide a high standard of patient care, but sometimes at great expense to themselves unless they take time off work for a while. In this scenario, the necessary certificate can be supplied directly to the medical workplace by the treating doctor without divulging the medical reasons for the temporary absence.
5. Advocate for a kinder, fairer medical workplace
Our harsh medical culture predisposes doctors to have mental health problems. Recommending information about resilience to doctors for complex issues such as workplace bullying, harassment, discrimination, racism and patient complaints or medico-legal action is as foolish and harmful as trying to fix a displaced compound fracture by covering it with a dressing.
Negative conditions at work must be addressed routinely as part of a comprehensive mental health management plan. As a profession, we can change this by stepping outside our consulting rooms to provide advocacy and leadership.
High-quality health consumer-centered care requires doctors to tailor treatments to the individual needs of their patients. Our doctor patients also require tailored treatment for their special needs. As treating doctors, we are skilled at adjusting our consultation styles to the level of health literacy of our diverse patients. For our doctor patients, we can appropriately adjust our approach to their high level of mental health literacy.
There is a high level of stigma surrounding mental illness, which is deterring access to early mental health treatment and contributing to rising suicide. The medical profession has a responsibility to dispel this stigma rather than to perpetuate it, and to encourage all patients to access optimal mental health care, including doctor patients.
When anyone says “I am depressed,” simple reassurance is not enough, but a willingness to listen fully can be a powerful skill.
Image credit: Shutterstock.com