From the Editor
If you had depression, would you tell people?
This week’s Reading is a paper from General Hospital Psychiatry that considers just this question. In it, the authors surveyed American female physicians, asking about mental disorders and why they would or wouldn’t choose to get help – and to tell people.
Would you share your mental health history?
This paper is paired with an essay written by Dr. Nathaniel P. Morris, a Stanford resident of psychiatry, who mulls mental illness and disclosure – and has a big disclosure of his own.
Depression and Disclosure
“‘I would never want to have a mental health diagnosis on my record’: A survey of female physicians on mental health diagnosis, treatment, and reporting”
Katherine J. Gold, Louise B. Andrew, Edward B. Goldman, Thomas L. Schwenk
General Hospital Psychiatry, November-December 2016
Medicine is a stressful occupation and physicians and medical trainees have higher risk for burnout and for suicide than the general population. Research has shown that both male and female physicians have similar risk factors for suicide as the general population including depression and other mental health conditions but also are more prone to job stress as a risk factor. Studies also demonstrate higher rates of psychological distress among female medical trainees as well as higher rates of depression or history of depression. While a larger number of suicides are completed by male physicians, a meta-analysis showed a higher rate of suicide for men compared with the general population (1.41) but an even more pronounced risk for female physicians whose rate is even higher (2.27).
Stigma regarding mental illness among medical trainees and physicians is possibly greater than in the general population. Stigma surrounding mental illness has been documented repeatedly in the general population over the last 40 years and limits appropriate help-seeking and treatment in all populations, most especially in the medical field.
A unique barrier to successful diagnosis and treatment of mental disorders among physicians and other professional groups such as lawyers is that in many states, these professionals are required to report any mental illness diagnosis or treatment to their state licensing board.
So begins a new paper published in General Hospital Psychiatry. In brief: they surveyed female physicians about experiences with mental disorders, and then did statistical analysis.
Here’s what the authors did:
· The authors identified a Facebook group with 57,000 members, consisting of female physicians who were mothers.
· They advertised their survey with 4 invitations. The survey was open for 8 weeks (February to April 2016).
· The survey consisted of 20 quantitative questions and 4 brief open questions which: “covered the domains of knowledge and attitudes about mental health questions on state medical licensing applications, as well as personal mental health experience, treatment, and reporting.” The open questions focused on women who had a history of mental illness.
· Statistical analysis was done, including a chi-squared.
Here’s what they found:
· 2,364 participated in the survey but 255 women didn’t answer most questions, leaving a sample size of 2,109.
· Demographically: Most participants were in their 30s (60%), and many were in primary care (42%) – though surgery was well represented (31%).
· Asked if they felt that they ever met criteria for a mental health disorder: “919 (44%) of women agreed and 136 (6%) were not sure.” !
· In terms of the formal diagnosis and treatment: “Among the respondents 689 (33%) noted that they had been given a mental health diagnosis at some point since medical school, 959 (46%) reported that they had been treated for a mental health condition, and 1,009 reported either diagnosis or treatment.”
· In terms of disclosure to a state licensing board, 942 (46%) reported that they were unsure of what was required of them. Just 56 (6%) who had a mental illness actually did disclose it. (And the disclosure experience was varied. One physician wrote: “I think I just had to include dates of treatment and medications. I just remember reporting a summary of care and no further action was needed.”)
· “Two of every five physicians in this study who believed that they had met the criteria for a mental illness but had not sought treatment reported that one reason for this was that they did not ever want to have to report mental illness or treatment to a state medical licensing board.” Of course, reasons varied (see graph below), with the most common answer being “felt I could get through without help.”
· Statistical analysis didn’t show significance for age, but specialists (surgeons and pediatricians) were less likely to disclose.
To our knowledge, this is one of the few studies assessing barriers to mental health treatment among female physicians, and the only study to query physician attitudes and responses to mental health questions on state medical licensing applications. Half of the physicians in our study acknowledged prior diagnosis or treatment for mental illness since they had completed medical school but this was rarely disclosed to their state medical board.
The authors then go on to conclude:
This study emphasizes the critical role of stigma in deterring treatment for physicians affected by mental illness. The data also raise serious concerns about how questions on medical licensing applications and physician beliefs about the negative consequences of reporting may contribute to this stigma and reluctance in help-seeking.
Responding to this paper, Dr. Nathaniel P. Morris writes in The Washington Post. In “Why doctors are leery about seeking mental health care for themselves,” he talks about disclosure.
You can find here:
He explains: “When I was a medical student, I suffered an episode of depression and refused to seek treatment for weeks. My fears about licensing applications were a major reason I kept quiet. I didn’t want a mark on my record. I didn’t want to check ‘yes’ to those forms.”
He makes a few points about the reluctance of physicians to seek help:
· “A 2011 study found that more than 60 percent of surgeons who had experienced suicidal thoughts were reluctant to get help because of licensing concerns…”
· “[A] 2008 survey also found that nearly 20 percent of physicians with moderate to severe depression would not seek care out of fear of losing their medical licenses.”
Dr. Morris notes how he struggled with the issue of seeking help. He offers the justification for disclosure requirements, noting that state medical boards are supposed to keep patients safe. He wonders, however, if this is the right approach. “I’ve seen little evidence to suggest that broad screenings make patients safer, and studies tell us these questions deter doctors from getting help.”
In my case, after years of school and training, I’m preparing to apply for my medical license. The other day, I downloaded the lengthy application. Most of the forms are straightforward. They ask for proof of medical school graduation, test scores, addresses and the like.
Then, there’s a question about mental disorders. I pause.
Should I have kept quiet?
A few thoughts:
1. The Gold et al. study is interesting. It seeks answers to some basic questions.
2. The methodology – using a Facebook group – is certainly creative and modern. But it’s also unusual. Let’s set aside for a moment if the members of a female physicians’ Facebook group are representative of American female physicians. Even if they are, the response rate is under 4%. And Facebook users vs. the larger population of female physicians? We can assume that Facebook users are younger. And, indeed, that’s what the authors found: “94% of our population was between the ages of 30 and 59 while a recent analysis of licensed U.S. physicians reported 70% of female physicians were aged 30–59…”
3. An epidemic of non-care? “Two of every five physicians in this study who believed that they had met the criteria for a mental illness but had not sought treatment.” The authors are very focused on licensing boards, but the most common reason given for not seeking help was that “felt I could get through without help.” Say what you want about the methodology, the result is not dissimilar to the result of other studies in that it shows that many physicians need help but wouldn’t get it. When considering physician health issues in a past Reading, I’ve quoted Dr. David Goldbloom, the senior medical advisor of CAMH. His comment is worth repeating: “it is a sobering reminder that the white coat is not Kevlar against the illnesses we treat, and our professional culture still has a long way to go in recognizing, accepting and supporting that we get sick, too.”
4. Disclosure to licensing boards is a complicated issue, as noted by Dr. Morris: one that touches on personal privacy and societal accountability. (For a Canadian angle on this issue, my annual College renewal requires no disclosure of mental illness; the resident colleagues I work with at the Scarborough and Rouge Hospital must complete more revealing forms.) And Dr. Morris is right that even the best of intentions can lead to problems: mandatory reporting may discourage help seeking in some cases. That said, there is a larger societal accountability for a practicing doctor – it’s difficult to be a good clinician when a person is struggling with mental illness, after all.
5. I’d like to thank Dr. Michael Kaufmann for helping me understand these issues. Dr. Kaufmann is medical director of the Ontario Medical Association’s Physician Health Program (PHP). For the record, the PHP’s number is: 1.800.851.6606.
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.