From the Editor

Today, we talk more about physician mental health problems than even a few years ago. But what would meaningful action look like? What are the evidence-based interventions?

Katherine Petrie (of the University of New South Wales) and her co-authors attempt to answer these questions in a new Nature Mental Health paper. They did a systematic review and meta-analysis by examining 24 studies involving almost 2 400 practicing physicians. “Our results indicate that a range of physician-directed interventions produce positive effects on symptoms of common mental disorders and that these moderate effects are maintained over time (up to 12 months).” We consider the paper and its implications.

In the second selection, from BMJ Mental Health, Yusen Zhai (of The University of Alabama) and co-authors draw on US survey data to look at trends of clinically significant anxiety, depression, suicidal ideation, and service utilization among medical students. The findings are troubling. “This study reveals a rising prevalence of clinically significant anxiety and depression self-reported by US medical students from 2018 to 2023.”

Finally, in the third selection, Ph.D. candidate Alexandra K. Rodriguez discusses her struggles with severe depression when she attended medical school. In a personal essay for PLOS Mental Health, she speaks about her recovery and the power of the arts. “When I dealt with suicidality, I could not conceptualize a future, let alone one with meaning. Sharing time creating with friends and singing lyrics that resonated with me helped me reframe my lowest period as an inflection point, one from which I could envision both fulfillment and joy.”

DG

Selection 1: “A systematic review and meta-analysis of interventions to reduce or prevent symptoms of common mental disorders and suicidality in physicians”

Katherine Petrie, Mikayla Gregory, Daniel A. J. Collins, et al.

Nature Mental Health, 9 July 2025

Physicians have elevated rates of common mental disorder (CMD), specifically depression and anxiety, and are at increased risk of death by suicide compared with all other professional groups and the general population. Despite the increasing awareness of mental ill health among physicians, there remains a lack of clear evidence and guidance regarding which, if any, interventions are able to effectively reduce the burden of mental ill health among this group of health professionals.

In 2019, we published a systematic review and meta-analysis that examined the effectiveness of interventions in reducing symptoms of CMDs and suicide among physicians. The review found a concerningly small evidence base overall and an absence of controlled studies examining organizational-level interventions. In the 5 years since the publication of this study, several major events have occurred that have shaped the research landscape and the working lives of physicians, the most obvious being the global COVID-19 pandemic…

In addition to the changing landscape in light of COVID-19, there is now an improved understanding of the multifactorial nature of physician mental health and the complex interaction between individual, job-, organizational- and system-level factors within medicine. Furthermore, the importance of addressing workplace factors alongside individual factors for employee mental health is now well established, with recent international guidelines recommending a multi-level intervention approach as best practice in establishing a mentally healthy workplace.

So begins a paper by Petrie et al.

Here’s what they did:

  • They conducted an “updated systematic review and meta-analysis on the effectiveness of interventions for reducing or preventing symptoms of common mental disorder (CMD) and suicidality among physicians.” 
  • They searched different databases, including MEDLINE, for “randomized and non-randomized controlled trials of interventions to reduce or prevent depression, anxiety, general psychological distress or suicidality among physicians.” 
  • The primary outcome: differences in symptoms of CMD following intervention. 
  • Random-effects meta-analyses and subgroup and sensitivity analyses were conducted. 

Here’s what they found:

  • 24 studies were included in the qualitative synthesis; of which, 21 were part of the meta-analysis. They involved a total of 2 336 currently practicing physicians.
  • Physician demographics. The mean age was 34.8 years with variable gender distribution (8 – 71% male), but included one all-female sample. 
  • Studies. 20 studies were physician only. The majority of studies was conducted in high-income countries (22 in total), most commonly in the US (50%). They focused on depression (14 studies) and anxiety (12).
  • Interventions. They included psychoeducation, mindfulness, and CBT.
  • Effect size. “Compared with controls, physician-directed interventions significantly reduced symptoms of CMD among physicians at post-intervention (standardized mean difference 0.45…) and follow-up with a small to moderate effect size.”
  • Intervention types. “Preliminary findings suggest that group-based, face-to-face and skills-based interventions show promise for reducing symptoms of CMD among physicians.”

A few thoughts:

1. This is a good study, looking at a relevant and under-studied problem, and published in a good journal.

2. The main finding in three words: the interventions worked.

3. To be a bit more specific: skill building care (like CBT) helped more than psychoeducation. The authors note that: “Our finding that interventions based on skills development were effective in reducing symptoms of CMD while psychoeducational approaches, in general, were not, is consistent with literature in other high-risk occupational groups and in the general working population.”

4. They see practical implications. “The direct and indirect costs of physician ill health to the health-care system (for example, presenteeism, absenteeism, turnover) should be a key consideration in this decision-making process and the use of protected time or continuing professional development points may be a means to encourage adherence and ensure program completion.”

5. This paper is new and fresh and on an important topic. And it represents an important step in the right direction. But is this the needed first step to successfully addressing physician mental health problems? After all, physicians with, say, depression respond to treatment – like everyone else. The larger problem isn’t that physicians aren’t human, so much as that we often like to think we aren’t. When commenting on physician mental health, Dr. David Goldbloom has quipped: “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.” Is the larger challenge then finding interventions that work – or changing the professional culture itself?

6. Like all studies, there are limitations. The authors note several, including: “the studies were heterogeneous in terms of outcome measure, intervention approach and delivery, which limits the extent to which broad conclusions can be drawn about the overall effectiveness of physician-directed interventions for CMD among physicians.”

7. Past Readings have considered physicians and health. Recently, we looked at a JAMA Network Open study that, drawing on a national survey of US docs, analyzed vacations, work during these vacations, and burnout. Spoiler alert: you should spend more time with the hammock if you are taking a break this August, and less time with the laptop. That Reading can be found here:

https://davidgratzer.com/reading-of-the-week/reading-of-the-week-ptsd-among-9-11-responders-the-new-nature-study-also-therapy-isnt-psychotherapy-and-physician-vacations-burnout/

The full Nature Mental Health paper can be found here:

https://www.nature.com/articles/s44220-025-00450-2

Selection 2: “Trends in clinically significant anxiety, depression, suicidal ideation and service utilisation among US medical students, 2018–2023”

Yusen Zhai, Laurence M. Boitet, John Soldner, et al.

BMJ Mental Health, 26 May 2025

Medical students face unique challenges in navigating the stressors of their training environments. Compared with their peers in other fields, they experience disproportionately higher rates of anxiety and depression. These mental health symptoms contribute to burnout, increased suicidality risk and threats to academic achievement, long-term career sustainability and clinical performance, ultimately impacting patient care and outcomes. External factors, such as the COVID-19 pandemic, further exacerbate anxiety and depression, highlighting the critical need for addressing medical student well-being to safeguard the future of healthcare. However, persistent barriers to help-seeking, including stigma and limited access to care, may contribute to treatment gaps.

So begins a short report by Zhai et al.

Here’s what they did:

  • They analyzed five waves of the Healthy Minds Study between the years 2018 and 2023. 
  • “The survey, administered throughout the academic year, collected data from US universities with diverse institutional and geographic characteristics for better representativeness.”
  • Study outcomes: clinically significant anxiety (more than 8 on a GAD-7), depression (more than 10 on a PHQ-9), past-year suicidal ideation (a yes-or-no question about suicidal thoughts), and current counselling use (a yes-or-no question about receiving counselling or therapy). 
  • They did analyses, including calculating prevalences. They also did multivariable logistic regression, adjusting for demographics.

Here’s what they found:

  • The sample included 5 313 students enrolled in MD programs.
  • Demographics. The mean age was 25.6 years and most participants were female (52.2%). Many were White (42.1%). 
  • Anxiety, depression, and counselling service utilization. Between 2018 and 2023, the prevalence of anxiety increased by 12.3 percentage points (from 21.6% to 33.9%), depression increased by 13.1 percentage points (from 14.0% to 27.1%), and counselling service utilization also rose by 17.2 percentage points (from 6.7% to 23.9%). “These upward trends remained statistically significant even after adjustment for participants’ demographic differences.”
  • Suicidal ideation. “Suicidal ideation prevalence remained relatively stable over the same period.”

A few thoughts:

1. This is an interesting and important study published in a good journal.

2. The main finding in a sentence: “The prevalence of anxiety and depression among US medical students have increased since 2018, paralleled by more but still insufficient counselling utilisation, suggesting a persistent treatment gap.”

3. Ouch.

4. The glass is both half full and half empty: “we observed a nearly threefold increase in counselling service utilisation, which could be attributed to greater awareness and improved accessibility of mental health resources. However, a gap remains between service utilisation and the prevalence of anxiety and depression, suggesting reluctance to seek care. This may be due to stigma, limited access to services or misattribution of symptoms to the inherent stress of medical school.” Circling back to my comments about the last selection, is part of the problem the professional culture itself, even among our students?

5. Like all studies, there are limitations. The authors note several, including “retrospective, self-reported data might introduce recall bias; however, the tighter timeframe (ie, past 2 weeks) used for the GAD-7 and PHQ-9 made the responses less susceptible to such bias.”

The full BMJ Mental Health short report can be found here:

https://mentalhealth.bmj.com/content/28/1/e301528

Selection 3: “Arts engagement for mental health: A strengths-based opportunity”

Alexandra K. Rodriguez

PLOS Mental Health, 7 July 2025

In October 2020, I faced a near suicide attempt that led to my first hospitalization. My lifelong struggle with severe anxiety and depression had reached an unprecedented peak, manifesting in both psychological and physical ways. My subsequent reality felt insurmountable. At the time, I was in my first year of medical school. While I was not faltering in my coursework, the lack of joy and balance in my life propelled my struggle with mental illness into an unprecedented space. As someone of Puerto Rican heritage, and knowing I was on track to become the first in my family to earn a doctorate, taking a leave of absence from medical school felt like a loss not only for myself but also for my family and broader community.

After recovering and returning home, the challenges remained. I experienced an absence of hope in the weeks and months following. I deeply felt that there was no path forward for me. In hindsight, I can see I was grieving the loss of a path I had envisioned for myself since early childhood. In addition to a perceived loss of purpose, the coming months consisted of new struggles heightened by navigating medication regimens and therapists.

Time spent engaging in the arts were the few distinct moments I can remember during that period that brought me any sense of levity.

So begins a paper by Rodriguez.

“The opportunity to return to medical school within a two-year window gave me the room to think – and breathe. I chose to use this time to pursue a master’s in public health, a degree I had intended to pursue later in my career. During that first semester, I began to engage in research with the University of Florida’s Center for Arts in Medicine, a place where I found a deep sense of purpose. During my undergraduate studies, I minored in Theatre, but I had never considered how I could merge that passion with my health focused career trajectory. I quickly realized that pursuing research at the intersection of arts and health allowed me to step into spaces as my whole self. In 2021, I engaged in work for the Centers for Disease Control and Prevention under Dr. Jill Sonke where we considered how the arts could be engaged to build both trust and confidence in COVID-19 vaccination.”

She notes the personal tie. “As my engagement continued, it became clear how my personal experience with the arts in supporting my mental health helped me to realize an alignment in passion and purpose as an artist and researcher. As I became more engrained in the work, a PhD in public health with a focus on arts and health became a path with intentionality and meaning that I was unable to vision for myself before.”

She reviews the literature and some projects:

  • “The World Health Organization’s review of the field and the epidemiological evidence built out by the EpiArts Lab has catalyzed research within the arts in public health space… research has shown that adults over the age of 50 who visited cultural venues every few months had a 32% lower risk of developing depression over 10 years.” 
  • “Internationally, public health grounded practices, such as arts prescribing, a form of social prescribing, have further mobilized opportunities for mental health support as it connects patients via referrals to arts engagement from their medical providers…”
  • “Arts for adolescent mental health is a burgeoning sub-field which offers promise both in relation to mental health promotion as well as treatment and management of mental illness. The literature has shown that arts engagement can reduce the risk of developing multiple forms of mental illness, such as depression, in adolescence as well as in older age.”

“As someone whose struggle with severe depression and anxiety began in adolescence, the concept that arts engagement can provide support for self-expression and emotion regulation – preventative or rehabilitative strategies for managing forms of mental illness – felt deeply compelling.”

She is now a Ph.D. candidate and has helped co-author a WHO report. “My mental health and wellbeing have been supported by the intentionality of my practice, its alignment with my strengths, and by prioritizing the creation of joy for myself and others.”

A few thoughts:

1. This is a thoughtful essay.

2. She is blunt and honest about her personal experiences.

3. We often reduce recovery to concepts like behavioural activation. There is a small but growing literature for interventions like exposure to nature and connecting with the arts. Do we need to be more imaginative with the patients in our care?

The full PLOS Mental Health paper can be found here:

https://journals.plos.org/mentalhealth/article?id=10.1371/journal.pmen.0000369


Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.