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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Re: The Stigma of Depression in Physicians
Physician, Please Don't Heal Thyself!
The Stigma of Depression in Physicians
Author's response to "Personal belief that not all Suicide is Depression."
Personal belief that not all Suicide is Depression.
A call to arms
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Jennifer L Middleton, Pittsburgh, PA Family Medicine Faculty Development Fellow
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Dr. Schwenk is indeed the referenced speaker; in retrospect, I should have acknowledged him specifically as such in the manuscript (and not just have cited the relevant reference), and I offer my apology to him for my oversight. I sincerely thank him for adding his considerable insights and resources to this online forum for all to share. Competing interests: None declared |
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Mick Oreskovich, Seattle, USA Addiction Psychiatrist, Medical Director and CEO, Washington Physicians Health Program
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Over the past twenty years, our physician health program in Washington state has monitored nearly 800 physicians with potentially impairing conditions. In the past four years, we have seen a tremendous spike in the incidence of mood disorders and are currently monitoring several physicians (20) following their near-lethal suicide attempts. Most of these fellow physicians had never received treatment for a mood disorder and had no idea of the severity of their episode. For the most part, they were self-diagnosed and self-treated. With two exceptions they were working in the 24 hours preceding their attempt. Several excellent educational resources have been developed since the JAMA consensus panel in 2003. Examples are the "Struggling in Silence" DVD by the American Foundation for Suicide Prevention and the excellent book on "The Physician as Patient" by Drs. Myers and Gabbard. From our experience, we have come to believe that physicians will be more inclined to take advantage of these resources if they become aware of their own vulnerability for the development of a mood disorder. Accordingly, we are developing a confidential online self-assessment survey of at-risk behavior which will give instant feedback to the physicians who are taking the survey and link them to both the educational resources and the clinical resources available in their community. Congratulations to Dr. Middleton for her powerful and poignant essay which leaves us with the compelling realization that we are our brothers' and sisters' keeper! Competing interests: None declared |
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Thomas L. Schwenk, Ann Arbor, MI USA Department of Family Medicine, University of Michigan
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I believe that I am the visiting professor to which Dr. Middleton refers in her important and well-written essay. Her personal reactions and observations highlight the very special, very powerful, and potentially very tragic nature of depression and suicide in physicians. The issues surrounding the physician who is also a patient (or the patient who is also a physician, as you choose to see it) are increased in both complexity and intensity when the medical issue is depression. We have recently published a survey of physician experiences with depression relative to medical staff and medical licensure sanctions (Schwenk TL, Gorenflo DW, Leja LM. The impact of depression on the professional status and mental health care of physicians. J Clin Psych, 2008;69:617-620.) It is clear that however much we have reduced stigma with regard to patients who are depressed, physicians who are depressed are still viewed differently than are physicians with other chronic medical illness. This stigmatization leads to inappropriate and dangerous behaviors up to and including self-prescription of antidepressants. We have a significant, and to date mostly unmet, responsibility to our profession, our patients, our colleagues, and ourselves, to address the issue of stigma in physicians who are depressed, so as to improve the quality of care and clinical outcomes, in particular reducing the likelihood of the type of tragedy described so well by Dr. Middleton. Competing interests: None declared |
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Jennifer L Middleton, PIttsburgh, USA University of Pittsburgh Department of Family Medicine faculty development fellow
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I thank Dr. Peschke for his response. I agree that I am certainly often guilty of assigning myself more control over others' outcomes than I actually have. In light of information I learned after my colleague's death (was seeking treatment for depression, as I alluded to in the piece), though, I respectfully reject the suggestion that my colleague may have committed suicide as a rational and non-illness-related act. I prefer to leave the debate over the existence of the "rational suicide" to others; we should focus our energies instead on providing high-quality, non- stigmatized mental health care for our professional colleagues, which is a need I hope we all can agree on. I concede that all suicide may not be depression, but that does not allow us to abrogate our responsibility to our suffering peers. Competing interests: None declared |
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Scott R. Peschke, Plymouth, WI USA Family Physician
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It is natural for physicians to ask themselves; "Is there anything I could have done to prevent this suicide?". Perhaps this was the deep desire of the physician, which if known to us, we would have done everything in our power to stop, even against their wishes. Some people subtly commit suicide when they smoke, drink and drive, or make other poor lifestyle choices. There may also a conscious choice some people make, like the old eskimo walking out into the snowstorm when food is becoming scarce, allowing the younger family members to survive. For some people it is a relief to get their affairs in order, provide for their familiy and make an informed decision for death, especially if they percieve a future which is not a life which they would want to lead. This certainly becomes more ethically challenging when a patient asks a physician to become involved in their death process whatever form it takes. I think that sometimes we do a disservice to our patients by not being able to assist, and thereby hasten their suicide, while they still are able to do so "by their own hands". Physicians certainly have the capability to be more effective than most, even without assistance. We assume that no one can wish for death like a "Catch 22" scenario; To wish for death means one is depressed and therefore not rational. As physicians we are trained to feel as though we are responsible, which although it is noble, it is also controling. Control is an illusion, and death is inevitable, the rest is all about timing. Competing interests: None declared |
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Michael F Myers, Vancouver, Canada Clinical Professor Psychiatry University of British Columbia
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Kudos to Dr Middleton for speaking out about such a tragic subject as physician suicide! As she so eloquently highlights, shame and stunned silence eclipse normal mourning when our medical colleagues kill themselves. I learned this first hand in 1962– my classmates and I buried ourselves in anatomy and biochemistry, when a fellow medical student and my room-mate asphyxiated himself over a long holiday weekend. As a psychiatrist and specialist in physician health, I not only have lost doctor patients to suicide but also hear regularly about doctors dying by suicide in medical communities across North America. Their families and health professional colleagues are shattered (1, 2) as are their patients (3). Depression (and substance abuse or dependence) are the most frequent underlying illnesses (4,5). So often these common maladies go untreated or are undertreated when the patient is a physician. Treatment adherence is patchy given the embarrassment associated with these disorders in doctors. As Dr David Satcher, former US Surgeon General, so smartly wrote “Suicide prevention is everyone’s business”. That includes each and every one of us in the house of medicine! Let’s tell our stories, fight stigma and reach out to each other. That will ease the suffering and isolation – and save lives. References: 1. Myers MF, Gabbard GO: The Physician As Patient: A Clinical Handbook for Mental Health Professionals. American Psychiatric Publishing, Inc., Washington, DC 2008 2. Myers MF, Fine C: Touched by Suicide: Hope and Healing After Loss. Gotham/Penguin Books, New York, 2006 3. Myers MF: Physician suicides leave many victims in their wake. Editorial. Winnipeg Free Press. October 1, 2006 4. Myers MF: Physicians Living With Depression (videotape). American Psychiatric Publishing, Inc., Washington, DC 1996 5. Myers MF: When Physicians Commit Suicide: Reflections of Those They Leave Behind (videotape). Media Services St Paul’s Hospital Vancouver BC. 1998 Michael F Myers, MD Vancouver, BC Canada E-mail: myers@telus.net Competing interests: None declared |
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