The Hidden Epidemic: Major Depression in Physicians
by Leslie Stern Walker, MD
Today's Christian Doctor - Spring 2006
Dr. Smith,* three years in practice, says, with tears forming in her eyes, “I don’t know what to do. I’ve been having trouble staying organized, concentrating, planning ahead, making decisions—things like that. I can’t do more than one thing at a time, which is not normal for me. I mean, all my life I’ve been the ultimate multi-tasker. But now I feel like I’m in slow motion . . . and not just my brain, my body, too.
"I dread going to work, because I know I’m not as productive as the others. I feel lazy and incompetent when I see them all charging through their schedules and paperwork, while my pile of undone stuff just gets higher and higher. And I worry about what they think, so I’m on edge all the time, much more irritable and sensitive than usual. As a Christian, I know my relationships should reflect the peace of God and that I shouldn’t worry. So on top of everything else, I feel guilty, too. I try to leave it with the Lord, but it seems that my prayers aren’t even getting past the ceiling.”
“It sounds like you feel trapped,” I reply.
“Or stuck,” she nods. “Like there’s no way out of it or around it, except . . . .” She pauses, looking deeply into my eyes as if wondering if she can entrust this secret to anyone. “Except—and I never in my wildest imagination expected this thought to cross my mind—except the ultimate escape, you know, dying. Am I losing my mind?”
“No, but your brain definitely isn’t working properly. You’re describing symptoms of major depression. Doctors have a particularly high risk of getting major depression. In fact, our lifetime risk is between 40 and 70 percent. And you’re right to be concerned about those thoughts about death. Women physicians commit suicide at a rate about three times that of women in the general population.”
Dr. Smith looks startled. “I would never actually kill myself. I just thought I was overwhelmed and worn out.”
“I know. I have lots of physicians with mood disorders in my practice. But most doctors with these symptoms don’t realize that they have an illness. They often wait much longer than you have to seek help. By the time I see them, their jobs are at risk, or their marriages are in serious trouble.”
“I don’t want that to happen,” Dr. Smith replies. “What should I do?”
We start to review her history, and I see the relief in her eyes. I’m confident that we can make a plan to help her get healthy again.
Had someone told you before medical school that if you became a physician you would have at least a 40 percent chance of experiencing an illness that kills 10-15 percent of its victims, would you have paid attention? What if someone told you on your first day of residency that male residents have a 20-40 percent chance of having this illness during residency, and female residents have a 40-60 percent chance of experiencing its disabling symptoms? Would you take care, pay attention, watch out? What if you knew that this illness might wreck your marriage, make you impatient and frustrated with your kids, make you indecisive and unproductive at work, or increase your risk for cardiovascular disease? Would you try to prevent it? Or would you aggressively treat it if you found yourself ill?
Unfortunately, most physicians do not.
Self-Treatment is Not a Good Idea
Major depression remains a quiet struggle for many physicians and their families. In comparison to law students and business students, medical students are more likely to have a first-degree relative with a history of major depression. This family history may contribute to our higher rates of major depression compared to colleagues in business and law. High stress and sleep deprivation may also play a role. Many of the traits that make us good doctors, like introversion, ability to delay gratification, and willingness to assume responsibility, are traits that also seem to correlate with an increased risk for major depression. But as doctors, we are trained to ignore our own symptoms in the need to care for others. Whether we are exhausted, angry, or grieving, we learn quickly that we are not to complain or slow down. The net result for a physician or medical student with major depression is delay in identification of the illness and even longer delay in seeking treatment.
Part of the problem is that so many of the DSM-IV symptoms can be attributed to normal aspects of medical practice, particularly during training and in specialties that demand long and unpredictable hours. Sleep deprivation alone can contribute to irritability, poor concentration, low energy, and low motivation and interest in doing activities we normally enjoy. The doctor whose wife wonders if he’s depressed says, “I’m just tired. It’s a stressful job.” He is unlikely to see the symptoms that are obvious to me: the hopelessness and sense of being trapped that make him want to quit, the dread that wakes him up early, the irritability that gets him in trouble with staff and family.
Most physicians learned a mnemonic for several of major depression’s cardinal symptoms according to the DSM manual. Perhaps you learned SIGECAPS: change in SLEEP, loss of INTEREST, abnormal GUILT, decreased ENERGY, decreased CONCENTRATION, change in APPETITE, PSYCHOMOTOR agitation or retardation, and thoughts of death or SUICIDE. These are a good starting point, but most of my physician patients are soldiering bravely on despite many of the symptoms, often able to put on a “game face” at work even though they work harder and harder to do their daily tasks. It’s at home where they may break down, as normal tasks become increasingly difficult, and lower frustration tolerance makes them unable to put up with normal family life.
However, many physicians with major depression lack the insight or energy that would be required for self-diagnosis. They are doing their best to do their work without inconveniencing others. And even if they consider the possibility that they may be depressed, the barriers to evaluation and treatment are significant. Taking time to see a doctor, especially a psychiatrist, seems too much of a burden. And what if other physicians or patients knew of the depression? Would they lose referrals or patients? It seems easier to do a quick curbside consult. Why not just self-prescribe the Zoloft and see if it works, or even better, grab a few samples from the cabinet? Besides, mental health care may require phone calls for preauthorization, or private information to be released through treatment planning forms. For busy medical students, residents, or practicing doctors, these burdens may seem insurmountable, so the symptoms continue to worsen and treatment is delayed.
Depression and Faith
For Christian physicians, the church may interfere with identification and treatment of depression. While most American evangelical Christians today would probably agree that schizophrenia or mania are clearly illnesses of the brain requiring medications, major depression has no such consensus. (Anxiety disorders are often seen in a similar light, as spiritual struggles and not brain illnesses.) Christians sometimes blame those with depression for not having enough faith, not praying enough, not trusting God to pull them through, or not confessing sin. I now recommend the award-winning CMDA/Zondervan book, New Light on Depression, to many of my patients, because it provides such a helpful perspective on the causes and treatments of major depression in Christians.
Other Christians suggest that God will use the “dark night of the soul” to cleanse and purify, so taking medications might interfere with the process, or that remission through medical treatment is inferior to remission gained by more spiritual means. It is clear than divine providence can use bad situations for good, so enduring illnesses such as cancer or lupus may certainly draw a Christian closer to God and bring her to a new level of spiritual maturity. But none of us would suggest not treating the cancer or the lupus! It’s the same with major depression. Some Christians may come through an episode with a deeper sense of God’s protection or a new understanding of purpose, but I don’t expect them to get there until I’ve treated aggressively first.
Most Christians with major depression experience a sense of distance from God. They no longer experience God’s presence during prayer or Scripture or worship. They often feel unworthy, guilty, and unforgiven, and they may lose the sense of God’s love and protection. These seem like spiritual struggles, and sometimes they are, but in Christians with major depression they are symptoms resulting from a dysfunctional brain. Until the depression lifts, that brain causes the depressed person to view all of life as bleak, hopeless, and futile. This injures relationships with spouses, family, friends, and God.
At the worst, when thoughts of death seem to be the only option to a life of such suffering and pain, Christians again blame the person with depression for lack of faith and hope. Instead, we need to come alongside that person and consider aggressive and immediate medical treatment for a life-threatening brain illness that renders the severely depressed person unable to see the possibility of recovery.
Many Christians who do recover from major depression using medications and psychotherapy are reluctant to admit it. Christians who describe success in resolving spiritual struggles over depression and anxiety without medications may intimidate others who have recurrent major depressions, or chronic anxiety disorders like obsessive-compulsive disorder. It still seems hard to see those problems as illnesses of the brain when demoralization and anxiety are so common to the human experience.
Christian doctors have the same problem. We agree that pathology in the brain causes strokes and Parkinson’s disease and multiple sclerosis, each of which carries approximately a 40 percent risk of major depression. We can identify and treat major depression in our patients. But we don’t like to consider our own brains as potentially dysfunctional, even though we have at least a 40 percent risk of major depression just by virtue of being physicians!
Finding Hope and Joy Again
The road to recovery from an episode of major depression is usually multi-faceted. Mild episodes may resolve with supportive psychotherapy or counseling, regular exercise, improved nutrition, and help with limit-setting in unhealthy work environments or difficult relationships. Moderate or severe episodes are more likely to require medications, and patients with psychotic symptoms or acute suicidal thoughts may require hospitalization and sometimes electroconvulsive therapy.
I remind patients that medications are often very helpful, but their job is limited. Medications help a dysfunctional brain, but major depression (perhaps even more than cancer or lupus) also affects the soul. Medicines often start the process of recovery, helping someone who has felt trapped and stuck to see new options and rekindle a sense of hope. Psychotherapy, sometimes including marriage counseling, may also be necessary to help individuals learn to set healthy boundaries in work and relationships.
But the ultimate hope of recovery from any illness lies only in Jesus Christ. I encourage patients to try to keep “going through the motions” of prayer, worship, and reading Scripture even when they can’t sense God’s love or presence. We never know at what point God’s love will break through the depression, allowing someone who has felt worthless and unlovable to feel the tender touch of the Lord again, or sometimes for the very first time. The body of Christ is also very important during major depression. There is no substitute for family and friends who pray with and for the depressed person. We also should help in tangible ways with cooking and cleaning and child care, and we should support life changes that allow for rest and a more reasonable work schedule.
Isaiah 61:3 describes the transformation that the Lord ultimately wants to work in all of us: “. . . to bestow on them a crown of beauty instead of ashes, the oil of gladness instead of mourning, and a garment of praise instead of a spirit of despair.” My hope is that if you are experiencing the symptoms described in this article, or if you see them in someone you know, you will consider the possibility of major depression. The sooner you get help, the sooner you may return to the abundant life that Jesus Christ wants you to have.
*Identity is disguised. Case is a composite.
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A Challenge to Licensing Boards: The Stigma of Mental Illness. Miles SH. JAMA 1998; 280: 865.
White Coat, Mood Indigo: Depression in Medical School. Rosenthal JM and Okie S. NEJM 2005; 353(11):1085-8.