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Destigmatizing Depression

It's not easy being the poster child for depressed physicians, but Alice Flaherty wears the role with aplomb. She relishes the opportunity to share her experiences with the world. Flaherty was featured in a recent article in The New York Times and in a documentary film on depression among medical professionals produced by the American Foundation for Suicide Prevention (AFSP), and she openly discussed a major depressive episode that eventually hospitalized her in her 2004 best-selling book, The Midnight Disease: The Drive to Write, Writer's Block, and the Creative Brain.

"People with mental illness have much less insight than they would normally. I've seen this over and over again with healthcare professionals that as soon as they get depressed they explain it away as unworthiness or something else." --Alice Flaherty

Flaherty speaks in a rapid-fire staccato about her still-born twin sons, lost after a difficult pregnancy more than 10 years ago, as she was about to start the residency portion of the Harvard-MIT M.D.-Ph.D. program. A postpartum depression morphed into mania and an eventual diagnosis of bipolar disorder. As a psychiatrist in training, Flaherty was fascinated by her own disease and began speaking publicly about her travails. During that time, she was approached by her peers and discouraged from talking about her mental illness.

Alice Flaherty will answer your questions about depression throughout October on CTSciNet, the Clinical and Translational Science Network, in the discussion group, "Maintaining Your Mental Health."

"One thing that appalled me is how many doctors told me I should hush it up," says Flaherty, who today is an assistant professor in the Neurology Department at Harvard Medical School in Boston and directs a fellowship program at Massachusetts General Hospital.

She didn't listen. And as she reached out, she found that her experiences resonated with other students who were isolated, enveloped in their own malaise. They began to seek her out and share their own experiences with depression. Their stories convinced her that there was an undercurrent of depression among a significant portion of her profession that no one wanted to talk about publicly.

"The more I talked, the more I met all these people who were saying, 'Oh yeah, I had all these problems when I was a resident or when I got my first job.' And they had never talked to anybody, so it was a sort of a relief for them that I was out of the closet," she says.

A common problem

(Courtesy, Alice Flaherty)
Alice Flaherty

Depression among medical trainees is well-documented. A recent large-scale survey of medical students and residents at six major medical schools revealed that one in five have mild to severe depression, a rate 15% to 30% higher than the general public. One out of every 17 even said they had thought about suicide. The study, reported in the journal Academic Medicine in February, brought to the fore the problem of depression among students immersed in the rigors of medical training.

"Certainly, medical school, residency, Ph.D. training, all those kinds of advanced degrees are set up with a lot of expectations, and by and large the people that are doing them are driven," says Deborah Goebert, a psychiatrist at the University of Hawaii, Manoa, and lead investigator of the study. These stressors, along with lack of sleep, financial concerns, and family pressures, can push people into an episode of clinical depression, she says.

Goebert says she initiated the study because an internal, anonymous survey of medical students at the University of Hawaii had revealed high rates of depression and suicidal thoughts, as well as a reluctance to seek counseling, despite the availability of a student counseling service. Goebert says the university actually stopped that study because of the alarming rate of depression and immediately began brainstorming ideas to address it. Within a year, they had set up a confidential service geared for medical students. The medical school now includes, throughout the curriculum, an explicit emphasis on the role of well-being, she says. The investigators are planning a follow-up study to measure the impact of the school's interventions.

(Courtesy, Liselotte Dyrbye)
Liselotte Dyrbye

A similar study that specifically addressed the relationship between burnout and suicidal thoughts found half of the 4287 surveyed medical students were feeling burned out and 11% had thought about suicide in the previous year, a figure substantially higher than that in the general population.

"It's sort of like you are standing on a diving board as a medical student and you are right at the end and you are doing okay, but then something happens in your personal life and you just tip over," says Liselotte Dyrbye, an internist at the Mayo Clinic in Rochester, Minnesota, and lead investigator of the study, which appeared in the Annals of Internal Medicine.

Recognizing Symptoms of Depression

According to AFSP, the core symptoms of depression are depressed mood or loss of interest or pleasure in usual activities during a 2-week period, as well as:

• change in appetite or weight

• change in sleeping patterns

• speaking and/or moving with unusual speed or slowness

• decrease in sexual drive

• fatigue or loss of energy

• feelings of worthlessness, self-reproach, or guilt

• diminished ability to think or concentrate, slowed thinking, or indecisiveness

Diagnosing depression among medical or doctoral students is often difficult because they "are all so tough and high-functioning," says Christine Moutier, a practicing psychiatrist and assistant dean for student affairs at the University of California, San Diego (UCSD), School of Medicine. "You can't use the usual standard of being disabled by symptoms. You have to use other measures such as how much distress there is, how much energy is this [depressed feeling] taking up, what's the severity of what they are dealing with internally, because usually it is hidden from their functional world."

Telling symptoms within the medical community include:

• low sense of personal achievement and loss of connection to and sense of meaning in one's work

• pessimism and cynicism

• depersonalization of patients and feeling emotionally exhausted by patient interactions

Source/additional information: American Foundation for Suicide Prevention


One problem is that the culture and environment of graduate and medical schools often discourage the acknowledgment of mental illness--and, by extension, discourage seeking treatment, says Laurie Raymond, director of the office of advising resources at Harvard Medical School. She says that, of the 250 to 270 medical students she counsels per year, about 45 of them are diagnosed with mild to severe depression. She has counseled graduate students in the medical sciences as well.

Indeed, the problem in basic science might be even worse. "My observation is that the people in the research world who have made it have had to work extraordinarily hard, and there is even less psychological talk in that world than there might be in the clinical world," she says. "My impression is that it is harder for them to ask for help."

For M.D.-Ph.D. students, the stresses of the extended training period, along with having to move back and forth from the clinical to the research worlds, can bring on bouts of depression, and certain transitions can be particularly difficult, says Michael Kerry O'Banion, director of the M.D.-Ph.D. program at the University of Rochester. (O'Banion is also a member of CTSciNet's Board of Advisers.)

"As they are starting their graduate years, they see that they are no longer a part of the community of medical students who are continuing in their education," he says. "So after 4 years in the graduate program, you might be mired in figuring out your thesis work, but people who you became very close to in medical school are now graduating and departing. For some M.D.-Ph.D. students, there can be a significant loss of a support system that they may have developed."

Signs of Suicide Crisis

According to AFSP, a suicide crisis is a time-limited occurrence signaling immediate danger of suicide. Suicide risk, by contrast, is a broader phrase that includes factors such as age, gender, psychiatric diagnosis, past suicide attempts, and traits such as impulsivity. The signs of crisis are:

Precipitating event: A recent event that is particularly distressing such as the loss of a loved one or a career failure.

Intense affective state in addition to depression such as desperation (anguish plus urgency regarding the need for relief), rage, psychic pain or inner tension, anxiety, guilt, hopelessness, or acute sense of abandonment.

Changes in behavior, including speech suggesting the individual is close to suicide. Such speech may be indirect. Be alert to statements such as, "My family would be better off without me." Sometimes those contemplating suicide talk as if they are saying goodbye or going away.

Actions as varied as buying a gun or suddenly putting one's affairs in order.

Deterioration in functioning at work or socially, increasing use of alcohol, other self-destructive behavior, loss of control, and rage explosions.

In an acute crisis, AFSP recommends the following: Do not leave the person alone. Take the person to an emergency room or walk-in clinic at a psychiatric hospital. If a psychiatric facility is unavailable, go to your nearest hospital or clinic. If the above options are unavailable, call 911 or the National Suicide Prevention Lifeline at 1-800-273-TALK (8255).

Source/additional information: AFSP, National Suicide Prevention Lifeline


Getting over the fear of asking for help

One of the biggest fears medical students face in seeking treatment for depression is being branded as unfit to be doctors and having a medical board question their ability to practice medicine. Such fears are common among students--and may be well-founded, because some state medical licensing boards can require formal psychiatric evaluations of applicants who report being treated for mental illness. However, most states are now guided by "enlightened policy in which mental illness is treated the same as any physical illness," says John Herman, director of the Massachusetts medical licensing board.

Herman says that if an individual is being treated and their depression is under control, the Massachusetts medical licensing board does not need to hear about it. "We are only interested if [a condition] is impairing, impeding, or interfering, and rendering the care of patients less safe," he says. (An article in the June 2009 issue of Academic Medicine lists each state's medical board's stance on questioning applicants about mental health issues.)

Not getting treated and having patient care suffer is a much more serious issue. Caregivers who have untreated depression can exhibit a disconnect, a depersonalization of patients that can hamper patient care, Herman says. (See the box above, "Recognizing Symptoms of Depression."). Licensing boards are concerned with whether the physician is competent to practice medicine; an untreated depression could render a physician unsafe to practice.

"People with mental illness have much less insight than they would normally," Flaherty says. "I've seen this over and over again with health care professionals that as soon as they get depressed, they explain it away as unworthiness or something else."

Ways to Combat Mild Depressive Episodes

Guard your sleep. A December 2008 Institute of Medicine report on resident duty hours says physicians should be getting at least 5 hours of continuous sleep after 16 hours of work. Seven to 8 hours per night is ideal.

Don't give up outside activities. People who give up activities and outlets they enjoy such as exercise, music, or art while in graduate school or medical training are more likely to report emotional distress, according to Liselotte Dyrbye, an internist and investigator at the Mayo Clinic in Rochester, Minnesota, who has studied suicidal thoughts among U.S. medical students. "You have to figure out how to incorporate into your life those outside things that give you pleasure," she says.

Seek a trusted mentor and support from peers. Having a mentor and peer support can help provide perspective when things aren't going well.

Carve out time for family and friends. Having an outlet away from work can provide needed respite. Isolating yourself is a danger sign for depression, says Christine Moutier, associate clinical professor of psychiatry and assistant dean for student affairs at the UCSD School of Medicine.

Find a way to process conflict. If you're struggling with experiments or feeling overwhelmed, find an outlet to help you elucidate and deal with the issue. Keep a journal or talk it out with friends or family.

Seek professional counseling. Talking with a trained professional will help you decide whether what you are experiencing is a transient episode or something more serious, Moutier says. "It can be done in a way that is completely confidential," she says. "Some doctors will opt not to use their insurance and to seek care outside of their hospital setting."

Don't allow yourself to suffer, Moutier adds: Help is available to you. "I don't know a single person, personally, who's had to deal with an adverse consequence because of their seeking appropriate care."

Source/additional information: Resident Duty Hours: Enhancing Sleep, Supervision, and Safety


With some students, cultural factors can make it more difficult to seek help, says Alan Kent, who was director of medical student counseling and career services at the University of Washington, Seattle, for 8 years. Students from rural areas and international students are often reluctant to acknowledge their emotional states, he says. "I learned from one of the students that there is no word for 'depression' in the Chinese language." Many Asian cultures equate depression with mental instability, or "craziness," making people from these cultures less likely to seek help.

(Courtesy, Christine Moutier )
Christine Moutier

To alleviate students' concerns, the university offers a dedicated, confidential counseling service for medical students. A similar program at the medical school at UCSD recently expanded to include residents and faculty. It allows students to seek confidential help outside the hospital where they are training.

Friends and colleagues are often unwilling to intervene. "This is the landscape of reality in 2009," says Christine Moutier, associate clinical professor of psychiatry and assistant dean for student affairs at the UCSD School of Medicine. "People have been so afraid to do something or say something if they notice that a colleague is suffering or impaired because you don't want to be seen as narcing on somebody. But we are trying to promote a culture where we actually care enough to reach out and help each other out. We are sometimes the last ones to realize that there is something treatable going on."

Flaherty says it's important to have a trusted mentor or colleague who can act as a sounding board and then be willing to listen to advice to seek professional help.

Flaherty herself followed the advice of a trusted mentor, who reached out to her when she was in the throes of depression and advised her to seek professional care. Now she runs a busy neurology laboratory at Harvard and is director of the movement disorders fellowship program at Massachusetts General Hospital. She is raising healthy twin girls and treats patients, many of them medical professionals. She has no regrets about going public with her bout of mental illness, which is now controlled with medication. She even partly credits her job in the psychiatry department at Harvard to her vocal advocacy of psychiatric treatment. "Only good things came to me because I talked about it," she says.

Photo (top): Sara Björk

Hede is a freelance writer in Chapel Hill, North Carolina.

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