I am depressed
My first response to a colleague who says ‘I am depressed’ is critical for a number of reasons. Doctors have toughemotional masks and it has been difficult for my colleague to trust someone anddisclose this. Because of the enormous stigma surrounding mental illness in themedical profession, chances are this doctor has been suffering quietly for a longtime, has not been sleeping and may be a risk, perhaps self-medicating withprescription medication or alcohol.
With this in mind, I must listen intently. If this is a doctor friend, I can help my colleague get the right treatment from a skilled independent GP. As GPs, we are in a better position than most patients to use our networks to find the right help, including accessing independent GPs outside our geographical area of practice to protect our confidentiality, doctors’ health advisory services or telehealth support for those of us who are working remotely or doing shift work.
When I see doctors as patients, listening is also my most powerful skill. Often the presenting problem is not the main reason for the consultation. A doctor patient may cry when I ask them how they feel because very few people ask doctors this question or take time to listen to the answer fully. Many doctors rarely disclose their stories of grief, trauma and injustice, and it is a relief for them to do so.
To obtain a full history, I usually need to dispel the myths of mandatory reporting. Personally, I have never had to report a doctor with mental illness as I find colleagues comply with treatment and take time off work if needed. My doctor patients continue to provide a high standard of patient care – but sometimes at great expense to themselves.
I keep a framework in my head to ensure I have covered all aspects of a comprehensive mental health assessment over a few consultations rather than use questionnaires which I find interfere with developing a therapeutic relationship. As part of a comprehensive assessment, I may find that doctor patients have atypical symptoms, such as uncharacteristic irritability or anger, difficulty concentrating or making decisions because of excessive worry, lack of empathy, social withdrawal and/or fatigue or low energy due to insomnia.
Of course, doctors have the same risk factors for depression as the general population. Unsurprisingly, we may have family histories of mental illness and alcohol and substance misuse, chronic illness or pain, negative life experiences and relationships, fractured family structures, family of origin histories of violence or suicide, and histories of child abuse. When our non-doctor patients with these common problems seek our help, we may experience “triggering” of our own histories. In addition, we often have perfectionist, self-critical, hypervigilant and task-oriented personality styles that make us great doctors, but put us at risk of failing our own impossible expectations. Only by fully understanding our potential vulnerabilities can we be proactive in addressing them.
I usually find that it is the very caring, dedicated and selfless doctors who are more at risk of mental illness. In my experience, when doctors recognise that theIr strengths can also be vulnerabilities, they find it easier to transcend problems and become even stronger. Instead of unfairly regarding mental illness as a weakness, we need to see it as an opportunity to become stronger with early optimal mental health management. Patients need doctors who are caring, dedicated and healthy – not selfless.
It is also important to cover the other aspects of a comprehensive history in a doctor patient: past history and family history, past/current medication, developmental history, education and work history and social history.
As doctor suicide is more common than in the general population, doctors are frequently traumatised by a colleague’s death and then placed at risk of suicide themselves. It’s not easy to ask my doctor patients: “Many people who are under extreme pressure feel like harming themselves. Have you ever felt this way?” but it is essential. Doctors have easy access to means, and ongoing suicide risk assessment is critical.
Doctor patients may present with a mixed pattern of depressive disorder, anxiety disorder and post-traumatic stress disorder related to acute and chronic exposure to patient trauma, violence, abuse and death, including suicide, which makes diagnosis and treatment challenging. Formal psychological treatments such as behavioural therapy, interpersonal therapy, acceptance therapy, and cognitive behavioural therapy are helpful, but may have limitations in doctors. Doctors tend to overthink due to having well developed negative mental filters and negative cognitive biases. Being risk averse is part of being a good doctor. It is not easy to overcome these strong traits by challenging negative thinking with the usual cognitive behavioural therapy techniques. Structured formal mindfulness-based cognitive behavioural therapy has been found to be an effective treatments for depression and I have found this works well for doctors. Antidepressant medication may also be required.
Regular follow-up is essential. It’s easy to fall into the trap of providing telephone follow up or repeat prescriptions for doctor patients too busy to attend in person. Ongoing care is required to prevent relapse of depression.
Unfortunately, many medical workplaces fail to support doctors when they request a lower patient load or time off work because of skeleton staff levels. Negative conditions at work have often pre-disposed a doctor to mental illness and have to be addressed.
Recommending information about resilience to doctors for complex issues such as workplace bullying, harassment, discrimination, racism, and patient complaints or medico-legal action is as foolish and harmful as trying to fix a displaced compound fracture by covering it with a dressing. The underlying issues require solutions.
As a treating doctor, I can advocate on my doctor patients’ behalf and ensure a doctor can take leave without divulging their mental illness to their employer which can be damaging. I can also refer appropriately to a psychologist or psychiatrist, taking care not to alienate my doctor patient in the process.
A medical career has never been more challenging and complex than ever before, and instead of being supportive, our harsh medical culture places us at risk of mental health problems. Surprisingly, many doctors are actually thriving in this tough environment and we need to share what works and what doesn’t, to support our colleagues.
What do you find helpful?
Clinical Professor Leanne Rowe is a GP, past Chairman of the RACGP and co-author of ‘Every Doctor: healthier doctors = healthier patients’ www.everydoctor.org
If this article has raised issues for you, help is available at:
Doctors’ Health Advisory
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Medical Benevolent Society (https://www.mbansw.org.au/)
AMA lists of GPs willing to see junior doctors (https://www.doctorportal.com.au/doctorshealth/)
Lifeline on 13 11 14
beyondblue on 1300 224 636
beyondblue Doctors’ health website: https://www.beyondblue.org.au/about-us/our-work-in-improving-workplace-mental-health/health-services-program