Depression in Medicine

JAMA recently published a meta-analysis of studies on depression in resident physicians, and it's understandably getting a fair bit of attention. The headlining number approximately 28.8% of residents report depression or depressive symptoms. This is almost certainly a bit of an over-estimate as depressive symptoms aren't necessarily equal to depression itself - particularly when it comes to the somatic symptoms of depression (fatigue, poor sleep, appetite changes), there can be multiple explanations aside from depression.

Still, it's likely not a gross over-estimation. A rate around 20% or so, with approximately half of that being only moderate depression, fits with what the more granular data in the study suggests as well as with my own personal experience. The challenge with depression in medical school is that there is a strong incentive not to let on that you're going through it. The stigma against physicians with mental health problems is lessening, but there are still risks to opening up about it, especially as so much in medical training is subjective. Admitting to dealing with depression wouldn't be met with scorn, but might lose a student or resident the benefit of the doubt when mistakes or misses happen - which they inevitably do for all learners. Showing outward signs of depression can be equally harmful to a trainee's prospects - fatigue, irritability, and disinterest are all significantly frowned upon, even in situations where it might be completely reasonable to feel all three. The outward appearance of strength and tranquility is demanded in trainees, despite having minimal opportunities to get away from medicine and drop their guard. Lastly, taking actual steps to address mental health issues like depression can be very difficult. I have enough trouble finding time to get to see my family physician, I can't imagine what it would be like to get the time to see a mental health professional, especially for the kinds of regular visits that are often optimal for dealing with these issues. Medicine simply doesn't permit that kind of flexibility for trainees. 

As a result, many mental health issues are driven underground, which can give the appearance that it is far less common than reported in the JAMA study as well as similar reports. I've seen a degree of hostility towards even addressing these issues by students or residents who may not recognize the extent of the problem - in some cases, even by those who have trouble recognizing that they themselves are struggling with poor mental health.

There's also an unfortunate notion to dismiss cases of poor mental health in medical trainees as a problem with the trainees themselves. A lack of mental toughness or fear of adversity is often thrown around. Yet I've seen exceptionally strong medical students struggle. They might be doing amazingly well on evaluations or in clinical performance, but be unable to keep up with their social lives, personal interests, or even basic hygiene. Overall, medical students are already being carefully selected to be the most capable, resilient individuals available - if significant groups of trainees are having difficulty with depression, even if we had an outstanding admissions system, I doubt we're likely to get more resilient individuals who are also equally capable.

Addressing this problem is challenging. There are no simple answers as the depression is multi-factorial and any potential solutions to depression in medicine would encounter numerous barriers and trade-offs. I don't believe small changes are going to cut it, however. I think the stats seen in this study will continue until some fundamental changes are made to the way we train our physicians and, likely, the way we organize our healthcare system in general.