Resident Depression: The Tip of a Graduate Medical Education Iceberg

Physiciansare rightfullyproudof their reputationasbeing intelligent, dedicated, hard-working, committed to the lifelong acquisition of new knowledge and skills, and able to overcome personal discomfort (particularly sleep deprivation) for the sakeof theneeds ofpatients.Physiciansare less proud and less willing to admit or discuss that, as a profession, they are at equal risk fordepressionandhigher risk for suicide than that of the general population,1-3 despite having seemingly better access to mental health care than many segments of the population. The literature describing the risk of depression and suicide in medical students is relatively rich4 and somewhat so forpracticingphysicians.1-3,5 Studiesofdepressionamongphysicians in training (residentsandfellows)are lesscommon,perhaps because residents in general are busier, more overwhelmed, more fatigued, more sleep deprived than either medical students or practicing physicians, and less accessible for surveys and interviews. The reasons that depression riskamongphysicians in training ismoredifficult to studymay be the very reasons they are more vulnerable to that risk. In this issue of JAMA, the study by Mata and colleagues6 fills that gap to a considerable extent with a meta-analysis of 31 cross-sectional and 23 longitudinal studies of depression amongphysicians in training.The results arediscouraging: the prevalenceofdepressionordepressive symptomsranged from 20.9% to 43.2%, depending on the nature of the assessment. This systematic reviewmakes it clear that themedical profession has a major problem. What is the profession willing and able to do about it? The 54 studies identified by Mata et al6 mostly used validated self-report questionnaires to assess eitherdepressionor depressive symptoms. These questionnaires, plus the structured interviews used in 3 studies, are highly heterogeneous in their construction, symptomsmeasured, and criteria used, with a wide range of resultant operating characteristics. The authors addressed this problemwith appropriate groupingsof instruments thatperforminsimilarways. Inanycase, thesubtle methodologic complexities of this systematic review pale in comparisonwith the fundamental finding that theextentofdepressive symptoms in physicians in training is extraordinarily high. Roughly a quarter to a third of physicians in training reported experiencing significant depressive symptomatology, if not overt clinical depression, at any point in time. The distinction between symptoms and disease may not be particularly important, because the functional effect of subsyndromaldepressionanddysthymiaapproaches thatof criterionbasedmajordepressivedisorder.7Thepersonalandprofessional dysfunction, not to mention the suicide rate that may derive from this symptom burden, should be disturbing to the profession; these findings couldbe easily construedasdescribing a depression endemic among residents and fellows. Discussionsaboutdepressionamongmedical studentsand physicians often involve questions about how the prevalence of depression in physicians compares with that of other professionsorpopulationgroups.The implicationseemstobe that perhaps theprofessionshouldnotbesoconcerned if theprevalence is similar to that of other high-stress groups. In general, the lifetime prevalence of depression is roughly similar to that of the general population, approximately 10% to 13% in male physicians and 20% in female physicians, comparedwith 16% in the overall general population.2,3,5,8 The rate ratios for suicide in male and female physicians compared with their general population counterparts are 1.41 and2.7, respectively.3 Little is knownabout depression in other professions. But such comparisons are not relevant.When physicians in traininghave suchahighburdenofdepressive symptomatology, in a caregivingandhelpingprofession it doesnotmatterwhether they aremoreor less likely tobedepressed than those inother professions.Theprevalenceisunacceptablyhigh,withbothpersonal andprofessional consequences. Studies amongmedical students and residentshavedemonstrated that burnout, adifferentbut closely relatedconstruct todepression, is associated withhigherself-reportedratesofcheatingonexaminations, lying aboutclinicaldata,medical errors, andethical lapses, aswell as lessaltruistic andcompassionatecare.9Relieving theburdenof depression among physicians in training is an issue of professional performance in addition to one of human compassion. The solutions to this endemic can be classified into 3 categories: provide more and better mental health care to depressed physicians and those in training, limit the trainees’ exposure to the training environment and system that are thought to contribute at least in part to poorer mental health and wellness, and consider the possibility that the medical training system needs more fundamental change. The first approach is appropriate irrespective of anyother changes. The profession has an obligation to provide appropriate medical and mental health care to all members of the medical profession.10 However, the best efforts fall short, mostly because of the high levels of stigma attached to seeking mental health care.11 Medical students and residents are Author Video Interview and JAMAReport Video at jama.com