Published in the April 2016 issue of Today’s Hospitalist
WHILE RESIDENCY is a necessary passage, a growing number of residents are feeling overwhelmed. That”s the takeaway of a recent study that points to disturbingly high rates of depression among residents.
A meta-analysis in the Dec. 8, 2015, issue of the Journal of the American Medical Association (JAMA) looked at 50-plus studies on residents and depression. The research, which together encompassed more than 17,000 residents, spanned an impressive 52 years, from 1963 to 2015. Most of those studies relied on self-reports of both depressive symptoms and major depression.
Despite a wide range of differing methodologies and depression criteria, the studies yielded strikingly similar results. The review found that estimates of depression or depressive symptoms ranged from 20.9% to 43.2%, depending on the instrument used. A secondary analysis of seven longitudinal studies showed a median absolute increase in depressive symptoms of 15.8% from residency onset.
“Bringing attention to the issue helped me deal with my own trauma.”
~ Douglas A. Mata, MD, MPH, Brigham and Women’s Hospital
Even more disturbing, the review found that rates of depression have been getting worse over the past half-century, increasing by 0.5% per calendar year.
Lead author Douglas A. Mata, MD, MPH, a resident at Boston’s Brigham and Women’s Hospital and a clinical fellow at Harvard Medical School, spoke to Today’s Hospitalist about those findings.
What motivated you to do the study?
When I was in medical school, a student in the year ahead of me committed suicide. A couple of years later, a former physician roommate did as well. And many friends and colleagues were dealing with depression and burnout issues, which was pervasive. Bringing attention to the issue helped me deal with my own trauma, and I felt it would also be a valuable service to the profession.
Was it hard to work with such a wide range of studies?
Study heterogeneity was definitely a challenge, which is why we presented a range of estimates.
Those estimates were much higher when depressive symptoms, not only a formal psychiatric diagnosis of major depression, were included. But full-blown major depression is not necessary for a person to experience significant problems. You can have symptoms below the threshold and still have impaired function.
What factors contribute to depression in residents?
Our study looked only at rates, not causes of depression. That said, I can offer some thoughts based on my own observations and previous studies. Even with improved schedules, residents are still working overnight call shifts a few nights a week. This is like taking a couple of transatlantic flights a week. We know that sleep deprivation is a well-established contributor to depression.
And if you are working 80 to 90 hours per week, you have no work-life balance. You do not have time to see friends and family or go to dinner with your girlfriend—assuming you find time to have a girlfriend. You see friends from college getting married and having families, and you wonder if this will ever happen for you. And you do not have the luxury to be ambivalent about your career choice because you are $200,000 in debt. That financial burden hangs over many residents’ heads.
Does the exposure to patient suffering have an impact?
Certainly, dealing with very sick patients takes a toll, especially in subspecialties like emergency medicine or oncology. Seeing patients in a state of trauma or terminal illness is wearing, and physicians often try to create an internal mental barrier. To some extent, you need to do that to survive. But turning off empathy all the time builds up emotion
that can manifest as depression later on.
Why are depression rates among residents increasing?
In many respects, practicing medicine today is harder than it was 25 to 30 years ago. Today’s inpatients are sicker, with an ever-expanding number of treatment options and clinical guidelines. Doctors now need to know much more than physicians did in the past.
There is also more work but not enough people to do it, so there is very little time to spend with each patient. And performance metrics, which are increasingly part of today’s hospital practice, create enormous pressure.
We have a proliferation of forms to fill out, buttons to push, paperwork to complete. Part of that burden falls on first-year residents, who become almost like professional secretaries. They spend relatively little time at the bedside and most of their time at the computer taking care of charts. Residents complain that they are drowning in a sea of paperwork. The reason they went into medicine— to have a direct impact on healing—is relegated to a minor position, so there is less compensation for the burdens and difficulties they encounter.
What impact does the culture of residency have on residents’ mental health?
There have been attempts to improve the old hierarchical system that disparages medical students, interns and residents. But many vestiges of that system still exist.
For example, the practice of “pimping”—a sort of pedagogic hazing in which senior physicians pose questions designed to intellectually embarrass junior physicians—can wear those doctors down. In the same issue of JAMA as our review, there was a study of medical students’ cartoon art. That study found that almost half those students drew horrorgenre cartoons depicting their supervising physicians, some focusing on that questioning process.
Do residents seek help for their depression?
I think that there is still stigma—or fear of stigma— that prevents residents from seeking help. They are afraid of going within their hospital system, concerned that their records will be available to all their colleagues and professors to see. And although depression is an “open secret,” it is not sufficiently discussed, and many feel they are the only ones experiencing it.
What do you think is needed for change?
I encourage residents to recognize that they are not alone and to seek help. But we also need to address causes of depression on a systemic level.
Our group is continuing to research causes of depression, and there are programs in which residents are happier. We need to study these programs to find out what they are doing differently. An editorial that accompanied our review in JAMA recommended a “national conversation on the fundamental structure and function of the graduate medical education system” to address the broader issues.
At Brigham and Women’s, we conduct seminars for residents at the beginning of each academic year to discuss personal wellness, risk factors for depression, and local in-house and external resources. One resource is our employee assistance program, led by our psychiatry department. Anyone can call that program 24 hours a day, seven days a week, and it is confidential.
Batya Swift Yasgur, MA, LMSW, is a freelance health care writer based in Teaneck, N.J.