By Niva Shrestha

DESTIGMATIZING MENTAL HEALTH AMONG PHYSICIANS AND MEDICAL STUDENTS

By Niva Shrestha

“I regret that only now, in my last annual meeting speech, am I telling you about my own struggles. My anxiety and depression were on the verge of derailing my career aspirations. My fear of being judged negatively and the dark shadow of stigma nearly kept me from seeking help.” – 2018 AAMC President’s Address by Darrell G. Kirch, MD7

n the pursuit of helping others, physicians and medical students often forget to take care of themselves. Physicians make a lifelong commitment to medicine, and good mental health is imperative to sustain that commitment. It is crucial to acknowledge that “suicide is the only cause of mortality that is higher in physicians than nonphysicians.”1 Historically, this is not a new phenomenon. Documentation dating back to the nineteenth century indicates that suicide rates among physicians has always remained higher than that of the general public.1 For decades, however, physicians have been taught to “power through” and “tough out” the most mentally demanding times of their lives. This unwillingness to acknowledge and address mental health fuels personal, professional and intuitional stigma surrounding physician mental health. By destigmatizing mental health among physicians and medical students, the medical profession can create a more inclusive, healthy community that can better serve one another and their patients. A myriad of reasons exists as to why physicians may feel uncomfortable seeking or asking for help. This fear often begins with the intense personal and professional pressure doctors put on themselves, beginning in medical school. Medical education is often the source of many mental health issues. Chronic, prolonged stress leads to anxiety, burnout and depression with potentially permanent consequences, such as suicide or compromised medical care. Sometimes this pressure stems from other responsibilities, personal factors or psychiatric illnesses. Whatever the cause of stress, addressing physician mental health starts in medical school. A recent meta-analysis discovered the prevalence of depression or depressive symptoms among medical students was 27.2% and suicidal ideation was 11.1%.2, 3

Fortunately, many medical schools are now taking steps to normalize student mental health discussions, making it culturally acceptable for medical students to ask for help. Providing staff clinical psychologists, having access to peer support groups, promoting Mental Health Awareness Week— which is October 3 through October 9 this year—and increasing transparency on the psychological struggles associated with medical school are ways in which modern medical schools are helping destigmatize mental health. Providing medical students with comprehensive mental health training and resources will set a solid foundation for competent, healthy future physicians. In a study of more than 9,900 programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) during 2000-2014, suicide was found to be the second leading cause of death among resident physicians.4 Barriers to care have led to

Ionly 1 in 4 trainees who wanted mental health treatment actually seeking care. Reportedly, the biggest barriers to care were “lack of time (77%), concerns about confidentiality (67%), concerns about what others would think (58%), cost (56%) and concern for effect on one's ability to obtain licensure (50%)”.4 These barriers are similar for attending physicians. These statistics demonstrate how doctors face not only professional but also personal and institutional stigma regarding mental health.5,6 As an institution, the AGEME in 2011 implemented an 80-hour resident work week and eliminated extended duration shifts for first-year residents. This is a small step in the right direction, acknowledging that all doctors have physical and mental limitations. However, to influence continued pr ogressive institutional change, the people who are a part of the health care system— physicians, other health care professionals, health care administrations and health care students— must first address their own biases about themselves and their colleagues seeking mental health treatment. Implicit biases about personal welfare as a physician can be so ingrained, that the person who needs help may not understand or recognize they need it. Some believe staying up all night to study or feeling chronically tired is a badge of honor—a reflection of their dedication to the medical profession—but it is not. There-

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fore, it is important to continue the conversation of mental health in all aspects of medical training, especially in continuing medical education. As medical knowledge evolves, so too will understanding of mental health and the vast resources available to physicians. Workplace policies should also evolve to recognize and support the pressing issue of physician mental health. In the past, physicians who struggled with mental health lived in fear: fear of being labeled as weak or incompetent, or fear of professional consequences after the admission of receiving professional help. Lack of professional support negatively impacts a physician’s critical thinking and ability to help patients. Therefore, destigmatizing and supporting mental health among all health care professionals is vital to the welfare of current and future generations of providers and patients. The stigma of mental health is not something that will disappear within a generation. While the stigma improves with each decade, there are still strides to be made. That can only happen if the medical community continues to prioritize mental health amongst themselves. Good mental health not only benefits the physician but also benefits their loved ones, colleagues and the patients they care for.

“But an extraordinarily empathic student affairs dean steered me to the treatment I needed. As a result, I am blessed to stand here today. Many of you have a story like mine. We need to tell our stories and beat back the stigma that causes so many of our learners and colleagues to suffer in silence. Speaking out and erasing the stigma around seeking help is a most worthy mountaintop to reach.” – 2018 AAMC Presi-

dent’s Address by Darrell G. Kirch, MD7

References 1. Albuquerque J, Tulk S. Physician suicide. CMAJ. 2019;191(18):E505. doi:10.1503/cmaj.181687 2. Rotenstein LS, Ramos MA, Torre M, et al. Prevalence of Depression, Depressive

Symptoms, and Suicidal Ideation Among

Medical Students: A Systematic Review and Meta-Analysis. JAMA. 2016;316 (21):2214-2236. doi:10.1001/jama. 2016.17324 3. Dyrbye LN, Thomas MR,

Shanafelt TD. Medical Student Distress: Causes, Consequences, and Proposed Solutions. Mayo Clin Proc.

December 2005;80(12):1613-1622 4. Aaronson AL, Backes K, Agarwal G, Goldstein JL, Anzia J. Mental Health

During Residency Training: Assessing the Barriers to Seeking Care. Acad Psychiatry. 2018 Aug;42(4):469-472. doi: 10.1007/s40596-017-0881-3.

Epub 2018 Feb 14. PMID: 29450842. 5. Gerada C. Doctors, suicide and mental illness. BJPsych Bull. 2018;42(4):165168. doi:10.1192/bjb.2018.11 6. Henderson M, Brooks SK, Del Busso L, et al. Shame! Self-stigmatisation as an obstacle to sick doctors returning to work: a qualitative study. BMJ Open. 2012;2(5):e001776. Published 2012 Oct 15. doi:10.1136/bmjopen-2012-001776 7. Kirch DG. AAMC President’s Address 2018 “The Mountaintops”. November 4, 2018.

Niva Shrestha is a second-year medical student at the University of Incarnate Word School of Osteopathic Medicine (UIWSOM) and a member of the BCMS Publications Committee.