From where I sit the doctor’s mental health debate has gone around in circles like a spinning top, only to fall over sideways. Almost discarded and relinquished to the toy box for another time. Stalwart warriors in this space are beginning to become very frustrated, and rightly so. As a stalwart warrior for many years, I have spoken to politicians, lobbied and campaigned extensively and despair as I hear about more suicides. Imagine the near misses or attempts nobody hears about.
But this article is not written as another to add to the growing content forming the doctor’s mental health debate. It is based on my concerns that we are losing focus and our campaigning may be off the mark. So may be our attempts at finding solutions.
I fear for medical students who read about the high suicide rate in the medical profession. I fear they will believe their future profession will cause them to become depressed. That they believe they are going to exchange valuable resources such as money, time, energy, enthusiasm, passion and drive for a lonely miserable existence. That they will follow Twitter feeds that debate this, and keep their head down even more.
These issues are not unique to medical students, and there are similar concerns for students of veterinary medicine, nursing, dentistry and pharmacy. Rather than seeing these professions as ‘callings’ to help others, they are directly blamed for causing mental illnesses such as depression in the very people chosen to commit to the calling.
As a psychiatrist, I have treated numerous medical students and doctors, as well as other members of the health professions. I have also spent time with family members who have lost a loved one to suicide. I use evidence based strategies to deliver best practice. Part of my work is thorough history taking, including a detailed past and family history. Just as with many other medical conditions, thorough exploration leads to revealing information. And these patients are no different to most of my other patients. Doctors in their 30’s will talk about a time in medical school that would have fulfilled the criteria for a major depressive episode, if they had told anybody about it . It may not be the first time that the patient has experienced suicidal thinking, but may be the first time they have told anybody about it. They may have a parent or sibling with a diagnosed mental illness, or a relative who was talked about as being unwell. They may have witnessed or experienced devastating childhood adversity, leading to problems with personality, but nevertheless gifted and skilled in so many other ways.
Medical training does not cause depression. But impairments in help seeking, both within the person and within the system, leaves that person untreated and vulnerable.
Mental illness is common in the community, so why do we believe that medical students, who live in the same community are somehow immune? That if we make them ‘resilient’ by offering a few lectures in medical school about managing stress we will ensure that they never go on to experience an episode of mental illness? Medical students, like everybody else who may have depression deserve early, evidenced based treatment delivered in a sensitive, caring and compassionate manner. And despite all the rhetoric, the lip service, the campaigns to educate to ask for help, there still lies an impediment to asking for help.
The very reason for this is the entrenched stigma the medical profession has about seeing mental illness as a weakness or impairment. It is an extreme case of ‘do as I say not as I do’. And medical students are exposed to that from the get-go. As consultants and leaders we may reinforce these ideas. Medical students may believe it to be true in themselves, holding their own stigma. The system is gruelling and unyielding at times, but this could be endured and even enjoyed if those who are struggling receive the help they need, rather than blamed or discouraged from speaking up.
I must be very clear that I am writing about depression, and not other issues such as vicarious traumatisation, compassion fatigue or even post traumatic stress disorder. These serious conditions occur as a result of external factors and should be seen as such. We are all vulnerable to these conditions by the very nature of our work. Yet even these conditions are stigmatised when we know that they can be treated as well.
The era of mandatory reporting, and variation in states such as New South Wales, have directly damaged doctor’s help seeking behaviour. Regardless of all the talk that doctors and medical students who are actively seeking help and not putting patients at risk do not need to be reported to AHPRA, the message is drowned out by anecdotal evidence and fear mongering. Competition for scarce training places, the introduction of more medical schools purely for money not clinical demand, and the high rates of bullying and harassment well documented in the profession can destroy one’s capacity to be brave enough to speak up.
So, as doctors we know that depression is an illness that is treatable and that early, evidence based interventions lead to recovery. We know that an episode is invariably brought on by a combination of internal (often genetic) vulnerability and external stressors, whether they be in personal or professional life. So is the solution that difficult?
Why don’t we apply a more logical and reasonable approach to this most awful situation? Make it as easy as possible for medical students and doctors to recognise they are experiencing symptoms of depression, and deliver that care just as we would for any of our patients? Eliminate external stressors that we can do something about, by actively campaigning to adopt Western Australia’s stance with regards mandatory reporting, and fight back about building more medical schools. Check in with our own feelings about stigma, and be honest. Would we regard a colleague as inferior if they were taking antidepressants? Would we feel the same if they took insulin for Type 1 diabetes?
There are many things we can do, and we must if we care about the next generation of doctors, as well as the current ones. And guess what, ad hoc mindfulness training, or throwing an afternoon barefoot bowls session for staff simply doesn’t cut it. Finding caring professionals, believing you are worth receiving help, and getting better is much more enduring and successful, and there are people out there who will do that. All you need to do is ask.