South African Family Practice

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Depression in doctors: A bitter pill to swallow

K Outhoff

To cite this article: K Outhoff (2019) Depression in doctors: A bitter pill to swallow, South
African Family Practice, 61:sup1, S11-S14, DOI: 10.1080/20786190.2019.1610232
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South African Family Practice 2019; 61(S1):S11-S14
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REVIEW

Depression in doctors: A bitter pill to swallow

K Outhoff

Faculty of Health Sciences, University of Pretoria, South Africa

*Corresponding author, email: kim.outhoff@up.ac.za

At some point in their career, at least a third of doctors suffer personal health problems such as injury, aging, or physical and mental
illness, which detract from their ability to function properly and to practice medicine safely. In most, impairment is amenable to
intervention, treatment, recovery or resolution. However, some conditions, notably depression, may be overrepresented in the
medical profession, under-recognized, stigmatised and undertreated, which may have fatal consequences.

Introduction 19.5%, comparable with women in the general population and

women professionals. It is thought that depression incidence
Depression is a common mental disorder. The latest (2015)
across ethnic groups is similar, except for Asian women doctors,
World Health Organization estimates revealed that over 320
whose rates are lower. Importantly, the cross sectional and
million people, equivalent to 4.4% of the global population,
longitudinal prevalence of depression or depressive symptoms
suffer from depression. South Africans account for an estimated
(15–43.2%) is significantly higher in medical students and
2.4 million of these, which translates to 4.6% of the local
registrars/residents than in the general population,6,7 which
population. Depression is more common in women (5.1%)
than in men (3.6%), and the absolute number of people with appears to increase with calendar year of study.8
depression is increasing, particularly in lower-income countries Risk factors
where populations are growing and aging.1 A meta-analysis
of 1994–2014 depression studies showed an aggregate point Although depression may affect anyone, the risk is increased
prevalence of 12.9%, a one-year prevalence of 7.2%, and a by genetic predisposition, early traumatic life events, later
lifetime prevalence of 10.8%.2 These discrepancies highlight that bereavements, illnesses, relationship breakdowns, poverty,
depression prevalence is difficult to assess accurately because of unemployment and problems caused by substance use.1 Stress
wide variations in diagnostic measures, and that studies using as a precipitating factor is a common theme.9 (Table I)
self-rated depression scales may produce significantly higher
point prevalences of depression than clinician-rated.
Table I: Is depression a stress-induced organic disorder?9
Doctors appear to suffer from depression more than the general Stress increases circulating pro-inflammatory cytokines, particularly
population and other professional groups.3 Recent meta‐analyses TNFα and IL-6 that activate microglia in the central nervous system
leading to further pro-inflammatory cytokine release.
of global studies estimate an overall prevalence of 27% in medical
The immune cascade may ultimately reduce monoamine
students, 29% in registrars and up to 60% in practising doctors.4
neurotransmitters, and in particular serotonin, as well as hippocampal
These figures differ widely between countries and specialties. neurogenesis.
For instance, a Cape Town study using a self-administered Beck’s Hypothalamic-pituitary-adrenal (HPA) axis dysregulation appears
Depression Inventory revealed clinically relevant moderate to critical in the pathogenesis of depression.
severe depression in 30% of public primary healthcare doctors,5 Depressed people demonstrate increased peripheral cortisol
while an Australian study found that 18% of medical students levels and glucocorticoid receptor resistance, including in the
hippocampus.
and 21% of doctors had previously been diagnosed with
The cycle of elevated chronic neuro-inflammation and glucocorticoid
depression. Medical students, younger doctors and women
functional resistance is accompanied by oxidative stress, as well as
reported higher rates of psychological distress and mental health structural and functional changes in the brain, which may be restored
problems than men and older doctors.4 Meanwhile in America, with antidepressant treatment.
there is some evidence that the prevalence of depression in
doctors is similar to the general population. A cohort of male
medical graduates from Johns Hopkins self-reported a lifetime Doctors are exposed to more work-related stressors than many
prevalence of 12.8%, similar to the 12% lifetime prevalence of other professional groups, and are therefore vulnerable to
major depression in American men, although their mean age of depression. These include long hours, extensive workloads,
onset was significantly older. Self-identified lifetime prevalence the growing intensity and complexity of the job, relentless
of depression in American women doctors has been estimated at contact with patient ill health and emergencies, high levels of

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S12 S Afr Fam Pract 2019; 61(S1):S11–S14

responsibility, rapid change within healthcare, institutional posttraumatic stress disorder, and suicidality.11 Importantly,
constraints such as discrimination and intimidation, lack of there appears to be considerable overlap between symptoms
autonomy, low levels of support, loss of job satisfaction, low of burnout and depression,16 a notion reinforced by an Austrian
morale and the inability to attend to their personal lives.4,7,10 study that found that the Hamburg Burnout Inventory subscales
Causes of work stress may vary with medical discipline: family correlated highly with the key features of depression (sadness,
practitioners may face increased demands on primary care lack of interest, and diminished energy) rather than with each
coupled with shrinking resources,7 while emergency care other, thus alluding to commonality between burnout and
doctors and oncologists may suffer elements of posttraumatic depression in doctors.13,17
stress. Furthermore, doctors facing complaints, often perceived
as shameful catastrophic personal events, are at significantly Doctors have higher suicide rates, and depression is one of the
increased risk of depression, anxiety and suicidal ideation.4 major risk factors:6 Two decades ago, doctors’ relative suicide risk
compared to the general population was estimated at 1.1–3.4
Personal attributes generally ensure patients are well cared for men and 2.5–5.7 for women.18 Compared to the general
for, yet also increase doctors’ risks of developing mental health population, suicide is reportedly 40% higher in men and 130%
problems. Conscientiousness, obsessiveness and perfectionism higher in women doctors.12 Conflicting evidence suggests
may be more common in doctors, leading perhaps to rigidity, that suicide risk is greatest in psychiatrists and anaesthetists,
over‐commitment, self‐criticism, and an inability to unwind community doctors and general practitioners.7 Besides mental
and replenish their inner resources.4 An inflated fear of making distress, additional risk factors for suicide in doctors in particular
mistakes and a sense of diminished patient care may result in
include alcohol or other drug misuse and access to prescription
doctors experiencing overwhelming feelings of guilt, failure,
medications. Drug overdose is the most common suicide method,
shame and low self-esteem.3
and is used significantly more than in the general population.4
Psychological defences that include depersonalisation and Suicidality may be reduced by better detection and adequate
dissociation may make it difficult to create or maintain personal treatment of depression and other mental health problems.6
attachments or to recognise when the emotional burdens of
Barriers to detection and effective treatment
work become unbearable. This may lead to spiralling distress,
and increase the risks of depression and suicide.3 In fact, it has Depression is difficult to diagnose (Table II). In primary care,
been asserted that more than 50% of US doctors experience 30–50% of cases are reportedly missed, and screening may
burnout, a syndrome of emotional depletion and maladaptive only be useful when a depressive disorder is suspected and in
detachment caused by prolonged occupational stress.11 This is high-risk populations.19 Considering that approximately only
particularly common in residents/registrars, and even more so 35% of doctors have a regular source of healthcare, it is not
in those pursuing surgical disciplines.11,12 A recent systematic surprising that depression may be more under-recognised in
review of 182 studies showed that overall physician burnout this population compared to other professional groups.20 Self-
prevalence ranged from 0-80.5%, figures highly dependent diagnosis is even more challenging.
on rating scales and cut-off points for burnout, and limited by
Denial, stoicism and silence may result in delayed help-seeking
nosological debate. Emotional exhaustion, depersonalization,
and low personal accomplishment ranged from 0–86%, 0–90%, and diagnosis.22 There may be a tacit expectation to be the
and 0–87%, respectively.13 “perfect” individual in the community, and from a doctor’s
perspective where illness is strongly perceived as (personal)
A 2018 survey of 545 South African doctors revealed that failure, and health as success, the pressure to be invincible
over 40% either agree or strongly agree that they feel burnt may be enormous. Mental distress may be misattributed to
out. Almost half cited heavier workloads, and the struggle to ineptitude or weakness, encouraging depressed doctors to
achieve an appropriate work/life balance, and more than a third conceal their illness from themselves and others. Self-judgement
experienced increasing stress and anxiety. An overwhelming compromises access to care. Furthermore, diagnostic criteria
majority (85%) agreed or strongly agreed that patient include impairment of functioning, which may provide a get-
expectations have increased in the last five years, and nearly out clause for diagnosing depression. Although absenteeism
60% found it most challenging to manage unrealistic patient occurs, presenteeism appears common in depressed doctors
expectations in a climate of increasing litigation.14 The results of
who are battling with issues surrounding a potential diagnosis
another 2018 study of 100 emergency doctors in Gauteng using
of depression.7 Doctors may thus become the walking wounded
the traditional Maslach’s Burnout Inventory–Human Services
as they soldier on while experiencing symptoms of depression
Survey, indicated that a large proportion are at moderate to high
such as feeling hopelessness, worthlessness, fatigue and
risk of burnout. Not surprisingly, substantially higher emotional
indecision.10 Self-medicating with alcohol or recreational drugs
exhaustion levels were manifest in registrars (100%) compared to
may strengthen the illusion that all is well, but pose an additional
medical officers and community service medical officers (86%).15
risk factor for delayed care and suicide. A high prevalence of
Although the prevalence is difficult to establish (there are alcohol misuse (49%), more than 5 times higher than in the
no standardised diagnostic criteria), burnout increases the general population (9%), has been demonstrated in US surgery
risk of psychiatric conditions, including depression, anxiety, residents.23
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Depression in doctors: A bitter pill to swallow S13

Table II: Major Depressive Episode - Abridged DSM-V criteria19 discouraging them from seeking help, or making a diagnosis
A Five of the following features should be present most of the day, or
more difficult.6 Depressed doctors thus face considerable
nearly every day, for two weeks, representing a change of functioning personal (self, friends, family), professional and institutional
(must include 1 or 2): stigma when trying to access care, potentially leaving them more
1. Depressed mood (feeling sad, empty, hopeless, tearful) nearly isolated and vulnerable.26 Other barriers to accessing mental
every day, for most of the day
health services include a pessimistic view of their value, fear of
2. Marked loss of interest or pleasure in all or almost all activities
3. Significant weight loss or gain (more than 5% change in 1 month) taking psychotropic medication, lack of energy or motivation,
or an increase or decrease in appetite nearly every day and cost.3,22
4. Insomnia or hypersomnia nearly every day
5. Observable psychomotor agitation or retardation Treatment and recommendations
6. Fatigue or loss of energy nearly every day
7. Feelings of worthlessness or inappropriate or excessive guilt (not When doctors do present for help, it may be difficult for the
merely self-reproach about being sick) treating doctor/healthcare professional to see the patient, rather
8. Diminished ability to think or concentrate, or indecisiveness, either
by subjective account or observed by others than a professional peer. Doctors may treat depressed doctors
9. Recurrent thoughts of death (not just fear of dying), suicidal differently, engaging in medical talk and discussing academic
ideation, a suicide attempt, or a specific plan for committing papers or the latest research instead of their usual patient-doctor
suicide
interaction. This social awkwardness may jeopardise effective
B The symptoms cause clinically significant distress or impairment in
treatment. Shared decision-making is discouraged initially, as
social, occupational or other important functioning.
the patient may benefit from taking a break from being a doctor
and the agonies of self-diagnosis/treatment and impaired
C The symptoms are not due to a medical/organic factor or illness.
judgement until his/her health improves.3

Episodes are classified as mild (few symptoms, mild functional Although depression may be a recurrent or chronic illness, full
impairment), moderate (minimum symptoms and functional remission is the treatment goal.27 Therapeutic options include
impairment between mild and severe), severe (most symptoms,
psychological and/or pharmacological, depending on disease
marked or greater functional impairment).19
severity. Psychological approaches include cognitive behaviour
(Adapted from American Psychiatric Association Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition. May 2013)21 therapy, interpersonal psychotherapy and behavioural
activation, which have strong evidence for efficacy in mild to
Failure to cope, coupled with the significant stigma that
moderate major depression, and as an adjunct to medication in
accompanies mental health problems, dissuades many from
severe depression.19
disclosing their depression. Doctors may fear naming, blaming
and shaming, sanctions and job loss.7 An American survey Antidepressants are recommended first-line treatments for
of 2106 women doctors revealed that although almost 50% moderate and severe major depression, irrespective of perceived
believed they had met the criteria for mental illness, they had cause, and for depression of any severity that has persisted for
not sought treatment because they felt “they could manage two or more years (persistent depressive disorder). Choice of
independently, had limited time, were fearful of reporting it antidepressant depends on individual and drug factors such as
to a medical licensing board, and because they believed that tolerability and relative safety in overdose. Selective serotonin
a diagnosis was embarrassing or shameful,”24 supporting the reuptake inhibitors (SSRIs) and other newer antidepressants at
view that fewer professions stigmatise mental health disorders full therapeutic dose are reasonable first line choices, whereas
more prominently than medicine.25 While some institutions offer older tricyclic antidepressants and monoamine oxidase
free confidential professional mental health access, this may inhibitors should generally be reserved for treatment failure.19
inadvertently be another potential source of stigmatisation. It According to guidelines, treatment should include scheduled
has been suggested that registrars in particular, should all have follow-ups to monitor progress and enhance adherence, with
a periodic mental health review, and rather than opting in, this access to a psychiatrist if there is a significant perceived risk of
should be an opting out service, in order to circumvent individual suicide, of harm to others or of severe self-neglect, if there are
stigmatisation.22 Interestingly, many will admit to burnout, but psychotic symptoms, a history or clinical suspicion of bipolar
not to depression. It has been suggested that the concept of disorder, if insufficiently experienced to assess or manage a
burnout avoids pathologising workers’ emotional responses to colleague’s condition and if two or more attempts to treat a
their jobs.13 patient’s depressive disorder with medication have failed, or
resulted in insufficient response.19 These general measures
Doctors are known to encounter discrimination in licensing,
improve outcomes.
health insurance, and/or malpractice insurance.3 Lack of
confidentiality and fear of documentation on their professional Duration of antidepressant treatment at therapeutic dose is
record may become additional barriers to accessing care. dictated by the risks of relapse. Where low, a minimum duration
Administrators (and doctors) may forget that a diagnosis of of 9-12 months after full remission should be considered, while
depression does not necessarily mean impaired professional two years or long-term treatment is advised in higher risk
abilities. Fears of breaches of confidentiality as well as judgement patients who have experienced two or more depressive episodes
may also compromise openness between depressed doctors in the last few years.19 Cognitive behavioural therapy added to
and their potential treating healthcare professionals, further medication should be considered for patients with residual
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S14 S Afr Fam Pract 2019; 61(S1):S11–S14

symptoms or at high risk of relapse, and mindfulness-based 12. Hochberg MS, Berman RS, Kalet AL, Zabar SR, Gillespie C, Pachter HL. The stress
cognitive therapy added to usual treatment may be useful for of residency: recognizing the signs of depression and suicide in you and your
fellow residents. Am J Surg. 2013;205:141-6.
preventing relapse in those with ≥ 3 previous episodes.19
13. Rotenstein LS, Torre M, Ramos MA, et al. Prevalence of burnout among
physicians: A systematic review. JAMA. 2018;320:1131-50.
Importantly, socio-cultural factors precipitating or maintaining
14. MPS News. Survey reveals over 40% of doctors feel burnt out 17 October
depression should be considered and addressed if possible. 2018 [Accessed 20 November 2018]. Available at: https://www.
Occupational stress resilience strategies include mindfulness,28 medicalprotection.org/southafrica/for-members/news-centre/
making time for exercise/hobbies/holidays, spending quality news/2018/10/17/during-mental-health-awareness-month-medical-
protection-survey-reveals-over-40-of-doctors-feel-burnt-out?utm_
time with partners/family/friends, limiting alcohol use, self-
unique=&utm_campaign=2239266_RSA%20MED%20Casebook%20
monitoring, limit setting, and attitudes that promote constructive Connect%20November%202018%20LS&utm_medium=email&utm_
and healthy engagement with the challenges at work.29 Increased source=MPS&dm_i=2FC5,1BZTU,46YDKP,4C965,1
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individual, but also at group, social and institutional levels.31,32 PJ, et al. Evidence-based guidelines for treating depressive disorders
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