The importance of physician mental health and well-being cannot be overstated. Medscape's Physician Burnout & Depression Report 2023 documented that physicians are suffering. They recognize that their colleagues are also experiencing distress, and they often fear seeking professional help because of the stigma surrounding mental health problems.

Physicians — like everyone else — are rarely trained in mental health topics, but learning a few basic concepts can help everyone recognize and understand personal and professional psychological keystones.

Those concepts include:

• Understanding how to obtain and maintain positive mental health

• Understanding mental disorders and treatments

• Decreasing stigma related to mental disorders

• Knowing when and where to seek help

If you feel vague about what constitutes mental health and mental illness, you're not alone. Most medical residents report that they never learned how to assess the mental health of their patients, let alone their own mental health.

A basic understanding of terms can be helpful. Consider mental health vs mental illness in the same ways that you think of physical health and physical illness. Everyone's physical health ebbs and flows over the course of their life, occasionally tipping into physical illness. It's the same for mental health: It waxes and wanes, moving along a spectrum of good and bad health.

Positive mental health is not the same thing as happiness. Happiness is a state of well-being, with a sense of meaning and deep contentment. A person with good mental health can be sad, and an unhappy person can have good mental health.

A person can experience poor mental health but not meet the criteria to be diagnosed with a mental illness. Mental health disorders are diagnosed by professionals who use the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), published by the American Psychiatric Association.

Everyone is going to have poor mental health at various points of their life, just like we are all likely to occasionally have a cold or the flu. Experiencing mental "unhealth" should be seen as a normal part of life that is neither good nor bad, but rather to be expected.

There are many symptoms of poor mental health, including:

• Confusion or difficulty concentrating

• Extreme fears, worries, or feelings of guilt

• Disengagement from typical endeavors

• Mood swings

• Low energy

• Sleeping problems

• Loss of appetite

• Withdrawal from normal activities and friends

Common causes of poor mental health vary depending on your stage of life. In adults, mental illness is often caused by the loss of a spouse, the loss of a job, the birth of a child, or moving to a new home. Whether the event is positive or negative, it may be disruptive in ways that decrease your mental well-being for a period of time.

Having poor mental health means there's a strain on your cognitive and adaptive systems that requires an adjustment. To combat that strain, we must take steps to support our mental health.

Promoting our mental health — the focus of Chapter 4 of this course — is an active process that requires daily investment and growth across one's lifespan. That effort is well-spent because it lowers the risk of developing a mental health disorder.

The high rates of burnout, depression, and suicide among physicians have been alarming for years.

• Burnout is a very real set of symptoms, but it is not a DSM-5 diagnosis.

• Clinical depression, sometimes called major depressive disorder, is a common and serious mood disorder that is diagnosed if a person meets specific criteria identified in DSM-5.

• DSM-5 lists 11 types of anxiety disorders, including panic disorder and social anxiety disorder. Each type has its own diagnostic criteria, typically including the duration and frequency of specific symptoms.

• Suicidal thoughts and suicide attempts may be present in individuals diagnosed with mental illnesses, including depression and/or anxiety. Suicidal ideation itself is not a DSM-5 diagnosis.

Physician burnout is a stress reaction that includes three dimensions: emotional exhaustion, depersonalization, and feelings of decreased personal achievement. Burnout is not a physician-specific condition, but physicians have very high rates of burnout compared with people in other professions.

A disturbing 53% of physicians responding to Medscape's most recent Burnout & Depression Report conducted in mid-2022 — said they were suffering from burnout. That was an increase from 47% a year earlier.

Burnout fuels mental illness, but it is not a mental health disorder.

Everyone talks about burnout because it is so prevalent and, despite all the talk, remains an unsolved problem. The majority of physicians know what burnout feels like: overwhelmed by demands without the capacity to meet the demands. The constant stress of being expected to accomplish more breeds a sense that no matter how hard you work, it is not enough.

Burnout is a long-term stress reaction, but it is not necessarily related to time. It doesn't emerge overnight, nor does it build up over years. Rather, it surfaces when a culmination of stressful events tip the scales, changing a physician's situation from acceptable to burned out.

Emotional exhaustion means being unable to emotionally replenish, restore, and come in fresh the next day. Each individual has a different threshold for emotional exhaustion. If you feel like your work is never enough — that no matter what you are providing for your patients or your health system, you are always being asked to give more — you may be experiencing emotional exhaustion.

Physicians are particularly vulnerable to emotional exhaustion because, by virtue of choosing to be physicians, they want to help others. Wanting to care for patients is an emotional experience as much as it is a profession. It may be hard for physicians to recognize their emotional exhaustion because they are so conditioned to prioritize their patients' problems over their own.

Depersonalization is an increasing loss — or lack — of empathy for patients. This may be evident in self-talk or comments to others that express:

• Dreading the day ahead

• Dreading certain types of patients

• Feeling frustrated that patients arrive late or are not doing what you told them to do

• Feeling agitated about routine patient presentations

• Feeling low tolerance for normal job aspects

Considering that physicians have trained for years to take care of patients, feeling frustrated with the daily tasks of providing that care can be demoralizing. It's important to recognize that patients are not the problem; the feeling of being on a treadmill is the problem. But when a physician is emotionally exhausted and not trained to recognize the symptoms of burnout, it is easy to shift negative feelings onto patients.

Decreased personal achievement is manifested in various ways, from a lack of interest in getting up to go to work to a lack of working toward goals that used to be meaningful.

Because physicians want to improve the quality of their patients' lives, doing so can be a source of achievement and satisfaction. In turn, it is very disorienting for physicians when, completely unanticipated, they feel their efficacy and achievement is decreasing.

As with depersonalization, a sense of decreased personal achievement can prompt physicians to blame their workplace or other external factors for feelings they do not fully understand.

Physician burnout is largely attributed to organizational and systemic factors that are beyond physicians' control. For many years, physicians have pointed to administrative hassles — considerable inbox work and frustration with electronic medical record technology — as top drivers of burnout.

The danger and the workload associated with the COVID-19 pandemic exacerbated physician distress levels.

According to research published by the Mayo Clinic, there are several new causes of burnout:

• Continuing waves of COVID-19 variants

• Mistreatment of health professionals

• Staffing shortages

• Politicization of vaccinations and anti-science attitudes

Symptoms of depression are different from a diagnosis of depression; the same is true for anxiety. Almost everyone will experience symptoms of anxiety and depression every day. The cause may be something big — a divorce or working in a COVID-19 ward, for example — or small, such as an unfamiliar public speaking engagement. Symptoms of anxiety or depression are natural expressions of our body telling us something new is happening.

When those symptoms become persistent, increase in intensity, and dominate our internal state without returning to a healthy baseline, they may meet the criteria for a diagnosable disorder. These criteria include experiencing specific symptoms for a period of time and the degree to which those symptoms negatively affect your roles and responsibilities.

It is a widely held myth that physicians have a greater tolerance for symptoms of anxiety and depression. Indeed, physicians often tolerate low-level symptoms of anxiety, depression, and burnout for long periods of time. This leads to greater suffering and a higher likelihood of mental illness moving into a mental health disorder.

Pre-COVID data presented at the 2018 American Psychiatric Association annual meeting revealed that in the US on average, over 350 physicians per year die by suicide. With between 28 and 40 estimated suicides per 100,000 physicians, the medical profession has the highest suicide rate of any profession. And it's more than twice the rate — 12.3 suicides per 100,000 people — of the general population.

A literature review presented by Deepika Tanwar, MD, a psychiatrist at Children's National Hospital in Washington, DC, summarized what is known about the physician suicide crisis:

• Physicians who die by suicide often have untreated or undertreated depression or other mental illnesses.

• Physician rates of depression — 19.5% of female physicians and 12% of male physicians — mirror those of the general population.

• Depression is more common among medical students and residents, with between 15% and 30% reporting symptoms of depression.

• The problem is not restricted to North America. Studies in Europe, Australia, Singapore, China, and other countries document high prevalence of anxiety, depression, and suicidality among medical students and physicians alike.