Depression Among Residents on the Rise

Liam Davenport

December 08, 2015

More than a quarter of physicians in residency training have depression or depressive symptoms, reveals a meta-analysis of more than 50 studies published over the past 5 decades.

The analysis, involving data on more than 17,000 residents, indicated that depression, which ranges in prevalence from 21% to 43%, not only is equally common among interns and upper-level residents but also that rates of the disease have shown a small but significant increase year to year.

"At the very least, this means that the problem is not getting better," said lead author Douglas A. Mata, MD, MPH, Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.

He told Medscape Medical News: "I hope that, by having this definitive number and also the evidence that it's actually not getting better and may be increasing, it will spur more people to pay attention to these issues and to ask the hard questions as to what we need to change to address it."

The study was published online December 8 in JAMA.

The researchers conducted a systematic search of the Embase, ERIC, Medline, and PsychINFO databases for studies on depression or depressive symptoms among residents published between 1963 and 2015.

After evaluation by two trained investigators, the team identified 31 cross-sectional studies, involving 9447 individuals and 23 longitudinal studies involving 8113 individuals. Results were pooled using random-effects meta-analysis to estimate depression rates. Of the studies, three used clinical interviews, and 51 used self-report instruments.

The overall prevalence of depression or depressive symptoms was 28.8%, ranging from 20.9%, using the nine-item Patient Health Questionnaire with a cutoff score of ≥10, to 43.2%, using the two- item Primary Care Evaluation of Mental Disorders questionnaire. There was significant heterogeneity between the studies (P < .001).

There were no significant differences in the prevalence of depression between cross-sectional and longitudinal studies, between those that focused on interns only and those that involved only upper-level residents, or between studies of nonsurgical residents only and those of both nonsurgical and surgical residents.

After adjusting for the assessment modality, there was a significant increase in the prevalence of resident depression every calendar year, at 0.5% per year (P = .04).

Interestingly, a secondary analysis of seven longitudinal studies indicated that there was a median absolute increase in depressive symptoms after starting residency training of 15.8%, at a relative risk of 4.5.

No Surprise

Discussing the findings, Dr Mata said that he was not surprised at the level of depression among residents.

"Having recently gone through medical school and being a current resident now, it's something that we see that surrounds you, unfortunately, all the time," he told Medscape Medical News. "The number of people I personally know who have dealt with these issues I can't even count on two hands."

He added: "It gets written about from time to time, but it's one of those open secrets in medicine, where people don't want to talk about it, in part because of the stigma associated with depression."

 
The number of people I personally know who have dealt with these issues I can't even count on two hands. Dr Douglas Mata
 

Although acknowledging that the study was not able to identify the drivers of depression among residents, Dr Mata suggested that "the process of even getting into medicine today has become quite complicated; it takes many years of delayed gratification."

Even when someone becomes a physician, he noted, the work hours are "incredible," and cases are more complicated than in the past, often involving patients with multiple comorbidities.

"In addition, the number of different diagnostic and treatment tools that are available today is exponentially greater than it used to be," he said. "I think this increase in complexity, along with the continued long hours and sleep deprivation in particular, is a major driver of the high rates of depression."

Another aspect of the working life of a physician today is the relatively small amount of time spent at the bedside, with a substantial proportion of the day taken up with clerical work.

Dr Mata also pointed out that, nowadays, physicians are "never away from the hospital." He said: "Residents are spending their day off still virtually in the hospital, because you can connect to the electronic medical system from home.

"You may set aside things during the week, like charting activities, preparing for next week's clinic, etc, that you don't have time to do at work, so you end up spending your day off virtually at work through the computer system."

One notable aspect of the study is the heterogeneity of findings, with a wide range of prevalence estimates for depression among residents. "So the question is, what is it about the settings...that are giving a low estimate? What decreased the risk of depression there?" Dr Mata asked. "Is it something to do with the program itself?"

Prevalence "Unacceptably High"

In an accompanying editorial, Thomas L. Schwenk, MD, dean, University of Nevada School of Medicine, Reno, argues that regardless of how levels of depression among residents compare with those seen in other professions, "the prevalence is unacceptably high."

Moreover, relieving the burden of depression among residents, he says, "is an issue of professional performance in addition to one of human compassion," given the link between residency depression and poor-quality patient care and increased medical errors.

He believes that there are three categories of solutions to the "endemic" levels of depression: "Provide more and better mental health care to depressed physicians and those in training, limit the trainees' exposure to the training environment and system that are thought to contribute at least in part to poorer mental health and wellness, and consider the possibility that the medical training system needs more fundamental change."

Speaking to Medscape Medical News, Dr Schwenk said that medical practice has changed dramatically since he graduated in 1975. "It's just so much more complicated, there's so many more ethical dilemmas, so much more technology."

He added that patients in general are "more demanding of perfect outcomes," which, in tandem with regulatory issues and malpractice threats, has created a "dramatically different situation."

In contrast, current residency programs are fairly similar to those of the past, he noted. Although praising efforts to standardize curricula and evaluations and provide opportunities for feedback, "in the process of doing that, I think we've lost a lot of the mentorship, the ability of senior physicians to guide residents."

Picking up on Dr Schwenk's point, Dr Mata said: "Certainly, in some medical centers and practices, attending physicians may be so overwhelmed themselves with patient care issues that they do not have time to teach as much as they would like."

The consequence, Dr Schwenk said, is that "everybody is so pressured and the productivity pressures are so huge that there's just not time to process all of the really intense and sometimes very traumatic things that take place."

He added: "I think we need to re-examine the resident experience, because something's clearly happening to really cause tremendous burdens on them."

High Physician Burnout

Dr Schwenk pointed out that there is a degree of overlap with concerns over resident depression and the high rates of physician burnout, as recently reported by Medscape Medical News.

 
I think we need to re-examine the resident experience, because something's clearly happening to really cause tremendous burdens on them. Dr Thomas Schwenk
 

He said: "When you look at these very high burnout rates, and you look at how discouraged physicians are with a lot of the regulatory burden, the malpractice stress, and the electronic medical records, and just the lack of joy and the lack of satisfaction, you kind of wonder what we're doing.

"We get these amazing medical students, incredibly talented, incredibly smart, with amazing commitment and altruism, and somehow, by the end of their residency, a pretty high proportion are pretty significantly discouraged and trying to find various ways to isolate their stresses.

"[They are] looking for specialities that have better lifestyles, are less demanding, sometimes with even less contact with patients, and you just wonder what we're doing to these students."

One point that Dr Schwenk and Dr Mata both emphasized is the need for more research to drill down into the causes of depression among residents. Dr Mata highlighted the Intern Help Study, a prospective cohort study included in the current analysis, which aims to follow individuals from medical school through their residency to identify factors affecting rates of depression.

Dr Mata said that, although the 'gold standard' study would be for psychiatrists to conduct diagnostic clinical interviews in a subset of participants, anonymity is needed to assess for depression among residents.

"If you think about it, a resident who has finished medical school has already memorized and knows well all of the classic symptoms for depression, and probably has assessed a patient themselves for depression in the past," he noted.

"So if you are concerned about retaliation or concerned about people thinking that you can't do your job, you can basically say what you need to say to get the result that you want. That's where the anonymity comes in."

Dr Schwenk noted: "This whole field is extremely difficult because of the stigmatization that goes with being depressed."

He explained that the stigma operates on two levels. "Depressed students, for example, experience public stigma, meaning that they feel like they're being stigmatized by those around them, but they also feel it personally."

He added: "They feel a certain inability to not be able to function, and they feel shame about that. And they feel like they are unworthy of attention.... It makes it hard to study this entire field, because residents and students in general won't respond and don't want to be further isolated."

Dr Schwenk continued: "Everybody asks me, because of some of my prior studies, should we have more intense work in diagnosing depression in students? Of course, the answer is 'yes,' but how do you go about that without further stigmatizing them, further labeling them, further singling them out to even greater stigma? It's not just an issue of, 'Let's make better diagnoses and let's provide better treatment'; it’s more complicated than that."

Concluding, Dr Schwenk said: "I think we've gotten better in destigmatizing depression as a mental illness worthy of attention in patients, but we haven't done a very good job of doing that for ourselves.

"We believe that we should be able to take care of it ourselves, we should be able to write it off, that we're supposed to be tough and commanding and decisive and always able to cope, and if we can't, we don't really know where to go from there."

This work was supported in part by a US Department of State Fulbright scholarship and by funding from the National Institutes of Health (NIH) and the NIH Medical Scientist Training Program. The authors have disclosed no relevant financial relationships.

JAMA. Published online December 8, 2015.Abstract, Editorial

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