Higher Rates of Depression in Female Interns Explained

Batya Swift Yasgur, MA, LSW

November 06, 2017

Work-family conflicts appear to largely explain higher rates of depression in female medical interns in comparison with their male counterparts.

Results from a prospective longitudinal cohort study of medical internship in the United States showed that men and women ended medical school with about the same levels of depression and that both sexes experienced a marked increase in depressive symptoms during their internship year. However, this increase was significantly greater among women.

When work-family conflict was taken into account, the disparity between the depressive symptoms of both sexes decreased by more than a third, suggesting that this issue plays a significant role in the female interns' depression.

"The current study increases our understanding of the gender disparity in depressive symptoms during medical training and the role of the work-family conflict in increasing that depression in men and women," study investigator Constance Guille, MD, associate professor at the Medical University of South Carolina, Charleston, told Medscape Medical News.

"Because women typically have more household and child care responsibilities, they have greater work-family conflicts during the year of internship, which in turn leads to the increased risk of depression in women interns, compared to men," she added.

The study was published online October 30 in JAMA Internal Medicine.

In Search of Modifiable Risk Factors

"Depression is common among training physicians, with 25% to 30% of trainees experiencing elevated depression," the authors write.

Previous research suggests the "burden of depression among physicians may fall disproportionately on women," and a "subset of studies" suggests that rates are higher among female physician trainees. However, most studies have not specifically explored factors that may explain the difference.

The researchers hypothesized that work-family conflict might drive sex disparity in depression during internship.

"Despite the increased presence of women in the medical workforce, female physicians take on significantly more household and childcare duties than their male counterparts," they write.

This "unequal division of domestic labor" means that women experience "competing, often incompatible, pressures" that "can result in the experience of work-family conflict."

"Over the years, we have identified a number of nonmodifiable factors that affect the relationship between depression in internship ― for example, history of depression, female gender, being depressed at the beginning of internship, adverse childhood, and trait neuroticism," Dr Guille said.

"We were also seeing consistently that, prior to the start of internship and after its completion, men and women seemed similar in terms of depressive symptoms. We wanted to understand why women are more prone to depression during that year and identify something potentially modifiable to decrease the gender disparity."

She noted that no previous studies have examined sex differences in work-family conflict among training physicians.

"The majority of studies investigating rates of depression in medical trainees have not examined gender differences save for two that reported women were more likely compared to men to experience higher depressive symptoms."

The investigators set out to examine whether depression disproportionately affects female physicians in comparison with male physicians during the internship year, and, if so, whether work-family conflict influenced the discrepancy.

The researchers surveyed 3121 medical school graduates who completed assessments 2 months prior to beginning their internship year and 6 months later. Of these, 2108 participants (68%) completed the 6-month survey.

The first assessment collected demographic information, including age, sex, ethnicity, number of children, and relationship status. Depressive symptoms were measured with the Patient Health Questionnaire (PHQ-9), and conflicts between work and family roles were assessed via the Work and Family Conflict Scale. The second assessment, which occurred 6 months later, utilized the PHQ-9 and the Work and Family Conflict Scale.

The mean age of the participants was 27.5 years (SD, 2.7 years); 49.7% (1591) were women.

Men were more likely than women to be married or engaged and to have children, but women were more likely than men to report having a history of depression.

Both male and female respondents to the 6-month survey experienced an increase in work-family conflict scores. The mean (SD) scores increased 19% from preinternship to month 6 of the internship year (18.78 [5.53] to 22.54 [5.59]; P < .001).

However, prior to the start of the internship year, there were no significant differences in mean (SD) work-family conflict scores between women and men (19.0 [5.4] vs 18.6 [5.7], respectively; P = .08).

In contrast, 6 months into the internship year, the mean (SD) work-family conflict scores were higher for women (22.8 [5.5]) than for men (22.2 [5.7]; P = .01). The average increases over time in work-family conflict scores were similar (P = .4) between women and men (increases of 3.9 ± 6.1 and 3.7 ± 6.3 points, respectively).

Prior to internship, depression scores were roughly similar for men and women; women's average scores were only 4% higher than those of their male counterparts (2.79 vs 2.68).

In addition, when work-family conflict was accounted for, the difference became "essentially negligible, with women's adjusted mean scores just 2% higher (2.96 vs 2.91) than those of the men."

Greater Work-Family Conflict for Women

Men and women both experienced an increase in symptoms of depression during their first 6 months of internship (equivalent to 2.50 points [a 93% increase] on the PHQ-9 score among men and 3.20 points [a 115% increase] among women).

For both sexes, increases in work-family conflict scores were statistically correlated with increase in PHQ-9 depression scores (ρ = 0.28; P < .001)

However, after adjusting for the potential confounding effect of changes in work-family conflict, the researchers found that the increases in PHQ-9 scores were "slightly attenuated," with an estimated increase of 58% (1.69 to 2.91) among men and 72% (2.13 to 2.96) among women.

Increases in mean depression scores were higher for women than men. Using an estimated sex-by-time interaction, the researchers found that the increase among women was 0.70 points higher (95% confidence interval [CI], 0.37 - 1.04) than the increase among men (3.20 vs 2.5; P < .001).

On the basis of an estimated sex-by-time interaction, the increase in depression scores in women (2.13 points) remained significantly higher (by 0.45 points; 95% CI, 0.11 - 0.78; P < .01) than among men (1.69 points), even after adjusting for changes in work-family conflict.

A comparison of the sex-by-time interaction differences between the nonadjusted and adjusted models showed that the estimated sex difference was 36% lower (0.70 points vs 0.45 points) after adjustment for work-family conflict.

Increases in the work-family conflict score affected men and women differently. Women whose work-family conflict score increased from 15 to 23 (ie, the 25th percentile at baseline to the 75th percentile) had, on average, a 3.8-unit corresponding increase in their PHQ-9 score.

By contrast, men whose work-family conflict score increased to a similar degree had, on average, only a 3.3-unit increase in their PHQ-9 score. The researchers described this interaction between sex, time, and work-family conflict scores as "moderately significant."

High Stakes

"I became interested in this subject during my residency when I saw the stress among interns and, in fact, an intern attempted suicide," said Dr Guille.

The high stakes of depression in interns goes beyond the deleterious effect on individual interns, she noted.

"Depression among physicians in training is associated with poor quality of patient care, medical errors, and career attrition. Work-family conflict associates with low job satisfaction and burnout that, in turn, negatively impacts patient care."

Dr Guille added that work-family conflict increases during internship, which imposes greater demands and is more time consuming than medical school.

"Compared to medical interns, medical students work fewer hours and have significantly less responsibility for patient care, which makes it easier for them to leave the hospital and attend to family responsibilities, resulting in less work-family conflict."

By contrast, medical interns work more than 80 hours a week and "are responsible for patients' lives and have very little to no control over their schedules." This makes it difficult for both men and women to balance work and family responsibilities.

Women are more susceptible to a higher degree of work-family conflict because, as demonstrated in previous studies, "female physicians take on significantly more household and childcare duties compared to male physicians.

"Therefore, female physicians are likely to experience even more competing and incompatible demands of work and family responsibilities compared to male physicians, resulting in more work and family conflict," she said.

She noted that this "gender gap is not unique to medicine." Any time a person has a "high degree of job demands and family responsibilities combined with a low degree of autonomy over their schedules, there will be work and family conflict."

Action Needed

Judy A. Shea, PhD, professor of medicine at the Hospital of the University of Pennsylvania, Philadelphia, and Lisa Bellini MD, professor of medicine, Perelman School of Medicine at the University of Pennsylvania, are coauthors of an accompanying editorial.

"This is one of the first studies to look at depression and work-family conflict together and longitudinally and the differing trajectories for both constructs between men and women are interesting and bear further scrutiny," Dr Shea and Dr Bellini commented to Medscape Medical News.

In their editorial, they encourage further research with a "broader arsenal of methods to study the complexities and interplay among work events and multiple mood states."

They emphasized the importance of taking action.

"We need to stop counting issues like depression and work-family conflict in medicine and focus on developing evidence-based interventions that are ideally individualized and adaptive to match evolving models of training."

Dr Guille concurred.

"On a systemic level, identifying a modifiable risk factor - family conflict - that drives depression can enable programs and interventions to be developed to reduce conflict," she said.

Some of these interventions might be "practical," such as providing assistance with child care or home-delivered meals and helping interns to have more control over their schedules.

"For example, rather than putting complicated cases at the end of the day, where the intern can't leave work predictably to attend to the family, those cases could be scheduled early in the day and relatively simple cases at the end of the day."

Another intervention would be to encourage physicians to overcome their reluctance to seek help for depression.

"There is stigma in the general public for getting help for mental health problems, and an added layer for doctors who are worried about what their colleagues will think or if it might potentially affect their licensure."

Prophylactic interventions are also important, she said. "Since we know there is uptick in depression during the internship year, we should be engaging in preventive interventions to give interns coping skills in advance."

Her research group previously conducted a study of a Web-based CBT program to be used prior to the start of internship. "Those randomized to the intervention were 60% less likely to have suicidal ideation during the internship year than those who were not."

It is important to "make it easier for interns to get help if they have problems, make it accessible, affordable, and do-able in the intern's schedule," she emphasized.

The study was funded by the National Institute on Drug Abuse, the National Institute of Mental Health, and the National Center for Advancing Translational Sciences. The authors and editorialists have disclosed no relevant financial relationships.

JAMA Intern Med. Published online October 30, 2017. Abstract, Editorial

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