Depression burden weighs heavily on resident physicians

Depression symptoms have reached a crisis level among doctors in training, suggests a new international review. It comes on the heels of a Quebec coroner's report following two suicides in a year by residents in the province.

The analysis published in Tuesday's issue of JAMA found the prevalence of depression or its symptoms was 29 per cent, based on 54 studies involving more than 17,000 physicians worldwide from 1963 to now.

The findings may affect the longterm health of resident doctors and patients since depression among residents was associated with lower-quality care in previous studies.

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A better understanding of the culture of specific residency programs and working environments could help reveal some of the root causes of depressive symptoms, study author Dr. Douglas Mata of Brigham and Women's Hospital in Boston and his co-authors said.

In October, Quebec coroner Jean Brochu's report into the 2014 suicide of University of Montreal medical resident Emilie Marchand pointed to the workplace culture as a factor.

Residents are generally busier, more overwhelmed, fatigued and sleep deprived than medical students or practicing physicians, Dr. Thomas Schwenk of the University of Nevada School of Medicine said in a journal editorial published with the research."The personal and professional dysfunction, not to mention the suicide rate that may derive from this symptom burden, should be disturbing to the profession; these findings could be easily construed as describing a depression endemic among residents and fellows," Schwenk said.

The prevalence of depression in the general population is 12 per cent, based on well-accepted international research, said Dr. Natasha Snelgrove, a fifth year psychiatry resident at McMaster University in Hamilton, Ont. and president of the Professional Association of Residents of Ontario.

For nearly a third of residents to be struggling shows it is a huge issue, Snelgrove said.

A lot of universities and medical organization groups are open to having conversations around fatigue management, resident wellness and stigma reduction, she said.

"A lot of that is very difficult and very slow to happen, and unfortunately tragic incidents like the two suicides in Quebec and other suicides across the country are still occurring because it's taking time to change that culture."The prevalence of depression was nearly double among young physicians compared with their older counterparts, which suggests something is putting the younger ones at risk, Snelgrove said. For example, residents generally have less autonomy during their training and face job uncertainty, particularly in areas that depend on hospital resources. She pointed to three changes needed to reduce the risk of depression and suicide among residents:

• Stigma — Residents who need help may fear speaking out because of the implications for their career and licensing.
• Improve access to truly confidential services.
• Change the culture that depicts doctors as super heroes who don't get sick when in reality they're just as vulnerable to depression as everyone else.

The training of medical professionals is like a boot camp where residents are left to sink or swim, said Dr. Ajantha Jayabarathan, a family physician in Halifax. She's been working in the field for about 25 years. 

Loss of empathy

Jayabarathan recalled how ill prepared she was to cope after witnessing a stillbirth or treating victims of homicide during the course of her residency training.

"As a result of being exposed to this trauma vicariously over and over again, it actually impacts on the world view of the practitioner themselves," Jayabarathan said. "As a result of it, they end up losing the very empathy and compassion that attracted us to that field in the first place." 

Jayabarathan recognized how time-pressed residents are when they need to learn skills quickly. But she called it unconscionable to leave residents to face storms without protection, such as supports known as Balint groups where doctors can debrief regularly to prevent burnout.

In the study, most of the participants were assessed based on self-reports, not measurements of depressive symptoms during a clinical interview, a limitation the researchers acknowledged.