This may come as a surprise, but while doctors are saving lives every day, they're also taking lives—their own. In the United States alone, 300 to 400 physicians die by suicide each year. Or put another way, a doctor a day is killing herself or himself. This is shocking—and it is tragic—because many of these deaths can be prevented.
Many physicians are not receiving the kind of care that they so artfully and skillfully provide for their own patients. In fact, detailed interviews with family members—as well as friends and colleagues—reveal that 10 to 15 percent of deceased physicians do not receive any care at all.
Their loved ones are left to grapple with the sad and chilling paradox that someone they loved and respected as a guardian and protector of life was unable to apply that to their own. Their worries, fears, and pleas for help went unheeded, and loved ones are left with heartache, regret, and the common refrain, "Something has to change."
"A good friend told me about her death. We didn't know right away that it was suicide. It was horrible to hear the truth. It came out that she had been struggling. Why is there so much stigma? Why is there that message of 'don't show any weakness' in the everyday world of medicine?"
These are the words of Pam Swift, M.D., author of Doctor's Orders: One Physician's Journey Back to Self. I spoke to her by telephone on September 18, 2015, about the loss of a doctor colleague to suicide.
Stigma attached to mental illness is not new, and, although not nearly as egregious as it once was, it is far from over. It is certainly not eradicated in the house of medicine. There are two types of stigma—enacted and felt. Although these terms were originally used to describe stigma associated with epilepsy, they can be extended to mental illness.
The Two Types of Stigma:
Enacted stigma is exterior and refers to discrimination against people with a psychiatric illness because of their perceived unacceptability or inferiority.
Felt stigma is interior and refers to both the fear of enacted stigma and a feeling of shame associated with having a mental illness. I believe that both types of stigma can be at play when a symptomatic physician decides to seek treatment.
What does enacted stigma look like?
Examples of enacted stigma tend to be more systemic (lack of parity in health insurance coverage and reimbursement, exclusion clauses in disability insurance contracts, blanket questions asked on medical license application forms) than specific to the doctor-patient relationship. But this does happen, albeit uncommonly.
A psychiatrist friend of mine who has zero felt stigma about his recurrent major depression had a very uncomfortable experience with a new psychiatrist he consulted in his home city. The psychiatrist was quite belittling and critical of him for not disclosing his "precondition" during interviews for psychiatry residency. Although my friend was asymptomatic all through training and completely adherent to treatment over that span of time, he was made to feel fraudulent and diminished by this doctor. Needless to say, with my assistance, he went elsewhere for treatment.
What does felt stigma look like?
Felt stigma can manifest itself in many ways in the treatment relationship. First, physicians who feel ashamed of having a mental illness will be inhibited and less forthcoming. They may be embarrassed to disclose key pieces of their personal and family history or to talk about certain symptoms like symptomatic drinking, abortive suicide attempts, an extramarital relationship, compulsive viewing of pornography, and so forth. The treating psychiatrist may not get a true picture of the illness complexity and severity.
Second, even well-intentioned physician-patients may be less treatment adherent. They miss or cancel appointments. They "forget" to take their medications or take them haphazardly. They assume a passive attitude to treatment rather than a collaborative and participatory one. They resist engaging in psychotherapy, especially explorative or insight-oriented modalities.
Third, they bolt from treatment at the first signs of symptom amelioration because each visit with the psychiatrist or each pill is a reminder that they are undergoing psychiatric treatment. A variant of this are physician-patients who seduce the psychiatrist into believing that they are far more improved than they really are, so visits are spaced out prematurely or treatment is suspended. And fourth, because of felt stigma, these same patients are reluctant to return for treatment when or if they relapse because they feel they've failed and they are ashamed of their "acting out" regarding the previously prescribed treatment.
What's the bottom line?
It behooves everyone to be patient and nonjudgmental with physician colleagues and themselves. It takes time to accept a stigmatized illness. Compassion conveys acceptance and understanding. And we must salute and thank those few physicians like Aaron Carroll, Nathaniel Morris, and Adam Hill who have shared their mental health challenges publicly. They are chipping away at stigma and saving lives.