MY first response to a colleague who says “I am depressed” is critical for a number of reasons. Doctors have tough emotional masks and it has been difficult for my colleague to trust someone and disclose this. Due to the enormous stigma surrounding mental illness in the medical profession, this doctor may have been suffering quietly for a long time, is probably sleep deprived and could be at risk, perhaps self-medicating with antidepressants, benzodiazepines or alcohol.
Simple reassurance is not enough.
I must listen intently. If this doctor is a friend, I can help them get the right treatment from another GP with mental health training and experience. As doctors, we are in a better position than most patients to use our networks to find the right help, including accessing independent GPs outside our geographical area of practice to protect our confidentiality, doctors’ health advisory services or telehealth support for those of us who are working remotely or doing shift work.
When I am the treating doctor, listening is also my most powerful skill because the presenting problem is usually not the main reason for the consultation. Often a doctor patient will cry when I ask them how they feel, because very few people ask doctors this question or take time to listen to the answer fully. Many doctors rarely disclose their stories of grief, trauma and injustice, and it is a relief for them to do so.
To obtain a full history, I must earn trust by reassuring my doctor patient about confidentiality and dispel the myths of mandatory reporting. I have never reported a doctor with mental illness to the medical board, as I find colleagues comply with treatment and take time off work if needed. My doctor patients provide a high standard of patient care – but sometimes at great expense to themselves.
I keep the following framework in my head to ensure I have covered all aspects of a comprehensive mental health assessment over a few consultations.
Address common risk factors
Only by fully exploring common risk factors can we be proactive in addressing them.
Of course, doctors have the same risk factors for mental illness as the general population. Unsurprisingly, our doctor patients may have family histories of mental illness and alcohol and substance misuse, chronic illness or pain, negative life experiences and relationships, fractured family structures, family of origin histories of violence or suicide, and histories of child abuse. These histories can be triggered repetitively when our doctor patients are caring for their own patients with these common problems.
In addition, we often have perfectionist, self-critical, hypervigilant and task-oriented personality styles that make us great doctors, but put us at risk of failing our own impossible expectations. In my experience, I find that it is the very caring, dedicated and selfless doctors who are more at risk of mental illness than those of us with tough emotional shields. When doctors become aware that their personality strengths can also be vulnerabilities, they allow themselves to set healthy boundaries and become even stronger than before.
Patients need doctors who are caring, dedicated and healthy – not selfless.
Recognise a mixed pattern of atypical symptoms
Doctor patients may present with a mixed pattern of symptoms related to depressive disorder, anxiety disorder and post-traumatic stress disorder due to acute and chronic exposure to patient trauma, violence, abuse and death, including suicide.
They often present with atypical symptoms, such as uncharacteristic irritability or anger, difficulty concentrating or making decisions because of excessive worry, lack of empathy, social withdrawal and/or fatigue or low energy due to insomnia.
Diagnosis and treatment can therefore be complex.
Ask the hard questions
To work through all the issues, it is important to cover the other aspects of a comprehensive mental health history in detail – past history, family history, past/current medication, developmental history, education, work history, social history, suicide risk, past and current suicidal thinking.
As suicide is more common among doctors than in the general population, doctors are frequently traumatised by a colleague’s death and then placed at risk of suicide themselves. It’s not easy to ask my doctor patients this question: “Many people who are under extreme pressure feel like harming themselves. Have you ever felt this way?” but it is essential. Doctors have easy access to means, and ongoing suicide risk assessment is critical.
Overcome the special pitfalls of management
It’s easy to fall into the trap of providing brief telephone follow-up or repeat prescriptions for doctor patients too busy to attend in person. Ongoing face-to-face care is required to prevent a relapse of mental health problems in any patient.
Formal psychological treatments such as behavioural therapy, interpersonal therapy, acceptance therapy, and cognitive behavioural therapy may be evidence-based in the general population, but may have limitations in doctors.
Doctors are trained to “overthink” and have well developed negative mental filters and negative cognitive biases. Being risk-averse is part of being a good doctor. It is not easy to overcome these ingrained traits by challenging negative thinking with the usual cognitive behavioural therapy techniques. Structured formal mindfulness-based cognitive behavioural therapy has been found to be an effective treatment for depression and I have found this works well for doctors. Antidepressant medication may also be required.
Like many GPs with mental health training, I am capable of providing these treatments, but it’s important for me to recognise that my colleague may prefer to be referred appropriately to a psychologist or psychiatrist.
Although doctors tend to take very little sick leave, many medical workplaces fail to support doctors when they request a lower patient load or time off work. Sometimes, my doctor patients require my support to take sick leave because of their fears for their career if they disclose mental health problems.
Unfortunately, these fears are often justified. In this scenario and with the doctor patient’s permission, the necessary certificate can be supplied directly to the workplace by the treating doctor, without divulging the medical reasons and without the need for the doctor patient to personally justify their temporary absence. This, of course, is the right of any employee.
Advocate for a kinder, fairer medical workplace
A medical career has never been more challenging and complex, and instead of being supportive, our harsh medical culture predisposes doctors to having mental health problems. Recommending information about resilience to doctors for complex issues such as workplace bullying, harassment, discrimination, racism, and patient complaints or medico-legal action is as foolish and harmful as trying to fix a displaced compound fracture by covering it with a dressing.
Negative conditions at work must be addressed routinely as part of a comprehensive mental health management plan. As a profession, we have the ability to change this by stepping outside our consulting rooms to provide advocacy and leadership.
High quality health consumer-centred care requires doctors to tailor treatments to the individual needs of their patients. Our doctor patients also require tailored treatment for their special needs. As treating doctors, we are skilled at adjusting our consultation styles to the level of health literacy of our diverse patients. For our doctor patients, we can appropriately adjust our approach to their high level of mental health literacy.
There is a high level of stigma surrounding mental illness in Australia, which is deterring access to early mental health treatment and contributing to rising suicide. The medical profession has a responsibility to dispel the stigma rather than to perpetuate it, and to encourage all patients to access optimal mental health care, including doctor patients.
When anyone says “I am depressed”, simple reassurance is not enough, but a willingness to listen fully can be a powerful skill.
Clinical Professor Leanne Rowe is a GP, past Chairman of the RACGP and co-author of Every doctor: healthier doctors = healthier patients www.everydoctor.org
If this article has raised issues for you, help is available at:
Doctors’ Health Advisory Service:
NSW and ACT … 02 9437 6552
NT and SA … 08 8366 0250
Queensland … 07 3833 4352
Tasmania and Victoria … 03 92808712
WA … 08 9321 3098
New Zealand … 0800 471 2654
Lifeline on 13 11 14
beyondblue on 1300 224 636
beyondblue Doctors’ health website
Suicide Callback Service 1300 659 467