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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.
In summary
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
AMA lists of GPs willing to see junior doctors
Lifeline on 13 11 14
beyondblue on 1300 224 636
beyondblue Doctors’ health website
Suicide Callback Service 1300 659 467
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Hi, Thanks For Your Top-Notch Article. Most Likely, Depression Is Caused By A Combination Of Genetic, Biological, Environmental, And Psychological Factors, According To The NIMH. Certain Medical Conditions May Also Trigger Depression, Including An Underactive Thyroid Gland, Cancer, Heart Disease, Prolonged Pain, And Other Significant Illnesses.
As a rural GP with long standing anxiety/depression I recently sought help when I became severely anxious and suicidal.Fortunately my new GP was excellent and so was the psychiatrist she referred me to and I was able to get a timely appointment.
I have taken the necessary time off work for several months ,exercised regularly and gone to a psychologist,taken my meds and am well back on track.
It is always worth seeking help and I am very grateful to still be here.
Dont let your own fears stop you from seeking help PLEASE
When a Doctor says they are depressed, take that VERY VERY seriously. In this age of punitive and recriminatory practices by the regulatory authorities, for a Dr to openly say they are depressed – that must ring alarm bells. No-one says so openly any more unless they are deeply distressed, we simply cannot afford the risk of disclosure.
Thank you Leanne for an excellent thoughtful insight into how we can assess and help manage doctors who feel depressed, or even just experiencing lowered moods and/or stress. Active listening and developing a trusting relationship is the key. Also providing advice to assist the doctors to build resilience through self care, which should be taught in Medical schools to help students develop resilience and better coping mechanisms to deal with ongoing stressors every Dr experiences, such as working in hospitals and dealing with difficult patients we may encounter.
Your book Every Doctor, co-authored with Professor Michael Kidd, provides excellent advice and strategies – I wish a book like this was available to me as medical student, now over 30 years ago! Thank you!
I have depression. It developed when everything was “sailing smoothly”. I have not been able to return to work for 5 months now. My GP tried me on several antidepressants one did work but gave me side effects. My GP referred me to a psychiatrist to look at medication options. I am seeing a clinical psychologist, 3 of them at different times. The one who helped me the most is a counsellor. The college helped by allowing me to make an appointment with a psychologist registered with them which turned out to be a not so good experience and I left the clinic quite suicidal and hopeless. What I am trying to say is please provide us with the help we need bearing in mind our line of work. Please listen. Please dont think that medications are needed. Listen. We all heal in different ways because we all come from different belief systems.
Reading through the above comments there are several things that urge me to comment. I think as GP’s whether specially trained or not it is imperative to recognise that you will be seeing mental health issues and you need to have adequate skills to support patients, enable them to be open in discussion and to be aware of your limitiations and abilities and arrange treatment where required. Sometimes it is simply providing a grounding or sounding board that helps prevent deterioration into depression, or it may be that a patient or doctor patient knows they will feel okay mentioning their problems. If you believe you have no skills and do not wish to deal with these issues then your patients are left with a significant barrier of feeling they need to seek help elsewhere.
As a retired Gp with lifelong issues with mood, i have had many occasions when what I see as openers for discussion of mood are ignored or brushed away. I have also had some good GP’s. It is also easier to be open and to push your needs when your experience of your own mood disorder is longer standing. As a GP- patient it is also common to have more exacting standards and to “drop” a GP who doesn’t seem to fulfil your criteria of quality. (However, the older you get the more you accept that the number that will meet your criteria is quite small and perhaps the criteria are too harsh!) However I write this in respect of those who are having first or early episodes of mood related problems.
Please do not believe you have no time or ability to help mental health problems. If you need to make time or learn a few skills then do so in the same way that you keep up with changes in medical care of other illnesses.
I have had several doctors (and therapists) say they would find it hard to be my doctor/therapist as they would feel intimidated ( never my intention), and insufficiently skilled. Doctors as patients don’t expect you to be perfect but they expect effort in trying to understand where they are coming from and advice/discussion as to what to do or where to head next. This also doesn’t mean simply asking what would you like? How about- I would normally suggest this, what are your thoughts?
Best wishes and encouragement to all.
It astounds me that any professional outside of those specifically and comprehensively trained and qualified to treat mental health problems would think themselves capable of dealing with the mental health of doctors, who as pointed out, are often blessed with intelligent minds that have maladaptive thinking. When will the general medical profession realize that they are not adequately trained to treat psychological and psychiatric problems, and stop pretending they have some special profession that only those who work as doctors can understand or treat? For heaven’s sake, a medical degree isn’t a psychological one, and a half-baked response to mental health problems is all one will get when you do not see the experts for help using evidence-based. Suggesting another doctor is qualified to help with genuine depression is like suggesting homeopathy is effective medicine. BTW the jury is still out on Mindfulness treatment protocols, and the British Psychological Society have named only CBT and IPT as clear evidence-based psychological treatments for depression.
An excellent article by a truly inspirational leader of her profession. Professor Rowe’s views are there to be listened to and acted upon by her colleagues as the exemplar of good practice and responses to extremely challenging situations.
I’m sick of hearing the tired old refrain that it’s stigma and fear of negative effects on career that deter doctors from seeking help for mental health problems. I’ve always had my own GP and have never been afraid of discussing mental health problems for those reasons.
What does put me off is multiple experiences of poor quality mental health care and lack of appropriate boundaries: one GP prescribing antidepressants at a first ever presentation with depression with minimal history taking, no questions about suicidal ideation, no discussion of potential drug side effects, and the only follow up being instructions to “make another appointment if you have any problems”; second GP (who was specifically recommended as having experience in treating other doctors) giving me, unrequested, a huge quantity of sample packs at the same time as decreasing frequency of followup (unrecognised deterioration led to suicide attempt by OD); a third GP at same practice as second GP (so using same patient record) who listed herself as having a special interest in mental health blithely prescribing antidepressant repeats for years without having actually read my notes or taken a history from me, seemingly completely unaware of the history of overdose until I mentioned it in one consultation; same GP later suggesting a diagnosis of bipolar disorder on the basis of noting ONE vague symptom listed on my summary sheet (“mood swings”), no attempt to clarify by taking further history; same GP putting pressure on me to seek a psychiatric second opinion from someone whose management strategy would more closely match her own preference, with no attempt to discuss my case with the psychiatrist who’d been successfully managing me for 10+ years; fourth GP taking a phone call about another patient’s mental health admission in the middle of the consultation where she was preparing my mental health treatment plan, declining my offer to step outside while she took the call, and discussing confidential details over the phone in front of me; gynaecologist who noted my history of mental health problems on a referral then proceeding to share details of his own mental health problems while in the middle of performing an invasive in-office procedure.
I’ve done my best to follow RACGP recommendations about being a good patient, but I give up – in future I’ll stick with self-referral to specialist mental health practitioners who seem to know what they are doing, and keep my mouth shut around everyone else.
Having been hounded out of a job for disclosing depression I would be very careful telling anyone anything about mental health issues if you’re a doctor. Almost any other illness would be more acceptable and have empathy and support associated with it in the workplace. But not depression. Seek help and keep it completely secret.
There isn’t always a reason for depression.
ie endogenous depression v. reactive depression.
(not DSM5 terminology)
Truth expressed eloquently.
It can be very difficult for a doctor with depression. I have had a long history of depression with recent exacerbation in conjunction with a severe eating disorder. It is very difficult for me to disclose exactly how awful, scared, depressed I feel to my treating team of GP, psychiatrist and psychologist. I think perfectionistic tendencies, thinking that we should be able to cope by ourselves, makes it difficult to admit we need help. I would encourage all doctors out there who are feeling like they need to seek help, to do so and continue to look for professional help that is right for them.
Feeling “depressed” is not an uncommon feeling for a human being when the life is not sailing smoothly as expected. Hence, how come a ‘Doctor’ could be spared from that situation? I do believe it’s just like having a “sore throat” or “runny nose”. Nevertheless, everybody from patients to peers expects a Doctor to be perfect possessing and demonstrating a high degree of resilience to negative emotions, On the contrary, just like “Sneezing” or “Coughing” expressing and sharing emotions gives a great relief to a human being, irrespective of his or her profession or the social stand
If only @AHPRA was not so invested in dissuading doctors from seeking preventive help.
Leanne, r u OK?
Move to WA and see a doctor
“Depression” is NOT a diagnosis. There is always a reason for depression – like “headache” or “shoulder pain”. Regardless of the aetiology (as you so beautifully point out), kindness is both the preventative and the cure for depression. A listening ear is sometimes all that is needed.