Looking back to 2007, Jennifer Middleton, M.D., M.P.H., a faculty member in a family medicine residency program in Pittsburgh, recalls that a physician who had just graduated from the program and was entering his first year of practice gave few signs that he was going to take his own life. And, she says, an intern at the residency who committed the same act several months later did not show obvious signs of depression.
A recent study suggests, however, that depression is common -- at slightly higher than 25 percent -- among medical interns and can be linked to multiple factors, including the stresses of the internship experience itself.
According to the study, which was published online April 5 by the Archives of General Psychiatry, there is a "marked increase" in symptoms of depression during medical internship, and those symptoms are related to specific individual, internship and genetic factors.
"Internship is known to be a time of high stress," the study says. "New physicians are faced with long work hours, sleep deprivation, loss of autonomy and extreme emotional situations."
For the study, 740 interns entering residency programs in traditional and primary care internal medicine, pediatrics, OB-Gyn, general surgery, and psychiatry were assessed for depressive symptoms using the nine-item Patient Health Questionnaire, or PHQ-9; various social and psychological factors; and the presence of a particular genotype.
Specifically, researchers sought to examine the interaction of stressors with 5-HTTLPR (serotonin-transporter-linked promoter region), a polymorphic region in the serotonin transporter protein gene SLC6A4 (solute carrier family 6 [neurotransmitter transporter, serotonin], member 4), which has been intensively investigated in depression.
Assessments were conducted at baseline (before beginning internship) and at three-month intervals throughout the internship year.
According to the study, the proportion of participants who met PHQ-9 criteria for depression increased from a baseline of 3.9 percent to a mean of 25.7 percent during internship. Almost 42 percent met criteria for major depression at one or more quarterly assessments.
Several factors measured before internship (female gender, U.S. medical education, difficult early family environment, history of major depression, lower baseline depressive symptom score and higher neuroticism) and during internship (long work hours, perceived medical errors and stressful life events) were associated with a greater increase in depressive symptoms. In addition, study participants with at least one copy of a less-transcribed 5-HTTLPR allele reported more depressive symptoms.
"In this study, we … used internship to model the relationship between 5-HTTLPR, stress and depression and found that the 5-HTTLPR low-functioning allele was associated with a significantly greater increase in depressive symptoms under stress."
The study authors conclude that further research is needed to "more fully explore the consequences of depression among interns, both on patients and the physicians in training themselves."
The director of practice improvement at the University of Pittsburgh Medical Center St. Margaret Family Medicine Residency Program, Middleton knows a lot about those consequences. She became a speaker and writer on resident physicians in crisis and physician suicide(www.annfammed.org) after a recently graduated resident -- a personal friend and colleague -- and a medical intern committed suicide a few months apart in 2007.
Middleton told AAFP News Now that physicians suffer depression at about the same rates as the general U.S. population, but they commit suicide at a two- to fourfold greater rate. Between 15 percent and 30 percent of residents suffer, or have suffered, from clinical depression, she said.
Because family physicians learn principles of behavioral medicine, faculty members and directors in family medicine residencies are more aware of the tendency of many residents to become depressed. In fact, every family medicine residency has behavioral health faculty, said Middleton.
"Family medicine does a decent job of being aware of these kinds of things," she said, noting that when she spoke at a workshop during a recent family medicine residency conference, almost all participants knew a physician who had committed suicide. "The awareness is there. But what is lacking is (an answer to the question), 'What do we do?'''
What is the result of that uncertainty? "Physicians tend to have their depression untreated or undertreated," said Middleton. "It's still a sign of weakness to have a depressed physician or to have a mental health problem. Depression is not as adequately treated (in physicians) as it is in the lay population."
The two physicians in Middleton's residency who committed suicide in 2007 showed few outward signs of depression, she said. The intern had a consistently positive personality, received outstanding reviews, and had a great social network and lots of friends. The recently graduated resident also was well liked and had a strong social network.
Friends, family and colleagues later learned that alcohol -- associated with depression -- was involved in one suicide. The other physician was receiving treatment for his depression when he took his life.
One important confounding factor, according to Middleton, is that "physicians know the warning signs of suicide, so they know how to not give off the signals and keep up the façade. (The two physicians she knew) didn't have any social impairment or any impairment in their work."
Residency programs should proactively educate themselves about depression in physicians through a comprehensive wellness program or a humanities curriculum that broaches the subject of physician mental health, said Middleton.
She also noted that much of the research on physician mental health is decades old.
Academic programs should encourage and support new research efforts into physician health prevalence and treatment options, said Middleton.
In addition, faculty members should build strong relationships with residents and assess their moods during adviser meetings and informal check-ins, according to Middleton. Her program has twice-monthly Balint groups, a support group and a humanities curriculum. All residents have a behavioral science adviser.
"There has to be a commitment to physician wellness and mental health," Middleton said.