Depression and suicide risk among physicians and nurses

Health care workers are not immune to psychosocial problems and often may face distinctive obstacles in dealing with them. Self-care among physicians, nurses, and other health care workers is not included as a part of their training but it is an issue that often comes up in the course of their daily routines or in their professional practice. The stresses of professional practice, shift work, and personal life can be quite demanding and in cases where the individual neglects or fails to notice the warning signs of depression can lead to tragic consequences. According to most available data there is an increased vulnerability for depression and suicide in health care workers, particularly physicians and nurses. Depression is a particular concern in the health care industry given that health care workers, especially physicians and nurses, are directly responsible for the well-being of their patients who are often forced to depend on them. When health care workers suffer from depression they also put the health and potentially the lives of other people at risk.

In 2007 The National Survey on Drug Use and Health published findings that indicated that there were high rates of depression in the personal care and health care industries relative to other professions between the years 2004-2006 ("The NSDUH Report"). Table I presents some of the comparison data from that study. As displayed in Table I the heath care industry had the third highest rate of depressive episodes (9.6%) behind personal care (e.g., caretakers) and the food service industry. As many of the personal care positions might also qualify as health care type functions, one could consider that all health care related positions combined most likely had nearly twice the incidence of depression than the seven percent average over all occupations for the years 2004 through 2006. When taken with the data concerning physician suicide, this would suggest that depression is a major concern in the health care industry.

Table I. Percentage of Major Depressive Episodes among Full-Time Workers Aged 18 to 64, by Occupational Categories: 2004-2006 Combined

Source: SAMHSA, 2004, 2005, and 2006 NSDUHs.

Moderate to high rates of depression have been observed in medical school students and nursing school programs (Levy, 144), as a result of overwork or working on different during different shifts, not feeling respected, and as a result of burnout (Felton, 240). Studies have found that health care professionals (medical doctors, midwives, and nurses) carry an elevated relative risk for developing affective disorders (Wieclaw et al., 316). Suicide rates for male physicians are 70% higher compared to men from other professions, whereas the rate of female physicians who commit suicide because of depression is between 250 to 400% higher compared to women in other professions (Levine and Bryant, 67-69). Often the risk for developing depression is related to certain job perceptions or experiences in these workers; however, there is some indication that there may be certain pre-disposing conditions in healthcare workers that may increase their risk for depression.

Predisposing Factors for Contracting Depression

There is a rich literature that has investigated predisposing factors for depression in physicians. Vaillant, Sobowale, and McArthur (372-375) reported evaluated students for psychological vulnerabilities while in college and followed up with them 30 years later to determine the effects of these vulnerabilities. Forty-seven of the students in the study became physicians. The results of the study indicated that the physicians, especially those involved in direct patient care, were more likely than matched controls to have depression, poor marriages, and substance abuse problems. However, a closer examination of the data revealed that the presence and severity of depression in the physicians was strongly associated with life issues that were present before attending medical school such as poor adjustment in childhood or adolescence and traits of dependency, pessimism, wishful thinking, and self doubt. In a later study McCranie and Brandsma (30-36) looked at personality antecedents of burnout among 440 physicians who had been given the Minnesota Multiphasic Personality Inventory (MMPI) before entering medical school. They were surveyed an average of 25 years later for symptoms of work-related burnout. The results indicated that higher burnout scores were significantly correlated with the earlier MMPI scales measuring poor self-esteem, feelings of inadequacy, obsessive worry, passivity, and social anxiety.

The research concerning predisposing factors that might serve as markers or vulnerabilities for later depression in nurses and other health care workers is not as extensive as it is for physicians. However, Ohler, Kerr and Forbes (69) did find that a history of insecurity, poor self-worth, and social anxiety did predispose nurses to depression.

It is interesting there is also a gender effect for the risk to develop depression. Most of the research indicates that female physicians may be more prone to developing depression than male physicians (Miller and McGowen, 369); however, Wieclaw et al. (318) found that male nurses may have higher risks for developing depression than female nurses. In any event the research indicates that there may be certain predisposing variables that can lead to a greater risk of developing depression in some health care workers. Gender, early problems with self-esteem, insecurity, and social withdrawal may leave some individuals more vulnerable to developing depression than others. In addition, perfectionism and perceived locus of control (whether or not one believes that they have control over their circumstances) have also been implicated as potential risk factors for depression (Miller and McGowen, 368).

Recognizing and Preventing Depression

The individual health care worker, managers, and coworkers should be on the lookout for the following symptoms in themselves and others as they relate to depression: 1) a loss of interest in activities both work related and personal activities; 2) feelings of guilt, worthlessness, and/or helplessness; 3) decreased energy or fatigue; 4) sleep disturbances (insomnia, early-morning waking, or oversleeping); 5) irritability; 6) loss of appetite and weight, or weight gain; 7) excessive crying; 8) difficulty concentrating, remembering, making decisions; and of course 9) thoughts of death or suicide. In the workplace, symptoms of depression also often may be recognized by: 1) decreased productivity; 2) problems with morale; 3) a lack of cooperation; 4) increased occurrence of safety risks or accidents; 5) increased absenteeism; 6) frequent statements about being tired all the time or complaints of unexplained aches and pains; 7) and increased alcohol and/or drug abuse.

Interventions to Deal with Depression

Employer Interventions

The development of programs to reduce work load, monitor hours, and give employees the perception of greater personal control and reduce stress can help minimize depression in the workplace. Mindfulness-Based Stress Reduction (MBSR) programs have been used to reduce stress. MBSR is based on the concept of becoming mindful and present in the moment without judgment and utilize contemplation, meditation, and practical applications to daily issues at work. These programs have decreased the stress level at work and have reduced burnout and depression in health care workers (Mackenzie, Poulin, and Seidman-Carlson, 107).

Programs which offer a conflict-management training to decrease potential stress for employees can be useful in decreasing depression in health care organizations. Such programs can decrease work-related stress and depression by creating a positive environment through personal empowerment of employees. Employees that have been exposed to such programs have demonstrated a significant reduction role overload, interpersonal strain, depression. Employees also found that conflict-management training assists them to manage the demands of their job. Providing opportunities for counseling or outlets to express concerns in a sanction-free environment can also help lessen burnout and depression. These findings also indicate that by making available even brief interventions for health care workers can reduce conflict, reduce stress, and increase the perceived sense of control that workers experience which would increase job satisfaction (Haraway and Haraway, 11-17).

Employee Interventions

Health care professionals can engage in several activities to avoid becoming depressed: 1) become educated about depression and its symptoms; 2) check themselves regularly and consult another professional, especially if they find their morale decreasing or feel constantly drained; 3) evaluate coworkers and discuss concerns; 4) take time each day for relaxation; 5) get regular exercise, nutrition, and rest; and 6) confide in trusted colleges and friends to develop a support system that will lessen the chances of becoming depressed or allow for one to recognize potential warning signs (Wallace, Lemaire, and Ghali 1718-1719).

It is clear from the research that depression is a major concern for health care workers; however, there are simple interventions and precautions that can be observed to recognize the warning signs and conditions that foster depression and to avoid its occurrence.