Monday, January 11, 2016

Why Can't We Get Help?

On January 8th, Bloomberg Business ran an article on how law students are reluctant to get treatment for psychiatric problems and for addictions. It's not that law students don't suffer from these problems; in fact, surveys show they do in significant and increasing numbers.  Natalie Kitro writes:

People preferred to leave their illnesses untreated than risk not becoming a lawyer. More than 60 percent of students said they didn’t get help for their reliance on drugs or alcohol because they were worried it would affect their career prospects or their chances of getting admitted to the bar. Before they can practice law, students have to pass a “character and fitness” screening, in which officials look into their personal histories with the aim of rooting out people who are too morally compromised to serve clients. The American Bar Association says potential red flags include “drug or alcohol dependency” and “mental or emotional instability.”

Law schools have tried in recent years to convey that students will not be penalized for admitting that they’re suffering, but the report suggested that the efforts haven’t gone far enough. It is tough to counter what the study characterized as a deeply rooted culture of fear in legal education that discourages students from admitting weakness. 

So much for our legal colleagues.  Today,  Dr. Aaron Carroll has a compelling article in the New York Times about why doctors don't get help for psychiatric disorders. "In silence is the enemy for doctors who have depression," Carroll courageously starts by talking about his own episode of illness.  Carroll notes:

Last month, a study in the Journal of the American Medical Association reviewed all of the literature on depression and depressive symptoms in resident physicians — those are doctors still being trained. They found more than 50 studies on the subject. Research shows that almost 30 percent of resident physicians have either symptoms or a diagnosis of depression.

He goes on to postulate:

What makes this all worse is that medicine is a profession in which admitting a problem carries a stigma that can have more impact than in others. A study published in 2008 surveyed physicians in Michigan, asking them about their work experiences and if they had depressive symptoms. More than 11 percent reported moderate to severe depression. About a quarter of them reported knowing a doctor whose professional standing had been hurt by being depressed.
Credit Jody Barton
Physicians with moderate to severe depression had a decrease in work productivity and job satisfaction. They were also two to three times more likely to say that they were worried about, or had difficulty getting, mental health care. Although the Americans With Disabilities Act, passed in 1990, prohibits employers from asking broad questions about illnesses when people apply for jobs, state medical licensing boards still ask specific questions about mental health.
Because of this, physicians are much more likely to avoid treatment. They’re also more likely to self-medicate.

Sometimes that medication is appropriate, as with anti-depressants. Often, it is not. A 2012 study in JAMA Surgery found that more than 15 percent of the members of the American College of Surgeons had a score on a screening test consistent with alcohol abuse or dependence. Among female surgeons, the prevalence was more than 25 percent. Those who were depressed were significantly more likely to abuse or be dependent on alcohol.

And if that's not enough, two weeks ago, KevinMD ran an article called "Don't poop wher you eat: Mental Health Services for Young Physicians".  Amy Ho talked about insurance requirements that residents in training often must get health care --including mental health care -- at the institutions where they work.   Ho talks about the 29% of residents who are depressed, and the reality of seeking mental health care at an institution where you work:

While privacy protection acts like HIPAA are real, they are difficult to trust when you know every single one of your co-workers and ancillary staff (nurses, attendings, etc.) have a password into your private file. Further, unrelated medical care (for example, an ER visit during work hours from a needle-stick accident) allows completely HIPAA-compliant access by one of your coworkers into all of your records.

There is a saying, “Don’t [poop] where you eat” — that is, to keep personal and professional separate. For many residents whose health care is limited only to their place of work, there are often no other options. Of depressed first-year residents, over half cited “perceived lack of confidentiality” as a barrier to treatment.

So I'd like to suggest that these issues of stigma have gotten worse, and not better.  When I was a medical student at an institution with a strong psychoanalytic bent, entering psychotherapy was considered part of what one did to get to know yourself better: essential if you were going to be a psychiatrist, but also not shameful if you believed the unexamined life was not worth living.  People talked openly about being in therapy.  The chief resident in psychiatry put his analysis schedule on the unit bulletin board (times not to disturb him).  A cardiologist told me he wanted to be a psychiatrist until he went into treatment and realized he only wanted to deal with his own issues.  People openly talked about going to therapy.   One of my classmates had a very serious suicide attempts -- it wasn't widely known, but I asked her roommate where she was headed one evening and the answer was to visit her in the ICU where she was on a ventilator.  I don't know what transpired from there, but I do know she wasn't kicked out of medical school--as she might have been today-- and she went on to graduate on time and to obtain a very competitive residency slot. It's not that it was such an ideal world -- many people at my undergraduate school died of suicide and I don't know if those people were in treatment or not. But in some circles, there was less concern with secrecy and stigma.

I believe that certain behaviors have always been, and always will be, stigmatized.  When your mental illness leaves you to suffer quietly, the problem is yours, and if we hadn't come to associate "mental illness" with mass murder, and the possibility of unpredictable, disruptive behaviors, if we didn't erode privacy with records in the cloud, and if we didn't make it so damn difficult and expensive to get good treatment,  then there should be no shame for seeking treatment for depression, anxiety, or even most substance abuse problems.  I'm not sure our society has ever been comfortable around florid psychosis, nor do I think it ever will be.

Okay, hold with me for one more article.  In yesterday's Washington Post there was the story of the Dallas District Attorney who's position was being threatened because she disappeared for a couple of months to get inpatient treatment for depression, and had been treated for substance abuse.  But this DA's illness was, per the media, not just about her own personal suffering.  In a paranoid state, she fired  colleagues, she was obviously intoxicated at work, and her illness left her impaired and made life difficult for others, until she got treatment and recovered.  A judge dismissed a lawsuit to oust her. I wish her all the best moving forward.  One might hope, however, that people in such powerful positions might feel it's safe to get help before their problems effect others. 


Joel Hassman said...

Stigma can only be impacted on in a positive and diminishing impact by those who are stigmatized, both patient and provider, stepping up and telling the truth and showing the hypocrisy and ignorance of those who are the loudest proponents of more punishment and ostracizing.

You know that, I know that, and yet, how many of our colleagues just at least figuratively sit in their office chairs and figure out how to make money and keep patients convinced they are sick and need to stay on meds the rest of their lives?

Claiming outrage and a desire for change is wonderful, but, it starts with the Man/Woman in the mirror, and what are you doing to call out your colleagues on their pervasive and pathetic hypocrisy and failure to adhere to the Hippocratic Oath?

Deeds not words define us. Oh, and doubt you will publish this comment, what is my batting average of posted comments with you in the past month...

Joel Hassman, MD