The mental health crisis among doctors is a problem for patients

Twice a week, Boston-area psychiatrist Elissa Ely volunteers at a US anonymous help line for physicians in crisis. The calls she takes are often from people in deep distress — physicians having panic attacks, abusing substances or alcohol, facing divorce or alienation from family and friends. A typical call, she said, could be from “an ER doctor who vomits before she goes in for her shifts; despair and depression; suicidality.”

But despite her callers’ high levels of mental distress, they’re often very resistant to her suggestions that they seek mental health care, said Ely. When she suggests doctors consider even just a “tincture” of an antidepressant or anti-anxiety medication, or find a therapist, she inevitably gets the same response, a long pause followed by a question: “Is this call really anonymous?”

She understands why so many respond this way. “These physicians are living in terror of losing their essential identity or losing their lives that they have created, and of losing their licenses,” she said. That fear isn’t unreasonable: Until recently, answering questions about current or prior mental health treatment was a condition of being allowed to work in most states and health care facilities.

Medicine has historically been a high-stress profession, and doctors have for decades faced higher depression and burnout risk than the rest of the population. But the pandemic amplified that risk: In one 2021 national survey, the percent of doctors with at least one manifestation of burnout increased by 43 percent from the pre-Covid-19 era — and these trends appear to be holding in 2023.

At the same time, doctors are less likely to seek treatment for mental health concerns for a variety of reasons. The pushback Ely hears is common: Many physicians say that despite their comfort with prescribing mental health treatment and care to patients, seeking mental health care for themselves remains highly stigmatized.

Meanwhile, major shifts in many doctors’ practice environments mean they have less and less control over how and how much they work — leading to even more work-related distress.

It all adds up to a situation that’s bad for both doctors and patients: As providers have increasing levels of mental distress, they’re more likely to leave medical practice. That’s a particularly bad outcome given the serious physician shortages the US health care system is already facing.

There are ways to improve doctors’ access to mental health treatment, and to at least somewhat reduce the upstream causes of their anguish. Those efforts require effort and time — but to anyone who cares about the US health care system and the people working within it, they’re well worth knowing about.

What’s causing such high levels of mental distress among doctors?

Physicians have high rates of mental distress — and they’re only getting higher. One 2023 survey found six out of 10 doctors often had feelings of burnout, compared to four out of 10 pre-pandemic. In a separate 2023 study, nearly a quarter of doctors said they were depressed.

Physicians die by suicide at rates higher than the general population, with women’s risk twice as high as men’s. In a 2022 survey, one in 10 doctors said they’d thought about or attempted suicide.

Not all doctors are at equal risk: Primary care providers — like emergency medicine, internal medicine, and pediatrics practitioners — are most likely to say they’re burned out, and female physicians experience burnout at higher rates than male physicians.

(It’s worth noting that other health care professionals — perhaps most prominently nurses — also face high levels of mental distress. But because nurses are more frequently unionized than doctors and because their professional culture isn’t the same as doctor culture, the causes and solutions are also somewhat different.)

Why do these health care providers have such high rates of mental health distress?

The answers fall under two big umbrellas, said Mona Masood, a psychiatrist who founded the physician support hotline where Ely volunteers. One is a professional culture that prizes efficiency, perfection, and self-sacrifice. Another is “moral injury” — the damaging effects of witnessing, participating in, or failing to prevent things that don’t align with the values that drew people to practicing medicine.

One example of moral injury is the massive amount of time doctors spend dealing with prior authorizations and insurance companies — and being blamed by patients for the financial strain caused by the US’s broken health insurance system. In one study, 61 percent of doctors said the main cause of their burnout was “too many bureaucratic tasks,” and another survey by the Physicians Foundation found reducing administrative burdens was the most effective solution for improving physician well-being.

Many physicians spend unpaid hours each day — the equivalent of nearly a full unpaid day each week — on “pajama time,” doctor slang for the time they spend documenting patient care in the chart from home. It’s not what they thought they signed up for when they went to medical school, and it’s bad for their mental health.

Doctors also blame other factors for emotional strain — most notably the lack of respect from coworkers, long working hours, and inadequate pay. But their overall impact is lower in comparison.

Doctors are under incredible stress. But they also feel stigmatized for getting help.

It’s a terrible bit of irony that for a profession subject to so many stressors, there are also so many barriers to getting relief.

As Masood points out, the medical profession stigmatizes seeking mental health care among physicians: In the Physicians Foundation survey, about half of all doctors had a peer who wouldn’t seek mental health care, and four out of five agreed there was substantial stigma around getting mental health care within their profession.

That stigma isn’t just an imagined fear. Institutional practices in effect punish physicians for seeking care, often with horrible consequences.

Before emergency medicine doctor Lorna Breen died by suicide early in the Covid-19 pandemic, she’d been overworked into a nearly catatonic state, hardly able to move or speak.

A few days into treatment — Breen’s first time ever receiving mental health care — she expressed fear “that now that she’d obtained mental health treatment this was going to ruin the career that she’d worked for her entire life,” said her brother-in-law, Corey Feist. Her family thought her fears were unfounded, but after her death, they learned that, in fact, Breen was partially right.

Most state medical licensing boards — but, in a tragic twist of irony, said Feist, not New York’s — required physicians to disclose current or prior mental health care. Many hospitals require the same before credentialing a physician to practice there. While that information might not be used to prevent a physician from practicing, the mere perception that it might is a source of stigma.

Breen was not alone: About 40 percent of doctors in the Physicians Foundation survey were either afraid or knew another physician who was afraid of seeking mental health care due to questions on medical licensure, credentialing, and insurance applications.

For doctors, work-related mental health strain strongly predicts their desire to leave the profession. And quitting kick-starts a doom loop: The more who leave, the bigger the workload for the doctors left behind — and the higher the risk that they, in turn, will burn out.

Play this cycle out a few times and it’s clear: If left unaddressed, the conditions that create burnout and depression, and create barriers to their prevention and treatment, could ultimately hollow out the medical profession.

How to improve doctors’ mental health

Meaningfully reducing physician depression and burnout requires smoothing the path to care for mental health distress — but also addressing its root causes.

Getting any kind of health care can be complicated in the US, but companies that employ doctors can take steps to make accessing mental health care a little easier. A 2022 American Hospital Association report includes a laundry list of questions intended to help hospital leadership determine how and whether their employees can access mental health care treatment — everything from “Are providers taking new patients?” to “Does your sick leave policy address behavioral health disorders?

Changing or removing invasive questions about mental health when doctors apply for jobs or licensure is also key for improving access to care. After Breen died, her sister and brother-in-law founded the Dr. Lorna Breen Heroes Foundation, in part to advocate for these changes. As a result of its work, more than 25 state licensing boards have removed intrusive questions about mental health from their applications, and 11 more are in the process of doing so.

“This is good,” said Ely, the psychiatrist who staffs the physician crisis hotline. “But that still leaves half the country whose physicians are living in fear.”

Outside of these questionnaire changes, Masood identifies two key tools for improving physician mental health.

The first one is peer support, which can come in the form of hotlines like the one Masood runs, grassroots groups like Physician Coach Support, and programs run by health care systems. The point of these programs is to engage physicians in identifying and providing support for mental distress among colleagues. Health care systems that have them train their employees to recognize and respond one-on-one to signs of emotional harm in each other.

These peer support programs can also help reduce the unsafe working conditions that often trigger the harm to begin with, said Rick van Pelt, who leads quality improvement initiatives at the University of Alabama Birmingham.

Medical errors and unexpected bad outcomes of care are among the most potent triggers of mental health crisis in physicians. So an environment where people aren’t afraid to quickly acknowledge medical errors, said van Pelt, also helps manage the emotions those errors generate. Health care facilities that have those kinds of environments — ones that encourage transparency and responsiveness to medical errors — also have better patient safety records.

Simply put: Working in a place that’s safer for doctors is also safer for patients.

The second key tool, Masood points out, is getting providers engaged in untangling the twisted and inefficient processes that most waste their time. Van Pelt studies one approach to this, which involves creating “accountable care teams” (ACTs) that work together to identify and solve the patient care hiccups that lead to worse outcomes for both doctors and patients.

Van Pelt gave an example from his work with the University of Alabama’s trauma unit, the state’s only Level I trauma center. The unit often had to turn away patients because it was full. A solution: reducing its patients’ length of stay to free up more beds. An ACT led to changes that shortened the units’ stays by an average of a day and a half — so successful that the hospital was able to stop routinely turning away patients.

When the pandemic started, van Pelt and other researchers at the university were just starting to study how well ACTs worked to improve hospital processes. What they found was that involvement in the teams “served as an element of psychological PPE,” or personal protective equipment, protecting the psyche in the same way that a mask and gloves protect the body, said Katherine Meese, the organizational behavior researcher who directs the university’s health care management and leadership center.

Compared with their colleagues, health care providers on the medical center’s ACT teams scored higher on measures of autonomy and several other metrics that predict worker well-being.

“So often when we think about mental health, we’re thinking about resources” like counseling or yoga, said Meese. “We’re not always as attuned to fixing the work” — that is, lightening the massive administrative burdens so many doctors bear.

But fixing the work is one of the key ways to increase health care workers’ baseline mental health. “We know that a connection to meaning and purpose in the work is important, especially as a part of mental health. Can we get friction out of the way of that connection?” said Meese.

It behooves us to try, said Ely. “ In the end, everything we do comes down to self-interest. And if you don’t take care of physicians, they are not going to be able to take care of us,” she said.