Depression, Not Burnout, Associated With Greater Suicidal Ideation in Physicians

Depression, but not burnout, appears to be associated with greater suicidal ideation in U.S. physicians, according to a study in JAMA Network Open. In contrast, burnout, but not depression, was associated with self-reported medical errors.

“Approximately 1 in 10 medical students, 1 in 4 interns, and 1 in 16 practicing physicians report some degree of suicidal ideation,” wrote senior author Mickey T. Trockel, M.D., Ph.D., of Stanford University School of Medicine and colleagues. “Addressing physician well-being and reducing suicide risk require understanding the associations between physician distress, including burnout and depression, and personal and professional outcomes.”

Previous studies have suggested burnout is a risk factor for depression and suicide in physicians and physicians in training. Few, however, have examined the association between burnout and suicidal ideation after adjusting for depression, according to Trockel and colleagues. To examine this association after accounting for concurrent symptoms of depression, the authors invited a random sample of U.S. attending and postgraduate trainee physicians to complete a survey assessing burnout, depression, and suicidal ideation. This cross-sectional study was conducted from November 12, 2018, to February 15, 2019.

The participants were evaluated using subscales of the Stanford Professional Fulfillment Index (PFI), Maslach Burnout Inventory–Human Services Survey for Medical Personnel, Mini-Z burnout survey, and the Patient-Reported Outcomes Measurement Information System (PROMIS) depression Short Form. In addition, the participants were asked about suicidal ideation, as well as any history of making medical errors and the types of errors made.

The authors analyzed the responses of 1,354 survey participants, 75 (5.5%) of whom reported having thoughts of taking their own life in the previous 12 months. Burnout was significantly associated with increased odds of suicidal ideation before but not after the data were adjusted for depression. In contrast, after the data were adjusted for overall burnout (PFI), sex, race/ethnicity, training status, and age category, each increase of one standardized point on the PROMIS depression scale was associated with 202% greater odds of suicidal ideation.

The authors found the opposite was true when examining the relationship between burnout, depression, and medical errors: Burnout, not depression, was associated with self-reported medical errors.

Trockel and colleagues noted several limitations to the study, including their inability to assess causality. “Future investigations are warranted to evaluate causal relationships between burnout, depression, suicidal ideation, and medical error,” they concluded.

For related information, see the Psychiatric News article “New Findings and Controversies in Physician Well-Being and Burnout” and the American Journal of Psychiatry article “The Elephant in the Room: What Burnout Is and What It Is Not.”

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Alleviating Conflict Between Work, Home Life May Improve Physician Mental Health

The medical internship year can be a challenging time for many physician trainees. A study published yesterday in JAMA Internal Medicine found that female medical interns are more likely than male medical interns to experience symptoms of depression. The study also found that the sex disparity in depression during the internship year may be driven in part by increasing conflict between work and personal obligations (work-family conflict). 

“Systemic modifications to alleviate conflict between work and family life may improve physician mental health and reduce the disproportionate depression disease burden for female physicians,” wrote psychiatrist Constance Guille, M.D., of the Medical University of South Carolina and colleagues. “Given that depression among physicians is associated with poor patient care and career attrition, efforts to alleviate depression among physicians has the potential to reduce the negative consequences associated with this disease.”

Guille and colleagues invited medical students matching to residency programs across all specialties throughout the United States during the 2015-2016 academic year to complete online assessments two months prior to the start of the internship year and again at six months into the internship year. As part of these assessments, the participants were asked to report depressive symptoms using the Patient Health Questionnaire (PHQ-9) and the degree to which work responsibilities interfered with family life (“family” was defined from participants’ perspective) using the Work and Family Conflict Scale.

Of the 3,121 students entering internships who completed the initial survey, 2,108 completed the six-month survey. The authors found that while men and women experienced a marked increase in depressive symptoms and work-family conflict over the first six months of their internship year, the increase in depressive symptoms among women was higher than the increase among men (mean increase in PHQ-9: 3.20 versus 2.5). When work-family conflict was accounted for, the sex disparity in the increase in depressive symptoms decreased by 36%.

The findings suggest that “work-family conflict [is] an important potentially modifiable factor associated with elevated depressive symptoms in training physicians,” Guille and colleagues wrote.

“Pilot programs designed to ease work-family conflicts among physicians through providing free home-delivered meals, childcare, and housecleaning are in their infancy,” the authors wrote. “Our findings suggest that these programs should be expanded in scope and number and that they should be rigorously tested to see if they not only reduce work-family conflict but also depression and its consequences, such as physician suicide, poor quality of patient care, medical errors, and career attrition.” 

For more about what APA is doing to address physician burnout and wellness, see the Psychiatric News article “Working Toward Wellness: Exploring Burnout and Resiliency in Physicians” by APA President Anita Everett, M.D. Addressing physician burnout and improving wellness is one of Dr. Everett's presidential initiatives.

For additional related information, see the Psychiatric News articles “How I Became Active in Fight For Trainee Wellness” by Matthew L. Goldman, M.D., M.S., and “Suicides of Young Physicians Raise Alarm About Burnout Among Trainees” by Carol Bernstein, M.D.

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