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Pearls


Treating depression in medical residents

Many depressed residents are relieved to share their problems with a professional who is there to treat, not teach, them

Vol. 10, No. 04 / April 2011

Residents in psychiatry and other specialties experience depressive illness at rates similar to or higher than the general population. Residency training is a major psychosocial stressor.1 Having to master a large body of medical knowledge while facing feared inadequacy or failure creates a demanding emotional climate for physicians in training. When added to other mood disorder risk factors, such as genetic vulnerability and fatigue, continuous performance demands can lead to the onset of a major depressive episode. Assisting the newest members of our profession by providing needed mental health treatment can be challenging but rewarding.

Are residents ‘special’ patients?

Some residents who realize they are depressed are tempted to self-diagnose and self-prescribe or obtain informal consultation from peers or family members who are physicians. The best treatment for depressed residents is to provide the same meticulous, excellent, and thoughtful care that you provide for your nonphysician patients. Many depressed residents who seek psychiatric treatment are relieved to share their symptoms and stresses with a professional who is there to treat, not teach, them.2

Residents from nonpsychiatric specialties may be assessed and treated by psychiatry faculty at their home institutions or by providers in the community. For psychiatrists who supervise residents, establishing liaisons with private practice clinicians who can offer rapid treatment access for physicians in training can be effective. To avoid conflicts of interest, it is crucial that psychiatry residents are treated by providers other than their own faculty.

Factors that may lead residents to avoid seeking treatment include:

  • The culture of medicine reinforces the stereotype that physicians are “strong” and “tough,” implying that the need for depression treatment is a weakness.
  • Fear of stigma can extend to fear of receiving negative evaluations by supervisors if depression is acknowledged.
  • Residents have logistic difficulties participating in treatment—a busy and inflexible schedule makes it hard to attend appointments.
  • Altruism can hinder some residents from obtaining self-care. These residents may perceive a “good doctor” as one who is self-sacrificing for his or her patients.

Treatment

The same collaborative approach to establishing a healthy therapeutic relationship with nonphysician patients is equally effective with physicians in training. Residents usually are open to using evidence-based combined modalities, eg, pharmacotherapy and specific structured psychotherapies such as cognitive-behavioral therapy or interpersonal psychotherapy.

Occasionally a resident will lobby for special treatment. For example, a resident may insist that the psychiatrist rearrange other patients’ appointments to accommodate the resident’s schedule. Also, residents may be unwilling or unable to see themselves in the patient role. They may attempt to define their treatment in singular and distinctive ways, setting themselves apart from nonphysician patients. These barriers can be overcome by setting appropriate boundaries with patients early in treatment. It is the psychiatrist’s responsibility to gently but firmly set limits with residents so that treatment can be effective.

Disclosure

Dr. Gay reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

References

1. Collier VU, McCue JD, Markus A, et al. Stress in medical residency: status quo after a decade of reform? Ann Intern Med. 2002;136:384-390.

2. Pitt E, Rosenthal MM, Gay TL, et al. Mental health services for residents: more important than ever. Acad Med. 2004;79(9):840-844.

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