Who heals the healer when depression strikes?

It was not the first time someone spoke in sad shock. It won’t be the last. “We didn’t think it was possible … there were no signs. He was a bubbly happy person who was always cracking jokes. But when I learned of the warning signs of suicide, they were all there. We just didn’t know what they were.” Dr. Stephanie Eloisa D. Miaco recalled the words after a lecture on adolescent mental health. The victim was not a youngster but an educator. Teachers, students and medical professionals alike can fall prey to depression, stress and ultimate bad outcomes. Miaco is a psychiatrist from Dumaguete City, the Philippines. She advocates in mental health and how to improve delivery of mental health services for all. A faculty member of the Silliman University Medical School, she writes about mental health issues for the Negros Chronicle. “Depression and suicide are ubiquitous matters in our society, even among physicians,” Miaco said. “Who heals the healer? Who heals the healer with mental illness in particular? While tackling this problem, it is in our best interests to get the word out on talking about raising mental health awareness amongst physicians. “High suicide rates among doctors have been reported for more than 150 years,” she said. “Doctors are consistently among the top occupations with the highest risk of death by suicide, reported Medscape, which calls suicide ‘the end stage of an eminently treatable disease process.’” Along with other medical professionals, Miaco discussed how to increase awareness of physician mental health, especially related to depression and suicide. “As a training officer, one of the statements I dread to hear is ‘I need to talk with you...’ as a prelude to the talk about quitting for the sake of their mental health,” said Dr. Helen Madamba, an obstetrics-gynecology infectious disease specialist at Vicente Sotto Memorial Medical Center in Cebu City, the Philippines. “People don’t talk about mental health enough,” she said. “When you ask, ‘How are you?’ you just get a cursory, ‘I'm OK.’ Later on, the person breaks down. “There is high-functioning depression,” Madamba said. “Sometimes I feel I use work to cope with depression, so I am often labelled a workaholic. When I've done all the work that needs doing and I find myself with no plans for the day, I feel sad.” Problems compound when colleagues are enablers. “My senior resident told me that it's normal to always feel tired in residency,” Madamba said. “If you're not tired, then you have to check if there's anything wrong.” When stresses build, it’s not uncommon for healthcare providers to suffer a brief reactive psychosis. Stressors can include “death of a loved one, professional loss such as unexpectedly losing one's job or otherwise becoming unemployed, or serious adverse changes in the patient's personal life.” “I had mine when I had 10 mortalities in one night during my internship rotation in internal medicine,” Madamba said. “We called it ‘killer duty.’ I cried for each patient, and I still do. Last year, I had my first OR death. I couldn’t work at all for a few days after.” Pressures also can lead to dysphoria, feeling very unhappy, uneasy or dissatisfied. “Dysphoria was occasionally felt during training,” Miaco said. “Even if you’d think about quitting, you’d just have to trudge on. Also, there was a need to talk and get processed by peers.” In these times, family support is crucial. “I had a difficult time during residency,” said Dr. Iris Thiele Isip Tan, an endocrinologist and professor at the University of the Philippines College of Medicine. “My service senior said to just go to work every day, and before you know it, it will be done. “My mom told me only those who are trustworthy can be given responsibility,” Tan said. “That helped me finish residency.” Problems compound when the establishment works against providers. “I’ve seen mostly depressive symptoms with colleagues who really felt the abuses of a dysfunctional health system,” said Dr. Remo-tito Aguilar, an orthopedic surgeon practicing in South Central Mindanao, the Philippines.  “They are overworked and not clear if service rendered is part of their training or job,” Aguilar said. Physicians face challenges in getting help for depression and other mental health issues. They are known as lifesavers -- virtually superhuman. Mental health issues could be seen as a sign of weakness. Unfortunately, "Suck it up" is not a prescription for cure. “Stigma and the fear of discrimination in employment is a massive issue,” said Dr. Gerard Crotty, a blood doctor and past president of the Irish Hospital Consultants Association. “Self-prescription is a risk,” he said. “There is fear of breach of confidentiality by going through the usual channels.” Miaco agreed that public perception of mental health issues stifles potential treatments. “Doctors stigmatize themselves when it comes to asking for help,” she said. This makes peer, health, work and environment support essential to detect problems early. “One needs to know if a physician is having mental health ‘difficulties’ already,” Aguilar said. “With a standardized training curriculum, we can define objectives. “We need to know what are must-do,” he said. “Then evaluate and assess only according to those standards.” Unfortunately, those new to the profession are left to fend for themselves. “Mental health is not included in orientation for new employees,” Madamba said. “There is not enough awareness nor programs to provide physicians with access to help. “In addition, bullying of trainees puts patients' safety at risk,” she said. “When trainers are not even aware that they are bullying their trainees, that's a challenge. How do you correct more senior consultants when they put trainees’ mental health at risk?” As with any other medical diagnosis or issue, discretion is essential, mixed with genuine avenues for help not colored by stigma. In some respects, mental health ills are mental cancers. Treatment is at hand if those afflicted are seen as ill rather than failures. “We now have a mentoring program with each resident assigned to a consultant who is expected to help a resident cope with the stresses of residency training,” Madamba said. “That ‘millennial thing’ is always an excuse. The fact that our generation was given a hard time does not necessarily mean we have to do the same for our trainees. “Always remind residents to learn from our mistakes, and that we fail only when we do not get back up when we fall,” she said. Mentoring is reinforced by perseverance. “Most residents of government hospitals are burned out and exhausted, but with a little help and lots of support, they eventually reach their finish line, overcoming challenges,” Madamba said. “Work out in the gym,” she said. “Exercise releases endorphins, which make you feel good. Encourage trainees to do simple Zumba dances as energizers, but health lifestyle should address mental health as well.”