Physician Depression, Burnout & Suicide - Consider Undermethylation

Data, Contributing Factors, When Strengths Relate to Vulnerabilities, Self Reliance, a Medical Culture That Keeps Physicians From Seeking Help & What Can Be Done

It can be easy to forget that medical professionals are vulnerable to stress, burnout, and even physical and mental health issues. Though we expect them to be well, physicians have a relatively high rate of depression. Physician suicide is twice the rate of the general population.

I’ll argue that doctors have biochemical and environmental factors contributing to both their strengths and vulnerabilities.

Though I’ll focus on physicians in this newsletter, much of what I’ll discuss applies to other medical professionals and caregivers.  In this newsletter, I’ll address:

• The higher rates of depression and suicide in physicians

• How undermethylation is likely a strong contributing factor

• How early family dynamics may be at play

• A medical culture that leaves physicians unsupported and reluctant to seek help

• Solutions

Because my health issues forced me to change the way I worked and lived, I’ve buffered myself from a lot of the stress many of my medical colleagues experience and that I write about here.

Data

Unless you’re a medical professional, the data might surprise you.  

• One meta-analysis estimated the depression rate among medical residents at 29% — while the rate among nonphysicians was 8%.  

• One survey found that, on average, 10% of physicians have had thoughts of suicide.  

• Depression (not surprisingly) is one of the most common factors associated with physician suicide.

  • 13.8% of physicians with symptoms of depression reported suicidal ideation.

• Physicians die by suicide at twice the rate of the general population. 

  • For male physicians, the rate is up to 40% higher than the general population.

  • For female physicians, up to 130% higher than the general population. Physicians have one of the highest rates of suicide of any profession.

• 12.9% of male physicians and 21.4% of female physicians meet the diagnostic criteria for alcohol abuse or dependence.  Prescription or illegal drug use is rare in physicians.

• Physicians who died by suicide were found in one study to be significantly less likely than the general population to have antidepressants present at the time of death. 

• Physicians are also less likely to seek mental health services than the general population.

Multiple Contributing Factors

As with anything, there’s likely an alignment of root factors. What makes medical professionals good at what they do (highly educated, driven, motivated to care for others, detail-oriented) is likely connected to their vulnerabilities to depression, addiction, and even suicide. 

Undermethylation

Specific vocations - medicine, accounting, engineering, and elite-level sports - will have a much higher incidence of undermethylation.  The Walsh Research Institute found that undermethylation (a methyl-folate imbalance) is the most common biochemical imbalance in depression.

Remember that methylation is needed for the breakdown of histamine and detoxification. Those who are undermethylated often have low serotonin activity (more depression and anxiety). Because of the high histamine, many also have high activity at the NMDA receptor, which translates to more addiction or obsessive-compulsive tendencies. The addiction could be to substances, but it could also be to work, over-functioning - doing too much. Who would sign up for 8-10 more years of education after college? Someone who is undermethylated might.

By itself, undermethylation can make physicians more susceptible to depression, addiction, and even suicide.

Early Family Dynamics

In addition to biochemistry, some doctors may have been the “gifted child” - not only in the traditional sense but gifted in their ability to observe and tune into the feelings and expectations of their parents at the expense of tuning into their feelings. Such a child can grow into an adult who feels most secure when caring for others. The goal for anyone in a caregiving profession is to tend to one’s well-being as an end to itself and to be better at caring for others.

While this gifted child dynamic doesn’t apply to all physicians, individuals from this dynamic usually end up in caregiving vocations. Some can even become addicted to helping others. In the 12-step world, this is referred to as codependency.

Not being tuned into one’s needs and feelings in a highly demanding workplace is a setup for burnout.

Emotional Exhaustion, Ruminations & Numbing

Though we are all wired for connection, we ultimately all have to learn how to be that caregiver to ourselves - to notice when we are stressed or doing too much, to know when we are sad, scared, or angry, to understand how to be present with ourselves and to know when to reach out for help when we need it.  Ideally, we learn this in our first three years. Many who haven’t will be forced to learn it later when an illness or crisis hits.

Stress, Worry & Ruminations

Undermethylation and/or a disconnect from feelings can increase one's likelihood of worry and ruminations. A calm demeanor often masks this type of anxiety. There is no shortage of what physicians might worry about:

• The well-being of their patients.

• The wellbeing of family members and friends who have come to rely on them for their care or advice.

• Having to tell someone that they have a terminal illness or having to tell someone their loved one just died.

• Mistakes made or fears about making mistakes.  Physicians who believe they have made a major medical error in the past three months are three times more likely to have suicidal ideation.  Aside from the potential harm to patients caused by medical mistakes, there can be a loss of confidence in decision-making and fears of getting sued.

• Getting sued. Almost one-third of doctors are sued for malpractice. That physicians are taught to expect to be sued doesn’t remove the stress.

• With the onset of COVID-19, many doctors feared getting COVID, spreading it to their families, and/or being unable to work.

• Angry, entitled, and lentiginous patients.

• The typical challenges in workplaces and families.

Burn Out

Much of the work of physicians extends beyond the work of caring for patients.  After a typical workday, many do administrative work, chart, complete prior authorization requests, respond to messages, and do other paperwork related to their practice.  Whether the long hours are due to systemic issues in the workplace, problems with delegating, or an inability to ask for help, there can be little room for self-care and attention to other parts of their life. 

Burnout alone is not directly associated with greater suicidal ideation in physicians; however, burnout combined with depression was associated with significantly increased odds of suicidal ideation.

Numbing

There’s only so much one can endure before one starts to numb what are otherwise healthy feelings. Remember, with undermethylation, the challenge can be low neurotransmitter activity. Getting to that numb place isn’t hard.

Many reading this have probably been on the receiving end of an encounter with a doctor who seemed to lack empathy or a desire for understanding. To be compassionate with others, we must first have compassion for ourselves.

Self Reliance

It can be much easier for physicians and other medical professionals to give help than to ask for help. Solving someone else's problem is easier than solving their own.  Self-reliance, again, can come from biochemical drivers aligning with early experiences, especially when there weren’t reliable adults responding to needs.  It can also come from the repeated act of providing care to others.

“For physicians, there is an incredible stigma associated with seeking help for mental health and saying you’re not okay,”… “We are trained to be tough, resilient, superhuman, make no mistakes — so you don’t show emotion, you don’t cry, you don’t ask for help. We’ve all fallen into that trap.” Dr. Debra Williams, former chair of the physician well-being committee for the American College of Emergency Physicians

The medical hierarchy can also reinforce self-reliance.  That doctors are referred to as “Doctor ______” creates what I see as an unhealthy dynamic with patients and with other medical colleagues.  Some will argue that such a title is professional and sets clear boundaries with patients. However, nurses, physical therapists, and other medical professionals are professional, have good boundaries, and do not have to be referred to with a title. 

Self-reliance is also reinforced by the risks to one’s career and livelihood if they ask for help.

“As long as you can lose your career seeking mental health care, there will be physicians who will not seek care until they are forced by crisis. If we want to support our physicians, we must begin by protecting them and allowing them safe spaces to receive care without retribution or punishment.” - Dr. Margot Savoy, SVP of education American Academy of Family Physicians

Physician Well-Being

We can all benefit from having healthier medical practitioners practicing what they preach - good rest, exercise, sleep, less stress, and time connecting with themselves, their friends, and family. 

I would love to see:

• Methylation and traits of undermethylation taught in medical school (along with many other root causes of brain symptoms). How amazing it would be if physicians could take what they learn about themselves and recognize and treat these vulnerabilities impacting many patients.

• Attachment dynamics taught in medical school. Again, we are all impacted by attachment dynamics. The better we can see how they play out in our work and relationships, the better we can care for ourselves and others.

• A flattening of hierarchies so physicians can enjoy what many other medical professionals have - peer support.

• Peer groups where physicians can discuss their professional challenges with others. There is so much to be gained from being heard and seen, having one’s feelings normalized, providing that for others, and learning how others are making changes in their work that support their well-being.

• The culture of medicine moves from:

  • Silence to awareness

  • Shame and perfectionism to a recognition that doctors are humans who feel, have health issues, and make mistakes

  • Self-reliance to seeking peer support or, when needed, professional support

  • Burnout to professional satisfaction

  • Numbing to compassion for self and others

• Licensure and credentialing applications that do not deter physicians from getting mental health services. The wording of applications could change from:

  “Have you ever had a mental healthcare condition or diagnosis?” to “Do you have health conditions impairing your ability to care for patients?”  If allopathic medicine better understood the physiologic drivers of brain symptoms, such demarcations between physical and mental health wouldn’t exist.

In the coming days, I’ll share information about a small peer group that Neil Nathan, MD, and I will facilitate for functional medicine practitioners interested in professional satisfaction and self-care while caring for complex patients. If you’d already like more information, please email me at ms@courtneysnydermd.com

Your thoughts, reactions, and questions are always welcome.

Have a good week,

Courtney

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