By Dr. Julie Alonso, WCI ColumnistTwo topics that people often shy away from in conversation are mental illness and money. Thankfully, as a psychiatrist and WCI columnist, I am comfortable talking about both. I last wrote about wellness and how to optimize it with a focus on lifestyle factors (nutrition, physical activity, sleep, social relationships, and interests), but those interventions can only do so much when someone really starts to feel like they’re drowning.
Sometimes, those remedies are simply not enough. There is a threshold between feeling stressed out and crossing into the territory of a psychiatric illness or substance use disorder. If you find yourself increasingly struggling on a persistent basis—particularly if it is starting to impact your functioning (whether it be social, family/relationships, work, or other areas)—that is the key time to recognize and address it.
Safeguarding your mental health is an important form of asset protection. Untreated mental illness or substance addiction can greatly impact your job, relationships, and overall well-being. There can be a big financial cost to ignoring mental health problems, especially in the long term.
Areas where mental illness can affect someone economically include lost productivity at work, increased medical expenses from putting off seeking care, hindering the motivation to plan for one’s future, and/or neglecting financial management and responsibilities. Plus, untreated mental illness raises the risk of new or worsening co-morbid medical problems and their related costs.
If mental illness or substance use becomes more severe, there can be impacts, such as having to take time off from work, go on disability status, or experience negative effects on a marriage or other important relationships. Less commonly, mood states like mania can lead to financial destruction if someone goes on big impulsive spending sprees or gives away large sums of money—both of which I have seen happen.
So, how can you access the support you need and also protect your career and livelihood?
Developing Insight
One of the most important steps is being forthcoming with yourself. Having insight and self-awareness is an important part of starting to get help. And truly, untreated mental illness can be costly.
Red flags may be when you start hearing from close family or friends that they are concerned about you. Oftentimes, others can notice mood or other changes more readily, and their observations are something to be taken seriously. If you’re prone to ignore or downplay other people’s concerns, it can sometimes take multiple conversations or situations compounding each other to move someone to the stage of readiness for change.
Generally, signs to look out for include: you find yourself feeling down much of the time, feeling frequently worried, lacking focus or concentration, falling behind in tasks, being more withdrawn, losing interest in things you previously enjoyed, having trouble clearing your mind, having difficulty relaxing, having a difficult time staying asleep, or noticing appetite changes.
More information here:
Which Medical Specialties Are the Most Burned Out?
How My Burnout Led to Rage That Could’ve Ended My Career
Seeking Help
As a mid-career psychiatrist, I have seen a shift over the years in decreasing the stigma around mental illness and a willingness for people to talk about these topics more in the lay public. However, the stigma still exists, and it can deter people from getting help sooner. It can be really difficult for high-achieving professionals, like physicians, to recognize themselves struggling and to seek help. But sitting on something like depression, anxiety, or addiction is usually not going to make things better. Yes, sometimes these issues can remit on their own with time or they can be addressed with intentional effort, but they also may remain present or worsen if left alone. Physicians are notoriously bad at obtaining help for themselves and are afraid of the stigma or losing their medical license (appropriately so in some cases).
However, mental illness affects physicians and other healthcare professionals in a disproportionately higher manner compared to the general public. Among successful professionals, admitting that you are struggling is hard. Shame, fear, denial, and feeling alone are just some of the things that come alongside. Seeking help amidst a full work schedule and personal obligations can be even harder.
But putting off the need for treatment can threaten your career or, much worse, your life. Overall, physicians have higher rates of depression than the general population. Additionally, female physicians have higher rates of major depression than age-matched women with other doctorate degrees. They also die by suicide at an alarmingly higher rate compared to other women professionals (250%-400% greater) and at about equal rates as male physicians (which is quite atypical when compared to other groups). This is not just a problem for physicians in longstanding practice either. Medical students and residents also have significantly higher rates of depression than the general population.
Professional Impairment
One of the worst things that can happen is that your mental state or substance use starts to impact your ability to function at work or, more seriously, threatens the health and safety of your patients.
As a forensic psychiatrist, I perform evaluations of impaired physicians and other medical professionals for my state medical board. I often see physicians who waited too long to recognize and address a significant mental illness, behavioral problems, or substance abuse issues. The evaluations I’ve done over the years have included referrals for: consequences of substance abuse (including legal charges like DUI), erratic behavior at work, boundary violations, agitation or violence toward others, criminal charges from poor decision-making, unhealthy reactions to severe stress, and the effects of untreated mental illness.
The barriers to getting help are many: busy schedule, cost, a shortage of psychiatrists and therapists, fear of stigma, and concern of having to disclose something to the medical board. While these are all valid concerns, the longer a problem is ignored, the more it tends to grow and the bigger impact it may have on functioning.
Many state medical boards have changed the way they word questions about psychiatric illness to align more with what they would ask about other medical illnesses. They have shifted away from asking about the mere diagnosis of a condition to a focus on a condition that would impair or preclude one from safely practicing medicine. It’s important to know how the state or states you are licensed in ask these questions. I just recently renewed one of my medical licenses, and the state asked if I was suffering from a condition I was not being appropriately treated for that could impair my judgment or interfere with me practicing in a competent and professional manner. It covered physical illness, mental illness, and substance use disorders under one question instead of separating them out as some states used to do. It also included a note that you can answer “no” if you are in compliance with a physician health program (PHP).
Most states now have PHPs where the purpose is to support the health and well-being of physicians and to divert physicians from medical board investigations and sanctions when possible. These programs typically offer confidential counseling and other educational and support resources. While they are not perfect, their aim is for rehabilitation instead of penalties. They provide an alternate pathway to accept help (hopefully sooner) and prevent issues from progressing.
There may be other mental health support resources available specifically for physicians or those in other healthcare fields. An example is my county medical society in Austin has a well-regarded program that has vetted local therapists who provide a limited number of confidential, free therapy sessions and even couples counseling. There are also Caduceus recovery groups for healthcare professionals who are struggling with addiction or maintaining sobriety. It may be more comfortable for some to take part in treatment groups when they are with other professionals who understand their experiences and unique stressors.
More information here:
Understanding Veterinarian Burnout and Mental Health
Budgeting for Personal Development and Putting $20,000 a Year into Yourself
Practical Steps
Once you recognize that you need to seek treatment, these are some steps to get started. This is not to underplay how difficult it can be to move forward. Finding the energy or motivation needed to overcome inertia is a real challenge. I often ask patients what made them come to treatment now when they have been struggling for months or years, and the answers are all across the board: lack of time, lack of money, denial of issues, not feeling ready to confront past trauma, cultural stigma against seeking psychiatric treatment, etc.
But one frequent commonality is noticing how their lives are impacted by whatever they are struggling with or noting that things have worsened recently. Think about how you might benefit from treatment or what goals you may work toward. Pick one or two actions and build from there.
- If there are situational factors, do whatever you can to alleviate or modify those stressors.
- Offload tasks or responsibilities that are causing distress as much as possible.
- Find a trusted psychiatrist and therapist to work with as your “team.”
- Utilize telemedicine if you prefer that modality or if traveling to appointments is a barrier to treatment. I have people see me in their (parked) cars, on their work breaks, in their home office, etc.
- Tap into your support network—close family, friends, and trusted colleagues. Accept their help. Ask them to check in on you at specified intervals if that would be helpful.
- Identify and practice coping strategies that work for you. Examples include meditation, mindfulness, progressive muscle relaxation, deep breathing, yoga, exercise, being outdoors, music, etc.
- Give yourself the same grace and permission to seek support as you would give to a loved one or to a patient.
- Schedule time intentionally for physical activity or social engagement; add an accountability buddy if helpful.
- Shore up lifestyle factors, especially making sure you are getting enough sleep—aim for a minimum of seven hours per night.
- Make sure you are eating enough. Get in some physical activity when you can.
- Look into whether your employer offers an Employee Assistance Program (EAP). These programs typically cover 6-10 sessions of therapy in a confidential setting that is paid for as an employee benefit.
- Utilize FMLA if you need to take time off for more serious issues and intensive treatment.
- If things get more severe, there are more high-acuity treatment program options both for psychiatric illness and for substance use disorders. These include Intensive Outpatient Programs (IOP), Partial Hospital Programs (PHP), or Residential Treatment Programs (RTC). Some of these have specialized tracks for physicians or professionals specifically.
The Bottom Line
Being a physician or healthcare professional comes with its unique stresses to our mental health and challenges or hesitations to access help when needed. However, the longevity of your career may depend on recognizing and intervening early rather than waiting until there are more severe impacts on your work or life.
Have you had to deal with mental health issues? How did you recognize them? Did you get help? Did you feel a stigma?
As I read this article, I was surprised to not see any mention of the much higher rates of not only depression, but of suicide among veterinarians. Female veterinarians have one of the highest rates among any profession, because of the often toxic workplace conditions but also from continuing nasty interactions with human clients. The lack of respect from clients has worsened badly since COVID and social media especially and has had severe emotional responses from veterinarians, often driving them from their jobs and the field completely.
I’m not sure I was aware of that so I don’t know if Julie was. A quick Google search shows some studies with conflicting results as well as a nice article from the BBC about it:
https://www.bbc.com/worklife/article/20231010-the-acute-suicide-crisis-among-veterinarians-youre-always-going-to-be-failing-somebody
We did publish this guest post about six months ago that talked about the mental health struggles of veterinarians from the POV of a vet. https://www.whitecoatinvestor.com/veterinarian-burnout-and-mental-health/
Hi Karen, I was not aware of that stat regarding veterinarians, particularly women. I appreciate you bringing this to the conversation as it’s an important topic to address given that the suicide rate is higher among multiple healthcare professions and particularly the increased risk among women compared to the general population.
Do you think the higher rates of mental illness in health care workers compared to the general public is due to the work itself? Seeing terrible things on a regular basis that most people would otherwise experience a handful of times in their life seems like a risk factor. Sort of like head trauma in football where one or two hits doesn’t do much but the cumulative effect leads to brain damage. Perhaps a reason to save in order to reduce work hours or get financially independent at a younger age.
I also wonder whether the perfectionism and achievement orientation needed for many to get a spot in medical school is also a risk factor.
Could be. Not sure anyone has really studied any of that.
Yes vicarious trauma is increasingly understood and it is a cumulative effect compared to acute traumas that can generate PTSD. The level of ultimate responsibility (and legal risks), long hours, night hours, and increasing loss of control around practice all likely contribute as well. Given the elevated physician suicide rates are compared to SES matched or education matched controls, there is clearly something going on.
Thanks for your question Greg. I think it’s probably multi-factorial as you mentioned and I think you pointed out what are likely a few significant factors. Exposure to trauma is a risk factor for depression, anxiety and suicide. Repeated or chronic trauma can compound that effect. For some, that can develop into PTSD as well. Common personality traits among doctors likely contribute – perfectionism and difficulty dealing with failure. Other factors may include a higher suicide mortality to attempt ratio, which may be related to greater medical knowledge of the lethality of drugs (and other methods) and easier access to them. Perhaps also the hesitancy to seek help leaving conditions like depression, Bipolar Disorder and/or Substance Use Disorders untreated.
It would really help prevent burnout and mental health exacerbation if all medics worked “normal” workweeks of 40 hours total including charting. I’m uncertain how that has eluded us but know that corporatization of medicine (and reduced pay per time spent), increased ‘paper’ or computer work, our codes of honor/ responsibility, and the starting education involving long and after hours shifts all contribute. Think how we could overcome the nursing shortages if they could work truly 8-9 hour shifts 4-5 days a week! Well, guess we’d also need to start offering part of the traveling nurse surcharges to the locals.
My last position was federal. I am quite envious of my daughter’s federal also salaried position which includes 40 hour work weeks, compressed schedules ie every other Friday off if desired, partial work from home options until this year, etc. etc. When I counsel her about saving for FIRE she reminds me that in her field people work into their 70s. I would still be working if I could have her schedule, even with the slightly lower pay, instead of FIREing 4 years ago.
Thank you for this insightful post. I especially appreciate the practical steps portion as I’m dealing with a bit of burnout currently.
Glad you found it helpful! Thanks for the feedback.
Thanks for discussing this under-discussed topic. I waited longer than I should have to seek help when I felt I was slowly drowning, but eventually did and with professional help and support of some close friends and family made it through a really really tough time. But it got so bad I could have seen a different outcome if I were in a place and time in life that I didn’t have close people to reach out to- which is scary.
I always knew I probably had anxiety (like waking at night frequency to ruminate on the decisions of the day, wondering if a different choice may have been 1% better somehow), but as someone who had managed till my mid forties to at least outwardly hold it together as a confident, decisive person in a relatively high pressure medical field, it was so hard to seek help and not feel like I was exposing weakness.
Also the fear that I’d have to report mental health issues on licensing and credential if paperwork was a big barrier to me seeking help sooner. I heard on a podcast recently that the working is changing state by state thanks to advocacy efforts to make that less of an issue, now framing it in terms of if anything causes impairment rather than just carrying a diagnosis. This should be more widely publicized because I think that fear of limiting future job prospects is a huge barrier to seeking help.