Suffering in Silence: Mental Health Stigma and Physicians' Licensing Fears

The growing national discussion around mental health care has exposed mental illness as the leading cause of disability in the United States. Given that almost 50% of Americans will meet diagnostic criteria for a mental health disorder during their lifetime (1), yet only 40% of individuals receive treatment for their illness (2), this increased awareness of mental illness is timely and valuable. Although much of the explanation for the 25% increase in the suicide rate over the past 20 years has focused on poor access to and financing of mental health care, cultural and societal stigma around mental illness have remained largely unchanged over the past two decades (3).

It is alarming that medical systems have been slow to respond to the growing mental health crisis. Part of the failure to adequately address mental health care may reflect physicians' own unwillingness to engage with mental health treatment. Studies have found that about 35% of physicians do not seek regular health care for themselves (4). In one study, almost 50% of female physicians did not seek treatment despite feeling that they met criteria for a mental disorder (5). Although multifactorial, the source of this reluctance appears to be closely related to concerns around licensure and the stigma of mental illness within the medical community. The stakes of physicians' poor self-health are dramatic, given that the suicide rate among physicians is 1.4–2.3 times higher than that of the general population (6). If members of the medical community cannot feel empowered to seek mental health care for themselves, it is perhaps naive to expect them to adequately address and treat serious mental illness in their patients (7).

The unfortunate impact of poor self-health on patient care is well known. Studies have consistently demonstrated that physicians' own health habits affect their health and prevention counseling (7) and that depression among providers is associated with lower-quality medical treatment (8). Unfortunately, the stigma around mental health for physicians begins early in medical training. Although medical students enter training with similar rates of depression as their nonmedical peers (9), their mental health worsens, on average, throughout the course of their careers. Prevalence rates of depression and anxiety among medical students have been recorded as between 25% and 56%, which is greater than the estimated prevalence in both age-matched cohorts and the general population (10). Furthermore, in a study of 4,287 students across seven medical schools, the burnout rate was estimated to be as high as 49.6%, with only 26.5% having recovered at the 1-year follow-up (11).

Similar to their full-fledged physician counterparts, few medical students seek medical treatment. A common reason for not doing so appears to be fear of professional consequences associated with disclosing mental illness. In one study, most medical students at a Midwestern medical school cited potential embarrassment if their peers knew that they had a mental illness (12). Furthermore, more students believed that disclosing mental illness could adversely affect their professional advancement. Perhaps in response to these perceptions, many medical trainees adopt a survival mentality to cope with stress and anticipate that their mental distress will decrease after training (13). Moreover, medical students who associate depression with personal weakness often perceive their academic environment as more competitive and psychotropic medications as less efficacious (12). Trainees may engender this stigma into their clinical careers.

Unfortunately, mental distress often continues beyond medical school. Depression, for example, has been shown to be more prevalent in resident and early-career trainee cohorts when compared with similarly aged college graduates in other careers, as are burnout, suicidal ideation, suicide attempts, and deaths by suicide (12). The American Foundation of Suicide Prevention estimates that between 300 and 400 physicians die by suicide each year (6). Like their medical student counterparts, however, practicing physicians and residents only rarely seek mental health care. For example, in a 2011 survey on suicidal ideation among American surgeons ≥45 years old, the authors reported that although suicidal ideation was 1.5–3.0 times more prevalent in this population compared with the general population, only 26.0% of respondents sought psychiatric help (14). As with medical students' reluctance to seek help, the source of physician hesitancy involves fears about licensing, a medical culture that can sometimes view help-seeking behavior as a marker of weakness rather than empowerment, discrimination in hospital credentialing, and consequences pertaining to personal and liability insurance due to disclosure of mental health diagnoses (15).

Fears surrounding medical licensing are well founded in many cases. Despite concerns from the American Psychiatric Association that licensing questions focused on the diagnosis or treatment of mental illness (as opposed to current impairment) would deter physicians from seeking help, recent studies indicate that only one-third of states have licensing and renewal questions that either inquire only about current impairment from a mental health condition or did not ask about mental health conditions altogether (16). Moreover, many analysts argue that the remaining state licensures are in violation of the Americans with Disabilities Act (17). Making matters worse, a 2007 study found that more than one-third of state medical licensing board executive directors believed that a mental health diagnosis alone was sufficient to impose sanctions on health care providers (18). Although state dependent, the repercussions of full mental health disclosure can include being asked to appear before state board examiners or to pay for a board-appointed physician examination. Some physicians may be required to provide testimony from primary care providers as to their fitness to practice, detailed medical records, or documentation of continued medical care (some of which may be stipulated). In some cases, licensing bodies may impose restrictions on a physician's practice (5).

There is currently no evidence to suggest that a physician's mental health diagnosis and treatment per se imply impairment or increased risk of harm to patients. In contrast, physicians reporting moderate to severe untreated depression, compared with those with mild depression, are 2–3 times more likely to report substantial effect on both their productivity and work satisfaction (19). In response to these issues, there has been an increase in activity around improving mental health for physicians and trainees. Medical schools are now required to have student wellness programs. And graduate medical education programs abide by work-hour restrictions to improve sleep and decrease fatigue, although this does not prohibit residents from underreporting the amount of time spent in-hospital. In addition, the Liaison Committee on Medical Education has mandated that all U.S. medical schools monitor students for fatigue, sleep deprivation, and duty hours. Although these advancements in addressing mental health and wellness within the medical profession are commendable, there are still many opportunities for improvement.

Like others who have addressed this topic, we recommend comprehensive programming that recognizes the importance of mental health to physicians and that provides them with healthy tools to overcome the demands of the profession. To our knowledge, there are no programs that require comprehensive and mandated coursework for medical trainees focusing on the prevalence of mental illness within the medical community while simultaneously teaching a range of coping skills and techniques. Such programs would be well placed with current efforts to improve access to psychiatric treatment and wellness resources for students and physicians.

We also recommend a revision of medical curricula that would better integrate mental health and cognition with physiology and pathology disciplines. Traditional teaching on this subject has used a dualistic framework that separates issues of the mind from the body. However, a rapidly growing body of literature highlights the impact of mental health on medical outcomes such as pain, postoperative opioid use, and other chronic health conditions, including diabetes and heart disease (20). These findings reflect an increased understanding of the developmental, physiologic, and neurobiological basis of disease. By training physicians to better understand mental illness as integrated with medicine, the medical community can work to destigmatize its own perceptions surrounding mental health.

Lastly, reconsideration of mental health questions on state licensing boards is a necessity, given the clear adverse effects of licensing fears on physician health. The consequences of mental health disclosure on licensing applications—both actual and perceived—pose formidable barriers for physicians who are experiencing mental illness. Campaigns to encourage physicians to seek treatment will likely go unheeded without concomitant legal safeguards for physicians' professional well-being and practice.

Key Points/Clinical Pearls