How Stigma Kills Doctors

“The greatest obstacle to good mental health is stigma. There needs to be greater recognition that depression is a disease with a huge physiological element. This will not only help doctors recognize it in themselves but it will help the broader society as they approach their patients this way.”

-The words of Mr Frank Watanabe from an interview I had with him on February 20, 2015. He lost his father Dr. August Watanabe to suicide June 9, 2009.

My research on physician suicide has found that at least 10-15 percent of doctors who take their lives have received absolutely no treatment for the illness that has driven that desperate and final act. Embarrassment, dishonor and faltering self-esteem — the hallmarks of stigma — play a huge role when a physician is living with a psychiatric disorder.

A few words about stigma. There are actually two types: enacted and felt. Although these terms were originally used to describe stigma associated with epilepsy, they have been extended to mental illness. Enacted stigma is exterior and refers to discrimination against people with a psychiatric illness because of their perceived unacceptability or inferiority. Felt stigma is interior and refers to both the fear of enacted stigma and a feeling of shame associated with having a mental illness(1)

I believe that both types are in play when an ailing physician begins to wonder if he or she might have a mental disorder. And among physicians the level of stigma is, in many if not most cases, notably higher than in the general population. Physicians much prefer being the helper, not the “helpee.” Their compassion toward their patients flies out the window when it comes to themselves. Stigma then fuels denial and the tendency to minimize the severity of their illness, even when a friend, family member, or colleague suggests, however gently and kindly, that they seem different — maybe sad, tired, or withdrawn — and there might be a problem.

It’s probably safe to say that virtually no one actually wants to admit that he or she is suffering from an anxiety or mood disorder or is abusing alcohol or other drugs. Most of us would rather just bury ourselves in our work (or our head in the sand) and simply hope that the problem will go away on its own. And if it doesn’t, we wait a while longer, even though we know we should really be reaching out for help. And all these symptoms of denial are that much more entrenched when the person with the problem is a physician.

Stigma (or the fear of being stigmatized) can have far more pernicious effects. Stigma kills. I believe it was perceived stigma that killed a patient of mine, a young doctor who ended his life with a lethal injection of potassium chloride he’d been stockpiling. He did this while he was out on a pass from our psychiatric inpatient unit. My hunch is that one of the final determinants in his decision to kill himself had to do with a perceived threat to his professional identity — the fear that he would not be allowed to continue his residency, which was his lifeline to normalcy and security — and to the fulfillment of his dreams. Although no one had said anything like this to him, because of the cognitive impairment that is a symptom of depression, he made a huge assumption that it would happen.

Sadly, this young man’s tragedy is as relevant today as it was when he died almost fifteen years ago. Speaking to loved ones, friends, and colleagues who have survived the suicide of a physician, I am constantly struck by the degree to which internalized stigma in the physician loved one was a driving force behind their death.

I asked the widow of a physician who died of an overdose if her husband might have sought help and didn’t tell her, her response was, “I don’t think so; we were very close; he didn’t keep secrets like that from me.” Then, after a long pause, she continued. “Well, I thought he told me everything but obviously I was wrong. He made this very big decision without consulting me.”

Fighting stigma in the house of medicine is a huge challenge but one way is going public with your story (2-4). And when doctors do this I always thank them. Not only are they making it a wee bit easier for other doctors to go for help but they are saving lives.