Coping with physician depression in the era of COVID-19

Physicians, just like the patients we serve, are facing an unprecedented emotional burden from the COVID-19 pandemic. First-line responders are at especially high risk of experiencing psychological hardship from the burden of disease, death, and anxiety, while non-front-line physicians are feeling the strain of worried patients, financial hardship, and uncertainty about the future.

Even during ordinary times, women physicians, resident physicians, and medical students face higher rates of depression than the general population. Every year, it is estimated that 400 physicians take their own lives, with women physicians facing a much higher risk of suicide than the general population.  Increased emotional stress from these difficult times may increase the risk of depression in physicians. Sadly, the toll of the coronavirus pandemic has already resulted in the loss of one of our emergency room physician colleagues.

Emotional contagion

Emotions, just like viruses, are contagious. Psychologist Steven Cohen, PsyD, notes that doctors, just like all others, are at risk of internalizing the negative feelings of the people around them. Physicians who work in a daily atmosphere of severe emotional distress, fear, and worry, must take special precautions to avoid being overwhelmed by these negative emotions.

According to Cohen, the first step to managing emotional distress is to simply acknowledge and examine our emotional reactions. Physicians often experience guilt, anxiety, or shame when we experience powerful emotions like sadness or anger. This discomfort leads us to try to repress these feelings. Because unexamined emotions lead to distraction, inattention, irritability, emotional exhaustion, and burnout, Cohen says that it is essential to acknowledge and reflect on these feelings. The simple act of labeling our emotions- “I feel deeply sad,” or “I feel helpless and angry”-can be a powerful tool in coping with these feelings.

This is especially important when we face emotions involved with patient death. Physicians who lose patients report feelings of self-doubt, failure, guilt, and powerlessness.   Physicians also report sadness after a patient’s death, including experiencing insomnia and crying.  Traditionally, grief in medical training has been considered weak or unprofessional, and doctors have been encouraged to keep their feelings inside. Rather than openly expressing grief, physicians instead use the technique of compartmentalization– putting the painful emotions into a metaphorical sealed box. We may also use other techniques to avoid our negative thoughts or emotions, including isolation and distraction.

The problem with these techniques is that they are emotional barriers that prevent us from addressing our feelings.  Instead, we must practice healthy coping mechanisms such as acknowledging our feelings and accepting support from others. 

Share your feelings

Physicians are often reluctant to share our negative emotions with others. Sometimes we choose not to share the negatives in our life because we do not want to burden our friends or partners.  This noble intention can cause a relationship rift because it does not allow others in our life to offer support.  Ultimately, that leads to our own isolation. It is critically important to open up about our feelings with those closest to us-a family member or trusted friend or colleague.

In some cases, we may need to reach out to a professional to help us cope with powerful emotions. Asking for help is not a sign of weakness. In fact, it takes more courage to ask for help than it does to suffer in silence. And getting help makes us better and stronger so that we can continue to help others.

According to psychologist Steven Cohen, one of the dangers to sudden traumatic events like the COVID-19 pandemic is that they can trigger sudden, intense feelings of helplessness and hopelessness, which can provoke suicidal thoughts even in people without any underlying mental conditions.  He notes that receiving adequate mental health care at the time of the serious event may help physicians to have improved emotional and cognitive resilience to withstand the impact of the trauma. It is essential to seek help early before negative thoughts become intrusive and dangerous.

To get the best result in managing depression symptoms, physicians must work with a trained clinician in a structured fashion. We must avoid treating ourselves or using friends or colleagues informally for medical care.  Instead, ask a trusted colleague or your primary care physician for a recommendation to a psychologist.

While physicians often worry that seeking psychological help may have an adverse effect on their career, there are ways to get help confidentially or even anonymously. For example, both the Collier County Medical Society and the Lee County Medical Society in southwest Florida provide free and completely confidential sessions for physicians in the community. During the pandemic, sessions are provided in a web-chat format. Many other physician organizations across the nation offer similar programs-reach out to your local organization to ask if a program exists, and if not, get one started! The LifeBridge Physician Wellness Program offers a free toolkit that helps organizations start confidential programs for doctors.  Another option for physicians without such a program is to consider using an online therapy service.

The importance of self-care

Well-known factors associated with physician depression include lack of sleep, dealing with death, making mistakes, 24-hour responsibility, self-criticism, and difficult relationships with coworkers and patients. These factors are likely to be compounded as physicians face increased pressure from the COVID-19 pandemic.

Doctors must acknowledge the need for self-care.  We must manage our physical needs for adequate sleep, nutrition, exercise, recreation, and social activities. We need to avoid turning to maladaptive techniques of self-care, such as overuse of alcohol or other substances. We must not overly self-criticize or demand perfection, especially in these unprecedented times. We must acknowledge that we cannot do it all, and we will sometimes fail, despite our best efforts.

Doctors must also care for themselves if they begin to fall ill-either physically or emotionally. Physicians are notorious for “presenteeism” – coming into work not only when we are exhausted or sick, but even when we are severely depressed. We may do this out of a sense of responsibility and irreplaceability, but sometimes we do it because of a dysfunctional strategy to manage depression.  Work can act as a sense of structure and routine that sometimes keeps us going and distracts our mind temporarily from negative thoughts.  However, lack of sleep, protracted work hours, and illness are associated with worsening depression, making this type of behavior counterproductive.

Although these are difficult times, we must remember that we are not alone. We are all in this together. Physicians are incredibly resilient-you do not get through medical school, internship, and residency without incredible fortitude. We will get through this as well. We just need a little help from our friends, family, each other, and perhaps, a good psychologist.

Rebekah Bernard MD is a family physician in Fort Myers, FL and the author of Physician Wellness: The Rock Star Doctor’s Guide.