“How Stigma Kills Doctors”
(and other loved ones - Ed.)

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“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.”     Mr. Watanabe lost his father Dr. August Watanabe to suicide June 9, 2009.

 

In May 2000 I was invited to meet with health professionals in Holland, Michigan, after the chief of staff at their local hospital killed himself. He was  a forty-four-year old surgeon, a devout Christian, and father of four daughters. The Holland community was in shock and reeling from the tragic loss of this very capable and beloved physician. While I was there, I met the doctor’s pastor and the pastor’s wife, who gave the eulogy at the doctor’s funeral. She gave me a printed copy of what she said:

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Depression is a silent killer.

It does its dark work best when we deny that it exists.

Its partner is shame.

Together they isolate,

Causing pain that is unbearable,

Distoring our perception of reality until

We are convinced that the world will be better off

Without us.

It causes irrational anger – confusion – fear,

Until one’s mind gropes for a way to stop the pain.

Its victrims have been among the world’s brightest –

Most talented – kindest – most faithful.

And now our brother has succumbed to this terrible disease.

Let us destroy the power of this illness by naming it.

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In these few words, she captured the destructive power of depression – the horrific pain, the distorted thinking, the emotional whirlwind, the powerlessness of the sufferer, and the fact that it can affect anyone. But, most important, she pointed out how silence and shame can fuel self-annihilation. And she concluded by exhorting the mourners to “destroy the power of this illness by naming it.” She makes the point that too often we dance around the disease of depression by euphemisms like “had a few problems” or “was kind of stressed out.”

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There are actually two types of stigma: 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 the psychiatric illness because of their perceived unacceptability or inferiority. Felt stigma is interior and refers to both the fear of enacted stigma and the feeling of shame associated with having a mental illness. I believe that both types are in play when a symptomatic physician begins to wonder if he 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.

 

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.

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It’s probably safe to say that virtually no-one actually wants to admit that he 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.

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But because it leads to denial, stigma (the fear of being stigmatized) can have far more pernicious effects. Stigma kills. I believe it was perceived stigma that killed a patient of mind, 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.

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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 from behind the death. Several received no treatment at all and ignored or rejected the attempts made by those who cared deeply about them to get them to seek help. 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 commented,” Well, I thought he told me everything but obviously I was wrong. He made this very big decision without consulting me.”