In the summer of 2014, two young New York physicians ended their lives within a week of each other. The first was a recent graduate of New York University School of Medicine; the second had just begun his residency at NewYork-Presbyterian/Weill Cornell Medical Center. In response, both institutions offered counseling services.

Also in response, Zina Meriden, now a fourth-year resident in the Johns Hopkins University School of Medicine’s Department of Psychiatry and Behavioral Sciences, began work on a video module to educate house staff across all Johns Hopkins residency programs about the signs and symptoms of depression. The module also discusses the obstacles residents face in seeking help and the support and treatment available to them at Johns Hopkins.

Only about half of depressed interns seek treatment, according to a study in the Journal of Graduate Medical Education. They don’t have time, worry about confidentiality and stigma, believe that their level of stress is to be expected during training, think they should be able handle their own health or fear the judgment of other doctors, Meriden says.

“Depression in physicians is something that is an extremely worrisome problem,” Meriden says. “The attitude in medicine is that we’re these invincible people immune to problems like depression, when in fact that’s not true.”

Last December, a meta-analysis published in JAMA found that the prevalence of depression among resident physicians stands at about 29 percent—more than three times the rate of the general public—and is on the rise. And physicians are not only more likely to attempt suicide than the general public but also to complete it, with women physicians killing themselves at between 2.5 and four times the overall rate, according to a study in The American Journal of Psychiatry.

Every year, as many as 400 doctors commit suicide in the United States, according to the American Foundation for Suicide Prevention. “That’s equivalent to one entire medical school,” Meriden notes.

Does the profession attract individuals especially vulnerable to depression? Are resources unavailable or inaccessible? Or do concerns about stigma and discrimination overpower the desire to seek help?

The answer appears to be all of the above and more, with little consensus on the exact reasons for the phenomenon or the best solutions but a growing sense that steps must be taken to improve conditions.

Most students arrive at medical school having led “relatively charmed lives,” says Margaret Chisolm, director of education for Johns Hopkins Bayview Medical Center’s Department of Psychiatry and Behavioral Sciences. They’ve earned A’s in high school and college, and successfully balanced school with extracurricular, community and family commitments. They have no reason to anticipate that medical school could throw them off their game. “They’ve managed well, so they think they are invincible.”

But then, during med school and residency, physician trainees face high levels of physical and mental exhaustion: time-consuming commitments, sleep deprivation and a role with life-or-death stakes in which they have not yet achieved mastery, says Karen Swartz, associate professor of psychiatry and behavioral sciences.

If all that stress coalesces into depression, it can play havoc with a new physician’s self-image, says Swartz, who serves as clinical programs director for the Mood Disorders Center and is advising Meriden on her video project. Some may come to view themselves as inferior doctors; others may decide medicine is not for them and consider leaving the profession.

But while depressed doctors may believe themselves unsuitable for the job, Swartz says that in her experience, the vast majority show no sign of impairment: Though their personal lives may suffer, the quality of patient care they provide generally does not. “What happens is they put all their energy into doing an excellent job. What they have is very little energy left for anything else,” she says.

The Road to Burnout

While the depression spotlight has lately been pointed at residents in particular, many believe their situation is best understood as one facet within the larger subject of physician burnout—a phenomenon coming under its own increasing scrutiny.

Jessica Bienstock, associate dean for graduate medical education, says that for many residents and faculty members, the “joy of medicine” has fallen by the wayside as the pace of practice has skyrocketed. Patients are sicker than they used to be, and they cycle in and out of the hospital faster.

Physicians once found joy in getting to know their patients, puzzling out diagnoses and treatments with them, and watching them get better, she says. Residency used to be a time of reflection and of learning from patient care.

“Most of us highly value personal relationships, the intellectual pursuit of knowledge and using that knowledge to help patients. Now we’re all moving so fast we can barely breathe,” says Bienstock, who also directs the Division of Education and the residency program for Johns Hopkins’ Department of Gynecology and Obstetrics.

The intensity of training makes residents especially susceptible to the forces responsible for burnout, says Roy Ziegelstein, the school of medicine’s vice dean for education. Trainees experience a kind of intense sensory overload, he says: “Residents finish their shifts with the emotional equivalent of ringing in the ears from the overwhelming stimulation.”

What most concerns him about trainees’ stress and their reaction to it is the tone it sets for their future professional and personal lives. “Residency is a time of professional and personal identity formation,” he says. “When habits and patterns develop, they may be very difficult to change in the future. If residents respond to the sensory overload by blocking out the personal suffering of their patients, those emotional earplugs may be difficult to ever remove. That has long-term effects on the way doctors interact with patients, and no doubt also with their friends and families.”

Even when residents recognize their stress and want to seek support or treatment, they may be discouraged by the profession’s culture of stoicism, a sense that doctors must always appear in control, strong and impervious to any vulnerability. That culture seeps into every aspect of a resident’s life—from giving the impression of certainty even when complex medical decisions must be made, to regularly going without sleep, to solving problems on their own, says one former resident.

When depressive symptoms do arise in physician trainees, says Chisolm, “I think they overestimate their ability to withstand and persevere. I think they underestimate their likelihood of suicide and overestimate their ability to cope.”

Ironically, that culture of resilience may be grounded in the very roots of residency with the emphasis its father, Johns Hopkins’ own William Osler, placed on “aequanimitas”—the equanimity he expected doctors to display. “It was a philosophy that doctors have to look like they have more intellectual and emotional invincibility as compared to what they really have,” Meriden says.

Vulnerable to Perfectionism

Many who take advantage of psychotherapy services at Johns Hopkins’ University Mental Health program—including medical residents and students—are perfectionists, says Michal Tsemach, one of four therapists on staff at the outpatient clinic. The clinic is accessible (and confidential) to all full-time students, house officers and postdoctoral fellows of the schools of medicine, nursing and public health. It also offers psychiatric services and psychiatric medication management, and makes referrals to community resources for specialized services, like addiction treatment.

“This population is very, very conscientious,” Tsemach says, of the medical students and residents she sees. “They have high standards for themselves, and often, when they feel short of perfection, it causes them great suffering. So many people depend on them, and that contributes to their stress.“

When one former Johns Hopkins medical student faced challenges with her mental health, the peers who would otherwise have been her support network were so consumed by their schedules and requirements that she felt isolated even within a caring community. The former student has requested anonymity. Like many physicians in training, she does not feel safe exposing what is still perceived as weakness, fearing it will translate into professional and personal discrimination.

She says she was initially passionate about medical school and a future in helping people. Of course, she’d heard med school was hard, but she’d always performed well under pressure and was confident in her abilities to handle tough challenges. But she quickly found herself caught up in work that seemed redundant, spending huge amounts of time on patient care activities, like documenting care into notes that are not read, that she felt made few real contributions to her patients or her team. “There isn’t a lot of feeling that what you’re doing and studying is translating into a real benefit,” she recalls.

And the very things that would have helped to restore both her mental health and sense of humanity, she says, felt mostly beyond reach. She was unable to plan time with friends and family. Even scheduling psychiatrist appointments or picking up prescriptions seemed like insurmountable challenges.

Without having predictable work schedules, it can be tricky for medical trainees to schedule counseling appointments in advance and to keep appointments with any regularity. For this reason, and because trainees may worry about burdening co-workers by stepping away from work on a regular basis or fear the stigma of going to a therapy session, some may avoid therapy altogether.

A resident’s job is an extraordinarily busy one, Chisolm agrees, often without any time off during the day on weekdays, and barely enough time on the weekends to stock the fridge and do laundry. The 2003 cap on duty hours to 80 per week is an improvement “but not really compatible with normal life,” she says.

Trainees are unlikely to prioritize self-care. They don’t always sleep when they can, eat well, exercise, socialize, make time for fun and address their routine health care. The environment is very much part of that: “It’s not in the culture to say, ‘I’m burned out; can I leave early?’ It’s not culturally acceptable, so you would have to have somebody offer to provide relief,” Chisolm says. “And if you don’t have leadership modeling that kind of offer of respite, then it’s not going to happen from the bottom up.”

Profession, Heal Thyself

The medical profession as a whole seems geared toward minimalizing the structural flaws of resident education and instead treating the symptoms of stress, argues Thomas Schwenk, dean of the University of Nevada School of Medicine. In the same issue of JAMA in which the meta-analysis appeared, Schwenk authored an editorial calling the disconnect between current medical practice and the physician training system a “crisis.”

Besides more and better mental health care for physicians and trainees and limiting exposure to the factors known to endanger wellness, Schwenk wrote, what’s most important is considering “the possibility that the medical training system needs more fundamental change.”

The former Johns Hopkins medical student couldn’t agree more. “The idea of teaching people how to be more resilient against stress instead of modifying these stresses is pushing the burden of responsibility onto the most powerless in the system,” she says.

Part of the reason that depression and burnout appear to be on the rise, Schwenk contends, is that while the practice of medicine is almost unrecognizable from 50 years ago, residency training at most institutions is practically unchanged. Technological advances raise complicated ethical decisions and questions with no easy answers.

“It’s become so intense, with dilemmas and conflicts never remotely thought of, and basically impossible decisions to make, in a hothouse environment,” Schwenk says. “We still teach the medical knowledge and skill aspects well, but physicians are so traumatized by the things they’re exposed to in the course of school and residency. There’s no debrief and discussion, no one’s stopping, and no one’s available to help you through things, and residents are on the front lines of this.”

Ziegelstein, who directed the internal medicine residency program at Johns Hopkins Bayview from 1997 to 2006, says that changes have occurred in residency training in recent years. At Johns Hopkins, he says such conversations do happen—maybe even more than they used to—both spontaneously, in patient care settings, and in planned forums, like the Ethics for Lunch series on the Johns Hopkins Bayview campus. The monthly case conference engages trainees, chaplains, nurses and others in a dialogue about ethical issues arising in practice.

“Given the challenges of these ethical issues, though, I can imagine that there will always be the sense that there can never be enough time devoted to them. These issues are seldom, if ever, ‘closed,’” says Ziegelstein.

Diagnosing Depression

The JAMA meta-analysis gathered data from some 54 studies. Most relied on a variety of self-report screening tools to determine if their subjects had depression, and only three involved the clinical evaluation that is the gold standard for diagnosing depression and mood disorders, Swartz says.

Ziegelstein believes that while the main point of the study is important, these methodological issues raise questions about the accuracy of the depression rates reported. For example, he notes that the specificities of the so-called “commonly used instruments for diagnosing major depressive disorder” included in the supplementary materials to the JAMA paper range from 66 to 88 percent, and therefore many individuals identified using such instruments do not actually have depression.

Without a clinical evaluation, it is impossible to sort out stress, grief or frustration from clinical depression. Most med students and residents are at an age where they’re grappling with educational transitions, including launching into a career, possibly relocating, and changing up their community and support system. They are also attempting to balance academic demands with personal and family demands. These transitions can be stressful and potentially precipitate depression.

The 20s also represent a time in life where any genetic predisposition to mood disorders is most likely to manifest. “It’s age of onset,” Swartz says. “You couple biological vulnerability with sleep deprivation and stress.”

A clinical evaluation is crucial in distinguishing between types of depression and a stress reaction, says Elizabeth Kastelic, who directs University Health Services’ Mental Health Services at Johns Hopkins. Depressive symptoms may be caused by stress, overwork, lack of sleep, relationship problems and the sense that one is not up to the task, Kastelic says. Other types of depression have a biological basis. Both need intervention, but a multipronged approach is required to ensure trainees receive the treatment that best targets their situation.

Kastelic would like to see a comprehensive approach taken in future research to determine whether the prevalence of depressive symptoms seen in medical trainees is rooted in something specific to medical training. Long, hard hours in an environment where one has not yet achieved mastery certainly could contribute, but the meta-analysis and other studies don’t show a definitive connection.

“We want to bring out the best in future physicians,” Kastelic says. “As such, schools and residency programs continually evaluate the training environment in order to produce the finest physicians. We also want to support the trainees along the way as needed.”

The Right Direction

The culture is not yet where it needs to be, but changes are definitely occurring in the profession, says Ziegelstein. At Johns Hopkins, faculty members are more likely now than in the past to ask residents about their lives outside of medicine, and residency directors routinely consider their trainees’ emotional health and well-being. Faculty members are already trained to recognize the signs of stress and depression in their patients; the trick is to apply those tools with trainees too.

Ziegelstein says that as residents and faculty members engage more in practices that promote wellness, they will be better able to dedicate themselves to the highest standards of the profession and find joy in providing care to their patients.

In just one example of the steps an individual residency program has taken here, the Department of Psychiatry and Behavioral Sciences two years ago took its first-year residents to the National Gallery of Art in Washington, D.C., for a writing exercise related to art. “I saw it as psychological respite from the suffering they’re surrounded by in the hospital and inspiration for the beauty of life and for ways they could incorporate it into their life outside of the hospital,” says Chisolm, who arranged the experience.

“Trainees need to be valued as human beings, not just workforce members,” Chisolm says. “Why would we not want for ourselves what we want for patients?”

More broadly speaking, improvements in residency training are very much on the radar of the Accreditation Council for Graduate Medical Education (ACGME), the nonprofit organization that reviews and accredits U.S. residency and fellowship programs. To further resident well-being, the ACGME has identified the need for system-level solutions requiring collaboration with other stakeholders—including hospital leadership, nurses and other members of the health care team.

Conversations are in the earliest stages, but members are looking at ways to use program requirements as tools to bring back the more reflective parts of residency, says Bienstock, who serves on the national task force rewriting the common program requirements. The group is looking beyond questions like number of hours worked, she says, and exploring how those hours are used in an attempt to recast residents as learners and to help them develop along a continuum of responsibility.

At the same time, the ACGME wants to make the development of personal resilience one of the responsibilities a hospital has toward its trainees, Bienstock says. No single solution could possibly apply to every resident and residency program, but the idea is to teach the skills needed to survive in a high-pressure system, with examples including mindfulness training and drop-in yoga, offered at times consistent with a trainee’s schedule—like 10 p.m., instead of the middle of the day.

At Johns Hopkins, Meriden’s video module, which is supported by research funding from the American Psychiatric Association, is nearing completion. She has met with a focus group of Johns Hopkins house staff to review the module. Once she revises it based on their feedback, she plans to share it with other Johns Hopkins house staff, using pre- and post-tests to measure the module’s efficacy. If the video is found to be an effective intervention, she hopes to offer it to academic institutions beyond Johns Hopkins.

“We’re excited to do the video module because med students and residents are unnecessarily suffering from a very treatable illness, and this information is something that could dramatically improve their quality of life,” Swartz says. “We want to get good information to those going through depression or supporting someone who is, and encourage them to get treatment, which—the majority of the time—is very helpful.”