Depressed Psychiatrists and Self-Prescribing

The biblical proverb ‘Physician, heal thyself’ is interpreted literally by some psychiatrists who reach for pharmaceutical samples if they find themselves slipping into a depression. Others may write prescriptions for themselves (or falsely in the name of a family member) in order to obtain antidepressant medication. Despite the ethics of this behavior [1] and Osler’s admonition ‘a physician who treats himself has a fool for a patient’ [2], a significant cluster of psychiatrists engage in this kind of practice [3].

What follows are some reasons for treating oneself. My intent is not to justify or defend but it is to explain with empathy and without judgment. These colleagues are already judging themselves harshly and do not need the criticism of others.

1. Symptoms of the illness itself. Shame, guilt, diminished self-esteem and unworthiness are common in depression. This constellation makes it hard to muster up the courage (and I use this noun deliberately) to approach a colleague or make a telephone call to reach out for help. These emotions coupled with the lowered energy and cognitive slowing that accompany depression also make self-medicating tempting and easier in an effort to relieve the pain. When anxiety is mixed with depression, this comorbid pairing distorts the person’s judgment and heightens the fear of breaches of confidentiality and reporting to medical licensing authorities. Asking for help becomes terrifying.

2. Knowledge about the illness. We know what the symptoms and signs of depression are, so self-diagnosing is not that tough. Here is a not uncommon scenario in my practice: “Hi Dr. Myers, this is Dr. Grant calling. I’m a psychiatrist in town, and the last few months I’ve been feeling stressed and down. I wondered about depression so I put myself on an SSRI about a month ago. I’m beginning to feel better now so I think I made the correct diagnosis. But I don’t want to treat myself. Can I come see you as a patient and let you assess me and take over my medication?”

3. Not having a primary care physician. When a psychiatrist already has a personal physician and an established relationship with that person, it is a bit easier to turn to him/her when one is depressed. However, many psychiatrists do not have a primary care doctor and even when they do, there is no guarantee of communication. I have treated many psychiatrists who self-medicated without informing their physician.

4. Internalized stigma in the psychiatrist. Despite our attraction to a stigmatized branch of medicine, our training in psychiatry and working daily in the field, we may not have fully purged ourselves of the outdated and erroneous myths about people with mental illness. Translate: strange, scary, dangerous, flawed, weak, less than, and so forth. And although the so-called culture of medicine is more enlightened than several decades ago, we still have a ways to go. If we become depressed, we can be very hard on ourselves, much more than if the illness is non-psychiatric. One of my psychiatrist-patients, now improved but still struggling with some residual symptoms of depression, had this to say when she began to develop neurological evidence of multiple sclerosis: “I feel very relieved, I might have something legitimate now”.

5. Enacted stigma. Enacted stigma is external [4]. It is the real and actual experience of prejudice, discrimination, or unfair treatment by others. In other words, the psychiatrist patient is truly being judged by the caretaker. It behooves us as psychiatrists that when or if we are called upon to treat our psychiatrist colleagues that we do so quickly and with thoroughness, equanimity, and kindness. Not all psychiatrists should be looking after other psychiatrists. Here is an example. While facilitating a group of physicians who had come together to mourn the suicide death of a psychiatrist in their small town, I recorded this statement from a psychiatrist colleague of his “I’m really pissed at him for killing himself. I know this sounds insensitive but he has sullied the reputation of psychiatrists. We already get enough bad press that shrinks are weird and all screwed up. His suicide only reinforces that belief”.

6. Autonomy and self-reliance. It is well known that many men and women who choose to study medicine are rugged individualists. Some are survivors of dysfunctional families, abuse, poverty, war, forced migration, and more. They have had to be strong and have not relied on others since childhood. They do not like to “burden” others with their problems. One psychiatrist patient of mine stopped mid-sentence about 20 minutes into his first visit with me and said “Shouldn’t you be looking after homeless schizophrenics?” Translate: I’m not worthy of your time. Another said “Am I whining? Please let me know if I am. I hate whiners”. Both had started themselves on antidepressant medications before consulting me.

7. Mistrust of psychiatrist colleagues. Sometimes the reluctance about seeing a psychiatrist is in part due to the illness—feeling vulnerable and mistrustful of others, plus not feeling very hopeful that anyone can help. Other times it is characterological and rooted in narcissistic or paranoid ideas and defenses. The psychiatrist self-medicates because he/she believes that no one can provide the kind of diagnostic or therapeutic thoroughness, accuracy, and safety that he/she can.

8. Unavailable resources. Some psychiatrists self-medicate because there is no one in their immediate environment whom they do not know professionally or personally. These are individuals who live and practice in smaller, rural, or underserved communities. At their most symptomatic, these psychiatrists may self-medicate until they can obtain coverage of their practices and journey to the nearest locale that has a psychiatrist who is truly at arms length and can provide the kind of care they need and deserve.

It is my hope that with a better understanding in all of us about some of the drivers of self-medicating, both internally and systemically, we can lower this tendency and remove some of the barriers to seeking treatment.

Note: All names and details are disguised in this piece, including the use of composites.

References

1. American Medical Association Council on Ethical and Judicial Affairs. Opinion 8.19, Self-treatment or treatment of immediate family members. In Code of Medical Ethics: Current Opinions with Annotations. Chicago, IL: American Medical Association; 1998.

2. Osler W. Sir William Osler: Aphorisms from his bedside teachings and writings. Bennett Bean R, Bennett Bean W, eds. Springfield, IL: Thomas; 1961.

3. Myers MF. Psychiatrists as patients: a 27-year study. Paper presented at International Conference on Physician Health. Vancouver BC. October 19, 2002. Unpublished.

4. Gray AJ. Stigma in psychiatry. J of the Royal Society of Medicine. Feb 2002;95(2):72-76.