DEPRESSION AMONGST DOCTORS. THE NIGERIAN RESIDENT DOCTORS IN FOCUS. ARD ISTH IS CONCERNED. Dr OKOGBENIN SHARES HER INSIGHTS.
Here is the highlight from the Questions and Answers session.
Q1. Good afternoon ma, could you please give us a brief overview of depression?
A1. Depression is an illness, characterized by persistent sadness, reduced or loss of interest in previously enjoyable activities and the inability to cope with daily activities for at least two weeks. It’s important to note that it is not just a simple transient emotional response but a clinical condition that can be treated. It is important again to recognize depression because it is very common in our environment and more worrisome to note that the prevalence is higher amongst doctors than non-doctors because of so many reasons which I think we are going to TALK ABOUT AS WE GO ON.
Q2. When do we say a person is depressed?
A2. Talking about clinical depression, there are specific criteria. Usually, we talk about the major symptoms (loss of energy, reduced interest and persistent sadness), and other minor symptoms (poor appetite, moody feeling, poor concentration, forgetfulness, poor sleep, low self-esteem, feeling of hopelessness). So, for you to say a person has depression, at least two (2) core symptoms plus two (2) minor symptoms must be present. Some persons may somatize their depression, having physical symptoms like headache, internal heat, palpitations, pains, peppery sensations instead of having the classical symptoms. In the words of Prof. Binitie of blessed memory, “Africans tend to externalize their depression”. For such persons, you may need to explore further to make this diagnosis where you look into any change in personality trait depending on the age group, like anger with adults, excessive sleep with children, and cognitive decline with the elderly.
Q3. How common is it in our environment?
A3. I was lucky to be a part of the team that did a recent study on the prevalence of depression amongst medical students in the six (6) geo-political zones across Nigeria. We looked at stress, drug use and anxiety and we found out that, the prevalence of depression across Nigerian medical students was 21.3 percent. So, you see that it even starts from medical school because of the stress of the training. Other studies in the general population put lifetime prevalence between 20 percent (women) and 15 percent (men). It is noted that one-in-six women have depression following child birth. So the figures are increasing by the day both for doctors and the general population. An American Study reported depressive symptoms as a universal experience in the first year of residency training. We are yet to have our Nigeria statistics on this, but so much work is going on.
Q4. Ma, concerning the rise in incidence of depression among doctors. What in your opinion could be accountable for this?
We may need to look at the risk factors that predispose the medical student and the resident doctors to depression. The residency training itself is a major psycho-stressor and so is medical school because of the excessive workload involved, not to forget the constant pre-occupation with failing exams. When this is combined with genetic predisposition, it becomes very easy for one to tilt into depression. Of course, a lot of other factors such as conflicts at work (with senior colleagues, patients, other health workers), derogatory/disparaging remarks ( trainers/senior colleagues) tends to take away self-esteem from the resident and it has been found that those with certain traits of self-criticism/perfectionism tend to be worst hit. Working round the clock, sleep deprivation, making medical errors and coming across a lot of poverty and social deprivation on the part of his/her patients and then frequent mortalities, all has its emotional toll on the doctor. Residency has job demand that outweighs job resources amidst authoritarian training methods, poor job satisfaction, remuneration squabbles especially in recent times. Again, family demands as the society expects so much from the doctor. People tend to tell you on one hand that, medicine is a humanitarian job for each time you complain about low wages but on the other hand, remind you that you earn some good income at the instance of asking money from you. Truth is, the doctor pays his bills too and the market woman may even jack up her fee when she realizes you are a doctor.
Q5. What preventive measure can a resident doctor take in the light of these psychosocial risk factors?
Yes, work load is excessive so there may be need for more hands to do the job. The doctor on his/her own part needs to play a role. A doctor is supposed to be able to balance work with leisure. Relaxation and enough time to sleep refreshes the brain. The doctor needs to create time and conserve energy by monetizing his/her stress and learning how to delegate and leverage some domestic task (driver, school-runs, house-help, laundry etc.) Also, Conflict reduction as much as you can, Healthy eating, exercises and reduction in alcohol and illicit substances which themselves are CNS depressants. These would give you more time to apply to the training itself and boost your confidence level thus, reducing the pre-occupation with failing exams. In short, the resident doctor would need to organize himself by planning time and energy.
Q6. In your opinion ma, are there specific inputs to be made into the training of doctors, from medical school through residency to reduce this problem?
Funding for the training programs cannot be overemphasized. Getting more hands to work by way of employment would help. Very pertinent to me is that our trainers need to be talked to,so as to reduce the disparaging/derogatory manner to addressing performance of the resident. The #TrainTheTrainers program should emphasize this. In fact, this calls for a paradigm shift. Residents should be treated with respect within a tension-free environment. One area to be looked into, is the possibility of creating a residency-mentorship program within every department where every resident is assigned to a mentor/educational supervisor whom he can direct his challenges, fears and concerns to. This could take the place of a counselling unit. I find it particularly shocking each time I hear that residents are not allowed to go on annual leave. This is wrong and condemnable no matter the structure of the departmental program bearing in mind that a doctor that comes down with depressive disorder ultimately, cannot be an effective doctor, Truth be said!
Let me say that one of the major barriers in managing depression in doctors is failure to present. Coupled with the fact that doctors are generally not so good at recognizing depression even in their patients, let alone themselves. For those that see the obvious symptoms in themselves, because of both social stigma and self-stigma, they refuse to present. A few may present to general practitioners outside their hospital environment for privacy sake but because they are not specialist, the treatment given is almost always never appropriate. Quite a number resort to self-medication which in itself poses more danger to the doctor. It is worthy of note that the issue of stigmatization is worse within the health workers’ community and this heightens the self-stigma amongst those with symptoms. The risk of being misunderstood as having other mental illnesses if seen approaching a mental health clinic, the fear of being appraised as ineffective by senior colleagues, the worry of being looked upon as an ineffective doctor by both patients and other health workers, are deep issues for him/her really.
Q8. Studies have shown that most depressed physicians do not seek any form of treatment. What could be done to encourage doctors seek help?
Thank you. We are raising awareness. If there is anyone to fight stigma better, it should be the doctors. But we as colleagues, need be the ones to help with this fight and not going behind him/her and be like “are you sure he is okay? Is he seeing his patients well? Is he still able to practice?” we should be our brothers’ keeper. If we find someone exhibiting depressive tendencies, the least we could do is approach them in love, speak to them and encourage them to seek help. Here at Irrua specialist teaching hospital, the department of mental health is ever willing to offer help. Our HELPLINE IS 08113953146. Help us share. Thank you.
Q9. How effective are the current treatment methods?
The good thing about depression is that treatment is very readily available, cheap and effective. They include PSYCHOTHERAPY, PHARMACOTHERAPY, AND ELECTRO-CONVULSIVE THERAPY. atimes, combined treatment options are offered. Whichever methods made available to someone based on the physician’s assessment, they are very effective. It is important to note that the prognosis is very good with doctors than non-doctors. Mental health accessibility is very easy. One can stroll into our consulting room without a referral. Again, however that we may offer VIP TREATMENT, its usually not the best as the patient is usually encouraged to come out with it without worry of what anyone might think. VIP TREATMENT also makes it difficult for your physician to talk about it freely, about suicidal tendencies and care plan. This surely wouldn’t help with overcoming self-stigma. It is the same type and quality of treatment offered to a non-doctor that would be offered to a doctor. We treat for as much as 6-9 months after which we place on maintenance therapy. Very important in treatment is, removal of the stressors. It is highly effective.
Q10. What are our fellow colleagues-Nigerian psychiatrists currently doing to stem this ugly trend within the doctors’ community?
Oh well, one of the things the Association of psychiatrist Nigeria is currently doing is raising awareness both within and outside the doctors’ community. I am sure most psychiatrist talk about it a lot on their online doctors communities like the MDCAN, ARD online chat rooms. I guess it is being taken as a serious matter as it would give the doctors hope that there is help just nearby. There are also dedicated news columns on our various national print media. We are gradually entering the online social media community. We are currently pushing for the NATIONAL MENTAL HEALTH BILL to be passed as it has a lot of provisions that would take care of the current challenges we face in managing this conditions as a nation. The last one passed is over 50 years old. Note, this is different from the NATIONAL HEALTH BILL.
Thank you very much for your time and With this, we come to the end of our questions. it has been exciting with you. We are sure doctors out there would benefit from this interview. We appreciate your patience and quality discussion.
Dr Mrs. Okogbenin is a medical Consultant and currently the head of department of psychiatry at the Irrua specialist teaching hospital, Edo State. She is widely read and publishes in various local and international journals. Her view are personal to her and there are no financial involvements in this exclusive interview. This was held on the 4th day of April, 2017.
