* If you are struggling with suicidal thoughts, please call 988 for help.
* The title for this piece is taken from the Mary Oliver poem More Evidence.
* Content warning: depression, suicidality
So often, residency feels like a glorification of being pushed to your breaking point. Little sleep. Life or death decisions, often made on the aforementioned little sleep. Patient care scenarios that are unbearably sad or even intensely morally distressing. The act of compartmentalizing those things and moving forward with your day. And these are just the things that happen at work. It’s little surprise that JAMA reported that 29% of residents experienced depression (and that was in 2015, before COVID). We all know this, programs know this, and that’s why we all have mandatory wellness training. Depression and depressive symptoms are often coped with by dark humor, alcohol, or just plain ignored by a group of highly functioning self-sacrificing people. But what happens when your mental illness can’t be laughed off in a re-shared instagram meme about depression? That happened to me.
I write this with the hope of helping someone in a similar situation feel that they are not alone, and that help is out there. The process of getting that help can – and often does – feel scarier than it should be, and isn’t always as supportive as you need. But I promise you that you (both the person you feel like right now, and a healthier version of you) are so worth that struggle.
My first confrontation with anxiety and depression came during pediatrics residency. As an intern, I felt paralyzed with fear whenever I had to make any decision independently. I became fixated on the idea that every decision I made was the wrong one, and that I was the worst doctor imaginable. Many interns have days like these, but my fear grew more and more debilitating. I started spontaneously crying during presentations on rounds halfway through my second year. Soon after, I couldn’t be at work without having a panic attack. Despite my very public and prolonged meltdown, no one ever asked if I was ok (although a rotation evaluation at the peak of this problem did say that I was “clearly going through some major personal issues” – I am now able to laugh about that one, I promise). Finally, I called one of my chiefs as a hysterical mess and took four days off work. Four days seems ridiculously short now, but at the time, I felt so guilty. Even residents with whom I was friendly made passive aggressive comments (“you don’t *seem* like you’re panicking,” “well you seem so much better after your vacation,” etc). When my program director offered me more time off, I declined, afraid of others’ judgment. I got on SSRIs and started seeing an incredible therapist through our hospital’s Employee Assistance Program (EAP).* Things slowly got back to a manageable standpoint.
* Side note – EAPs are programs offered by some hospitals/residency programs that provide financial support for confidential third-party counseling services. Essentially, you find a provider that is covered through your EAP and the program will directly pay your therapist. Your therapist isn’t directly employed by your program and is bound by confidentiality rules to not talk to your program (or anyone else) about your sessions (with notable exceptions being for your safety – i.e. if you are actively suicidal). If your program/hospital offers an EAP, chances are they will tell you that they only offer X number of free sessions. The EAP that my pediatrics residency used was very flexible about providing more free sessions – all I had to do was ask and say “Yup, still depressed,” and they indefinitely extended the financial support.
I continued taking a daily SSRI all the way through pediatric residency and the year I worked as a pediatric hospitalist. I then started anesthesia residency in 2020, and had a baby in March 2021. Luckily, I work in a large, baby-positive residency program, and was able to take off four months without significantly impacting the call pool or facing disapproval from program administrators.
A long, messy list of causes pushed me into an episode of very severe postpartum depression/anxiety. While on maternity leave, I could still function by just doing the bare minimum to manage the problem, but really struggled to bond with my baby or even feel like a mom at all. Then, I went back to work, and all those problems intensified rapidly. Not only did I feel like the world’s worst mom for leaving my kid (even though I didn’t even like staying at home!), I felt like a terrible partner for leaving so much work to my husband. On top of that all, I felt like a horrible resident – constantly tired, distracted, always needing to pump, and behind my peers after my leave. Those feelings of inadequacy in all arenas spiraled into a constant mental state of self-blame and loathing.
Very slowly, and then all at once, I was the most depressed I’ve ever been. Every waking moment of my day was filled with an internal chorus of, “I hate myself. I’m a terrible person. The worst mother ever. I want to sleep forever. I wish I were dead.” I still got up and did all the tasks that made me look like a functioning human. But I felt completely hopeless, and like things would never get any better.
Finally, in late October, I hit my breaking point. I knew I was depressed, but thought that if I could just find a way to be better and more efficient at all my responsibilities, I would be happier. I emailed a female attending in my department who I really respect to ask for a chat about how I could be doing things better. When we actually sat down…I lost it. Between hysterical sobs and a well-timed case of the hiccups, I managed to tell her that I was severely depressed and barely coping. When she asked how she could help, I was so overwhelmed that I could only be honest – I asked for a break. And amazingly, a break was what I got. This angel of a human being immediately jumped to my aid and helped me coordinate a leave of absence with my program director and my chiefs. Once I had finally worked up the courage to say something, the amount of people in my program ready to do anything they could to help me was really astonishing.*
* I recognize that this loving, supportive, and frankly life-saving attitude unfortunately would not be universal among residency programs. My program is large and has ample resources to cope with the absence of a resident for an extended period of time. The culture of my program is also probably more progressive than average when it comes to views on mental health and resident wellness.
Through coordination with program leadership and my chiefs, I arranged to take the following two and a half months off of work. I informed my therapist and primary care doctor of my leave, and requested a referral to a psychiatrist for medication management. At the beginning, I had a few meetings with program leadership and attendings for “planning” purposes, not that much planning actually happened. People universally meant well, but sometimes said things that felt terribly out of touch or frustrating. Even the psychiatrist, after taking my history, seemed to care more about the impact my leave of absence would have on the call schedule of my program than he did about my depression. He was taken aback when I requested to be enrolled in an intensive outpatient (IOP) therapy program, and actually tried to dissuade me from going. Interactions like these were incredibly disheartening and made me even more doubtful and ashamed of myself than I had been previously. Luckily, I had a really good therapist in my corner who strongly advocated for me when I felt like I didn’t have a voice, and then helped me learn how to articulate what I needed.
With one-on-one time with my therapist, IOP, a medication switch, and most importantly, time, I slowly started to get better. I went back to work in January 2022 still anxious, still prone to self-blame and shame, but actually able to function. It has been almost a year and a half, and while my depression is still a part of my life, it isn’t my whole life. Showing myself kindness did not make me a bad doctor, and it’s the reason I am still here today.
If you’ve made it all the way to the end of this epically long story (or if you scrolled hoping for a TL;DR), here are the things I think are worth summarizing:
- Take advantage of the free mental health services offered by your program. The terms may be even more generous/permissive than initially explained to you.
- Telling someone, anyone, just one person how you are feeling, is simultaneously a small and a really big step toward making things better.
- Other doctors, sometimes even ones whose job it is to take care of people with mental illnesses, do not cope well when confronted with the reality of a fellow physician who is mentally ill. Their lack of insight is not an indictment of your brain. (This does not make their (usually) well-meaning comments any less stressful to hear, but with time, you will hopefully learn to not let them add to your shame.)
- Physicians, especially residents, spend an immense amount of time functioning well in high-stress environments. You are probably pretty well-practiced at hiding your distress, even to other physicians. Consequently, no one is going to swoop in and rescue you unless you advocate for yourself. Ask for the extra therapy sessions. Demand to be in the intensive outpatient therapy program, if that’s what you think you need. Unless you tell other people, you are the only one who knows what is going on inside your head. Telling people what you need is scary, but it can also save your life.
- Your life is worth it. Your happiness is worth it. There are some elements of self-care that can be put on hold during residency, but making your brain a safe place for you to live is not one of them.