Depression in Physicians: An Overlooked Issue in Mental Health

Depression is a common mental disorder that presents with depressed mood, loss of interest, feelings of guilt or low self-esteem. It affects an estimated one in 15 adults (6.7%) in any given year. One in six people (16.6%) will experience depression at some point in their lifetime. It can strike at any time; but usually it first appears during the late teens to mid-20s. Women usually experience depression more than men. Depression is one of the most common mental health issues among physicians worldwide due to high-intensity training and work overload. Recent systematic reviews and meta-analysis indicated that the prevalence of depression among physicians worldwide was around 28.8% which is quite higher than in the rest of the general population. Depressed physician makes more medical error than others. The burden of depression could lead to a low quality of life, ultimately suicidal attempts. So identifying risk factors for depression must be addressed and solved properly with utmost priority. This article reviews the prevalence of depression in physicians based on recently published literature related to this arena.


Introduction
Depression is the fourth leading cause of the global burden of disease. It is a highly prevalent psychiatric disorder that tends to be recurrent and chronic. World Health Organization (WHO) has predicted that depression will be the second leading cause of early death or disability by 2020. Physicians are vulnerable to some mental disorders such as anxiety, depression, and occupational burnout, because of their exposure to high levels of occupational stress, high-intensity training period, long time working hour. [1][2][3][4][5] Adverse mental health among physicians can hinder their professional performance and affect the quality of healthcare provided and make more medical errors. 1,2 Studies also report conflicting findings of resident depression depending on specialty, postgraduate year, sex and other characteristics.
These issues will inevitably have negative effects on patients' health and the development of the healthcare system based on manpower sources. Therefore, interest in the psychological well-being of physicians has increased recently, warranting further research regarding factors that influence the mental health of physician.
Worldwide prevalence of depression among physicians is around 28.8% (20-40%). 2 Both developing and developed countries were high in the prevalence of depression in physicians. Percentage was more marked in study from Egypt (73.8%) 6 , USA (41%) 7 . Fewer studies are found in Asian countries. But the rate was high eventually (30.1%). [8][9][10] One study from Bangladesh showed the percentage of depression was 11.5% 8 which was less than from other countries' data.
Mental health problems of physicians must be addressed properly and need to take a realistic step to mitigate the problem to get better service from physicians.

Materials and Methods
For reviewing search was done in PubMed, PubMed Central, Google Scholar and BanglaJOL with searching keywords ranging date from January 2009 to November 2019. There are few full downloadable articles, and total 30 articles were found. After exclusion of repetition and screening selection was done finally on the basis of exclusion criteria. Nine articles were selected for review. Searching words were: prevalence of depression on physician, prevalence of depression on physician in Bangladesh, predictors of depression on physician and demographic pattern of depression on physician. English articles that discussed depression on physician, fully downloadable articles in PDF form found in PubMed, PMC, Google Scholar and BanglaJOL from January 2012 to December 2019 were included. Among the articles seven original articles were chosen for analysis (Table I).

Discussion
The practice of medicine is unique and more challenging than any other profession in the world. It is associated with a great degree of both personal and professional satisfaction [10][11][12] , but a high level of occupational stress and burnout is also a burning issue. The mental health of physicians is a neglected one. The majority of the physicians are unaware of their mental sickness and they ignore the topic which ultimately makes a burden on society and increased the rate of burnout. Unfortunately the incidence of suicidal tendency is increased day by day among physicians. 2,3,13 In the present paper we have compared seven recent studies of different counties including Bangladesh regarding the status of depression among physicians. All the studies showed an increased rate of depression among physicians due to various causes. 2,3,13-15

Epidemiology of depression
Review of these seven studies involving 6624 physicians demonstrated the mean age of the study subjects varied from 30.5±2.7 to 39.75±9.1 years in different studies. 6,7,9,10-12 Total 10.4-73.8% screened positive for depression or depressive symptoms. Egyptian study showed the highest rate of depression (73.8%) 6 whereas less percentage was found in a study in Bangladesh (11.5%) 8 . Another study from the USA showed 41% of depression among anaesthesiology trainees. 7

Etiology of depression
Causes of depression among physicians are multifactorial. Different studies showed that work overload, long working hours, unsecured working environment, compromised treatment, difficult relationships with senior doctors/staff, lack of sleep, dealing with death etc. contributed to physicians' depression. [16][17][18][19] Unexamined factors such as the institutional cultures, social culture may contribute to the risk for depressive symptoms. 1,2,6,20,21 A better understanding of culture and working environments may help elucidate some of the root causes of depressive symptoms.

Effects on self, society and health care
The development of depression will increase the danger of such future episodes and larger longrun morbidity having an effect on the longrun health of physicians. 1

Conclusion
This review estimates the prevalence of depression or depressive symptoms among physicians ranging from 10.4-73.8% depending on the instrument used and increased with time. To mitigate the problem we have to find out the root causes. Every problem is individualized. Further study is needed to identify effective strategies for preventing depression among physicians.