Among physicians in training, depression has been associated with reduced quality of life and increased burnout,¹⁷ resulting in poor quality of patient care and decline in the physician work force.¹⁸ Recently, investigators have established a strong association between depression and perceived medical errors^17,19,20 and noted that medical errors are of a magnitude relevant to patient safety.²⁰ These studies suggest that reducing rates of depression among training physicians is a crucially important public health issue.

Unfortunately, physicians are often reluctant to seek mental health treatment,²¹ and their peers are hesitant to intervene despite their professional responsibility to report impairment among their colleagues. Physicians frequently seek treatment only when their psychological distress and suboptimal performance has garnered the attention of insurance companies, police, and review boards.²² Despite the elevated prevalence of depression among physicians and its associated high costs to physicians and patients, it is unclear why doctors underuse mental health treatment. The only study to date identifying barriers to mental health treatment in the medical profession is among medical students, and it found that the most frequently cited barriers to treatment in this population included lack of time, concerns regarding confidentiality, stigma, cost, fear of documentation on academic record, and fear of unwanted intervention.²³ At present, little is known about why doctors underuse mental health treatment.

Of the 42.5% (278 of 654) of interns who screened positive for depression, 22.7% (63 of 278) reported starting treatment at some point during intern year. Among the interns who sought treatment, 39.7% (25 of 63) reported use of therapy plus medication, 33.3% (21 of 63) reported use of therapy without medication, and 27% (17 of 63) reported medication use only. Of the 42 participants that received medication, 64.2% (27 of 42) started an antidepressant and 23.8% (10 of 42) started a benzodiazepine. Two interns (4.8% [2/42]) reported having started on antidepressants and benzodiazepine, two interns (4.8% [2/42]) reported starting on mood stabilizers, and 1 intern (2.4% [1/42]) reported having started on mood stabilizers and benzodiazepine.

There were no differences in age (, P = not significant [NS]), sex (, P = NS), history of depression (, P = NS), marital status (, P = NS), institution (, P = NS), or specialty (, P = NS) among depressed interns who sought mental health treatment and those that did not. In contrast, interns who had previously sought mental health treatment were more likely to seek treatment during internship (, P = .01).

Given the high incidence of depression found among interns, preventative approaches are warranted. In a recent review, Beekman and colleagues²⁶ found that prevention of depression among high-risk groups is effective with overall preventative interventions reducing the onset of depression by 25% to 50%. Preventative strategies included both medication and therapy. Although interns may be reluctant to start prophylactic medication, psychological interventions alone have been shown to be effective in reducing the incidence of depression. A recent meta-analysis of 19 randomized control trials by Cuijpers and colleagues²⁷ demonstrated that psychological interventions, primarily using cognitive behavioral therapy, reduce the incidence of depression by 22%. Given the well-known demands and stressful nature of internship, equipping interns with cognitive coping skills to combat the stress of the intern year would likely be welcomed by interns.

Other valid approaches for populations at high risk for depression include screening and early intervention. Screening of depressive symptoms in interns is highly feasible. Data from our study demonstrate that interns are willing to complete confidential online questionnaires related to depression with on average 69% of subjects completing all quarterly assessments and 88% of subjects completing at least 1 follow-up survey. Providing interns with feedback about their depression rating scale score, compared with normative data for those of similar age and gender, may help interns recognize a current depressive episode. Screening and early recognition of depression, however, is only useful if followed by early intervention and appropriate treatment.

Recently, investigators have begun using Internet-based mental health interventions to reach those in need of mental health services. Fortunately, the effect size of interventions for a variety of anxiety and mood disorders delivered over the Internet is quite high with most effect sizes for depression being greater than 0.5.²⁸ This delivery format has a number of potential benefits over in-person treatment for medical interns: it ensures complete confidentiality, is low or no cost, allows for flexibility in time of day it is accessed, obviates travel burden to and from sessions, and provides tools for interns to manage problems on their own and little association with psychiatry, all of which are likely to increase service use among trainees.

Another shorter term approach to addressing the high incidence of depression among interns is to better understand and identify factors within residency that are “depressogenic.” We examined a number of within-residency factors from 13 community and university hospitals throughout the United States including over 55 residency programs. Interestingly, institution and medical specialty were not found to predict depression, but factors universal to all interns such as increased work hours and medical errors predicted an increase in depressive symptoms during the intern year.²⁴ Although intern work hours have been reduced, it appears that continued efforts in this direction may improve not only patient safety but also physician mental health. Given the association of depression and medical errors,^17,19,20,24 interventions aimed at helping physicians cope with the feelings of distress, guilt, and shame often associated with medical errors would likely be a helpful and welcomed intervention.

It should be noted that rates of depression found in our study are higher than most studies screening for depression among medical residents (7%–49%).^2–,13 One reason may be that prior studies were cross-sectional, whereas our study assessed depressive symptoms every 3 months. Multiple assessments during the year likely increased the chances of identifying a new case of depression and may account for these findings. On average 25.7% of interns met criteria for depression at each of the follow-up assessments.²⁴ These findings are consistent with other studies that also assessed the point prevalence of depression among medical residents.^17,19,20

There are potential limitations to the data presented in this article. First, we assessed depression through a self-report inventory rather than a diagnostic interview. We chose this method, as opposed to an in-person assessment, based on previous data demonstrating that anonymity is necessary to accurately ascertain levels of depression among medical students.³⁰ Based on these data, we employed the PHQ, which has a diagnostic validity comparable to that of clinician-administered assessments.²⁹ Nonetheless, it would be important to validate these findings using structured clinical interviews for diagnosis. Second, a subject participation rate of 58% is much lower compared with other studies that have used similar methods of assessing medical residents via online questionnaires.^17,19,20 The low response rate of 58% may reflect an additional study requirement of providing a DNA sample; however, this is not confirmed. Although there were only modest differences in age and gender between those who chose to take part in the study and those who did not, our results should be extrapolated with caution. Third, we measured perceived barriers to mental health treatment that may not reflect actual barriers to care. However, the barriers assessment was administered at the end of the intern year and are thus more likely to reflect actual barriers to treatment in the group of interns that received care. Fourth, it is important to note that our data analysis determined whether each subject met criteria for depression and whether the subject used psychiatric care at any of the 4 assessments. Thus, we do not definitively know if depressive symptoms preceded care use. Lastly, it is important to note that our study was restricted to interns and thus our results may not hold true for advanced residents or physicians who have completed their training.

In an effort to facilitate effective mental health treatment, we must reduce the obstacles to care identified by depressed medical interns. Providing confidential and convenient access to services, including protected time for interns to attend appointments, would likely increase the use of mental health services. For depressed interns who do not believe that mental health treatment can be helpful, education about the efficacy of available evidence-based depression treatments may be an important intervention.

A challenging barrier to overcome is perceived social stigma. There is a long-standing belief, often referred to as the “hidden curriculum,” in residency education that perpetuates the idea that psychiatric disorders and psychological problems are shameful. This belief is reflected in our data with more than half of depressed interns expressing concern about what others would think if they received mental health treatment and 43% believing that their colleagues would have less confidence in them if they sought mental health treatment. Shifting attitudes regarding mental illness and treatment in the medical profession is difficult but necessary in order for physicians to receive appropriate mental health care. Furthermore, because physicians' own health maintenance influences their counseling of patients, a shift in attitudes will likely improve the mental health care of patients.¹