A new review of the literature, presented last month at the American Medical Association’s International Conference on Physician Health at Seabrook Island, S.C., details new viewpoints on the sources of physician impairment. According to the reviewers, there is an increasing awareness of psychiatric disorders among physicians.

The presentation, by Daniel P. Chapman, Ph.D., M.Sc., a psychiatric epidemiologist at the Centers for Disease Control and Prevention, and Keith E. Wyche, M.D., a cardiology fellow at Emory University School of Medicine, was titled "Emerging Perspectives on Physician Impairment: Self-Medication and the Slippery Slope."

The team searched for articles referencing the keywords "physician impairment," "mental disorders," and "substance abuse" published between 1989 and 1999. The type of publication was reviewed to determine whether it was a state/local medical journal or a national/specialty medical journal.

Of the 84 articles that Chapman and Wyche found, more articles appeared in national/specialty publications in more recent years. From 1989 to 1995, only 48 percent were found in national publications, whereas from 1996 to 1999, 82 percent were published in national journals. According to Chapman and Wyche, this indicates an increasing awareness of physician impairment overall.

The study also found an increasing awareness of psychiatric disorders among physicians. Only 8 percent of articles regarding physician impairment referenced mental disorders between 1989 and 1995. From 1996 to 1999, 23 percent of the articles did so.

Chapman told Psychiatric News that the prevalence of physician impairment is hard to measure. "As previous researchers have pointed out, more population-based studies on physician health and impairment are needed to provide the necessary denominator data to arrive at meaningful estimates."

In reviewing the literature, Chapman and Wyche note that research showed that the initiation and use of benzodiazepines and opiates by physicians escalate between medical school and residency, and these medications are frequently used in the guise of self-treatment. Alcohol use is also more prevalent in physicians than in their nonphysician peers, research shows. In contrast, illicit drug use appears to be less common in physicians than in an age-matched sample of the general population.

However, physicians may be more likely to report their substance abuse in physician-impairment studies than the general population would to a health care professional.

"Physicians are also less likely to report any psychiatric disorder," said Linda Logsdon, M.D., chair of APA’s Committee on Physician Health, Illness, and Impairment. "The stigma associated with self-prescribing isn’t as bad as it used to be, but for physicians to come out and say they have a psychiatric disorder would still be quite monumental."

Michael F. Myers, M.D., APA Area 7 Trustee and corresponding member of the Committee on Physician Health, Illness, and Impairment, agrees. "The stigma for a physician to seek treatment for depression, as an example, is great. It is getting better, but most physicians still won’t make that phone call. When they finally do, they will tell you they dialed everything but the last number many times before."

Myers, who practices in Vancouver, B.C., has treated a number of physicians who finally made the call to get treatment. He has also had input from colleagues all across North America that mirrors his own experience.

"Anecdotally, we do seem to be seeing an increase in the number of physicians being treated for things like depression," Myers said. But exactly why this is so "is a very complicated question."

He noted that the profession of medicine has perhaps gotten more stressful and difficult, especially as managed care has advanced. He added, however, that the education process has gotten more rigorous as well.

"Our education," observed Myers, "may be working for us, with better awareness and understanding of things like depression; more physicians are seeing it in themselves, so diagnosis may be better."

Chapman and Wyche propose the "slippery-slope" model of physician impairment. Many people have inherent genetic and hereditary factors that may predispose an individual to substance abuse or psychiatric disorders. Physicians have additional factors that may add to their risk.

"Physicians, as highly educated people, often have a high need for achievement, perfectionism, and compulsivity," said Chapman. These characteristics, along with educational and professional stressors, may lead to self-care deficits, followed by self-treatment, an option that may distinguish physicians from other highly educated groups. The physician then "slides" into a declining "slope" of substance abuse and potential psychiatric illness, all of which lead directly to physician impairment.

Myers agreed. "I really like this model, because it is biopsychosocial." He noted physicians usually are horrible followers of their own advice. "Self-care deficits are very real. A physician will make strong recommendations to his patients about things like preventive exams yet hasn’t seen a doctor himself in 30 years."

Myers said that the incidence of self-medication may also be rising, particularly the use of antidepressants by physicians. "Before SSRIs, physicians were reluctant to self-prescribe things like antidepressants," Myers said. "The side effects were significant; physicians didn’t want those side effects noticed because someone might think something was wrong. SSRIs are easier, cleaner medications with far fewer side effects."

Myers does get calls from physicians who have started themselves on SSRI therapy and, possibly due to the effects of the medication, are feeling well enough to turn treatment over to him.

Myers supported Chapman and Wyche’s conclusions regarding the message the profession needs to send to physicians caught on the "slippery slope." Chapman said these physicians need to know that their colleagues are aware of their behavior and are concerned, that they are not alone, and that help is available.

"Most importantly, if impaired physicians seek help, this does not mean that they are a ‘bad’ doctor," Chapman commented. "Seeking treatment will only make them a better doctor."

Unfortunately, in the absence of effective treatment, the end point of the "slippery slope" is very grim, noted Wyche. "Impairment can result in license revocation, incarceration, and death. But with treatment, doctors can and do resume lives of professional and personal success.

Both Myers and Logsdon agreed that the review of publications by Chapman and Wyche does have at least one very important benefit, promoting discussion about substance abuse and psychiatric disorders as sources of physician impairment. "These issues do need to be brought out into the open; they have largely been ignored in the past," said Logsdon.