Customize your JAMA Network experience by selecting one or more topics from the list below.
Physicians are familiar with the yearly routine of being screened for tuberculosis, reviewing their vaccine status, and getting the influenza vaccination. Should physicians also be screened for mental health conditions such as depression or burnout?
The prevalence of and challenges associated with depression, burnout, and suicide have been increasingly recognized. Physicians die by suicide at rates higher than the general population, and suicides are more often related to job stress and inadequate treatment.1 Although definitive data on comparative rates of mental illness among physicians are lacking, resident physicians likely experience depression more than the general population.2
Physicians with common mental disorders often do not receive the care they need. Medical interns have identified barriers to seeking treatment such as concerns about confidentiality or judgments of colleagues; preference to manage problems on their own; concern about harming their career; and practical factors such as time, cost, and limited access to care.2
Hospitals and other health care institutions are focusing more on improving retention of physicians and preventing resource-intensive adverse outcomes such as leaves of absence, attrition, or even suicide. As institutions work toward improving the well-being of clinicians, an important question should now be asked: Should institutions be responsible for ensuring that physicians are regularly screened for mental health conditions? To our knowledge, the only physician screening program described in the literature is the American Foundation for Suicide Prevention’s Interactive Screening Program,3 a confidential web-based screening platform, although data are not yet available on the effect of physician mental health screenings on mental health outcomes.
Residency and fellowship training programs are also considering this question following the 2017 update to the Accreditation Council for Graduate Medical Education (ACGME) Common Program Requirements, which states that a training program, “in partnership with its Sponsoring Institution, must … provide access to appropriate tools for self-screening.”4 Rates of reported depression are particularly high in both medical students and residents.5,6
This Viewpoint reviews the potential risks and benefits of implementing a mental health screening protocol for physicians (see Box). Institutional leaders and those who would be screened will need to consider multiple complex factors to adequately address the issues raised herein.
Detect at-risk physicians and link to mental health treatment
Create opportunity for education and to potentially reduce stigma about seeking help
Follow US Preventive Services Task Force recommendations for annual depression screening
Loss of confidentiality
Potential negative effect on licensure in certain states
Inadequate access to care
Concern about institutional liability
False-positive screening results
Screening physicians for mental health conditions is consistent with the premise that early detection can create opportunities for engaging at-risk physicians in evidence-based treatments. Screening tools have been validated for detection of suicidal ideation, depression, alcohol use disorders, and other mental illnesses in the general population. Based on 9 good- to fair-quality trials, the US Preventive Services Task Force (USPSTF) “recommends screening adults for depression in clinical practices that have systems in place to assure accurate diagnosis, effective treatment, and follow-up.”7
A 7-item Physician Well-Being Index has been validated as a brief measure of mental quality of life, fatigue, and suicidal ideation. This index has been used to identify physicians whose level of distress may adversely influence their practice,8 but its use has not yet been shown to increase rates of referral or improve physician mental health outcomes.
Data on the effect of mental health screening on mental health outcomes in physicians also are limited. However, conducting screenings may create opportunities for education and stigma reduction aimed at supporting physicians in need of help.
Screening physicians for mental illness should consider multiple potential risks.
Confidentiality is widely regarded as a barrier to physician access to mental health services. Institutions often have difficulty identifying appropriate mechanisms for online screenings, in-person meetings, protected medical records, and referrals to treatment that ensure and preserve confidentiality.
Some states still include what some consider inappropriate questions about a history of mental health care on either the initial or reapplication licensure questionnaire despite advocacy at the Federation of State Medical Boards to remove them. Given the present risk of being subjected to mandated reporting in certain states, some physicians are understandably concerned that seeking mental health care might force them to report incomplete information in the application or risk investigation by a state medical board.9 Physicians must be made aware of state licensure requirements regarding mental health, and they should be educated about the difference between seeking help for depression and undergoing assessment for impairment that might lead to referral to a physician health program.10
Screening can only be effective when positive screens lead to referral for appropriate treatment. Physicians (and others in the general population) frequently have difficulty finding mental health services that are affordable and accessible. Furthermore, many employee health benefit plans may not adequately cover in-network or out-of-network mental health services.
Assuming direct oversight of a screening program may cause concerns about liability for institutional leadership. Although health systems and departments may conduct anonymous screenings for a needs assessment or to measure the prevalence of mental health disorders, these are superficial surveys if positive screens are not linked to care.
Although the USPSTF recommends depression screening in the adult population, there is a lack of consensus as to whether this improves outcomes. False-positive screen results may result from abnormal sleep schedules related to work demands that lead to above-threshold scores on depression screening questionnaires. Furthermore, individuals experiencing burnout may endorse items that lead to false-positive depression screen results that are more likely due to workplace issues than a depressive episode.
Given this complex balance of risks and benefits, the following strategies may be useful.
The American Foundation for Suicide Prevention offers an example of an Interactive Screening Program that provides subscribing institutions access to a customizable software tool to conduct screenings that are anonymous, confidential, and web-based.3 Responses are analyzed and triaged, and, if necessary, a counselor helps facilitate a referral for mental health treatment.
Another approach is to conduct mental health screenings along with the annual physical examinations and other health screenings that some institutions require. Integration into primary care could reduce stigma by incorporating screening into traditional evaluation and referral processes and allow for service coverage with employee health insurance.
Development of a comprehensive well-being program could increase utilization of mental health services and improve physician satisfaction. The infrastructure of a comprehensive program could help ensure confidentiality mechanisms to further reduce barriers.
It is not clear how often physicians are currently screened for depression, burnout, and suicide. However, with increasing concern that these increasingly common problems affect physicians’ well-being and may affect patient outcomes, it is important to carefully evaluate the risks and benefits of mental health screening for physicians. Further research is needed to assess the outcomes of implementing screening and referral programs. In the meantime, health care institutions should consider these factors as part of any strategy to ensure that physicians have appropriate access to the mental health services they need.
Corresponding Authors: Richard F. Summers, MD, Perelman School of Medicine, University of Pennsylvania, 950 Haverford Rd, Ste 302, Bryn Mawr, PA 19010 (email@example.com).
Published Online: November 30, 2018. doi:10.1001/jama.2018.18403
Conflict of Interest Disclosures: Dr Summers reports that he served as chair of the American Psychiatric Association's Workgroup on Psychiatrist Well-Being and Burnout. No other disclosures were reported.
Additional Contributions: We thank Laurel Mayer, MD, of the New York State Psychiatric Institute, who received no compensation, as well as the members of the American Psychiatric Association's Workgroup on Psychiatrist Well-Being and Burnout for their contributions to the development of this article.
Goldman ML, Bernstein CA, Summers RF. Potential Risks and Benefits of Mental Health Screening of Physicians. JAMA. Published online November 30, 2018. doi:10.1001/jama.2018.18403
Create a personal account or sign in to: