Karen Swartz, MD is Director of Clinical and Educational Programs at the Johns Hopkins Mood Disorders Center. Depression, suicide and the specific relations to medicine and surgery are discussed in this sobering podcast. (Music Credit: Sunshine, Simon Jomphe Lepine.)
Karen Swartz, MD is Director of Clinical and Educational Programs at the Johns Hopkins Mood Disorders Center. Depression, suicide and the specific relations to medicine and surgery are discussed in this sobering podcast. (Music Credit: Sunshine, Simon Jomphe Lepine.)
My name is Phil Pierorazio, and I'm a urologic oncologist, a surgeon. Like many of you, I absolutely love what I do, and I would not choose another profession. But I've struggled professional identity, practice efficiency and wellness over the years. operate with Zen is a podcast designed to explore a mindful approach to surgery and to being a surgeon. By discussing these struggles and mindful solutions, I hope together, we can create a community of strong and healthy surgeons enjoy. And welcome to operate with Zen today we have the pleasure of talking with Dr. Karen Schwartz, Dr. Schwartz, introduce yourself to the crowd.
Karen Swartz, MD:Well, it's good to be here with you. I'm a psychiatrist at Johns Hopkins, and my focus is on mood disorders. So I mainly treat patients who have depression and bipolar disorder.
Phillip Pierorazio:So Dr. Schwartz and I have gotten to know each other through some of the wellness initiatives at Hopkins. And as you can imagine, in any big academic and non academic center, there can be challenges, especially over the last couple of years with COVID. And issues with burnout and resiliency. And specifically, what we're going to talk about today is going to be depression and suicide, which has been really poignant over the last couple of years to say the least. So, Karen, if you don't mind, just give us kind of your input and a little brief background here. And just depression, suicide, and physicians, what do we need to know?
Karen Swartz, MD:Well, the first thing to know is that suicide doesn't fall out of the sky. There have been studies where they go after a suicide and they try to get as much information as they can about the person from work family, everyone. And 90 plus percent of the time, suicide is linked to some kind of psychiatric problem. Unfortunately, it's often not treated or even recognized, but sort of the putting together the pieces later. So when people try to think of suicide as an independent thing, that's not very helpful. Going to medical school does not protect you from depression, 20% of women in 10% of men will have a depressive episode at some point in their life. And the reason that physicians are at higher risk of suicide than the general public is because we are terrible patients. And there are particular burdens and concerns that physicians have about seeking care, because they worry what will this mean for my license? What will this mean for you know, how I practice what this mean for what people think of me. So as a psychiatrist who's taking care of a lot of doctors, I think that getting treated for depression is always better. But I think that there is an enormous issue that comes up when we have physicians saying, I'm pretty sure that's going to be a risk for me to actually get depression treatment. Suicide comes from a lack of depression treatment, suicide prevention comes from recognizing and treating depression. Yeah.
Phillip Pierorazio:And I think it's, you know, in my non professional psychiatric experience here, I think one of the things I've seen too, or notice is doctors and other people in high power professions are really good at evading the system, hiding those symptoms, hiding the issues that are going on until it's too late.
Karen Swartz, MD:Well, you take doctors, what do we share what we're good at school, right? You can't go to medical school if you're not good in school. And so you have very intelligent people, usually with an incredible work ethic. So until it's a disaster, you really can push on and keep doing it. I mean, anyone that survived internship knows how to keep going and put up with being miserable. Well, that's a bad trait when it comes to depression, because it means you just keep going. And you know, when depression starts, it's much easier to treat, if you recognize it early. But so often with physicians, they put it off and put it off and say, Well, you know, it's just that I'm under stress this or that they come up with a 1000s of reasons that they don't really have depression. The other thing is, there's so much stigma that no one wants that diagnosis. I mean, no one's looking to have a heart attack or have cancer or anything else. So it's not like we're trying to have other conditions. But this one feels like a failure to many people. And I think with physicians, it very much feels like oh my gosh, you're telling me to see a psychiatrist. Oh, I've really screwed up now, which is obviously just wrong, but it's how people feel. And it's unfortunately I think the reaction that some might get from colleagues.
Phillip Pierorazio:If you don't mind, take us back a little bit to medical school, give us kind of just basics of depression, but if I can Ask you to spin it a little bit. What do you really see in physicians if there's anything that stands out about the way physicians may present? Oh, absolutely.
Karen Swartz, MD:So if you think about depression, there are three key areas. One is about mood. One is about physical symptoms, and one is about how you feel about yourself. Okay? So the mood, most people don't have a lifetime, the movie version of crying, sad, a lot of people feel irritable, or they lack feeling, or they just have an inability to get excited or feel joy, right. So that's the mood change. Some people are sad, some are irritable, some feel nothing. But almost everyone has this diminished ability to enjoy themselves. And again, if you're working really hard, you might, you know, not say that plus, you go to med school, you can put off your big rewards for a while. So you're not used to everyday being a party you're not used to everyday being fun, this might be rewarding, might be challenging, but you know, you might not notice, oh, wow, I just went on this big vacation with my family, I couldn't even enjoy it. That's often depression. But if you're just working hard, you might misinterpret and say, Well, yeah, it wasn't a great week, but it was really busy and stressful. So that's the problem. That's the mood part, the physical part has some very physical symptoms, not being able to sleep, having appetite change, often losing appetite, occasionally, comfort eating. And then just a sense of fatigue, which is hard if you work long hours, so you just write that off. But the other thing that happens is that people have changes in their thinking. And this is something that goes into both sort of your sense of vitality, where you're slow down, you have trouble making decisions, which is a big issue for physicians, you know, I have trouble making decisions as quickly as I need to. And then it starts attacking your confidence. So you start wondering, maybe I did the wrong thing, or maybe I'm not taking good care of my patients, or maybe I'm not doing a great job, that symptom. So of attitude change hits everyone with depression in different ways. So you know, teenage girl might say I'm fat and ugly, and, and a middle aged man might say I'm a bad provider, but physicians in my experience, it, it really attacks their confidence about am I good doctor, most of us, that's an important role. So you'll lose your competence and one of your most important roles. And then, of course, the most serious symptom, people could have thoughts about suicide. But with physicians, if you can't think you have cognitive distortions, you're slowed down, you feel like your brains not working, then you start thinking Why can't function and you can get pretty quickly. I've seen physicians get quickly from I can't function, I'm not a good doctor, I don't really see my future to what's the point of being alive that. And there's a danger, because physicians are obviously medically trained. So there's a clear gender bias and suicide where men are more likely to die than women in general. But female physicians have a very high rate of death when they make suicide attempts because women take pills, and female physicians know which pills to take, they're not going to do you know, something, someone without medical training might take 10 ibuprofen and think it might hurt them, but of course it won't. And then taking the pills, get them into treatment, that's a whole positive, whereas a female physician, it's going to take a lethal dose of something often. And then it's just tragically no opportunity to help.
Phillip Pierorazio:You can really gather a sense of, you know, whatever metaphor you want to use, whether it's a whirlpool or quicksand, but you could see how quickly a physician certainly losing that identity of not only am I having trouble struggling, but no longer am I am I who I thought I was. And it can be. I can imagine that be tremendously harsh. And just
Karen Swartz, MD:to build on not just you, I thought I was but I'm not good at what I think my purpose is, you know, many of us, I think, well being too dramatic. We go into medicine, because you know, it's a vocation, it's more than a job, given the demands, the hours, years of training everything, you have to feel pretty passionately about it to do it. And so you have a group of people where this is something that matters more than a job. And then suddenly you think you're terrible at the thing that you really value. Because you're not going to think but I'm a great dad, I'm a great mom, because you're being negative about anything. So it's like, I'm good at nothing. And if I don't have this, what do I have? So it really is a dangerous hole that people fall into.
Phillip Pierorazio:Yeah, and just to kind of highlight that, you know, when we talk about a mindful approach to surgery and medicine purposes, a huge part of that. And so when people are struggling, and we typically put this in the context of burnout, which I want to ask about in a second, but when we put that in the context of One of the ways out of it or around it is to talk about purpose, right? And your sense of purpose and who you are. And what you're going to be is one way to pull yourself out of this. But you could really imagine how tragic this could be, if you've lost your purpose and your sense of purpose, especially.
Karen Swartz, MD:And then the other part of it is, of course, that there are these cognitive distortions. So you can't even have a logical conversation. And with burnout, the thought is, it's if you've been overwhelmed, but your thinking is so clear, there are cognitive distortions that come with depression that endanger your life, because you start twisting things in the most negative way. And so when someone says, No, let remind you of what you love, or let's talk about what your purpose is, you're saying, I don't know what you're talking about. Because I have no purpose, I screw everything up. Everything has the most negative connotation. And that is really dangerous.
Phillip Pierorazio:Yeah, I have a really good friend who's struggled with substances and other issues throughout his life and had suicide attempts. And, you know, when talking about his past, and others pest that he now tries to help work through those issues, that's one of the things he keeps coming back to not only you don't think you have a purpose, but you don't think you can help anyone else around you. You don't serve a purpose for anyone else, even though that's really not true. But that's the distortion you talk about.
Karen Swartz, MD:And then what is what is the point of anything free to be when you think, Well, I don't, I'm not contributing anything. I wouldn't say we physicians are good with just going with the flow, right? We think, Well, that's all screwed up. Forget about it.
Phillip Pierorazio:Financially, we touched briefly on burnout and some of the symptoms of burnout, not having joy kind of feeling fatigued, you know, they can overlap a little bit, draw some clear distinctions, if you don't mind. Why do you burnt out? And when do you need to seek help? Or when does a colleague need to seek help for depression?
Karen Swartz, MD:Sure. So burnout in a big way we talk about that is that people get they're exhausted, right? They're emotionally exhausted, they become cynical, there's a sense of being detached, and you feel like you're not achieving things that you're not able to do good. What you don't have is that sense that you're a screw up, that you don't have personal work, people have this sort of, I can't stand this job, I'm not really sure I'm connected to the patients. But usually, people are able to enjoy themselves on the weekends when they're with their families or friends, they're able to feel joy, if they're not at work, it's very much this sort of like work is not giving me positives now, and I can't, you know, I'm just kind of done with it, which is different than all throughout my life, can't enjoy things, I'm not able to, you know, feel those things. And with depression, there's this whole combination of symptoms that people don't have with burnout, I can't think my I'm slowed down my decision making now if you get fatigued enough, that's a whole different subject. But in general, people can think when they're burned out, they're just, they're just sick of it, which is different than I can't think my brains not working. And now I'm distorting everything. I don't think that most people who are burned out are having the same kind of cognitive distortions where they feel like, I am not a good person, and I am not a good doctor. That's depression. I think it's great that there's been a lot more discussion about burnout, resilience and all these wellness issues. I worry that any doctor would rather be viewed as burnt out than depressed. And so I worry tremendously that physicians who are depressed will say, Oh, it's burnout. And then suddenly, they're not getting what they really hate, and burnout, you. Purpose, being more purposeful, making more time, taking time for activities you enjoy having a better work, life balance, all of those things really help finding some aspect. I think it was 20% I heard tait shanafelt, who's one of the the national leaders and looking at burnout, I'm pretty sure he said, If you love your job, 20% of the time that's protective against burnout. Okay, so make sure you love something about your job, that isn't going to do anything for depression. Love your job, 20% of the time when you're depressed? Well, first, you can't because you don't have these positive feelings. But you know, those kind of structural changes or changes in the way you operate, they help a lot of burnout. That is not enough for depression.
Phillip Pierorazio:It's great point. And I can you know, as we were kind of planning the session and talking about topics, one of the main goals we had is to kind of lower stigma about depression as people seek help. So let's talk a little bit about treatment. And let's try and lower some of the stigma about what treatment involves. So if you think you're depressed, and you end up being, too depressed? What does that mean, as a physician, as a surgeon, as a high functioning professional? What does that mean for you?
Karen Swartz, MD:Well, the first thing that I want to stress is that very few people function well if they're severely depressed. So getting treatment as a way to get back to your higher level of functioning, we all want to function well. I remember talking to a teenager who said he couldn't play lacrosse well, when he was depressed, and I'm from Pittsburgh, I don't know about across, like, explain that to me. And what he said was, while you're playing lacrosse, you have a million decisions to make as you're running down the field. Should I pass? Should I keep it showed you this? When should I shoot the and I thought that those are a lot of decisions. So he said, when I'm depressed, I can't make decisions quickly. I cuz you look at the field, and you look. So as physicians, we're making a million decisions a day. I'm a psychiatrist, not a surgeon. But I imagine when you're in the O R, there a million decisions you're making constantly, should I do this? Or that or approach it this way? Or that right? Three ways I could do it, what should I do, and they need to be automatic like that. For me, as a psychiatrist, when I'm talking to patients, I need to be able to say you've just said this, I'm trying to have this discussion, I'm trying to how, what should I respond, if you're not able to do that quickly, you're not going to generate any kind of confidence. So you have to be effective in the O R, you have to be able to make decisions to be effective in any field of medicine, you have to be able to think, use your memory, make decisions. So if you're depressed, that gets affected. And so when people say, I don't want to take medicine, or I don't want to be in psychotherapy, it's like so you'd rather just be less functional, because you're not functioning well. Now, that's a tricky argument to make if you don't have a relationship, because people say, don't tell me I'm not doing my job, I said, I'm telling you your risk of not being able to do your job if you don't get treatment. Now, there are plenty of physicians I've taken care of that really are functioning fine. But it's taking everything out of them. So they have nothing when they go home. And I've seen other professionals to from all kinds of professions, they, they can manage to still work, but it takes every ounce of their energy and focus. So by the time they get home to their families, they can barely do anything. And so that's, you know, obviously causing another whole level of trouble. So if you just think, Okay, I have depression, I'm going to get treatment. If it's very mild, you're never going to go to treatment, because you'll figure something out, you'll do the improved exercise, you'll get a better diet, you'll try to reduce stress, you'll be much more careful about your sleep, and being careful about sleep is really important. So okay, you'll do those things. But most people that come to treatment, it's more impairing than that it's getting in the way of functioning. And so every study that's ever been done of outpatient shows that the combination of psychotherapy, so talking through what's going on, maybe identifying stressors coming up with new ways to approach things, and medication is superior. Many people will say, Well, I don't want to be on medicine, and I'll say, okay, so if you had asthma, you just toughed it out. Because I'm old enough that that's what they asked kids to do in the seven days. Just take some deep breaths and don't use your inhaler. And younger residents here. They're like, what is the stupidest thing I've heard is right, because we had some very limited ideas about reactive airways disease in the 70s. When by the way, I was not a doctor, I'm not that old. But but the point is, we've learned more, most people are able to take medication with it being very well tolerated. A lot of people say, Well, look, I'm worried about side effects like Well, there are 40 options, we can work with these options to get you something. Yeah, if you're a surgeon, you can't have a hand tremor, okay? Most antidepressants Don't cause a hand tremor. So people will try to put up roadblocks to say, Well, clearly, I can't do that. Because of these risks like, Well, clearly, you're trying to come up with every reason not to do it. How about you actually go get some information about what might be helpful to you?
Phillip Pierorazio:I just want to highlight, you know, Roy Baumeister, who's a psychologist, I believe, put forward concept of ego depletion, which is kind of exactly what you're talking about in high functioning individuals basis. Listen, we've got a limited store of energy. And if you're using all of your energy to get through your day, because you're depressed, then you've got nothing left at the end of the day. I think it's a really valuable point, something I recently read about. So
Karen Swartz, MD:I completely agree. And I think that what people don't understand is that it's hard to do medicine if you can't be connected to your patients. And so if you're taking all of your energy just to just to see people write your notes, do your surgeries, do the procedures show up in clinic, that can be very good. I also think that we're, as a group talking about stigma. It doesn't help that there's extra after Lauren abrines tragic deaths from suicide, there's been more focus on physician suicide, which is a good thing. And they're trying to put forward some regulations and laws that might make it not standard practice for some medical boards who say, are you in treatment? Which is a terrible question to ask, no one says, Do you have COPD to a degree that it might impair your functioning? No one's asking that. And so I think it makes people nervous in surveys and physicians, it's one of the top reasons people say I don't want to get treatment, because I want to be able to, you know, check that box. No, it's like, actually, that person is more likely to not function well, or, God forbid, make a mistake, because they're not getting treatment they need and so it's absurd, we this, we've put up this huge barrier for people to get what they need.
Phillip Pierorazio:So we can ask you a little bit more about antidepressant medications? What's a typical course? Is this a lifelong? You know, medication is something you're on forever. How does that kind of work? How to most people progress through a course of depression?
Karen Swartz, MD:I think that that is a great question. So they have people fall into three groups, we just don't know which group you're in. Some people have one episode, and they never have symptoms. Again, some people have one episode, and the next episode is going to be in 15 years. And some people have one episode. And if they don't stand medicine, the symptoms will come back quickly. But we don't know which group anyone persons in and there's not a really good way to predict. And so when someone's had a depressive episode, the usual practice would be to say, We want you well, completely well and stable for six months to a year on medicine, and then it's very reasonable to taper. I just tried to say, hey, can we not taper when you just got a brand new job, you just charged your faculty position? You've just become an intern, you know, fill in the blank. If not, then because it's a little bit of a stress test, maybe you're in the third group, and you need to stay on medicine. And we don't know. What I can tell you is lots of professional people who are very logical will say, I don't really want to be on this medicine, I'll say, oh, please tell me the side effects. Maybe we can switch. I don't really have side effects. Okay, so you don't have any side effects, you feel better. But you just don't want to be on it. That's right. Okay. And I think people that treating hypertension sometimes have the same problem, I don't mean that it's only depression. But I think it's much more stigmatizing for someone to know you're on an antidepressant. And so that's where the psychotherapy comes in. Now, so if I can be treated, and feel well, what helped me understand what the downsides are from that or what gets in the way. So it's not necessarily lifetime, that it's hard to know what percent are in those three groups. But some people, it's just clear, and then once people are well, you'll see in 15 years, you need to go back on medicine, that's fine. You'll know what's happening and do it more quickly, and hopefully have an opportunity to feel better more quickly.
Phillip Pierorazio:And if you wouldn't mind sharing just some of, you know, kind of the common or typical patient experiences. You started in depression. You start in psychotherapy, one week, two weeks, four weeks, six weeks, what's the course like what are people experiencing?
Karen Swartz, MD:That's a great question. So the frustrating thing about antidepressants that there are two things that are frustrating one is unlike colleagues and infectious disease, I don't have anything like sensitivities and specificities right, so I can't No, we obviously choose based on the symptoms people are having, sometimes wanting to match the side effects. So someone's really slowed down, maybe you get something a little more activating someone's having terrible problems with sleep, something a little more sedating, or at least not so activating, but it'll interrupt sleep, but we can't know. So sometimes it's a little trial and error. But still most of the time, most people are going to respond to what you start with. So that's good. The second part that's hard is that it can take four to six weeks on a full dose to get a benefit. Now, most people feel a little something after a couple of weeks, but for the first few weeks, with antidepressants, you usually feel nothing. So you're on medicines, maybe you have side effects, and you doubt what you're doing, because going to med school doesn't change that idea that medicine should work quickly. I remember knowingly calling my internist to say, I don't feel better. It's like we started the antibiotics yesterday, like you went to med school. You know, that's unrealistic. It's like I don't care. I should be feeling better. So when we literally have medicines that are not like pain medicines or antibiotics, but are going to take weeks when you already the illness makes you doubt that you have a treatable illness. The illness makes you negative about everything. If you don't have ongoing contact, people don't stay on medicine. The psychotherapy can help sooner because at least you have someone saying, Well, I don't think any of those things your brains telling you are true. Let's look at the evidence, you have a very devoted spouse or your kids seem to love being with you, or, you know, you're telling me you're terrible. But let's look at the facts of how you're performing it work. So having an objective person starting to work on challenging those distortions and challenging the negative ideas that can be helpful much more quickly, which is why it's so important to pair right. So if you said, I'll take medicine, but I won't talk to anyone. It's like, Okay, that's better than doing nothing. But it delays feeling better. And it I think, increases suffering. And it sets you up to say give up, this isn't going to work much more quickly, which is a shame.
Phillip Pierorazio:So I'm going to shift a little from from depression to a little more focused on on suicide. And there was a study in I think it was Jama last year, looking at depression, burnout, and suicide, and it clearly said, it's depression that's linked to suicide, not burnout, right. And we've all seen the social media stories we've seen. I can remember seeing so many people, grieving for colleagues who they've lost to suicide. I would say throughout my life, I've been kind of peripherally peripherally and frequently involved with suicide, but in the last year, lost a colleague and a friend to suicide. It seems really real at the moment, can you just kind of give us a, you know, kind of touch what's going on, within the
Karen Swartz, MD:medical community? I mean, you know, the rest of the world, if you watch a football game on the weekend, you would think there is no pandemic, right? We're just, we're back to normal. There are, they're resilient, I see those. And I think, Oh, my goodness, what is this going to be? Right? So we have taken people that are not protected from getting depression, we have dramatically increased work stress, we've dramatically increased work hours, we've reduced sleep, and we've set people up. And I think it's very clear that within this pandemic, that the individuals that are more vulnerable to depression, they're having the return of symptoms or having more symptoms. And so you're having more people with more severe depression, which is a setup. And so that's independent of depression has its own, you know, sort of ups and downs and periodicity. So we've taken an entire world stressed it and we've taken a subset of people, physicians, nurses, you know, medicine, people in medicine, and we've really stressed the system. And so I do not think that's done anything good. We also have no idea yet what COVID does to say, the brain getting COVID. And obviously, medical professionals have a risk there from exposure and nothing good. I'm sure it's nothing good. And so, you know, we all of those things are, are coming together at the same time. I also don't think that we've had, I mean, think how hard it is to get people just get vaccinated, let alone take care of themselves in other ways. I don't mean, medical people were getting vaccinated, but people just are in the sort of emergency mode. So they're not taking care of themselves or not taking time off if they need to. My guess is that there could be situations where people are saying, Ooh, time off, we're really stretched, maybe you could not, you know, those kinds of things. And that worries me too. But it's, it's bad, the overall suicide rate doesn't seem to have gone up. But that's partly because with some groups, young kids at home, they had more family support. But if I'm with you, anecdotally, it seems like a very, very rough time to be a physician,
Phillip Pierorazio:or medical student or nurse,
Karen Swartz, MD:or nurse or OT, respiratory therapists. I mean, just the medical field, we've we've really, and I don't know that those who aren't in our field really understand what it's been like, you know, people that have been doing their advertising job from home. That's not to mean that it's not stressful for them. I'm not trying to minimize or anything, but we've had a particular level of stress and worry, that is really high. That also comes from, you know, for some that are working in those. And they're really demand and working in the emergency department working in the ICU. I mean, they're on the front lines, but then others that aren't able to get maybe the support or do what they need to do because beds are being taken up by that and say like, I want to do the surgery for you, but we can't yet or just watching patients, their families can't come to visit. You can't We can't practice like we normally would practice. I think every field is facing that. So everything's just a little harder. It's a little more complicated. We're wearing PPE all time just these small things, but when you're depressed, small things feel like that. big things, and medium or large sized things seem overwhelming. And suddenly, it's a pretty big stress can be just devastating. And I think we're seeing that. Which is why if you have some depression, you're just at a very different risk than if you're lucky enough not to.
Phillip Pierorazio:So the next question is kind of a tough one. But how do we make sense of something that makes no sense? Like suicide? You know, he sees people, with families that love them, and they love their families clearly and outwardly. They, we know they're stressed at work, we know they could be having issues, but they're really good at what they do. How do we make sense of this as outsiders?
Karen Swartz, MD:Well, the way I make sense of it is that almost always, the person had depression. And they could have Bipolar depression, or but they have depression. So what does depression do? It distorts your thinking. So you can't believe that you're good at your job, you can't believe that your family loves you because you feel like a screw up. So why would they love me? And so when you start with that premise that that person wasn't thinking, clearly, they couldn't know the truth of their life, they couldn't believe the truth of their life, then it starts making a little more sense. Alright, so that person thought they were a screw up, they're about to be fired, your spouse was going to leave them, their kids didn't care about them, then you start saying, oh, okay, so none of those things are true. Usually, none. But there is an illness that can take all of your thoughts and distort it to the worst. That's, that's pretty amazing. And that's why people don't say, Well, no, come on. That's not what's happening. It's like, no, 25 years of plus of doing this as an attending, that's what's happening. Literally, your thoughts get so distorted, you cannot remember what's true sometimes. And I don't even mean the most severe episodes, when people are delusional, they really have false ideas. It's just you say your wife really cares about you. Like, I think I don't really think she's happy with me. I've been taken care of many people that think their spouse is about to leave them. They're about to get fired, all these terrible things are about to happen because they've taken a small kernel truth, and then the negative is exploded. So to me, I think we're lucky that suicide is such a relatively rare outcome among depression, because depression is a setup to think the worst about your life, the worst about yourself and the worst about your life. So that's how it makes a sick, twisted logic to me like, right, if you're thinking that way, of course, that's how you react. But it's hard to think that people we care about could have their thoughts distorted in that way. And there's also the fear that, oh, my gosh, if it happened to him, could happen to me. I've said this, to many people going to medical school did not protect you from getting medical problems. Depression is a medical problem. Being smart and hard working is not a protection against asthma, or depression, or anything. So, you know, I don't have an idea. But we do a little bit. We do. I'm a good person, like, sure. Sure. I mean, you're you do. Oncology hot, like that doesn't being a good person doesn't protect you from getting cancer. Sometimes it feels like the opposite, right? Like, oh, you're really good person. These really bad results, kind of that weird idea that I think we all have had a moment of thinking over the years, like, oh, gosh, the nicest person, this happens to the nicest person.
Phillip Pierorazio:No, and we always, we always say to right, it seems so much more tragic. When we lose a colleague to the disease, they treat it right. And then you're right. We're not immune to any of it. But But you're right. And, and we kind of tell those stories all the time, about the greats we lost to the disease they treated,
Karen Swartz, MD:right? Because there's sort of that sense of weight, the head of the cancer center as cancer, it's like, well, 78 year old men get cancer, it gets sort of the whole thing. It's like, well, let's look at the numbers. 20% of women 10% of men, some of them are going to have depression. Thankfully, the you know, the number of deaths among the many, many people depression is small, but they're higher among physicians and other you know, that's one of the occupations that puts you a particular risk.
Phillip Pierorazio:So we've talked a lot about the individual on what somebody could experience as a colleague or a friend, what could we be looking out for in each other, and our colleagues and our friends and our peers in our trainees? What are what could be some tip offs that somebody needs help?
Karen Swartz, MD:Well, thank you might see at work. So let's just start there is that the person isn't processing information that they're slowed down, they're not making decisions? Well, they're not having good reactions, because that's what happens with depression. Usually you get slowed So your reaction if you're a surgeon, your reaction times down, but you know your internal medicine, you're not making decisions quickly, you're not responding to that person's gone into heart failure, we need to get them diuretics. Yeah. Something you're, we all remember that first day of internship, you're looking for a senior nurse to just confirm that you're about to do the right thing. Well imagine that going on all the time with someone experienced because they're doubting themselves, they're not having confidence. So slow down, quieter, harder to make decisions, missing details, not getting not accomplishing what they would normally do on a day like, but you're not done with that yet, you know, those kinds of things. And then, maybe sad, but a lot of irritability, being withdrawn, feeling overwhelmed. And sometimes people even say, you know, they'll, they'll be lacking cause like, I don't know, why are you even asking me? I don't have any good ideas about that. Or why would you want my input? You could imagine those kinds of statements. The problem with depression, it's entirely internal, pretty much like you can observe those things. But people could be quite depressed, and all those things would be fine. I think that's what shocking is, like, we didn't notice anything that's like, right, maybe there was nothing to notice. Because this is someone taking every ounce of their energy to be okay at work. So that's possible, too. Which is why we actually need friends, too. I mean, in the middle of this, I think having buddies that will say, Are you doing okay, this is really hard. Are you doing okay? But you might actually have a real conversation. When people ask you, are you okay, on the hallway? The answer is, yes. That's the only acceptable answer. You need someone where that if you ask the question, they actually think you have the time and interest to hear the answer.
Phillip Pierorazio:And I think as you know, you know, before I left Hopkins, we started a wellness initiative and going to continue it here at Penn where I am now. But I think one of the most important things about a wellness initiative is that you identify someone with whom it's okay to talk about these things. Lower the stigma, whether it's me or another colleague, someone else, it's okay to talk about these things, we should be talking about these things. And we should ask the questions, hoping for an honest answer. And we should feel empowered to give an honest answer when we're not feeling our best.
Karen Swartz, MD:And you have to actually be someone who's comfortable hearing it, right. As a psychiatrist. I remember someone saying to me one time, it's like, you know what I like about talk. You know what I like when talking to psychiatrists, whatever, I say, you're not going to be shocked. You've heard it, you understand. So when I ask someone, if they're suicidal, again, that if you're that worried, you should be getting professional involved, but when I'm asking that, I'm prepared for whatever the answer is. I'm not asking you're not suicidal, are you? Which is very clear, like, I cannot hear it. If you are, that will scare me, please don't give me the right answer. And so I think when you ask a question, like, Okay, you do know the answer to that question, right? We're smart. Oh, the answer that question is, yeah, I'm fine. Versus, I really want to know how you're doing. This. is this so hard? Maybe you feel comfortable sharing, I have been exhausted, I wonder if I'm a little burned out myself, I have to do better. I wondered how you're doing. That's a very different thing than we are doing okay.
Phillip Pierorazio:I think one of the skills for people who may not feel confident talking to people about how they feel, is to just first of all, just give space, sometimes let somebody sit with an answer or sit with a question. Just giving them space may allow them to open up and feel a little more comfortable with you even if you may not feel comfortable on the on the inside there. And the second thing is, is sometimes just mirror what they're giving you. You know, if they look concerned, look, concern back and and show them what they're showing you and whether you want to say a mindful approach or a neuropsychological approach. I mean, there's science behind this and why those why those interactions work. And if you if you want to learn how to do this, you can absolutely seek out training, whether it's through coaching or else to kind of learn these techniques. But if you're interested in others, there's ways to ask them.
Karen Swartz, MD:And all of that is speaking to the same thing. You're demonstrating your comfort level with having the conversation. And sometimes that's like, I really want to know how you're doing this. This has been really tough, and I'm genuinely interested. And then it's what you just said, Shut up. Don't fill in the space. Don't you know? I remember one of my first supervisors saying all you young psychiatrist talk too much. You have to be comfortable with silence let someone think, because they have to decide if they're going to tell you how they feel. Then they have to figure out how they feel then they have to articulate how they feel. That takes a minute Shut up. I thought that is good advice I'm gonna give to young people for the rest of my career. Talk less.
Phillip Pierorazio:It's really good advice.
Karen Swartz, MD:I think more.
Phillip Pierorazio:Yeah, it's and it's really hard for surgeons, I will tell you because we are trained in the opposite, to be expert to be decisive, to be firm and quick, where sometimes you really need to step back in the mindful analogies from the expert mind, to the beginner's mind, you want to be a beginner with somebody else, you want to be curious about what's going on with them and display that curiosity. And you may get somewhere with them that they didn't even know they were really going to be honest with you.
Karen Swartz, MD:Well, that's it. Because the truth is physicians often are in the trap, that they're going so fast, they don't know how they're feeling. They're sleeping, okay, because they're exhausted, they might be depressed, and if they weren't exhausted, they wouldn't be sleeping. They're bright. So even though they're operating at 60%, they can do their job. They're skilled, because they practice so much that even though they're not at their best they can, they're fine. They are functioning fine. They're just miserable. But people deserve to be more than miserable. And if you get miserable enough, long enough, you could be in danger, which obviously, is just, and I'll just say this about suicide, it is devastating for entire communities, the devastation for a family is obviously profound, but whole communities. Because I'll speak for myself, I think it feels like a failure. It feels like we failed the person and we didn't we as a community didn't support them. As a profession. It feels like a failure. And, you know, I think that's, I don't think that's necessarily bad. I don't know if that's fair. I think it's probably not fair, but it just feels awful. I'm not an oncologist, but I suspect there's an understanding that some patients are going to die from cancer eventually. And I don't I think we have an expectation that this should never happen. But the fact that it happens so often because the person wasn't getting treatment is tragic.
Phillip Pierorazio:Absolutely
Karen Swartz, MD:highly educated medical professionals, who usually thankfully, because of their jobs, have access to treatment, they're connected in the community, they could get connected, and they just don't, won't.
Phillip Pierorazio:I think that's absolutely one of the feelings. I think anybody who's experienced, whether it's a loved one, or a colleague or friend, who, who's who they've lost to suicide, is you you go through a process of grieving, but you definitely go through a process where what could I have done differently? Where were my failures? How could I have helped them and that's also where it's so hard to make sense of,
Karen Swartz, MD:oh, and depression is very treatable. It's not I don't think we can prevent every suicide. I think that's an unrealistic goal. But many when you hear that someone has died from suicide, and they were in no treatment, that to me is just like, oh, man, maybe if they were, because it in the realm of medical problems, it's very treatable. There's some things that are not treatable, and fake stage four pancreatic cancer, you're not having unrealistic ideas, but the expectation is that people depression are going to get better.
Phillip Pierorazio:And then just to be clear, since we've given kind of pretty objective advice throughout this, too, if someone is having suicidal ideation, what's the best way to respond? How should we be acting?
Karen Swartz, MD:It's an emergency, someone having suicidal thoughts, it's an emergency. And so they need an emergency evaluation with a professional, going to medical school and being someone's friend is absolutely not prepared you to decide they're okay or not. And I think what you have to say to them is, and I've said this to my own friends, when I've been worried, I said, Look, I can't be objective about you, I don't want you to be feeling this awful, we have to get you to see someone. And that's often manageable. Again, if you're in the world of medicine, that doesn't necessarily mean that you're going to the ER or an urgent care center. It could be that you're arranging for an emergency appointment, but it's an emergency. And an objective person with experience needs to assess that. And I think that, you know, we've all gotten enough training to say, Well, no, I asked him, they said they were fine. It's like, okay, your, your closest friend was reassuring to you. Come on, and it's a terrible position. I've said to be like, I cannot be in the position of about objectively deciding if you're okay, because I so desperately want you to be okay. You have to do this for me. I need you to see someone who can talk with you about this, etc. Now, if someone is you're worried that they're actively going to harm themselves, or they're saying look, I've gone and got a gun or I have the pills or whatever. That's a 911 true emergency that you just have to interrupt that.
Phillip Pierorazio:Thank you. So we're getting towards the end of our time here. Is there anything you want to talk about any questions you want to ask anything else? We need to cover today.
Karen Swartz, MD:Well, what? So you're a physician who's not a psychiatrist. What do you think gets in the way of people saying, I mean, there's the general were bad patients. But what do you think is contributing to this stigma? Because it's terrible. It's profound. It's no, it's terrible.
Phillip Pierorazio:Yeah, I think I get machismo is probably the wrong word. But it's, it's a sense of, we need to project this ability that we can't be harmed, we're infallible. And that's how we protect our patients. That's how we take care of our colleagues. And so if we're secretly suffering, then we we can't be who we think we are. I think it attacks our identity. And it attacks our purpose as you're brought up for and I think that's why we really struggle with it. And then all of a sudden, you add on psychotherapy, and a medication. And now you've got some huge barriers. And so, you know, I don't have a solution. I don't have an answer. But I think the first step is that this is talking about it and saying, it's okay to talk about these things. It's okay to be on medications. It's okay to be in therapy. Most people don't need lifelong treatment. But if you do, you're better for it.
Karen Swartz, MD:Right? Most of us if we had AFM would probably like to not have a stroke and would would take a blood thinner. I mean, if I ever have a bite I, my father has a fib. He is doing well. Takes us Xarelto every day, he's very careful about it. I have a good friend whose dad is recovering from a stroke, because he was really resistant to the recommendation to be on blood thinner. Okay, there's nothing tricky about this, right? It's like, oh, wow, okay.
Phillip Pierorazio:Oh, yeah. No, and I think you brought up a great point before that, that I never really thought about was when you fill out applications, this is the only question that the medical boards get to ask you, right? It's about your psychiatric history, which you're right isn't really fair. And if you think about the behavioral psychology of that, right, that is a huge stigma creating phenomenon as well, too. And maybe that's a real, a real opportunity for impact from kind of a, you know, whether you want to call it legislative or
Karen Swartz, MD:we have to legislate that you're not allowed to ask those questions, those questions are discriminatory. There's no other way. It's not stigma, that's discrimination, we have decided there are a group of conditions. Now, look, if you've afib, and you might pass out in the Omar have a stroke or something that could potentially impair your ability to function. The presumption is that you have someone treating you and you're being responsible enough to say I can't function or they have colleagues that are monitoring you or whatever. But it's just pure discrimination. It has to stop. And I think the only way to do it around the country. So it's just done is to have some sort of national legislation, but you're not allowed to do that.
Phillip Pierorazio:I think it's a great point. And I think, hopefully, somebody out there listening with legislative interests, can get out there and advocate for for, you know, all of us.
Karen Swartz, MD:Well, and the the fallout of Dr. Lerner brains tragic death is that these things are being talked about, right, that the thought of What are barriers to oh, this is a barrier to treatment that there is the discussion about should we have legislation and obviously, the psychiatric community? Of course, we should have legislation. It's long overdue, and why has this been permitted for so long?
Phillip Pierorazio:Wonderful. So Karen, I'm just gonna flip through some of the notes and just summarize some points. And if there's anything else you want to bring up as a kind of, you know, walk through these. But importantly, you pointed out some statistics in the in the beginning of this 20% of women 10% of men will have a major depressive episode in their lifetime. Men are more likely to die if they commit if they have a suicide attempt. However, female physicians are particularly at risk, because they're more likely to take pills. One of the reasons physicians struggle, particularly we said it were kind of terrible patients. But we talked about all of the other more subtle reasons why physicians why it's really tough to diagnose depression in physicians and why they may be particularly at risk for suicide. We went over the the basics of depression and not only is it just mood, physical and self, but it's this twisting of your thoughts that really distorts your thinking and the way you interpret kind of the world and your interactions that can affect your your or contribute to a loss of purpose, a loss of being and who you are. And that's really what attacks who we are. I think as physicians, that's the one beauty of our field is Throughout all the burnout and other things you talked about, we have a very clearly defined purpose and a variety of specialties and subspecialties. But we're here to help people. And when you lose that purpose, you really may not have anything else left to left to stand on. I think you talked really strongly about what to look for in, in each other and our colleagues. And in physicians, this may be something as subtle as slow processing, or tough time making decisions, or someone who's always highly functional not being as functional as they were, you may not pick up on the mood issues, you may not pick up on sadness, this may be kind of some subtle cognitive issues or irritability. And it's okay, and we should be looking out and asking each other if you notice something different. They may just say, now I'm having a bad day. But if you're there for somebody you may have an opportunity to, to help someone and potentially save someone's life.
Karen Swartz, MD:Absolutely, it really comes down to one simple thing. Depression is a treatable medical problem. And we all have to sort of come to appreciate that. And even though we know that from med school, I hope everyone knows that from med school. It's not as understood or believed as cardiac disease is a medical problem. And so I think if we are able to move past the it's my lack of character, or this is a failing on my part. I think that will allow people to be more open to getting the treatment that they deserve. People deserve not to suffer.
Phillip Pierorazio:Thank you, Dr. Schwartz. I can't thank you enough for spending time with me today. I know people will really appreciate this conversation and hopefully it really helps people out there. Like to thank everybody for listening and look forward to talking to you again.