Clinical, Featured, GME, Housestaff Wellness, Intern Year, Psychiatry
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Shining a Light on Medical Student and Resident Depression

The following manuscript was submitted to the May 2019 Mental Health theme issue.

If you or someone you know is in crisis, please contact the National Suicide Prevention Lifeline at 1-800-273-8255.

One afternoon early during my intern year, I was sitting with my face pressed up against a “happy light” in the windowless resident work room. Leave it to psychiatry to make sure its residents had access to one of these.

Beside me were my co-intern friends, typing away at notes, engaging in our favorite afternoon pastime — joking around. To us overworked residents, humor is our own best medicine.

One peer, feeling particularly fatigued, sighed heavily as she put her head on her desk and asked in an incredulous tone: “Guys, am I clinically depressed?”

My friend responded: “I think you would know if you were actually depressed.”

Hearing this stirred mixed feelings in me; on the one hand I was happy we were so open with each other, but on the other I disagreed that insight into one’s own depression is accessible. It was not for me — and later that night I was inspired to share my story with the intention to start a conversation on how difficult it can be for someone to distinguish depression from the ups, downs, and typical exhaustion of medicine, and subsequently, to get help.

During my fourth year of medical school, I was completely unaware that I was suffering from clinical depression. Even now as I write this, I struggle to put my finger on how it all started. Was my appetite the first thing to go? Or the loss of enjoyment in socializing and sex? Maybe it was all three at once. It is truly too hard to tell.

At the beginning of residency interview season, I noticed I had no appetite. Growing up, I adored food, and my family ate three hearty meals a day. My hobby as a runner also meant that I was always hungry. However, as the interview season started, my sense of taste was so dull that my usual peanut butter oatmeal was just a bowl of mushy fuel I had to get through each morning. Amidst all of the free, decadent meals on the interview trail, everyone else’s suits grew tighter while mine loosened.

Meanwhile, I also began to lose interest in my favorite activities, like running. The usual endorphins that accompanied my runs became more and more transient, if there at all. The Chicago weather was not the only thing keeping me from lacing up my shoes or leaving the house, but a lack of motivation. If I enjoyed anything about running still, it was the pain it brought to my legs because it allowed me to feel some sense of relief.

The majority of my limited energy was spent convincing myself and others that I was happy. I would say, “I am doing fine, I am doing okay. I have nothing to complain about.” Each night, I collapsed from pure exhaustion and did not know how to do anything but continue to withdraw. I began to lose touch with my long-term boyfriend and loathe the idea of intimacy. I rationalized this by thinking, “Maybe we have grown apart,” and decided to abruptly end our relationship.

What provided me a temporary lift from my haze was alcohol, and I turned to its euphoria again and again. I binge drank with my peers, surrounded by their drunken giggles, hugs and kisses. I experienced a relieving high from the laughter of friends and strangers at a time when I regularly felt nothing. Inevitably, the pleasure would wear off, and I was often hit by a gut-wrenching wave of loneliness that knocked the wind out of me. I recall one night when I ghosted my friends at a party as the first few tears began to fall. I slipped into an Uber and the driver asked me, “Are you alright?” I smiled through the tears and reassured the dumbstruck middle-aged man, telling him I am doing fine, I am doing okay, silently hoping he would not ruin my Uber rating.

As I continued to button up my suit for interviews and zip up my party dress for the many celebrations that accompanied the close of the year, I was completely blind to what lay underneath. “It’s just a phase,” I told myself. Single, in my twenties, nervous about the future. My schoolwork and career had not suffered; I continued to perform well in my last rotations and still enjoyed working with patients. However, a dark cloud had formed over my closest relationships and I emotionally distanced myself from friends. I found myself consumed with anxiety before social events big and small, worried people could see into the depths of my soul and know my imperfections. For instance, my best friends and I had planned a graduation trip months in advance and I uncharacteristically cancelled on them at the last minute.

Feeling desperate, I started to contemplate ways out. The third-floor balcony of my apartment building suddenly looked like an appealing place to jump. I was seduced by a fleeting, but thrilling thought to leap into the cool, dark night and instantly wash all the pain away. While cutting vegetables before dinner the blade of my knife reflected the gleam of a smile as I pondered how easy it would be to cut an artery in my wrist. Each time I laid my head down to sleep I wished that maybe I would not wake up. In the past, I had never contemplated or even dreamed of myself as someone who would ever self-harm, but now I could not stop thinking about it. Luckily, my strong love of family and friends compensated for this powerful new desire.

Around the height of my depression, I was accepted into my dream psychiatry residency program, yet I was still clueless as to what was going on with the emotions in my own head. On paper, things looked perfect, and this idea that things were going right unleashed a Pandora’s box of fresh panic and pushed me over the edge. Now with more time around family and close friends, I could not hide in my own darkness anymore. I felt so terribly guilty that I did not know which was worse, continuing to suffer from the guilt or expose it to others. Finally, I told my best friends in medical school, and my mom, everything. They all were saddened because they had noticed my decline months before but had not spoken up.

My story has a happy ending because I connected with the help I needed. Three months prior to the start of residency, I used my health insurance to meet a psychiatrist and also participated in daily group therapy for a month. I was shocked at how after a few weeks, I started to feel well again. Before I moved to accept my position, I reached out to my residency mentor and she assisted me in finding a psychiatrist and therapist in my new city and schedule an appointment for the week of my arrival. My program supported me in arranging my work schedule to allow for the visits I needed. Though residency has had its many challenges and my depression ebbs and flows, overall I am thriving and well-supported.

Unfortunately, I know this cannot be said for all medical students and residents struggling with depression and anxiety, and I know there are many. What if I had leapt off my porch one winter night walking up the steps all alone, craving that sweet release? What if my mom or friend had spoken up sooner? What if I moved to my new city and had a breakdown while responsible for the treatment of very sick patients?

One of my first and most memorable patients of residency was a senior college student who was transferred to the psychiatry unit from the trauma unit after he had survived a suicide attempt. He jumped off a cliff after receiving news that he had not earned enough credits to graduate on the same night that his parents were flying in for his graduation weekend. Recently, I found myself at that very cliff watching the sunset on one of my days off, and the perspective I experienced there was incredible. For many high-achieving individuals like college students or those of us in the medical field, depression can be so hard to recognize because on the outside things can look good — “things are okay.” Ideally, we are able to name and share our feelings with a support system, as my friend did in the work room. However, often we are in so much pain and so dissociated from our feelings that we have no insight and must depend on others to help us recognize our struggles.

It might be scary to ask a peer or co-worker if they are feeling depressed or sad, but I would counter that fear with the following quote from my therapist: “The severity of one’s symptoms times the length of silence equals the amount of suffering.” I yearn for the day when every medical student and resident, from the first-year medical student to the PGY4 neurosurgeon, can have free weekly or monthly therapy built into their training schedule if they so desire or require it, whether it is just to have an outsider to vent to or someone to fulfill more intense needs.

Until that goal is achieved, we all have a responsibility to help each other and speak up when we notice someone acting off or uncharacteristically estranging themselves from life’s people and pleasures. As a community, we must advocate for each other and know the systems in place for quickly connecting to mental health professionals in our programs and communities. We all live with masks of one sort or another, but no one is invincible. If we can help each other loosen these masks and connect with the care we need, we will have many more beautiful faces smiling into the sun.

Image source: Photo by danny howe on Unsplash.

Alison Cesarz, MD Alison Cesarz, MD (1 Posts)

Resident Physician Contributing Writer

University of California San Diego School of Medicine

Alison (Al) Cesarz is finishing her intern year in psychiatry at the University of California San Diego. Her clinical interests include early childhood trauma, the adolescent and young adult age group, mental health in the Latino population and psychotherapy. Another passion of hers is the mental health and well being of medical students and residents. She is open and accessible to sharing her own treatment journey, collaborating on methods for improvement, and working to break mental health stigma within the walls of medicine. In her free time, she enjoys reading fiction/nonfiction, writing, trail running, cooking and exploring the natural wonders of her new home city.