Physicians are demonstrably poor at recognizing depression in patients, let alone themselves. Furthermore, they are notoriously reluctant to seek treatment for any personal illness. This may be especially true in the case of potential mental illness. A survey of American surgeons revealed that although 1 in 16 had experienced suicidal ideation in the past 12 months, only 26% had sought psychiatric or psychologic help. There was a strong correlation between depressive symptoms, as well as indicators of burnout, with the incidence of suicidal ideation. More than 60% of those with suicidal ideation indicated they were reluctant to seek help due to concern that it could affect their medical license. [24] Other studies [25] reveal that this concern about regulatory intervention is a very common concern hampering help seeking for mental health issues. In addition, other research suggests that 1 in 3 physicians has no regular source of medical care. [26]

Reluctance to recognize depression in a colleague is a tendency shared and imposed by other physicians, who may be well intentioned, habitually emotionally distanced from colleague/competitors, and/or feeling temporarily vulnerable themselves. Even when healthy, physicians find it difficult to ask for help of any kind. When they are depressed and feeling less than adequate, they find it even more difficult—and when they can bring themselves to ask, they sometimes find that the help they need is remarkably difficult to obtain.

To some extent, however, physicians’ reluctance to reach out is self-imposed. They may feel an obligation to appear healthy, perhaps as evidence of their ability to heal others. Inquiring about another physician’s health can shatter this mutual myth of invulnerability, and volunteering support or assistance unasked may seem like an affront to a colleague’s self-sufficiency. Thus, the concerned colleague or partner may say nothing, while wondering privately if the colleague has become impaired.

Unconsciously defending against this painful vulnerability, partners or significant others may also fail to notice significant depression or withdrawal, attributing behavioral changes instead to stress or overwork. Nearly every article about a physician’s suicide contains a quotation from some close contact, occasionally a spouse, saying something like, “I never had any idea that he/she was suffering.” [27] Of course, many physician obituaries omit the fact that the “sudden death” was a completed suicide.

Depressed physicians who do reach out may find that they receive only limited understanding or sympathy from colleagues. There is no specialized training for a physician's physician (as there is, for example, for the pope's confessor). Most physicians either shrink from this role or perform it poorly.

For many experiencing depression, the early symptoms are physical. A physician unable to diagnose his or her own symptoms commonly feels incompetent. To admit one’s inability to diagnose oneself to another colleague is to admit failure. When this admission is met with avoidance, disbelief, or derision by a reluctant treating physician, it can only reinforce a depressed physician’s feelings of worthlessness and hopelessness.

Physicians find it painful to share their experience of mental illness with others and know that doing so is somewhat risky; therefore, published accounts of physician depression are very difficult to find. However, recent highly publicized cases of resident and physician suicides and subsequent sharing of experiences of depression by physicians [28] suggest that either the incidence of depression is rising, or we are beginning to be more able to admit and to address the immensity of the problem.

Marriage is in most popultations considered to be an effective buffer to emotional distress. This does not seem to be true for women physicians. [23] It is believed that physician divorces are less frequent compared to the general population, but marital problems are common, perhaps in part because of the tendency of physicians to postpone addressing marital problems and to avoid conflict in general. [29] Marital problems, separation, or divorce can certainly contribute to depressive symptoms, which can increase the likelihood of suicidality if unaddressed.

Physicians are a "high control" population (along with law enforcement, lawyers, and clergy), and situations that decrease physicians' ability to control their environment, workplace, or employment conditions predictably play a higher role in physician suicide than they do in lower control populations. [23] The massive changes that have taken place in medicine in the past several decades, leading to increased workloads and regulatory requirements coupled with decreased ability to control income and patient safety and liability concerns also predictably lead to higher levels of stress, job dissatisfaction, burnout, and depression in physicians.

Litigation-related stress can precipitate depression and, occasionally, suicide. [30, 31] The suicide note of a Texas emergency physician, written the day after he settled a malpractice case, read, “I hope that my death will shed light on the problem of dishonest expert testimony.” [32] Some physicians have completed suicide upon first receipt of malpractice claims, after judgments against them in court, or after financially motivated settlements foisted upon them by a malpractice insurer solely in order to cut the insurer’s losses. Any settlement in a malpractice case is by law reported to the National Practitioner Data Bank, which is yet another source of distress and stigma that can contribute to depression.

Other physicians have attempted or completed suicide in response to employment discrimination relating to judgments or settlements or upon the realization that they are no longer able to practice because of discrimination by liability insurers who refuse to insure them because of past judgments or settlements or because of regulatory licensure investigations or limitations or databank reporting, [33, 34] or in the setting of forced hospitalization or treatment for chemical dependency when a dual diagnosis has not been justified under medically accepted standards. [35]