by Sara Solovitch

BP Magazine
Winter 2007, Volume 3, Number 1

One morning when she was 27, Suzanne Vogel-Scibilia, MD, went to work, a young, up-and­ coming resident psychiatrist at a major Pittsburgh hospital and left, hours later, as a person with bipolar disorder.

The diagnosis-her own and later confirmed-took place as she was routinely questioning a distraught patient who after spraying her neighbor vvith a hose, had been brought into the emergency room by police.

How much sleep had the woman been getting, Dr. Vogel-Scibilia asked. "Not much," she answered. "Maybe a couple hours a night."

And I'm thinking, me too.

How about food? Was she eating?

"Oh, I had some dinner last night," the woman responded. "I wasn't very hungry."

And I'm thinking, that's interesting. Same as me.

Was she under stress? "Sure," the woman said. "But you know what's really annoying me? They're talking about me on the PA system."

And at that moment, I could hear the PA system and they're not talking about her. They're talking about me. And I'm not hearing a damn word this woman is saying. I'm just thinking. 'What diagnosis does this woman have? Bipolar?' Oh my god! Suzanne, you've got biPolar disorder!

Dr. Vogel-Scibilia was convinced that her diagnosis-which she now traces back to age 15, the first time she attempted suicide-would mark the end of her career.

The medical profession doesn't look kindly on mental illness within its ranks. Michael Myers, MD, clinical professor of psychiatry at the University of British Columbia, Vancouver, British Columbia. and former president of the Canadian Psychiatric Association, argues that the stigma attached to mental illness is greater in medicine than anywhere else. Worst of all, he says, are psychiatrists who suffer from "internalized stigma."

'Just because we've trained in psychiatry doesn't mean we've purged ourselves of out-dated and discriminatory attitudes," says Dr. Myers.

"I've looked after psychiatrists who feel dreadful-some actually say they feel fraudulent-that they are taking care of depressed people when they themselves are on antidepressants. I say, 'Hold on a minute, I'm sure there's an endocrinologist out there who has diabetes.'"

Research shows that doctors in general are at greater risk of depression, mood disorders, and suicide than other professionals. "Psychiatrists commit suicide at rates about twice" the rate of other physicians, according to a 1980 study by the American Psychiatric Association, which found that "the occurrence of suicide by psychiatrists is quite constant year-to-year, indicating a relatively stable oversupply of depressed psychiatrists."

"It's an oversimplification to say it's all due to the stress and strain of practicing medicine," cautions Dr. Myers, a specialist in physician mental health. "It's more to do with who we are: Many of us in medicine are wounded healers.We're interested in practicing medicine precisely because we come from families with problems."

Higher rates of family dysfunction, parental alcoholism, sexual and physical abuse, parental death, and psychiatric hospitalization were reported among female psychotherapists than in other women professionals in a 1993 study in the journal Professional Psychology, confirming the image of wounded healers.

Continues Dr. Myers: "Coupled with that, there are certain personality traits among people who become doctors. 'We're perfectionistic; you have to be if you want to practice proper medicine. And people who are that way are hard on themselves."

Yet the stigma of mental health continues to create what he and others haye called "a conspiracy of silence" among doctors-psychiatrists in particular.

Disclosure

By her last year of college, Beth Baxter, MD, "knew" there was "something wrong" with her brain; during the previous four years. the top student and class president had routinely slept only four hours a night. She would enter the cafeteria only during off-hours, eating peanut butter sandwiches day after day, just to avoid running into her classmates. She fought suicidal urges and had already made several half-hearted attempts.

In her second year of medical school at Vanderbilt University, she became convinced that the songs being played on the radio were carrying messages to her. Her grades began to slip for the first time, so she took a break and visited her grandparents' cattle ranch in Texas. While there, she went missing. She left on an imagined meeting with friends and followed some "messages" on the radio. Found wandering a day later, she was picked up by police on the side of a highway.

So began Dr. Baxter's first hospitalization when she was diagnosed as having bipolar disorder. She managed to return and graduate from medical school, hiring a tutor to talk through all of her class notes.

She was accepted into an internship in internal medicine in Memphis, Tennessee. "They accepted me before they knew I had bipolar disorder," she recalls. "The dean of students told them I'd had counseling, but it wasn't fully explained, and they were kind of angry when they found out." A year later when she transferred to Rochester, New York, she changed special ties. "Because," she says, "I knew how much good a psychiatrist could do and I wanted to do that for somebody else."

After her residency, her symptoms worsened: she became increasingly depressed and suicidal; she tried to slash her neck and had to return to her hometown of Nashville, Tennessee, where she was hospitalized for a year and the doctors told her parents that the most she could expect was to work on an assembly line. And the diagnosis had now changed to schizophrenic affective disorder.

"I was a pretty sorry sight," she recalls. ''I'd lost 70 pounds and I had a movement disorder - jerky hands and feet."

By this time, however, her parents had become active in the local chapter of NAMI (National Alliance on Mental Illness). When the local NAMI officers learned that a doctor was hospitalized in Nashville, they approached her with a request: would she write an educational training program for people who have mental illnesses? Baxter completed the project while she was still on suicide watch.

Little by little she began to come back. "A psychiatrist there had a lot of hope in me," she says, "and that hope was really important."

Dr. Baxter is still on medication; the last time she was hospitalized was in 2000, when a prescription change failed to work. But today, she runs a large private practice in Nashville, where - just as in medical school, when she hired a tutor ­ she now retains an older and more experienced psychiatrist "to help me talk through my cases and review how they're going."

She talks about her experiences openly, addressing NAMI workshops around the country, speaking at physician conferences, and often sharing her story with patients - "to show that you can recover from serious problems in your life."

She is famous around town for giving away little clay turtles from Guatemala: she sees turtles as a symbol of perseverance and determination, and has hundreds of clay, plastic, and ceramic turtles throughout her house.

Openness, for Dr. Baxter, was hardly a matter of choice: her medical history made disclosure an all too obvious decision. "But I still think it's good when people know," she says. "Then, when I got sick and bad things happened, they were more compassionate."

Dealing with BP in Practice

Mental Health Awareness Week in Canada features an annual campaign called the Four Faces of Mental Health. It's a way of putting a human face on conditions, such as bipolar disorder, schizophrenia, and depression. For the first time last year, one of the four faces was a doctor.

"I had to convince myself to do it," concedes Michael Pare, MD, a Toronto, Ontario, general practice psychotherapist. ''I'm always telling my depressed patients that they don't have to feel ashamed: They're not bad; they're not crazy; they're not weak. But doctors - while we're taught to say that - are not actually following through and admitting it. If it [mental illness] isn't our fault, then why is it so bad to stand up and be counted?"

After a "very, very difficult childhood," Dr. Pare sunk into a major depression in his mid 20s. "Literally, every day was like a terror, like being alive was the worst possible thing," he says. "It's impossible for me to remember the feeling, but I do remember my knowledge of it. Like when I opened my eyes in the morning, it was like, 'Oh no, I'm still alive.'"

He swallowed a lot of pills one day and fell into a coma for a week, recovering only after undergoing a lumbar puncture, or spinal tap.

A few years ago, Dr. Pare was invited to address a large group of psychiatrists on the subject of depression. It was a professional talk, but at the end, he impulsively made mention of his own experience.

"I said, 'Interestingly enough, I've suffered from major depression.' And there was no reaction. No one came up to me after the talk. I thought I was dropping a bomb, but not one person acknowledged it. And these were psychiatrists who work with depression every day."

Despite his own candor, Dr. Pare typically counsels young doctors against disclosing any history of mental illness at the beginning of their careers. Most young doctors don't need to be told. Consider the case of M., a 24-year-old California woman diagnosed as having bipolar disorder dming her second year of medical school in Lebanon. She is so fearful of one day being denied a medical license that she refuses to see a psychiatrist now that she is back in the U.S.

Instead, she orders her medications online. They cost $400 a month and they're generic, but they have one overriding advantage: they arrive unmarked from India and Australia.

"1' d go to any lengths to have my medication," she says. "If I go to a psychiatrist here, my whole future is ruined ­ everything I worked for. There are always questions on the residency or licensing applications - do you have a medical condition? That's why it's so important to keep it to myself."

That fear is widespread. A 2001 survey of Michigan psychiatrists found that half of them would rather self-treat than risk having a history of mental illness on their health insurance record.

And with good reason, according to psychiatrists who point to the widely publicized case of Steven Miles, MD, whose own bipolar disclosure turned into a cause celebre.

In 1994, Dr. Miles, a well-respected gerontologist and professor of biomedical ethics at the University of Minnesota Medical School, had sought help for depression from a psychiatrist who diagnosed bipolar disorder II. After a few weeks on medication - and with no interruption in his teaching or clinical work - Miles began to recover.

But several months later, on filling out the annual renewal form for his state medical license, he answered the questionnaire affirmatively when asked if he had ever been diagnosed with or treated for manic depression, schizophrenia, compulsive gambling, or other psychiatric conditions.

Though he had never been the subject of a patient's complaint, and though his name appeared regularly on lists of the state's "Top 100 doctors," the Minnesota Board of Medical Practice began an investigation, demanding a letter from his psychiatrist and full access to the records of his psychotherapy sessions.

Dr. Miles refused, and for the next four years he fought the board, arguing that its policy was overly invasive and served to deter physicians from seeking help for mental health disorders. After a protracted standoff and threats of legal action, the licensing board eventually changed its policy.

Today, many state licensing boards have adopted similar changes, but there is no consistent state-to-state policy. Nor is there any specific system for physician health care in the U.S.; the only health programs aimed at doctors are those restricted to drug and alcohol treatment.

In Canada, a physician wellness program has been set up in every province; its directors have joined to create a federal network, Canadian Physician Health Network, to share information and strategies. Under this system, a doctor who has bipolar disorder, for example, can be assisted and will be monitored at least three to five years, after which - if he or she is deemed stable - the monitoring is decreased or even removed.

Here's how it works for one Toronto doctor, a 41-year-old resident psychiatrist who last year was diagnosed as having bipolar disorder. A, as he asked to be identified, was someone who didn't "do" just residency. He simultaneously created a banking project for residents, invested $8,000 of his own money into a biotech company, organized a charitable organization for autism, conducted research into schizophrenia, and juggled a series of home renovation projects.

"I always have to self-monitor to slow down," he explains ruefully, "because the rest of the world doesn't operate as fast as my world does."

Then last year, everything crashed. "A secretary made a note saying I was speaking too fast, had taken time off from work, and that I'd asked for a referral to a psychiatrist. And suddenly, there's this note going around saying I have bipolar disorder - and no one had even diagnosed me at the time."

After a letter was sent off to the Ontario College of Physicians and Surgeons, the self-regulating body for the province's medical profession, A's first instinct was to fight.

"I don't want to be labeled just because I'm outside the box," he says. "No way in hell was I going to have a label like that. I didn't want someone labeling my enthusiasm - even though I realized some of my experiences were perhaps bizarre."

His psychiatrist reassured him, however, that he was not alone, that other physicians had similar problems, and that the system's checks and balances would allow him to continue in his career.

"I thought that was a bunch of hogwash," A says. "All my faculties are based on my judgment and if that's taken away from me how can I practice when people's lives are dependent on my judgment?"

That insight doesn't always mitigate the irritating presence of the system's checks and balances. To A they feel like an albatross, like he's being "policed."

"I have to inform my program director that I have an illness," says A, checking off the list. And everything I say to my psychiatrist becomes open to the College of Physicians and Surgeons. They want me to see a mood disorder specialist. I have a case manager to keep an eye on me and make sure I'm functioning on all cylinders.

"I also have the people who 'supervise' me at work," A continues. "So all these eyes are on me. It feels like I'm being policed even though I'm not being policed."

The choice is no longer his. His behavior had become so erratic that he could no longer deny his problems by working harder and plugging in the answers that he knew would get him off the hook with his fellow psychiatrists.

"With our specialized training we may be able to rationalize or deny our symptoms," says Mamta Gautam, MD, an Ottawa, Ontario, psychiatrist who restricts her practice to physicians.

"And, a doctor's ability to function at work is often the very last thing to go. In fact, you see that most people don't have any idea that a colleague is struggling, because if anything they're more productive than before. When, really, it's just a mechanism - to keep working and stay with what's known rather than stop and reflect."

Coping and Reaching Out

Long before Dr. Vogel-Scibilia examined the patient who had bipolar and saw herself reflected back, she had figured out ways of adapting to her seasonal mood swings. Anticipating depression in winter, she scheduled her most challenging coursework for the fall.

'I'd do the research, pick the cards, and do the bibliography," she says, "so if I had to write the paper I'd just have to write the text out. I would try to compensate for things, study stuff in advance."

Now a practicing clinical psychiatrist in Beaver, Pennsylvania, she operates an independent mental health clinic and serves as clinical assistant professor at Western Psychiatric Institute, the same hospital where she did her residency and diagnosed herself.

Today, she is president of NAMI at the national level and a consultant for psychopharmacology projects at the National Institute of Mental Health and is a grant reviewer for the federal government.

But at least once a week, she gets a call from a young medical student or resident doctor - usually, she says, it's a psychiatric resident secretly struggling v.rith mental illness. Some of them offer to fly or drive long distances for a consultation.

"I have this theory," she says. "If you were a patient before you were a doctor you don't have so much trouble being in a patient role. But if you've been the doctor first and then you get sick, you have a hell of a hard time being a patient.

"You could do a study [about physicians having mental illnesses], but there'd be no sample, because nobody would agree to be interviewed. Actually I could just poll my friends. The trouble is it wouldn't be a random sample. It would be the friends of Suzanne."

Sara Solovitch also wrote "People Like Me, " which appeared in the Summer issue of bp Magazine.