Time to Act: Destigmatizing Mental Health Care for Health Care Professionals

The data are alarming:

• One in five physicians reported they were depressed and one in 10 had thoughts of suicide or attempted suicide according to a 2022 Medscape survey.¹

• It is estimated that 119 physicians die by suicide in the United States each year.²

• Suicide is the leading cause of death among male residents and the second leading cause of death among female residents.³

The reasons for these frightening rates are complex and include workplace factors such as unrelenting work schedules, dwindling sense of autonomy, vicarious trauma, moral injury, and increased administrative burden. Cultural factors in medicine including rewards for self-sacrifice, an emphasis on self-sufficiency and perpetuation of the hero myth also impact mental health. In addition to addressing the upstream factors that contribute to mental health concerns among the health care workforce, health care systems also need to ensure that providers have access to appropriate treatment.

Sadly, even when treatment resources are available, many health care professionals are hesitant to seek, let alone discuss, mental health care. Licensure board and hospital credentialing questions investigating one’s personal history and the implication that privileges could be denied keep many from reaching out for help. Forty to 65 percent of physicians report they have been reluctant to seek mental health care due to concern it would negatively impact receiving/renewing medical licenses or the hospital privileging process. ^{4, 5}

In response to the emotional crisis, untreated mental health concerns, and startling suicide statistics, advocacy groups have promoted imperative changes. In 2016, the American Medical Association (AMA) requested that state medical boards stop asking applicants about a history of mental health and substance abuse issues, focusing instead only on current health issues. ⁶ The 2018 policy of the Federation of State Medical Boards (FSMB) recommended that state licensure boards evaluate whether questions about mental health, addiction or substance use are needed; distinguish between diagnoses and impairments; comply with Americans with Disabilities Act applications which investigate a specific time frame (eg, 2 years) rather than a lifetime history; and that state medical boards consider providing “safe haven nonreporting,” for people currently receiving recommended treatment but whose abilities to provide medical care are not impaired.

A 2021 review showed that 39 states now ask questions focusing only on current impairment rather than illness, diagnosis, or previous treatment and that 17 no longer require disclosure of mental health conditions. ⁷ According to the Dr Lorna Breen Heroes’ Foundation, as of November 2022, 19 states have medical licensure applications that align with recommendations from the FSMB (https://drlornabreen.org/removebarriers/). However, it is important to note that these data only focus on physicians, and not other members of the health care workforce. How closely the credentialing processes for individual health systems align with these recommendations is also unknown.

In March 2022, bipartisan federal legislation supporting the well-being of health care workers to prevent burnout and suicide (and named for Dr Lorna Breen) was signed into law. ^{3, 8} Also in 2022, the Office of the Surgeon General (OSG) commented on this issue. Among the highlights of its report Addressing Health Worker Burnout the U.S. Surgeon General’s Advisory on Building a Thriving Health Workforce, ⁹ the OSG calls for protecting the health, safety, and well-being of all health care workers; eliminating punitive policies for seeking mental health and substance use care; and transforming organizational cultures to prioritize health worker well-being. The OSG directs health care organizations to review and revise policies to ensure health workers are not deterred from seeking care for physical and mental health as well as for substance use treatment. In October 2022, the National Academy of Medicine (NAM) released the National Plan for Health Workforce Well-Being. ¹⁰ It identifies supporting mental health and reducing stigma as a priority area, and includes recommendations to address needed changes at the organizational and state levels. Organizations are encouraged to conduct awareness campaigns promoting mental health treatment as well as addressing systemic obstacles that contribute to mental health issues (such as high workload and lengthy administrative requirements).

Members of the health care workforce are often unaware that these changes are occurring, however. Thus, there is a need to bring greater awareness to the positive changes that have occurred while also continuing to support health care clinicians and learners to advocate for change where needed.

The following resources are particularly relevant for STFM members who wish to learn more and engage in this issue.

• Dr Lorna Breen Heroes’ Foundation: This resource includes a map to assess state application alignment with FSMB recommendations and toolkits for advocating for change with licensing boards and credentialling committees. The website includes the ability to directly send an email to your state medical board: https://drlornabreen.org/removebarriers/

• American College of Physicians. This organization offers toolkits for advocating for change with licensing boards and credentialling committees which includes sample letters and a slide deck addressing the need to change language on applications. See: Advocacy Toolkit: Modernizing License and Credentialing Applications to Not Stigmatize Mental Health

STFM staff and leadership have been working with the AAFP, AMA, AAMC, and others to stay informed on their work to approach this issue from a regulatory and systems perspective. Collaboration among these organizations has the potential for greater reach and impact. Following the leads of the above-mentioned organizations, STFM is also working actively to close these gaps. A task force has been assembled and has begun the task of educating our members to mobilize a response. We have identified three goal areas: (1) to increase awareness of changes in state licensing applications designed to reduce stigma for seeing mental health care, (2) create opportunities and provide resources to support STFM members to engage in advocacy to address this issue at their state and local levels, and (3) develop resources for program directors to best respond to stigmatizing questions in graduate licensing applications.  

We recently launched a resource page on the STFM website to house links to advocacy toolkits and additional educational materials: Resources for Reducing Mental Health Stigma (stfm.org). We will add additional information in the future for program directors who respond to questions about mental health on credentialing forms for residents. We are implementing a communication and education campaign to bring more awareness about this issue (eg, this column, an STFM podcast, an Annals of Family Medicine update, and conference presentations, among others). Finally, we are excited to announce that we will be offering an Advocacy Station at the 2023 STFM Annual Spring Conference in Tampa, Florida, which will help our members identify the most effective ways of communicating their support for this issue to their licensing boards and policy makers back home.  

Addressing the systemic issues that impact the mental health and well-being of our health care learners and workforce can feel overwhelming. Changing the culture around seeking mental health care and reducing fear of negative ramifications for taking care of one’s emotional well-being is one important step that can make a difference. Join us in taking action!