Psychiatric Disorders Among Professional Women Weiner, MD; Sue Marten, MD; Eliza Wochnick, MD; Mary A. Davis, MD; Roberta Fishman, MSW; Paula J. Clayton, MD
Amos
\s=b\ A group of 111 women physicians and 103 women PhDs, selected from the general community, were studied for the presence of psychiatric illness. Fifty-one percent of the MDs and 32% of the PhDs were diagnosed as having primary affective disorder (P < .01). Other psychiatric disorders were found in less than 10% of each group. Depression among the psychiatrists was significantly more common (73%) than among the other physicians (46%). More than 50% of all the women reported prejudice in training
employment, and depressed subjects reported prejudice more often than well subjects. The presence of children and depression were shown to disrupt a woman's professional career. The finding of a high prevalence of affective disorder among women physicians is consistent with the reported excessive suicide risk for this group. (Arch Gen Psychiatry 35:169-173, 1979) or
higher prevalence of suicide among male physicians when compared to control popula¬
Wiether
there is
a
controversial issue.'" However, there is
tions remains a evidence that women physicians are especially prone to suicide.'-' '"" Investigations show that the vast majority of persons who commit suicide are psychiatrically ill,"1517 that suicide is highly correlated with affective disorder1" !1 and with alcoholism.16·1'19·28 Affective disorder is more frequent in women than in men,2" "" and there is evidence that affective disorder is more prevalent among those with high Accepted for publication July 20, 1977. From the Department of Psychiatry, Washington University School of Medicine, St Louis. Reprint requests to Department of Psychiatry, Washington University School of Medicine, 4940 Audubon Ave, St Louis, MO 63110 (Dr Welner).
educational level and high social achievement.31-1'-39 It would seem, therefore, that women in the above categories would be especially vulnerable to affective disorder. However, to our knowledge, there is no evidence to support this conclusion. Thus, given the high correlation between suicide and affective disorder and the high rate of suicide by women physicians, a study of the prevalence of affec¬ tive disorder in women physicians was indicated. The purpose of the study was to determine whether there is a high prevalence of affective disorder among women physicians and whether, if present, it is related to high educational and social status or is associated with some other aspect of being a physician. To control for educational and social status, we compared women physi¬ cians to women PhDs for prevalence of affective disor¬ der. CLINICAL POPULATION AND METHOD A list of all women physicians in the St Louis area was obtained by using telephone directories; local, state, and national medical directories; and lists of staff members from all St Louis area hospitals. All physicians associated with the Department of Psychiatry at Washington University School of Medicine were excluded from the study. A comparable list of women PhDs was compiled by obtaining names of staff members from each college in the St Louis area, several large St Louis industries, a number of local school systems, and state and local welfare agencies. Each woman physician was contacted by a trained interviewer (one of three women psychiatrists), told the purpose and scope of the study, and was systematically interviewed. An informed consent was obtained from each participant. The interview covered education, area of specialty and work history, marital history, obstetric history, experience of prejudice in training and
Downloaded From: http://archpsyc.jamanetwork.com/pdfaccess.ashx?url=/data/journals/psych/12310/ by a University of California - San Diego User on 06/05/2017
practice, social history, and psychopathology in the subjects and their families. The PhDs were selected to match the MDs for age, marital status, and race and were similarly interviewed. The data were analyzed to determine (1) the prevalence of affective and other psychiatric disorders in each group, and (2) whether in groups of highly educated women, prejudice, marriage and childbearing, training, and employment were associated with the presence of psychopathology, particularly depression. Psy¬ chiatric diagnoses were determined according to the criteria that were proposed by Feighner et al.'0 Corrected 2 and t test were used to analyze the data. RESULTS
One hundred forty-one women MDs were contacted. One hundred thirty-eight were interviewed; three refused. Of the 116 PhDs who were contacted, 112 were interviewed and 4 refused. As noted, the PhDs were closely matched to the MDs for age, marital status, and race. The 138 MDs included 111 white subjects, 7 blacks, 5 from India, and 15 Orientals. The 112 PhDs included 103 white subjects, 4 blacks, 2 from India, and 3 Orientals. Because of the small numbers in the other categories, the study included only the white groups, 111 MDs and 103 PhDs. Of the 111 women MDs, 48 (43%) were found to have no mental illness. Fifty-seven (51%) had primary affective disorder (53 unipolar, 4 bipolar). Of the remaining six, one had alcoholism; one, anxiety neurosis; one, phobic neurosis; one, cancer with secondary depression; and two, undiagnosed psychiatric disorder. Of the 103 women PhDs, 60 (58%) had no mental illness. Thirty-three (32%) had primary affective disorder (32 unipolar, one bipolar). Of the remaining ten, two had phobic neurosis and eight, undiagnosed psychiatric disorder. The undiagnosed groups consisted of subjects in whom the clinical picture did not meet the diagnostic criteria for an established psychiatric disorder. A significantly higher prevalence of primary affective disorder was found in MDs than in PhDs (P < .01). Also, a significantly higher number of PhDs had no psychiatric disorder when compared to the MDs (P < .05). No signifi¬ cant differences were found when other psychiatric disor¬ ders were compared. The mean age at the time of the interview was as follows: depressed MDs, 45.0 ± 12.4 years; well MDs, 48.4 ± 16.2 years; depressed PhDs, 41.0 ± 12.1 years; well PhDs, 45.0 ± 12.2 years. The differ¬ ences between and within the groups were not signifi¬ cant.
study of religious affiliation showed that a signifi¬ cantly higher number of PhDs were agnostic or atheistic both in the depressed and well groups (depressed MDs 14%, depressed PhDs 42%, < .01; well MDs 4%, well PhDs 23%, < .02). No other religious affiliation was either overrepresented or underrepresented when the groups were compared. Depressed MDs, depressed PhDs, or the two groups combined did not report more religious affiliation A
than the well groups. The prevalence of women who had never married was similar in the four groups and ranged between 25% and 31%. Being single was not associated with a young age (single depressed MDs, 41.2 years; single well MDs, 46.6
single depressed PhDs, PhDs, 45.3 years).
years;
37.3 years; and
single well
The number of women whose marriages ended in divorce not significantly different when the four groups were compared (12.8% for depressed MDs, 11.1% for well MDs, 8.3% for depressed PhDs, and 17.4% for well PhDs). was
Nature of
Depressive Illness
Of the 57 women MDs who had depression, two had bipolar illness and two had periods of hypomania between the episodes of depression (bipolar 2)." Fifty-three had unipolar affective disorder, including three who had psychotic depression. Of the 33 PhDs who had depression, one had bipolar illness and 32 had unipolar affective disorder. None had psychotic features. The mean age of onset of illness for the MDs was 29.2 ± 11.7 years and for the PhDs 28.2 ± 7.8 years. The mean number of depressive episodes in 56 out of 57 MDs was 2.7 ± 2.1. (The remaining physician had a 25-year course of illness with multiple episodes of depression and partial remissions.) Twenty MDs (35%) had only one episode of depression. The mean length of the longest or only depressive episode in each subject was 14.9 ± 17.4 months. The mean number of depressive episodes for the 33 PhDs was 1.9 ± 0.8. Thirteen (39%) of the PhDs had only one depressive episode. The mean length of the longest or only episode in each subject was 10.8 ± 13.5 months The Global Assessment Scale'2 measures the severity of the depressive episode both in terms of psychopathology and impairment in function. The scale ranges from 1 to 100, with lower scores indicating greater severity. The mean global assessment scale rating for the most severe depressive episode in each MD was 51.2 ± 8.9, and for the PhDs was 56.2 ± 12.7. Forty-two percent of depressed MDs and 33% of depressed PhDs were found to be symptomatic at the time of the interview. Seven percent of the depressed MDs were treated as inpatients, 32% as outpatients, 19% medicated themselves with antidepressants, and 40% sought no treatment. Three percent of the depressed PhDs received inpatient treat¬ ment, 61% were treated as outpatients, and 36% were not treated at all. None treated herself. These rates refer to lifetime treatment. It would appear that depressive illness in women physi¬ cians is not only more frequent than in women PhDs, but tends to be somewhat more severe. All the above variables reflected this trend, however significance was only reached (P < .05) when the mean number of episodes of depressive illness was compared. The excess of PhDs who sought outpatient care was offset by the number of MDs who treated themselves with antidepressants. Within both the group of MDs and PhDs all subjects were divided into those with one episode vs more than one; those who were treated vs those who were not; those who were symptomatic at the time of the interview vs those who were well. Comparisons between these subgroups did not indicate any differences in characteristics or severity of depression. Also, the mean age at the time of interview of either MDs or PhDs who had only one episode of illness
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not lower than that of MDs or PhDs who had more than one episode. In 17 (28%) of the depressed MDs the onset of depression occurred prior to entering medical school. All of these subjects had subsequent depressive episodes: five in training (9%), four in practice (7%), and eight in both (14%). In 22 (39%), onset of depression occurred during practice. In the remaining 18 (33%), the onset of depression was during training in medical school or residency. Of these, 7 (12%) had subsequent episodes during practice and 11 (19%) had all their depressive episodes during training. Six of the 11 were still in training when interviewed. was
Prejudice, Career Disruption, and Depression Prejudice was considered to be present if a subject
that during training or employment her income was lower than her male counterpart's or that she was strongly discouraged or prohibited from pursuing her career. (A few examples of reported prejudice were as follows: A PhD who could not be employed in the Depart¬ ment of Anatomy because women were not accepted; an MD who was constantly subjected to criticism and deroga¬ tory remarks from patients as well as peers; a PhD who was refused job interviews because of her sex; an MD who was not allowed to take the urology course in medical school and whose practice was therefore limited to women and children.) Table 1 presents the prevalence of the prejudice that was encountered by depressed and well MDs and PhDs. It should be noted that half or more of the subjects in all four groups reported prejudice. However, the prevalence of prejudice was higher in the depressed groups, the difference being significant at the .02 level when the total number of depressed subjects was compared to the total number of well subjects. The mean age at time of interview of the depressed MDs who reported prejudice was 45.4 ± 13.5 years and that of the well MDs who reported prejudice was 43.3 ± 14.2 years. The corresponding ages for the PhDs were 39.1 ± 11.7 years and 44.1 ± 14.1 years. The majority of both depressed MDs (79%) and well MDs (71%) reported prejudice during training. Regarding the chronology between prejudice and depression, unfortu¬ nately, subjects were not asked whether incidents of prejudice were associated with episodes of depression. However, in the previous section, data are presented that do not support a strong association between depression and training (a period where most incidents of prejudice were reported). In the absence of direct data linking incidence of reported prejudice and depression, it is conceivable that prejudice, like training, is not likely to be associated with periods of depression. It is interesting to note that the group of depressed MDs and PhDs who were found to be symptomatic at the time of the interview, did not overreport or underreport prejudice when compared to depressed subjects who were well at the time of interview. Career disruption was considered to be present when a subject had worked less than full time or quit work for more than a year. As shown in Table 2, for both depressed and well women the prevalence of disruption was signifi¬ cantly higher in those who had children, compared to those
Table
Encountered Women Professionals
1.—Prejudice
by p
Depressed Well
MD
PhD
(Corrected 2)
38/57(67%) 24/48(50%)
23/33(70%) 29/60(48%)
NS NS
NS
(corrected ')
"Prejudice
well MDs
encountered well PhDs,
plus
NS
Amos
\s=b\ A group of 111 women physicians and 103 women PhDs, selected from the general community, were studied for the presence of psychiatric illness. Fifty-one percent of the MDs and 32% of the PhDs were diagnosed as having primary affective disorder (P < .01). Other psychiatric disorders were found in less than 10% of each group. Depression among the psychiatrists was significantly more common (73%) than among the other physicians (46%). More than 50% of all the women reported prejudice in training
employment, and depressed subjects reported prejudice more often than well subjects. The presence of children and depression were shown to disrupt a woman's professional career. The finding of a high prevalence of affective disorder among women physicians is consistent with the reported excessive suicide risk for this group. (Arch Gen Psychiatry 35:169-173, 1979) or
higher prevalence of suicide among male physicians when compared to control popula¬
Wiether
there is
a
controversial issue.'" However, there is
tions remains a evidence that women physicians are especially prone to suicide.'-' '"" Investigations show that the vast majority of persons who commit suicide are psychiatrically ill,"1517 that suicide is highly correlated with affective disorder1" !1 and with alcoholism.16·1'19·28 Affective disorder is more frequent in women than in men,2" "" and there is evidence that affective disorder is more prevalent among those with high Accepted for publication July 20, 1977. From the Department of Psychiatry, Washington University School of Medicine, St Louis. Reprint requests to Department of Psychiatry, Washington University School of Medicine, 4940 Audubon Ave, St Louis, MO 63110 (Dr Welner).
educational level and high social achievement.31-1'-39 It would seem, therefore, that women in the above categories would be especially vulnerable to affective disorder. However, to our knowledge, there is no evidence to support this conclusion. Thus, given the high correlation between suicide and affective disorder and the high rate of suicide by women physicians, a study of the prevalence of affec¬ tive disorder in women physicians was indicated. The purpose of the study was to determine whether there is a high prevalence of affective disorder among women physicians and whether, if present, it is related to high educational and social status or is associated with some other aspect of being a physician. To control for educational and social status, we compared women physi¬ cians to women PhDs for prevalence of affective disor¬ der. CLINICAL POPULATION AND METHOD A list of all women physicians in the St Louis area was obtained by using telephone directories; local, state, and national medical directories; and lists of staff members from all St Louis area hospitals. All physicians associated with the Department of Psychiatry at Washington University School of Medicine were excluded from the study. A comparable list of women PhDs was compiled by obtaining names of staff members from each college in the St Louis area, several large St Louis industries, a number of local school systems, and state and local welfare agencies. Each woman physician was contacted by a trained interviewer (one of three women psychiatrists), told the purpose and scope of the study, and was systematically interviewed. An informed consent was obtained from each participant. The interview covered education, area of specialty and work history, marital history, obstetric history, experience of prejudice in training and
Downloaded From: http://archpsyc.jamanetwork.com/pdfaccess.ashx?url=/data/journals/psych/12310/ by a University of California - San Diego User on 06/05/2017
practice, social history, and psychopathology in the subjects and their families. The PhDs were selected to match the MDs for age, marital status, and race and were similarly interviewed. The data were analyzed to determine (1) the prevalence of affective and other psychiatric disorders in each group, and (2) whether in groups of highly educated women, prejudice, marriage and childbearing, training, and employment were associated with the presence of psychopathology, particularly depression. Psy¬ chiatric diagnoses were determined according to the criteria that were proposed by Feighner et al.'0 Corrected 2 and t test were used to analyze the data. RESULTS
One hundred forty-one women MDs were contacted. One hundred thirty-eight were interviewed; three refused. Of the 116 PhDs who were contacted, 112 were interviewed and 4 refused. As noted, the PhDs were closely matched to the MDs for age, marital status, and race. The 138 MDs included 111 white subjects, 7 blacks, 5 from India, and 15 Orientals. The 112 PhDs included 103 white subjects, 4 blacks, 2 from India, and 3 Orientals. Because of the small numbers in the other categories, the study included only the white groups, 111 MDs and 103 PhDs. Of the 111 women MDs, 48 (43%) were found to have no mental illness. Fifty-seven (51%) had primary affective disorder (53 unipolar, 4 bipolar). Of the remaining six, one had alcoholism; one, anxiety neurosis; one, phobic neurosis; one, cancer with secondary depression; and two, undiagnosed psychiatric disorder. Of the 103 women PhDs, 60 (58%) had no mental illness. Thirty-three (32%) had primary affective disorder (32 unipolar, one bipolar). Of the remaining ten, two had phobic neurosis and eight, undiagnosed psychiatric disorder. The undiagnosed groups consisted of subjects in whom the clinical picture did not meet the diagnostic criteria for an established psychiatric disorder. A significantly higher prevalence of primary affective disorder was found in MDs than in PhDs (P < .01). Also, a significantly higher number of PhDs had no psychiatric disorder when compared to the MDs (P < .05). No signifi¬ cant differences were found when other psychiatric disor¬ ders were compared. The mean age at the time of the interview was as follows: depressed MDs, 45.0 ± 12.4 years; well MDs, 48.4 ± 16.2 years; depressed PhDs, 41.0 ± 12.1 years; well PhDs, 45.0 ± 12.2 years. The differ¬ ences between and within the groups were not signifi¬ cant.
study of religious affiliation showed that a signifi¬ cantly higher number of PhDs were agnostic or atheistic both in the depressed and well groups (depressed MDs 14%, depressed PhDs 42%, < .01; well MDs 4%, well PhDs 23%, < .02). No other religious affiliation was either overrepresented or underrepresented when the groups were compared. Depressed MDs, depressed PhDs, or the two groups combined did not report more religious affiliation A
than the well groups. The prevalence of women who had never married was similar in the four groups and ranged between 25% and 31%. Being single was not associated with a young age (single depressed MDs, 41.2 years; single well MDs, 46.6
single depressed PhDs, PhDs, 45.3 years).
years;
37.3 years; and
single well
The number of women whose marriages ended in divorce not significantly different when the four groups were compared (12.8% for depressed MDs, 11.1% for well MDs, 8.3% for depressed PhDs, and 17.4% for well PhDs). was
Nature of
Depressive Illness
Of the 57 women MDs who had depression, two had bipolar illness and two had periods of hypomania between the episodes of depression (bipolar 2)." Fifty-three had unipolar affective disorder, including three who had psychotic depression. Of the 33 PhDs who had depression, one had bipolar illness and 32 had unipolar affective disorder. None had psychotic features. The mean age of onset of illness for the MDs was 29.2 ± 11.7 years and for the PhDs 28.2 ± 7.8 years. The mean number of depressive episodes in 56 out of 57 MDs was 2.7 ± 2.1. (The remaining physician had a 25-year course of illness with multiple episodes of depression and partial remissions.) Twenty MDs (35%) had only one episode of depression. The mean length of the longest or only depressive episode in each subject was 14.9 ± 17.4 months. The mean number of depressive episodes for the 33 PhDs was 1.9 ± 0.8. Thirteen (39%) of the PhDs had only one depressive episode. The mean length of the longest or only episode in each subject was 10.8 ± 13.5 months The Global Assessment Scale'2 measures the severity of the depressive episode both in terms of psychopathology and impairment in function. The scale ranges from 1 to 100, with lower scores indicating greater severity. The mean global assessment scale rating for the most severe depressive episode in each MD was 51.2 ± 8.9, and for the PhDs was 56.2 ± 12.7. Forty-two percent of depressed MDs and 33% of depressed PhDs were found to be symptomatic at the time of the interview. Seven percent of the depressed MDs were treated as inpatients, 32% as outpatients, 19% medicated themselves with antidepressants, and 40% sought no treatment. Three percent of the depressed PhDs received inpatient treat¬ ment, 61% were treated as outpatients, and 36% were not treated at all. None treated herself. These rates refer to lifetime treatment. It would appear that depressive illness in women physi¬ cians is not only more frequent than in women PhDs, but tends to be somewhat more severe. All the above variables reflected this trend, however significance was only reached (P < .05) when the mean number of episodes of depressive illness was compared. The excess of PhDs who sought outpatient care was offset by the number of MDs who treated themselves with antidepressants. Within both the group of MDs and PhDs all subjects were divided into those with one episode vs more than one; those who were treated vs those who were not; those who were symptomatic at the time of the interview vs those who were well. Comparisons between these subgroups did not indicate any differences in characteristics or severity of depression. Also, the mean age at the time of interview of either MDs or PhDs who had only one episode of illness
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not lower than that of MDs or PhDs who had more than one episode. In 17 (28%) of the depressed MDs the onset of depression occurred prior to entering medical school. All of these subjects had subsequent depressive episodes: five in training (9%), four in practice (7%), and eight in both (14%). In 22 (39%), onset of depression occurred during practice. In the remaining 18 (33%), the onset of depression was during training in medical school or residency. Of these, 7 (12%) had subsequent episodes during practice and 11 (19%) had all their depressive episodes during training. Six of the 11 were still in training when interviewed. was
Prejudice, Career Disruption, and Depression Prejudice was considered to be present if a subject
that during training or employment her income was lower than her male counterpart's or that she was strongly discouraged or prohibited from pursuing her career. (A few examples of reported prejudice were as follows: A PhD who could not be employed in the Depart¬ ment of Anatomy because women were not accepted; an MD who was constantly subjected to criticism and deroga¬ tory remarks from patients as well as peers; a PhD who was refused job interviews because of her sex; an MD who was not allowed to take the urology course in medical school and whose practice was therefore limited to women and children.) Table 1 presents the prevalence of the prejudice that was encountered by depressed and well MDs and PhDs. It should be noted that half or more of the subjects in all four groups reported prejudice. However, the prevalence of prejudice was higher in the depressed groups, the difference being significant at the .02 level when the total number of depressed subjects was compared to the total number of well subjects. The mean age at time of interview of the depressed MDs who reported prejudice was 45.4 ± 13.5 years and that of the well MDs who reported prejudice was 43.3 ± 14.2 years. The corresponding ages for the PhDs were 39.1 ± 11.7 years and 44.1 ± 14.1 years. The majority of both depressed MDs (79%) and well MDs (71%) reported prejudice during training. Regarding the chronology between prejudice and depression, unfortu¬ nately, subjects were not asked whether incidents of prejudice were associated with episodes of depression. However, in the previous section, data are presented that do not support a strong association between depression and training (a period where most incidents of prejudice were reported). In the absence of direct data linking incidence of reported prejudice and depression, it is conceivable that prejudice, like training, is not likely to be associated with periods of depression. It is interesting to note that the group of depressed MDs and PhDs who were found to be symptomatic at the time of the interview, did not overreport or underreport prejudice when compared to depressed subjects who were well at the time of interview. Career disruption was considered to be present when a subject had worked less than full time or quit work for more than a year. As shown in Table 2, for both depressed and well women the prevalence of disruption was signifi¬ cantly higher in those who had children, compared to those
Table
Encountered Women Professionals
1.—Prejudice
by p
Depressed Well
MD
PhD
(Corrected 2)
38/57(67%) 24/48(50%)
23/33(70%) 29/60(48%)
NS NS
NS
(corrected ')
"Prejudice
well MDs
encountered well PhDs,
plus
NS
