‘A Scarlet Letter’: States Aim to End Stigma of Doctors Seeking Mental Health Care

Medical doctors face higher rates of burnout and depression, and are twice as likely to die by suicide compared with the general population. The risks were magnified during the height of the COVID-19 pandemic.

But the problem existed long before the pandemic — and it remains. More than 40% of physicians, as well as medical school students and residents, cite fear of disclosure requirements on licensure forms as a main reason why they don’t seek mental health care.

That’s according to the American Medical Association, which represents physicians and medical students around the nation. The AMA and other groups have been pushing for legislative and regulatory changes.

More states and health systems are amending licensure and credentialing forms to remove mental health-related questions, such as asking about whether a doctor sought mental health care or treatment or received a mental health diagnosis. Others have codified such changes into state law.

The rationale for asking about mental health was to ensure patient safety. The AMA says safety can be addressed with general language that asks if the physician is suffering from any impairment that could interfere with patient care.

“Having any past diagnosis of a mental health need or a substance use problem is often not relevant,” said Dr. Jesse Ehrenfeld, the president of the AMA. “The key inquiry ought to be whether the impairment represents a current concern for safety and the physician’s ability to provide competent professional care.”

Ehrenfeld recalled a classmate who had applied for a medical license in Colorado. He said that in response to a question about any prior mental health diagnosis or treatment, she responded that she’d seen a psychologist in high school. That held up her license for nine months, Ehrenfeld said.

Nationwide, at least 29 states have updated their forms to remove such questions in line with AMA standards, and as of September of last year, 375 hospitals had changed credentialing questions, according to the AMA.

Advocates say destigmatizing mental health care for doctors is paramount as the nation grapples with a shortage of health care workers. More than 76 million Americans live in federally designated shortage areas, and that’s projected to worsen as physicians consider leaving the field, driven by burnout and chronic overload.

In 2020, at the start of the COVID-19 pandemic, Virginia became the first state to enact a law mandating a program that provides physicians with 24/7 confidential mental health support without fear of repercussions against their licenses.

Arguing the questions violate the Americans with Disabilities Act, other groups — including the Federation of State Medical Boards and the Dr. Lorna Breen Heroes’ Foundation — have also recommended updates to licensure application forms. The foundation is a physician mental health advocacy nonprofit named after New York City emergency room physician Dr. Lorna Breen, who died by suicide on April 26, 2020, after the hospital where she worked was inundated with COVID-19 patients.

In a U.S. Centers for Disease Control and Prevention study released this month, a quarter of health care providers reported mental health symptoms severe enough for a diagnosis. Among those, only 38% reported seeking care, while 20% said they didn’t need care, despite severe symptoms. An estimated 300 to 400 physicians die by suicide each year, with women physicians dying at higher rates.

Breen’s brother-in-law, Corey Feist, who is the foundation’s president and co-founder, said many doctors don’t seek help because they “assume that the rules are against them.”

“They avoid getting mental health treatment, or if they do get mental health treatment, they treat it as a scarlet letter,” Feist said.

The foundation has a communications toolkit for hospital systems and licensing bodies to help them disseminate updated forms to the workforce.

State and federal changes

The foundation also tracks state changes, and last year recognized licensing bodies in South Carolina, Tennessee and Virginia for meeting the foundation’s recommendations. Just last week, another board in Washington state joined the list, Feist said.

At the federal level, the Dr. Lorna Breen Health Care Provider Protection Act became law in 2022. It requires the U.S. Department of Health and Human Services to award grants to hospitals and professional associations to develop programs to promote mental health among providers. The law also requires dissemination of best practices for suicide prevention and campaigns to encourage providers to seek support.

Licensure application changes are a start, experts say. But broader changes will be needed to gain physicians’ trust so that they will seek care, said Dr. Kyra Reed, an emergency room physician in Indiana and an advocate for breaking barriers to mental health care for physicians.

“A culture change takes time,” Reed said. “You do have to have a reflection in leadership and in systems that reflect genuine caring and concrete strategies to support physicians in need.”

One strategy to combat mistrust, she said, is for health care employers to provide opt-out therapy services as part of employment from the beginning of a person’s tenure. “If you standardize something, then you normalize intervention, which then makes people feel less stigmatized,” she said.

Reed went through her own experience of postpartum depression in 2020 and now shares her story at national conferences and with peers to destigmatize the issue.

“I was more worried about my career and job in that moment than calling for help. That was a stark moment for me,” she said. “As a physician … you think you should be able to help yourself, because you help others in that situation. And when you can’t, it’s mind-boggling.”

New laws and volunteer groups

In 2020, at the start of the COVID-19 pandemic, Virginia became the first state to enact a law mandating a program that provides physicians with 24/7 confidential mental health support without fear of repercussions against their licenses. The law was updated last year expanding to dentists, dental hygienists and dental students.

Other states have passed similar laws since then, including Arizona, Georgia, Indiana and South Dakota, according to the AMA, and provisions of a Minnesota law went into effect last year.

Meanwhile, volunteer groups have helped with access to care outside of employee assistance programs, which some doctors may avoid using, fearing a lack of confidentiality.

The Oregon Wellness Program supports licensed physicians and physician assistants, medical students, nurses and nurse practitioners in the state. Run by volunteer psychiatrists, the program receives state funding and serves about 1,000 health professionals per year.

“Often people are insured through their employer, and so there was fear that the employer would then know that they were seeking mental health services,” said volunteer psychiatrist Dr. Mandi Hudson. “It offers a level of protection and confidentiality that didn’t previously exist.”

Through the program, health care workers can be seen without having to wait six months or a year to get an appointment, Hudson said.

The Physician Support Line is a national mental health hotline for doctors that was launched in response to the pandemic. At its peak, the line took an average of 30 calls per day.

“We were just volunteer people coming together, doing this work,” said Chicago-based psychiatrist Dr. Smita Gautam. “We’re not affiliated to any health care organization, health care system, university, medical board for any licensure organization. So, we are a very independent grassroots organization, and we’ve kept it that way so that physicians feel free to talk to us.”

Gautam added that fear of licensing issues is a concern she hears often from physicians — including those practicing in states where forms have updated.

“This has sort of percolated so much that even if a physician is in a ‘friendly state,’ they may not know about it. There’s this free-floating anxiety about, ‘Will I get reported?’” she said.

Stateline is part of States Newsroom, a nonprofit news network supported by grants and a coalition of donors as a 501c(3) public charity. Stateline maintains editorial independence. Contact Editor Scott S. Greenberger for questions: info@stateline.org.

by Nada Hassanein, Virginia Mercury

Virginia Mercury is part of States Newsroom, a nonprofit news network supported by grants and a coalition of donors as a 501c(3) public charity. Virginia Mercury maintains editorial independence. Contact Editor Samantha Willis for questions: info@virginiamercury.com.