On the Other Side of the Stethoscope: Mental Health on the Physician Developmental Continuum

1. On the Other Side of the Stethoscope: Mental Health on the Physician Developmental Continuum Andreea L. Seritan, M.D. Carol Kirshnit, Ph.D. Sue Barton, Psy.D., Ph.D.

2. Objectives • Recognize mental health difficulties in medical students, residents, and practicing physicians • Understand barriers to seeking care • Discuss strategies to overcome the culture of silence • Allow ourselves to take care of our own needs

3. Depressive symptoms in medical students (MS) and residents (R) • 2,000 MS + R surveyed, response rate 89% • Six medical schools, 2003-04 • Center for Epidemiologic Studies-Depression scale (CES-D) • Primary Care Evaluation of Mental Disorders (PRIME-MD) depression measures Goebert et al. Acad Med 2009; 84:236-241

4. Depressive symptoms in MS and R: Results Returned surveys: • 1,343 MS (response rate 95%), 679 R (64%) • 52% women • 7% were receiving MH treatment currently • 17% reported h/o depression • Of these, 69% had received treatment • 30% had FH of depression Goebert et al., 2009

5. Depressive symptoms in MS and R: Results • 12% probable major depression (CES-D > 21) • 9.2% mild-moderate depression (CES-D 16-21) • MS more likely (25%) to be depressed than R (11.9%) • MS1, 2, 3 more likely depressed than MS4 • Women: significantly more depression (15.2%) than men (7.9%) Goebert et al., 2009

6. Depressive symptoms in MS and R: Results • 5.7% reported SI • SI significantly more frequent in those with major depression (68.5%) than mild-moderate depression (20.4%) • Respondents with h/o depression 3.7 more likely to report SI • Respondents with FH of depression 2.3 more likely to report SI Goebertet al., 2009

7. Depressive symptoms in MS and R: Results • Reported SI: MS 6.6% > R 3.9% • Highest rate SI: MS4 (9.4%) (different than previous studies) • No gender differences in SI • Ethnic differences: AA 13% > Hispanic 7.6% > Asian 6.3% > Caucasian 4.5% Goebert et al., 2009

8. MS illness and impairment • 9 medical schools, written survey exploring attitudes toward personal health care and potentially impairing illness in peers • Responders: 955 MS (52% response rate) • 3 vignettes: MS discovered to have serious sx and potential impairment due to mental illness, substance abuse, or diabetes Roberts et al., Compr Psychiatry 2005; 46:229-237

9. MS illness and impairment • Vignette 1: Your anatomy lab partner has become increasingly withdrawn over the last 4 weeks. Lately, she has been very irritable, tearful, and self-critical. Today, she talked about dropping out of medical school. She said that she does not care about life and has actually thought about effective ways to commit suicide. Roberts et al., Compr Psychiatry 2005; 46:229-237

10. MS illness and impairment • Physician impairment: the presence of a physical, mental, or substance-related disorder that interferes with the ability to practice medicine competently and safely

11. MS illness and impairment: Responses • “Tell no one but encourage him/her to seek professional help”: 50% women, 48% men • “Seek advice”: 38% women, 38% men • “Notify Dean’s office”: 12% women, 15% men • No difference whether mental/medical illness • Women more likely to preserve confidentiality • School-dependent (2 withhold, 4 more open) Roberts et al., Compr Psychiatry 2005; 46:229-237

12. Barriers to MS seeking care • Confidentiality concerns • Limited time, insurance, resources • Stigma • Perform self-diagnoses, informal consultations • Concern about seeking care from faculty at their medical school • Fear of documentation on academic record • Reluctance to report a colleague’s illness • “Culture of silence”

13. MS empathy and burnout • Minnesota medical schools (Mayo, U Minn x2) • 1,087 students • Interpersonal Reactivity Index (IRI): cognitive (perspective-taking) & emotive empathy • Burnout inventory: emotional exhaustion, depersonalization, personal accomplishment • QOL measure Thomas et al., JGIM 2007; 22:177-183

14. MS empathy and burnout • Burnout: professional distress syndrome that leads to decreased effectiveness at work • Dissatisfaction at work may “spill over” into professional life, but burnout is primarily related to professional sphere • Burnout ≠ depression (global impairment) • Prodrome? Thomas et al., JGIM 2007; 22:177-183

15. MS empathy and burnout: Results • Response rate 50% (545 MS, 54.6% women) • MS mean scores for both cognitive and emotive empathy higher than similar-age college students • No significant differences over 4 yrs of training or gender Thomas et al., JGIM 2007; 22:177-183

16. MS empathy and burnout: Results • Empathy scores inversely correlated with measures of burnout • ↑ depersonalization associated with ↓ empathy in both genders • ↑ emotional exhaustion assoc with ↓ emotive empathy in men, trend in women • ↑ personal accomplishment correlated with ↑ empathy in both genders

17. MS empathy and burnout: Results • Depressive sx correlated with ↓ cognitive & emotive empathy scores in women • Overall QOL correlated with empathy scores • Women: QOL social activity correlated with empathy scores • Women: cognitive empathy negatively correlated with years in school Thomas et al., JGIM 2007; 22:177-183

18. MS burnout and SI • 7 medical schools • Cross-sectional 2007, longitudinal 2006-07 • 2,248 student responders in cross-sectional, 858 MS longitudinal (5 schools) • Maslach Burnout Inventory, PRIME-MD • 50% reported burnout • 11% reported SI in previous year Dyrbye et al., Ann Int Medicine 2008; 149:334-341

19. MS burnout & personal life events • Minnesota, 545 MS (50% response rate) • 45% reported burnout • Frequency of + depression screen (PRIME-MD) and at-risk alcohol use decreased among more senior students; burnout frequency increased • No. negative personal life events in last 12 months stronger correlation with burnout than year in training Drybye et al., Acad Med 2006; 81;374-384

20. Race, ethnicity and MS well-being • 3080 MS, response rate 55% • 5 medical schools, 2006 • Classify ethnicity • Maslach Burnout Inventory, PRIME MD, SF-8 • Has your race adversely affected your medical school experience? • Depression, Burnout, Quality of Life (QOL) Drybye et al ., Arch Int Med 2007; 167: 2103

21. Race, ethnicity and MS well-beingResults • No difference in response rate by minority status • 50% of MS positive for depressive sxs (no differences between minority and non-minority) • 47% of MS met criteria for burnout • Non-minority students more likely to be burned out (p=.03) Dyrbye et al., 2006

22. Race, Ethnicity, and MS Well-BeingResults • Minority students (46 of 406) more likely than non-minority students (28 0f 1278) to report race adversely affecting medical school experience • Identified: racial discrimination, racial prejudice, feelings of isolation, interpersonal and communication differences Dyrbye et al., 2006

23. Race, ethnicity, and MS well-beingResults • Minority students who reported adverse effects of race were more likely than minority students who did not to: • meet criteria for burn-out (p=.001) • screen positive for depressive sxs (p=.004) • have lower mental QOL scores (p=.001) • Non-minority students who reported adverse effects of race were not more likely to experience burn-out, depressive sxs or lower QOL than their peers

24. Personal health care of residents • 141 R, UNMSOM 2000-2001 • Confidentiality concerns about receiving care at their institution (being seen by another resident, MS whom they supervise, or past or future attending) • Outside care preferred for mental illness • Women > men, primary care R > specialty R Dunn et al., Acad Psych 2008; 32:20-30

25. Mental illness in MD’s • Major depression lifetime prevalence in U.S. male MD’s: 12.8% (general population 12%) • Major depression prevalence in women MD’s 19.5% (= general population women) • Ethnic differences: Asian female MD’s lower • Suicide relative risk: 1.1-3.4 in male MD’s • Suicide relative risk: 2.5-5.7 in female MD’s Center et al., JAMA 2003; 289: 3161-3166

26. Struggling in silence • 300-400 physicians die each year by suicide • Methods: OD, firearms • Risk factors: depression (90%), alcohol abuse • Higher completion/attempt ratio • In general population, completed suicides by men = 4 x women • In MD’s, completed suicide by men = women American Foundation for Suicide Prevention

27. High risk for suicide MD profile • Male or female, white • Age: > 45 (female), > 50 (male) • Divorced/separated, single, marital disruption • Depression, bipolar d/o, anxiety • Alcohol, drugs (25% suicides while intoxicated) • Workaholic, risk-taker (high stakes gambler, thrill seeker) Center et al., JAMA 2003; 289: 3161-3166

28. High risk for suicide MD profile (cont.) • Physical symptoms (chronic pain, debilitating illness) • Change in professional status − threat to status, autonomy, security, financial stability, recent losses, increased work demands • Narcissistic injury • Access to means (legal medications, firearms) Center et al., JAMA 2003; 289: 3161-3166

29. Is it the environment? • Harvard Study of Adult Development: 47 MD’s • Only those with preexisting psychological difficulties evident at college entry had later psychiatric problems • No evidence of ↑ occupational stress in MD’s • Stressful events thought to precipitate suicide are often a result of the person’s behavior Center et al., JAMA 2003; 289: 3161-3166

30. Physician suicide • Physician personality: driven, perfectionistic, self-reliant (Gabbard JAMA 1985; 254: 2926-2929) • Combination of character vulnerability, mental illness, stressors, impulsivity, available means

31. Protective factors • Effective treatment for mental/medical illness • Family/social support • Resilience • Coping skills • Religious faith • Restricted access to lethal means Center et al., JAMA 2003; 289: 3161-3166

32. Barriers to MDs seeking care 35% MDs have no regular healthcare provider Discrimination in: • Medical licensing • Hospital privileges • Professional advancement Shift in professional attitudes & institutional policies needed to support MDs seeking help Center et al., JAMA 2003; 289: 3161-3166

33. Suicide rates among physicians: a meta-analysis • 25 international studies, 1966-2003 • Suicide rate ratios compared to general population in period/region under study • Male physicians: 1.41 x general population • Female physicians: 2.27 x general population Schernhammer & Colditz, Am J Psychiatry 2004, 161: 2295-2302

34. Iraq war veterans • 2008 U.S. army suicides in active members (128 confirmed, 15 pending investigation): fourth consecutive year of increasing rates • 20/100,000 soldiers (2008 = 2x 2005 rate) • Jan 2009: 24 suicides vs. 16 combat deaths in Iraq and Afghanistan The Canadian Press, 2/14/2009

35. Substance abuse • 2% MDs have active substance use problem • 8-18% MDs will be affected during lifetime • Emergency medicine residents CAGE scores: 12.5% c/w alcoholism vs. 1% estimated by PDs McNamara, Margulies, Ann Emerg Med 1994; 23:1072-1076 • Self-reported lifetime substance abuse and dependence: highest in psychiatrists, EM MDs Hughes et al., J Addict Dis 1999;18:23-37

36. Substance abuse • Self-reported past yr. use of alcohol, tobacco, MJ, cocaine, opiates, benzos • 5,426 MDs, 12 specialties • EM MDs: ↑illicit drugs • Psychiatrists: ↑ benzos • Anesthesiologists: ↑opiates • Surgeons: tobacco, lower rates o/w • Pediatricians: overall low rates Hughes et al., 1999 • If you suspect something is wrong, it probably is

37. Symptoms of Clinical Depression • Sad, anxious or “empty” mood • Sleeping too little or too much • Changes in weight or appetite • Loss of pleasure or interest in activities once enjoyed, including sex • Feeling restless or irritable

38. Symptoms of Clinical Depression • Trouble concentrating, remembering or making decisions • Fatigue or loss of energy • Feeling guilty, hopeless or worthless • Physical symptoms that do not respond to treatment • Thoughts of death or suicide

39. Other possible manifestations of depression in students/colleagues • Social isolation or withdrawal from peer group; avoidance of group activities • Missing classes • Drop in work or school performance, as evidenced by lower grades, less attention or focus on academic/work tasks • Pessimism and/or apathy about performance and attainment of future professional goals • Increased alcohol and/or substance abuse

40. Some warning signs of potential self-harm • Sudden improvement in mood in someone who has appeared depressed for a while • Tying up loose ends; finishing up tasks or responsibilities that have not been attended to for a long time • Giving away valued possessions to others • Not making plans or looking forward to future events

41. Approaching the Depressed Medical Student or Physician Colleague • Take the lead and be gently assertive: As a general rule, it is easier and safer for healers to be in the healing role and much harder to be in a position of vulnerability. Reach out and don’t wait for them to come to you. • Normalize their experience: Remind him/her of the difficult realities of medicine. Your training and your work is inherently stressful and challenging. Hence, feeling distressed or overwhelmed is natural at times. If you are comfortable, self-disclosure or sharing examples of others who have struggled can be powerfully validating.

42. Approaching the Depressed Medical Student or Physician Colleague Be a good observer: Do not tell someone how you think they may be feeling, as this could be experienced as either threatening or condescending. Rather, observe and reflect their behavior, and ask them to ascribe meaning (e.g., I notice you’ve been late to clinic/class a lot lately. How are things going for you?) • Be reassuring: Even though depression and other emotional problems can impact work performance at times, it doesn’t mean you’re a bad doctor. It means you need to take steps to take better care of yourself.

43. Approaching the Depressed Medical Student or Physician Colleague • Be willing to offer flexibility and space for the person to get the help they need: All the compassionate listening and caring for our students and colleagues won’t amount to much if we don’t offer real opportunities for students and staff to avail themselves of the resources they need in times of emotional distress. Furthermore, individuals probably need to hear very clearly that there will be no negative repercussions for them seeking and receiving help in times of need.

44. Approaching the Depressed Medical Student or Physician Colleague • Speak clearly and directly: Once the conversation is opened, don’t be afraid to use words like “depression” or “suicide.” If people are struggling with these issues, it can a relief to have an opportunity to discuss them. • Know your resources: Be ready to offer real help in the form of information about how a person in your environment can get help quickly, if necessary.

45. UCD Resources for Physicians and/or Medical Students • For Medical Students: Counseling and Psychological Services (CAPS) Emil Rodolfa, Ph.D., Director Ph: 530-752-0871 • For Residents: Graduate Medical Education Margaret Rea, Ph.D. Psychologist Ph: 916-734-0676

46. UCD Resources for Physicians and/or Medical Students • Medical Staff Health Committee Andreea Seritan, MD, Psychiatrist & Chair Ph: 916-734-5764 • For Faculty/Staff: Carol Kirshnit, Ph.D., Psychologist, Program Supervisor Academic & Staff Assistance Program Ph: 916-734-2727

47. Resources • National Mental Illness Screening Project 1-800-573-4433 www.nmisp.org • National Mental Health Association (NMHA) www.nmha.org • Campaign on Clinical Depression: Information on depression, its treatment and referrals to local screening sites: 1-800-228-1114 • NMHA Information Center: Free materials on a variety of mental health topics, and referrals to local organizations and support groups: 1-800-969-NMHA

48. Resources • National Institute of Mental Health • Information on depression and other mental illnesses: 1-800-421-4211 www.nimh.nih.gov • National Depressive and Manic-Depressive Association • Information on local patient support groups: 1-800-82-NDMDA www.ndmda.org

49. Resources • National Alliance for the Mentally Ill • Family support and self-help groups: 1-800-950-NAMI www.nami.org • American Psychiatric Association • Information and referrals to psychiatrists in your area: 1-888-852-8330 www.psych.org

50. Resources • American Psychological Association • Information and referrals to psychologists in your area: 1800-964-2000 www.apa.org or helping.apa.org • National Association of Social Workers • Information and referrals to social workers in your area: 1-800-638-8799 www.socialworker.org