Physicians, Residents, Medical Students: Burnout Syndrome, Depression and Suicide

1. Physicians, Residents, Medical Students: Burnout Syndrome, Depression and Suicide Rakesh Patel, MD, MBA, FACP Assistant Professor East Tennessee State University

2. Now Lets Talk About… DEPRESSION AND SUICIDE IN PHYSICIANS RESIDENTS MEDICAL STUDENTS

3. Goals and Objectives, cont • Learn to recognize burnout syndrome, depression, and suicidality in yourselves and educate medical students and residents to do so as well. • Better identify those physicians at high risk of suicide. • Conclude the need to establish regular source of health care and seek help for mood disorders, substance abuse, and/or suicidality.

4. I am a … • Medical Student • Resident • Psychiatrist • Other Physician • Psychologist/Therapist • All others not noted above who came to enjoy this lecture

5. Rank the professions from highest to lowest rate of depression. • Artist • Nursing Home Employee • Doctors and Nurses • Lawyers

6. Depression Among Professionals These include: • Nursing Home Employees and Childcare Providers • Food Service • Social Worker • Doctors and Nurses • Artist • Teachers • Secretaries and Administrative Support • Maintenance Workers • Financial Advisors • Lawyers Source: October 2007 report by the Office of Applied Studies, Substance Abuse and Mental Health Services Administration (SAMHSA), an agency within the U.S. Department of Health and Human Services.

7. Video http://www.doctorswithdepression.org/ American Foundation for Suicide Prevention Physician Depression and Suicide Prevention Project. American Foundation for Suicide Prevention.

8. What is Depression? • Common symptoms of depression: • Lost of interest in the things that were previously pleasurable • Depressed and Sadness • Hopelessness • Other may Include: • Anxiety • Increased feeling of guilt • Irritability • Impatience • Sleep disturbances • Tearfulness • Difficulty concentrating • Appetite changes (loss/gain) • Increased Isolation • Somatic Pain • Substance abuse

9. What is Major Depression? Per DSM-IV, at least 5 of the following symptoms and the symptoms cause distress or impairment in social, occupational, or other important functioning • * Depressed mood • * Decreased interest or pleasure in activities • Significant variations in weight or appetite. • Insomnia or Hypersomnia. • Psychomotor agitation or retardation. • Daily fatigue or energy loss. • Feelings of worthlessness or guilt. • Difficulties in concentration or decisiveness. • Recurrent thoughts of death or suicidal ideation, plan, or attempt. * One of these symptoms must be present

10. Depression in General • Estimated 19 Million Americans Suffer from Depression • Women suffer from depression twice as much as men. • Regardless of racial and ethnic background or economic status. • Depression in people 65 and older increases the risk of stroke and other medical complications. • The economic cost of depressive illnesses is $30 million to $44 billion a year.

11. Depression in General, cont • More Americans (24 million) suffer from depression than coronary heart disease (17 million), cancer (12 million), and HIV/AIDS (1 million). • Even though effective treatments are available, only one in three depressed people gets help. • Although most depressed people are not suicidal, two-thirds of those who die by suicide suffer from a depressive illness. • About 15 percent of the population will suffer from depression at some time during their life. Thirty percent of all depressed inpatients attempt suicide.

12. Depression in Our Profession • Depression is as common among the medical profession as the general population • Males: 12% • Females: 18% • However depression is more common in medical students and residents • Estimated at 15-30% (screen positive) • Preliminary study found that residents who experienced depression may be as much as 6 times more likely than nonaffected controls to make medication errors. Other studies have confirmed the association of depression with self-perceived medication and other errors. Shaw DL, Wedding D, Zeldow PB. Suicide among medical students and physicians, special problems of medical students. In: Wedding D, ed. Behavior and Medicine. 3rd ed. Hogrefe and Huber: 2001:78-9 (chap 6). Fahrenkopf AM, Sectish TC, Barger LK, et al. Rates of medication errors among depressed and burnt out residents: prospective cohort study. BMJ. Mar 1 2008;336(7642):488-91. West CP, Tan AD, Habermann TM, Sloan JA, Shanafelt TD. Association of resident fatigue and distress with perceived medical errors. JAMA. Sep 23 2009;302(12):1294-300.

13. Depression in Physicians • Again: Higher rates in medical students (15 – 30%) and Higher rates in interns and residents (30%)  Higher than the General Population. • Lifetime rates of depression in women physicians were 39% compared to 30% in age matched women with PhD’s  Higher than the General Population. • Lifetime rates of depression in male physicians (13%) may be similar to rates of depression in men in the general population, or they may be slightly elevated. Concerns of underestimating the prevalence secondary to limited self reporting Welneret al., Arch Gen Psych, 1979; Clayton et al., J Ad Dis, 1980; Frank & Dingle, Am J Psych, 1999 Wieclawet al., OccupEnviron Med, 2006; Center et al., JAMA, 2003; Valko& Clayton, Am J Psych, 1975 Kirsling& Kochar, PsycholRep, 1989

14. Let us now speak about… SUICIDE

15. Today I’m struggling with the awkward conversations regarding your death. “I would have helped if I had only known,” so many said. Did you fear losing the respect of your colleagues and coworkers if they had indeed known? The culture of medicine demands that physicians suppress vulnerability or need,1,2 and this ethos does not accept help-seeking behavior.2 1. Center C, Davis M, Detre T, et al. Confronting depression and suicide in physicians: a consensus statement. JAMA. 2003;289 (23): 3161–3166. 2. Miller NM, McGowen RK. The painful truth: physicians are not invincible. South Med J. 2000;93 (10):966–973.

16. How about Suicide!! It is estimated that on average ? Physicians commit suicide a year in the United States!

17. Answer is… • 100 -200 • 200 -300 • 300 - 400 • 400 - 500

18. Suicide In General • The latest data available from the Centers for Disease Control and Prevention indicates that 38,364 suicide deaths were reported in the U.S. in 2010. • This latest rise places suicide again as the 10th leading cause of death in the U.S. • Nationally, the suicide rate increased 3.9 percent over 2009 to equal approximately 12.4 suicides per 100,000 people. The rate of suicide has been increasing since 2000. This is the highest rate of suicide in 15 years.

19. Suicide in General Most recent figures from the Centers for Disease Control for the year 2010.All rates are per 100,000 population.

20. Suicide in General • Every 13.7 minutes someone in the United States dies by suicide. • Nearly 1,000,000 people make a suicide attempt every year. • 90% of people who die by suicide have a diagnosable and treatable psychiatric disorder at the time of their death. • Most people with mental illness do not die by suicide.

21. Suicide in General, cont • Recent data puts yearly medical costs for suicide at nearly $100 million (2005). • Men are nearly 4 times more likely to die by suicide than women. Women attempt suicide 3 times as often as men. • Suicide rates are highest for people between the ages of 40 and 59. • White individuals are most likely to die by suicide, followed by Native American peoples.

22. Physician Suicide • Positive: • Physicians worldwide have a lower mortality risk from cancer and heart disease relative to the general population • Physicians have decreased smoking and other common risk factors for early mortality * Source: Gagné P, Moamai J, Bourget D. Psychopathology and suicide among Quebec physicians: a nested case control study. Depress Res Treat. 2011;2011:936327.

23. Physician Suicide • Negative: • Physicians are reluctant to address depression, a significant cause of morbidity and mortality that disproportionately affects them. • Significantly higher risk of dying from suicide than the general population • Among Medical Students: after accidents, suicide is the most common cause of death. • To Note: • Suicide is usually a result of UNTREATED or INADEQUATELY TREATED DEPRESSION, connected with knowledge of and access to lethal means* * Source: Gagné P, Moamai J, Bourget D. Psychopathology and suicide among Quebec physicians: a nested case control study. Depress Res Treat. 2011;2011:936327.

24. Physician Suicide • Physicians have a higher rate of completion than the general population • 1.4 – 2.3 times higher • Interestingly Female physicians attempt suicide less than Males BUT same completion rate as males • So they are more likely to complete a suicide making them 2.5 – 4 times more than the general population.* * Sourcea: Frank E, Dingle AD. Self-reported depression and suicide attempts among U.S. women physicians. Am J Psychiatry. Dec 1999;156(12):1887-94. Schernhammer ES, Colditz GA. Suicide rates among physicians: a quantitative and gender assessment (meta-analysis). Am J Psychiatry. Dec 2004;161(12):2295-302

25. Physician Suicide, cont • Most common psychiatric diagnosis among those physicians that complete suicide: • Depression and Bipolar Disorder • Alcoholism and other Substance Abuse • Most common means of suicide by physicians • Medication Overdose and Firearms * Sourcea: Frank E, Dingle AD. Self-reported depression and suicide attempts among U.S. women physicians. Am J Psychiatry. Dec 1999;156(12):1887-94. Schernhammer ES, Colditz GA. Suicide rates among physicians: a quantitative and gender assessment (meta-analysis). Am J Psychiatry. Dec 2004;161(12):2295-302

26. Per the American Foundation for Suicide Prevention: Depression and Suicide • Each year in the U.S., roughly 300 to 400 physicians die by suicide. • Physician deaths from smoking-related illnesses decreased 40 to 60 percent after targeted educational campaigns to reduce smoking among physicians. Suicide rates among physicians are not decreasing, presumably because little attention has been paid to this issue. • Depression is a major risk factor in physician suicide. Other factors include bipolar disorder and alcohol and substance abuse.

27. Per the American Foundation for Suicide Prevention: Depression and Suicide, cont • There is no evidence that work-related stressors are linked to elevated rates of suicide in physicians. • Medical students have rates of depression 15 to 30 percent higher than the general population. • Contributing to the higher suicide rate among physicians is their higher completion to attempt ratio, which may result from greater knowledge of lethality of drugs and easy access to means.

28. Per the American Foundation for Suicide Prevention: Gender Statistics • In the U.S., suicide deaths are 250 to 400 percent higher among female physicians when compared to females in other professions. • Among male physicians, death by suicide is 70 percent higher when compared to males in other professions. • In the general population, males complete suicide four times more often then females. • However, female physicians have a rate equal to male physicians. • Women physicians have a higher rate of major depression than age-matched women with doctorate degrees. Source: AFSP’s Physician Depression and Suicide Prevention Project was launched in 2002, with a conference in San Diego. A consensus statement was later drafted and published in the Journal of the American Medical Association in 2003.

29. Profile of Physicians at High Risk of Suicide Silverman M (ed): Physicians and suicide, in The Handbook of Physician Health: Essential Guide to Understanding the Health Care Needs of Physicians. Edited by Goldman LS, Myers M, Dickstein LJ. Chicago, Il., American Medical Association, 2000 Center C, Davis M, Detre T, et al: Confronting depression and suicide in physicians: a consensus statement. JAMA 2003; 289:3161–3166

30. Why Us • Our own reluctance to recognize depression in our colleague • Many stating, “I never had any idea that he or she was suffering from …” • Our own reluctance to seek help (makes us look weak/unhealthy?) • When depressed physicians do reach out they may find only limited sympathy from their own colleagues Myers M, Gabbard G. The Physician as Patient: A Clinical Handbook for Mental Health Professionals. American Psychiatric Publishing; 2008.

31. Why Us, cont • Many clinicians are uncomfortable in treating fellow physicians in general, especially for mental health issues. * • Many times the first signs are physical /somatic complaints making depression harder to diagnosis. • Marital problems, Litigation Issues are common precipitants of depression Myers M, Gabbard G. The Physician as Patient: A Clinical Handbook for Mental Health Professionals. American Psychiatric Publishing; 2008.

32. Why Us, cont Medical licensure applications and renewal applications: • frequently require answering questions regarding the physician’s mental health history • may be out of compliance with the provisions of the Americans with Disabilities Act (ADA). • Some states allow physicians enrolled in treatment to be able to check “no” as long as compliant Polfliet SR. A National Analysis of Medical Licensure Applications. J Am Acad Psychiatry Law. 2008;36:369- 74. Altchuler SI. Commentary: Granting medical licensure, honoring the Americans with disabilities act, and protecting the public: can we do all three?. Acad Med. Jun 2009;84(6):689-91. Schroeder R, Brazeau CM, Zackin F, Rovi S, Dickey J, Johnson MS, et al. Do state medical board applications violate the Americans With Disabilities Act?. Acad Med. Jun 2009;84(6):776-81.

33. How about Malpractice Insurers? ANSWER THIS: Have you ever had an ILLNESS OR DISABILITY that impairs or could impair your ability to practice your profession. It is including but not limited to alcoholism, drug addiction, compulsive disorders, tremors, multiple sclerosis, or rheumatoid arthritis? If YES, the details required on a separate sheet must include the name and addressof your treating physician.

34. How about Malpractice Insurers? • Discrimination in obtaining insurance coverage is a common, but little publicized, problem for physicians with mental illness. • Health, disability, and liability insurance may all be denied to a physician who admits to depression. Louise B Andrew, MD, JD; Chief Editor: Barry E Brenner, MD, PhD, FACEP. Physician Suicide. Medscape. Updated: Mar 8, 2012

35. How about Malpractice Insurers?, cont • Even if disability insurance has previously been procured, its use may subject physicians to repeated humiliating and invasive examinations by detached and dubious “independent medical examiners” for the insurer, whose motivation is to cut company losses. • Many physicians affected by mental illness feel that insurers expect them to adhere to the standard prescription “physician, heal thyself.” Louise B Andrew, MD, JD; Chief Editor: Barry E Brenner, MD, PhD, FACEP. Physician Suicide. Medscape. Updated: Mar 8, 2012

36. Where do Physicians go for help in Tennessee? Tennessee Medical Foundation's Physicians Health Program(PHP) • Professional assistance to physicians suffering chemical dependence, mental or emotional illness, or both. • The PHP’s purpose is to protect patients from identifiably impaired physicians and to afford impaired physicians every opportunity to be rehabilitated to productive medical practice. Source: http://health.state.tn.us/boards/Me/complaints.htm

37. Where do Physicians go for help in Tennessee?, cont Tennessee Medical Foundation's Physicians Health Program(PHP) • Assist physicians and their families with a wider range of problems. • rage issues, inability to get along with other group members, and various psychological issues that inhibit a physician’s ability to practice his or her healing arts. • Success rate approaching 90 percent (ahead of the national par), the TMF-PHP intervenes with some 150-200 individual physicians, residents, and medical students across the state each year. • The PHP has developed a highly successful, professionally managed program to help salvage the practices—and the lives—of impaired physicians. Source: http://health.state.tn.us/boards/Me/complaints.htm

38. How Does the Physician’s Health Program Work? • Identification • The Tennessee Medical Foundation (TMF) maintains a 24-hour phone line for family members, patients, and co-workers to report, confidentially, their concerns about a physician. • Verification • The TMF PHP medical director and / or case managers attempt to verify the reported behavior. If the behavior is not verified, the process is halted or the information is held for further inquiry. • Interview • If the need for help is substantiated, the physician is asked to make an appointment for an interview with TMF PHP personnel. In exchange for support, the physician is invited to follow the recommendations of the PHP in seeking specified treatment at his or her own expense.

39. How Does the Physician’s Health Program Work?, cont • Treatment • All treatment is carried out in approved hospitals and treatment facilities. The length of treatment is based upon the physician's individual needs. Physicians affected by other emotional or behavioral conditions are treated with an initial evaluation and subsequently prescribed inpatient and / or intensive outpatient therapy. • Re-Entry • Re-Entry into practice usually occurs within one or two weeks following treatment. During this period, the PHP is often the physician’s strongest – and sometimes only- ally. The PHP medical director and case managers work in concert with the treatment center’s recommendations to establish contractual ground rules for re-entry into practice. • Aftercare • Aftercare is a minimum five-year process. It is guided by an individualized contract, comprised of recommendations of the PHP and the treatment facility. • Family Support. Active and comprehensive program for family members, which at a minimum includes: • Families of newly identified physicians are provided opportunities to receive help through support programs, sponsoring families, and professional therapist. • Caduceus Al-Anon groups are available. Meetings are held on a regular basis for the purpose of self-help and group therapy.

40. Where do Medical Students go when they need help? • PARC Program : Professional & Academic Resource Center • Single dwelling house in a residential neighborhood near the campus, which was selected for the privacy of students and student families. • Counseling services - individual, family, marriage, and group counseling. • Counseling services for medical students and immediate family are provided at no cost to Quillen students. • Respecting the students' need for privacy, every effort is made to protect the confidentiality needed for an effective therapeutic relationship. • To contact PARC, please call Phil Steffey • (423) 232-0275 • 24 Hour pager 854-0342

41. Where do Residents go when they need help? • ETSU’s Resident Assistance Program (RAP) is a confidential counseling and referral service for ETSU Medical School Residents and their Families. • GOALS: • encourage self referral so that you can be helped with training issues, personal and marital concerns before they lead to more serious difficulties. • assist residents with substance abuse problems through evaluation and treatment so as to reduce risk to patients and restore residents to health and effective training and practice. Substance abuse services are coordinated with the State programs of the Physicians Health Program of the Tennessee Medical Foundation. A department chair or program director may recommend that a resident see RAP services, but residents are especially encouraged to request consultation on their own

42. Who do they contact? • Dr. McGowen (Associate Professor of Psychiatry at ETSU) • You may call 24 hours a day, seven days a week for support and assistance when you need it. • Call: pager (423) 610-2048 - 24 Hours a Day. • She may arrange an appointment with you in her office to discuss various options. These discussions are completely confidential. • Your privacy is an important element of the RAP program. • The RAP program is completely independent of your department. • All conversations, over the telephone or in person, are confidential.

43. The services offered… • The majority of services are out-patient in nature. A range of in-patient and out-patient psychiatric services can be accessed, however, and include intensive individual and group psychotherapy for individuals and couples, medication management, and drug and alcohol rehabilitation and after care • The counseling sessions with Dr. McGowen are free to all residents and their immediate family members. If Dr. McGowen refers you to another physician, your health insurance through the University will cover the first six sessions at no cost for the resident and/or family member.

44. Educational Video The American Foundation for Suicide Prevention has created a video on the topic for physicians and other medical trainees http://www.afsp.org/index.cfm?fuseaction=home.viewPage&page_ID=9859BF59-CF1C-2465-128DAE02D3C9B309 American Foundation for Suicide Prevention Physician Depression and Suicide Prevention Project. American Foundation for Suicide Prevention.

45. For Further Information Resources related to physician depression and suicide: • American Foundation for Suicide Prevention at www.afsp.org • Black-Bile at www.black-bile.com