Transcript On the Other Side of the Stethoscope: Mental Health

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.
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
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
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
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
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
Goebert et al., 2009
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
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
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become increasingly withdrawn over the last 4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
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
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
Barriers to MS seeking care
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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”
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
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
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
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
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
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
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
Race, ethnicity and MS well-being
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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
Race, ethnicity and MS well-being
Results
• No difference in response rate by minority
status
• 50% of MS positive for depressive sxs (no
differences between minority and nonminority)
• 47% of MS met criteria for burnout
• Non-minority students more likely to be
burned out (p=.03)
Dyrbye et al., 2006
Race, Ethnicity, and MS Well-Being
Results
• 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
Race, ethnicity, and MS well-being
Results
• 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
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
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
Struggling in silence
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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
High risk for suicide MD profile
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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
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
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
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Physician suicide
• Physician personality: driven, perfectionistic,
self-reliant (Gabbard JAMA 1985; 254: 2926-2929)
• Combination of character vulnerability, mental
illness, stressors, impulsivity, available means
Protective factors
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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
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
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
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
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
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
Symptoms of
Clinical Depression
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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
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
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
Some warning signs of potential selfharm
• 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
Approaching the Depressed Medical
Student or Physician Colleague
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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.
Approaching the Depressed Medical
Student or Physician Colleague
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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.
Approaching the Depressed Medical
Student or Physician Colleague
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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.
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.
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
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
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
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
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
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