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. Goals and Objectives • 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.

3. Lets First Talk About… BURNOUT SYNDROME

4. Burnout Syndrome: What is it? MaslachBurnout Inventory measures 3 main areas: • Emotional Exhaustion**measures feelings of being emotionally overextended and exhausted by one's work. Exhaustion is a depletion of emotional energy, distinct from physical exhaustion or mental fatigue. Emotional Exhaustion is a clear signal of distress in emotionally demanding work. • Cynicism or Depersonalization measures an unfeeling and impersonal response toward recipients of one's service, care treatment, or instruction. The depersonalization measured by this scale is a problem in careers that value and mandate personal sensitivity to service recipients. • Professional Efficacy/Accomplishment measures feelings of competence and successful achievement in one's work. This sense of personal accomplishment emphasizes effectiveness and success in having a beneficial impact on people. Source: Maslach Burnout Inventory. The leading measure of burnout. Christina Maslach, Susan E. Jackson, Michael P. Leiter, Wilmar B. Schaufeli, & Richard L. Schwab

5. The Questions on the Inventory 1) I feel emotionally drained from my work 2) I feel used up at the end of the day 3) I feel tired when I get up in the morning and have to face another day at work 4) I can easily understand how clients feel about things 5) I feel I treat some clients as if they were impersonal objects. 6) Working with people all day is a real strain for me 7) I deal effectively with the problems of clients 8) I feel burned out from my work 9) I feel I am positively influencing other peoples' lives through my work 10) I have become more callous toward people since I took this job 11) I worry that this job is hardening me emotionally 12) I feel very energetic 13) I feel frustrated by my job 14) I feel I am working too hard on my job 15) I don't really care what happens to some clients 16) Working with people directly puts too much stress on me 17) I can easily create a relaxed atmosphere with clients 18) I feel exhilarated after working closely with clients 19) I have accomplished many worthwhile things in this job 20) I feel like I am at the end of my tether 21) In my work, I deal with emotional problems very calmly 22) I feel clients blame me for some of their problems

6. Study done in June 2011 by Mayo Clinic and American Medical Association reported that nearly 1 in 2 U.S. physicians report at least one symptom of burnout. Source: “Burnout and Satisfaction With Work-Life Balance Among U.S. Physicians Relative to the General U.S. Population,” Archives of Internal Medicine, Aug. 20, 2012

7. Burnouts among doctors • HIGH Job Stress and LOW Personal Autonomy leads to higher chances of BURNOUT! • Increase prevalence among medical students, residents, and physicians.

8. Burnout Rates by Specialties Source: “Burnout and Satisfaction With Work-Life Balance Among U.S. Physicians Relative to the General U.S. Population,” Archives of Internal Medicine, Aug. 20, 2012

9. Please Answer This! “My Work Schedule Leaves Me Enough Time For My Personal/Family Life” • Strongly Agree • Agree • Neutral • Disagree • Strongly Disagree

10. Satisfaction with Work-Life Balance by Specialty Source: “Burnout and Satisfaction With Work-Life Balance Among U.S. Physicians Relative to the General U.S. Population,” Archives of Internal Medicine, Aug. 20, 2012

11. Does Physician Compensation Make a Difference on Satisfaction? Medscape Physician Compensation Report: 2012 Results

12. Burnout: Residents • In residents studies showed an average rates of burnout as high as 41-90% • The burnout levels increase quickly within the first few months of residency • Interestingly, ACGME changes to work hour duties for residents have showed decreased burnout rates moderately but… • In a study in published in 2005* noted: • 13% fewer residents experienced high emotional exhaustion • There was a trend toward fewer residents with high depersonalization (61% vs 55%; P = .13) • Fewer residents with a positive depression screen (51% vs 41%; P = .11). • Personal accomplishment did not change. • The assessment of self-reported quality of care did not significantly change from 2003 to 2004. • Residents reported attending fewer educational conferences per month (18.99 vs 15.56; P = .01). • Overall residency satisfaction decreased 6 mm on a 100-mm visual analogue score (P = .02). * GopalR, Glasheen JJ, Miyoshi TJ, Prochazka AV. Burnout and internal medicine resident work-hour restrictions. Arch Intern Med. 2005 Dec 12-26;165(22):2595-600.

13. Before and After ACGME Work Hour Restrictions Percentage of residents with high Maslach Burnout Inventory subscale scores by year. DP indicates depersonalization; EE, emotional exhaustion; and PA, personal accomplishment. Error bars indicate 95% confidence intervals

14. Studies examining burnout among residents Source: JAMA. 2004;292(23):2880-2889. doi:10.1001/jama.292.23.2880

15. What is a balanced life? Is this you?

16. Does Burnout Lead to Depression or Is It The Other Way Around? • Actually it can go both ways. • Lets look at in terms of the Conservation of Resources (COR) theory which is based on the presence of downward spirals. • Deficiency of resources in one area, which leads to the exhaustion of resources in other areas. • Depression  Lack of energy  Accelerated job burnout OR • Overburdened at work  Physical and mental exhaustion  Accelerate symptoms of depression

17. Decreasing Burnout • Notice self burnout and realistic recognition • Exercise: A study* show that Physical Exercise DOES decrease burnout and depression. • Supportive help and talking with others about issues and stressors • Professional resources • Forming firm Boundaries so to avoid increased stressand problems • Using Humor and Laughter • Finding Non-Medical Hobbies • Working in various clinical settings or changing up clinical duties periodically * Source: Toker, S., & Biron, M. (2012, January 9). Job Burnout and Depression: Unraveling Their Temporal Relationship and Considering the Role of Physical Activity. Journal of Applied Psychology.

18. Now Lets Talk About… DEPRESSION ANDSUICIDE IN PHYSICIANS RESIDENTS MEDICAL STUDENTS

19. Depression and Suicide Among Us Some Questions you may be thinking of. • What are the Overall professions with the highest to lowest rate of depression. • Why do physicians have higher rates of depression than the general population? • Which physicians specialty has the highest suicide rate? Others? • How do most physicians commit suicide? • Which gender of physicians has the higher suicide rate?

20. Depression Among Professionals • 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: Health Magazine. Information compiled from a 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.

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

22. 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

23. 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

24. 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.

25. 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.

26. 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.

27. 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

28. Let us now speak about… SUICIDE

29. How about Suicide!! It is estimated that on average 400 Physicians commit suicide a year in the United States!

30. 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.

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

32. 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.

33. 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.

34. 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: GagnéP, Moamai J, Bourget D. Psychopathology and suicide among Quebec physicians: a nested case control study. Depress Res Treat. 2011;2011:936327.

35. 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: GagnéP, Moamai J, Bourget D. Psychopathology and suicide among Quebec physicians: a nested case control study. Depress Res Treat. 2011;2011:936327.

36. 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. SchernhammerES, Colditz GA. Suicide rates among physicians: a quantitative and gender assessment (meta-analysis). Am J Psychiatry. Dec 2004;161(12):2295-302

37. 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. SchernhammerES, Colditz GA. Suicide rates among physicians: a quantitative and gender assessment (meta-analysis). Am J Psychiatry. Dec 2004;161(12):2295-302

38. 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.

39. 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 generalpopulation. • 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.

40. 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.

41. 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

42. 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.

43. 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.

44. 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. AltchulerSI. 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.

45. 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.

46. 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

47. 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

48. 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

49. 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

50. 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.