Out of the Silence: Medical Student Depression and Suicide A Companion Presentation Paula J. Clayton, M.D. Charles F. Reynolds III, M.D. Sid Zisook, M.D.

2 Suicide and Other Illness Rates Among Physicians Suicide  Little attention to problem  Suicide rate is higher than among the general population, especially among women physicians  Suicide rates in physicians are not changing  Depression is a major risk factor Smoking  Heightened attention to problem  Mortality rates from smoking- related cancer, heart disease and stroke are lower than for the general population  Smoking-related deaths have declined 40%–60% since 1960

3 Suicide Rates Among Physicians Standardized Mortality Rate Actual/Expected Actual/Expected  Male physicians/age matched males in the general population 1.41  Female physicians/age matched females in the general population 2.27 Schernhammer E, Colditz G, Am J Psych, 2004 Schernhammer E, NEJM, 2005

4 Schernhammer E, Colditz G, Am J Psych, 2004

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6 Suicide and Occupation Study in Denmark Methods  Subjects who died by suicide from 1991–1997 while aged 25–60 and for each, 25 controls of same gender who were born in the same year: 3,195 suicides (898 females), 63,900 controls ResultsRR  Highest risk of suicide is among medical doctors2.73  Higher risk of suicide by poisoning in physicians  Higher risk in females working in male-dominated occupations  Particularly high-risk in doctors who have been admitted to the hospital with a psychiatric disorder Agerbo et al., Psych Med, 2007

7 Suicide and Occupation Study in Denmark Suicide, five highest occupational rate ratios: Occupation DISCO-88* RR (95% CI) Highest Medical doctors (1.77–4.22) A residual group without occupation (1.87–3.28) Nursing associate professionals (1.34–3.11) Elementary occupations (largely unskilled manual workers) (1.47–2.68) Plant and machine operators and assemblers (1.22–2.76) *DISCO: Danish version of the International Classification of Occupations Agerbo et al., Psych Med, 2007

8 Additional Facts  In the general population, the male suicide rate is four times that of females; in physicians the rates are equal  Physicians have higher rates of completion to attempts which may result from greater knowledge of lethality of drugs and easy access to means Nordentoft M, Laegeforeningens Forlag Kobenhavn 2007, pp. 22

9 Risk Factors For Suicide Major risk factors include mental disorders:  Major depressive disorder  Bipolar disorder, depression  Alcohol abuse  Drug abuse  Other disorders

10 Epidemiology of Depression in Physicians Lifetime rates of depression in women physicians were 39 percent compared to 30 percent in age matched women with PhD’s, both being higher than the general population figures Lifetime rates of depression in women physicians were 39 percent compared to 30 percent in age matched women with PhD’s, both being higher than the general population figures 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 elevated. Data from Denmark using population-based case controls and hospital or outpatient care for a first-time ever diagnosis of depression (broadly define) show that male physicians have elevated rates of care 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 elevated. Data from Denmark using population-based case controls and hospital or outpatient care for a first-time ever diagnosis of depression (broadly define) show that male physicians have elevated rates of care Rates of depression are higher in medical students (15%–30%), interns (30%), and residents than in the general population Rates of depression are higher in medical students (15%–30%), interns (30%), and residents than in the general population Welner et al., Arch Gen Psych, 1979 Clayton et al., J Ad Dis, 1980 Frank & Dingle, Am J Psych, 1999 Wieclaw et al., Occup Environ Med, 2006 Center et al., JAMA, 2003 Valko & Clayton, Am J Psych, 1975 Kirsling & Kochar, Psychol Rep, 1989

11 Depression in Medical Faculty  A survey of physician well-being and health behaviors at an academic health center found that nearly 30 percent of respondents (attendings and house staff) reported past or present depressive symptoms. This correlated with female gender, younger age, living alone, and not having a primary care physician Reinhardt et al., Med Educ Online, 2005

12 Women Physicians and Addiction  969 impaired physicians from 4 state physician health programs Female: 125 Male: 844 Alcohol was primary abused substance for all WomenMen Age, average p < OR* OR* Med for psych problem Past suicidal ideation Current suicidal ideation Made attempt under influence Made attempt not under influence Abused sedatives *OR (odds ratio) >1.5 = statistically significant results Wunsch et al., J Add Dis, 2007

13 Another Risk Factor: Family History of Mood Disorders  Several of the studies with interns and physicians indicate that depressed physicians, compared to appropriate controls, had positive family histories of depression and more previous depressions Waterman, Jt Comm J Qual Patient Saf, 2007 Clayton et al., JAD, 1980 Valco & Clayton, Am J Psych, 1975 The Pharos, Winter 2008

14 Another Important Issue  There is no evidence that stressors in general are linked to elevated rates of suicide in physicians Gross et al., Arch Intern Med, 2000

15 Access of Care and Barriers to Care  35 percent of physicians do not have a regular source of health care  Low rates of seeking help among medical students: –Only 22 percent of those screening positive for depression used mental health services –Only 42 percent of those with suicidal ideation received treatment  Reasons: –lack of time (48%) –lack of confidentiality (37%) –stigma (30%) –cost (28%) –fear of documentation on academic record (24%) Gross et al., Arch Intern Med, 2000

16 Access of Care and Barriers to Care cont.  Among practicing physicians, barriers to mental health care include: –discrimination in medical licensing –hospital privileges –health insurance –malpractice insurance Miles SH, JAMA, 1998 APA, Am J Psych, 1984

17 Additional Barriers to Adequate Mental Health Care for Physicians  Professional attitudes that broadly discourage admission of health vulnerabilities  Professional attitudes and lack of knowledge about psychiatric illnesses  Physician-patients’ concerns about breaches of confidentiality by the treating clinician  Compromised treatment due to collegial relationships; deference from the treating clinician may give more freedom to the physician- patient to control the focus of therapy and to self-medicate

18 Licensing and Physician Mental Health  Invited analysis of all State Medical Boards on policies regarding mental illness  35/50 responded  37 percent indicated that a diagnosis of mental illness was sufficient for sanctioning (although only 69% of these asked about it)  40 percent indicated that the diagnosis of substance abuse was sufficient for sanctioning and the majority had questions about it  Survey urged that sanctioning be on basis of impairment for physical or psychiatric illness  Arkansas and 18 other states focus on impairment Hendin et al., Fed Bull, 2007

19 Suicide Inquiry in Primary Care Using standardized depressed patients with 154 participating physicians. In 36 percent of 298 encounters, suicide was explored. It was significantly more likely to happen when:  the “patient” portrayed major depression  if the “patient” made a request for an antidepressant  in an academic setting  among physicians with personal experience with depression Feldman et al., Annuals of Family Med, 2007

20 Patient Vignette: A Depressed Medical Student  Patient: Blanca Blanca is a first-year medical student at a large West Coast university. Having always been an outstanding student, Blanca was overwhelmed with anxiety when struggling with her academics for the first time. She recalls feeling both distracted by her sadness and hampered by her anxiety while attempting to study for exams. Yet, like many others, Blanca did not recognize her feelings as being symptoms of depression and anxiety. Initially, Blanca’s fear that therapy would be just another stressor in her already-packed schedule prevented her from seeking treatment. Eventually she became so desperate to “fix” her mental state that she visited a physician. Upon being assessed, Blanca was referred to a psychiatrist and began taking medication for both depression and anxiety. She also participated in talk therapy with the

21 Patient Vignette: A Depressed Medical Student cont. school psychologist. Blanca admits that upon hearing of her diagnoses — major depression and generalized anxiety disorder — she was taken by surprise. Indeed, her reaction typifies that of many newly diagnosed individuals: “It was hard to take. Because there’s always the sense of that’s never me. ‘That’s never going to be me.’ But it was.” Though Blanca recognizes that receiving treatment does not lighten the work load of medical school, she does feel very strongly that the combination of medication and therapy has helped her to handle her work, and her life, more efficiently. Blanca now uses her experiences to help other medical students, as part of a peer mentoring group.

22 Patient Vignette: A Depressed Surgeon  Patient: Robert Robert is a plastic surgeon who practices in the Midwest. Like so many others, he did not consider the possibility that he was depressed until someone else suggested it to him. He recalls having a professor in medical school tell him that he needed to “get over” being depressed if he wanted to go on to become a doctor, a reflection of the attitudes held toward medical students and doctors seeking treatment for mood disorders. Though many, and indeed perhaps most, depressed people find it nearly impossible to be productive at work, Robert found that the more time he devoted to work, the less time he had to feel depressed. While his intense drive to work benefited Robert with regard to his career, he felt as though the rest of his life was suffering for it.

23 Patient Vignette: A Depressed Surgeon Despite his unhappiness, Robert was reluctant to seek treatment, mainly due to concerns over stigma. The stigma attached to a physician receiving psychiatric services has the potential to affect many aspects of his career, including his referral base, his reputation as a competent physician, both among colleagues and patients, and even his license to practice medicine. Once he finally did enter treatment, Robert was happy to learn that his concerns were unfounded, and his career — and his life — only benefited from his decision to get treatment. His only regret is that he did not seek treatment sooner, as he feels that the years he spent denying his depression were wasted. Invigorated by his new outlook on life, Robert is now leaving his plastic surgery practice and pursuing a lifelong dream, to work in a hospice.

24 Patient Vignette: A Bipolar Physician  Patient: Alice Alice is a neurologist specializing in movement disorders at a prestigious hospital in the Northeast. She began experiencing intense feelings of sadness after delivering stillborn twins, which she attributed to the grieving process. She dismissed others’ comments that she seemed withdrawn and depressed. In fact, Alice did not begin to recognize anything unusual within herself until she began experiencing what she calls “extreme agitation” wherein she felt that her mind was overwhelmed with ideas. Wanting to keep track of this constant flow of ideas, Alice began to write compulsively (known as “hypergraphia”). She filled countless notebooks, and when there was no paper around, she even wrote on her own skin. Although this type of behavior could cause a disruption of a person’s normal functioning, Alice felt good about her

25 Patient Vignette: A Bipolar Physician cont. urge to write. Indeed, she says it felt “like I was doing work.” Alice also recalls that she felt no need to see a psychiatrist, and only relented once her Chairman suggested she should. Once her treatment began, Alice received what she calls “significant” medication therapy and participated in psychotherapy (“talk therapy”). While she feels that the majority of her psychological improvement came from the medication, she also acknowledges that the psychotherapy helped her to deal with her feelings more adequately. As she learned more about the mania that enveloped her, Alice’s scientific curiosity was piqued. Eventually Alice felt compelled to write a book, The Midnight Disease, that combined her personal experiences with those of famous writers, as well as medical case histories. Alice now uses her experience with bipolar illness to help her understand her patients better.

26 Discussion Questions 1. What are your first thoughts after seeing this video? 2. How many of you DO NOT have a close friend or relative who has had a major depressive episode? For those who haven't, are you surprised that you are in the minority on this? 3. How many of you DO NOT have a close friend, relative or classmate (that you know of) on a SSRI? 4. How many of you have had a close friend, relative or classmate who has taken their own life? Are any of you surprised at the high number? Were you aware before this morning that the suicide rates are higher among medical students and physicians than our non-medical counterparts?

27 Discussion Questions cont. 5. If medical students tend to be smarter than average, relatively healthy, have excellent resources available to them and know more about health promoting behaviors than most, wouldn’t you expect the rate of depression to be lower than in the general population for young adults? Is it? Why Not? How do you explain the "paradox"? 6. Some studies have found higher than expected rates of suicide among medical students. Do you have any ideas why that might be the case? Any other ideas? 7. In the general population, men have higher rates of suicide than women. Among physicians, however, women physicians have rates equal to male physicians. Do you have any ideas why that might be the case? 8. What should we as a medical profession be doing about it?

28 Discussion Questions cont. 9. In the video, could Blanca just as easily have been a man? Would her story and treatment be as believable? Would she be as open to being taped? 10. In what ways do you identify with the feelings expressed in the video about the White Coat ceremony? About what happens in the way you feel about yourselves in the ensuing months? 11. At least 3/4 of you are no longer in the upper 1/4 of everything you do. Is anyone willing to comment on what that feels like? What are some of the other stresses unique to being a medical student? Which of those do you think can be remedied by feasible “coping” strategies? Any examples of some of those strategies that have worked?

29 Discussion Questions cont. 12. The video talked about stigma and other roadblocks to care. Is any of that true at our school? Do any of you have any ideas what we can do about it? 13. In you heart of hearts, do you see major depression as an illness? Is it something like laziness or self-pity that you can will yourself out of; is it more like diabetes that happens to us, but that we can do a lot regarding lifestyle changes to control; or is more like a developmental disorder that is pretty much out of our control? How do you think most psychiatrists would answer that question? What about most orthopedic surgeons? Most medical school deans? Your classmates? Your parents? Your future patients?