Preventing Physician Depression and Suicide Department of Psychiatry UNMC Top causes of death among residents #1 Neoplastic #2 Suicide Higher rates of death early in residency (first two years) Unchanged over the last 15 years Yaghmour  et al. Causes of Death of Residents in ACGME-Accredited Programs 2000 Through 2014: Implications for the Learning Environment. Acad Med. 2017 Jul;92(7):976-983 Suicides cluster at certain times of year Higher in the first (July) and third quarters (after winter holidays) of academic year Physician Suicide Is a Multi-Faceted Problem Individual factors The training environment Culture of medicine An estimated 400 physicians die by suicide in the US per year Center C, Davis M, Detre T, Ford DE, Hansbrough W, Hendin H, Laszlo J, Litts DA, Mann J, Mansky PA, Michels R, Miles SH, Proujansky R, Reynolds CF 3rd, Silverman M M (2003). Confronting Depression and Suicide in Physicians. JAMA, 289(23), 3161. Risk Factors for Suicide (1/2) Mental disorders (particularly depression) Alcohol and/or other substance use disorders Previous suicide attempt(s) Family history of suicide Impulsive or aggressive tendencies Easy access to lethal means (e.g., firearms) Losses and other events (e.g., the breakup of a relationship or a death, academic failures, legal difficulties, financial difficulties, or bullying) Isolation, a feeling of being cut off from other people Feelings of hopelessness US Public Health Service, The Surgeon General's Call to Action to Prevent. Suicide. Washington, DC: 1999. Risk Factors for Suicide (2/2) Trauma or abuse history Chronic physical illness, including chronic pain Exposure to the suicidal behavior of others Cultural and religious beliefs (e.g., belief that suicide is noble resolution of a personal dilemma) Unwillingness to seek help because of the stigma attached to mental health and substance use disorders or to suicidal thoughts Barriers to accessing mental health treatment US Public Health Service, The Surgeon General's Call to Action to Prevent. Suicide. Washington, DC: 1999. Suicide Warning Signs – Talk A person who is considering suicide may talk or write about: Killing themselves Death or dying Feeling hopeless, helpless or worthless Having no reason to live No sense of purpose in life Being a burden to others Feeling trapped Unbearable pain Suicide Warning Signs – Behavior Concerning behaviors, especially if related to a painful event, loss or change: Increased alcohol and/or drug misuse Searching for a way to end their lives, e.g., searching online for materials or means Withdrawing from activities Isolating from family, friends and community Reckless behavior or more risky activities, seemingly without thinking Sleeping too much or too little Tying up loose ends Visiting or calling people to say “goodbye” Giving away valued possessions to others Aggression Fatigue Not making plans or looking forward to future events Suicide Warning Signs – Mood A person who is considering suicide may display one or more of the following: Depression Anxiety Loss of interest Dramatic mood changes Irritability Humiliation Agitation Rage Sudden improvement in mood after he/she had appeared depressed for a while Predictors of Depression in Physicians Difficult relationships with senior doctors, staff, and/or patients Lack of sleep Dealing with death Making mistakes   Loneliness 24-hour responsibility Self-criticism Bright RP, Krahn L. Depression and suicide among physicians. Current Psychiatry. 2011; 10(4):16-30. Protective Factors Against Suicide Effective clinical care for mental, physical and substance use disorders Easy access to a variety of clinical interventions and support for help seeking Connectedness– Strong connections to individuals, family, community and social institutions Support from ongoing medical and mental health care relationships Skills in problem solving, conflict resolution and nonviolent ways of handling disputes Cultural and religious beliefs that discourage suicide and support instincts for self-preservation US Public Health Service, The Surgeon General's Call to Action to Prevent. Suicide. Washington, DC: 1999. Barriers to Treatment Social and professional stigma– Fear of recrimination by colleagues, facilities where they work, credentialers, or licensing boards Perceived lack of confidentiality– Fear that his/her illness will be documented in his/her academic record Accessibility– Difficulty finding a local provider who he/she trusts, but is not a colleague Reluctance to seek treatment Time constraints Affordability An attempt to diagnose and treat themselves Seeking and receiving “VIP treatment” from other health care providers Belief that treatment does not work Bright RP, Krahn L. Depression and suicide among physicians. Current Psychiatry. 2011; 10(4):16-30. Lack of Mental Health Treatment (1/2) Fears about the potential for seeking mental health care to negatively impact one’s professional reputation, ability to get or maintain licensure, or malpractice insurance are largely unfounded What is more likely to harm a physician’s reputation, licensure and insurance, are unaddressed and worsening mental health conditions Gold KJ, Sen A, Schwenk TL. Details on suicide among US physicians: Data from the National Violent Death Reporting System. General Hospital Psychiatry. 2013; 35(1), 45-49. Lack of Mental Health Treatment (2/2) In cases where physicians died by suicide, depression is found to be a significant risk factor leading to their death at approximately the same rate as among non-physician suicide deaths Physicians who took their lives were less likely to be receiving mental health treatment compared with non-physicians who took their lives Gold K J, Sen A, & Schwenk T L. Details on suicide among US physicians: Data from the National Violent Death Reporting System. General Hospital Psychiatry. 2013; 35(1), 45-49. Burnout Emotional exhaustion– Tired, nothing left to give, no pleasure Depersonalization– Cynicism, going through the motions, like a robot, automatic pilot Decreased sense of accomplishment– Never good enough, not worthwhile Stress and Productivity Approaching a Depressed 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 vulnerabiReach out and do not 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 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 have 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 does not mean you are a bad physician It means you need to take steps to take better care of yourself 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, trainees and colleagues will not amount to much if we do not offer opportunities for them 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 Speak clearly and directly– Once the conversation is opened, do not 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 Please see “Suicide Prevention” Resource Document provided by the GME office.