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Wellbeinganddistressareonacon3nuumofmentalhealth.

Over3me,ourindividualunderlyingriskandprotec3vefactorsinteractwitheverydaypsychosocialeventsleadingtoadynamicandcomplexinterac3on.Whilethehumancondi3onisontheonehandinherentlyandenormouslyresilient,therearespecificandknownriskfactorsthatcanimpedethatnaturalresilience.Someoftheseriskfactorsaregene3c/biological/psychologicalontheindividuallevel,andsomeareatthelevelofhome,community,andworkenvironment.

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BeforecomingtoAFSP,IservedasadeanforstudentsandmededatUCSD,andanimportantpartofmyownpath,isthatwehadlostanumberofpeopletosuicideovertheyears.By2002whenaprominentburnsurgeontookhislife,whichrockedourworld,wehadalreadynotedthelossofseveralothercolleaguesoverthepriordecade,andwhileeachonehasuniquecircumstances,westartedtowonderifwecoulddosomethingtopreventfurthertragiclosses.

TheMedicalStaffExecu3veCommiSeechargedthePhysicianWell-BeingCommiSee(PWBC)toconductananonymoussurvey.

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Theeduca3onalcampaignincludesGrandRoundstoallClinicalDepts,andotherkeygroupssuchasresidencyprogramdirectors,housestaffandstudents.

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RESEARCHSHOWSTHATTHEREAREMULTIPLE,INTERACTINGCAUSES/RFsforSUICIDEHereyoucanseethemul3-factorialnatureofsuicideriskthatstartswiththeunderlyinglayersof:-biologicalfactors(mentalillness,gene3csandbiologicalpredisposi3onsrelatedtoserotonin,dopamine,HPAaxis)-psychologicalfactors(suchastraitslikeperfec3onism,cogni3veinflexibility,humilia3on,waysofperceivingselfandinterpre3ngevents,ac3onsofothers)-pasthistory(familydynamic/rejec3on,h/ochildhoodabuse,familyhistoryofhealthproblems)

Thenaddthedynamicflowofmul3plelifeissuesandevents,superimposedonthoseunderlyingriskfactors:-includingrela3onships,financial,employment,onsetorongoinghealthproblems,currenttraumaorloss-foryoungpeople,stressesathome,schoolandwithpeerrela3onships,contagion-exposuretoapeerorcelebritysuicide

Thislayerofcurrentlifestressorsmayintersectwithaperson’sunderlyingriskfactors,suchasapersonwholoseshisjob,andhasah/omooddisorder(biological),andwhoseiden3tyandsenseofself-worthiscenteredonhisjob(psychological-senseofself),andwhosecogni3ontendstobeinflexible,soheseesnowayoutofthesitua3on.Thesefactorscancometogethertoleadtohopelessness,andalackofproblemsolvingorhopeforthefuture.Addtraitsofaggressionanddriveonthehopelessness,andaccesstomeans,andyouhaveahighrisksitua3on.

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Wecanseeglimmersofunderlyingfactorsbutsome3mestheyarecleareronceyouknowwhattolookfor.Totheoutsidepersonortothemedia,itcanbeverydifficulttoevenseetheunderlyingriskfactors.

Butthehumanmindseeksanswersandclosure,andwethink(appropriately)intermsofcauseandeffect.Soinmostcases,asuicidalactorcompletedsuicideisaSributedprimarilytoexternalfactorswithonlyglimpsesofthemoreinvisiblebutcri3calissues.Wemustlearntorecognizeriskfactorsandwarningsignssowecan“connectthedots”thatamounttoelevatedrisk.

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Anguishanddespairareextremelyprivate,internalexperiences.Whatgetsexpressedoutwardlyishighlyvariable,withsomeindividualswearingtheiremo3onsontheirsleeve,andotherskeepingtheiractualthoughtsandemo3onsfairlyhiddenfromview.ThisisthereasonpayingaSen3ontoevensubtlebutdis3nctbehavioralchangesthatrepresentadeparturefromtheperson’s“usualself”ispartoftheeduca3oninvolvedinsuicidepreven3on.

Andthisisawaytounderstandthecommonmisunderstandingaboutsuicidebeingcausedbyasingleeventorloss,orthemainfocusbeingonexternalevents.

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WewilldobeSeronceweunderstandthewarningsigns,thesignalsforchangesinMHandriskthatarepossiblepointsofinterven3on.

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Youcanthinkofmentalhealthdisordersas*Necessarybutnotsufficient*whenitcomestosuicide.

50-60%oftheMHproblemsincasesofsuicidearemooddisorderslikedepressionandbipolardisorder20%SubUsedisorders10-15%Psycho3cdisorders10%PersonalityD/OslikeBorderlinePDPTSD,Anxiety

Comorbiditybetweenmul0pleMHcondi0ons,and/ormedicalcondi0onsismorecommonthannot

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RoleofCULTURALFACTORS

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Forphysiciansthegendergapismuchmorenarrowsincefemalephysicians’suiciderateis2-4Xhigherthannon-physicianfemales,andformalesit’smoremodestlyelevated.

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Thereareregionalculturaldifferences,differingfirearmsownershiprates,anddifferinglevelsofaccesstohealthcare/MHcarefromoneareaofthecountrytothenext.Therearenotonlystatebystatedifferencesinsuiciderates,butcountytocountydifferencesaswell.

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Thistablepresentsthees3matedcasefatalityratefordifferentmethods.BecauseitcombinesdatasetsthatdidNOTincludeaSemptsthatdidnotpresentformedicalaSen3on,itoveres3matesthefatalityrateforpar3cularmethodslikeoverdose,sincemanypeoplewhooverdosedon’tgototheER.

ThistablecoversallU.S.suicidedeathsin2001andes3matedvisitstotheemergencydepartment(ED)fornonfatalself-harm(basedonana3onally-representa3vesampleofemergencydepartments).“CaseFatalityRa3o”(%fatal)isthepropor3onofcasesrecordedinayearthatarefatal.TheEDes3mateoverstatesED-treatedsuicideaSemptsbecausenon-suicidalself-harmcannotbedisaggregatedfromactualsuicideaSempts;atthesame3me,itunderes*matesnonfatalsuicidea1emptssincemanysuicidea1emptsdonotresultincare.

Source:VyrostekSB,AnnestJL,RyanGW.Surveillanceforfatalandnonfatalinjuries–UnitedStates,2001.MMWR.2004:53(SS07);1-57.hNp://www.cdc.gov/mmwr/preview/mmwrhtml/ss5307a1.htm

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EricaFrankatEmoryatthe3me,nowatUnivBC,2000NatlOccupa3onalMortalitySurveillancedatabase.Alldeathsbetween‘84-95.OccupcodedaccordingtoU.S.CensusBureau,anddeathcodedbyICD-9.Na3onalOccupa3onalMortalitySurveillancedatabaseandarederivedfromdeathsoccurringin28statesbetween1984and1995

FrankE1,BiolaH,BurneSCA.MortalityratesandcausesamongU.S.physicians.AmJPrevMed.2000Oct;19(3):155-9.AbstractCONTENT/OBJECTIVES:Norecentna3onalstudieshavebeenpublishedonageatdeathandcausesofdeathforU.S.physicians,andpreviousstudieshavehadsamplinglimita3ons.Physicianmorbidityandmortalityareofinterestforseveralreasons,includingthefactthatphysicians'personalhealthhabitsmayaffecttheirpa3entcounselingprac3ces.METHODS:DatainthisreportarefromtheNa3onalOccupa3onalMortalitySurveillancedatabaseandarederivedfromdeathsoccurringin28statesbetween1984and1995.Occupa3oniscodedaccordingtotheU.S.BureauoftheCensusclassifica3onsystem,andcauseofdeathiscodedaccordingtotheninthrevisionoftheInterna3onalClassifica3onofDiseases.RESULTS:AmongbothU.S.whiteandblackmen,physicianswere,onaverage,olderwhentheydied,(73.0yearsforwhiteand68.7forblack)thanwerelawyers(72.3and62.0),allexaminedprofessionals(70.9and65.3),andallmen(70.3and63.6).Thetoptencausesofdeathforwhitemalephysicianswereessen3allythesameasthoseofthegeneralpopula3on,althoughtheyweremorelikelytodiefromcerebrovasculardisease,accidents,andsuicide,andlesslikelytodiefromchronicobstruc3vepulmonarydisease,pneumonia/influenza,orliverdiseasethanwereotherprofessionalwhitemen.CONCLUSIONS:Thesefindingsshouldhelptoerasethemythoftheunhealthydoctor.Atleastformen,mortalityoutcomessuggestthatphysiciansmakehealthypersonalchoices.

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EvaSchernhammer(HarvardAssocProfofMedandEpid)Lookedatstudiesfrom1966-2003ofphysiciansuicidedeathratesfromanycountry.Found25studies,avoidedoverlapping3meframesandcountries.

Includedinthismeta-analysisare6U.S.studies:Rose,PiSs,RishandPiSs,GRO,Ullmann,Frank.AllU.S.ratesarerightshiredevenfurthertotherightofthedoSedline.

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SimilarmethodologybySchernhammer.13studiesmetthecriteriarelatedtowomenphysiciansuiciderates.

TheNa3onalViolentDeathRepor3ngSystem(NVDRS)isimplementedin32states(formerlyonlyin17atthe3meofthisstudy).Itisanimportantsuicidesurveillancemechanismandcombinesinfofrommul3plesources:deathcert,coronerdata,medicalexaminerinfo,toxicology,lawenforcement.

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hSp://www.ncbi.nlm.nih.gov/pmc/ar3cles/PMC3549025/#!po=34.0000

Non-physicianwerenon-MDprofessionals.

Physicianswereatsignificantlyhigheroddsthanthenon-physiciansofhavingan3psycho3cs(OR:28.7,CI:7.94–103.9,p<0.0005),benzodiazepines(OR:21.0,CI:11.4–38.6,p<0.0005),orbarbiturates(OR:39.5,CI:15.8–99.0,p<0.0005)presentontoxicologytes3ng.Therewasnosignificantdifferencewithrespecttoan3depressants,opiates,amphetamines,cocaine.Physicianswerelesslikelytohavebloodalcohollevelabove0.08percent.

Studymethodologycouldnotdiscernself-prescribingvintreatment.OtherstudiesfindlowratesofMHcareseeking,andhigherratesofselfandcolleague-prescribing(AdamsIntJSocPsych2010andSchwenkJClinPsych2008)

Itisspeculatedthatphysiciansuicideratesmaybeevenhigherduetomiscodingondeathcer3ficates,some3mesdeliberately.AdeathcanbecodedasanaccidentalODratherthaninten3onal.

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SenSetal.ArchGenPsychiatry.2010;67(6):(doi:10.1001/archgenpsychiatry.2010.41)

Context:Althoughtheprevalenceofdepressionamongmedicalinternssubstan3allyexceedsthatofthegeneralpopula3on,thespecificfactorsresponsiblearenotwellunderstood.Recentreportsofamodera3ngeffectofagene3cpolymorphism(5-HTTLPR)intheserotonintransporterproteingeneonthelikelihoodthatlifestresswillprecipitatedepressionmayhelptounderstandthedevelopmentofmoodsymptomsinmedicalinterns.Objec0ves:Toiden0fypsychological,demographic,andresidencyprogramfactorsthatareassociatedwithdepressionamonginternsandtousemedicalinternshipasamodeltostudythemodera3ngeffectsofthispolymorphism.Design:Aprospec0vecohortstudy.SeLng:ThirteenUShospitals.Par0cipants:Sevenhundredfortyinternsenteringpar3cipa3ngresidencyprograms.MainOutcomeMeasures:Subjectswereassessedfordepressivesymptomsusingthe9-itemPa3entHealthQues3onnaire(PHQ-9),aseriesofpsychologicaltraits,andthe5-HTTLPRgenotypepriortointernshipandthenassessedfordepressivesymptomsandpoten3alstressorsat3-monthintervalsduringinternship.Results:ThePHQ-9depressionscoreincreasedfrom2.4priortointernshiptoameanof6.4duringinternship(P.001).TheproporWonofparWcipantswhometPHQ-9criteriafordepressionincreasedfrom3.9%priortointernshiptoameanof25.7%duringinternship(P.001).Aseriesoffactorsmeasuredpriortointernship(femalesex,USmedicaleduca3on,difficultearlyfamilyenvironment,historyofmajordepression,lowerbaselinedepressivesymptomscore,andhigherneuro3cism)andduringinternship(increasedworkhours,perceivedmedicalerrors,andstressfullifeevents)wasassociatedwithagreaterincreaseindepressivesymptomsduringinternship.Inaddi3on,subjectswithatleast1copyofaless-transcribed5-HTTLPRallelereportedagreaterincreaseindepressivesymptomsunderthestressofinternship(P=.002).Conclusions:Thereisamarkedincreaseindepressivesymptomsduringmedicalinternship.Specificindividual,internship,andgene3cfactorsareassociatedwiththeincreaseindepressivesymptoms.

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S3gmareduc3onasacoretenantofeffec3vesuicidepreven3onstrategy:Preven3onprogramsthathavedemonstratedimpactonsuicideratesorproxiessuchassuicidalbehaviorincludes3gmareduc3on.Forexample,intheUSAirForcesuicidepreven3onprogram,s3gmareduc3onwasaprominentthemeinmanyofits11tac3cs.From1996through2002,a33%reduc3oninsuicideswasaccomplished(Knox2003).Byreducings3gmaandraisingawarenessamongalllevelsoftheforce,thisprogramtookanearlypopula3on-basedinterven3onapproachandtaughtmembershowtointerveneatthefirstsignsofdistressordysfunc3on,possiblylongbeforetheriskofsuicidewasimminent;whilealsorecognizingmorecri3calacutesignsofsuiciderisk.S3gmawasaddressedintheleadership,throughouttheranks,andwasalsogiventhebackingofpolicychangesthatprotectedtheprivacyandprofessionalreputa3onofthosewhowerereferredforhelp.(Knox2003)Inthisapproach,s3gmareduc3onisaprominentandcentraltenantaroundwhichmanyeduca3onalefforts,policychange,individualandgroupbehaviorisshapedinordertobecomeasafetynettorecognizesuicideriskandpreventsuicides.Thisisverysimilartotheapproachtowardsuicidepreven3oninaphysicianpopula3onIco-ledattheUniversityofCalifornia,SanDiegoSchoolofMedicine(Mou3er2012),whichI’mdelightedtosayiss3llgoingstrong.

Studiesofs3gmaandsuicideratesindifferentgeographicalregions:Methodologicallylessrigorousthanprospec3vestudydesign,aretheretrospec3veandcrosssec3onalanalysesthatlookforassocia3onsbetweenfactors.Byusingasta3s3calapproachcalledmul3plelogis3cregressionanalysis,theoddsthatpar3cularfactorsrelatetoeachothercanbecalculated.InaDutchstudyofs3gmaandhelpseeking,ReyndersetalcomparedvariousregionsofhighandlowsuiciderateswithintheNetherlands,andfoundthatinregionswithlowsuiciderates,peoplehavemoreposi0veaLtudestowardhelpseekingandexperiencelessselfs0gmaandshameaboutmentalhealthproblems.Conversely,intheregionwithahighersuiciderate,senseofs0gmaandshameaboutmentalhealthproblemswere

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Theprevalenceofself-iden3fieddepressioninUniversityofMichiganmedicalstudentsisconsistentwiththatfoundinseveralpriorstudies,approximately10%to25%dependingonseverityandthespecificinstrumentsused.4-5,10-12Moststudentswithhighdepressionscoresorwhohadthoughtsaboutsuicidedidnotreportacurrentorpastdiagnosisortreatmentofdepression.However,theself-percep3onofpreviousdepressiveepisodes,evenifnotformallydiagnosed,wassignificantlyassociatedwithbothhighdepressionscoresandtheprevalenceofsuicidalthinking.Theseresultssuggesttheimportanceofdevelopingamedicalschoolcultureinwhichmedicalstudentshavetheopportunitytodiscusstheirmentalhealthconcerns,irrespec3veofactualdiagnosisortreatment,inasafeandconfiden3alway.Wherethisdiscussionmightbestoccurisunclearbecausepoten3als3gmaisseenascomingfromseveralsources,includingotherstudents,facultymembers,andcounselors.Manymedicalschoolshavesmall-groupsezngsledbyfacultymentors,butapproachingtheseissuesinsuchavenuemayhaverisksandunintendedconsequencesthatwouldneedtobeexploredbeforeimplementa3on.Theprevalenceofdepressivesymptomsissignificantlyhigherinfemalethaninmalemedicalstudents,consistentwithpreviousstudiesofmedicalstudentsandphysicians.3-5,10-11Theriskofsuicidalidea3onwasalsohigherinfemalestudents,althoughnotreachingsta3s3calsignificance.Thesefindingsareconsistentwiththeknownincreasedriskofsuicidalidea3onaswellassuicidecomple3oninfemalephysicians.15Whencombinedwiththefindingthatmenweremorelikelythanwomentoagreethatdepressedmedicalstudentsmaybedangerousintheirpa3entcareandareundesirablemembersofthemedicalcareteam,theseresultssuggestpoten3aldirec3onsforfurtherstudyregardingsexdifferencesinhowmedicalstudentsexperiencetheireduca3onalenvironment.Therearealsodifferencesbetweenfirst-andsecond-year(preclinical)andthird-andfourth-year(clinical)medicalstudentsintheirviewsofdepression,withpreclinicalstudentsmorelikelytoendorsethatdepressedmedicalstudentswouldprovideinferiorcaretotheirpa3ents,areunabletocopewithmedicalschoolstress,andarelessintelligentthantheirpeers.Theseresultscouldreflectthean3cipatoryanxietyexperiencedbypreclinicalstudentsastheylookaheadtotheclinicalyearsorcouldsuggestthatmedicalstudentsmaybecomemoreaccep3ngandsuppor3veofdepressedstudentsastheybecomemoreclinicallyknowledgeableandexperienced.Educa3onal,preven3ve,andclinicalinterven3onsmayneedtobeframeddifferentlyforpreclinicalthanforclinicalstudents.

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Theminorityofmedicalstudentsscreeningposi3vefordepressionorsuicidalidea3onreceivementalhealthservices.Lackof3me,cost,confiden3alityconcerns,s3gmaandfearsofpuni3vesanc3onarethemostorencitedbarriers.Allofthesebarrierscanberemovedoratleastdiminishedbyconcertedac3on"fromthetopdown."

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“DoStateMedicalBoardApplica3onsViollatetheAmericanswithDisabili3esAct?”RobinSchroederetal,AcadMed2009ContentAnalysisof51medicalallopathiclicensingapplica3ons

FoundthatlessthanhalfstatesMedLicensingapplica3onques3onsfollowedthebasicstandardsofADAof1990

-Focusonimpairmentoffxnandsafeprac3ce-Timelimit-Offlimittopics

Thisstudyprovidesdetailedcharacteriza3onofthes3gmaperceivedbymedicalstudentsrepor3ngdepressionandthedifferencesbetweendepressedandnondepressedstudentsintheirbeliefsaboutthes3gmaofdepression.Comparedwithstudentswithlowself-iden3fieddepression,studentswithhighscoresmorefrequentlyagreedthattheopinionsofdepressedmedicalstudentswouldbelessrespected,thatthecopingskillsofdepressedmedicalstudentswouldbeviewedaslessadequate,thattheywouldbeviewedaslessabletohandletheirresponsibili3esbyfacultymembers,andthattellingacounseloraboutdepressionwouldberisky.Studentswithhighscoreswouldalsobelesslikelytoseektreatmentifdepressedthanwouldstudentswithlowscores.Thesedatacouldreflectthecogni3vedistor3onknowntooccurinpa3entswithdepression,32suchthatdepressedstudentscouldhaveaninaccurateandexcessivelynega3veviewofhowtheyareviewedbyotherstudents.Thedatacouldalsoindicateanaccuratepercep3onbydepressedstudentsthattheyare,infact,viewedaslesscapable.Thefindingsmayreflectamedicalschoolenvironmentinwhichdepressedstudentsares3gma3zedbecauseoftheirdiseaseratherthanonthebasisofperformance.Insuchanenvironment,revealingdepressiontofriends,facultymembers,andresidencyprogramdirectorscouldhaverealandadverseconsequences.Theseresultssuggestthatnewapproachesmaybeneededtoreducethes3gmaofdepressionandtoenhanceitspreven3on,detec3on,andtreatment.Thecharacteris3csofmedicaleduca3onemphasizingprofessionalcompetenceandoutstandingperformancemightbeexploredasreinforcing,ratherthanpoten3allysabotaging,factorsinthecrea3onofaculturethatpromotesprofessionalmentalhealth.Theeffec3vecareofmentalillness,themaintenanceofmentalhealthandeffec3veemo3onalfunc3on,andthecareofprofessionalcolleagueswithmentalillnesscouldbetaughtaspartoftheethicalandprofessionalresponsibili3esoftheoutstandingphysicianandbecomeacri3calcomponentoftheteaching,rolemodeling,andprofessionalguidancethatmedicalstudentsreceiveaspartoftheircurriculuminprofessionalism.

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