From the Editor
“Burnout is notoriously difficult to characterize.”
So comment the authors of a new American Journal of Psychiatry paper.
In recent years, we have been collectively speaking much more about physician burnout, but we often lack basic data. Using an online survey, Dr. Richard F. Summers (of the University of Pennsylvania) and his co-authors attempt to find out how common it is among North American psychiatrists. While there are many surveys of physicians, this one focuses on our specialty. What do they find? “Psychiatrists, like other physicians, have substantial burnout.”
In the second selection, we look at a new essay by Dr. Sally Satel (of Yale University). Writing in USA Today, she discusses the presidential campaign of Kanye West and the unusual comments that he has made. “None of this is funny.” She notes that he has a history of mental illness, and wonders how journalists should have covered the story.
Please note that there will be no Reading next week.
“Well-Being, Burnout, and Depression Among North American Psychiatrists: The State of Our Profession”
Richard F. Summers, Tristan Gorrindo, Seungyoung Hwang, Rashi Aggarwal, Constance Guille
The American Journal of Psychiatry, 14 July 2020 Online First
In 2017, the American Psychiatric Association (APA) Board of Trustees Workgroup on Psychiatrist Well-Being and Burnout was charged by Anita Everett, M.D., then president of APA, with studying psychiatrist well-being and burnout. The workgroup surveyed APA members to determine the prevalence of symptoms of burnout and depression and to identify demographic and practice characteristics that contribute to higher levels of burnout and depression.
Burnout is notoriously difficult to characterize, but Maslach’s definition points to emotional exhaustion, depersonalization, and decreased personal efficacy as key elements and conceptualizes burnout as a response of individuals to a stressful workplace. Burnout is regarded as an experience rather than as a diagnostic entity, and it is better understood dimensionally rather than categorically. By contrast, depression reflects specific psychiatric diagnostic characteristics and is conceptualized as an individual problem arising in response to a unique set of biological, psychological, and social vulnerabilities. There is a lack of consensus on the relationship between burnout and depression, with different authors viewing them as either the same or as different constructs.
Richard F. Summers
So begins a paper by Summers et al.
Here’s what they did:
- North American psychiatrists were invited to participate in an online survey, which was open from October 30, 2017, through December 10, 2018.
- The survey included the Oldenburg Burnout Inventory (or OLBI) and the Patient Health Questionnaire-9 (or PHQ-9). There were also questions about demographics and practice.
- With regard to the OLBI, the authors write that it is: “a 16-item scale designed to measure burnout across a wide variety of occupations that has been extensively used internationally. The OLBI was chosen because it includes questions that reflect both burnout and well-being and is highly correlated with the Maslach Burnout Inventory…”
- Statistical analyses were done, including a linear regression analysis.
Here’s what they found:
- A total of 2 588 individuals completed the online survey; after physicians from other specialties and non-physicians were excluded, the sample was 2 084 psychiatrists.
- “The sample was 58.5% female (41% of APA members are female), and the age breakdown reveals a higher proportion of resident-fellow and early-career psychiatrists in our sample than in the APA membership.”
- “The mean OLBI score of the sample was 40.4 (SD=7.9); 78% of respondents had scores that were above the cutoff score of 35, indicating a positive screen for burnout. The mean PHQ-9 score of the sample was 5.1… 16% of respondents had a PHQ-9 score ≥10, consistent with moderate to severe depression.”
- After the analysis, burnout scores were associated with depression, female gender, self-report of having no control over schedule, and practice in inpatient, community, government settings.
These data replicate the finding that psychiatrists, like other physicians, have substantial burnout. Although categorical cutoff points in burnout scales have questionable significance because burnout is best understood as a dimensional phenomenon, 78% of psychiatrists in our sample had OLBI scores above the cutoff score of 35. Although this is higher than the rate of 47% that Shanafelt et al. found using the Maslach Burnout Inventory, the rates cannot be directly compared even though the OLBI and the Maslach scale are highly correlated. Sixteen percent of our respondents reported moderate or severe depression, consistent with the range of estimates in the literature.
A few thoughts:
- This topic is important.
- Though some work has been done on the physician experience, the psychiatry focus is good.
- What group seemed to be particularly at high risk? “Our findings suggest that female psychiatrists appear to be at risk for high levels of both burnout and depression. This may in part explain the significant reduction in female physician work hours and attrition from medicine. Increased vulnerability to burnout and depression among female physicians has been hypothesized to be related to greater challenges with work-home balance, gender inequality in pay, sexual harassment, and frustration regarding greater aspirations for the extent of care they want to provide relative to male physicians and the constraints on their ability to do so.”
- The study runs with a short paper by Dr. Summers, “The Elephant in the Room: What Burnout Is and What It Is Not.”
“Burnout is not a medical diagnosis or illness…”
“Burnout is not a reflection of entitlement, millennial culture, laziness, or an erosion of standards in physician behavior.”
“Burnout is not depression, because it is a normal response to a stressful workplace, although there is substantial overlap between burnout and depression.”
“Burnout involves the loss of meaning in work, frequently a sense of curtailed autonomy, and almost always a loss of connection to community.”
“Burnout is an umbrella term for a wide range of experiences with similarities and significant differences. Burnout can include moral injury, anxiety, trauma, cognitive impairment, and functional difficulty. It may occur at any point in the career life cycle.”
“Burnout appears to be a risk factor for psychiatric problems, such as depression, anxiety disorders, substance use, posttraumatic stress disorder, and neurocognitive problems, as well as family and relationship problems.”
- Like all studies, there are limitations. The authors note the possibility of selection bias: “our sample may not be representative of psychiatrists nationally and is subject to selection bias.” After all, people struggling with burnout may be more interested in participating in such a survey. The overall number of participants was respectable (just over 2 000), but it isn’t robust compared to the total number of APA members (almost 39 000).
- Though there is much to like, the main finding – 78% of psychiatrists screened positive for burnout – seems very high. Is there a problem with the survey? Is there a problem with the screening tool itself? To return to the opening quotation: is burnout notoriously difficult to characterize, and notoriously difficult to capture meaningfully in a survey?
- Do you wonder what your OLBI score is? You can do the scale on the APA website:
- What to think about physician burnout and what are steps to address it? I did a podcast interview with Dr. Treena Wilkie, Deputy Physician-in-Chief, Medical Affairs and Practice, at CAMH. You can listen here:
The AJP paper can be found here:
“Take Kanye West’s illness more seriously than his presidential ambitions”
USA Today, 22 July 2020
On the Fourth of July, Kanye West, the billionaire hip hop star, tweeted that he was running for president. He quickly paid $35,000 to qualify for the ballot in Oklahoma and then filed paperwork with the Federal Election Commission.
The media rushed in. West, is an uber-celebrity married to uber-celebrity Kim Kardashian and a man given to wild, often amusing pronouncements. And so, his early riffs were treated as a humorous curiosity, a relief from the COVID-19 epidemic.
But what was happening here was not the least bit funny. You don’t have to be a psychiatrist (as I am) to know that West is not in a rational frame of mind. The proper reaction is neither to take him seriously nor to laugh at him.
So begins an essay by Dr. Satel.
She notes that West has a history of illness.
“West has a serious psychiatric condition: bipolar illness (once called manic-depressive illness). The Forbesjournalist who interviewed him on July 8 should have suspected it, especially when West said to him, ‘You know I was out there, ended up in the hospital, people were calling me crazy. I’m not crazy.’” She notes that he has been hospitalized in the past.
Dr. Satel focuses on some recent comments.
- “West will establish a new political party called the ‘Birthday Party’ because ‘when we win, it’s everybody’s birthday.’”
- “He is suspicious of a coronavirus vaccine, which he terms ‘the mark of the beast. They want to put chips inside us.’”
- “On July 19, West held his first campaign rally in Charleston, S.C. He broke down in tears, claiming his brain was too big for his skull.”
She also notes the concern of West’s wife, who has publicly spoken about being worried.
Dr. Satel expresses concern with the way journalists covered the story. She quotes Meg Kissinger of Columbia University School of Journalism: “It was the journalistic duty of the Forbes writer to mention West’s mental illness. It’s almost as if the article lampooned him. What is the point of an article without such context or perspective?”
How could the coverage have been different? Dr. Satel writes: “If journalists feel they must cover famous people when they are in the throes of mental illness, they must include information about their subjects’ known psychiatric history. Readers – and prospective voters – need context and subjects need dignity when they are vulnerable. The public should take the talented Mr. West’s disease seriously, but not his political plans.”
A few thoughts:
- This essay makes important points.
- Dr. Satel has written widely. Though some of her views are controversial, we should appreciate the clarity of her writing for a general audience.
- Stigma has faded. But is the coverage of West’s comments not an example of a society that remains fundamentally uncomfortable with discussing mental illness – or worse?
The full essay can be found here:
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.