From the Editor
In December, the Readings included the Meta et al. paper from JAMA considering depression and residents. The review – which included more than 50 papers – found that the prevalence of depression or depressive symptoms among resident physicians was 28.8%.
Dr. David Goldbloom’s comment on the paper is worth repeating: “it is a sobering reminder that the white coat is not Kevlar against the illnesses we treat, and our professional culture still has a long way to go in recognizing, accepting and supporting that we get sick, too.”
This week we look again at physicians and mental health. The first selection is an essay by a doctor in which he discusses his suicidal thoughts. Then, with an eye on practical interventions to help doctors at risk, we consider the JAMA Psychiatry study on CBT for interns (with a modern twist).
The Doctor’s Story
“By the end of my first year as a doctor, I was ready to kill myself”
Anonymous, The Guardian
6 January 2016
On my morning drives to the hospital, the tears fell like rain. The prospect of the next 14 hours – 8 am to 10 pm with not a second’s respite from the nurses’ bleeps, or the overwhelming needs of too many sick patients – was almost too much to bear. But on the late-night trips back home, I’d feel nothing at all. Deadbeat, punch-drunk, it was utter indifference that nearly killed me. Every night, on an empty dual carriageway, I had to fight with myself to keep my hands on the steering wheel. The temptation to let go – of the wheel, the patients, my miserable life – was almost irresistible. Then I’d never have to haul myself through another unfeasible day at the hospital.
By the time I neared the end of my first year as a doctor, I’d chosen the spot where I intended to kill myself.
So begins a moving story of a doctor pushed to the edge.
The doctor notes: “Doctor suicide is the medical profession’s grubby little secret.” Even though it’s not much discussed, it’s not so uncommon. “Female doctors are twice as likely as the general population to take our own lives.”
What makes this essay so moving isn’t the statistics, but the author’s willingness to discuss his personal experience:
It wasn’t just exhaustion that drove me into depression. Plenty of jobs are busy. But there is something uniquely traumatic about being responsible for patients’ lives, while being crushed under a workload so punitive it gives neither the time nor space for safe assessment of those patients. Days were bad enough, but nights on call were terrifying.
A personal reflection: in my residency, I can’t recall ever having a conversation on this topic – with a colleague or a supervisor. A sign of the times: a resident writes about his experience; a newspaper is willing to publish the essay.
Fortunately, this doctor achieves recovery with medications and CBT. This leads us to a larger question: what can we do about suicidal ideation in residents?
Preventing Suicidal Ideation
“Web-Based Cognitive Behavioral Therapy Intervention for the Prevention of Suicidal Ideation in Medical Interns: A Randomized Clinical Trial”
Constance Guille et al., JAMA Psychiatry
Physicians are at high risk for suicide compared with the general population. A meta-analysis of physician suicide revealed that male physicians are 1.41 times more likely and female physicians are 2.27 times more likely to die by suicide compared with their counterparts in the general population.According to the American Foundation for Suicide Prevention, 300 to 400 physicians die by suicide each year, equating to approximately 1 physician dying by suicide every day.
Physicians in training are at high risk for suicide and suicidal ideation. A review of prospective studies conducted during 1982-2002 identified high rates of suicidal ideation among physicians during their first postgraduate year, or internship year. These findings are consistent with several studies demonstrating elevated rates of suicidal ideation in medical trainees.
So begins an important new paper published in JAMA Psychiatry.
The paper notes a significant problem: suicide among physicians is significantly higher than among the general population. Complicating a complicated situation: doctors tend to be reluctant to seek mental health treatment. What makes this paper so interesting is that the authors attempt to find an intervention to address this. (Hey, it’s my clinician’s bias: good studies identify problems; the best studies identify solutions.) And the paper has modern twist: the CBT used is web based (or wCBT, as they term it).
Essentially, the study authors did a randomized-controlled trial involving interns (PGY1s) at two hospitals.
Here’s what they did:
· Interns at two university hospitals were invited to participate three months before their training started (July 2009 or July 2011). The 352 interns were sent an email and offered gift cards.
· 199 agreed to participate and were deemed eligible. They were randomized into two groups. The Attention-Control Group (ACG) received four weekly emails with information on mental illness (including symptoms of depression, suicide and where to obtain treatment). The intervention group was directed by email each week to CBT exercises offered through a secure website.
· The web-based CBT program was MoodGYM; this Australian program is interactive, and consists of four-30 minute sessions.
· Both the ACG and intervention groups were emailed regularly for weeks after the first emails. The former group received more information; the latter group was invited to review a CBT module.
· Suicidal ideation was assessed using the 9th item on the PHQ-9. That scale was used at several points: 3 months before internship, then at 3, 6, 9 and 12 months into the first residency year.
· Statistical analysis was done including independent-sample t-tests.
Here’s what they found:
· 199 were randomized to either group. Of the 99 in the ACG, 15 were lost to follow up; of the 100 in the intervention group, 19 were lost to follow up.
· Demographics at a glance: the median age was 25.2; gender was roughly equal; 43% identified themselves as being members of a minority/racial group. There were no significant demographic differences between the groups.
· 82% completed at least one module in the intervention group. Two, three and four modules were completed by 78%, 65%, and 51%. (!)
· “Over the course of internship year, 12% of interns (12 of 100) in the wCBT group endorsed suicidal ideation during at least 1 follow-up assessment compared with 21.2% of interns (21 of 99) in the ACG.”
· After taking into account factors like gender and mental health history, “interns assigned to the wCBT group were 60% less likely to endorse suicidal ideation during internship year compared with those assigned to the ACG…” (!) See figure below.
· The wCBT effect size was 1.97; the number needed to treat was 11. (!)
The authors note:
To our knowledge, this is the first study to evaluate the feasibility, acceptability, and efficacy of an intervention that targets the high rate of suicidal ideation among medical interns.
In terms of a future direction, with an eye on the drop-out rate, they conclude:
Approximately half of interns assigned to wCBT completed all 4 of the assigned CBT modules. Future studies aimed at better understanding which modules are most effective at reducing suicidal ideation would be of great benefit. Further research is needed to better understand the mechanism by which wCBT reduces suicidal ideation among interns and to determine whether the positive benefits of wCBT on suicidal ideation are sustained over time.
· This is an important and timely study.
· There is much to like here. Suicide prevention works best when it’s targeted. The authors carefully pick a sub-population and use an evidence-based intervention (CBT).
· The paper runs with an editorial written by the University of Pittsburgh’s Charles F. Reynolds III. He notes: “The intervention is evidence based and efficient with respect to time and money, 2 barriers that impede treatment of clinical depression. As a web-based intervention, it is also private, circumventing the concerns that could attend face-to-face treatment. Finally, it also has the potential for scalability, pending further research in other training programs, that is, for expanded use by the 24 000 medical trainees who begin their first postgraduate year annually.”
· I’m enthusiastic, but not quite that enthusiastic. The results are both robust and problematic. On the one hand, interns did far better if they did the CBT modules – good. On the other hand, many people dropped out – ouch. That, unfortunately, is the problem with simple web-based interventions like MoodGYM. (In another paper looking at people with depression, the MoodGYM drop-out rate was 74%.) That’s not to suggest that web-based interventions can’t be used, but that a more interactive design may be needed to fully engage people.
Reading of the Week. Every week I pick a reading — often an article or a paper — from the world of Psychiatry.