From the Editor

Mindfulness programs, apps for sleep, resilience training. More and more corporations are offering these types of wellness interventions. Indeed, employee mental health services have become a billion-dollar industry. As reporter Ellen Barry recently observed in The New York Times: “These programs are a point of pride for forward-thinking human resource departments, evidence that employers care about their workers.” But are employees actually feeling better?

In a new paper for Industrial Relations Journal, William J. Fleming (of the University of Oxford) used survey data involving more than 46 000 British employees from 233 organizations, and considered several well-being efforts – including, yes, mindfulness programs, apps for sleep, and resilience training. He looked at several subjective well-being indicators. “Results suggest interventions are not providing additional or appropriate resources in response to job demands.” We look at the study and its implications.

In the second selection, Marcus V. Ortega (of Harvard University) and his co-authors look at physician burnout over time, drawing on US survey data for JAMA Network Open. With the pandemic, not unexpectedly, they found that physicians reported more burnout. “Findings of this survey study suggest that the physician burnout rate in the US is increasing.”

And in the third selection, author Trina Moyles writes about her brother and his suicide in a deeply personal essay for The Globe and Mail. She discusses her grief, the reaction of others, and her attempts at finding closure. She argues that we need to speak more openly about this topic. “Suicide: The word fires like a gunshot, so I’ve found myself whispering it.”


Selection 1: “Employee well-being outcomes from individual-level mental health interventions: Cross-sectional evidence from the United Kingdom”

William J. Fleming

Industrial Relations Journal, 10 January 2024

The promotion of workers’ well-being is commonplace in the contemporary British workplace. The best estimates for the prevalence of corporate action on well-being come from the Chartered Institute of Personnel and Development who survey all employers annually. Their most recent data shows over half of UK employers report a ‘formal wellbeing strategy’, with another third providing at least ad hoc support. These counts rose steadily over the past decade, and it now seems safe to assume that a majority of British workers have some exposure to health and well-being narratives and policies…

The benefits of individual-level approaches have been extensively researched, as well as increasingly debated. There is a large scholarship of experimental work testing the effects of participation in initiatives, with systematic reviews of controlled trials for stress management, resilience training, mindfulness and more. Despite the apparent scale, there are continual calls for more evidence from practitioners and academic researchers, led in part by technical, methodological limitations, but also a desire for more realist evaluation.

So begins a paper by Fleming.

Here’s what he did:

  • He used the 2017 and 2018 data from the Britain’s Healthiest Workplace survey, “a multi-level, repeated cross‐sectional survey, with data collected at both employee and organisation levels.”
  • The survey included a list of 90 well‐being interventions.
  • He used several measures, including the Short Warwick–Edinburgh Mental Well‐Being Scale (SWEMWBS), a seven‐item scale that “was used as a measure of mental health as it most closely adheres to the positive dimension of worker mental well‐being addressed by these interventions.”
  • He did several analyses, including a clustered Bayesian PSA.

Here’s what he found:

  • The surveys included 46 226 workers from 233 organizations.
  • Demographics. “Financial and insurance services are slightly over‐represented in the survey coverage. Employee respondents are also all voluntary, and I make the similar assumption that those who complete the survey are those most engaged in well‐being discourses and practices. Internal response rates vary by organisation size, with larger employers having lower response rates on average. At the individual level, women, younger workers, those on mid‐to‐high incomes, and white workers are all overrepresented.”
  • No benefit. “For the following specific types of interventions, estimates indicate no difference between participants and nonparticipants: relaxation practices, time management, coaching, financial well‐being programmes, well‐being apps, online coaching, sleep apps and sleep events.” 
  • Positive benefit. “Volunteering is the only type of intervention to suggest benefits for workers’ well‐being.”
  • Negative benefit. “A negative estimate was calculated for resilience and stress management across all well‐being outcomes (except work engagement) and for mindfulness on Kessler, self‐rated mental health and life satisfaction.”

A few thoughts:

1. This is an impressive study, drawing on significant data and focusing on many common interventions. 

2. The interventions were collectively a bust. One exception: Workers who were given the opportunity to do volunteer work.

3. This summary doesn’t quite capture the nuance of the paper.

4. Among the limitations: the paper looked at one point in time. That begs the question: was the study tainted by selection bias? After all, the people who chose a mindfulness program, for example, may have had worse wellness to begin with. To address that, Fleming analyzed responses from workers with high pre-existing levels of work stress, comparing those who did and did not participate. Still, the programs didn’t seem to help. (!)

5. Are you surprised?

The full Industrial Relations Journal paper can be found here:

Selection 2: “Patterns in Physician Burnout in a Stable-Linked Cohort”

Marcus V. Ortega, Michael K. Hidrue, Sara R. Lehrhoff, et al.

JAMA Network Open, 6 October 2023

Physician burnout is described as a state of emotional, physical, and mental exhaustion caused by prolonged stress in the workplace. The causes of burnout are multifactorial, including loss of autonomy, high workload, and poor work-life balance. Physicians with burnout are more likely to make medical errors, have lower patient satisfaction scores, and have higher rates of absenteeism. Burnout exacerbates the already existing shortage of physicians in certain areas and specialties, leading to longer wait times and decreased access to care for patients. Furthermore, burnout is also associated with a reduction in the overall quality of care.

Available evidence suggests that the physician burnout rate is increasing. A large national survey study from nearly 10 years ago found an alarming level of physician burnout, with 45.8% of physicians reporting at least 1 symptom of burnout when assessed with the Maslach Burnout Inventory (MBI). During the COVID-19 pandemic, a few studies described a sharp increase in burnout rates in the US…

Although the physician burnout rate appears to be increasing nationally, analyses of burnout are often subject to multiple limitations that are common to survey methods.

So begins a paper by Ortega et al.

Here’s what they did:

  • “This survey study was conducted in 2017, 2019, and 2021 and involved physician faculty members of the Massachusetts General Physicians Organization. Participants represented different clinical specialties and a full range of career stages. The online survey instrument had 4 domains: physician career and compensation satisfaction, physician well-being, administrative workload on physicians, and leadership and diversity.”
  • The main outcome: physician burnout measured with the Maslach Burnout Inventory.

Here’s what they found:

  • 1 373 physicians participated in all 3 surveys – 72.9% of the original 2017 cohort. 
  • Demographics. The majority were male (50.3%) and White (67.1%), with the largest proportion of respondents (34.8%) reporting between 11 and 20 years of experience.
  • Response rate. The response rates were 93.0% in 2017, 93.0% in 2019, and 92.0% in 2021. 
  • Burnout. The burnout rate decreased from 44.4% in 2017 to 41.9% in 2019 and then increased to 50.4%. “Most physicians stayed in the same state of burnout throughout the 3 periods.”
  • Factors. Burnout was most associated with female physicians (OR, 1.47) and those practicing primary care (OR, 2.82); it was less associated with more experience (OR, 0.21).
  • Across time. Compared with 2019, in 2021 the Exhaustion score increased by 20.0% (RR, 1.20…), Cynicism score increased by 20.0% (RR, 1.20…), and Reduced Personal Efficacy score increased by 9.0% (RR, 1.09…).”

A few thoughts:

1. This is a nice study, looking at an important topic. The data is over three-time periods and included burnout subscales. Past work has been coloured by poor response rates; here, the response rates were robust.

2. The big finding in a sentence: “the odds of burnout doubled from 2019 to 2021.”

3. The significance? The authors see a connection to the pandemic. “We found increasing burnout during the pandemic. Pandemic-related uncertainties have also taken an emotional and physical toll at the personal level and affected the labor force scarcity. A study that investigated the workforce impact of the pandemic found that 3 in 4 physicians felt overworked and that half of the physicians were considering a change in employment during the pandemic.”

4. Are you surprised?

5. Of course, there are clear limitations, including that physicians were affiliated with one hospital in one state.

6. Past Readings have considered burnout. In one, we looked at a Perspectives paper from the NEJM. Dr. Srijan Sen (of the University of Michigan) argued that separating burnout from depression is problematic: “Expanding reform efforts to encompass depression and mental health more broadly will not reduce the urgency of reforming our health care system. Rather, it will increase the likelihood that physicians who are struggling can access the spectrum of available evidence-based individual interventions.”

That Reading can be found here:

The full JAMA Netw Open paper can be found here:

Selection 3: “We need to talk openly about suicide”

Trina Moyles

The Globe and Mail, 20 January 2024

I was filming a time-lapse of low clouds passing over an illuminated grain field when my parents called with the news that my brother had taken his own life.

It was a Sunday morning of the May long weekend. Nothing yet was in bloom. Even the buds on the deciduous trees remained tightly closed like clenched fists.

The words spoken aloud – ‘your brother killed himself’ – struck with a gale force. He was my only brother. Older by three years. He left without a note, or explanation.

I stared out at the field of equal light and shadow. The clarity of the moment severed me: My brother was gone and I wasn’t sure how I would go on living without him.

So begins an essay by Moyles.

She discusses people’s reactions. “‘Men are too good at ending their lives on their first attempt,’ a friend with a clinical mental-health background wrote. Another said that it was ‘better to treat it like a car accident.’ Someone even told me: ‘Don’t dwell on it.’ People’s judgments of my brother’s death filtered into conversations without invitation. ‘I’ve never understood how someone could do that,’ a colleague said to me, weeks after. ‘It’s just so selfish.’”

And she writes about her own reaction. “My grief felt vastly different – a world apart – from the grief of losing a loved one to cancer, a heart attack or a car accident. A part of me wished that he’d died in one of those emotionally cleaner, more understandable and socially acceptable ways. Where his death would be perceived as tragic, but also somewhat heroic, and I could mourn and speak openly about it without causing distress, or discomfort to others.”

Why do people think about suicide differently? “Maybe it’s because it wasn’t so long ago that someone who attempted to end their life could be imprisoned for it. Suicide was decriminalized in Canada in 1972, but the criminality associated with the act remains embedded in the way we talk about it. We use the expression ‘commit suicide’ as though it’s an individual, shameful act, and not a symptom of a much wider social phenomenon.”

She looks for answers. “After my brother died, I began to play journalist, even detective. I scrolled back to the last words I wrote to him, a text message that read (much to my devastation) ‘UGH, TRAFFIC,’ justifying the reason why I was nearly an hour late for dinner. I pored through messages that dated back to 2007 when we both joined social-media platforms. My mind replayed every memory, trying to find meaning buried in the way I remembered him, us, and our beautifully complicated life together as siblings.”

“I’m not convinced that my brother actively made a choice to leave, or that there was anything deliberate about what happened that morning. We would all later lament: but he was at his best. Building a house for his family. Managing a business. Coaching hockey. Yes, he struggled with anxiety and depression – as many of us do. Sometimes I wonder if his emotions were just too much, even for a split second, swept over by a tsunami of hurt. Maybe it was lightning-quick.”

Ultimately, she doesn’t really find answers, and recognizes our vulnerability. “Although we don’t like to admit it, maybe suicide is more random than we understand. We are fallible. We are fragile. Sometimes, we have dark thoughts. Sometimes, we make mistakes. I do not hold anger around the so-called ‘selfishness’ of my brother’s act. I empathize because I know it could’ve happened to anyone – even me.”

She concludes by calling for more openness in conversations about suicide. “[W]hen we do not avert our gaze from the subject, we help to ease the burning shame and suffering of those around us. Empathy grows from the ashes of loss the way fireweed blooms not long after a wildfire.”

A couple of thoughts:

1. This is both a beautiful essay and one that is tough to read – raw.

2. She makes good points about suicide and the larger stigma about mental illness. The Washington Post recently ran an article on obituaries acknowledging deaths by suicide. You can find it here:

The full Globe essay can be found here:

Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.