The Suicide Prevention, Depression Awareness, and Clinical Engagement Program for Faculty and Residents at the University of California, Davis Health System

Suicide risk among residents and PhD students: A systematic review of the literature

Residents and PhD students (any discipline) are susceptible to various mental health issues, including suicidal thoughts and behaviors. This systematic review aimed to (1) estimate the prevalence of suicide-related outcomes among residents/PhD students and (2) assess the associated variables. PubMed, PsycINFO, and Scopus databases were searched for articles documenting quantitative information about suicide-related outcomes among residents and PhD students from inception until April 30, 2023. Sixty studies were included. Estimates of the current prevalence of the following suicide-related outcomes were: death wishes (DW), 9.1%; suicidal ideation (SI), 8.6%; suicidal planning (SP), 3.2%; non-suicidal self-injury (NSSI), 1.9%; suicide attempt(s) (SA), .8%. Additionally, estimates of the lifetime prevalence were: lifetime SI (L-SI), 25.9%; lifetime SP (L-SP), 10.0%; lifetime SA (L-SA), 3.1%. Depression, burnout, hopelessness, loneliness, low quality of the relationship with the supervisor and experiencing workplace mistreatment frequently co-occurred with the assessed outcomes. Many outcomes (DW, SI, SP, L-SI, L-SP, L-SA) had a higher prevalence compared to the general population, while some (SI, NSSI, SA) were lower compared to undergraduates. Interventions for individuals at risk in this population are vital together with the modification of the work environment and the promotion of a supportive academic and professional culture to reduce suicide risk.

Assessment of Adverse Childhood Experiences, Adverse Professional Experiences, Depression, and Burnout in US Physicians

OBJECTIVE

To assess associations of adverse childhood experiences (ACEs) and adverse occupational experiences (AOEs) with depression and burnout in US physicians.

PARTICIPANTS AND METHODS

We performed a secondary analysis of data from a representative sample survey of US physicians conducted between November 20, 2020, and March 23, 2021, and from a probability-based sample of other US workers. The ACEs, AOEs, burnout, and depression were assessed using previously published measures.

RESULTS

Analyses included data from 1125 of the 3671 physicians (30.6%) who received a mailed survey and 6235 of 90,000 physicians (6.9%) who received an electronic survey. The proportion of physicians age 29-65 who had lived with a family member with substance misuse during childhood (673 of 5039[13.4%]) was marginally lower (P <.001) than that of workers in other professions (448 of 2505 [17.9%]). The proportion of physicians age 29-65 who experienced childhood emotional abuse (823 of 5038 [16.3%]) was similar to that of workers in other professions (406 of 2508 [16.2%]). The average physician depression T-score was 49.60 (raw score ± SD, 6.48±3.15), similar to the normed US average. The AOEs were associated with mild to severe depression, including making a recent significant medical error (odds ratio [OR], 1.64; 95% CI, 1.33 to 2.02, P<.001), being named in a malpractice suit (OR, 1.30; 95% CI, 1.07 to 1.59, P=.008), and experiencing one or more coronavirus disease 2019-related AOEs (OR, 1.76; 95% CI, 1.56 to 1.99, P<.001). Having one or more ACEs was associated with mild to severe depression (OR, 1.58; 95% CI, 1.38 to 1.79, P<.001). The ACEs, coronavirus disease 2019-related AOEs, and medical errors were also associated with burnout.

CONCLUSION

Assessing ACEs and AOEs and implementing selective primary prevention interventions may improve population health efforts to mitigate depression and burnout in physicians.

Burnout Interventions for Resident Physicians: A Scoping Review of Their Content, Format, and Effectiveness

CONTEXT.—

Physicians face a high rate of burnout, especially during the residency training period when trainees often experience a rapid increase in professional responsibilities and expectations. Effective burnout prevention programs for resident physicians are needed to address this significant issue.

OBJECTIVE.—

To examine the content, format, and effectiveness of resident burnout interventions published in the last 10 years.

DESIGN.—

The literature search was conducted on the MEDLINE database with the following keywords: internship, residency, health promotion, wellness, occupational stress, burnout, program evaluation, and program. Only studies published in English between 2010 and 2020 were included. Exclusion criteria were studies on interventions related to the COVID-19 pandemic, studies on duty hour restrictions, and studies without assessment of resident well-being postintervention.

RESULTS.—

Thirty studies were included, with 2 randomized controlled trials, 3 case-control studies, 20 pretest and posttest studies, and 5 case reports. Of the 23 studies that used a validated well-being assessment tool, 10 reported improvements postintervention. These effective burnout interventions were longitudinal and included wellness training (7 of 10), physical activities (4 of 10), healthy dietary habits (2 of 10), social activities (1 of 10), formal mentorship programs (1 of 10), and health checkups (1 of 10). Combinations of burnout interventions, low numbers of program participants with high dropout rates, lack of a control group, and lack of standardized well-being assessment are the limitations identified.

CONCLUSIONS.—

Longitudinal wellness training and other interventions appear effective in reducing resident burnout. However, the validity and generalizability of the results are limited by the study designs.

Physician Suicide Prevention and the Ethics and Role of a Healing Community: an American College of Physicians Policy Paper

Suicide is a major global public health issue, and in recent years, there has been increasing recognition of the problem of physician suicide. This American College of Physicians policy paper examines, from the perspective of ethics, the issues that arise when individuals and institutions respond to physician suicides and when they engage in broader efforts aimed at physician suicide prevention. Emphasizing the medical profession as a unique moral community characterized by ethical and professional commitments of service to patients, each other, and society, this paper offers guidance regarding physician suicide and the role of a healing community. The response to an individual physician suicide should be characterized by respect and concern for those who are grieving, the creation of a supportive environment for suicide loss survivors, and careful communication about the event. Because suicide is a complex problem, actions aimed at preventing suicide must occur at the individual, interpersonal, community, and societal levels. The medical community has an obligation to foster a culture that supports education, screening, and access to mental health treatment, beginning at the earliest stages of medical training.

The Suicide Prevention, Depression Awareness, and Clinical Engagement Program for Faculty and Residents at the University of California, Davis Health

OBJECTIVE

The objective of the study is to present results of a depression and suicide screening and treatment referral program for physicians at an academic medical center.

METHODS

An anonymous web-based screening questionnaire was sent to all physicians at a large academic center. Responses were classified as indicating either high, moderate, or low risk for depression and suicide. Physicians at high and moderate risk were contacted by a counselor through a messaging system. The counselor's message contained information on risk level and an invitation to meet in person. High-risk respondents who did not reply to the message or declined to meet received mental health resources. Respondents who met with the counselor were offered individualized treatment referrals and to participate in a 1-year follow-up of self-reports every 3 months.

RESULTS

The questionnaire was sent to approximately 1800 residents, fellows, and faculty from February 2013 through March 2019. A total of 639 questionnaires were received, 100 were excluded for various reasons, and 539 were used to conduct analyses (14.4% response rate). The majority of respondents were classified at moderate (333 [62%]) or high (193 [36%]) risk for depression or suicide. Eighty-three respondents were referred for mental health care, and 14 provided data for the follow-up study.

CONCLUSIONS

Results of screening physicians for depression and suicide at one academic medical center highlight the challenges of engaging most of them in this activity and the satisfaction of the minority who successfully engaged in a treatment referral program.

Information and Communication Technology Use in Suicide Prevention: Scoping Review

BACKGROUND

The use of information and communication technology (ICT) in suicide prevention has progressed rapidly over the past decade. ICT plays a major role in suicide prevention, but research on best and promising practices has been slow.

OBJECTIVE

This paper aims to explore the existing literature on ICT use in suicide prevention to answer the following question: what are the best and most promising ICT practices for suicide prevention?

METHODS

A scoping search was conducted using the following databases: PubMed, PsycINFO, Sociological Abstracts, and IEEE Xplore. These databases were searched for articles published between January 1, 2013, and December 31, 2018. The five stages of the scoping review process were as follows: identifying research questions; targeting relevant studies; selecting studies; charting data; and collating, summarizing, and reporting the results. The World Health Organization suicide prevention model was used according to the continuum of universal, selective, and indicated prevention.

RESULTS

Of the 3848 studies identified, 115 (2.99%) were selected. Of these, 10 regarded the use of ICT in universal suicide prevention, 53 referred to the use of ICT in selective suicide prevention, and 52 dealt with the use of ICT in indicated suicide prevention.

CONCLUSIONS

The use of ICT plays a major role in suicide prevention, and many promising programs were identified through this scoping review. However, large-scale evaluation studies are needed to further examine the effectiveness of these programs and strategies. In addition, safety and ethics protocols for ICT-based interventions are recommended.

Conceptualizations of Mental Disorder at a US Academic Medical Center

How health care professionals conceptualize mental illness has received relatively little attention in existing literature. This survey explored how health care professionals, academic faculty, and trainees at a US academic medical center (departments of psychiatry, neurology, family medicine, and geriatric medicine, as well as medical students, nurses, and social workers) conceptualize the notion of mental disorder. Respondents (N = 209) were asked to rate their agreement or disagreement with a variety of conceptual statements. Overall, distress and impairment were seen as essential features of mental disorder, and the presence of a biological abnormality was not considered necessary. There was significant correlation between disease status and biological etiology attribution for all conditions except homosexuality. Psychology trainees and psychologists were significantly less likely to call a condition a disease compared with other groups. There was a general lack of consensus regarding conceptual issues fundamental to psychiatry. Conceptualizations of mental disorder held by respondents were complex and did not fit easily within the "biological psychiatry" paradigm.

Continuing Professional Development: Reflections on a Lifelong Learning Process

In the ever-changing fields of health care, continuing professional development (CPD) and lifelong learning are essential for patient care, regulatory requirements, personal growth, and job satisfaction. However, no specific systems in approaching CPD have been delineated, and most health professionals are left to their own devices to manage it, on top of all their other professional responsibilities. This article (1) outlines the importance of CPD, (2) describes potential systematic approaches to CPD and potential ways to assess their effectiveness, and (3) reviews resources available to incorporate into a systematic approach.

Adverse Childhood Experiences in Medical Students: Implications for Wellness

OBJECTIVE

The primary purpose of the study was to assess the prevalence of adverse childhood experiences (ACEs) in a cohort of third-year medical students and characterize their childhood protective factors.

METHODS

The authors developed a web-based anonymous survey distributed to all third-year medical students in one school (N = 98). The survey included the 10-item ACE Study questionnaire, a list of childhood protective factors (CPF) and questions to assess students' perception of the impact of ACEs on their physical and mental health. The medical school's IRB approved the student survey as an exempt study. The authors computed descriptive and comparative statistical analyses.

RESULTS

Eighty-six of 98 students responded (88% response rate). Forty-four students (51%) reported at least one ACE exposure and 10 (12%) reported ≥ 4 exposures. The latter were all female. The average difference in the ACE score between male and female medical students was - 1.1 (independent t test with unequal variances t(57.7) = - 2.82, P = .007). Students with an ACE score of ≥ 4 were significantly more likely to report a moderate or significant effect on their mental health, compared with students with scores ≤ 3 (chi-square test, P = < .0001). Most students reported high levels of CPF (median score = 13 of a maximum score = 14). ACEs and CPF were inversely associated (Pearson correlation = - 0.32, P = .003).

CONCLUSIONS

A sizeable minority of medical students reported exposure to multiple ACEs. If replicated, findings suggest a significant vulnerability of these medical students to health risk behaviors and physical and mental health problems during training and future medical practice.

Suicide Among Health Care Practitioners and Technicians in Colorado: An Epidemiological Study

Suicide is a public health concern with risks that vary between occupation groups. Many suicide victims with a health care occupation die by poisoning, but few studies have epidemiologically studied this association. The objective of this study was to quantify the increased risk of suicide death by poisoning among health care professionals in Colorado. Eleven years (2004-2014, N = 8,753) of suicide deaths in Colorado were compiled from the Colorado Violent Death Reporting System. A retrospective cohort study using multivariate logistic regression was conducted to examine the risk associated with having a health care occupation and eventual suicide death by poisoning, compared independently to firearm and hanging methods. Suicide victims with a health care occupation were more likely to die by poisoning rather than by hanging (RR 1.54, 95% CI: 1.41-1.68) or firearm (RR 1.79, 95% CI: 1.60-2.01), when compared to suicide victims without a health care occupation. The association between health care occupation and suicide method was significantly (p = .032) modified by gender. The results show that health care workers who die by suicide have an increased risk of eventual suicide death by poisoning rather than by firearm or hanging. These results can be used to inform tailored suicide prevention efforts in health care professionals.

Update on the UC San Diego Healer Education Assessment and Referral (HEAR) Program

Burnout, depression and suicide are rampant amongst health care professionals. Current evidence shows the problem is worsening. In the aftermath of physician suicides, the Physician Wellbeing Committee created the UC San Diego Healer Education Assessment and Referral (HEAR) Program in 2009 in collaboration with the American Foundation for Suicide Prevention (AFSP). This article chronicles the HEAR program from inception through June 2017. Initially created to address medical students, residents and faculty physician duress, HEAR has now expanded to embrace pharmacists, nurses and clinical staff within UC San Diego Health. HEAR operates through two mechanisms: 1) a program of ongoing education and outreach, and 2) encouragement of all personnel to annually engage in the online, anonymous, interactive screening program, created by the AFSP (known as SDSQ at UC San Diego Health). Since inception in May 2009 through June 2017, 1,537 UC San Diego health care personnel have been screened, 320 individuals have dialogued with a counselor either in person, by phone or electronically, and more than 300 have been referred confidentially for evaluation and treatment by a mental health professional, usually a community psychiatrist. While tracking death by suicide remains challenging, we have reason to believe that the prevalence of suicide has diminished during this time. The UC San Diego HEAR Program is one cost-effective model for addressing this current crisis in U.S. health care. This AFSP model has been adopted by many other schools of medicine and is now ready for use with clinicians of all disciplines.And whoever saves a life, it is considered as if he saved an entire world.— Mishnah Sanhedrin 4:5; Babylonian Talmud Tractate Sanhedrin 37a

Web-Based Tools and Mobile Applications To Mitigate Burnout, Depression, and Suicidality Among Healthcare Students and Professionals: a Systematic Review

OBJECTIVE

Being a healthcare professional can be a uniquely rewarding calling. However, the demands of training and practice can lead to chronic distress and serious psychological, interpersonal, and personal health burdens. Although higher burnout, depression, and suicide rates have been reported in healthcare professionals, only a minority receive treatment. Concerns regarding confidentiality, stigma, potential career implications, and cost and time constraints are cited as key barriers. Web-based and mobile applications have been shown to mitigate stress, burnout, depression, and suicidal ideation among several populations and may circumvent these barriers. Here, we reviewed published data on such resources and selected a small sample that readily can be used by healthcare providers.

METHODS

We searched PubMed for articles evaluating stress, burnout, depression, and suicide prevention or intervention for healthcare students or providers and identified five categories of programs with significant effectiveness: Cognitive Behavioral Therapy (online), meditation, mindfulness, breathing, and relaxation techniques. Using these categories, we searched for Web-based (through Google and beacon.anu.edu.au -a wellness resource website) and mobile applications (Apple and mobile. va.gov/appstore ) for stress, burnout, depression, and suicide prevention and identified 36 resources to further evaluate based on relevance, applicability to healthcare providers (confidentiality, convenience, and cost), and the strength of findings supporting their effectiveness.

RESULTS

We selected seven resources under five general categories designed to foster wellness and reduce burnout, depression, and suicide risk among healthcare workers: breathing (Breath2Relax), meditation (Headspace, guided meditation audios), Web-based Cognitive Behavioral Therapy (MoodGYM, Stress Gym), and suicide prevention apps (Stay Alive, Virtual Hope Box).

CONCLUSIONS

This list serves as a starting point to enhance coping with stressors as a healthcare student or professional in order to help mitigate burnout, depression, and suicidality. The next steps include adapting digital health strategies to specifically fit the needs of healthcare providers, with the ultimate goal of facilitating in-person care when warranted.

Burnout in Orthopaedic Surgeons: A Challenge for Leaders, Learners, and Colleagues: AOA Critical Issues

Burnout, depression, suicidal ideation, and dissatisfaction with work-life balance have been reported in all medical specialties and at all stages of medical education and practice experience. Burnout consists of progressive emotional, attitudinal, and physical exhaustion. Physicians with burnout may treat patients as objects and feel emotionally depleted. Burnout is characterized by a loss of enthusiasm for work (emotional exhaustion), feelings of cynicism (depersonalization), and a low sense of personal accomplishment. The most complete study of emotional burnout among different medical specialties demonstrated that orthopaedic surgery is one of the specialties with the highest burnout rate. Qualitative descriptive studies are available. There was a 45.8% burnout rate among physicians in the U.S. in 2012, and a 2014 update suggested even higher rates. Burnout has a correlation with medical education. Burnout rates are similar to those in the general population when medical students enter school, and increase steadily through medical education prior to residency. Burnout rates in residents are high, reported to be between 41% and 74% across multiple specialties. This impacts our young physician workforce in orthopaedics. The purpose of this review is to provide the available information that characterizes burnout and addresses the issues inherent to preventing burnout, and to build awareness in orthopaedic surgeons. Wellness "goes beyond merely the absence of distress and includes being challenged, thriving, and achieving success in various aspects of personal and professional life." The challenge for the orthopaedic community is to develop interventions and strategies that are personalized to the individuals in this specialty.

"I would never want to have a mental health diagnosis on my record": A survey of female physicians on mental health diagnosis, treatment, and reporting

INTRODUCTION

Physicians have high rates of suicide and depression. Most state medical boards require disclosure of mental health problems on physician licensing applications, which has been theorized to increase stigma about mental health and prevent help-seeking among physicians.

METHODS

We surveyed a convenience sample of female physician-parents on a closed Facebook group. The anonymous 24-question survey asked about mental health history and treatment, perceptions of stigma, opinions about state licensing questions on mental health, and personal experiences with reporting.

RESULTS

2106 women responded, representing all 50 states and the District of Columbia. Most respondents were aged 30-59. Almost 50% of women believed that they had met the criteria for mental illness but had not sought treatment. Key reasons for avoiding care included a belief they could manage independently, limited time, fear of reporting to a medical licensing board, and the belief that diagnosis was embarrassing or shameful. Only 6% of physicians with formal diagnosis or treatment of mental illness had disclosed to their state.

CONCLUSIONS

Women physicians report substantial and persistent fear regarding stigma which inhibits both treatment and disclosure. Licensing questions, particularly those asking about a diagnosis or treatment rather than functional impairment may contribute to treatment reluctance.