Underrecognition and un-dertreatment of stress-related psychiatric disorders in physicians: Determinants, challenges, and the impact of the COVID-19 pandemic

Medical practitioners’ duties are highly stressful and performed in a particularly challenging and competitive work environment. Stress and burnout among physicians have emerged as a worldwide public health problem in recent years. A high level of distress and burnout can lead to clinically significant behavioral health problems, such as stress-related psychiatric disorders. Mounting evidence shows that physicians have higher risks of insomnia, anxiety, and depression than the general population, especially during the coronavirus disease 2019 pandemic. However, the behavioral health problems of these vulnerable healthcare professionals are noteworthy for being underrecognized and undertreated. In this mini-review, we summarize the current progress of studies on the prevalence and determinants of distress and stress-related psychiatric disorders among phy-sicians and their healthcare-seeking behaviors. We discuss future research directions and the clinical approach that may maximize self-awareness and promote prompt and adequate treatment for clinically significant behavioral health problems of physicians.

Risks of treated anxiety, depression, and insomnia among nurses: A nationwide longitudinal cohort study

The high level of occupational stress and burnout among nurses can lead to insomnia, anxiety, and depression. However, the actual risks for healthcare-seeking for these stress-related mental health problems among nurses are still unclear. The aim of this study was to explore the risks and influencing factors of treated anxiety, depression, and insomnia among nurses. We used claims data obtained from the 2010 National Health Insurance Research Database (NHIRD) in Taiwan. Hospital nurses who had at least 3 coded ambulatory care claims or 1 inpatient claim with a principal diagnosis of anxiety, depression, or insomnia were identified. A cohort of 46,120 nurses and 92,240 matched controls were included. All the study subjects were followed up until the onset of any of the aforementioned outcomes, death, or the end of 2012. Results showed that the adjusted hazard ratios (HRs) for treated anxiety, depression, and insomnia among all the nurses were 0.91 (95% CI, 0.88–0.95), 0.59 (95% CI, 0.55–0.63), and 1.43 (95% CI, 1.38–1.48), respectively. Furthermore, the risks of these psychiatric problems in healthcare-seeking nurses were affected by age, gender, hospital level, and job tenure. Our findings suggest that hospital nurses have lower hazards of treated anxiety and depression than the general population, although they have a higher hazard of treated insomnia. There may be undertreatment in some subgroups of nurses with different demographic and working characteristics.

Second-generation antipsychotic medications and risk of chronic kidney disease in schizophrenia: population-based nested case-control study

OBJECTIVES

The study aims to compare the risk of chronic kidney diseases (CKDs) between patients with schizophrenia using first and second-generation antipsychotics.

SETTING

Datasets of 2000-2013 National Health Insurance in Taiwan were used.

PARTICIPANTS

The National Health Insurance reimbursement claims data have been transferred to and managed by the National Health Research Institute in Taiwan since 1996. We used the Psychiatric Inpatient Medical Claims database, a subset of the National Health Insurance Research Database, comprising a cohort of patients hospitalised for psychiatric disorders between 2000 and 2013 (n=2 67 807). The database included patients with at least one psychiatric inpatient record and one discharge diagnosis of mental disorders coded by the International Classification of Diseases, Ninth Revision (ICD-9) codes 290-319. The age of patients at first admission was restricted to 18-65 years.

PRIMARY OUTCOME

CKD (ICD-9 code 582, 583, 585, 586, 588) requiring hospitalisation or three outpatient visits. The diagnosis of CKD follows the criteria of 'Kidney Disease: Improving Global Outcomes' in Taiwan. CKD is defined as a kidney damage as albumin-to-creatinine ratio >30 mg/g in two of three spot urine specimens or glomerular filtration rate <60 mL/min/1.73 m² for 3 months or more.

RESULTS

We found that the risks for CKD were higher for those who used second-generation antipsychotics (SGAs) longer cumulatively than those who did not. Using non-users, patients did not have any SGA records, as reference group, the risks for CKD comparing those using SGAs for 90 to 180 days with non-users and those using SGAs for more than 1000 days were 1.42 (1.06-1.91) and 1.30 (1.13-1.51), respectively.

CONCLUSIONS

The current study suggests the relationship between using SGAs and risk of CKD.

The bidirectional relationship between anxiety, depression, and lower urinary track symptoms: A nationwide population-based cohort study

BACKGROUND

Evidence has shown a positive correlation between lower urinary tract symptoms (LUTS) and anxiety/depression, but the direction and strength of the association are still unclear. We aimed to test the bidirectional association between LUTS and anxiety/depression using a longitudinal population database.

METHODS

Using claims data obtained from the Taiwan National Health Insurance Research Database, 17,489 patients with LUTS and 34,978 non-LUTS matched controls (cohort 1); and 45,707 patients with anxiety, 19,306 patients with depression, 91,414 non-anxiety, and 38,720 non-depression matched controls (cohort 2) were enrolled between 1999 and 2008. All subjects were followed at least three years or until the date of death or the end of 2011 to estimate the risk of developing anxiety/depression (cohort 1) or LUTS (cohort 2).

RESULTS

After controlling for age, gender, and medical comorbidities, LUTS patients were 2.12 (95%CI: 1.95-2.30) and 2.03 (95%CI: 1.76-2.33) times more likely to develop anxiety and depression, respectively. After controlling for age, gender, and medical comorbidities, patients with anxiety and depression were 2.01 (95%CI: 1.88-2.14) and 2.37 (95%CI: 2.13-2.65) times more likely to develop LUTS, respectively.

LIMITATIONS

The incidence of anxiety, depression, and LUTS may be under-estimated because only healthcare-seeking subjects were enrolled in our study.

CONCLUSIONS

Our findings suggested a bidirectional relationship between administrated anxiety/depression and LUTS in the cohorts. Further studies are warranted to clarify the underlying mechanisms.

Relapse insomnia increases greater risk of anxiety and depression: evidence from a population-based 4-year cohort study

OBJECTIVE

We investigated the longitudinal impacts of insomnia on the subsequent developments of anxiety and depression during a four-year follow-up. We further categorized individuals with insomnia into different insomnia subgroups to examine whether the risk of anxiety and depression varies by subtype.

METHODS

Participants were identified from National Health Insurance enrollees in Taiwan during 2002-2009. The study included 19,273 subjects with insomnia and 38,546 matched subjects without insomnia. All subjects did not have previous diagnosis of insomnia, sleep apnea, anxiety, or depression.

RESULTS

Compared with non-insomniacs, insomniacs had a higher risk of developing anxiety only [adjusted hazard ratio (HR) = 8.83, 95% CI = 7.59-10.27], depression only (adjusted HR = 8.48, 95% CI = 6.92-10.39), and both anxiety and depression (adjusted HR = 17.98, 95% CI = 12.65-25.56). When breaking down the insomnia subgroups, individuals with a relapse of insomnia (adjusted HR = 10.42-26.80) had the highest risk of anxiety only, depression only, and both anxiety and depression, followed by persistent insomnia (adjusted HR = 9.82-18.98), then remitted insomnia (adjusted HR = 4.50-8.27). All three insomnia subgroups had a greater four-year cumulative incidence rate than the non-insomnia group for anxiety only, depression only, and both anxiety and depression (p < 0.0001).

CONCLUSION

Our findings reinforce the clinical predictor role of insomnia in the future onset of anxiety or/and depression. Awareness of insomnia and treatment of insomnia should be recommended at clinics, and patterns of insomnia should be monitored to help treatment and control of subsequent psychiatric disorders. Future research with comprehensive data collection is needed to identify factors that contribute to different insomnia subtypes.

The Functional Significance of Affect Recognition, Neurocognition, and Clinical Symptoms in Schizophrenia

OBJECTIVES

The complex relationship and exact extent of the contribution of plausible indictors to social functional outcome in schizophrenia remain unclear. The present study aimed to explore the functional significance of clinical symptoms, neurocognition, and affect recognition simultaneously in schizophrenia.

METHODS

The clinical symptoms, basic neurocognition, facial emotion recognition, and social functioning of 154 subjects, including 74 with schizophrenia and 80 nonclinical comparisons, were assessed.

RESULTS

We observed that various subdomains of social functioning were extensively related to general intelligence, basic neurocognition, facial emotion recognition, and clinical symptoms, with different association patterns. Multivariate regression analyses revealed that years of education, age, sustained attention, working memory, and facial emotion recognition were significantly associated with global social functioning in schizophrenia.

CONCLUSION

Our findings suggest that affect recognition combined with nonsocial neurocognition demonstrated a crucial role in predicting global social function in schizophrenia.

Gender ratios of administrative prevalence and incidence of attention-deficit/hyperactivity disorder (ADHD) across the lifespan: A nationwide population-based study in Taiwan

To verify the hypothesis that there is different gender ratio of attention-deficit/hyperactivity disorder (ADHD) among adults compared to children and adolescents in the clinical setting among Asian population. The nationwide population-based database containing data on enrollees in the National Health Insurance program in Taiwan during 2000-2007 was used in this study, and we investigated the lifetime gender ratios of administrative prevalence and incidence in healthcare-seeking ADHD patients (n=228,029). The male-to-female ratios of diagnosed incidence and prevalence of child/adolescent ADHD (age <20 years) ranged from 3.39 to 4.07 and 3.87-4.31, respectively. The male-to-female ratios of diagnosed incidence and prevalence of ADHD in the adult group (age 20-65 years) ranged from 0.24 to 0.76 and 0.35-0.98, respectively. In conclusion, there was substantially increased female-to-male ratio in adults ADHD compared to children and adolescents in the clinical setting. Further researches on the management and mechanism are needed.

Risks of Treated Insomnia, Anxiety, and Depression in Health Care-Seeking Physicians: A Nationwide Population-Based Study

High occupational stress and burnout among physicians can lead to sleep problems, anxiety, depression, and even suicide. Even so, the actual risk for these behavioral health problems in health care-seeking physicians has been seldom explored. The aim of this study was to determine whether physicians have higher odds of treated insomnia, anxiety, and depression than the normal population.This is a nationwide population-based case-control study using the National Health Insurance Research Database in Taiwan for the years 2007 to 2011. Physicians were obtained from the Registry for Medical Personnel in 2009. Hospital physicians who had at least 3 coded ambulatory care claims or 1 inpatient claim with a principal diagnosis of insomnia, anxiety, or depression were identified. A total of 15,150 physicians and 45,450 matched controls were enrolled. Odd ratios (ORs) of insomnia, anxiety, and depression between physicians and their control counterparts were measured.The adjusted ORs for treated insomnia, anxiety, and depression among all studied physicians were 2.028 (95% confidence interval [CI], 1.892-2.175), 1.103 (95% CI, 1.020-1.193), and 0.716 (95% CI, 0.630-0.813), respectively. All specialties of physicians had significantly higher ORs for treated insomnia; among the highest was the emergency specialty. The adjusted ORs for treated anxiety among male and female physicians were 1.136 (95% CI, 1.039-1.242) and 0.827 (95% CI, 0.686-0.997), respectively. Among specialties, psychiatry and "others" had significantly higher risks of anxiety. Obstetrics and gynecology and surgery specialties had significantly lower risks of anxiety. The adjusted ORs for treated depression among physicians in age groups 35 to 50 years and >50 years were 0.560 (95% CI, 0.459-0.683) and 0.770 (95% CI, 0.619-0.959), respectively. Those in the psychiatry specialty had significantly higher risks of depression; internal and surgery specialties had significant lower risks of depression.Hospital physicians have lower odds of treated depression than the general population, although they have higher odd of treated insomnia and anxiety. Undertreatment was noted in some sex, age, and specialty subgroups of physicians. Additional studies are needed to determine how to eliminate barriers to their use of psychiatry resources.

Health service utilization of heroin abusers: a retrospective cohort study

AIMS

This study aimed to determine the patterns of medical service utilization among heroin users and to identify the factors associated with the frequency of utilization.

METHODS

We conducted a retrospective/prospective cohort study of 789 heroin-using adults in a catchment area, collecting data on their usage of medical care, including inpatient care, emergency visits, and outpatient care, in a 2-year observation period. We interviewed and reviewed the medical records of 789 heroin users in a methadone clinic of a general hospital in a rural area of Taiwan. The demographic data, records of service use, diagnoses, and information on viral infection status from Jan. 1, 2007 to Dec. 31, 2008 were collected. Most patients were middle-aged and unemployed, had a basic educational level, and began their first heroin use in their twenties.

RESULTS

The health service utilization of heroin users was mostly for infectious diseases, orthopedic conditions, and gastroenterological disorders mainly due to blood-borne or local infections and traumatic injury. Heroin users utilize fewer outpatient or inpatient services, but more emergency care than the general public. The major correlates of inpatient and emergency service utilization were HIV status and education level.

CONCLUSIONS

Our findings suggest that integrated outpatient services may help to enhance medical service accessibility and adherence, and also imply the necessity of putting more effort into promoting health management and safe behaviors in heroin users, particularly the lower-educated addicts.

The association of healthcare seeking behavior for anxiety and depression among patients with lower urinary tract symptoms: a nationwide population-based study

Lower urinary tract symptoms (LUTS) have a negative impact on the quality of life, and may relate to anxiety and depression. The objective of this study was to test the hypothesis that LUTS are associated with anxiety and depression using a nationwide population-based database in Taiwan. Data were obtained from a random population sample of about one million enrollees in the National Health Insurance program from 2001 to 2009, and consisted of 22,980 LUTS patients and 45,960 matched controls. The records of healthcare seeking for anxiety and depression were collected 2 years before and after the diagnosis of LUTS. The results showed that patients with LUTS had a significantly higher prevalence of anxiety or depression than the matched controls (11.45% vs. 5.72%). After controlling for sociodemographic variables and other major systemic diseases, the odds ratios for anxiety, depression, either anxiety or depression, and both anxiety and depression, were 2.05, 2.19, 2.14, and 2.56, respectively. There was an association between LUTS and the stress-related common mental disorders, and there seemed to be an additive effect of anxiety and depression on the association with LUTS. These findings imply a psychological role in the pathogenesis or sequelae of LUTS.

Increased risks of healthcare-seeking behaviors of anxiety, depression and insomnia among patients with bladder pain syndrome/interstitial cystitis: a nationwide population-based study

PURPOSE

To explore the association between bladder pain syndrome/interstitial cystitis (BPS/IC) and the risk of subsequent healthcare-seeking behavior for common mental disorders in Taiwan using a population-based administrative database.

MATERIALS AND METHODS

Both BPS/IC subjects and their age- and sex-matched non-BPS/IC control subjects who had no previous insomnia and mental diseases, including anxiety, depression, were subsequent serviced for these mental disorders by psychiatrists from the recruited date between 2002 and 2010. The risk of outcomes was assessed with Kaplan-Meier curves; and the impact of BPS/IC was estimated with Poisson regression analysis and Cox proportional hazards models.

RESULTS

We included 16,185 BPS/IC subjects and 32,370 non-BPS/IC subjects, with a mean age of 46 years and 73.5 % of women. Difference of the prevalence of hypertension, diabetes, chronic kidney disease, and hyperlipidemia between groups was not significant difference. Subjects with BPS/IC had a significant higher incidence rate of anxiety, depression, and insomnia than the matched controls (92.9 vs 38.4, 101.0 vs 42.2, 47.5 vs 23.0; per 10,000 person-year). After adjusting for age, sex, and common comorbidities in multivariable analysis, BPS/IC remained a significant predictor with hazard ratio and 95 % confidence incidence, 2.4 (2.2-2.7), 2.4 (2.2-2.6), and 2.1 (1.8-2.4) for anxiety, depression, and insomnia, respectively.

CONCLUSION

Patients with BPS/IC are at risk of development of anxiety, depression, and insomnia. These findings can help guide urologists, urogynecologists, and psychiatrists toward early identification and treatment of psychological complications that may develop in BPS/IC patients.

Epidemiology of treated attention-deficit/hyperactivity disorder (ADHD) across the lifespan in Taiwan: a nationwide population-based longitudinal study

Objectives

We used insurance claims of a nationally representative population-based cohort to assess the longitudinal treated prevalence and incidence of attention-deficit/hyperactivity disorder (ADHD) in children, adolescents and adults.

Methods

Participants were identified from among National Health Insurance enrollees in Taiwan from 1999 to 2005. We identified study subjects who had at least one service claim during these years with a principal diagnosis of ADHD. A total of 6,173 patients were recorded in the treated ADHD cohort during the 6-year study.

Results

There was a significant increase in the treated prevalence rate of ADHD during the study period, from 64.65 per 100,000 in 2000 to 145.40 per 100,000 in 2005 (p = .001). An increase in the treated incidence rate of ADHD, from 44.67 per 100,000 in 2000 to 81.20 per 100,000 in 2005, was also observed (p = .013). However, the treated prevalence of ADHD was still lower than that of the community data in Taiwan. The peak treated prevalence of ADHD was at age 7–12 years for both males and females, and the peak treated incidence of ADHD was at age 0–6 for females and age 7–12 for males. Overall, the treated incidence and prevalence rates dropped abruptly after age 13–18 (both p<.001) for males and females (p<.001 for both). Male vs. female ratios of treated prevalence and incidence were both above 1 before age 25–30 years, but below 1 thereafter.

Conclusion

Although an increasing number of people with ADHD sought treatment during 1999–2005 in Taiwan, the treated prevalence of ADHD was still lower than that of the community data. The treated incidence and prevalence of ADHD fell dramatically after age 13–18. However, more women than men sought treatment in adulthood. There may be under-diagnosis and under-treatment of ADHD, especially among females and adults.

The Chinese Facial Emotion Recognition Database (CFERD): a computer-generated 3-D paradigm to measure the recognition of facial emotional expressions at different intensities

The Chinese Facial Emotion Recognition Database (CFERD), a computer-generated three-dimensional (3D) paradigm, was developed to measure the recognition of facial emotional expressions at different intensities. The stimuli consisted of 3D colour photographic images of six basic facial emotional expressions (happiness, sadness, disgust, fear, anger and surprise) and neutral faces of the Chinese. The purpose of the present study is to describe the development and validation of CFERD with nonclinical healthy participants (N=100; 50 men; age ranging between 18 and 50 years), and to generate normative data set. The results showed that the sensitivity index d' [d'=Z(hit rate)-Z(false alarm rate), where function Z(p), p∈[0,1]], for all emotions was 0.94. The emotion was more readily detected in happiness, and less easily detected in surprise and sadness. In general, this study replicated the previous findings on the recognition accuracy of emotional expression with the Westerner faces. However, our paradigm extends the previous work by including a wider sensitivity range to differentiate subtle perception of emotion intensities. The CFERD will be a useful tool for emotion recognition assessment in affective neurosciences research, especially for the Chinese and cross-cultural studies.

The role of serotonin and possible interaction of serotonin-related genes with alcohol dehydrogenase and aldehyde dehydrogenase genes in alcohol dependence-a review

Alcohol dependence is believed to be a multifactorial, polygenic disorder involving complex gene-gene and gene-environment interactions and confounded by heterogeneity and sociocultural factors. Serotonin (5-Hydroxytryptamine, 5-HT) is thought to be involved in many aspects of alcohol consumption, abuse, and dependence. There was some evidence that serotonin-related genes might interact with the alcohol dehydrogenase (ADH) and the aldehyde dehydrogenase (ALDH) genes in the development of alcohol dependence. In the current review, we discuss the role of serotonin and possible interaction of serotonin-related genes with ADH and ALDH genes in alcohol dependence.

The Value of Patient-administered Depression Rating Scale in Detecting Cognitive Deficits in Depressed Patients

Background

The aims of this study was to clarify how accurate the depressed patients perceive their cognitive symptoms, and verify the appropriateness of the depressive rating scales in evaluating cognitive deficits in major depressive disorder (MDD) patients.

Methods

The subjects consisted of 19 well-characterized medication-free patients with MDD and 19 healthy volunteers. The clinical and neuropsychological assessments, including Hamilton Rating Scale for Depression (HAM-D), Taiwanese Depression Questionnaire (TDQ), Finger Tapping Test, Wechsler Memory Scale-Revised, Stroop Color-Word Test, and Continuous Performance Test, were administered at the time of recruitment and repeated six months after treatment.

Results

Depressed patients exhibited significant impairment in several neurocognitive domains. Neurocognitive impairment was correlated with both the affective and somatic factors, but not with the cognitive factors of TDQ. The similar results were shown after 6-month treatment.

Conclusions

Our results suggest that the MDD patients do not perceive their cognitive dysfunction correctly. The depression rating scales, especially the patient-administered scale, need to be validated for measuring neurocognitive deficits of MDD patients in the future, if cognitive component is suspected as one of the major domains of self-rating scale.

Keywords

Major depressive disorder; Cognitive deficits; Depression rating scale

Residual Cognitive Deficit in Adults with Depression who Recovered after 6-month Treatment: Stable versus State-Dependent Markers

BACKGROUND

Knowledge of depression-related disturbances in cognitive functioning is advancing, but little is known about the cognitive response to treatment for major depression, especially in younger adults. This study investigated the deficits in multiple cognitive domains in middle-aged patients with major depressive disorder (MDD), using a prospective follow-up study design.

METHODS

The sample consisted of 13 medication-free MDD patients and 13 education- and age-matched healthy controls. All subjects were administered clinical measures as well as a comprehensive neurocognitive test battery aimed at assessing multiple cognitive domains at the time of recruitment. Patients remitted after 6 months following treatment repeated the neurocognitive assessment.

RESULTS

There were significant differences between the depressed subjects and controls at baseline. MDD patients with remitted symptoms still showed significant deficits in executive function and motor function, but not in memory or attention domains. Patients had significant improvement in memory and attention domains only, once their depressive symptoms had subsided; while executive functioning as well as motor functioning remained unchanged.

CONCLUSIONS

Executive functioning and motor functioning deficits might be stable vulnerability indicators for MDD, and memory and attention impairment might serve as state-dependent indicators for MDD.

KEYWORDS

Major depressive disorder; Remission; Residual; Cognitive deficits; Follow-up.