Action needed to reduce depression and suicide during medical training

By Will Boggs MD

NEW YORK (Reuters Health) - Education, screening and treatment are needed to reduce the high levels of depression and suicide among physician trainees, psychiatrists say in a new report.

"Early career physicians in residency and fellowship have demonstrated incredible resilience and motivation by graduating from medical school," Dr. Ravi Navin Shah from Columbia University Medical Center and New York State Psychiatric Institute, New York, and Dr. Shah's colleague Dr. Matthew Goldman told Reuters Health in a jointly drafted email.

"Despite that, studies suggest that initiation of residency is a risk factor for increased symptoms of depression and thoughts of suicide. It is for this reason that we recommend national guidelines to ensure that training institutions educate, screen, and treat trainees for mental illness during this high-risk period," they wrote.

JAMA published guidelines in 2003 to encourage prevention and depression treatment for physicians, but these proposed interventions have not been widely adopted, Dr. Shah and colleagues note in JAMA Psychiatry, online March 4.

The Accreditation Council for Graduate Medical Education (ACGME) requires programs to have processes to assess fatigue and burnout among trainees and to provide access to confidential counseling. But Dr. Shah and colleagues say these regulations should go further to require specific strategies to promote mental health among all trainees.

They recommend as first steps educating the academic community about these issues, encouraging mental health screening, and fostering help-seeking behavior and access to care for trainees.

"The U.S. Preventive Services Task Force recommends that all patients in primary care receive mental health screening," Drs. Shah and Goldman said. "Trainees are at higher risk for depression than cardiopulmonary illness; however, it is more likely that a trainee will undergo auscultation of their heart and lungs than screening for mental illness during their annual physical exam. It is for this reason that we recommend regular screening for depression and substance abuse during occupational health annual visits."

"Given that physicians may be discouraged to engage in mental health care and substance abuse treatment due to concerns about medical licensure and malpractice insurance coverage, there is a need for a state-by-state assessment of these policies in order to clearly explain any possible repercussions to all physicians, particularly trainees early in their careers," the two authors said in their email.

The authors also recommend further research. "We are not aware of any studies that have demonstrated a significant reduction in depression and suicide among medical trainees specifically," Dr. Shah and Dr. Goldman said.

"The UCSD program described in the article came closest to implementing a strategy for reducing suicide," they added. "As the authors of that study state in their abstract, 'The program was well received in its first year, and while demonstrating the prevention of suicides is difficult, the authors are encouraged by the program's results thus far.' The USAF example highlighted in the article did show a reduction in suicide over the course of their comprehensive intervention, which suggests that similar strategies may be effective in preventing suicide."

Dr. Charles F. Reynolds III from the University of Pittsburgh, past president of the American Foundation for Suicide Prevention, said the authors of the 2003 JAMA statement "also emphasized the importance of peer-to-peer support in encouraging appropriate help seeking by medical students and residents. Peers are in a good position to recognize depression and related issues in each other and could be proactive in helping one another. This point deserves greater emphasis."

"The authors of the JAMA Psychiatry commentary correctly underscore the importance of taking early, pre-emptive steps," Dr. Reynolds told Reuters Health by email. "One promising model, developed by Dr. Helen Christensen and colleagues at the University of New South Wales in Sydney, involves providing a course of cognitive behavioral therapy to senior medical students before they embark upon graduate medical education. Dr. Christensen's data, as I understand them, suggest that 'inoculation' approaches like this reduce the incidence of common mental disorders/symptoms during the following year of increased stress and risk."

"I think that this type of learning-based approach makes sense, by teaching people coping strategies in advance of a stressful, demanding time," he said. "By reducing the incidence of depression, it reduces or eliminates one of the important proximal risk factors for suicide."

Dr. Reynolds added, "Depression kills. Treatment works. Help each other. Get treatment. Continue changing the culture of institutional medicine to support appropriate help seeking."

"The ACGME should heed the recommendations and issue appropriate guidelines to training programs," he concluded. "The Institute of Medicine should commission a study of the problem of physician suicide, much as it did in its earlier report on residents' work hours."

SOURCE: http://bit.ly/1AwiFlN

JAMA Psychiatry 2015.

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