Prevalence of Depression in RCRMC Family Medicine Residency

Prevalence of Depression in RCRMC Family Medicine Residency Bob Chiang, M. D. , Kris Lee, M. D. , Ted Lee, M. D. , Laurie Wellman, Ph. D. June 2009, Moreno Valley, CA

INTRODUCTION v Depression is a major public health problem and a leading predictor of functional disability and mortality. v The annual economic consequences of depression have been estimated at 83 billion dollars in the US. 6 v Prevalence of Depression 14 • General population 4. 5% • Medical students/residents 15%

Prevalence of Depression Survey from 2, 000 medical students and residents Goebert, D. Acad Med. 2009 Feb; 84(2): 236 -41

Prevalence of Depression Goebert, D. Acad Med. 2009 Feb; 84(2): 236 -41

Prevalence of Depression Goebert, D. Acad Med. 2009 Feb; 84(2): 236 -41

INTRODUCTION v A stressful environment is a known risk factor for depression; yet there is no protocol established for early detection of and intervention for depression in family medicine residencies. v. Depression has been correlated to increased medical errors in pediatrics residents in a prospective cohort study. 13

Suicide in Physicians v Depression in interns leads to suicidal ideation, marital problems, inability to work and thoughts of leaving medicine. 9 v Physicians who make suicide attempts are much more likely than nonphysicians to succeed. 12

Drug Abuse in Physicians Survey from 1, 785 residents Am J Psychiatry. 1992; 149(Oct): 10

Drug Abuse in Physicians Am J Psychiatry. 1992; 149(Oct): 10

BACKGROUND v DSM-IV Diagnostic Criteria for Major Depressive Episode 7 • 5 (or more) symptoms present during the same 2 -week period, change from previous functioning; at least 1 symptoms is either depressed mood or loss of interest or pleasure. 1. depressed mood most of the day, nearly every day. 2. markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day 3. significant weight loss when not dieting or weight gain or decrease or increase in appetite nearly every day. 4. insomnia or hypersomnia nearly every day 5. psychomotor agitation or retardation nearly every day 6. fatigue or loss of energy nearly every day 7. feelings of worthlessness or excessive or inappropriate guilt nearly every day 8. diminished ability to think or concentrate, or indecisiveness, nearly every day 9. recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

BACKGROUND v Personal Health Questionnaire (PHQ)15 • 3 -page self-administered questionnaire • well validated in two large studies v 9 item depression scale (PHQ-9) • • used as a diagnostic instrument used as a depression severity tool possible scores ranging from 0 to 27 higher scores are correlated with other measures of depression severity

BACKGROUND

OBJECTIVE v. Screen for depression among family medicine residents and to demonstrate similarities or differences among different year level.

METHOD v RCRMC family medicine residents of all year levels were included in the study. v In 2009, trainees were asked to complete the PHQ-9 survey. v The survey could be conducted on-line through a survey website or on paper turned in anonymously. v Confidentiality was guaranteed: the only requested identifier was PGY level.

RESULTS v 23 of 27 residents participated in the study. v 9 interns, 8 PGY-2, 6 PGY-3 v 1 of 23 residents met criteria of clinical depression. v. Positive screening 3. 8% v. No resident admitted to suicidal ideation.

RESULTS v. Respondents admitted to 0 -8 symptoms of depression. (Mean 0. 956, SD 1. 89). v. PHQ-9 total scores ranged from 0 -18. (Mean 4. 22, SD 4. 32). v. One-way ANOVA analysis showed that there was no significant difference in the total depressive score among the different PGY levels. (p = 0. 456)

TOTAL SCORES Results of PHQ-9 Total Scores PGY 1 No of surveys 9 Score range 0 - 10 Score mean 3. 444 Score median 3 PGY 2 8 0 -9 3. 625 4 PGY 3 6 0 - 18 6. 167 4. 5

ONE-WAY ANOVA No of surveys Score mean Standard deviation PGY 1 9 3. 444 3. 46811 PGY 2 8 3. 625 2. 92465 PGY 3 6 6. 167 6. 67583 One-way ANOVA: significance (p) = 0. 456

DISCUSSION v Prevalence of depression in general population 4. 5% -5. 4%14 • Less participation in each higher training level (also demonstrated in other studies 16) • Residents with depressive symptoms may have opted not to participate v High number of depressive symptoms associated with poor health and impaired functioning, whether or not the criteria for a diagnosis of major depression are met 14

DISCUSSION v Most students and interns with major depression do not seek treatment. 9 v Only half of depressed residents seemed aware of their depression; only a few were being treated. 13 v Only 29% of depressed people report contacting mental health services. 14 v Of those with severe depression, only 39% reported contact. 14

Riverside County Resources v Handouts of Riverside County Employee Assistance Services given during orientation • EAS rep came to discuss availability of services. • Self-referral or referral by supervisor/co-worker • EAS only available during limited weekday business hours. v Yearly “Mental Health Month” emails to all county employees • “Mental Health Month” activities at outside campus, >20 miles away.

RCRMC Resident Resources v. Once yearly retreat with behavioral scientist – 2 -3 hours v. Once quarterly review with faculty advisor – 5 -20 minutes v. Once monthly “Resident Support” meetings – 30 -45 minutes

DISCUSSION v A retrospective review of different interventions for burnout in residents/ medical students: v Workshops, resident assistance program, self-care intervention, support groups, didactic sessions, stress -management/coping training, breathing exercises: alone or in various combinations. v None achieved an A-level SORT rating. 15

COMMON STRESSORS v. Heavy workload v. Sleep deprivation v. Difficult patients v. Poor learning environments v. Financial concerns v. Information overload v. Career planning Goebert, D. Acad Med. 2009 Feb; 84(2): 236 -41

THE INTERN’S PSYCHE Psychological Evolution of First Year Resident Excitation Insecurity 1 month 2 months Depression 1 month Unending tedium 2 months Feeling great joy or pride Self-confidence Peterlini M, Med Educ. 2002 Jan; 36(1): 66 -72.

PERCEIVED STRESSORS Factors Perceived As Stressful By Interns Time away from family and friends Lack of time for own personal activities 44% 41% Sleep deprivation or fatigue 38% Making a mistake 38% Working hours 33% Lack of time to study 18% Lack of emotional support 13% Kirsling RA, Psychol Rep. 1989 Oct; 65(2): 355 -66

COPING METHODS Coping Methods Most Utilized By Interns Talking with a spouse/friend Talking with fellow intern 74% 63% Doing physical exercise 33% Religion or spiritual activities 15% Talk with chief resident 11% Talk with attending 1% Talk with program director 0% Kirsling RA, Psychol Rep. 1989 Oct; 65(2): 355 -66

RECOMMENDATIONS v. Areas for Intervention • Encourage self-knowledge • Encourage seeking help • Foster atmosphere of communication • Multiple methodologies (discussion, lecture, readings, physical and mental exercises)

RECOMMENDATIONS v. Active Surveillance • Various groups (by class, by gender, with different faculty or residents) • Formal/informal • Frequent repetition

RECOMMENDATIONS v. Work to relieve stressors • Sleep deprivations • Poor learning environment v. Active teach/model coping methods • Encourage support among residents • Active involvement of attendings

FOR FURTHER STUDY v. Longitudinal survey of current FM residents v. Monitor for change • Among the different years of training • Throughout the year for each class of residents v. Comparison of different FM programs in the local area

CONCLUSION “It is simply unacceptable for new—or more established— physicians and other health professionals to be in such great pain. It is improper for us to sacrifice our own health, family, and community in order to care for others. Part of our calling is to relieve suffering. We cannot relieve the suffering of others if we, ourselves, are suffering. Poets and musicians may function better when they are melancholy, but physicians do not. “We need to take care of ourselves. That is not selfish. It is smart, and no one else will do it for us. We also need to take care of our residents. Who else will? What message are we giving when we ignore them? We need to show residents and each other that they and we matter. ” 16

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