by : Kevin Pho
I wrote last year in USA Today about the impact of physician burnout. Not only do doctors suffer, but so do their patients.
Burnout starts early in residency, with entering interns having a depression rate of 4%, similar to the general public. But after the first year of residency, that number balloons to 25%.
Now, another study adds fuel to this disturbing trend.
A paper published in the Archives of General Surgery looks at the prevalence of physician burnout in surgeons:
In a national survey, one in 16 surgeons reported contemplating suicide, researchers reported.
An increased risk of suicidal ideation was linked to three factors: depression, burnout, and the perception of having made a recent major medical error …
… But only about one in four of those who reported thinking about taking their own lives sought psychiatric or psychologic help.
The rate of suicidal ideation in surgeons, at 6.3%, was almost double of that in the general population (3.3%).
Physician burnout is a phenomenon that’s often ignored. The practice environment is deteriorating, with increasing time pressures and worsening bureaucratic burdens. Little of this is addressed in the national health conversation, or in the recently passed health reform law.
As more doctors burnout and quit medicine, patients will suffer. It’s certainly not an ideal situation as more than 30+ million newly-insured patients will be looking for physicians to care for them in the coming years.
And for the physicians who stay, burnout will impact the care they give to patients — including a decrease in empathy and an increase in medical errors.
Burnt out doctors feel they have little recourse. In the Archives study,
Only 130 surgeons — 26% of those who had recent suicidal thoughts — had sought psychiatric or psychologic help.
Among the 501 doctors who reported suicidal thoughts, 301 said they were reluctant to seek help because of worry that it could affect their medical license.
That’s unacceptable. Hospitals need to better recognize the signs of burnout and increase the support they give to depressed physicians.
Another consideration would be to better monitor work hours to ensure proper work-lifestyle balance. Today, doctors in training are strictly regulated to ensure they work no longer than 80 hours a week. Once they graduate and practice in the real world, that oversight ceases. There is nothing to prevent doctors from working days at time, which can happen at an understaffed, rural hospital, for instance.
The same zeal that goes into limiting residents’ work hours should be applied to doctors in the real world, to ensure their workload doesn’t drive them to burnout and potential suicide.
About 60% of patients suffering from depression do not find any benefit from their first antidepressant. Up to 20% of patients find depression impossible to overcome even after 1 year. Assertive treatment of depression from the get go is essential to helping recover from depression.
Psychiatrists don’t have a shared definition of treatment resistant depression. However, most would agree that your depression may be treatment resistant if it has not resolved almost completely after adequate trials of at least 2 separate treatments.
You, with your doctor and/or therapist, must then consider the following strategies to beat it :
Confirm diagnosis:
Make sure that your depression is not a phase of Bipolar disorder – it can be tricky, but must be ruled out. Co-occurring addiction, anxiety or other psychiatric illness should be diagnosed and treated. Psychiatric diagnosis still remains a subjective enterprise. Get a second opinion regarding your diagnosis. Even if you like your therapist or psychiatrist, and intend to get treatment from them forever and ever, get a second opinion from a different psychiatrist.
Follow treatment recommendations:
Take your medicine as prescribed. Maintain your frequency of psychotherapy. These things take time to work. Don’t skip doses or sessions. And don’t give up on any treatment prematurely.
Optimizing medication:
Your dose of antidepressant may need adjusting to get better results. Some antidepressants work better at higher doses. Others have a window of dosing in which they may work the best for you while having the fewest side-effects.
Switching medication:
There are about 30 antidepressants belonging to about 8 classes available in the US. Even among patients who have had trials of multiple medicines, most have tried only 2-3 classes. Talk to your doctor about trying medicines from classes that you have not tried yet.
Adding a medication:
If you have partial response to a given medicine, adding another medicine that is compatible with the first medicine may allow you to build on the effectiveness of the above medicine. Talk to your doctor about this. The medicine added could be another antidepressant, or a medication that is known to help antidepressants be more effective (e.g., T3, lithium).
Talk therapy (psychotherapy, counseling):
If you are not already in psychotherapy, you must consider adding this to your treatment regimen. Psychotherapy typically does not work as quickly as medication, but tends to have lasting benefit. Ask for a referral to a therapist who treats using one of the consistently proven therapies in depression – interpersonal therapy or cognitive behavior therapy.
TMS (Transcranial Magnetic Stimulation):
This is a treatment that involves repeatedly delivering very, very short magnetic pulses to the part of the brain that is most believed to be involved in depression. It was cleared in 2008 by the FDA as effective in those who have failed treatment with 1 adequate trial of an antidepressant. It has few side-effects, but carries with a minuscule risk of seizures. It is an outpatient treatment that does not require sedation or anesthesia.
Electroconvulsive therapy (a.k.a. electroshock therapy):
This is probably the most effective treatment for depression, but to be effective it requires that a seizure (convulsion) be triggered. Therefore, it must be conducted in a hospital setting, using sedation and muscle relaxation. It may impair memory in a lasting manner in some patients.
Most importantly, choose treatment with a physician, psychiatrist or therapist who will systematically evaluate how any chosen treatment is working. He or she should also be willing to change the medication regimen if it does not work in adequate doses over a 3-month period.
Through all of this you must also:
Practice living well:
Eat a balanced diet. Excercise some everyday (to the extent your body allows and your physician approves). Minimize smoking, drinking. Attempt to connect with loved ones frequently. None of this may be easy when you are depressed, but overcoming treatment resistance requires you to do your part to the extent that you can.
by : Dheeraj Raina
Depression Clinic of Chicago
