more_vertImages of people incarcerated, unkempt and kept in chains, mocked, and uncared for dominate the history of psychiatry, particularly from the middle ages to the early 20th century. Locked up for years, and forcibly sedated or sterilised, those with mental ill health were subject to inhumane conditions and removed from society, often under the supervision of doctors. What of now? How have things improved for those with mental illnesses?
Preference: Psychiatry
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What I’ve learned from 687 doctor suicides
Five years ago today I was at a memorial. Another suicide. Our third doctor in 18 months.
Everyone kept whispering, “Why?”
I was determined to find out.
So I started counting dead doctors. I left the service with a list of 10. Five years later I have 547.
[Now I’ve got 687 doctor suicides on my registry (as of 11/12/17). If you’ve lost a doctor or medical student to suicide, please (confidentially) submit names here.]
Immediately, I began writing and speaking about suicide. So many distressed doctors (and med students) wrote and phoned me. Soon I was running a de facto international suicide hotline from my home. To date, I’ve spoken to thousands of suicidal doctors; published a book of their suicide letters (free audiobook); attended more funerals; interviewed surviving physicians, families, and friends. I’ve spent nearly every waking moment over the past five years on a personal quest for the truth of “Why.” Here are 34 things I’ve discovered:
High doctor suicide rates have been reported since 1858. Yet more than 150 years later the root causes of these suicides remain unaddressed.
Physician suicide is a public health crisis. One million Americans lose their doctors to suicide each year.
Most doctors have lost a colleague to suicide. Some have lost up to eight during their career—with no opportunity to grieve.
We lose way more men than women. For every woman who dies by suicide in medicine, we lose seven men.
Suicide methods vary by region and gender. Women prefer to overdose and men choose firearms. Gunshot wounds prevail out West. Jumping is popular in New York City. In India doctors are found hanging from ceiling fans.
Male anaesthesiologists are at highest risk. Most die by overdose. Many are found dead in hospital call rooms.
Lots of doctors die in hospitals. Doctors jump from hospital windows or rooftops. They shoot or stab themselves in hospital parking lots. They’re found hanging in hospital chapels. Physicians often choose to die where they’ve been wounded.
“Happy” doctors die by suicide. Many doctors who die by suicide are the happiest most well-adjusted people on the outside. Just back from Disneyland, just bought tickets for a family cruise, just gave a thumbs up to the team after a successful surgery—and hours later they shoot themselves in the head. Doctors are masters of disguise. Even fun-loving happy docs who crack jokes and make patients smile all day may be suffering in silence. We are all at risk.
Doctors’ family members are at high risk of suicide. By the same method. Cardiothoracic surgeon Thomas Gahagan died by hanging himself, leaving behind seven children ages three to fifteen. Two died by hanging themselves as adults. Another physician died using the same gun his son used to kill himself. Kaitlyn Elkins, a star third-year medical student, chose suicide by helium inhalation. One year later her mother Rhonda died by the same method. At Rhonda’s funeral, I asked her husband if he thought his wife and daughter would still be alive had Kaitlyn not pursued medicine. He replied, “Yes. Medical school has killed half my family.”
Doctors have personal problems—like everyone else. We get divorced, have custody battles, infidelity, disabled children, deaths in our families. Working 100+ hours per week immersed in our patients’ pain, we’ve got no time to deal with our own pain. (Spending so much time at work actually leads to divorce and completely dysfunctional personal lives).
Patient deaths hurt doctors. A lot. Even when there’s no medical error, doctors may never forgive themselves for losing a patient. Suicide is the ultimate self-punishment.
Malpractice suits kill doctors. Humans make mistakes. Yet when doctors make mistakes, they’re publicly shamed in court on TV, and in newspapers (that live online forever). We continue to suffer the agony of harming someone else—unintentionally—for the rest of our lives.
Doctors who do illegal things kill themselves. Medicare fraud, sex with a patient, DUIs may lead to loss of medical license, prison time, and suicide.
Academic distress kills medical students’ dreams. Failing boards exams and being unmatched into a specialty of choice has led to suicides.
Doctors without residencies may die by suicide. Dr. Robert Chu, unmatched to residency, wrote a letter to medical officials and government leaders calling out the flawed system that undermined his career prior to his suicide.
Assembly-line medicine kills doctors. Brilliant, compassionate people can’t care for complex patients in 10-minute slots. When punished or fired for “inefficiency” or “low productivity” doctors may choose suicide. Pressure from insurance companies and government mandates further crush the souls of these talented people who just want to help their patients. Many doctors cite inhumane working conditions in their suicide notes.
Bullying, hazing, and sleep deprivation increase suicide risk. Medical training is rampant with human rights violations illegal in all other industries.
Sleep deprivation is a (deadly) torture technique. Physicians have suffered hallucinations, life-threatening seizures, depression, and suicide solely related to sleep deprivation. Resident physicians are now “capped” at 28-hour shifts and 80-hour weeks. If they “violate” work hours (by caring for patients) they are forced to lie on their time cards or be written up as “inefficient” and sent to a psychiatrist for stimulant medications. Some doctors kill themselves for fear of harming a patient from extreme sleep deprivation.
Blaming doctors increases suicides. Words like “burnout” and “resilience” are often employed by medical institutions as psychological warfare to blame and shame doctors while deflecting attention from inhumane working conditions. When doctors are punished for occupationally induced mental health conditions (while underlying human rights violations are not addressed), they become even more hopeless and desperate.
Sweet, sensitive souls are at highest risk. Some of the most caring, compassionate, and intelligent doctors choose suicide rather than continuing to work in such callous, uncaring and ruthlessly greedy medical corporations.
Doctors can’t get confidential mental health care. So they drive out of town, pay cash, and use fake names to hide from state medical boards, hospitals, and insurance plans that ask doctors about their mental health care and may then exclude them from state licensure, hospital privileges, and health plan participation. (Even if confidential care were available, physicians have little time to access care when working 80-100+ hours per week).
Doctors have trouble caring for doctors. Doctors treat physician patients differently by downplaying psychiatric issues to protect physicians from medical board mental health investigations. Untreated mental health conditions may lead to suicide.
Medical board investigations increase suicide risk. One doctor hanged himself from a tree outside the Florida medical board office after being denied his license. He was told to “come back in a year and we will reinstate your license.” Meanwhile he lost everything and was living in a halfway house.
Physician Health Programs (PHPs) may increase suicide risk. Forcing doctors with occupationally induced mental health issues into these 12-step programs with witnessed random urine drug screens (when they’ve never had a drug problem!) is humiliating and unethical. So doctors hide their mental health conditions for fear of being punished by PHPs. [Note: PHPs have helped some doctors with substance abuse especially]
Substance abuse is a late-stage effect of lack of mental health care. Since doctors may lose their license for seeking mental health care or get locked into PHPs; they self-medicate with alcohol, illicit drugs, or self-prescribe psychotropic medications.
Doctors develop on-the-job PTSD. Especially true in emergency medicine. Then one day they “snap” like this guy.
Cultural taboos reinforce secrecy. Suicide is a sin in many religions. Islam and Christian families have asked that I hide the suicides of family members. Indian families often claim a suicide is a homicide or an accident, even when it’s obviously self-inflicted.
Media offers incomplete coverage of suspicious deaths. Articles about doctors found dead in hospital call rooms claim “no foul play.” No follow-up stories.
Medical schools and hospitals lie (or omit the truth) to cover up suicides—even when media and family report cause of death. Medical student Ari Frosch stood in front of a train, yet his school reported he died at home with his family. Though the family of psychiatrist Christine Petrich shared that she bought a gun and killed herself (after just getting her hair done and planning a surprise trip to Lego Land and Disney for her kids) on their GoFundMe page, her employer wrote she “passed away.” Shouldn’t the department of psychiatry take a more active interest in physician suicide?
Euphemisms cover up doctor suicides. Suicide is omitted from obituaries, funerals, clinics, hospitals, and medical schools. Instead we hear “passed away unexpectedly in her sleep” and “he went to be with the Lord.”
Secrets will not save us. We’re unlikely to make a medical breakthrough on a hidden medical condition.
Doctors choose suicide to end their pain (not because they want to die). Suicide is preventable. We can help doctors who are suffering if we stop with all the secrecy and punishment.
I’ve been shunned for speaking about doctor suicide. After being invited by the American Medical Association to deliver my TEDMED talk, I was disinvited shortly before the event because they were “uncomfortable” with physician suicide.
Ignoring doctor suicides leads to more doctor suicides. Thankfully, an Emmy-winning filmmaker is completing a documentary on physician suicide this month. International film tour begins in 2018. Contact filmmaker to have a screening at your medical school or hospital.
Dr Pamela Wible is a physician based in Oregon in the United States. She blogs here.
Doctorportal hosts a dedicated doctors’ health service providing support and information about suicide prevention in the medical community.
For support and information about suicide prevention, call Lifeline on 13 11 14
Postnatal depression: men get it too
Over the past few years, there has been an increase in media reports about postnatal depression and other maternal mental illnesses, and campaigns have led to greater understanding about the need for more specialist services. Although this is encouraging, very little is said about fathers. But men can get postnatal depression, too.
Currently, only mothers can be diagnosed with postnatal depression. The psychiatrists’ “bible”, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), includes a diagnosis of “peripartum depression”. Peripartum depression is a form of clinical depression that is present at any time during pregnancy, or within the four weeks after giving birth, although experts working in perinatal mental health tend to be more flexible, extending that period to the first year after giving birth.
In many ways, postnatal depression varies little from traditional depression. It, too, includes a period of at least two weeks where the person experiences low mood or a lack of motivation, or both. Other symptoms include poor sleep, agitation, weight changes, guilt, feelings of worthlessness, and thoughts of death and dying. But the biggest difference is that a depression at this time involves a significant additional person: the child.
Evidence suggests that the long-term consequences of postnatal depression on the child can be damaging, including developmental problems, poor social interaction, partner-relationship problems and greater use of health services (including mental health services).
Around 7-20% of new mothers experience postnatal depression. A common view is that it is caused by hormonal changes. Although this is partly true, it is far more likely that life factors are responsible, such as poverty, being younger, lack of support and birth trauma. Another potential cause is the sudden overwhelming responsibility of having a baby to care for, and the life changes that it entails.
Depressed mothers also feel intensely guilty about the way they feel about their baby, and fear shame and stigma from society. As a result, at least 50% of mothers will not report a mental health problem. Other mothers will not tell their health provider out of fear of having their child taken away by social services.
Pushish Images/Shutterstock.com
Mounting evidence
All of the above factors can equally apply to fathers. But there is no formal diagnosis of postnatal depression for fathers. Yet evidence from several countries, including Brazil, the US and the UK, suggests that around 4-5% of fathers experience significant depressive symptoms after their child is born. Some other studies claim that prevalence may be as high as 10%.
The cause of these feelings in fathers is similar to what we see with mothers, but there are extra complications. Men are much less likely to seek help for mental health problems, generally.
Societal norms in many nations suggest men should suppress emotion. This is probably even more a factor for fathers, who may perceive their role as being practical and providing for the family. Fathers – especially first-time fathers – might experience many sudden changes, including significant reduction in family income and altered relationships with their wife or partner. These are major risk factors for depression in fathers.
The importance for supporting fathers at this time is as vital as it is for mother. Evidence suggests that a father’s depression can have a damaging effect on their child’s development. Despite this, it has been shown that fathers are also less likely than mothers to seek help, and that health professionals are less likely to consider that fathers need support, compared with mothers. More evidence is needed to build a case that fathers need support as much as mothers.
Poorly equipped
It has been argued that, until recently, health professionals have been poorly equipped to recognise and treat mental illnesses associated with the birth of a child. Recent campaigns in the UK have led to changes in policy, funding and health guidelines. However, the recent revision of the National Institute for Health and Care Excellence (NICE) guideline on perinatal mental health does not address fathers’ needs. Despite a campaign to address this having support from several professionals and academics, a NICE spokesperson told the BBC that guidelines are unlikely to be changed as there is no evidence that men experience postnatal depression. However, if we discount hormonal factors in new mothers, the remaining risk factors for postnatal depression also apply to fathers. And we need support that recognises that.
Andrew Mayers, Principal Academic in Psychology, Bournemouth University
This article was originally published on The Conversation. Read the original article.
Nine steps to managing insomnia in primary care
It’s one of the most common reasons people visit their GPs, and the drugs used to treat it can be highly addictive. Insomnia can have nebulous causes and varying symptoms, which often make it difficult to manage.
A new Viewpoint published this month in JAMA brings together the latest evidence and recommendations for managing insomnia. The authors say insomnia disorder can be diagnosed if sleep difficulties occur at least three nights a week for at least three months, as long as the patient has had adequate opportunity for sleep and the sleeplessness cannot be explained by medications, substance abuse or any other disorder.
Cognitive behavioural treatment (CBT) is the recommended initial treatment for chronic insomnia. Brief behavioral treatment for insomnia, an approach derived from CBT, can also be used, and involves four simple interventions to help increase “sleep drive”:
- Reducing time in bed to match actual sleep duration;
- Getting up at the same time each day, regardless of sleep duration;
- Not going to bed unless sleepy;
- Not staying in bed unless asleep.
Pharmacological treatment is best for patients with acute insomnia, in conjunction with CBT, although the evidence for drugs in managing insomnia disorder remains weak. If medication is prescribed, the approved drugs for insomnia are benzodiazepines and benzodiazepine receptor agonists, the melatonin receptor agonist ramelteon, the tricyclic doxepin and the orexin receptor antagonist suvorexant. But these medications should be used only on a short-term basis, and in shared decision-making with the patient.
Here are are nine key steps to managing insomnia:
- Assess sleep and daytime symptoms and treat any comorbid conditions.
- For acute insomnia, consider a short-acting hypnotic (eg, temazepam or zolpidem 3-4 nights weekly for 3-4 weeks), then taper and discontinue.
- For chronic insomnia disorder, start the patient on an cognitive behavioral intervention.
- Assess sleep and daytime symptom response to treatment.
- If symptoms continue with CBT, consider combined treatment using a drug appropriate for sleep onset or sleep maintenance symptoms.
- If symptoms continue with pharmacotherapy, consider switching class of hypnotic (eg, benzodiazepine or benzodiazepine receptor agonist to doxepin, ramelteon, or suvorexant).
- If symptoms continue, evaluate other contributing factors (eg, life events, new medical or psychiatric disorder) and address with psychosocial, behavioral, or medical treatment.
- If the insomnia disorder is completely treatment-resistant, refer to a sleep specialist for evaluation of other sleep-wake disorders, including sleep apnea.
- Monitor for long-term treatment response and sequelae such as depressive or anxiety disorder, substance use disorder, or neurodegenerative disorder.
Source: JAMA
New study looks at welfare of kids with gay parents
The health outcomes of children brought up by lesbian and gay parents have become a flashpoint in the campaign over Australia’s postal survey on same-sex marriage, with opposing sides arguing over the few studies that have explored the issue.
Now a new US study, which claims to have avoided some of the flaws of previous research, has delivered its verdict, finding no significant differences in emotional and mental well-being between children of heterosexual and gay parents.
The study involved over 21,000 children between the ages of 4 and 17, around 1% of whom had a lesbian, gay or bisexual (LGB) parent, who were surveyed using a six-item Strengths and Difficulties Questionnaire. Results showed fears that children growing up in households with LGB parents might be harmed by the experience are “unwarranted,” the authors from the University of California and other bodies said.
“We found little evidence that LGB-parented families negatively impact children’s psychological well-being,” they wrote.
They said a key strength of their study was a more truly representative population sample compared with previous work, where participants were often self-selecting, therefore opening the research up to possible selection bias. Previous studies had also confined themselves to children being parented by couples and ignored those brought up by a single parent.
Bisexual parents were more likely to report that their children had emotional and mental health difficulties, although when adjusted for higher psychological stress in the parents, this difference disappeared.
The authors speculated that bisexual parents were more likely to experience “invisibility” about their identity, which might account for their higher levels of stress, and that the study findings supported further destigmatisation of sexual minority parents.
The study found higher levels of single parenting in LGB families. The authors say this could be at least partly explained by policies that constrain LGB people’s ability to form families, including their earlier inability to get married.
The authors said emerging research indicated that children of LGB parents often cite their nontraditional family structure as a source of strength and pride.
“The study findings are consistent with the growing body of research highlighting the overall resilience of children raised by sexual minority parents,” the authors conclude.
You can read the study here.
Improving bipolar disorder with computers
A Harvard study has shown for the first time that computerised brain training can result in improved cognitive skills in individuals with bipolar disorder.
In a paper published in the October 17, 2017 edition of The Journal of Clinical Psychiatry, the researchers suggest that brain exercises could be an effective non-pharmaceutical treatment for helping those with bipolar disorder function more effectively in everyday life.
The researchers found that the cognitive exercise regimen from BrainHQ online brain exercises and computer apps drove a large improvement in a standard measure of overall cognitive ability, as well as significant improvements in other cognitive measures.
Participants in the study also showed a large gain on the sub-domain measure of memory and visual learning, and a trend toward a medium-sized gain in the sub-domain of speed of processing.
The researchers assessed study participants again six months after the training ended, and they found that the gain in overall cognition persisted and that there was even a slight further improvement.
Lead investigator for the study, Dr Eve Lewandowski, said problems with memory, executive function, and processing speed are common symptoms of bipolar disorder and have a direct and negative impact on an individual’s daily functioning and overall quality of life.
“Improving these cognitive dysfunctions is crucial to helping patients with bipolar disorder improve their ability to thrive in the community,” Dr Lewandowski said.
The authors believe the findings demonstrate this type of non-pharmaceutical intervention can significantly improve cognition in patients with bipolar disorder, as well as suggesting that once the brain is better able to perform cognitive tasks, it will continue to strengthen those processes even after patients stop using the treatment.
While medications are available that help with the mood symptoms of bipolar, the authors identified that there are no current medications that help improve cognitive function. Some prior studies have been done with cognitive training in bipolar disorder, but such studies have often been small and lacked control groups.
Dr Lewandowski believes that this novel approach using computerised brain training, once fully developed, will be able to offer affordable and easily accessible web-based interventions which will be effective for a broad group of patients.
The study was conducted by independent researchers at Harvard Medical School and McLean Hospital, an affiliate of Harvard Medical School.
SANE Australia believes up to one person in 50 will develop bipolar disorder at some time in their lives.
MEREDITH HORNE
[Essay] Mental health and human rights in Russia—a flawed relationship
When the Soviet Union disintegrated in 1991, new independent psychiatric associations were established in many of the former Soviet republics, and groups of reform-minded psychiatrists initiated projects to discard the old Soviet psychiatric system, a system notorious for its political abuse of psychiatry and characterised by an almost exclusively biological orientation and institutional form of care. Russia was no exception and even boasted some of the most prominent mental health reformers, such as psychiatrist Yuri Nuller in St Petersburg1 and the Moscow-based lawyer Svetlana Polubinskaya, an associate of the Institute of State and Law who formulated the Soviet Union’s last law on psychiatric help and Russia’s first law on psychiatric care, which was adopted in 1992.
The link between nutrition and mental illness
Poor nutrition is contributing to the increasing numbers of people suffering mental illness, a large psychiatry conference has been told.
Professor of Clinical Psychology at the University of Canterbury Julia Rucklidge says a well-nourished body and brain is better able to withstand ongoing stress and recover from illness.
She says it’s time Australian and New Zealand psychiatrists and psychologists “get serious” about the critical role nutrition plays in mental health.
“Not a single study has shown that a western diet that is heavily processed, high in refined grains, sugary drinks and takeaways and low in in fresh produce is good for us,” Prof Rucklidge said.
“The western diet is associated with poor mental health and eating a diet more akin to the Mediterranean diet improves mental health,” she said.
For more than a decade Professor Rucklidge has been leading research investigating the role of nutrition in mental health.
A previous paper – led by Prof Rucklidge – published in the British Journal of Psychiatry showed taking macronutrients improved ADHD symptoms, including attention, hyperactivity and impulsivity, compared to participants on placebo.
Professor Rucklidge told the the New Zealand Conference of the Royal Australian and New Zealand College of Psychiatrists in Tauranga on Tuesday that nutrition matters and that optimising nutrition is a safe and viable way to avoid, treat or lessen mental illness.
People are what they eat, Prof Rucklidge says.
“Every time we put something in our mouths we can choose to offer ourselves something nutritionally deprived or something nourishing,” Professor Rucklidge said.
The Royal Australian and New Zealand College of Psychiatrists (RANZCP) agrees psychiatrists need to think about the “whole person” and the relationship between mind and body, in particular nutrition.
Research has shown people with a severe mental illness die up to 25 years earlier than those without a serious mental illness, often due to preventable physical health conditions.
They experience much higher rates of cardiovascular disease, diabetes and respiratory conditions.
“Psychiatrists have a key role to play in ensuring that people with mental illness are not further burdened by avoidable chronic physical health conditions,” said Dr Kym Jenkins, President of the RANZCP.
Let’s be clear about what health policy produces
BY PROFESSOR STEPHEN LEEDER, EMERITUS PROFESSOR PUBLIC HEALTH, UNIVERSITY OF SYDNEY
Australian health policy is fragmentary. Some bits make sense; others – if you accept that the purpose of our health systems is to help sick and injured people and to prevent illness and accidents – are wide of the mark.
The “helping” transaction, principally between doctor and patient, gets reduced, by bureaucratic policy-making, to dollar measurement. The “customer” (no longer a “sufferer” patient) is an alert, informed, inquisitive individual, competent to comparison-shop about the dollars and make decisions in their best medical interest.
This is a seriously misguided view of health care. Doctors take account of the vulnerability and degree of “illness” of each patient – physical, emotional, social and economic. These factors affect patients’ ability to comparison-shop between hospitals and doctors, and to make (wise?) choices.
Think back to when you or a close family member was sick; you wanted the best care and the best doctor, especially one whom you know and who knows you.
Productivity is complex, measured primarily in dollars. Other measurements are, at best, “flaky”. At its heart, productivity concerns the simple goal of job efficiency. When the product is a material good – shoes, cars, groceries – we can find ways, through outsourcing or technological change, to increase productivity, ie throughput (which can be measured) and measurable cost.
Years ago, I witnessed the automation of the aluminium smelting industry near Newcastle… one man in an air-conditioned shovel machine replaced many workers who had filled the smelting pots with bauxite.
But there are roles, especially interpersonal relations, which do not lend themselves to this type of efficiency gain through substitution. Medicine has a mixture of activities, some highly technical (such as biochemical measurements, where machines are progressively doing better than we can) and those where human relations are paramount (think of psychiatry).
For decades, until he died in May, William Baumol, economist at New York University’s Stern School of Business, had an interest in these distinctions. Musicians, teachers and doctors are among those for whom human interactions are crucial. These aspects of their work are not amenable to efficiency reform. Mozart’s string quartet No 4 demands the same human effort and emotion to produce (and to listen to) today as it did way back in 1772.
Baumol’s 2012 book, The cost disease: why computers get cheaper and health care costs don’t, gives an account of this distinction.
You might think – and I would agree – that a patient’s consultation with a specialist would be considered a primarily human interaction, as is the referring doctor’s choice of specialist. Exploring options for this choice is surely personal, between the referring doctor and the patient, involving the specialist’s personality, expertise, special interests, location, and which hospital they work or operate at.
The discussion about referral could, in some respects, but only in some, be better informed if there were readily available information about the specialist’s clinical record and co-payment policy.
But what could the ACCC have been thinking in promoting a referral process where the patient could take their referral letter to any consultant of their choice or to any outpatient clinic? That all of medicine, not just the technical aspects, can be made more efficient by dehumanising it?
The “Occupy Health Policy” assumes that the private sector can do everything more efficiently than the public and that the “outputs” can be measured in dollar terms. The ‘bean-counters’ overlook the values which doctors and nurses place on caring for individual patients, and which leads many to work far beyond what they are paid to do.
By all means, let’s use technology to best advantage and look at appropriate pricing for technologically-assisted health care. Choosing Wisely and similar campaigns lead in this direction, as does the review of MBS items to ensure that consultations, investigations and procedures do, indeed, provide ‘health’ value for money. But to believe that a “bizonomic” solution will fit the human side of Medicine is like seeking a technological replacement for members of an orchestra and their audience. Do that – focus on the money and not the purpose of health care – and you will wreck it.
[Comment] Post-partum depression—a glimpse of light in the darkness?
There can be little doubt about the importance of mood episodes in pregnancy and following childbirth.1 Mood episodes are common—post-partum depression is the most common medical complication of maternity, affecting around one in ten new mothers.2 They can also be severe—episodes of post-partum psychosis represent some of the most serious episodes of illness seen in psychiatry.3 Perinatal mood episodes cause substantial impairment to women and have a wide ranging impact on their babies, families, and society.