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Preference: Psychiatry

913

Stress and burnout in intensive care medicine: an Australian perspective

A call for a multilevel response to an evolving challenge

Intensive care medicine (ICM) is an evolving high stakes specialty. Emerging evidence raises questions about the welfare and sustainability of the ICM workforce. Clinician burnout is a phenomenon resulting in consequences for both intensive caregivers and patients.

While resident doctors, fellows and new consultants across many specialties display high levels of stress and burnout relative to the general population,1 ICM clinicians are disproportionately affected, rating higher on stress, burnout and compassion fatigue indices.2 Paediatric intensivists have markedly higher burnout rates than general paediatricians.3 An Australian ICM study described an 80% rate of psychological stress and discomfort in a practising ICM specialist population, with many reporting burnout symptoms.4

Burnout is a state of psychological distress related to chronic stress. Prevalence estimation using different tools, alternate metrics and cut-off points have made epidemiological studies of ICM clinician burnout challenging.5 The Maslach Burnout Inventory is the most commonly used burnout instrument in this area and scores three major characteristics of burnout: emotional exhaustion, depersonalisation and low levels of personal effectiveness.4 Intensive care unit (ICU) physicians and nursing staff have similar rates of burnout symptomatology, with ICU nurses reporting higher emotional exhaustion rates and ICU physicians reporting higher rates of depersonalisation and reduction in professional achievement.6 These trends suggest specific risk factors within the ICM environment.

The burnout syndrome has been described in Australian emergency medicine clinicians.7 Some protective influences appear to be ongoing professional development, dedicated non-clinical time, and a feeling of teamwork.7 Burnout does not necessarily correlate with job satisfaction, with predisposing factors in this group including younger age, workplace conflict, a lack of exercise, and excessive alcohol consumption.7 In addition to many of these stressors, intensive care clinicians are repeatedly exposed to high stakes, ethically challenging decision-making processes. The high “density” of ethical decision making in ICM contributes to moral distress and may be exacerbated by the provision of “disproportionate care”, where there is a perceived inappropriate or harmful mismatch between the level of care provision and a patient’s needs.8

Care of the health care provider and quality of patient care are interconnected. Physician burnout has been associated with lower patient satisfaction, reduced health outcomes and medical error.2 Burnout symptoms reduce potential ICM workforce capacity through increased sick leave and decreased staff retention.2 The consequences of burnt out clinicians may ripple through an entire organisation, compromising interactions between individuals and teams.

Evolving trends in Australia may further exacerbate the problem of burnout. These changes include greater intensivist coverage and shift work, an increasingly fractionalised workforce with unequal gender balance, and an evolving external and ward ICM responsibility. The move towards physically larger Australian ICUs has coincided with enhanced societal expectations of clinical outcome and an increase in interventional medicine.

We advocate for a multilevel strategy in order to address ICM workforce sustainability and welfare. The prevention and remediation of burnout requires consideration of both individual and systemic factors.9

At an individual level, a holistic approach to the ICM clinician, not just as a service provider, is required. A balance must be facilitated between work, life, clinical and non-clinical duties and career progression. Stress prevention and resilience strategies include mindfulness and cognitive techniques, coaching, mentoring and, perhaps most importantly, peer discussion.

Leadership from clinicians will be important to drive change at an institutional level. Compassionate staffing, flexible rostering, ensured leave and ongoing employee assistance programs should be broadly available. Clinicians themselves will need to foster an acceptance of their own vulnerability and cultivate an environment where open dialogue about stressors is respected.10

The College of Intensive Care Medicine and the Australian and New Zealand Intensive Care Society have roles to play in the development of performance indicators for workplace stress and burnout, with complementary advocacy for a safe, sustainable workplace. The ICM training model should encompass self-assessment and resilience skills, supported by commensurate training of trainee supervisors and senior staff.

A broader societal discussion about the antecedents of moral distress and disproportionate care is required. Shared health goal setting before crises and preparing for realistic, appropriate decisions at the end of life continue to be of great importance. Such projects may be supported at government level, with direct expert input from ICM clinicians.

While there is increasing evidence of the physical and emotional effects of the unique ICU environment on inter-professional practitioners, there remains a paucity of coordinated interventions aimed at understanding and addressing ICM clinician burnout. We advocate for a multilevel response in order to improve the welfare and sustainability of the Australian ICM workforce.

The importance of taking care of our own

I’ve read a lot of articles lately about the issues of mental health and suicide in medicine, and to those within medicine there is no surprise about the sentiment in these articles. Each one addresses a different issue, although often talks about a “profession that eats its young” or the “importance of standing up for yourself”. In times of emotional upheaval, we all want to find the root cause an issue and fix it as soon as possible. This is especially so for us physicians and surgeons, ever ready to treat illness as effectively and as quickly as possible. In this spirit, many a person is quick to the conclusion that “This is it! This is the problem! If we just fix these things everything will be better!”. I just don’t think it’s that simple. It never has been and it certainly isn’t now.

Never in my time as a doctor have I ever seen a patient and have expected them to solve their problems by themselves. And yet, this is what we often expect of our colleagues, or our colleagues think it is what’s expected of them. If someone is under-performing, too often the system assumes the problem is with them. Individually we can be kind, compassionate and caring. Collectively as a workforce, we can sometimes be cold, unfeeling and quite simply just out of time. There are systemic supports in place for the underperforming doctor, but we fall through the cracks so easily time and time again. And most of us are so busy just trying to get the job done that we don’t even notice those falling off the edge, let alone help them back up.

We have a system where unhealthy rosters make it near impossible to take leave in times of stress or crisis. We have a system in which part-time employment is practically non-existent and approaches to change this are met with 1950s attitudes about professionalism and practice. We have almost no opportunity for those who are burned out or mentally unwell to gradually return to work in a supervised and supportive manner. And we certainly don’t have a workforce in which it is OK to be mentally ill. Mentally ill doctors are outcasts; pariahs amongst scores of highly functioning practitioners. This is not helped by the fact that in all states except Western Australia, you are expected to report these critically unwell colleagues to a registration board that has an incredibly unhealthy approach to conditions and notifications, thus making the problem worse.

Personally, I’ve worked in wonderful workplaces. I’ve seen initiatives for better rostering supported. I’ve seen part-time work embraced as a way to improve training and workforce flexibility. I’ve seen a colleague supported back to work in a manner that suited their illness. But I’m concerned that while these examples exist all over the country, they are not the primary way of doing business in medicine. Healthy workplaces need to be the rule, not the exception.

There are plenty of reasons for why this is the case. We know how hypercompetitive medicine is, even after medical school. We know there is an ever-tightening workforce with fewer job prospects. We can talk about the divorce of clinical management from administrative management and the distance between clinicians and departmental rostering and staffing. But I don’t want to talk about these things. I want to move forward.

I want to talk about you about the actions that we can take. Chances are, you’re a healthy doctor-in-training, with strong social supports and an optimistic future. We are the ones who needs to stand up for our unwell colleagues. We are the ones who will be able to change the system and make the profession a healthy and sustainable one again. Don’t expect those who suffer from mental illness to make the first steps; you don’t expect it from your unwell patients and it’s cruel to expect it from your unwell colleagues. Maybe it’s something as small as a frank discussion around unhealthy rules and regulations at your hospital or practice, but it’s a start and an important one at that. Systems change isn’t just about helping those in crisis. It’s about enabling those who are doing well to help those around them.

I’m not writing this to you as a motivating plea to naively revolutionise a whole profession overnight. I’m writing this to you because I’m tired. I’m tired of seeing my friends having to deal with the onslaught of depression and anxiety that this job can bring their way. Not just for them, but because I know all too well that mental illness doesn’t discriminate, and that most of the difference between a healthy doctor and an unhealthy one is luck half the time. We’re just not that special. That’s why we need profession-wide organisations like the AMA. We can’t expect a handful of people to shoulder the burden. The whole profession has to bear it, and take ownership of the future.

You may or may not agree with my sentiment and my position in this article. But surely we can all agree that when doctors-in-training are committing suicide and leaving the profession, there is something terribly wrong with our culture and our workplaces. So let’s change it. It’s as simple, and as complicated, as that.

Until next time,

Z

Dr John Zorbas

Chair, AMA Council of Doctors in Training

Latest news

[Correspondence] Gender and health: between nomenclatures and continuums

Addressing transgender health in a Lancet Series and in The Lancet Psychiatry1 constitutes a milestone for health professionals and social scientists. I draw conclusions from some of these papers on how we consider health, disease, and gender, and on the purpose of the nomenclatures we have developed and use.

Supportive care of women with breast cancer: key concerns and practical solutions

Due to a steady decline in breast cancer mortality rates and increasing longevity, about 176 556 Australians diagnosed with breast cancer in the preceding 29 years were alive in 2010.1 About 16 000 new cases of breast cancer are expected to be diagnosed in 2016, of which most women will be cured.2 To achieve the current 90% 5-year disease-free survival, a variety of treatments are employed, including surgery, radiotherapy, chemotherapy, biologic therapy and endocrine therapy. However, as a result of these treatments, a large cohort of women (and some men) is living with the after-effects of either the diagnosis of or treatment for breast cancer. Some of these patients may have significant supportive care needs for many years after their diagnosis, and a range of clinicians may be involved in their care.3 Some patients with metastatic breast cancer also live for many years and may share these supportive care needs.

Supportive care of these patients aims to alleviate the burden of cancer treatment or of cancer itself, from diagnosis to the end of life, irrespective of whether the cancer has recurred or not.3 The physical and psychological morbidities associated with treatment have long term impacts on role functioning at work and at home. Good supportive care can aid in the management of a range of problems that are experienced after a diagnosis of breast cancer (Box).

Many health care practitioners play a part in the follow-up care of women with breast cancer, including medical and radiation oncologists, surgeons, general practitioners, psychologists, psychiatrists breast care nurses, general practice nurses, allied health practitioners (eg, physiotherapists, dietitians, pharmacists) and complementary practitioners. Survivorship care plans are designed to document who of these professionals is responsible for aspects of follow-up care, to help identify and manage supportive care needs of affected women. To date, no single follow-up strategy has been identified that suits the needs of all women, or improves their survival, so flexibility is key. With such a variety of treatment options and modalities available, good communication between practitioners should be maintained throughout the follow-up period.

Here, we briefly describe several problems that commonly affect women diagnosed with early stage breast cancer, along with management strategies pertinent to both generalist and specialist clinicians.

Symptoms due to oestrogen suppression

Tamoxifen has been a standard post-operative endocrine therapy for pre-menopausal oestrogen receptor positive breast cancer. However, recent results from randomised trials4,5 have led to changes in recommendations for pre-menopausal women considered to be at higher risk of cancer recurrence, determined on the basis of clinical-pathologic factors. Young women may now be treated with a combination of ovarian function suppression by 4-weekly gonadotropin-releasing hormone (GnRH) agonist injections plus an oral aromatase inhibitor, resulting in ultralow oestrogen levels over several years. Laparoscopic bilateral oophorectomy is a non-reversible alternative to GnRH injections. Ovarian function suppression, initiated prior to and continued during chemotherapy, may also be recommended in pre-menopausal oestrogen receptor negative cancer, to reduce the risk of premature menopause and improve future fertility prospects.6 Management of the effects of endocrine therapy is particularly important given accumulating data supporting treatment for 10 years or more after diagnosis.7

Adding treatment that suppresses ovarian function to oral endocrine therapy increases the frequency of several toxicities including vasomotor symptoms, insomnia, depression, vaginal dryness, loss of libido, bone density loss and musculoskeletal symptoms.6 Hypertension and glucose intolerance and/or diabetes are also more frequent in women undergoing ovarian suppression; therefore, young women rendered post-menopausal for years by GnRH injections should be assessed for these conditions.

Ovarian suppression and use of aromatase inhibitors result in bone density loss, and women should be advised to receive adequate dietary calcium, vitamin D supplementation if they are at risk of deficiency, avoid smoking, and participate in regular weight-bearing exercise. Among pre-menopausal women assigned to receive ovarian suppression plus an aromatase inhibitor for 5 years, low bone density (T score < −1.0) was reported in 38.6%, including 13.2% with osteoporosis (T score < −2.5).5 Women undergoing ovarian suppression and/or aromatase inhibitor therapy should undergo bone density monitoring. This is rebatable by Medicare for women aged under 45 years with amenorrhea for at least 6 months. Breast cancer treatment-induced bone density loss in pre-menopausal woman can be prevented with a 6-monthly dose of an intravenous bisphosphonate (zoledronic acid).8 While this is not currently an approved or Pharmaceutical Benefits Scheme-subsidised indication in Australia, generic formulations are relatively inexpensive.

Vasomotor symptoms are common in women treated for breast cancer, and hormone replacement therapy is contraindicated. Lifestyle measures including weight loss, prevention of weight gain, and exercise are recommended, although the evidence for reducing vasomotor symptoms is weak.9 Effective non-oestrogenic pharmacological therapies include selective serotonin reuptake inhibitors and serotonin–norepinephrine reuptake inhibitors, GABA analogues (gabapentin, pregabalin) and clonidine.10 Among selective serotonin reuptake inhibitors, paroxetine and fluoxetine are best avoided in women taking tamoxifen, owing to potent inhibition of tamoxifen metabolism.11 Cognitive behavioural therapy and hypnosis can reduce vasomotor symptoms, while acupuncture and mindfulness-based stress reduction have also shown promise.10

Aromatase inhibitor musculoskeletal syndrome

Most women diagnosed with early breast cancer have hormone receptor positive disease and most will benefit from at least 5 years of adjuvant endocrine treatment.4 Aromatase inhibitors (AIs) lead to superior disease-free survival and in some instances overall survival compared with tamoxifen. As a result, AI use in post-menopausal women has been increasing and in 2008 overtook that of tamoxifen.12

Arthralgia and other joint-related symptoms are common in menopausal women but are also a significant toxicity of AIs and the most common cause of treatment discontinuation.13 Lintermans and colleagues described a syndrome of arthritis, arthralgia, myalgia, musculoskeletal pain, carpal tunnel syndrome, joint stiffness and/or paraesthesia associated with AIs, now commonly referred to as aromatase inhibitor musculoskeletal syndrome (AIMSS).14

Clinical trials of adjuvant AIs report AIMSS in up to 36% of patients; however, community-based series report considerably higher rates. In a survey of Australian women taking AIs, 82% of women reported AIMSS.15 Any joint can be affected but hands, hips, feet and knees were most commonly involved. The syndrome typically presents within 8 weeks of commencement of an AI but may have a later presentation with slow worsening of symptoms over 6–24 months. In the Australian women surveyed, a third had considered stopping AI therapy, and 18% had discontinued because of AIMSS. Reduced adherence has been associated with an increased risk of relapse.16

Despite more than a decade of research into interventions for AIMSS, there are still limited data supporting effective interventions. In the Australian survey, women found anti-inflammatories, paracetamol and yoga most beneficial for treating AIMSS.15 Studies have been unable to demonstrate a benefit from duloxetine, testosterone, glucosamine, chondroitin sulfate, fish oil, antidepressants, anticonvulsants, bisphosphonates, vitamin D supplements or acupuncture.17 Prescription anti-arthralgia medication use does not appear to reduce AI discontinuation.18 The most compelling current data support exercise in previously inactive women.19 Other options to improve tolerance and reduce discontinuation include switching to tamoxifen or trialling an alternative AI.20

Sexual dysfunction

The impact of cancer and its treatment on sexuality is increasingly recognised. Deleterious changes in sexual function are experienced by 50–70% of women after breast cancer and persist long after diagnosis.21 Physical sexual side effects of cancer and its treatment may include vaginal atrophy (dryness or tightness), decreased desire or motivation, pain during penetration, absent or muted orgasms, and urinary dysfunction. It is not unusual for women to experience poor body image and changes to their sense of femininity, which contribute to lower interest in sex. With deteriorating sexual function, anxiety and depression can increase in cancer survivors and their partners. This causes overall quality of life to decline, rendering sexual difficulties one of the most distressing survivorship concerns.22

Both pharmacological and psychosocial interventions can help manage post-treatment changes to sexuality.21 Non-hormonal options include use of a pH-balanced vaginal gel21 or lignocaine gel23 to reduce dyspareunia and vaginal dryness, and allow comfortable resumption of intercourse in women entering menopause after chemotherapy or endocrine treatment. If non-hormonal strategies are ineffective, vaginal oestrogen can be considered after discussion about the potential risks and benefits, in consultation with the treating oncologist. Despite systemic absorption of these preparations having the potential to stimulate oestrogen-dependent breast cancer, vaginal oestrogen has not been shown to increase the rate of breast cancer recurrence.24 Sexual dysfunction is worse with AIs than with tamoxifen, so switching endocrine therapy can be an effective treatment strategy. While pharmacological interventions address physical sexual dysfunctions, psychosocial interventions have led to improved sexual and relationship satisfaction.21 The core components of effective psychosocial interventions to improve sexual function include psychoeducation (empowerment-oriented, evidence-based education), coping and communication skills training, mindfulness training and sensate focusing.21

Despite the availability of pharmacological and psychosocial interventions, many women do not discuss sexual concerns with their health professionals and, consequently, do not access effective interventions. Availability of internet-based interventions may help overcome barriers to accessing care. An Australian randomised trial, the Rekindle study, is assessing the feasibility of delivering psychoeducational support to cancer survivors and their partners using an internet-based approach.25 Women can self-refer and register on the study website (www.rekindleonline.org.au).

Alopecia

Hair loss can be a very distressing side effect for patients undergoing adjuvant chemotherapy and sometimes leads to patients declining treatment. It can be a major psychological issue for some patients, both male and female, and may attract unwanted attention, breaching privacy.26 Chemotherapy drugs can cause atrophy and loss of the hair root bulb, resulting in total alopecia or partial atrophy of the hair shaft, making it more susceptible to trauma from normal hair care. Permanent partial alopecia sometimes occurs after current standard chemotherapy for breast cancer.27

Scalp cooling is an effective method of minimising chemotherapy-induced alopecia. Reduced scalp temperature reduces drug penetration to the hair follicle via vasoconstriction. This reduces the cellular uptake of the drug and the degree of hair loss. Cooling is applied by either a gel cap or a coolant system before, during and after the chemotherapy infusion. Effectiveness varies depending on the dose, schedule, agent used, duration of cooling, age, hair type and temperature of the scalp.28 Breast cancer studies do not indicate a higher rate of scalp metastases or altered survival.29

Close coordination between medical and nursing staff and hair care professionals is required for effective implementation, with increasing availability in Australia. Patient information can be found at https://mns.org.au/home/our-services/list-of-services/cancer-care/scalp-cooling-system.

Fear of cancer recurrence

Fear of cancer recurrence (FCR) is commonly defined as fear of cancer returning or progressing in the same organ or another body part.30 Up to 70% of cancer survivors experience moderate-to-severe FCR, and help with managing FCR is a frequently cited unmet need.31 Younger early stage breast cancer patients and those with more physical symptoms and greater psychological distress appear particularly vulnerable to experiencing FCR.32 Further, FCR is relatively stable over time and appears to have little association with objective recurrence risk.32 Severe FCR may impair quality of life and increase psychological distress.31 It is also associated with greater health care usage, including increased unscheduled GP and oncologist visits and, conversely, lower breast surveillance imaging rates.33

Identification and management of FCR should take a multidisciplinary approach, with primary care providers as a key point of contact. Routine screening for FCR is recommended at the completion of primary treatment and during follow-up consultations with GPs and specialists across all points in the diagnosis, treatment and survivorship trajectory.34 Used in conjunction with patient and carer reports, self-report instruments can assist in clarifying the severity and impact of FCR on an individual’s social, emotional and occupational functioning.35 All cancer survivors should be provided with information on FCR and education on recurrence rates and their interpretation. Proposed components of a clinical definition of FCR include (i) high levels of preoccupation, worry, rumination or intrusive thoughts; (ii) maladaptive coping; (iii) functional impairments; (iv) excessive distress; and (v) difficulties making plans for the future.36 Referral to a psychologist is recommended if FCR is associated with one or more of these five items, with psychiatrist referral if medical management is indicated.37 Several psychological interventions based on cognitive behavioural models are currently being trialled (eg, Conquer Fear).38 Until interventions with strong evidence are available, practitioners’ experience in cancer and survivorship issues should guide referral to psychosocial services.

Pain

Pain is a common and feared complication of cancer; 53% of people at any stage of disease experience pain.39 Further, 25–60% of breast cancer survivors have persistent pain after treatment, including breast, chest wall, axillary and lymphoedema-related pain from surgery and radiotherapy; peripheral neuropathy from chemotherapy; and musculoskeletal symptoms from AI use.40 Poor pain control can interfere with quality of life, function, mood, sleep and relationships, and cause caregiver distress. The key principles of pain management apply in people with active cancer and in cancer survivors: screen for pain; conduct a comprehensive assessment to determine the mechanism and cause; treat the cause; treat associated distress; and give evidence-based therapies.

Management of pain after a diagnosis of breast cancer includes exercise, appropriate referral (eg, to a lymphoedema therapist), and analgesics such as paracetamol or non-steroidal anti-inflammatory agents. For patients with neuropathic pain, duloxetine may be beneficial.40 The role of opioids in this population is under question due to long term adverse effects and lack of evidence for benefit. A multidisciplinary approach with non-pharmacological strategies should be considered in this group.41

Self-management strategies can enhance the achievement of pain-related goals and sense of control.42,43 Each person has a different goal for what is an acceptable pain score. A patient-held pain management plan can be negotiated between health professionals and patients, allowing patients to be more involved in their own care. For patients with chronic pain after breast cancer treatment, the goal may be to live well despite pain, rather than to completely eliminate it.

Cognitive impairment

Up to 70% of women complain of cognitive impairment or dysfunction after breast cancer diagnosis and treatment,44 with distressing effects on their quality of life and functional abilities. Increasing evidence suggests that cancer itself, in addition to anti-cancer treatments, is responsible for deteriorations in cognitive function.44 Measurement of cognitive changes includes neuropsychological testing, functional assessments of everyday activities and self-reported assessment; however, objective and subjective measures are not well correlated.

The mechanism for cognitive deterioration is likely multifactorial and may include direct neurotoxicity, immune dysregulation, oxidative damage, changes in sex hormone levels, microvascular clots or genetic predisposition.44 Given the strong association between self-reported cognitive impairment, sleep disturbance, fatigue, and anxiety and depression, it is important that women are screened and treated for these problems where they are present.

While it is difficult to predict who is at greatest risk of cognitive impairment and to prevent it occurring, there is growing evidence that cognitive rehabilitation interventions can alleviate these symptoms. Computerised cognitive training and brief cognitive behavioural treatments improve a range of cognitive outcomes including self-reported cognitive impairment, speed of information processing, cognitive flexibility, delayed memory and verbal fluency.44,45 Women should be informed that cognitive changes are a possibility and that spontaneous recovery is likely within the first 6–12 months after treatment. Patients experiencing prolonged or profound cognitive changes could be referred initially for cognitive rehabilitation using available online programs such as BrainHQ (www.brainhq.com), followed by cognitive behavioural treatments in those with persistent symptoms.

Lack of exercise

Evidence strongly supports the benefits of exercise as a form of medical treatment after a breast cancer diagnosis. Exercise plays an important role in treatment-related symptom control, reducing the severity and number of treatment-related side effects and symptoms (including sleep disturbances, cognitive impairment, pain, fatigue and lymphoedema), as well as improving function and fitness during and after treatment.46 Exercise during and beyond treatment for breast cancer also contributes to improved self-confidence, self-image, self-efficacy and self-esteem, and reduced depression and anxiety.46 Further, high quality cohort studies have shown that women who exercise regularly during and after breast cancer treatment experience a 20–40% reduction in all-cause mortality, disease recurrence and breast cancer deaths, independent of other prognostic factors including stage of disease and being overweight or obese.47

In Australia, despite availability of clinic- and community-based breast cancer-specific exercise programs such as YWCA Encore (http://www.ywcaencore.org.au), exercise does not form part of the standard breast cancer care provided for the majority of women. Yet the need is great, with most breast cancer survivors being classified as either sedentary or insufficiently active during treatment. Women commonly reduce their exercise levels after their diagnosis, rather than initiate or maintain an exercise regime.48 Therefore, the question is not whether such women should be active during and after their treatment, but how they become and stay sufficiently active to live healthy lives beyond their breast cancer experience.

Ideally, exercise will not only prevent declines in function, but will maintain or increase function. As a minimum, each exercise session should be of moderate intensity (inducing shortness of breath) for at least 10 minutes in duration, including both aerobic and resistance-based exercise. Current guidelines suggest increasing exercise duration, frequency and intensity, up to at least 150 minutes of exercise each week.49 An exercise prescription from a doctor or other qualified health professional (such as an exercise physiologist) is most effective when combined with behaviour change strategies, taking into account exercise preferences, barriers and motivators.50

Conclusion

Identification and management of the supportive care needs of women with a past diagnosis of breast cancer is relevant to both breast cancer specialists and a wide variety of clinicians and allied health practitioners. Good supportive care can not only improve patients’ quality of life but also their survival outcomes.

Box –
Supportive care needs experienced by women with breast cancer

  • Endocrine treatment-related morbidity such as hot flushes, arthralgia, osteoporosis and genitourinary symptoms
  • Physical and psychological impact on sexual function
  • Alopecia
  • Fear of cancer recurrence
  • Pain — eg, chest wall, breast, axilla and musculoskeletal
  • Impaired memory, concentration and cognition
  • Deconditioning and suboptimal exercise levels

NHMRC funding of mental health research

A case for better alignment of research funding with burden of disease

Mental health research has long been the poor cousin in medical research, despite mental illness being both an independent and comorbid risk factor for every major medical disease, and a significant contributor to morbidity and mortality. Of the five major non-communicable disease areas, mental illness has the largest impact on the world economy by reducing gross domestic product.1 Yet, 11 times more money is donated from the private and corporate sectors to cancer research than to mental health research. In addition, cancer research receives twice the funding from governments.2

This pattern is reflected in the funding distribution from the National Health and Medical Research Council (NHMRC) in Australia, where mental health research has received a lower proportion of NHMRC health funding compared with other National Health Priority Areas such as cancer, diabetes and cardiovascular disease. Between 2001 and 2010, for example, mental health received about 9.5% of NHMRC funding.3 NHMRC funding for suicide research was lower than funding for falls, skin cancer and motor vehicle accidents, despite the fact that suicide is responsible for more deaths.4 In 2015, when NHMRC announced the membership of its strategic committees, there were no members with mental health expertise, in contrast to previous years.

We tested whether the proportional NHMRC funding to mental health has changed since our 2010 analysis, by estimating the number and dollar value of NHMRC funding schemes awarded to mental health-related topics during 2015. We also compared burden of disease estimates with NHMRC funding for mental health to determine whether the proportion of funding allocated to mental health-related research is in line with its effect on the population.

Using data from the October–November 2015 announcement of NHMRC results, we conducted a search of the following fields: grant title, field of research, all keywords and research summary. Our search used the following text strings: mental health, mental illness, depressi*, anxi*, psychosis, schizophrenia, substance use, alcohol use, smoking, adhd, stimulants, cocaine, heroin, amphetamine, sleep, obsessive, autism, panic, ptsd, suicid* and bipolar. The search conservatively counted psychosocial research with any mental health component as 100% “mental health”.

In 2015, the NHMRC funded 1037 projects or fellowships across all health categories, which were worth a total of $763 million. Of these, 85 were on the topic of mental health, constituting 8.6% of funding (Box). In 2009, the proportion of the total funding allocated to mental health was 9.5%. Recent data from the Australian Institute of Health and Welfare5 suggest that the burden of disease for mental disorders is 12.1%, or 14.6% if suicide and self-inflicted injuries are included, with mental and substance misuse disorders accounting for the largest burden in younger age groups. If funding was proportional to the burden of disease (disability adjusted life years), mental health research was short $26.6 million or 41% of the total funding. A comparison of cancer, cardiovascular and diabetes research using a similar search strategy found that 14.3%, 15.5% and 5.7% of funding went to these areas. Based on the burden of disease for these disease areas (18.5%, 14.6% and 2.3% respectively), these funding figures represent a smaller relative shortfall for cancer research ($32.1 million, 29%), a small gain for cardiovascular research ($7.1 million, 6%) and a large net gain for diabetes research ($17.6 million, 41% gain).

Our analysis indicates that, in the major NHMRC funding announcement for 2015, mental health research received significantly less funding than its disease burden (8.6% versus 12.1%), and less total funding than the average received in the previous decade (8.6% versus 9.5% for 2001–2010). This funding pattern is in contrast to the United Kingdom, where the research investment in mental health by the government has increased as a proportion of overall spend by 1.5% over the decade 2004–2014.2 The present analysis had limitations, such as not being able to deal with the problem of infrastructure and clinical environment in detail, compare in detail the nature of cardiovascular and cancer research, or reconfirm the high quality of Australian mental health research.3

There are many potential reasons as to why mental health research does not receive NHMRC funding proportional to disease burden. Given that the problem is not the quality of the research (mental health research outperforms other disciplines on the world stage),3 the working hypothesis remains that the primary causes are capacity (limited number of active mental health researchers) and the nature of mental health research (NHMRC category descriptors do not favour translational research — real-world trials are rarely flawless). Considering the capacity concern, it is disappointing that the number of opportunities provided to early- and mid-career fellowship applicants in mental health remains low.

The prevalence of depression and suicide rate has not changed in the past decade, while the costs of mental health to the community are increasing rapidly. Recent figures indicate that the government spent about $4.5 billion on mental health with about 21% of this spent on hospital funding; 21% on carer funding and 20% on the Medicare Benefits Schedule. These spends represented an increase of between 13% and 53% over the past 7 years.6 Critically, this investment has not increased access to evidence-based mental health care, which remains low at 11–20%.7 Yet, research funding has remained stagnant over the same period, with considerable decreases after adjusting for inflation. Mental health research has the potential to transform the lives of Australians and to save costs.

So what is to be done? First, impress upon the public, scientists, government and politicians the importance of research as the key solution to managing the escalating costs of mental health — estimated to be $4.5 billion, which represents an increase of up to 53% over the past 7 years.6 Second, recognise that research funding in Australia has to change, as in the UK, where the proportion of funding to mental health has increased by 1.5% from 2004–2014.2 Third, we need to determine the reasons for low yields from philanthropy and non-government support for mental health, and actively overcome barriers and capture funds.

We call on the Australian government to develop a clear, empirical basis for using health priorities to allocate funding from the emerging Medical Research Future Fund that accounts for indices such as burden of disease and building capacity in underfunded areas. The government approved the establishment of the Medical Research Future Fund in 2015 to drive innovation in medical research, with funding guidelines currently being developed. The resulting doubling of investment in medical research in Australia offers a unique opportunity to overcome the gap in the funding of mental health research identified here. The mental health community (consumers, researchers, clinicians and the wider community) look forward to continuing to contribute ideas to the Australian Medical Research Advisory Board regarding a more equitable distribution of research funding.

Box –
Counts and funding for major NHMRC grants and fellowship categories announced on 9 November 2015

Category

Number awarded

Number awarded related to mental health

Total funding across all domains ($)

Funding related to mental health ($)

Career development fellowship

55

5 (9.1%)

23 915 192

2 184 844 (9.1%)

Early career fellowship

124

13 (10.5%)

38 102 059

3 779 955 (9.9%)

Research fellowship

69

8 (11.6%)

51 239 170

6 070 820 (11.8%)

Development grant

24

0

14 142 312

0

Standard project grant

483

48 (9.9%)

404 722 995

48 622 759 (12.0%)

NHMRC–ARC dementia research development fellowship

76

6 (7.9%)

43 669 587

3 308 618 (7.6%)

Total (all schemes)

1037

85 (8.2%)

$763 481 138

$65 746 208 (8.6%)

ARC = Australian Research Council. NHMRC = National Health and Medical Research Council.

Obsessive compulsive disorder linked to birth events

A range of perinatal factors appear to be associated with higher risk for children later developing obsessive compulsive disorder (OCD).

Complications in the perinatal period have been associated with other psychiatric disorders. Few studies suggest perinatal complications may also play a role in OCD, but the studies had weaknesses that preclude firm conclusions.

Gustaf Brander from the Karolinska Institutet in Stockholm, Sweden, and co-authors, examined a potential link using a population-based birth cohort of 2.4 million children in Sweden born between 1973 and 1996 and followed up through to 2013. Of the 2.4 million individuals, 17,305 people were diagnosed with OCD at an average age of 23.

The study, published by JAMA Psychiatry, reports that independent of shared familial mitigating factors, maternal smoking during pregnancy, presenting as breech, delivery by cesarean section, preterm birth, low birth weight, being large for gestational age and Apgar distress scores were associated with a higher risk for developing OCD.

The mechanism linking OCD to perinatal factors remains to be identified.

Limitations include a study group weighted toward more severe cases that does not represent the totality of all patients with OCD in Sweden. Also, there are missing cases.

“The findings are important for the understanding of the cause of OCD and will inform future studies of gene by environment interaction and epigenetics,” the study concludes.

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Suicide by health professionals: a retrospective mortality study in Australia, 2001–2012

The known The risk of suicide may be higher for medical practitioners and nurses than for those in other occupations. This problem had not been assessed at a national level or by sex. 

The new Age-standardised rates of suicide were higher for female medical practitioners, and for male and female nurses, than for other occupations. The rate of suicide for health professionals with access to prescription medicines was higher than for health professionals without ready access to these means. 

The implications Suicide prevention initiatives should focus on workplace factors and differential risks for men and women employed as health professionals. 

In general, health professionals are healthier and live longer than the general population.1 However, research has identified elevated rates of suicidal ideation and death by suicide among certain groups of health professionals, including doctors, nurses and dentists.2–4

Suicides by health professionals typically have two distinguishing features. First, they are more likely to involve poisoning5–7 than methods such as hanging, which is more common in the general population.8 Second, women working in health professions appear to be at particular risk; whereas in the general population the rate of suicide for men is nearly four times as high as that for women,8 the rates of suicide among female health professionals are comparable with those of their male peers.2–4 These two findings may be related, as the lethality of self-poisoning increases with access to prescription medicines, and women are more likely than men to choose poisoning as the method of suicide. Other possible explanations for the elevated rates of suicide among female health professionals include greater exposure to work-related stressors.9

Australian research on suicide by health professionals has been restricted to Queensland;6 there are no published analyses at the national level. Further, research has been restricted to studying doctors and nurses, with a notable lack of published data on the burden of suicide in other health care professions in Australia. A better understanding of whether suicide rates are elevated for all health professionals, or for medical professionals specifically, would assist efforts to prevent suicide. We therefore used a national register of occupationally coded suicide cases to determine the rates of suicide by health professionals in Australia and the suicide methods used, and to compare these with data for suicides by people in other occupations. We also assessed whether suicide rates for female health professionals were higher than for their male colleagues.

Methods

Study design

We conducted a nationwide study of deaths by suicide between 2001 and 2012. The study included all employed adults with a known occupation who were at least 20 years old at the time of their death.

Ascertainment of suicide deaths

We identified suicide cases using the National Coronial Information System (NCIS). The NCIS is an internet-based data storage and retrieval system that enables coroners, government agencies, and researchers to monitor external causes of death in Australia and to identify cases for further investigation and analysis. The NCIS provides basic demographic information, as well as employment status and occupation at the time of death as recorded in coronial files.

The quality and completeness of NCIS data vary between cases, particularly for the early years of the scheme (the system was launched in 2000), and suicide may be under-reported because of legislative and professional differences between states and between coroners.10 In addition, there is a significant lag between deaths and their recording in the NCIS caused by the duration of the coronial process, meaning that 2012 was the most recent complete year with full available data for inclusion in our study. Nevertheless, the NCIS offers the best available information on suicide mortality in Australia, and is used as the basis for compiling the official death statistics published by the Australian Bureau of Statistics (ABS).

We classified suicide methods according to the International Classification of Disease, 10th revision (ICD-10), codes X60–X84.11 We were unable to code the method of suicide for 5.4% of cases.

Ascertainment of occupational groups

Our study only included persons employed in a known occupation at the time of death. Occupational information was coded according to the Australian and New Zealand Standard Classification of Occupations (ANZSCO) to the four digit level.12 Information on the coding procedure we used is included in Appendix 1.

We divided occupations into two broad groups: health professions, and all other occupations. “Health professions” included all health care-related occupations classified by ANZSCO as professions, based on the educational requirements and skills required for the job (ANZSCO codes 25xx and 2723). It did not include health care workers who are classified as community and personal service workers (code 1220), such as paramedics and Indigenous health workers. We analysed data for three health profession groups: medical practitioners (code 253x), midwifery and nursing professionals (code 254x), and other health professions, which included health diagnostic and promotion professions (codes 251x and 252x; such as pharmacists and optometrists), therapy professions (code 252x; such as physiotherapists and occupational therapists), and psychologists (code 2723). The “other occupations” category included all people employed in any other occupation at the time of death.

Ascertainment of population size

We extracted ABS 2006 census data (the midpoint of our study) on the size of the population aged 20–70 years, by age, sex and occupation, using TableBuilder (http://www.abs.gov.au/websitedbs/censushome.nsf/home/tablebuilder?opendocument&navpos=240). Age was coded into 10-year bands; ANZSCO codes were used for occupation.

Statistical analysis

Descriptive analysis and age-standardised suicide rates

We report the age and sex of individuals in the four occupational groups: medical practitioners, nurses and midwives, other health professions, and all other occupations. We also report the suicide methods used by members of these groups. Suicide rates per 100 000 person-years were calculated for each of the four groups, stratified by sex. These rates were age-standardised to the Australian standard population (2001),13 restricting the standard population to those aged 20–70 years (the range of ages at death for the analysed health professionals).

Regression models

We compared the rates of suicide for the four occupational groups in negative binomial regression models. We used the “other occupations” group as the reference category, and the model was controlled for year of death, age and sex. We initially tested for effect modification by sex by including an interaction term in the model; as there was strong evidence of effect modification, in this article we report models stratified by sex.

We then assessed the influence of occupational access to prescription medicines by comparing suicide rates among health professionals who have ready access to prescription medicines in the course of their work with those for health professionals who do not. We defined health care professions with access to these lethal means as registered professions whose members are legally allowed to prescribe, supply or administer prescription medicines. This includes doctors, nurses and midwives, dental practitioners and pharmacists (Appendix 1). We did not include optometrists and podiatrists, although some practitioners in these professions are permitted to prescribe certain medicines. We assumed that sex would not be an interacting factor, as male and female health professionals would have the same level of knowledge about and access to prescription medicines.

For all models, coefficients were transformed to incidence rate ratios (IRRs) to aid interpretation. Analysis was undertaken in Stata 13.1 (StataCorp).

Ethics approval

The study was approved by the Deakin University Human Research Ethics Committee (reference, 2015-278) and the Justice Human Research Ethics Committee (reference, CF/15/13534).

Results

We identified 9828 suicides in Australia during the 12-year study period by employed adults aged 20–70 years, including 369 (3.8% of all suicides) by health professionals (Box 1). The age-standardised rate of suicide for male medical practitioners was 14.8 per 100 000 person-years, and 22.7 per 100 000 person-years for male nurses and midwives; the rate for men in other (non-health care) occupations was 14.9 per 100 000 person-years. The age-standardised rate of suicide among female health professionals was 6.4 per 100 000 person-years for medical practitioners, 8.2 per 100 000 person-years for midwives and nurses, and 4.5 per 100 000 person-years for other health professionals; this compares with 2.8 per 100 000 person-years for women in other occupations. Crude suicide rates by occupational group and sex are summarised in Appendix 2.

Hanging as the method of suicide was much less common among doctors (24%) and nurses and midwives (28%) than among other health professionals (43%) and those in other occupations (48%) (Box 2). Practitioners in these groups used self-poisoning (doctors, 51%; nurses and midwives, 40%) more often than did members of other occupations (10%).

A significant interaction between sex and occupation with respect to suicide rate was detected (χ2 test, P < 0.001), so models stratified by sex were calculated. After adjusting for year and age, we found a significantly higher suicide rate for men employed as nurses and midwives than for men in occupations other than health professions (IRR, 1.50; P = 0.006) (Box 3). The suicide rate for male “other health professionals” was slightly lower than for men employed in non-health care occupations (IRR, 0.75; P = 0.061). For women, being employed as a doctor (IRR, 2.52; P < 0.001) or as a nurse or midwife (IRR, 2.65; P < 0.001) was associated with significantly higher suicide rates than for women in non-health care occupations.

The rate of suicide among health professionals with ready access to prescription medicines was 1.62 times that for health professionals without this access (P < 0.001) (Box 4).

Discussion

In this national study of suicide in Australia, we found important sex differences between health professionals and other occupational groups in the epidemiology of suicide. The rate of suicide among women employed in any health profession was higher than for women in other occupations; the difference was statistically significant for women employed as nurses or medical practitioners. Compared with that for men in other occupations, the suicide rate was higher only among male health professionals in the fields of nursing and midwifery. Further, the rate of suicide was 62% higher among health professionals with ready access to prescription medicines than among health professionals without such access. Our findings also suggest that suicide rates across the entire working population have decreased slightly over time, and that suicide rates are lower among older working people (those over 50 years of age) than among younger working people (20–39 years of age) (Box 3, Box 4).

Sex-related stressors

Almost 15 years ago, Hawton and colleagues14 speculated that the rate of suicide by female health professionals would decline as more women entered the medical professions. Unfortunately, rates have not declined, despite the increasing number of women in these professions. It has been suggested that women working in male-dominated areas of medicine face a number of barriers that hinder their career advancement.15,16 In addition, female professionals may still feel pressure to undertake child care and household roles, leading to considerable gender role stress. This premise has been supported by studies in which young female doctors reported considerable pressure associated with combining work and family.17

Occupational gender norms may also play a role in explaining the high suicide rate among male nurses and midwives. These occupations are organised to reinforce traditionally feminine behaviours of caring and support. Qualitative research has found that some male nurses experience anxiety about the perceived stigma associated with their non-traditional career choice.18 These anxieties may constitute a risk factor for suicide for men in these occupations.

Work-related stressors

There is strong evidence that doctors experience a considerable number of psychosocial job stresses, including work–family conflict,19 long working hours, high job demands, and the fear of making mistakes at work.20 These psychosocial job stressors have been associated with common mental disorders (anxiety and depression) in several prospective cohort studies.21 Those working in caring professions, including nursing, may be particularly exposed to trauma, and they may also experience it vicariously through contact with patients and their families. Further, many health professionals operate their own businesses and may thus experience the stress of being sole operators.22

Suicide by self-poisoning

We found strong evidence of higher rates of suicide by self-poisoning among health professionals than by people in other occupations. We also found a higher rate of suicide for health professionals with ready access to prescription medicines than for health professionals without such access. These findings are consistent with those of several other studies. For example, a national study based on Danish population registers found differences in the use of medicinal drugs for deliberate fatal overdoses. Compared with teachers, who employed them in 22% of suicides, medicinal drugs were used far more frequently by nurses (55%), doctors (56%) and pharmacists (66%).2 An analysis of the Queensland suicide register found that poisoning was used more often by medical professionals (59% of suicides) and nurses (44%) than by education professionals (24%) and other groups (19%).6 A recent review of nine studies of suicide by nurses concluded that medication poisoning was the predominant method used for taking their own lives.5 Similarly, pharmacists employed poisoning as a suicide method more often than other employed people.7 It thus appears likely that access to prescription medicines as a lethal means is a risk factor in suicide by health professionals.

Limitations of our study

Major strengths of the study include the use of the best available individual-level data on suicide in Australia, the inclusion of multiple health care professions, and coverage of an entire national population over a 12-year period. We note, however, a number of limitations. First, under-reporting of suicide in the NCIS because of misclassification of the cause of death is a problem, as in any official record of deaths.10 Second, our study only included people who were employed at the time of death, so that health professionals who had stopped working because of illness, who were suspended from medical practice or de-registered, or who had retired were not included in our analysis. In addition, occupation may have been miscoded by police when collecting information, or during the coding process, despite independent coding by two researchers and the use of a structured approach to classification. Third, data on the method of suicide is incomplete, as initial data collection from the NCIS did not include this information. We have subsequently obtained these data for most suicides, but were unable to match suicide method for a small proportion of cases. Fourth, we note that the ANZSCO list of health professions is not perfectly aligned with the occupations regulated as health professions under the National Registration and Accreditation Scheme for health practitioners. For example, dental hygienists are a registered health profession, but are not listed as a health profession by ANZSCO; nutrition professionals are not a registered health profession, but are listed as such by ANZSCO.

The suicide rates for men in several of the jobs classified as “other occupations” (the denominator for our risk estimation) were particularly high, including men employed in lower skilled occupations and in technical and trade occupations.23 This circumstance will have affected the results of our analysis, as it will have reduced the calculated IRR when comparing suicide rates in male health professionals with those in other occupations. We did not have sufficient data to analyse suicide rates within specific medical specialties, such as anaesthesia, or within smaller health professions, such as dentistry. We cannot exclude the possibility that men working in these occupations may be at increased risk of suicide. Finally, we acknowledge the different age structures of the population of those in medical professions and of the standard Australian population; those employed in health professions were substantially older.

Conclusion

Our findings suggest that the rate of suicide among women employed in a range of health professions, including medicine, is markedly higher than that for women in other, non-health care occupations. An understanding of the specific stressors and risk factors experienced by women in these professions may shed additional light on targeted prevention strategies. Attention should also be given to the high rate of suicide among men, including those employed in health care. Strategies targeted at health professionals should also pay heed to the higher rate of suicide among professionals with access to prescription medicines.

Box 1 –
Age-standardised rates of suicide by employed adults aged 20–70 years, Australia, 2001–2012, for health professional groups and for all other occupations

All persons

Men

Women

Medical practitioners

Number of suicides

79

62

17

Mean age, years

44.7

46.3

39.0

Population*

53 672

34 649

19 023

Adjusted suicide rate† (95% CI)

12.2 (9.4–15.0)

14.8 (11.0–18.7)

6.4 (3.4–9.5)

Midwives and nurses

Number of suicides

216

49

167

Mean age, years

44.1

41.6

44.8

Population*

198 961

17 710

181 251

Adjusted suicide rate† (95% CI)

9.5 (8.0–11.0)

22.7 (14.8–30.7)

8.2 (6.7–9.7)

Other health professionals‡

Number of suicides

74

47

27

Mean age, years

43.9

45.8

40.7

Population*

88 633

34 800

53 833

Adjusted suicide rate† (95% CI)

7.6 (5.7–9.6)

11.5 (8.0–14.9)

4.5 (2.3–6.6)

Other occupations

Number of suicides

9459

8172

1287

Mean age, years

40.3

40.4

39.6

Population*

8 060 397

4 441 462

3 618 935

Adjusted suicide rate† (95% CI)

9.6 (9.3–9.8)

14.9 (14.5–15.2)

2.8 (2.6–3.0)

* Australian Bureau of Statistics 2006 census data. The data for health professionals exclude non-clinicians. † Age-standardised rate per 100 000 person-years. ‡ Nutrition, medical imaging, occupational and environmental health professionals, optometrists and orthoptists, pharmacists, other health care diagnostic and promotion professionals, chiropractors and osteopaths, complementary health therapists, dental practitioners, occupational therapists, physiotherapists, podiatrists, audiologists and speech pathologists and therapists, psychologists.

Box 2 –
Suicide methods used by health professionals and by members of other occupations aged 20–70 years, Australia, 2001–2012

* General practitioners and resident medical officers, anaesthetists, specialist physicians, psychiatrists, surgeons, other medical practitioners. † Midwives, nurse educators and researchers, nurse managers, registered nurses. ‡ Nutrition, medical imaging, occupational and environmental health professionals, optometrists and orthoptists, pharmacists, other health care diagnostic and promotion professionals, chiropractors and osteopaths, complementary health therapists, dental practitioners, occupational therapists, physiotherapists, podiatrists, audiologists and speech pathologists and therapists, psychologists.

Box 3 –
Negative binomial regression model comparing suicide rates for health professionals with rates for members of other occupations aged 20–70-years, Australia, 2001–2012, stratified by sex

Suicides

Population*

Incidence rate ratio (95% CI)

P

Men

Occupation

Medical practitioners

62

34 649

1.01 (0.78–1.31)

0.929

Midwives and nurses

49

17 710

1.50 (1.12–2.01)

0.006

Other health professionals†

47

34 800

0.75 (0.56–1.01)

0.061

Other occupations (reference)

8172

4 441 462

1

—

Age‡

60–70 years

531

379 933

0.75 (0.64–0.88)

< 0.001

50–59 years

1406

917 291

0.82 (0.71–0.95)

0.007

40–49 years

2344

1 146 076

1.07 (0.94–1.23)

0.295

20–39 years (reference)

4049

2 085 321

1

—

Year (as continuous variable)§

8330

4 528 621

0.98 (0.97–1.00)

0.017

Women

—

Occupation

Medical practitioners

17

19 023

2.52 (1.55–4.09)

< 0.001

Midwives and nurses

167

181 251

2.65 (2.22–3.15)

< 0.001

Other health professionals†

27

53 833

1.41 (0.96–2.08)

0.083

Other occupations (reference)

1287

3 618 935

1

—

Age‡

60–70 years

65

216 119

0.74 (0.56–0.97)

0.030

50–59 years

287

775 659

0.90 (0.76–1.06)

0.200

40–49 years

406

1 042 075

0.94 (0.80–1.10)

0.439

20–39 years (reference)

740

1 839 189

1

—

Year (as continuous variable)§

1498

3 873 042

0.96 (0.95–0.98)

< 0.001

* Australian Bureau of Statistics 2006 census data. The data for health professionals exclude non-clinicians. † Nutrition, medical imaging, occupational and environmental health professionals, optometrists and orthoptists, pharmacists, other health care diagnostic and promotion professionals, chiropractors and osteopaths, complementary health therapists, dental practitioners, occupational therapists, physiotherapists, podiatrists, audiologists and speech pathologists and therapists, psychologists. ‡ All occupations. § *Incidence rate ratio refers to the effect of a one-year increase in time on the suicide rate.

Box 4 –
Negative binomial regression model of suicide rate, comparing suicide rate for health professionals with access to prescription medicines with that for members of all other occupations aged 20–70-years, Australia 2001–2012

Suicides

Population*

Incidence rate ratio (95% CI)

P

Occupation

Health professionals without access to lethal means (reference)

55

64 365

1

—

Health professional with access to lethal means†

314

276 091

1.62 (1.20–2.17)

0.001

Other occupations

9459

8 060 397

0.98 (0.75–1.29)

0.887

Age‡

60–70 years

596

596 052

0.76 (0.66–0.88)

< 0.001

50–59 years

1693

1 692 950

0.86 (0.76–0.97)

0.013

40–49 years

2750

2 188 151

1.03 (0.92–1.16)

0.571

20–39 years (reference)

4789

3 924 510

1

—

Sex‡

Women

1498

3 873 042

0.22 (0.20–0.25)

< 0.001

Men (reference)

8330

4 528 621

1

—

Year§

9828

8 401 663

0.98 (0.96–0.99)

< 0.001

* Australian Bureau of Statistics 2006 census data. The data for health professionals exclude non-clinicians. † Pharmacists, dental practitioners, generalist medical practitioners, anaesthetists, internal medicine specialists, psychiatrists, surgeons, other medical practitioners, midwives, nurses. ‡ All occupations. § Incidence rate ratio refers to the effect of a one-year increase in time on the suicide rate.

Suicide by health care professionals

Health professionals are human beings — and therefore not immune to mental health problems

The paper by Milner and colleagues1 is a useful reminder that the medical and associated professions are not immune to suicide. Based on data from the National Coronial Information System, it is the most comprehensive study of its type in Australia.

However, as would be anticipated in an examination of a low base rate phenomenon such as suicide, even their 12-year sample included only 369 suicides in a wide range of health professionals. Nevertheless, when grouped broadly into medical practitioners (79 suicides), nursing and midwifery (216), and all other health care professionals (74), some significant findings emerged.

The importance of the availability of a means of suicide was confirmed, with increased rates of suicide among health care professionals with ready access to prescription medications. Also confirmed in an age-adjusted analysis was a significantly higher suicide rate for women in both the medical and nursing professions than for women employed in non-health care occupations, and a non-significant increase in the suicide rate for women in other health professions. There was no significant difference between the suicide rates for male medical practitioners and for men employed outside the health care professions, but there was a significantly higher suicide rate among men in the nursing profession (including midwifery) and, perhaps unexpectedly, a non-significantly lower rate for men in other health professions.

It is interesting that a United Kingdom study (223 suicides by doctors over a 17-year period) similarly found an elevated suicide rate among female medical professionals, but also a significantly lower rate for their male colleagues than for men in the general population.2 The UK statistics were sufficient to allow analysis of individual specialties: the risks for anaesthetists, community health doctors, general practitioners and psychiatrists were greater than for doctors in general hospital medicine.

It is pertinent to note that the comparison groups for these two studies were different, and this limits both the interpretation of the two studies and, more particularly, their comparison.

Milner and colleagues discuss a number of contributing factors that might explain their findings, including the potential importance of a perceived conflict of occupational gender norms, particularly for men who choose a career in nursing or midwifery. Similarly, the higher suicide rate for women in the medical professions could be interpreted as a result of their breaking into a male-dominated domain. However, although the sex ratio among medical practitioners has changed markedly over the past few decades, this would not explain the higher suicide rates in the other two health care professional categories.

It may be that the health care professions are particularly demanding and stressful, and it is fair to say that this is a common perception, particularly within the professions themselves. Indeed, it has been reported that female and younger medical practitioners in Australia perceive their work as more stressful than do other medical practitioners.3 However, the authors who reported these findings, from a survey conducted by a market research company, conceded that the lower than ideal response rate meant that the results might not represent the views of all practitioners; further, they also acknowledged that few doctors reported being “highly impacted” by their mental symptoms.

It is easy and non-threatening to seek external explanations for these and similar findings. A less frequently canvassed factor may be that people select for themselves the helping professions in order to fulfil their own dependency needs. We are all subject to inherited, developmental, and psychodynamic influences; while this does not imply that any personal psychopathology is necessarily involved in pursuing a health care profession, none of us is impervious to our personal needs. If, as is inevitable in our careers, we are sometimes unable to fulfil all the expectations of all our patients — expectations occasionally fuelled by unrealistic depictions in the media of the outcomes that can be expected — anxiety and depression may ensue, at times paired with drug and alcohol misuse that can result in an increased risk of suicide.

Milner and colleagues suggest that further enquiries could shed light on opportunities for targeted prevention strategies, a not uncommon conclusion to studies in this area. However, while the proposition seems reasonable, it is hardly realistic, bearing in mind the low base rate of suicide and the challenges involved in identifying individuals at risk. For example, although the rate of suicide among female medical practitioners was significantly higher than in the broader female workforce, the term “suicide rate” is not particularly helpful when one considers that the total number of suicides by female medical practitioners in Australia over 12 years was 17 (by comparison: more than 2000 suicides are recorded each year in Australia).4

This comment should not be interpreted nihilistically, but as a pointer to the need for a more pragmatic and practical approach. Facets such as ensuring good workplace relationships and equal opportunity, eliminating bullying, reducing access to means of suicide, and addressing the stigma that still attaches to seeking help for mental disorders, are clearly important, as they are for all workplaces.

More specifically, as health care professionals we need to appreciate that we are not immune to mental disorders, including alcohol and drug dependence, and the latter is of particular concern because of our ready access to prescription drugs. For those experiencing emotional distress, the services of an empathetic GP are a good start. For those without a GP, peer review meetings, which can counter the isolation of some practices, and the advice of local professional bodies can be helpful. However, these cannot be seen as definitive approaches to the problem, but rather as facilitators for obtaining the professional care that would be offered to anyone in the community.

Voluntary euthanasia laws in Australia: are we really better off dead?

Ethical and moral implications make euthanasia a complex question

I sat alone in a windowless room for a week at a time reading coroners’ case files about how nursing home residents had died by suicide. There were times when I had to clock off early for the day because I was emotionally drained and I wanted to preserve my own sanity. There were times when a seemingly minor feature of someone’s story made me stop and shake my head in disbelief, and even brought me to tears. Some of the stories were tragic. Some were relatable, even understandable. Some were political statements, others a statement of the deficiencies of our aged care and mental health systems.

You would perhaps think that this experience would make me one of the fiercest advocates for voluntary euthanasia and assisted dying, but you would be mistaken. Instead, this experience left me with a profound sense of the complexities of suicide among older adults and how often and easily these can be overshadowed by the euthanasia debate.

My research uses existing medico-legal information generated for coroner’s investigations to examine the frequency and nature of intentional deaths, including suicides, among older adults who are living in accredited residential aged care services in Australia. In the first year of my research, to understand what had been previously studied, I conducted a systematic review of peer-reviewed articles examining completed suicides among nursing home residents. The results of the review showed a lack of research in this area internationally and in Australia.1 It was surprising to find that we still know so little about suicide in the nursing home setting, considering the ageing population2 and growing demand on aged care services,3 coupled with the fact that older adults have one of the highest suicide rates in Australia4 and around the world.5

The aim of my research is to better understand suicide among nursing home residents in an Australian context, generate much-needed discussion about ageing, aged care and dying in Australia, and improve the quality of care and quality of life for older adults residing in aged care facilities. As part of my work, I started listening to the Andrew Denton podcast Better off dead, which deals with the complex issue of voluntary euthanasia.6

Each episode begins with a disclaimer stating that the podcast is not about suicide. However, in my experience, separating the question of suicide among older adults from the euthanasia debate has proven to be substantially more difficult.

People like to simplify things, to look at things through a single lens (usually their own); however, as with any problem with ethical or moral implications, euthanasia is not straightforward and there is a vast grey expanse between black and white.

When I began my research, I believed I was pro-euthanasia because, like many people, I thought that if my parents or I were suffering, I would want to have euthanasia as an option. However, I quickly learnt that what I actually wanted was a better aged care system and quality of life for my parents, and for myself, when the time comes, and that the question of euthanasia is just a small part of that.

So who are we talking about when we discuss voluntary euthanasia laws?

Are we talking about the 75-year-old woman who has been a member of the euthanasia society for years, who still has all her mental faculties but is starting to feel her physical health declining, and has made a conscious decision about how she wants her life to end?

Or are we talking about the 80-year-old man who has been suffering from depression for years following the loss of his spouse that everyone assumed he would just “get over” with time, and who has since developed some cognitive impairment where some days he is lucid and others he is not? Would he be considered capable of making an informed decision about voluntary euthanasia? If not, would he get the support and treatment he needs or would he end up killing himself anyway?

My concern is that vulnerable older people may continue to slip through the cracks between voluntary euthanasia laws for the terminally or chronically ill and a lack of services and support for older adults with serious emotional and mental health needs.

Every person’s story is different and we must be careful not to lump them all together. To do so would be to neglect those who need or want help. Do older adults not deserve the same help and prevention initiatives as anyone contemplating suicide? Would we say to a 35-year-old man suffering from depression after going through a divorce: “we get it … go ahead”? No, we would make sure that he receives all the possible support and treatment.

I am neither for nor against euthanasia. I am somewhat of a fence sitter; a position which, in this case, I consider to be a good thing. I have always liked to think through any big decision in my life; to look at it from different perspectives and weigh the pros and cons. I am not saying we should not have a system in place to allow for voluntary euthanasia in particular cases; I am saying that we need to carefully consider how we go about allowing euthanasia because we cannot afford to get it wrong. We cannot, in good conscience, establish voluntary euthanasia laws before first looking at our aged care and mental health systems.

Eliciting and responding to patient histories of abuse and trauma: challenges for medical education

Toward trauma-informed medical education

Traumatic experiences such as childhood abuse, family violence, elder abuse and combat exposure influence both physical and mental health, health-related behaviour, and the ways in which patients interact with medical practitioners.1,2 Despite greater knowledge of the pervasive sequelae of psychological trauma, the implications for medical practice and for medical education are not well articulated. Many doctors lack confidence and remain ill-informed or avoidant when dealing with patients’ psychological trauma.3,4 The consequences of this include non-recognition of somatisation and of psychiatric disorders, delay in instituting proper treatment, and costs to the patient and health care system of unnecessary investigations and treatments.5,6 Here, we discuss why and how we should better train doctors to elicit and respond to patient histories of trauma.

High prevalence of trauma and its clinical sequelae

The lifetime prevalence of exposure to traumatic events is high (74.9% in Australian adults).7 Most people who experience trauma do not develop mental illness; however, trauma and abuse are substantial contributors to the burden of mental and physical ill health. The risk of post-traumatic stress disorder after trauma is about 10%,8 but childhood abuse and neglect in combination with later life stress contribute to the development of mental illnesses as diverse as psychoses, depression, eating disorders and addictions, as well as a range of physical illnesses.2,9 There are also clear associations between past trauma and abnormal illness behaviour10 and, related to this, increased health care use.6 These sequelae of patient trauma pervade all medical specialties and also dentistry.1

Incorporating teaching about trauma in medical curricula: key issues

Although there are several studies that describe training interventions for specific forms of trauma,3,11,12 there is little in the literature on current practices in medical education, either in Australia or elsewhere. The diversity in general structure, content and methods of medical curricula as outlined by the Australian Medical Council (AMC) probably extends to trauma-relevant components.13 Despite this diversity, it is possible to offer initial considerations for trauma-informed education. We focus on six interrelated aspects: communication skills; knowledge of the health effects of trauma and abuse; knowledge about the effects of trauma and abuse disclosures on doctors and other health professionals; specific knowledge relevant to different medical specialities and settings; teaching formats and methods; and the need for a staged, incremental, integrated program, structured to achieve continuity between undergraduate, prevocational and specialist phases.

Communication skills curricula13 in pre-clinical and clinical phases afford opportunities for trauma-specific education, but are also relevant to junior hospital and specialty training. Common issues that need to be addressed include the personal discomfort many doctors experience asking about trauma and abuse; when not to screen for or discuss trauma; and when to seek advice from senior colleagues, as overconfidence can be harmful, leading to patient distress and even re-traumatisation. Communication skills education should extend to discussion of services relevant to different forms of trauma, such as social work, refuges, police and the courts. Here, it would be valuable for medical students to visit these settings or meet with workers from them.

Training needs to be realistic in that doctors often work in settings that are not conducive to asking about trauma, such as busy emergency departments, hospital wards that lack privacy, and overloaded outpatient clinics, often with a lack of psychiatric support. However, these realities should not be a pretext for avoiding clinically competent trauma-informed practice. We do not propose that doctors become trauma therapists; rather that they become competent in empathically recognising and eliciting information about trauma, and at effective referral of patients to relevant services, including psychology and psychiatry.

Exposure to patients who have experienced trauma or abuse evokes a range of psychological reactions in students and trainees, from normal discomfort and distress through to vicarious traumatisation.3,4,14 In addition, there may be unhelpful, if not harmful, responses: doctors may adopt an avoidant “don’t ask, don’t tell” style; over-investigate; refer patients to other clinicians; exhibit stigmatising attitudes toward patients; or become over-involved.4 Course content on these issues could be introduced early and developed further during clinical and postgraduate phases.

There are many opportunities pre-clinically to learn about the effects of abuse and trauma on human development, including the short and long term effects on the brain and behaviour. Relevant knowledge can be taught within sections of the curriculum devoted to neuroscience, cognitive science and population health. In addition, medical humanities have a powerful capacity to expand our knowledge and understanding of diverse human experiences, including trauma, and to foster empathy. Every clinical specialty that medical students and trainees encounter in hospital training brings opportunities to learn specialty-specific trauma knowledge and skills. For example, rotations in paediatrics and in obstetrics and gynaecology are opportunities for teaching about child abuse and about family violence.

Trauma is an everyday part of clinical discourse within psychiatry and a key dimension of academic and clinical learning in psychiatry rotations. However, trauma-informed education is relevant to all clinical specialties. Relevant specific knowledge encompasses common clinical presentations of trauma in those specialties; how trauma-relevant inquiry can be embedded within the specialty-specific clinical interview; clinical, social and legal services relevant to various forms of abuse; and legal requirements regarding mandatory reporting.

Some medical students and trainees have their own experiences of trauma, including childhood trauma and abuse, but also vicarious trauma stemming from clinical encounters, such as witnessing horrific physical injury or disfigurement. Post-traumatic stress disorder in medical practitioners is often unrecognised.14 Such experiences may increase or may impair empathic capacity to engage with traumatised patients.

Although the AMC standards discuss the stressful and traumatic nature of medical work and provide recommendations about availability of counselling, peer support and other measures, they construe the reality of trauma as external to the core business of medical education.13 Instead, we propose that learning about the emotional impacts of clinical work should be core medical education, to be dealt with in lectures, tutorials, simulations — that is, a range of appropriate, complementary educational methods, as is done for other topics. In addition, curricula should include safe, confidential, non-coercive opportunities for experiential learning in small groups, allowing participants to reflect on and share their own emotional reactions to patients and understand how these reactions can shape their clinical practice. Ideally, some teaching should be conducted jointly with students from other disciplines, notably nursing.

The AMC standards stress the centrality of clinical clerkships in the development of clinical competence and judgement.13 We agree, but when it comes to trauma-informed clinical teaching, there are several entailments. Teaching about trauma has to become a routine, everyday feature of clinical teaching in wards and clinics, not something outsourced by referral to psychiatry or social work. Clinician teachers in all specialties need to acquire the skills to do such teaching and to act as role models. Given the limited evidence base, it is premature to recommend a mix or staging of methods, and this should be a focus of future research and curriculum innovation.

The medical education literature is marked by separate discourses on differing forms of trauma. For example, education regarding intimate partner violence has been extensively explored and excellent curricula have been implemented.3,13,14 However, patients have often experienced several concurrent or sequential traumas; and the clinical sequelae of different traumas have many similarities, demand similar clinical skills (albeit allied with different bodies of specific knowledge), and thus present similar challenges for medical education. Valuable educational synergies are likely if the currently disparate, unconnected trauma-relevant elements in medical curricula are integrated.

These considerations point to the need for the creative design and evaluation of staged, incremental, integrated programs, structured to achieve continuity between undergraduate, pre-vocational and specialist phases of medical education. We do not propose removing the various trauma-specific educational components from medical curricula and replacing them with some form of generic trauma education. We do propose, however, examining creatively how they may be better integrated to become mutually reinforcing.

Conclusion

Trauma-informed health care is an invaluable concept which we propose should extend to trauma-informed medical education.15 Although the arguments for trauma-informed medical education are compelling, new lines of educational research will be needed to guide curriculum design and build on the small body of work already available.3,4,11,12,16 It is likely that if doctors of all kinds have the knowledge, skills and attitudes to deal competently with abuse and trauma, we can expect improvements in patient care and health service costs, and in the health and wellbeing of medical practitioners. These possibilities deserve empirical study. As well as becoming better clinicians, medical students and trainees will also become better teachers and role models and, as they move into more senior and leadership roles, advocates for competent trauma-informed medical care.