The(mental)healthproblemsfacedbymedicalstudentsanddoctors:

Disclosureandhelp-seeking

ProfessorDebbieCohenOBESchoolofMedicineCardiffUniversity

Overview

• Whatdowereallyknow?

• Should/CouldOHdomore?

• Couldwebemoreeffective?

Medicalstudentsanddoctors

Mentalillhealthindoctorsandmedicalstudents

Stress,burnout…whatsoutthere

ARE WE GETTING IT RIGHT?

Stress,burnout…whatsoutthere

ARE WE GETTING IT RIGHT?

MaintainingahighstandardofprofessionalbehaviourYourstudieswillbringyouintocontactwithpatientsandmembersofthepublic,whocanbephysicallyandemotionallyvulnerable.Becauseofthis,andthefactthatyou’llbejoiningatrustedprofession,weexpect,youtounderstandthatthereisadifferenceinthestandardofbehaviourexpectedofstudentsoncoursesthatbringthemintocontactwithpatientsandthepublic.Specifically,yourbehaviouratalltimes,bothintheclinicalenvironmentandoutsideofyourstudies,mustjustifythetrustthatpatientsandthepublicplaceinyouasafuturememberofthemedicalprofession.Weandyourmedicalschoolwillsupportyouinyourjourneyfromstudenttodoctor,whichincludesteachingandassessmentonprofessionalism.

FitnesstoPractise(MedicalStudents)

MedicalStudentsandtheirMentalHealth

• Medicalstudentsdisplaysignificantlyhigherincidencesofcommonmentalhealthproblemsthanthegeneralpopulation

• Thereasonsarecomplexandrelatetotheintensityandthenatureofthecourseandthepersonalitiesthatarebothattractedtoandrecruitedintomedicaltraining(Tyssen 2000,2007,FirthCozens2001)

• Problemsareexacerbatedbylearntbehavioursandthehiddencurriculumwhereillhealthisminimisedandresilienceisanexpectedoutcome(Chew-Graham etal,2003, Hillis etal,2010).

StudentsandmentalillhealthinUK(n=1122)

• 30%(343)declaredtheyhadexperiencedorreceivedtreatmentforamentalhealthconditionwhileatmedicalschool.

• 80%ofthosewhodisclosedthoughtthelevelofsupportavailabletothemwaseitherpoororonlymoderatelyadequate.

• 15%(167) revealedthattheyhadconsideredcommittingsuicideatsomepointduringtheirstudies.

Billingsley,2015StudentBMJ

Depressionandstressamongstundergraduatemedicalstudents

• Theburdenofbecomingarolemodel• Theimpactofnewlyacquiredmedicalknowledgeandexperienceofpatients’illnessonthestudents’perspectiveontheirownhealth

• Therelationshipbetweenwellnessandprofessionalidentity

Ludwigetal2015BMCMedicalEducation,15:141,

Qualitativestudybasedonessaysinyear3students:

DoctorsandmentalillhealthinUK

• Doctorshavehigherratesofmentaldisorderthanthegeneralpopulation1

• Doctorsaremorelikelytohaveworkrelatedmentalillhealththanothersintheworkingpopulation2

• Understandingofdoctors’attitudestodisclosingtheirownmentalillhealthhasimprovedbutmanyassumptionsarestillmadeabouttheirperceivedobstaclestoseekinghelp1

1 DepartmentofHealth2008, 2HealthPolicyandEconomicResearchUnit2007,

SuicideandAddictions• Riskofsuicideamongstdoctorsishigherthaninmanyother

occupations.

• Anaesthetists,communityhealthdoctors,GPsandpsychiatristshadsignificantlyincreasedratesofsuicidecomparedwithgeneralhospitaldoctors.

• DoctorsoftenfindthemselvesunderextremepressurewhenbeingreferredtotheGeneralMedicalCouncil(GMC)inrelationtoacomplaintorinvestigationofhealthconcerns.

• TheBritishMedicalAssociation(BMA)hasestimatedthat1in15doctorshavesomeformofdrugoralcoholdependencyatsomepointintheircareer.

Whathasbeendonesofar?

Governanceandtraining

StandardsandCarePathways

Competencyframeworks

Afewthings…

• WhataboutBurnOut?

• Dosymptomsequatetodisorders?

• Disclosure– whatwenowknow,orstilldon’tknow

• A three-dimensionalsyndromethatmeasures:• Emotionalexhaustion• Depersonalisation• PersonalAccomplishment

It is not unidimentional, not just emotional exhaustion and is syndrome related to the workplace environmentIt is not a diagnosis

BurnOut

Comparisonofself-reportandclinicalinterviews.Do

studentsoverreportanxiety?

ComparisonofHADSandclinicalinterviewdatain50medicalstudents

Aims

• IsHospitalAnxietyandDepressionScale(HADS)anaccuratescreeningtoolfordepressionandanxietyinmedicalstudents?

• Wouldalternativecutoffpointsforthispopulationbeappropriate?

Method

• RecruitedmedicalstudentsfromCardiffUniversity

• Studentswereoffereda£10voucherfortakingpart

• StudentswereinvitedtocompleteHADSandthenundertakeaclinicalinterview.

• ClinicalinterviewandHADSdatacompared

ClinicalInterviews(SCAN)• SchedulesforClinicalAssessmentinNeuropsychiatry(SCAN)clinicalinterviewtechnique.

• TheSCANclinicalinterviewdataisusedtoderiveclinicaldiagnosesaccordingtoICD-10.

HADS

• HospitalAnxietyandDepressionScale

• Twosubscales:AnxietyandDepression

• Optimumcutoff“caseness”foreachsubscale=8(probablepresence)

Results

50studentsrecruitedacrossallyeargroupsatSchoolofMedicine(CardiffUniversity)

Conclusions• HADSselfreportquestionnairemaybeanappropriate

questionnaireforscreeningforanxietyanddepressioninmedicalstudents.

• Usersmaywishtoconsiderwhethertoa)ReduceHADS-Dsubscalecut-offto≥7b)RaiseHADS–Asubscalecutoffof≥13

Cautionwithinterpretingitems.Symptomsdon’tequatetodisease!

Disclosure

Positivenextsteps…

Disclosure:whatdowereallyknowandwhatmightmakeadifference?

Obstacles

• Lackofknowledgeaboutwheretofindhelpandtheprofessionalimplicationsofseekingit.

• Longworkhoursandshiftscanimpedeaccess,andthisproblemisexacerbatedinisolatedgeographiclocations.

• Ageandlevelofexperience• 8%ofdoctorssurveyedwouldchoosenottoturntoanyonefortreatmentofmentalillness,preferringtoself-medicateorhavenotreatmentatall.

AimsResearchprogramme(3Stages)todevelopasimple‘tool’tosupportdoctorsandmedicalstudentsintheirdecisiontodisclosetheirownmentalillhealth.

Workalreadycompleted:Stage1:AUKwide surveyStage2:Qualitativeinterviewswith46doctorsandmedicalstudentsacrosstheUK

Work underway:Stage3:Developmentandpilotofa‘tool’(decisionaid)toenableearlierdisclosure

Stage1SurveyAnanonymousonlinesurveywith1,946UKdoctors,bothwithandwithoutahistoryofmentalillhealth.

KeyFindings:• Foralldoctors,whattheythinkthey

woulddoisdifferenttowhattheyactuallydowhentheybecomeunwell.

• Doctorsnotfullyawareoftheirdisclosureoptionsoruseestablishedsupportpathways

• Ageandspecialityarearisk(youngerandhospitaldoctorsmoreatrisk)

Whowouldyoutellfirstintheworkplace?

(Thosewithouthistoryofmentalillhealth,n=570)

Yourlinemanager14%

YourClinicalDirector

8%TheMedicalDirector

1%

YourAppraiser1%Afriendwhoisa

healthcareprofessional17%

Acolleague30%

Yourmentor5%

YourEducationalSupervisor

13%

TheOccupationalHealthDepartment

6%

YourDeanerySupportUnit0%

Aconfidentialemployeewellbeing

serviceofferedbyyouremployer

2%

Other3%

QualitativeInterviews

Aims:1. Tofurtherunderstandthethoughtprocessesand‘tipping

point’todisclosure2. Todetermineviewsonapotentialtool

Focusoftheinterviews

• Reasonstodiscloseratherthannottodisclose

• Driverstodisclose

• Whatfactorscontributedtotheirdecision-making

Help seeking

• Seekingtreatment,diagnosisorsupportformentalillhealth

• Seekingadjustmentsorsupportwithinjoborstudies

• Patientsafety

• Someonlywenttofamilyorfriends.

Initialprimarydisclosurethenoftenenabledsubsequentandfurtherdisclosures

Disclosing at ‘crisis point’

• Psychoticepisode• Feelingsuicidal• Carryingoutactswithsuicidalintention• SectionedSomeparticipantsdidnotseekhelpuntiltheywereatcrisispointAnactofkindness

• Supportearlierdisclosure

• Targetmostatriskpopulations•• Acceptability

• Confidentiality

Tooldevelopment– wherewearenow

HowcanOHbemoreeffective?

Howcanwe:• Reachthoseatriskearlier

• Influenceserviceprovision- evidencebased

• Moreproactive

Thankyou

cohenda@cardiff.ac.uk