Prevalence of Depression in RCRMC Family Medicine Residency Bob Chiang, M.D., Kris Lee, M.D., Ted...

Prevalence of Depression in Prevalence of Depression in RCRMC Family Medicine RCRMC Family Medicine

Residency Residency

Bob Chiang, M.D., Kris Lee, M.D.,

Ted Lee, M.D., Laurie Wellman, Ph.D.June 2009, Moreno Valley, CA

INTRODUCTIONINTRODUCTION

Depression is a major public health problem and a leading predictor of functional disability and mortality.

The annual economic consequences of depression have been estimated at 83 billion dollars in the US.6

Prevalence of Depression14

• General population 4.5%• Medical students/residents 15%

Prevalence of DepressionPrevalence of Depression

0%

2%

4%

6%

8%

10%

12%

14%

Student PGY 1 PGY 2 PGY 3 PGY 4

Minor DepressionMajor DepressionSuicidal ideation

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

Survey from 2,000 medical students and residents


0%

2%

4%

6%

8%

10%

12%

14%

16%

Male Female

Minor DepressionMajor DepressionSuicidal Ideation



0%2%4%6%8%

10%12%14%16%18%20%

Caucasian Asian AfricanAmerican

HispanicIndigenous

Minor Depression

Major Depression

Suicidal Ideation


INTRODUCTIONINTRODUCTION

A stressful environment is a known risk factor for depression; yet there is no protocol established for early detection of and intervention for depression in family medicine residencies.

Depression has been correlated to increased medical errors in pediatrics residents in a prospective cohort study. 13

Suicide in PhysiciansSuicide in Physicians

Depression in interns leads to suicidal ideation, marital problems, inability to work and thoughts of leaving medicine.9

Physicians who make suicide attempts are much more likely than nonphysicians to succeed. 12

Drug Abuse in PhysiciansDrug Abuse in Physicians

0%

5%

10%

15%

20%

25%

30%

Ane

s

EM FM IM OB

Path Ped

Psy

Rad

Surg

Oth

er

BZD

Opiates

Amph

Survey from 1,785 residents

Am J Psychiatry. 1992;149(Oct):10

Drug Abuse in PhysiciansDrug Abuse in Physicians

0%10%20%30%40%50%60%70%80%90%

100%

Ane

s

EM FM IM OB

Path Pe

d

Psy

Rad

Surg

Oth

er

Alcohol

Marijuana

Cocaine

Am J Psychiatry. 1992;149(Oct):10

BACKGROUNDBACKGROUND

DSM-IV Diagnostic Criteria for Major Depressive Episode7

• 5 (or more) symptoms present during the same 2-week period, change from previous functioning; at least 1symptoms is either depressed mood or loss of interest or pleasure.

1. depressed mood most of the day, nearly every day. 2. markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly

every day3. significant weight loss when not dieting or weight gain or decrease or increase in appetite

nearly every day. 4. insomnia or hypersomnia nearly every day 5. psychomotor agitation or retardation nearly every day 6. fatigue or loss of energy nearly every day 7. feelings of worthlessness or excessive or inappropriate guilt nearly every day8. diminished ability to think or concentrate, or indecisiveness, nearly every day 9. recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a

specific plan, or a suicide attempt or a specific plan for committing suicide


Personal Health Questionnaire (PHQ)15

• 3-page self-administered questionnaire • well validated in two large studies

9 item depression scale (PHQ-9)• used as a diagnostic instrument• used as a depression severity tool• possible scores ranging from 0 to 27• higher scores are correlated with other measures of

depression severity

OBJECTIVEOBJECTIVE

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

METHODMETHOD

RCRMC family medicine residents of all year levels were included in the study.

In 2009, trainees were asked to complete the PHQ-9 survey.

The survey could be conducted on-line through a survey website or on paper turned in anonymously.

Confidentiality was guaranteed: the only requested identifier was PGY level.

RESULTSRESULTS

23 of 27 residents participated in the study.9 interns, 8 PGY-2, 6 PGY-31 of 23 residents met criteria of clinical

depression.Positive screening 3.8%No resident admitted to suicidal ideation.

RESULTSRESULTS

Respondents admitted to 0-8 symptoms of depression. (Mean 0.956, SD 1.89).

PHQ-9 total scores ranged from 0-18. (Mean 4.22, SD 4.32).

One-way ANOVA analysis showed that there was no significant difference in the total depressive score among the different PGY levels. (p = 0.456)

TOTAL SCORESTOTAL SCORES

Results of PHQ-9 Total Scores

No of surveys

Score range

Score mean

Score median

PGY1 9 0 - 10 3.444 3

PGY2 8 0 - 9 3.625 4

PGY3 6 0 - 18 6.167 4.5

ONE-WAY ANOVAONE-WAY ANOVA

No of surveys

Score mean Standard deviation

PGY1 9 3.444 3.46811

PGY2 8 3.625 2.92465

PGY3 6 6.167 6.67583

One-way ANOVA: significance (p) = 0.456

DISCUSSIONDISCUSSION

Prevalence of depression in general population 4.5%-5.4%14

• Less participation in each higher training level (also demonstrated in other studies 16)

• Residents with depressive symptoms may have opted not to participate

High number of depressive symptoms associated with poor health and impaired functioning, whether or not the criteria for a diagnosis of major depression are met14


Most students and interns with major depression do not seek treatment. 9

Only half of depressed residents seemed aware of their depression; only a few were being treated. 13

Only 29% of depressed people report contacting mental health services.14

Of those with severe depression, only 39% reported contact.14

Riverside County ResourcesRiverside County Resources

Handouts of Riverside County Employee Assistance Services given during orientation• EAS rep came to discuss availability of services.• Self-referral or referral by supervisor/co-worker• EAS only available during limited weekday business

hours.Yearly “Mental Health Month” emails to all county

employees• “Mental Health Month” activities at outside campus, >20

miles away.

RCRMC Resident ResourcesRCRMC Resident Resources

Once yearly retreat with behavioral scientist – 2-3 hours

Once quarterly review with faculty advisor – 5-20 minutes

Once monthly “Resident Support” meetings – 30-45 minutes


A retrospective review of different interventions for burnout in residents/ medical students:

Workshops, resident assistance program, self-care intervention, support groups, didactic sessions, stress-management/coping training, breathing exercises: alone or in various combinations.

None achieved an A-level SORT rating.15

COMMON STRESSORSCOMMON STRESSORS

Heavy workloadSleep deprivationDifficult patientsPoor learning environmentsFinancial concernsInformation overload Career planning


THE INTERN’S PSYCHETHE INTERN’S PSYCHE

Psychological Evolution of First Year Resident

Excitation 1 month

Insecurity 2 months

Depression 1 month

Unending tedium 2 months

Feeling great joy or pride

Self-confidence

Peterlini M, Med Educ. 2002 Jan;36(1):66-72.

PERCEIVED STRESSORSPERCEIVED STRESSORSFactors Perceived As Stressful By Interns

Time away from family and friends 44%

Lack of time for own personal activities 41%

Sleep deprivation or fatigue 38%

Making a mistake 38%

Working hours 33%

Lack of time to study 18%

Lack of emotional support 13%

Kirsling RA, Psychol Rep. 1989 Oct;65(2):355-66

COPING METHODSCOPING METHODSCoping Methods Most Utilized By Interns

Talking with a spouse/friend 74%

Talking with fellow intern 63%

Doing physical exercise 33%

Religion or spiritual activities 15%

Talk with chief resident 11%

Talk with attending 1%

Talk with program director 0%

Kirsling RA, Psychol Rep. 1989 Oct;65(2):355-66

RECOMMENDATIONSRECOMMENDATIONS

Areas for Intervention• Encourage self-knowledge• Encourage seeking help• Foster atmosphere of

communication• Multiple methodologies

(discussion, lecture, readings, physical and mental exercises)


Active Surveillance• Various groups (by class, by gender, with

different faculty or residents)• Formal/informal• Frequent repetition


Work to relieve stressors• Sleep deprivations• Poor learning environment

Active teach/model coping methods • Encourage support among residents• Active involvement of attendings

FOR FURTHER STUDYFOR FURTHER STUDY

Longitudinal survey of current FM residentsMonitor for change

• Among the different years of training• Throughout the year for each class of residents

Comparison of different FM programs in the local area

CONCLUSIONCONCLUSION

“It is simply unacceptable for new—or more established— physicians and other health professionals to be in such great pain. It is improper for us to sacrifice our own health, family, and community in order to care for others. Part of our calling is to relieve suffering. We cannot relieve the suffering of others if we, ourselves, are suffering. Poets and musicians may function better when they are melancholy, but physicians do not.

“We need to take care of ourselves. That is not selfish. It is smart, and no one else will do it for us. We also need to take care of our residents. Who else will? What message are we giving when we ignore them? We need to show residents and each other that they and we matter.” 16

REFERENCESREFERENCES

1. Goebert D, Thompson D, Takeshita J, Beach C, Bryson P, Ephgrave K, Kent A, Kunkel M, Schechter J, Tate J. Depressive symptoms in medical students and residents: a multischool study. Acad Med. 2009 Feb;84(2):236-41.

2. Hendrie HC, Clair DK, Brittain HM, Fadul PE. A study of anxiety/depressive symptoms of medical students, house staff, and their spouses/partners. J Nerv Ment Dis. 1990 Mar;178(3):204-7.

3. Dyrbye LN, Thomas MR, Massie FS, Power DV, Eacker A, Harper W, Durning S, Moutier C, Szydlo DW, Novotny PJ, Sloan JA, Shanafelt TD. Burnout and suicidal ideation among U.S. medical students.

4. Baldassin S, Alves TC, de Andrade AG, Nogueira Martins LA. The characteristics of depressive symptoms in medical students during medical education and training: a cross-sectional study. BMC Med Educ. 2008 Dec 11;8:60.

5. Rosal MC, Ockene IS, Ockene JK, Barrett SV, Ma Y, Hebert JR. A longitudinal study of students' depression at one medical school. Acad Med. 1997 Jun;72(6):542-6.

6. Depression: Clinical manifestations and diagnosis. UpToDate – Online.7. DSM-IV. American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental

Disorders (4th ed.). Washington, DC.8. Kroenke K, Spitzer RL. The PHQ-9: a new depression diagnostic and severity measure. Psychiatr

Annals 2002;32: 509-21.

REFERENCESREFERENCES

9. Editorial. Major Depression During Medical Training. JAMA, Nov 4, 1998, Vol 260, No. 17

10. Peterlini M, Tibério IF, Saadeh A, Pereira JC, Martins MA. Anxiety and depression in the first year of medical residency training. Med Educ. 2002 Jan;36(1):66-72.

11. Kirsling RA, Kochar MS, Chan CH. An evaluation of mood states among first-year residents. Psychol Rep. 1989 Oct;65(2):355-66.

12. Schernhammer E. Taking their own lives -- the high rate of physician suicide. N Engl J Med. 2005 Jun 16;352(24):2473-6

13. Fahrenkof AM, et al. Rates of medication errors among depressed and burnt out residents: prospective cohort study. BMJ 2008;336;488-491.

14. Pratt LA, Brody DJ. NCHS Data Brief: Depression in the United States Household Population, 2005-2006. Number 7, September 2008 http://www.cdc.gov/nchs/data/databriefs/db07.htm. Accessed 5/23/09

15. McCray LW, et al. Resident Physician Burnout: Is There Hope? Fam Med 2008;40(9):626-32.

16. Clever LH. Who Is Sicker: Patients—or Residents? Residents’ Distress and the Care of Patients. Ann Intern Med. 2002;136:391-393.

Prevalence of Depression in RCRMC Family Medicine Residency Bob Chiang, M.D., Kris Lee, M.D., Ted...

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