Physician-Directed Interventions Can Help With Depression, Anxiety, Suicidality

By Will Boggs MD

NEW YORK—Physician-directed interventions are moderately effective for reducing symptoms of depression, anxiety and suicidality, according to a systematic review and meta-analysis.

Compared with the general population and other professional groups, physicians have a higher prevalence of depression, anxiety and suicidal ideation. On average, one physician a day dies by suicide in the U.S.

For their analysis, online February 7 in The Lancet Psychiatry, Dr. Samuel B. Harvey of the University of New South Wales, in Randwick, Australia, and colleagues found eight studies with data on a total of 1,023 physicians.

All of the studies involved physician-directed interventions, mostly including individual or group cognitive behavioral therapy (CBT) or mindfulness training. The researchers' search did not identify any controlled trials of organizational-level interventions.

Three studies showed a significant reduction in symptoms of depression (standardized mean difference, 0.53); four studies showed a significant reduction in general psychological distress (SMD, 0.65); one study showed a significant reduction in anxiety (SMD, 0.71); and one study showed a significant reduction in suicidal ideation during an internship year (risk ratio, 0.40), compared with control groups.

The pooled mean effect size was nominally greater for group-based interventions (SMD, 0.78) than in the single individual-based study (SMD, 0.39); effect sizes were similar for studies with a non-active control group (SMD, 0.62) and a study with an active control group (SMD, 0.74).

CBT or mindfulness-based interventions had nonsignificantly higher effect sizes (SMD, 0.79), compared with other approaches (SMD, 0.46).

"Given the prevalence of mental health morbidity among physicians, these findings should both guide the type of physician-focused interventions that are adopted among this group and serve as a call to action for the urgent need for more comprehensive rigorous research regarding individual and organizational interventions aimed at improving the mental health of physicians," the researchers conclude.

Dr. Ronald M. Epstein of the University of Rochester School of Medicine and Dentistry, in New York, who co-authored a linked editorial related to this report, told Reuters Health by email, "We need to move beyond just thinking about burnout to address the full spectrum of transient and enduring physician distress. Even the stress of a single medical catastrophe in an otherwise well-functioning physician can have consequences. Medical culture - typically stoical, individualistic, perfectionistic, and punitive - needs to change. Strong and enlightened leadership can make an important difference."

"The relative neglect of the problem is troubling, especially given that health care professionals have our lives in their hands and their mental well-being is essential to good, safe, humane, compassionate care," he said. "I have personally known seven physicians who died by suicide, many precipitated by stressors at work. They often were not functioning well prior to their suicides. And suicide is only the tip of the iceberg. I am disheartened at the trivialization of the problem and lack of funding for research to develop interventions."

"Health care institutions, health care educational programs, and the general public (should) insist on proactive and comprehensive programs to address the mental health of physicians and other health professionals," Dr. Epstein said. "This needs to be more than window-dressing. Real-time resources, thought, and wisdom need to go into the development of a culture of medicine that promotes openness about human vulnerabilities and collective resolve to address them. Otherwise, the public will be endangered and will not receive the quality of interpersonal and technical care that they deserve."

Dr. Jodie Eckleberry-Hunt is a health psychologist from Fenton, Michigan, who has researched various aspects of physician wellness, including burnout, depression, and suicide. She told Reuters Health by email, "I don't know that it is surprising, yet it is sad, how few published quality interventional studies exist for treatment of physician distress, especially given the overwhelming evidence that it is a problem. It is a dilemma that physicians feel so inundated with work that there is no time/energy left to participate in such studies, and organizationally, I don't yet see meaningful investment in changing this dynamic."

"First, I see a moral obligation to care for those who serve at the front lines of patient suffering and pain," she said. "The secondary trauma they experience, in addition to all of the other frustrations, is able to be ameliorated. We just need to make it a priority and find the best delivery model. Second, at the end of the line is the patient, and this is a public health issue. It is not just a physician problem. Extreme physician distress does have an impact on patient care, outcomes, and mishaps."

"So much more work needs to be done," said Dr. Eckleberry-Hunt, who was not involved in the new study. "This is where efforts should now be focused instead of just describing the problem. The problem is clear. It is what do we do with it. I think we need to think out of the box, and it is essential that organizations do more than give lip service support."

Dr. Harvey did not respond to a request for comments.


Lancet Psychiatry 2019.



January 16, 2019 ShareFacebookTwitterGoogle+


Douglas A. Landy, MD

(Part 1 in a series)
On April 12, 2011, I tried to kill myself.
I have bipolar II disorder, diagnosed after my suicide attempt. On that day, I had been in a mixed hypomanic/depressed state, forced to face the fact that I’d been doing something that was wrong and seen as bad by others. Sex is a common theme in mania and hypomania, and I saw nothing wrong with writing erotic fiction instead of working during the day, and then sharing it with my coworkers. I kept rewriting the stories, making them more and more explicit, in a vain attempt to match the hypomanic eroticism in my mind. As a result, people complained, and I was placed on administrative leave the moment I came to work that morning.
I remember sitting with the executive director of the hospital where I worked when he told me I was being placed on administrative leave, and that the human resources department would not allow him to tell me why. He said they would contact me to let me know, and all I needed to know was that I was to leave the premises immediately and stay away until further notice. I had a sneaking suspicion as to what the problem was, and I left as asked. I stopped to get a small pad of paper, went to a Starbucks, and while I sipped my tea, I wrote a suicide note which I left in the car for my wife to find after I was gone.
I was absolutely certain my professional life was over. And if that was the case, so was my personal life. I felt I had disappointed and ruined family, friends, and acquaintances, who would forever see me as useless and a disappointment. The shame and humiliation were unbearable. Telling people what had happened, what I had done, was a horrifying thought. I felt there was no other option left for me other than to hide forever. Death was the one thing that made sense, as if I’d been up for three days straight and all I wanted to do was to sleep, forever. I wanted to be securely in the grave beyond blame, beyond recrimination, beyond shame, beyond family, beyond friends or hope. It seemed there was truly nothing left.
Rereading these words doesn’t express a tiny fraction of how awful I felt. It seems that in that moment, I switched from hypomania to depression. I went to the medicine cabinet and took all of my medications at once. I laid down and waited for death to overtake me.
When I woke and realized I had failed, an even more profound sense of hopelessness overwhelmed me, and I laid in bed for 3 or 4 days, getting up only to have a drink of water now and then. My wife kept asking me what the problem was, but I had no energy or interest in responding. Eventually she more or less dragged me to the doctor to whom I admitted my suicide attempt. He arranged for immediate hospitalization and my life started to turn around.
A Survivor’s Perspective
I plan to write a series of blog posts about suicidefrom the perspective of a survivor. Being a mental health clinician, I have spent the time since my attempt trying to understand myself from many different perspectives and hope to share these hard-won insights with you. Let me start with some background.
I’ve been more often depressed than hypomanic. My hypomania comes about most commonly in relation to having been administered testosterone since my levels are low, and low testosterone can be used to treat depression. Unfortunately for me, the testosterone switched me from depression to hypomania 3 times that it was tried, the above being the last.
I am now 63 and first had depression at the age of 21, after the loss of my first serious relationship. There were episodes of depression throughout my life, which responded to SSRIs. There is also a strong history of depression in my family; both of my sisters have been depressed, my father had problems with depression later in life, and my mother had panic disorder. Family members beyond first-degree relatives have had difficulties with anxiety and depression as well.
For those of us who’ve experienced depression, it’s been a psychosocial stressor that has tilted us into the pit of despair: one sister with a postpartum depression, another with problems with her children, and me with a sense of loss of personal and professional identity.
In my case, the sense of loss of such identity was ineluctably intertwined with a sense of isolation and hopelessness. The certainty of ghastly loneliness and being misunderstood, even willfully so by others (which is how I felt) both led to the final common pathway of self-destruction as the only way out of the morass.
This introductory blog is here to explain why I have the views that I do about suicide, from a clinician-survivor. The coming blog posts will review what I’ve learned about myself and other suicidal patients, and how that can help your work with them. I hope the hard-earned skills I’ve developed can be of use to you and beneficial to your patients.

Walther A, Breidenstein J, Miller R. Association of testosterone treatment with alleviation of depressive symptoms in men: a systematic review and meta-analysis. JAMA Psychiatry. 2018 Nov 14;[Epub ahead of print].

Douglas A. Landy, MD, graduated Hahnemann University School of Medicine (now part of Drexel University) in 1983. He is a board-certified psychiatrist, and practices primarily in an inpatient setting with additional work in the Emergency Room and nursing home consultations. He has had experience in sleep medicine and forensic psychiatry, and has an interest in traumatic brain injury. He lives in Rochester, New York



February 22, 2019 
Gabriella Gobbi, MD, PhD

Cannabis use during adolescence is associated with an increased risk of developing depression or suicidal behavior in young adulthood, even in teens with no depressive symptoms prior to starting cannabis, according to a systematic review and meta-analysis published online in JAMA Psychiatry.

“When we started this study, we expected depression to be a factor attributable to cannabis consumption, but we were quite surprised about suicide behavior rates,” said researcher Gabriella Gobbi, MD, PhD, of McGill University in Montreal, Quebec, Canada. “Indeed, a significant percentage of suicidal attempts are linked to cannabis.”

The systematic review and meta-analysis spanned 11 studies and 23,317 people. After adjusting for baseline depression, anxiety, and suicidality, the odds ratio of developing depression between ages 18 and 32 with adolescent cannabis use, compared with no cannabis use, was 1.37, researchers reported. The odds ratio for suicidal ideation was 1.50, and for suicide attempt was 3.46. The odds ratio for anxiety was a statistically insignificant 1.18.

“The study suggests the diagnosis of depression in approximately 7% of Canadians and Americans between the ages of 18 and 30 is linked to cannabis, meaning 25,000 young Canadians and 400,000 young Americans suffer from depression because of earlier cannabis consumption,” said researcher Nancy Mayo, PhD, of McGill University.

According to the authors, more than 20% of adolescents in the United States report monthly use of cannabis. In Canada, 15- to 25-year-olds constitute the majority of the population reporting cannabis use.

“It is clear that a lot of young people consuming cannabis are at risk of developing depression and suicidal behavior, so it is very important for authorities to be more proactive in campaigning for prevention,” said Dr. Gobbi. “We hope the findings will spur public health organizations to apply preventative strategies to reduce the use of cannabis among youth.”

—Jolynn Tumolo



Social Media Linked to Higher Risk of Depression in Teen Girls

By Reuters Staff

LONDON—Teenage girls are twice as likely as boys to show depressive symptoms linked to social media use - mainly due to online harassment and disturbed sleep, as well as poor body image and lower self-esteem, researchers have found.

In a study analyzing data from nearly 11,000 young people in Britain, researchers found that 14-year-old girls were heavier users of social media, with two-fifths of them using it for more than three hours a day, compared with a fifth of boys.

The study also found that 12 percent of light social media users and 38 percent of heavy social media users (five-plus hours a day) showed signs of having more severe depression.

When the researchers looked at underlying processes that might be linked with social media use and depression, they found 40 percent of girls and 25 percent of boys had experience of online harassment or cyberbullying. Disrupted sleep was reported by 40 percent of girls compared with 28 percent of boys. Anxiety and poor sleep are both linked to depression.

Girls were also more affected when it came to social media use and concerns about body image, self-esteem and appearance, the researchers found, but here the gap with boys was smaller.

Yvonne Kelly, a professor at University College London's Institute of Epidemiology & Health Care who co-led the research, urged parents and policymakers to note its results.

"These findings are highly relevant to current policy development on guidelines for the safe use of social media and calls on industry to more tightly regulate hours of social media use for young people," she said in a statement.

She said families may also "want to reflect on when and where it's ok to be on social media" and consider restrictions on teenagers having mobile devices in their bedrooms.

The study, funded by the UK Economic and Social Research Council (ESRC), was published online January 4 in EClinicalMedicine, published by The Lancet.


EClinicalMedicine 2019.


Share this page