- Email: [email protected]
The Radiologist and Depression
ORIGINAL ARTICLE
The Radiologist and Depression Claire E. Bender, MD a , Jay R. Parikh, MD b, Elizabeth Kagan Arleo, MD c, Edward Bluth, MD d Abstract Clinical depression affects physicians, including radiologists. Medical professionals, including radiologists, may be more comfortable treating a patient than being one, and psychiatric issues may be regarded as taboo for discussion, so the issue of clinical depression in the specialty and subspecialty has not received widespread attention. Specifically, a review of the national and international literature in PubMed, Scopus, and Google reveals few publications dedicated to the issue of clinical depression in radiology; although statistically, they must exist. The purpose of this report is to define the terms and describe the manifestations and scope of the issues related to clinical depression, with special attention given to risk factors unique to radiologists, such as working in low ambient light or near different fields of magnetic strength. By the end of the article, it is the authors’ hope that the reading radiologist will be aware of, and open to, the possibility of clinical depression in a colleague or within his or herself because clinical depression is common and it is important to get help. Key Words: Radiologist, resident/trainee, depression, seasonal affective disorder J Am Coll Radiol 2016;-:---. Copyright 2016 American College of Radiology
Physician, heal thyself. —Luke 4:23 (King James Version)
There are three things extremely hard: steel, a diamond and to know one’s self. —Benjamin Franklin
INTRODUCTION Clinical depression affects physicians, including radiologists. Medical professionals, including radiologists, may be more comfortable treating a patient than being one, and psychiatric issues may be regarded as taboo for discussion, so the issue of clinical depression in the specialty and subspecialty has not received widespread attention. Specifically, a review of the national and international literature in PubMed, Scopus, and Google reveals few publications dedicated to the issue of clinical depression in radiology; although statistically, they must exist. The a
Mayo Clinic, Rochester, Minnesota. Department of Radiology, MD Anderson Breast Care With Memorial Hermann, Houston, Texas. c Weill Cornell Imaging at New York Presbyterian, New York, New York. d Department of Radiology, Ochsner Clinic Foundation, New Orleans, Louisiana. Corresponding author and reprints: Claire E. Bender, MD, Mayo Clinic, 200 First Street SW, Rochester, MN 55905; e-mail: [email protected]. The authors have no conflicts of interest related to the material discussed in this article. b
ª 2016 American College of Radiology 1546-1440/16/$36.00 n http://dx.doi.org/10.1016/j.jacr.2016.03.014
purpose of this report is to define the terms and describe the manifestations and scope of the issues related to clinical depression, with special attention given to risk factors unique to radiologists, such as working in low ambient light or near different fields of magnetic strength. By the end of the article, it is our hope that the reading radiologist will be aware of, and open to, the possibility of clinical depression in a colleague or within his or herself because clinical depression is common and it is important to get help.
DEFINITIONS In 2013, the American Psychiatric Association published the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which is used within the profession as a classification and diagnostic tool for mental disorders [1]. DSM-5 serves as the universal authority in the diagnosis of the spectrum of psychiatric conditions. It does not provide recommendations on treatment. The DSM does have its scientific critics, but it serves as the reference standard for clinicians and researchers. In the manual, depressive disorders include the following diagnoses and their specific diagnostic criteria: n n
n n
disruptive mood dysregulation disorder, major depressive disorder (including major depressive episode), persistent depressive disorder (dysthymia), premenstrual dysphoric disorder,
1
n
n
substance- or medication-induced depressive disorder, and unspecified depressive disorder.
The bipolar and related disorders have been moved to a separate chapter in DSM-5. DSM-5 states that “common to all these disorders is the presence of sad, empty, or irritable mood, accompanied by somatic and cognitive changes that significantly affect the individual’s capacity to function” [1]. The manual adds that what differs among the disorders are issues of duration, timing, and presumed etiology. Under major depressive disorder section, the three most common diagnostic criteria (A-C) are listed as follows [1]: A. Five (or more) of the following symptoms have been present during the same two-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of pleasure. Note: Do not include symptoms that are clearly attributable to another medical condition. 1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (eg, feels sad, empty, hopeless) or observation made by others (eg, appears tearful). Note: In children and adolescents, can be irritable mood. 2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation). 3. Significant weight loss when not dieting or weight gain (eg, a change of more than 5% of body weight) or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain). 4. Insomnia or hypersomnia nearly every day. 5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down). 6. Fatigue or loss of energy nearly every day. 7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick). 8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others). 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. B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. 2
C. The episode is not attributable to the physiological effects of a substance or to another medical condition. Note: Criteria A-C represent a major depressive episode. Also, responses to a significant loss such as financial ruin or loss of a loved one, can result in feelings of intense sadness, insomnia, weight loss and can be a normal response, not a major depressive episode.
MANIFESTATIONS AND SCOPE OF DEPRESSION IN MEDICAL PROFESSIONALS, INCLUDING RADIOLOGISTS From an observational standpoint, Michalak et al [2] described the possible manifestations of mental illness in physicians which may include the following: (1) severe irritability and anger resulting in interpersonal conflict; (2) marked vacillations in energy, creativity, enthusiasm, confidence, and productivity; (3) erratic behavior at work; (4) inappropriate boundaries with patients, staff members, or peers; (5) isolation and withdrawal; (6) increased errors in or inattention to work duties; (7) personality change and mood swings; (8) inappropriate dress or change in hygiene; (9) sexually inappropriate comments or behavior; (10) diminished or heightened need for sleep; (11) frequent job changes or moves; and (12) inconsistency in performance or absenteeism. Lindeman et al [3] found that the rate of depression among physicians is comparable with that among the general population. The lifetime prevalence of depression among physicians is 13% in men and 20% in women [4]. Vaillant et al [5] noted that certain personality traits common to physicians, such as selfcriticism and perfectionism, may increase risk for depression and substance abuse. Frank and Dingle [4] reported a small study of 163 female radiologists, of whom 15.3% reported histories of depression. Firth-Cozens [6] outlined a variety of predictors of depression in physicians such as, (1) difficult relationships with senior doctors, staff members, or patients; (2) lack of sleep; (3) dealing with death; (4) making mistakes; (5) loneliness; (6) 24-hour responsibility; and (7) self-criticism. Bright and Krahn [7] stated that depression and other mood disorders in physicians may be underrecognized and not adequately treated because physicians might (1) be reluctant to seek treatment, (2) attempt to diagnose and treat themselves or turn to alcohol or illicit drugs for help, or (3) see and receive “special” treatment from other health care providers. In a recent multisite anonymous study of more than 2,000 medical students and residents, including radiology Journal of the American College of Radiology Volume - n Number - n Month 2016
residents, 12% reported probable major depression, and an additional 9.2% had probable mild or moderate depression [8,9]. The authors concluded that depression remains a significant issue for medical trainees and stressed the importance of ongoing mental health assessment, treatment, and education for these groups. In a 2011 educational exhibit at the annual meeting of the European Society of Radiology, Silva et al [10] reported a study of anxiety and depression in 219 radiology residents of different years, which found that 51% of the residents had anxiety and 55% showed depression.
RISK FACTORS SPECIFIC TO MEDICAL PROFESSIONALS INCLUDING RADIOLOGISTS Stress at work is common. Stress-related conditions are not diagnosable as mental illness, but they can lead to impaired function at work, which in the medical profession means a potential impact on patient care [11,12]. Stressors among physicians include, (1) working in an acute environment (interventional radiology, highthroughput outpatient practice); (2) increasing threats of litigation; (3) decreasing cohesiveness (turf issues); (4) overwork and exhaustion; (5) balancing career and family; (6) physical illness; (7) authoritarian hierarchies intolerant of perceived weakness or failure; (8) “system issues” (poor morale, shrinking funds); (9) increasing emphasis on efficiency; (10) increasing requirements for formalized accountability; (11) increasing emphasis on patients’ rights; and (12) financial difficulties. All of these factors are applicable to radiologists, as studies have shown. Specifically, in a 2008 study, Magnavita et al [13] investigated the association between work stress and psychological health in 314 radiologists and radiation oncologists who completed questionnaires that included 18 questions on the Goldberg anxiety and depression scales; 31% were found to be at risk for anxiety disorders, and 17% were found to be at risk for depression on the basis of their responses. In a 2014 follow-up study of 654 radiologists, Magnavita and Fileni [14] found that radiologists “who perceive demand as excessive in relation to their power of control.have an increased risk of being anxious, depressed, and affected by psychic disorders.” There is controversy as to whether burnout is a form of depression or a distinct phenomenon [15]. Burnout is described as a three-dimensional syndrome made up of (emotional) exhaustion, cynicism (also termed depersonalization), and lack of professional efficacy (or reduced Journal of the American College of Radiology Bender et al n The Radiologist and Depression
personal accomplishment) that develops in response to chronic occupational stress [16-18]. In a 2012 Mayo Clinic national study, 46% of all responding US physicians reported feeling burned out; by specialty, radiology reported 40% burnout [19]. Bianchi et al [11] provided a major review of the literature and concluded that there is a fragile overlap between burnout and depression. The recent increase in burnout among radiologists has been noted and recommendations to avoid the problem have been offered for individuals and practice leaders. One approach to preventing or treating burnout is to correct the underlying risk factors, especially inadequate staffing, stress, lack of control, and too much call. Another approach to preventing or treating burnout is to focus attention on the individual, which may require a change in lifestyle balance or seeking counseling, career coaching, and/or psychotherapy [20]. In DSM-5, seasonal affective disorder (SAD) is listed as a subtype of recurrent major depressive episodes within a major depressive disorder. Causes of SAD include reduced sunlight and the associated disruptions in circadian rhythm and potentially serotonin and melatonin levels as well [21,22]. Radiologists work in environments characterized by low ambient light. Therefore, they may be at increased risk for SAD, as well as major depressive disorder. In a recent randomized controlled trial of 122 patients with major depression, Lam and Levitan [22] published the “first study to show that light treatment is an option for people with nonseasonal depression, which is much more common than seasonal depression” [23]. For radiologists potentially affected by regular exposure to low ambient light, this raises the possibility of using bright-light therapy either in the office or at home. Another risk factor unique to radiology is MRI and its associated magnetic fields. Specifically, in a study presented at the European Congress of Radiology in 2013 of 40 MRI technologists who completed a questionnaire that included the Beck Depression Inventory, 25% were found to have clinical depression; although not demonstrative of cause and effect given the small sample size, the strong association raised the possibility of the effect of chronic exposure to a changed magnetic field on mental health [24]. Although the cohort of this study was MRI technologists, the results raise the possibility of relevance to radiologists specializing in clinical MRI or MRI research, who may spend increased time in Zone III, “an area near the magnet room where the fringe, gradient, or 3
(radiofrequency) magnetic fields are sufficiently strong to present a physical hazard to unscreened patients and personnel” [25].
LIFE IMPACT Suicide Risk In 2002, the American Foundation for Suicide Prevention convened an expert panel to evaluate the issue of physician depression and suicide and the barriers to treatment. In its consensus statement [26], the foundation noted that although the suicide rate for US physicians is not current, physicians have a higher rate of suicide compared with the general population. Hampton [27] stated that the chances that a physician will commit suicide are about 70% higher for male physicians than for men in the general population and between 250% and 400% higher for female physicians than other women. It was noted that the two greatest risk factors for suicide are having a mental disorder and having a substance abuse disorder [26]. It is believed that there are 400 physician suicides each year [28]. The most common psychiatric diagnoses in physicians who commit suicide are depression, bipolar disease, alcoholism, and substance abuse. The most common means of suicide among physician are firearms and medication overdoses [4,29]. In 2010, in the United Kingdom, a radiologist committed suicide after a medical error, which the radiologist attributed to himself, that led to the death of a patient [30]. The issue of suicidal patients presenting for diagnostic radiology has also been raised [31]. Medical Licensure Issues State licensing and specialty boards vary in their application process and management. The mission of state medical boards, which have licensing authority over physicians in each state, is to protect the public by ensuring the quality, integrity, and safety of health care provided by physicians [9,32]. The governing board for diagnostic radiology and radiation oncology is the ABR, which specifies criteria for maintenance of certification in detail on its website (www.abr.org). Most states have physician health programs, which are not associated with state medical licensing boards [32]. They may permit a physician enrolled in the health program who is compliant with treatment to check “no” on the mental health questions on licensure applications. On the other hand, in some states, the response of a diagnosis of mental illness is sufficient to 4
sanction a physician. These states further indicate that if there is no evidence of impairment, a sanction is likely to be temporary, but it is the perception of this type of sanction that can lead to physicians’ reluctance, both within and outside radiology, to seek help for mental health conditions.
CONCLUSION: RADIOLOGISTS AND DEPRESSION Clinical depression affects medical professionals including radiologists, and the signs and symptoms have been delineated in this report. If these resonate with you or someone you work with, confidential help is available either through local mental health facilities or nationally through the Federation of State Physician Health Programs (www.fsphp.org) and the National Alliance on Mental Illness (www.nami.org). There is a public health benefit associated with radiologists’ seeking treatment for depression and suicidality. If practices and state licensing boards develop model regulations and policies that encourage radiologists to seek help, this would be of value. Education forums through continuing medical education on physician depression, suicide, and the risks and resources for help should also be developed for physicians in general and specific to radiologists as well. TAKE-HOME POINTS -
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The lifetime prevalence of depression in physicians is 13% in men and 20% in women. Physician depression may be underrecognized and not adequately treated. Physicians have a higher rate of suicide compared to the general population.
REFERENCES 1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington, Virginia: American Psychiatric Publishing; 2013. 2. Michalak EE, Yatham LN, Maxwell V, et al. The impact of bipolar disorder upon work functioning: a qualitative analysis. Bipolar Disord 2007;9:126-43. 3. Lindeman S, Laara E, Hakko H, et al. A systematic review on genderspecific suicide mortality in medical doctors. Br J Psychiatry 1996;168: 274-9. 4. Frank E, Dingle AD. Self-reported depression and suicide attempts among U.S. women physicians. Am J Psychiatry 1999;156:1887-94. 5. Vaillant GE, Sobowale NC, McArthur C. Some psychological vulnerabilities of physicians. N Engl J Med 1972;287:372-5. 6. Firth-Cozens J. Individual and organizational predictors of depression in general practitioners. Br J Gen Practice 1998;48:1647-51. 7. Bright RP, Krahn L. Depression and suicide among physicians. Curr Psychiatry 2011;10:16-30.
Journal of the American College of Radiology Volume - n Number - n Month 2016
8. Goebert D, Thompson D, Takeshita J, Beach C, et al. Depressive symptoms in medical students and residents: a multischool study. Acad Med 2009;84:236-41. 9. Hendin H, Reynolds C, Fox D, Altchuler SI, et al. Licensing and physician mental health: problems and possibilities. J Med Licens Disc 2007;93:6-11. 10. Silva GCCD, Sousa EG, Koch HA, Santos AASM. Anxiety and depression in the performance of residents in radiology and medical imaging. Presented at: Annual Meeting of the European Society of Radiology; 2011. 11. Bianchi R, Schonfeld IS, Laurent E. Burnout-depression overlap: a review. Clin Psychol Rev 2015;36:28-41. 12. Maslach C, Jackson SE. The measurement of experienced burnout. J Org Behav 2007;2:99-113. 13. Magnavita E, Fileni A, Magnavita G, et al. Work stress in radiologists: a pilot study. Radiol Med 2008;113:329-46. 14. Magnavita N, Fileni A. Association of work-related stress with depression and anxiety in radiologists. Radiol Med 2014;119: 359-66. 15. Brown SD, Goske MJ, Johnson CM. Beyond substance abuse: stress, burnout, and depression as causes of physician impairment and disruptive behavior. J Am Coll Radiol 2009;6: 479-85. 16. Moskowitz PS, Johnson M. Career satisfaction declines precipitously among radiologists: survey finds unhealthy coping strategies for stresses brought on by changing work environment. Diagn Imaging 2001; March:63-9. 17. Maslach C, Jackson SE, Leiter MP. Maslach Burnout Inventory manual. 3rd ed. Palo Alto, California: Consulting Psychologists Press; 1996. 18. Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annu Rev Psychol 2001;52:397-422.
19. Shanafelt TD, Boone S, Tan L, Dyrbye LN, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general population. Arch Intern Med 2012;172:1377-85. 20. Harolds JA, Parikh JR, Dutton SC, Bluth EI, et al. Burnout of radiologists: frequency, risk factors, and remedies: a report of the ACR Commission of Human Resources. J Am Coll Radiol. In press. 21. Mayo Clinic Staff. Seasonal affective disorder (SAD). Available at: http://www.mayoclinic.org/diseases-conditions/seasonal-affectivedisorder/basics/definition/con-20021047. Accessed December 1, 2015. 22. Lam RW, Levitan RD. Pathophysiology of seasonal affective disorder: a review. J Psychiatry Neurosci 2000;25:469-80. 23. Bakalar N. Light therapy for all seasons. The New York Times. December 1, 2015:D4. 24. Forrest W. High-field MRI exposure linked to techs’ depression. Available at: http://www.auntminnie.com/index.aspx?sec¼ser&sub¼def&pag¼ dis&ItemID¼102794. Accessed March 11, 2013. 25. AD Elster. MRI suite: ACR safety zones. Available at: http://mri-q. com/acr-safety-zones.html. Accessed March 1, 2016. 26. Center C, Davis M, Detre T, et al. Confronting depression and suicide in physicians: a consensus statement. JAMA 2003;289:3161-6. 27. Hampton T. Experts address risk of physician suicide. JAMA 2005;294:1189-91. 28. Andrew LB. Physician suicide. Available at: http://emedicine. medscape.com/article/806779-overview. Accessed July 20, 2015. 29. Austin AE, van den Huevel C, Byard RW. Physician suicide. J Forensic Sci 2013;58(Suppl 1):S91-3. 30. Jamieson A. Patient died and radiographer took his own life after fatal mistake at hospital. The Telegraph May 3, 2010. 31. Penzias A. The suicidal patient in radiology [poster]. Boston: Massachusetts General Hospital. 32. Bender CE, Heilbrun ME, Truong HB, Bluth EI. The impaired radiologist. J Am Coll Radiol 2015;12:302-6.
Credits awarded for this enduring activity are designated “SA-CME” by the American Board of Radiology (ABR) and qualify toward fulfilling requirements for Maintenance of Certification (MOC) Part II: Lifelong Learning and Self-assessment. Scan the QR code to access the SA-CME activity or visit http://bit.ly/ACRSACME.
Journal of the American College of Radiology Bender et al n The Radiologist and Depression
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The Radiologist and Depression Claire E. Bender, MD a , Jay R. Parikh, MD b, Elizabeth Kagan Arleo, MD c, Edward Bluth, MD d Abstract Clinical depression affects physicians, including radiologists. Medical professionals, including radiologists, may be more comfortable treating a patient than being one, and psychiatric issues may be regarded as taboo for discussion, so the issue of clinical depression in the specialty and subspecialty has not received widespread attention. Specifically, a review of the national and international literature in PubMed, Scopus, and Google reveals few publications dedicated to the issue of clinical depression in radiology; although statistically, they must exist. The purpose of this report is to define the terms and describe the manifestations and scope of the issues related to clinical depression, with special attention given to risk factors unique to radiologists, such as working in low ambient light or near different fields of magnetic strength. By the end of the article, it is the authors’ hope that the reading radiologist will be aware of, and open to, the possibility of clinical depression in a colleague or within his or herself because clinical depression is common and it is important to get help. Key Words: Radiologist, resident/trainee, depression, seasonal affective disorder J Am Coll Radiol 2016;-:---. Copyright 2016 American College of Radiology
Physician, heal thyself. —Luke 4:23 (King James Version)
There are three things extremely hard: steel, a diamond and to know one’s self. —Benjamin Franklin
INTRODUCTION Clinical depression affects physicians, including radiologists. Medical professionals, including radiologists, may be more comfortable treating a patient than being one, and psychiatric issues may be regarded as taboo for discussion, so the issue of clinical depression in the specialty and subspecialty has not received widespread attention. Specifically, a review of the national and international literature in PubMed, Scopus, and Google reveals few publications dedicated to the issue of clinical depression in radiology; although statistically, they must exist. The a
Mayo Clinic, Rochester, Minnesota. Department of Radiology, MD Anderson Breast Care With Memorial Hermann, Houston, Texas. c Weill Cornell Imaging at New York Presbyterian, New York, New York. d Department of Radiology, Ochsner Clinic Foundation, New Orleans, Louisiana. Corresponding author and reprints: Claire E. Bender, MD, Mayo Clinic, 200 First Street SW, Rochester, MN 55905; e-mail: [email protected]. The authors have no conflicts of interest related to the material discussed in this article. b
ª 2016 American College of Radiology 1546-1440/16/$36.00 n http://dx.doi.org/10.1016/j.jacr.2016.03.014
purpose of this report is to define the terms and describe the manifestations and scope of the issues related to clinical depression, with special attention given to risk factors unique to radiologists, such as working in low ambient light or near different fields of magnetic strength. By the end of the article, it is our hope that the reading radiologist will be aware of, and open to, the possibility of clinical depression in a colleague or within his or herself because clinical depression is common and it is important to get help.
DEFINITIONS In 2013, the American Psychiatric Association published the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which is used within the profession as a classification and diagnostic tool for mental disorders [1]. DSM-5 serves as the universal authority in the diagnosis of the spectrum of psychiatric conditions. It does not provide recommendations on treatment. The DSM does have its scientific critics, but it serves as the reference standard for clinicians and researchers. In the manual, depressive disorders include the following diagnoses and their specific diagnostic criteria: n n
n n
disruptive mood dysregulation disorder, major depressive disorder (including major depressive episode), persistent depressive disorder (dysthymia), premenstrual dysphoric disorder,
1
n
n
substance- or medication-induced depressive disorder, and unspecified depressive disorder.
The bipolar and related disorders have been moved to a separate chapter in DSM-5. DSM-5 states that “common to all these disorders is the presence of sad, empty, or irritable mood, accompanied by somatic and cognitive changes that significantly affect the individual’s capacity to function” [1]. The manual adds that what differs among the disorders are issues of duration, timing, and presumed etiology. Under major depressive disorder section, the three most common diagnostic criteria (A-C) are listed as follows [1]: A. Five (or more) of the following symptoms have been present during the same two-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of pleasure. Note: Do not include symptoms that are clearly attributable to another medical condition. 1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (eg, feels sad, empty, hopeless) or observation made by others (eg, appears tearful). Note: In children and adolescents, can be irritable mood. 2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation). 3. Significant weight loss when not dieting or weight gain (eg, a change of more than 5% of body weight) or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain). 4. Insomnia or hypersomnia nearly every day. 5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down). 6. Fatigue or loss of energy nearly every day. 7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick). 8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others). 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. B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. 2
C. The episode is not attributable to the physiological effects of a substance or to another medical condition. Note: Criteria A-C represent a major depressive episode. Also, responses to a significant loss such as financial ruin or loss of a loved one, can result in feelings of intense sadness, insomnia, weight loss and can be a normal response, not a major depressive episode.
MANIFESTATIONS AND SCOPE OF DEPRESSION IN MEDICAL PROFESSIONALS, INCLUDING RADIOLOGISTS From an observational standpoint, Michalak et al [2] described the possible manifestations of mental illness in physicians which may include the following: (1) severe irritability and anger resulting in interpersonal conflict; (2) marked vacillations in energy, creativity, enthusiasm, confidence, and productivity; (3) erratic behavior at work; (4) inappropriate boundaries with patients, staff members, or peers; (5) isolation and withdrawal; (6) increased errors in or inattention to work duties; (7) personality change and mood swings; (8) inappropriate dress or change in hygiene; (9) sexually inappropriate comments or behavior; (10) diminished or heightened need for sleep; (11) frequent job changes or moves; and (12) inconsistency in performance or absenteeism. Lindeman et al [3] found that the rate of depression among physicians is comparable with that among the general population. The lifetime prevalence of depression among physicians is 13% in men and 20% in women [4]. Vaillant et al [5] noted that certain personality traits common to physicians, such as selfcriticism and perfectionism, may increase risk for depression and substance abuse. Frank and Dingle [4] reported a small study of 163 female radiologists, of whom 15.3% reported histories of depression. Firth-Cozens [6] outlined a variety of predictors of depression in physicians such as, (1) difficult relationships with senior doctors, staff members, or patients; (2) lack of sleep; (3) dealing with death; (4) making mistakes; (5) loneliness; (6) 24-hour responsibility; and (7) self-criticism. Bright and Krahn [7] stated that depression and other mood disorders in physicians may be underrecognized and not adequately treated because physicians might (1) be reluctant to seek treatment, (2) attempt to diagnose and treat themselves or turn to alcohol or illicit drugs for help, or (3) see and receive “special” treatment from other health care providers. In a recent multisite anonymous study of more than 2,000 medical students and residents, including radiology Journal of the American College of Radiology Volume - n Number - n Month 2016
residents, 12% reported probable major depression, and an additional 9.2% had probable mild or moderate depression [8,9]. The authors concluded that depression remains a significant issue for medical trainees and stressed the importance of ongoing mental health assessment, treatment, and education for these groups. In a 2011 educational exhibit at the annual meeting of the European Society of Radiology, Silva et al [10] reported a study of anxiety and depression in 219 radiology residents of different years, which found that 51% of the residents had anxiety and 55% showed depression.
RISK FACTORS SPECIFIC TO MEDICAL PROFESSIONALS INCLUDING RADIOLOGISTS Stress at work is common. Stress-related conditions are not diagnosable as mental illness, but they can lead to impaired function at work, which in the medical profession means a potential impact on patient care [11,12]. Stressors among physicians include, (1) working in an acute environment (interventional radiology, highthroughput outpatient practice); (2) increasing threats of litigation; (3) decreasing cohesiveness (turf issues); (4) overwork and exhaustion; (5) balancing career and family; (6) physical illness; (7) authoritarian hierarchies intolerant of perceived weakness or failure; (8) “system issues” (poor morale, shrinking funds); (9) increasing emphasis on efficiency; (10) increasing requirements for formalized accountability; (11) increasing emphasis on patients’ rights; and (12) financial difficulties. All of these factors are applicable to radiologists, as studies have shown. Specifically, in a 2008 study, Magnavita et al [13] investigated the association between work stress and psychological health in 314 radiologists and radiation oncologists who completed questionnaires that included 18 questions on the Goldberg anxiety and depression scales; 31% were found to be at risk for anxiety disorders, and 17% were found to be at risk for depression on the basis of their responses. In a 2014 follow-up study of 654 radiologists, Magnavita and Fileni [14] found that radiologists “who perceive demand as excessive in relation to their power of control.have an increased risk of being anxious, depressed, and affected by psychic disorders.” There is controversy as to whether burnout is a form of depression or a distinct phenomenon [15]. Burnout is described as a three-dimensional syndrome made up of (emotional) exhaustion, cynicism (also termed depersonalization), and lack of professional efficacy (or reduced Journal of the American College of Radiology Bender et al n The Radiologist and Depression
personal accomplishment) that develops in response to chronic occupational stress [16-18]. In a 2012 Mayo Clinic national study, 46% of all responding US physicians reported feeling burned out; by specialty, radiology reported 40% burnout [19]. Bianchi et al [11] provided a major review of the literature and concluded that there is a fragile overlap between burnout and depression. The recent increase in burnout among radiologists has been noted and recommendations to avoid the problem have been offered for individuals and practice leaders. One approach to preventing or treating burnout is to correct the underlying risk factors, especially inadequate staffing, stress, lack of control, and too much call. Another approach to preventing or treating burnout is to focus attention on the individual, which may require a change in lifestyle balance or seeking counseling, career coaching, and/or psychotherapy [20]. In DSM-5, seasonal affective disorder (SAD) is listed as a subtype of recurrent major depressive episodes within a major depressive disorder. Causes of SAD include reduced sunlight and the associated disruptions in circadian rhythm and potentially serotonin and melatonin levels as well [21,22]. Radiologists work in environments characterized by low ambient light. Therefore, they may be at increased risk for SAD, as well as major depressive disorder. In a recent randomized controlled trial of 122 patients with major depression, Lam and Levitan [22] published the “first study to show that light treatment is an option for people with nonseasonal depression, which is much more common than seasonal depression” [23]. For radiologists potentially affected by regular exposure to low ambient light, this raises the possibility of using bright-light therapy either in the office or at home. Another risk factor unique to radiology is MRI and its associated magnetic fields. Specifically, in a study presented at the European Congress of Radiology in 2013 of 40 MRI technologists who completed a questionnaire that included the Beck Depression Inventory, 25% were found to have clinical depression; although not demonstrative of cause and effect given the small sample size, the strong association raised the possibility of the effect of chronic exposure to a changed magnetic field on mental health [24]. Although the cohort of this study was MRI technologists, the results raise the possibility of relevance to radiologists specializing in clinical MRI or MRI research, who may spend increased time in Zone III, “an area near the magnet room where the fringe, gradient, or 3
(radiofrequency) magnetic fields are sufficiently strong to present a physical hazard to unscreened patients and personnel” [25].
LIFE IMPACT Suicide Risk In 2002, the American Foundation for Suicide Prevention convened an expert panel to evaluate the issue of physician depression and suicide and the barriers to treatment. In its consensus statement [26], the foundation noted that although the suicide rate for US physicians is not current, physicians have a higher rate of suicide compared with the general population. Hampton [27] stated that the chances that a physician will commit suicide are about 70% higher for male physicians than for men in the general population and between 250% and 400% higher for female physicians than other women. It was noted that the two greatest risk factors for suicide are having a mental disorder and having a substance abuse disorder [26]. It is believed that there are 400 physician suicides each year [28]. The most common psychiatric diagnoses in physicians who commit suicide are depression, bipolar disease, alcoholism, and substance abuse. The most common means of suicide among physician are firearms and medication overdoses [4,29]. In 2010, in the United Kingdom, a radiologist committed suicide after a medical error, which the radiologist attributed to himself, that led to the death of a patient [30]. The issue of suicidal patients presenting for diagnostic radiology has also been raised [31]. Medical Licensure Issues State licensing and specialty boards vary in their application process and management. The mission of state medical boards, which have licensing authority over physicians in each state, is to protect the public by ensuring the quality, integrity, and safety of health care provided by physicians [9,32]. The governing board for diagnostic radiology and radiation oncology is the ABR, which specifies criteria for maintenance of certification in detail on its website (www.abr.org). Most states have physician health programs, which are not associated with state medical licensing boards [32]. They may permit a physician enrolled in the health program who is compliant with treatment to check “no” on the mental health questions on licensure applications. On the other hand, in some states, the response of a diagnosis of mental illness is sufficient to 4
sanction a physician. These states further indicate that if there is no evidence of impairment, a sanction is likely to be temporary, but it is the perception of this type of sanction that can lead to physicians’ reluctance, both within and outside radiology, to seek help for mental health conditions.
CONCLUSION: RADIOLOGISTS AND DEPRESSION Clinical depression affects medical professionals including radiologists, and the signs and symptoms have been delineated in this report. If these resonate with you or someone you work with, confidential help is available either through local mental health facilities or nationally through the Federation of State Physician Health Programs (www.fsphp.org) and the National Alliance on Mental Illness (www.nami.org). There is a public health benefit associated with radiologists’ seeking treatment for depression and suicidality. If practices and state licensing boards develop model regulations and policies that encourage radiologists to seek help, this would be of value. Education forums through continuing medical education on physician depression, suicide, and the risks and resources for help should also be developed for physicians in general and specific to radiologists as well. TAKE-HOME POINTS -
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The lifetime prevalence of depression in physicians is 13% in men and 20% in women. Physician depression may be underrecognized and not adequately treated. Physicians have a higher rate of suicide compared to the general population.
REFERENCES 1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington, Virginia: American Psychiatric Publishing; 2013. 2. Michalak EE, Yatham LN, Maxwell V, et al. The impact of bipolar disorder upon work functioning: a qualitative analysis. Bipolar Disord 2007;9:126-43. 3. Lindeman S, Laara E, Hakko H, et al. A systematic review on genderspecific suicide mortality in medical doctors. Br J Psychiatry 1996;168: 274-9. 4. Frank E, Dingle AD. Self-reported depression and suicide attempts among U.S. women physicians. Am J Psychiatry 1999;156:1887-94. 5. Vaillant GE, Sobowale NC, McArthur C. Some psychological vulnerabilities of physicians. N Engl J Med 1972;287:372-5. 6. Firth-Cozens J. Individual and organizational predictors of depression in general practitioners. Br J Gen Practice 1998;48:1647-51. 7. Bright RP, Krahn L. Depression and suicide among physicians. Curr Psychiatry 2011;10:16-30.
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8. Goebert D, Thompson D, Takeshita J, Beach C, et al. Depressive symptoms in medical students and residents: a multischool study. Acad Med 2009;84:236-41. 9. Hendin H, Reynolds C, Fox D, Altchuler SI, et al. Licensing and physician mental health: problems and possibilities. J Med Licens Disc 2007;93:6-11. 10. Silva GCCD, Sousa EG, Koch HA, Santos AASM. Anxiety and depression in the performance of residents in radiology and medical imaging. Presented at: Annual Meeting of the European Society of Radiology; 2011. 11. Bianchi R, Schonfeld IS, Laurent E. Burnout-depression overlap: a review. Clin Psychol Rev 2015;36:28-41. 12. Maslach C, Jackson SE. The measurement of experienced burnout. J Org Behav 2007;2:99-113. 13. Magnavita E, Fileni A, Magnavita G, et al. Work stress in radiologists: a pilot study. Radiol Med 2008;113:329-46. 14. Magnavita N, Fileni A. Association of work-related stress with depression and anxiety in radiologists. Radiol Med 2014;119: 359-66. 15. Brown SD, Goske MJ, Johnson CM. Beyond substance abuse: stress, burnout, and depression as causes of physician impairment and disruptive behavior. J Am Coll Radiol 2009;6: 479-85. 16. Moskowitz PS, Johnson M. Career satisfaction declines precipitously among radiologists: survey finds unhealthy coping strategies for stresses brought on by changing work environment. Diagn Imaging 2001; March:63-9. 17. Maslach C, Jackson SE, Leiter MP. Maslach Burnout Inventory manual. 3rd ed. Palo Alto, California: Consulting Psychologists Press; 1996. 18. Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annu Rev Psychol 2001;52:397-422.
19. Shanafelt TD, Boone S, Tan L, Dyrbye LN, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general population. Arch Intern Med 2012;172:1377-85. 20. Harolds JA, Parikh JR, Dutton SC, Bluth EI, et al. Burnout of radiologists: frequency, risk factors, and remedies: a report of the ACR Commission of Human Resources. J Am Coll Radiol. In press. 21. Mayo Clinic Staff. Seasonal affective disorder (SAD). Available at: http://www.mayoclinic.org/diseases-conditions/seasonal-affectivedisorder/basics/definition/con-20021047. Accessed December 1, 2015. 22. Lam RW, Levitan RD. Pathophysiology of seasonal affective disorder: a review. J Psychiatry Neurosci 2000;25:469-80. 23. Bakalar N. Light therapy for all seasons. The New York Times. December 1, 2015:D4. 24. Forrest W. High-field MRI exposure linked to techs’ depression. Available at: http://www.auntminnie.com/index.aspx?sec¼ser&sub¼def&pag¼ dis&ItemID¼102794. Accessed March 11, 2013. 25. AD Elster. MRI suite: ACR safety zones. Available at: http://mri-q. com/acr-safety-zones.html. Accessed March 1, 2016. 26. Center C, Davis M, Detre T, et al. Confronting depression and suicide in physicians: a consensus statement. JAMA 2003;289:3161-6. 27. Hampton T. Experts address risk of physician suicide. JAMA 2005;294:1189-91. 28. Andrew LB. Physician suicide. Available at: http://emedicine. medscape.com/article/806779-overview. Accessed July 20, 2015. 29. Austin AE, van den Huevel C, Byard RW. Physician suicide. J Forensic Sci 2013;58(Suppl 1):S91-3. 30. Jamieson A. Patient died and radiographer took his own life after fatal mistake at hospital. The Telegraph May 3, 2010. 31. Penzias A. The suicidal patient in radiology [poster]. Boston: Massachusetts General Hospital. 32. Bender CE, Heilbrun ME, Truong HB, Bluth EI. The impaired radiologist. J Am Coll Radiol 2015;12:302-6.
Credits awarded for this enduring activity are designated “SA-CME” by the American Board of Radiology (ABR) and qualify toward fulfilling requirements for Maintenance of Certification (MOC) Part II: Lifelong Learning and Self-assessment. Scan the QR code to access the SA-CME activity or visit http://bit.ly/ACRSACME.
Journal of the American College of Radiology Bender et al n The Radiologist and Depression
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