the rising tsunami of residents with adhd, anxiety, depression and rage ranjan sudan, md
TRANSCRIPT
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The Rising Tsunami of Residents with ADHD, Anxiety, Depression and Rage
Ranjan Sudan, MD
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Depression, Anxiety, ADHD, Rage How big is the problem Who is at risk The role of program director in dealing with
trainees with mental health disorders
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Reasons for perceived rise in incidence of mental health disorders Actual increase in incidence Colleges have become more inclusive Greater availability of medications allowing
more affected individuals to attend college Lesser stigma, allowing more students to seek
treatment Disruption of health care after leaving home Discontinuation of medication after leaving
home Use of alcohol or other drugs along with
antidepressant medication Increased academic pressure or sleep
deprivation
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Depression - Diagnostic Criteria Persistent sad mood Loss of pleasure in activities that were once
pleasurable Significant change in body weight or appetite Difficulty in sleeping or oversleeping Physical slowing or agitation Feelings of inappropriate worthlessness or
guilt Difficulty thinking or concentrating Thoughts of suicide (Five or more of these symptoms in the same
two weeks)
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Other related conditions Dysthymia (lower grade depression) Bipolar disorder (cycling of mood)
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State of Health of College Students National College Health Assessment (NCHA II) Survey of 105781 respondents (28.5%
response rate) 6.5% reported ADHD 3.8 had learning disability 4.7 % had psychiatric condition (other than
ADHD) 0.7% had speech or language disability
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Mental Health (past 12 months)Percent Male Female Total
Felt things were hopeless
38.7 48.6 45.1
Felt Overwhelmed by all you had to do
77 91.4 86.3
Felt so depressed that it was difficult to function
26.9 33.3 31.1
Felt overwhelming anxiety
40.5 56 50.6
Seriously considered suicide
6.3 6.4 6.4
Attempted suicide
1.1 0.9 1.1
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Diagnosed or treated by a professional (Top diagnosis in past 12 months)Percent Male Female Total
Anxiety 7.2 13.9 11.6
Depression 7.4 12.4 10.7
Panic Attacks 2.7 6.6 5.3
ADHD 5.0 4.3 4.6
Bipolar Disorder 1.2 1.4 1.4
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Reasons for Depression New sources of stress, including
separation from family, sharing close living quarters with strangers
formation of new social groups intense academic pressures the balancing of social engagements with
academic and other life responsibilities. Most handle these stresses and challenges
well Others have difficulty adjusting and
experience emotional turmoil
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Factors contributing to depression Genetics and biology play an important role in
determining individual susceptibility Personality Life experiences Values and beliefs Family and surrounding environment.
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Consequences of depression Hamper academic performance Decreased immunity may increase
predisposition to physical illness Link to substance abuse Increase risky sexual behavior Interfere dramatically with a student’s quality
of life, self esteem and interpersonal relationships
Risk of suicide.
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Suicide Females have higher rates of depression and
are at greater risk for suicidal thoughts and attempts than males
However males are more likely to complete a suicide attempt
At the Massachusetts Institute of Technology (MIT)12 students have committed suicide between 1990 and 2003 that have resulted in two lawsuits for neglect
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ADHD Trouble focusing Act without thinking Hyperactive Estimated that 3% of medical students have
ADHD
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ADHD Hard time paying attention
inability to pay attention to details difficulty with sustained attention in tasks or play
activities apparent listening problems difficulty following instructions problems with organization
May be restless blurting out answers before hearing the full
question difficulty waiting for a turn or in line problems with interrupting or intruding
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Treatment Behavioral interventions Medications
Stimulants Non-stimulants Antidepressants
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Medication misuse Sharing of medications Prescription of medications
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Disruptive Behavior Behavioral disturbance may lead to
“disruptiveness” Misbehavior as a trainee may later lead to
misbehavior as an attending surgeon Roughly 5% of surgeons regularly exhibit
disruptive behavior, which affects Communication, and may contribute to hospital
errors Morale and functioning of the training program The trainee’s career The functioning of the patient care team Attrition
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Disruptive behavior Since 2009 The Joint Commission mandates
that hospitals have specific policies addressing disruptive behavior
Such policies are usually triggered in the more extreme circumstances
Ideally behaviors should be identified and rectified long before they get to that stage
Difficult to identify patterns of problem behaviors – may take a year or two to accumulate evidence
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Promoting Professionalism Pyramid 4 graduated interventions Informal conversations for single incidents Non punitive “awareness interventions”.
Involves self reflection. Leader-developed action plans when the
behavior is a pattern Imposition of disciplinary action, when action
plan fails
If behavior is severe, threatens safety, then the above is not followed
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ADA…. The ADA places a stiff burden on those who
possess medical information Definition is tricky so work with HR or legal Recovered alcoholic is covered under ADA but
not active alcoholism at the work place Trainee must request accommodation before
an institution must reasonably try to accommodate
Accommodation depends on residents abilities, the specialty and the institution
Once PD learns of a resident’s disability They must make suitable accommodation Protect privacy from peers, faculty and staff
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A word of caution - ADA PD should not
Initiate discussions of a medical nature (unlawful prying)
Require medical or psychiatric evaluation as a condition for employment
Instead refer to Employee Health for a fit for duty evaluation
The less the PD knows about a resident’s medical condition, the more discretion the program has to take academic and employment decisions without fear of liability under ADA
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Program Director Role The PD aims for every trainee to successfully
complete the educational program The PD is the point person when a problem is
identified and becomes in charge of Monitoring the workplace behavior of trainees
before they are identified as problem residents Remediation or corrective action plans when
needed Every program must have carefully designed
policies to protect trainee’s due process and avoid litigation
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Action Plan An obviously impaired resident must be
removed from duty in the interest of safety Consult with GME office
They will know who else should be involved Know your institutional and local resources
Such as mental health professionals State licensing board rules PHPs Rehabilitation or treatment centers
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Summary Recognize that anxiety, depression and ADHD
is more common place than you think Entry into residency is a particularly
vulnerable time Women are more predisposed to anxiety and
depression But men are more likely to complete suicide Do not try to diagnose trainees, but best to
have employee health engage in the process Engaging trainees in activities outside of work
helps build a supportive network
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Mental Health issues in Health Professionals
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Role of Program Director
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Summary