The Rising Tsunami of Residents with ADHD, Anxiety, Depression and Rage - PowerPoint Presentation

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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 r

isk

The

r

ole

of p

rogram 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

N

ew

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

V

alues

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