Okay good morning everyone we're gonna go ahead and get started. Are you this morning? Okay that's excellent. All right well it is my honor and pleasure to introduce, I'm probably not introducing him to most of you, I'm presenting him to most of you, Dr. Sid Zisook who is a University of California San Diego Distinguished Professor of Psychiatry. He completed medical school at the Stitch Loyola School of Medicine and residency at Massachusetts General Hospital. Dr. Zisook was the founding director of the UCSD Healer Education Assessment and Referral, known as the HEAR program, dedicated to preventing and reducing nurse and physician mental health stigma, burnout, and suicide. He currently directs the UCSD Physician Peer Support Program. Dr. Zisook. Thank you. Well we've got a small enough group to be as informal as you would like to be, so please don't wait on ceremony. Interrupt, raise your hand, speak up at any time and we can make this a discussion. I don't need to go through every slide. I'm going to be talking about caring for ourselves. When I got the notice of this award, I was given an hour and a half, which is unusual, and basically told I can talk on anything I wanted, and it's a difficult choice, but I decided to talk about what I'm kind of most passionate about most recently in my career, and that's taking care of ourselves and each other. So that's going to be the topic today, and let me move along here. Disclosures, I do get research support from Compass. There's a company in the UK that is hoping to market psilocybin therapy for depression, so it's been a fun kind of relationship with them. I'm getting an award today, and I'm so very proud of that, and I was so shocked when I heard about it for education, and I must say I thought I would have a slide of all the people I'm thankful to, and I couldn't do it because it would not fit on any ten slides. So certainly anything that I've done as an educator, I really have been so fortunate to have wonderful, wonderful students and trainees in the past, in the present, and perhaps for a while more in the future. One of my past trainees is sitting here, Christine Moutier, who actually was the co-founder of the HERE program that you mentioned, and I'll be talking more about that in some of the work that we did together, which was a program dedicated to really enhancing physician wellness, decreasing burnout, and preventing suicide. I've also been very fortunate to have a cadre of tremendous teachers and mentors throughout my career, colleagues, friends, training partners, family, friends, my wife especially, who's put up with me and being a workaholic, doing all the things you need to do to win this kind of award, which is all the things we say not to do to other people, and that's weekends and nights of work. And a special shout out to Deepak Prabhatar, who nominated me for the award, and when he asked about if it was okay to nominate me, I said, well don't bother with that, there's no way that's going to happen, but he persisted and convinced me and couldn't be here today, but thank you, Deepak. What I'm going to do is talk about some of the stresses that are unique to psychiatric trainees and psychiatrists, things we all know that we deal with in our practices, differentiate burnout from depression, which I think is critical, so important for us to do, and talk a little bit about some of the strategies that we may be able to utilize to optimize our own well-being and mental health, minimize burnout, depression, and suicide risk. And first, before getting into how difficult our profession is, it's also a wonderful, gratifying place to be. There is nothing that probably made our mothers prouder. If you can remember back to the day you let her know that you were pre-med, what made her prouder, I guess, is when you told her you actually got accepted to med school and started, and we all went into it for all the right reasons, because we really wanted to take care of people. And it is a calling, and it is extraordinarily gratifying, but it's also a very stressful and can be traumatic occupation. And because of the stresses that are associated with being a physician, the ACGME, the AMA, the AAMC, and essentially every other medical organization are now calling on us to prioritize our well-being and our mental health, and that of our trainees and our colleagues, recognizing how important it is for us to take care of ourselves so that we can take care of others in the best possible way. So some of the manifestations of physician stress are listed here, and at the top I start with imposter syndrome. We can all relate to that. Who here has not felt like an imposter from time to time? I remember, actually, my first day as an intern. At night, I had a patient who had a cardiac arrest, and I had no idea what to do, and I felt, boy, I really needed help. I needed the resident to be there, and I wondered, what was I doing here? Why did I waste my time in med school? I didn't know anything. I was an imposter. I thought, as I recall, that that was a feeling that would go away over time, but I must say, more than 50 years later, still there, and I think we can all relate to that. I'm not going to talk more about imposter syndrome. Next on the list is acute stress and trauma. I will talk a little bit about that. Burnout, depression, other mental health conditions like substance use and abuse, anxiety disorders, and finally, suicide. And what I'm going to stress is the acute stress and trauma, burnout, depression, and suicide. I won't talk too much about the others. First, acute stress and trauma, sometimes called second victim syndrome. It's a term many of us don't like because we don't really like to think of ourselves as victims. We're survivors, but it's when a medical activity creates stress in and of ourselves. A health care provider involved in an unanticipated adverse event, a medical error, or a patient-related injury feels victimized in the sense that he or she is traumatized by the event. That's what we mean by second victim syndrome. We've all experienced it. The consequences of this second victim condition is feeling personally responsible for whatever it is that went wrong. We failed our patients, we second-guess our clinical skills, our knowledge base, feel guilty about what went wrong, we have trouble sleeping, feeling self-doubt, guilt, fear, anger, embarrassment, a whole host of feelings that go along with this kind of secondary trauma, and it may enhance our vulnerability. Burnout, depression, and substance misuse, if it's allowed to fester, doesn't get help and go away, and very often it's shrouded in a cloud of silence. We don't talk about these events because we feel guilty and shameful that they've occurred. Every specialty has their own unique traumas. In surgery, it may be a patient dying during elective surgery. In psychiatry, the trauma that is we most likely to have that may induce the second trauma syndrome is when a patient dies by suicide. When patients in our care complete suicide, like in other instances of this secondary trauma, we suffer in a veil of silence, and I remember the first patient I had who died by suicide was also very early in my outpatient year of psychiatry, and I was given a patient by our chief resident who was the daughter of a patient he had been seeing for years, and she had a postpartum depression, and I felt so honored by the fact that he was giving the patient to me to take care of, and I saw the person once, I did an evaluation, and then before our next appointment I got a call that she had died by suicide, and I was crushed, and the chief resident who referred the patient to me, he and I never talked about it. He never mentioned it, I never mentioned it. I never talked about it with my supervisor. I never talked about it with my wife. I bore it inside. I never thought much about it until many, many years later when we started to get, you know, recognized that this was a common thing. Actually, it was at a symposium at either the APA or ADPERT, the Residency Training Meeting, I'm not sure which one, that Joan Anza, who was the training director at Northwestern, had with some of her residents where they were talking about their experiences with patient suicide, and I found that really impactful and made me think about some of the patients I had lost, including that one that I had never talked about for, it had been about 30 years by then. So what we need to do is shift from a culture of silence to one where we care and we share, and I've listed three strategies that I've been involved in that relate to trying to shift that culture. One is having a proactive plan, another is something we call collateral damages, I'll say more about that, and the last one is peer support. So be prepared. So after patient suicides at our institution at UCSD, and Christine will remember this well, like many institutions we would also often have M&Ms, and where the resident would present the case in front of all the other residents and faculty, and our residents felt really traumatized by this, they hated it, because they felt that they were being blamed, they were, you know, being scrutinized, usually the attending who was involved with them wasn't there for whatever reason, and they were so alone, and one of our residents finally decided, hey enough of this, let's find a way that we can actually support each other instead of blaming each other, and she started a committee called the SAVE Committee, Suicide and Serious Adverse Events, that has now gone on for about 20-25 years, it's run by residents, it always has a faculty advisor, so there's continuity, the faculty advisor is the same person year-to-year, but the residents run it, and they have prepared an educational program and a method to support the residents during when a patient dies by suicide, and so the chief resident or senior resident in the service will call other people on the committee, other people who need to know, the residency training director, the chair, and let them know, there will be a debriefing on the service that would include all of the people involved, including medical students, staff, nurses, faculty, other residents, etc., the somebody from the committee will contact the resident and ask them if they need some time off, and if they do arrange to have coverage, so the resident doesn't have to do it themselves, they'll have somebody in the wings that that person can talk to for more care and support, and so there's a whole system now that is made for support. That committee has also taken over Grand Round, so if there is an M&M, the resident does not present the case alone, but the team presents the case with other residents, and it's clear that this has now become a much supportive environment, so proactive. They also, once a year, present to all of the other faculty and residents about this committee, about supporting each other, and they present during that time something we call collateral damages, which is a video that we made years ago that is the hallmark of the video, are several both senior faculty members, Jim Lomax on the left, Glenn Gabbard, Joan Anzia, and myself, talking about their own instances of patient suicide, their own reactions, what it was like, and a number of residents who also told their stories in the video, and we made this video available, we actually gave it to every residency training program in the country, and then later on it became available through the American Foundation for Suicide Prevention and through the residency training program for other sites who wanted to get it, and the cornerstone is the individuals talking about their own experiences. It was interesting, right after we made this, you all, I'm sure you all know Glenn Gabbard, who's the analyst, analyst, great writer about analysis and a wonderful teacher, when our psychoanalytic society in San Diego heard about the fact that I had done something with Glenn Gabbard, they immediately wanted me to come to one of their meetings and talk about it, give a presentation about Glenn Gabbard and what we learned about suicide prevention, and I said fine, but what I'd really like to do is have a panel of the psychoanalysts who were in the psychoanalytic society also present their own experiences of dealing with suicide, and the person who invited me, who was the president of the society at the time, said oh no, we can't do that, there's no way anyone would volunteer for something like that, it would ruin their reputation, they'd never get another patient, and so I agreed anyway, and instead of having them join me in a panel, I showed Glenn Gabbard's video of his patient's suicide, and after that about eight minute video, I couldn't give the rest of my presentation because there was non-stop interaction with people getting up to talk about their experiences, to talk about how much they got out of this and how much they gained from it, so you know, starting the conversation was critical, so it's a, we're proud of this collateral damages, and I'm going to show you an example of it, and this is Jim Lomax, who was at that time the vice chair for education at Baylor, talking about his own experience. First patient was someone I saw about two and a half years after I'd finished my residency, she was referred to me by the senior faculty member at our private not-for-profit hospital after her third inpatient stay for recurrent major depression. During that last hospitalization, in addition to the depression, she revealed for the first time that she had had a sexual molestation by her father during her childhood, and that helped us to understand the pronicity and treatment resistance of her depression, but also indicated that more than just pharmacotherapy was going to be necessary for her, eventually coming to some helpful resolution. So I began to see her shortly after her discharge, and worked on both pharmacotherapy and psychotherapy for this complicated, severe recurrent depression. At that time, the treatment with antidepressants was a lot less well-defined, and usually a shorter duration than it has subsequently become. And a few months after we started to work together, her depression symptoms had gone, and she was beginning to feel much brighter in a variety of ways. And the last time I saw her, she was actually talking about reducing the antidepressant medication because of its mostly anticholinergic side effects at the time. The very last time I saw her, as she was leaving the session, she smiled and twirled around in a kind of a cheery voice, said, how do you like my new dress? And that kind of caught me off guard. She had been very cautious and circumspect about most everything we had talked about, even though we had been doing what she and I both thought were relatively good work. I probably mumbled something about this is something important we ought to talk about the next time we get together, and she left the session after that. About two hours later, after she left, I got a call from her in my office while I was seeing another patient. I accepted the call because my secretary said that she sounded worried. The patient did, and she had told me at that time that she had taken an overdose. Well, I had never thought about what I was going to do in a circumstance like this, so I asked her if she thought she could call the ambulance to come to her house. She said she could, and I arranged with my secretary to call my patient's husband at his place of work. I knew she was the mother of two young kids, six and eight years old, and I was worried about them and was trying to get as much help there as quickly as possible, and this was before a 911 system was available in Houston. I kept working that afternoon, and a bit later I got a call from the emergency room where she had been taken, saying that she had apparently tried to make herself vomit up the medicines, but it aspirated instead, and she was going to be referred to an intensive care unit in our medical center. I just felt awful at the time. I was worried about what had happened, about what I had missed, the uneasiness with the way in which she and I had ended that last session, and I absolutely dreaded going to the intensive care unit where she was, and for a while the news just got worse. When I talked to the internist who was taking care of her, he told me that she was essentially brain dead, and shortly after that, over the next 12 or so hours, she became a multi-organ donor for various people at the time. At the intensive care unit, I met her mother, who had not met before, and her husband, and talked with them some, and began a kind of an alliance with the mother. I learned more detail about something my patient had told me about, and things kind of became a little bit more coherent, in that her mother had made a serious suicide attempt, too, having shot herself through the roof of the mouth, and leaving herself blinded when the news of my patient's relationship with her father, her mother's husband at the time, became evident. Over the next couple of weeks, after my patient died and the organ transplantations were arranged, I helped my patient's kids be seen by a child and adolescent psychiatrist, and met with her mother a couple of more times. My patient's father also came to the intensive care unit, but I did not ever speak to him. During the time that I met with my patient's mother, she told me a bit more about the experiences of the very turbulent childhood my patient had experienced, and I mostly listened to her telling me about the amount of guilt she had about becoming a model for her daughter's suicide. I felt pretty uncomfortable about my role in that, too, because it seemed to me that my awkwardness at our last session and parting probably complicated my patient's sense of guilt and responsibility for her exploitation by her father. Of course, those are things that I'll never really know about, and neither will my patient's mother. I also got a call not too long after this happened from the senior faculty member in our department who had referred the patient to me. He was actually quite supportive and told me about a very high-visibility suicide that he had had as a resident in another state. He tried to tell me that this was part of a sort of an occupational hazard of psychiatrists in a way, which I guess is theoretically true, but the abstract truth of that did not help very much the things I was feeling at the time. So the hallmark of the collateral damages is several people giving their accounts like this. I chose Jim's because he was hoping he'd be at the APA this year, and if he was, he would be here and comment on it, but it also really illustrates a lot of the common threads that we see in all these cases. One, the last 30 seconds of a session, usually often the most important part, it's not, you know, say, time is up, see you next week. After he said time is up, she stood at the door and said, I like my new dress, and like any of us, he had no idea how do you respond to that other than, well, we can talk about it next time, and he's still haunted by that, you know, 40, 50 years later, wondering what he could or should have said differently that might not have, in his mind, resulted in her 10 minutes later overdosing, and that's typical of the way we often feel about these kind of events, and in the collateral damages, there's a discussion where we all get together and talk about, you know, how do you deal with family, you know, all sorts of the issues that come up around this, but also Glenn Gabbard talks a little bit about summing up the commonalities of all the cases, and one of the commonalities is something that Dr. Gabbard calls the triangle of compulsion, which is part and parcel of our personality, that most of us have a heightened sense of doubt, capacity for guilt, an exaggerated sense of our responsibility, all of those ingredients can be quite healthy and quite adaptive and help us to learn from our errors and read and keep going, but when left unchecked, they can really become very maladaptive and get in the way and, you know, create difficulties relaxing, difficulties cutting back, difficulties taking vacations, a heightened sense of responsibility for what we do, a hypertrophied guilt feelings that interfere with the healthy pursuit of happiness, and this, you know, several of the people in the video, including Jim, after their experience with a patient suicide, ended up getting in therapy and dealing with some of these issues and found it very, very helpful. Gabbard also talks about the fact that we as psychiatrists often feel that that we can take on the angel of death and outwrestle her and beat her to it. Our oncology colleagues don't have that fantasy. They recognize that death is part of life, their patients are going to die, and they're dealing with terminal illnesses. We tend to think that we can solve the problem if we're only good enough and strong enough and know enough that suicides won't exist and take a disproportionate amount of blame on ourselves and don't provide ourselves the self-compassion that we would provide other people. So the third way of, I think, dealing with issues of second victim syndrome is supporting each other and starting a physician peer support program in whatever program you're in or institution you're in or partnership you're in. We're just starting one here at UCSD and, you know, there is good data that professionals don't want to go to professionals for mental health care and they would prefer, if they can, to see other physicians to talk about what's going on, especially physicians who have been there and done that. So a peer support program is one way to get that started, especially if a peer supporter knows resources and can ultimately make referrals to mental health care when it's appropriate. So that would be, I think, a third way of trying to combat and minimize the second victim syndrome in psychiatry, and I'm going to skip this because of time, but all three of those techniques or maneuvers, you know, the proactive planning, the save committee, collateral damages, peer support, all really are ways of enhancing our ability to talk together. Talk helps and we're stronger together. Second thing, area of distress to talk about, is burnout. We all know what that is and I'm not going to spend time trying to define it. Many of us have felt it, have gone through it, have dealt with it, and hopefully come out on the other end. This is data from 2024 Medscape survey of thousands of physicians from all specialties looking at the prevalence of burnout, and we see the top of the list are emergency medicine physicians who are really stressed and beleaguered these days. 63% met the criteria for burnout. In this it was, you know, are you feeling burnt out most of the time? That was the criteria. And at the top of the list are some of the primary care specialties that deal with acute patients like emergency medicine, OB-GYN, pediatrics, family medicine, etc. Psychiatry is towards the bottom. Good news that we are one of the least burnt out specialties, but before we take too much relief in that, we're still, 39% of us, feeling burnt out in the last two weeks. So despite the fact that we may be better off than our emergency room colleagues in this regard, we're still struggling way more than is ideal. There's been an increase in burnout, especially after COVID, and an increase, especially true in women physicians, and all surveys of burnout show women physicians tend to be, have higher rates of burnout than male physicians. And we could spend the rest of the hour talking about why, but I think it's, a lot of it is fairly obvious. This is data from UCSD, from our HERE program, where we have a questionnaire that we ask all of our faculty, physicians, trainees to take at least once a year, showing, and this was, you know, kind of burnout levels in the two years before COVID versus in the two years right after COVID, and we found a pretty significant increase in burnout. And that's been true nationally, internationally as well, that burnout has been increasing. This is some of the things from the Medscape survey that physicians say about burnout. I barely spend enough time with most patients, just running from one to the next, and then after work, I spend hours documenting, charting, dealing with reports. I feel like an overpaid clerk, something that, again, many of us can identify with. Where's the relationships with patients that used to make this worthwhile? Everyone's in a foul mood. Staff calls in sick. We're all running around trying to find things and get things done. It seems to never end. Home is as busy and chaotic as work. I never relax. So these are some of the comments about burnout that, again, many of us can relate to these sentiments. What contributes most to psychiatrist burnout? So in the Medscape, the Medscape did a survey of psychiatrists looking at what is it in your practice that leads to burnout. At the top of the list, it's too many bureaucratic tasks, like charting, like paperwork, like pre-authorizations for care, like calling the pharmacist to argue with them about ordering something for your patient, etc. 68% of people said that that really contributed to their burnout. For me, EHR, electronic medical records, was the main culprit, and still is, and makes clinical practice less pleasurable for me than it ever was before when my notes used to be status quo, or getting better, or getting worse. That was enough, and it's not that way anymore. So documentitis, bureaucratitis, and all the trainings one has to do to maintain your license or privileges, have really gotten in the way. So how do we minimize burnout? Well, we can, from the top down, institutions, departments, programs, need to implement and support wellness-enhancing interventions, and that's where most of it's at. But we're not helpless as individuals, and there are things we can do for ourselves as well to promote self-care activities, enhance our resilience, and decrease or prevent burnout. So, and I won't go into this in detail, this comes from the Surgeon General's report on burnout last year, looking at all of the institutional and health care and governmental ways that need to take place to reduce burnout, including for licensing issues to, you know, not ask about whether you've had psychiatric treatment as a way of a red flag for getting your license, and you know, including health care organizations and medical care for all, etc. And basically what the Surgeon General's report said, it all has to come from a really strong trust in our leaders looking out for us and prioritizing our health as well, and making mental health accessible, and minimizing some of that documentitis that we're all troubled by. And the summary is shifting burnout from a me problem to a we problem. So the institutions really need to come forward with us, but also there's a recognition that the culture of medicine is a major culprit here, and we're now starting to talk more and more of the culture. The culture of medicine that we've all inherited, that's been ongoing for over a hundred years now, is that who needs sleep, who needs to take time out for lunch, eat and drink when you can, exercise if and when you can. I can always do more, I can get it done, I have to be perfect or it's a personal failure. I can't tell anyone if I have any doubts or vulnerabilities, what will they think of me, it'll ruin my reputation, they'll think I'm weak. If I just keep working harder and harder, everything will be okay, and I can never say no. That's the culture of medicine we've inherited, and pretty much the culture that was institutionalized in the Declaration of Geneva, adopted in 1948, which states the health and well-being of my patient will be my first consideration. Well, if that's your first consideration, where's your family, where's yourself? So there is emerging in the last few years a culture clash, the culture of resilience and wellness, which is very different, which says we all need adequate time for sleep, we all need hobbies, we all owe it to our families to spend time with them. In order to be the best you can be and take the best care of your patients, you need to take care of yourself. It's good to ask for advice when you need it, it's good for you and your patients. Trying to have everything under rigid control is not good for me or anyone else. So this is the new culture that we are teaching our med students and residents, and they're buying into it, but most of us are lagging behind, and there's clashes in residency program because they're expecting the culture of wellness that we're talking about to really be institutionalized, and we're a little bit slow to get there. So that's a clash that we need to continue working on and dialoguing with. The Declaration has been shifted as of 2017 to now state I will attend to my own health, well-being, and abilities in order to provide the best care of the highest standard. We're better together, all right. So you can target burnout from starting, you know, with medical students, pass-fail systems that a lot of schools are starting institute, taking some of the pressure off of exams and grades, fewer quizzes, having clinical experiences earlier on. When many of us went to med school, you didn't see a patient until your third year. Now they're integrating it into the first year more and more, and that's been very successful in diminishing burnout. At residency programs, having wellness champions, having more electives, not being bogged down by ACGME requirements of so many months of this and so many hours of this, but rather individualizing and prioritizing residents' passions and interests in the training by providing way more electives than we've traditionally done, by having outpatients introduced earlier in the program, and reducing call-and-flow burden, which I think we haven't gone far enough when I'm going to come back to that in a little bit. At the faculty level and practice level is more administrative support, scribes, focus on valued activities and community, and peer support as I mentioned earlier. And for all of us, creating this culture that prioritizes our emotional well-being and mental health, respect, community, time for valued and fulfilling activities in addition to caring for patients. So what can we do for ourselves in the meanwhile while we're waiting for the institutions to come forward? Well, realistic recognition. Recognize that we're human, we're vulnerable, we need to take care of ourselves. That's the first step. Have an inner circle of one to three trusted individuals with whom you can safely disclose concerns. For me, that's always been critical. When I started my career at the University of Houston, Rich Duvall was my best friend there and another psychiatrist starting his career in consult liaison psychiatry. We started every morning playing racquetball at 6 in the morning and we had lunch together and we talked about our patients and our struggles together. When I went to California, Steve Schuchter, same exact role, playing racquetball again but at lunchtime instead of 6 in the morning. And having at least one person, Christine was that person for a while when she was at UCSD, that you can confide in, that can confide in you, for me has been an absolute critical part of maintaining my well-being and minimizing, if not actually preventing burnout. Consider mindfulness courses, support groups, reading groups, other groups, reaching out to others, advocating for others that help us feel better, prioritizing our self-care and our needs by connecting, exercising, having a hobby outside of medicine. I do better at, this is what I say, not what I do. Medicine's my hobby and that's why I can't conceive of retiring. I hope you all do better and find a hobby outside of medicine. And finally, identifying and prioritizing your values, thinking about what's important to you and making sure you have time in your life for that. And this is just a little cartoon snip of prioritizing values if it works. There's a well-known story about a university professor who wanted to make a point about how we make the most of our time. The professor stood before his class with some items in front of him. When the class began, without speaking, he picked up a large empty jar and proceeded to fill it with rocks about two inches in diameter. He then asked the students if the jar was full. They agreed that it was full. So the professor then picked up a box of pebbles and poured them into the jar. He shook the jar lightly and watched as the pebbles rolled into the open areas between the rocks. The professor then asked the students again if the jar was full. They chuckled and agree that it was indeed full this time. The professor picked up a box of sand and poured it into the jar. The sand filled the remaining open areas of the jar. Now, said the professor, I want you to recognize that this jar signifies your life. The rocks are the truly important things, such as family, health and relationships. If all else was lost and only the rocks remained, your life would still be meaningful. The pebbles are the other things that matter in your life, such as work or school. The sand signifies the remaining small stuff and material possessions. If you were to put sand into the jar first, there is no room for the rocks or the pebbles. The same can be applied to your lives. If you spend all your time and energy on the small stuff, you will never have room for the things that are truly important. Pay attention to the things in life that are critical to your happiness and well-being. Take time to look after your health, play with your children, go for a run, write a letter to your grandmother. There will always be time to go to work, clean the house or watch TV. Take care of the rocks first. The things that really matter set your priorities. The rest is just pebbles and sand. So the critical thing here is pay attention to what your own rocks are and they may be very different for different people, but if you walk into almost any cemetery in the world, you don't see on the headstones how many papers someone wrote, how much money they made, how many patients they saw. You see, you know, beloved father, beloved son, beloved daughter, etc. They're really important things that stand out and I think prioritizing those important things for ourselves is really critical for our well-being. So, third topic, moving along from second victim through burnout to depression. Okay, don't have to define depression to anyone in this room. It's a highly prevalent disorder, no less so in physicians than in anyone else. Some surveys say maybe more so, probably about the same. A source of great misery and dysfunction. Often depression is chronic and if it's not chronic, recurrent. It comes back. You don't just get depressed and get over it again and you're fine for the rest of your life. It's certainly a risk for suicide, perhaps the most actionable risk for suicide, but if it's ignored or misidentified, sometimes as burnout, it's a missed opportunity. Okay, this is just a quote from William Styron who wrote so eloquently about his own depression. The pain is unrelenting. One does not abandon, even briefly, one's bed of nails, but is attached to it wherever one goes. So, we did a little study on some, you know, data at UCSD looking at how many people met our criteria for burnout, which was basically like the Medscape one. You know, are you feeling burnt out most of the time for the last couple of weeks, and met criteria for depression based on a PHQ score of 10 or greater, which is moderate to more severe depression. And we found that only one-third of the faculty and physicians and trainees at UCSD had no burnout or depression. Two-thirds had one or the other or both. More people had burnout than depression. Sometimes if you had burnout, you didn't have depression, but almost always if you had depression, you also met criteria for burnout, because depression affects everything you do, including your satisfaction at work and your performance at work. So, if you were depressed, you almost invariably also met criteria for burnout, which is a problem because burnout carries no stigma, and people can say, oh, I'm burnt out, I'm not depressed, and miss the opportunity for treatment. We looked at some of the associated features. So, the blue columns on the far left represent people who had neither burnout nor depression, that lucky one-third. The green bars are people who met criteria for burnout alone, not depression. The gray bars on that are people who met criteria for depression, but not burnout. And the red bars are both, depression and burnout. And what you can see in terms of anxiety, intense loneliness, hopelessness, despair, suicidal ideation, that the gray bars and the reddish bars are about the same. That if you're depressed, you are really impaired with anxiety, with loneliness, with hopelessness, despair, and high suicidal ideation, just about as much as you have burnout and depression. So, depression carries the weight there. If you have burnout without depression, you have considerably less of all of these. So, depression, burnout's not innocuous, it's not innocent, we all want to stamp it out, doesn't feel good, but it doesn't carry the weight of depression. So, if we miss depression, because we're mis-focusing on the burnout, it can have dire consequences. So, how do you differentiate? Well, burnout's a response to chronic stress, major depression may or may not be triggered by a stressful life event, like job stress, in a vulnerable person. Burnout manifests primarily in the workplace, when you go home, when you're on vacation, when you're in another setting, you tend to feel better. Whereas, major depression tends to be very persistent and pervasive, it's there with you all the time, it affects everything you do, all of your relationships, etc. Burnout may include feelings of sadness and depletion, so that's why there's this overlap and why it can be misidentified, because it has some of the symptoms of depression, but some of the other symptoms of depression, like morbid feelings of worthlessness, psychomotor changes, suicidal thoughts and actions, tend to not be part of burnout, unless that burnout also is accompanied with depression. So they would be red flags to look further than burnout. Burnout usually responds to distraction, rest, exercise, companionship, time away from work. Major depression may temporarily respond to any of those, but not in a sustained way. No stigma attached to burnout. Lots of stigma attached to depression, including among psychiatrists. And no evidence that antidepressants are of any help whatsoever for burnout, whereas an individual with depression may respond to antidepressant medications or psychotherapy. And so there are marked differences, but even more important than trying to differentiate someone who's feeling sad and depleted, is this burnout or is this depression, is the recognition that in somebody who's undergoing job stress and has the manifestations of burnout, there may also be a hidden depression that requires our attention. So they often coexist. Important to recognize depression, even in the context of job stress and burnout, or missed opportunities. So the Medscape survey asked people, why have you not gotten help for your depression when you're depressed? Because most physicians who are depressed don't get help for it. And all of the most common reasons relate to stigma. 51% because depression says something negative about me. 42%, I worry people will think less of my professional abilities. I worry people will think less of me. I fear for the medical board, or my employer might find out. I look at depression as a weakness. So those are the common reasons people don't get help. Other reasons people don't get help is we're not very accessible. And a lot of us don't take insurance, and people wanna use insurance. And even people who do take insurance have wait lists miles long, which isn't always very accommodating to someone who's struggling with a major depressive disorder or even suicidal ideation. There's a couple of studies I wanna quickly mention dealing with depression in residency. And there are not a lot of residents here in the room, but it applies, I think, to all of us. So a 2015 review of 31 studies almost 10,000 individuals looked at depression during residency and found a prevalence rate of about 20% based on the PHQ score of 10 or more. That's pretty high. One in five residents meet these criteria for depression in all specialties. The increase, when they start the residency, they're actually not depressed. Very few are depressed. Most of them are feeling as good as they ever felt because they're finally getting into the specialty they've been honing for. There are many getting into the program they wanted. And the rates are low, but within the first few months, the rates skyrocket, go way up quickly. I think probably after the first night of call, but maybe that's just me thinking about how obnoxious call can be. The other study, which is just a beautiful study, Srijan Sen and his colleagues at the University of Michigan have been doing this for years now, was a 2021 review of over 16,000 first-year residents who started their training beginning in 2007, and he's been doing it yearly since, and this was dated through 2019. And what they found was that over this time, baseline depressive symptoms measured from before the start of internship had actually increased over time, which is pretty consistent with community norms. Depression seems to be creeping up. And so starting the internship, which means they're more vulnerable. There are more women going into medicine and they're more depressed starting their internship, which means they're more likely to be vulnerable to increases in depression during internship. But what they found was that the development of depressive symptoms associated with internship or worsening of depression associated with internship actually decreased substantially over time from 2007 to 2016. So they asked why. And there was a very direct correlation between the decrease in depression during internship, despite the heightened risk factors that were related to the new ACGME rules about the workload, about duty hours, about prioritizing sleep for residents. And there was a direct relationship between decreased work hours, increased sleep, and increased treatment for mental health problems with less depression. In fact, the percentage of individuals who were in treatment for depression increased from 9% in 2007 to 24% in 2017. So major increase, but only to 24%. And this is a graphic of the relationship between the number of work hours horizontally and changes in depression scores during internship. You see, the more hours you work, it goes exponentially up. In this particular study, the mean number of work hours was 63, so that even after these guidelines trying to make residency more palatable with life, we're still demanding our residents to work at least 63 hours a week. And that doesn't count the reading time at home and the preparation, et cetera. At baseline, interns' median PHQ score was two points, so that was low, but went up in direct proportion to the amount of work hours. At a level of more than 90 work hours, 33% met criteria for depression. So food for thought. So if decreased work hours and increased sleep lead to less depression during internship, and the data's strong that it does, would even fewer work hours and more optimal sleep dramatically drive mental health improvements further? And if the answer is yes, why aren't we doing it? Why are we still having these outlandish schedules for call and for float when we know that it's not healthy? So I think that's food for thought. The other food for thought, dramatic changes in the utilization of mental health services during this time were associated with reduced depression. But only a quarter of those people who were depressed were in treatment. So if we made that one in four into three in four, would we be doing even much better? And of course we would. So we've gotta do something about stigma, we've gotta do something about access to care. That's a segue to the next section. This is a quote from a medical student about one of the ways of reducing stigma is sharing our stories, again, talking with each other. This was his quote. We need open forum discussions about depression and suicide that include personal testimonials from students and physicians. We need to share our experiences in person, in writing, over social media. Collectively, we must accept our human vulnerability and thereby foster connection. Openness is our liberation, let us speak. So now I wanna show an example of a physician. This was a medical student at the time at the University of Michigan talking about her own depression and the effects it's had on her and others. And although medical student, I think what she's talking about is very applicable to all of us at all of our stages. It's no secret that medical school is challenging. You have a lot less ownership over your time. You have a lot of demands on you intellectually, academically, logistically. After about a year, year and a half, the constant sleep deprivation and the constant demands really just began to wear on me. I had really lost touch with the things that were the most important to me, the things that I valued the most about myself. My intellectual curiosity, my interest in helping other people and really my will to live. The rate of depression, anxiety, and even suicidal feelings are incredibly high among residents at Michigan and medical students around the country. I just was so frustrated and so down on myself and so unsure of my ability to be successful. I've never had thoughts like this before. Just kind of these like intrusive thoughts of, it would be better if I just stepped into the street right now and a car ran me over. People fail to recognize their colleagues who are suffering. And what made the difference here is that people were attuned to the issue of depression and suicidality in medical trainees. Because they were attuned to it, they were able to recognize what I was going through. Three different levels, down three counts. Go down two, three, up four. What I had was one person in a position of power recognizing that I wasn't lazy or weak or fragile, that I was sick. I pride myself in being a work hard, play hard, resilient person. She said, Rahal, would you consider seeing a psychiatrist? In the fragile state that I was in, I recognized that she had a point. I do not exaggerate when I say it saved my life. It was a very gradual process of getting better from over six months to a year. I took medication, I took time off school. And yeah, I do see my psychiatrist. I make time for things in the interest of my mental health. There was a resident in the fall who committed suicide at our school. I couldn't get out of it. I couldn't get over how that could have been me. I wrote an essay about my own struggle with depression and suicidality while in medical school and published it in the journal of the American Medical Association. We had an instinct initially to push back and say, have you thought about how this will affect your career and how other people view you? But quickly, you know, came to realize that that was sort of the point and that she's willing to sort of take that risk for all the good it would do for other people. As an aspiring doctor. As a doctor. I may be committing professional self-sabotage. By telling my story. But the tears of my colleagues. The tales of deferred suicide attempts. My colleagues have confided. In the tragic deaths of bright minds. Here and around the country. Lend strength to my determination. To say, me too. I've received like hundreds of letters from around the world. Once Rahael and her cohort are the ones running medicine, I'm confident that the stigma will be gone. I needed to put energy into showing people that it's okay to be vulnerable and that I had had this experience and that there were many other people that were suffering and that it didn't have to be that way. Wrong number, but. I need a. So let me. I'm gonna fairly quickly go through the next segment which is physician suicide just because we're running out of time. But suicide is real. It's not going away. This is just data showing how it's actually increasing here in the United States. And there are certain populations that are particularly vulnerable. Non-Hispanic American Indian, Alaskan Native people. Non-Hispanic white people following veterans. People who live in rural areas. People working in certain industries and occupations like mining, construction, farming, healthcare. And young people who identify as gay, lesbian, transsexual, et cetera. What leads to suicide, and this comes directly from the AFSP, the American Foundation for Suicide Prevention. There's no single cause. It's complex and most often occurs when stressors and health issues converge to create an experience of unendurable psychic pain, hopelessness, and despair. The person at that suicidal moment feels like they have no choice. There's nothing else they can do to escape this unendurable pain. Conditions, depression is the most common actionable condition that often underlies suicide and suicide attempts. An estimated 400 physicians die by suicide in the United States each year. That's the equivalent of three graduating classes of residents, of medical students. Three graduating classes each year in the United States alone die by suicide. And I think, and I bet Christine would agree, that that's a gross underestimate because so many people die and we don't know about it and it's hidden. But at least this many. Physician suicide in some ways a little bit different than others and this comes from studies kind of looking at people after they've died by suicide and gathering as much information as they can. More common in female physicians and in the general population of females. So suicide probably is no more common in male physicians than other males. Female physicians, relative to other females, very high risk. It's true for nurses as well, especially female nurses compared to other females. It's the leading cause of death amongst male residents. The second leading cause of death amongst female residents. Cancers are a more common cause of death amongst females even in those years. More likely to have job problems than other non-physicians who died by suicide. So that's a warning. Let's take burnout very seriously. Burnout may or may not be associated with suicide on its own, but work stress is more common in people who have died by suicide than in other populations. So we've got to do a better job of minimizing work stress and making medicine the calling and profession it was meant to be that's satisfying and enduring and that we can really thrive in. Higher proportion of physician suicides are by overdose compared to others than the general population. And depression is as significant a risk factor as among non-physicians. But strikingly, physicians who took their lives are no more likely to be receiving mental health care than others. Despite our knowledge, despite our resources, despite our good insurance, despite our colleagues in psychiatry, we're no more likely to be getting care than others. So the major barriers need to be addressed. Diagnosis and treatment due to stigma and dire consequences of coming forward that people fear. We can't predict suicide, but we can sometimes prevent it by identifying those at risk, providing support, connection, hope, removing barriers to care, improving access to care, delivering evidence-based treatment for associated conditions, and employing evidence-based treatments for suicide prevention as well. The American Hospital Association came out with a beautiful, I think, a pamphlet on suicide prevention and evidence-based interventions, and they really honed down the triggers for suicide into stigma, excess, and job stressors. And that's the segue to the program Christine and I started at UCSD in 2009, which is meant to really address stigma, increase access to care, and address job stressors in various ways. And because of time, I was gonna go into details on all of these. I'm not gonna do that. But it's a program that is readily available to any institution, any medical school, any residency program. And in fact, many of them have instituted it. The VA has access to this program. The part of what the program is uses the American Foundation for Suicide Prevention Interactive Screening Program, where individuals are screened for risk, and those who are screened at high or even moderate risk, we reach out to. We reach out to non-pejoratively, non-judgmentally, supportively with counselors who try to engage them in further dialogue, and when appropriate, make referrals. And we have a cadre of individuals who are available who will accept our referrals, accept the insurance of our house staff, of our faculty, of the staff, et cetera. And it's worked out very, very well. The ISP alone, that Interactive Screening Program, is not enough because not everyone takes it. Even some who do don't respond to it, don't go back and speak with the counselors. So through the years, we've added more and more components like free, no cost, no EHR psychotherapy for residents. We have added where new residents coming into specialties like internal medicine, we actually give them appointments that they can cancel out of if they want, but we give them appointments with our counselors from the program to just talk about how are things are going, what can we do for you, let them know about resources and make that connection. That's been very successful, very popular, and has led to lots of referrals for people for mental health care. So I'm not gonna go into the rest of this in detail because we don't have time. I'll just read one of the quotes from one of the persons early on. I was at a fork in the road that could lead to two dramatically different paths. You helped me pick the longer one, if you know what I mean. We get quotes from people who have participated in this program called the HERE Program, Healer Education Assessment and Referral Program that are extraordinarily gratifying and make us keep going with this. And again, it's a program that we're happy to help any institution or individual bring to their own programs. So final comments. We owe it to our patients, our students, our colleagues, our loved ones, and ourselves to care for our emotional and mental needs. We also need to look out for our colleagues. Targets to enhance physician well-being and health and reduce physician burnout and suicide include primarily the culture of medicine itself and continuing to bring the culture of wellness to the culture that we've inherited, the culture of professionalism, reduce stigma, increase access to care, and continue to deal with work-related stressors for residents by decreasing work hours, by increasing the ability to sleep and have the kind of activities that they're passionate about and went into medicine for in the first place. Together, we can shift the culture, reduce stigma, increase access, and manage work-related stressors. And I apologize for going longer than I intended, but we do have time for your comments, thoughts, Q&A. Before we get to that, before we get to the questions, thank you, Dr. Zizek, for your lecture. This is the Vestermark Psychiatry Educator Award Lecture, and just gonna tell you a little bit about the award. It recognizes excellence, leadership, and creativity in the field of psychiatric education and is given annually, well, not quite true because it's not always awarded, to a psychiatric educator for outstanding contributions to the education and development of psychiatrists. The award was established in 1969 in memory of Seymour Vestermark, MD, Chief of the National Institute of Mental Health Training Branch from 1948 to 1959, and an authority in the field of professional mental health education. The award concentrates on the field of psychiatric education in its broadest context with special emphasis on preparation of teachers, use of new educational tools, and improved teaching techniques in the field of mental health. And we are proud to award the Vestermark Psychiatry Educator Award, of course, to Dr. Sidney Zizek. Thank you so much. And now we can do Q&A. Congratulations on your award. Thank you. I think what I would like to say is that the talk emphasizes the importance of taking care of the individual, and which is what the title of your topic was. I think the emphasis is taking care of the individual. What I would like to suggest that we add to this is how to help prepare our individual doctors, learn to take care of the system, or how to heal the system. There are four things that constitute our system. Medical knowledge, the practitioners, the processes, and the organization. And we are not preparing our students enough to take care of those broken processes and the broken system. And it's like saying to a seed, let's make better seeds, but not looking at the soil. I think it goes back to your collateral damage slide, that sense of doubt, guilt, and enhanced sense of responsibility. You're placing all that on, you need to get stronger, you need to get better, and not really emphasizing what we need to do to take care of the system. And even in your job stressors, all the six solutions that you have pointed out are all taking care of the person and not the system. So I would like to say that that needs to be an added emphasis, especially by leaders. And it's a really important thing to consider. So 100% agree with you, absolutely. I think we don't have to be passive and not take care of ourselves at the same time. But the work's got to be done at the organizational level, institutional level, government level. And to the extent that we can influence them and push them and advocate for what we need, we're going to make that move faster. And it's happening. And all of the institutions are really starting to address it. It is getting better, but there's still a lot of work to be done, miles to go before we sleep. Thank you. Thank you for a wonderful talk and for using your platform with the award to address this super important topic early in the conference. David Young, Nashville, Tennessee, VA. So my question for you is about one specific, very generalized aspect of psychiatry work. And that is time that we get with patients. I think that we would all widely agree that in mental health, we need a bit more time with patients for our evaluations compared to a lot of other medical specialties. And yet, it seems like a lot of colleagues, especially maybe outside psychiatry, may not recognize that. Insurance companies may not be recognizing that. What kind of comments would you have on really just trying to reform systems so that we can have the time with patients that we need, so that they can feel like they can tell their stories and not feel like their doctors are so rushed? Yeah, it's a great point. I wish I had an answer, because that's one of those things that the institution, that's getting worse. That's not getting better. And people who are working for universities, for health care systems, for Kaiser, wherever it is, a psychiatrist, they're getting less hours, less time with patients, more turnover, less ability to do psychotherapy with patients. And as individuals, I think we need to keep pushing. We've had more graduates of our program in recent years going to practice where they're doing psychotherapy, where they're seeing people for an hour at a time. I just had dinner with three of our former residents last week, and they're doing it. But in order to do that, they've not allied with any of the groups in town, and they don't take insurance. So they're only available for the wealthy. And so some of the wealthy in San Diego are getting really good care and spending an hour at a time with their psychiatrist, and their psychiatrists are loving their practice. That's not good enough either, because that ought to be available to everybody. And we just need to keep pushing. In November, vote. That's something we can all do. My name is Guru Thapa. I'm a psychiatrist from the University of Arkansas for Medical Sciences, and I just retired. But in the last seven, eight years, I was the director of our campus wellness for medical students, other students, residents, faculty. So first of all, I wanted to say congratulations for all the work you've done. And I couldn't agree with you more with your presentation, being lived through that and being involved in that, the interactive screening program, and all the other stuff we've talked about. And also, as our other colleague mentioned about the institutional factors, when I first started this job, at that time, everybody was talking about burnout, burnout, burnout, meditate, you know. And pretty soon, we stopped talking about it, because really, the driving force was the institutional factors. And like you said, the good news is it's changing slowly, and not necessarily because they've all of a sudden had this wonderful change of heart. It costs the institutions a lot of money each time a physician leaves burnout. So I think this is a really important topic. So my question, really, is to Dr. Williams, you're the chair of the scientific committee, why did you put this meeting at eight o'clock in the morning? It's been 20. No. I think this is such an important thing. It's an award. And I think many of our residents and other psychiatrists really need to hear this. So, I thank you. Okay, that's fair. Okay, you're about to get a very boring response to that question. The dance of putting together all of the sessions with speakers like Dr. Zizek and others who are in so many different places at one time, and putting those together, it's a giant Jenga puzzle that only works so many ways. And unfortunately, we can't have everyone at ideal times. The puzzle just doesn't work that way. So I wish we could, we just can't. I know that you have to say that. Sure. Even I had difficulty. I had difficulty making it to my own eight o'clock session yesterday, so I understand. Me too. Do we have time for one more? We have time for maybe one or two more. Okay, and we have time for one or two more comments or questions or thoughts. Okay, one more question. You know, in talking about improving systems and processes, I got really heavily involved in learning about quality improvement and lean methodology. And just last year in my hospital, I studied what a social worker goes through in order to evaluate a patient. And what a patient goes through as they come through the intake office. And we were able to redesign our EMR in order to save one hour of social worker time per patient and eliminate all those wasteful steps they have to take. And I think that's a skill that more residents will enjoy. They will enjoy feeling empowered and they will enjoy changing systems for the better. So there's definitely more things that can be done to teach our students to take care of systems better. Yeah, I agree. The EHR could be fixed and could be made much more user-friendly. And it's been such a struggle. In my institution, every time they try to fix it, it seems to get worse or harder for people my age to at least take advantage of the effects. We're really lucky to have Dr. Moutier with us today, who again started the HEAR program with me at UCSD years ago. One of the joys of being an academician is training people who end up really contributing to the field. You mentioned you were at the University of Arkansas. The new chair there is a friend of Christine's, a former trainee of mine, now a chair of a major department. Christine is the medical director of the American Foundation for Suicide Prevention and is doing incredible work for all of us. So. Thank you, Sid. And my comment and my question is a bit more personal. So I came into residency training 29 years ago and was incredibly blessed to have you as my program director. I was someone who had, like many of us, had a complicated background, came in with incredible vulnerabilities. I'd already had to take a leave of absence from medical school, had disclosed that was for significant mental health reasons in my application. And I did that because I already had the signals that it was safe to do so only in your program, not necessarily where I had applied in other places around the nation. So I had this incredible blessing of starting out my training and my life as a psychiatrist in a culture that was shaped by your views. And I remember, year after year, being part of the residency selection process later on, that you actually view lived experience as a strength in the balance of things, and not only as a risk. And it carries through in all of the work that you've done and that we've been able to do together. I now have the privilege of working at AFSP and focusing on suicide for our nation. And that whole journey is in large part due to the platform and the culture that you had created there, and that you have created for so many of us at UCSD. I guess my question is, you're from a generation where this was not the norm, and it's still not really the norm, but things have changed tremendously. What set you up to be able to believe this so fully and to preach it against tide of other leaders and so forth at the time? First, thank you. Do we have a couple hours? One of the things that I was very fortunate in terms of my own mentors and education, I went to a medical school, Loyola Medical School in Chicago which really was unusual because it did value us as individuals and treated us well and listened to us. And that was a good starting point. In my residency, my mentor, Aaron Lazar, was a real mensch, some of you know what that is. Yet it's for a good person with a good heart. And in fact, the two areas that he really got well-known in, one was what he called the consumer approach to psychiatry, and that means listening to your patients and what they want, paying attention to them. And his second major contribution was on the appropriateness and strength of apology, of being able to say, I'm sorry, and being able to learn and grow from our mistakes. And so influences like that, I think were really, really impactful. And experiences in life, my parents, I owe a lot to them. But I mentioned the one-to-one with colleagues and having relationships throughout my career with individuals who shared values and we could grow together has been so important. And that continues to be a sustaining aspect of development, but thank you for the comments. And I wanna congratulate you on behalf of all of us. I agree, this lecture should have been, everyone here should have heard it. I thought it was fantastic. Thank you, Sid, and congratulations. Thank you again to Sid for your lecture.

Dr. Sid Zisook

UC San Diego

physician self-care

mental health

burnout prevention

HEAR program

Physician Peer Support

mental health stigma

depression

healthcare providers

systemic changes

Vestermark Psychiatry Educator Award