South African Psychiatry - February 2019

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SASOP HEADLINE He completed his medical degree and psychiatry specialization at the University of KwaZulu-Natal and his PhD at Stellenbosch University. His research interests include schizophrenia, consultation-liaison psychiatry, health services and medical education. He is the Deputy Editor of the South African Journal of Psychiatry. 2.2 MEDICAL PRACTITIONERS AND EMPLOYEE WELLNESS Wellness, in particular mental wellness, of medical practitioners and students has attracted much media and other attention during the past year following, for example, successful and public suicides by prominent professionals and students on several campuses. Statistics are quoted which rate the suicide figure at 10,7 per 100 000 people for the South African general population as the 6 th highest in Africa. 1 AS FAR AS SUICIDE AND MEDICAL PRACTITIONERS ARE CONCERNED, A SYSTEMATIC REVIEW OF PUBLISHED STUDIES ON SUICIDE AMONG PHYSICIANS SHOWED THAT THESE PROFESSIONALS HAVE A 2.5 TIMES HIGHER CHANCE OF COMMITTING SUICIDE THAN THE GENERAL POPULATION (DAMASCENO, 2017). 2 Similarly, another meta-analysis on the topic reported elevated physician’s suicide ratios (higher for women) compared with the general population (Schernhammer, ES, 2004). 3 Details on suicide among US physicians in seven states included that having a known mental health disorder, or a job problem, contributed significantly to the increased risk of physicians successfully committing suicide (Gold et al., 2013). 4 In a cohort of about 20,000 doctors employed by the National Health Service of the UK who died between 1962 and 1979, the death rate from accidental poisoning involving prescription drugs (overdose) were significantly raised among male consultants (most apparent in obstetricians and gynaecologists), while the death rate from (self) injury and poisoning for female consultants, were largely a twofold excess of suicide (significantly raised for anaesthetists), Carpenter et al. (1997). 5 Sheikhmoonesi and Zarghami (2014) noted that some studies identified certain specialties such as psychiatry, anaesthesiology and dentistry as higher risk for physician suicide. 6 They also reported on risk factors/attributes in women physicians who had attempted suicide to include the history of depression, alcohol abuse or dependence, sexual abuse, domestic violence, poor current mental health and family history of psychiatric disorder. 8 Furthermore, those who suffer from obesity, chronic fatigue syndrome, worsening health, eating disorders, overworking, career displeasure, and job stressors have also been reported as high risk physicians. 8 Kõlves and De Leo reported on suicide in medical doctors and nurses compared to educational professionals in Queensland, Australia, and found that female medical doctors in this study had significantly higher suicide rates than educational professionals, similarly for nurse of both sexes. 7 Studies included in the mentioned systematic reviews also reported expressive levels of psychic suffering while concluding that suicide among physicians is associated with the exercise on their professional role in the society and workplace (Damasceno et al., 2017) and were calling for more information about suicide among health professionals. IN TERMS OF DEPRESSION, MAJOR DEPRESSIVE DISORDER AND OTHER MENTAL DISORDERS, SHEIKHMOONESI AND ZARGHAMI (2014) OBSERVED THAT THE LITERATURE ALSO SUGGESTS THAT PHYSICIANS WHO KILL THEMSELVES ARE MORE CRITICAL OF OTHERS AND OF THEMSELVES AND MORE LIKELY TO BLAME THEMSELVES FOR THEIR OWN ILLNESSES. Furthermore, there is some evidence that physicians do not welcome the idea of approaching colleagues for help, and instead utilize alcohol or drugs, while resorting to isolation. 8 Some of the “ten facts” about physician suicide and mental health listed by the American Foundation for Suicide Prevention (www. afsp.org) include that: (1) suicide is generally caused by the convergence of multiple risk factors, the most common being untreated or inadequately managed mental health conditions; (2) in cases where physicians died by suicide, depression is found to be a significant risk factor leading to their death at approximately the same rate as among non-physician suicide deaths; and (3) drivers of burnout include work load, work inefficiency, lack of autonomy and meaning in work, and work-home conflict Burnout per se, consisting of the three dimensions of emotional exhaustion, depersonalization and reduced professional accomplishment (Maslach et al., 2001), 8 does not constitute a clinical medical diagnosis, but nevertheless has a significant impact on sufferers, their work environment and productivity. Collier 10 and Dr Sandra Roman, advisor to the Quebec Physicians Health Program, both cited a 2012 study 10 which found that 45.8% of physicians in the US over time reported at least one symptom of burnout. Furthermore, burnout is a leading cause of medical 82 * SOUTH AFRICAN PSYCHIATRY ISSUE 18 2019
SASOP HEADLINE errors, as well as affecting the prescribing habits, test ordering and professionalism of doctors. 11 Selfawareness, is being identified by these authors, as an important factor to address the problem, referring to a useful tool in this regard, the Maslach Burnout Inventory, a self-administered questionnaire. 11, 12 In addition to the individual practitioners, who have to recognize their own vulnerabilities and possible risky coping mechanisms, strategies to intervene and alleviate the effects of burnout, include, on an organizational level, to acknowledge the existence of the problem, to develop targeted interventions and to promote resilience and self-care. ON A LEADERSHIP/MANAGERIAL LEVEL, IT INCLUDES TO REVIEW LEADERSHIP STYLES, TO RESPECT OPINIONS AND TO EMPOWER TEAM MEMBERS TO DO THEIR WORK AND ADVANCE IN THEIR CAREERS. 11 While, per regulations, cases of impaired physicians, medical interns and students have to be reported to the Health Committee of the local Health Professional Council of South Africa, this Committee clearly states its objectives with assistance to such professionals, including to: (1) establish mechanisms for the early detection of impairment; (2) undertake informal assessment of reports; (3) oversee the implementation of treatment programs of impaired professionals. In other words, to facilitate recovery, rehabilitation and reintegration of sufferers of mental and substance related conditions. 11 Dhai et al., and Knapp van Bogaert and Ogunbanjo earlier identified the scope of the problem and ethical challenges of the South African impaired physician. 12, 13 They alluded to the potential dilemma that fellow physicians may experience to report an impaired colleague and to weigh up the privacy of the practitioner and the safety of patients, while suggesting that early on during training, medical education should put more emphasis on doctors realizing their limitations and recognizing their humanity and fallibility. In the meantime the discussion on how to support colleagues in terms of peer review and relations have been started by some professional associations, for example, by the South African Medical Association (SAMA) and the South African Society of Psychiatrists (SASOP). This includes raising the awareness amongst medical practitioners that vigilance is required, while stigma (including self and professional stigma) should not be allowed to delay appropriate interventions when needed. The SAMA has started to address the issue by a series of articles in its “INSIDER” publication for members, where medical practitioners have spoken out on their own experience with depression and suicidal ideation and its impact on them as people and professionals. 14 The SAMA and SASOP are also considering the best strategies to de-stigmatise mental illness in the health care profession, to assist healthcare professionals dealing with mental illness and occupational, professional and personal difficulties, and to create an environment conducive to professional exchange and debate, networking and support. An important resource in this regard, seems to be a publication edited by Brower and Riba on this important topic of mental health and related problems among physicians, including trainees. The book, according to a review, “addresses the all-too-common human response of ‘suffering in silence’ and refusing to seek help for professional, (as well as) personal issues that have ramifications for physicians who work in safety-sensitive positions where clear-headed judgment and proper action can save lives”. 15 REFERENCES 1. https://www.iol.co.za/thepost/sas-suicide-rate- 6th-highest-in-africa-17065768; https://africacheck.org/reports/5facts-sadextent-suicide-south-africa/; http://www.702.co.za/articles/318667/onesuicide-every-hour-in-south-africa 2. Damasceno KS, de Sousa Barbosa E, Pimentel JVC, et al. Suicide among Physicians and Methodological Similarities of MEDLINE/ PubMED and BVS/BIREME Open Access Bibliographic Databases: A Systematic Review with Metanalysis. Health, 2017; 9: 352-375; DOI: 10.4236/health.2017.92025 February 23, 2017 3. Schernhammer ES & Colditz, GA. Suicide Rates Among Physicians: A Quantitative and Gender Assessment (Meta-Analysis). American Journal of Psychiatry. 2004; 161(12):@295-2302; Published Online: 1 Dec 2004; https://doi. org/10.1176/appi.ajp.161.12.2295 4. Gold KJ, Sen A, Schwenk TL. Details on suicide among US physicians: data from the National Violent Death Reporting System. Gen Hosp Psychiatry. 2013 Jan-Feb;35(1):45-9. doi: 10.1016/j.genhosppsych.2012.08.005. Epub 2012 Nov 2. 5. Carpenter LM, Swerdlow AJ, Fear NT. Mortality of doctors in different specialties: findings from a cohort of 20000 NHS hospital consultants. Occup Environ Med. 1997 Jun;54(6):388-95. 6. Sheikhmoonesi F, Zarghami M. Prevention of Physicians’ Suicide. Iran J Psychiatry Behav Sci. 2014 Summer; 8(2): 1–3. 7. Kõlves K, De Leo D. Suicide in medical doctors and nurses: an analysis of the Queensland Suicide Register. J Nerv Ment Dis. 2013 Nov;201(11):987- 90. doi: 10.1097/NMD.0000000000000047. SOUTH AFRICAN PSYCHIATRY ISSUE 18 2019 * 83
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ISSN 2409-5699 ABOUT the discipline
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South African Psychiatry - February 2019

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