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

1. The Rising Tsunami of Residents with ADHD, Anxiety, Depression and Rage Ranjan Sudan, MD

2. 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

3. 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

4. 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)

5. Other related conditions • Dysthymia (lower grade depression) • Bipolar disorder (cycling of mood)

6. 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

7. Mental Health (past 12 months)

8. Diagnosed or treated by a professional (Top diagnosis in past 12 months)

9. 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

10. 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.

11. 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.

12. 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

13. ADHD • Trouble focusing • Act without thinking • Hyperactive • Estimated that 3% of medical students have ADHD

18. 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

19. Treatment • Behavioral interventions • Medications • Stimulants • Non-stimulants • Antidepressants

21. Medication misuse • Sharing of medications • Prescription of medications

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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 yourinstitutional and local resources Such as mental health professionals State licensing board rules PHPs Rehabilitation or treatment centers

29. 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

37. Mental Health issues in Health Professionals

38. Role of Program Director

39. Summary