Of all specialist physicians, those working in psychiatry are the least likely to report being burned out, according to the 2016 Medscape Lifestyle Report.1 At 40%, psychiatrists are 3% more chilled even than dermatologists. Highest in the burnout stakes are critical care physicians, with 55%. Cardiologists come in at 50% and oncologists 46%.
Burnout was somewhat more common among female than male psychiatrists (43% vs 36%) but the proportion of burned out women in the profession has in fact been falling since 2013, when the figure stood at 62%. Among men, there has been a slight increase over the same period.
Data on the severity of burnout show a pattern similar to that for frequency. On a scale of 1 to 7, where 1 means that burnout does not interfere with my life, and 7 means so burned out I’m thinking of quitting medicine, psychiatrists averaged 3.9, level with rheumatologists at the bottom of the table. Critical care doctors were again top of the league, with 4.7.
The top cause of burnout reported by psychiatrists – by a substantial margin – was too many bureaucratic tasks (rated 4.3 on a scale of 1-7, where 1 equals does not contribute at all, and 7 equals significantly contributes). A cluster of factors tied for second place: inability to provide patients with the quality of care that they need, insufficient income, too many hours at work, maintenance of certification, and increased computerisation all had scores of 3.4.
Difficult colleagues, staff and employers were ranked as relatively unimportant reasons for burnout (scores of 2.6-2.7).
Burnout is an aspect of physicians’ personal lives that could have a profound effect on the quality of patient care. So too is bias.
Specialists were asked whether they thought they were biased in relation to certain groups of patients. Forty-eight percent of psychiatrists admitted that they were. This put them towards the head of a table topped by emergency medicine (62%). Unsurprisingly, bias in relation to patients was thought to be a factor by only 10% of pathologists.
However, while 48% of psychiatrists admitted experiencing bias, only 11% said that bias affected the way they treated a patient - and this may have been either a positive or negative effect.
Psychiatrists rated intelligence, followed by language differences, as the patient characteristics most likely to trigger bias. Race and gender were the least likely factors.
The likelihood of self-reported bias decreased with age, being cited by 67% of respondents under the age of 35 but only 38% of those aged 56 to 65. Psychiatrists who reported burnout were more likely than their non-burned out colleagues to report bias. The likelihood of bias was not related to presence or absence of spiritual belief or to liberal/conservative political allegiance.
One potential source of bias not asked about in the Medscape survey was comorbid substance abuse. This important topic was the focus of a presentation at the 2015 meeting of the American Academy of Addiction Psychiatry.2
Bernadine Han (Weill Cornell Medical College, New York) reported that psychiatry residents had more negative attitudes towards patients with substance use disorder in addition to mental health problems than towards patients with schizophrenia or depression alone. The extent of this negativity increases over the course of training.
According to the Medscape survey, psychiatrists are among the happiest physician specialties outside work: 63% said they were extremely or very happy. This was also true of happiness at work (37% rating themselves as extremely or very happy). In both settings, male psychiatrists were more likely to be happy than their female counterparts.
Of all specialists, psychiatrists were the least likely to exercise twice a week (43%). Those most likely to exercise regularly were dermatologists (72%). Paradoxically, though, psychiatrists were among the specialists least likely to be overweight. Excessive weight was admitted to by 35% of psychiatrists compared to 51% of pulmonary physicians.
Over 15,800 physicians (representing 25 specialties) responded to the survey.
Compared against other specialist physicians, psychiatrists are less likely to suffer burnout but more likely to admit to bias towards or against certain groups of patients.
People suffering from mental illness need to know that they are worth it – to be empowered and have self-esteem. The 2016 EPA symposium on overcoming the stigma of mental illness updated us on work to tackle this pervasive problem.
While progress is evident and inspiring, we need much more. Prof Wolfgang Gaebel (Heinrich-Heine-University, Dusseldorf), and President of the EPA, reminded us that if we don’t do anything, nothing will be done, and things will stay the same.
‘The stigma of mental illness is still the main obstacle to the development of mental health services and a heavy burden for all touched by mental illness’ Prof Wolfgang Gaebel
Self-stigma is believing the stereotypic or stigmatising views about you are true. It reduces empowerment, self-esteem, self-efficacy. Both stigma and self-stigma impact quality of life. People avoid seeking help and get stuck in a hopeless situation. Empowerment – the sense of self-realisation – allows people to overcome their powerlessness and motivates them to pursue a better future.
There are a number of actions and strategies against different levels of stigma – social, institutional and self-stigma. These actions target knowledge, attitudes and discriminative behaviour. However, the evidence for effective anti-stigma interventions addressing people with mental health problems is scarce.
Prof Gaebel presented the first results from the STEM study. This is the first randomised controlled trial to test psycho-educational therapy addressing stigma-coping and empowerment in patients with depression and schizophrenia. The trial, carried out in different health care settings in Germany, involved two groups:
Intervention: regular psycho-education (8 sessions) and stigma-coping and empowerment (3 sessions plus 1 booster session).
Control: regular psycho-education (11 sessions plus 1 booster session).
The main endpoint was the long-term improvement of perceived quality of life (WHO-QOL) compared to the control group. More than 300 patients (65%) completed the 12-month follow-up. Three-quarters of the patients had depression, and a quarter had schizophrenia.
Overall, as well as in the depressed subgroup, there was no difference between the intervention and control arms in WHO-QOL at 12 months. In the schizophrenia group, there was in fact a non-significantly higher WHO-QOL among controls. These results are surprising.
The statistical analysis is still in progress and no definitive conclusions have been drawn.
Possible reasons for lack of effect may be that the intervention and control groups were actually managed in a very similar way– only 4 of the 12 sessions addressed different topics (i.e. included empowerment). Also, the good standard of basic treatment in both groups might make it difficult to see an intervention effect.
Prof Sara Evans-Lacko (London School of Economics and Political Science), described the current state of research on social exclusion and stigma in Europe.
Literature mapping was used to select relevant articles published between 2007 and 2012 - 810 articles were included in the analysis. The patients in these studies suffered from a range of mental disorders including depression and schizophrenia. By far, most of the articles were from the UK, followed by Germany and the Netherlands. Very few came from Eastern European countries. The research was primarily in detection, screening and diagnosis.
Her conclusion is that despite growing interest in this field, there is still little research looking specifically at ways of protecting against and reducing stigma and promoting resilience and social inclusion.
Prof Yoram Cohen, Acting President of Global Alliance of Mental Illness Advocacy Networks (GAMIAN)-Europe asked the question: seven years after ratification of the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD), are there any advances for patients with mental health conditions?
The UNCRPD is a beacon of light to follow. It recognises that discrimination based on disability is a violation of the person’s inherent dignity and worth. The contributions made by persons with disabilities to the overall well-being of their communities are valuable. And autonomy and independence for persons with disabilities, including the freedom to make their own choices, are important.
Despite the ideals proclaimed in the UNCRPD, care in many mental health facilities around Europe is still of poor quality and in some cases may hinder recovery.
The misconception that people with mental health problems are not able to take responsibility, manage their affairs and make decisions about their lives contributes to ongoing marginalisation in their communities.
Bert Johnson, President of EUFAMI – the European Federation of Associations of Families of People with Mental Illness – highlighted the harsh reality of stigma and the fact that it goes to the heart of what it is to be human.
Families also suffer from stigma. The Caring for Carers (C4C) survey assessed the experiences of family members caring for their relative with severe mental illness from a number of countries. A third of carers reported that they are treated differently because of the mental illness of the person they care for. People felt reluctant to invite guests to their home and withdrew from relationships.
The recommendations to counter stigma are common sense, Mr Johnson told the audience – but it is putting them into practice that counts. These include education about mental health and the care required, and raising public awareness of the impact of mental illness on families.
The stigma of mental illness is a major challenge for patients and their families.
A: Cognitive deficits are really important to patients and this is often what they come in to the office to report – particularly when they have seen an improvement in their mood. Many of my patients think that these residual effects are actually related to their antidepressant treatment.
These can be residual symptoms that interfere with functional activity. In daily life, this may be seen at work and at home, where memory is affected, with patients not remembering what tasks they have to do.
A: My strategies for dealing with cognitive symptoms in patients with depression include trying to use an antidepressant with wider aspects – or I may use addition drug therapies or cognitive remedial strategies. Not all patients are the same and it needs an individual approach.
An interview with Dr Narcis Cardoner, Psychiatrist, Bellvitge Hospital, Barcelona, ES about cognitive symptoms of depression
