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

Ranjan Sudan, MD

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

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

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)

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

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

Mental Health (past 12 months)Percent Male Female Total

Felt things were hopeless

38.7 48.6 45.1

Felt Overwhelmed by all you had to do

77 91.4 86.3

Felt so depressed that it was difficult to function

26.9 33.3 31.1

Felt overwhelming anxiety

40.5 56 50.6

Seriously considered suicide

6.3 6.4 6.4

Attempted suicide

1.1 0.9 1.1

Diagnosed or treated by a professional (Top diagnosis in past 12 months)Percent Male Female Total

Anxiety 7.2 13.9 11.6

Depression 7.4 12.4 10.7

Panic Attacks 2.7 6.6 5.3

ADHD 5.0 4.3 4.6

Bipolar Disorder 1.2 1.4 1.4

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

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.

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.

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

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

ADHD

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

Treatment Behavioral interventions Medications

Stimulants Non-stimulants Antidepressants

Medication misuse Sharing of medications Prescription of medications

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

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

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

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

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

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

Action Plan An obviously impaired resident must be

removed from duty in the interest of safety Consult with GME office

They will know who else should be involved Know your institutional and local resources

Such as mental health professionals State licensing board rules PHPs Rehabilitation or treatment centers

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

Mental Health issues in Health Professionals

Role of Program Director

Summary