A Psychiatrist, a Veterinarian, and an Emergency Physician Resolve to Improve Mental Health

COMMENTARY

Dr Moffic is an editorial board member and regular contributor to Psychiatric Times. He was a tenured Professor at the Medical College of Wisconsin. Currently, Dr Moffic is focused on three major advocacy initiatives: physician burnout, climate change, and Islamophobia. Dr Gaspar is a veterinarian at Veterinary Information Network, Chicago,IL. Dr Levin is Chair, Wellness Section, American College of Emergency Physicians, Milwaukee, WI.

Between animal and human medicine there are no dividing lines-nor should there be.

–Rudolf Virchow, MD, father of cellular pathology

On the shortest day of the year in December 2018, the American Psychiatric Association’s (APA) daily featured a dark subject about the suicide rate in veterinarians, also reported in the Journal of American Veterinary Medical Association¹ Both the field of psychiatry and veterinary medicine have in common our concern for our own suicides.² Indeed, a few days later, on Christmas Eve, Medscape Psychiatry reported its top news article for 2018: “NYU Resident, Medical Student Die by Suicide 5 Days Apart.”³

A terrible truth of student suicides is that those who start medical school and residency are generally psychologically healthy. One can deduce, then, that educational systems themselves factor into suicides.⁴ Veterinarians and physicians, including psychiatrists, have the highest rates of suicide of any professions and higher than the general population. The paradox is that we are all devoted to healing, yet the ultimate vessels of our well-being-our lives-are being lost by our own hands.

Moreover, suicide is the tip of the iceberg of our personal psychological distress and disorders. Our mutual professions have higher rates than the general population for clinical depression, epidemic rates of burnout, and related problems. Those healers with the most compassion seem most at risk for burning out.⁵ No wonder quality-of-care suffers.

For the public, the prevalence of mental disorders has increased to over 20%, and most never receive any effective treatments. Outside of formal diagnostic disorders, a host of other public psychological problems are cause for concern.⁶ These include the fact that over half of adolescents already have had a significant life trauma; cosmetic surgery procedures are booming, perhaps as a response to body dysmorphia; rates of xenophobia and related prejudices (ie, racism, sexism, anti-Semitism, Islamophobia) are rising; people are suffering mental repercussions of climate instability; technology is being overused and misused; and our society is pervasively lonely.

The American Psychiatric Association Foundation, the funding arm of the APA, called for “A Mentally Healthy Nation for All” in 2018. However, simple math suggests that we are moving toward mental dis-ease.⁷

Historically, beyond a general altruistic calling, many believed that those who chose to be veterinarians, psychiatrists, or other kinds of physicians, were often doing to so to address some traumatic and/or inspiring medical or psychological experience in their childhood. For veterinarians, that would likely involve beloved animals. That emotional tie to the past could leave us vulnerable to frustration in helping our patients. Such frustration results more and more from the systems we work in that have become more corporate and business-oriented, with the consequence of controlling how we practice, decreasing our empowerment, and providing obstacles for our ability to heal and fulfill our callings.

Along the way, those entering our fields start out under a mountain of debt with an income that fails to keep up with opportunities to alleviate that debt. That can lead to career choices that emphasize reimbursements over the passion to treat certain populations which may not be as financially lucrative. A balanced home life with children and family is a dream that is pushed more into a distant future.

With all these stressors, it would not be surprising that mental health care for ourselves would be needed. Indeed, when psychiatrists conducted more psychotherapy, psychiatrists in training were expected to receive their own psychotherapy. But no more. Professionals in our fields often are even more reluctant than the public to get such care because of stigma and the negative consequences of people knowing about one’s mental illness. Many fear loss of jobs and/or licensure. The tragedy is that intervention is often successful, and the recipient can enjoy the benefit of true empathy for the psychological suffering of everyday patients

Until recently, psychiatry has not focused much attention on mental health challenges less severe than diagnosable disorders. Unfortunately, the field has largely neglected wellness and burnout, even to the extent of not trying to better understand and define what these colloquial terms mean.

What a loss it has been, and will continue to be, if psychiatry does not expand its range of concerns and seek to resolve them. Perhaps our absence is even associated with the rise of burnout at epidemic levels. After all, our expertise in deeper psychological processes, which are often counterintuitive, has been missing. For instance, there has been an almost universal quest for more resilience in physicians. Certainly, developing resilience is helpful for psychological and post-traumatic growth. Yet, that resilience is almost part and parcel of becoming a veterinarian or physician. Can we have “too much” resilience-that is, do we ignore psychological problems and instead soldier on as we have been taught to do?

Psychiatry and veterinary medicine

We in psychiatry can do better with veterinarian patients, who have unique challenges. The desires of animal owners, who are the clients, may conflict with how the veterinarian wants to help the animal patient. Owners can be critical of the costs and blame the veterinarian for being greedy and not loving the animals “enough,” causing unnecessary guilt. Fortunately, some of us in psychiatry have experience trying to help animals, whether that be behavior modification techniques, the use of medications, and appreciating that service dogs can be ancillary healers. Animals and humans, too, share some of the same mental health challenges, including loneliness and loss.

In turn, perhaps veterinarians can help us deal with death. Although rare in psychiatric practice, deaths directly related to psychiatric practice are suicides, homicides, and medication adverse effects. Veterinarians have an acute understanding of death in their animal patients. Those who have learned to positively cope may help psychiatrists in processing the rare patient suicide. The potential to work together is mutual, as our expertise in grief can help veterinarians who are overwhelmed by such losses. For some veterinarians, can taking the lives of so many animals blur the ethics of taking one’s own life?

Only in recent years has psychiatry become familiar with euthanasia. Physician-assisted deaths are now available in some states and various European countries. The role of psychiatry in screening and/or treating patients who request death varies. Intense debate surrounds the ethics of participating or not; both sides seem to share a commitment to compassion and respect for human dignity and rights, but draw different moral conclusions.⁸ Such assisted deaths may increase as the world population ages and health care resources become more limited. As radical as it may sound, perhaps veterinarians can help prepare us for such roles.

Emergency medicine and burnout

Emergency medicine has made strides in developing programs to increase wellness and to reduce burnout after burnout rates soared to epidemic levels. Attention expanded from focusing on individual physician wellness to the greater influence of systems that dis-empower physicians from healing as best as we know we can. In 2018, Medscape reported that their efforts may be paying off as their burnout rate dropped strikingly.⁹

Addressing mental “unwellness”

The alarming suicide rate of veterinarians is an unexpected wake-up call. We need to act. With so much in common, our professions can learn from one another, and we suggest ten strategies to address “unwellness”:

1. Label our high rates of suicide, mental disorders, burnout, and xenophobia a national mental health care crisis and find the best ways to communicate this to the public and politicians.

2. Normalize self-disclosure of our own emotional problems; and convey as much compassion, validation, and mercy to one another as we do to our patients.

3. Expand psychiatry beyond integrated medicine into integrated veterinary medicine.

4. Consider the use of safe, accurate, and effective screening tools for suicidality, depression, trauma, burnout, racism, and resilience.

5. Help develop research-based interventions for conditions that may be less severe than DSM disorders.

6. Develop psychologically engaging communities via prevention, treatments, maintenance, self-actualization, community actualization, and disaster planning.

7. Include veterinary medicine with all the medical specialties in the National Academy of Medicine coalition that is working on wellness and burnout and, in turn, have psychiatry included in joint endeavors like the One Health Initiative, which is devoted to the well-being of people, animals, plants, and the environment.

8. Learn from emergency medicine that these problems will not be solved quickly but need an ongoing commitment.

9. Pull together conferences, books, small retreats, and related projects that include all healing professions and physician specialties, mental health care professionals, nurses, dentists, veterinarians, and other allied health caregivers.

10. Be active politically to advocate for leadership that embraces the mental health of mankind as its business.

The three of us know through experience that our fields can work together successfully, as illustrated by a retreat last October for veterinarians from all over America. With the facilitation and overlapping expertise of the authors, they shared and discussed their workplace stories that needed to be heard.

Therefore, as the year 2019 begins, we hope that we are representing our professions well, and we resolve to do whatever we can to solve our mental health challenges. Will you join us?

_{Have something to say? Contact us at editor@psychiatrictimes.com and your comment might be considered for posting at the end of this article with a response from the authors.}

References:

1. Tomasi SE, Fechter-Leggett ED, Edwards NT, et al. Suicide among veterinarians in the United States from 1979 through 2015. J Am Vet Med Assoc. 2019;;254:104-112.

2. Center C, Davis M, Detre T, Ford DE, et al. Confronting depression and suicide in physicians: a consensus statement. JAMA. 2003;289:3161-3166..

3. Frellick M. NYU Resident, Medical Student Die by Suicide 5 Days Apart. Medscape. May 10, 2018.

4. Mata D, Ramos MA, Bansal N, et al. Prevalence of depression and depressive symptoms among resident physicians: A systematic review and meta-analysis. JAMA. 2015;314:2373-2383

5. Carpenter-Song E, Torrey WC. “I always viewed this as the real psychiatry”: providers perspective on community psychiatry as a career of first choice. Community Ment Health J. 2015;51:258-266.

6. Hedges C. America: The Farewell Tour. New York: Simon & Schuster; 2018.

7. Higgens: E. Is mental health declining? Sci Am Mind. 2018;28:20-21, 2017. https://www.scientificamerican.com/article/is-mental-health-declining-in-the-u-s. Accessed January 23, 2019.

8. Moran M. AMA debates council report on physician-assisted suicide. Psychiatric News. December 14, 2018.

9. Peckman C. Medscape National Physician Burnout & Depression Report. Medscape.  January 17, 2018. https://www.medscape.com/slideshow/2018-lifestyle-burnout-depression-6009235. Accessed January 23, 2019.