IACAPAP Textbook of Child and Adolescent Mental Health

MISCELLANEOUS

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WELLBEING:IDENTIFICATION AND PREVENTION OF
BURNOUT, DEPRESSION AND SUICIDEAMONG CHILD MENTAL HEALTH
CLINICIANSFrances Javier, Julie Chilton & Andrés Martin

Frances Javier MD
Julie Chilton MD
Andrés Martin MD, MPH
All from the Yale Child
Study Center, New Haven,
Connecticut 06510, USA
Conflict of interest: none
declared

Courtesy of the Mayo Clinic
This publication is intended for professionals training or practicing in mental health and not for the general public. The opinions
expressed are those of the authors and do not necessarily represent the views of the Editor or IACAPAP. This publication seeks todescribe the best treatments and practices based on the scientific evidence available at the time of writing as evaluated by the authorsand may change as a result of new research. Readers need to apply this knowledge to patients in accordance with the guidelines andlaws of their country of practice. Some medications may not be available in some countries and readers should consult the specific drug
information since not all dosages and unwanted effects are mentioned. Organizations, publications and websites are cited or linked toillustrate issues or as a source of further information. This does not mean that authors, the Editor or IACAPAP endorse their content or
recommendations, which should be critically assessed by the reader. Websites may also change or cease to exist.
©IACAPAP 2019. This is an open-access publication under the Creative Commons Attribution Non-commercial License. Use,
distribution and reproduction in any medium are allowed without prior permission provided the original work is properly cited and theuse is non-commercial. Send comments about this book or chapter to jmreyATbigpond.net.au
Suggested citation: Javier F, Chilton J, Martin A. Wellbeing: Identification and Prevention of Burnout, Depression and Suicide AmongChild Mental Health Clinicians. In Rey JM, Martin A (eds), IACAPAP e-Textbook of Child and Adolescent Mental Health. Geneva:
International Association for Child and Adolescent Psychiatry and Allied Professions 2019.

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IACAPAP Textbook of Child and Adolescent Mental Health

My name is Adam. I am a human being, a husband, a father, a pediatricpalliative care physician, and an associate residency director. I have a historyof depression and suicidal ideation and am a recovering alcoholic. Several
years ago, I found myself sitting in a state park 45 minutes from my home, ona beautiful fall night under a canopy of ash trees, with a plan to never comehome. For several months, I had been feeling abused, overworked, neglected,
and underappreciated. I felt I had lost my identity. I had slipped into a deep
depression and relied on going home at night and having a handful of drinks
just to fall asleep. Yet mine is a story of recovery: I am a survivor of an
ongoing national epidemic of neglect of physicians’ mental health.
Click here to access the full article

Some readers may question the need for this chapter in this textbook. Given
the dearth of child mental health professionals globally, looking after the needsof this invaluable workforce should be a priority for administrators, managers
and the clinicians themselves to ensure optimal performance in meting the needsof their young patients and their families.
While the association between burnout and physical illness, particularly
cardiovascular disease has been known for some time, its association with mental
health problems among medical professionals has received less attention. With ahigher prevalence of depression, suicide, and substance abuse among healthcare
professionals worldwide compared to the general population, Adam’s story is not
an exception. Rather, it is a window to the experience of:• 22-42% of psychiatrists from Germany, Japan, UK, and Scotland witha lifetime prevalence of depression (Braun et al, 2010; Deary, Agius &Sadler, 1996; Koreki et al, 2015; White et al, 2018);• 20-25% of psychiatric trainees from 22 countries with a history ofactive and passive suicidal ideation, respectively (Beezhold et al, 2017);• an estimated 400 physicians who die by suicide each year in the US(Frank, Biola & Burnett, 2000);• 79% of physicians managed in physician health programs for substanceabuse in the US and Canada who continue to be licensed and practicing
five years after program completion (McLellan et al, 2008);• and many more worldwide who go unmeasured.
21-67% of mental health workers in Europe and the US, spanning multiple
disciplines—nurses, occupational therapists, social workers, psychologists, andpsychiatrists—have been reported to have high levels of burnout (Morse et al,2012; Rohland, 2000; Sharon & Leah, 2007; Siebert, 2005; Webster & Hackett,1999).
Although many of the studies available in the literature investigatedphysicians—with scarce data in other disciplines—this information may be
used to infer how the multidisciplinary members of the mental health team arepossibly being affected by the interpersonal and emotionally demanding natureof their work.
Due to the epidemic of burnout, depression, and suicide in medicine, the focus
on wellbeing (or wellness) has garnered increased attention both in the media

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Click on the image above
to watch the video andlearn how “placing a priority
on mental health enables
healthcare professionals
to better take care ofthemselves and theirpatients.”(Image and video
courtesy of the Mayo Clinic)

Burnout is a work related
psychological syndrome
with three dimensions:emotional exhaustion,
depersonalization,and reduced personal
accomplishment.

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IACAPAP Textbook of Child and Adolescent Mental Health

Table J.12.1
Impact of burnout and depression on health outcomes at the individual, patientand healthcare system level.

INDIVIDUAL

PATIENT CAREHEALTHCARE SYSTEM• Physical symptoms• Decreased quality of care

• Decreased productivity• Mental health symptoms• Increased medical error• Increased provider turnout• Depression (Ahola et al,
2005; Wurm et al, 2016)• Lower patient satisfaction• Less patient access• Lower patient adherence• Increased costs• Suicide (Shanafelt et al,
2011; van der Heijden etal, 2008)• Longer recovery times• Substance abuse• Broken relationships• Poor self-care• Motor vehicle accidents
and within healthcare systems. Despite a lack of consensus on the operational
definition of both wellbeing (Brady et al, 2018) and burnout (Rotenstein et al,2018), various wellness programs and initiatives have cropped up as a responseto the problem. But, what if the solutions themselves are exacerbating, insteadof solving, the problem?
Wellbeing is a multifaceted concept with physical, mental, and social
dimensions (World Health Organization, 1946); therefore, programs promoting
wellbeing should also be multifaceted, with the burden not only placed on theindividual, but also on the system as a whole (Shanafelt & Noseworthy, 2017).
The goal of this section is to open an international dialogue on enhancing
wellbeing in the field of child and adolescent psychiatry and allied professions.

BURNOUT
It is debated whether burnout is a distinct construct (Maslach & Leiter, 2016)or a subset manifestation of other mental disorders such as depression, anxiety,or posttraumatic stress disorder (Leiter & Durup, 1994; Mitani et al, 2006;
Wurm et al, 2016); or job stress (Morse et al, 2012). First described in 1974
(Freudenberger, 1974; Ginsburg, 1974), the current, widely accepted definitionof burnout is a work-related psychological syndrome with three dimensions:emotional exhaustion, depersonalization, and reduced personal accomplishment(Maslach & Leiter, 1996). Depression manifests itself with depressed mood,anhedonia, feelings of guilt or worthlessness, fatigue, decreased concentration ordecision making capacity, increased or decreased appetite, sleep problems, andsuicidal ideation (American Psychiatric Association, 2013).
Burnout and depression have been shown to have a positive correlation, withthe emotional exhaustion dimension of burnout having the strongest association
with depression (Wurm et al, 2016). However, it remains inconclusive whether
burnout is an earlier phase in the development of depression, or whether having
depression negatively impacts the work experience, thus leading to burnout.

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Various studies, including longitudinal data, are consistent with both hypotheses.
Notably, burnout has consistently been shown to have individual, systemic,
and economic consequences (Peterson et al, 2008; Salyers et al, 2017; Salyers
et al, 2015; West et al, 2018). Conversely, wellbeing initiatives in healthcare
systems have shown to be wise financial cost-saving measures downstream(PricewaterhouseCoopers, 2014).

DEPRESSION AND SUICIDE
Independent of the association between burnout and depression, there isan increased prevalence of depression and suicide among healthcare providers.
Suicide is a complex behavior caused by multiple converging risk factors, the mostcommon of which is inadequate recognition or management of mental healthconditions (Gold et al, 2013). A study of US physicians who died by suicide
found they were less likely to have received mental health treatment compared
to non-physicians, even though both groups had similar rates of depression.
Psychosocial risk factors related to job problems (such as having made a medical
error) were associated with suicide in physicians, whereas death of a loved one or
having had a recent crisis was associated with suicide in the general population(Gold et al, 2013). Stigma, confidentiality concerns, reluctance to seek help,
attitudes towards self-treatment, fear of professional repercussions, limited time,
and work demands are some of the cited reasons for the high rates of physician
suicide (Maslach & Leiter, 2016). It is possible that physicians have become
skilled at compartmentalizing and coping with death and crisis as part of theirprofession. However, they may have more difficulty when it comes to copingwith threats to their own self-identity as physicians, which tends to encompass
both their professional and personal lives (Gold et al, 2013).

Click on the image above toaccess a short video about
depression (3:47)

CHILD AND ADOLESCENT MENTAL HEALTHPROVIDERS
Mental health providers face many of the same challenges as other healthcare
professionals, like increased workloads, long work hours, staff shortages, limited
support or supervision, and a lack of meaningful autonomy. (Edwards et al,
2000; White et al, 2018). However, mental health providers appear to havehigher rates of depression, suicidal ideation, suicide attempts, and higher burnout
scores when compared to medical providers in other fields. For example, a study
from Finland found psychiatrists to have higher rates of suicidal ideation, andchild psychiatrists to have higher rates of suicide attempts, than other physicians(Korkeila et al, 2003). Similarly, another study showed pediatric mental healthnurses to have greater physiologic indicators of chronic stress, and higher burnout
scores, than nurses working in the neonatal intensive care unit (Morelius et al,2013).
Caring empathically for patients with mental health needs may requireclinicians to spend more time in emotionally draining encounters thanpractitioners in some other fields of medicine. Chronic exposure to traumatic
narratives requires diligent emotional regulation and self-care, and may still resultin vicarious traumatization, also known as secondary trauma or compassion
fatigue (Boscarino et al, 2010; Cetrano et al, 2017), despite best efforts. Vicarious
trauma is a recognized occupational hazard which may present an additional
challenge when working with children with mental illness and their families.
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Click on the image above toaccess a TED talk about thecost of vicarious trauma

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IACAPAP Textbook of Child and Adolescent Mental Health

Table J.12.2
Selected instruments that can be used to assessburnout, depression, suicidality, and wellbeing (click on the measure toaccess the instrument.
MEASUREDESCRIPTION
Burnout

Maslach Burnout Inventory – A 22-item survey covering three areas:
Human Services Survey (MBI- emotional exhaustion (EE), depersonalization
HHS) for Medical Personnel (DP), and low sense of personal
accomplishment (PA).
A 16-item survey covering two areas:
exhaustion (physical, cognitive, and affective
Oldenburg Burnout Inventory aspects) and disengagement from work
(negative attitudes toward work objects, work
content, or work in general).

Click on the image above tolearn how to lead the way byseeking help (4:56)

Physician Work-Life Study’s A single-item survey with a stem assessing
Single Item (embedded in the level of burnout with corresponding“Mini-Z”)
response options.
Copenhagen Burnout
Inventory

A 19-item survey covering three areas:
personal (degree of physical andpsychological fatigue and exhaustion related
to work) and client-related (or a similar termsuch as patient, student, etc.) burnout.

Depression and Suicide
The Patient Health
Questionnaire-9 (PHQ-9)

A 9-item self-report component of the
PRIME-MD (Primary Care Evaluation of
Mental Disorders) measuring depression andsuicidal ideation.

The Center for Epidemiologic A 20-item survey assessing the nine group
Studies Depression Scale of symptoms of depression as defined by the
Revised (CESD-R)
DSM-5.
Columbia-Suicide Severity A 6-question screening tool evaluating
Rating Scale (C-SSRS)
suicidal ideation severity and behavior.
Beck Scale for Suicide
Ideation (BSS) (not free)

A 21-item evaluation with 5 screening
questions for suicide risk.
Wellbeing

Stanford Professional
Fulfillment Index

Well-being Index

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A 16-item survey that covers burnout(work exhaustion and interpersonal
disengagement) and professional fulfillment.
A 7- or 9-item survey identifying distressin a variety of dimensions (burnout,
fatigue, low mental/physical quality of life,
depression, and anxiety/stress).

5IACAPAP Textbook of Child and Adolescent Mental HealthDetection
There are several psychometrically-sound tools that can be used to assessburnout, depression, suicidality, and wellbeing. A curated list of these instruments,
which can be used by individuals or rolled out by specific programs, institutions,or health care systems, is provided in Table J.12.2.

Possible solutions
What matters is what can each one of us can do to detect and help ourcolleagues avoid or overcome these problems. Evidence-based strategies tocombat burnout, depression, and suicide risk among health care providers are
not one-size-fits-all, but may serve as a starting point to tackle the burnout
crisis. Given that burnout is a work-related syndrome, it is not surprising that
according to research top-down interventions implemented by organizations
have the greatest impact. However, meta-analyses on physician burnout suggestthat both individual-focused and systemic or organization-driven interventions
can reduce burnout (Panagioti et al, 2017; Regehr et al, 2014; West et al, 2016).
The most successful interventions combine different approaches including
structural changes such as workload or schedule improvements, fostering
effective communication among members of the healthcare team, promoting
team work, and cultivating a sense of autonomy (Panagioti et al, 2017). Both,individuals and organizations have a vested interest in preventing burnout inorder to mitigate its consequences.

The Hungarian Doctor by
Theodore-Joseph-Louis
Geirnaert. The State Hermitage
Museum, Saint Petersburg

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IACAPAP Textbook of Child and Adolescent Mental Health

Table J.12.3

Selected individual interventions with some evidence of effectiveness

INTERVENTIONTARGETSSTUDY POPULATION

Finding meaning anda sense of calling↓ Likelihood of burnout

Physicians (Shanafelt et al, 2009; Yoon et al, 2017)↓ Burnout scores

Cognitive behavioral
therapy (CBT)↓ Suicidal ideation

Psychosocial skills
and communication
training

Mental health professionals, physicians (Awa et al,2010), and residents (Guille et al, 2015)↓ Burnout scores

Hospital social workers (Cohen & Gagin, 2005) andforensic mental health nurses (Ewers et al, 2002)

Mindfulness↓ Burnout scores

Physicians (Goodman & Schorling, 2012; Krasner
et al, 2009; Ospina-Kammerer & Figley, 2003),
resident physicians (Goldhagen et al, 2015;
Rosdahl & Kingsolver, 2014), nurses, psychologists,and social workers (Goodman & Schorling, 2012)

Stress management
training (long term
effects seen withrefresher training)↑ Personal
accomplishment↓ Emotional exhaustion↑ Wellbeing

Self-care andexercisePeer to peer support/
small groups topromote community↓ burnout↑ Engagement andmeaning

Physicians, nurses, hospital staff, psychologists,social workers, and health educators (Rowe, 2006;
Winefield et al, 1998)

Physicians, nurses and resident physicians(Alexandrova-Karamanova et al, 2016; Lebensohn
et al, 2013; Weight et al, 2013)

Physicians (West et al, 2014)↓ Depersonalization

Systemic Interventions•••

Shanafelt & Noseworthy (2017) presented the drivers of physician
burnout and engagement (summarized in Figure 3 of their article),and suggested organizational strategies that can be implemented (Table
J.12.3).
The Stanford University Emergency Department time banking
intervention program provides support to alleviate work-life conflicts
and observed a 60% improvement in physician attrition and satisfaction.
The Healthy Workplace Study showed improved satisfaction and lower
burnout scores among primary care physicians with the initiation of
workflow optimization with increased support and quality improvement
projects (summarized in that study’s Table 1).

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IACAPAP Textbook of Child and Adolescent Mental Health•Weekend breaks for intensive care unit physicians in a clusterrandomized trial showed better perception of work-life balance, lower
job distress, and decreased burnout.
A peer-led physician small-group skills-class with protected time fromclinical duties at the Mayo Clinic promoted engagement and finding
meaning in work.

•

Individual
Selected individual interventions with some evidence of effectiveness are presented
in Table J.12.3

CONCLUSION
Information specific to child and adolescent psychiatry providers is scarce,
but available data suggest that we are at an even higher risk for developing
burnout, depression, and suicide compared to our colleagues in other fields of
medicine, who are already at a high risk compared to the general population.
Personal and situational factors contribute to these providers’ experience, andinitiatives promoting wellbeing should target both systems and individuals.
Currently, many of the interventions place the burden on the individual. By
offering skills training, promoting physical exercise, or hosting social eventswith limited or no change to the workflow, these well-meaning solutions may
further overwhelm an already overburdened practitioner, instead of alleviating
the problem – an approach that has been aptly criticized by Drozdowicz (2017)as putting “lipstick on a pig”.
There is no simple answer to the crisis we are facing. The providers in thestudies presented, which tend to be physicians from developed countries,
would face different challenges compared to non-physicians, and would also be
different from mental health providers in developing parts of the world who
may be serving as the only provider for an entire country or region. There is no
simple answer to the crisis and the overall goal is not only to have absence of
burnout/depression/suicide etc., but also to achieve a meaningful and well-lived
life, which is defined differently by each individual. Therefore, the process to getto that end result will also vary.

Click on the image above toaccess a TED talk on how achild psychiatrist channeled
his own experience withdepression into raisingawareness for children’s
mental health (18:41)

ADDITIONAL RESOURCES
Australia and New Zealand:•Royal Australian and New Zealand College of Psychiatrists•

Australasian Doctors Mental Health Network Survey•

Heads Up (Better mental health in the workplace, not just for
health professionals) Please add bullet point:•

Mood Gym interactive self-help tool

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IACAPAP Textbook of Child and Adolescent Mental HealthEurope:•Royal College of Psychiatrists•

Doctors Support Network•

EU Framework for Action on Mental Health and Wellbeing

North America:•

American Psychiatric Association (APA)•

American Foundation for Suicide Prevention (AFSP)•

Stanford Medicine WellMD Center•

American Medical Association (AMA) Online Module•

National Academy of Medicine

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Clinician wellbeing

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