Carmelle Peisah

Secrets to psychological success: Why older doctors might have lower psychological distress and burnout than younger doctors

Background: Doctors have long been exposed to situations that can induce psychological distress. Long hours, little acknowledgement, poor sleep and high-stress work environments all contribute to making doctors prone to psychological distress and burnout, which have been much studied in younger doctors, but less so in older doctors. Little is known about whether there are differences in psychological distress among different age groups of doctors. Methods: Doctors (n = 158) were recruited from in and around the St George Hospital, a major teaching hospital in Sydney, Australia. Participants completed a self-report questionnaire, comprising the Maslach Burnout Inventory (MBI), and Kessler 10 Psychological Distress Scale. Demographic details were collected. A subsample (n = 51) completed a semi-structured interview about issues related to burnout. These data were subjected to qualitative analysis. Results: Older doctors and doctors with more years of experience had significantly lower scores on MBI subscales of Depersonalization and Emotional exhaustion, and K-10 measured psychological distress. Aspects of working conditions such as being in private practice were associated with increased scores on MBI subscales of Personal accomplishment, and lower scores on MBI subscales of Emotional exhaustion and Depersonalization, and K-10 measured psychological distress. Older doctors more frequently worked in private practice. These quantitative findings were supported by the qualitative data that suggested that older doctors perceived that they experienced less psychological distress compared with earlier in their careers, which they attributed to the development of protective defences in their relationship with patients and the liberation afforded by accumulation of experience and changed work conditions. Conclusions: Findings from this study suggest that older, more experienced doctors report lower psychological distress and burnout than younger doctors which the older doctors attributed to lessons learned over their years of training and practice. It may be of considerable value to find ways to more efficiently pass on these lessons to younger doctors to aid them in dealing with this challenging profession. By soliciting older doctors to aid in this transfer of knowledge, this approach may also have the added benefit of assisting older doctors in transitioning from an active clinical practice to a role of mentoring the new physician cohort.

A 25-year longitudinal, comparison study of the outcome of depression.

BACKGROUND There is still a relative paucity of information about the long-term course of depression. METHODS Consecutive patients admitted to a teaching hospital psychiatry unit with symptoms of depression, previously assessed at 6 months and 2, 5 and 15 years after index admission, were reviewed at 25 years (N = 49, including eight informants of deceased probands, of an original 145 with major depression (DEPs)). Prospective psychiatric (N = 22) and retrospective surgical (N = 50) control groups assessed after 25 years were used for comparison. RESULTS A further decade of follow-up confirmed the chronicity of depression. Of depressed patients (DEPs) followed for the full 25-year-period only 12% of the 49 original DEPs recovered and remained continuously well, 84% experienced recurrences, 2% experienced an unremitting course and another 2% died by suicide. Note that in the first 15-year-period 6% (9/145 DEPs) committed suicide, a further 38 died and 32 were lost to follow-up. They experienced an average of three episodes of depression over the 25 years. In the decade since the 15-year follow-up, 27% improved in clinical outcome (including four of five previously chronically depressed patients), 55% remained unchanged and 18% worsened; and the number of episodes per year declined. Patients initially diagnosed with neurotic or endogenous depression had similar long-term outcomes. The criteria for a current DSM-III-R disorder were met by 37% of DEPs, including 11% with depression or dysthymia. On the global assessment of functioning scale 78% of the DEPs had some impairment compared to 62% of psychiatric controls and 40% of surgical controls. CONCLUSION Even after 25 years, severe depressive disorders appear to have poor long-term outcomes. Patients with chronic outcomes over 15 years can improve when followed over longer periods.

Early dementia diagnosis and the risk of suicide and euthanasia

Diagnosis of dementia is occurring earlier, and much research concerns the identification of predementia states and the hunt for biomarkers of Alzheimers disease. Reports of suicidal behavior and requests for euthanasia in persons with dementia may be increasing.

Neuropsychological performance and dementia in depressed patients after 25-year follow-up: a controlled study.

BACKGROUND Previous research has yielded conflicting evidence regarding the long-term cognitive outcome of depression. Some studies have found evidence for a higher incidence of subsequent cognitive impairment or dementia, while others have refuted this. METHOD Depression, neuropsychological performance, functional ability and clinical variables were assessed in a sample of patients who had been hospitalized for depression 25 years previously. RESULTS Data were available on 71 depressed patients (10 of whom were deceased) and 50 surgical controls. No significant differences were found between depressed subjects and controls on any neuropsychological measure. Ten depressed patients but no controls were found to have dementia at follow-up (continuity corrected chi2 = 5.93, P < 0.01). Presence of dementia was predicted by older age at baseline. Vascular dementia was the most common type. CONCLUSIONS We conclude that this study did not find evidence that early onset depression is a risk factor for Alzheimers disease, but that for a small subgroup there appears to be a link with vascular dementia. Several plausible explanations for this link, such as lifestyle factors, require further investigation.

The impaired ageing doctor

Retirement may be voluntary and involuntary,1 although the former is clearly the preferred option. It is tragic when doctors’ distinguished careers are tarnished by declining clinical judgement, knowledge or skill and it is thus advisable that doctors retire before age adversely influences their performance. Yet, because there is great variability in the rate of ageing and the previous mandatory retirement age of 65 years is neither applicable nor appropriate, it is difficult to recommend an age at which retirement is desirable or necessary. Many doctors are selfemployed and most enjoy their work and their patients. When and why should they retire? This paper aims to outline briefly: (i) the problems that occur with ageing, (ii) the New South Wales Medical Board (NSWMB)’s approach to older impaired doctors and (iii) the issues of proactive retirement planning and voluntary retirement. In addition to our interest in the mental health of older people, we write this paper from the viewpoint of a NSWMBappointed psychiatrist and the member of the NSWMB responsible for chairing the Doctors’ Health Program.

Decisional capacity: toward an inclusionary approach

Capacity, defined as the ability to make ones own decisions, has traditionally been seen as a dichotomous or categorical construct. People either have capacity, and are therefore afforded autonomy, or they lack capacity, and are therefore provided with a proxy decision-maker. In a way this concept – and the related practice of conceptualizing capacity as an all or nothing phenomenon – resembles the situation of Kafkas protagonist Gregor Samsa in Metamorphosis (1972 (in German 1915)). The opening lines of this breathtaking essay are world famous. In English they run as follows: “As Gregor Samsa awoke one morning from uneasy dreams he found himself transformed in his bed into a gigantic insect.” As a consequence of this categorical change, Gregor is excluded and despised of. He is no longer considered an agent and ends up squashed by apples by his own relatives. Although the parallel may seem far-fetched, the atmosphere of estrangement and alienation resembles what can happen to people who are diagnosed with dementia or other mental disorders, when suddenly their health professionals turn to their relatives to make healthcare and other decisions and they themselves are no longer afforded a role – read for example Maartens experience in Bernlefs novel Out of Mind (1989 (in Dutch 1984)). Fortunately, this situation is changing and we are moving toward a more sophisticated approach, away from a categorical and exclusionary practice toward a more dimensional and inclusionary concept of capacity. One of the fundamental ideas underlying this alternative approach is that capacity assessments should primarily be undertaken not to judge whether people are capable or not to decide “autonomously,” but rather to assess what kind of support people with decision-making disabilities (DMD) need in order to be involved in decision-making and thus to promote their autonomy. This paradigm shift has been heralded by a number of human rights frameworks such as the European Convention on Human Rights and the United Nations Convention on the Rights of People with Disabilities (UNCORPD, 2012). These conventions promote autonomy and the enjoyment of equal recognition before the law for people with disabilities, thus underscoring the right of people with disabilities to enjoy legal capacity on an equal basis with other members of society. Importantly, UNCORPD Article 12 (2012) specifically recommends that signatories “take appropriate measures to provide access by persons with disabilities to the support they may require in exercising their legal capacity.” This obligation translates into a major challenge for healthcare and legal professionals alike. How do we support maximum participation in decision-making for those who lack decisional capacity? Some years ago, Beltram (1996) summarized the challenge of accurately assessing decisional capacity, referring to the usefulness of “pragmatic models of shared decision-making.” However, there is no consensus yet as to how models of supported decision-making might be utilized by people with DMD. In this contribution we propose a practical model for supported decision-making, which is inclusionary and founded in ethical and human rights frameworks. To this end we will first discuss how the ethical concept of autonomy has evolved during the past decades and how changing views on autonomy relate to support in decision-making.

Practical guidelines for the acute emergency sedation of the severely agitated older patient

The vulnerability of older people to serious underlying medical illness and adverse effects of psychotropics means that the safe and effective treatment of severe agitation can be lifesaving, the primary management goals being to create a safe environment for the patient and others, and to facilitate assessment and treatment. We review the literature on acute sedation and provide practical guidelines for the management of this problem addressing a range of issues, including aetiology, assessment, pharmacological and non‐pharmacological strategies, restraint and consent. The assessment of the agitated older patient must include concurrent assessment of the likely aetiology of, the risks posed by, and the risks/benefits of management options for, the agitation. A range of environmental modifications and non‐pharmacological strategies might be implemented to maximize the safety of the patient and others. Physical restraints should only be considered after appropriate assessment and trial of alternative management and if the risk of restraint is less than the risk of the behaviour. Limited evidence supports a range of pharmacological options from traditional antipsychotics to atypical antipsychotics and benzodiazepines. It is advised to start low and go slow, using small increments of dose increase. Medical staff are frequently called to sedate agitated older patients in hospital settings, often after hours, with limited access to relevant medical information and history. Safe and effective management necessitates adequate assessment of the aetiology of the agitation, exhausting all non‐pharmacological strategies, and resorting to pharmacological and/or physical restraint only when necessary, judiciously and for a short‐term period, with frequent review and the obtaining of consent as soon as possible.

The greying intensivist: ageing and medical practice - everyone's problem.

The medical profession is ageing in parallel with the wider community, with more Australian doctors working into their 70s. This has implications for workforce planning and raises questions about competence. However, no Australian specialist college has policies relating to the special circumstances of ageing practitioners. Ageing practitioners are affected by a number of age‐related sensory and neurocognitive changes, including a decline in processing speed, reduced problem‐solving ability and fluid intelligence, impaired hearing and sight, and reduced manual dexterity. A policy of mandatory retirement is not consistent with the wide individual variations in cognitive ageing. However, there may be an age ceiling, which varies by medical specialty and individual. Studies show that older doctors in several specialties perform worse than their younger colleagues. Older doctors, many of whom are found to be cognitively impaired, are more likely to be reported to the authorities for poor performance. The wisdom and experience of older doctors is of great value. However, work adaptations may need to be considered. For intensivists, these could include part‐time work towards retirement, reduced after‐hours call and shift work, and reduced exposure to acute crisis intervention, with an increased focus on mentoring, teaching, administration and research.

A test for mental capacity to request assisted suicide.

The mental competence of people requesting aid-in-dying is a key issue for the how the law responds to cases of assisted suicide. A number of cases from around the common law world have highlighted the importance of competence in determining whether assistants should be prosecuted, and what they will be prosecuted for. Nevertheless, the law remains uncertain about how competence should be tested in these cases. This article proposes a test of competence that is based on the existing common law but which is tailored to cases of assisted suicide. The test will help doctors, other health professionals and lawyers determine whether the suicidal person was able to competently request assistance. Such knowledge will help to reduce some of the current uncertainty about criminal liability in cases of assisted suicide.

World psychiatric association section of old age psychiatry consensus statement on ethics and capacity in older people with mental disorders

The World Psychiatric Association (WPA) Section of Old Age Psychiatry, since 1997, has developed Consensus Statements relevant to the practice of Old Age Psychiatry. Since 2006 the Section has worked to develop a Consensus Statement on Ethics and Capacity in older people with mental disorders, which was completed in Prague, September 2008, prior to the World Congress in Psychiatry. This Consensus meets one of the goals of the WPA Action Plan 2008–2011, ”to promote the highest ethical standards in psychiatric practice and advocate the rights of persons with mental disorders in all regions of the world“. This Consensus Statement offers to mental health clinicians caring for older people with mental disorders, caregivers, other health professionals and the general public the setting out of and discourse in ethical principles which can often be complex and challenging, supported by practical guidance in meeting such ethical needs and standards, and to encouraged good clinical practice. Copyright