Suicide Prevention Awareness

Host Jean Fisher Brinkley discusses ways to overcome the stigma associated with mental health issues in medical professionals and strategies and resources for getting help with guest Dr. Christine Moutier, Chief Medical Officer for the American Foundation for Suicide Prevention.

Host: Jean Fisher Brinkley
Guest: Dr. Christine Moutier
Producer: Sylvia French-Hodges

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Email your questions to:  podcast@ncmedboard.org.

Transcript

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Intro music: 0:00 

Podcast Introduction: 0:10  

Hello and welcome to the very first episode of MedBoard Matters.  

I’m your host, Jean Fisher Brinkley.  

The North Carolina Medical Board is looking forward to exploring timely and important topics on this podcast, and we are jumping right in with this episode on suicide prevention awareness.  

September is Suicide Prevention Awareness Month, and September 17 is National Physician Suicide Awareness Day.  

You may know that medical professionals are at increased risk for suicide relative to other professions due to the unique stressors of healthcare work.  

A survey published earlier this year, the Medscape Survey on Physician Burnout & Suicide, found that nearly one in four physicians surveyed said they had contemplated suicide, and a little more than 1 percent had actually attempted it. Of those who indicated they were burned out, depressed or suicidal, more than 60 percent, 60 percent said they had no plans to seek help.  

If suicide in healthcare seems like a slightly unusual topic for a medical board to be discussing, well, it really isn’t.  

Here’s how the Medical Board thinks about the issue. The North Carolina Medical Board was created to regulate medicine “for the benefit and protection of the people of North Carolina.”  

And the bottom line is that medical professionals who are well are going to be better able to take good care of patients. So, the medical board sees wellness, which certainly includes getting appropriate treatment for depression, as something that harmonizes perfectly with its statutory mandate. And frankly one of the best ways we think we can help is by simply talking about mental health, and how important it is for NCMB’s licensees to take care of themselves.  

Here, I want to pause and address anyone in our audience who may currently be in crisis. First, understand that you are not alone. And second, please get help. There are so many different ways to get assistance, and we’ll be discussing some of them in just a little bit.  

Now let me introduce my special guest, Dr. Christine Moutier.  

Dr. Moutier is chief medical officer of the American Foundation for Suicide Prevention. Dr. Moutier earned her medical degree and completed training in psychiatry at the University of California, San Diego. She has been a practicing psychiatrist, a professor of psychiatry, a medical school dean and medical director of the Inpatient Psychiatric Unit at the VA Medical Center in La Jolla, California.  She is a national leader in the field of suicide prevention, and we are so honored to have her with us.  

Interview: 02:48
Jean: So, so I wanted to ask you first of all, just thank you again Dr. Moutier for…for joining me and I wondered if you would start by telling me how you got started working in the area of suicide prevention. It is such a specific field and I have a feeling there's a story there. 

Dr. Moutier: Yes, absolutely, and thank you so much for you know, having me on and spotlighting this important topic of physician well-being, and suicide prevention. 

My own story that has led me to focus on suicide prevention as really my soul mission personally and professionally at the national level, did start with my own personal journey while I was a medical student. Like all of us human beings and…and including us as physicians, I had my own, and really kind of first significant mental health experience while I was a medical student and it was one of those almost cliche stories of a high achieving kid that I was. I'm half Asian, so I grew up in a household where your value is defined by your achievements and…and you know children in the home put on a happy face, so even just processing anxiety, conflict, sadness, anger, those weren't things that were culturally part of my upbringing. And it all works well for a high achieving student and kid until there, until something starts to shift and for me during medical school, it was that sense of, you know, what if I'm not the top of the class. And I hadn't developed coping mechanisms for that level of anxiety to even start shifting away from more of a perfectionistic approach to my not just my studies, but my life. And so it led to a crisis of sorts that I'm, that I wouldn't want to go through or wish on anyone…um taking a year off of medical school. I tried to drop out of medical school.  

Jean: Wow! 

Dr. Moutier: Well, thankfully I didn't. 

But I got help and got mental health support and therapy for the first time at that…at that time in my young adult life and…and obviously I came back to medical school. I finished training. By the time I was chief resident at University of California, San Diego School of Medicine, in the Department of psychiatry, I had become much more open about my own...my own experiences not in any intentional or significant way, but I think because I had become a chief resident in a position where others, you know I'm teaching and mentoring and advising. It became clear that lots of people, medical students, trainees, faculty had personal struggles of various different kinds, including mental health struggles that…that were mostly kind of locked away because of the cultural environment that at the time, this was some, maybe 25 years ago now, was pretty stifling in terms of like…I think the prevailing attitude was, if you have mental health concerns, you shouldn't go into medicine. 

Like it was, it was almost like you…you, we wouldn't have that kind of person in our profession. Of course, that's...it's wrong on so many levels because these are health and human issues that cut across you, know all professions and all people groups. So that was really the start of it. And then the second part of the story is that a few years later, I became a Dean in the medical school, Assistant Dean for Student Affairs and Medical Education, and in that role, what…what was happening in the University and…and you know, lots of different progress and change, and health disparities and important work going on, on all levels of course, at the School of Medicine, but there were suicides among the faculty, and it was not, it was not a small number. It ended up being more than a dozen death by suicide among faculty physicians over a period of 15 years, and that…that…it just, I think, intersected with my own passion and I was in a position of leadership to be actually sort of put in charge of, quote unquote, figuring it out, and doing something about it and so that started a path of…of actually developing a program for the physicians and trainees at UCSD, which is still going strong today. It's called the HERE program. It's now in its 12th to 13th year. Really successful program that I think led to not only saving lives but a whole lot of policies and culture change towards, being a more supportive and just, I think, authentic community of practice where mental health experiences are, you know, can be accepted as…as a part of the…the physician’s journey. 

Jean: Thank you so much for sharing that. Wow. It's very powerful to hear you relate your story like that. I do want to get back to this question of the culture and medicine, but before that I wondered if you could just talk a little bit just about prevalence of suicide among healthcare professionals because I…I know I've read and heard that physicians specifically have the highest rate of suicide of any profession. Is that accurate? 

Dr. Moutier: Well, let me first just say that suicide rates by occupation are not the most accurate data set in the world, to put it mildly. The CDC does collect data at the time of death about occupation, but it…it's…it's coded in some various different ways across the states and counties, so that and many professions are lumped together. So what we have from the CDC is really a look at all health professions all in one bucket and among the, among occupational groups, the health professions do have higher rates, and then there's additional research looking at death by suicide compared to in physician populations compared to non-physician populations in those same regions of the world. And those research studies also show elevated rates. So, I think it is safe to say that it, that physicians are among the higher suicide rate occupational groups. Although I wouldn't venture to say that they top the charts because there are some groups actually with enormously high rates. For example, in the agricultural industry, farmers fishing industry, construction industry, law enforcement, and physicians. I would say interestingly, all of those which, if you think about it, what not that they, not that we can draw conclusions across all up, you know all of those, but there is a, there are some cultural themes of stoicism, a macho culture where you are, you're…you play a role that sort of extra, in the case of physicians, you know, caregiving to others healers not…not necessarily needing help ourselves and…and in the case of law enforcement and physicians and also by the way like airline pilots, there is also an issue of public safety that has…has perhaps led to some misunderstanding about how mental health may or may not come to bear when it comes to the public safety role that those professions are in.  

Jean: OK, you know you're leading me right back to where I wanted to go, but so in some ways that it seems that our society is becoming more comfortable talking about mental health. Generally. I see public figures posting about their struggles with depression or other mental health issues all the time. And do you think it is getting any easier for medical professionals to do the same? 

Dr. Moutier: It…it is. I think it you know the way I see cultural change happen, not just in medicine, but a cross like larger swaths of…of the national, you know, community within our country. It always happens. this way where there's like a strong but really tiny sort of vocal movement that starts to pop up. And that I think it's beyond that tiny movement now within medicine so that you have individuals speaking out as physicians. The National Suicide Prevention Week at which is a national thing that happens in September. So wonderful timing that we're actually doing this now. A group of physicians started the National Physician Suicide Awareness and Prevention Day, which is on September 17th of 2020 this year. So and…and not just that, but you have people like Doctor Weinstein who wrote about his own really significant experience that included hospitalization and significant treatment for…for severe mental illness, and published his narrative in the New England Journal of Medicine and you see narratives like that all over the place. They’re…they're not one off anymore and you know, say what also happened at the national level within the sort of field of medicine, particularly academic medicine, is that it reached a tipping point, where I think the data was…was hard to refute any longer. And then with the…the consecutive two suicide deaths of two medical interns in New York City in 2014. That for… or probably a variety of reasons, was a sort of lightning rod and a turning point so that the AAMC, the ACGME, the AMA, the National Academy of Medicine, sort of 1 by 1 have taken up the issue. Now some of them will couch it more along the lines of physician burnout wellness, but some also specifically include suicide prevention.  

Jean: Great, so it sounds like clearly there has been growth and progress. Especially, you mentioned the program that you established at UC San Diego. That's fantastic. I wonder, though, if we could just still talk…I wonder if the word is getting down to the grassroots, so to speak, with the students with the residents with physicians themselves. Because it…it does seem to me that as a society, we still do expect our medical providers to be superhuman and superheroes just don't have problems, right? So, I wonder if the people doing the work on the front lines, the clinicians, do you think that they understand that it's acceptable for them to say I need help? I can't sustain this level of intensity forever. 

Dr. Moutier:  Yeah, it's a great point you're making because it…it takes time for top down culture change to actually be taken up by… 

Jean:  Right.  

Dr. Moutier: …the people who are either the most junior in the profession or the most vulnerable and so that is absolutely true. And I don't think that probably most practitioners are as in touch with…with all of these truly quite remarkable changes that have been going on in terms of this sort of movement of attitudinal change and policy change on the part of these national organizations. The other thing that’s…that's a barrier that will probably always be with us when it comes to mental health, distress, and suicide risk, is that is our human nature itself, and this is a tough one. But you know when you're the one feeling not yourself, it feels scary and also by the way those…those experiences stem from the organ in our body, the brain, and so we're having we're in a place where our…our very kind of brain processing, might be distorting things. You know, cognitive distortions are really common. Our brain does lie to us, and when we're not feeling our best, there's sort of an extra layer of shame, so that if you think about even the very primal instinct that animals, even insects…insects have when they are, they are feeling under threat, is to ball up. To withdraw and to go silent and…and basically you know, hide. And so what I think is…is especially important for us as colleagues or us as leaders in health systems, in…in a clinical setting or a training setting, is to be aware of both levels of sort of if you want to call it stigma, the part we're talking about now is really the self-stigma that isn't even a conscious thing. It  happens automatically and we have to actually overcome that, so that then, when you're when you're looking at behavioral signs of possible deterioration in mental health or suicide risk, you actually need to take very subtle changes as possible sort of tips of the iceberg in terms of larger shifts that are going on in their level of risk.  

Jean: OK, one last question on this topic, and that is what can be done to make it more comfortable for medical professionals to talk about their mental health and to ask for help? 

Dr. Moutier: Yes, it…it really takes a multi-pronged strategy, that is, that is sort of like a public health approach where you start with the layer of universal education and you…you…you basically run a long sustained long running educational campaign, if you will, that prioritizes this message that it is normal for physicians to be human beings and to have mental health as dynamic along the continuum of…of mental health experiences. As…as any human being and that we will do better for ourselves as individuals for our patient care, and for ourselves as a profession if we treat it without stigma, just like we would a physical health issue. We have ways of addressing those for physicians, and if we keep that as our anchor, that will ground us both personally or if you're addressing a concern in a colleague or a trainee. But also, for example, one of the, one of the biggest barriers in help seeking for physicians has been what…what I now consider a pretty outdated way of…of…of...of addressing mental health concerns, which…which could be summed up by the state medical boards approach to inquiring about mental health concerns on the licensing forms. And that has been a specific focus. A movement of change that the Federation of State Medical Boards has been taking on in a very proactive, but evidence-based way, and I've been involved with them at various times in their effort. I'm actually aware that the North Carolina State Medical Board has been really like top of their class in terms of the changes that had been made to treat mental health just like physical health. So that really according to the Americans with Disabilities Act, you don't ask about the health issue itself. You keep the questions focused solely on current impairment, and impairment from safe practice. So that's really important for people to realize, especially in the state of North Carolina. That that is not a barrier. You do not have to check a box. If you're getting treatment for depression, and that has never come close to impairing your practice, which by the way, for the vast majority of us, as physicians who engage in therapy, or need antidepressants or…or you know psychiatric treatment. It, just like medical conditions, very rarely impede our safe practice. The same is true of mental health conditions. 

Jean: Well, thank you very much for mentioning that. We are more than three years in now from removing that question from the renewal questionnaire. I believe it was 2018 that we removed it from the license application question. But it is definitely something that we want people to know about that. Instead of a question, there is now a statement that simply says if you have any medical or mental health concern, please take care of yourself and you know that…that's basically it. You know we're not asking anyone to disclose that information to the board. So… 

Dr. Moutier: Yeah, again, I…I just, I really commend you for making that change. I. I'm not even sure if you are aware of this, but in 2018, I wrote an invited paper for the Federation of State Medical Boards which was published in their Journal of Medical Regulation and they…they wanted me to speak to that. It was quite an incredible opportunity for me to just say what I think state medical boards should do, and that was that was my top recommendation. Exactly what your state medical board has done. So again, kudos to you all.   

Jean: Well, thank you very much. We certainly hope the change has encouraged more people to get the help they need. Now, we are going to take a short break and then I will continue speaking with Dr. Christine Moutier. 

NC PHP Segment: 20:44 
If you are in crisis right now, or know someone who is, I want to mention a free resource that is available to physicians and PAs.   

If you are ready to get help, call 919-870-4480. That’s 919-870-4480. That number will connect you with the North Carolina Professionals Health Program and it is answered 24 hours a day, seven days a week.  

Just say that you are interested in getting help. You will be put in touch with someone who will schedule an initial assessment and make a recommendation for treatment. You will also receive a referral to a mental health professional in your area who specializes in working with medical professionals.   

And again, there is no charge for this service.   

Interview Continues: 21:40 

Jean: Welcome back to our conversation with Dr. Christine Moutier. Dr. Moutier, we may have listeners who do not happen to be in North Carolina or who prefer to use a different resource than the one that we just mentioned. What suggestions do you have for listeners who are interested in getting some help? 

Dr. Moutier: Great, thank you so much for letting me shine a light on these resources specifically for physicians, and some are for other frontline health workers that include physicians. But it's pretty incredible that during this period of Covid there have been several brand new resources that I'm going to mention. So, the main national crisis resource that is really reliable and important to know about is the National Suicide Prevention Lifeline. And you can call it if you're the person in distress, or if you're the one helping someone in distress. And that's 1-800-273-TALK (8255). The other national resource we use for the whole general public, that's very safe and confidential, is the crisis text line, where you can text the word talk to 741741. But the ones that are specific for physicians now on a national basis include a new resource called the Physician Support Line. And they have a website:  physiciansupportline.com and their number is 1-888-409-0141. They are staffed by voluntary psychiatrists who do not record the information anywhere but will provide highly confidential advising to any physician who…who called, so it's quite an incredible new resource. There are some other ones that I will mention the Emotional PPE project. And the…the way to find that is emotionalppe.org, and that is a listing of mental health professionals who have specifically given of  their time to provide free therapy or treatment to frontline health workers and physicians. So those are two really special ones. And then two of my favorite, just sort of physician resources, are the Federation of State Physician Health Program website, has a fantastic listing of resources that include things like virtual treatment options including virtual recovery group, for those who…who experience addiction or in recovery. And then the last one I'll mention is the National Academy of Medicine. And they have a gathering of Covid clinician resources. If you search that under National Academy of Medicine and you'll see links to probably all of the above that I just mentioned as well. 

Jean: That is great. I am, I'm so glad to hear that there are so many resources available. 

Dr. Moutier: Yes, yeah it…it really is. You know Covid has been such an interesting time of really almost normalizing the experience of struggle at some level and so more than ever, I think stigma is sort of removed from the equation because it's everyone who is experiencing some level of stress or strain, if not really significant, depression, anxiety, PTSD, you know, substance use those kinds of things.   

Jean: That… that is such a great point. Now I wanted to shift the focus just a little bit to listeners who are not struggling with depression themselves but are interested in what they can do to help a colleague or friend that they think might be having trouble. It seems to me that many, if not most people would want to help a struggling colleague if they could, but we just don't know how. We don't know what to say. Can you offer some strategies? 

Dr. Moutier: Absolutely thank you for this because it's really true that we all want to help. We actually have…have polls of the general public as well as with health care professionals, and everyone wants to be able to help, but…but a significant portion say they don't have the skill set, and I think the first thing to know as a physician is that when it comes to your colleagues and your trainees, you are not their treating physician and that actually relieves you of your usual instincts, that can actually ironically present a barrier. I've heard a lot of confusion in the past. Maybe this is done now, I hope. That if a trainee, if they were to uncover a trainee who's experiencing suicidal thoughts, for example, that they would be obligated to report that to some you know board or body. That is not true. That would be like saying you're obligated to report a trainee who's having you know an acute crisis related to their appendix or…you know, in your, not in the role of a clinician. This is either your colleagues, this is your community, and so you can treat them much more like you would treat a neighbor, or you know someone in your…in your faith community, that and…and. So what I would say is when you work side by side with people overtime, you learn their mannerisms and their daily kind of behavioral little quirks and habits. We all do that; we just pick up on those things and so trust your instinct when you notice that something seems off. It might be subtle. It might be just an issue of like they seem late when they're not. Usually someone who shows up late or it's the way that their tone of voice that they're speaking in in a way that makes them seem more overwhelmed or hopeless despondent, trapped like they feel like they are a burden. You know, they're not doing anyone any favors. When people start talking about others would be better off without me. And those are all really significant indicators that…that your colleague is at risk. And what I would do is engage them in a, in a caring and private conversation. You can consider it like a coffee chat type conversation where you simply open up a conversation in a very open-ended supportive way and hope that they will. You can tell them I'm not here to judge you, I really want to understand what you're going through so that I can be a supportive colleague and really just leave it open ended and let them share and you might…you might need to tell them why you're having the conversation. I think you don't need to keep that a secret 'cause they might be thinking, you know, remember if they're in distress, to their mind is going to be a world thinking about “am I in trouble”? “Did I do something wrong?” So, a lot of reassurance and I'm approaching you because I noticed you just don't seem yourself. You know, you…you showed up late few times and that's just not like you. I'm wondering and I've heard you talk about the things you're going through at home. I'm wondering if you're OK and how I might support you better but really, I just want to understand what you're going through.  

Jean: OK, now I'm imagining this myself. What if someone deflects and says hey, thanks for your concern, but I'm fine, but you really don't believe them? I mean, most of us, as you said, with your example about the insect, is most of us have the instinct to withdraw and deflect and to hide. And you know, I guess that's something that I have wondered about personally. Is how hard do you push? You don't want to make things worse.  

Dr. Moutier: Right. Well, I would…I appreciate you bringing that up because I think it will happen a good portion of the time, because your timing may not line up with their readiness to share and to open up. But…but if you think about it rationally, and don't take it personally, 'cause I think you know if we do that then we get sort of, we might get scared or think that they thought we were being intrusive. You know the truth is they just may not be ready to share yet. And this is this is a voluntary conversation. You know, you're just you're trying to be a supportive friend and colleague. I think just saying, hey, that is no problem at all, but just know that I'm here and then I think you know over days and weeks if you continue to notice the same things or you know the situation seems to be worsening, I would try again. And…and…I, you have to fight your own instinct to feel like you're being intrusive or a pest, but remember, especially in the profession of medicine we have to help overcome those…those barriers that have been there historically forever and those human instincts. And in a sense, in that way, we are our brothers and sisters, keepers in that we are also protecting them and the profession by…by kind of going out of our way a little bit extra. 

Jean: Is there anything else that you would like to add on the topic, specifically of intervening? 

Dr. Moutier: Well, I would just let people know about our website afsp.org, where all of these messages that I'm sharing where there…there are lots of those types of messages and maybe deeper dives on our website where you can learn about how to have the brave caring conversation, we call it. If you're not sure how to find treatment for a loved one or for a patient, we have a treatment finder link page. If you're interested in getting more involved in the advocacy arena of suicide prevention and now even in the arena of physician suicide prevention, there are legislative and advocacy things going on, and you can sign up to get our…our policy alerts by becoming a voluntary field advocate. So, there are so many different ways that people can get involved, but I think just the main message I would leave you with in terms of your own role with colleagues, is just to not…don't…don't underestimate the influence you have as just a supportive colleague and how much that might mean to…to someone, particularly when they're struggling. 

Jean: Well, Dr. Moutier, thank you again for your time and your valuable insights. I hope we've given listener some practical strategies that they can apply. 

Dr. Moutier: Thank you so much Jean. It was really great speaking with you. 

Jean: Same here and…and thanks again.  

Closing Thoughts: 31:56 

Well that brings us to the end of the first episode of MedBoard Matters. I hope you got something useful out of it, and I hope you will join us again. Until then, I’m your host Jean Fisher Brinkley. Be well.  

If you have any comments or questions about today’s episode, please email us at: podcast@ncmedboard.org