OCD & Anxiety Lecture SeriesRegister today on EthosAll dates: 9:00 am – 12:15 pm

Sessions I & II - Friday, March 26, 2021Session I: Core Concepts in Diagnosing and Treating Obsessive Compulsive Disorder with Cognitive Behavioral Therapy - Jon Hershfield, MFT

Session II: Medication Protocols for Obsessive Compulsive Disorder, New Research, and Differential Diagnosis - Robert Hudak, MD

Sessions III & IV - Friday, April 23, 2021

Session III: Treating Pediatric Obsessive Compulsive - Aureen Pinto Wagner, PhDSession IV: Working With Families and Treatment Refusal - C. Alec Pollard, PhD

Sessions V & VI - Friday, May 21, 2021Session V: Inhibitory Learning Theory in Exposure-based Treatment of Obsessive Compulsive Disorder - Jonathan Abramowitz, PhDSession VI: Disgust and Not Just Right Experiences in Obsessive Compulsive Disorder - Dean McKay, PhD

1

Psychology WorkshopsRegister today on EthosAll dates: 9:00 am – 12:15 pm

Friday, March 12, 2021, 9:00 am – 12:15 pm, Virtual Classroom Evidence Based Care for Refugee, Asylee, and Immigrant PatientsRachel R. Singer, PhD and Renee DeBoard-Lucas, PhD

Friday, May 7, 2021, 9:00 am - 12:15 pm, Virtual Classroom A Workshop on Motivational interviewing: Gaining Traction with Patients Who Feel Stuck Rachel Smolowitz, PhD

Friday, June 5, 2021, 9:00 am – 12:15 pm, Virtual Classroom Clinical Suicidology: Innovations in the Assessment and Treatment of Suicidal RiskDavid Jobes, PhD, ABPP

3

Disclosure Statements

Sheppard Pratt holds the standard that its continuing medical education programs should be free of commercial bias and conflict of interest. In accord with Sheppard Pratt's Disclosure Policy, as well as standards of the Accreditation Council for Continuing Medical Education (ACCME) and the American Medical Association (AMA), all planners, reviewers, speakers and persons in control of content have been asked to disclose any relationship he /she (or a partner or spouse) has with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients, during the past 12 months. All planners, reviewers and speakers have also been asked to disclose any payments accepted for this lecture from any entity besides Sheppard Pratt Health System, and if there will be discussion of any products, services or off-label uses of product(s) during this presentation.

Michael F. Myers, MD, reports as having no financial interest, arrangement or affiliation with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients, during the past 12 months. He will not discuss any products or services consumed by, or used on patients in this presentation.

Event Planners/Reviewers Disclosures: The following event planners and/or reviewers are reported as having no financial interest, arrangement or affiliation with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients, during the past 12 months: Todd Peters, M.D., Sunil Khushalani, M.D., Faith Dickerson, Ph.D., Carrie Etheridge, LCSW-C, Tom Flis, LCPC, Laura Webb, RN-BC, MSN, Stacey Garnett, RN, MSN, Heather Billings, RN, and Jennifer Tornabene.

4

Sheppard Pratt Approval Statements

Physician Statement: Sheppard Pratt is accredited by The Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. Sheppard Pratt takes responsibility for the content, quality, and scientific integrity of this CME activity. Sheppard Pratt designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Nurse Statement: Sheppard Pratt is an approved provider of continuing nursing education by Maryland Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation. Sheppard Pratt takes responsibility for the content, quality, and scientific integrity of this CME activity. This provides 1.0 contact hours for nurses.

Psychologist Statement: Sheppard Pratt is authorized by the State Board of Examiners of Psychologists as a sponsor of continuing education. Sheppard Pratt takes responsibility for the content, quality, and scientific integrity of this CME activity. Sheppard Pratt designates this educational activity for a maximum of 1.0 contact hours for Psychologists.

Social Worker Statement: Sheppard Pratt is authorized by the Board of Social Work Examiners of Maryland to offer continuing education for Social Workers. Sheppard Pratt takes responsibility for the content, quality, and scientific integrity of this CME activity. This activity is approved for 1.0 contact hours in Category I credits for Social Workers.

Counselor Statement: Sheppard Pratt has been approved by NBCC as an Approved Continuing Education Provider, ACEP No. 5098. Programs that do not qualify for NBCC credit are clearly identified. Sheppard Pratt is solely responsible for all aspects of the program. This activity is available for 1.0 NBCC clock hours.

5

Learning Objectives

After attending this program, participants will be able to:

1. Discuss the insights gleaned from the loved ones of doctors who have killed themselves.

2. Explain the ways in which stigma works against timely and effective life-saving treatment of suicidal physicians.

3. Describe systemic, educational, and therapeutic changes that will help to save lives of symptomatic physicians.

Physician Suicide: How Postvention Informs Prevention

(Psychiatry Grand Rounds Sheppard Pratt Feb 10, 2021)

Michael F Myers, MD

Professor of Clinical Psychiatry

SUNY Downstate Health Sciences University

Brooklyn NY

Setting the stage….

• “No one who has not been there can comprehend the suffering leading up to suicide, nor can they really understand the suffering of those left behind in the wake of suicide.”

• Kay Redfield Jamison PhD. From the Foreword. MF Myers and C Fine “Touched by Suicide: Hope and Healing After Loss”

Setting the tone….

“…..any man’s death diminishes me, because I am involved in Mankinde…”

John Donne, Meditation XVII “No Man Is an Island” (1624)

8

The problem of physician suicide

• We lack evidence to claim physician and non-physician suicide rates differ.

• Among suicide victims, physicians had more mental health problems than non-physicians.

• Previous suicide attempt was more likely in female vs. male physicians.

• Male-to-female proportion of suicides was lower in physicians (2:1) than others (4:1).

• Ye GY, Davidson JE, Kim K, Zisook S. Physician death by suicide in the United States: 2012-2016. J Psych Research 134 (2021) 158-165.

9

The problem of physician suicide

• Three meta-analyses = inconsistent results

• MDs of both genders are at elevated risk (Schernhammer and Colditz, 2004) and (Dutheil et al, 2019)

• Only female MDs are at elevated risk (Duarte et al, 2020)

• Also, a 2016 report of suicide rates from 32 states in the US found 26 occupational groups to have a higher rate than the general population, but MDs were not among them (Peterson et al, 2020)

10

Some background……(Myers MF. Why Physicians Die

by Suicide: Lessons Learned from Their Families and Others Who Cared)

• In January 2015 I began interviewing survivors of suicide loss – individuals who had a relationship with the deceased physician

• Family members, colleagues and friends, room-mates, professors, students, training and clerkship directors, therapists, and patients

• I also interviewed physicians who had attempted suicide and did not die

• My small “data base” over time significantly increased by word of mouth and call outs

11

Some background………

• My objective was (is) simple: to capture the words, emotions, voices, observations, hunches, speculations of individuals who knew the physician in some capacity over time – both long and short

• My hypothesis was (is) that this information is precious and unique – that it will add to what we already know from robust physician health research on what factors drive self-destruction in doctors

• Also, can we learn anything that resides outside of the psychiatric illness drivers of suicide?

12

The interviews

• Both in person and over the telephone (and Skype)

• USA, Canada, UK, Australia

• Semi-structured but never at the expense of offering the interviewee the opportunity to “tell their story.”

• I’ve always been respectful of the context – that I am entering the world of individuals in the midst of grieving and healing – necessitating great care, sensitivity and humility

• Bidirectional gain, hopefully – learning and comfort

13

The interviews

• Number of decedents = 51

• Number of interviews = 82

• In person = 30

• Telephone/Skype = 52

• Duration = 45 minutes to 2 hours

• Myers MF. “Toward Preventing Physician Suicide: The Humanity of Colleagues Upon Losing One of Their Own” Paper to be presented International Conference on Physician Health. London. April 29, 2021

14

Findings/Results

15

Number one

• Concern – shared and unshared with the decedent – about the heavy toll taken on the health and functioning of their loved one by the demands of medical training and medical work

• Or the strain of their personal/family problems

• Many made statements about the individual’s burnout, depression, sleep disruption, turning to alcohol or other forms of self-medicating, irritability, obsessiveness with getting caught up, withdrawing from them and/or family life

16

Number two

• At least 15% of MDs killed themselves without receiving an assessment or Rx by a health professional

• Their families are calling for increased education about common psychiatric illnesses in doctors:

• Basic education for families i.e. what to watch for in the physician, how to talk about it, treatment options

• Education for physicians themselves i.e. symptoms and behavioral changes to heed

17

Physicians who received no treatment

• “I pleaded with my wife to get help and she kept saying, over and over again ‘No, I’ll be fine, just give me time, this will all go away. Sure I’m depressed…but this is a very busy and demanding rotation…I’ve only got a few more weeks then whoopee – vacation, can’t wait.’ I knew she had seen a shrink in medical school and that went badly. The asshole came on to her. So she was leary, scared. I couldn’t change her mind.”

• Words of Mr Doe. He lost his wife Dr Kay, a resident, to KClinfusion in 1998

Physicians who received no treatment

• “My husband took pills and scotch, the pills were self-prescribed, there was a bill from the pharmacy after he died. He did it in his office. Just like his father, he was a doctor too. But the family covered it up. They said it was cancer. He couldn’t live in the real world. Problems with his kids weighed on him. He got depressed and refused to see a psychiatrist. He just withdrew into a dream world. Then he was gone.”

• The words of Mrs Hill. Her husband killed himself in 1989.

Physicians who received no treatment

• “My partner and I were together for 17 years. He told me that he had tried to kill himself in medical school. But he was fine then, until AIDS hit. He was a ground zero doctor. He came home crying almost every night ‘my patients have so much I can’t fix.’ Then our friends got sick and died of AIDS. He withdrew and pushed me away. He swallowed Tylenol pills and used booze to cope. I watched him slowly die. There was no way he’d go for help. I pleaded with him. He just wanted to die.”

• The words of Mr RT who lost his partner to suicide in the 1990s

Number three

• For those doctors in care, stigma was huge and adversely affected the therapeutic alliance and treatment adherence

• Survivors are calling for education of those who treat physicians about unique fiduciary issues when one doctor treats another, paying attention to boundaries, fears of confidentiality breaches, being welcoming and taking charge of the treatment

21

A grieving widow

“I’m wondering about all that can go wrong when one doctor goes to another doctor for help. In my husband’s case, one of his doctors was someone who was once his employee…I really wonder about a power imbalance…like too many connections, too close, too much history. I’m not faulting her, I’m not blaming her…

22

A grieving widow

…it’s possible that he went to her because he already knew her, liked her, respected her. But she may have let him get away with too much, wasn’t firm enough with him, or maybe she let him ‘manipulate’ her. I don’t know, it’s all speculation, but I’m looking for things we can learn. Losing Art was, and is, so hard. I’m just trying to spare other families this heartache.”

The words of Dr Gray (pseudonym) who lost her physician husband to suicide

23

A grieving psychiatrist

“Since Carla’s death, I’ve thought very deeply about her – and our work together. I wonder how much she kept from me, how much she didn’t share. She was in recovery and being monitored – and although I didn’t have to file any reports to the physician health program, I wonder if that inhibited her from being fully truthful with me. Just the process of oversight, I wonder how much that might work against

24

A grieving psychiatrist

doctors being completely forthcoming with their therapists. And putting your best foot forward, how much does that play a role when doctors go for help? I learned a lot after her death that she had never shared with me. I wish I had grilled her more. Losing a patient to suicide is like a psychic bomb. It’s very traumatic – you feel betrayed, you’re angry, you feel so guilty and very ashamed. It’s very haunting. I’ve become a suicide hawk.”

The words of Dr Wilson who lost a physician, a resident, to suicide in 2015

25

Stigma, Rx alliance and Rx adherence• “My dad never really stuck to the treatment you

provided for him, Dr. Myers. He just hated being a patient. He felt so ashamed. I tried hard too, but even my support wasn’t enough”

• Words spoken to me by the medical student son of my patient, a psychiatrist, at the memorial service after his death by suicide

Number four

• Unrecognized suicidal behavior, including despair, by all involved – the doctor her/himself, loved ones, colleagues, treating persons, and more

• Again, survivors are calling for more education of physicians and those who treat them

27

Under-diagnosis of suicidal despair

“I spent a week with my dad at Christmas about 5 months before he died. He was not himself. There was a personality change. He was normally very decisive. He became incapable of making even minor decisions. He didn’t want to go out to restaurants and he used to love that. Then my sister passed away. He was clearly depressed….

Under-diagnosis of suicidal despair

I confronted him. He disagreed. I told him he needed an antidepressant. He said they were dangerous! But he finally agreed and talked to his doctor the next day and started one about one week later. This was shortly before he died. Friends have said that they think he had a psychotic depression that maybe wasn’t fully picked up.”

The words of Frank Watanabe who lost his father Dr August Watanabe to suicide June 9, 2009

29

Number five

• The shortcomings of treating physicians in isolation on a 1:1 basis and eschewing collateral information from significant others, especially family members

• Resides in an erroneous assumption on the part of treating personnel that because their patient is a physician, that the individual is being completely forthcoming, insightful, honest and comprehensive in volunteering symptoms and behavioral changes

30

Physician loved ones not interviewed

Spouses should be included as far as practically possible in the care of their partner, they should be acknowledged as their ‘unofficial carer’ and not viewed as an appendage or positioned on the periphery of any planned care and treatment programmes; spouses should be seen as another resource in monitoring the health of their partner,

Physician loved ones not interviewed

to be primed in recognizing signs of a relapse of their partner’s illness, and in effect be the eyes and ears of the responsible medical officer in the interim period between regular and planned appointments.

• The words of Dave Emson who lost his wife Dr Daksha Emson and daughter Freya to ‘extended suicide’ in London in 2000

• Myers MF. Becoming a Doctors’ Doctor: A Memoir. Amazon. New York. 2020

32

Dr Daksha Emson and Freya

33

Physician loved ones not interviewed

“Mental health professionals who treat doctors need to realize that if you only see the physician, you’re only getting their side of the story, what they want you to know or what they’re willing to share with you. You must talk with the family members who live with the person, your patient, and have their own particular observations, hunches, ideas and fears….

34

Physician loved ones not interviewed

The more we perpetuate the silence surrounding suicide the more survivors suffer after losing a loved one to suicide and the more isolated that suicidal people themselves feel and the more at risk they are for dying of their suicidality.”

Words of Dr Judy Melinek, forensic pathologist and co-author with TJ Mitchell ‘Working Stiff: Two Years, 262 Bodies, and the Making of a Medical Examiner’. She lost her father, a psychiatrist, to suicide 1983.

Myers MF. Why Physicians Die by Suicide: Lessons Learned from Their Families and Others Who Cared. Amazon. New York. 2017

35

Number six

• Some interviewees reported that they felt abandoned by their physician loved one’s medical colleagues and friends after the death

• Some attempt survivors felt this too

• Although many understand this as awkwardness and nervousness on the part of these individuals, they are still left with a sense of stigmatized aloneness

• They are calling for more education in medical school and beyond about suicide bereavement and the importance of “showing up”

36

Feeling shunned by medical colleagues

“My husband’s funeral was on a bright sunny day in August. Only a couple of the doctors from the hospital where he had been Chief of Staff attended. I put it down to summer vacation. When I mentioned this 6 months later in my support group, Sam who lost his dermatologist sister to suicide said that he noticed the same thing at her service. ‘If she had died of cancer, there’d be standing room only’.”

The words of Dr AB whose husband killed himself in 2008

37

Feeling shunned by medical colleagues

(From an email penned to me by a physician who survived a near lethal suicide attempt. Subject line “halfway through your book”)

“I am stunned at the breadth of information I did not know. Needless to say, my impulsive poorly planned event was decided and acted on in about 30 minutes. Healthy with therapy, and doing well otherwise. One thing that I have noticed over and over again, is physicians varying ability to cope with my event….

38

Feeling shunned by medical colleagues

living in a smaller community, my story is well known. When talking with someone and they figure out who I am, a wall goes up. What was a collegial appointment turns into an emotionless contact. I have become that thing they don’t understand and don’t want to admit exists. Thank you for speaking out to all of us.”

John Doe, MD

39

Number seven

• A salute to survivors

• Survivors of physician suicide are hosting grand rounds, speaking at events, writing articles and books, and volunteering at postvention events

• Ditto for physician survivors of suicide attempts

• They are committed to making a difference – to save even one ailing doctor’s life – and to honor their deceased physician loved one, to remember and to ensure that he/she has not died in vain

40

Some examples of survivors

• Virginia Leary-Majda and Dr Lev Gertsik – the John A Majda, MD Memorial Fund at UCSD School of Medicine

• Gary Marson book “Just Carry on Breathing: A Year Surviving Suicide and Widowhood”

• Peter J Warshaw book “Convergence”

• Sally Heckel film “Unspeakable”

• Matthew Ogston “Naz and Matt Foundation” https://www.nazandmattfoundation.org

41

Examples of survivors of suicide attempts• Dr Janine O’Kane – interviewed in the videotape on

narratives on physician suicide (Myers 1998)

• Dr William Hynes – urologist – author of “The Last Day” Annals of Internal Medicine May 3, 2016

• Dr Douglas A Landy – psychiatrist – author of “Suicide: A Survivor’s Perspective” https://www.psychcongress.com/blog/suicide-survivors-perspective

42

A grieving training director

• “It is with a heavy heart that I write this….The unbearable has happened at the University of Kentucky. Last Friday we discovered that one of our residents was tragically taken from us. It appears that the resident took their own life….This is a catastrophic loss for our program and for his family and friends. While I am immensely embarrassed that I lost a resident ‘on my watch’ and guilty that I didn’t see this coming, this needs to be

43

A grieving training director

said…I make this information public in order to shine a bright light on a problem that often lurks in the dark. Suicide, and specifically suicide in our trainees, is a significant risk and we are at higher risk than the general public. In order to face this issue, we must acknowledge its existence. We must ‘speak its name’. We must learn about it and talk about it.”

Dr Chris Doty from an email that he sent to his colleagues in EM in January 2016

44

A grieving room-mate

• “I saw him briefly when he dropped something off back at the apartment. This was the last time I saw him. He looked at me and shook my hand. He said something, a common use of words, he looked me in the eye. Later in the afternoon I got a text message from a friend of his friend about his death.

45

A grieving room-mate

I was shell-shocked, thank god my friend was with me. I stayed with him and his girlfriend for about a week or so. This hurts so much. I’ve repeated to myself ‘what were you thinking Todd?’. I’m so fortunate to have started therapy and I have very strong supports in my life.”

Fragments of a telephone interview I had with DrBillings (pseudonym) about losing his room-mate, Todd, another physician, to suicide

46

A grieving class-mate and room-mate: my story 1962• The words of our landlady: (it was Monday October

8 at around 8pm.)“I have sad news to tell you. It’s about your room-mate Bill. His parents called a couple of hours ago. They said he won’t be coming back to medical school. He died over the weekend. They said it was suicide.” I was stunned and felt sick to my stomach.

• Myers MF. Becoming a Doctors’ Doctor: A Memoir. Amazon. New York. 2020, page 4-5.

47

A grieving patient

“My family doctor was more like a friend to me than a doctor. She really, really cared about me as a person, not just someone with aches and pains. She always took the time to ask about my kids, and especially my mom, who has Alzheimer’s. I think she was like this with all her patients. I can’t believe she’s gone. And in such a sad way.”

The words of Ms Samson who lost her GP to suicide in 2008 in Australia. She volunteers at Beyond Blue, in suicide prevention.

48

Systemic, educational, and therapeutic initiatives

49

Collectively we are making a difference!• National and International Conferences on

Physician Health

• National Physician Suicide Awareness Day was launched on Monday September 17, 2018

• Moral Injury of HealthCare (Drs Wendy Dean and Simon Talbot) https://fixmoralinjury.org/

• NHS Practitioner Health Programme – Dr Clare Gerada

• Dr Geoff Toogood – campaign #CrazySocks4Docs

• Dr Kieran Allen - @ManyHatsNetwork

50

Collectively we are making a difference!• National Academy of Medicine

• American Psychiatric Association

• American Medical Association

• American Medical Women’s Association

• ACGME

• Association of American Medical Colleges

• American College of Emergency Physicians

• Physician Support Line 1 (888) 409-0141

• Dr. Lorna Breen Health Care Provider Protection Act

51

To sum up…..

• “Since suicide is a complex health outcome with many drivers of risk, preventing suicide requires a strategic, multi-pronged, evidence-based attack that can be sustained over time.”

• Moutier C, Myers MF, Feist JB, Feist JC, Zisook S. Preventing clinician suicide: A call to action during the Covid-19 pandemic and beyond. Acad Med. In Press 2021

52

In appreciation

• To all the individuals who have been interviewed for their generosity and commitment to prevention

• To all my colleagues and friends in the physician health movement and the field of suicidology

• To all of you for coming. Please share your insights with your colleagues who can’t be here today

• To the many physicians whose tragically interrupted lives have informed this work

• Contact: 718 270-1166 or michael.myers@downstate.edu or www.michaelfmyers.com

53