Depression and anxiety are common conditions with prevalence ranging between ten to twenty percent in the general population for any twelve-month period. 1 Depression in the working age population is estimated to cost $12 billion annually in medical care and approximately $44 billion annually in lost productivity. 2 Mental health affects physical health, job performance and healthcare utilization. Stress, depression and anxiety disorders contribute to absenteeism and lack of confidence. 3 Despite knowledge about stressors and health hazards, health professionals are often not aware of the factors that contribute to their own general and mental health. Several factors have been identified that contribute to burnout and lack of job satisfaction in Emergency medicine. Various coping methods have been identified which can reduce stress; however, stressors and the subsequent development of anxiety and depression must be identified before intervention methods can be utilized.
The Brief Patient Healthcare Questionnaire (Brief PHQ) is a validated dual-purpose screening tool. This questionnaire has been widely used in primary care settings to screen for depression. Additionally, it has been used successfully to identify the severity of depression and to identify symptoms of anxiety. 4 We used the PHQ-9 to examine the prevalence of depression and anxiety symptoms among health care workers, particularly physicians within an inner city Emergency department (ED).
The objectives of this study were to: identify the prevalence of depression and anxiety among healthcare workers in the emergency department, determine if rates of depression and/or anxiety differ between genders or professional roles, assess the level of functional difficulty due to depression/anxiety, determine the validity of the Brief PHQ as it pertains to healthcare providers, and offer resources for therapeutic intervention to participants of the study.
Materials and Methods
An open label, nonrandomized, prospective survey was conducted in 2004-2005 after IRB approval. A convenience sample of non-union staff including resident physicians, attending physicians, nurses and ancillary staff was invited to participate in the survey. Written consent was obtained prior to survey completion. A list of mental health resources was made available to all participants. Staff completed an anonymous two-page survey that included demographic information, smoking history, Brief PHQ-9, and history of medical treatment for depression and/or anxiety. Responses for nine questions (PHQ-9) were compiled for a total score to determine depression severity. Individuals with scores > 10 or positive response to suicidal ideation were classified as exhibiting symptoms of depression. Refer to Appendix. Remaining questions evaluated presence of panic symptoms and other anxiety symptoms.
Data analysis was done using Microsoft Access 2000. Descriptive statistical analysis was performed using Minitab for windows, version 12.1. Differences between dichotomous variables were assessed with the Chi Square statistic. All statistical tests were analyzed using an alpha value of 0.05 and beta value of 0.2.
Survey was completed by 83 members of the emergency department staff. Eighty six percent of the surveys were completed by physicians, fifty-nine percent of whom were resident physicians. The sample did not adequately reflect nursing or ancillary staff. The average age was 35 years and slightly more males than females completed the survey (53% vs. 43%). (Table 1)
The average PHQ-9 was 3.6 indicating minimal depression. The average depression score for resident physicians was higher than for attending physicians (4.4 versus 2, p&ln;0.05). Females were found to have higher rates of depression than males, however the difference was not significant (3.6 vs. 2.9, p=0.29). Eight percent of the respondents had PHQ-9 depression severity scores suggestive of moderate depression with prevalence higher in resident than attending physicians. One individual had suicidal ideation and was not receiving medication with PHQ-9 score indicative of mild depression. (Chart 1 and 2). Several physicians who had PHQ-9 scores indicative of depression and/or anxiety were not receiving medication.
The prevalence of undiagnosed anxiety/panic disorders was less than that of undiagnosed depression. (Chart 3) Table 2 highlights the factors that contributed to symptoms of anxiety. These factors include appearance, health-related concerns, financial difficulties and work-related stress.
Thirty-seven percent of those surveyed reported that the symptoms of depression and/or anxiety caused some degree of difficulty functioning. The PHQ-9 scores for those who reported functional difficulties were higher and correlated with the diagnosis of depression symptoms (8.8 vs. 2.0).
|POSITION||AGE AVG (YRS)||MALE N (%)||FEMALE N (%)||BLANK N (%)||TOTAL N (%)|
|Total||35.32||44 (53%)||36 (43%)||3 (4%)||83|
|ISSUE||NOT BOTHERED||BOTHERED A LITTLE||BOTHERED A LOT|
|a. Worrying about health||47%||48%||5%|
|b. Weight or appearance||33%||60%||7%|
|c. Sexual difficulties||74%||22%||4%|
|d. Partner difficulties||68%||22%||10%|
|e. Stress as a care giver||68%||25%||7%|
|f. Stress at work||51%||41%||8%|
|g. Financial difficulties||45%||45%||10%|
Several studies have demonstrated that self-reported rates of depression are similar in physicians and the general population with a lifetime prevalence of approximately 12 percent. 2 Prevalence of depression among medical students and resident physicians has been shown to be as high as fifteen to thirty percent. 1 We administered a Brief Health Questionnaire (Brief PHQ) to determine if the rate of depression and anxiety among our emergency department staff was consistent with the previously reported findings. Our results revealed that the rates of depression in the emergency department staff are similar to those of the general population. Moreover, it is estimated that 25% of the general population suffers from an anxiety disorder with 3.5% experiencing panic symptoms. 2 Our findings revealed a similar prevalence of panic symptoms in the ED physician staff. The four major factors that contributed to symptoms of anxiety included weight or appearance, health related concerns, financial difficulties and work related stressors.
Unfortunately, nurses and ancillary staff did not participate and the difference between professional roles and depression could not be ascertained.
Emergency medicine is a specialty known to be associated with occupational stress, anxiety, depression, and burnout. Burnout is characterized as emotional exhaustion, depersonalization, and lack of sense of personal accomplishment. 5 In 1996, Goldberg et al surveyed 1,272 emergency medicine (EM) physicians using the Maslach Burnout Inventory. Sixty percent of the physicians polled registered in the moderate to high burnout ranges. 6 Independent variables associated with higher levels of stress and depression among EM physicians included female gender, marital status and level of training. 7 Additional factors include high patient loads, high patient mortality, peer competition, long hours and sleep deprivation. 8
Depression and anxiety are known to cause decreased levels of productivity and absenteeism. Identification of employees at risk of clinical depression is crucial to early intervention and increased productivity and career longevity. In a study by Gallery et al, 12.4% of EM physicians surveyed indicated they were likely to leave the specialty within one year and 26.7% planned on leaving within five years. 9
Coping strategies have been employed to help physicians manage stress and depression. Some of these strategies include debriefing, counseling, stress management classes and medical therapy.
The survey indicated that the level of depression and anxiety in our ED staff is consistent with the general population. The Brief PHQ appears to be a reasonable screening tool to screen for depression, severity of depression and anxiety in a physician sample. This may be a useful tool to screen other physician groups and monitor levels of depression in subsequent years of residency training when early intervention and coping strategies may be employed.
Williams S, Dale J, Glucksman E, Wellesley A. Senior house officers’ work related stressors, psychological distress, and confidence in performing clinical tasks in accident and emergency: a questionnaire study. BMJ.1997;713:718.