Symptoms of depression in ICU physicians

Work and family are two domains from which most adults derive satisfaction in life; equally they are the common sources of stressful experiences. There is a perception in the community that work is increasingly the source of much of our stress and distress. Intensive care unit (ICU) physicians are generally perceived as very dedicated, perfectionist and exigent professionals. The culture of medicine accords low priority to physicians’ mental health.

Some studies have documented depressive and other psychiatric manifestations in women physicians and other professionals, and speculated that these symptoms are related to stress [1]. However, the prevalence of depressive symptoms in ICU practitioners has received little recent scientific attention. ICU doctors also are thought to be susceptible to “burnout,” a description for work-related distress that combines emotional exhaustion, depersonalization (treating people in an unfeeling, impersonal way), and a sense of low personal accomplishment [2]. Burnout is a problem that is specific to the work context, in contrast to depression, which tends to pervade every domain of a person’s life [3].

A recent report from the Centers for Disease Control and Prevention indicated that 9% of American adults met the criteria of current depression [4]. Coomber et al. [5] reported that approximately one third of U.K. ICU doctors appeared distressed and 10% reported depressive symptoms. Most of the attention has been focused on junior doctors and their long working hours. However, there also have been reports of distress among senior hospital doctors [6, 7]. Because these factors are closely linked and because few studies have previously investigated depression in the intensive care environment, we designed a study to assess depressive symptoms among all intensivists (interns, residents, fellows, attending physicians). We hypothesized the following: 1) there is a high rate of depressive symptoms among intensivists; 2) presence of depressive symptoms in intensivists could be associated with the severity of illness of patients; and 3) depression in intensivists may be associated with organizational factors, such as workload and relationships with colleagues.

This study related to the prevalence of depressive symptoms was an ancillary study of the survey dedicated to the burnout among French ICU physicians [2].

A total of 189 of the 318 (59.4%) French ICU directors accepted to participate. A total of 1,189 surveys were sent on March 6, 2004, and the survey took place on March 25, 2004. A total of 901 surveys were returned (75.8% response rate).

Prevalence of the symptoms of depression in intensivists and desire to leave the job

Mean CES-D scale score was 14.2 ± 9.2 for the entire population. Finally, 23.8% of the respondents were included in the group of intensivists presenting depressive symptoms. As expected, mean CES-D scale score was higher for intensivists included in the “presence of depressive symptoms” group than in the absence of depressive symptoms (27.5 ± 6.9 vs. 10 ± 4.9, respectively; p < 0.0001).

Fifty-eight percent of these intensivists presenting symptoms of depression wished to leave their job compared with only 33% of those who did not exhibit signs of depression as assessed by the CES-D scale (p < 0.0001).

As shown in Figure  1, the respondents who presented symptoms of depression reported more sleep problems, more eating disorders and more altered relationships with their relatives than intensivists who did not present such symptoms.

Factors associated with the presence of depressive symptoms

Univariate analysis (Tables  3 and 4)

	Presence of depressive symptoms N = 214	Absence of depressive symptoms N = 687	P
Age, yr (mean ± SD)	41 ± 10	39 ± 10	0.14
Women, %	23	29	0.11
Married or with a partner, %	70	71	0.89
Number of children, %
· 0	39	43	0.32
· ≥1	61	57
Practicing a religion, %	37	33	0.32
Travelling time to work, min (mean ± SD)	24 ± 17	23 ± 18	0.37
Status
· Interns/residents or fellows, %	34	40	0.14
· Attending physicians, %	66	60
ICU practice, mo [median (IQR)]	84 (18–190)	55 (6–160)	0.03
ICU mortality, year 2003, %	18.5 ± 5.5	19.6 ± 5.8	0.02
SAPS II score, year 2003	39 ± 5	40 ± 5	0.16
During the last 7 days:
· Death of at least one of your patients, %	69	67	0.58
· Withholding decided of your own, %	13	10	0.23
· Withholding decided by the team, %	65	67	0.51
The day of the survey:
· Withholding/withdrawing, %	30	27	0.29
· Probable death of one of your patients,%	48	46	0.55

Data are mean ± SD or median (IQR) unless otherwise indicated.

	Presence of depressive symptoms N = 214	Absence of depressive symptoms N = 687	P
Unit factors
Teaching hospital, %	53	47	0.17
Number of ICU beds*	14.3 ± 7.3	15.7 ± 9.1	0.04
Patients admitted, year 2003, number*	579 ± 306	619 ± 318	0.13
Intensivists (excluding interns and residents) working in the ICU, number	6.0 ± 2.4	6.0 ± 2.6	0.95
Intensivist absenteeism for more than 1 week, year 2003, %	39	32	0.09
Compensation for overtime, %	30	34	0.23
Relief of service until the next working day after a night shift, %	36	48	0.002
Discussion group, %	39	43	0.29
Psychologist, %	23	25	0.62
Intensivist factors
Working hours per week, hours*	60 ± 13	58 ± 12	0.03
Full-time ICU activity, %	72	69	0.47
High level of burnout, %	81	36	0.0001
Night shifts per month, number*	5.1 ± 1.9	4.7 ± 1.9	0.008
Period since the last nonworking day, days**	4 (3–8)	4 (3–6)	0.002
Period since the last nonworking weekend, days**	10 (4–19)	7 (4–15)	0.0001
During year 2003:
· No. of conflicts with a nurse**	2 (0–5)	2 (0–4)	0.23
· No. of conflicts with a colleague intensivist**	2 (1–5)	1 (0–3)	0.0001
During the last 7 days:
· Night shift, %			0.07
- 0	12	17
- 1	32	37
- 2	42	34
- ≥3	14	12	0.001
· Conflict with a nurse, %	19	11	0.0001
· Conflict with a colleague intensivist, %	29	12	0.0001
· Conflict with a patient’s family, %	11	7	0.07
The day of the survey:
· Night shift before the survey, %	19	15	0.16
· Off the day before, %	14	19	0.10
· Patients-to-intensivist ratio*	7.3 ± 4.7	7.5 ± 4.9	0.56

Whereas age and status were not associated with depressive symptoms, respondents with depressive symptoms had a longer ICU practice than those not presenting such symptoms. No factor reflecting the severity of illness as well as patients’ deaths and decision of withholding/withdrawing had an impact on the presence of depressive symptoms. The presence of a discussion group and/or a psychologist was not associated with less depressive symptoms. In contrast, there were more intensivists with a high degree of burnout in the group presenting depressive symptoms. To be relieved of service until the next working day after a night shift was protective (decreased rate of depressive symptoms). The workload was associated with the presence of depressive symptoms (working hours per week, number of night shifts per month, delay from the last working day, weekend, or week).

Intensivists with depressive symptoms declared more conflicts with nurses or colleagues during the previous 7 days. Finally, relationships with other nonintensivists colleagues and chief nurses were worse for ICU physicians experiencing depressive symptoms (Figure  2).

Multivariate analyses

Multivariate analyses were performed to evaluate the independent relationship between the presence of depressive symptoms and all factors with a p value < 0.2 by univariate analysis. Multiple logistic regression (Table  5) showed that the presence of a high level of burnout was strongly related to the presence of depressive symptoms. In contrast, no demographic factors regarding ICU physicians and no factor related to the severity of illness of patients were retained by the model. Organizational factors were in contrast associated with the presence of depressive symptoms. Workload (a long period from the last nonworking weekend, absence of relief of service until the next working day after a night shift) and impaired relationships with other intensivists were independently associated with the presence of depressive symptoms. In contrast, the quality of the relationships with other physicians (from other departments) was associated with the absence of depressive symptoms (protective effect). Multivariate analysis using a GEE methodology identified the same independent factors associated with the presence of depressive symptoms (Table  5).

	Logistic regression		GEE
Variable	OR (and 95% CI)	P value	OR (and 95% CI)	P value
Demographic factor:
None
Intensivist factor:
- High level of burnout*	6.79 (4.13-11.18)	0.0001	6.82 (4.5-10.33)	0.0001
Organizational factors:
- Relief of service until the next working day after a night shift*	0.61 (0.38-0.99)	0.047	0.64 (0.41-0.99)	0.04
- Period since the last nonworking weekend, for each day	1.023 (1.004-1.041)	0.016	1.023 (1.006-1.04)	0.009
- Conflict with a colleague intensivist during the last 7 days*	2.52 (1.49-4.26)	0.001	2.47 (1.41-4.34)	0.001
- Relationships with other physicians, for each additional point of the 0–10 rating scale	0.89 (0.79-0.99)	0.043	0.88 (0.78-0.99)	0.049

*,Dichotomized variable.

Continuous variables included in the model: age; working hours per week; ICU practice; night shifts per month; period since the last nonworking weekend; relationships with nurses; relationships with chief nurses; relationships with other physicians; number of ICU beds; patients admitted, year 2003; ICU mortality, year 2003; SAPS II score, year 2003.

Categorical variables included in the model: sex; status (interns/residents or fellows-attending physicians); intensivist absenteeism for more than one week, year 2003; conflict with a nurse during the last 7 days; conflict with a colleague intensivist during the last 7 days; conflict with a patient’s family during the last 7 days; teaching hospital; relief of service until the next working day after a night shift; off the day before the survey; night shift before the survey; high level of burnout.

As expected, this study reported a high rate of depressive symptoms among intensivists. The presence of depressive symptoms was not associated with patients’ severity of illness. In contrast, depression in intensivists was associated with organizational factors, such as workload and relationships with colleagues.

Approximately a quarter of the physicians included in the present study exhibited signs of depression. Coomber et al. [5] reported that 12% of U.K. ICU physicians showed clinically important levels of depression. In a 2002 survey of internal medicine trainees, 40% of female residents and 32% of male residents reported four or five symptoms of depression [12]. It is very interesting to observe that the respondents with depressive symptoms included in the present study had a longer ICU practice compared with those who had not.

In the general population, risk factors for major depression include being a woman [13]. Frank and Dingle reported that women physicians with histories of self-identified depression shared many attributes, such as not being partnered, or being dissatisfied with career and work [14]. This was not the case in the present study where gender was not associated with depressive symptoms.

In the study by Coomber et al. [5], there was no relationship between the level of depression and the age, the reported hours worked in the previous week, or the number of ICU beds for which they were responsible. This lack of association with work hours has been noted so far [15]. In the present study, we did not report any association between work hours and depression. However, there was an inverse relationship between symptoms of depression and the delay since the last nonworking weekend, suggesting that a sufficient period of rest is probably a more important factor than the number of work hours. ICU organizational aspects therefore are very important and could be a major issue in decreasing physicians’ depression. Chronic sleep deprivation may be a contributive factor that explains such a high rate of physicians presenting depressive symptoms [16–18]. Longer resting periods could be therefore useful to improve physicians’ psychological health. Depressive disorders are likely associated to job-related burnout. More specifically some studies suggest that burnout leads to depressive symptoms [19, 20]. In the present study, the presence of a high level of burnout was strongly related to the presence of depressive symptoms.

The limitations of this study include the biases of self-reporting (e.g., skipping questions, nondisclosure, same day of completion of the questionnaire by the intensivists and different interpretations of meaning), the lack of standardized interviews or specific criteria for making psychiatric diagnoses, incomplete information (e.g., no items on mental health treatment). The responders may not represent the whole French ICU physician community in terms of psychiatric morbidity, but we had no way of exploring the state of mental health of the nonresponders. Nonetheless, we would argue that the level of morbidity we have detected is likely to be a conservative estimate, because it can be argued that nonresponse is associated with “burnout” and “depression.” However, we do recognize that such conjecture needs further investigation, because nonresponse may be simple disinterest rather than overwork and lack of time. The study was done in 2004. The working conditions may have change since 2004, in particular concerning the number of ICU physicians who leave the hospital after a night shift. This could have modified the prevalence of depressive symptoms. However, we have no available information to indicate that the rate of intensivists leaving the hospital early in the morning following a night shift has increased recently. Additional investigations are necessary to design appropriate interventions that could be implemented to decrease depression rate in ICU doctors.

It is important to diagnose and to treat depression, because treatment is associated with improved work productivity [21], and with a reduction of suicide [22]. Interventional studies designed to evaluate whether alteration of ICU organization is able to decrease the prevalence/incidence of depressive symptoms are warranted. It is an important objective individually (to increase the intensivist well-being) but also collectively (ICU caregivers and patients) by potentially reducing intensivists’ turnover.