Assessing Student Burnout, Treatment Acquisition, and Barriers to Care to Prompt Changes in a Student Mental Healthcare Program.

OBJECTIVE: Medical students demonstrate disproportionately higher levels of burnout and depression than their non-medical age-matched peers. Few studies have been conducted about rates of treatment acquisition and the barriers to care among students with mental health concerns. This study further characterizes rates of burnout, obstacles to treatment, and program preference for medical students at The University of Michigan. METHODS: In June 2020, a 31-question survey eliciting information regarding student burnout, well-being, barriers to care, and improvements to overcome such barriers was sent to 588 current and recently graduated medical students at The University of Michigan. Participation was anonymous and voluntary, with optional response to each question. RESULTS: Ultimately, 312 (53%) students responded. Pre-clinical and core clinical students were significantly more burned out than clinical elective students, with pre-clinical students' odds ratio (OR) of 2.45 and core clinical students' OR of 2.48. Most participants (81%) reported concerns regarding their emotional well-being. Two-thirds (66%) indicated a new or previously diagnosed mental health concern, with 37% of these students never having sought treatment. Commonly reported barriers to care and suggested improvement to mental health services are outlined. Commonly reported barriers to care were financial concerns, time constraints, and stigma-related fear of career-ending consequences. CONCLUSIONS: This study showed stratification of the high levels of burnout among medical students. Student-driven feedback and survey results can help prompt medical schools to develop more robust mental healthcare models and drive much-needed structural changes.

Assessment and treatment of insomnia in adult patients with alcohol use disorders.

Insomnia in patients with alcohol dependence has increasingly become a target of treatment due to its prevalence, persistence, and associations with relapse and suicidal thoughts, as well as randomized controlled studies demonstrating efficacy with behavior therapies and non-addictive medications. This article focuses on assessing and treating insomnia that persists despite 4 or more weeks of sobriety in alcohol-dependent adults. Selecting among the various options for treatment follows a comprehensive assessment of insomnia and its multifactorial causes. In addition to chronic, heavy alcohol consumption and its effects on sleep regulatory systems, contributing factors include premorbid insomnia; co-occurring medical, psychiatric, and other sleep disorders; use of other substances and medications; stress; environmental factors; and inadequate sleep hygiene. The assessment makes use of history, rating scales, and sleep diaries as well as physical, mental status, and laboratory examinations to rule out these factors. Polysomnography is indicated when another sleep disorder is suspected, such as sleep apnea or periodic limb movement disorder, or when insomnia is resistant to treatment. Sobriety remains a necessary, first-line treatment for insomnia, and most patients will have some improvement. If insomnia-specific treatment is needed, then brief behavioral therapies are the treatment of choice, because they have shown long-lasting benefit without worsening of drinking outcomes. Medications work faster, but they generally work only as long as they are taken. Melatonin agonists; sedating antidepressants, anticonvulsants, and antipsychotics; and benzodiazepine receptor agonists each have their benefits and risks, which must be weighed and monitored to optimize outcomes. Some relapse prevention medications may also have sleep-promoting activity. Although it is assumed that treatment for insomnia will help prevent relapse, this has not been firmly established. Therefore, insomnia and alcohol dependence might be best thought of as co-occurring disorders, each of which requires its own treatment.

Predicting completion of outpatient opioid detoxification with clonidine.

Completion rates for outpatient opioid detoxification with clonidine generally range from 20-40%, but few studies have examined the correlates of successful completion. Of 29 consecutive patients, we compared those who completed detoxification with clonidine (n=12) to those who did not (n=17). Patients who completed treatment were significantly (p< 0.05) more likely to depend on opioids other than heroin, have private health insurance, and report low levels of subjective withdrawal symptoms. Patients with two or three of these characteristics were about seven times more likely to complete treatment than patients with none or one. Although it may not detoxify most opioid-dependent patients, clonidine will likely play a continued role in selected patients when a non-narcotic agent is desirable. The study findings may help target patients who could benefit the most from outpatient clonidine detoxification.