Emotional exhaustion and burnout among medical professors; a nationwide survey.

BACKGROUND: Although job-related burnout and its core feature emotional exhaustion are common among medical professionals and compromise job satisfaction and professional performance, they have never been systematically studied in medical professors, who have central positions in academic medicine. METHODS: We performed an online nationwide survey inviting all 1206 medical professors in The Netherlands to participate. They were asked to fill out the Maslach Burnout Inventory, a 'professional engagement' inventory, and to provide demographic and job-specific data. RESULTS: A total of 437 Professors completed the questionnaire. Nearly one quarter (23.8%) scored above the cut-off used for the definition of emotional exhaustion. Factors related to being in an early career stage (i.e. lower age, fewer years since appointment, having homeliving children, having a relatively low Hirsch index) were significantly associated with higher emotional exhaustion scores. There was a significant inverse correlation between emotional exhaustion and the level of professional engagement. CONCLUSIONS: Early career medical professors have higher scores on emotional exhaustion and may be prone for developing burnout. Based upon this finding, preventive strategies to prevent burnout could be targeted to young professors.

Rivastigmine for ECT-induced cognitive adverse effects in late life depression (RECALL study): A multicenter, randomized, double blind, placebo-controlled, cross-over trial in patients with depression aged 55 years or older: Rationale, objectives and methods.

Background: Cognitive side-effects are an important reason for the limited use of electroconvulsive therapy (ECT). Cognitive side-effects are heterogeneous and occur frequently in older persons. To date, insight into these side-effects is hampered due to inconsistencies in study designs and small sample sizes. Among all cognitive side-effects, confusion and delirious states are especially troublesome for patients, relatives and clinicians. In particular inter-ictal delirium-like states are worrisome, since they may lead to premature treatment discontinuation. Besides a need for further insight into determinants of cognitive side-effects of ECT, there is a great need for treatment options. Methods and design: The Rivastigmine for ECT-induced Cognitive Adverse effects in Late Life depression (RECALL) study combines a multicenter, prospective cohort study on older patients with depression, treated with ECT, with an embedded randomized, placebo-controlled cross-over trial to examine the effect of rivastigmine on inter-ictal delirium. Patients are recruited in four centers across the Netherlands and Belgium. We aim to include 150 patients into the cohort study, in order to be able to subsequently include 30 patients into the trial. Patients are included in the trial when inter-ictal delirium, assessed by the Confusion Assessment method (CAM), or a drop in Mini Mental State Examination (MMSE) score of ≥4 during ECT, develops. In the cohort study, comprehensive measurements of ECT-related cognitive side-effects-and their putative determinants-are done at baseline and during the ECT-course. The primary outcome of the clinical trial is the effectiveness of rivastigmine on inter-ictal delirium-severity, assessed with a change in the Delirium Rating Scale-Revised-98. Secondary outcomes of the clinical trial are several ECT-characteristics and side-effects of rivastigmine. Discussion: This study is the first clinical trial with a focus on ECT-induced, inter-ictal delirium. The cohort provides the basis for recruitment of patients for the cross-over trial and additionally provides an excellent opportunity to unravel cognitive side-effects of ECT and identify putative determinants. This paper describes the rationale and study protocol. Clinical trial registration: EudraCT 2014-003385-24.

Long-term outcome of bipolar depressed patients receiving lamotrigine as add-on to lithium with the possibility of the addition of paroxetine in nonresponders: a randomized, placebo-controlled trial with a novel design.

OBJECTIVE: In two previous manuscripts, we described the efficacy of lamotrigine versus placebo as add-on to lithium (followed by the addition of paroxetine in nonresponders) in the short-term treatment of bipolar depression. In this paper we describe the long-term (68 weeks) outcome of that study. METHODS: A total of 124 bipolar depressed patients receiving lithium were randomized to addition of lamotrigine or placebo. After eight weeks, paroxetine was added to nonresponders for another eight weeks. Responders continued medication and were followed for up to 68 weeks or until a relapse or recurrence of a depressive or manic episode. RESULTS: After eight weeks, the addition of lamotrigine to lithium was significantly more efficacious than addition of placebo, while after addition of paroxetine in nonresponders both groups further improved with no significant difference between groups at week 16. During follow-up the efficacy of lamotrigine was maintained: time to relapse or recurrence was longer for the lamotrigine group [median time 10.0 months (confidence interval: 1.1-18.8)] versus the placebo group [3.5 months (confidence interval: 0.7-7.0)]. CONCLUSION: In patients with bipolar depression, despite continued use of lithium, addition of lamotrigine revealed a continued benefit compared to placebo throughout the entire study.

Increased sensitivity for angry faces in depressive disorder following 2 weeks of 2-Hz repetitive transcranial magnetic stimulation to the right parietal cortex.

According to the cognitive neuropsychological hypothesis of antidepressant action, the onset of subjectively experienced therapeutic effects to treatment is preceded by favourable changes in psychological functioning that can be measured by implicit methods. The aim of this study was to examine additional data to explore this hypothesis in an intention-to-treat repetitive transcranial magnetic stimulation (rTMS) study targeting the right parietal cortex. Changes in depression scores from baseline and the sensitivity for recognizing emotional facial expressions were studied in 28 patients with depressive disorder receiving ten sessions of real (n=14) or sham (n=14) rTMS treatments in a double-blind, sham-controlled design. In the patient group results showed significantly higher sensitivity for recognizing angry facial expressions in response to receiving real compared to receiving sham rTMS treatment. Overall mood improvement was similar across real and sham rTMS treatments. However, the sensitivity for recognizing angry facial expressions was correlated to the percentage decrease in depression scores. These results provide the first preliminary support for the cognitive neuropsychological hypothesis of antidepressant action in rTMS treatment.

Partial clinical response to 2 weeks of 2 Hz repetitive transcranial magnetic stimulation to the right parietal cortex in depression.

The aim of this treatment study was to evaluate the therapeutic effects of repetitive transcranial magnetic stimulation (rTMS) over the right parietal cortex in depression. In a double-blind, sham-controlled design ten consecutive sessions of 2 Hz rTMS (inter-pulse interval 0.5 s) at 90% motor threshold to the right parietal cortex (2400 pulses per session) were applied to 34 patients with the primary diagnosis of DSM-IV depression and a score of > or =15 on the 17-item Hamilton Rating Scale for Depression (HAMD). The primary outcome measures were the percentage change from baseline on the 17-item HAMD scores after ten sessions, and the percentage of clinical (defined as > or =50% reduction in HAMD score) and partial clinical (defined as > or =30% reduction in HAMD score) responders. Reduction of HAMD scores in the real rTMS treatment (mean real+/-S.D., -19.9+/-32.5%) was not statistically different from the sham rTMS treatment (mean sham+/-S.D., -5.6+/-28.4%), and the number of clinical responders did not differ between treatments. However, a significant greater number of partial clinical responders were observed in the real (43.8%) compared to the sham rTMS treatment (6.3%). This study provides the first evidence showing that 2 Hz rTMS over the right parietal cortex may have antidepressant properties, and warrants further research.

Improving patients' beliefs about antidepressants in primary care: a cluster-randomized controlled trial of the effect of a depression care program.

OBJECTIVE: Many depressed patients have negative beliefs about antidepressants, leading to poor adherence, unfavorable depression outcome, and low perceived well-being, role functioning, and quality of life. Interventions to ameliorate beliefs are therefore needed. METHOD: In a cluster-randomized controlled trial conducted from September 1999 to January 2001, 2 interventions to improve management of major depressive disorder in primary care were compared: (1) a depression care program (DCP), providing enhanced patient education, stimulation of active participation of general practitioners and patients in the treatment process, discussion of benefits and costs of taking antidepressant medication, and systematic follow-up and (2) a systematic follow-up program (SFP). Thirty general practitioners were randomly assigned, and 211 patients with current major depressive disorder (diagnosed according to DSM-IV) were included. All patients were prescribed a selective serotonin reuptake inhibitor. Beliefs were assessed at baseline, at week 10, and at week 26. Differences in change of beliefs between DCP and SFP groups were analyzed. RESULTS: Changes in patients' beliefs were more favorable in the DCP condition at week 10 and week 26, compared with SFP only (beliefs concerning appropriate medication-taking, week 10: effect size = 0.39, p = .012; week 26: effect size = 0.55, p = .001; beliefs concerning harmfulness, week 10: effect size = 0.45, p = .011; week 26: effect size = 0.62, p = .002). CONCLUSION: The depression care program ameliorates beliefs about antidepressants in primary care patients with major depressive disorder. The study results encourage the implementation of a depression care program in order to improve beliefs about antidepressant medication in primary care patients diagnosed with major depressive disorder.

Initial rate of improvement in relation to remission of major depressive disorder in primary care.

OBJECTIVE: In depression treatment, switching treatment after lack of initial improvement, e.g., after 6 weeks, may result in a better outcome. The extent of the lack of initial improvement, as well as the timing of its assessment on the basis of which treatment change may be considered, remains unclear. This study compared the relationships of several grades of symptom improvement after 2 and 6 weeks with remission after 10 weeks in depressed patients treated with antidepressants in primary care. METHOD: This was a prospective cohort study, conducted between January 1999 and September 2001 in primary care practices in the Netherlands, of 172 patients starting selective serotonin reup-take inhibitor (SSRI) treatment for major depressive disorder, diagnosed according to DSM-IV criteria. At weeks 2 and 6, patients were classified as unimproved, partially improved, or improved. For each category, we calculated the proportion of remission at week 10. The primary outcome measure was the Beck Depression Inventory. RESULTS: Of the unimproved or partially improved patients at week 6, 29% (95% CI = 18 to 43) and 27% (95% CI = 17 to 40) attained remission at week 10, respectively. CONCLUSION: These data suggest that, in primary care, depression treatment with an SSRI should be reconsidered in depressed patients who are unimproved or partially improved by week 6.

Correction: Psychological Distress in the Hospital Setting: A Comparison between Native Dutch and Immigrant Patients.

[This corrects the article DOI: 10.1371/journal.pone.0130961.].

Psychological Distress in the Hospital Setting: A Comparison between Native Dutch and Immigrant Patients.

BACKGROUND: Prevalence of psychological distress (i.e. depressive and anxiety symptoms) in medically ill patients is high. Research in the general population shows a higher prevalence of psychological distress among immigrants compared to natives. Our aim was to examine the prevalence of psychological distress in the hospital setting comparing immigrant and native Dutch patients and first and second generation immigrant patients. METHODS: Prevalence of psychological distress was assessed using the extended Kessler-10 (EK-10) in 904 patients in a Dutch general teaching hospital. Logistic regression was used to calculate odds ratios to determine differences between native and immigrant patients and first and second generation immigrants in the prevalence of psychological distress. We adjusted for demographic and social variables, socio-economic status, physical quality of life, history of psychiatric disease and health care use. RESULTS: Of 904 patients, 585 were native Dutch patients and 319 were immigrant patients. The prevalence of psychological distress in native compared to immigrant patients was 54% and 66% respectively, with especially high prevalences among Turkish and Moroccan immigrant patients. The crude OR for prevalence of psychological distress for immigrant patients versus native patients was 1.7 (95% CI 1.2-2.2) and for first versus second generation immigrant patients 2.1 (95% CI 1.2-3.5). After full adjustment ORs were 1.7 (95% CI 1.2-2.3) and 2.2 (95% CI 1.2-4.1) respectively. CONCLUSION: Immigrant patients and first generation immigrant patients were more likely to have psychological distress compared to native patients and second generation immigrant patients respectively. We found a particularly high prevalence of psychological distress in Turkish and Moroccan immigrants.

Improving adherence to antidepressants: a systematic review of interventions.

BACKGROUND: Effectiveness of antidepressant medication is reduced by patients' nonadherence. Several interventions to improve adherence in patients diagnosed with unipolar depression have been tested. OBJECTIVE: To systematically review the effectiveness of interventions that aimed to improve adherence to antidepressant medication in patients with unipolar depression. METHOD: Systematic review of English-language articles of randomized controlled trials obtained by a computerized literature search of MEDLINE (1966-January 2002) using the terms patient compliance, patient dropout, treatment refusal, patient education, adherence, clinical trial, randomized controlled trial, controlled trial, depressive disorder, and depression; PSYCINFO (1984-January 2002) using the terms random, clinical, control, trial, adherence, compliance, noncompliance, dropouts, patient education, depression, major depression, affective disorders, and dysthymic disorder; EMBASE (1980-January 2002) using the terms patient compliance, patient dropouts, illness behavior, treatment refusal, patient education, clinical trial, controlled study, randomized controlled trial, and depression; and the Cochrane Controlled Trials Register (no restrictions) using the terms random*, complian*, adheren*, pharmacotherapy, regimen*, educat*, medicat*, depression, and depressive disorder. RESULTS: Educational interventions to enhance adherence failed to demonstrate a clear benefit on adherence and depression outcome. However, collaborative care interventions tested in primary care demonstrated significant improvements in adherence during the acute and continuation phase of treatment and were associated with clinical benefit, especially in patients suffering from major depression who were prescribed adequate dosages of antidepressant medication. CONCLUSION: We found evidence to support the introduction of interventions to enhance adherence with antidepressant medication in primary care, not only because of better adherence but also because of better treatment results. Because collaborative care interventions require additional resources, a better understanding of the mode of action of different programs is needed to reduce avoidable costs. The effectiveness of educational interventions needs more evidence.

Publication pressure and burn out among Dutch medical professors: a nationwide survey.

BACKGROUND: Publication of scientific research papers is important for professionals working in academic medical centres. Quantitative measures of scientific output determine status and prestige, and serve to rank universities as well as individuals. The pressure to generate maximum scientific output is high, and quantitative aspects may tend to dominate over qualitative ones. How this pressure influences professionals' perception of science and their personal well-being is unknown. METHODS AND FINDINGS: We performed an online survey inviting all medical professors (n = 1206) of the 8 academic medical centres in The Netherlands to participate. They were asked to fill out 2 questionnaires; a validated Publication Pressure Questionnaire and the Maslach Burnout Inventory. In total, 437 professors completed the questionnaires. among them, 54% judge that publication pressure 'has become excessive', 39% believe that publication pressure 'affects the credibility of medical research' and 26% judge that publication pressure has a 'sickening effect on medical science'. The burn out questionnaire indicates that 24% of medical professors have signs of burn out. The number of years of professorship was significantly related with experiencing less publication pressure. Significant and strong associations between burn out symptoms and the level of perceived publication pressure were found. The main limitation is the possibility of response bias. CONCLUSION: A substantial proportion of medical professors believe that publication pressure has become excessive, and have a cynical view on the validity of medical science. These perceptions are statistically correlated to burn out symptoms. Further research should address the effects of publication pressure in more detail and identify alternative ways to stimulate the quality of medical science.

[The happy scientist]. / De gelukkige wetenschapper.

INTRODUCTION: The H-index is a frequently used scale to rank scientists on their scientific output. Whether subjective feeling of happiness is influenced by the level of the H-index on scientists has never been investigated. OBJECTIVE: To investigate the relation between the level of the H index as a measure of scientific success and feelings of unhappiness among Dutch professors. DESIGN: Descriptive; national online questionnaire. METHOD: All medical professors working at the Dutch university medical centres were invited to participate in an online questionnaire. Pressure to publish was measured by a questionnaire developed for this purpose and signs of burnout were measured on the Utrecht Burnout Scale. The area of emotional exhaustion on this scale was used to measure feelings of unhappiness. Every professor was asked for his or her H-index as an outcome measure. RESULTS: A total of 437 professors completed the questionnaire. Those in the highest tertile of the H index had significantly lower scores for emotional exhaustion (p < 0.025). Younger age was correlated with an, on average, higher score for emotional exhaustion. Professors with children living at home had a 25% higher score on emotional exhaustion than those who did not (p < 0.01). CONCLUSION: The H index appears to be of influence on emotional exhaustion: a lower H index is associated with higher scores on emotional exhaustion while a high H index is associated with lower scores.

Efficacy and safety of lamotrigine as add-on treatment to lithium in bipolar depression: a multicenter, double-blind, placebo-controlled trial.

OBJECTIVE: Lamotrigine is one of the pharmacologic options for the treatment of bipolar depression but has only been studied as monotherapy. This study compared the acute effects of lamotrigine and placebo as add-on therapy to ongoing treatment with lithium in patients with bipolar depression. METHOD: Outpatients (N = 124) aged 18 years and older with a DSM-IV bipolar I or II disorder and a major depressive episode (Montgomery-Asberg Depression Rating Scale [MADRS] score > or = 18 and Clinical Global Impressions-Bipolar Version [CGI-BP] severity of depression score > or = 4) while receiving lithium treatment (0.6-1.2 mmol/L) were randomly assigned to 8 weeks of double-blind treatment with lamotrigine (titrated to 200 mg/d) or placebo. The primary outcome measure was mean change from baseline in total score on the MADRS at week 8. Secondary outcome measures were response (defined as a reduction of > or = 50% on the MADRS and/or change of depression score on the CGI-BP of "much improved" or "very much improved" compared to baseline) and switch to mania or hypomania (defined as a CGI-BP severity of mania score of at least mildly ill at any visit). Patients were included in the study between August 2002 (Spain started in October 2003) and May 2005. RESULTS: Endpoint mean change from baseline MADRS total score was -15.38 (SE = 1.32) points for lamotrigine and -11.03 (SE = 1.36) points for placebo (t = -2.29, df = 104, p = .024). Significantly more patients responded to lamotrigine than to placebo on the MADRS (51.6% vs. 31.7%, p = .030), but not on the CGI-BP change of depression (64.1% vs. 49.2%, p = .105). Switch to mania or hypomania occurred in 5 patients (7.8%) receiving lamotrigine and 2 patients (3.3%) receiving placebo (p = .441). CONCLUSION: Lamotrigine was found effective and safe as add-on treatment to lithium in the acute treatment of bipolar depression. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00224510.

A cluster randomized trial comparing two interventions to improve treatment of major depression in primary care.

BACKGROUND: Many patients with major depression are non-adherent to antidepressant medication and do not receive care according to current guidelines. There is increasing evidence that treatment of depression in primary care can be improved. Comparison between effective interventions may help to establish the active ingredients of such interventions. METHOD: In a randomized trial two interventions to improve treatment of major depression in primary care were compared (1) a depression care programme, targeting general practitioners (GPs), patients, and systematic follow-up, and (2) a systematic follow-up programme. Thirty GPs were randomized and 211 primary-care patients with current major depression were included. All patients were prescribed a selective serotonin reuptake inhibitor. Outcome measures included adherence to antidepressant medication, and depression outcome. RESULTS: No significant differences in adherence rates and treatment outcome measures were demonstrated between interventions at week 10 or week 26. Adherence rates were high and treatment outcome was favourable. CONCLUSIONS: The depression care programme was not superior to the systematic follow-up programme. Systematic follow-up in depression treatment in primary care seems to be an intervention per se, having the potential to improve adherence and treatment outcome.