Updated. Is the local government and local church involved in seeking to help? Why do some US cities struggle more with homelessness? A new book explores a key component of the issue: housing supply.
[ Note / SH]: Illegal Substance Use Data also “show high rates of comorbid disorders such as anxiety disorders—which include generalized anxiety disorder, panic disorder, and post-traumatic stress disorder.5–9 Substance use disorders also co-occur at high prevalence with mental disorders, such as depression and bipolar disorder,6,9–11 attention-deficit hyperactivity disorder (ADHD),12,13 psychotic illness,14,15 borderline personality disorder,16 and antisocial personality disorder.10,15 Patients with schizophrenia have higher rates of alcohol, tobacco, and drug use disorders than the general population.17 … the overlap is especially pronounced with serious mental illness (SMI). Serious mental illness among people ages 18 and older is defined at the federal level as having, at any time during the past year, a diagnosable mental, behavior, or emotional disorder that causes serious functional impairment that substantially interferes with or limits one or more major life activities. Serious mental illnesses include major depression, schizophrenia, and bipolar disorder, and other mental disorders that cause serious impairment.18 Around 1 in 4 individuals with SMI also have a Substance Abuse Disorder ….
@ColburnGregg March 16, 2022:
The problem of homelessness has steadily worsened across the United States in recent decades, but some cities and metro regions have fared far worse than others.
A new book by University of Washington professor Gregg Colburn and Seattle-based data scientist and policy analyst Clayton Page Aldern examines these places’ disparate trends and the many causes that have been ascribed to homelessness. One by one, and with compelling data, Colburn and Aldern dismantle the common storylines that have blamed homelessness on individuals or cities’ social policies. Their research finds that the cause actually lies in these places’ very different housing markets.
Sightline interviewed the authors about their findings. Their book, Homelessness Is a Housing Problem: How Structural Factors Explain U.S. Patterns, is available from University of California Press.
Watch also, Matthew Desmond on the impact of Evictions — not always with just cause — on the nations homelessness problem
How Did This Research Begin for You?
It began with the observation that much of the conversation around homelessness in our region, and across the country, lacks focus. Various explanations—individual, structural, and political—have dominated this conversation. There’s a perception that homelessness is a product of certain types of people who tend to gravitate toward certain types of cities. If you live on the West Coast, for example, you know the cities we’re talking about. Seattle, Portland, San Francisco, Los Angeles: all these cities have high per capita rates of homelessness.
But there’s actually significant variation in rates of homelessness around the country. The chart below shows that according to the 2019 point-in-time (PIT) count (the annual census of homelessness around the country), in King County, about 5 in every 1,000 people experience homelessness on a given night. In sunny Miami-Dade County in Florida, that number is closer to 1 per 1,000. What accounts for the difference? Specifically, what explains the variation in homelessness rates around the country? Our research seeks to answer those questions by zooming the lens out from the individual experiencing homelessness to the city in which they live.
What Factors Do People Think Drive Homelessness
If you watch the local news or spend time on Nextdoor, you have a sense of what these factors are. For many observers, homelessness is a function of mental illness, drug use, and overly generous social policies. These explanations are often supported by anecdotes, and certainly academic research confirms that a range of individual vulnerabilities, including poverty, substance abuse, and mental illness, increase one’s risk of homelessness. We both live in the Puget Sound region, and we know what it’s like to walk around downtown Seattle, where you encounter a lot of people who are probably sleeping outside and who might also be living with a serious mental illness or a substance use disorder. It’s not a huge analytical leap for people with housing to connect these individual conditions to Seattle’s homelessness problem.
But there are a couple of issues with this conclusion. First, the people sleeping on the street only represent a subset of the total population of people experiencing homelessness. In the 2020 count, chronic homelessness (what policy makers call being homeless for at least a year and living with some kind of physical or mental disability, including mental illness, a chronic health condition, and substance use disorder) accounted for less than 30 percent of the homeless cases in King County, while the chronic unsheltered population made up less than 17 percent of total cases. Second, we know that mental health and drug use can be both a cause of homelessness and a consequence. The trauma associated with homelessness is significant; that drug use and mental illness might result from this experience is not surprising. Research confirms this relationship.
Despite this complexity, the fundamental question remains: Does variation in rates of these individual risk factors like poverty explain variation in rates of homelessness witnessed across the country? In other words, do we have more homelessness in Seattle because we have more poor people or more drug users? Our research suggests the answer is no.
The graphics above demonstrate that variation in rates of homelessness cannot be explained by variation in rates of individual factors such as poverty and mental illness. In fact, where poverty is higher, homelessness is lower, which is perhaps a counterintuitive result. Similarly, there are not higher rates of people with serious mental illness in locations with high rates of homelessness. Therefore, high rates of homelessness are not the result of more people with certain individual vulnerabilities residing in those locations.
Poverty rates in Detroit, for instance, are far higher than in San Francisco, but rates of homelessness in Detroit are but a fraction of those observed in the Bay Area.
That’s not to suggest that poverty or mental illness aren’t risk factors for losing your housing. Certainly, the lower your income, the higher your chance of experiencing homelessness. It would be strange if that weren’t the case. We prefer to think of these factors as precipitating events that may lead to losing one’s housing. But the conditions have to be right for these risks to be realized as such. The point is that these individual vulnerabilities, which are clearly risk factors for homelessness, have different consequences in different locations. The consequence of being poor in Seattle, for example, is very different than in Cleveland.
Beyond individual explanations, some observers argue that there is something unique about the political or natural environment of cities with high rates of homelessness—that maybe it has to do with mild climates or generous welfare benefits, for example. But our research demonstrates that neither of these community-level factors explain variation in homeless rates. And if these individual, political, or climatic explanations don’t hold, something else must drive this variation.
How Does a Places Housing Market Connect With Homelessness
These are the conditions—the structural factors—that explain the observed variation. In our data set, housing market conditions explain the most variation in rates of homelessness observed around the country. Cities with higher rents and lower rental-vacancy rates (i.e., tighter housing markets) see higher per capita rates of homelessness. This is where a fuller picture comes into view. Individual risk factors help account for who in a given city might lose their housing at any given point in time, but housing markets—rents and vacancy rates—set the context in which those risk factors are expressed. Without looking at housing markets, you can’t explain why Seattle has a much higher rate of homelessness than Chicago, Minneapolis, or Dallas. The fundamental conclusion is that the consequences of individual vulnerabilities are far more severe in locations with less accommodating housing markets.
What Would It Take to Address the Problems?
This is a big question! We think it needs to start with perception. Homelessness needs to be understood as a problem driven by a lack of access to housing. It is a market failure. People are forced out of stable housing or are unable to access it when housing markets don’t provide sufficient and affordable options.
A natural follow-up question is, why is housing scarce in some locations and more abundant in others? The two core forces of economics—demand and supply—can help us understand differences by location. Generally speaking, the demand for housing is driven by population and income growth. All else equal, a growing population and higher wages will increase the demand for housing. Without any change in supply, this increase in demand will lead to higher prices. But we know that many metropolitan areas accommodate rapid population growth by building much more housing. (Charlotte, North Carolina, comes to mind.) In doing so, these cities’ rents remain more moderate and their vacancy rates remain higher. In Seattle, we’ve had rapid population growth and only modest increases in the housing stock, which translates to a housing deficit and the associated higher prices that basic economic theory would predict.
If we assume that strong population and employment growth will continue in our region over the next few decades (an assumption supported by estimates from the Puget Sound Regional Council), how will we create the necessary housing to accommodate this growth?
First, we must reconsider our land use policy. We cannot accommodate all the people who want to live in our region while maintaining such a high level of single-family zoning. The built environment in our region has to densify. Second, we have to build a lot more housing of all types. We need more market-rate housing, middle-income housing, affordable housing, and supportive housing for people experiencing homelessness. Investments and commitments at one subset of the housing market won’t be enough. Providing access to housing for low-income households will require public support, and the region has found the dollars to make major investments in infrastructure before. (Consider our $54 billion commitment to Sound Transit 3.)
But building alone won’t end homelessness. We also need a system that meets people where they are and ensures they’re connected to these housing opportunities and other appropriate services when they need them. A well-functioning homelessness response system is one that’s nimble, frictionless, personalized, respectful, and responsive to people’s needs.
That’s the last bit of advice, by the way: Ask people what they need.
What Gives Hope?
A lot of people are working to end homelessness, and a lot of people with lived experience of homelessness are working to ensure that others never lose their housing. The prospect of a system co-designed by people who could have used it in the past gives us hope. We are also heartened by the increased attention housing has received in policy discussions across cities and counties in Washington, as well as in the state legislature. The growing understanding of the housing crisis has caught the attention of policy makers, corporations, and civic leaders. Now we just have to convert this attention to establishing policies and programs that actually create more housing for people who need it.
Gregg Colburn
© 2024 Sightline Institute.
The Never-Ending Loop: Homelessness, Psychiatric Disorder, and Mortality
May 29, 2020
By Lilanthi Balasuriya, MD, MMS
Eliza Buelt, MD
Psychiatric TimesVol 37, Issue 5Volume 37Issue 5
Mental health conditions are highly prevalent in homeless populations. Further research and advocacy are needed to address the obstacles that homeless individuals encounter in accessing mental health care.
With a lifetime and 1-year prevalence of homelessness in the US population found to be 4.2% and 1.5%, respectively, and the total number of people who experience some form of homelessness over the course of a year is estimated to be 2.5 to 3.5 million individuals, homelessness is a serious problem. Mental illness, in addition to adverse childhood experiences and substance use, are risk factors for homelessness. Although estimates of the prevalence of mental illness vary, studies looking at mental illness in the homeless population have generally found a high prevalence of mental disorders. The most common disorders may be alcohol and drug dependence (Figure).1
There is clearly a link between psychiatric disorders and homelessness; disentangling the nature of this relationship is complicated. Regardless of mental health status, people who are homeless generally have a history marked by poverty and social disadvantage, including considerable poverty in childhood and lower levels of education, and they are likely to belong to an ethnic minority.2 Mental illness had preceded homelessness in about two-thirds of the cases
Homelessness in turn has been associated with poorer mental health outcomes and may trigger or exacerbate certain types of disorders. For example, findings indicate that homelessness is related to higher levels of psychiatric distress and lower perceived levels of recovery from serious mental illness.3
Impact of homelessness on premature morbidity
Homelessness is associated with substantially increased morbidity and mortality from many causes including infectious diseases, cardiovascular disease, cancer, unintentional injury, suicide, homicide, and substance use. The unsheltered homeless have an even greater burden, with higher mortality than sheltered homeless. Among a large group of homeless adults in Boston, disparities in deaths attributed to tobacco, alcohol, and drug use accounted for almost 60% of the mortality gap between homeless adults and the general population.4
In accordance with findings in the general population, there also is a strong association between psychiatric disorders and suicide in homeless populations. The prevalence of suicidal ideation and suicide attempts is extremely high in mentally ill homeless persons. In a large sample of homeless adults with serious mental illness, almost 8% reported a suicide attempt within the previous 30 days.5 The highest rates of suicidal ideation and suicide attempts were in the group aged 30 to 39 years, in contrast to the general population with peaks of suicidality in young adults and the elderly.
Wellness in Physician Colleagues
Challenges in accessing psychiatric care
General guidelines were created for primary care physicians working with the homeless in the US in 2004, and in 2018 the Street Medicine Institute began publishing international clinical guidelines targeting the primary care needs of specifically street-dwelling homeless individuals.6,7
Unfortunately, similar guidelines for psychiatrists working with the street-homeless population are still lacking.
Assessment and Management of Bipolar Disorder in Older Adults
December 28th 2023
Addressing Substance Use Disorders in Physicians to Sustain Wellness
January 10th
Nurturing Resilience in the Wounded Healer
January 9th 20
When thinking about challenges to accessing care, it is critical to understand the heterogeneous nature of homelessness. The structures of support and oppression for each individual may vary significantly based on the surrounding community and resources.
Fundamental basic needs. A qualitative study highlighted the basic human needs that often take priority over seeking psychiatric care.8 Access to adequate nutrition, water, shelter, and protection from the elements are the reality homeless individuals encounter daily, and these issues take priority over psychiatric needs, which are often not addressed until a crisis occurs.
The effects of illness. Having mental health care needs itself may be a barrier to accessing psychiatric care. Motivation to make and attend appointments may be low if an individual is suffering from depression, amotivation, anhedonia, anxiety, paranoia, hypervigilance, history of trauma, substance use, or negative past experiences with the health care system related to mental illness. Moreover, homeless people may have experienced greater trauma, have traumatic brain injuries, and cognitive impairment-all of which may affect interactions with the health care system and health literacy.
Similarly, comorbid medical illness may be a barrier, as these needs may take priority over psychiatric care. Many homeless people have medical issues such as diabetes, hypertension, tuberculosis, and ischemic heart disease. These needs often necessitate resources such as intensive case management and assertive outreach to maintain treatment.
Transportation. Homeless individuals often lack adequate transportation; consequently they are unable to do the necessary tasks involved in care-getting laboratory work completed, picking up medications, and getting to mental health appointments. Public transportation may not always be a solution, as it often requires multiple transfers, can be unreliable and, in some areas, may be limited or may not exist. Most significantly, homeless individuals may lack the resources to pay for fares.
Cost of care. For persons who are homeless, small expenses can be a significant barrier to accessing mental health care. Moreover, they may not be cognizant of resources available to them through Medicaid or the Affordable Care Act.
Communication. Although some homeless adults and youth have access to cell phones, there is higher turnover of both phones and phone numbers, which can pose a barrier to consistent communication. Keeping a cell phone charged is a challenge for those without reliable access to electricity. Similarly, with lower internet use, homeless people are likely to have less access to important information, including care and resources. Language barriers may also affect access to care, particularly in limited resource settings.
Stigma and vulnerability. Stigma and discrimination continue against homeless individuals who also have mental health conditions. Setting health care goals may feel unattainable when pressing issues like basic survival are more salient. Homeless people with mental illness are also highly vulnerable to violence, with a reported lifetime incidence of 74% to 87% of violence being perpetrated against them.9 Psychiatric care may include prescribed psychotropics that affect alertness and pose a danger for someone who is at increased risk for victimization and violence. Furthermore, those who have a history with the legal system, reintegrating into society, parole, or strained finances may further impact their ability to acquire care.
Solutions
Briefly, solutions to the problem of homelessness include finding and implementing innovative models of care such as street psychiatry, integrated primary care, and mental health care models; Veterans Administration Homeless Models (Homeless Patient Aligned Care Teams H-PACT); and utilizing allies in the housing and rehabilitation services domains to find specialized housing opportunities. Taking a team-based approach is essential, as the mental health care needs of homeless people are often complex and include many aspects of the social determinants of health. Multidisciplinary teams often include case managers, social workers, housing specialists, and vocational specialists. Medical students can also play an integral part in providing mental health care for homeless persons.
Recovery models and holistic, patient-centered, trauma-informed care are important as perceived discrimination, stigma, and distrust may be present. Communication barriers must also be addressed. This includes the advance development of plans regarding communications and finding creative ways to address potential barriers. Solutions should be tailored to fit the individual needs of the patient, including special needs that may occur around patients with dual diagnoses, women, families, and children. Although beyond the scope of this article, effective public policy can play a role in reducing homelessness.
Conclusion
Mental health conditions are highly prevalent in homeless populations. Although homeless individuals have higher mortality related to many causes, access to care is poorer than that for the general population. Further research and advocacy are needed to address the obstacles that homeless individuals encounter in accessing mental health care.
Disclosures:
Dr Balasuriya is a Medical Resident and Dr Buelt is an Instructor, Department of Psychiatry, Yale University School of Medicine, New Haven, CT; Dr Tsai is Campus Dean and Professor, School of Public Health, University of Texas Health Science Center, Houston, TX. The authors report no conflicts of interest concerning the subject matter of this article.
References:
1. Fazel S, Khosla V, Doll H, Geddes J. The prevalence of mental disorders among the homeless in western countries: systematic review and meta-regression analysis. PLoS Med. 2008;5:e225.
2. Sullivan G, Burnam A, Koegel P. Pathways to homelessness among the mentally ill. Soc Psychiatry Psychiatr Epidemiol. 2000;35:444-450.
3. Castellow J KB, Townley G. Previous homelessness as a risk factor for recovery from serious mental illness. Community Ment Health J. 2015;51:674-684.
4. Baggett TP, Chang Y, Singer DE, et al. Tobacco-, alcohol-, and drug-attributable deaths and their contribution to mortality disparities in a cohort of homeless adults in Boston. Am J Public Health. 2015;105:1189-1197.
5. Prigerson HG, Desai RA, Liu-Mares W, Rosenheck RA. Suicidal ideation and suicide attempts in homeless mentally ill persons: age-specific risks of substance abuse. Soc Psychiatry Psychiatr Epidemiol. 2003;38:213-219.
6. Bonin E, Hoeft J, Brehove T, et al. General Recommendations for the Care of Homeless Patients. Adapting Your Practice. 2010.
7. Board of Directors, Street Medicine Institute. Street Medicine Clinical Guidelines, 2018.
8. Paudyal V, MacLure K, Buchanan C, et al. “When you are homeless, you are not thinking about your medication, but your food, shelter or heat for the night”: behavioural determinants of homeless patients’ adherence to prescribed medicines. Public Health. 2017;148:1-8.
9. Roy L, Crocker AG, Nicholls TL, et al. Criminal behavior and victimization among homeless individuals with severe mental illness: a systematic review. Psychiatr Serv. 2014;65:739-750.
10. O’Toole TP, Johnson EE, Aiello R, et al. Tailoring care to vulnerable populations by incorporating social determinants of health: the Veterans Health Administration’s “Homeless Patient Aligned Care Team” program. Prev Chronic Dis. 2016;13:E44.
Wellness in Physician Colleagues
Jan 19, 2024
By Susan J. Noonan, MD, MP
Working in the health care profession is a privilege, yet it also carries some personal risks. Only when clinicians who have sought and successfully received help for depression, suicidality, and other mental illness come forward to share their experience will more of clinicians in need of psychiatric treatment feel comfortable seeking and receiving that care.
Working in the health care profession is a privilege, yet it also carries some personal risks that we often don’t fully recognize. Medicine attracts high achievers with a strong work ethic and social and moral responsibility, devoted to the well-being of others and skilled in controlling complex situations. However, this may result in repeated exposure to stressful work conditions, affecting our well-being and leading to psychological distress that may manifest in various ways.1 How one copes with their emotions can affect one’s sense of well-being and the care they provide to patients and family members.
Current literature reports a challenge to well-being and mental health, as well as burnout in clinicians and medical staff. Before the COVID-19 pandemic, burnout, depression, and suicide rates were found to be more common in physicians than in the general population.4-8 Since the pandemic, these numbers have increased dramatically9-11 and are amplified in clinicians on the frontlines of the health care crisis.12-17 Sadly, far too many health care professionals fear the ramifications of receiving mental health services. Untreated or inadequately treated mental illness poses a greater risk not only to the physician’s mental health but also to the welfare of their patients.18
The Case for a Social Classification of Social Psychopathologies
February 2nd 2024
I have previously described the inherent nature, demands, and culture of the medical profession that contribute to physician stress and burnout, and the barriers to disclosure.19-21 An inverse relationship between demands or stress and performance has been described22; in health care, this may affect patient care and outcomes. Prolonged stress can also lead to burnout, which is a state of emotional, physical, and mental exhaustion and the result of too many demands on one’s strength, resources, time, and energy, with the sense of having reached the limits of your endurance and ability to cope.
COVID-19 introduced more complexity, bringing increased workload and demands, uncertainty, disruption of work and home environments, loss of autonomy with increasing oversight and regulation, having to choose between competing obligations and responsibilities, and increased moral distress, creating ethical trade-offs, conflict, and a gap where patient care delivery is inconsistent with clinical training and experience.
Stress, burnout, and mental illness in clinicians remain hidden secrets and often go untreated. Many physicians fail to recognize or acknowledge emotional distress or mood disorder symptoms in themselves and, when they do, they find it difficult to ask for help, perpetuating the myth of invulnerability and a tradition of self-sufficiency. Stigma is a major barrier to physicians seeking mental health care.23 Nearly 40% of physicians report reluctance to seek mental health care due to fear of repercussions to their medical licensure, professional advancement, and fewer patient referrals, thus negatively affecting their career and livelihood.24 Until recently, approximately two-thirds of states in the US have “character and fitness” or mental health questions on their licensing applications,25 so clinicians need to be aware of their state licensing requirements and the wording of and response to questions. Fortunately, the Dr Lorna Breen Heroes’ Foundation helped to make strides in changing licensure queries about mental health as part of their Wellbeing First Champions Challenge (Figure 2).
Figure 2. States Making Positive Licensure Changes
All this strikes a familiar chord with me as a physician who has personal experience living with depression. As a medical student, trainee, and then later in practice, I sometimes found myself in deep despair, with both physical and emotional pain, unable to work or participate in and enjoy life. I was able to be focused and intent at work, fastidious about the care of my patients, and strived to make sound clinical decisions that would do no harm—and to my knowledge, I was able to succeed at that. It was later, at home, when I would crumble. Although the hallmark of my professional life has been compassion and understanding toward others, for many years I could not expect to receive the same in return. I felt private emotional pain and simultaneously found myself caring for and counseling those who had the very same illness as me.
I quickly learned that I should not speak of these issues to anyone for fear of being considered too weak and impaired to practice. Like too many physicians, I was hesitant to seek professional care because of the negative impact it would have on my career. My only choice was to be silent and hypervigilant. The reality of no support and no treatment was very isolating.
I eventually received treatment and survived, thanks to a team of extraordinary mental health professionals who worked overtime on my behalf. As a physician seeking help for depression, I needed to step aside and embrace the role of a patient and allow myself to receive care. I had to learn to trust and defer to others, and that receiving help is not a sign of weakness. Recovery is a lifelong process, and I had to accept that it’s OK to pause and hit the reset button.
We currently have clinician wellness programs in many major and academic hospitals and medical societies. This can only help to provide psychoeducation and support and decrease the stigma of mental health issues and clinicians’ reluctant to seek treatment. Moreover, in March 2022, President Joseph R. Biden signed into law the Lorna Breen Health Care Provider Protection Act,26 which establishes grants for training health care professionals in evidence-based strategies to reduce and prevent suicide, burnout, and other mental health conditions.27
Over time I have learned how best to manage stress, emotional distress, and mood disorders. The following are some suggestions I encourage you to consider.
Care for yourself physically, mentally, and emotionally. Aim for sufficient and regular sleep, exercise, relaxation, a balanced diet and nutrition, and social connection. Maintain relationships with friends and support individuals—those who sustain you.
Understand that self-care is not self-indulgent. It is a smart way to protect yourself using all the effective tools and resources available to not only function in the world but also contribute and thrive. Paying attention to your own needs does not mean you are ignoring your responsibilities, work, or your loved ones’ needs. Instead, it enables you to be a more available and effective health care professional, partner, parent, caregiver of senior parents, and/or coworker.
Prioritize and balance responsibilities, activities, and the demands placed on you. Set work and work-home boundaries, limits, and realistic expectations. Do your best to manage life’s little daily stressors, pace yourself, learn to say no on occasion, and delegate when necessary.
Adapt and implement effective coping strategies for stress, burnout, and emotional health.
Look to your own needs and wants and seek to do what increases your self-esteem, makes your life rewarding and rich, and sustains you. Nurture yourself and participate in and enjoy the moments of life. Include time and space for pleasurable experiences (eg, hobbies, interests, skills, music, sports, pets, or volunteer work).
Reach out to colleagues and clinician wellness programs as needed. Ask for help and support—this is not a sign of weakness or failure.
An article by Rothbard28 has offered some additional suggestions regarding work and work-home balance, communication, identifying and managing goals, tasks and responsibilities, and self-advocacy. The World Health Organization has created a statement to “improve mental health and psychological well-being”29 that is also in support of these goals.
Stigma continues to exist around mental health issues. Although the medical profession and society in general have become more open and accepting of those challenges, much more work remains. Improving the way mental illnesses are regarded includes education about these conditions as a biologic illness with effective treatment options. Our institutions need policy change and a cultural shift in the way mental health is perceived, 30 creating environments that encourage openness and wellness and offer time and support for treatment and to heal. Anything that deters health care professionals from seeking help poses a greater risk to themselves and to their patients as a result of untreated or inadequately treated mental illness. Thus, it’s imperative that physicians, nurses, and other health care professionals feel that they can get the help they need—free of shame, guilt, stigma, or negative professional repercussions.
Psychoeducation and policy change are not enough to accomplish change. Exposure to and social contact with those who have lived experience and continue to function and thrive is essential. Only when our medical colleagues who have sought and successfully received help for depression, suicidality, and other mental illness come forward to share their experience will more of us in need of psychiatric treatment feel comfortable seeking and receiving that care.
Dr Noonan is a physician, mental health and wellness coach; author of 5 books on managing mental health and mood disorders with a print and video blog; consultant; group facilitator; and certified peer specialist. Dr Noonan is the inaugural recipient of the National Depression and Bipolar Support Alliance Peer Support Specialist of the Year 2022. Her most recent book, published by Johns Hopkins University Press, is Reconnecting After Isolation: Coping With Anxiety, Depression, Grief, PTSD, and More.
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2. Ryff CD. Psychological well-being revisited: advances in science and practice of eudaimonia. Psychother Psychosom. 2014;83(1):10-28.
3. Creating a healthier life: a atep-by-step guide to wellness. Substance Abuse and Mental Health Services Administration. 2016. Accessed December 5, 2023. https://store.samhsa.gov/sites/default/files/sma16-4958.pdf
4. Mata DA, Ramos MA, Bansal N, et al. Prevalence of depression and depressive symptoms among resident physicians: a systematic review and meta-analysis. JAMA. 2015:314(22);2373-2383.
5. Dyrbye LN, West CP, Satele D, et al. Burnout among US medical students, residents, and early career physicians relative to the general U.S. population. Acad Med. 2014;89(3):443-451.
6. Schwenk TL, Davis L, Wimsatt LA. Depression, stigma, and suicidal ideation in medical students. JAMA. 2010;304(11):1181-1190.
7. Rotenstein LS, Torre M, Ramos MA, et al. Prevalence of burnout among physicians: a systematic review. JAMA. 2018;320(11):1131-1150.
8. Medscape National Physician Burnout, Depression & Suicide Report 2019. Medscape.January 16, 2019. Accessed December 5, 2023. https://www.medscape.com/slideshow/2019-lifestyle-burnout-depression-6011056?faf=1
9. Ettman CK, Abdalla SM, Cohen GH, et al. Prevalence of depression symptoms in US adults before and during the COVID-19 pandemic. JAMA Netw Open. 2020;3(9):e2019686.
10. Czeisler MÉ , Lane RI, Petrosky E, et al. Mental health, substance use, and suicidal ideation during the COVID-19 pandemic — United States, June 24-30, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(32):1049-1057.
11. Pfefferbaum B, North CS. Mental health and the Covid-19 pandemic. N Engl J Med. 2020;383(6):510-512.
12. Adibe B. Rethinking wellness in health care amid rising COVID-19–associated emotional distress. JAMA Health Forum. 2021;2(1):e201570.
13. Pappa S, Ntella V, Giannakas T, et al. Prevalence of depression, anxiety, and insomnia among healthcare workers during the COVID-19 pandemic: a systematic review and meta-analysis. Brain Behav Immun. 2020;88:901-907.
14. Carmassi C, Foghi C, Dell’Oste V, et al. PTSD symptoms in healthcare workers facing the three coronavcirus outbreaks: what can we expect after the COVID-19 pandemic. Psychiatry Res. 2020;292:113312.
15. Shanafelt T, Ripp J, Trockel M. Understanding and addressing sources of anxiety among health care professionals during the COVID-19 pandemic. JAMA. 2020;323(21):2133-2134.
16. Preti E, Di Mattei V, Perego G, et al. The psychological impact of epidemic and pandemic outbreaks on healthcare workers: rapid review of the evidence. Curr Psych Rep. 2020;22(8):43.
17. Ortega MV, Hidrue MK, Lehrhoff SR, et al. Patterns in physician burnout in a stable-linked cohort. JAMA Netw Open. 2023;6(10):e2336745.
18. Fahrenkopf AM, Sectish TC, Barger LK, et al. Rates of medication errors among depressed and burnt out residents: prospective cohort study. BMJ. 2008;336(7642):488-491.
19. Hague OS, Stein MA, Marvit A. Physician, heal thy double stigma – doctors with mental illness and structural barriers to disclosure. N Engl J Med. 2021;384(10):888-891.
20. Arnold-Forster A, Moses JD, Schotland SV. Obstacles to physicians’ emotional health—lessons from history. N Engl J Med. 2022;386(1):4-7.
21. Shanafelt TD, Schein E, Minor LB, et al. Healing the professional culture of medicine. Mayo Clin Proc. 2019;94(8):1556-1566.
22. Avoiding job burnout — where are you on the stress curve? LeaderSharp Group. September 16, 2015. Accessed December 5, 2023. https://www.leadersharp.com/publications/avoiding-job-burnout-where-are-you-on-the-stress-curve/
23. Corrigan PW, Watson AC. Understanding the impact of stigma on people with mental illness. World Psychiatry. 2002;1(1):16-20.
24. Dyrbe LN, West CP, Sinsky CA, et al. Medical licensure questions and physician reluctance to seek care for mental health conditions. Mayo Clin Proc. 2017;92(10):1486-1493.
25. Saddawi-Konefka D, Brown A, Eisenhart I, et al. Consistency between state medical license applications and recommendations regarding physician mental health. JAMA. 2021;325(19):2017-2018.
26. Dr. Lorna Breen Health Care Provider Protection Act. March 18, 2022. Accessed December 5, 2023. https://www.congress.gov/117/plaws/publ105/PLAW-117publ105.pdf
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