Abstract

Methods

We first conducted a peer-reviewed literature search of PubMed for articles evaluating stress, burnout, depression, and suicide prevention or intervention programs for healthcare providers using the keywords “burnout prevention”, “burnout intervention”, “depression prevention”, “depression intervention”, and “suicide prevention” with each of the following terms: “healthcare provider”, “healthcare worker”, “health professional”, “healthcare student”, “physician”, “doctor”, “resident”, “medical student”, “nurse”, “nursing student”, “pharmacist”, “pharmacy student”, “physician assistant”, “medical assistant”, and “social worker”. With the exception of MoodGYM, the interventions used in these studies were neither web-based nor mobile applications. Nonetheless, our search identified six treatment approaches that are commonly applied to healthcare professionals to effectively reduce burnout: (1) web-based Cognitive Behavioral Therapy (CBT), (2) meditation, (3) breathing, (4) relaxation techniques, (5) mindfulness training and (6) suicide prevention apps.

Next, we searched Google and the wellness resources website beacon.anu.edu.au for online tools to prevent burnout, depression and suicide. Mobile applications specifically aimed at health professionals were queried using Apple App Store, Google Play Store, and US Department of Veterans Affairs App Store (mobile.va.gov/appstore). However, this general online search also yielded no healthcare worker-specific wellness resources. We subsequently searched for online tools and mobile applications in the aforementioned 5 categories of interventions used for healthcare professionals (web-based CBT, meditation, breathing mindfulness and relaxation techniques) in order to identify those with proven efficacy for other populations that also satisfy the criteria specific to healthcare providers. For the US Department of Veterans Affairs App Store, we excluded wellness apps that are catered towards a specific patient population, such as PTSD Coach, Fam Coach, CPT Coach, and PE Coach for PTSD; Vet Change for alcohol abuse; Concussion Coach for Traumatic Brain Injury; CBT-I for insomnia; Stay Quit Coach for smoking cessation; and Parenting to Go for parents. All searches were conducted between November 1, 2016 and December 31, 2016.

Applying a strategy similar to the American Psychiatric Association “app evaluation framework” [36], the results of these searches were summarized to describe the content, format, duration, cost, effectiveness, confidentiality or privacy, and convenience (i.e., easy access anywhere and anytime) (see Table 1). A diverse group of healthcare professionals at one west coast public university [12, 14] reviewed this summary and selected 1 to 2 well-developed resources to recommend for each category along the spectrum of stress, burnout, MDD and suicidality. The selection criteria included the strength of significant findings supporting resource effectiveness and the potential to circumvent the aforementioned key barriers to treatment (i.e., by being convenient, accessible, affordable, and confidential). For each category, the final 1 to 2 resources were largely determined by the research findings that support their effectiveness.

Results

The general online search generated 14 web-based tools and 22 mobile applications. The content, format, duration, advantages, and disadvantages of each tool are summarized in Table 1. From the 36 resources, based on the significant research findings that support their effectiveness, the workgroup of reviewers selected a total of 7 web-based tools or mobile applications applicable to each category of distress: 1 for stress (Breath2Relax), 2 for burnout (Headspace, UC San Diego meditation audios), 2 for depression (MoodGYM, Stress Gym) and 2 for suicide prevention (Virtual Hope Box, Stay Alive). Breath2Relax is a mobile app that provides various guided breathing video and audio tutorials [37]. Headspace is a meditation mobile app shown to reduce depressive symptoms and improve positive affect among smartphone owners [28]. Although many sites and institutions provide guided meditation audios, not every source includes mindfulness-based stress reduction (MBSR) (e.g., health.uscd.edu/specialties/mindfulness/programs/mbsr/Pages/audio.aspx), which has been shown to decrease burnout and improve mental well-being [39]. Through its five weekly modules, MoodGYM, a web-based Cognitive Behavioral Therapy (CBT) program developed by Australian National University, has been shown to decrease suicidal ideation in medical interns [29]. Stress Gym, on the other hand, offers eight self-paced CBT modules and step-by-step stress management guides, with success in reducing stress among Navy officers [40]. Virtual Hope Box is a suicide prevention app that improves users’ ability to cope with unpleasant thoughts and emotions [30]. Finally, Stay Alive, a suicide prevention app developed by the Grassroots Suicide Prevention, provides a customized safety plan, breathing and grounding exercise tutorials, online discussion forum, and links to other suicide prevention resources.

Discussion

Only recently have burnout, depression and suicidality been recognized nationally as significant challenges faced by healthcare students and professionals. Applying a strategy similar to the “app evaluation framework” [36], we searched for digital health resources aimed at mitigating burnout, depression and suicidal thoughts and behaviors. Such resources designed for the general population are rapidly emerging [32, 33]. To help healthcare programs navigate these evolving resources, we compiled a list of 7 web-based tools and mobile applications designed to foster wellness and mitigate burnout, depression, and suicide risk that have features that could satisfy the unique needs of healthcare workers. Of note, of all those reviewed, only MoodGym is evidence-based, only a minority (10) show any evidence of efficacy, and none specifically target healthcare professionals. Even so, they represent resources with the potential to reach a broad range of healthcare providers and surmount some of the obstacles preventing so many healthcare students and professionals from pursuing the help that they need. As such, they could also serve as a catalyst for some to pursue more established treatments, such as formalized psychotherapy, when indicated. Future efforts could (1) evaluate whether such tools are effective in healthcare professionals and (2) apply user-centered design to optimize these resources for healthcare providers and thus improve their relevance and efficacy.

The recommendations herein should be considered in the context of several limitations. First, the list of recommended resources was not generated from an exhaustive search process and may therefore have failed to identify other web- or app-based tools that satisfy our a priori defined criteria for inclusion. For instance, only included articles written in English were evaluated. Likewise, our search also relied upon PubMed or general searches and may have failed to identify valuable resources that did not appear in these venues. Additionally, since we did both literature and consumer product searches, our searches may especially be limited by terminology. Second, our criteria in selecting the final 7 resources within 5 categories focused on efficacy and our assessment of their potential to overcome healthcare professionals’ commonly cited barriers to pursuing treatment. The choice of categories and this assessment was based on the literature and the collective judgment of the diverse workgroup of healthcare students and professionals; it was not objective nor was it subjected to validation by a test group. Also, while we favored digital resources that claimed confidentiality, we nonetheless recognize the limits of internet-based resources – even those that are designed to be confidential – which may not fully protect a person’s anonymity in all instances. Users may be rightfully concerned about Internet monitoring, particularly while they are at work, which may be the most vulnerable time to use these digital resources. Concerns about data breaches and the sale of personal information are also valid and warrant careful consideration. Lastly, in this review, only tools that were publicly available at the time of the search were queried. Given the rapid development of mobile and web-based technology and the growing spotlight on wellness research over the past few years, it is likely that new tools have emerged as of January 1^st, 2017. Hence, to support our recommendations and keep the pace with this rapidly evolving trend, our findings remain to be further refined, validated, and updated through research.

To our knowledge, with the exception of MoodGYM, which demonstrated promising results among medical interns, most of these resources have not yet been tested among healthcare providers. Future research evaluating the effectiveness of these resources among healthcare workers is needed. We do offer a few caveats for programs planning to recommend such resources. First, none of the resources identified in this report is considered a suitable replacement for face-to-face interventions for suicide prevention or the treatment of MDD. Rather, they can be used to bridge the obstacles to intervention and, in doing so, hopefully serve as a catalyst for individuals to seek direct support. These resources may also help individuals during periods of “watchful waiting” in primary care or as an adjunct to more traditional therapy. We also see these interventions as niched more for managing stress, burnout and relatively mild depressive symptoms, where professional help may not yet be indicated. Second, we recommend that programs consider implementing “guided” internet-based interventions for suicide prevention or the treatment of moderate to severe MDD that directly facilitate prompt referrals to in-person care [44]; we are aware that the evidence showing that self-guided interventions are less effective than clinician-guided interventions is not conclusive [32, 45]. Third, we recommend that programs find innovative ways to monitor the use of these resources and solicit ongoing feedback on their utility to guide real-time improvement. Since healthcare professionals may be motivated to choose digital resources out of a concern about their privacy, finding ways to monitor their use without the real or perceived compromise of confidentiality represents a challenge moving forward.

By intervening with technology-based resources at the burnout stages, near the base of the pyramid of distress (see Figure 1), we hope to enhance healthcare students’ or professionals’ coping with the customary stresses and strains of their everyday life, and thus create upstream effects of preventing burnout, reducing depressive symptoms, and even attenuating suicide risk. Future efforts could test the effectiveness of this approach in large scale, multi-site, longitudinal studies, with the goal of improving the wellness of healthcare students and providers.

Acknowledgments

Footnotes

References