Why are we so bad at calling for help?
Doctors’ Mental Health
With 58% of doctors now suffering from some form of anxiety or depression – and 46% saying their condition had worsened since last March – we begin serialising sections of a new book edited by Dr Clare Gerada. This month: Doctors and mental illness.
A medical degree gives no protection from the normal vicissitudes or hardships of life. Doctors have the same mental illnesses as the general population.
Where doctors do differ is not in the illnesses they get, but rather in how they present, their prevalence, potential impact and outcome.
Perhaps the most significant difference is how hard it is to cross that invisible boundary from professional to patient, even when that boundary is for a physical, rather than a psychological disorder.
I am guilty of this myself. When knocked off my bike en route to my evening surgery, instead of abandoning ship and going to the accident and emergency department, I hailed a taxi and completed the clinic – with blood oozing from my foot and in great pain.
It did not cross my mind that I could have cancelled and sought help. This was a physical illness. It is even harder for doctors to seek help for mental illness. For doctors, mental illness is their shameful secret, hidden from sight.
This means large numbers of depressed and anxious doctors are denied help – usually through their own reluctance to seek it. It is vital that this ‘secret’ comes into the open and that they are able to receive appropriate treatment.
This is not just for the doctor’s sake, but also for their patients, since untreated mental illness is linked to more medical errors.
High rates of mental illness in doctors are a global phenomenon. In every system – privately, insurance or nationally funded – and across all specialties, ages, gender, and levels of seniority, doctors are at risk of mental illness.
Depression
A review in 2010 identified 19 papers on depression and anxiety in doctors. The reported rate varied from 14% to 60%.
Current levels of depression, as determined by an Australian survey, showed similar rates to the general population, but higher than for other Australian professionals. Approximately 21% of doctors reported having ever been diagnosed with or treated for depression and 6% had a current diagnosis.
Another review published in 2014 found 112 articles on depression in American doctors. Rates of depression ranged from 1% to 56%, an enormous variance, reflecting sample size, methodology used and cut-off limits for ‘caseness’.
The larger and more robust studies included in this review found between 22% and 35% of doctors reported between four and five symptoms of depression.
A similar figure was found in another systematic review, which included 54 cross-sectional and longitudinal studies involving 17,560 hospital trainees from 18 countries.
Similar levels of depression were found regardless of the country in which the study was done, and gave a pooled prevalence of around 30%. There is a trend for newer studies to find higher rates, which, while modest, is notable given the reduction in duty hours and improved working conditions over the last decade.
A study of American interns found the percentage of doctors meeting the diagnosis of severe depression increased from 4% before starting work to 27% one year later. Overall, over the 12 months, 42% of the doctors met the criteria for depression at one or more of the quarterly assessments, though only 23% sought help.
The pressure to address overwhelming medical needs, intensity of workload, difficult clinical encounters and being sued or facing complaints are all contributors to high rates of mental distress.
Anxiety
Everyone is familiar with the term ‘anxiety’ and no part of our daily lives can be free from it. Where anxiety becomes a problem is when it becomes pervasive and the symptoms begin to interfere with work, life and relationships.
Three of the most common anxiety disorders doctors suffer from are generalised anxiety disorder (GAD), panic disorder and post-traumatic stress disorder (PTSD), with GAD being the most common.
GAD is characterised by out-of-control, intrusive anxiety present for most days, about several subjects for more than six months.
Anxiety is less well studied among doctors than depression has been, and studies are of lower quality, as they do not tend to use formal diagnostic instruments, and therefore ‘anxiety’ tends to encompass a range of different diagnoses, from ‘stress’, ‘psychological distress’, generalised anxiety or phobic anxiety states.
Evidence-wise, it is not possible to say whether rates of anxiety are more, less or the same as in the general population. Experience-wise, generalised anxiety is a common finding in the doctors we see in our service, either presenting alone or alongside a depressive disorder.
I would suggest that anxiety is almost pathognomonic of being a doctor in today’s healthcare system. There are so many anxiety-provoking events in clinical practice that it has become normal for doctors to ignore their racing heart, fearful thoughts or the vague feeling of constant nausea in their everyday lives.
Post-traumatic stress disorder
Exposure to traumatic events is generally unavoidable in medicine, but more so for those who work at the front line of acute care such as A&E, intensive care, anaesthetists, surgeons and obstetricians.
For all doctors, though, contact with dying patients, serious injury, patients with intense pain and distress is commonplace in their everyday clinical lives.
Outside their consulting rooms, doctors also experience further traumatic events from being subjected to bullying, complaints, assault or racism.
Most people who are exposed to a traumatic event have no adverse long-term problems and resume their normal functioning. Some may even have an increase in well-being, confident that they handled the event or themselves well.
A small number, however, will experience a range of adverse psychological effects, including PTSD.
Symptoms include persistent thoughts, images, flashbacks or dreams in response to reminders of the event, the desire to avoid discussion or reminders of the trauma and a host of other symptoms such as loss of interest, withdrawal and anger.
Symptoms need to be present for more than one month and not caused by medication, substance use or other illness.
Awareness is increasing that those working in the front line of healthcare also suffer from this disorder.
A past chairman of the GMC once remarked that doctors should take a leaf out of army personnel and learn to be resilient. He was referring to dealing with complaints and referrals to the regulator, but his comments were taken as a general view that doctors were not resilient enough to survive the rough and tumble of a career in medicine.
I imagine he now regrets this comment, but the sentiment behind it, that working in the NHS is akin to serving in the armed forces, seems a good analogy given the prevalence of PTSD in healthcare staff.
Alcohol and drug misuse
Over the decade, my service has cared for hundreds of doctors with various forms of addiction, mainly alcohol and drug, but also others too, including gambling, sex and porn addiction.
I am often struck how far doctors need to fall before they reach out for care. Often, they continue drinking and using drugs despite serious relationship difficulties, problems at work, loss of livelihood, housing and physical illness.
This is the nature of addiction, compulsion to use, despite harm done to self and others. Untreated, the doctor is likely to present in a crisis, potentially following a drink-drive offence, being caught stealing drugs from work or having an accident.
Some die before they get the chance to present at all, whether through accident or suicide.
Overall, drug and alcohol use are probably lower in doctors than in the general population, though in the absence of large studies, it is not possible to be certain.
Personality disorder
An individual with a personality disorder thinks, feels, behaves or relates to others differently. There is scant research into doctors with this disorder, possibly due to it being uncommon, but also because of the difficulty of diagnosing it.
It is likely to be even less common in medicine, as medicine selects against some traits common in people with personality disorders – such as poor impulse control, lack of empathy – and for ones such as resilience and obsessiveness.
In my experience, where personality disorder does present, it is accompanied by performance issues at work or professional misconduct, such as boundary violations.
When you look back into these doctors’ histories, often there are repeated complaints the doctor was ‘not a team player’, they become angry when stressed and elicited fear, shame and rage in others, and consequently distress in their teams. Not all disruptive behaviour is due to an underlying personality disorder, some might be just bad behaviour.
Consequences of mental illness
Whether doctors have the same, lower or higher rates of mental illness than the general population is not the main issue.
What is important is ensuring that this group, who, after all, have a critical role to play in the care of millions of people, receive timely help such that they do not pose a risk, not just to themselves but also to the patients they manage.
Doctors with mental illness are more likely to stay at work than not – a term called presenteeism – and working at suboptimal levels due to their symptoms.
There is evidence that medical errors are more common in depressed doctors, both an increase in self-reported errors and also when objectively measured. Depression is closely correlated with fatigue, which might explain the higher levels of medical errors found in doctors with this condition.
Mental illness matters, as it has a significant macroeconomic impact too. In the UK, the total cost to employers of mental health problems among their staff is estimated at nearly £26bn each year: £8.4bn from sickness absences and £15.1bn from reduced productivity at work.
While these figures are for all staff, doctors are an expensive resource and their absenteeism will place a large hole in services finances.
A mentally unwell doctor is likely to enter a downward spiral as feelings of hopelessness and worthlessness lead to declining performance and a greater risk of errors, causing further despair.
Patient care and professional standing can then be placed at risk, possibly leading to more complaints and concerns. This is why it is so important to minimise the barriers to accessing care.
It appears that doctors do have higher rates of mental illness, certainly in the more common conditions, such as depression and anxiety. It is perhaps not surprising given the nature of their work.
Dr Clare Gerada (right) is medical director of the Practitioner Health Programme, London, and a former RCGP chairman
