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Towards the end of 1997, at the request of the NSW Minister for Health, the NSW Doctors’ Mental Health Implementation Committee was established to implement the Doctors' Mental Health Working Group Report and Recommendations (dated 29 May, 1997). This Committee, which has representatives from all areas of the medical profession, has produced the Doctors’ Mental Health Policy, Strategies for Area Health Services, Strategies for the Medical Schools, Strategies for NSW Branches of Medical Colleges and Strategies for Rural Divisions of General Practice in NSW. Part of the purpose of the Committee was to conduct a comprehensive literature review. During 1998, the Committee’s Working Party and consultant conducted a literature search and the articles were summarised by Ms Carmel Kendall. The NSW Medical Board provided financial support and the library of Gladesville Macquarie Hospital assisted in obtaining the articles. The Committee has since been refining this summary, with particular assistance from Ms Penny Johnston. Dr Gary Galambos, as part of his Dissertation project for the Royal Australian and New Zealand College of Psychiatrists, did the final review, edit and update. The Rozelle Hospital, of Central Sydney Area Health Service, kindly produced copies of the literature review for distribution at its launch at the Inaugural Doctors’ Health Conference in November 1999. I would like to thank all those who contributed to this review of the literature on doctors’ mental health. Dr Tony Williams
Doctors hold responsible positions in the general community, being trusted with the power and authority to make decisions and give advice that frequently have significant implications for members of the community. It is important that the mental functioning of doctors is adequate because adverse consequences are likely to flow on to the patients, as well as families, colleagues and healthcare employers, of doctors who become significantly impaired from an untreated mental disorder. Smith1 considers self-regulation to be the main distinguishing feature of a profession. Developing the Policy and Strategies for the implementation of preventative and intervention programs represents the NSW Doctors’ Mental Health Implementation Committee’s attempt to promote self-regulation by the medical community as a means of reducing the morbidity and mortality of mental disorder in the medical profession2. With the exception of cirrhosis, doctors are in relatively good physical health. The prevalence of smoking, cardiovascular disease and cancer—in fact, standard mortality ratios overall—are lower than that of the general population3,4,5. However, doctors are likely to be at risk of developing the same mental health problems that occur in the general community, such as substance use disorders, mood disorders, anxiety disorders, psychotic disorders and even personality disorders. In addition, doctors appear to be at risk of developing distinct patterns of mental health problems and they have a reduced likelihood of obtaining early and optimal treatment for them. Up until the past two or three decades there has been little attention given to ensuring that members of the medical community obtained the services that they themselves have provided for others. There are three factors influencing the development of mental disorder in doctors and the delivery of psychiatric care to impaired doctors. Firstly, there are vulnerability factors within doctors themselves. There have been consistent findings of increased stress, marital discord, alcoholism, opiate abuse, depression and death by suicide, accident and cirrhosis in the medical community. In addition, anxiety disorders, such as phobias, OCD and PTSD, psychotic disorders, such as bipolar disorder and schizophrenia, and even personality disorders, are likely to be at least as common within the medical community as occur within the general population. Secondly, there are unique factors to the practice of medicine that influence the development of stress-related health problems in doctors. Thirdly, there are factors that relate to the culture of the medical community and the complexities and obstacles for both the impaired doctor and the treating doctor regarding the formation of the therapeutic relationship. The obstacles to treatment appear to be particularly pronounced when the problems are of a psychosocial or psychiatric nature3. Despite their high reported prevalence of mental health and stress-related problems, doctors thus appear to be at risk of ‘falling through the cracks’ when it comes to accessing and receiving adequate clinical care. These factors provide deserving reasons for developing a specific campaign and a resource that targets the prevention and early intervention of mental disorder arising within the medical community6. This literature review discusses the findings of studies and articles identified relating to these factors.
Personality factors in doctors represent a two edged sword as they may be adaptive in one context but destructive in another. Personality traits and defences that may be adaptive for doctors’ work practices (professional functioning) may easily become vulnerability factors for mental health problems7,8. The reasons why doctors choose medicine as a profession may provide clues about their personalities. Hume and Wilhelm asked interns about their motivating factors for doing medicine9. The main reasons provided were intellectual challenge (91.3%), altruism (85%), job security, social status, to earn others’ approval (38.6%) and parental pressure (33%). Vaillant found that difficult childhoods, such as exposure to family members with mental disorder, may attract those people to study medicine. These early traumas may cause doctors to be vulnerable to developing mental health problems10. Survey reports reveal that doctors tend to be obsessional, perfectionistic, ambitious, self-sacrificing and rigid7,11. They often place high expectations on their own performance7, have a low tolerance for uncertainty1,11,12 and difficulty with emotional expression11. Researchers have reported that doctors appear to have inadequate coping skills to deal effectively with stress13,14,15. They may share a dynamic of replacing their own needs with those of their patients10,11,16,17. Doctors with mental disorder have a tendency to deny, minimise and rationalise their own symptoms and behaviours3,8,15,17,18,19,20. There are numerous forces for doctors to defend against. There is the narcissistic injury of a tainted self-image caused by mental disorder, where they may perceive themselves as flawed and inadequate. This may be unacceptable because of the collective denial of the medical community17,19,20,21 and because of society’s fantasy of doctors as omnipotent and invulnerable1,3,15,19. There is the guilt and shame that arise as a result of the stigma of mental illness, which also occurs within medical subculture3,22. Mental illness represents helplessness and loss of control, which is particularly threatening to doctors accustomed to positions of power, authority and control. Doctors with ‘illusions’ of grandiosity and indispensability do not wish to give up these defences12,17. Vaillant noted that almost half the doctors in his longitudinal study had unsatisfactory marriages compared with one third of the controls10. The reasons may relate more to personality factors and communication styles than number of hours worked23.
In a large study of random medical practitioners in NSW (n=1,125) examined by questionnaire, 19% reported marital disturbance, 18% "emotional disorders", 3% alcohol problems and 1% drug abuse24. The prevalence of depression and alcohol abuse amongst young doctors in Britain and North America has been reported as high as 30-50%25,26,27, while a large study of NSW interns failed to duplicate these results9. There is controversy in the medical literature about whether or not doctors’ prevalence rates for mental disorder are higher than that of other professional groups. This is because reliable data on this topic has been hard to obtain. Common deficiencies in studies identified were selection bias and inconsistencies amongst the sample groups, making them difficult to compare. Many studies were uncontrolled, contained small numbers, had retrospective designs and used rating scales of psychological distress rather than structured diagnostic instruments. There are large gaps in the literature regarding the prevalence of mental disorder in general practitioners, private sector specialists and rural doctors. There was a lack of consideration of disorders other than depression and drug use. Most studies in the area related to doctors working in Europe and North America. Different countries appear to have a different focus of attention. There have also been significant changes in the demographics of the medical workforce, medical training, practice of medicine and provision of rehabilitation services for impaired doctors over the past 30 years. The increased proportion of women entering medical school, changes to the selection process and introduction of more rigorous training schemes may make recent studies harder to compare with older ones. The changes in legislation, regulatory measures and treatment approaches to impaired doctors in both the international and local contexts further complicates attempts to assess the extent of the problem.
A large Canadian study of interns, residents and specialists (n=1,805) revealed that 23% of the doctors (compared to 15% in community studies) experienced significant depressive symptoms on a self-rated depressive scale questionnaire28. Female doctors have been found to be up to twice as likely as their male peers to be depressed8,28. Studies have consistently reported variations within specialty groups. The highest depression rates in the Canadian study were in obstetrics and gynaecology residents, followed by interns and psychiatry residents. Rates were also high in those working in radiology, anaesthetics, surgery and paediatrics28. Many overseas studies have consistently found depression to be highest in interns, with rates of greater than 30% reported, and a pattern of falling frequency following the intern year. A prospective study of 68 American interns, with self-report questionnaires (using Research Diagnostic Criteria) given at monthly intervals, indicated a fall from 30% during internship to 15.1% prevalence of depression by post-graduate year two29. In another significant American study, retrospective diagnoses of depression were studied by comprehensive structured interviews of 53 American residents at the end of their internship year25. Significant depressive episodes were found in 30% of the participants, often associated with marital problems during those periods. Of the depressed individuals, 50% had a family history for depression compared with 14% in the non-depressed group. In Australia, where work hours and conditions have improved in recent years, these high rates have not been found. Hume and Wilhelm conducted a prospective one-year study on 130 interns9. General Health Questionnaire and Beck Depression Inventory scores were similar at the start and end of the year and the interns reported few episodes of mood disorder during the year when asked at the conclusion. In fact, compared with 17% seeking help for psychological problems before starting internship, only 8% had reported seeking help during the year. Possible reasons for the low rate of psychological distress compared with overseas studies were: a mentor program was trialed for one year during the study; local work conditions are probably better than overseas; the inability to monitor the interns regularly during the year may have given the appearance of reduced rates; there was reticence amongst distressed interns to fill in questionnaires during the periods of distress. The rates of dissatisfaction and anger were found to be high, with 72% reporting having "often" experienced significant episodes of anger through the year. The imposition of increased government regulation and university fees and the perception of diminished future prospects may have contributed to this finding.
Evidence of the medical profession being more prone to suicide than the general population has been considered incontrovertible by some authors4,7,11. The NSW Medical Board’s statistics reported a suicide rate of 19.1 per 100,000 registered doctors between 1992-1997 (compared with a community rate of 12 per 100,000)30. Rates are likely to be higher since many suicides are not reported or notified to the Medical Board. It has been determined that more than three-quarters of doctors who suicide are depressed and, in many, alcohol and drug abuse are significant contributory factors15,31. Men have been consistently found to be 1½ to double the risk of the general population, whilst women have rates that are three to five times average risk in Australian, British and American studies4,30,32. Vocational areas over-represented in suicide figures are anaesthetics, general practice, psychiatry and emergency medicine7. Young doctors, rural doctors and doctors on conditional registration are also over-represented30.
Alcohol consumption appears to be higher in the medical profession than the general population, especially in British studies11,33,34. Adverse childhood experiences10, older age, disappointment with career, high levels of stress and ‘burnout’, and high rates of smoking and benzodiazepines use have all been associated with increased alcohol consumption by doctors. Doctors have a 3½ times greater death rate from cirrhosis than that of the general population33,34. Alcoholism is the major cause of impairment in doctors over 50 year old and it is probably under-reported in other age groups8,35. Older doctors are more likely to have marital problems preceding and following alcohol misuse36.
Substance abuse is a major cause of impairment in doctors and can affect any medical specialty or age group13,30,37. In Australia, studies have found estimates of 0.5-1.3% of the medical community suffering from a substance use disorder15,24. Doctors have consistently been found to have higher rates of drug dependency than pharmacists, dentists and veterinary surgeons in the international literature15. This is an argument against the proposition that access to potentially addictive drugs is the primary factor in the high rates amongst doctors. Family background, personality traits and the stress of practice have been argued to be the major factors11. On the other hand, trainee anaesthetists have been singled out as a particularly at risk subgroup. Vaillant et al conducted a prospective study of 45 doctors over 20 years, finding they took more sedatives, tranquillisers and stimulants than matched controls (n=90), but he found no difference in the use of alcohol or cigarettes13. It was postulated that unhappy childhoods and personality factors, such as dependency, pessimism and self-doubt, were conducive to drug dependency, which has been reinforced by other studies14,37,38. It has been suggested by Ellard that the trend over the past decade in Australia has been one of increased numbers of younger doctors abusing a wider range of substances, including illicit drugs15. This is concordant with the pattern of drug use in the general population. An important Australian study involved the retrospective review of file notes of 79 medical practitioners in NSW who had self-administered opiates for non-medical purposes and subsequently had their access to these drugs withdrawn39. The majority were aged between 30-39 years, with females tending to be in older and males younger age brackets. Young men tended to use more than one drug. Most doctors over 45 years of age had medical conditions for which they were taking the opiates and were depressed. There was an over-representation of general practitioners in rural locations and emergency department hospital doctors. Most abused pethidine, obtained from their doctor’s bag. Over 20% of the doctors reported injection of drugs whilst on duty and 43% had used opiates for at least two years prior to getting caught. Three of the ten doctors (3.8% of the study group) were considered to have died by suicide during the study period. Over 20% reported consulting a psychiatrist for non-drug related problems prior to their authority to prescribe being revoked, with more than 15% citing depression as a factor in their drug use (compared with 8.6% of controls having a history of mental disorder). A major limitation of the study was that significant changes to the rehabilitation system in NSW had transpired during the span of the study (1985-1994). It did not consider how the doctors’ outcomes may have been influenced by these changes in local context. It is likely that towards the latter stage of the time period of the study the doctors may have fared better due to the less punitive and more rehabilitative approach to their management.
It has been proposed that doctors’ high levels of anxiety are more due to their work environment than to high trait anxiety or neuroticism11. There are unique stresses in medicine17. Doctors’ mortality from motor vehicle accidents has been found to be twice as high as that of the general population4,11. It has been speculated that this may relate to long and disruptive work hours. Particular concern has been expressed regarding the impact of shift work and extended hours on the sleep patterns and personal life of junior doctors in the hospital sector25,40,41,42. Doctors experience continuous exposure to traumatic stimuli1,38,43 in the face of clinical responsibility to relieve suffering7. There are the competing needs of their patients versus their family3,7,11. They are frequently confronted with ethical dilemmas in the course of their work38. Australian doctors have not been spared the economic climate of rationing and waning resources that has occurred in other industrialised countries44. At the same time they have been exposed to a consumerist movement of increasing demands for accountability, with legislative and medicolegal consequences. There has been a rising tide of public mistrust and negative public depictions of the medical profession. These trends have been associated with increased levels of external control and scrutiny3,38. The conflict between the increasing expectations of the community and employers in the face of tightening resources has caused growing stress for clinicians faced with these daily dilemmas. Stress in young doctors at the beginning of their career has been found to relate to a number of factors. Specifically, there are concerns about competence, overwork8,45, talking to psychiatric patients, presenting cases, dealing with death and suffering, relationships with unreasonably demanding consultants26,33 and sleep deprivation8. ‘Job burnout’—exhaustion leading to negative self-concept and job attitudes—is associated with high workload, inadequate resources, treatment failures and diagnostic difficulties. The accumulated amount of face to face clinical work performed may be a risk factor in the development of stress related disorders17. Higher stress levels have been found in specialists working in acute medical settings, such as HIV medicine, oncology, emergency departments and intensive care units15,46. Lower stress levels are present in doctors working in better-resourced and more cohesive teams27,47. The large variation in the rates of suicide amongst different specialties may reflect varying degrees and types of occupational stress11. The degree of isolation experienced by doctors, both professionally and geographically, may also place doctors at increased risk3 of stress-related disorders and suicide, although this has been inadequately addressed in the literature.
Doctors have a unique status within the health system because they are identified as healers by their patients, families, colleagues and themselves. Perhaps, then, it is not surprising that they should have difficulty in changing role from provider to beneficiary of medical assistance when they are ill11,15,48,49. Avoiding entering the role of patient may be a reason why doctors prefer self-diagnosis and treatment. This may allow them to avoid shame, loss of credibility, loss of control and expenditure of time obtaining formal consultation. They may be overconfident in their ability to remain objective. Doctors may also conceal symptoms and suicidal ideas because they fear hospitalisation, loss of medical registration, exposure and stigmatisation3,18,19,22. There is an acceptance of using drugs to combat distress within hospital environments and a ‘physician heal thyself’ mentality within the medical subculture,15,19 which foster inappropriate responses to health problems in doctors19,20,21,49. Doctors’ self-treatment may not provide them with optimal management because of their biased perspective, knowledge gaps, denial, neglect or impaired judgement. Doctors’ ready access to drugs of addiction may place them at risk of developing a substance disorder15 if they self medicate7. Doctors may have a negative or dismissing attitude to psychiatry12,15, psychiatrists or people with mental illness50,51. Menendezi summarised the sparse literature available of doctors’ impressions of each of these groups52. None fared well. Medical students commonly held negative attitudes about psychiatry, perceiving the vocation to have lower prestige compared to other specialties and to be unscientific, imprecise and outside medicine’s mainstream. They saw psychiatrists as fuzzy thinkers, aloof, self-centred and poor communicators who had wasted their medical education because they lost their general medical skills. Doctors perceived psychiatric patients to be hard to like, identify with, develop a therapeutic alliance with or treat, although interesting and challenging. These stereotypes may have negative consequences for the likelihood of referral to a psychiatrist, agreement to proceed with a referral, conflict arising between a doctor-patient and psychiatrist and rates of dropout51,53. These factors may lead to delayed referral, misdiagnosis and inadequate treatment of the impaired doctor. This in turn may continue the cascade of suffering by the doctor and their families, students, colleagues and patients. Treating another physician as a patient creates a unique therapeutic situation which doctors tend to prefer to avoid. There are pitfalls and difficulties relating to privacy, confidentiality, denial, boundary setting and control issues53. Colleagues and treating doctors may inadvertently collude with impaired practitioners’ inadequate self-management, such as when they engage in brief corridor consultations. Doctors worldwide manage their impaired colleagues poorly. They often choose to turn the other way rather than develop ways of responding1,5,12,19,54. When doctors do accept their role as patients, they often identify themselves as ‘special patients’12. Doctors treating doctors may respond by rescuing—being overindulgent, overanxious and overprotective. Alternatively, they may be defensive and denying—avoiding, rationalising and minimising the severity of the illness due to denial and discomfort7,12,15,17,55. The most difficult problem for the therapist is over-identification with the doctor-patient17. Many psychiatrists feel intimidated8, embarrassed and anxious treating fellow doctors. These factors may result in under-treatment and mistreatment12. There is a paucity of literature addressing the practical issues of psychiatric treatment of doctors with mental disorder. The Canadian Psychiatric Association’s Position Paper on the treatment of the mentally ill doctor emphasised that doctor-patients should obtain the same benefits of patient status that any patient would obtain. The doctor-patient should receive an empathic and comprehensive bio-psycho-social assessment that should include questions about professional and ethical behaviour with their patients18. When doctors make contact for help, they may experience an exacerbation of worthlessness, guilt and fear, so they should be seen as soon as possible. They may underestimate how unwell they are. Impaired doctors may mask symptoms by using their knowledge to deny key symptoms through the use of jargon and by self-medicating. At considerable risk are depressed and drug abusing anaesthetists, intensive care specialists and psychiatrists because they have the prerequisite knowledge to successfully complete suicide and ready access to intravenous drugs and equipment15,18. Treatment should be assertive. Hospitalisation, if necessary, should not be delayed or avoided but provided at an alternative site from their home hospital. Inservice education of nursing staff should ensure care is sensitive but firm. The treating psychiatrist can expect confidentiality to be raised by the sick physician as an issue of high concern18. Conflict-of-interest situations occur where the treating psychiatrist has had a professional relationship with the physician or belongs to the same College; this may make impaired psychiatrists particularly reluctant to seek help18. Davis suggests that the therapist obtain supervision and second opinion in these circumstances17. It has also been recommended that involving the doctor-patient’s family in assessment, education and treatment processes should be encouraged12,17. In situations where an official regulatory body refers the physician to a psychiatrist for treatment, the Canadian Psychiatric Association suggests that this relationship be seen as embedded in a disciplinary context18.
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© 1998-2004.
Citation suggestion: Dr Gary Galambos, Doctors
Mental Health Literature Review (http://www.dmh.org.au/dmh/literature_review.html)
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