11 April 2016

Why doctors’ mental health should be a concern for us all

When medical students enter university, their mental health is no different from that of the rest of the population. By the end of their first year, however, it is significantly worse.

By Michael Brooks

When medical students enter university, their mental health is no different from that of the rest of the population. By the end of their first year, however, it is significantly worse. Stress accumulates throughout their training and, for many, things do not improve. A new study demonstrates what a problem this has become – especially for the doctors involved.

Debbie Cohen and colleagues at Cardiff University carried out a survey of almost 2,000 British doctors at various stages of their career. Of these, 60 per cent had experienced mental illness (the figure is 82 per cent in England) but most had not sought help.

Even the doctors don’t see it coming. In the survey, most medical professionals who have never experienced mental health problems say that they would disclose any problem that arose. But attitudes change when it actually happens. “You don’t do what you think you would do,” Cohen says.

The figures differ according to stage of career. Trainees and junior doctors are less likely to admit to having a problem – perhaps unsurprisingly, given the perception that it may damage their future. Disclosure rates also differ by career track. Among GPs, 84 per cent say that they would disclose; 39 per cent do so. Trainees disclose at the same rate as GPs but are more aware that they won’t: only 62 per cent say that they would disclose a mental illness. Locums and specialist staff are the least deluded and the least open: they acknowledge the lowest likelihood of disclosure (60 per cent) and they follow through, with 38 per cent making a disclosure of an issue.

The reasons for not disclosing vary widely. There is certainly a lack of understanding about the support available. There are also concerns about being labelled and about confidentiality. Cohen and her colleagues are now designing an online tool to make disclosure easier. “We have considerable interest from all stakeholders and we aim for it to be disseminated widely across NHS organisations, deaneries and medical schools eventually,” she says.

Britain’s NHS reforms should make this an urgent priority, because the alternative is what the Cohen report calls “maladaptive coping strategies”. Research indicates that doctors learn these behaviours early on. The best known – because of its high prevalence even among trainee doctors – is alcohol and substance abuse, including misuse of prescription drugs. These coping strategies are not sustainable in the long term, leading to high levels of burnout and breakdown.

In many ways, much of these findings is not news. We have known for a long time that doctors have a higher rate of mental illness than the general population. We have not, however, considered the consequences. Some of the more alarming outcomes of having stressed and depressed doctors are pathological cynicism, an unwillingness to care for the chronically ill and decreased empathy. It is clear that no one benefits when doctors begin to go under.

Combing through the literature, one phrase stands out time and again: “particularly female doctors”. This group experiences a higher degree of anxiety than male doctors. Perhaps that is because, as a large Canadian study showed, female doctors are twice as likely to be depressed as their male counterparts. That becomes even more likely if they have children (no such relationship has been recorded for male colleagues who have children). Though more likely to disclose mental health problems, female doctors are less likely to turn to colleagues for help. The reasons are not uniform but reluctance to show weakness in the workplace, especially if there is an atmosphere of prejudice, is likely to play a significant role. Because of long shifts – often into the night – many have to endure journeys home in the dark, and feel vulnerable to attack. Once home, women suffer more, too, adjusting between children and work.

In the UK, the situation is about to get worse. The government’s assessment of the contract it has just imposed on junior doctors includes an admission that it will have an “indirect adverse effect on women”. This is justified as “a proportionate means of achieving a legitimate aim”.

Everything we know about doctors’ mental health indicates that the quality of care provision goes down as doctors get more stressed. The risk of suicide is higher than in many occupations (the rate among women doctors exceeds that of the general female population). It is also now clear that it won’t only be patients who die as a result.