Indian Journal of Psychological Medicine

GUEST EDITORIAL
Year
: 2020  |  Volume : 42  |  Issue : 2  |  Page : 105--107

Are specialist treatment services needed for doctors with mental health problems?


Sanju George1, Sandip Deshpande2, Roy A Kallivayalil3,  
1 Department of Psychiatry and Psychology, Centre for Behavioural Sciences and Research, Rajagiri College of Social Sciences, Kalamassery, Kochi, Kerala, India
2 Department of Psychiatry, People Tree Maarga, Bengaluru, Karnataka, India
3 Department of Psychiatry, Pushpagiri Institute of Medical Sciences, Tiruvalla, Kerala, India

Correspondence Address:
Prof. Sanju George
Centre for Behavioural Sciences and Research, Rajagiri College of Social Sciences, Kalamassery, Kochi - 683 104, Kerala
India




How to cite this article:
George S, Deshpande S, Kallivayalil RA. Are specialist treatment services needed for doctors with mental health problems?.Indian J Psychol Med 2020;42:105-107


How to cite this URL:
George S, Deshpande S, Kallivayalil RA. Are specialist treatment services needed for doctors with mental health problems?. Indian J Psychol Med [serial online] 2020 [cited 2020 Apr 7 ];42:105-107
Available from: http://www.ijpm.info/text.asp?2020/42/2/105/273410


Full Text



In this brief paper, we will look at whether doctors who experience mental health difficulties require specialist treatment services. In doing so, as there is only limited research evidence in this area from India, we will also look at what international evidence informs us. Although our discussion here is limited to doctors, the core issues discussed are equally relevant to doctors in training (medical students and postgraduate students). We acknowledge that early interventions are of utmost importance in terms of prevention of mental health problems; hence, any proposed service should also accommodate doctors early in their careers—medical students and post-graduate trainees.

The practice of medicine is a risky “business” that exposes its practitioners to wide-ranging risks to their own health, especially mental health. Such risks have been categorized into occupational and individual.[1] Occupational stressors include high expectations from patients, demanding work environments, poor support structures, lack of time, resources to maintain a work–life balance, and so on. Other proposed explanations for doctors being more vulnerable/at risk for mental health problems have included psychological theories, such as “helping profession syndrome“[2] and '”compulsive caregiving theory;”[3] individual vulnerability;[4] socio-environmental factors specific to medical training (such as over competitiveness related to exams and career advancement, easy access to drugs, a “macho” culture) and later, professional practice (such as more knowledge of and easy access to drugs, peer attitudes, and socialization opportunities); and stress at work.

A more recently discussed concept is that of “moral injury”[5] among doctors, described as the inability to just be a doctor and the inability to do what they know is right for the patient because they are caught up in targets and rules and regulations. This too can lead to stress and burnout. Perhaps, it is most likely that stressors are multifactorial in doctors, with an interplay of various stressors/risks and individual vulnerability, buffered by individual resilience, ultimately determining who develops mental illness.

Medical practitioners suffer from high rates of mental health problems, such as anxiety,[6] depression,[7] substance misuse,[8],[9] and emotional exhaustion and burnout.[10] Precise prevalence estimates are lacking and the existing studies abound with methodological limitations. However, international evidence has noted that:

The career-time prevalence of depression in doctors in the United Kingdom (UK) is 10 to 20%[7]Studies from the United States of America (USA) and Canada have also noted high rates of suicide, substance misuse, and burnout among their doctors.[1][INLINE:1]

In the largest study to date from India, Grover et al.[11] studied psychological problems and burnout among medical professionals and found that “a significantly higher proportion of doctors in Indian setting experience stress, depression and burnout” and concluded that stress, depression, and burnout were associated with “long working hours and negative patient-related outcomes, adverse doctor-patient interactions, and interpersonal interactions among the colleagues.” They[10] also noted that compared with faculty members, residents/students (postgraduate trainees) had higher rates of stress, depression, and burnout. Although conditions like depression, anxiety, substance misuse, and stress tend to be more common among medical practitioners, a minority (just as in the general population) will also need help for severe mental illnesses, such as schizophrenia.

Despite doctors having higher risks and higher rates of mental illnesses, they are reluctant to seek timely professional help. Barriers to timely help-seeking include stigma, fears about confidentiality, feelings of guilt and shame, poor insight, anxieties about the potential impact on their career, fears about the negative response from colleagues and employer/s, mistrust of regulatory bodies, lack of awareness about where to get help, and so on.[12] White et al.,[13] in a survey of 319 psychiatrists from the UK noted concerns about confidentiality, stigma, and career implications as the most common reasons for psychiatrists not disclosing their own mental health difficulties. Undiagnosed and untreated mental illness in doctors can negatively affect the doctor, their family, and their patients. It can impair a doctor's performance, risk professional misconduct, can risk patient safety and undermine public confidence in the medical profession. These barriers are of great concern and a missed opportunity because early and appropriate treatment interventions are effective in this “patient” group.

Doctors with mental health problems are “different;” hence, they deserve more intellectual attention and resource allocation and warrant specialist treatment services. They differ from nondoctors in the following ways:

High-risk professionExpensive and scarce resourceLimited insight and acknowledgment of problemsEasier access to drugs and tendency to self-medicateBarriers to help-seekingIssues of patient safety and public confidenceIssues with the medical council.

This said, we acknowledge that not all would subscribe to the view that doctors are “different,” and debating this issue is crucial in answering the question we pose in this paper—“Are specialist treatment services needed for doctors with mental health problems?”

Furthermore, should confidential, easy to access, and appropriate professional help/treatment be available, more doctors would seek timely help. International evidence is very much in favor of such specialist treatment services for doctors: The Physician Health Programs in the USA,[14],[15] The Program for the Integral Care of the Ill Physician in Spain,[16] and the Practitioner Health Programme in England[17],[18],[19] are some of the popular healthcare services for doctors in distress. A recent study from the UK specifically called on the employers to take measures to reduce the stigma of mental illness among doctors so that doctors would seek timely help for their own psychological issues.[20]

 A Specialist Treatment Service for Doctors in India: Call for a Pilot



Now, we consider what a specialist treatment service for doctors with mental health problems should be like. Any strategy aimed at preventing/minimizing mental health problems in doctors should consist of primary, secondary, and tertiary prevention strategies. Here, primary prevention refers to preventing the onset of mental health problems (interventions targeted at awareness-raising, enhancing coping skills, teaching stress management techniques, etc.). Such primary intervention strategies should especially target medical students, as they are early in their medical careers; hence, these interventions are likely to have the most impact. Secondary prevention implies early diagnosis (measures for screening, reducing stigma, facilitating easy access, supportive “culture” to seek help, etc.) and treatment of such disorders (easy to access and professional treatment). Tertiary prevention includes offering treatments/interventions to prevent or minimize the chronic negative consequences of mental health disorders in doctors.

It is also worth noting here that the World Psychiatric Association (WPA), in its position statement on e-Mental health,[21] recommends the use of digital technologies to “support, deliver and enhance mental health services and improve the mental health and wellbeing of individuals”—this includes a wide range of digital technologies and digital technology aids that can help deliver psychiatric/psychological services.

If a comprehensive prevention strategy seems the best way forward, a logical question follows: who/which organization should help conceive and implement such a strategy? There are interesting, albeit preliminary, initiatives underway in India. First is the Cochin branch of the Indian Medical Association's (IMA) “Hope” service—a confidential telephone helpline and face-to-face consultation service for doctors and their families suffering from mental health issues. This service commenced functioning in January 2019 only, and preliminary evaluation findings favor its feasibility and acceptability.[22] Second is the IMA National Standing Committee for Emotional Health and Emotional Well-being of Medical Students and Doctors' “Doctors 4 Doctors” (D-4-D) Programme. This program is being planned as a joint venture of the IMA, Indian Psychiatric Society (IPS), and the Royal College of Psychiatrists (RCPsych), UK (South Asian Division).

Both our preliminary work in India and the UK, and the international literature suggest that such multiagency, multidisciplinary, and collaborative ventures are the way forward. Any such pilot program should also have built-in evaluative components for its appropriateness, adequateness, and effectiveness.

 Conclusion



To conclude, medical professionals are at a high risk of developing mental health problems such as depression, anxiety, stress, and substance misuse. Despite this, doctors are reluctant to seek timely and appropriate professional help for their own mental health difficulties. Undetected and untreated mental health problems often result in considerable negative consequences to the doctor, their family, and their patients. Given the above unique features, we recommend specialist treatment services for doctors who experience mental health difficulties. More debate is warranted on what the structure and functions of such a service ought to be and how it can be translated from strategy into action.

References

1Brooks S, Gerada C, Chadler T. Review of literature on the mental health of doctors: Are specialist services needed? J Ment Health 2011;20:146-56.
2Malan D. Individual Psychotherapy and the Science of Psychodynamics. London: Butterworth; 1979.
3Tillett R. The patient within – psychopathology in the helping professions. Adv Psychiatr Treat 2003;9:272-9.
4Firth- Cozens J, Caceres Lema V, Firth RA. Speciality choice, stress and personality: Their relationships over time. Hosp Med 1999;60:751-5.
5Kane L. How Healthcare Is Causing' Moral Injury' to Doctor. Medscape 2019.
6Kroenke K, Spitzer RL, Williams JB, Monahan PO, Lowe B. Anxiety disorders in primary care: Prevalence, impairment, comorbidity, and detection. Ann Intern Med 2007;146:317-25.
7Firth-Cozens J. A perspective on stress and depression. In Cox J, King J, Hutchinson A, McAvoy P, editors. Understanding Doctors' Performance. Oxford: Radcliffe Publishing; 2006. p. 22-5.
8Bennett J, O'Donovan D. Substance misuse by doctors, nurses and other healthcare workers. Curr Opin Psychiatry 2001;14:195-9.
9Ghodse H, Galea S. Misuse of drugs and alcohol. In Cox J, King J, Hutchinson A, McAvoy P, editors. Understanding Doctors' Performance. Oxford: Radcliffe Publishing; 2006. p. 38-45.
10Isaksson KE, Gude T, Tyssen R, Aasland OG. Counselling for burnout in Norwegian doctors: One year cohort study. BMJ 2008;337:a2004.
11Grover S, Sahoo S, Bhalla A, Avasthi A. Psychological problems and burnout among medical professionals of a tertiary care hospital of North India: A cross-sectional study. Indian J Psychiatry 2018;60:175-88.
12Gerada C. Healing doctors through groups: Creating time to reflect together. Br J Gen Pract 2016;66:e776-8.
13White A, Shiralkar P, Hassan T, Galbraith N, Callaghan R. Barriers to mental healthcare for psychiatrists. Psych Bull 2006;30:382-4.
14DuPont R, McLellan AT, Carr G, Gendel M, Skipper GE. How are addicted physicians treated? A national survey of physician health programs. J Subst Abuse Treat 2009;37:1-7.
15McLellan AT, Skipper GS, Campbell M, DuPont RL. Five year outcomes in a cohort study of physicians treated for substance use disorders in the United States. BMJ 2008;337:a2038.
16Bosch X. First impaired physicians therapy program appears to be successful in Spain. JAMA 2000;283:3186-7.
17Gerada C. Doctors, suicide and mental health. BJPsych Bull 2018;42:165-8.
18Gerada C. Doctors and mental health. Occup Med 2017;67:660-1.
19Brooks SK, Gerada C, Chalder T. The specific needs of doctors with mental health problems: Qualitative analysis of doctor-patients' experiences with the Practitioner Health Programme. J Ment Health 2017;26:2:161-6.
20Rimmer A. Doctors still see own mental health problems as sign of weakness, research finds. BMJ 2019;365:1861.
21World Psychiatric Association. Position statement on e-Mental health. 2018. Available from: http://www.psikiyatri.org.tr/userfiles/file/WPA13.pdf. [Last accessed on 2019 Oct 21].
22George S, Menon V, Sameed S, Hazzein A, Haneesh MM, Rahman J, et al. The establishment and short-term evaluation of a specialist and confidential service for doctors with mental health difficulties in India. Asian J Psychiatry 2019;44:65-7.