WELL before the coronavirus disease 2019 (COVID-19) pandemic hit our health care system, it was apparent that a substantial number of doctors worldwide were experiencing mental illness (here and here), suicidal ideation and suicide mortality (here and here). While there is some debate as to whether doctors are at increased risk of depression compared with the general population, what is clear is that they are certainly not immune to mental health problems, and rates of suicide among doctors are disturbingly elevated in many countries. International and Australian data have identified medical professionals as one of the occupations at highest risk for suicide (here and here). These problems are compounded by the fact that doctors are also unlikely to seek professional help for mental health problems for many reasons, including attitudinal and cultural barriers within the profession, concerns around confidentiality, mandatory reporting and potential negative career ramifications.
COVID-19 has affected the mental health of many Australians, including health care workers on the frontline. Australian doctors have watched their colleagues in America and Europe deal with overwhelming numbers of patients with COVID-19 and learnt of many doctors who have died or become seriously ill with infections they have contracted while working on the frontline. Although so far we have been, relatively speaking, spared the horrors seen overseas, many doctors have been highly stressed by the current situation.
It is imperative that we use this crisis to refocus attention on the mental health of doctors in Australia. We suggest that now is the right time to strategically examine what needs to be done moving forward to prioritise doctors’ mental health. This article aims to re-invigorate efforts to develop sustainable long term collaborative plans to improve doctors’ mental health and prevent suicide into the future.
What needs to be done?
Encourage help seeking (and cultural change to reduce stigma within medicine)
There are now a number of evidence-based initiatives to support doctors and other health care workers in Australia. The federal government recently announced a new portal for accessing many of these services, which can be accessed via a smartphone application or online. Doctors should be encouraged to access these free services and others recommended by Professor Leanne Rowe recently in her recent InSight+ article.
However, while a step in the right direction, this is not enough. Individual-directed strategies are only one piece of the solution.
We know that many of the stressors doctors face are based in the workplace and due to upstream factors at a team, organisational and systemic level. Work-related stressors include increasing administrative burden, inadequate rest time between shifts, exposure to traumatic and critical incidents, excessive workloads in time-critical contexts, high patient loads, understaffing and working long hours. These issues are not sufficiently managed by individual-level strategies directed at doctors themselves. What is needed are systemic and practical changes to the working environment and processes.
Controlled trials have shown that organisational strategies such as rescheduling of work hours and rosters, modifying local working conditions, and reducing workloads result in reductions in burnout and occupational stress in health care workers (here, here and here). While these are important outcomes, what we really need to know is what type of organisational-based strategies can prevent symptoms of mental disorder and suicidality among doctors. A recent review identified only eight individual-level controlled trials examining the effectiveness of interventions to reduce symptoms of common mental disorder and suicide among doctors, and no trials of organisational-level approaches in this population.
Models of workplace mental health have now established that comprehensive multilevel approaches are required for employee mental health (here and here). This involves individual, team-based, organisational and system-level strategies being implemented simultaneously, alongside managerial support and a genuine commitment to cultural change. These models provide a blueprint for the next steps our health care system needs to take to improve doctors’ mental health and prevent suicide.
Suggested next steps
- Controlled trials of multilevel interventions with large samples of doctors to inform us about what solutions actually prevent various mental health outcomes.
- We already know that working in understaffed and stretched hospital systems creates situations that damage the wellbeing of doctors and generates additional barriers to help seeking and taking sick leave. Long term funding and investment in adequate staffing and resourcing is required by government.
- Adjusting shift scheduling, establishing rostering practices and mandating healthy working hour maximums needs to be explored at a national level. The 2016 Australian Medical Association audit of work hours revealed that one in two doctors are working unsafe shifts with inadequate sleep and recovery, ingredients essential for mental health.
- Senior staff need to be educated and trained in how to manage the mental health of junior doctors. Promising results have been demonstrated in other at-risk occupations and these need to be explored in medicine.
- Broader cultural change within the medical profession needs to occur to combat stigma and encourage disclosure. The announcement of federal funding for help-seeking and support initiatives is a move in the right direction. However, broader cultural change is needed. This will require leadership and changes to be made in the way that we are educating and training the next generation of doctors.
A priority must be increased funding and investment in organisational and systemic interventions to address workplace risk factors and to continue to support and rigorously evaluate initiatives already underway in this area. As we recognise the vital role doctors play in community health post-COVID-19, now is the perfect opportunity for clinicians, hospitals, policy makers and academics alike to focus efforts towards improving the mental health of our medical workforce.
Katherine Petrie, PhD candidate and Research Assistant at Black Dog Institute and School of Psychiatry, University New South Wales (firstname.lastname@example.org).
Associate Professor Samuel Harvey, Chief Psychiatrist, Black Dog Institute, University of New South Wales (email@example.com).
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.