Medical professionals are at greater risk for mental health concerns than the general population, likely due to the inherent stressors of their work.1,2,3 Stigma, lack of time/access, and confidentiality concerns have been indicated as potential barriers to seeking treatment.1 Effective interventions are available and must be made more accessible to avoid unnecessary suffering.
The Stigma of Getting Mental Health Assistance as a Medical Professional
Sermo, a global data collecting platform of over 800,000 anonymous, verified medical professionals, recently surveyed over 4500 physicians,4 asking them about the reasons why they or other medical professionals might be afraid to talk about and seek help for mental health issues. The survey focused specifically on burnout and suicidality, and 64% of those surveyed reported being afraid that there would be professional repercussions if they sought professional help for either of these concerns.
Respondents further indicated that they believe these issues are not openly discussed within the medical profession due to:
- Fear of professional repercussions (46%)
- Embarrassment and shame (23%)
- Wanting to preserve their privacy (13%)
- Being uncomfortable talking about these issues at work (12%)
- Sense of hopelessness (6%)
Other perceived barriers to physicians accessing mental health treatment have been identified as: lack of time and convenient access; preference to handle one’s own problems; and confidentiality concerns.5 The stigma associated with accessing help for mental health concerns stems from a number of issues that need to be addressed among not only medical professionals, but by society as a whole.
There appears to be a lack of education and understanding with respect to the following:6
- Mental illnesses are first and foremost, physiologically based. They are based in the physiology of the mind and body. Suffering from mental illness is not about weakness, character flaw, or anything a person has done wrong.
- Symptoms need to be detached from shame. Why is it that some people are ashamed of the lack of energy and feelings of hopelessness that they experience as symptoms of depression, but are not ashamed of the fever and cough they might experience as symptoms of influenza?
- “Helpers” will, at times, also become the ones who need help. This is a basic fact of the nature of being human. Sometimes one is in both roles at the same time.
- Effective treatments are available.
Wendy Dean, MD, CEO & Co-founder of Moral Injury of Healthcare, LLC states: “Healthcare workers face numerous barriers to getting mental health support. Breaking down each one is critical to sustaining our healthcare workforce. The following are concrete actions and initiatives to help toward that end:54
- Remove licensure questions that stigmatize mental health care.
- The Lorna Breen Health Care Provider Protection Act, re-introduced March 4th 2021, proposes a grant program to support mental health care for health professionals involved in the COVID-19 response. It also advocates for research on reducing barriers to mental health treatment.
- Humans Before Heroes, a new initiative by the American Medical Women’s Association, highlights the emotional toll of balancing work with home life, the physical risk of contracting COVID, exhaustion, and grief.
The conditions permissive of the syndemic are larger sociocultural, political, and economic factors. The pandemic can be the impetus for us to reassess our societal values and investments to better prepare for the future. But our healthcare workforce cannot wait for that larger conversation to happen. It is time to act, now, to break down barriers and rebuild better care for us all.”
How COVID-19 Is Affecting the Mental Health of Medical Professionals
The COVID-19 pandemic has resulted in extraordinary, prolonged stressors for medical health professionals. The increased frequency, duration, and intensity of experiencing the following types of stressors, while providing medical care during the pandemic, is resulting in negative mental health consequences for health workers.
Effects of the COVID-19 pandemic on the mental health of medical professionals includes:7,8,9,10,11
- Distress related to witnessing patients dying alone – without access to loved ones to comfort them.
- Guilt, shame, grief, and/or feelings of helplessness regarding being unable to save patients who are dying from the virus.
- Having to choose which patients are given access to limited life-saving resources.
- Increased risk of “moral injury” – which refers to intense distress (i.e., psychological, social, behavioral, and/or spiritual) that one might experience following a traumatic event, or series of events, in which one’s actions or lack of actions, or an event that one has witnessed, conflicts with one’s conscience and moral values.
- Anxiety and fear at work, due to lack of access to Personal Protective Equipment (PPE), staffing, medical equipment, and/or perceived support.
- Fear of becoming infected oneself and/or infecting one’s loved ones.
- Lack of access to one’s usual coping strategies (e.g., going to a gym, socializing, vacations, good sleep, comfort from family and friends).
- A perceived lack of public and/or political support and actions to stop the spread of the virus.
While we are still in the early stages of research regarding the impact of COVID-19 on the mental health of medical professionals, a number of recent studies have provided us with some insight as to what has been emerging thus far.
A systematic review of more than 40 studies highlights the prevalence rates of mental health issues facing healthcare workers on the frontlines of the pandemic, including:12
- Depression 14%-45%
- Anxiety 12%-36%
- Acute stress reaction 5%-33%
- Post-traumatic stress disorder (PTSD) 7%-37%
- Insomnia 34%-36%
- Occupational burnout 3%-43%
These early results are consistent with those found in more comprehensive research into the impact of the SARS outbreak on the mental health of front-line medical professionals.13,14
Medical Professionals & Burnout
Burnout is defined as the consequences of prolonged severe stress in helping professions. Medical professionals can often feel exhausted and fatigued because they spend so much time and energy helping others.
Burnout is characterized by three types of symptoms:15
- Physical and mental exhaustion – and possibly psychosomatic pain
- Frustration and disconnection from one’s work and/or colleagues
- Reduced productivity at work and/or home
Factors that contribute to burnout among medical professionals have been identified as:16
- Lack of social and peer support
- Feelings of lack of control and fairness
- Conflicting values
- Perceived lack of adequate rewards
Prevalence rates of burnout among nurses and other medical professionals have been found to be quite high:17,18,19,20,21
- 74% for medical residents
- 47% for critical care physicians
- 65-80% for emergency medicine physicians
- 24%-33% for ICU nurses
- 14%-86% for nurses
Burnout among medical professionals has been linked to negative professional and personal outcomes, including:17,22,23
- Increased self-reported medication errors
- Difficulty concentrating at work
- Poor decision-making
- Hostile attitudes towards patients
- Difficulties in co-worker relationships
- Marital issues
- Physical, mental and emotional fatigue
- Increased risk of depression, anxiety, alcohol and drug use
- Increased risk of suicide
- Sleep disturbance
Ongoing access to confidential screening for burnout, as well as the implementation of proactive measures to address the factors that appear to contribute to burn-out, need to be included in institutional policies and procedures to support employee wellness. Individuals also need to take steps to implement wellness strategies in their own lives.
There is an even deeper problem underlying (or sometimes mislabeled as) burnout that can be explained by the term moral injury, which represents “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.”24 While many physicians experience symptoms of burnout like exhaustion and frustration, burnout implies that those experiencing it lack resourcefulness or resilience, which does not resonate with many medical professionals. Instead, moral injury encompasses the deeper problem of having to make decisions that go against what they know would be best for their patients.
According to an article entitled, “Physicians aren’t ‘burning out.’ They’re suffering from moral injury” in Stat News, “Burnout is itself a symptom of something larger: our broken health care system. The increasingly complex web of providers’ highly conflicted allegiances—to patients, to self, and to employers—and its attendant moral injury may be driving the health care ecosystem to a tipping point and causing the collapse of resilience.”24
Medical Professionals & Depression
Severe depression can feel like the flu, minus the fever, cough, and congestion. Physical symptoms of depression can include fatigue, lack of energy, changes in sleeping and eating patterns, changes in weight, and restlessness/agitation or slowed physical responses.25 In cases of severe depression, one’s limbs might feel heavy, it can be difficult to get out of bed, and concentration and decision-making can be impaired. Ongoing depression can lead to feelings of hopelessness, despair and suicidal ideation/behaviors.
In comparison to the general population, which has a prevalence rate of 7%,25 medical professionals have been found to be at higher risk for depression.3
The prevalence rate of depression within specific groups of medical professionals are cause for concern:3,5,17,26,27,28,29
- 16%-39% among medical students
- 20% to 42.5% among medical residents
- 15% among post-graduate medical students
- 46.5% among physicians
- 10% among nurses
Effective, evidence-based treatments for depression are available, usually in the forms of medication and therapy.30
Medical Professionals & Anxiety
Generalized anxiety disorder is an illness that is characterized by: excessive worry, muscle tension, irritability, restlessness; fatigue; difficulty concentrating; and sleep disturbance.25 This illness can cause significant impairment and/or distress in one or more areas of a person’s life such as their work life or social life. Medical professionals are at higher risk for generalized anxiety disorder in comparison to the general population, which has a prevalence rate of 3%.25
Prevalence rates among specific groups of medical professionals have been determined to be:26,27,31
- 41.2% among nurses
- 11% among physicians
- 16% among medical post-grads
- 20% among medical students
Effective treatments for anxiety are available. The recommended treatments for anxiety disorders such as generalized anxiety disorder, panic disorder, agoraphobia, use medication, various styles of therapy, or a combination of the two.32
Medical Professionals & Sleep Disorders
Sleep disorders refer to ten different types of sleep-wake disorders (e.g., restless leg syndrome, nightmare disorder, narcolepsy) among which insomnia is the most common. It is estimated that approximately one-third of the general population report insomnia symptoms.25 Among physicians, 20%-61% reported sleep problems, with 12% reporting moderate to severe insomnia.33 Among hospital workers, 41% screened positive for a sleep disorder.34
Sleep can have a huge impact on mental health. Sleep issues can be indicative of the presence of depression, anxiety, burnout, and/or PTSD. Additionally, persistent sleep disorders can lead to the development of mental illness and substance use disorders.25 Thus, it is imperative that a full assessment be completed to identify any concurrent disorders that might be present, and guide treatment. Treatments for sleep disorder include therapies like Cognitive Behavioral Therapy, Biofeedback, Mindfulness training, or in some cases, medication.
Medical Professionals & Substance Use Disorders
Substance use disorders are characterized by physiological, behavioral, and cognitive symptoms that show the individual is continuing to use substances despite the significant problems substance use is causing in different areas of their life.25 Medical professionals are not immune to substance use disorders.
It is estimated that 10% of nurses engage in substance abuse, and that among 6% of nurses, substance abuse will negatively impact their work.34 In one study, 39% of physicians met the criteria for substance use disorders, with the most common addiction being alcohol, followed by opiates.27
A large survey of medical doctors found the following statistics related to substance use disorder:33
- 44% reported binge drinking
- 5% met criteria for alcohol dependency
- 44% used some type of non-illicit drugs
- 34% indicated they used substances to feel better
- 22% indicated they used substances to deal with stress
Treatment of substance use disorder typically involves both pharmacological and psychotherapeutic interventions that are tailored to the needs of the individual and the type of substance.36
Medical Professionals & PTSD
Post-traumatic stress disorder (PTSD) refers to the symptoms that develop after a traumatic event, which overwhelm the ability of the body and mind to process and store information.37,38,39,40 Medical professionals who engage in emergency work, are often subjected to “repeated or extreme exposure to aversive details of… traumatic event(s)” experienced by others, which can lead to PTSD.25
In fact, these health care professionals have a higher rate of PTSD than the general population (prevalence rate of about 8%).25 Additionally, PTSD rates have been found to be higher among medical professionals who work in underserved and remote areas, medical residents, those who are involved in malpractice litigations, and those who are indirectly exposed to trauma.41
Generally, prevalence rates of PTSD for medical professionals have been found to be:21,42,43,44
- 18%-33% for nurses
- 13% for medical residents
- 16% for physicians
Depending upon the severity of symptoms and the preferences of the individual, treatment might take the form of a trauma-focused psychotherapy, and/or medication (e.g., SSRIs).45
Medical Professionals & Suicide
A person’s mind can turn to suicide when the mind and body exhaust strategies to deal with unbearable pain, and turn to death as the last hope to end suffering. Suicidal thoughts and/or impulses demand outside supports. Medical professionals often face a greater risk for suicidal thinking.
Given that medical professionals are at higher risk for mental illness, and mental illness increases suicide risk it is not surprising that:46,47,48,49,50,51
- Nurses are at greater risk for suicide than the general population
- The suicide rate for physicians has been found to be between two and five times the rate of that for the general population
- Among emergency medicine physicians, 14% reported contemplating suicide at some point during thier career, and 6% had “actively considered suicide” in the preceding year.
- A survey of almost 8,000 American surgeons indicated that 6% experienced suicidal ideation during the preceding 12 months. Suicidal ideation was independently associated with both depression and burnout.
This level of suffering is both a tragedy and unnecessary. Effective treatments and supports are available. Given that individuals who experience suicidal ideation are more likely to also be experiencing mental illness,it is important that a full psychiatric assessment be completed to identify the primary illness(es) that require treatment.52
In cases of active suicidality (i.e., high intensity, with a plan that is accessible, and strong intention), emergency services should be contacted immediately. In situations where suicidal ideation is more passive and not imminent, treatment should include medical and counseling professionals at minimum
Coping With Stress & Prioritizing Mental Health as a Medical Professional
As a medical professional, you are giving your time, energy, compassion, etc. to your patients on a daily basis as part of your work. In order to keep giving, your “cup” must stay filled. Thus, it is imperative that you find ways to refill your cup on a daily basis. If your cup becomes empty, you will struggle to cope and function in different areas of your life, and your physical and mental health will be impacted.
We all have a “window of tolerance” for the amount of distress that we can manage at a particular point in time.51 When we are operating within our window, we are able to function, cope, make decisions, and move forward in our lives. We know we are on the “edge” of our window, when we say to ourselves or others, “If one more thing happens, I am going to lose it.”
There are strategies we can purposefully use to cope with stress better, including:6
- Directly address the source of the distress—if it is possible, and safe to do so
- Obtain medical support and/or professional counseling support as needed
- Self-soothing strategies—using the senses to calm and energize
- Taste: Having a favorite food or hot drink
- Touch: Wearing comfortable clothes, or petting an animal
- Sight: Looking at nature, a picture of a loved one, or favorite place
- Sound: Listening to music or the sounds of nature
- Smell: Breathing in the scents of nature, lighting a scented candle
- Mindfulness strategies
- Practice self-compassion—a helpful rule to live by, is if you wouldn’t say it to a loved one, don’t say it to yourself. Treat yourself with kindness.
- Make time for physical activity—which helps support physical and mental health.
- Find people you can be honest with to talk about what you are experiencing.
- Accept help from others.