Abstract
A postal survey of 3,512 doctors in Birmingham was carried out to assess attitudes to becoming mentally ill. The response rate for the questionnaire was 70% (2,462 questionnaires). In total, 1,807 (73.4%) doctors would choose to disclose a mental illness to family and friends rather than to a professional. Career implications were cited by 800 (32.5%) respondents as the most frequent reason for failure to disclose. For outpatient treatment, 51.1% would seek formal professional advice. For inpatient treatment, 41.0% would choose a local private facility, with only 21.1% choosing a local NHS facility. Of respondents 12.4% indicated that they had experienced a mental illness. Stigma to mental health is prevalent among doctors. At present there are no clear guidelines for doctors to follow for mental healthcare. Confidential referral pathways to specialist psychiatric care for doctors and continuous education on the vulnerability of doctors to mental illness early on in medical training is crucial.
Introduction
One in four people in the UK suffer from a mental illness.1Although doctors are generally physically healthier than the general population they have higher rates of mental illness and suicide.2–4 Stigma to mental health and by extension to mental health services is a barrier for doctors being assessed and treated for a mental illness. With the adage ‘doctors make the worst patients’ this is an especially potent issue in spite of various anti-stigma campaigns. The literature in this area is primarily based on doctors with an active mental illness, substance misuse, anxiety and depression.5–7 There are no studies encompassing all specialties that have sought doctors’ views regarding disclosure and treatment if they became mentally ill. For this study the views of doctors on the prevalence of mental illness, their preference for disclosure, and treatment should they develop a mental illness in addition to their own experiences of mental illness were studied.
Participants and methods
A confidential questionnaire was sent to all 3,512 doctors identified as working in the major teaching hospitals and general practice surgeries in Birmingham. The mailing list was obtained from each hospital's medical staffing department. The nine-item questionnaire was based on a review of the literature, discussion with colleagues and a pilot study. It comprised broadly of three sections. The first collected information on the respondents’ perception of prevalence of mental illness in doctors in comparison to the general population and then in comparison with psychiatrists. The second required doctors to identify to whom they were most likely to disclose a mental illness. The third asked doctors their preference of treatment in both an outpatient and inpatient setting. The identifiable information requested was the grade of the doctor and whether they had experienced mental illness in the past. A free-text box was included at the end for comments and complete anonymity was maintained.
Statistical analysis
A series of two-sample chi-square tests (χ2) were carried out to examine association between certain categorical variables. Phi (φ) was used as a measure of effect size.
Results
Of the 3,512 questionnaires sent to doctors, 2,462 were returned (response rate 70.1%). The respondents comprised 677 (27.5%) consultants, 273 (11.1%) specialist registrars (SpRs), 441 (17.9%) senior house officers (SHOs), 542 (22.0%) general practitioners (GPs), and 529 (21.5%) doctors who classed themselves as ‘other’.
Perception of prevalence of mental illness in doctors
Of the respondents, 634 (25.8%) felt the prevalence of psychiatric illness in doctors was higher than that of the general population. Only 153 (6.2%) respondents felt that psychiatric illness was more prevalent than that of psychiatrists. A mental illness was reported to have been experienced by 306 doctors (12.4%).
There was little difference between the non-psychiatrists and psychiatrists when estimating incidence of mental illness in doctors compared to the general population (Table 1). Only 6.2% of doctors thought that mental illness was more prevalent in their own specialty compared to psychiatrists. Conversely, 33.6% of psychiatrists thought that mental illness in their profession was higher than that of other specialties. As can be seen from Table 1, psychiatrists were slightly more likely to report having experienced mental illness (χ2 = 24.66; df = 1; p = 0.001; φ = 0.094).
Comparisons between non-psychiatrists and psychiatrists on all questions.
Disclosure of one's mental illness
The majority of doctors, 1,807 (73.4%), were most likely to disclose their mental illness to their family or friends; 317 (12.9%) to a professional/governmental institution; 159 (6.5%) to their colleagues; and 178 (7.2%) would not choose to disclose the illness. The most important factor for doctors that would affect their decision to disclose their mental illness was career implications in 800 (32.5%), professional integrity 731 (29.7%), stigma 489 (19.9%), and ‘other’ reasons 442 (18.0%).
Consultants were more likely than any other group to put forward professional integrity as the factor influencing disclosure. SHOs were less likely to disclose mental illness to colleagues or professional/governmental institutions and were more likely to tell family or friends compared with consultants and GPs (χ2 = 107.1; df = 12; p = 0.001; φ = 0.21). SHOs were also more likely to cite stigma and career implications as the main influence on their choice to disclose than both consultants and GPs (χ2 = 92.3; df = 12; p = 0.001; φ = 0.19).
Table 2 shows doctors’ choices for disclosure and the factors which influenced their choices. The modal choice for disclosure was family/friends and of those who would prefer this, the majority voiced concerns about career implications and professional integrity.
Doctors’ preference for disclosure about mental illness and the factors which influenced their choices.
There were no significant differences between the non-psychiatrists and psychiatrists (Table 1) about to whom they would disclose their mental illness.
Treatment of mental illness
Informal advice for outpatient treatment was selected by 1,000 (40.6%) respondents, 1,259 (51.1%) chose formal advice, 119 (4.8%) would self-medicate and 84 (3.4%) opted for no treatment. There was no significant difference between the different grades of doctor in their choice of outpatient treatment for mental illness.
In the event of developing a mental illness requiring inpatient treatment 1,010 (41.0%) doctors would opt for a local private facility; 520 (21.1%) responders would choose a local NHS mental health hospital; 474 (19.3%) would choose a distant NHS mental health hospital; and 458 (18.6%) would go to a distant private hospital. As can be seen, the majority of those who chose a distant NHS hospital or a distant private facility were motivated by confidentiality; almost half of those who chose a local private hospital were influenced by confidentiality (χ2 = 967.9; df = 9; p = 0.001; φ = 0.63). Interestingly only 618 (25.1%) would make the decision based on the best quality of care available (Table 3).
Doctors’ preference for inpatient care for mental illness and the main reason for their choice.
In the event of requiring inpatient treatment for mental illness, a local private facility was preferred by all groups (particularly by GPs) apart from SHOs (as shown in Table 4) who were the only group to prefer a distant private facility over all other options. When making decisions on inpatient treatment, 63.7% of SHOs were influenced by confidentiality or stigma as opposed to only 45.1% of consultants (χ2 = 208.9; df = 12; p = 0.001; φ = 0.29) (Table 5). The majority of the senior doctors (consultants, SpRs and GPs), were more likely to cite quality of care and convenience compared to junior doctors (χ2 = 67.52; df = 12; p = 0.001; φ = 0.159).
Preference for inpatient care for mental illness as a function of grade/level.
Factors affecting preference for inpatient care as a function of grade/level.
However, when compared to psychiatrists, non-psychiatrists were more likely to choose informal or formal professional advice and were less likely to self-medicate (χ2 = 120.33; df = 3; p = 0.001; φ = 0.206) if they experienced a mental illness requiring outpatient treatment. If inpatient treatment was required for mental illness, non-psychiatrists were more likely to choose a local NHS hospital and less likely to choose a distant private facility than psychiatrists (χ2 = 73.6; df = 3; p = 0.001; φ = 0.161). However, for both groups a local private hospital was the most popular choice. When asked what would influence the decision about inpatient treatment, non-psychiatrists were more likely to cite quality of care and convenience than psychiatrists and less likely to cite confidentiality and stigma (χ2 = 69.38; df = 3; p = 0.001; φ = 0.157), although confidentiality was still the biggest influence for both groups.
Doctors who had experienced mental illness were more likely to prefer formal over informal advice for outpatient treatment (χ2 = 29.76; df = 3; p = 0.001; φ = 0.110). This group also preferred to be treated in a local NHS hospital compared to a distant NHS hospital for inpatient treatment. These doctors were less likely to cite confidentiality as influencing their decision over inpatient treatment (χ2 = 27.12; df = 3; p = 0.001; φ = 0.105).
Discussion
This is the first large-scale study to investigate the views of non-psychiatrist UK doctors on disclosure and treatment preferences in the event of them becoming mentally ill. It was carried out in one city (Birmingham) and covered all specialties. Although generalisability of the results cannot be assumed, the high response rate (70%) and open text comments confirmed the importance of this issue to the participants. There is scope for more research in this field especially among other healthcare professionals.
Doctors have higher morbidity for depression and substance misuse as well as higher rates of suicide than the general population.2–4 In this study, 12% of doctors reported having experienced a mental illness and the British Medical Association (BMA) estimates that 1 in 15 doctors will have a problem with alcohol or drugs at some point in their lives.8The training involved to become a doctor is associated with psychiatric morbidity in medical students and few seek help because of the stigma that it may affect their career progression.9,10
Despite the term ‘stigma’ dating back to the medieval ages its relevance to mental illness in 21st-century Britain is all too familiar. The media have at times addressed this issue unsympathetically with crimes committed by people with mental illness prioritised in the news and the dramatisation of the ‘sectioning’ of celebrities under the Mental Health Act. Attempts have been made to address stigma including the Changing Minds campaign by the Royal College of Psychiatrists and the Department of Health's Action on Stigma.11,12 Over three quarters of doctors who cited stigma as a factor influencing their decision to disclose a mental illness would do so first to family or friends rather than to a professional. This was highlighted in the case of Dr Daksha Emson who suffered with a mental illness and battled with stigma throughout her career in psychiatry, which ended prematurely with her taking her own life.13
Disclosing one's mental illness to a GP should, ideally, be a straightforward decision for doctors to make. Traditionally, doctors have avoided mental health services due to attitudes formed in medical school, a perceived lesser importance of mental health as well as a tendency to treat oneself.14Doctors also tend to be unsure about mental health and are less likely to recognise a problem, not only among themselves but also in their colleagues. This leads to gross underreporting and thus potential worsening of the illness.15Only 12.9% of respondents would disclose their illness to a professional, citing career implications and professional integrity as being the main reasons. This often results in the majority of doctors presenting late to mental health services putting themselves, and by extension their patients, at risk. If a doctor is suspected of impaired fitness to practise the General Medical Council (GMC) have clear guidelines, which advise how doctors can report their colleagues, if required. The culture of medicine encourages an image of invincibility and denial of vulnerability to illness creating a barrier to doctors seeking healthcare guidance. Options for doctors who feel they are mentally unwell are lacking.
Doctors suffering from stress and its related problems can access confidential counselling support for example, the BMA help line, Doctors Support Network and National Counselling Service for Sick Doctors. Specialist psychiatric help by local mental health teams can be accessed via a GP or occupational health department. Only half of all doctors requiring outpatient intervention would seek formal psychiatric advice and an even smaller number would opt for informal advice. The failure to seek appropriate help when ill is prevalent among the wider medical profession.16Issues of trust and concerns about confidentiality may act as barriers to medical practitioners seeking help for psychiatric illness.17
One of the most important factors influencing where a doctor is treated is the issue of confidentiality. Despite confidentiality being a principal factor for maintaining trust within the medical profession, this does not seem to correlate with the results of this study. There seems to be no confidence among doctors that their mental health data will remain confidential. This may imply that doctors lack confidence in the current system and raises the question, how confidential is confidentiality? The current practice in the UK of keeping electronic records means that hospitals are intraconnected with numerous computers. This increases the potential of people accessing other colleagues’ personal information. This lack of confidence in confidentiality may explain the trends in doctors self-medicating with alcohol and substance misuse.
The results show that psychiatrists are more likely to feel a greater burden of stigma compared to their non-psychiatrist colleagues. This is surprising as one would expect psychiatrists to be tackling stigma on a daily basis. On the surface it would seem psychiatrists are not practising what they preach. It was also found that psychiatrists are more likely to experience a mental illness at some point in their lives. However, this may be due to the fact that non-psychiatrists are not disclosing their mental illness or are failing to recognise it.18
A text box was provided for free comments at the end of the questionnaire. It was interesting to note that, of the doctors who ‘had’ experienced a mental illness and been in touch with local mental health services, they generally reported a very positive experience. However some did report that if an option of a specialist unit for doctors ‘did’ exist, this would be the first choice. A key issue of confidentiality will still remain. Some may also argue that the very existence of separate specialised units adds to the problem of stigma.
Strengths and weaknesses
This study addresses an important issue and includes a unique insight of doctors’ views towards mental health. The large sample size added to the strength of the study and the high response rate confirmed the importance given to this topic by the doctors involved. The study could have been expanded to include gender and subspecialty. Specific mental illnesses could have also been examined. The study could also be expanded to include other mental healthcare professionals.
Conclusion
Education on stigma and its consequences should be made more prominent in medical schools and training courses for junior doctors. So far anti-stigma campaigns have targeted a large audience. Studies have shown that smaller campaigns that are targeted towards specific groups are much more successful.19Junior doctors are receptive to education on physician impairment and substance misuse and this should be a mandatory component of their training.20Further education is required on training medical students and doctors on how to detect mental illness at an early stage. The medical school curriculum could incorporate training on consultation skills for situations in which the patient is also a doctor.
A greater emphasis is required to educate doctors on mental health and the provision of an option to confidentially refer themselves to mental health teams. Doctors are reluctant to utilise occupational health services for fear that they will be seen as a problem that is best removed rather than rehabilitated. Similarly with the GMC, the association of reporting mentally ill doctors with disciplinary measures could be revisited with a separate more humanistic approach – a return to the previous system. Trusts should develop clear protocols for the records of healthcare professionals and access should potentially be restricted. The common pathway into NHS psychiatric services remains via the GP which, according to this study, most doctors may avoid.
The concept of stigma to mental illness is one that has evolved over time and will require a consistent and long-haul effort to tackle if doctors are expected to gain the confidence to ask for and accept psychiatric help. This research clearly shows that doctors are concerned about confidentiality and stigma and a medical service is required which meets their needs. Consideration should be given to the establishment of regional assessment and treatment services. One of the authors (AW) currently provides an occupational health psychiatric session based in the occupational health department. If such fully funded and well advertised sessions were available to doctors on a regional basis it could provide the necessary ease of accessibility accompanied by confidentiality. Additional access to psychological therapies and local private inpatient care should encourage psychiatrically ill doctors to seek treatment therefore reducing the risk to themselves and in turn to their patients.
Acknowledgements
Ethical approval was granted by South Birmingham Ethics Committee (application number 07/H1207/158). Funding was obtained from the Jubilee Fund, Birmingham and Solihull Mental Health NHS Trust, Birmingham, to cover stationary, postage costs and secretarial time. The authors did not receive any personal funding in relation to the study.
- © 2009 Royal College of Physicians
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