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 Table of Contents  
REVIEW ARTICLE
Year : 2022  |  Volume : 9  |  Issue : 1  |  Page : 13-17

Mental health problems among mental health professionals: A neglected issue


Department of Psychiatry, King George's Medical University, Lucknow, Uttar Pradesh, India

Date of Submission22-Mar-2022
Date of Decision18-May-2022
Date of Acceptance20-May-2022
Date of Web Publication14-Jun-2022

Correspondence Address:
Dr. Sujita Kumar Kar
Department of Psychiatry, King George's Medical University, Lucknow, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijamr.ijamr_67_22

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  Abstract 

Mental health issues are common among health professionals due to the enormously stressful nature of their work. The paucity of workforce, resources, and high patient load, are liable to make mental health professionals, including psychiatrists, overburdened. The work pressure, demand-output mismatch, and burden of expectations from psychiatrists may make them distressed despite their training in stress management. This review discusses key mental health issues faced by psychiatrists, their possible attributes, and remedial measures.

Keywords: Mental health, mental health professional, psychiatrist, stress


How to cite this article:
Kar SK, Shankar A, Singh A. Mental health problems among mental health professionals: A neglected issue. Int J Adv Med Health Res 2022;9:13-7

How to cite this URL:
Kar SK, Shankar A, Singh A. Mental health problems among mental health professionals: A neglected issue. Int J Adv Med Health Res [serial online] 2022 [cited 2022 Aug 8];9:13-7. Available from: https://www.ijamhrjournal.org/text.asp?2022/9/1/13/347471


  Introduction Top


Mental health is an important and essential aspect of the overall health of an individual. Several social, psychological, and biological factors interact to determine an individual's level of mental health. Rapid societal change, unstable working environments, social isolation, unhealthy lifestyle habits, and physical diseases are often correlated with poor mental well-being. At some point in their lives, one in four individuals in the world get affected by mental health-related conditions.[1] Currently, about 970 million individuals suffer from psychiatric illnesses, rendering them among the world's leading causes of disability.[2] Mental health professionals, though considered to be the flagbearers of mental health, are no exceptions and are vulnerable to mental health problems. However, their own mental well-being is generally believed to be good, due to which their mental health needs are often neglected. Psychiatrists have been shown to suffer from a variety of mental health conditions, which is the focus of this review.


  Prevalence of Mental Health Issues Among Mental Health Professionals Top


Psychiatrists suffer from a variety of mental health problems and the rates are substantial. A recent online survey of 2084 North American psychiatrists found high levels of burnout in 78% of the participants. Further, among 16.1% of psychiatrists, the high Patient Health Questionnaire-9 scores were suggestive of significant levels of depression.[3] Another survey of 154 Japanese psychiatrists reported significant depressive symptoms in 34.4% of participants.[4] An indirect evidence of mental health issues among psychiatrists is suicide, the rates of which are reported to be high in this group. An older study reported that suicide rates are the highest among psychiatrists, of all physicians, and substantially more (58–65/100,000) compared to that of the general population (11/100,000);[5] similar high rates are endorsed by recent literature in this area too.[6] Burnout has consistently been reported to be high among psychiatrists, despite variation in prevalence rates across different international studies.[3],[7],[8] Among Thai psychiatrists, the prevalence of high-level burnout was found to be 49.3%.[9] A survey on Egyptian psychiatrists revealed that about 86% have moderate to high levels of emotional exhaustion, whereas about 57.5% have moderate to high levels of depersonalization.[10] An Indian study reported the prevalence of burnout to be 46% among the participant psychiatrists.[11]

Moreover, studies on physicians including psychiatrists indicate that substance use disorders are common in this group with rates comparable to that of the general population (between 6 and 15%).[12] Psychiatrists have easy access to medications with abuse potential, which may increase the risk of abuse. Among the medical disciplines, anesthesiology, emergency medicine, surgery, and psychiatry, are reported to have higher rates of substance use relative to other medical specializations while psychiatrists have been thought to be particularly susceptible to drug abuse problems.[13] However, there is an overall paucity of literature on the prevalence of other mental health problems in psychiatrists.


  Nature of Mental Health Issues among Mental Health Professionals Top


Mental disorders, as much as they afflict the general population, can affect psychiatrists as well. These disorders may lie anywhere on the spectrum of mild to severe. However, due to the stressful nature of their job, the prevalence and presentation of mental health problems may differ from the general population. Burnout and stress-related problems, anxiety, depression, substance use disorders, and suicide risk has been reported to be common in psychiatrists.[9] Psychiatrists, anesthetists, emergency medicine specialists, and community health physicians are reported to have a substantially higher risk of suicide compared to doctors in other specialties.[6],[9] Psychiatrists kill themselves at a greater rate than individuals serving in the military.[10] In comparison to physicians and surgeons, psychiatrists had significantly greater levels of neuroticism, openness, agreeableness, and lower levels of conscientiousness.[11] Several studies mention the increased use of substances among psychiatrists, particularly benzodiazepines, amphetamines, and marijuana, with benzodiazepines being the preferred substance.[7],[8] This suggests the use of these substances as self-medication for their sleep, anxiety, and stress-related problems. Furthermore, the relatively easy availability of prescription medications further increases the risk of use of such agents.[7]


  Causes of Mental Health Issues Among Mental Health Professionals Top


Mental health issues among psychiatrists are a matter of concern. Attempts have been made to identify the factors responsible for differences in mental health problems among them. High burnout and stress have been the commonly implicated factors.[14] Issues that make psychiatry a stressful occupation include abuse from patients, limited resources, crowded hospital wards, incoordination between the mental health team (psychiatrist, psychologist, psychiatric nurse, and psychiatric social workers), high job demands, poorly specified consultant job roles, accountability without authority, and loneliness.[15] A Finnish web-based survey studied differences in stress-inducing factors, job-related factors, and well-being in terms of job satisfaction and psychological distress between psychiatrists and other medical specialists; psychiatrists were found to have greater stress levels, lesser job satisfaction, and higher patient-related perceived stress.[16]

Globally, there is a shortage of manpower in mental healthcare. In India, currently, there are about 9000 psychiatrists, and every year 700 new psychiatrists' graduate. This amounts to 0.75 psychiatrists per lakh population, while the desired figures are around 3 per lakh population.[17] This shortage of psychiatrists is more conspicuous in rural areas.[18] This may result in increased work-related stress. Dealing with patients who are threatening and violent is stressful for mental health professionals. Abuse and verbal harassment from patients also have a detrimental effect on the mental health of mental healthcare professionals. Besides, the nature of work that demands fulfilling considerable public expectations can be stressful.[19] The longer psychiatrists work in a stressful environment, lesser they may enjoy dealing with the patients, giving rise to dissatisfaction and diminished humanistic attitudes toward mental illness.[20]

A Scottish study found that psychiatrists have unique personality characteristics in comparison to physicians and surgeons which may make them vulnerable to stress. Work-related emotional weariness and depressive symptoms were found to be more common among mental health professionals with these personality trait-related vulnerability factors.[11] The high prevalence of common mental illnesses including stress-related disorders in mental health professionals might be explained by the personality-related risk factors.

Mental health professionals always work in collaboration (collaboration between psychiatrists, psychologists, psychiatric social workers, and psychiatric nurses). Any conflict within the team may adversely affect their mental health.[21],[22] Further, at times, they have to manage with limited manpower resources or untrained personnel (such as nurse, social workers, or paramedics, who have not received any formal training in mental health, but posted under psychiatry in general hospital psychiatry units) in the team, which may result in overburden and distress due to inequal work distribution in the team.[21],[22] Similarly, unfavorable workplace environments, low pay, and long working hours give rise to stress and may lead to the development of mental health issues.[14] A negative association has been found between the level of psychosocial support and emotional exhaustion in this group. Specifically, mental health professionals with poor psychosocial and workplace support experience greater emotional exhaustion.[23] A study from Nigeria reported that common forms of psychological distress among mental health nurses were inadequate personal accomplishment, emotional exhaustion, and depersonalization. Poor financial support and role conflicts were found to be predictors of emotional exhaustion.[24] Higher duration of working hours was associated with high burnout among psychiatry residents.[25] A strong inverse relationship was found between burnout and job satisfaction of psychiatrists.[26] Psychiatrists with less burnout have better job satisfaction. Burnout is an important risk factor, which may lead to the development of depression, anxiety disorders, stress-related disorders, substance use disorders, and neurocognitive problems.[27]

Psychiatrists often work in highly emotionally demanding settings and situations.[14] [Figure 1] below explains how an emotionally demanding situation is linked to the psychological distress of mental health professionals.
Figure 1: Conceptual pathway linking an emotionally demanding situation with psychological distress

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In an emotionally demanding situation, failure to meet the emotional demand results in feelings of stress and guilt. In response to this, sufferers may attempt to deliberately fulfill the emotional need or may avoid the situation as an escape. Escaping the situation may result in temporary relief from stress, but in the long run, it is more likely to aggravate stress and guilt. An attempt to meet the emotional demand may actually lead to the fulfillment of the demand, resulting in the resolution of stress and guilt; however, if the emotional demand is not met despite efforts, it may further contribute to feelings of stress and guilt.

Not only work-related stress but also stress at the personal level can increase the vulnerability of mental health professionals to mental health issues. Family upbringing is also an important parameter that influences distress levels among mental health professionals. One of the studies observed that therapists experience higher rates of physical assault, sexual abuse, parental alcoholism, psychiatric hospitalization of parents, and family discord.[27] Conflicts between job responsibilities and personal life can also contribute to poor mental health. The negative impact of work pressure on personal life has been cited as a primary cause of poor mental health.[23] Literature also mentions about increased martial disharmony among mental health professionals.[28],[29]

The course and outcome of mental health disorders in this population are influenced by reluctance and delay in help seeking. Even in today's age, there is considerable stigma surrounding mental health issues. Furthermore, because of the common public notion that psychiatrists are good at coping with problems such as stress, fear, anxiety, and depression, the latter may ignore their own mental well-being. This conviction is also seen among non-psychiatry health-care practitioners.[30] A factor that is very much unique to psychiatrists is stigma which leads to the development of stress and other mental health issues among mental healthcare professionals.[14] The society expects mental health practitioners to be patient, caring, strong, inspiring, readily accessible, free of tension, and grievances, and at the same time, stigmatizes professionals in psychiatry and mental health.[30]

Suicide is a common negative outcome in patients with psychiatric illnesses. When a patient with psychiatric illness commits suicide, it may impact the mental well-being of mental health professionals dealing with the patient.[14],[31],[32] Studies conducted on the impact of clinical supervision on levels of burnout among psychiatric nurses found that adequate and effective clinical supervision of psychiatric nurses during their interaction with patients, reduced their levels of burnout.[33],[34] Gender may have an important association with psychological distress; female mental health professionals are at a higher risk of stress, depression, and anxiety.[32]

Empathy is an important virtue and professional requirement of mental health professionals; they are shown to score high on empathy compared to physicians of other specialties.[35] However, it can be a challenging task to maintain an affective distance with the patients while, simultaneously, demonstrating empathy. A failure to maintain this stance can potentially drain the care provider and adversely affect their mental health.[36]

Mental health professionals go through similar stress as experienced by other health professionals due to the emotional burden and chronic nature of their patient's illness. Thus, to provide better care to their patients, they themselves must be mentally and physically healthy.[37] Literature mentions that mental health professionals may have compromised financial health, which in turn may affect their mental well-being.[38]

In exceptional circumstances, like the ongoing COVID-19 pandemic, the prevalence of mental health issues is likely to change depending upon the degree of exposure to COVID-19 and variations in work pressure. In majority of the countries, the healthcare infrastructure and manpower are exhausted due to the exponential increase in COVID-19 cases, which resulted in the involvement of mental health professionals in COVID-care duties. In addition, the emerging burden of mental health issues as a result of the pandemic have resulted in increased workload and stress of mental health professionals.[30] During the COVID-19 pandemic, loneliness and complaining behavior are found to be predictors of burnout among medical personals working in psychiatry wards.[39]


  Recommendations and Remedial measures Top


There is a need to promptly identify stress and other psychological issues among psychiatrists so that timely interventions can be provided to promote their mental well-being.[40] In this regard, it is important that psychiatrists acknowledge their distress and seek help for the same. Thus, 'self-care' can be a valuable addition to the clinical training of potential therapists.[41] Mindfulness plays an important role in maintaining self-care and well-being.[42] Some evidence indicates that lifestyle variables and paying adequate attention to one's non-professional life (family life, hobbies, passion) may have a protective impact.[15] Recommendations for reducing staff stress and eventual burnout include enabling more opportunities for temporary removal from direct patient care.[20] High levels of colleagues and mentors' support at work may have a positive impact on mental health.[19] To handle a challenging task, work satisfaction and feelings of adequacy will increase a sense of personal achievement and contribute to a strongly positive work experience. High levels of work satisfaction protect mental health, reduce the risk of emotional fatigue, and prevent burnout.[19]

The advantage with mental health professionals is that they have a better understanding and awareness about mental health issues and possible remediation strategies. The remedial measures should focus more on insight-oriented training.[37] Various approaches that reduce work burden, improve managerial and administrative skills, and enhance management of emotions, may be helpful in preventing mental health issues.[43] As clinical supervision is found to be effective in reducing burnout and distress among mental health professionals,[33],[34] adequate mentoring and supervision of young and inexperienced mental health professionals by senior and experienced mental health experts will help in reducing burnout among them. To facilitate this, there should be adequate online and offline support systems in organizations. Young mental health professionals should explore and avail all opportunities to improve their skills for confidently managing the mental health issues of their clients, which is likely to reduce their level of distress.


  Conclusion Top


The issue of mental health of mental healthcare providers is often overlooked but critical to their well-being and ability to discharge their duties efficiently. Consequently, it is also a public health issue and, therefore, requires adequate focus. However, mental health practitioners often neglect their own mental health. Promoting the mental health of mental health professionals can have beneficial spin-offs on the mental health of patients. International and national bodies like the World Psychiatric Association (WPA) and the Indian Psychiatric Society (IPS) should look into these issues with greater urgency to come up with solutions that have good uptake and efficacy.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
The World Health Report 2001: Mental Disorders affect One in Four People. Available from: https://www.who.int/news/item/28-09-2001-the-world-health-report-2001-mental-disorders-affect -one-in-four-people. [Last accessed on 2022 Apr 07].  Back to cited text no. 1
    
2.
Ferrari AJ, Santomauro DF, Herrera AM. Global, regional, and national burden of 12 mental disorders in 204 countries and territories, 1990–2019: A systematic analysis for the Global Burden of Disease Study 2019. Lancet Psychiatry 2022;9:137-50.  Back to cited text no. 2
    
3.
Summers RF, Gorrindo T, Hwang S, Aggarwal R, Guille C. Well-being, burnout, and depression among North American psychiatrists: The state of our profession. Am J Psychiatry 2020;177:955-64.  Back to cited text no. 3
    
4.
Koreki A, Nakagawa A, Abe A, Ikeuchi H, Okubo J, Oguri A, et al. Mental health of Japanese psychiatrists: The relationship among level of occupational stress, satisfaction and depressive symptoms. BMC Res Notes 2015;8:96.  Back to cited text no. 4
    
5.
Rosen DH. Suicide rates among psychiatrists. JAMA 1973;224:246-7.  Back to cited text no. 5
    
6.
Hawton K, Clements A, Sakarovitch C, Simkin S, Deeks JJ. Suicide in doctors: A study of risk according to gender, seniority and specialty in medical practitioners in England and Wales, 1979-1995. J Epidemiol Community Health 2001;55:296-300.  Back to cited text no. 6
    
7.
Firth-Cozens J. Improving the health of psychiatrists. Adv Psychiatr Treat 2007;13:161-8.  Back to cited text no. 7
    
8.
Bennett J, O'Donovan D. Substance misuse by doctors, nurses and other healthcare workers. Curr Opin Psychiatry 2001;14:195-9.  Back to cited text no. 8
    
9.
Wang L. Psychiatrists Have the Highest Suicide Rate of Any Profession. It's Time to Do Something about It. Medium; 2020. Available from: https://medium.com/invisible-illness/psychiatrists-have-the-highest-suicide-rate-of-any-profession -its-time-to-do-something-about-it-7d63e2f2fe21. [Last accessed on 2020 Nov 17].  Back to cited text no. 9
    
10.
Wang L. Psychiatrists Have the Highest Suicide Rate of Any Profession. It's Time to do something about It. Medium; 2020. Available from: https://medium.com/invisible-illness/psychiatrists-have-the-highest-suicide-rate-of-any-profession -its-time-to-do-something-about-it-7d63e2f2fe21. [Last accessed on 2022 May 18].  Back to cited text no. 10
    
11.
Deary IJ, Agius RM, Sadler A. Personality and stress in consultant psychiatrists. Int J Soc Psychiatry 1996;42:112-23.  Back to cited text no. 11
    
12.
Cottler LB, Ajinkya S, Merlo LJ, Nixon SJ, Ben Abdallah A, Gold MS. Lifetime psychiatric and substance use disorders among impaired physicians in a physicians health program: Comparison to a general treatment population: Psychopathology of impaired physicians. J Addict Med 2013;7:108-12.  Back to cited text no. 12
    
13.
Kaliszewski M. October 30 PU, 2019. Substance Abuse in Doctors – Statistics & Treatment Options. American Addiction Centers. Available from: https://americanaddictioncenters.org/medical- professionals/substance-abuse-among-doctors-key-statistics. [Last accessed on 2020 Nov 16].  Back to cited text no. 13
    
14.
Rössler W. Stress, burnout, and job dissatisfaction in mental health workers. Eur Arch Psychiatry Clin Neurosci 2012;262 Suppl 2:S65-9.  Back to cited text no. 14
    
15.
Kumar S. Burnout in psychiatrists. World Psychiatry 2007;6:186-9.  Back to cited text no. 15
    
16.
Heponiemi T, Aalto AM, Puttonen S, Vänskä J, Elovainio M. Work-related stress, job resources, and well-being among psychiatrists and other medical specialists in Finland. Psychiatr Serv 2014;65:796-801.  Back to cited text no. 16
    
17.
Garg K, Kumar CN, Chandra PS. Number of psychiatrists in India: Baby steps forward, but a long way to go. Indian J Psychiatry 2019;61:104-5.  Back to cited text no. 17
[PUBMED]  [Full text]  
18.
Merwin E, Hinton I, Dembling B, Stern S. Shortages of rural mental health professionals. Arch Psychiatr Nurs 2003;17:42-51.  Back to cited text no. 18
    
19.
Harvey SB, Laird B, Henderson M, Hotopf M. The mental health of health care professionals: A review for the Department of Health. London: National Clinical Assessment Service. 2009.  Back to cited text no. 19
    
20.
Pines A, Maslach C. Characteristics of staff burnout in mental health settings. Hosp Community Psychiatry 1978;29:233-7.  Back to cited text no. 20
    
21.
Shoesmith W, Awang Borhanuddin AF, Pereira EJ, Nordin N, Giridharan B, Forman D, et al. Barriers and enablers to collaboration in the mental health system in Sabah, Malaysia: Towards a theory of collaboration. BJPsych Open 2019;6:e4.  Back to cited text no. 21
    
22.
Bentham W, Vannoy SD, Badger K, Wennerstrom A, Springgate BF. Opportunities and challenges of implementing collaborative mental health care in post-Katrina New Orleans. Ethn Dis 2011;21:S1-7.  Back to cited text no. 22
    
23.
Jenkins R, Elliott P. Stressors, burnout and social support: Nurses in acute mental health settings. J Adv Nurs 2004;48:622-31.  Back to cited text no. 23
    
24.
Alabi MA, Ishola AG, Onibokun AC, Lasebikan VO. Burnout and quality of life among nurses working in selected mental health institutions in South West Nigeria. Afr Health Sci 2021;21:1428-39.  Back to cited text no. 24
    
25.
Nimmawitt N, Wannarit K, Pariwatcharakul P. Thai psychiatrists and burnout: A national survey. PLoS One 2020;15:e0230204.  Back to cited text no. 25
    
26.
Kader N, Elhusein B, Elhassan NM, Alabdulla M, Hammoudeh S, Hussein NR. Burnout and job satisfaction among psychiatrists in the Mental Health Service, Hamad Medical Corporation, Qatar. Asian J Psychiatr 2021;58:102619.  Back to cited text no. 26
    
27.
Summers RF. The elephant in the room: What burnout is and what it is not. Am J Psychiatry 2020;177:898-9.  Back to cited text no. 27
    
28.
Rollman BL, Mead LA, Wang NY, Klag MJ. Medical specialty and the incidence of divorce. N Engl J Med 1997;336:800-3.  Back to cited text no. 28
    
29.
Ly DP, Seabury SA, Jena AB. Divorce among physicians and other healthcare professionals in the United States: Analysis of census survey data. BMJ 2015;350:h706.  Back to cited text no. 29
    
30.
Kar SK, Singh A. Mental health of mental health professionals during COVID-19 pandemic: Who cares for it? Asian J Psychiatr 2020;53:102385.  Back to cited text no. 30
    
31.
Fothergill A, Edwards D, Burnard P. Stress, burnout, coping and stress management in psychiatrists: Findings from a systematic review. Int J Soc Psychiatry 2004;50:54-65.  Back to cited text no. 31
    
32.
Fresán A, Guízar-Sánchez D, Yoldi-Negrete M, Robles-García R, Tovilla-Zárate CA, Heinze G, et al. Identifying risk factors for self-reported mental health problems in psychiatry trainees and psychiatrists in Mexico. Acad Psychiatry 2021;45:698-707.  Back to cited text no. 32
    
33.
Hyrkäs K. Clinical supervision, burnout, and job satisfaction among mental health and psychiatric nurses in Finland. Issues Ment Health Nurs 2005;26:531-56.  Back to cited text no. 33
    
34.
Edwards D, Burnard P, Hannigan B, Cooper L, Adams J, Juggessur T, et al. Clinical supervision and burnout: The influence of clinical supervision for community mental health nurses. J Clin Nurs 2006;15:1007-15.  Back to cited text no. 34
    
35.
Hojat M, Gonnella JS, Nasca TJ, Mangione S, Vergare M, Magee M. Physician empathy: Definition, components, measurement, and relationship to gender and specialty. Am J Psychiatry 2002;159:1563-9.  Back to cited text no. 35
    
36.
Zinn W. The empathic physician. Arch Intern Med 1993;153:306-12.  Back to cited text no. 36
    
37.
Moore KA, Cooper CL. Stress in mental health professionals: A theoretical overview. Int J Soc Psychiatry 1996;42:82-9.  Back to cited text no. 37
    
38.
Britt SL, Klontz BT, Tibbetts R, Leitz L. The financial health of mental health professionals. J Financ Ther 2015;6:17-32.  Back to cited text no. 38
    
39.
Karcz E, Zdun-Ryżewska A, Zimmermann A. Loneliness, complaining and professional burnout of medical personnel of psychiatric wards during COVID-19 pandemic-cross-sectional study. Healthcare (Basel) 2022;10:145.  Back to cited text no. 39
    
40.
Rabin S, Feldman D, Kaplan Z. Stress and intervention strategies in mental health professionals. Br J Med Psychol 1999;72:159-69.  Back to cited text no. 40
    
41.
Shapiro SL, Brown KW, Biegel GM. Teaching self-care to caregivers: Effects of mindfulness-based stress reduction on the mental health of therapists in training. Train Educ Prof Psychol 2007;1:105-15.  Back to cited text no. 41
    
42.
Richards K, Campenni C, Muse-Burke J. Self-care and well-being in mental health professionals: The mediating effects of self-awareness and mindfulness. J Ment Health Couns 2010;32:247-64.  Back to cited text no. 42
    
43.
Hardy P, Costemale-Lacoste JF, Trichard C, Butlen-Ducuing F, Devouge I, Cerboneschi V, et al. Comparison of burnout, anxiety and depressive syndromes in hospital psychiatrists and other physicians: Results from the ESTEM study. Psychiatry Res 2020;284:112662.  Back to cited text no. 43
    


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