Barriers to mental healthcare for psychiatrists

AIMS AND METHOD

To determine the opinions of psychiatrists on mental illnessamong themselves and their colleagues a postal survey was conductedacross the West Midlands.

RESULTS

Most psychiatrists (319/370, 86.2%) would be reluctant to disclosemental illness to colleagues or professional organisations(323/370, 87.3%). Their choices regarding disclosure and treatmentwould be influenced by issues of confidentiality (n=245, 66%),stigma (n=83, 22%) and career implications (n=128, 35%) ratherthan quality of care (n=60, 16%).

CLINICAL IMPLICATIONS

The stigma associated with mental illness remains prevalentamong the psychiatric profession and may prevent those affectedfrom seeking adequate treatment and support. Appropriate, confidentialspecialist psychiatric services should be provided for thisvulnerable group, and for doctors as a whole, to ensure thattheir needs, and by extension those of their patients, aremet.

Introduction

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Introduction

In recent years the stigma associated with mental illness hasincreasingly been recognised as an important factor influencingthe accessing of mental healthcare by the general population.This has led to a concerted effort to reduce stigma by promotingtreatment in the community, anti-stigma campaigns, etc.

There has been less interest in the impact of stigma on theaccessing of mental healthcare by medical professionals ingeneral and psychiatrists in particular, despite the fact thatthis may be a particularly vulnerable group. It is well-recognisedthat doctors have high rates of mental illness (Caplan, 1994)but are often reluctant to seek help, which may explain thehigh rate of suicide among the profession (Richings et al, 1986).According to the General Medical Council, psychiatrists haveone of the highest rates of psychiatric morbidity among hospitaldoctors and there is concern that this is not adequately recognisedand managed. The British Medical Association (2005) estimatesthat 1 in 15 doctors, at some point in their lives, will havesome kind of problem with alcohol or drugs.

Mental illness may be particularly stigmatising for those workingin a stressful profession where vulnerabilities are not readilytolerated. There is evidence that avoidance of appropriatehelp-seeking behaviour by doctors starts as early as medicalschool and is linked to perceived norms, which dictate thata mental health problem may be viewed as a form of weaknesswith implications for subsequent successful career progression (Chew-Graham et al, 2003).

The aim of this study was to investigate the views of psychiatristson the prevalence of mental illness among their colleagues,their own experiences of mental illness and their preferencesfor disclosure and treatment should they develop mental illness.

Method

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Method

The authors used their own clinical experience and discussionwith colleagues to inform the design of a nine-item questionnaire (Table 1) which sought psychiatrists’ views on mentalillness among the profession. Ethical approval was obtainedfrom the South Birmingham Ethics Committee. The questionnairewas piloted locally and then sent with a covering letter and stamped addressed return envelope to all 510 psychiatristsidentified as working in the West Midlands region. Anonymitywas maintained.

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Table 1. Responses to questionnaire on attitudes to mental illness among doctors

The questionnaire sought information on the respondents’perceptions of the prevalence of mental illness among psychiatristscompared with the general population and other medical professionals.Respondents were asked whether they had ever experienced mentalillness, what their disclosure and treatment preferences wouldbe should they develop mental health problems and what factorswould influence these decisions. A freetext box was includedfor any additional comments.

The ${chi}$ ² test was used to determine whether there was an associationbetween having experienced mental illness and the responsesto the other questions. P $≤$ 0.05 was considered significant. Theassociated effect sizes of these tests ( ${varphi}$ or Cramer’s ${varphi}$ ) were also computed. The significant two-sample ${chi}$ ² associationsare reported.

Results

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Results

Completed questionnaires were returned by 370 of the 510 psychiatrists(a response rate of 72.6%); 195 respondents (52.7%) describedthemselves as consultants, 102 (27.6%) as senior house officersand 42 (11.4%) as specialist registrars. All questions wereanswered by all 370 respondents.

Roughly a third (124) of respondents considered that psychiatristshave a higher incidence of mental illness than the generalpopulation. Over a third (135) considered that they had a higherincidence of mental illness than other medical professionals(Table 1).

Disclosure of mental illness
In the event of developing a mental illness most respondents (n=240, 64.9%) would choose to disclose this to family andfriends rather than to colleagues (n=51, 13.8%) or professionalinstitutions (n=47, 12.6%); 32 (8.7%) would disclose this tono one. Career implications were the most frequent reason forfailure to disclose mental illness (n=128, 34.7%), followedby professional integrity (n=102, 27.5%) and stigma (n=83,22.4%).

Treatment preferences
As a first treatment preference for a moderate depressive disorder,less than half (n=162, 43.9%) would seek formal professionaladvice; 114 (30.9%) would choose informal professional advice,73 (19.8%) self-medication and 20 (5.4%) no treatment. If theywere to require inpatient treatment, 171 (46.2%) would choosea local private facility, with only 15 (4.1%) choosing a localNational Health Service (NHS) facility. Overwhelmingly the most influential factor governing this choice was confidentiality,which was cited by 245 respondents (66.2%). Only 60 (16.3%)would make the decision based on the best quality of care.

Experience of mental illness
Eighty-one respondents (22%) indicated that they had, at sometime, experienced a mental illness which had affected theirpersonal, social and working life.

Those who had experienced mental illness were more likely todisclose future mental illness to no one ( ${chi}$ ²=10.719, d.f.=3, P=0.013; Cramer’s ${varphi}$ =0.174) and were more likely to cite stigma, and less likely to cite career implications and professional integrity, as the most important reason for this decision thanthose who had not experienced mental illness ( ${chi}$ ²=8.395, d.f.=3, P=0.039, Cramer’s ${varphi}$ =0.154).

Discussion

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Discussion

This is the first study to investigate the views of UK psychiatristson their own and their colleagues’ experiences of mentalillness. As it was carried out in only one region of the UK,generalisability of the results cannot be assumed. Moreover,the responses may reflect what the respondents believe to beprofessionally desirable responses. None the less the findings are worthy of discussion.

The stigma associated with mental illness is well-recognisedand remains prevalent. The Royal College of Psychiatrists hasrecognised the deleterious effect of discrimination and prejudiceagainst people with mental illnesses and has attempted to addressthis with its Changing Minds campaign (Crisp et al, 2004). Psychiatrists should therefore be aware of the devastatingeffects of stigmatising those with mental illness, but thatdoes not prevent them from suffering its consequences whencoping with mental illness themselves (Hausman, 2002).

Mental illness is a broad term covering a variety of illnesseswhich differ from each other in many significant ways, notleast in how they are perceived by others. As such they attracta variety of different reactions from the public and professionalsand carry differing implications for the professional competenceof those affected. The methodology of our study did not allowus to distinguish between different types of mental illness,but our findings suggest that psychiatrists recognise thatsuch illnesses are not uncommon among the profession.

Psychiatrists will be well aware of the profound impact thatsuch illnesses can have on both their personal lives and theirprofessional competency. It is therefore particularly worryingthat, in the event of developing such illnesses, the majorityof psychiatrists would be reluctant to seek help. Moreover,in the event that they did seek help, treatment choice wouldbe influenced by concerns over loss of confidentiality andstigma rather than perceived quality of care. This is consistentwith the findings of a survey in the USA (Lehmann, 2001) which showed that half of all psychiatrists with a depressive illnesswould self-medicate rather than risk having mental illnessrecorded in their medical notes.

Stigma was cited more frequently as a factor influencing choiceof future treatment by those who had personal experience ofmental illness than by those who had not. This may reflectpast experiences of those who had been mentally ill. Thereis some evidence (Hausman, 2002) that psychiatrists who sufferfrom mental illness experience isolation, a lack of compassionand discrimination by their own professional colleagues. Itis recognised that psychiatrists often hold stigmatising and discriminatory attitudes towards their patients (Corker, 2001)and it is not surprising that these attitudes extend to theircolleagues who experience mental illness. The Royal Collegeof Psychiatrists (2001) acknowledges that doctors, includingpsychiatrists, are sometimes found to be prejudiced by patientsand that it is likely that doctors’ attitudes towardspeople with mental illnesses mirror those of the general population.

Failure to seek appropriate help when ill is prevalent amongthe wider medical profession (Forsythe et al, 1999). Again,issues of trust and concerns about confidentiality may actas barriers to medical practitioners seeking help for psychiatricillness (Thompson et al, 2001; Davidson & Schattner, 2003).Such attitudes are already prevalent among junior doctors (Shadbolt, 2002)and medical students (Hooper et al, 2005).

The culture of medicine may be a barrier to doctors seekinghealthcare as it encourages an image of invincibility and denialof vulnerability (Thompson et al, 2001; Davidson & Schattner, 2003),and accords low priority to the mental health of its practitioners(Center et al, 2003). One of the authors (A.C.W.) runs specialistpsychiatric clinics for doctors of all specialties and theviews expressed by its attenders appear to be similar.

Recommendations
Our findings suggest that some psychiatrists, and presumablyby extension other doctors, experience mental illness whilepractising without obtaining good and appropriate treatment,thus putting themselves and their patients at risk. Strategiesaimed at challenging the culture of doctors’ self-relianceshould start in medical school and a ‘no blame’ culture in which doctors who are mentally ill are acceptedand supported rather than stigmatised and punished should beencouraged. All doctors should be appropriately trained forconsultations in which the patient is also a doctor.

We would advocate the provision of confidential specialist psychiatric services for doctors. These should be recognised and fundedposts rather than simply being tagged on to existing clinicalservices. The provision of well-advertised but confidentialreferral pathways would be essential. There is some evidencethat such a ‘doctor’s doctor’ would be welcomedby senior NHS staff (Forsythe et al, 1999). We believe thatthere should also be specialised in-patient facilities available,either regionally or nationally and there is some evidencethat out-of-area specialist care for psychiatric illness wouldbe welcomed by medical practitioners (Forsythe et al, 1999).

References

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