Is the Mental Wellbeing of Doctors Becoming an Increasing Concern?

Research Paper Title

Depressive symptoms in residents of a tertiary training hospital in Malaysia: The prevalence and associated factors.

Background

The mental wellbeing of doctors is becoming an increasing concern in the world today.

In Malaysia, residency is a challenging period in a doctor’s life, with many changes professionally and possibly in their personal lives as well.

This study aims to determine the prevalence of depressive symptoms and the socio-demographic correlates among residents in a tertiary training hospital in Malaysia.

It is a cross sectional study and all residents were approached to participate in the study.

Methods

The instruments used were a socio-demographic questionnaire and the Patient Health Questionnaire 9 (PHQ-9).

Chi-square test was used to explore the association between the socio-demographic correlates, and those that were found to have significant associations were further tested using multivariate logistic regression.

Results

The prevalence of depression among residents was 25.1 %. Longer working hours, missing meals, and working in Department of Surgery and Department of Anaesthesia was significantly positively associated while having protected study time, CME/lectures, leisure/hobbies and exercise were negatively associated with depression.

The Department of Rehabilitation Medicine had a significantly negative association with depression. After logistic regression, longer working hours and a lack of protected study time was significantly associated with depression in the respective departments.

Conclusions

In summary, the prevalence of depression among residents is high and is associated with longer working hours, missing meals and a lack of protected study time are significantly associated with depression.

Remedial steps should be taken to improve the mental health among residents.

Reference

Nair, N., Ng, C.G. & Sulaiman, A.H. (2021) Depressive symptoms in residents of a tertiary training hospital in Malaysia: The prevalence and associated factors. Asian Journal of Psychiatry. doi: 10.1016/j.ajp.2021.102548. Online ahead of print.

What is Psychiatry?

Introduction

Psychiatry is the medical specialty devoted to the diagnosis, prevention, and treatment of mental disorders. These include various maladaptations related to mood, behaviour, cognition, and perceptions. Not to be confused with Clinical Psychology or psychology.

Initial psychiatric assessment of a person typically begins with a case history and mental status examination. Physical examinations and psychological tests may be conducted. On occasion, neuroimaging or other neurophysiological techniques are used. Mental disorders are often diagnosed in accordance with clinical concepts listed in diagnostic manuals such as the International Classification of Diseases (ICD), edited and used by the World Health Organisation (WHO) and the widely used Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association (APA). The fifth edition of the DSM (DSM-5) was published in 2013 which re-organized the larger categories of various diseases and expanded upon the previous edition to include information/insights that are consistent with current research.

The combined treatment of psychiatric medication and psychotherapy has become the most common mode of psychiatric treatment in current practice, but contemporary practice also includes a wide variety of other modalities, e.g., assertive community treatment, community reinforcement, and supported employment. Treatment may be delivered on an inpatient or outpatient basis, depending on the severity of functional impairment or on other aspects of the disorder in question. An inpatient may be treated in a psychiatric hospital. Research and treatment within psychiatry as a whole are conducted on an interdisciplinary basis with other professionals, such as epidemiologists, nurses, or psychologists.

Etymology

The term psychiatry was first coined by the German physician Johann Christian Reil in 1808 and literally means the ‘medical treatment of the soul’ (psych- ‘soul’ from Ancient Greek psykhē ‘soul’; -iatry ‘medical treatment’ from Gk. iātrikos ‘medical’ from iāsthai ‘to heal’).

A medical doctor specialising in psychiatry is known as a psychiatrist.

Theory and Focus

Psychiatry refers to a field of medicine focused specifically on the mind, aiming to study, prevent, and treat mental disorders in humans. It has been described as an intermediary between the world from a social context and the world from the perspective of those who are mentally ill.

People who specialise in psychiatry often differ from most other mental health professionals and physicians in that they must be familiar with both the social and biological sciences. The discipline studies the operations of different organs and body systems as classified by the patient’s subjective experiences and the objective physiology of the patient. Psychiatry treats mental disorders, which are conventionally divided into three very general categories:

  1. Mental illnesses;
  2. Severe learning disabilities; and
  3. Personality disorders.

While the focus of psychiatry has changed little over time, the diagnostic and treatment processes have evolved dramatically and continue to do so. Since the late 20th century, the field of psychiatry has continued to become more biological and less conceptually isolated from other medical fields.

Scope of Practice

Though the medical specialty of psychiatry uses research in the field of neuroscience, psychology, medicine, biology, biochemistry, and pharmacology, it has generally been considered a middle ground between neurology and psychology. Because psychiatry and neurology are deeply intertwined medical specialties, all certification for both specialties and for their subspecialties is offered by a single board, the American Board of Psychiatry and Neurology, one of the member boards of the American Board of Medical Specialties. Unlike other physicians and neurologists, psychiatrists specialise in the doctor-patient relationship and are trained to varying extents in the use of psychotherapy and other therapeutic communication techniques. Psychiatrists also differ from psychologists in that they are physicians and have post-graduate training called residency (usually 4 to 5 years) in psychiatry; the quality and thoroughness of their graduate medical training is identical to that of all other physicians. Psychiatrists can therefore counsel patients, prescribe medication, order laboratory tests, order neuroimaging, and conduct physical examinations.

Ethics

The World Psychiatric Association issues an ethical code to govern the conduct of psychiatrists (like other purveyors of professional ethics). The psychiatric code of ethics, first set forth through the Declaration of Hawaii in 1977 has been expanded through a 1983 Vienna update and in the broader Madrid Declaration in 1996. The code was further revised during the organisation’s general assemblies in 1999, 2002, 2005, and 2011.

The World Psychiatric Association code covers such matters as confidentiality, the death penalty, ethnic or cultural discrimination, euthanasia, genetics, the human dignity of incapacitated patients, media relations, organ transplantation, patient assessment, research ethics, sex selection, torture, and up-to-date knowledge.

In establishing such ethical codes, the profession has responded to a number of controversies about the practice of psychiatry, for example, surrounding the use of lobotomy and electroconvulsive therapy.

Discredited psychiatrists who operated outside the norms of medical ethics include Harry Bailey, Donald Ewen Cameron, Samuel A. Cartwright, Henry Cotton, and Andrei Snezhnevsky.

Approaches

Psychiatric illnesses can be conceptualised in a number of different ways. The biomedical approach examines signs and symptoms and compares them with diagnostic criteria. Mental illness can be assessed, conversely, through a narrative which tries to incorporate symptoms into a meaningful life history and to frame them as responses to external conditions. Both approaches are important in the field of psychiatry but have not sufficiently reconciled to settle controversy over either the selection of a psychiatric paradigm or the specification of psychopathology. The notion of a “biopsychosocial model” is often used to underline the multifactorial nature of clinical impairment. In this notion the word model is not used in a strictly scientific way though. Alternatively, a “biocognitive model” acknowledges the physiological basis for the mind’s existence but identifies cognition as an irreducible and independent realm in which disorder may occur. The biocognitive approach includes a mentalist aetiology and provides a natural dualist (i.e. non-spiritual) revision of the biopsychosocial view, reflecting the efforts of Australian psychiatrist Niall McLaren to bring the discipline into scientific maturity in accordance with the paradigmatic standards of philosopher Thomas Kuhn.

Once a medical professional diagnoses a patient there are numerous ways that they could choose to treat the patient. Often psychiatrists will develop a treatment strategy that incorporates different facets of different approaches into one. Drug prescriptions are very commonly written to be regimented to patients along with any therapy they receive. There are three major pillars of psychotherapy that treatment strategies are most regularly drawn from. Humanistic psychology attempts to put the “whole” of the patient in perspective; it also focuses on self exploration. Behaviourism is a therapeutic school of thought that elects to focus solely on real and observable events, rather than mining the unconscious or subconscious. Psychoanalysis, on the other hand, concentrates its dealings on early childhood, irrational drives, the unconscious, and conflict between conscious and unconscious streams.

Practitioners

Refer to Psychiatrist.

All physicians can diagnose mental disorders and prescribe treatments utilising principles of psychiatry. Psychiatrists are trained physicians who specialise in psychiatry and are certified to treat mental illness. They may treat outpatients, inpatients, or both; they may practice as solo practitioners or as members of groups; they may be self-employed, be members of partnerships, or be employees of governmental, academic, non-profit, or for-profit entities; employees of hospitals; they may treat military personnel as civilians or as members of the military; and in any of these settings they may function as clinicians, researchers, teachers, or some combination of these. Although psychiatrists may also go through significant training to conduct psychotherapy, psychoanalysis or cognitive behavioural therapy, it is their training as physicians that differentiates them from other mental health professionals.

As a Career Choice

Psychiatry was not a popular career choice among medical students, even though medical school placements are rated favourably. This has resulted in a significant shortage of psychiatrists in the United States and elsewhere. Strategies to address this shortfall have included the use of short ‘taster’ placements early in the medical school curriculum and attempts to extend psychiatry services further using telemedicine technologies and other methods. Recently, however, there has been an increase in the number of medical students entering into a psychiatry residency. There are several reasons for this surge including the interesting nature of the field, growing interest in genetic biomarkers involved in psychiatric diagnoses, and newer pharmaceuticals on the drug market to treat psychiatric illnesses.

Subspecialties

The field of psychiatry has many subspecialties that require additional training and certification by the American Board of Psychiatry and Neurology (ABPN). Such subspecialties include:

  • Addiction psychiatry focuses on evaluation and treatment of individuals with alcohol, drug, or other substance-related disorders, and of individuals with dual diagnosis of substance-related and other psychiatric disorders.
  • Brain Injury Medicine.
  • Child and adolescent psychiatry is the branch of psychiatry that specialises in work with children, teenagers, and their families.
  • Clinical neurophysiology.
  • Consultation-liaison psychiatry, also known as psychosomatic medicine. Liaison psychiatry is the branch of psychiatry that specialises in the interface between other medical specialties and psychiatry.
  • Epilepsy.
  • Forensic psychiatry.
  • Geriatric psychiatry is a branch of psychiatry dealing with the study, prevention, and treatment of mental disorders in the elderly.
  • Hospice and palliative medicine.
  • Pain medicine.
  • Sleep medicine.

Additional psychiatry subspecialties, for which ABPN does not offer certification, include:

  • Biological psychiatry is an approach to psychiatry that aims to understand mental disorders in terms of the biological function of the nervous system.
  • Cognition diseases as in various forms of dementia.
  • Community psychiatry is an approach that reflects an inclusive public health perspective and is practiced in community mental health services
  • Cross-cultural psychiatry is a branch of psychiatry concerned with the cultural and ethnic context of mental disorder and psychiatric services.
  • Emergency psychiatry is the clinical application of psychiatry in emergency settings. Forensic psychiatry utilises medical science generally, and psychiatric knowledge and assessment methods in particular, to help answer legal questions.
  • Global Mental Health is an area of study, research and practice that places a priority on improving mental health and achieving equity in mental health for all people worldwide, although some scholars consider it to be a neo-colonial, culturally insensitive project.
  • Learning disability.
  • Military psychiatry covers special aspects of psychiatry and mental disorders within the military context.
  • Neurodevelopmental disorders.
  • Neuropsychiatry is a branch of medicine dealing with mental disorders attributable to diseases of the nervous system.
  • Social psychiatry is a branch of psychiatry that focuses on the interpersonal and cultural context of mental disorder and mental well-being.

In larger healthcare organisations, psychiatrists often serve in senior management roles, where they are responsible for the efficient and effective delivery of mental health services for the organization’s constituents. For example, the Chief of Mental Health Services at most Veterans Administration (VA) medical centres is usually a psychiatrist, although psychologists occasionally are selected for the position as well.

In the United States, psychiatry is one of the few specialties which qualify for further education and board-certification in pain medicine, palliative medicine, and sleep medicine.

Research

Psychiatric research is, by its very nature, interdisciplinary; combining social, biological and psychological perspectives in attempt to understand the nature and treatment of mental disorders. Clinical and research psychiatrists study basic and clinical psychiatric topics at research institutions and publish articles in journals. Under the supervision of institutional review boards, psychiatric clinical researchers look at topics such as neuroimaging, genetics, and psychopharmacology in order to enhance diagnostic validity and reliability, to discover new treatment methods, and to classify new mental disorders.

Clinical Application

Diagnostic Systems

Psychiatric diagnoses take place in a wide variety of settings and are performed by many different health professionals. Therefore, the diagnostic procedure may vary greatly based upon these factors. Typically, though, a psychiatric diagnosis utilises a differential diagnosis procedure where a mental status examination and physical examination is conducted, with pathological, psychopathological or psychosocial histories obtained, and sometimes neuroimages or other neurophysiological measurements are taken, or personality tests or cognitive tests administered. In some cases, a brain scan might be used to rule out other medical illnesses, but at this time relying on brain scans alone cannot accurately diagnose a mental illness or tell the risk of getting a mental illness in the future. A few psychiatrists are beginning to utilise genetics during the diagnostic process but on the whole this remains a research topic.

Diagnostic Manuals

Three main diagnostic manuals used to classify mental health conditions are in use today. The ICD-10 is produced and published by the WHO, includes a section on psychiatric conditions, and is used worldwide. The Diagnostic and Statistical Manual of Mental Disorders, produced and published by the American Psychiatric Association, is primarily focused on mental health conditions and is the main classification tool in the United States. It is currently in its fifth revised edition and is also used worldwide. The Chinese Society of Psychiatry has also produced a diagnostic manual, the Chinese Classification of Mental Disorders.

The stated intention of diagnostic manuals is typically to develop replicable and clinically useful categories and criteria, to facilitate consensus and agreed upon standards, whilst being atheoretical as regards aetiology. However, the categories are nevertheless based on particular psychiatric theories and data; they are broad and often specified by numerous possible combinations of symptoms, and many of the categories overlap in symptomology or typically occur together. While originally intended only as a guide for experienced clinicians trained in its use, the nomenclature is now widely used by clinicians, administrators and insurance companies in many countries.

The DSM has attracted praise for standardizing psychiatric diagnostic categories and criteria. It has also attracted controversy and criticism. Some critics argue that the DSM represents an unscientific system that enshrines the opinions of a few powerful psychiatrists. There are ongoing issues concerning the validity and reliability of the diagnostic categories; the reliance on superficial symptoms; the use of artificial dividing lines between categories and from ‘normality’; possible cultural bias; medicalisation of human distress and financial conflicts of interest, including with the practice of psychiatrists and with the pharmaceutical industry; political controversies about the inclusion or exclusion of diagnoses from the manual, in general or in regard to specific issues; and the experience of those who are most directly affected by the manual by being diagnosed, including the consumer/survivor movement. The publication of the DSM, with tightly guarded copyrights, now makes APA over $5 million a year, historically adding up to over $100 million.

Treatment

General Considerations

Individuals with mental health conditions are commonly referred to as patients but may also be called clients, consumers, or service recipients. They may come under the care of a psychiatric physician or other psychiatric practitioners by various paths, the two most common being self-referral or referral by a primary care physician. Alternatively, a person may be referred by hospital medical staff, by court order, involuntary commitment, or, in the UK and Australia, by sectioning under a mental health law.

Persons who undergo a psychiatric assessment are evaluated by a psychiatrist for their mental and physical condition. This usually involves interviewing the person and often obtaining information from other sources such as other health and social care professionals, relatives, associates, law enforcement personnel, emergency medical personnel, and psychiatric rating scales. A mental status examination is carried out, and a physical examination is usually performed to establish or exclude other illnesses that may be contributing to the alleged psychiatric problems. A physical examination may also serve to identify any signs of self-harm; this examination is often performed by someone other than the psychiatrist, especially if blood tests and medical imaging are performed.

Like most medications, psychiatric medications can cause adverse effects in patients, and some require ongoing therapeutic drug monitoring, for instance full blood counts serum drug levels, renal function, liver function or thyroid function. Electroconvulsive therapy (ECT) is sometimes administered for serious and disabling conditions, such as those unresponsive to medication. The efficacy and adverse effects of psychiatric drugs may vary from patient to patient.

For many years, controversy has surrounded the use of involuntary treatment and use of the term “lack of insight” in describing patients. Mental health laws vary significantly among jurisdictions, but in many cases, involuntary psychiatric treatment is permitted when there is deemed to be a risk to the patient or others due to the patient’s illness. Involuntary treatment refers to treatment that occurs based on the treating physician’s recommendations without requiring consent from the patient.

Mental health issues such as mood disorders and schizophrenia and other psychotic disorders were the most common principle diagnoses for Medicaid super-utilisers in the United States in 2012.

Inpatient Treatment

Psychiatric treatments have changed over the past several decades. In the past, psychiatric patients were often hospitalised for six months or more, with some cases involving hospitalisation for many years.

Average inpatient psychiatric treatment stay has decreased significantly since the 1960s, a trend known as deinstitutionalisation. Today in most countries, people receiving psychiatric treatment are more likely to be seen as outpatients. If hospitalisation is required, the average hospital stay is around one to two weeks, with only a small number receiving long-term hospitalisation. However, in Japan psychiatric hospitals continue to keep patients for long periods, sometimes even keeping them in physical restraints, strapped to their beds for periods of weeks or months.

Psychiatric inpatients are people admitted to a hospital or clinic to receive psychiatric care. Some are admitted involuntarily, perhaps committed to a secure hospital, or in some jurisdictions to a facility within the prison system. In many countries including the United States and Canada, the criteria for involuntary admission vary with local jurisdiction. They may be as broad as having a mental health condition, or as narrow as being an immediate danger to themselves or others. Bed availability is often the real determinant of admission decisions to hard pressed public facilities. European Human Rights legislation restricts detention to medically certified cases of mental disorder, and adds a right to timely judicial review of detention.

People may be admitted voluntarily if the treating doctor considers that safety isn’t compromised by this less restrictive option. Inpatient psychiatric wards may be secure (for those thought to have a particular risk of violence or self-harm) or unlocked/open. Some wards are mixed-sex whilst same-sex wards are increasingly favoured to protect women inpatients. Once in the care of a hospital, people are assessed, monitored, and often given medication and care from a multidisciplinary team, which may include physicians, pharmacists, psychiatric nurse practitioners, psychiatric nurses, clinical psychologists, psychotherapists, psychiatric social workers, occupational therapists and social workers. If a person receiving treatment in a psychiatric hospital is assessed as at particular risk of harming themselves or others, they may be put on constant or intermittent one-to-one supervision and may be put in physical restraints or medicated. People on inpatient wards may be allowed leave for periods of time, either accompanied or on their own.

In many developed countries there has been a massive reduction in psychiatric beds since the mid 20th century, with the growth of community care. Standards of inpatient care remain a challenge in some public and private facilities, due to levels of funding, and facilities in developing countries are typically grossly inadequate for the same reason. Even in developed countries, programmes in public hospitals vary widely. Some may offer structured activities and therapies offered from many perspectives while others may only have the funding for medicating and monitoring patients. This may be problematic in that the maximum amount of therapeutic work might not actually take place in the hospital setting. This is why hospitals are increasingly used in limited situations and moments of crisis where patients are a direct threat to themselves or others. Alternatives to psychiatric hospitals that may actively offer more therapeutic approaches include rehabilitation centres or “rehab” as popularly termed.

Outpatient Treatment

Outpatient treatment involves periodic visits to a psychiatrist for consultation in his or her office, or at a community-based outpatient clinic. Initial appointments, at which the psychiatrist conducts a psychiatric assessment or evaluation of the patient, are typically 45 to 75 minutes in length. Follow-up appointments are generally shorter in duration, i.e. 15 to 30 minutes, with a focus on making medication adjustments, reviewing potential medication interactions, considering the impact of other medical disorders on the patient’s mental and emotional functioning, and counselling patients regarding changes they might make to facilitate healing and remission of symptoms (e.g. exercise, cognitive therapy techniques, sleep hygiene – to name just a few). The frequency with which a psychiatrist sees people in treatment varies widely, from once a week to twice a year, depending on the type, severity and stability of each person’s condition, and depending on what the clinician and patient decide would be best.

Increasingly, psychiatrists are limiting their practices to psychopharmacology (prescribing medications), as opposed to previous practice in which a psychiatrist would provide traditional 50-minute psychotherapy sessions, of which psychopharmacology would be a part, but most of the consultation sessions consisted of “talk therapy.” This shift began in the early 1980s and accelerated in the 1990s and 2000s. A major reason for this change was the advent of managed care insurance plans, which began to limit reimbursement for psychotherapy sessions provided by psychiatrists. The underlying assumption was that psychopharmacology was at least as effective as psychotherapy, and it could be delivered more efficiently because less time is required for the appointment. For example, most psychiatrists schedule three or four follow-up appointments per hour, as opposed to seeing one patient per hour in the traditional psychotherapy model. Because of this shift in practice patterns, psychiatrists often refer patients whom they think would benefit from psychotherapy to other mental health professionals, e.g. clinical social workers and psychologists.

Brief History

The earliest known texts on mental disorders are from ancient India and include the Ayurvedic text, Charaka Samhita. The first hospitals for curing mental illness were established in India during the 3rd century BCE.

The Greeks also created early manuscripts about mental disorders. In the 4th century BCE, Hippocrates theorised that physiological abnormalities may be the root of mental disorders. In 4th to 5th Century B.C. Greece, Hippocrates wrote that he visited Democritus and found him in his garden cutting open animals. Democritus explained that he was attempting to discover the cause of madness and melancholy. Hippocrates praised his work. Democritus had with him a book on madness and melancholy. During the 5th century BCE, mental disorders, especially those with psychotic traits, were considered supernatural in origin, a view which existed throughout ancient Greece and Rome,[98] as well as Egyptian regions. Religious leaders often turned to versions of exorcism to treat mental disorders often utilising methods that many consider to be cruel or barbaric methods. Trepanning was one of these methods used throughout history.

The Islamic Golden Age fostered early studies in Islamic psychology and psychiatry, with many scholars writing about mental disorders. The Persian physician Muhammad ibn Zakariya al-Razi, also known as “Rhazes”, wrote texts about psychiatric conditions in the 9th century. As chief physician of a hospital in Baghdad, he was also the director of one of the first psychiatric wards in the world. Two of his works in particular, El-Mansuri and Al-Hawi, provide descriptions and treatments for mental illnesses.

Abu Zayd al-Balkhi, was a Persian polymath during the 9th and 10th centuries and one of the first to classify neurotic disorders. He pioneered cognitive therapy in order to treat each of these classified neurotic disorders. He classified neurosis into four emotional disorders: fear and anxiety, anger and aggression, sadness and depression, and obsession. Al-Balkhi further classified three types of depression: normal depression or sadness (huzn), endogenous depression originating from within the body, and reactive clinical depression originating from outside the body.

The first bimaristan was founded in Baghdad in the 9th century, and several others of increasing complexity were created throughout the Arab world in the following centuries. Some of the bimaristans contained wards dedicated to the care of mentally ill patients, most of whom suffered from debilitating illnesses or exhibited violence. Specialist hospitals such as Bethlem Royal Hospital in London were built in medieval Europe from the 13th century to treat mental disorders, but were used only as custodial institutions and did not provide any type of treatment.

The beginning of psychiatry as a medical specialty is dated to the middle of the nineteenth century, although its germination can be traced to the late eighteenth century. In the late 17th century, privately run asylums for the insane began to proliferate and expand in size. In 1713 the Bethel Hospital Norwich was opened, the first purpose-built asylum in England. In 1656, Louis XIV of France created a public system of hospitals for those suffering from mental disorders, but as in England, no real treatment was applied.

During the Enlightenment attitudes towards the mentally ill began to change. It came to be viewed as a disorder that required compassionate treatment. In 1758 English physician William Battie wrote his Treatise on Madness on the management of mental disorder. It was a critique aimed particularly at the Bethlem Hospital, where a conservative regime continued to use barbaric custodial treatment. Battie argued for a tailored management of patients entailing cleanliness, good food, fresh air, and distraction from friends and family. He argued that mental disorder originated from dysfunction of the material brain and body rather than the internal workings of the mind.

The introduction of moral treatment was initiated independently by the French doctor Philippe Pinel and the English Quaker William Tuke. In 1792 Pinel became the chief physician at the Bicêtre Hospital. Patients were allowed to move freely about the hospital grounds, and eventually dark dungeons were replaced with sunny, well-ventilated rooms. Pinel’s student and successor, Jean Esquirol (1772-1840), went on to help establish 10 new mental hospitals that operated on the same principles.

Although Tuke, Pinel and others had tried to do away with physical restraint, it remained widespread into the 19th century. At the Lincoln Asylum in England, Robert Gardiner Hill, with the support of Edward Parker Charlesworth, pioneered a mode of treatment that suited “all types” of patients, so that mechanical restraints and coercion could be dispensed with – a situation he finally achieved in 1838. In 1839 Sergeant John Adams and Dr. John Conolly were impressed by the work of Hill, and introduced the method into their Hanwell Asylum, by then the largest in the country.

The modern era of institutionalized provision for the care of the mentally ill, began in the early 19th century with a large state-led effort. In England, the Lunacy Act 1845 was an important landmark in the treatment of the mentally ill, as it explicitly changed the status of mentally ill people to patients who required treatment. All asylums were required to have written regulations and to have a resident qualified physician. In 1838, France enacted a law to regulate both the admissions into asylums and asylum services across the country. In the United States, the erection of state asylums began with the first law for the creation of one in New York, passed in 1842. The Utica State Hospital was opened around 1850. Many state hospitals in the United States were built in the 1850s and 1860s on the Kirkbride Plan, an architectural style meant to have curative effect.

At the turn of the century, England and France combined had only a few hundred individuals in asylums. By the late 1890s and early 1900s, this number had risen to the hundreds of thousands. However, the idea that mental illness could be ameliorated through institutionalisation ran into difficulties. Psychiatrists were pressured by an ever-increasing patient population, and asylums again became almost indistinguishable from custodial institutions.

In the early 1800s, psychiatry made advances in the diagnosis of mental illness by broadening the category of mental disease to include mood disorders, in addition to disease level delusion or irrationality. The 20th century introduced a new psychiatry into the world, with different perspectives of looking at mental disorders. For Emil Kraepelin, the initial ideas behind biological psychiatry, stating that the different mental disorders are all biological in nature, evolved into a new concept of “nerves”, and psychiatry became a rough approximation of neurology and neuropsychiatry. Following Sigmund Freud’s pioneering work, ideas stemming from psychoanalytic theory also began to take root in psychiatry. The psychoanalytic theory became popular among psychiatrists because it allowed the patients to be treated in private practices instead of warehoused in asylums.

By the 1970s, however, the psychoanalytic school of thought became marginalized within the field. Biological psychiatry re-emerged during this time. Psychopharmacology became an integral part of psychiatry starting with Otto Loewi’s discovery of the neuromodulatory properties of acetylcholine; thus identifying it as the first-known neurotransmitter. Neuroimaging was first utilised as a tool for psychiatry in the 1980s. The discovery of chlorpromazine’s effectiveness in treating schizophrenia in 1952 revolutionised treatment of the disorder, as did lithium carbonate’s ability to stabilise mood highs and lows in bipolar disorder in 1948. Psychotherapy was still utilised, but as a treatment for psychosocial issues.

In 1963, US president John F. Kennedy introduced legislation delegating the National Institute of Mental Health to administer Community Mental Health Centres for those being discharged from state psychiatric hospitals. Later, though, the Community Mental Health Centres focus shifted to providing psychotherapy for those suffering from acute but less serious mental disorders. Ultimately there were no arrangements made for actively following and treating severely mentally ill patients who were being discharged from hospitals, resulting in a large population of chronically homeless people suffering from mental illness.

Controversy and Criticism

Controversy has often surrounded psychiatry, with scholars producing critiques. It has been argued that psychiatry: is too influenced by ideas from medicine, causing it to misunderstand the nature of mental distress; that its use of drugs is in part due lobbying by drug companies resulting in distortion of research; that the concept of “mental illness” is often used to label and control those with beliefs and behaviours that the majority of people disagree with; and that it confuses disorders of the mind with disorders of the brain that can be treated with drugs. Critique of psychiatry from within the field comes from the critical psychiatry group in the UK.

The term “anti-psychiatry” was coined by psychiatrist David Cooper in 1967 and was later made popular by Thomas Szasz. The word “Antipsychiatrie” was already used in Germany in 1904. The basic premise of the anti-psychiatry movement is that psychiatrists attempt to classify “normal” people as “deviant;” psychiatric treatments are ultimately more damaging than helpful to patients; and psychiatry’s history involves (what may now be seen as) dangerous treatments, such as the frontal lobectomy (commonly called, a lobotomy). Several former patient groups have been formed often referring to themselves as “survivors.” In 1973, the Rosenhan experiment was conducted to determine the validity of psychiatric diagnosis. Volunteers feigned hallucinations to enter psychiatric hospitals, and acted normally afterwards. They were diagnosed with psychiatric disorders and were given antipsychotic drugs. The study was conducted by psychologist David Rosenhan, a Stanford University professor, and published by the journal Science under the title “On being sane in insane places”.

The Church of Scientology is critical of psychiatry, whereas others have questioned the veracity of information the Church of Scientology provides to the public.

What is a Psychiatrist?

Introduction

A psychiatrist is a physician who specialises in psychiatry, the branch of medicine devoted to the diagnosis, prevention, study, and treatment of mental disorders.

Psychiatrists are medical doctors and evaluate patients to determine whether their symptoms are the result of a physical illness, a combination of physical and mental ailments or strictly mental issues. A psychiatrist usually works within a multi-disciplinary team, which may comprise clinical psychologists, social workers, occupational therapists, and nursing staff. Psychiatrists have broad training in a bio-psycho-social approach to assessment and management of mental illness.

As part of the clinical assessment process, psychiatrists may employ a mental status examination; a physical examination; brain imaging such as a computerised tomography (CT), magnetic resonance imaging (MRI), or positron emission tomography (PET) scan; and blood testing. Psychiatrists prescribe medicine, and may also use psychotherapy, although they could also primarily concentrate on medical management and refer to a psychologist or other specialised therapist for weekly to bi-monthly psychotherapy.

Subspecialties

The field of psychiatry (in the US) has many subspecialties (also known as fellowships) that require additional training which are certified by the American Board of Psychiatry and Neurology (ABPN) and require Maintenance of Certification Programme (MOC) to continue. These include the following:

  • Clinical neurophysiology.
  • Forensic psychiatry.
  • Addiction psychiatry.
  • Child and adolescent psychiatry.
  • Geriatric psychiatry.
  • Hospice and palliative medicine.
  • Pain management.
  • Psychosomatic medicine (also known as consultation-liaison psychiatry).
  • Sleep medicine.
  • Brain injury medicine.
  • Further, other specialties that exist include:
    • Cross-cultural psychiatry.
    • Emergency psychiatry.
    • Learning disability.
    • Neurodevelopmental disorder.
    • Cognition diseases as in various forms of dementia.
    • Biological psychiatry.
    • Community psychiatry.
    • Global mental health.
    • Military psychiatry.
    • Social psychiatry.
    • Sports psychiatry.

The United Council for Neurologic Subspecialties in the US offers certification and fellowship programme accreditation in the subspecialty ‘Behavioural Neurology and Neuropsychiatry’ (BNNP) – which is open to both neurologists and psychiatrists.

Some psychiatrists specialise in helping certain age groups. Paediatric psychiatry is the area of the profession working with children in addressing psychological problems. Psychiatrists specialising in geriatric psychiatry work with the elderly and are called geriatric psychiatrists or geropsychiatrists. Those who practice psychiatry in the workplace are called occupational psychiatrists in the US and occupational psychology is the name used for the most similar discipline in the UK. Psychiatrists working in the courtroom and reporting to the judge and jury, in both criminal and civil court cases, are called forensic psychiatrists, who also treat mentally disordered offenders and other patients whose condition is such that they have to be treated in secure units.

Other psychiatrists and mental health professionals in the field of psychiatry may also specialise in psychopharmacology, psychotherapy, psychiatric genetics, neuroimaging, dementia-related disorders such as Alzheimer’s disease, attention deficit hyperactivity disorder (ADHD), sleep medicine, pain medicine, palliative medicine, eating disorders, sexual disorders, women’s health, global mental health, early psychosis intervention, mood disorders, and anxiety disorders such as obsessive-compulsive disorder (OCD) and posttraumatic stress disorder (PTSD).

Psychiatrists work in a wide variety of settings. Some are full-time medical researchers, many see patients in private medical practices, consult liaison psychiatrists see patients in hospital settings where psychiatric and other medical conditions interact.

Professional Requirements

While requirements to become a psychiatrist differ from country to country, all require a medical degree.

US and Canada

In the US and Canada one must first attain the degree of M.D. or D.O., followed by practice as a psychiatric resident for another four years (five years in Canada). This extended period involves comprehensive training in psychiatric diagnosis, psychopharmacology, medical care issues, and psychotherapies. All accredited psychiatry residencies in the United States require proficiency in cognitive-behavioural, brief, psychodynamic, and supportive psychotherapies. Psychiatry residents are required to complete at least four post-graduate months of internal medicine or paediatrics, plus a minimum of two months of neurology during their first year of residency, referred to as an “internship”. After completing their training, psychiatrists are eligible to take a specialty board examination to become board-certified. The total amount of time required to complete educational and training requirements in the field of psychiatry in the US is twelve years after high school. Subspecialists in child and adolescent psychiatry are required to complete a two-year fellowship program, the first year of which can run concurrently with the fourth year of the general psychiatry residency program. This adds one to two years of training.

The United Kingdom and the Republic of Ireland

In the UK, psychiatrists must hold a medical degree. These degrees are often abbreviated MB BChir, MB BCh, MB ChB, BM BS, or MB BS. Following this, the individual will work as a Foundation House Officer for two additional years in the UK, or one year as Intern in the Republic of Ireland to achieve registration as a basic medical practitioner. Training in psychiatry can then begin and it is taken in two parts: three years of Basic Specialist Training culminating in the MRCPsych exam followed by three years of Higher Specialist Training referred to as “ST4-6” in the UK and “Senior Registrar Training” in the Republic of Ireland. Candidates with MRCPsych degree and complete basic training must re-interview for higher specialist training. At this stage, the development of special interests such as forensic, child/adolescent takes place. At the end of 3 years of higher specialist training, candidates are awarded a CCT (UK) or CCST (Ireland), both meaning Certificate of Completion of (Specialist) Training. At this stage, the psychiatrist can register as a specialist, and the qualification of CC(S)T is recognised in all EU/EEA states (subject to Brexit). As such, training in the UK and Ireland is considerably longer than in the US or Canada and frequently takes around 8-9 years following graduation from medical school. Those with a CC(S)T will be able to apply for Consultant posts. Those with training from outside the EU/EEA should consult local/native medical boards to review their qualifications and eligibility for equivalence recognition (for example, those with a US residency and ABPN qualification).

Netherlands

In the Netherlands, one must complete medical school after which one is certified as a medical doctor. After a strict selection programme, one can specialise in psychiatry: a 4.5-year specialisation. During this specialisation, the resident has to do a 6-month residency in the field of social psychiatry, a 12-month residency in a field of their own choice (which can be child psychiatry, forensic psychiatry, somatic medicine, or medical research). To become an adolescent psychiatrist, one has to do an extra specialisation period of 2 more years. In short, this means that it takes at least 10.5 years of study to become a psychiatrist which can go up to 12.5 years if one becomes a children’s and adolescent psychiatrist.

India

In India, an MBBS degree is the basic qualification needed to do Psychiatry. After completing MBBS (including internship) one can attend various PG Medical Entrance Exams and take MD in psychiatry which is a 3-year course. Diploma Course in Psychiatry or DNB Psychiatry can also be taken to become a Psychiatrist.

Pakistan

In Pakistan, one must complete basic medical education, an MBBS, then get registered with Pakistan Medical and Dental Council as a General Practitioner after a one-year mandatory internship, House Job. After registration with PMDC, one has to go for FCPS-I exam, after that four-year training in Psychiatry under College of Physicians and Surgeons Pakistan. Training includes rotations in General Medicine, Neurology, and Clinical Psychology for 3 months each, during first two years. There is a mid-exam IMM (Intermediate Module) and a final exam after 4 years.

Medical Students & Doctors: Mental Health & Stigma

Research Paper Title

Reducing Mental Health Stigma in Medical Students and Doctors towards their Peers with Mental Health Difficulties: A Protocol.

Background

Mental health problems are over-represented in doctors and medical students. However, stigma and ‘a culture of shame’ are formidable barriers to mental health services and consequently many doctors and medical students with mental health difficulties continue to suffer in silence despite the availability of effective treatment.

Indeed, a recent study on over 2,100 female physicians who met the diagnostic criteria for a mental disorder revealed that 50% were reluctant to seek professional help due to fear of exposure to stigma.

Left untreated or undertreated, mental health problems in doctors can result in impairment of occupational functioning, compromise patient safety and place considerable strain on the economy (by increasing the amount of sick leave taken).

Moreover, the consequences of mental health stigma in the medical profession can be fatal. Dr Daksha Emson, a psychiatrist with bipolar affective disorder, tragically killed herself and her baby daughter during a psychotic episode. An independent inquiry into Dr Emson’s death concluded that she was the victim of stigma in the National Health Service.

The mental health of medical students and doctors, in all of its aspects, must therefore be addressed with the urgency that it demands. Stephanie Knaak and colleagues conducted a data synthesis of evaluative studies on anti-stigma programmes for healthcare providers and identified six key ingredients one of which was a personal testimony from a trained speaker who has lived experience of mental illness.

In this paper the authors outline a study protocol with the aim of answering the following research question, ‘Does attending an anti-stigma programme comprised of a medic with first-hand experience of a mental health condition cause immediate and sustained reductions in mental health stigma from medical students and doctors towards their peers with mental health difficulties?’

Reference

Hankir, A., Fletcher-Rogers, J., Ogunmuyiwa, J., Carrick. F.R. & Zaman, R. (2020) Reducing Mental Health Stigma in Medical Students and Doctors towards their Peers with Mental Health Difficulties: A Protocol. Psychiatria Danubina. 32(Suppl 1), pp.130-134.

Reviewing Work & Mental Health in Doctors

Research Paper Title

Work and Mental Health in Doctors: A Short Review of Norwegian Studies.

Background

Previous studies have found relatively good physical health in doctors, whereas several studies now report relatively high levels of mental distress among them. This applies in particular to stress, burnout, and depressive symptoms – and especially among medical students and young doctors early in their careers. However, we lack representative prevalence studies of mental disorders among doctors. There is little empirical support for the notion that there is more mental distress in medical students compared to that in other university students, nor do they differ from other students with respect to personality traits.

Despite this, several studies have found more suicide among physicians than in other occupational groups. This may be partly due to their attempts in committing suicide being more frequently successful; yet, this may also represent the tip of an iceberg of frustration and inadequate mental health care among medical doctors.

Presumed Risk Factors from Longitudinal Studies

What do we know about individual and work-related predictors and risk factors of mental distress from the prospective and longitudinal studies so far? Some landmark early follow-up studies in the United States and United Kingdom put doctors’ work and mental health on the agenda in the 1970’s and 1980’s. In the following, we will pay most attention to the Longitudinal Study of Norwegian Medical Students and Doctors (NORDOC). This study has since 1993/1994 followed repeatedly 2 cohorts of medical students (N = 1052) with 6 years apart for 20 years (2014), and there is now an ongoing 25-year follow up.

There are 2 main hypotheses with regard to possible risks factors. First, it may be due to individual factors such as personality traits, past mental health problems, etc. Second, contextual stress may influence mental health among doctors, whether this is unhealthy working conditions or negative life events (i.e., stress outside of work). Both individual and work-related factors seem to be of importance. Individual factors may be more important with respect to more severe clinical mental disorders, whereas work-related factors are more important for stress, burnout, and minor emotional disturbance.

In terms of individual factors, NORDOC has included personality traits, as one of very few studies in doctors. Neuroticism personality trait is related to vulnerability, self-criticism, low self-esteem, and proneness to stress compatible with the modern common term “hypersensitivity.” This trait predicts stress, anxiety, and depression in the general population, and, as expected, in NORDOC it predicts work stress, burnout, and even severe depressive symptoms among doctors. Studies among medical students and young doctors have found the combination of conscientiousness (or obsessiveness) and neuroticism seems to be especially important for school and work stress. In addition, NORDOC has identified a particular trait (reality weakness) that is associated with severe personality pathology. This trait predicts independently a need for mental health treatment, lack of help-seeking, severe depressive symptoms, and even aggravation of suicidal ideation among medical students and doctors. Another important individual factor is the increased rate of female medical students and young doctors. In Norway, there has been an increase from 55% to 70% of women in medical schools during the past 2 decades. We have previously found little gender differences in NORDOC, but a recent study among Norwegian medical students find considerable reduction in subjective well-being in 2015 compared to that 20 years ago, and this reduction was most prominent among the female students. This reflects recent trends in Norway and other Western societies which observe increased anxiety and depressive symptoms among young female adults.

With regard to contextual stress, it seems that both work-related stress and stress outside of work are of importance. NORDOC studies have found that demanding patient work is associated with mental health problems early in the medical career, and that difficulty with balancing life – such as work–home interface stress – is a sustaining problem over the course of the career. The detrimental role of such stress is also in keeping with studies among US doctors. Work–home stress predicts burnout (emotional exhaustion) in a NORDOC 5-year follow-up study. A promising finding is that such stress was less prominent in the youngest cohort of Norwegian doctors 10 years after leaving medical school. This may be due to increased coverage of kindergarten as well as changed and more liberal gender roles in our Scandinavian society over recent years.

There are also studies that associate time pressures and burnout with suicidal ideation among medical students and doctors. Sleep-deprivation due to call work and long hours may be one important reason for more depressive symptoms measured in young doctors. A recent NORDOC study of life satisfaction during 15 years of the career controlled for all possible individual factors, and found the following work-related predictors and possible risk factors: work–home stress, lack of colleague support, and emotional demands at work. Doctors often feel a 24/7 responsibility and obligation for individual patients and their treatment and this puts extraordinary emotional demands on this occupational group.

Does Stress among Doctors have Consequences for their Patient Care?

Many studies can indicate lowered quality of patient care among stressed doctors with burnout, but a large majority of these studies build on self-report by the doctors themselves of more errors and poorer care. We lack an empirical foundation for the notion that stress and burnout really impair doctors’ functioning with respect to observed poorer quality of care. There are 2 classical observation studies demonstrating that long hours and time pressures interfere with doctors functioning, but we lack studies that find burnout to lead to observed errors or poorer care. The burnout concept and scales are not very valid with respect to impaired functioning, for example, with respect to valid cut-off for defining a case.38 On the other hand, depression and other mental disorders lead to poor functioning. We need more studies on working conditions and the levels of stress and poor health among young doctors that lead to lowered patient care.

What are the Most Common Mental Disorders among Doctors?

In general, doctors may have the same disorders that strike anyone else; doctors are not invincible. Although depressive symptoms seem to be prevalent in the early years of the medical career, some of this may be due to exhausting work stress by frequent on-call work. We lack representative studies on the occurrence of valid depression among doctors compared to that in other occupational groups. Suicide is more common among doctors than among other groups of academics, but since it is also very common in veterinarians, this may also be due to available knowledge and means (drugs) for committing suicide during mental health deterioration. Alcoholism and drug abuse is an additional known risk factor for suicide and the SAD triad (suicidal behaviour–alcoholism–depression) may be particularly important for medical doctors. From clinical experience with doctor–patients, we know the slippery slope from self-medication with tranquilisers to cope with the stresses to dependency of alcohol and drugs, in addition to other boundary violations. There are very few clinical studies including diagnostic interviews among doctors. One previous Spanish study emphasises the importance of dual diagnoses, especially in alcohol dependence and mood disorders. From own experience, we know that bipolar disorder (type II) is quite common among physicians, but we lack sound empirical studies that compare occurrence of mental disorders in doctors with that in other groups. American impaired physician programs have for many years shown high and promising recovery rates (70–80%). The programmes used to focus on addiction and substance abuse, but they now put increasing emphasis on psychiatric diagnoses. A family history, opioid use, and psychiatric comorbidity predicted relapse of substance abuse among doctors and other healthcare workers.

In Norway, we have implemented a successful low-threshold intervention, the Villa Sana programme. This intervention seems to reduce burnout in doctors. It includes 2 separate schemes, a 1-day individual counselling scheme, and a 1-week group-based scheme in a psychiatric hospital. The Norwegian Medical Association pays for the programme that is free for all doctors.

With respect to medical students and young doctors, we have also a large longitudinal study on mindfulness-based stress reduction. This is a randomised-controlled trial of second year medical and psychology students, and they have now been followed-up for 6 years, for the medical students into the first 2 postgraduate years. The reduction of emotional distress by mindfulness training is most prominent in female students.46 The training has a stronger impact among those with vulnerable personality (high neuroticism and conscientiousness). During the follow-up, there is an increase in active coping and reduction in passive or avoidance coping – the effects on ways of coping may be important psychological mechanisms of mindfulness training.

Future Research Challenges

We need more long-term follow-up studies that use validated instruments to capture changes in working conditions and their impact on physician health. For instance, there are few studies in doctors of Karasek’s Demand-Control model. There are more studies by this model in other healthcare workers. More studies are required that measure the effect of physicians’ health problems on their performance and patient care. Gender issues are important, since there are now more women entering the medical career. As mentioned, we also need more studies with diagnostic interviews that compare frequency of valid disorders in samples of physicians with that in other groups. Doctors are nowadays moving, and we should study the effect of globalisation on doctor’s health. Cross-national disparities may be due to differences in the health systems, working conditions, etc. Finally, we need more studies on positive psychology and factors that may promote and enhance well-being among physicians.

Reference

Tyssen, R. (2019) Work and Mental Health in Doctors: A Short Review of Norwegian Studies. Porto Biomedical Journal. 4(5), pp.e50. Published online 2019 Sep 9. doi: 10.1097/j.pbj.0000000000000050.