Patients are not the only ones bending under the weight of the ongoing Covid-19 pandemic—the first year of the pandemic was associated with a major uptick in mental health and substance abuse visits among physicians, according to findings from a population-based cohort study published in JAMA Network Open.
Elevated rates of depression and drug or alcohol abuse among physicians are not a new phenomenon; however, the emergence of Covid-19 in 2020 largely exacerbated these risks, according to study authors Daniel T. Myran, MD, MPH, of the Ottawa Hospital Research Institute in Ottawa, Ontario, Canada, and colleagues.
“In addition to the general societal disruption from the Covid-19 pandemic, physicians face specific occupational stressors, including a potentially greater risk of exposure to SARS-CoV-2, with consequent concerns over personal health and infecting family, friends, and colleaguesinadequate personal protective equipmenthigh, and at times overwhelming, workloads,” Myran and colleagues explained. “There are additional concerns about trauma arising from moral distress when physicians face difficult decisions regarding the allocation of scarce resources or balancing their needs and those of their patients.”
While previous studies have demonstrated increased incidence of high stress, depression, and burnout among physicians during the pandemic, those analyses primarily included small cross-sectional samples, and few studies have compared changes in mental health before and during the pandemic. What’s more, no studies have examined changes in mental health care use among physicians.
Myran and colleagues conducted their study to help fill these knowledge gaps, using health administrative data to assess changes in outpatient mental health and substance abuse visits among Canadian physicians both before and during the Covid-19 pandemic.
“In a population-level cohort study of 34,055 unique physicians, the annual rate of outpatient mental health and substance use visits by physicians increased by 27.0% (from 816.8 to 1,037.5 per 1,000 physicians) during the first 12 months of the Covid-19 pandemic compared with the preceding 12 months,” they found. “After adjusting for demographic and physician characteristics and a history of health care use related to mental health, visits increased on average by 13% per physician (aIRR, 1.13; 95% CI, 1.07-1.19). Although not statistically significant, greater increases in the frequency of visits were observed among female physicians and physicians in rural areas. We did not observe a large difference in changes in visits between physicians who did or did not care for patients with suspected or confirmed Covid-19 in the ED or hospital. The largest relative increases in the rate of visits occurred in physicians without a mental health and substance use history, which was significantly greater than increases in physicians with a mental health and substance use history.”
“This parallel fear of being labeled with a mental health disorder within the profession of medicine has existed long before the current pandemic,” Bernard P. Chang, MD, PhD, of Columbia University Irving Medical Center in New York City, wrote in an accompanying editorial. “Be it out of a culture of reticence and fear of professional/personal repercussions, health care workers have shown a historical hesitation to seek support and treatment for mental health disorders. Taken in this context, despite the alarming increase in mental health visits described by Myran et al in this study, their results are somewhat encouraging insofar as we are now seeing more clinicians seeking professional help and guidance for mental health concerns.”
Chang noted that in addition to encouraging use of local mental health resources, health care workers should be directed to digital health programs and telemedicine to increase adoption of mental health care while allowing for discretion and flexible scheduling. And, he added, it will also be necessary to address the broader occupational stressors, such as high patient volume, documentation burden, and staffing problems, that have plagued health care workers before the Covid-19 pandemic even began.
For their analysis, Myran and colleagues collected linked health administrative data from the Ontario Health Insurance Plan (OHIP). Their cohort consisted of 34,055 physicians, residents, and fellows who registered with the College of Physicians and Surgeons of Ontario from 1990-2018 and were practicing from 2017-2021.
“Our study time frame (March 11, 2020, to March 10, 2021) covers the first wave of Covid-19 and state of emergency in Ontario (March-May 2020), along with a phased reopening during a period of declining and then relatively low case incidence of Covid-19 (June-September 2020),” the study authors explained. “This period was followed by a second wave starting in mid-September 2020, which continued until March 2021.”
The study’s primary outcome was an outpatient visit—including telemedicine and virtual care—by a physician to another physician related to mental health or substance abuse; in order to assess possible changes in overall health-seeking behavior by physicians during this period, the secondary outcome was all outpatient visits by physicians to another primary care or specialist physician, for any cause.
Of the 34,055 practicing physicians included in the analysis, the mean age was 41.7 years, 52.6% were men, and 96.4% lived in an urban region. The most common physician specialty represented was family medicine (31.0%). A total of 5,839 physicians (17.1%) had one or more mental health visits in the two years prior to the pandemic.
Among the findings:
- Prior to the pandemic, on average, 23.0% (95% CI, 22.7-23.2) of all-cause outpatient visits by physicians were due to mental health and substance use; during the first 5 months of the pandemic, 28.3% (95% CI, 26.4-30.2) of visits were due to mental health and substance abuse. In the following 7 months of the pandemic, visits due to mental health and substance abuse returned to pre-pandemic levels “owing to an increase in all-cause outpatient visits by physicians.”
- During the pandemic, the crude annual number of visits per 1,000 physicians increased by 27.0%; the rate of visits per physician increased by an average of 13%.
- Increases in mental health care visits were observed across multiple subgroups, “with no significant differences between men (aIRR, 1.07; 95% CI, 0.97-1.18) and women (aIRR, 1.16; 95% CI, 1.09-1.25) (P=0.10), older (aIRR, 1.10; 95% CI, 0.97-1.24) and younger physicians (aIRR, 1.14; 95% CI, 1.07-1.21) (P=0.55), and urban (aIRR, 1.13; 95% CI, 1.06-1.19) and rural physicians (aIRR, 1.30; 95% CI, 0.84-2.00) (P=0.72), and for physicians who provided infrequent (aIRR, 1.23; 0.89-1.70), more frequent (aIRR, 1.05; 0.77-1.43), or no (aIRR, 1.13; 95% CI, 1.06-1.21) (P=0.72) care for Covid-19 patients in the ED or hospital during the first year of the pandemic.”
- The relative increase in the rate of visits by physicians without a history of mental health and substance use visits was “significantly greater (aIRR, 1.72; 95% CI, 1.60-1.85) than by physicians with a mental health and substance use history (aIRR, 0.98; 95% CI, 0.92-1.07).”
The largest increases in mental health visits during the pandemic were for anxiety and adjustment reactions, “which would be expected to begin and/or worsen in the context of highly stressful circumstances, such as a pandemic,” Myran and colleagues added. “… These findings suggest that generally, physicians have displayed resiliency during the pandemic, but a small group of physicians may have developed very high new mental health care needs during the pandemic, which are possibly related to pandemic-specific stressors.”
The study authors also noted that their findings may be partially explained by reduced barriers to mental health care access during the pandemic due to a large expansion of virtual care options.
Importantly, while the Covid-19 pandemic may have exacerbated physician mental health concerns, “findings from this study and previous work have documented that many of these concerns predate the start of the pandemic,” Myran and colleagues argued, highlighting the need for interventions designed to address not only unique pandemic-related stressors, but also pre-pandemic factors.
“A recent report by the Ontario Medical Association, based on physician self-identified priorities, recommends that system reforms, such as reducing documentation and administrative work, ensuring fair and equitable pay for all work, and improving work life balance, are critical to protecting the mental health and well-being of physicians,” they wrote. “Our work highlights additional solutions, which may include improving access to mental health services for physicians (i.e., continuing the delivery of virtual mental health care).”
“The heroic efforts of the health care workforce during the Covid-19 pandemic have extracted a great toll on the mental health of many health care professionals,” Chang wrote in his editorial. “Prioritizing clinician mental health will not only be vital toward supporting clinician health and professional longevity, but also toward ensuring a health care workforce well equipped to face the challenges of the ongoing pandemic and future public health challenges on the horizon.”
Study limitations included low levels of care-seeking behaviors among physicians and the possibility that mental health/substance use visits were incorrectly coded in some cases due to concerns over discrimination from regulatory bodies and stigma; the available diagnostic algorithm is not fully reliable in discerning the exact cause for a mental health visit; and use of mental health services delivered by non-physician professionals were not included in the analysis.
Disclosure:
Myran was supported as a Research Fellow Salary Award from the Canadian Institutes of Health Research and the University of Ottawa Department of Family Medicine. Coauthors Simon, McFadden, and Gerin-Lajoie are employees of the Canadian Medical Association. Coauthor Sood reported receiving speaker’s fees from AstraZeneca outside the submitted work.
Chang had no relevant relationships to disclose.
by
John McKenna, Associate Editor, BreakingMED™
Kaiser Health News
Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation, which is not affiliated with Kaiser Permanente.
