Mental Health Problems Among Young Doctors. an Updated Review of Prospective Studies 2002

treatment, for individual prevention, and for establishinghealthy working conditions.

That doctors are not invincible was highlighted by tworecent representative nationwide studies, from England4

and Finland,5 which found a higher prevalence of self-reported mental disorders among physicians of both gendersthan in the general population. Both depression6 and suicide7

have been found to be more prevalent among physicians, inparticular early in their career.8,9 Depression and anxietymay be complicated by the development of substance abuse.10

Furthermore, there is evidence11 that the youngest doctorsare more at risk of making serious mistakes, and one mightexpect this to be due to higher levels of emotional distress, inaddition to lack of experience.

However, knowledge of the prevalence of psychiatric dis-orders is not sufficient for prevention and adequate treat-ment of mental health problems among young physicians.We also need to identify factors that predict such problems.This information should be collected through prospectiveand longitudinal studies. Unfortunately, such research isstill scarce, despite two landmark investigations conductedin the United States in the 1970s.12,13 These studies exam-ined only male physicians and did not address the first post-graduate years. Moreover, most recent studies have been

REVIEW

Mental Health Problems among Young Doctors:An Updated Review of Prospective Studies

Reidar Tyssen, MD, PhD, and Per Vaglum, MD, PhD

Previous studies have shown the medical community to exhibit a relatively high level of cer-tain mental health problems, particularly depression, which may lead to drug abuse andsuicide. We reviewed prospective studies published over the past 20 years to investigatethe prevalence and predictors of mental health problems in doctors during their first post-graduate years. We selected clinically relevant mental health problems as the outcomemeasure. We found nine cohort studies that met our selection criteria. Each of them had lim-itations, notably low response rate at follow-up, small sample size, and/or short observationperiod. Most studies showed that symptoms of mental health problems, particularly of de-pression, were highest during the first postgraduate year. They found that individual factors,such as family background, personality traits (neuroticism and self-criticism), and copingby wishful thinking, as well as contextual factors including perceived medical-schoolstress, perceived overwork, emotional pressure, working in an intensive-care setting, andstress outside of work, were often predictive of mental health problems. The studies re-vealed somewhat discrepant findings with respect to gender. The implications of thesefindings are discussed. (HARVARD REV PSYCHIATRY 2002;10:154–65.)

From the Department of Behavioural Sciences in Medicine, Facultyof Medicine, University of Oslo, Oslo, Norway.

Original manuscript received 1 August 2001; revised manuscript re-ceived 26 November 2001, accepted for publication 29 November2001.

This research was supported, in part, by a grant from the ResearchCouncil of Norway.

Reprint requests: Reidar Tyssen, MD, PhD, Department of Behav-ioural Sciences in Medicine, P.O. Box 1111, Blindern, N-0317 Oslo,Norway (e-mail: [email protected]).

© 2002 President and Fellows of Harvard College

154

The mental health of physicians is of concern not only tothemselves, but also to others. First, psychological problemsof doctors can be detrimental to patient care, by impeding di-agnosis and treatment.1 Second, such problems can seriouslyinhibit the learning capacity and academic performance ofmedical postgraduates.2 Third, they may indicate a workingsituation that is too stressful and therefore needs to bechanged.3 Knowledge about the predictors of mental healthproblems among physicians constitutes a basis for adequate

cross-sectional in design, which does not allow clear separa-tion of the effects of personality and other individual factorsfrom the impact of current working conditions on mentalhealth. Generally, one cannot expect mental health problemsamong doctors to be caused by factors other than would beseen among nondoctors. Research on physicians’ mentalhealth should examine predictors that may be particularlystrong among doctors, possibly allowing the doctors or theiremployers to prevent or change these conditions. For ex-ample, previous research1 has suggested sleep deprivationdue to heavy on-call work as one such factor among postgrad-uates. Ideally, a comprehensive study of predictors should in-clude possible individual factors, such as genetic/biological,sociodemographic, and personality factors, as well as exter-nal stressors, or contextual factors, such as work conditionsand life events. The assumption is that both individual andcontextual factors are important for mental health and pro-fessional development in this phase of life,14 a notion basedon human developmental theory.15 To our knowledge, nostudy to date has included all these variables, but a few haveinvestigated several of them.

Although prospective studies following physicians fromthe early phase of their medical career are somewhat difficultto find during ordinary database literature searches (see be-low), we have been able been to identify a small number ofthem. We will examine those published over the last twodecades and discuss the important information they providefor clinical and preventive work. During the discussion, wewill also incorporate results from cross-sectional research.Due to the limitation of space and the few prospective studiesamong medical postgraduates, we have not reviewed studiesthat have substance abuse as an outcome.* In the present re-view we have included all other prospective studies that haveused mental health problems of clinical importance as anoutcome. In addition to possible predictors, we were also in-terested in information regarding the prevalence of mentalhealth problems during the first years of medical practiceand any change in such problems within this period.

METHODS

We searched the Medline and PsycLit databases for relevantprospective studies published in English from January 1981through May 2001. Further limitations included a total ob-servation period of at least 6 months and a sample size of at

least 40. The study subjects were in their first postgraduateyears of training—interns or residents in the United States,preregistration house officers, house officers, or senior houseofficers in the U.K. and Norway. We also required mentalhealth problems to be of clinical relevance—for example, de-pressive symptoms as determined by standardized mea-sures, or perceived need for treatment due to mental healthproblems. We therefore excluded studies of clinically less rel-evant stress, such as work-related pressures.

As mentioned above, identifying studies relevant to ourpurposes was difficult using ordinary Medline and PsycLitsearch strategies. For example, combining search terms withthe subject heading “medical profession” would retrieve allabstracts that include the words “doctor” or “physician.” Wefound that the combination of “mental disorders” and “in-ternship and residency” yielded 210 references in Medline.Fewer than ten of these articles concerned problems amonginterns and residents; most of the rest involved postgraduateeducation in psychiatry, residents as the caring professional,and so on. For this reason, most of the identified cohort stud-ies were found in the bibliographies of papers, book chapters,and a previous review,6 and through our own research in thefield.17,18 Nevertheless, we cannot be certain that we found allof the studies.

RESULTS

Only nine prospective investigations19–27 met our selectioncriteria. Table 1 provides an overview of these studies, in-cluding country, response rate, sample size, design, observa-tion time, main outcome variable, “case” prevalence, andsynopsis of predictors. Four studies were from the UnitedStates, three were from the U.K., and two were from Norway.Sample size ranged from 40 to 396 participants, and observa-tion time from 6 months to 3.5 years. Below we provide ashort description of each study. The text emphasizes identi-fied predictors, while the table provides prevalence and mostother numerical information.

Clark and colleagues19 carried out diagnostic interviewsof interns from the departments of internal medicine, obstet-rics, surgery, and pediatrics at one U.S. medical center andfollowed up 6 months later. Both a family history of depres-sion and a high level of neuroticism predicted onset of de-pressive symptoms during the first 6 months of internship.Gender, marital status, personal history of mental disorder,life events, and workload (perceived or objective) were not re-lated to depressive symptoms. The strength of this study isthe use of interview and several validated predictor mea-sures; however, the sample size was rather small, and fewparticipants were female. Therefore, false-negative findings(type II errors) cannot be ruled out.

In a study involving monthly observations (survey),

Harvard Rev Psychiatry

Volume 10, Number 3 Tyssen and Vaglum 155

*A previous review16 found that despite the lack of solid evidence fora higher prevalence of drug abuse among young doctors compared totheir contemporaries in the general population, alcohol problems ap-pear to increase with age more among physicians and attorneys thanin the general population, and rates of problem drinking appear to besimilar in male and female physicians.

156 Tyssen and VaglumHarvard Rev Psychiatry

May/June 2002

TAB

LE

1.

Pro

spec

tive

Stu

die

s o

f Men

tal H

ealt

h P

rob

lem

s am

on

g Y

ou

ng

Do

cto

rs

Res

pon

seW

omen

Ob

serv

atio

nM

ain

“Cas

e”P

red

icto

rs/

Stu

dy

Cou

ntr

yP

osit

ion

rate

(%

)n

(%)

Des

ign

per

iod

outc

ome

pre

vale

nce

com

men

ts*

Cla

rk e

t al

.19U

SA

Inte

rns

7155

20P

rosp

ecti

ve6

mo

Dep

ress

ive

27%

Neu

roti

cism

,su

rvey

/ in

terv

iew

sym

ptom

spa

ren

tal h

isto

ryat

bas

elin

e(B

DI)

of d

epre

ssio

nR

eube

n20

US

AIn

tern

al87

68N

AL

ongi

tudi

nal

1 y

Dep

ress

ive

29%

(PG

Y-I)

,In

ten

sive

car

em

edic

ine

surv

eysy

mpt

oms

33–3

7%u

nit

rot

atio

n;

resi

den

ts(C

ES

DS

)(i

nte

nsi

vede

crea

se w

ith

care

un

its;

tim

eP

GY-

I,P

GY-

II)

Fir

th-C

ozen

s21E

ngl

and

Jun

ior

7117

041

Lon

gitu

din

al2

y D

epre

ssiv

e28

%O

lder

fath

ers,

6,29

hou

se

surv

eysy

mpt

oms

self

-cri

tici

sm,6,

28

offi

cers

(SC

L-9

0-D

)de

pen

den

cy(P

RH

Os)

trai

t,28

fem

ale

gen

der,

sle

epde

priv

atio

nG

irar

d et

al.22

US

AIn

tern

alm

edic

ine

75–9

540

39L

ongi

tudi

nal

3 y

Dep

ress

ive

NA

Dec

reas

e w

ith

resi

den

tssu

rvey

and

anxi

ety

tim

esy

mpt

oms

Bal

dwin

et

al.23

Sco

tlan

dS

enio

r 95

142

45L

ongi

tudi

nal

2 y

Psy

chol

ogic

al30

%“F

eeli

ng

hou

sesu

rvey

/di

stre

ssov

erw

hel

med

”of

fice

rsin

terv

iew

(GH

Q-2

8)(w

ork-

rela

ted

fact

ors)

;30

seve

re d

epre

ssio

nm

ore

com

mon

inw

omen

th

an in

men



Wil

liam

s et

al.24

En

glan

dS

enio

r 64

–82

171

NA

Lon

gitu

din

al6

mo

Psy

chol

ogic

alN

AP

revi

ous

hou

sesu

rvey

dist

ress

psyc

hol

ogic

alof

fice

rs(M

HI/

GH

Q)

dist

ress

; low

incr

ease

inco

nfi

den

celi

nke

d to

hig

hps

ych

olog

ical

dist

ress

Hai

ner

&U

SA

Fam

ily

78–8

228

0N

AL

ongi

tudi

nal

2.5

yD

epre

ssiv

e7%

(PO

MS

),U

nh

appy

Pal

esch

25m

edic

ine

surv

eysy

mpt

oms

3% (B

DI)

chil

dhoo

d,re

side

nts

(BD

I/P

OM

S)

dou

bts

abou

tca

reer

Tys

sen

Nor

way

Jun

ior

5837

156

Pro

spec

tive

1 y

MH

PT,

11%

MH

PT,

Pre

viou

s m

enta

let

al.26

,31

hou

se

surv

eysu

icid

al14

% s

uic

idal

heal

th p

robl

ems/

offi

cers

idea

tion

thou

ghts

suic

idal

th

ough

ts,

(PR

HO

s)(S

FG

PQ

)n

o pa

rtn

er,

neu

roti

cism

,n

egat

ive

life

even

ts, j

obst

ress

, men

tal

dist

ress

Tys

sen

et

al.27

Nor

way

Sen

ior

6339

656

Lon

gitu

din

al3.

5 y

MH

PT

17%

Pre

viou

s m

enta

lh

ouse

surv

eyh

ealt

h p

robl

ems,

offi

cers

,m

edic

al s

choo

lfa

mil

yst

ress

,m

edic

ine

extr

over

sion

,re

side

nts

wis

hfu

l th

inki

ng;

incr

ease

inpr

oble

ms

wit

hti

me26

,27

BD

I,B

eck

Dep

ress

ion

Inve

nto

ry;C

ES

DS

,Cen

ter f

or E

pide

mio

logi

cal S

tudi

es D

epre

ssio

n S

cale

;GH

Q-2

8,G

ener

al H

ealt

h Q

ues

tion

nai

re, 2

8-it

em v

ersi

on;M

HI,

Men

tal H

ealt

hIn

ven

tory

;MH

PT,

men

tal h

ealt

h p

robl

ems

in n

eed

of tr

eatm

ent;

NA

,in

form

atio

n n

ot a

vail

able

; PG

Y, p

ostg

radu

ate

year

;PO

MS

,Pro

file

of M

ood

Sta

tes;

PR

HO

s,pr

ereg

istr

atio

nh

ouse

offi

cers

;SC

L-9

0-D

, Sym

ptom

Ch

eckl

ist-

90 D

epre

ssio

n S

cale

;SF

GP

Q,S

uic

idal

Fee

lin

gs in

th

e G

ener

al P

opu

lati

on Q

ues

tion

nai

re (q

ues

tion

s de

velo

ped

by E

. S. P

ayke

l).

*Ref

eren

ces

are

list

ed fo

r fi

ndi

ngs

from

add

itio

nal

stu

dies

of t

he

sam

e co

hor

t.

Reuben20 followed all internal medicine house officers fromone U.S. hospital for 1 year. The officers were divided intothree cohorts: postgraduate years 1, 2, and 3. Mental healthproblems peaked during the first 6 months after graduation,with 38% showing depressive symptoms. Prevalence of suchsymptoms generally decreased over the years, although it re-mained high during the first and second postgraduate yearsamong individuals on intensive-care rotations. The overallprevalence of depressive symptoms in the sample (15%) ap-proximated that in the general population. Unfortunately,the sample was relatively small, and the authors provided noinformation about gender differences.

Firth-Cozens21 followed a cohort of medical students atthree U.K. universities for 2 years, commencing in theirfourth (i.e., penultimate) year in medical school and contin-uing until the beginning of the first postgraduate year. Shefound that women postgraduates had more depressivesymptoms, although no gender difference had been seen inmedical school.28 A combination of older fathers, high self-criticism, and poor current diet provided the best model forpredicting depressive symptoms in the first postgraduateyear; neither previous depressive symptom scores in med-ical school nor current work hours were significantly relatedto postgraduate symptoms.6,28,29 High scores on dependencytrait measures in medical school predicted depressive symp-toms in men but not in women.28 Regarding work-relatedstress, she found that “overwork,” “relations with consult-ants [senior specialists],” “effects on personal life,” and“making decisions” were highly correlated with stress anddepressive symptoms among the junior doctors.21 In addi-tion, sleep deprivation was associated with depressivesymptoms. The strengths of this study are its large and rep-resentative sample and its longer follow-up. However, al-though several validated measures were employed, a com-prehensive personality instrument was not administered atbaseline.

Girard and colleagues22 conducted a longitudinal surveyof two classes of internal medicine residents at one U.S. uni-versity, with observations every 2–3 months over all 3 yearsof training. Anxiety and depressive symptoms were mostprominent during the first year; they then decreased and re-mained low for the remainder of the observation period.Perceived competence and level of satisfaction increasedsteadily after the initial year. Although the study had quite along follow-up of the same cohort and involved several obser-vations, it is weakened by small sample size. The psychomet-ric properties of the anxiety and depression measurement in-struments are unclear, since they had been used in only oneprevious study. The authors provided no information aboutthe effects of gender.

Baldwin and colleagues23 studied a fairly representativecohort of a Scottish university class. Participants were fol-lowed up during their second or third year after graduation

(when they were senior house officers) after being initially in-terviewed 1–2 years earlier. Women reported more symp-toms on the severe depression subscale. The follow-up identi-fied “a perception of being overwhelmed,” which was relatedto both “objective” job-related factors (number of emergencyadmissions, number of deaths on the ward, number of minormenial tasks to be completed) on the one hand and anxietyand depressive symptoms on the other.30 The authors foundno significant relationship between number of hours workedand psychiatric symptoms. Nevertheless, the use and utilityof the prospective design in the present papers is somewhatunclear.

Williams and colleagues24 followed senior house officers inthe accident and emergency departments of 27 London hos-pitals, studying the effects of work-related stressors on men-tal distress at four points over 6 months. The outcome ofinterest was psychological distress, as measured by an in-strument derived from the Mental Health Inventory and theGeneral Health Questionnaire. Confidence scores regardingcarrying out a range of clinical and practical tasks were alsodetermined, and a lower increase in confidence was linked tohigher psychological distress at follow-up. Work-related fac-tors commonly related to distress were communication diffi-culties (dealing with demanding or aggressive patients orpediatric patients), intensity of the workload, uncertaintyabout whether to admit patients, and problems with dis-charge or referral of patients. Personal concerns and stress-ful life-events were of little importance; the effects of genderwere not reported. The strength of this study is its broad andopen approach to any work-related stress. However, theauthors did not thoroughly control for confounding effects byusing multivariate statistical methods, and an additional ob-servation period is needed to identify the direction of causallinks.

A large American longitudinal study by Hainer andPalesch25 followed residents in family medicine in South Car-olina over 2.5 years. Despite a representative number of eli-gible residents, the longitudinal response rate was too low toensure generalizability: only 27–28% completed the psycho-logical inventories twice, and only 7–8% did so three times.(The response rates differed slightly among the various out-come measures.) Repeated-measures analysis of the out-come scores showed no significant effects of age, gender, race,current postgraduate year, or training site. Some significantunivariate associations were seen—for example, betweenhigh inventory scores and uncertainty about career choice oran unhappy childhood. However, multivariate methods werenot utilized, probably due to the high attrition rate and thesmall sample size. The low percentage of residents complet-ing the inventories more than once is the main limitation ofthis study.

In our own longitudinal investigation, we examined a na-tionwide cohort of individuals graduating from medical


May/June 2002

schools in Norway. This was followed up 1 year later, whenthese trainees were at the end of their internship year,26,31

and again 3.5 years after baseline, when they were seniorhouse officers/residents.27 (In Norway specialty trainingtakes 4–5 years after the internship year.) During internshipwe studied two independent variables: mental health prob-lems in need of treatment (MHPT)26 and suicidal thoughts.31

Among individuals with a perceived need for help during in-ternship, 54% still had not sought professional assistance bythe end of the year. The best predictors in medical school ofMHPT during internship were previous MHPT, neuroticism,and not having a partner/spouse. During the internship year,negative life events (in particular, broken relationships) andcurrent job stress (such as emotional pressure/demands frompatients) were also related to MHPT in an adjusted model.Neither long working hours nor sleep deprivation during on-call shifts was significant in this regard. When we examinedsuicidal thoughts during internship, we found that both pre-vious suicidal ideation (in medical school) and neuroticismwere independent predictors. Furthermore, single maritalstatus and some work-related factors (interruptions at work,time pressure, working fewer hours per week) were linked tosuicidal thoughts, but the impact of these variables was me-diated by mental distress (anxiety and depressive symp-toms). We did not find gender to have any effect. The strengthsof this study are its large and representative sample size andits use of validated predictor variables in multivariate statis-tical analyses. Nevertheless, only 58% responded at the firstfollow-up. Another limitation is the use of single items asoutcome measures, which reduces the reliability of the re-sponses.

In a third study27 of the original cohort, we analyzed med-ical school predictors of MHPT in the fourth postgraduateyear. Two-thirds of the subjects were senior house officers,and one-fourth were training in family medicine (outside ofhospitals); the remaining ones were either serving as re-search fellows, training in an administrative position, orunemployed/on leave. The prevalence of MHPT over the pre-vious year had increased from 11% to 17%, with no genderdifference. Among individuals with perceived need for help,58% had not actually sought it. The best predictor model con-sisted of previous MHPT, perceived medical school stress, ex-troversion, and coping by wishful thinking. Individual stu-dents at risk could not be predicted (best positive predictivevalue, 0.40). The perceived medical school stress measurewas the single predictor with the highest sensitivity andmight therefore be used to determine a subgroup of studentssuitable for group-oriented intervention. A major strength ofthis study is its long follow-up with a large nationwidesample, allowing a comprehensive predictor model. How-ever, personality and coping were not measured in all partic-ipants at baseline, so the predictive effects of these variablesmay have been exaggerated.

SUMMARY OF FINDINGS FROM THEPROSPECTIVE STUDIES

Three studies19–21 showed a peak of depressive symptomsduring the first postgraduate year (approximately 30% ofrespondents); one23 found high levels of distress to persistduring postgraduate years 2 and 3. Two investigations,25,26

however, indicated low levels of mental illness symptomsthroughout training; one27 even showed a rise after the firstpostgraduate year. Thus, conclusions are inconsistent as towhether the need for treatment increases, decreases, or evenstays flat throughout postgraduate training, although opin-ion appears to lean toward more difficulty earlier in the post-graduate years. In addition, although some studies21,23 re-vealed more depressive symptoms among female than malepostgraduates, others19,26,27 did not.

Regarding individual predictors, three investiga-tions19,21,25 found a relationship between such factors as hav-ing a family history of psychopathology,19 an older father,21 oran unhappy childhood25 and later difficulties. Furthermore,five studies19,21,26,27,31 pointed to personality traits as pre-dictive of forthcoming problems; traits in the neurotic/self-critical spectrum seem to have the highest impact. Threelarge investigations24,26,27 showed that previous emotionaldisturbance predicted current disturbance, while two stud-ies19,21 failed to show this. Hence, mental health in previousyears seems to be of importance, although the findings are in-consistent. One study examining coping strategies27 showedthat coping by wishful thinking was most important. Alto-gether, considerable evidence supports the impact of individ-ual predictors, particularly personality traits. Nevertheless,the only study that tested the screening properties of individ-ual variables27 found that risk for problems during the post-graduate years could not be predicted in medical school.

With respect to contextual factors, five studies21,24,26,30,31

related work-related stress such as perceived overload, emo-tional pressure from demanding patients, and time pressureto mental health problems. However, these are associatedcurrent factors, not true predictors of future difficulties. Nev-ertheless, one study27 revealed that perceived stress at med-ical school predicted problems nearly 4 years later. Four in-vestigations21,26,30,31 found that working long hours was of noimportance, whereas one20 showed more distress in residentson an intensive care unit rotation, and another24 found that alower increase in confidence was related to more distressamong house officers in accident and emergency depart-ments.

Considering stress outside of work, two large studies26,31

found that having no partner and negative life events pre-dicted mental health problems in adjusted models, whereastwo others19,24 showed personal life stress to have little or noeffect. Although the findings are inconsistent, they seem toindicate that such factors are of some importance.



DISCUSSION

Each of the identified prospective studies has weaknessesthat reduce the internal and external validity of the findings.Most of the studies used availability samples, and the repre-sentativeness of these samples is unclear. Since the researchwas done in the United States and Europe, findings that aresimilar among studies may indicate more-general tenden-cies. However, there is a lack of studies from developing na-tions and also a shortage of comparative studies withmatched controls from the general population. Since we havenot included research on substance abuse, which is often con-current with affective disorders, we may have missed someimportant predictors. Very few investigations involved abroad spectrum of variables that could theoretically impactupon mental health. Only two of the reviewed studies27,29 uti-lized an observation period longer than 1 year and analyzedmultivariate models of the predictor variables measured atbaseline. Not all studies measured and controlled for person-ality, so the importance of factors such as perceived compe-tence and perceived work-related factors could have beenovervalued. Only one investigation19 used structured diag-nostic interviews to measure psychiatric disorders; however,its findings appeared very similar to survey findings.20,21

Overall, the knowledge that we have obtained from thesestudies should generally be regarded as preliminary. Pro-spective studies currently being conducted among youngdoctors in the United States, the U.K., Switzerland, Finland,and Norway may provide answers to the questions that re-main open. Since findings in the prospective studies to dateare limited and sometimes inconsistent, we will also discussthem in relation to cross-sectional studies.

Prevalence of Mental Health ProblemsThe prevalence of depressive symptoms estimated by this re-view corresponds well with that shown in a cross-sectionalstudy of 1800 interns and residents8 (i.e., a peak of depressivesymptoms [31%] on the Center for Epidemiological StudiesDepression Scale during the first postgraduate year) andalso confirmed an overall prevalence higher than that in thegeneral population. However, the finding that 17% hadMHPT in the fourth postgraduate year27 corresponds wellwith what has been seen in studies of perceived need and psy-chiatric disorder in the general population.32,33 From thesefindings one might suspect that compared to the general pop-ulation, postgraduates have higher depressive symptomscores but a similar prevalence of mental health problemsand need for treatment. However, the symptom scores mayreflect stresses unrelated to valid mental disorders.18 Thus,there is a need for comparative studies using similar diag-nostic interviews in postgraduates and matched controls inthe general population. The identified lack of help-seekingamong young doctors with emotional problems26,27 concurs

with other cross-sectional data,34 and the reasons for notseeking professional care should be explored.

Individual PredictorsAge or level of training. Available evidence indicates thatemotional disturbance declines over the years of residency;in Firth-Cozens’s cohort35 it remained at a lower level even inthe eighth year after graduation. This could indicate thatmost of the early emotional problems stem from a lack ofskills and competence, as suggested by two of the studies.22,24

However, cross-sectional investigations36,37 have found highlevels of mental distress among older and more experienceddoctors, such as hospital consultants, so this issue should befurther explored.

Gender. Although only two studies21,23 showed more de-pressive symptoms among female than among male post-graduates, we have considerable cross-sectional data fromNorth America8,38 pointing in that direction. Furthermore,the lack of gender difference in the Norwegian cohort con-trasts with findings among physicians who are older (mean,31 vs. 43 years).17,39 Among the older physicians, more de-pressive symptoms were seen in women. This indicates aharmful impact of work and life stress among female doctorsover the years, which accords with findings that stressful lifeevents pose a greater risk for depression among women thanamong men.40

Family background and previous mental health. Theharmful impact of an unhappy childhood and early disposi-tional factors in even the closest family is in accordance withthe findings of two previous longitudinal studies.12,13 Sincethese investigations did not control for personality traits, it isunclear whether the impact of such family and childhoodvariables is mediated via personality variables; however,this is likely. The finding that earlier disturbances were pre-dictors of ensuing problems concurs with what has been de-termined in other life-stress research.41 One of the studies19

showed no effects of previous depression in a controlledmodel in a smaller sample, but this may be a false-negativeresult. The clinical importance of the stability and consis-tency of emotional disturbance is emphasized by our findingof a 21-fold greater risk of serious suicidal ideation duringinternship among those who reported such ideation in med-ical school than among those who did not.31

Personality factors. The finding that self-criticism is astrong predictor of depressive symptoms, particularly amongmale doctors, concurs both with follow-ups later in a physi-cian’s career13,35 and with representative cross-sectionaldata.17 In the general population neuroticism has beenlinked not only to distress but also to depression,42 and thepresent finding that low perceived competence is a corre-


May/June 2002

late22,24 may also be related to this personality trait. A highlevel of extroversion remained an adjusted predictor, but thismay be an artifact of a higher response rate at follow-up.27 Inother words, extroverted individuals respond with more will-ingness in surveys like this and may therefore express moreneed for treatment. However, this finding needs replication.Whether physicians have traits different from those seen inother academic populations remains unclear, although Vail-lant and colleagues’ study13 may support this position, atleast among male physicians. One previous investigation43

has revealed lower general self-esteem among male medicalstudents than in the general population, while another44 hasfound favorable characteristics (e.g., deeper intellectual cu-riosity, higher aspiration levels) among U.S. postgraduatephysicians compared to the general population. Additionalcomparative studies are needed to clarify whether individu-als who become physicians possess more vulnerability fac-tors than other academic groups, or whether the work of aphysician is especially stressful for persons with such per-sonality traits.

Coping strategies. The coping strategy of wishful think-ing was a predictor even when researchers controlled for per-sonality, and this is in accord with research suggesting thatcoping is not necessarily trait dependent.45 Furthermore,wishful thinking belongs to the emotion-focused spectrum ofcoping, which has been associated with less-aggressive alter-ation of practices following a mistake,46 so it may be espe-cially harmful among doctors. Emotion-focused coping isassociated with escape/avoidance behavior, and a problem-focused coping strategy is obviously more beneficial for theperformance of technical tasks at busy hospital settings.46

However, more research is needed regarding the role of cop-ing strategies, both because very few such studies have beenconducted among doctors and because ways of coping can bemodified by educational and therapeutic interventions.

Contextual FactorsFactors related to medical work, job stress, and work-ing conditions. One study27 found that perceived medicalschool stress was a feasible predictor, and also that it partlymediated the effect of a personality trait (reality weakness,which includes perceptions and ideations on the borderlinebetween reality and fantasy47) on mental health during thefourth postgraduate year. Previously, perceived medicalschool stress had been validated cross-nationally as a mea-sure of current anxiety and depressive symptoms amongmedical students.43,48 The importance of this measure may bethat, besides being related to mental distress and personal-ity, it captures the experience of stress specific to the medicalschool context. Furthermore, it probes a threat (“medicalschool is cold and threatening”), and other research49 has re-vealed that the degree of contextual threat experienced in a

stressful life event (such as postgraduate training) deter-mines its “depressogenic” effect.

The high level of distress associated with intensive careunit rotations20 points to the importance of work settings. Ad-ditionally, the lack of perceived competence in skills that waslinked to emotional disturbance was, in fact, found among ac-cident and emergency postgraduates.24 Cross-sectionaldata50 indicate similar levels of depressive symptoms throughall years of emergency medicine residency. The clinical im-portance of such findings is exemplified by high risks for bothsubstance abuse51 and motor vehicle accidents52 duringtraining in this specialty.

Only one study21 found that sleep deprivation was associ-ated with emotional disturbance, while three others26,30,31

failed to show this. Nevertheless, loss of sleep among thepostgraduates has been extensively studied, and it has beenlinked to fatigue and emotional disturbance in some investi-gations.1,53 Norwegian junior doctors’ work hours and on-callwork have been adjusted downward over the preceding twodecades, so that may be one reason why the number of work-ing hours failed to be predictive in this cohort. Another rea-son may be that the present review focuses upon mentalhealth problems as an outcome and not fatigue, which ismore directly related to sleep loss. The overlap betweenchronic exhaustion and depression contributes to the com-plexity of this matter, which should be studied further. Lackof sleep induces both emotional and cognitive disturbance atwork1,53 and may thereby result in serious mistakes. Thispossibility was dramatically highlighted in 1984 by the fatalLibby Zion case in New York, after which residency trainingwas changed in that state.54

None of the four studies21,26,30,31 that included number ofwork hours as a predictor showed any link between longhours and emotional disturbance. Other research55 has alsofailed to show a clear link between working long hours andmental impairment of employees. On the contrary, it is per-ceived work conditions (e.g., job stress, lack of autonomy)that appear to be associated with problems.45,55

What kind of perceived work-related stress do youngphysicians find most difficult to tolerate? The reviewed stud-ies pointed to feeling overworked and having a sense of highintensity and urgency at the workplace, such as is experi-enced in intensive-care units. The stressful impact of per-ceived overwork concurs with the findings in other studies ofyoung doctors.34,56 Furthermore, the importance of time pres-sure and interruptions at work is in partial accordance withKarasek’s Decision Control Model,55 which shows the combi-nation of high demand and low control—“low decision lati-tude”—to be pathogenic for mental health. In what to ourknowledge is the only study that demonstrates a predictiveeffect of work conditions on mental health, this model hasbeen validated among U.S. doctors in midcareer.3 Lower per-ceived autonomy among junior doctors compared to their



senior colleagues has previously been identified.37,57 How-ever, studies of this model that focus on medical postgradu-ates are lacking. The present finding that “emotionaldrainage” occurs when caring for difficult and severely ill pa-tients concurs with the concept of burnout58 and also the find-ings of other studies among doctors.36 The relevance of theburnout concept among young doctors still needs additionalexploration. Firth-Cozens’s study21 found that relating toconsultants and other senior colleagues was highly corre-lated with stress and depressive symptoms among first-yearpostgraduates. This is convergent with other reports of inad-equate support from senior staff and a largely unmet need forcounseling among young doctors.56,59 Although none of thestudies reviewed showed any gender differences in predic-tors, several other investigations60–62 have found that femaledoctors experience more conflicts between career and familylife, and more problems stemming from sexual harassment,prejudice from patients, and lack of same-gender role mod-els. Research on job-related stress factors among youngphysicians should therefore be controlled for possible gendereffects.

Other studies63,64 have provided evidence showing thatthe perception of difficult work conditions among doctors ismediated through mental distress that may be caused by asusceptible personality and factors unrelated to their jobs. Amajor problem of research investigating the importance ofwork has been a lack of control for personality and past prob-lems. Our finding,26 that the level of experienced job stress(emotional pressure and demanding patients) among internswas important even when adjusted for personality, showsperceived stress to be independent of individual traits andtherefore underscores the importance of such stress.

Stress outside of work. Two of the studies reviewed26,31

found that negative life events (in particular, divorce andpartner problems) were independently related to suicidalideation and mental health problems, both at medical schooland during internship, even when the researchers controlledfor personality. Negative effects of such life stress among doc-tors were also found in two recent large controlled cross-sectional studies.65,66 Evidence is increasing that difficultiesin balancing the home/work interface may determine doc-tors’ career choices and influence their views on workingpart-time.67 Nevertheless, there have been few studies on theinfluence of life events on young physicians.

CLINICAL, EDUCATIONAL, ANDOCCUPATIONAL IMPLICATIONS

Internship and residency have been identified as especiallystressful phases of a physician’s career. This may have nega-tive consequences for both learning and patient care. The

transition from being a student with no clinical responsibil-ity to being an intern or resident with clear clinical responsi-bilities (particularly when on call) is a stressful life event formost trainees. Since internship in surgery and internal med-icine may be mandatory, this also represents an additionalstressful situation for some young doctors who would neverchoose to work in these departments. The dramatic changefrom being a student to becoming a doctor is also often paral-leled by other stressful life events, such as moving away fromfriends and family, living alone for the first time, experienc-ing changes in a personal relationship, and becoming a par-ent with “double work” responsibilities. In sum, these simul-taneous life events quite naturally represent a greatchallenge to trainees who are vulnerable to the developmentof a mental disorder. This transitional phase may be morestressful for female doctors, who in addition may experienceless-supportive workplaces. Assurance of optimal mentalhealth during this critical learning phase is therefore espe-cially important.

Together, the high prevalence of mental problems and thelow rate of treatment-seeking emphasize the need for low-threshold mental health services for medical students andyoung doctors. Since predicting individuals at risk is impos-sible, these services should be uniform throughout the yearsof training. Furthermore, the treating clinician should re-member that important stressors might derive from situa-tions other than the workplace. A large U.S. study68 has pro-vided evidence of a relatively good prognosis among youngdoctors who have been emotionally impaired, with almost80% continuing in medicine.

In addition to having a stressful occupation, many physi-cians may also be vulnerable because of traits such as neu-roticism, dependency, self-criticism, low self-esteem, narcis-sism, and compulsiveness. These traits may be modifiedthrough psychotherapy, which should focus upon increasingthe ability to tolerate and handle feelings of nonperfection,lack of approval, helplessness, and hopelessness. The nega-tive impact of a susceptible personality may also be amelio-rated through stress-management techniques. Since copingstrategies are amenable to change, inefficient ones, such aswishful thinking and consuming alcohol, should be targets ofpreventive intervention. However, controlled studies of theeffects of such interventions are needed.

Although personality appears to be more important thanobjective working conditions as a vulnerability factor, weshould note that we found a relationship between job stressand both suicidal thoughts and mental health among the in-terns and that the relationship was stable when we con-trolled for personality and previous mental health. Thisshows that the employer should be very sensitive to howyoung physicians experience their working conditions. Hos-pitals and workplaces should ensure adequate supervision


May/June 2002

and a learning climate that nurtures both increased clinicalknowledge and better communication skills for the juniordoctors. The impact of such factors on the mental health ofphysicians should also be investigated in future studies. Theuse of various forms of social support at the workplace, suchas peer process groups, peer mentoring of junior residents bysenior residents, appropriate socializing outside of the work-place, and related approaches, is likely to be very importantin helping young physicians to manage workplace and lifestressors.

In conclusion, young doctors belong to an occupationalgroup that exhibits a relatively high level of depressivesymptoms, and both individual and contextual factors seemto influence such problems. This suggests that the doctors re-quire support so as to ensure optimal patient care. Such sup-port could involve a work milieu and an education systemthat foster good clinical competence, peer social support, andthe ability to cope with stress and that provide a low-threshold psychiatric service. Whether physicians as a grouphave more susceptibility traits than other occupationalgroups, and whether medical practice is especially stressfulfor some vulnerable individuals, remains unresolved. Therelative importance of such factors beyond the first post-graduate years is still unclear; the impact of learning betterstress-management techniques as students or young doctorsalso remains unknown. We hope that future research willprovide some answers to these open questions.

REFERENCES

1. Firth-Cozens J. Stress, psychological problems, and clinical per-formance. In: Vincent C, Ennis M, Audley RJ, eds. Medical ac-cidents. Oxford, England: Oxford University Press, 1993:131–49.

2. Girard DE, Hickam DH. Predictors of clinical performanceamong internal medicine residents. J Gen Intern Med 1991;6:150–4.

3. Johnson JV, Hall EM, Ford DE, Mead LA, Levine DM, Wang NY,et al. The psychosocial work environment of physicians: the im-pact of demands and resources on job dissatisfaction and psychi-atric distress in a longitudinal study of Johns Hopkins MedicalSchool graduates. J Occup Environ Med 1995;37:1151–9.

4. Wall TD, Bolden RI, Borrill CS, Carter AJ, Golya DA, Hardy GE,et al. Minor psychiatric disorder in NHS trust staff: occupationaland gender differences. Br J Psychiatry 1997;171:519–23.

5. Töyry S, Räsänen K, Kujala S, Äärimaa M, Juntunen J, Ka-limo R, et al. Self-reported health, illness, and self-care amongFinnish physicians: a national survey. Arch Fam Med 2000;9:1079–85.

6. Firth-Cozens J. Depression in doctors. In: Robertson MM, Ka-tona CLE, eds. Depression and physical illness. New York: Wiley,1997:95–111.

7. Lindeman S, Läärä E, Hakko H, Lönnqvist J. A systematic re-

view on gender-specific suicide mortality in medical doctors. Br JPsychiatry 1996;168:274–9.

8. Hsu K, Marshall V. Prevalence of depression and distress in alarge sample of Canadian residents, interns, and fellows. Am JPsychiatry 1987;144:1561–6.

9. Arnetz BB, Hörte LG, Hedberg A, Theorell T, Allander E, MalkerH. Suicide patterns among physicians related to other academ-ics as well as to the general population: results from a nationallong-term prospective study and a retrospective study. Acta Psy-chiatr Scand 1987;75:139–43.

10. Brooke D, Edwards G, Andrews T. Doctors and substance mis-use: types of doctors, types of problems. Addiction 1993;88:655–63.

11. Baldwin PJ, Dodd M, Wrate RM. Junior doctors making mis-takes [Letter]. Lancet 1998;351:804.

12. Thomas CB, Greenstreet RL. Psychobiological characteristics inyouth as predictors of five disease states: suicide, mental illness,hypertension, coronary heart disease and tumor. Johns HopkinsMed J 1973;132:16–43.

13. Vaillant GE, Sobowale NC, McArthur C. Some psychologic vul-nerabilities of physicians. N Engl J Med 1972;287:372–5.

14. Skovholt TM, Rønnestad MH. The evolving professional self:stages and themes in therapist and counselor development. NewYork: Wiley, 1995.

15. Papalia DE, Olds SW, Feldman RD. Human development. 7thed. Boston: McGraw-Hill, 1998.

16. Flaherty JA, Richman JA. Substance use and addiction amongmedical students, residents, and physicians. Psychiatr ClinNorth Am 1993;16:189–97.

17. Vaglum P, Falkum E. Self-criticism, dependency and depressivesymptoms in a nationwide sample of Norwegian physicians.JAffect Disord 1999;52:153–9.

18. Tyssen R. Mental health problems among medical students andyoung physicians: a nationwide and longitudinal study [Doc-toral dissertation]. Oslo: University of Oslo, 2001.

19. Clark DC, Salazar-Grueso E, Grabler P, Fawcett J. Predictors ofdepression during the first 6 months of internship. Am J Psychi-atry 1984;141:1095–8.

20. Reuben DB. Depressive symptoms in medical house officers: ef-fects of level of training and work rotation. Arch Intern Med1985;145:286–8.

21. Firth-Cozens J. Emotional distress in junior house officers. BMJ1987;295:533–6.

22. Girard DE, Hickam DH, Gordon GH, Robison RO. A prospectivestudy of internal medicine residents’ emotions and attitudesthroughout their training. Acad Med 1991;66:111–4.

23. Baldwin PJ, Dodd M, Wrate RM. Young doctors’ health, II:Health and health behaviour. Soc Sci Med 1997;45:41–4.

24. Williams S, Dale J, Glucksman E, Wellesley A. Senior house offi-cers’ work related stressors, psychological distress, and confi-dence in performing clinical tasks in accident and emergency: aquestionnaire study. BMJ 1997;314:713–8.

25. Hainer BL, Palesch Y. Symptoms of depression in residents: aSouth Carolina Family Practice Research Consortium study.Acad Med 1998;73:1305–10.

26. Tyssen R, Vaglum P, Grønvold NT, Ekeberg Ø. The impact of jobstress and working conditions on mental health problems among



junior house officers: a nationwide Norwegian prospective co-hort study. Med Educ 2000;34:374–84.

27. Tyssen R, Vaglum P, Grønvold NT, Ekeberg Ø. Factors in medicalschool that predict postgraduate mental health problems inneed of treatment: a nationwide and longitudinal study. MedEduc 2001;35:110–20.

28. Brewin CR, Firth-Cozens J. Dependency and self-criticism aspredictors of depression in young doctors. J Occup Health Psy-chol 1997;2:242–6.

29. Firth-Cozens J. The role of early family experiences in the per-ception of organizational stress: fusing clinical and organiza-tional perspectives. J Occup Org Psychol 1992;65:61–75.

30. Baldwin PJ, Dodd M, Wrate RW. Young doctors’health, I: How doworking conditions affect attitudes, health and performance?Soc Sci Med 1997;45:35–40.

31. Tyssen R, Vaglum P, Grønvold NT, Ekeberg Ø. Suicidal ideationamong medical students and young physicians: a nationwideand prospective study of prevalence and predictors. J Affect Dis-ord 2001;64:69–79.

32. Sandanger I, Nygård JF, Ingebrigtsen G, Sørensen T, DalgardOS. Prevalence, incidence and age at onset of psychiatric dis-orders in Norway. Soc Psychiatry Psychiatr Epidemiol 1999;34:570–9.

33. Rabinowitz J, Gross R, Feldman D. Correlates of a perceivedneed for mental health assistance and differences between thosewho do and do not seek help. Soc Psychiatry Psychiatr Epidemiol1999;34:141–6.

34. King MB, Cockcroft A, Gooch C. Emotional distress in doctors:sources, effects and help sought. J R Soc Med 1992;85:605–8.

35. Firth-Cozens J. Individual and organizational predictors of de-pression in general practitioners. Br J Gen Pract 1998;48:1647–51.

36. Ramirez AJ, Graham J, Richards MA, Cull A, Gregory WM.Mental health of hospital consultants: the effects of stress andsatisfaction at work. Lancet 1996;347:724–8.

37. Kapur N, Borrill C, Stride C. Psychological morbidity and jobsatisfaction in hospital consultants and junior house officers:multicentre, cross sectional survey. BMJ 1998;317:511–2.

38. Whitley TW, Allison EJ Jr, Gallery ME, Heyworth J, CockingtonRA, Gaudry P, et al. Work-related stress and depression amongphysicians pursuing postgraduate training in emergency medi-cine: an international study. Ann Emerg Med 1991;20:992–6.

39. Hem E, Grønvold NT, Aasland OG, Ekeberg Ø. The prevalence ofsuicidal ideation and suicidal attempts among Norwegianphysicians: results from a cross-sectional survey of a nationwidesample. Eur Psychiatry 2000;15:183–9.

40. Maciejewski PK, Prigerson HG, Mazure CM. Sex differences inevent-related risk for major depression. Psychol Med 2001;31:593–604.

41. Depue RA, Monroe SM. Conceptualization and measurement ofhuman disorder in life stress research: the problem of chronicdisturbance. Psychol Bull 1986;99:36–51.

42. Kendler KS, Neale MC, Kessler RC, Heath AC, Eaves LJ. A lon-gitudinal twin study of personality and major depression inwomen. Arch Gen Psychiatry 1993;50:853–62.

43. Bramness JG, Fixdal TC, Vaglum P. Effect of medical schoolstress on the mental health of medical students in early and lateclinical curriculum. Acta Psychiatr Scand 1991;84:340–5.

44. Hojat M, Nasca TJ, Magee M, Feeney K, Pascual R, Urbano F, etal. A comparison of the personality profiles of internal medicineresidents, physician role models, and the general population.Acad Med 1999;74:1327–33.

45. Lazarus RS, Folkman S. Stress, appraisal, and coping. NewYork: Springer, 1984.

46. Wu AW, Folkman S, McPhee SJ, Lo B. How house officers copewith their mistakes. West J Med 1993;159:565–9.

47. Torgersen S, Alnæs R. Localizing DSM-III personality disordersin a three-dimensional structural space. J Pers Disord 1989;3:274–81.

48. Vitaliano PP, Russo J, Carr JE, Heerwagen JH. Medical schoolpressures and their relationship to anxiety. J Nerv Ment Dis1984;172:730–6.

49. Kendler KS, Karkowski LM, Prescott CA. Stressful life eventsand major depression: risk period, long-term contextual threat,and diagnostic specificity. J Nerv Ment Dis 1998;186:661–9.

50. Whitley TW, Gallery ME, Allison EJ Jr, Revicki DA. Factors as-sociated with stress among emergency medicine residents. AnnEmerg Med 1989;18:1157–61.

51. Hughes PH, Baldwin DC Jr, Sheehan DV, Conard S, Storr CL.Resident physician substance use, by specialty. Am J Psychiatry1992;149:1348–54.

52. Steele MT, Ma OJ, Watson WA, Thomas HA Jr, Muelleman RL.The occupational risk of motor vehicle collisions for emergencymedicine residents. Acad Emerg Med 1999;6:1050–3.

53. Samkoff JS, Jacques CH. A review of studies concerning effectsof sleep deprivation and fatigue on residents’performance. AcadMed 1991;66:687–93.

54. Brensilver JM, Smith L, Lyttle CS. Impact of the Libby Zion caseon graduate medical education in internal medicine. Mt Sinai JMed 1998;65:296–300.

55. Karasek R, Theorell T. Healthy work: stress, productivity, andthe reconstruction of working life. New York: Basic, 1990.

56. Schwartz AJ, Black ER, Goldstein MG, Jozefowicz RF, EmmingsFG. Levels and causes of stress among residents. J Med Educ1987;62:744–53.

57. Falkum E. Norwegian doctors today: psychosocial work-envi-ronment and job satisfaction. In: Larsen Ø, Olsen BO, eds. Theshaping of a profession: physicians in Norway, past and present.Canton, Massachusetts: Science History Publications, 1996:481–90.

58. Maslach C, Jackson SE. The measurement of experiencedburnout. J Occup Behav 1981;2:99–113.

59. Garrud P. Counselling needs and experience of junior hospitaldoctors. BMJ 1990;300:445–7.

60. Firth-Cozens J. Sources of stress in women junior house officers.BMJ 1990;301:89–91.

61. Frank E, Brogan D, Schiffman M. Prevalence and correlates ofharassment among US women physicians. Arch Intern Med1998;158:352–8.

62. Hojat M, Gonnella JS, Xu G. Gender comparisons of youngphysicians’ perceptions of their medical education, professionallife, and practice: a follow-up study of Jefferson Medical Collegegraduates. Acad Med 1995;70:305–12.

63. Deary IJ, Blenkin H, Agius RM, Endler NS, Zealley H, Wood R.Models of job-related stress and personal achievement amongconsultant doctors. Br J Psychol 1996;87:3–29.


May/June 2002

64. Firth-Cozens J, Hardy GE. Occupational stress, clinical treat-ment and changes in job perceptions. J Occup Org Psychol 1992;65:81–8.

65. Weinberg A, Creed F. Stress and psychiatric disorder in health-care professionals and hospital staff. Lancet 2000;355:533–7.

66. Frank E, Dingle AD. Self-reported depression and suicide at-tempts among US women physicians. Am J Psychiatry 1999;156:1887–94.

67. Evans J, Goldacre MJ, Lambert TW. Views of UK medical grad-uates about flexible and part-time working in medicine: a quali-tative study. Med Educ 2000;34:355–62.

68. Smith JW, Denny WF, Witzke DB. Emotional impairment in in-ternal medicine house staff: results of a national survey. JAMA1986;255:1155–8.



Copyright of Harvard Review of Psychiatry is the property of Taylor & Francis Ltd and its content may not be

copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written

permission. However, users may print, download, or email articles for individual use.

Mental Health Problems Among Young Doctors. an Updated Review of Prospective Studies 2002

Documents

Transcript of Mental Health Problems Among Young Doctors. an Updated Review of Prospective Studies 2002