Mental health stigma in the medical profession: Where do we go from here?

Abstract

Mental health conditions are highly prevalent among physicians with high rates of depression, anxiety, stress-related disorders, suicidal ideation and burnout reported among medical practitioners at all levels of training and practice. This phenomenon is in part contributed by a highly stressful clinical environment with an often suboptimal support system for doctors. Concerningly, there is hitherto a striking reluctance amongst medical trainees/practitioners to seek treatment/help for mental health-related conditions due to fear of associated stigma and negative career repercussions. In this article, we sought to raise awareness of the mental health stigma that has long been prevailing in the medical community, and review the key drivers of such stigma at the individual, community and organisational level. In general, drivers of mental health stigma in the medical profession include self-stigmatisation predisposed by physician personality and character traits, societal stereotypes about mental illness permeating through the medical community, and systemic constructs such as mandatory mental health declarations for medical licensure that perpetuate the unfortunate perception that mental illness appears synonymous with job impairment or incompetency. To destigmatise mental health issues in the medical profession, we herein propose multi-pronged strategies which can practically be implemented: 1) normalisation of mental health issues through open dialogue and sharing, 2) creating a supportive, “psychologically friendly” work environment through increased accessibility to workplace mental health support services, peer support systems, and reduction of psychiatric “name-calling” practices, and 3) reviewing systemic practices, in particular the mandatory mental health declarations for medical registration, that perpetuate mental health stigma.

Introduction

Mental health conditions are highly prevalent among physicians, with reportedly 29% having depressive symptoms, up to 24% experiencing anxiety and 4–16% being afflicted with post-traumatic stress disorder.¹ Moreover, burnout occurs in more than one in three physicians.² This is not entirely surprising as the clinical work environment is known to be highly challenging – with common sources of stress including heavy workload, long hours, time/resource constraints, uncertainty, committing medical errors, experiencing moral distress, workplace bullying, and handling abusive patients, complaints or medicolegal disputes.^3,4 When left unchecked, such stressors may precipitate mental health problems.

Concerningly, there remains a striking reluctance among medical trainees and practitioners to seek treatment for mental-health-related conditions due to fear of stigma and negative career repercussions.^1,5, 6, 7 These concerns were highlighted in a 2021 study, where 40% of surveyed physicians agreed that ‘many doctors believe that a doctor with a history of depression or an anxiety disorder is less competent’, and 47% believed that ‘doctors are less likely to appoint doctors with a history of depression or an anxiety disorder’.⁸ Elsewhere, nearly 40% of physicians expressed that they would be unwilling to seek treatment for a psychiatric condition due to medical licensure fears.⁷

In this article, we sought to review the prevailing drivers of mental health stigma in the medical profession, and offer practical strategies to achieve successful destigmatisation to enhance physician mental well-being.

Personal and systemic factors that drive mental health stigma in the medical community

At the individual level, self-stigmatisation predisposed by physician personality and character traits often pose barriers to help-seeking behaviour for mental health conditions.⁵ For instance, physicians generally have a strong sense of duty, self-sufficiency and invulnerability and perfectionistic tendencies, and may associate psychological distress with feelings of shame, embarrassment, self-doubt and insecurity.^5,9 This might then lead to maladaptive coping strategies, where physicians may delay seeking professional treatment, self-medicate, become socially withdrawn or engage in other self-destructive behaviours.^5,9

At the societal level, stereotypes about mental illness remains prevalent and unfortunately permeate the medical community as well. For example, it is not uncommon for physicians to hold prejudice against those with mental illness and view them as ‘occupationally impaired’.¹⁰ In 2007 study, 37% of US executive directors of State Medical Boards surveyed held the belief that having a psychiatric diagnosis was by itself sufficient to warrant the sanctioning of physicians.¹¹ Besides internal prejudices, outwardly cavalier attitudes towards mental health issues are commonly demonstrated in everyday language used by physicians, for instance, describing incoherent/inconsistent behaviour as ‘schizophrenic’, name-calling organised people as having ‘OCD’, depicting people with mood swings as being ‘bipolar’, and using words like ‘crazy’, ‘mad’ and ‘psychotic’ as verbal insults.^12,13

At the organisational level, there is a lack of concerted effort to allay the genuine fears and concerns of negative career repercussions that can result from seeking psychiatric treatment. In particular, mandatory mental health declarations for medical licensure continues to be a widespread practice in many countries, such as the USA,^7,14 Canada, ¹⁵ Australia,¹⁶ New Zealand,¹⁷ Singapore¹⁸ and Malaysia,¹⁹ with its justification being the need to assess a physician's ‘fitness to practise’. Once a psychiatric condition is declared, physicians are often subject to stringent requirements set by local medical boards in order to be granted a medical licence to practice. These may include attending formal interviews/assessments by state board examiners or board-appointed physicians, providing detailed medical/psychiatric reports and regular interim updates on clinical/treatment progress, and being subjected to additional supervisory requirements or restrictions on scope of clinical practice.^6,18

Practical strategies to reduce mental health stigma in the medical profession

Strategy 1: Normalise mental health issues through open dialogue and sharing

To normalise mental health issues within the medical profession, it is necessary to foster candid dialogue and sharing on such topics. These sharing sessions may either take place in small group settings or larger forums, essentially adopting a similar format to Balint groups20, 21 or Schwartz rounds,²² where physicians are given a safe space to reflect on difficult and emotionally challenging clinical encounters, receive validation and support from fellow colleagues, and avoid developing maladaptive coping strategies. For these initiatives to gain greater traction, it might be beneficial to have designated institutional champions of practitioner mental health, whose roles in education, advocacy, relationship building and navigating institutional boundaries would not be dissimilar to champions of other clinical causes such as patient safety.²³

Strategy 2: Create a supportive, ‘psychologically friendly’ work environment

First, the accessibility of workplace mental health support services can be optimised, either through equipping on-site occupational health physicians with adequate psychiatric training,²⁴ or creating free, confidential, easily accessible mental health services for physicians at/near their workplace on a self-referral basis, such as the NHS Practitioner Health service available in the UK.²⁵

Second, less medicalised interventions such as peer support services, which offer advice, mentorship and a listening ear, serve as an added layer of ‘psychological safety net’.²⁶ However, providers of such services must be able to recognise and refer clients who need formal psychiatric assessment and treatment (eg those with severe symptoms, or at risk of self-harm or causing harm to others) in a timely fashion.

Third, to allay the fears of mental health stigma arising from seeking professional treatment, adequate assurance must be provided by healthcare senior management that a supportive rather than punitive approach will be adopted for practitioners with psychiatric diagnoses. Furthermore, the mental health declaration processes must be more transparent, with greater clarity on assessment criteria and what to expect in terms of subsequent reporting, follow-up and job implications.

Finally, ‘psychiatric name-calling’ should be avoided in workplace conversations, to avoid perpetuating negative stereotypes of mental health conditions or trivialising actual, debilitating conditions by misappropriating clinical terminology for colloquial use. In addition, anti-bias workshops for healthcare workers to recognise implicit bias and reduce the use of stigmatising language²⁷ can likewise be adopted for this purpose to reduce mental health stigma.

Strategy 3: Review systemic practices that perpetuate mental health stigma

Mandatory mental health declarations for medical licensure continue to be standard practice in many countries,^15,18,19,28 which inadvertently perpetuate mental health stigma by linking psychiatric conditions to performance impairment.

However, the need for indiscriminate, mandatory mental health declarations for medical licensure is actually not evidence-based, as the mere presence of a psychiatric diagnosis does not accurately predict fitness to practice,^6,7 notwithstanding the actual ramifications of delayed help-seeking behaviours caused by mental health stigma on physician wellbeing and clinical outcomes. Moreover, there is significant underreporting of mental health diagnoses to medical boards which further undermines its purported efficacy.²⁹

In 2018, the US Federation of State Medical Boards provided four key recommendations on mental health-related disclosures in medical licensure: declaring only conditions that cause impairments, declaring only current impairments, providing safe-haven non-reporting options, and promoting the use of supportive language.³⁰ Unfortunately, across individual US states, there remains highly varied and suboptimal implementation rates of these recommendations,^14,28 with a particular reluctance to adopt safe-haven non-reporting and supportive language.²⁸

While it is a welcome recommendation to have the scope of mental health declarations narrowed to ‘only conditions that cause current impairment’, the term ‘impairment’ remains poorly defined. This is because assessing the likelihood and degree of impairment caused by mental health conditions on clinical performance is not only difficult, but also often subjective, depending on the person making the assessment and the clinical context of practice. Moreover, the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for psychiatric conditions typically warrant the presence of ‘impairment’ to psychosocial functioning to distinguish between disorder and non-disorder,³¹ which implies that all diagnosed mental health conditions cause ‘impairment’. Therefore, we suggest that ‘impairment’ in the context of mental health declarations in medical licensure applications should only refer to conditions that currently pose a reasonably significant risk of affecting clinical performance and patient care based on the expected scope of practice, which should be professionally determined by the applicant's psychiatrist. In addition, to adopt a more accurate and empathetic approach to ‘fitness to practice’ assessments, medical licensing boards should involve psychiatrists in the formulation and appraisal of licensing applications.³²

In our view, the UK medical licensure model is perhaps one of the most balanced approaches that can reduce mental health stigma among physicians, while also adequately safeguarding patient interests. Essentially, since 2013, the UK General Medical Council (GMC) has adopted a fairly progressive approach to mental health declarations, where medical practitioners are instructed to consult a ‘suitably qualified colleague’ if they know or suspect that they have a serious transmissible condition or any condition that could affect clinical judgment/performance, and must follow their professional advice on necessary changes required in their clinical practice.^33,34 However, unlike most other jurisdictions, the GMC does not actually make a distinction between physical and mental health conditions, nor mandate declarations unless there is serious communicable disease involved or a failure to abide by the above guidance.^33,34

Conclusion

Mental health stigma remains highly prevalent in the medical profession – but we must be take actionable steps to overcome it. Healthcare practitioners have always been exhorted to deliver the best care for patients that is in line with their professional ethos – however, the health of these practitioners should not be neglected.