Amin A. Muhammad Gadit  ( Discipline of Psychiatry, Memorial University of Newfoundland, St. John's, NL, Canada. )

It has been often reported that medical students and doctors undergo severe stress and fall victim to mental ill health. A number of medical professionals develop serious mental illnesses during their career and may either leave practice altogether or are compelled to limit their professional activities. This is a grave situation as doctors deal with patients and if not in good  health there can be negligence in the management. Registration authorities specifically emphasize on getting treatment and advice under these circumstances. The Department of Health of the United Kingdom has published a document1 inspired by the case of a brilliant female psychiatrist of Indian origin who suffered from bipolar affective disorder. This doctor in the phase of acute episode of illness killed her infant daughter and committed suicide. This episode was the result of her temporary non-compliance with the medications. Doctors in general are reluctant to seek advice because of the worries related to confidentiality and stigma associated with mental illness.1 Research suggests that doctors have higher rates of mental disorder than the general population.2-4 Up to 7% of doctors have a substance abuse problem during their lifetime.5 Suicide rates are also high, particularly among female doctors, anaesthetists, General Practitioners and psychiatrists.6 Among the risk factors and sources of stress that lead to mental health problems are: work pressure, high demand and low control work environment, poor relationship with colleagues and service pressures.1 However, genetic vulnerability and other social factors are also important factors in the development of mental illnesses. Every individual is vulnerable to physical as well as mental illnesses and so are the people who deal with treatment of such illnesses. Mental illnesses have acquired alarming proportions among the world's population and carry a high level of morbidity and functional disability. Among the doctors as mentioned earlier, one of the particular vulnerable group is that of psychiatrists when it comes to mental illness. According to the General Medical Council, psychiatrists have one of the highest rates of psychiatric morbidity among hospital doctors which is not adequately recognized or managed and British Medical Association estimated that 1 in 15 doctors at some point in their lives will have problems with alcohol or drugs.7 As mental illnesses carry a huge burden of stigma, the psychiatrists who suffer from it cannot escape the consequences of its devastating effects.8 Stresses play a big role in the life of medical doctors which leads to mental health morbidity. Considerable number of psychiatrists however would treat themselves for depression according to a study.9 Depression and suicide rates among psychiatrists have been reported as one of the highest among physicians. Self treatment is because of the reasons of stigma, permanent insurance record, fear of dismissal from a training programme, loss of hospital privileges, fear of losing referrals, looked down upon by peers and problems of ego/self-esteem.9 However, the issue of mental illness among the psychiatrists is a pertinent one as they are responsible for addressing mental health issues of the patients approaching them for treatment. The question of efficiency and competence is of utmost importance here in view of the nature of mental illnesses. For example, depression causes slowness, impaired concentration and diminished interest. The excessive vulnerability of psychiatrists for mental ailment is possibly due to the selection factor i.e. the physician's choice to enter into this field or the ignorance of the concerned selection committee allowing the candidate to enter into this specialty training. One should consider the developmental background where faulty psychodynamics may play a crucial role in making the individual highly vulnerable especially when one is opting for this discipline where listening to patients is the vital factor. Identification of circumstances akin to the patients can cause great disturbance in the psyche of the treating psychiatrist. Personality make-up which is both genetic as well as developmental may cause detrimental effect with performance in practice if there is an established yet probably undiagnosed personality disorder. Paranoid type of disorder has been reported more often followed by obsessional and borderline type of disorders. Many psychiatrists in practice have caused a lot of trouble to the colleagues in the form of bullying and harassment may be as a result of these personality issues.10 Personality disorders are often missed in young professionals. Antisocial behaviours and unexpected dependent behaviours are observed in men particularly when rejected in personal relationships. Interestingly borderline personality disorders are more described among women.11 Particular issues needing attention among psychiatrists are those of adjustment problems, relationship problems, unresolved grief, dysfunctional family legacies and chronic medical illnesses.11 The concerned health system may suffer because of this problem as there will be absenteeism, unavailability or inefficient services, medical errors which can at times be devastating and possible legal issues. It is important to either prevent or manage this problem. This should start from undergraduate medical education. The selection committees for medical schools should select candidates who are not only academic achievers but at the same time should have stable personalities. Medical schools should emphasize on the dangers of drugs and alcohol, develop constructive interests outside medicine and encourage the importance of devoting appropriate time to family life. The psychiatrists in particular and other physicians in general should continue benefiting from continued medical education programmes, monitor one's own mental and emotional health, seek psychiatric help for any mental health problem, remain aware of their vulnerability especially if there is family history, refer themselves to counseling services, modify their life style, devise a stress free work schedule and convince themselves that it is not a stigma to seek help for mental ailments. The concerned organizations or employers should avoid stigmatizing or writing unfavourable references for those doctors who become mentally ill and therefore seek treatment. Health system policy makers should be aware of the fact that nobody is immune to mental illness in this present era of competition and chaos. At present, we do not know statistically as how many doctors are suffering from mental illness as no empirical study is in evidence. It is also not known about the magnitude of impact this can cause upon patient care. Pakistan Medical and Dental Council do not have a clear guideline in this issue. The problem can have serious consequences and therefore it is high time that PMDC should formulate some guidelines for sick doctors while health policy makers should make special provisions for doctors suffering from mental ill health.
References
1.Department of Health. Mental health and ill health in doctors. (Online 2008) Cited 2008 Sept 16. Available from URL: www.dh.gov/publications.
2.Williams S, Michie S, Pattani S. Improving the health of the NHS workforce: Report of the partnership on the health of the NHS workforce. 1998; Nuffield Provincial Hospital Trust, London; 1998.
3.Wall TD, Bolden RI, Borrill CS, Carter AJ, Golya, DA et al. Minor psychiatric disorders in NHS trust staff: occupational and gender differences. Br J Psychiat. 1997; 171: 519-23.
4.Ghodse H. Doctors and their health-who heals the healers? In: Ghodse H, Mann S, Johnson P. Doctors and their health. Sutton: Reed Healthcare Limited  2000; pp 10-4. 5.Bennett J, O'Donovan D. Substance misuse by doctors, nurses and other healthcare workers, Current Opin Psychiat 2001; 14: 195-9.
6.Hawton K, Clements A, Sakarovitch C, Simkin S, Deeks JJ. Suicide in doctors: a study of risk according to gender, seniority and specialty in medical practitioners in England and Wales, 1979-1995. J Epidemiol Community Health 2001; 55: 296-300.
7.White A, Shiralkar P, Hassan T, Galbraith N, Callaghan R. Barriers to mental healthcare for psychiatrists. Psychiatric Bulletin 2006; 30: 382-4.
8.Hausman K. Psychiatrists not immune to mental illness-or stigma. Psychiatric News 2002; 37:8.
9.Balon R. Psychiatrist attitudes toward self-treatment of their own depression. Psychother Psychosom 2007; 76: 306-10.
10.Gadit AA, Mugford G. A pilot study of bullying and harassment among medical professionals in Pakistan, focusing on psychiatry: need for a medical ombudsman. J Med Ethics 2008; 34: 463-6.
11.Goldman LS, Myers M, Dickstein LJ. American Medical Association. The Handbook of Physician Health: The Essential Guide to Understanding the Health Care Needs of Physicians. Chicago: Am Med Assoc 2000; p: 39-79.