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In Sickness And In Health

Introduction

&ldquo;What did I even achieve?&rdquo;

&ldquo;Why can&rsquo;t I be how I want to be?&rdquo;

&ldquo;Is this it?&rdquo;

And a million other questions may arise when you are not feeling your best. 
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Depressive disorders, mood disorders, in fact the entirety of mental health, is a lesser understood subject. It&rsquo;s bad enough that mental health continues to be a taboo, at times shunned by the most educated even, but it&rsquo;s sadder that society has somehow categorised who should be &ldquo;allowed&rdquo; to have <a href="https://www.merisehat.pk/article/mental-health">mental health</a> problems. This scrutiny is done on the basis of gender, race, socioeconomic status and even profession. No matter how organised this categorisation sounds, it is incorrect, unfair and devastating. 
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Mental health is your psychological well-being that not only affects your personal, career and professional life, but also your health. Depression or any other mental health illness, can either directly affect your appetite and cause weakness, or bring your immune system down to an extent that it gets susceptible to harmful organisms. 
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Moreover, it is seen that symptoms, such as those in anxiety in particular, can alter the physiological processes of the autonomic nervous system i.e. respiration and heart rate. Thus, increasing the risk of certain malicious diseases.&nbsp; 
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Healthcare practitioners, including the nursing staff, paramedics, and all those involved in patient care are part of an extremely noble, but immensely stressful profession. Whether they are sick or healthy, patient care is an obligation they cannot ignore. Moreover, providing hope to patients who believe they will never recover is a major part of the job description. But do you ever think how scary it can be for healthcare professionals to provide this hope, regardless of their own fears?&nbsp; &nbsp; &nbsp;&nbsp;

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Understanding Mental Health Issues Faced By The Medical Community

According to the World Health Organization (WHO), in 2015, almost 4.4% of the global population was diagnosed with depression, which is around 320 million people<a href="#accordion">[1]</a>. Studies prove that except for the United States of America, where there are an equal number of depressed doctors as the general population, other countries report a greater incidence of depression among doctors and other related health professionals than the rest of the population.&nbsp; 
&nbsp;

Current statistics report the prevalence of depression as 27% in medical students, 29% in registrars and up to 60% in practicing doctors<a href="#accordion">[1]</a>.&nbsp;Furthermore, a study conducted using Beck&rsquo;s Depression Inventory, revealed that 30% of the primary healthcare workers in a public setup were moderate to severely depressed<a href="#accordion">[1]</a>. In China, where health workers&rsquo; mental health wasn&rsquo;t taken into consideration until the 21st Century, the prevalence of depressive symptoms varies between 31.7% to 65.3%<a href="#accordion">[2]</a>.&nbsp; 
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There are no set criteria that enables only a certain population to be exclusive to mental health disorders. It can happen to almost anyone, but there are sure factors that have been proved to put healthcare workers at a greater risk than others. These risk factors include: 
&nbsp;

<ul>
	<li>Working longer hours</li>
	<li>Extensive workload</li>
	<li>Ever-growing intensity and complexity of the job description</li>
	<li>Relentless contact with patient&rsquo;s ill health and emergencies</li>
	<li>Higher responsibilities</li>
	<li>Post-traumatic stress due to the severity of the patient&rsquo;s condition</li>
	<li>Feelings of guilt, failure, shame and low self-esteem due to fear of failure, or actually failing to execute a task&nbsp;</li>
	<li>Discrimination in their licensing procedures specifically</li>
</ul>

&nbsp;

One term to understand while discussing the mental health of healthcare workers is &lsquo;burnout&rsquo;. According to the International Classification of Diseases (11th edition), or ICD-11, burnout is a phenomenon seen in workplaces where excessive pressure from the office surroundings can drain a person to an extent that they can&rsquo;t function properly anymore.&nbsp; 
&nbsp;

Burnout is characterised by three aspects:

1. Being unnecessarily exhausted.

2. Having negativity related to the workplace, in this case around patients.

3. Major reduction in efficiency. 
&nbsp;

Further research reports that a reason exclusive to low- and middle-income countries is the unfair ratio of physicians to the general population. This increases the workload which in turn raises the risk of burnout in healthcare providers. Thus, ultimately affecting patient care. Many cross-sectional studies signify that burnt-out medical practitioners were twice as likely to make errors, and had a 17% risk of being sued for malpractice<a href="#accordion">[3]</a>. This reduced efficacy can in turn aggravate burnout, as well as instill a factor of guilt for not being efficient enough. 
&nbsp;

According to a study carried out in the US, in 2017, almost 44% of physicians showed at least one symptom of burnout while the number was 54% in 2014<a href="#accordion">[3]</a>.&nbsp;

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Moral injury is defined as the psychological distress which results from the actions, or the restricted ability of the practitioner, that may violate their moral or ethical code. A fine example is a doctor having to decide between saving one patient over the other, purely on practical grounds. This may put profound emotional and psychological stress. Although the moral injury is not a disease itself, it may shake a healthcare practitioner&rsquo;s core and lead to feelings of self-doubt, unnecessary yet strong guilt and ambiguity in their actions. For example, paramedics hold themselves accountable for not being able to do enough on-site, regardless of correctly analyzing the severity of the condition<a href="#accordion">[3]</a>.

&nbsp;

An unjust stereotype that prevails in our society is that a person who works in the healthcare industry is not allowed to be compromised medically themselves. This puts unnecessary pressure on the healthcare workers as it is idealised that their efficiency is subject to their own health. Due to the unfair perception set, medical workers not only feel frustrated, but they use alternative ways for instant gratification which in turn makes matters even worse for them.&nbsp; 
&nbsp;

Studies prove that alcohol misuse in healthcare providers was 49%, five times higher than the general population (9%)<a href="#accordion">[1]</a>. Furthermore, a survey conducted in the United States in 2016 revealed that although 50% of the female doctors acknowledged that while they met the criteria for a disturbed mental state, they did not consider starting appropriate treatment as they wanted to deal with it independently<a href="#accordion">[1]</a>. Or, because they believed the diagnosis was shameful or embarrassing 
.&nbsp;

Therefore, there is a dire need of changing perceptions<a href="#accordion">[1]</a>.

&nbsp;

The treatment is as complicated as diagnosing mental health disorders in healthcare professionals. The relevance lies with the fact that professionals who have dedicated their lives to serving patients find it hard to fit in the role of a patient themselves. Nevertheless, it is important to ensure appropriate treatment. The treatment plan includes a pharmacological and psychological approach. Antidepressants are the first-line medications. The most widely used antidepressants are selective serotonin re-uptake Inhibitors (SSRIs). These are usually initiated for 9-12 months in the beginning, irrespective of the reason.&nbsp; 
&nbsp;

Studies also prove that medical practitioners have a higher suicide rate than the general population. Hence, encouraging treatment plans is of utmost importance. The psychological approach includes cognitive behavioural therapy (CBT) and support groups to normalise the conception of being unwell. Moreover, exercises like adopting new hobbies, restricting alcohol intake, and taking up healthy challenges might be helpful in the process<a href="#accordion">[1]</a>.

&nbsp;

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The mental health of doctors or other healthcare professionals was already a neglected topic, but after the pandemic things took a turn for the worse. Numerous studies have recently been dedicated exclusively to the impact of COVID-19 on the mental health of healthcare providers.&nbsp; 
&nbsp;

As of 30th July, COVID-19 has caused more than 6.4 million global deaths<a href="#accordion">[4]</a>. The sudden patient influx, presence of unorthodox symptoms, and their management, along with the unpredictability of COVID-19 have further increased the burden on healthcare practitioners. A meta-analysis conducted across 65 studies, involving 97,333 health care workers from 21 countries, identified a high prevalence of moderate depression (21.7%), anxiety (22.1%), and PTSD (21.5%) during the COVID-19 pandemic<a href="#accordion">[3]</a>. Another survey reported trauma-related stress, with a prevalence ranging from 7.4% to 35%, particularly among women, nurses, frontline workers and workers who experienced physical symptoms<a href="#accordion">[3]</a>. In fact, nurses have shown a higher incidence of depression and PTSD than physicians<a href="#accordion">[3]</a>.

&nbsp;

Conclusion

Doctors are mere humans; as fragile or strong as any other person alive. Just because their job involves treating illnesses, doesn&rsquo;t mean that they are not bound to get ill themselves. The stereotype built for healthcare professionals restricts them to get diagnosed, and if they do, prevents them from getting treatment efficiently. 
&nbsp;

The statistics collected have been recent and alarming, yet not much attention has been paid to the situation. This needs to change not only for the sake of humanity but also for the stagnant progress of our healthcare industry. Having our medical workers burnt out does not only put patient care at risk but also aggravates their mental health itself. 
&nbsp;

Key Points

<ul>
	<li>Mental health is your psychological well-being that not only affects your personal, career and professional life but also your health.</li>
	<li>&nbsp;Healthcare practitioners, including nursing staff, paramedics and all those involved in patient care are an integral part of the health system.</li>
	<li>Data proposed by the World Health Organization (WHO) in 2015 shows that almost 4.4% of the world&rsquo;s population is diagnosed with depression, which is around 320 million people.</li>
	<li>Prevalence of depression was found to be 27% in medical students, 29% in registrars and up to 60% in practicing doctors.</li>
	<li>Risk factors that make healthcare practitioners vulnerable to mental disorders are working longer hours, extensive workload, ever-growing intensity and complexity of the job description, relentless contact with patient&rsquo;s ill health and emergencies, higher responsibilities, post-traumatic stress due to the severity of patient presentation, feelings of guilt, failure, shame and low self-esteem due to fear of failure.&nbsp;</li>
	<li>According to ICD-11, burnout is a phenomenon seen in workplaces where excessive pressure from the office surroundings can drain a person to an extent that they can&rsquo;t function properly anymore.</li>
	<li>Burnout is characterised by being unnecessarily exhausted, having negative thoughts related to the workplace, and major reductions in efficiency.</li>
	<li>In 2017 almost 44% of US physicians showed at least one symptom of burnout, while the number was 54% in the year 2014.</li>
	<li>Many cross-sectional studies signify that burnt-out medical practitioners were twice as likely to make errors, and had a 17% risk of being sued for malpractice.</li>
	<li>Moral injury is defined as the psychological distress that results from actions, or the restricted ability of the practitioner, that may violate their moral or ethical code.</li>
	<li>A survey conducted in the United States in 2016 revealed that although 50% of the female doctors acknowledged the fact that they had met the criteria for a disturbed mental state, they did not consider starting appropriate treatment.</li>
	<li>&nbsp;The treatment plan for depression includes pharmacological and psychological approaches, in which antidepressants are the first-line medications.</li>
	<li>However, any medication should be started only after being officially prescribed by a certified healthcare practitioner.</li>
	<li>Studies also prove that medical practitioners have a higher suicide rate than the general population.</li>
	<li>Summarising 65 studies, involving 97,333 healthcare workers in 21 countries, a high prevalence of moderate depression (21.7%), anxiety (22.1%), and PTSD (21.5%) was present among them during the COVID-19 pandemic.</li>
</ul>

[1] Ignacio Mora-Magaña, Sherman A. Lee, Isaac Maldonado-Castellanos, Carlos Jiménez-Gutierrez, José Mendez-Venegas, Azareel Maya-Del-Moral, Margarita D. Rosas-Munive, Amanda A. Mathis, Mary C. Jobe. (2022) Coronaphobia among healthcare professionals in Mexico: A psychometric analysis. Death Studies 46:2, pages 280-289.

[2] Gong, Yanhong et al. “Prevalence of anxiety and depressive symptoms and related risk factors among physicians in China: a cross-sectional study.” PloS one vol. 9,7 e103242. 22 Jul. 2014, doi:10.1371/journal.pone.0103242