Poor psychological health among Hungarian physicians

Information about the prevalence of psychological morbidity among physicians is limited. Nevertheless, available data suggest that physicians may experience major psychiatric disorders such as depression, or burnout, anxiety, substance abuse disorders, and symptoms of general psychological distress such as sleep disturbance, tiredness, and muscle aches (Firth-Cozens, 2001; Robinson, 2003). For example, a study from the United Kingdom reported high prevalence of psychological morbidity including anxiety (54%) among specialists (Caplan, 1994). In another study, 27% of the respondents scored high (4 points or higher) on the General Health Questionnaire’s 12-item version (GHQ-12), suggesting likely psychiatric morbidity (Ramirez, et al., 1996). In line with these results, our findings also show high prevalence of psychological morbidity among physicians in Hungary. In particular, more than 50% of physicians reported anxiety and associated somatic symptoms (e.g., sleep disturbance or tiredness).

A number of studies explored the prevalence of depression among physicians at various stages in their career. The importance of continued empirical research on the prevalence and psychosocial characteristics of depression among physicians is heralded by the fact that according to data 21% to 64% of doctors’ admissions to psychiatric hospitals are due to depression. A study by Wachtel, Wilcox, Moulton, Tammaro, and Stein (1995) reported that the prevalence of depression in a sample of physicians was between 3%

and 10%. Other studies found a rate of 10% to 20% for depression among doctors (Ford, Mead, Chang, Cooper-Patrick, Wang, & Klag, 1998; Frank & Dingle, 1999). Our results about the prevalence of self-reported depression among physicians (around 8%) are comparable with these findings.

Although gender differences in perceived psychological distress among physicians have been described (Jenkins, et al., 1997), our study showed no significant difference in the prevalence of anxiety or depression among female and male physicians. We originally hypothesized that female physicians would report higher prevalence of perceived distress outcomes (e.g., psychological and somatic morbidity) compared to men due to

higher demands in their roles and consequently higher level of stress (Nazroo, et al., 1998). Although our study did identify a significantly higher level of job strain among female physicians compared to men, contrary to our hypothesis, it has not translated into higher prevalence of psychological diseases (with certain exceptions that are discussed below) reported by female physicians. Lack of gender disparity in the prevalence of anxiety and depression among female and male physicians may in part be due to methodological limitations in the assessment of these diseases (self-report measures and lack of validated instruments such as the GHQ or the Beck Depression Inventory) or to the fact that male physicians may experience additional stressors (other than work-family conflict) that increase the prevalence of stress-related anxiety and depression. Another potential explanation may be that the different forms of work- family conflict (i.e., stress or time based work-to-family or family-to-work conflict) experienced by female and male physicians may have differential impact on the development of psychological and somatic morbidities. These hypotheses would require further research.

According to some studies, depression among physicians appears to be as prevalent as in the general population. For example, in a prospective study in the United States, the lifetime prevalence of self-reported clinical depression among physicians was found to be 12.8%, which is almost the same as that among males aged 45-54 (12%) (Ford, et al., 1998). Another study showed that the lifetime prevalence of self-reported depression among female physicians in the United States was 19.5%, which is comparable to that in the general female population and among female professionals (Frank & Dingle, 1999). Other data, however, show that psychological morbidity is more prevalent among physicians than in the general population (Töyry, et al., 2000). In addition, research by our group also found higher prevalence of depression among male and female physicians compared to other professional groups or the normative population (Győrffy, Ádám, & Kopp, 2005a). A recent longitudinal study in Hungary about the prevalence of psychological morbidity and its stressor predictors showed high prevalence of depression among employees. This study identified job strain as a significant predictor of clinical depression in the whole population (Jakab & Lázár, 2007).

Attention to depression is of critical importance as depression has been identified as a major risk factor of suicide among physicians (Silverman, 2000). The suicide rate among physicians is 50% higher than that of the general population (Zabow, 2004).

Although suicide incidence rates vary depending on gender and country, female physicians in general have been reported to have an increased relative suicide risk when compared to female professionals. Among physicians as a whole, male physicians appear to be at higher risk of suicide compared to women doctors based on absolute numbers and incidence rates. However, a recent review suggests that the suicide rate of female physicians might be close to that of their male counterparts (Lindeman, Laara, Hakko, & Lonnqvist, 1996).

Our results show that the prevalence of self-reported suicidal ideation (reported as other psychiatric/psychological diseases) among physicians was around 2%. We argue that under-reporting may be accountable for the low prevalence of certain psychological diseases including suicide or substance abuse reported by physicians in our study. This is further supported by our previous research (Győrffy, Ádám, Csoboth, & Kopp, 2005b), which shows high prevalence of suicidal ideation among physicians. This study also found that the prevalence of suicidal ideation among female and male physicians is more than 60% higher than that in the normative population (20.3% and 12.1% for female and male physicians, respectively, vs. 12.3% and 7.6% for females and males in the normative population). Furthermore, the prevalence of suicidal ideation among female physicians was as much as that among male doctors (Győrffy, et al., 2005b).

Although the prevalence of self-reported substance abuse was negligible in our sample (0.5%), evidence suggests that it may be higher among Hungarian physicians than that reported in our current study. According to the data in one of our recent studies, physicians’ use of tranquilizers was more prevalent (up to 8%) than that in the normative population (up to 4%) (Ádám, Győrffy, Harmatta, Túry, Kopp, & Szényei, 2008). Substance abuse is an important cause of physician impairment (defined as unfit to perform work due to mental illness or substance misuse), with a lifetime prevalence of about 10% to 15%, and alcohol dependence, which varies from 8% to 15%. The most

common drug of abuse is alcohol, followed by opiates (Broquet & Rockey, 2004). Drug abuse has been shown to be facilitated by self-prescribing (Farber, Gilbert, Aboff, Collier, Weiner, & Boyer, 2005; Hicks, Cox, Espey, Goepfert, Bienstock, Erickson, et al., 2005).

5.3.1.1 Manifestation of physician burnout

In our study, burnout (emotional exhaustion, depersonalization, and low personal accomplishment) emerged as the second most prevalent psychological morbidity reported by physicians. Our findings demonstrate that female physicians experienced significantly higher mean levels of emotional exhaustion compared to male physicians.

In addition, significantly more female than male physicians scored high on the emotional exhaustion subscale of the MBI. These results are the first to show high psychological morbidity among Hungarian female physicians in terms of burnout.

There is a growing body of evidence about the increased prevalence of burnout among medical professionals (Ramirez, et al., 1996; Grassi & Magnani, 2000; Shanafelt, et al., 2002; Visser, Smets, Oort, & de Haes, 2003). The comparison of our results with those from studies conducted among medical doctors in different countries shows that the proportion of Hungarian physicians in general (irrespective of specialties and gender) who experience high levels of emotional exhaustion or depersonalization is similar to that of British surgeons but lower than that of Italian or American doctors. Hungarian physicians appear to report low personal accomplishment more frequently than their colleagues in other countries (35% vs. 13-31%, respectively) (Ramirez, et al., 1996;

Grassi & Magnani, 2000; Shanafelt, et al., 2002) (Table 19). Although personal accomplishment appears to be less closely related in structural models to emotional exhaustion and depersonalization, which are thought to have a central but not exclusive role in the development of burnout, it may develop independently and in parallel with exhaustion (Leiter, 1993). This may be observed in certain organizational environments characterized by role conflict or work overload that on the one hand intensify emotional exhaustion and on the other hand simultaneously reduce personal accomplishment

through disabling participative decision making and social support, which serve as significant facilitators of personal accomplishment (Maslach, et al., 1996). On the basis of our findings and those by Schaufeli and Janczur (1994) about the high prevalence of low personal accomplishment among medical professionals, it would seem plausible to assign a more central and independent role for the personal accomplishment dimension of the MBI opposite or in addition to the emotional exhaustion and/or depersonalization dimensions in defining burnout levels among physicians in certain societies, like the Hungarian, where participation of women in the work force is significant and the family plays a more central role.

Table 19: Cross-cultural comparison of the prevalence of high levels of burnout among medical professionals.

High emotional

exhaustion score (%)

High

depersonalization score (%)

Low personal accomplishment score (%)

Hungarian physicians (2006) N=420

25 17 35

Italian general practitioners (2000)^a N=182

32 27 13

British surgeons (1993-94)^b N=161

27 19 32

American general internal medicine residents (2001)^c N=115

53 64 31

a Grassi and Magnani, 2000.

b Ramirez, et al., 1996.

c Shanafelt, et al., 2002.

Our findings about significant gender differences in self-reported burnout experienced by physicians confirm those that have shown higher emotional exhaustion levels for women and higher levels of depersonalization for men (Maslach, et al., 1996). Similarly, research by Linzer, McMurray, Visser, Oort, Smets, and de Haes, (2002) also revealed gender differences in physician burnout in the United States and identified more work hours and less work control as potential predictors of higher levels of burnout among female physicians in the United States compared to men. Of note, the same research suggested that the lack of gender differences in physician burnout found in the Netherlands might be attributed to higher work control and less work hours among female physicians compared to men. Less work hours seen among Dutch female physicians may be explained by the high proportion of female physicians (75%) working part-time in the Netherlands (Heiligers & Hingstman, 2000). Similarly, the proportion of female physicians working part-time in other Western countries is around 20% to 50% (McMurray, Cohen, Angus, Harding, Gavel, Horvath, Paice, Schmittdiel,

& Grumbach, 2002). Conversely, our data show that only around 3% of female physicians in Hungary worked part-time. Part-time employment in Hungary among female workers is less than 6% and is the lowest in the European Union. Based upon our results and those of Linzer, et al. (2002), it is not unreasonable to suggest that the lack of part-time employment and the significantly higher number of workload, job demands, job stress as well as significantly lower support in the workplace may have contributed to the higher levels of burnout among female physicians in Hungary.