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Mental health in health professionals

“The qualities which make a good and caring doctor are also the qualities which place us at higher risk of mental illness.” Rebecca Black, BMJ Opinion, March 25, 2019.

If today you are struggling, please seek help.
Talk to a friend or a colleague, speak to your GP or one of the many support organisations at the end of this document.
You are not alone, and help is available.

Despite being a rewarding and highly sought-after profession, a medical career entails a gruelling training pathway, and involves entering into a complex medical culture with a constant battle to achieve a work–life balance.

In recent years, there has been substantial debate and concern about the mental health of health professionals in the UK, including the effects of work-related stress, burnout and mental health problems such as depression and anxiety, and substance misuse.

The risk is greater than that of the general population and is increasing over time in line with the growing demands and complexity of the job, a faster pace of work and diminishing resources.

This article was reviewed in November 2024. It is an amalgamation of the following publications and a sprinkling of team opinion!

Mental health and wellbeing in the medical profession: BMA report, October 2019.
Caring for doctors, caring for patients (GMC 2019).
The state of medical education and practice in the UK: The Workforce Report (GMC 2019).
What could make a difference to the mental health of UK doctors? Review by the Society of Occupational Medicine (Sept, 2018).
Doctors and suicide (BJGP 2018; bjgp18X695345).
Preventing suicides among doctors; Rebecca Black: BMJ opinion, March 25, 2019.

How common are mental health problems in health professionals?

Doctors report substantially higher rates of psychological distress and suicidal thoughts than the general population.

GPs are even more vulnerable to burnout (particularly emotional exhaustion), work-related stress and common mental health problems than doctors in most other specialties.
This has been linked to the increased demands placed on primary care, along with diminishing financial and staffing resources.
The pressure of working through and beyond COVID-19 has increased work-related stress and rates of burnout among health professionals (GMC National Training Survey, 2022 results).
Trainee and junior doctors are also at particular risk. In the UK, a third of trainee doctors report that they experience burnout to a high or very high degree (BMJ 2022;378:e070442).
We are less likely to seek help, and diagnosis is more likely to be delayed.

Nurses are also at considerable risk of work-related stress, burnout and mental health problems such as depression and anxiety. The rate of suicide among female nurses is also greater than the general working population. Rates of poor mental health appear to be increasing due to rising demands, staffing shortages and diminishing resources. Satisfaction with job demands, control and role clarity are lower among nurses than other professional groups in the UK, and are strongly linked to stress and burnout (Society of Occupational Medicine 2020, Mental Health and Wellbeing of Nurses and Midwives in the UK).

Mental health problems most commonly affecting clinicians

There may not be clear boundary lines between each of these groups of conditions. The bottom line is, if you are struggling, please seek help; you are not alone.

Work-related stress	Burnout	Psychiatric conditions
‘An adverse reaction to excessive pressures or other types of demand placed on them.’ Healthcare workers consistently report higher levels of stress, anxiety and depression related to their work than any other group. GPs working in the UK currently find their work more stressful than those working in other countries. Work-related stress can occur for many reasons. You may find the article on stress management helpful.	We are at high risk of burnout, starting as early as the first year of GP training. Burnout is characterised by: Emotional exhaustion. Depersonalisation. Reduced personal accomplishment. This is such a common and important topic that we have written a separate article – read this now if you think you or a colleague may be affected.	“And, to be honest with you, that kind of er — the best way that I could describe that is that it’s kind of like a dark shadow that’s in the corner of the room […] I basically felt like I was treading water but drowning slowly.” – GP (BMJ Open 2018; 8(1):e017361). This encompasses all mental health conditions, and they may not be directly related to our working role (although working conditions will clearly have an impact on our mental health!). Around 6000 new patients registered with NHS Practitioner Health in 2022. Most reached the threshold for a formal diagnosis of mental illness. The most common problems were moderate to high anxiety and depression, and one-third reported thoughts about ending their life or had made plans to kill themselves before seeking help (Practitioner Health, Mental Illness and Suicide). 93.8% (!) of GPs were classed as likely to be suffering from a minor psychiatric disorder in a cross-sectional survey (BJGP 2019;69(684):e507). Suicide risk is also higher compared with the background population: 1.41-fold increased risk for men and 2.27-fold increased risk for women.

What causes mental health problems in clinicians?

A wide range of factors can increase the risk of mental health problems in clinicians. Being aware of these can help us evaluate our own risk and spot colleagues who might be having difficulties:

Demographics	Differences in age/sex have no consistent relationship. Black and minority ethnic doctors may be more likely to experience workplace bullying and harassment. International medical graduates are at greater risk of stress due to less social support because of separation from families.
Personality/coping style	Individuals with the following personality traits/coping styles may be more at risk (and some of these tend to cluster in the medical profession!): Neuroticism (experience intense emotions with less emotional control/more emotional reactivity). Introversion (tendency to be concerned with our own thoughts/feelings). Tendency to perfectionism/self-criticism (often unrealistic expectations of self!). Workaholism. Over-commitment. Need for control and approval of others.
Work factors	“I think when you’re dealing with really difficult problems, you’re dealing with lots of sadness, you’re dealing with loads of stuff that you can’t change, and people bring in and they park with you their problems and their sadness, and they feel better for that and you feel worse.” – GP (BMJ Open 2018; 8(1):e017361). The GMC report identified an ABC of doctors’ needs: Autonomy/control: having control over our work lives. Belonging: being connected to others, being cared for and caring for others in the workplace, and to feel valued, respected and supported. Competence – being effective and able to deliver high-quality care. There are current challenges in these being met! GPs have a higher risk of mental health problems than most other specialties. There is an increased risk associated with: Early career stage (junior doctors). Lack of job satisfaction or regrets about career choice (BMJ 2022;378:o2157). Perceiving specialty to be low prestige may contribute to depression. Medical complaints increase the risk of burnout, mental health problems and suicide risk. Distress is usually proportionate to the severity of the complaint.
Work–life balance	Adequate time to physically and mentally recover from the impact of work is essential in protecting mental health. Many GPs struggle to achieve this. There is much more information on this in the Burnout in health professionals and Building resilience articles. NOTE: working part time does not automatically reduce these risks as intensity of work rises and ability to take breaks may be even less.
System/organisation factors	These are consistently the strongest predictors of mental health problems in UK doctors. Specific issues cited are: High perceived workload. Work intensity. Lack of autonomy and control. Feeling unappreciated and poorly rewarded. Lack of support in the workplace. There is also often a disconnect between clinicians’ expressed values (what they see as meaningful and important about their work) and the (re)structuring of the health service. That much of this is outside our circle of influence is difficult and can lead to almost ‘learned helplessness’. Working out what we can and cannot influence can be helpful – but needs time and clear headspace!

Has primary care workload changed and does that matter?

Yes.

Perception of intensity, or pace of work, has a stronger effect on the mental health of clinicians than objective workload. This affects us in primary care in many ways. A retrospective cohort study in the BJGJ found that (BJGP 2024; 74(747):e659):

In primary care, the overall clinical workload has tripled between 2005 and 2019, with sustained increases in consultation rates and duration apparent until 2014.
≥3 serious chronic conditions increased from 9.7% in 2007 to 16.1% in 2019) has led to capacity constraints. The rates of increase in direct clinical contact have plateaued as the system appears to be nearing (or exceeding) saturation. However, higher levels of administrative work make up for this decline in face-to-face or telephone consultations.
Analysis of 2023 workforce data showed an 11.8% fall in the number of full-time equivalent GPs, yet there has been a 41% increase in the number of patients per GP since 2014.

The proportion of NHS funding directed to general practice has declined from 10.6% in 2005/2006 to 6.8% in 2020/2021, with secondary care services being given a greater share of healthcare spending.
71% of GPs in the UK found their job to be very or extremely stressful.
The 2022 National GP Worklife Survey reported that rates of job satisfaction decreased significantly between 2019 and 2021. Respondents reported greatest satisfaction with their colleagues, and least satisfaction with the hours of work and the (lack of) recognition received from carrying out good work. Other stressors included increased workload, increasing demands from patients, having insufficient time to do the job justice, paperwork and dealing with problem patients.

This increase in workload is compounded by other factors, including:

Changing patient expectations: increased self-diagnosis and a more ‘consumer’ 24/7 culture.
Increased focus on accountability and regulations, leading to a greater need for documentation, administrative tasks and evidence-gathering procedures.
Understaffing due to difficulties in recruitment and retention of key staff.

This leaves us feeling pressured for time, overwhelmed and anxious about ‘missing something important’. We may feel frustrated that we are unable to perform the role to the best of our abilities.

Insufficient time may lead to a reduction in the quality of patient care and an unacceptable level of risk, which is also likely to be a cause of professional anxiety.

This is all compounded by limited opportunity for clinicians to interact with each other through meetings, handovers or social events; this is an increasing problem in primary care which leads to a lack of collaboration and a growing sense of professional isolation, and is particularly problematic for locums.

The impact of the pandemic on clinician wellbeing

The COVID-19 pandemic necessitated substantial changes in primary care as clinicians rapidly changed working practices and managed evolving guidelines amid uncertainty and personal risk. Challenges included coping with rapid change, risk of infection, remote working, high levels of demand/an increasing workload, reduction in face-to-face patient care, and vaccination delivery.
Research suggests that these stressors had a marked negative impact on clinician psychological wellbeing, with an increase in stress and burnout in clinicians (BJGP 2022;72(718):e316-e324). There was a reported 40% increased use of mental health support services across all health professional groups during the pandemic (BJGP 2022;72(718):e325).
Personal experiences of illness or death among colleagues due to COVID-19 have also been associated with higher rates of emotional exhaustion and reduced sense of personal accomplishment among clinicians.
Importantly, female GPs reported worse outcomes on all aspects of psychological wellbeing. Women may be more open in discussing difficulties and seeking support, but may also have experienced greater pressures during the pandemic because of wider caring responsibilities.
Despite the increased risk of COVID-19 among some ethnic minority groups in the UK, there was a lack of evidence exploring the impact of ethnicity on measures of psychological wellbeing.

The consequences of mental health difficulties in health professionals

“Don’t suffer in silence; seek help. If you or someone you know might need help with a mental health concern, including stress or depression, or an addiction problem, help is available.“ (Claire Gerada, BJGP 2018)

Poor mental health among doctors has wide-ranging implications, both for the individual and patient care.

Impact of mental health difficulties	Consequence and what, if anything, can be done?
Working while sick: ‘presenteeism’	We under-report ALL illness and take 1/3 fewer sick days than other health professionals. This is exaggerated further when it comes to mental health conditions. Why do we do this? Perceived stigma of mental illness within the profession! Perception that sick leave is a sign of weakness/incompetence. Fear about lack of confidentiality and privacy. Fear of ‘landing your colleagues in it’ because of lack of cover. Sense of duty to patients and need to provide continuity. Concern about registration and fitness to practice. The concern is that often, when diagnosed, we are sicker, and there is a risk of errors and adverse patient outcomes. Please seek help if you are unwell. ‘Put on your own oxygen mask first’. Ultimately, your colleagues, patients and family will thank you for it. If we have had mental health problems in the past, we can help our colleagues seek help by being willing to talk about our own story. Does your work team trust each other enough to practice this kind of vulnerability regularly? How could you change things to make this happen?
Retention/staff turnover	The 2021 National GP Work–Life Survey found that over a third (33.4%) of GPs reported a considerable or high likelihood of leaving direct patient care within the next 5 years. This figure was even higher (60.5%) in those aged 50y or over. For younger GPs (aged <50y), the proportion with a high intention to leave was lower (15.5%), but is still at its highest ever level compared with previous surveys. Factors that can encourage retention include: Job satisfaction and good working conditions. Sub-specialisation. Portfolio careers. Recognition and respect. NOTE: these intrinsic factors were all more important than extrinsic factors like money! See the articles on Building resilience and Burnout in health professionals for more suggestions. How can you look after each other as a primary care team? Do you make space to talk about this? Could you? See suggestions below.
Patient outcomes	The 2019 GMC report states that: Doctors with high levels of burnout had between 45% and 63% higher odds of making a major medical error. Interestingly, few other studies have investigated the direct link between mental health in doctors and patient care. In one study of 556 GPs, even those with high levels of burnout showed no impact on patient-rated and independently-rated interpersonal skills or patient-centredness. This shows, potentially, our incredible work ethic at maintaining a high level of functioning despite significant personal challenge. But this comes at a cost and requires considerable emotional energy – likely to exacerbate burnout and mental health problems in the long term!
Suicide	A systematic review which looked at suicide in doctors from the 1960s until March 2024 (BMJ 2024;386:e078964) found that suicide rates for physicians have decreased over time, and that the suicide rate for male doctors is currently no higher than the general population. However, for female doctors, rates of suicide remain higher than the general population, with a risk ratio of 1.76 (CI 1.4–2.21). A high level of heterogeneity exists across studies, suggesting that the risk may vary among different physician populations. Further research is needed to identify specialities or groups at higher risk of suicide. A BMJ editorial explored some of the reasons that clinicians may be vulnerable to suicide (BMJ 2024;386:q1758). Risk factors include family history of suicide, past experiences of trauma or abuse, isolation, mental illness and drug misuse. Personality traits such as perfectionism, obsessiveness and competitiveness, when combined with highly-stressful work environments, can lead to guilt, low self-esteem and a persistent sense of failure. Some clinicians may also have greater access to potentially-dangerous drugs, including opiates and anaesthetic agents. Being the subject of a complaint or regulatory process can also be a major contributing factor to mental illness and suicide in clinicians. Receiving a complaint leads to a significantly increased risk of depression and to thoughts of self-harm or suicide. Distress and suicidal ideation increased with the severity of the complaint, and levels were highest after a referral to the regulator. The protracted nature of regulatory processes may also play a role. If you are going through a complaint, seek support (even if you don’t yet feel you need it); if a colleague is going through a complaint, proactively offer support.

How can we improve mental health in clinicians?

“If they [doctors] are to give their all to patients and make patients their first concern, then the quid pro quo is that the system (the NHS) cares for them and does everything morally, ethically, and practically that it can to remove or, at the very least, reduce the causes of their distress.” (Clare Gerada, BJGP 2018)

There are effective ways to improve the mental health of doctors. They can be split into:

Primary prevention: prevention of workplace stress and burnout.
Secondary prevention: personal resilience and self-care (discussed in Burnout in health professionals and Building resilience articles).
Tertiary interventions: treatment and rehabilitation.

Primary interventions: prevention of workplace stress and burnout

Primary interventions have been shown to lead to larger and more consistent improvements in preventing mental health problems than secondary initiatives. These suggestions are things that we can implement as individual practices. Clearly, NHS-wide changes are also needed.

Intervention	Examples
Mentoring/coaching and positive team working	Formal peer support networks and groups (some of us may have this in our practices or through practitioners’ groups from VTS, or even Balint groups). Coaching or mentoring may be available through your local deanery/appraisal team. Structural planning of the day to ensure everyone can attend coffee breaks, lunch breaks and team meetings.
Schwartz Rounds®	Developed in the USA: one-hour session held monthly as a safe space to share and reflect on social/emotional and ethical challenges of work. 3 or 4 individuals from the multidisciplinary team share an account of their experience in delivering patient care. There is then a facilitated discussion with the audience based on their reflection and insights. These are a source of support, and lead to increased empathy and understanding. In primary care, a well-chaired significant event meeting could serve this purpose.
A ‘culture’ of positive mental health	The culture of our organisation is set in the conversations we have. If we talk about and value self-care, help-seeking and ‘vulnerable leadership’ where we can be open about our own challenges, we can reduce the stigma associated with mental illness in clinicians. This should start as soon as we begin our training!
Allow flexible work patterns/‘job crafting’	Flexibility of working patterns seems to be more important than simply reducing hours worked. Sometimes, we might be able to think more creatively about how our days are organised. Who said the only way is 2 clinics with visits and admin crammed in the middle and the end? If this doesn’t suit you, experiment with a change?

Secondary interventions: personal resilience and self-care

This is discussed in more detail in the Building resilience article but should not be seen as a panacea for addressing as many of the causative workplace factors as possible.

Tertiary interventions: treatment and rehabilitation

Clinicians need medical, psychological and occupational health support to get better. They may need their working conditions to be adapted to their needs for a prolonged period of time.

Following best practice in dealing with absence applies as much to mental health problems as physical disorders; it should include an emphasis on maintaining confidentiality, and explicitly look at how to overcome any barriers to return to work. This may be best achieved by specialist occupational health services, although these are rarely available in most areas.

Practitioner Health is a free, confidential NHS service. It provides comprehensive assessments and treatment of a wide range of mental health and addiction issues, and offers support with returning to work after absence. Treatment may include CBT, brief psychotherapy, medication and provision of fit notes. Most consultations take place online using video technology.

Preventing suicide in clinicians

Clinicians are human. We should not have to sacrifice our lives for our professions.

What can we do to prevent the most tragic outcome for health professionals with mental health problems?

A BMJ editorial (BMJ 2024;386:q1758) highlighted some ways that we can act to reduce mental distress and suicide risk among doctors. While this paper focused on doctors, these recommendations apply to other groups of clinicians:

Pay attention to the basic emotional and psychological needs of staff, including working patterns that allow a sensible work–life balance.
Address issues in the workplace that are conducive to poor mental health, including lack of teamwork, bullying, a culture of naming and shaming, and lack of support when things go wrong.
Provide access to early intervention and confidential mental health treatment services and psychological support, particularly during periods of high stress such as during the investigation of complaints or serious incidents.
For female clinicians, who remain at a higher risk of suicide than the general population, it is also important to understand more about likely contributing factors (such as discrimination and sexual harassment), and to develop gender-specific interventions to protect female clinicians’ mental health.

Coping with the suicide of a colleague

Grief is a lonely experience, and especially so following a suicide.

The repercussions following suicide are immense, and doctors will inevitably be hugely affected by the suicide of a colleague. For many, co-workers are like an extended family. They may feel guilty for not providing their colleague with more support, and unfairly blame themselves for missing tell-tale signs of depression, anxiety or burnout, or vital clues that someone close to them was about to take their own life. More often than not, they work within the same health system as their friend/colleague/relative, and may be under the same organisational pressures.

Following a suicide, colleagues may experience mental health problems such as anxiety and depression. Far from being a one-off tragedy in itself, suicide can cause guilt, shame and higher rates of suicide in loved ones left behind.

Interventions to provide support for bereaved colleagues can help by providing accurate information about the death of a colleague and avoiding misinformation. Staff are likely to need support to cope with a potentially-traumatic experience, with a clear aim of preventing other suicides.

A final thought…

Although this makes sobering reading, it is the reality that many of us are facing in our day-to-day lives. There is some good news, however; the wellbeing and mental health of doctors is increasingly being recognised as a crucial issue which is key to delivering good, safe and effective care to patients. While there is help and support out there, sometimes we are our own worst enemies and fail to make the most of it. We do not take the time off that we need, and we decline to take sick leave, to access help and to admit when we are struggling.

If you do just one thing this month, we suggest you take an inventory of your own mental health. If you are in the 93% of GPs who might be suffering from stress or any other mental health problem, please look after yourself and get the help needed to enable you to thrive both at work and at home. Practicing self-care and compassion will ensure that you are able to spend many more years delivering the excellent, empathetic and compassionate care that our patients deserve.

Mental health in health professionals

As GPs, we are at greater risk of burnout, work-related stress and mental health problems than the general population and other doctors.

All doctors, but particularly females and juniors, have an increased risk of suicide, and this is strongly associated with experiencing a complaint.

Personality factors and organisational factors, particularly high perceived workload, increase the risk.

Seek help if you need it! Delays in recognition and treatment have worse outcomes.

Look at factors within your control – can you implement changes in your practice culture to look after each other and reduce the stigma of mental illness? This is mainly about the conversations we have and a willingness to be vulnerable.

Independent confidential mental health and occupational health support are important. Use your own GP, or, if that is not possible/desirable, there are lots of suggestions below.

Useful resources:
Websites (all resources are hyperlinked for ease of use in Red Whale Knowledge)

NHS Practitioner Health (a free and confidential NHS primary care mental health and addiction service with expertise in treating health and care professionals)

For other sources of support, see our associated article: Support for health professionals.

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Mental health in health professionals