Annual rates of outpatient visits for mental health and substance use among Ontario physicians increased by 27 percent during the first year of the COVID-19 pandemic, according to a study published in JAMA Network Open. There were 1,038 visits per 1,000 physicians during the first year of the COVID-19 pandemic, compared to 817 in the previous year.
Overall, there were 26,266 mental health visits made by physicians in the year before the pandemic compared to 31,936 in the first year of the pandemic.
The proportion of health care visits by physicians related to mental health also increased. Pre-pandemic, 23 percent of all outpatient visits by physicians were mental health visits. In the first five months of the pandemic, this increased to 28.3 percent, then returned to 23 percent during the next seven months as all-cause visits increased.
Physicians, like other health care workers, faced enormous work-related stressors during the pandemic. These included potentially greater risk of exposure to COVID-19, concerns of infecting their friends, family and colleagues, and challenging workloads.
"Surveys of physicians during the COVID-19 pandemic have found increased reports of depression, anxiety, and burnout. However, because these surveys generally only capture a single point in time and many had a very low response rate, it was unclear how reflective they were of physician mental health overall," said lead author Dr. Daniel Myran, a family physician, public health and preventive medicine specialist, and postdoctoral fellow at the University of Ottawa Department of Family Medicine and The Ottawa Hospital. "To help understand how COVID-19 has been impacting physician mental health we looked at changes over time in health care visits by physicians."
Dr. Myran and his colleagues linked anonymized data from 34,000 practicing physicians in Ontario to the health administrative databases at ICES. They looked at all in-person and virtual care outpatient visits to a psychiatrist or primary care physician that were coded as related to mental health or substance use.
The study's findings suggest the pandemic has placed a considerable strain on the mental health of physicians. "We found a large increase in mental health visits by physicians during the first year of the COVID-19 pandemic, which raises real concerns about worsening physician mental health," said Dr. Myran. "We found that more physicians were accessing mental health services during the pandemic, and that physicians who accessed services did so more often."
"Physician mental health can be a sensitive topic, so protecting physician privacy was a key part of this innovative research. A specialized team ensured all physician data was anonymous and that it was never possible to identify an individual physician," said co-senior author Dr. Peter Tanuseputro, a physician-scientist at The Ottawa Hospital, ICES, and the Bruyère Research Institute and assistant professor at the Department of Medicine, University of Ottawa.
There were no significant differences in increases of mental health visits between men and women, older and younger physicians, urban or rural physicians, or between physicians who cared directly for patients with COVID-19 in the emergency department or admitted to hospital and those who did not.
"We were surprised to see no change in mental health visits by physicians who provided direct care to COVID-19 patients in hospital, as in other studies they reported greater mental health impacts," said co-senior author Dr. Manish Sood, a physician-scientist and Jindal Research Chair for the Prevention of Kidney Disease at The Ottawa Hospital, and associate professor at the University of Ottawa. "We did notice that this group of physicians, which included individuals in critical care, emergency medicine, and internal medicine, already had lower rates of mental health visits pre-pandemic. This could mean they have greater resilience, more reluctance to seek care, or have work schedules that are a barrier to seeking care. However, it's important to note that our study only looked at the first year of the pandemic, and the situation has changed since, particularly with the omicron variant now putting incredible pressure on the healthcare system."
The researchers note that the expansion of virtual care options during the pandemic may have played a role in increased mental health visits by physicians.
"There is a lot of stigma in the medical profession when it comes to mental health and accessing services," says Dr. Tanuseputro. "It's possible that virtual appointments reduced some of these barriers because they fit more easily into a physician's schedule and were less visible to their colleagues."
Aside from insights into the COVID-19 pandemic, the research team also noticed some general patterns about mental health visits by physicians when they looked at the over 50,000 visits included in the study.
First, female physicians had higher rates of mental health visits compared to male physicians (1,059 per 1,000 physicians vs. 596 per 1,000 physicians), which is consistent with what's seen in the general population.
Second, some specialties had far more mental health visits than others. For example, psychiatrists had the highest rate of annual visits at 3,442 per 1,000 physicians while surgeons had the lowest rate of visits at 370 per 1,000 physicians.
"Not all physicians are the same, and some specialties face different pressures and realities. The differences we saw between specialties may be explained by specialty-specific attitudes towards seeking care for mental health," said Dr. Sood. "For example, previous studies have shown that many psychiatrists report routinely attending therapy for both personal and professional reasons, while other work has highlighted that surgeons are less likely to seek mental health care due to perceived stigma. These findings suggest on ongoing need to destigmatize physician mental health, and to encourage physicians to seek mental health care when they need it."
"While the pandemic may have exacerbated physician mental health concerns, our study suggests that many of these concerns predate the pandemic," said Dr. Myran. "Going forward, mental health interventions for physicians should focus both on stressors specific to COVID-19 as well as pre-pandemic factors, many of which may require system-level changes and reinvestment in the healthcare system."
"Physicians were experiencing burn out from overburdened and under-resourced health systems long before the pandemic," says Dr. Katharine Smart, President of the Canadian Medical Association. "This study illustrates the impact of the pandemic on an already exhausted physician workforce. When we talk about health system capacity, we are often talking about people—the physicians, nurses, and many other health professionals who care for us all. We must prioritize their health and well-being as we navigate future waves of the pandemic and plan for a post-pandemic health system."