7. Treat mental injury

Early evidence-based management

The following sections are deliberately brief because it is critical that the evidence-based treatment of any mental health condition should be determined only after a comprehensive psychiatric assessment by a clinician experienced in treating mental health conditions such as:

1. Burnout

2. Adjustment disorder

3. Dysthymia

4. Depression

5. Seasonal affective disorder

6. Anxiety

7. Panic disorder

8. Acute stress disorder

9. Post traumatic stress disorder

10. Substance abuse disorder

11. Suicidality

Doctors experiencing work-related mental injury often mask their symptoms by burying themselves in heavy workloads and withdrawing from family and friends. The most common signs of work related mental injury can be persistent poor concentration and difficulty with decision-making. Other common symptoms that can be masked in doctors who have heavy workloads include loss of interest in anything outside work, withdrawal from people, excessive guilt, taking too much personal responsibility for things going wrong, being easily offended or defensive and uncharacteristic anger, frustration or excessive cynicism.

Self-diagnosis is flawed and atypical symptoms may make diagnosis challenging.

Medical workplaces often fail to support doctors with mental health issues, and stigmatise mental illness as a weakness. This often leads to late recognition of problems, inadequate treatment, and crisis situations. Ideally, early treatment should follow a comprehensive psychiatric assessment to address conditions like burnout, depression, anxiety, and PTSD. Effective treatments such as cognitive behavioural therapy (CBT) and mindfulness-based cognitive therapy (MBCT) can help, but doctors working in toxic, hazardous environments require employers to make significant cultural changes in the workplace for optimal recovery.

Not only do many medical workplaces predispose doctors to mental injury, they can stigmatise mental illness as a weakness. Doctors can feel embarrassed about seeking help or fearful of mandatory reporting, leaving them to struggle alone without treatment and reluctant to reach out to other colleagues when feeling vulnerable.

Mental health problems in doctors are often recognised late because we tend to function at work at a high level despite having psychiatric symptoms. Doctors have a tendency not to take sick leave and are well practiced in wearing emotional disguises, often continuing to provide a high standard of patient care at the expense of their own health.

When a mental illness is unrecognised and untreated or undertreated, a doctor may be pushed into crisis, resulting in an abrupt departure from work with little support from the workplace to return to work on lighter duties. This is not only damaging for the doctor affected, but for those remaining in the workplace who make a mental note not to divulge their own ill health.

While work stressors can exacerbate pre-existing mental illness, more often, a previously very healthy doctor will first develop a mental health problem because of the failure of a medical workplace to respond adequately to acute traumatic experiences, chronic mental fatigue, stress and burnout, which predispose them to developing anxiety and depression. Additionally, medical staff rosters often contain little redundancy or flexibility, making taking time off or advance leave requests near impossible.

Vicarious traumatisation, where doctors become distressed after repeatedly being exposed to trauma, is also commonly under recognised. Doctors who have had past histories of exposure to child abuse or domestic violence when younger are at particular risk of being re-traumatized at work.

When a doctor admits the need for time off due to mental health concerns, the medical workplace can be unsupportive because ‘everyone is burnt out and depressed’ – or worse, discriminatory. When a doctor returns to work following time off for a mental illness, there are often no light duties – patient care demands a fully functioning doctor and there is little understanding for doctors unable to pull their weight. A doctor in this situation will justifiably feel a sense of injustice when their mental health condition is ignored or not validated, and they have to prove that they are or have been unwell.

Sadly, many medical workplaces do not recognise the clear benefits of helping doctors to stay at or return to work, both for the individual doctor and the medical workplace, particularly at a time of medical workplace shortage. A mental illness will inevitably relapse when an unwell doctor returns to the same mentally unhealthy environment, there are unrealistic expectations on return to work or the employer does not acknowledge the ongoing sources of stress or trauma.

Many psychologists, psychiatrists and other mental health workers routinely seek supervision and debriefing to work through the vicarious effects of consulting clients. And yet, doctors tend not to reach out for support, debriefing or professional help because of the negative stigma attached to mental illness. This requires an attitudinal change.

Most other first responders have formal training and post-incident interventions to try to minimise the negative impact of repetitive trauma. Doctors tend to go from one crisis to the next, from one day to another, bouncing back from adversity to care for the next patient and console the next anxious relative. All of us can withstand a bad day, a tragic loss or a temporary excessive workload, but when this becomes chronic, we inevitably become triggered. This is why formal postvention after any traumatic experience must become accepted as an essential part of workplace support for doctors as well as other clinicians and non-clinicians.

Formal early optimal mental health treatment is preferable for all types of depression as it results in a better prognosis. The following are examples of effective formal psychological therapies:

• Cognitive behaviour therapy (CBT) is a psychological treatment that recognises thinking patterns (cognition) and behaviour patterns that affect the way we feel. By thinking more rationally about common difficulties, it helps to shift negative or unhelpful thought patterns and reactions to a more positive and solution-orientated approach.
• Interpersonal therapy (IPT) is a psychological therapy that focuses on skills to strengthen personal relationships and overcome relationship and other problems.
• Behaviour therapy/behavioural activation is a major part of cognitive behaviour therapy, but it focuses on planning activities that are pleasant and enjoyable to help overcome social withdrawal and inactivity.
• Mindfulness-based cognitive therapy (MBCT) is different to the treatments above as it helps change our process of thinking, not only the content of our thoughts. It helps us to let go of unhelpful thoughts and emotions, as well as realising that we do not have to respond to every thought or emotion. It is about learning to develop a new relationship to our thoughts and emotions. Mindfulness encourages us to notice when automatic thoughts are occurring and to alter our reaction. It encourages our attention to our attention, without making any judgements about whether thoughts are positive or negative.

In offering formal psychological therapies, it is important to recognise that doctors may find it difficult to reduce critical self-talk, overthinking, over-checking or negative cognitive bias. These common thought habits are part of the risk-averse nature of everyday medical practice. Juggling excessive demands through multi-skilling is a common way to successfully attend to hundreds of patients and thousands of important decisions each week. In response to being challenged to change their thinking patterns, it is common for doctors to become frustrated that they cannot stop ‘faulty’ thinking patterns or intrusive worrying.

Individual psychological therapies may also be counterproductive when doctors are working in toxic cultures, where bullying, harassment or discrimination are being tolerated. For example, helping doctors with anger management skills may not be helpful when anger as a response to injustice, inequity and poor quality of patient care is justified. Some challenging experiences in medicine cannot be solved with ‘rational thinking’. Sometimes it is better to sit with sadness, fear, pain and uncertainty for a while. At other times, it is more effective to challenge a negative workplace culture than to focus on strengthening individual skills.

It can take time for psychological therapies to work because brain habits and conditioning do not change easily. It can help to rest, accept overthinking without judging it as good or bad, and practice muscular relaxation regularly. Seeking out supportive family and friends, planning simple pleasant experiences, and creating worthwhile goals outside of medicine can also help.

If formal psychological therapies do not help, it may help to seek a second opinion. More often, antidepressant treatment may be required after a thorough assessment by an experienced treating family physician/general practitioner and/or psychiatrist.

All workplaces, including largely government funded public hospitals and general practices, are legally obligated to provide psychologically and physically safe workplaces for all employees and contractors including doctors. Directors and senior officers and practice owners can face civil and criminal penalties if they fail to uphold WHS laws which result in mental or physical injuries to employees. Suicide due to work related mental injury should result in investigations by regulators to determine whether fines or imprisonment apply for employers due to industrial manslaughter.

For more information on where to seek help refer to topic 9.

Helpful references

https://www.mentalhealthcommission.gov.au/projects/mentally-healthy-work/national-workplace-initiative

https://www.safeworkaustralia.gov.au/workers-compensation/workers-compensation-psychological-injuries

Mental health - Resources | Safe Work Australia https://www.safeworkaustralia.gov.au/safety-topic/managing-health-and-safety/mental-health/resources

https://www.safeworkaustralia.gov.au/safety-topic/managing-health-and-safety/mental-health

Common mental illnesses

1. Burn-out is defined in the ICD-11 classification is as follows:

It is a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed. It is characterized by three dimensions:

• feelings of energy depletion or exhaustion;
• increased mental distance from one’s job, or feelings of negativism or cynicism related to one's job; and
• reduced professional efficacy.

2. Adjustment disorder according to the ICD 11 classification is: a maladaptive reaction to an identifiable psychosocial stressor or multiple stressors (e.g. divorce, illness or disability, socio-economic problems, conflicts at home or work) that usually emerges within a month of the stressor. The disorder is characterised by preoccupation with the stressor or its consequences, including excessive worry, recurrent and distressing thoughts about the stressor, or constant rumination about its implications, as well as by failure to adapt to the stressor that causes significant impairment in personal, family, social, educational, occupational or other important areas of functioning.

Adjustment disorder may manifest as chronic concentration or sleep problems or increase in alcohol use. Common symptoms include sadness, excessive worry, difficulty concentrating, feeling hopeless, nervous and overwhelmed, not enjoying life, food or social connection, crying, insomnia and suicidal thoughts or behaviours. It often resolves within six months unless the stressor persists. 

3. Dysthymia tends to be less recognised than depression as the symptoms are not as severe or present every day. According to ICD-11, ‘Dysthymic disorder is characterised by a persistent depressive mood (i.e., lasting 2 years or more), for most of the day, for more days than not. In children and adolescents depressed mood can manifest as pervasive irritability. The depressed mood is accompanied by additional symptoms such as markedly diminished interest or pleasure in activities, reduced concentration and attention or indecisiveness, low self-worth or excessive or inappropriate guilt, hopelessness about the future, disturbed sleep or increased sleep, diminished or increased appetite, or low energy or fatigue. During the first 2 years of the disorder, there has never been a 2-week period during which the number and duration of symptoms were sufficient to meet the diagnostic requirements for a Depressive Episode’.

4. Major depression, according to the ICD-11, is ‘characterised by a period of depressed mood or diminished interest in activities occurring most of the day, nearly every day during a period lasting at least two weeks accompanied by other symptoms such as difficulty concentrating, feelings of worthlessness or excessive or inappropriate guilt, hopelessness, recurrent thoughts of death or suicide, changes in appetite or sleep, psychomotor agitation or retardation, and reduced energy or fatigue’.

Antenatal and postnatal depression in women during pregnancy and in the year following childbirth often result from a combination of factors and affect not only the mother but her relationship with her baby and partner, as well as the child’s development.

5. Seasonal affective disorder (SAD) is a mood disorder that has a seasonal pattern related to the variation in light exposure in different seasons over a few years. It is usually found in countries with shorter days and longer periods of darkness, such as in the cold climate areas of the Northern Hemisphere. However, doctors who are not exposed to much sunlight, such as radiologists or those working night shifts, may also be at risk of SAD. Light therapy can be an effective treatment for this form of depression.

6. Anxiety and fear-related disorders, according to the ICD-11, ‘are characterised by excessive fear and anxiety and related behavioural disturbances, with symptoms that are severe enough to result in significant distress or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning. Fear and anxiety are closely related phenomena; fear represents a reaction to perceived imminent threat in the present, whereas anxiety is more future-oriented, referring to perceived anticipated threat. A key differentiating feature among the anxiety and fear-related disorders are disorder-specific foci of apprehension, that is, the stimulus or situation that triggers the fear or anxiety. The clinical presentation of anxiety and fear-related disorders typically includes specific associated cognitions that can assist in differentiating among the disorders by clarifying the focus of apprehension’.

Anxiety disorders are usually caused by a combination of factors, which may include personality factors, difficult life experiences, family history, substance abuse and physical health problems such as thyroid disorders. Stressful events may predispose one to the development of anxiety disorders, including frequent job changes, change in geography, relationship problems, exposure to trauma or verbal, sexual, physical or emotional abuse and/or death or loss of a loved one.

Symptoms of anxiety disorders may include feeling nervous or restless, muscle tension, increased heart rate or palpitations, rapid breathing and sometimes acute hyperventilation, sweating, trembling, feeling weak or tired and difficulty concentrating or thinking about anything other than worrying issues. It is common for people with anxiety disorders to present with other somatic symptoms such as difficulty breathing, gastrointestinal disorders, sensations of choking or a lump in the throat, chest pain and feeling faint or dizzy.

Types of anxiety and other fear-related disorders include:

• persistent excessive or unrealistic worries which interfere with life, work or activities (generalised anxiety disorder)
• uncontrollable compulsions or obsessions, including over-checking, fear of germs, overcleaning, overcounting and repeating routine activities and actions (obsessive-compulsive disorder)
• intense excessive worry related to social situations (social anxiety disorder)
• an intensely irrational fear of everyday objects and situations (phobia)
• recurrent panic attacks (panic disorder)

7. Panic Disorder

According to ICD-11, ‘Panic disorder is characterised by recurrent unexpected panic attacks that are not restricted to particular stimuli or situations. Panic attacks are discrete episodes of intense fear or apprehension accompanied by the rapid and concurrent onset of several characteristic symptoms (e.g. palpitations or increased heart rate, sweating, trembling, shortness of breath, chest pain, dizziness or light headedness, chills, hot flushes, fear of imminent death). In addition, panic disorder is characterised by persistent concern about the recurrence or significance of panic attacks, or behaviours intended to avoid their recurrence, that results in significant impairment in personal, family, social, educational, occupational, or other important areas of functioning’.

Symptoms of a panic attack can include:

• Heightened vigilance for danger and physical symptoms
• Anxious and irrational thinking
• A strong feeling of dread, danger or foreboding
• Fear of going mad, losing control or dying
• Feeling lightheaded and dizzy
• Tingling and chills, particularly in the arms and hands
• Trembling, shaking or sweating
• Feelings of unreality and detachment from the environment
• Fear of losing control, of going ‘crazy’ or of dying are also common

People may start avoiding activities or certain situations to minimise or avoid the possibility of a future attack.

Suggestions on how to cope with a panic attack include:

• Avoid ‘self-talk’ that focuses your attention on your symptoms. Telling yourself to ‘Stop panicking!’ or ‘Relax!’ is usually counterproductive.
• Remind yourself that the symptoms of a panic attack are uncomfortable, but not life-threatening and when you experienced this before, nothing bad happened to you.
• Try to focus your attention on something else. For example, slow your breathing by inhaling in for the count of four, holding your breath for two and exhaling on the count of six. Or try to recall the words from a favourite song.
• Try not to leave the situation; if you allow the symptoms to pass, you will restore confidence in your ability to cope next time.

Formal psychological therapies, relaxation therapy and online mental health resources used in depression are also very effective in managing panic disorders.

8. Acute stress is defined as a short-term justified reaction to a stressful event, such as the onset of a pandemic. It can last between two days and four weeks. After experiencing an episode of trauma, it is a normal reaction to have cycling of strong emotions, usually for about ten days. The cycling may involve memories of the event and avoidance behaviour, sometimes with associated feelings of numbness and denial.

9. Post-traumatic stress disorder (PTSD) according to the ICD11, may develop following exposure to an extremely threatening or horrific event or series of events. It is characterised by all of the following:

• Seek regular debriefing from a skilled GP, psychologist, or psychiatrist, preferably independent from your workplace.
•  Avoid contact with the bully; if not possible, keep interactions brief and professional.
•  Enlist support from trusted colleagues, especially other victims, and address "splitting" promptly.
•  Do your best work, avoid seeking the bully's approval, and refrain from sharing vulnerabilities.
•  Practice extreme self-care outside of work and stay connected with supportive people.
•  Don’t internalise the bully’s irrational behaviour or waste time ruminating on responses.
•  Obtain and follow your workplace's anti-bullying policy and document any objective evidence of bullying.
•  In a complaints process, ensure confidential meetings without the bully present and demand an apology if appropriate.
•  Maintain a constructive relationship with your manager during the process, avoid being defensive, and use facts in your complaint.
•  Be mindful that written communications may be scrutinised in an investigation; remain professional at all times.
•  If the manager is the bully or involved, escalate the complaint to higher management or HR.
•  Leadership must ensure effective occupational health and safety policies are in place, including non-compliance penalties.
•  If patient care is compromised, seek medicolegal support and advice from your MDO.

For more information on where to seek help, refer to topic 9.

• Re-experiencing the traumatic event or events in the present in the form of vivid intrusive memories, flashbacks, or nightmares. Re-experiencing may occur via one or multiple sensory modalities and is typically accompanied by strong or overwhelming emotions, particularly fear or horror, and strong physical sensations;
• Avoidance of thoughts and memories of the event or events, or avoidance of activities, situations, or people reminiscent of the event(s); and
• Persistent perceptions of heightened current threat, for example as indicated by hypervigilance or an enhanced startle reaction to stimuli such as unexpected noises. The symptoms persist for at least several weeks and cause significant impairment in personal, family, social, educational, occupational or other important areas of functioning.

PTSD is characterised by feelings of intense fear, helplessness or horror following a traumatic event. This disorder can develop in the months after witnessing traumatic deaths or suicides as first responders (including doctors), being involved in major motor vehicle accidents, medical emergencies, natural disasters, homicide, family violence, physical or sexual assault, stalking, threats, home invasion or property damage.

Common features of PTSD include the following:

• Repeatedly reliving the traumatic event through unwanted and recurring memories, often with nightmares
• Being overly wound up with insomnia, irritability, lack of concentration and constantly on the lookout for signs of danger
• Avoiding activities, places, people, thoughts or feelings associated with the traumatic event to avoid painful memories
• Feeling emotionally numb or cut off and detached.

After witnessing a traumatic event, we can seek informal debriefing, and if appropriate, professional counselling. However, there are many reasons why doctors do not seek help. We regard traumatic events and delivering bad news as a normal part of our job. Often, we do not have the ability to confide in family and friends about our personal reactions to a traumatic event as patient confidentiality is involved. We may not take the time to attend debriefing or counselling, and instead of resting and taking time out after a traumatic event, we often have to respond to our patient, their family and sometimes the whole community fallout following an incident. In order to deal with an emergency at hand, we learn to put our feelings on hold and delay our own reaction to a traumatic incident.

Complex post-traumatic stress disorder (Complex PTSD) according to ICD-11, is a ‘disorder that most commonly occurs after prolonged or repetitive events from which escape is difficult or impossible. All diagnostic requirements for PTSD are met. In addition, Complex PTSD is characterised by severe and persistent:

• Problems in affect regulation;
• Beliefs about oneself as diminished, defeated or worthless, accompanied by feelings of shame, guilt or failure related to the traumatic event; and
• Difficulties in sustaining relationships and in feeling close to others.’

Doctors, of course, are vulnerable to these disorders by being repetitively exposed to trauma, death or unexpected negative outcomes. Doctors may also be at risk of repetitive vicarious traumatisation after listening to the stories of patients who have experienced traumatic events.

Doctors working in rural and remote areas may experience even greater stress when responding to significant incidents or catastrophes. This is because they are often working in isolation, and sometimes with inadequate or poorly maintained equipment and facilities. Rural doctors often know the victims of traumatic events personally or socially, and may suffer greater self-recrimination and an excessive burden of responsibility. They may be exposed to possible sanctions from community members of rural towns when resuscitation attempts have not been successful. Despite these special challenges, it can be particularly difficult for rural doctors to take time away from busy practices to attend to personal distress and grief.

As doctors, we can underestimate the seriousness of post-traumatic stress disorder. It is essential to seek incident debriefing, and professional help with a family doctor or general practitioner, grief counsellor, psychologist or psychiatrist in a timely manner. Psychotropic medication may be required.

10. Disorders Due to Substance Use include disorders that result from a single occasion or repeated use of substances that have psychoactive properties, including certain medications. Disorders related to fourteen classes or groups of psychoactive substances that have important clinical and public health consequences are included, and categories are also available for other specified substances.

Typically, initial use of these substances produces pleasant or appealing psychoactive effects that are rewarding and reinforcing with repeated use. With continued use, many of the included substances have the capacity to produce dependence. They also have the potential to cause numerous forms of harm, both to mental and physical health.

According to ICD-11, ‘Alcohol dependence is a disorder of regulation of alcohol use arising from repeated or continuous use of alcohol. The characteristic feature is a strong internal drive to use alcohol, which is manifested by impaired ability to control use, increasing priority given to use over other activities and persistence of use despite harm or negative consequences. These experiences are often accompanied by a subjective sensation of urge or craving to use alcohol. Physiological features of dependence may also be present, including tolerance to the effects of alcohol, withdrawal symptoms following cessation or reduction in use of alcohol, or repeated use of alcohol or pharmacologically similar substances to prevent or alleviate withdrawal symptoms. The features of dependence are usually evident over a period of at least 12 months but the diagnosis may be made if alcohol use is continuous (daily or almost daily) for at least 3 months’.

11. Suicidality

Suicidality and suicidal thinking is a psychiatric emergency. 

Please contact your treating GP, mental health professional or call the Doctors’ Health Line 24/7: 1800 006 888 to be directed to your local doctors’ health service. Doctors’ Health Services are free and available across Australia for doctors and medical students.

OR

NSW and ACT: 02 9437 6552

NT and SA: 08 8366 0250

Queensland: 07 3833 4352

Tasmania and ACT: 1300374 377

Victoria: 1300 330 543

WA: 08 9321 3098

Lifeline: 13 11 14

With confidential help you can heal and recover. Please reach out to a family member or friend immediately. You are not alone.

When doctors are affected by serious mental health conditions like bipolar disorder, schizophrenia, substance use disorders, or cognitive decline, early, proactive support is essential due to increased suicide risk and reduced insight. If you think you are suffering from any of these conditions, please access urgent care. Your mental illness can be treated effectively. You can take time off work under the supervision of your treating doctor with a confidential medical certificate without mandatory reporting.

If you believe your colleague is at risk of suicide, please intervene sensitively and with care, not as a treating doctor but as a trusted friend. Your friend requires urgent professional help.

Effective suicide prevention strategies include the following domains and are tailored to the diverse needs within the medical profession:

• Prevention Every doctor needs an annual comprehensive preventive health assessment for routine screening including mental health screening.
• Early intervention Every doctor could consider attending their own doctor at least every six months for routine debriefing for common negative experiences.
• Intervention Every doctor must have their own trusted doctor if they have a mental illness, including major depression, adjustment disorders, eating disorders, obsessive compulsive disorders, anxiety disorders or psychosis.
• Postvention Every doctor should have a trusted doctor in case of crisis or for acute debriefing after exposure to trauma, especially following the suicide of a patient or colleague.

Many studies have highlighted alarming gender differences: higher rates of depression, anxiety, suicidal ideation, suicide attempts, and burnout among female doctors and students. These disparities may be linked to gender-specific factors like intimate partner violence, postnatal depression, eating disorders, PTSD, and workplace bullying or harassment.

Concerns around confidentiality and mandatory reporting are often misplaced—privacy is protected, and reporting usually applies only when there’s a risk of serious harm. Medical institutions must do more to support different groups within the profession and normalise seeking care. Every doctor should have a trusted GP and feel safe reaching out for help.

None of this is easy, but we can prevent the tragedy of doctor suicide — together.

For more information on where to seek help, refer to topic 9.