Living in a culture where doctors are seen as healthy people who treat sick patients creates a paradox for a doctor moving into a patient role. Accordingly, many doctors do not make use of usual channels for accessing healthcare1
and continue to treat themselves despite guidelines to the contrary.2
Much expert opinion about barriers to healthcare for doctors is available in the literature, but the quality of the data available is limited.3
Moving into the role of a patient with psychological illness has been described as particularly challenging.4
There is increasing concern about doctors' mental health and effectiveness in accessing mental-health services.5–7
Out of this concern, a literature documenting, researching and recommending interventions for medical students and doctors is emerging.8–11
The research base is limited. Individual case information has been made available.12 13
Questionnaire surveys provide important information about attitudes,14 15
but the depth and complexity they are able to contribute to our understanding are limited. We need more understanding about how doctors do and do not access mental healthcare. This is likely to be helpful in addressing barriers to healthcare for doctors. Moreover, Kay et al3
point out similarities between doctors and the general population in accessing mental healthcare. Thus, increasing understanding of barriers for doctors accessing mental healthcare may have implications for the wider population. Likewise, research in the general population has demonstrated the importance of family and community contacts in facilitating access to mental-health services.16
So, we need more understanding of how this may also be important for doctors.
The aim of this paper is to develop a more in-depth understanding of how doctors do and do not access mental healthcare from the perspectives of doctors themselves and people they have contact with through the process.
The data presented in this paper are drawn from a more wide-ranging multiperspective qualitative study on doctors as patients of psychiatrists.
Recruitment was challenging. We sought information-rich participants, doctors with experience as a patient of a psychiatrist who were fluent in English and had capacity to consent. We approached seven doctors who were known to one or other of the researchers through personal or collegial contact as having had experience as patients of psychiatrists. Five agreed to participate. Formal channels such as the Medical Council and support providers to doctors declined to participate because of concerns about confidentiality. One of the researchers (PR) had been involved in developing an informal support network for doctors with mental-health issues, and three potential participants were identified via this role. Two agreed to participate. She also put out an invitation to participate in the study to members of a currently developing local internet site for peer support for doctors. One member specifically declined, and there were no other responses. Two were identified and referred to the researchers by other participants. One self-identified to the researchers following listening to a presentation of preliminary data. One was referred by a treating psychiatrist.
Eleven doctors, five men and six women, were interviewed. The age range was 32–54. The number of years since graduation was 5–28 years. Diagnoses identified by the doctors themselves were Depression, Psychotic Depression, Bipolar Disorder, Generalised Anxiety Disorder, Brief Psychotic Episodes, Bipolar disorder with a differential diagnosis of Schizophrenia, Borderline traits and Poly Substance Dependence.
Nine were working in clinical medicine at the time of the interview, five as specialists. Six were working in psychiatry, two as specialist psychiatrists and four as generalists with a special interest in psychiatry. One was working in General Practice. At the time of initial identification of mental-health needs, only two were working in psychiatry. Six were working in General Practice, two were in specialist training positions, one was a house surgeon, one was a student, and one was a specialist. The range of time off work owing to illness was up to 2 years.
Psychiatrists with experience of treating doctors as patients were recruited separately. Eleven were approached. They were selected by the researchers to provide a range of orientations and practice type. Three declined interview. Eight were interviewed. The range of years since qualification as a psychiatrist was 12–39 years. Estimated numbers of doctors treated ranged from 8–12 to 60–70. All had private-practice experience, and most, but not all, of their experience of treating doctor–patients had been in the private sector.
Eight contact people (friends, family or colleagues) were identified by the doctors with experience as patients. Four of these were themselves doctors, two of whom had also been recruited as doctors with experience as patients of psychiatrists. In total, 25 participants were interviewed.
Participants were interviewed individually by the two researchers together for one or two interviews of up to 90 min each. The interviews were initially open. The participant was invited to choose a place to begin. Most told their story. This part of the interview was not time-limited, and a second interview was scheduled when needed. Participants were encouraged to range broadly over their experience, with prompts such as, ‘Can you tell us more about that?’ Questioning in the interview was focused towards bringing forward the experiences, thoughts, values, etc of the participant—for example, ‘How did you decide to …?,’ ‘How did you experience/understand that?,’ ‘What were your hopes/fears when you …?’
A tentative checklist of relevant issues was developed initially from published personal accounts, personal and clinical contact with doctors with mental-health issues, and seminars for psychiatrists treating doctors. This was revised and developed in accord with ongoing data analysis of interviews. Most issues were covered in the open part of the interview. If not, they were specifically enquired about. Issues from the checklist relevant to this paper were identifying and managing vulnerability, other people knowing, identifying mental illness (what helped and hindered this?), decision to access care (how was this made?), finding/choosing a psychiatrist, talking to colleagues, friends, family, etc, stigma, and worry about and experience of the Medical Council.
Ethical approval was obtained from the Ministry of Health Ethics Committee (No AKY/04/12/344).
The interviews were transcribed verbatim from recordings by a typist and reviewed by one of the researchers (JS). Identifying data were removed. A grounded-theory approach to data analysis was used.17 18
The transcripts were closely read by each of the researchers individually and independently coded using the Qualitative Solutions and Research NVIVO computer software (QSR International, Doncaster, Australia). The two sets of codes and themes were then extensively and continuously discussed and compared. Convergence and divergence in accounts were both explicitly sought, with particular emphasis on exceptions. Emerging themes and higher-level codes were fed into the ongoing interviewing process. This process was repeated, at times in part and at times in whole, through the data-collection process. In returning to the transcripts, the recoding was focused on both confirmation and disconfirmation of hypotheses, and an evolving analysis of themes. Additional depth to this process was contributed by comparing and contrasting accounts from different groups of participants.
Both researchers are doctors with decades of experience working in psychiatry across a range of disorders and service types. One of the researchers has personal experience of psychosis and depression (PR). Both researchers have experience as network members of doctors engaging as patients of psychiatrists and limited experience in engaging with doctors as patients. One of the researchers is working as a child and adolescent psychiatrist, using biological as well as psychological approaches and compulsory care (JS). The other researcher is working psychologically with people with severe and chronic psychiatric disorder (PR). Both are committed to working creatively and reflectively, developing strategies for empowering and enabling people who are using mental-health services19