key: cord-0687574-pjujia6u
authors: Johns, G.; Samuel, V.; Waddington, L.
title: Prevalence and predictors of mental health outcomes in UK doctors and final year medical students during the COVID-19 pandemic
date: 2022-05-13
journal: J Affect Disord
DOI: 10.1016/j.jad.2022.05.024
sha: c038f8027c53dc19351d164f625af8f978a85099
doc_id: 687574
cord_uid: pjujia6u

Background The mental health of doctors is an ongoing concern, both prior to and during the COVID-19 pandemic. This study aimed to: i) assess the prevalence of symptoms of depression, anxiety, PTSD, and burnout in UK doctors and final year medical students during the pandemic, and ii) analyse the hypothesised relationships between psychological flexibility, intolerance of uncertainty and resilience with these mental health outcomes. Methods A cross-sectional online study of UK-based doctors and final year medical students was conducted between 27/09/2020 and 31/01/2021. Outcomes were measured using the PHQ9, GAD7, PCL-5, and aMBI. Independent variables included the CompACT-SF, IUS-12, and CD-RISC-10. Descriptive statistics, between-group analyses, and multiple regression were performed. Results Prevalence of anxiety symptoms was 26.3%, depression 21.9%, PTSD 11.8%, and burnout 10.8%. Psychological flexibility negatively predicted all outcomes, apart from low personal achievement. Intolerance of uncertainty positively predicted anxiety and PTSD scores. Resilience negatively predicted scores on burnout subscales. Limitations Cross-sectional design and non-probability sampling method means that assumptions about causality cannot be made and may have implications for bias and generalisability of results. Conclusion Doctors and medical students in the UK reported high levels of mental health symptoms during the pandemic, between September 2020 and January 2021. All three independent variables explained significant variance in mental health outcomes. Psychological flexibility was the most consistent predictor, over and above sociodemographic variables and other psychological predictors. These findings have implications for interventions to improve retention of our essential medical workforce, and for providing support at future times of national crisis.

The global high prevalence of depression, anxiety and burnout has been documented in systematic reviews and meta-analyses focussing on doctors (Mata et al., 2016; Rotenstein, 2018) , and medical students (Rotenstein, 2016; Hope, 2014; Puthran et al., 2016; Erschens et al., 2019) . Since the beginning of the pandemic, there have been concerns regarding the potential psychological impact on this already at-risk population. This has led to studies being conducted across the world, spanning a wide range of medical specialities and geographical locations. 2020. In response to these concerns, the BMA (2021) called for immediate measures to address the health, safety, and mental wellbeing of doctors in the UK.

Given that the UK and the rest of the world will be dealing with the residual effects of COVID-19 for many years to come, it is vital that both the physical and psychological needs of doctors are supported. While there are a number of external and organisational factors that can affect doctors" wellbeing, it is important to quantify the prevalence of distress and understand the individual factors that may reduce or increase vulnerability to emotional sequalae.

To date, a small number of UK-based studies have focussed on the mental health of doctors in specific specialities during the pandemic (Shah et al., 2020;  mental health outcomes for doctors across a wide range of specialities during the pandemic:

Psychological flexibility is associated with reduced risk of a wide range of psychopathology (Gloster et al., 2020; Kashdan et al., 2010; Masuda et al., 2011; Tyndall et al., 2020) and may act as a mediator and/or moderator in the relationship between stressful life events and a range of mental health outcomes (Palm & Follette, 2011; White et al., 2013; Bryan et al., 2015; Gloster et al., 2017; Fonseca et al., 2020; Kashdan et al., 2020) . Studies focussing specifically on doctors (Solms et al., 2019; Wood et al., 2020; Jokić-Begić et al. 2020; Buck et al., 2019) found higher psychological flexibility was associated with lower burnout and psychological distress. While recent studies in the general population found higher levels of psychological flexibility were inversely related to anxiety, depression, and distress during the pandemic (Kroska et al., 2020; Dawson & The Abbreviated Maslach Burnout Inventory (aMBI) was used to measure burnout. The measure consists of three subscales that assess the subdomains of emotional exhaustion (EE;), depersonalisation (DP), and low personal accomplishment (LPA). Scores on the aMBI are pro-rated, as described in Colville et al. (2017) . Subscale cut-offs are based on recommended cut-offs for the full MBI (Maslach et al., 1996) . Scoring above or below the specified cut-off for all three subscales is considered necessary for burnout (Maslach & Leiter, 2021) .

Research indicates that the aMBI is a valid and reliable substitute for the full MBI (Riley et al., 2018) . In the current study, internal consistency was broadly acceptable (EE α=.73, DP α=.69, LPA α=.61).

The Comprehensive assessment of Acceptance and Commitment Therapy processes-Short Form (ComPACT-SF; Morris, 2019) was used to measure Hierarchical multiple regression was performed to assess the ability of the three key independent variables of psychological flexibility (COMPACT-SF), intolerance of uncertainty (IUS-12), and resilience (CD-RISC-10) to predict continuous scores on mental health measures. Nine control variables (frequency of contact with COVID patients; sex; ethnicity; pre-existing mental health conditions; early registration; adverse COVID-related event; adverse non-COVIDrelated event <12 months; clinically vulnerable group-self; clinically vulnerable group-close other) were entered at step-one, and the additional three psychological predictor variables were included in the model at step-two. Control variables were coded as dichotomous categorical variables, apart from career grade and age range (multiple categorical) and frequency of contact with COVID patients (continuous). All three primary IVs were continuous. the increased sensitivity to normality, linearity and homoscedasticity for multiple regression. A p-value of <.05 was considered significant, and all tests were 2tailed.

Three-hundred-and-forty-six participants completed the core set of questionnaires. Due to the recruitment strategy used, an accurate response rate was not calculable. Final year medical students comprised nearly a quarter of the sample, 46.2% were foundation doctors (F1, F2), 30% were middle or senior grade doctors. A majority of participants were female, under thirty, and white. Preexisting mental health condition(s) were reported by over a fifth of respondents, while 71.2% reported their frequency of contact with COVID-19 patients as either "sometimes", "often" or "all the time". Full details of respondent demographics can be found in Table 1 .

The proportions of participants scoring above cut-off were 26.3% for anxiety, 21.9% for depression, 11.8% for PTSD, 56.8% for emotional J o u r n a l P r e -p r o o f Journal Pre-proof exhaustion,36.4% for depersonalisation, 27.2% for low personal achievement, and 10.8% for burnout. Median (IQR) scores were 6.0 (3.0-10.0) for the GAD7, 5.0 (2.0-9.0) for the PHQ9, 8.0 (2.0-19.0) for the PCL-5, 30.00 (18.00-39.00) for emotional exhaustion, 6.67 (1.67-11.67) for depersonalisation, and 37.33 (32.00-42.67) for low personal achievement. Supplementary Tables 1 and 2 provide a full breakdown by sociodemographic variables, and severity thresholds.

The prevalence of suicidal thoughts was assessed by question nine on the PHQ9 "Thoughts that you would be better off dead, or of hurting yourself in some way". Overall prevalence was 7.3%. Those who reported a pre-existing mental health condition had the highest rate of suicidal thoughts at 24.3%.

Further breakdown is provided in Supplementary Table 3. 3.3 Group differences in mental health symptoms Analysis of median scores on the GAD-7 (anxiety) and PHQ-9 (depression) revealed significant group differences, with higher scores in females vs males, in those reporting pre-existing mental health conditions vs those without, in those reporting a significant non-COVID-related adverse event in the past twelve months vs those who had not, and in those reporting a significant COVID-related J o u r n a l P r e -p r o o f Journal Pre-proof adverse event vs those who had not for both measures. For the PCL-5 (PTSD) the same group differences were found, with the exception of sex, which was not significant.

For median emotional exhaustion (EE) there were significantly higher median scores for females vs males. There were also significant differences across career grades. F2s and senior grades recorded the same median scores, higher than the other groups. For median scores on low personal achievement (LPA), none of the subgroup were statistically significantly different.

Supplementary Tables 2-7 present full statistics for all group comparisons.

Spearmans rho correlation analysis revealed all primary IVs were statistically significantly associated with all mental health outcomes. Further details, including effect sizes, are presented in table 13. In the final model, statistically significant step-one variables were: sex, early registration, close relative/same household with a clinically vulnerable group; significant step-two variables were psychological flexibility and resilience. For the depersonalisation model, the variables entered at step-one explained 5.1% of the variance in symptoms. At step-two, the total variance explained by the model as a whole was 13.3%, F (12, 312) =3.981, p =<.0005. The three primary IVs explained an additional 8.2% of the variance in symptoms. In the final model, statistically significant step-one variables were: adverse COVID life event and frequency of contact with COVID patients. The only significant step-two variable was psychological flexibility.

For the low personal achievement model, the variables entered at step-one within the previous two weeks, compared with 5.2% of doctors without a preexisting mental health condition. The increased suicide risk among doctors has previously been highlighted (Ventriglio et al., 2020) . F2s were statistically more likely to have higher symptoms of emotional exhaustion and depersonalisation compared with final year medial students, providing support for previous reports that burnout seems to peak at F2 (Taylor, 2020). Participants who had experienced a COVID-related adverse event were also more likely to have higher symptoms of depression, anxiety and PTSD, as were participants who had experienced a non-COVID-related adverse event within the previous twelve months. These results highlight some important at-risk groups, which may be useful for targeting future interventions. These findings also suggest a need for greater consideration and support to be given to the impact of recent adverse life experiences, both inside and outside of the workplace. Given the high rates observed across career grades, support should be targeted towards doctors at all career stages.

Frequency of contact with COVID patients and experience of a COVIDrelated adverse event were only significant in the multiple regression models as J o u r n a l P r e -p r o o f Journal Pre-proof predictors of PTSD and depersonalisation. Interestingly, although experience of a COVID-related adverse event was positively associated in all other significant relationships, it was negatively associated with depersonalisation. A tentative hypothesis for this finding is that these experiences may lead to increased empathy towards patients, partially protecting them from feelings of depersonalisation (cynicism). However, this hypothesis would need to be empirically tested before drawing this conclusion.

The current study found that psychological flexibility demonstrated Resilience negatively predicted emotional exhaustion and low personal achievement scores. However, neither processes were able to predict outcomes as consistently or as strongly as psychological flexibility.

It is important to consider the potential overlap in the underlying constructs of the three primary IVs in this study, as well as the features that distinguish them. Psychological flexibility appears to be a much broader concept than IoU, but both incorporate the idea that distress arises from avoidance. While 

The findings from the current study may be relevant to future iterations of conceptual models that seek to explain the pathway to mental health difficulties for medical students and doctors, such as the one proposed by Hancock and Mattick (2020). Within their model, IoU and resilience were identified as possible modifying or mediating variables; however, the current study suggests that psychological flexibility may be an even more salient variable in this pathway. In order to effectively address the question of mediating or moderating relationships, further longitudinal research is needed to adequately explore mechanisms of causality.

Psychological flexibility is a construct that is considered amenable to change. A meta-analysis (Levin et al., 2012) 

This study has some important limitations. A cross-sectional survey-based design was adopted, which means that assumptions about causality cannot be made. Similarly, since a non-probability sampling method was used, a sampling frame could not be established, and it was not possible to calculate a response rate. More senior staff grades and male doctors were under-represented, and there were no participants from Northern Ireland. At-risk doctors may have been too busy or distressed to take part in the study or, alternatively, the study may have attracted a greater number of doctors with a history of mental health conditions, due to personal relevance and interest. Self-report measures can also introduce bias due to social desirability. Further, the data collection timeframe may have influenced results, given the variability in cases over this period and the potential implications this may have for reported distress. All of these factors may have implications for the risk of bias and generalisability of results. Finally, J o u r n a l P r e -p r o o f since "gold standard" diagnostic interviews were not possible, the reported estimates may not reflect the true prevalence of mental health conditions within this population.

There has been a wealth of research assessing the prevalence of mental health problems in healthcare workers during the pandemic and their associated sociodemographic risk factors. However, few studies have explored the hypothesised underlying psychological processes that may be modifying these outcomes. Further strengths of this study include the UK-wide coverage and sample size. In addition, the use of standardised and validated outcome measures offers more robust support to findings from larger-scale staff surveys (e.g., BMA, 2021) that predominantly utilise idiosyncratic measures to estimate prevalence of mental health problems. Finally, while some studies have looked at the role of J o u r n a l P r e -p r o o f Table 3 . Hierarchical multiple regression: predictors of anxiety (GAD7) and depression (PHQ9) symptoms Anxiety Depression

Step 1 (control variables)

Step 2

Step 1 (control variables)

Step J o u r n a l P r e -p r o o f Journal Pre-proof Table 4 . Hierarchical multiple regression: predictors of PTSD (PCL-5) and depersonalisation (aMBI subscale) symptoms PTSD (PCL-5) Depersonalisation (aMBI)

Step 1 (control variables)

Step 2

Step 1 (control variables)

Step Emotional Exhaustion (aMBI) Low Personal Achievement (aMBI)

Step 1 (control variables)

Step 2

Step 1 (control variables)

Step  Doctors reported high levels of anxiety, depression and PTSD symptoms.

 Females and those with pre-existing mental health conditions had worse symptoms.

 Psychological flexibility, intolerance of uncertainty and resilience explained significant variance.

 Psychological flexibility was the strongest and most consistent predictor of outcomes.

J o u r n a l P r e -p r o o f

The impact of treatment components suggested by the psychological flexibility model: A meta-analysis of laboratory-based component studies

Psychological flexibility mediates the relations between selfconcealment and negative psychological outcomes

MBI: Maslach burnout inventory

How to Measure Burnout Accurately and

The impact of mindfulness-based interventions on doctors" well-being and performance: A systematic review

Mental health amongst obstetrics and gynaecology doctors during the COVID-19 pandemic: Results of a UK-wide study

Keep the fire burning: a survey study on the role of personal