Mental health in the medical profession: Support for students
Dr Stuart Dorney, Dr Greg Kesby
Much has been reported about the prevalence of mental health concerns amongst medical students and doctors, both internationally and in Australia.
In 2013, beyondblue released the results from its national survey of Australian medical students and doctors. Among the survey’s key objectives was to better understand the issues associated with the mental health of Australian medical students and doctors, and to increase awareness of these issues across the profession and the wider community. 
The survey included questions about general mental health status, substance use, suicidal ideation and self-harm, workplace and life stressors, levels of burnout, impact of mental health symptoms, treatment and coping strategies employed to address mental health symptoms, barriers to seeking treatment and support, and attitudes regarding doctors with mental health conditions. The survey was completed by 1,811 (27%) of the 6,658 students and 12,252 (28.5%) of 42,942 doctors sampled.  Most of the students who participated were aged 22-25 years old (45.1%), female (62.6%), non-Indigenous (98.8%), located in a metropolitan region (66.5%), and worked part-time on average 12 hours per week (50%).  The responses from the survey were compared with the responses from the National Survey of Mental Health and Wellbeing, conducted by the Australian Bureau of Statistics in 1997. 
beyondblue found that very high levels of psychological distress was three times higher in medical students than in the general population (9.2% and 3.1% respectively), and two times higher than levels reported by interns (9.2% and 4.4% respectively).  Students also reported higher rates of burnout and emotional exhaustion, with the highest rates being reported by females. 
When it came to perceptions about mental health within the medical profession, a high proportion of respondents held the view that doctors who had a mental health issue were stigmatised as a consequence, a finding particularly prevalent amongst those respondents who had been diagnosed with a mental illness themselves. Students with a current mental health diagnosis, compared with those not currently diagnosed, were more likely to report they felt doctors with a history of mental illness were less competent (52.4% and 38.2% respectively). Furthermore, 42% of students with a current mental health diagnosis felt that doctors tended to advise colleagues not to divulge their history of depression or anxiety disorders, compared to 22.6% of students who were not currently diagnosed with depression or anxiety.  This finding is particularly disturbing and probably explains the considerable reluctance of some medical students and members of the medical profession to seek independent help for mental health issues, and instead pursue a pathway of self-diagnosis and self-treatment with its associated risks. Too often we see students and medical practitioners only first presenting for appropriate independent care when they are acutely unwell or in crisis. This is unnecessary and needs to change.
The Medical Council of New South Wales has published a guideline for self-treatment and treating family members, which encourages all medical practitioners (and students) to have their own, independent general practitioner and advises practitioners against self-diagnosis or initiating treatment for themselves or their family members.  The Medical Board of Australia’s Good medical practice: a code of conduct for doctors in Australia also advises medical practitioners who know or suspect they have a health condition or impairment that could adversely affect their judgement, performance, or patients’ health not to rely on their own assessment of the risk they pose to patients and to instead consult their doctor about whether, and in what ways, they may need to modify their practice. 
Just as we would recommend to patients, it is important for medical students and doctors to adopt a healthy lifestyle through a balanced diet and regular exercise. It is also vital to ensure that immunisations are kept up to date, alcohol is consumed within the National Health and Medical Research Council guidelines, and that illicit drug use and prescription drug misuse is avoided. It is also helpful to have a strong personal support network and develop interests outside of medicine.
Key to addressing health issues, including mental illness, is early intervention. Medical students should feel comfortable and be encouraged to seek independent, objective advice from a general practitioner as early as possible when mental health issues arise, and in providing care medical practitioners must endeavour to provide a non-judgemental and supportive environment that good medical practice dictates for all patients. In addition to seeking advice and treatment from a general practitioner, psychologist, or psychiatrist, there are a range of early intervention services and supports available to promote optimal care, including the various university health services, university medical facilities, beyondblue, Headspace, Lifeline, and the Doctor’s Health Advisory Service, available in each state and territory.
Under the Health Practitioner Regulation National Law (NSW) (the National Law), impairment is one of the grounds under which a complaint or notification can be made about a student or practitioner. This often generates fear amongst students as to whether their mental health issues will exclude them from graduating and practising as a medical practitioner. However, it needs to be appreciated that the term “impairment” has a specific meaning under the National Law. It refers to a physical or mental impairment, disability, condition, or disorder (including substance abuse or dependence) that is linked to a student’s capacity to undertake clinical training, or a doctor’s capacity to practise medicine.  In some instances notification is mandatory.
While recent media reports and editorial columns have suggested that mandatory reporting laws in all states and territories excluding Western Australia may be a barrier to medical students and doctors accessing support and treatment for mental health problems, there is no reliable evidence to support such claims and no reason that this should be the case. The purpose of mandatory reporting is to act as a safeguard when medical students and doctors are unwilling or unable to seek help and manage any risk to public safety by compelling practitioners to raise serious concerns with the regulatory authorities. The threshold for making a mandatory notification about an impaired colleague is high. A practitioner treating a medical student or doctor is not automatically required to make a mandatory notification simply because they have a mental health issue. The National Law states it is only when a practitioner has formed a reasonable belief that a fellow practitioner has placed the public at risk of substantial harm in the practice of the profession because of their impairment that they are required to make a mandatory notification. 
Education providers also have an obligation to make a mandatory notification if they have formed a reasonable belief that a student undertaking clinical training has a health issue that may place the public at substantial risk of harm. The formation of a reasonable belief may well be influenced by factors such as whether the medical student is receiving appropriate treatment and advice or has made a voluntary notification. 
Medical students and doctors who believe they may have an impairment are encouraged to make a voluntary notification to the Australian Health Practitioner Regulation Agency (AHPRA).  For individuals with mental health issues who self-notify or who are the subject of a notification to AHPRA, there are remedial, non-disciplinary programs, which differ from state to state, that are designed to support students to remain in study and doctors to remain in practice whilst receiving appropriate treatment, provided it is safe for them to do so.
In NSW, the Medical Council’s Health Program aims to protect the public while at the same time supporting medical students and doctors affected by health issues, including mental illness. Not everyone with a mental health issue who self-notifies or is the subject of a notification to AHPRA enters into the Health Program. Many are assessed as having a psychiatric illness that is under appropriate management, with the student/doctor having appropriate insight and support networks, and are therefore not considered to place the public at a significant risk of harm. That is, they are not considered “impaired” as defined in the National Law. Most of those who do enter the Health Program remain in practice or study, subject to conditions on their registration tailored to address their particular circumstances and designed to ensure public safety while they undertake treatment and rehabilitation. Participants remain under the care of their own treating practitioners, but also undergo independent reassessment by Council-nominated practitioners from time to time. Participants in the Health Program meet with Council delegates, usually at six to 12 monthly intervals, and as they progress in their rehabilitation and recovery, the conditions on their registration are gradually eased, until the Medical Council considers that they no longer require being under the Council’s surveillance and consequently exit the Health Program. Whilst return to unconditional practice is a goal of the Program, some participants, for example those with a recurring psychiatric illness, may remain on the Program indefinitely, albeit with low level conditions and occasional review by the Council.
Many participants have had great success on the Health Program and have found the experience of significant benefit. For example, one participant, who had suffered from depression since his teenage years, found the Program’s impact on his work and personal life to be “only positive”. He said the Program encouraged him to set realistic work schedules, engage in activities outside the workplace, develop insight into the demands that he had previously placed on himself, and establish strong networks of support, both personally and professionally. Upon exiting, he said the Program had assisted him to successfully return to practice and engage in a “full and meaningful life”. Another, who had been self-prescribing and suffering from depression, and by his own assessment entered the Health Program “at a time when I was out of control and rapidly heading towards disaster”, found the Program forced him to confront his problems, encouraged him to maintain engagement with a treating psychiatrist, and enabled him to stop his prescription drug misuse and eventually return to full time work. He attributes his professional survival to his involvement in the Health Program and, at the time of exiting the Program, was receiving consistent feedback that he was excelling in his practice of medicine.
We are a caring profession, and we need to care for ourselves as well as each other. The Medical Council and other regulatory authorities encourage everyone with mental health issues, including medical students and doctors, to seek appropriate care – and seek it early. We recognise that some will be reluctant or unable to do so – through fear, or a lack of insight, or simply due to the lack of energy and initiative that may accompany their illness. You are therefore all encouraged to reach out to your colleagues if you suspect they may be suffering in silence. Offer those who appear to be troubled with life assistance in accessing appropriate support. Help them frame their thinking around whether they should self-notify to AHPRA. You can start by simply asking “Are you okay?”
 beyondblue. Doctors’ mental health program. https://www.beyondblue.org.au/about-us/programs/workplace-and-workforce-program/programs-resources-and-tools/doctors-mental-health-program (accessed Nov 2015).
 beyondblue. National mental health survey of doctors and medical students. 2013. http://www.beyondblue.org.au/docs/default-source/default-document-library/bl1148-report—nmhdmss-exec-summary_web (accessed Nov 2015).
 Medical Council of NSW. Guideline for self-treatment and treating family members. 2014. http://www.mcnsw.org.au/resources/1460/Guideline%20for%20self-treatment%20and%20treating%20family%20members%20PDF.pdf (accessed Nov 2015).
 Medical Board of Australia. Good medical practice: a code of conduct for doctors in Australia. http://www.medicalboard.gov.au/Codes-Guidelines-Policies/Code-of-conduct.aspx (accessed Nov 2015).
 Medical Board of Australia, Information on the management of impaired practitioners and students. 2012. http://www.medicalboard.gov.au/documents/default.aspx?record=WD12%2F7049&dbid=AP&chksum=Pzr054PF7tcB6ZQnesHKvA%3D%3D (accessed Nov 2015).
 Medical Board of Australia, Guidelines for mandatory notifications, http://www.medicalboard.gov.au/Codes-Guidelines-Policies/Guidelines-for-mandatory-notifications.aspx (accessed Nov 2015).