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Mental health

Infectious diseases Research 1 May 2023 Open Access

Mental health and wellbeing of health and aged care workers in Australia, May 2021 – June 2022: a longitudinal cohort study

Evidence-based mental health and wellbeing programs for workers in health care organisations are needed

Sarah L McGuinness · Owen Eades · Kelsey L Grantham · Shannon Zhong · Josphin Johnson · Peter A Cameron · Andrew B Forbes · Jane RW Fisher · Carol L Hodgson · Jessica Kasza · Helen Kelsall · Maggie Kirkman · Grant M Russell · Philip L Russo · Malcolm R Sim · Kasha Singh · Helen Skouteris · Karen Smith · Rhonda L Stuart · James M Trauer · Andrew Udy · Sophia Zoungas · Karin Leder

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Medical education Editorials 3 April 2023 Free

Distress and career regret in doctors: are we really that different to other professions?

Health departments should support the professional training they require and show that their employees are valued The COVID‐19 pandemic has again focused attention on the mental health and wellbeing of doctors, particularly those in training. An earlier meta‐analysis (54 studies during 1963–2015 that included a total of 17560 trainee doctors) found that 21–43% (pooled estimate: 28.8%) had symptoms of depression during residency.1 The cross‐sectional online survey of Australian orthopaedic trainees in late 2021 reported by Kollias and colleagues in this issue of the MJA2 found even higher rates of distress and burnout: 39 of 88 respondents (44%) met the Physician Well‐Being Index criterion for distress (a short 7‐item measure); 55 (63%) had experienced burnout during the preceding 30 days. Those who reported distress were more likely to regret having chosen medicine as their career.2 How concerning are these findings? Survey rates of various indicators of poor wellbeing (distress, depression, burnout) derived from nationally representative population‐based surveys are generally 30–50% lower than reported for doctors,3 leading to the conclusion that poorer wellbeing is more frequent among doctors than other adults. However, there are reasons why junior doctors should have better mental health than other workers,3 including the fact that they often enjoy socio‐economic advantage,4 are by definition well educated, have successfully negotiated early adulthood (when most chronic mental illness emerges), and have a vocation with purpose and minimal likelihood of unemployment. One explanation for the discrepancy is that single occupation surveys have important limitations. Most have relatively low response rates (38% in the study by Kollias and colleagues2), raising the problem of respondent bias producing a “grumpy worker effect”. A United Kingdom meta‐analysis found rates of distress in single occupation studies to be fairly consistent at one‐quarter to one‐third of respondents across a broad range of professions, significantly higher than rates for the general adult population.5 The authors concluded that being recruited to “stress surveys” may lead to selection bias or over‐reporting, and that this problem is shared by many occupations.5 When we examined rates for various professions derived from repeated national representative surveys in Australia with very high response rates (greater than 90%), the prevalence rates of mental ill‐health were in the range 4–22% in 2019, and 8–22% in 2020;6 the prevalence was lower for doctors, with higher rates of pay and life satisfaction, than for the other professions examined (lawyers, engineers, accountants, nurses and midwives, and teachers).6 Over the past few years, even before COVID‐19, professional bodies in Australia have reported similarly low morale, burnout, and job dissatisfaction among emergency service workers,7 architects,8 and teachers.9 So are doctors any different to other professionals? We do differ in two key ways: the length and depth of our apprenticeship, and who pays for our professional training. Medical schools in Australia have changed radically in recent decades: thirteen of twenty‐one medical programs are now graduate entry degrees, often providing accelerated four‐year, instead of five‐ or six‐year, programs. To compete internationally, most graduate programs provide MD qualifications, cramming into these shorter courses a research project that once required an extra year. Recording “learning experiences” and continuing workplace assessment fill students’ days, while professionalism, communication, and ethics courses compete for time with pre‐clinical and ward‐based learning, with (at my university, at least) extensive attendance requirements. As a result, medical students are older when they graduate and have acquired more debt than earlier generations;10 more have competing family and parental responsibilities than younger undergraduate medical students, and less of the downtime many older clinicians had when they were studying. The number of medical graduates in Australia increased from 2733 in 2010 to 3637 in 2019 (33% over nine years).11 Career progression in many specialities is slowed by bottlenecks, while other areas, including general practice and psychiatry, struggle to fill training roles. Nevertheless, in 2019 more final year students wanted to pursue surgery as a career than any other speciality except “adult medicine”, and only one final year student wanted to work in addiction medicine!11 After graduation, junior doctors face a mixture of excessive and conflicting demands. The social connections and support that help deal with long and stressful work hours are undermined by training rotations to far‐flung hospitals and frequent early year job changes. We do not know the ages of the surgical trainees in the survey by Kollias and colleagues,2 but most were probably in their thirties. Career regret and jealous glances at schoolfriends in professional careers, often fully qualified and many earning six‐figure salaries in their late 20s, and paying their personal trainers more per hour than a junior doctor receives, are understandable. Given the similar rates in other professions, distress and career regret are likely to affect a minority of trainees. However, the authors of a new meta‐analysis of longitudinal studies12 suggested that increasing resources and reducing work demands for junior doctors would improve their work engagement and clinical care. The same may be true for students, who may also need guidance about career pathways and community needs. After demanding weeks in hospitals, a junior doctor's weekends are regularly spent preparing for expensive exams (and paying HECS debts), unlike most other young professionals who have had protected study leave and for whom exams are paid. Surely it is time that health departments act like good employers, and fund and support the professional training they require and show that their employees are valued?

Nicholas Glozier

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Environmental health Perspectives 26 October 2022 Open Access

The 2022 report of the MJA–Lancet Countdown on health and climate change: Australia unprepared and paying the price

Australia’s transition to renewables and zero carbon remains unacceptably slow

Paul J Beggs · Ying Zhang · Alice McGushin · Stefan Trueck · Martina K Linnenluecke · Hilary Bambrick · Anthony G Capon · Sotiris Vardoulakis · Donna Green · Arunima Malik · Ollie Jay · Maddie Heenan · Ivan C Hanigan · Sharon Friel · Mark Stevenson · Fay H Johnston · Celia McMichael · Fiona Charlson · Alistair J Woodward · Marina B Romanello

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Mental health Letters 15 August 2022 Free

Social and occupational outcomes for young people who attend early intervention mental health services: a longitudinal study

To the Editor: The article by Iorfino and colleagues1 presents interesting follow‐up data on young people attending two mental health clinics. For 1510 of 2901 young people who presented in 2008–2018 with anxiety, mood or psychotic disorders, the authors identified trajectories in social and occupational functioning over 2years. Iorfino and colleagues describe the model as “primary care‐based” and “low intensity”, but it is neither generalist primary care nor low intensity as it comprises headspace plus specialised services and hospitalisation if needed. Several limitations, including 48% of patients excluded and the lack of a comparison group, make any conclusions problematic. Box 3 suggests little average change, but a latent class analysis suggests that one‐third participants who were well functioning at baseline had good functional outcomes, while the remaining two‐thirds “had generally poor functional outcome patterns”. The data are compatible with a range of conclusions, including “findings suggest that employment and engagement in education and training are protective” or “the treatment model makes no discernible difference to young people’s social and occupational functioning”. Yet Iorfino and colleagues claim that “findings suggest that the current primary care‐based model meets the needs of only a minority of young people seeking care” and call for “more comprehensive and multidisciplinary approaches because of substantial comorbidity, ambiguous or attenuated symptomatology”. This sounds like general practice, where undifferentiated illness and multimorbidity are the norm. Contrary to Iorfino et al, who state that “conclusions about the effects of specific treatments cannot be drawn”, McGorry in the accompanying editorial2 claims that findings “clearly illustrate what else is needed” — “more sustained, expert, and multidisciplinary care”. He uses the editorial to champion headspace and request yet more financial support. McGorry characterises the two‐thirds with persisting poor functioning as the “missing middle” for whom he advocates scaling up his model of care, developed for people with psychosis, to “be rapidly installed across the nation”, claiming “Countless lives and futures will be saved”. Given the uncertainty of the evidence, it is difficult to understand how such sweeping claims have survived the peer review process. Decisions on investment in mental health care should be based not on rhetoric, but on a rigorous and impartial review of the evidence and research to develop the evidence base.

Katharine A Wallis · Nicholas A Zwar · Paul P Glasziou

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Mental health Letters 15 August 2022 Free

Social and occupational outcomes for young people who attend early intervention mental health services: a longitudinal study

In reply: In response to Wallis and colleagues,1 their interpretation of the Iorfino et al2 article is incorrect. Being fully acquainted with the youth mental health service described, I am clear that what was provided to most patients in the sample reported is in fact low intensity and primary care. Multiple publications on headspace, two independent evaluations3,4 (a third is in progress), and the huge national dataset routinely collected by headspace are also broadly consistent with the findings of this article. It is true, as Wallis and colleagues state, that in headspace, as in general practice more widely, there is a large subset of patients with multiple morbidity and more complex and persistent conditions. That is the whole point of the article. While most patients in primary care with medical complexity are generally able to access and secure tenure within the next tier of care (ie, specialist care), that is simply not the case for young people with mental ill health and mental illness. This leads to Wallis and colleagues’ critique of the solution that Iorfino et al proposed, and upon which I elaborated in my editorial.5 This solution — namely that platforms of multidisciplinary care with more secure tenure be established as a back‐up system — is pretty obvious and is a feature in all credible recent blueprints for reform. For young people aged 12–25years, this means expanding the diagnostic reach and national coverage of the six (soon to be eight) regional early psychosis platforms. Wallis et al describe my characterisation of such a proposal as “rhetoric”. In fact, the early psychosis model of care is supported by Cochrane level 1 evidence and three decades of worldwide experience and scaling up across many high income countries, including the United Kingdom, the United States, Canada, Denmark and Hong Kong. They are now the international standard of care for this group of patients. Indeed, the existing early psychosis programs funded by the federal government are producing functional outcomes as good or better than anywhere in the world, with high fidelity.6 They most assuredly save lives and futures. In any event, we can all agree that “decisions on investment in mental health care should be based not on rhetoric, but on a rigorous and impartial review of the evidence and research to develop the evidence base”. That is exactly the approach that my colleagues and I, and indeed the whole early intervention field, have always pursued, and continue to, as we expand the diagnostic coverage of these programs.

Patrick D McGorry

Infectious diseases Narrative review 18 July 2022 Open Access

Review of management priorities for invasive infections in people who inject drugs: highlighting the need for patient‐centred multidisciplinary care

Using a multidisciplinary, pragmatic, patient-centred, non-judgemental approach may allow people who inject drugs to achieve improved outcomes for invasive infections and reduce their risk of subsequent admissions

Lucy O Attwood · Megan McKechnie · Olga Vujovic · Peter Higgs · Martyn Lloyd‐Jones · Joseph S Doyle · Andrew J Stewardson

Mja2 51623

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