Physician PTSD During COVID-19: The Unseen Toll
—Following the COVID-19 pandemic, the prevalence of post-traumatic stress disorder in physicians is significantly higher than in the general population and higher than it was in physicians prior to the pandemic.
Prior to the emergence of COVID-19, studies showed that physicians were at risk for posttraumatic stress disorder (PTSD) and that its prevalence was higher in them than other populations. At the height of the pandemic, the level of stress on health-care workers was unprecedented, as they faced high caseloads and mortality rates, limited resources, long hours, and ongoing risk of contracting the disease themselves.
The ramifications of COVID-19 on prevalence of and risk factors for PTSD among physicians during the pandemic is the focus of a new systematic review and meta-analysis led by Canadian researchers. Published in JAMA Network Open, it reveals that risk of PTSD was higher in female physicians, older physicians, and trainees and that targeted interventions are needed to support physicians during traumatic events such as pandemics.1
“Our research team previously found mental health visits by physicians increased after COVID-19,” says corresponding author Manish M. Sood, MD, of the Ottawa Hospital Research Institute. “The new analysis shows that nearly 1 in 5 physicians experienced PTSD during COVID-19, which is a shockingly high number.”
Dr. Sood, first author Mihir Kamra, BS, and colleagues based that conclusion on assessment of 57 published studies published between December 2019 and November 2022. All reported on PTSD as a probable diagnosis via validated questionnaires or clinician diagnosis. Nearly 29,000 physicians across 25 countries were represented in the literature.
A review across continents
To identify PTSD, the Impact of Event Scale-Revised (IES-R) was used in 24 of the reports assessed), the PTSD Checklist (PCL) for Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-V) (PCL-5) for 23 reports) primary care (PC) PTSD for 4 reports, and other validated questionnaires for six reports. Only one questionnaire was used in each study. The studies were carried out in Europe, Asia, Africa, Australia, North America, and South America, and one study had respondents from 101 countries.
Reality of PTSD prevalence
Of the physicians questioned, 18.3% (pooled prevalence; 95% CI, 15.2%-21.8%) were found to have probable or clinically concerning PTSD. The proportion varied by type of questionnaire used: 3% to 67% for IES-R, 2.3% to 41.9% for PCL, and 9.5% to 22.7% for PC-PTSD. “Physicians were faced with multiple stressors,” says Dr. Sood, “including passing illness to family/loved ones, getting sick themselves, witnessing death and morbidity, and being responsible for allocating scarce resources.”
Factors influencing PTSD rates
Of the 14 studies that stratified PTSD outcomes by sex, the investigators found that 92.3% revealed a higher prevalence of PTSD overall in females (mean 26.9%) vs males (mean 18.8%) (P<.001). The odds ratio also was higher for females (1.93; 95% CI, 1.56-2.39; P<.001).
Ten of the studies (17.5%) stratified PTSD by age, eight of which showed a lower prevalence among younger vs older physicians. A higher prevalence of PTSD in physicians was associated with being ≥30 years of age in 4 of the studies, whereas different ages—<50 years, ≥35 years, >35 years of age, and >55 years—were identified by each of the remaining four studies.
Associations of PTSD with physician career stage (trainee vs attending) were assessed by 16 studies (28.1%). Mean prevalence in trainees was 31.0% vs that of the attendings with a mean of 24.7% for attendings (OR 1.33; 95% CI, 1.12-1.57).
The last grouping evaluated was specialty, investigated in 13 of the studies (22.8%). Emergency medicine and anesthesiology, specialties in which physicians have a high likelihood of treating COVID-19 patients, were most often represented, with mean prevalences of PTSD of 23.4% and 16.1%, respectively. Mean prevalences in other specialties were as follows: surgery 22.4%, family medicine 31.2%, internal medicine 21.9%, critical care 14.8%, and otolaryngology 23.0%. The few studies that reported on front-line specialties (emergency medicine, anesthesiology, and critical care) found the highest proportion of PTSD among emergency medicine physicians.
Limitations
Numerous study limitations were noted by the authors. Generalizability was limited by low or unreported response rates. Because most of the studies did not look at changes before and during the pandemic for physicians vs the general population, it was difficult to distinguish between physician-specific changes in PTSD and COVID-19-related changes in the general population. In addition, it was difficult to compare the studies to get an accurate prevalence because scales and cutoffs differed in the various studies. Having only two longitudinal studies in their review made it difficult for the researchers to evaluate changes in PTSD prevalence during the pandemic or before vs after the pandemic. Use of self-reports also could have affected accuracy of the data.
The authors also noted that their definition of PTSD was similar to that for adjustment disorder; therefore, some cases of PTSD may have actually been adjustment disorder, or vice versa. Finally, all of the articles reviewed were in English, which may have limited the number of studies included from other countries.
Moving forward from here
The risk of PTSD in physicians found by the authors is three times higher than the general population and much higher than what had been reported in physicians prior to the pandemic. The authors believe there is a need for system-level changes to support the health of physicians and that, says Dr. Sood, “the climate in medicine is changing such that physicians are able to discuss mental health issues with less stigma.”
Regarding future investigation, the researchers wrote that “… additional research regarding physician PTSD in general, such as studies temporally unrelated to the COVID-19 pandemic, would better help characterize physician PTSD in typical healthcare climates. Such research can highlight any variances in risk factors among physicians who were and were not impacted by the COVID-19 pandemic, which can better shed light on how the pandemic influenced physician wellness.”
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