Stresses experienced by psychiatrists and their role in burnout: a national follow-up study

Characteristics and Habits of Psychiatrists and Neurologists With High Occupational Well-Being: A Mixed Methods Study

Objective

To identify the characteristics that distinguish occupationally well outliers (OWO), a subset of academic psychiatrists and neurologists with consistently high professional fulfillment and low burnout, from their counterparts with lower levels of occupational well-being.

Participants and Methods

Participants included faculty physicians practicing psychiatry and neurology in academic medical centers affiliated with the Professional Well-being Academic Consortium. In this prospective, longitudinal study, a mixed qualitative and quantitative approach was used. Quantitative measures were administered to physicians in a longitudinal occupational well-being survey sponsored by the academic organizations where they work. Four organizations participated in the qualitative study. Psychiatrists and neurologists at these organizations who competed survey measures at 2 consecutive time points between 2019 and 2021 were invited to participate in an interview.

Results

Of 410 (213 psychiatrists and 197 neurologists) who completed professional fulfillment and burnout measures at 2 time points, 84 (20.5%) met OWO criteria. Occupationally well outliers psychiatrists and neurologists had more favorable scores on hypothesized determinants of well-being (values alignment, perceived gratitude, supportive leadership, peer support, and control of schedule). Ultimately, 31 psychiatrists (25% of 124 invited) and 33 neurologists (18.5% of 178 invited) agreed to participate in an interview. Qualitatively, OWO physicians differed from all others in 3 thematic domains: development of life grounded in priorities, ability to shape day-to-day work context, and professional relationships that provide joy and support.

Conclusion

A multilevel approach is necessary to promote optimal occupational well-being, targeting individual-level factors, organizational-level factors, and broader system-level factors.

The association between workload, alcohol use, and alcohol misuse among psychiatrists in China

Aim

Survey alcohol use and workload among Chinese psychiatrists and explore their associations.

Methods

We conducted an online questionnaire among psychiatrists working in large psychiatric institutions across the country. We collected data including demographic factors, alcohol use, and workload. Alcohol use was assessed using the Alcohol Use Disorder Identification Test-Consumption (AUDIT-C), and workload-related questions included working hours, night shifts, and caseloads.

Results

In total, 3,549 psychiatrists completed the survey. Nearly half (47.6%) reported alcohol use, and the percentage of alcohol use in males (74.1%) was significantly higher than in females. 8.1% exceeded the AUDIT-C cutoff scores for probable alcohol misuse (19.6%in males and 2.6%in females). AUDIT-C scores were significantly correlated with working hours per week (p = 0.017) and the number of outpatient visits per week (p = 0.006). Regressional analysis showed that alcohol use was significantly associated with the following factors: longer working hours (Working more than 44 h/week, OR = 1.315), having an administrative position (OR = 1.352), being male (OR = 6.856), being single (OR = 1.601), being divorced or widowed (OR = 1.888), smoking (OR = 2.219), working in the West (OR = 1.511) or the Northeast (OR = 2.440). Regressional analysis showed that alcohol misuse was significantly associated with the following factors: fewer night shifts (Three to four night shifts/month, OR = 1.460; No more than 2 night shifts/month, OR = 1.864), being male (OR = 4.007), working in the Northeast (OR = 1.683), smoking (OR = 2.219), frequent insomnia (OR = 1.678).

Conclusion

Nearly half of the psychiatrists in China reported alcohol use and 8.1% had probable AUD. Alcohol consumption is significantly associated with several workload-related factors, such as long working hours, heavy caseload, and administrative duties. Alcohol misuse was inversely associated with the number of night shifts per month. While the direction of causality is unclear, our findings may help identify vulnerable professional groups and develop more targeted interventions to improve healthcare professionals' well-being.

Burnout, stress and intentions to leave work in New Zealand psychiatrists; a mixed methods cross sectional study

BACKGROUND

Demand for mental health services in New Zealand and internationally is growing. Little is known about how psychiatrists are faring in this environment. This study aimed to investigate wellbeing of psychiatrists working in the public health system in New Zealand, identify the main risk factors for work-related stress, gauge perceptions of how workload has changed over time, assess job satisfaction and whether individuals intend or desire to leave their work.

METHODS

Psychiatrists working in New Zealand who were also members of the Association of Salaried Medical Specialists were invited to participate in an online survey. Main outcome measures were degree of burnout and stress experienced at work. Supplementary measures included perceived workplace demands and levels of support. Predictor variables included perceptions of changes to workloads over time, degree of job satisfaction and intentions to leave work. Logistic regression assessed characteristics associated with burnout and job satisfaction as well as intentions to leave work. Free text comments were analysed thematically alongside quantitative trends.

RESULTS

368/526 responded (70% response rate). 34.6% met the criteria for burnout and 35.3% scored with high work stress. There were no significant patterns of association with demographic variables but significant correlation with all but one predictor variable; having experienced a change to the demands of the on-call workload. 45% agreed they would leave their current job if able and 87% disagreed that they are working in a well-resourced mental health service. Respondents emphasised the impact of growing workloads and expressed concerns about their ability to provide optimal care in these circumstances.

CONCLUSIONS

High burnout appears to affect one in three psychiatrists in New Zealand. Many attribute their feelings of burnout to demand for their services. These findings may assist with better workforce planning for psychiatry and emphasises potential consequences of demand for and poor resourcing of mental health services for the retention and wellbeing of doctors in psychiatry worldwide.

Development and Assessment of the Personal Emotional Capital Questionnaire for Adults

(1) Background: The present study developed and evaluated a personal emotional capital questionnaire (PECQ) for adults that assessed 10 domains of personal emotional capital. (2) Method: Initially, 100 items were created and then administered to students attending Semnan University and Semnan University of Medical Sciences in Iran. Of the 700 questionnaires distributed, 527 were completed in full. Students were sampledusing the multi-stage random cluster method. Exploratory factor analyses, Cronbach’s alpha, and test–retest reliability were used to evaluate the scale. (3) Results: The ten components ofthe PECQ were confirmed. Test–retest correlations after 30 days were high, as was Cronbach’s alpha (0.94). Thecomponents highly correlatedwith overall emotional capital. The PECQ displayed convergent validity as it positively correlated with the Keyes’s Mental Health Continuum—Short Form and students’GPAs. The PECQ displayed divergent validity as it negatively correlated with measures of depression, anxiety and stress (Depression Anxiety and Stress Scale (DASS21)). Differences in overall PECQ scores and its components were examined for several variables including gender, age, marital and employment status, academic program, and field of study. PECQ scores were not sensitive to the order of administering questionnaires. (4) Conclusion: The results suggest that the PECQ is a valid and reliable measure of personal emotional capital and supports its use in adults.

A Systematic Review of Job Demands and Resources Associated with Compassion Fatigue in Mental Health Professionals

Psychosocial hazards in mental healthcare contribute to the development of compassion fatigue in mental health professionals. Compassion fatigue has a negative impact on the mental health and wellbeing of professionals that can impair the quality of services provided to clients. The majority of research on compassion fatigue has focused on individual-level variables such as gender, history of trauma and age, among others. It is also imperative to understand the role played by alterable work-related characteristics in contributing to the development of compassion fatigue in order to attenuate its impact on mental health professionals and their clients. The present review examined articles exploring work-related factors associated with compassion fatigue. Fifteen quantitative studies were included and their quality was assessed using a checklist. An inductive content-analysis approach was adopted to synthesise the themes emerging from the data. The results suggested a theoretical model consistent with the Job Demands-Resources model, wherein job demands (such as workplace trauma, workload and therapeutic settings) are associated with compassion fatigue, and job resources (such as supervisors', coworkers' and organisational support) mitigate the impact of job demands. In addition to person-oriented factors, work-related factors are critical for the prevention of compassion fatigue.

Thai psychiatrists and burnout: A national survey

Objectives

To explore the prevalence and factors that contribute to burnout among Thai psychiatrists.

Background

The practice of psychiatry can lead to emotional fatigue. As rates of emotional illness in Thailand continue to climb, increasing demands are placed on a limited number of psychiatrists. This can lead to burnout, and multiple negative physical and mental health outcomes.

Materials and methods

Electronic questionnaires were sent to all 882 Thai psychiatrists and residents via a private social media group managed by the Psychiatric Association of Thailand. The questionnaire included demographic data, the Maslach Burnout Inventory (MBI), the Proactive Coping Inventory, and questions about strategies that Thai psychiatrists believed reduce/prevent burnout.

Results

Questionnaires were sent and 227 (25.7%) responded. According to MBI, 112 (49.3%) of respondents reported high level of emotional exhaustion, and 60 (26.4%) had a high level of depersonalization. Nearly all respondents (99.6%) maintained a high level of personal accomplishment. Working more than 50 hours per week (p = 0.003) and more patients per day (p = 0.20) were associated with higher levels of burnout. Feeling satisfied with work (p<0.001) and having a good support system from family (p = 0.027) and colleagues (p = 0.033) were associated with lower levels of burnout. The coping mechanisms related to lower levels of burnout included more emotional support seeking (p = 0.005), more proactive coping (p = 0.047), and less avoidance (p = 0.005).

Conclusions

Compared to a previous study on burnout among Thai psychiatrists in 2011, in this study, the prevalence of high levels of burnout had increased dramatically from 17.1% to 49.3%. An intervention to decrease workload, strengthen social support and encourage proactive coping mechanisms may be beneficial for relieving burnout.

Interventions to minimise doctors’ mental ill-health and its impacts on the workforce and patient care: the Care Under Pressure realist review

Background

The growing incidence of mental ill-health in health professionals, including doctors, is a global concern. Although a large body of literature exists on interventions that offer support, advice and/or treatment to sick doctors, it has not yet been synthesised in a way that takes account of the complexity and heterogeneity of the interventions, and the many dimensions (e.g. individual, organisational, sociocultural) of the problem.

Objectives

Our aim was to improve understanding of how, why and in what contexts mental health services and support interventions can be designed to minimise the incidence of doctors’ mental ill-health. The objectives were to review interventions to tackle doctors’ mental ill-health and its impact on the clinical workforce and patient care, drawing on diverse literature sources and engaging iteratively with diverse stakeholder perspectives to produce actionable theory; and recommendations that support the tailoring, implementation, monitoring and evaluation of contextually sensitive strategies to tackle mental ill-health and its impacts.

Design

Realist literature review consistent with the Realist And Meta-narrative Evidence Syntheses: Evolving Standards quality and reporting standards.

Data sources

Bibliographic database searches were developed and conducted using MEDLINE (1946 to November week 4 2017), MEDLINE In-Process and Other Non-indexed Citations (1946 to 6 December 2017) and PsycINFO (1806 to November week 2 2017) (all via Ovid) and Applied Social Sciences Index and Abstracts (1987 to 6 December 2017) (via ProQuest) on 6 December 2017. Further UK-based studies were identified by forwards and author citation searches, manual backwards citation searching and hand-searching relevant journal websites.

Review methods

We included all studies that focused on mental ill-health; all study designs; all health-care settings; all studies that included medical doctors/medical students; descriptions of interventions or resources that focus on improving mental ill-health and minimising its impacts; all mental health outcome measures, including absenteeism (doctors taking short-/long-term sick leave); presenteeism (doctors working despite being unwell); and workforce retention (doctors leaving the profession temporarily/permanently). Data were extracted from included articles and the data set was subjected to realist analysis to identify context–mechanism–outcome configurations.

Results

A total of 179 out of 3069 records were included. Most were from the USA (45%) and had been published since 2009 (74%). More included articles focused on structural-level interventions (33%) than individual-level interventions (21%), but most articles (46%) considered both levels. Most interventions focused on prevention, rather than treatment/screening, and most studies referred to doctors/physicians in general, rather than to specific specialties or career stages. Nineteen per cent of the included sources provided cost information and none reported a health economic analysis. The 19 context–mechanism–outcome configurations demonstrated that doctors were more likely to experience mental ill-health when they felt isolated or unable to do their job, and when they feared repercussions of help-seeking. Healthy staff were necessary for excellent patient care. Interventions emphasising relationships and belonging were more likely to promote well-being. Interventions creating a people-focused working culture, balancing positive/negative performance and acknowledging positive/negative aspects of a medical career helped doctors to thrive. The way that interventions were implemented seemed critically important. Doctors needed to have confidence in an intervention for the intervention to be effective.

Limitations

Variable quality of included literature; limited UK-based studies.

Future work

Use this evidence synthesis to refine, implement and evaluate interventions.

Study registration

This study is registered as PROSPERO CRD42017069870.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 19. See the NIHR Journals Library website for further project information.

Professional Burnout of Psychiatrists in a Veterans Health Administration: Exploring the Role of the Organizational Treatment

Psychiatrists in the Veterans Health Administration (VHA) are susceptible to professional burnout due to the unique needs of veterans combined with high organizational demands. The current study examined the mediating role of organizational factors in the direct relationship between providing primarily pharmacological intervention and professional burnout. Data from 125 VHA psychiatrists revealed that fair treatment by superiors and sufficient resources independently mediated the direct relationship that the percent of time devoted to pharmacological intervention had with emotional exhaustion and cynicism. Psychiatrists who feel unfairly treated and lack sufficient resources reported more professional burnout. Implications and future directions are discussed.

Personal resilience in psychiatrists: systematic review

Aims and methodThe concept of personal resilience is relevant to physician well-being, recruitment and retention, and to delivering compassionate patient care. This systematic review aims to explore factors affecting personal resilience among psychiatrists, in particular, those that may impair well-being and those that facilitate resilience practice. A literature search was performed of the Ovid®, Embase®, CINAHL and PsycINFO databases, using keywords to identify empirical studies involving psychiatrists that examined resilience, stress and burnout from the past 15 years. RESULTS: Thirty-three international English language studies were included, showing that a combination of workplace, personal and non-workplace factors negatively and positively influenced well-being and resilience.Clinical implicationsGiven that workplace factors were the most commonly cited, it would appear that any resilience package that predominantly targets interventions at the workplace level would be particularly fruitful. Future research, however, needs to address the absence of a universal measurement of well-being and its moderators so that any potential interventions are better evaluated.Declaration of interestNone.

Burnout in mental health professionals: A systematic review and meta-analysis of prevalence and determinants

This study aimed to estimate the level of burnout in mental health professionals and to identify specific determinants of burnout in this population. A systematic search of MEDLINE/PubMed, PsychINFO/Ovid, Embase, CINAHL/EBSCO and Web of Science was conducted for original research published between 1997 and 2017. Sixty-two studies were identified as meeting the study criteria for the systematic review. Data on the means, standard deviations, and prevalence of the dimensions of burnout were extracted from 33 studies and included in the meta-analysis (n = 9409). The overall estimated pooled prevalence for emotional exhaustion was 40% (CI 31%-48%) for depersonalisation was 22% (CI 15%-29%) and for low levels of personal accomplishment was 19% (CI 13%-25%). The random effects estimate of the mean scores on the Maslach Burnout Inventory indicate that the average mental health professional has high levels of emotional exhaustion [mean 21.11 (95% CI 19.98, 22.24)], moderate levels of depersonalisation [mean 6.76 (95% CI 6.11, 7.42)] but retains reasonable levels of personal accomplishment [mean 34.60 (95% CI 32.99, 36.21)]. Increasing age was found to be associated with an increased risk of depersonalisation but also a heightened sense of personal accomplishment. Work-related factors such as workload and relationships at work, are key determinants for burnout, while role clarity, a sense of professional autonomy, a sense of being fairly treated, and access to regular clinical supervision appear to be protective. Staff working in community mental health teams may be more vulnerable to burnout than those working in some specialist community teams, e.g., assertive outreach, crisis teams.

Measuring Burnout Among Psychiatry Clerkship Directors

OBJECTIVE

The primary purpose of this study was to determine the prevalence of burnout among Psychiatry clerkship directors.

METHODS

Psychiatry clerkship directors were solicited via email to complete an electronic version of the Maslach Burnout Inventory-General Survey and the Respondent Information Form.

RESULTS

Fifty-four out of 110 surveys (49%) were completed. Fourteen percent of respondents scored in the "high exhaustion" category, 21.6% scored in the "low professional efficacy" category, 20.4% scored in the "high cynicism" category, and 15.1% of respondents met threshold for at least two of the three categories. Those who scored in the "low professional efficacy" category reported higher levels of salary support for research, while those who scored in the "high cynicism" category reported lower levels of salary support at a trend level. Those who scored in the "high cynicism" category were younger.

CONCLUSIONS

Approximately 14-22 percent of psychiatry clerkship directors reported some level of burnout depending on the subscale used. Future studies should aim to better identify those clerkship directors who are at greatest risk for becoming burned out by their educational role and to clarify the link between salary support for research, age, and burnout.

Work-life balance and welfare

OBJECTIVES

An online survey and focus groups were conducted, providing qualitative information on the work-life balance of psychiatrists and trainees in Australasia.

METHODS

An invitation to participate in an anonymous online welfare survey was emailed to all the Royal Australian and New Zealand College of Psychiatrists trainees, Fellows, and Affiliates. Following this, nine focus groups were held across Australia and New Zealand.

RESULTS

Responses received were thematically analysed. The emergent patterns are presented in this report.

CONCLUSIONS

Our research suggests that work-life balance can be subjectively and objectively measured. There are phases of good and bad work-life balance, depending on stage of career and other commitments. Work-life balance may be an indicator of the health of individuals and organisations. Due to its complexity, with intrinsic and extrinsic factors involved, solutions are unlikely to be simple. Further studies are needed to substantiate our findings.

Dual role as a protective factor for burnout-related depersonalization in oncologists

PURPOSE

This study compared self-reported burnout between dual-role oncologists (oncologists who also do psychosocial work) and single-role oncologists, to explore if dual role is protective against or a risk factor for burnout.

METHODS

Dual-role oncologists from across China (n = 131) were consecutively recruited via the Chinese Psychosocial Oncology Society and asked to identify single-role oncologist peers (n = 168) working in the same institution. Participants completed an anonymous online questionnaire, which included measures of demographic and work characteristics, Maslach Burnout Inventory-Human Services Survey, the Short Version Effort-Reward Inventory, the Job Demands-Resources (JD-R) Scales, and Work and Meaning Inventory. Fully adjusted multivariate analyses compared burnout scores for the 2 groups.

RESULTS

Group analysis revealed single-role participants' scores indicated significantly poorer performance than dual-role participants for depersonalization (DP), work-family conflict (JD-R demands scale), and decision authority (JD-R scale). Single-role participants showed an increased risk of DP. Higher effort-reward imbalance ratio predicted greater DP in single-, dual-role and pooled participants, and emotional exhaustion (EE) in pooled- and dual-role participants. Overcommitment was independently associated with EE in all 3 groupings, with JD-R scores among pooled- and dual-role groups, while higher decision authority scores were associated with decreased EE. Work and Meaning Inventory was associated with a decreased risk of DP among pooled and dual-role participants.

CONCLUSION

Differences in burnout-related DP scores between dual- and single-role oncologists are consistent with a protective effect from a psychosocial orientation in oncologists.

Risk of burnout among early career mental health professionals

Burnout is a stress-related syndrome that often affects mental health professionals (MHPs) and may have serious consequences on personal well-being as well as on the quality of provided psychiatric care. Established literature shows a high risk to develop burnout among MHPs. Few data are available on the incidence and on the clinical implications of the burnout syndrome in the early phases of MHP professional career. We confirmed the presence of burnout among early career MHPs: early career psychiatrists showed a lower sense of personal accomplishment, while non-medical MHPs tended to have more depersonalization and suffered from higher levels of depression. Specific programmes to identify the presence of the burnout syndrome and to cope with it should be taught within mental health training curricula. Burnout is a stress-related syndrome that often affects professionals working in emotionally loaded and highly interpersonal environments. Mental health professionals (MHPs) are long known to be at high risk to develop the burnout syndrome, but this has rarely been investigated in professionals in an early phase of career. The aim of the present study was to evaluate the presence of the burnout syndrome and of depressive symptoms among early career psychiatrists and 'non-medical' MHPs. One hundred MHPs (including 50 psychiatrists and 50 non-medical MHPs) were screened for the presence of burnout and depression, with the Maslach Burnout Inventory and the Beck Depression Inventory - revised, respectively. The relationships of burnout with socio-demographical and professional characteristics were also explored. We confirmed the presence of burnout among both groups of early career MHPs, but psychiatrists had a significantly higher degree of emotional exhaustion and a lower sense of personal accomplishment, while non-medical MHPs adopted more frequently depersonalization as a coping strategy and had higher scores for depression, which is associated with higher level of burnout. The risk of developing burnout should be properly addressed in training curricula and strategies to overcome it should be systematically taught, in order to promote personal well-being and efficient team work in mental health settings.

Being satisfied at work does affect burnout among psychiatrists: a national follow-up study from New Zealand

BACKGROUND

Burnout and job satisfaction in psychiatrists has been an area of considerable interest. Longitudinal studies on the subject are lacking, rendering it difficult to establish whether burnout changes with time or whether low job satisfaction may predict high burnout with time in psychiatrists.

AIMS

This longitudinal study of burnout and job satisfaction in a cohort of New Zealand psychiatrists was conducted to examine if initial scores on the Job Diagnostic Survey (JDS) predicted scores on the Maslach Burnout Inventory (MBI) three years later and vice versa.

METHODS

Three questionnaires (a socio-demographic questionnaire, the JDS and the MBI) were sent to all registered psychiatrists in 2008, which included all those who had participated in a study three years earlier. Scores on these three questionnaires were compared for those who had participated in both studies.

RESULTS

The overall number of psychiatrists reporting a high level of emotional exhaustion (EE) did not change across the two phases. The number of psychiatrists reporting high levels of depersonalization (DP) increased from 31 (13%) to 45 (20.2%); the mean DP score for the cohort significantly increased by 17.5% (p < .01). Those reporting reduced personal accomplishment (PA) increased from 90 (37.7%) to 98 (43.9%); the mean PA score for the cohort significantly reduced by 14.5% (p < .001). Low scores on skill variety, task Identity, and feedback of the JDS were significantly correlated with high EE scores three years later, whereas low scores on skill variety were significantly correlated with high scores on DP, and low scores on task significance and feedback were correlated with low scores on PA three years later.

CONCLUSIONS

Paying attention to aspects of job satisfaction may assist us in developing specific interventions for psychiatrists who may score high on different dimensions of burnout.

Understanding burnout according to individual differences: ongoing explanatory power evaluation of two models for measuring burnout types

Background

The classic determination of burnout is by means of the dimensions exhaustion, cynicism and inefficacy. A new definition of the syndrome is based on clinical subtypes, consisting of “frenetic” (involved, ambitious, overloaded), “underchallenged” (indifferent, bored, with lack of personal development) and “worn-out” (neglectful, unacknowledged, with little control). The dimensions of overload, lack of development and neglect form a shortened version of this perspective. The aims of this study were to estimate and to compare the explanatory power of both typological models, short and long, with the standard measurement.

Methods

This was a cross-sectional survey with a randomly sample of university employees (n=409). Multivariate linear regression models were constructed between the “Maslach Burnout Inventory General Survey” (MBI-GS) dimensions, as dependent variables, and the “Burnout Clinical Subtype Questionnaire” (BCSQ-36 and BCSQ-12) dimensions, as independent variables.

Results

The BCSQ-36 subscales together explained 53% of ‘exhaustion’ (p<0.001), 59% of ‘cynicism’ (p<0.001) and 37% of ‘efficacy’ (p<0.001), while BCSQ-12 subscales explained 44% of ‘exhaustion’ (p<0.001), 44% of ‘cynicism’ (p<0.001), and 30% of ‘efficacy’ (p<0.001). The difference in the explanatory power of both models was significant for ‘exhaustion’ (p<0.001), and for ‘cynicism’ (p<0.001) and ‘efficacy (p<0.001).

Conclusions

Both BCSQ-36 and BCSQ-12 demonstrate great explanatory power over the standard MBI-GS, while offering a useful characterization of the syndrome for the evaluation and design of interventions tailored to the characteristics of each individual. The BCSQ-36 may be very useful in mental health services, given that it provides a good deal of information, while the BCSQ-12 could be used as a screening measure in primary care consultations owing to its simplicity and functional nature.

Burnout and psychiatrists: what do we know and where to from here?

Medicine in most parts of the world is becoming a stressful profession. Psychiatrists represent a high-risk group among doctors for experiencing burnout, alcohol and drug use, posing suicide risk and other forms of work-related stress. There are reports that entrants in the profession of psychiatrists are decreasing globally. Conceptual issues related to burnout are explored and factors contributing to burnout in psychiatrists are reviewed. Methodologically sound studies are needed to help us understand positive aspects of psychiatry as a profession and the environment psychiatrists work in. Effective treatment programmes for burnout are also needed not only to reduce suffering but also to retain psychiatrists in the profession.

Factors associated with use of community mental health services by schizophrenia patients using multilevel analysis

Background

Persons with schizophrenia and related disorders may be particularly sensitive to a number of determinants of service use, including those related with illness, socio-demographic characteristics and organizational factors. The objective of this study is to identify factors associated with outpatient contacts at community mental health services of patients with schizophrenia or related disorders.

Methods

This cross-sectional study analyzed 1097 patients. The main outcome measure was the total number of outpatient consultations during one year. Independent variables were related to socio-demographic, clinical and use of service factors. Data were collected from clinical records.

Results

The multilevel linear regression model explained 46.35% of the variance. Patients with significantly more contacts with ambulatory services were not working and were receiving welfare benefits (p = 0.02), had no formal education (p = 0.02), had a global level of severity of two or three (four being the most severe) (p < 0.001), with one or more inpatient admissions (p < 0.001), and in contact with both types of professional (nurses and psychiatrists) (p < 0.001). The patients with the fewest ambulatory contacts were those with diagnoses of persistent delusional disorders (p = 0.04) and those who were attended by four of the 13 psychiatrists (p < 0.001).

Conclusions

As expected, the variables that explained the use of community service could be viewed as proxies for severity of illness. The most surprising finding, however, was that a group of four psychiatrists was also independently associated with use of ambulatory services by patients with schizophrenia or related disorders. More research is needed to carefully examine how professional support networks interact to affect use of mental health.