Introduction

Burnout, depression, and suicide are problems among physicians that drastically affect patient care.1 In a systematic review collecting data of 170 studies, burnout in physicians was associated with a twofold risk of patient safety incidents.1 While fortunately the overall rate in suicide in physicians has dropped between 1980 and 2020 according to a meta-analysis, the suicide rate in female physicians is still significantly higher than in the general population.2 In a global study with 40 participating countries during the SARS-CoV-2 pandemic, clinical depression was detected in 13.07% of physicians and distress symptoms in an additional 15.11% of physicians.3 Of the overall healthcare staff, 47.15% had reported an increase in anxiety and 10.48% even reported an increase in suicidal thoughts.3

The aim for this project was to gather studies or evaluations concerning the overall mental health of physicians in Germany, especially trainees in psychiatry, and compile those in a narrative mini-review. The question was how much data had been collected in this subsection of the population and if there were any approaches, individually or systemically, to improve the mental health of physicians in Germany. Furthermore, it was of interest whether any new factors concerning the mental health had arisen in the past years. To our knowledge there has not been a review addressing this question regarding German physicians. To review the existing literature on the topic, search terms “depression OR burn-out OR psychiatric AND doctor AND Germany” were entered into PubMed with a specified search for the time frame of 2018 until August 2023. Additionally, the websites of the German governments’ health ministry and large German medical associations (such as the occupational unions as well as the specialist associations) were searched. Relevant findings were narratively synthesized and the findings, with their derived limitations and future perspectives, discussed.

Psychiatric symptoms in physicians prior to the SARS-CoV-2 pandemic

In the 2019 study of “Marburger Bund” – the largest professional association of physicians in Europe – physicians showed to be overwhelmed by their workload and felt that extended working hours were damaging their private life.4 At that time, around 15% of physicians reported to have undergone psychiatric or psychotherapeutic treatment due to work-related mental issues, like exhaustion or depression.4

Another study also conducted in Germany in the same year reported that almost every second physician reported perceiving psychiatric symptoms on themselves. Among physicians under 45 years of age, the self-reported rate of depression-like symptoms was around 31% – more than any other age group.5

Impact of the pandemic

The occurrence of notable levels of depressive and anxiety symptoms among physicians during the SARS-CoV-2 pandemic was substantially greater than before the outbreak, reaching as high as 34%.6,7 Particularly notable was the observation of an increased workload among trainees during the second wave of the SARS-CoV-2 pandemic, with 31.56% reporting a significant increase and further 25.04% reporting a manageable increase.8 64% of trainees have expressed that their professional workload exerts a detrimental impact on their personal lives, manifesting as social isolation, health complications, and sleep disorders.8 In a survey of outpatient psychiatrists and neurologists, 18% reported substantial anxiety while a third felt financially threatened.9

Help seeking behaviour in physicians

In general, physicians show a tendency to trivialize their psychological issues, with 39% describing it as not severe enough to seek help.5 Interestingly, 10% of the physicians report avoiding to seek help in order to not have their problems known.5

A cross-sectional survey conducted among physicians ≤35 years of age reported that around 22% used a medication related to work-related stress at least once.10

Developing the disease you are studying – mental health problems within the psychiatrist population

Bearing in mind that psychiatrists professionally advise people on how to treat mental diseases and avoid relapses, how do psychiatrists fare themselves compared to other specializations and the general population? Data from the early stages of the SARS-CoV-2 pandemic showed more than a third of the psychiatrists reporting high or very high concerns and stated high to very high anxiety levels.9 Compared to surgeons, they perceived higher anxiety levels even though the contact with the virus was significantly less for the psychiatrists.11 Similarly, the subjective burden during the first year of the SARS-CoV-2 pandemic was reported to be higher in mental health workers than health care workers in somatic disciplines.12 In accordance with this, changes due to the SARS-CoV-2 pandemic in the conditions of the work place, such as wearing a mask while communicating with patients, were associated with an increase in moral distress among medical personnel working in psychiatry.13 In terms of effort reward imbalance, a pre-pandemic comparison between psychiatrists and physicians working in intensive care units showed a significant lower imbalance for the psychiatrists.14 This was reinforced by a cross-sectional study among physicians under the age of 40 which showed psychiatrists to have lower rate of high-degree burnout.15 However, compared to the general population, psychiatrists showed a higher occurrence of depressive symptoms by 4 percentage points.14 At the same time, they seek treatment less often with only 6.62% in total.14 Interestingly, this number has increased between 2006 and 2016, same as the number of psychiatrists having received an official psychiatric diagnosis, while the number of psychiatrists showing symptoms of depression remained the same.14

Psychiatric symptoms in students

Since the stress factors of workplaces in mental health are not likely to change dramatically any time soon, it is worth taking a look at the future generation of physicians and their learning pattern. Quite concerningly, a study among 591 medical students showed that 68.5% had risky work-related behaviour and experience patterns. Those were further divided into “overexertion” (39.8%) and “burnout” (18.3%).16 While the sample showed a decrease of the behaviour pattern “overexertion” throughout the years of the curriculum the opposite was true for the behaviour pattern “burnout”.16 Whether this shift took place from one risky pattern to the other or among risky-healthy patterns remains to be determined. Taking a look at the teaching methods, a survey among medical students found that only roughly nine percent of the sessions touched upon the communication in emotionally challenging situations, the majority of which were conducted in psychosocial specializations.17 Similarly, an unrelated study found a sudden high amount of missing answers in their questionnaire study including the Connor-Davidson-Resilience-Scale for the self-rated item “I am able to handle unpleasant feelings”, indicating a difficulty in discussing this subject.18 Moving from medical students to PhD students, an overall high level of burnout was detected in a study using self-report. This showed around 20% having clinical levels of depression and consecutively linking poor mental health to low satisfaction with the PhD training.19

A systematic approach to the problem - not yet a reality

A general program for preventing mental disorders or helping physicians to deal with stress does not exist in Germany.

Some attempts to rectify this have been made: there are two established hotlines – the Burnout Hotline by the Deutsche Ärztinnenbund [https://www.aerztinnenbund.de/Burnout_Hotline.0.293.1.html, retrieval date 24.08.2023] and the PSU (Psychosoziale Unterstützung) Helpline [https://psu-helpline.de/, retrieval date 24.08.2023] – designed for doctors suffering from burnout. Furthermore, regional medical associations are planning to provide help for physicians suffering from addictions, but the program is not yet put into effect.20 The recently established program Aufeinander Achten (= “to look after each other”) by the University of Freiburg, which is based and associated with On The Move e.V., helps medical students identify psychiatric symptoms among their peers and trains them in first aid for mental health [https://aufeinanderachten.de/, retrieval date 23.08.2023].

A study among trainees showed promising results by creating training networks for family physicians. When training programs are structured, it helps foster a sense of professionalism among physicians, which in turn leads to decreased emotional exhaustion and depersonalization while increasing personal satisfaction.21

Discussion

The present narrative mini-review is based on existing studies regarding the mental health of physicians in Germany. We could only find a few articles related to the mental health of psychiatrists in Germany. In general, there is an obvious lack of information about the psychological state of medical trainees in mental health. Legislative measures aimed at reducing working hours have already demonstrated a positive impact through the reduction of occupational stress levels, emotional fatigue, and depression.4 Nevertheless, a direct approach to these issues is basically non-existent. Most of the time the focus is put on working conditions and infrastructure instead of directly on the wellbeing of the physicians. At the same time, the results show a difficulty in seeking help by the physicians themselves for their mental health problem due to avoidance of having their problem known. This is an indicator of the still persisting stigma around mental health.

Comparing the data to other countries bears the difficulty of comparing studies with different designs and outcome measurements. Additionally, this task is further complicated by the impact of the SARS-CoV-2 pandemic, rendering a comparison between studies of different countries which were conducted prior the SARS-CoV-2 pandemic and now with severe limitations. One systematic review of 182 studies conducted in 45 countries looking into the prevalence of burnout among physicians before the SARS-CoV-2 pandemic could not reliably determine an association between burnout and geography.22

Conclusion

Burnout and depression present significant challenges to the mental well-being of physicians in Germany. While there is some data about mental illness in physicians and even information about the impact of the SARS-CoV-2 pandemic, there is a lack of information about the well-being of trainees in terms of mental health. This is a topic which should be explored further in the future.

So far, there is no systemic approach or program for physicians struggling with their mental health. It is crucial to establish a strong foundation for cultivating physicians who possess the ability to develop healthy habits and self-awareness, seek assistance when necessary, and employ effective coping strategies during periods of stress. According to the collected data, a systemic approach seems warranted. Whether this is best implemented by the government, the insurance companies, or the employers can be discussed further.

Declaration of interest

All authors declare that there is no conflict of interest.

Acknowledgements

None.

Role of funding

Neither author has received any financial sponsorship in regards to the topic or the submitted paper.

Author contributions

Conceptualisation: EV; Formal Analysis: EV, JR; Investigation: EV, JR; Methodology: JR; Writing – original draft: EV; Writing – review and editing: JR.

Not applicable.