INTRODUCTION
In Switzerland and neighboring nations such as France, Italy, and Germany, burnout poses a significant challenge for healthcare professionals.1 A survey conducted in 2010 revealed that over 30% of Swiss physicians reported symptoms of burnout.2 These concerns have been exacerbated by the COVID-19 pandemic. A recent review found that around 40% of medical workers experienced acute stress disorder following the onset of the COVID-19 pandemic, with 29% experiencing burnout.3 It is worth noting that already in the pre-COVID-19 period rates of burnout differed among countries, with France showing a prevalence of 45% and Germany at 50.3%, according to a meta-analysis.4
Psychiatrists and trainees in psychiatry face unique stressors compared to other medical specialties. These include second-hand trauma, compassion fatigue, and the impact of patient suicides.5,6 These stressors, when combined with a chronic shortage of clinicians in psychiatric services, result in an increased workload for trainees. Factors such as insufficient supervision, high workload, and demographic variables like younger age and female gender contribute to the severity of stress outcomes.7–11
One support agency for such issues in Switzerland is ReMed. ReMed is a non-governmental, independent organisation with the fundamental goal of assisting Swiss physicians in stressful times. Once a physician reaches out to ReMed, a counsellor will contact them within 72 hours to analyse the situation, discuss the first steps (including taking the anamnesis, providing support and redirecting to other professionals where needed) and accompany the individual throughout the crisis. Established in 2010, the underlying principles of ReMed include medical confidentiality, data privacy, and obtaining the physician’s consent for all actions.12 Unlike regulatory bodies, ReMed does not conduct investigations, issue sanctions, or grant access to the Swiss Medical Association (FMH) for their case files. Its structure includes the FMH Central Board for strategic decisions, an executive committee, program management for structural development, and back office.
Over the years, ReMed has supported approximately 1500 doctors in crisis, with a yearly increase in demand (+33% in 2022, +11% in 2021, +5% in 2020).8 The main reasons for contact have been workplace stress, depression, anxiety, and self-doubt. Interestingly, the majority of those seeking advice were from German-speaking Swiss regions and females, with their average age dropping from 45 to 40 years.12 During the COVID-19 pandemic, ReMed expanded its services, including online coaching and tools for managing stress and preventing overwork.
Project objectives
The aim of this quality improvement project is to explore the challenges that psychiatric trainees are currently facing in the Swiss healthcare system as well as the opportunities offered by the ReMed network as a potential support system.
MATERIALS AND METHODS
Ethics and dissemination
Referring to swissethics (Swiss umbrella organisation of the cantonal Ethics Committees), as well as to CIOMS guidelines for epidemiological studies, our work can be classified as a quality control and improvement project.13,14 The primary intent behind gathering this data was to analyse and potentially enhance the use and functioning of ReMed in the psychiatric traineeship framework in Switzerland. Ethics committee approval is not required for this type of project if the criteria of minimal risk, collection of consent from participants and total anonymisation of data in all phases of the project are guaranteed, as is the case in the present article.
During the month of June 2023, we conducted an online anonymous survey, disseminated via the Swiss Psychiatric Trainee Association and the Romandy Post Graduate Formation Institute (CEPUSPP) newsletters, to assess mental distress among Swiss Psychiatry and Psychotherapy trainees and their familiarity with ReMed. The survey was conducted entirely online. The questionnaire was developed through a brainstorming session among the authors, drawing on insights from current literature, including best practices for questionnaire development.
Materials
The survey, created specifically for this quality improvement project, was delivered in English to facilitate dissemination and understanding in all linguistic regions and national origins of possible participants, and structured as follows. The first section aimed to collect socio-demographic information (gender, age, year of training).
In the second section, participants were asked to rate their mental health at the beginning of their training on a scale of 0 (very bad) to 4 (excellent). We then asked participants to rate the impact of specific symptoms such as depression, burnout, insomnia, substance abuse, suicidal ideation, panic attacks, and eating disorders on their training. These were the only symptoms queried, and participants rated them on a scale from 0 (none) to 4 (very much). The symptoms were chosen based on their prevalence and impact on healthcare professionals, as evidenced by prior studies.1 Throughout the survey, participants are asked to make a self-assessment, regardless of any diagnosis they may have received.
To assess symptom severity and frequency, we used a five-point Likert scale to categorize responses from “Not severe at all” to “Extremely severe.” Participants were also asked how often they experienced these symptoms, with options ranging from “never” to “daily.”
Finally, we asked participants whether they had already thought of seeking help for their mental health (possible answers: ‘Never’, ‘Once’, ‘Twice’, ‘More than twice’) and whether they were aware of ReMed. Trainees who were not familiar with the service were provided with an explanation of its functions and a direct link to the website for more information.
In the third section, we asked participants which care providers they contacted or would contact if they were to seek help for their own mental health and then whether they had already used ReMed’s services for this purpose.
The fourth section was divided into two parallel sections according to the use of ReMed. (1) Those who had used it were asked which factors positively or negatively influenced their decision to contact ReMed and finally to evaluate the experience overall (‘Unhelpful’, ‘Neither helpful nor unhelpful’, ‘Helpful’). (2) For those who had never directly used ReMed’s services, we first asked why they had not done so and then asked them to consider what factors might positively or negatively influence this choice.
In the fifth and final section, we asked participants to express their agreement by means of a 5-points Likert scale (from “I disagree” to “I agree”) regarding the statement: ‘I feel that there is a stigma associated with seeking help from services such as ReMed’.
Statistical Analysis
Data were summarized the appropriate measures and analyzed using Cronbach’s alpha to test consistency of the questionnaire and Kruskal-Wallis’s Test, Chi-Squares Test or Fisher’s Exact Test when appropriate to test the distribution of the sample and possible differences between groups and subgroups. The statistical analysis was conducted using R, version 4.2.1. For the analyses performed, we established a significance level of Alpha = 0.05.
RESULTS
Participants and Demographic
A total of 57 psychiatric trainees responded to the survey, representing approximately 3.8% of the total number of psychiatric trainees in Switzerland (n= 1510).15 Of these, 54.4% were female (n= 31), while 45.6% were male (n=26), with a median age of 34 years (IQR 30-38). Following age grouping, 56.1% were under-35 (n=32), while 43.9% were over-35 (n=25). This regrouping arose from the need to investigate possible differences between younger and older trainees, obviating the limitation of the sample size and its non-normal distribution. Demographic data are described in the Table. The sample was evenly distributed by gender, age, and training year as we found no statistically significant differences.
Self-reported symptoms of psychological distress during training
The respondents rated their mental health at the beginning of the training with a median value of 3 (IQR 2-3), with no statistically significant differences by gender or age. Regarding symptoms related to psychological distress during training, the 89.5% of responders reported at least one symptom of distress of at least mild degree. Burnout, depression, and insomnia showed a severity-weighted average prevalence (severity score ≥ 3) of 26. Other symptoms like suicidal ideation, substance abuse, panic attacks, and eating disorders were reported with lesser or mild severity. Prevalence and symptom severities were evenly distributed among the groups, except for burnout with a higher prevalence in females (45.2% medium-high severity symptoms vs. 15.4% in males, OR 4.41, P=.02) and for suicidal ideation in young trainees (34.4% of under-35s vs. 8.0% in the over-35s, OR 0.17, P=.03). Sixty-three-point two percent of respondents reported suffering frequently (at least monthly or more often) from such symptoms, with higher frequency in females (71.0% vs. 53.8%, x2 = 1.12, P=.29), although not statistically significant. Ten-point five percent of trainees reported suffering from these very severely, with no statistically significant differences by gender or age group. Lastly, the Cronbach’s alpha for the questionnaire was measured at 0.67, indicating a moderate level of internal consistency.
Seeking help from mental healthcare providers and ReMed
In our sample, 71.9% of participants stated that they had thought about seeking professional help at least once. Despite this, only a minority (23.7%, n=14) knew ReMed and only 3 had used it (5.1%). In case of need, most would turn to a private psychiatrist or psychotherapist (61.4%, n=35) or to their supervisor (17.5%, n=10).
Factors influencing the use of ReMed were also explored. Since only three participants had used ReMed, their responses were aggregated during the analysis and no subgroup analysis was performed. Facilitating factors mainly included the free nature of the service (59.3%, n=32), quick response time (57.4%, n=31), and the possibility of remote communication (online counselling) (25.9%, n=14). Factors that might hold participants back from contacting ReMed included fear that confidentiality might be compromised (40.7%, n=22), fear of career repercussions (38.9%, n=21), and not having an established relationship with the provider (33.3%, n=18). We found no statistically significant differences by gender or age. In attempting to assess the perceived stigma associated with seeking help for one’s mental health, we found that 29.8% of the participants (n=17) agreed with the statement “I feel there is a stigma associated with seeking help from services like ReMed.”, while 43.9% said they neither agreed nor disagreed (n=25).
DISCUSSION
The psychological burden crisis among the healthcare personnel has emerged in recent years, particularly after the COVID-19 crisis as a critical and urgent concern. In this article we wanted to address the gap between the awareness of the entity of this burden and the knowledge among the psychiatric trainees of the existing Swiss support system ReMed.
The significant incidence of burnout and psychological distress in psychiatrists is well documented in the literature.2,3,16,17 This is presumably due to exposure to personal distress induced by being constantly in contact with patients suffering from mental disorders, as well as the systemic stressors coming from institutions, such as personnel shortage and work overload.18 This is even more pronounced in trainees.19,20 Indeed, factors characteristic of trainees such as insufficient supervision, excessive workload, and young age have been documented as important risk factors for psychological distress. High levels of different symptoms of psychological distress also emerged in the psychiatric trainees we were able to contact. Almost all participants (89.5%) reported at least one symptom of distress of at least mild degree, with burnout, depression, and insomnia showing a severity-weighted average prevalence (graded ≥ 3) of 26.1%, and other symptoms, such as suicidal ideation, substance abuse, panic attacks and eating disorders, to a lesser or mild degree. Differences also emerged among the respondents to our survey that follow the risk factors already described in the literature. Specifically, females declared a higher incidence of burnout symptoms (45.2% medium-high severity symptoms vs. 15.4% in males, P=.03) and suffering more frequently from psychological distress symptoms in general (71.0% monthly or more often in females vs. 53.8% in males, P=.03). Secondly, the younger subgroup showed a higher frequency of suicidal thoughts (34.4% of under-35s vs. 8.0% in the over-35s).
A possible explanation from earlier research for female psychiatric trainees in Switzerland giving higher rates of burnout might lie in a combination of work-life balance challenges, societal gender roles and expectations, workplace dynamics including gender-based discrimination, and the emotional labor associated with their roles, as per earlier research.8–11 These factors, though non-specific to Swiss literature alone, may contribute to increased stress and risk of burnout.
As healthcare workers face mental distress, the increased individual burden may lead to reduced patient care quality, higher attrition rates, and even greater strain on an already overburdened system.21 The COVID-19 pandemic has only intensified these pressures, requiring immediate attention and comprehensive solutions. Understanding the full scope and nuances of this crisis is essential for devising effective strategies to support healthcare professionals. By addressing burnout and mental distress, we can try to shape a more resilient and compassionate healthcare system capable of meeting the multifaceted challenges of the post-COVID era.
We observed a glaring lack of awareness about the ReMed support system among our respondents, despite its potential to enhance the well-being of this critical workforce.22 This lack of awareness prompts questions about the visibility of ReMed and suggests that proactive dissemination strategies are needed. Exploring possible institutional barriers to the program’s promotion is another crucial avenue for future research. The study also raises questions about the regional differences in burnout prevalence. A comparative analysis with similar studies from other countries could offer valuable insights into whether the burden experienced by Swiss trainees is a localized issue or part of a broader trend.
Despite the potential benefits of using ReMed, factors such as limited awareness and perceived stigma limit its utilization. It’s equally worth noting that only a maximum of three sessions through the ReMed system is available.12 In case of need for a longer course treatment, referral to a specialist through the insurance system is necessary. That might account in some cases for a drawback concerning the access to a proper treatment. It’s worth noting that while our study identified these as potential obstacles, the presence of stigma was not strongly supported by our data. Comparative studies with similar programs in other countries could provide additional perspectives on this aspect.23,24 To overcome these challenges, introducing ReMed at the start of psychiatric training could be a promising approach. European initiatives that have successfully reduced stigma, such as the “Time to Change” campaign in the UK, could serve as models for Switzerland.
The data obtained from our survey would seem to confirm that there is currently a psychological burden among psychiatric trainees in Switzerland. We must note, however, that these data are derived from only a small proportion of Swiss psychiatric trainees and that we cannot exclude a responder bias for those who are most subject to psychological stress. However, since our main objective remains to assess what role ReMed could play in providing help to the category of psychiatric trainees, we consider the results to be sufficiently robust.
In summary, the urgency of addressing mental distress among psychiatric trainees in Switzerland is evident. While ReMed offers a viable avenue for support, there is a clear need for broader awareness and potentially institutional changes to enhance its utilization. By adopting proven strategies from other countries and coupling them with institutional support, Switzerland could not only improve the well-being of its medical workforce but also the quality of patient care.
CONCLUSIONS
Despite the high prevalence of psychological distress symptoms highlighted in this study among psychiatric trainees, most are unaware of the support offered by ReMed. This lack of awareness represents a missed opportunity to address the significant mental health challenges facing this group, especially in the context of the COVID-19 pandemic. While our findings did indicate some level of perceived stigma associated with using mental health services like ReMed, this was not as prominent as initially thought. Therefore, while stigma may be a concern for some, the primary focus should be on increasing awareness and accessibility to ReMed as a support mechanism.
Our study underscores the urgent need for targeted interventions, both at the individual and institutional levels. Implementing these strategies could not only alleviate the individual burden of mental distress among trainees but also potentially contribute to an overall improvement in the quality of patient care.
DECLARATION OF CONFLICT OF INTEREST
Davide Zani is a member of the editorial board of the International Journal of Psychiatric Trainees and had no interference with the editorial handling of this article as per internal guidelines. The authors declare not other conflict of interest. This study was supported by the Swiss Association of Psychiatric Trainees without external funding. The authors declare that they have no connection of any kind with those responsible for ReMed and their services.