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REVIEW

Mental Health Problems among Young Doctors:
An Updated Review of Prospective Studies
Reidar Tyssen, MD, PhD, and Per Vaglum, MD, PhD

Previous studies have shown the medical community to exhibit a relatively high level of certain mental health problems, particularly depression, which may lead to drug abuse and
suicide. We reviewed prospective studies published over the past 20 years to investigate
the prevalence and predictors of mental health problems in doctors during their first postgraduate years. We selected clinically relevant mental health problems as the outcome
measure. We found nine cohort studies that met our selection criteria. Each of them had limitations, notably low response rate at follow-up, small sample size, and/or short observation
period. Most studies showed that symptoms of mental health problems, particularly of depression, were highest during the first postgraduate year. They found that individual factors,
such as family background, personality traits (neuroticism and self-criticism), and coping
by wishful thinking, as well as contextual factors including perceived medical-school
stress, perceived overwork, emotional pressure, working in an intensive-care setting, and
stress outside of work, were often predictive of mental health problems. The studies revealed somewhat discrepant findings with respect to gender. The implications of these
findings are discussed. (HARVARD REV PSYCHIATRY 2002;10:154–65.)

The mental health of physicians is of concern not only to
themselves, but also to others. First, psychological problems
of doctors can be detrimental to patient care, by impeding diagnosis and treatment.1 Second, such problems can seriously
inhibit the learning capacity and academic performance of
medical postgraduates.2 Third, they may indicate a working
situation that is too stressful and therefore needs to be
changed.3 Knowledge about the predictors of mental health
problems among physicians constitutes a basis for adequate
From the Department of Behavioural Sciences in Medicine, Faculty
of Medicine, University of Oslo, Oslo, Norway.
Original manuscript received 1 August 2001; revised manuscript received 26 November 2001, accepted for publication 29 November
2001.
This research was supported, in part, by a grant from the Research
Council of Norway.
Reprint requests: Reidar Tyssen, MD, PhD, Department of Behavioural Sciences in Medicine, P.O. Box 1111, Blindern, N-0317 Oslo,
Norway (e-mail: reidar.tyssen@basalmed.uio.no).
© 2002 President and Fellows of Harvard College

154

treatment, for individual prevention, and for establishing
healthy working conditions.
That doctors are not invincible was highlighted by two
recent representative nationwide studies, from England4
and Finland,5 which found a higher prevalence of selfreported mental disorders among physicians of both genders
than in the general population. Both depression6 and suicide7
have been found to be more prevalent among physicians, in
particular early in their career.8,9 Depression and anxiety
may be complicated by the development of substance abuse.10
Furthermore, there is evidence11 that the youngest doctors
are more at risk of making serious mistakes, and one might
expect this to be due to higher levels of emotional distress, in
addition to lack of experience.
However, knowledge of the prevalence of psychiatric disorders is not sufficient for prevention and adequate treatment of mental health problems among young physicians.
We also need to identify factors that predict such problems.
This information should be collected through prospective
and longitudinal studies. Unfortunately, such research is
still scarce, despite two landmark investigations conducted
in the United States in the 1970s.12,13 These studies examined only male physicians and did not address the first postgraduate years. Moreover, most recent studies have been

Ideally. In a study involving monthly observations (survey). which does not allow clear separation of the effects of personality and other individual factors from the impact of current working conditions on mental health. During the discussion. and two were from Norway. sociodemographic. Further limitations included a total observation period of at least 6 months and a sample size of at *A previous review16 found that despite the lack of solid evidence for a higher prevalence of drug abuse among young doctors compared to their contemporaries in the general population. we will also incorporate results from cross-sectional research. and workload (perceived or objective) were not related to depressive symptoms. or perceived need for treatment due to mental health problems. residents as the caring professional. while the table provides prevalence and most other numerical information. a comprehensive study of predictors should include possible individual factors. and rates of problem drinking appear to be similar in male and female physicians. personal history of mental disorder.. we were also interested in information regarding the prevalence of mental health problems during the first years of medical practice and any change in such problems within this period. sample size. Generally. previous research1 has suggested sleep deprivation due to heavy on-call work as one such factor among postgraduates. preregistration house officers. we cannot be certain that we found all of the studies.S. and a previous review. but a few have investigated several of them.6 and through our own research in the field. For example. Four studies were from the United States. and so on. no study to date has included all these variables. The text emphasizes identified predictors. Therefore. three were from the U. observation time.K. possibly allowing the doctors or their employers to prevent or change these conditions. most of the rest involved postgraduate education in psychiatry. life events. As mentioned above. false-negative findings (type II errors) cannot be ruled out. depressive symptoms as determined by standardized measures. and Norway. house officers.5 years. Tyssen and Vaglum 155 least 40. Below we provide a short description of each study. Table 1 provides an overview of these studies. including country.K.* In the present review we have included all other prospective studies that have used mental health problems of clinical importance as an outcome. surgery. we have been able been to identify a small number of them.15 To our knowledge. such as work-related pressures. For example. the sample size was rather small. we have not reviewed studies that have substance abuse as an outcome. “case” prevalence. and synopsis of predictors.” We found that the combination of “mental disorders” and “internship and residency” yielded 210 references in Medline. or contextual factors. METHODS We searched the Medline and PsycLit databases for relevant prospective studies published in English from January 1981 through May 2001. such as work conditions and life events. The strength of this study is the use of interview and several validated predictor measures. Number 3 cross-sectional in design. We will examine those published over the last two decades and discuss the important information they provide for clinical and preventive work. most of the identified cohort studies were found in the bibliographies of papers. obstetrics. one cannot expect mental health problems among doctors to be caused by factors other than would be seen among nondoctors. We therefore excluded studies of clinically less relevant stress. identifying studies relevant to our purposes was difficult using ordinary Medline and PsycLit search strategies. The assumption is that both individual and contextual factors are important for mental health and professional development in this phase of life.17. such as genetic/biological. however. main outcome variable. Gender. combining search terms with the subject heading “medical profession” would retrieve all abstracts that include the words “doctor” or “physician. and few participants were female. Due to the limitation of space and the few prospective studies among medical postgraduates.Harvard Rev Psychiatry Volume 10. Research on physicians’ mental health should examine predictors that may be particularly strong among doctors. or senior house officers in the U. and observation time from 6 months to 3. as well as external stressors. In addition to possible predictors. book chapters. The study subjects were in their first postgraduate years of training—interns or residents in the United States. response rate.14 a notion based on human developmental theory. and personality factors. Although prospective studies following physicians from the early phase of their medical career are somewhat difficult to find during ordinary database literature searches (see below). alcohol problems appear to increase with age more among physicians and attorneys than in the general population. Sample size ranged from 40 to 396 participants. . medical center and followed up 6 months later. marital status. Both a family history of depression and a high level of neuroticism predicted onset of depressive symptoms during the first 6 months of internship. RESULTS Only nine prospective investigations19–27 met our selection criteria. We also required mental health problems to be of clinical relevance—for example.18 Nevertheless. and pediatrics at one U. For this reason. Fewer than ten of these articles concerned problems among interns and residents. design. Clark and colleagues19 carried out diagnostic interviews of interns from the departments of internal medicine.

6. sleep deprivation Neuroticism. Prospective Studies of Mental Health Problems among Young Doctors 2y 3y 2y 1y 6 mo Observation period Depressive and anxiety symptoms Psychological distress (GHQ-28) Depressive symptoms (SCL-90-D) Depressive symptoms (BDI) Depressive symptoms (CESDS) Main outcome 30% NA 29% (PGY-I).23 Scotland USA Clark et al. PGY-II) 28% 27% “Feeling overwhelmed” (work-related factors).29 self-criticism.28 female gender.22 Baldwin et al.6.USA England USA Reuben20 Firth-Cozens21 Girard et al. 33–37% (intensive care units.19 Senior house officers Internal medicine residents Junior house officers (PRHOs) Internal medicine residents Interns Country Position Study 95 75–95 71 87 71 Response rate (%) 142 40 170 68 55 n 45 39 41 NA 20 Women (%) Longitudinal survey/ interview Longitudinal survey Longitudinal survey Prospective survey/ interview at baseline Longitudinal survey Design TABLE 1. parental history of depression Intensive care unit rotation. PGY-I.30 severe depression more common in women than in men Decrease with time Older fathers.28 dependency trait. decrease with time “Case” Predictors/ prevalence comments* 156 Tyssen and Vaglum Harvard Rev Psychiatry May/June 2002 .

PRHOs. POMS. wishful thinking. medical school stress.Family medicine residents USA Norway Norway Hainer & Palesch25 Tyssen et al.5 y 6 mo MHPT MHPT. Profile of Mood States.24 England Harvard Rev Psychiatry Volume 10. doubts about career 11% MHPT. Number 3 Tyssen and Vaglum 157 . Paykel). 28-item version.5 y 1y 2. S.31 Tyssen et al. neuroticism. Senior house officers. SCL-90-D. SFGPQ. increase in problems with time26. CESDS. *References are listed for findings from additional studies of the same cohort.27 NA BDI. GHQ-28. Mental Health Inventory. Center for Epidemiological Studies Depression Scale. postgraduate year.26. job stress.27 63 58 78–82 64–82 396 371 280 171 56 56 NA NA Longitudinal survey Prospective survey Longitudinal survey Longitudinal survey 3. Beck Depression Inventory. MHI. low increase in confidence linked to high psychological distress 7% (POMS). Previous mental 14% suicidal health problems/ thoughts suicidal thoughts. information not available. family medicine residents Junior house officers (PRHOs) Senior house officers Williams et al. extroversion. preregistration house officers. no partner. NA. PGY. suicidal ideation (SFGPQ) Depressive symptoms (BDI/POMS) Psychological distress (MHI/GHQ) Previous psychological distress. MHPT. Suicidal Feelings in the General Population Questionnaire (questions developed by E. mental health problems in need of treatment. Symptom Checklist-90 Depression Scale. Unhappy 3% (BDI) childhood. mental distress 17% Previous mental health problems. General Health Questionnaire. negative life events.

it is weakened by small sample size.e.” and “making decisions” were highly correlated with stress and depressive symptoms among the junior doctors. Confidence scores regarding carrying out a range of clinical and practical tasks were also determined.S. The officers were divided into three cohorts: postgraduate years 1. and 3.5 years. since they had been used in only one previous study. universities for 2 years. a comprehensive personality instrument was not administered at baseline. Baldwin and colleagues23 studied a fairly representative cohort of a Scottish university class. high selfcriticism. The authors provided no information about the effects of gender. Firth-Cozens21 followed a cohort of medical students at three U. neither previous depressive symptom scores in medical school nor current work hours were significantly related to postgraduate symptoms.158 Tyssen and Vaglum Reuben20 followed all internal medicine house officers from one U. Nevertheless.” “relations with consultants [senior specialists].28 A combination of older fathers. In our own longitudinal investigation. probably due to the high attrition rate and the small sample size. Perceived competence and level of satisfaction increased steadily after the initial year. and poor current diet provided the best model for predicting depressive symptoms in the first postgraduate year. or training site. between high inventory scores and uncertainty about career choice or an unhappy childhood. (The response rates differed slightly among the various outcome measures. with 38% showing depressive symptoms. Women reported more symptoms on the severe depression subscale. although no gender difference had been seen in medical school. Unfortunately. the authors did not thoroughly control for confounding effects by using multivariate statistical methods. Williams and colleagues24 followed senior house officers in the accident and emergency departments of 27 London hospitals. sleep deprivation was associated with depressive symptoms. commencing in their fourth (i. The low percentage of residents completing the inventories more than once is the main limitation of this study. However. Some significant univariate associations were seen—for example.28. Work-related factors commonly related to distress were communication difficulties (dealing with demanding or aggressive patients or pediatric patients).” “effects on personal life. university. Personal concerns and stressful life-events were of little importance.21 In addition. number of minor menial tasks to be completed) on the one hand and anxiety and depressive symptoms on the other. studying the effects of work-related stressors on mental distress at four points over 6 months. the use and utility of the prospective design in the present papers is somewhat unclear. hospital for 1 year. She found that women postgraduates had more depressive symptoms. The strengths of this study are its large and representative sample and its longer follow-up. and a lower increase in confidence was linked to higher psychological distress at follow-up. and only 7–8% did so three times. intensity of the workload. uncertainty about whether to admit patients.S. multivariate methods were not utilized. Anxiety and depressive symptoms were most prominent during the first year. The overall prevalence of depressive symptoms in the sample (15%) approximated that in the general population.K. although several validated measures were employed.” which was related to both “objective” job-related factors (number of emergency admissions. as measured by an instrument derived from the Mental Health Inventory and the General Health Questionnaire.) Repeated-measures analysis of the outcome scores showed no significant effects of age. The follow-up identified “a perception of being overwhelmed. number of deaths on the ward. the effects of gender were not reported. Girard and colleagues22 conducted a longitudinal survey of two classes of internal medicine residents at one U.6. However.. although it remained high during the first and second postgraduate years among individuals on intensive-care rotations.28 Regarding work-related stress. gender. Mental health problems peaked during the first 6 months after graduation. they then decreased and remained low for the remainder of the observation period. race. the sample was relatively small. The strength of this study is its broad and open approach to any work-related stress. However. Prevalence of such symptoms generally decreased over the years.30 The authors found no significant relationship between number of hours worked and psychiatric symptoms. current postgraduate year. and the authors provided no information about gender differences. with observations every 2–3 months over all 3 years of training. and an additional observation period is needed to identify the direction of causal links. penultimate) year in medical school and continuing until the beginning of the first postgraduate year. Despite a representative number of eligible residents. Participants were followed up during their second or third year after graduation Harvard Rev Psychiatry May/June 2002 (when they were senior house officers) after being initially interviewed 1–2 years earlier. and problems with discharge or referral of patients. The psychometric properties of the anxiety and depression measurement instruments are unclear. 2. she found that “overwork. the longitudinal response rate was too low to ensure generalizability: only 27–28% completed the psychological inventories twice.29 High scores on dependency trait measures in medical school predicted depressive symptoms in men but not in women. we examined a nationwide cohort of individuals graduating from medical . The outcome of interest was psychological distress. Although the study had quite a long follow-up of the same cohort and involved several observations. A large American longitudinal study by Hainer and Palesch25 followed residents in family medicine in South Carolina over 2.

when these trainees were at the end of their internship year. A major strength of this study is its long follow-up with a large nationwide sample. Three large investigations24. The strengths of this study are its large and representative sample size and its use of validated predictor variables in multivariate statistical analyses. or unemployed/on leave. five studies19. time pressure. or even stays flat throughout postgraduate training.27. We did not find gender to have any effect.25. Thus. decreases. Although the findings are inconsistent. traits in the neurotic/ self-critical spectrum seem to have the highest impact. The perceived medical school stress measure was the single predictor with the highest sensitivity and might therefore be used to determine a subgroup of students suitable for group-oriented intervention. three investigations19. one23 found high levels of distress to persist during postgraduate years 2 and 3. allowing a comprehensive predictor model. whereas one20 showed more distress in residents on an intensive care unit rotation. The best predictors in medical school of MHPT during internship were previous MHPT. and time pressure to mental health problems. with no gender difference. mental health in previous years seems to be of importance. one27 even showed a rise after the first postgraduate year. conclusions are inconsistent as to whether the need for treatment increases. we found that both previous suicidal ideation (in medical school) and neuroticism were independent predictors. although opinion appears to lean toward more difficulty earlier in the postgraduate years.24.31 found that working long hours was of no importance. others19.23 revealed more depressive symptoms among female than male postgraduates. when they were senior house officers/residents. personality and coping were not measured in all participants at baseline.Harvard Rev Psychiatry Volume 10.27 did not. the remaining ones were either serving as research fellows. With respect to contextual factors. particularly personality traits. perceived medical school stress. Another limitation is the use of single items as outcome measures. Furthermore. whereas two others19. two large studies26. one study27 revealed that perceived stress at medical school predicted problems nearly 4 years later. training in an administrative position.19 an older father. Individual students at risk could not be predicted (best positive predictive value. Number 3 schools in Norway.31 pointed to personality traits as predictive of forthcoming problems. the only study that tested the screening properties of individual variables27 found that risk for problems during the postgraduate years could not be predicted in medical school. Furthermore. Altogether.24 showed personal life stress to have little or no effect.5 years after baseline. negative life events (in particular. but the impact of these variables was mediated by mental distress (anxiety and depressive symptoms). broken relationships) and current job stress (such as emotional pressure/demands from patients) were also related to MHPT in an adjusted model. so the predictive effects of these variables may have been exaggerated.31 Among individuals with a perceived need for help during internship.27 showed that previous emotional disturbance predicted current disturbance. Considering stress outside of work.) During internship we studied two independent variables: mental health problems in need of treatment (MHPT)26 and suicidal thoughts. we analyzed medical school predictors of MHPT in the fourth postgraduate year.27 (In Norway specialty training takes 4–5 years after the internship year. Tyssen and Vaglum 159 SUMMARY OF FINDINGS FROM THE PROSPECTIVE STUDIES Three studies19–21 showed a peak of depressive symptoms during the first postgraduate year (approximately 30% of respondents). five studies21. only 58% responded at the first follow-up.30.26. One study examining coping strategies27 showed that coping by wishful thinking was most important. working fewer hours per week) were linked to suicidal thoughts. The prevalence of MHPT over the previous year had increased from 11% to 17%. considerable evidence supports the impact of individual predictors. which reduces the reliability of the responses. Nevertheless.25 found a relationship between such factors as having a family history of psychopathology.26. . 54% still had not sought professional assistance by the end of the year. When we examined suicidal thoughts during internship. Two investigations. In a third study27 of the original cohort. while two studies19.21 failed to show this. However. Hence.26. Four investigations21. they seem to indicate that such factors are of some importance. This was followed up 1 year later. 0.26.31 related work-related stress such as perceived overload. these are associated current factors.30. and one-fourth were training in family medicine (outside of hospitals).26 however. although some studies21. indicated low levels of mental illness symptoms throughout training.21. and another24 found that a lower increase in confidence was related to more distress among house officers in accident and emergency departments. Two-thirds of the subjects were senior house officers. Neither long working hours nor sleep deprivation during oncall shifts was significant in this regard. Nevertheless. During the internship year. and coping by wishful thinking. Nevertheless. and not having a partner/spouse. The best predictor model consisted of previous MHPT. Among individuals with perceived need for help. However. although the findings are inconsistent. 58% had not actually sought it. extroversion. single marital status and some work-related factors (interruptions at work.21 or an unhappy childhood25 and later difficulties.26.40).31 found that having no partner and negative life events predicted mental health problems in adjusted models.26. neuroticism. emotional pressure from demanding patients.31 and again 3. In addition. not true predictors of future difficulties. Regarding individual predictors.21.

we will also discuss them in relation to cross-sectional studies. so this issue should be further explored.. 43 years). The harmful impact of an unhappy childhood and early dispositional factors in even the closest family is in accordance with the findings of two previous longitudinal studies. the knowledge that we have obtained from these studies should generally be regarded as preliminary. Although only two studies21. Very few investigations involved a broad spectrum of variables that could theoretically impact upon mental health.33 From these findings one might suspect that compared to the general population. This could indicate that most of the early emotional problems stem from a lack of skills and competence. Since findings in the prospective studies to date are limited and sometimes inconsistent. The finding that self-criticism is a strong predictor of depressive symptoms. the finding that 17% had MHPT in the fourth postgraduate year27 corresponds well with what has been seen in studies of perceived need and psychiatric disorder in the general population.21 Overall. we may have missed some important predictors. this is likely.34 and the reasons for not seeking professional care should be explored. Since we have not included research on substance abuse. Prospective studies currently being conducted among young doctors in the United States. Most of the studies used availability samples. Only two of the reviewed studies27.39 Among the older physicians. in Firth-Cozens’s cohort35 it remained at a lower level even in the eighth year after graduation. cross-sectional investigations36. but this may be a false-negative result. Finland.42 and the present finding that low perceived competence is a corre- ..160 Tyssen and Vaglum DISCUSSION Each of the identified prospective studies has weaknesses that reduce the internal and external validity of the findings. we have considerable cross-sectional data from North America8.29 utilized an observation period longer than 1 year and analyzed multivariate models of the predictor variables measured at baseline. there is a need for comparative studies using similar diagnostic interviews in postgraduates and matched controls in the general population. Available evidence indicates that emotional disturbance declines over the years of residency.32. however.13 Since these investigations did not control for personality traits.12. Not all studies measured and controlled for personality. Individual Predictors Age or level of training. This indicates a harmful impact of work and life stress among female doctors over the years.38 pointing in that direction. findings that are similar among studies may indicate more-general tendencies.18 Thus. the U. postgraduates have higher depressive symptom scores but a similar prevalence of mental health problems and need for treatment. Since the research was done in the United States and Europe. and Norway may provide answers to the questions that remain open.40 Family background and previous mental health. such as hospital consultants. the lack of gender difference in the Norwegian cohort contrasts with findings among physicians who are older (mean.27 concurs Harvard Rev Psychiatry May/June 2002 with other cross-sectional data. However. The identified lack of help-seeking among young doctors with emotional problems26. However.23 showed more depressive symptoms among female than among male postgraduates.31 Personality factors. however.41 One of the studies19 showed no effects of previous depression in a controlled model in a smaller sample.35 and with representative cross-sectional data. its findings appeared very similar to survey findings. there is a lack of studies from developing nations and also a shortage of comparative studies with matched controls from the general population.17 In the general population neuroticism has been linked not only to distress but also to depression. it is unclear whether the impact of such family and childhood variables is mediated via personality variables.22. Switzerland. Only one investigation19 used structured diagnostic interviews to measure psychiatric disorders. 31 vs. Gender. concurs both with follow-ups later in a physician’s career13.37 have found high levels of mental distress among older and more experienced doctors. The clinical importance of the stability and consistency of emotional disturbance is emphasized by our finding of a 21-fold greater risk of serious suicidal ideation during internship among those who reported such ideation in medical school than among those who did not.K. the symptom scores may reflect stresses unrelated to valid mental disorders.20. as suggested by two of the studies. Furthermore. so the importance of factors such as perceived competence and perceived work-related factors could have been overvalued. Prevalence of Mental Health Problems The prevalence of depressive symptoms estimated by this review corresponds well with that shown in a cross-sectional study of 1800 interns and residents8 (i.24 However. which accords with findings that stressful life events pose a greater risk for depression among women than among men.e. particularly among male doctors. more depressive symptoms were seen in women. a peak of depressive symptoms [31%] on the Center for Epidemiological Studies Depression Scale during the first postgraduate year) and also confirmed an overall prevalence higher than that in the general population. and the representativeness of these samples is unclear. The finding that earlier disturbances were predictors of ensuing problems concurs with what has been determined in other life-stress research. which is often concurrent with affective disorders. However.17.

24 may also be related to this personality trait. One study27 found that perceived medical school stress was a feasible predictor. The stressful impact of perceived overwork concurs with the findings in other studies of young doctors. Additional comparative studies are needed to clarify whether individuals who become physicians possess more vulnerability factors than other academic groups. lack of autonomy) that appear to be associated with problems.46 so it may be especially harmful among doctors.30.48 The importance of this measure may be that. but this may be an artifact of a higher response rate at follow-up. after which residency training was changed in that state. One previous investigation43 has revealed lower general self-esteem among male medical students than in the general population.53 and may thereby result in serious mistakes. Additionally. The high level of distress associated with intensive care unit rotations20 points to the importance of work settings. Whether physicians have traits different from those seen in other academic populations remains unclear. higher aspiration levels) among U.46 However. it captures the experience of stress specific to the medical school context. although Vaillant and colleagues’ study13 may support this position. postgraduate physicians compared to the general population.54 None of the four studies21. deeper intellectual curiosity. and this is in accord with research suggesting that coping is not necessarily trait dependent. the lack of perceived competence in skills that was linked to emotional disturbance was. Emotion-focused coping is associated with escape/avoidance behavior. both because very few such studies have been conducted among doctors and because ways of coping can be modified by educational and therapeutic interventions. Lack of sleep induces both emotional and cognitive disturbance at work1.g. Previously.26. loss of sleep among the postgraduates has been extensively studied. besides being related to mental distress and personality. or whether the work of a physician is especially stressful for persons with such personality traits. On the contrary.31 failed to show this.g.30. Another reason may be that the present review focuses upon mental health problems as an outcome and not fatigue. Only one study21 found that sleep deprivation was associated with emotional disturbance. doctors in midcareer.55 which shows the combination of high demand and low control—“low decision latitude”—to be pathogenic for mental health. Coping strategies. it probes a threat (“medical school is cold and threatening”). wishful thinking belongs to the emotion-focused spectrum of coping. and also that it partly mediated the effect of a personality trait (reality weakness. Furthermore.31 that included number of work hours as a predictor showed any link between long hours and emotional disturbance.S. extroverted individuals respond with more willingness in surveys like this and may therefore express more need for treatment. in fact. The clinical importance of such findings is exemplified by high risks for both substance abuse51 and motor vehicle accidents52 during training in this specialty.24 Cross-sectional data50 indicate similar levels of depressive symptoms through all years of emergency medicine residency. so that may be one reason why the number of working hours failed to be predictive in this cohort. The coping strategy of wishful thinking was a predictor even when researchers controlled for personality. which includes perceptions and ideations on the borderline between reality and fantasy47) on mental health during the fourth postgraduate year. it is perceived work conditions (e.53 Norwegian junior doctors’ work hours and on-call work have been adjusted downward over the preceding two decades. the importance of time pressure and interruptions at work is in partial accordance with Karasek’s Decision Control Model. and it has been linked to fatigue and emotional disturbance in some investigations.. job stress. this model has been validated among U. However. perceived medical school stress had been validated cross-nationally as a measure of current anxiety and depressive symptoms among medical students. and working conditions.45 Furthermore. which should be studied further. which has been associated with less-aggressive alteration of practices following a mistake. A high level of extroversion remained an adjusted predictor. at least among male physicians. which is more directly related to sleep loss.55 What kind of perceived work-related stress do young physicians find most difficult to tolerate? The reviewed studies pointed to feeling overworked and having a sense of high intensity and urgency at the workplace. while three others26. more research is needed regarding the role of coping strategies. this finding needs replication. such as is experienced in intensive-care units.1.3 Lower perceived autonomy among junior doctors compared to their . Nevertheless. while another44 has found favorable characteristics (e.43.27 In other words. found among accident and emergency postgraduates.S.56 Furthermore. job stress. and a problemfocused coping strategy is obviously more beneficial for the performance of technical tasks at busy hospital settings.45. The overlap between chronic exhaustion and depression contributes to the complexity of this matter. This possibility was dramatically highlighted in 1984 by the fatal Libby Zion case in New York. Contextual Factors Factors related to medical work.Harvard Rev Psychiatry Volume 10. In what to our knowledge is the only study that demonstrates a predictive effect of work conditions on mental health. Other research55 has also failed to show a clear link between working long hours and mental impairment of employees. Number 3 late22..34. and other research49 has revealed that the degree of contextual threat experienced in a Tyssen and Vaglum 161 stressful life event (such as postgraduate training) determines its “depressogenic” effect.

even when the researchers controlled for personality. this also represents an additional stressful situation for some young doctors who would never choose to work in these departments. In sum. inefficient ones. Research on job-related stress factors among young physicians should therefore be controlled for possible gender effects. divorce and partner problems) were independently related to suicidal ideation and mental health problems.162 Tyssen and Vaglum senior colleagues has previously been identified. dependency. controlled studies of the effects of such interventions are needed. which should focus upon increasing the ability to tolerate and handle feelings of nonperfection. and compulsiveness.S. the high prevalence of mental problems and the low rate of treatment-seeking emphasize the need for lowthreshold mental health services for medical students and young doctors. experiencing changes in a personal relationship. and becoming a parent with “double work” responsibilities. The dramatic change from being a student to becoming a doctor is also often paralleled by other stressful life events. Firth-Cozens’s study21 found that relating to consultants and other senior colleagues was highly correlated with stress and depressive symptoms among first-year postgraduates. Our finding. and more problems stemming from sexual harassment. A large U. helplessness. narcissism. The negative impact of a susceptible personality may also be ameliorated through stress-management techniques.64 have provided evidence showing that the perception of difficult work conditions among doctors is mediated through mental distress that may be caused by a susceptible personality and factors unrelated to their jobs. However.66 Evidence is increasing that difficulties in balancing the home/work interface may determine doctors’ career choices and influence their views on working part-time. such as wishful thinking and consuming alcohol. This transitional phase may be more stressful for female doctors. these services should be uniform throughout the years of training.31 found that negative life events (in particular. Negative effects of such life stress among doctors were also found in two recent large controlled crosssectional studies.37. This is convergent with other reports of inadequate support from senior staff and a largely unmet need for counseling among young doctors. Since predicting individuals at risk is impossible. Together. Since coping strategies are amenable to change. these simultaneous life events quite naturally represent a great challenge to trainees who are vulnerable to the development of a mental disorder. Two of the studies reviewed26. Although personality appears to be more important than objective working conditions as a vulnerability factor. Other studies63. and hopelessness. both at medical school and during internship. there have been few studies on the influence of life events on young physicians. Furthermore.57 However. study68 has provided evidence of a relatively good prognosis among young doctors who have been emotionally impaired. living alone for the first time. the treating clinician should remember that important stressors might derive from situations other than the workplace.56. The Harvard Rev Psychiatry May/June 2002 transition from being a student with no clinical responsibility to being an intern or resident with clear clinical responsibilities (particularly when on call) is a stressful life event for most trainees. several other investigations60–62 have found that female doctors experience more conflicts between career and family life. prejudice from patients. lack of approval.36 The relevance of the burnout concept among young doctors still needs additional exploration. low self-esteem. Since internship in surgery and internal medicine may be mandatory. These traits may be modified through psychotherapy. such as moving away from friends and family. studies of this model that focus on medical postgraduates are lacking. In addition to having a stressful occupation. AND OCCUPATIONAL IMPLICATIONS Internship and residency have been identified as especially stressful phases of a physician’s career. should be targets of preventive intervention. Hospitals and workplaces should ensure adequate supervision . CLINICAL. we should note that we found a relationship between job stress and both suicidal thoughts and mental health among the interns and that the relationship was stable when we controlled for personality and previous mental health.26 that the level of experienced job stress (emotional pressure and demanding patients) among interns was important even when adjusted for personality. A major problem of research investigating the importance of work has been a lack of control for personality and past problems. This may have negative consequences for both learning and patient care.59 Although none of the studies reviewed showed any gender differences in predictors. EDUCATIONAL. Stress outside of work. and lack of same-gender role models.65. who in addition may experience less-supportive workplaces. Assurance of optimal mental health during this critical learning phase is therefore especially important. many physicians may also be vulnerable because of traits such as neuroticism. shows perceived stress to be independent of individual traits and therefore underscores the importance of such stress. self-criticism.67 Nevertheless. The present finding that “emotional drainage” occurs when caring for difficult and severely ill patients concurs with the concept of burnout58 and also the findings of other studies among doctors. with almost 80% continuing in medicine. This shows that the employer should be very sensitive to how young physicians experience their working conditions.

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