In Depth | Why India’s resident doctors are neck-deep in mental health crisis

Representative image (Source: https://www.pexels.com/)

India’s medical education and profession regulator recently asked medical colleges across India to furnish details of post-graduate medical students, or resident doctors, who have died by suicide during the last five years.

In a circular just ahead of World Mental Health Day on October 10, the National Medical Commission (NMC) wrote to principals of over 600 medical colleges in the country that an anti-ragging committee formed under it recently held its first meeting and expressed concerns over incidents of suicide and suicidal tendency among the medical students.

Although all incidents of suicide and suicidal tendency are not linked to ragging but in some cases they are, said the NMC circular, asking colleges to share, within a week, details of department-wise PG students who have ended their lives over the last 5 years, dropouts and the details of their working hours and weekly offs.

This may be the first formal attempt by the regulator to address the issue of bad working conditions and the grave mental health of resident doctors, who are often called the backbone of the hospitals attached to institutions.
A neglected issue
The development has brought to the fore a burning, yet the neglected issue of mental health concerns in healers under training in the country’s institutes teaching medicine.

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While many in the profession and even those outside agree that work is stressful, sadly, the issue of mental health is still a subject of taboo in the medical profession in the Indian context. This is despite numerous studies showing that doctors have a higher suicide risk-- 2.5 times more than the general population.

A meta-analysis of suicides committed by doctors between 2010 and 2019, published in the Indian Journal of Psychiatry (IJP) last year, highlighted that a majority of those taking the extreme step were PG medical students.

Stressful long working hours, starvation for long hours, inadequate diet, sleep deprivation, inadequate rest, high levels of personal expectations, knowledge of lethal suicide methods, easy access to potentially fatal drugs, apathy, and fearlessness towards death were some of the contributing factors, said the study.

As per the National Mental Health Survey 2016, the treatment gap for mental health care is alarming -- more than 80 percent in India -- and this figure may be as bad for healthcare professionals.

Disturbing figures
There is no official data on how many doctors or resident doctors have died by suicide in India but a scientific report, based on scanning media reports, found that thirty suicides by doctors were reported between 2016 March and 2019 March, out of which 18 were females and 12 males.

More than 80 percent of the victims were younger than 40 years and twenty-two were from medical education institutions. Of the medicos, eight were MBBS students and ten were postgraduate students. Nineteen suicide reports about doctors mentioned that they were depressed.

The highest increase in mortality caused by unnatural causes in the general population worldwide has been attributed to depression, followed by substance-use related disorders, schizophrenia and personality disorders.

However, among medical students and professionals in India, analyses have found that academic stress is the leading cause of suicides, followed by mental illness and harassment.

Academic stress was simply the tip of the stress iceberg in HCPs, said the study published in the IJP. “Stressfully long working hours for graduate interns, postgraduate resident doctors, junior physicians and nursing professionals significantly impact their mental well-being,” it said.

“They often starve for long hours, consume fast food to save time, have sleep deprivation and are inadequately rested between duty shifts. This significantly leads to burn-out and stress.”

Experts, too, warn that many students may be perceiving medicine as enticing and prestigious to pursue as a career but it is not a cakewalk.

“Strenuous hours, balancing academics and practical/internship work, disturbance in sleep, appetite schedules, along with not being left with much time for anything else, may result in severe adjustment issues or mental health conditions,” said clinical psychologist Ruchi Sharma, who is attached with HCMCT Manipal Hospital in the national capital.

Expectation versus reality
Sharma says that the gap between the ‘expected’ versus the ‘reality’ may be quite overwhelming for students.

The stigma surrounding mental health and under-reporting or ignoring of ‘red flags’ or crucial symptoms, just attributing them to being a ‘part of the process’ of becoming a doctor, can have grave consequences, she underlines.

“Social stigma, paired with expectations of parents, relatives and society in general may lead to impulsive behaviour when a student feels hopeless and stuck,” Sharma added. “A common thought process in promoting self-harm is avoidance of embarrassment and guilt which may happen due to leaving the UG PG course midway or dropping out, inviting criticism by those around them.”

Anxiety, threat of violence
Dr R V Asokan, a senior member of the Indian Medical Association, pointed out that in various surveys it was found that doctors are under continuous anxiety and feel threatened at the workplace.

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The major cause is workplace violence and abuse, with attendants often demanding immediate relief of their patients’ suffering and sometimes ending up hitting the doctor in outrage.

“These emotional outbursts severely affect the mental well-being of resident doctors and their ability to perform skills also gets reduced under threat,” he said.

Lack of resilience
According to Dr Kedar Tilwe, consultant psychiatrist, Fortis and Hiranandani Hospitals in Mumbai, medical education is associated with a combination of the excessive burden of expectation and sheer tenacious hard work essential to keeping up with the knowledge required.

In addition to this, the uncertainties due to the Covid-19 pandemic, increased workload and new protocols that doctors need to adapt have added to the existing stress- both physical and mental, he said.

Tilwe stressed that the current system is more focused on improving the technical knowledge of the students and there is often a lack of resilience-building measures, which can result in worsening any potential mental health crisis that they may face.

Hope ahead
Some laudable efforts are being taken in the field of mental health awareness, especially amongst doctors at the UG level, which include improving their access to counselling and mentorship programs. However, the implementation measures need to be quicker and uniform with efforts to curb stigmatisation of the help-seeking behaviour.

Dr Rohan Krishnan of the Federation of All India Medical Association hoped that the new move by the NMC will lead to actions that may result in a better working environment for medical students, who often study and work under trying and unfavourable circumstances.