Introduction

The Coronavirus Disease 2019 (COVID-19) pandemic has exacerbated mental health challenges among physicians. Physicians have self-reported high levels of anxiety, depression, burnout, and stress during the COVID-19 pandemic [1–5]. A US multicenter survey of physicians from May to October 2020 (n = 3,128) found that a quarter (25%) had anxiety, a third (30%) were stressed, and almost half reported burnout [4]. In Canada, the Canadian Medical Association’s National Physician Health Survey in November 2021 (n = 4,121) found that 59% of survey respondents reported that their mental health had worsened since the onset of the pandemic [5]. During COVID-19, physicians have faced specific stressors, including increased risk of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection [6], shortages in protective equipment [7], changes to workloads, presenteeism (working in poor mental or physical health) [8], and being in situations that invoke moral distress (i.e., when resource shortages prevent one from providing the usual standard of care) [9]. We previously reported a 27% increase in outpatient visits for mental health and addiction (MHA) for Ontario physicians during the first year of the COVID-19 pandemic compared to the year pre-pandemic [10].

While evidence suggests that physicians’ mental health has worsened during the COVID-19 pandemic, data suggests that the pandemic has impacted the general population’s mental health [11–17]. A study of the US general population found that self-reported mental health worsened as the pandemic continued: with 33.0% of respondents in September 2020 reporting symptoms of anxiety and depression compared to 30.9% in June 2020 [15]. In Canada, a repeated cross-sectional survey found that the percent of individuals aged 18 years and older who screened positive for symptoms of depression, anxiety, or posttraumatic stress disorder increased from 21% in the fall of 2020 to 25% in the spring of 2021 [11]. Importantly, comparing pre-pandemic differences and pandemic changes in physician and non-physician mental health has 2 primary challenges. First, most evidence is from cross-sectional surveys, which cannot directly compare mental health outcomes before the pandemic to during the pandemic. Consequently, apparent changes in rates of mental health distress may reflect a methodological change (e.g., a different study population or measure) or a COVID-19 impact. Second, few survey studies pre-pandemic [18,19] and none during the pandemic have directly compared MHA of physicians and non-physicians, which limits comparability due to potential differences in sampling, questions posed, and outcomes (e.g., physician surveys measuring burnout versus public surveys reporting depression). Consequently, it is unclear if the worsening mental health among physicians is due to specific occupational stressors, reflective of general societal stressors during the pandemic, or a combination. In addition, it is unclear how physician mental health and use of mental health services compares to the general public, both before and during COVID [18,19].

To address these gaps, we used population-level health administrative data to compare physicians’ mental health service use to the general public in Ontario, Canada. These databases capture essentially all outpatient visits to a physician and emergency department visits and hospitalizations through the provinces single-payer universal health system. This approach allowed us to longitudinally compare mental health service use changes in physicians and non-physicians and adjust for differences in age and sex. We specifically focused on differences in rates of MHA visits between physicians and non-physicians pre-pandemic and their changes during the pandemic. In addition, we examined differences in visit type (psychiatry, family medicine), in-person versus virtual visits, and acute care visits, as the COVID-19 pandemic led to policy changes that increased access to outpatient virtual care services by renumerating much broader use of telephone and virtual-based care [20]. Given physician-specific occupational stressors, we hypothesize that increases in MHA visits during the COVID-19 pandemic compared to the pre-pandemic period would be greater for physicians relative to non-physicians.

Methods

Results

Overall, our study population included 41,814 physicians practicing in Ontario between 2017 and 2021 and 12,054,070 members of the non-physician population of Ontario aged 18 or older (S1 Fig). The characteristics of physicians and non-physicians on March 11, 2020 are presented in Table 1. For physicians, the mean (SD) age was 47.4 (14.0) years, 22,347 (56.5%) were men, 19,677 (49.7%) lived in the wealthiest quintile neighborhoods in Ontario, and 37,659 (95.1%) lived in an urban region. In contrast, non-physicians were older (mean (SD) age of 50.5 (17.6) years), more likely to be female (51.5%), poorer (20.0% living in the richest quintile neighborhoods in Ontario), and less likely to live in an urban residence (89.4%). On March 11, 2020, a great proportion of physicians, 2,362 (6.0%), than non-physicians, 518,034 (4.7%), had 1 or more psychiatry visits in the 2 years before the start of the pandemic and physicians who saw a psychiatrist had over twice the mean annual number of psychiatrist visits compared to non-physicians (19.2 versus 7.0) Table 1. In contrast, fewer physicians, 6,021, (15.2%) than non-physicians, 2,377,604 (21.7%), had 1 or more family medicine visits in the 2 years before the pandemic with a comparable mean number of annual visits (3.6 in physicians versus 4.0 in non-physicians) Table 1. The random sample of the non-physician population taken on March 10, 2020 did not differ by sociodemographic characteristics (age, sex, income, rurality) or co-morbid mental health service use in the past 2 years than the entire non-physician population of Ontario, S3 Table.

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Table 1. Characteristics of physician and non–physicians on March 11, 2020.

https://doi.org/10.1371/journal.pmed.1004187.t001

Rates of overall outpatient MHA visits differed between physicians and non-physicians before and during the COVID-19 pandemic (Fig 1). Before the pandemic, the crude rates of MHA visits were higher in physicians than non-physicians (888.4 visits per 1,000 person-years in physicians versus 615.5 in non-physicians) (Tables 2 and S4 for crude IRR). However, after adjusting for sociodemographic characteristics (age, sex, income, and rurality), this difference was not significant (aIRR 1.00; 95% CI 0.91 to 1.10) (Table 3). During the COVID-19 pandemic, there was an increase in the rate of outpatient MHA visits for both physicians and non-physicians compared to pre-pandemic rates. The crude rate of outpatient MHA visits per 1,000 person-years increased by 23.2% in physicians (888.4 pre-pandemic to 1,094.7 during the pandemic) and 9.8% in the non-physician population (615.5 pre-pandemic to 675.9 during the pandemic) (Table 2). After adjustment, outpatient MHA visit rates increased for both physicians (aIRR 1.39, 95% CI 1.28, 1.51) and the non-physician population (aIRR 1.12, 95% CI 1.09, 1.14) (Table 3) and the increase was greater in physicians. Models with age specified as continuous versus cubic spline had comparable results see S7 Table.

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Fig 1. Age and sex standardized monthly rates of outpatient MHA visits overall, to psychiatrists, and to family physicians among physicians and non–physicians.

Historic rates depict rates from March 2018 to August 2019. COVID–19, Coronavirus Disease 2019; MHA, mental health and addiction.

https://doi.org/10.1371/journal.pmed.1004187.g001

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Table 2. Rates of MHA visits in physician and non–physicians in the 36 months pre–pandemic (March 11, 2017–March 10, 2020) and during the first 18 months of the pandemic (March 11, 2020–August 11, 2021).

https://doi.org/10.1371/journal.pmed.1004187.t002

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Table 3. Poisson regression models comparing differences pre–COVID–19 and changes during COVID–19 pandemic in MHA visits between physicians and non–physicians.

https://doi.org/10.1371/journal.pmed.1004187.t003

Physicians and non-physicians had different patterns of MHA visits by provider type. Pre-pandemic, the crude and adjusted rate of outpatient psychiatry visits was over 3 times higher in physicians than non-physicians (aIRR 3.91, 95% CI 3.55, 4.30). Psychiatrists had 8.2 times the rate of outpatient visits to another psychiatrist than the non-psychiatrist physician population (3,584.7 visits per 1,000 person-years versus 437.6) (S5 Table). In contrast, pre-pandemic, the crude and adjusted rates of outpatient MHA visits to family physicians were lower in physicians than non-physicians (aIRR 0.62, 95% CI 0.58, 0.66) (Table 3). During the pandemic, physicians had a larger increase in MHA visits to both psychiatrists and family physicians than non-physicians.

There was a large increase in outpatient virtual MHA visits for physicians and non-physicians during the COVID-19 pandemic (Fig 2). Pre-pandemic rates of virtual outpatient MHA visits in the physician and non-physician population were low. On average pre-pandemic, 2.3% of physician outpatient visits and 7.2% of non-physician outpatient visits were virtual (Table 2). In comparison, during the first 18 months of the pandemic, 88.7% of physician outpatient visits and 75.7% of non-physician outpatient visits were virtual (Table 2). This increase in virtual care visits was mirrored by large declines of in-person care for both groups (Fig 2 and Table 2). During the pandemic, the adjusted increase in rates of virtual MHA visits among physicians (aIRR 77.03, 95% CI 50.64, 117.16) was greater than in non-physicians (aIRR 11.69, 95% CI 11.14, 12.26) (Table 3).

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Fig 2. Age and sex standardized monthly rates of virtual and in–person outpatient MHA visits among physicians and non–physicians.

COVID–19, Coronavirus Disease 2019; MHA, mental health and addiction.

https://doi.org/10.1371/journal.pmed.1004187.g002

Before the COVID-19 pandemic, the crude and adjusted rates of acute care visits were much lower in physicians (3.1 per 1,000 person-years) than non-physicians (21.0 per 1,000 person-years, aIRR 0.19, 95% CI 0.16, 0.23) (Tables 2 and 3). During COVID-19, changes in acute care visits did not differ between physicians (aIRR 1.03 95% CI 0.81, 1.30) and non-physicians (aIRR 0.90 95% CI 0.92, 0.99).

The types of outpatient MHA visits by physicians and non-physicians are in S6 Table. In both periods, over 65% of MHA visits in physicians were for anxiety, and approximately 15% were for a mood disorder. A much higher proportion of outpatient MHA visits were related to drug and alcohol use in non-physicians (approximately 20% of visits) than physicians (approximately 5% of visits).

Discussion

Prior research on physician mental health before and during the COVID-19 pandemic has been limited by small study sizes, reliance on self-reported surveys rather than measuring actual health care visits, and lack of comparison to the general population as a control for the society-wide impacts of the pandemic. To our knowledge, this is the largest study to examine the use of mental health services by physicians and non-physicians. Using 5 years of population-level administrative health data for more than 12 million individuals, we found substantial differences in mental health service use between physicians and non-physicians before the COVID-19 pandemic. Further, we found that the COVID-19 pandemic was associated with a much larger increase in physicians’ MHA visits than non-physicians.

We found that pre-pandemic physicians had similar rates of MHA outpatient visits relative to non-physicians after accounting for differences in sociodemographic characteristics. Previous studies have found that physicians’ self-reported mental health and well-being (e.g., burnout and work-life dissatisfaction) are worse compared to non-physicians [18,19]. This discrepancy may be explained by physicians’ reluctance to seek care due to stigma, confidentiality concerns, fear of licensing implications, and impacts on their career development/progression [24–26]. In addition, a culture of self-treatment [27,28] and a preference to seek help from professionals that are not physicians (e.g., psychologists) [24] may contribute to physicians’ underuse of outpatient mental health services. Interestingly, we found physicians had much higher psychiatry visits rates than non-physicians and lower primary care visit rates that persisted after excluding psychiatrists (whom we previously documented access psychiatry services at very high rates) [10]. This finding is likely partially explained by different access to specialized psychiatric services or access through colleagues. Finally, we found a much higher proportion of outpatient MHA visits were related to drug and alcohol use in non-physicians (approximately 20% of visits) than physicians (approximately 5% of visits). This finding may reflect lower levels of substance use among physicians or a reluctance of physicians to seek help for addictions services due to fear of licensing implications and stigma [26].

MHA visits increased in both physicians and non-physicians during the COVID-19 pandemic, consistent with reports of worsening mental health in both groups [1–5,11–16].

However, physicians had a larger increase in MHA visits than non-physicians and in prior work, we showed that increases in MHA visits in physicians during the pandemic were driven both by greater incident mental health visits and greater intensity of mental health service use for those with preexisting mental health conditions [10]. There are a few possible reasons for these findings. First, these findings likely reflect a higher mental health burden on physicians than non-physicians due to occupational stressors. The Canadian Medical Association National Physician Health Survey found the most frequent occupational stressors contributing to worsening mental health among physicians during COVID were increased workload/lack of work-life integration, longer periods of social isolation, rapidly changing policies/processes, and lack of human resources [29]. Second, these findings may reflect better physician access to mental health care services during the pandemic, particularly outpatient psychiatric services. Third, these findings may be due to greater reductions in barriers to accessing mental health care services for physicians compared to non-physicians. The expanded virtual care options [20] may have allowed physicians with MHA issues predating COVID-19 to access services easily (e.g., more flexible timing and appointment location). Indeed, the uptake of virtual visits was higher among physicians than in the general population. Finally, these findings may also be due to a reduction in mental health stigma among physicians due to the COVID-19 pandemic. During COVID-19, there was frequent messaging by governments and physician organizations concerning the mental health impacts of the pandemic. It is possible that conversations regarding physician mental health during the pandemic reduced stigma and increased treatment access.

While the COVID-19 pandemic has exacerbated physicians’ mental health concerns, high levels of burnout predated the pandemic. Our research suggests that an important intervention to help improve physician health and access to mental health services would be to continue virtual mental health services. The pandemic has also placed considerable additional strain on the health system. We suspect the physician mental health burden will continue after the COVID-19 pandemic as physicians work through critical backlogs (e.g., surgical and cancer care) with sicker patients and increase workloads and staffing shortages—as physicians reduce their practice hours or leave the profession [30–32]. Consequently, ongoing surveillance on physician mental health during later stages of the pandemic and recovery is indicated. Importantly, our findings suggest a pressing need for interventions to mitigate physician burnout and mental health concerns. A wide variety of interventions including increasing treatment access and system-level changes aimed at improving work-life balance such as reducing the stress and administrative burden of physician work have been proposed and will require a substantial increase in health system investment [3]. Finally, there should be further research into the patterns of mental health service use by physicians to understand care continuity and quality.

Conclusions

During the first 18 months of the COVID-19 pandemic, physicians had a greater increase in outpatient MHA visits relative to the general population. These findings suggest that the mental health of physicians may have been more negatively impacted by COVID-19 than the general population. Interventions aimed at reducing occupation stressors and workplace mental health promotion are indicated. Continuation of virtual care options will likely enable better access and utilization of care when needed.

Supporting information