By Shannon Firth

Among physicians in Ontario, more than one in 10 had an outpatient visit for a mental health or substance use concern over the last 2 decades.

Visits increased from around 12% in the years before the COVID-19 pandemic to north of 14% from 2020 to 2023.

The growth in mental health visits across most specialties during the pandemic may reflect both an increase in mental distress and improved access to mental health care, the study authors say.

More than one in 10 early- and mid-career physicians sought care for mental health or substance use (MHSU) in Ontario each year across nearly 2 decades of visits analyzed.

Among nearly 30,000 physicians, the proportion with one or more outpatient MHSU visits from 2003 to 2022 was 11% overall.

And from a rate of 12.1% in 2018-2019, the rate grew during the pandemic to 14.6% in 2020-2021 and 15.2% in 2021-2022, before declining to 14.4% in 2022-2023, according to Daniel Myran, MD, MPH, of the North York General Hospital in Toronto, and colleagues.

"What surprised us most was how stable mental health and substance use-related visits were over the past 20-year period," said Myran.

"Our findings suggest that current concerns over a physician mental health crisis may not reflect a new crisis but rather highlight a longstanding pattern of adverse physician mental health that was exacerbated during the pandemic," Myran and team wrote.

Prior to the pandemic, physicians' use of healthcare visits for MHSU differed broadly by specialty. From 2018 to 2019, 28% of psychiatrists, 14.2% of family physicians, and 9.7% of physicians in all other specialties had one or more MHSU visits. During the pandemic, use rose across all specialities, except psychiatry, in which the rate of visits remained flat.

"Given ongoing discussions about worsening physician mental health, we expected to see gradual increases over time. This suggests to me that physician mental health and burnout are not a new problem but a longstanding challenge in medicine," Myran said.

With regard to substance use disorders, physicians typically present very late for treatment due to the implications for licensing, Myran noted. About 0.5% of visits during the study period were for substance use disorders.

"If some physicians increased substance use during the pandemic, it may take time for that to be observed in actual healthcare visits," he added.

In the pre-pandemic period, anxiety and mood disorders were the greatest drivers of MHSU visits, with 8.4% and 2.4% of physicians, respectively, having one or more visits from 2018 to 2019. Reasons for visits varied little prior to the pandemic, with the exception of an increase in attention deficit-hyperactivity disorder (ADHD) -- a difference that likely mirrors trends in the general population, said Myran.

The overall growth in visits during the pandemic reflects both "a true increase in mental distress" among some physicians and improved access to mental health care, due in part to the rise of virtual care, Myran said in an email. A potential decline in mental health stigma may also have been a contributing factor, he added.

As for the study's implications, Myran said he hoped it would "encourage physicians who are struggling with mental health or addiction and have not yet sought care to do so." For policymakers, the findings highlight the need to invest much more in system-level factors that support physician well-being, Myran added.

For this analysis, the authors focused on early and mid-career physicians (defined as being in the first 5 years of independent practice and in years 6 through 15, respectively) who registered with the College of Physicians and Surgeons of Ontario from 1990 to 2018.

Myran and team used the college's registration data, which was linked to health administrative data, to track physicians' outpatient MHSU visits to a psychiatrist or family physician. They then estimated the annual age- and sex-standardized proportion of physicians with at least one outpatient MHSU visit each year.

The authors also categorized the visits by reason -- anxiety, mood, and substance use disorders; ADHD; adjustment reactions; or other reasons -- and specialty, categorized as family medicine, psychiatry, and all other specialties.

A strength of the study was the use of data capturing every physician in Ontario using objective measures of mental health-care seeking, Myran noted.

Limitations included the study's focus on mental health treatment rather than symptoms as well as exclusion of visits to other healthcare providers, including psychologists, which might have underestimated the true prevalence of mental health concerns.