Working conditions, psychological distress and suicidal ideation: cross-sectional survey study of UK junior doctors.

BACKGROUND: Evidence attests a link between junior doctors' working conditions and psychological distress. Despite increasing concerns around suicidality among junior doctors, little is known about its relationship to their working conditions. AIMS: To (a) establish the prevalence of suicidal ideation among junior doctors in the National Health Service; (b) examine the relationships between perceived working conditions and suicidal ideation; and (c) explore whether psychological distress (e.g. symptoms of depression and anxiety) mediates these relationships. METHOD: Junior doctors were recruited between March 2020 and January 2021, for a cross-sectional online survey. We used the Health and Safety Executive's Management Standards Tool; Depression, Anxiety and Stress Scale 21; and Paykel Suicidality Scale to assess working conditions, psychological distress and suicidality, respectively. RESULTS: Of the 424 participants, 50.2% reported suicidal ideation, including 6.1% who had made an attempt on their own life. Participants who identified as LGBTQ+ (odds ratio 2.18, 95% CI 1.15-4.12) or reported depression symptoms (odds ratio 1.10, 95% CI 1.07-1.14) were more likely to report suicidal ideation. No direct relationships were reported between working conditions (i.e. control, support, role clarity, strained relationships, demand and change) and suicidal ideation. However, depression symptoms mediated all six relationships. CONCLUSIONS: This sample of junior doctors reported alarming levels of suicidal ideation. There may be an indirect relationship between working conditions and suicidal ideation via depressive symptoms. Clearer research exploring the experience of suicidality in junior doctors is needed, including those who identify as LGBTQ+. Systematic interventions addressing working environment are needed to support junior doctors' mental health.

Relationship between working conditions and psychological distress experienced by junior doctors in the UK during the COVID-19 pandemic: a cross-sectional survey study.

OBJECTIVES: This paper explored the self-reported prevalence of depression, anxiety and stress among junior doctors during the COVID-19 pandemic. It also reports the association between working conditions and psychological distress experienced by junior doctors. DESIGN: A cross-sectional online survey study was conducted, using the 21-item Depression, Anxiety and Stress Scale and Health and Safety Executive scale to measure psychological well-being and working cultures of junior doctors. SETTING: The National Health Service in the UK. PARTICIPANTS: A sample of 456 UK junior doctors was recruited online during the COVID-19 pandemic from March 2020 to January 2021. RESULTS: Junior doctors reported poor mental health, with over 40% scoring extremely severely depressed (45.2%), anxious (63.2%) and stressed (40.2%). Both gender and ethnicity were found to have a significant influence on levels of anxiety. Hierarchical multiple linear regression analysis outlined the specific working conditions which significantly predicted depression (increased demands (ß=0.101), relationships (ß=0.27), unsupportive manager (ß=-0.111)), anxiety (relationships (ß=0.31), change (ß=0.18), demands (ß=0.179)) and stress (relationships (ß=0.18), demands (ß=0.28), role (ß=0.11)). CONCLUSIONS: The findings illustrate the importance of working conditions for junior doctors' mental health, as they were significant predictors for depression, anxiety and stress. Therefore, if the mental health of junior doctors is to be improved, it is important that changes or interventions specifically target the working environment rather than factors within the individual clinician.

'You know where we are if you need us.' The role of primary care in supporting patients following pancreaticoduodenectomy for cancer: a qualitative study.

BACKGROUND: Ten per cent of patients diagnosed with pancreatic cancer undergo pancreaticoduodenectomy. It is known that these patients have unmet psychological support needs, and GPs are key in enabling effective coordination of care for people living with life-shortening conditions. AIM: To explore patients' perspectives on the role of primary care in their management, and their sources of support. DESIGN & SETTING: Inductive qualitative study of patients who had undergone pancreaticoduodenectomy between 6 months and 6 years previously for pancreatic or distal biliary duct cancers. Participants were recruited by clinical nurse specialists (CNSs) from a single NHS trust in Northwest England. METHOD: Semi-structured interviews, either face-to-face or via video link, were conducted with 20 participants. Interviews were audio-recorded, transcribed, and anonymised. Thematic analysis utilised principles of constant comparison. RESULTS: Participants described immense treatment burden and uncertainty around the role of the GP in their ongoing care. They recognised that GPs may have little experience of patients who have undergone pancreaticoduodenectomy, but felt that GPs can play a vital role in offering support. Participants wished for emotional support postoperatively, and valued support networks including family and friends. However, they found expressing their deepest fears difficult. Participants felt they would value greater recognition by primary care of both physical and psychological sequelae of major pancreatic surgery, and the impact on their families. CONCLUSION: Patients may feel themselves to be a 'burden' to both healthcare professionals and their own support networks following pancreaticoduodenectomy. Primary care is in a key position to proactively offer psychological support.

Patient reported self-help strategies and the perceived benefits for managing sub-threshold depressive symptoms: A nested qualitative study of Australian primary care attendees.

BACKGROUND: Subthreshold depression is common in primary care, but there is little information about the self-help strategies that patients use and the perceived benefits of these. AIM: This study sought to elicit the self-help strategies that primary care attendees identified as beneficial for the self-management of subthreshold depressive symptoms and the implications for general practitioners. METHOD: Semi-structured telephone interviews were conducted with 14 people (April-May 2017) from the Target-D randomised controlled trial (RCT). Target-D investigated whether using a patient-centred clinical prediction tool and an e-health platform to match mental health management options to prognosis was beneficial for improving depressive symptoms at 3 months compared to usual care. Interviews were thematically analysed to identify self-help strategies and their perceived benefits. RESULTS: Four overarching domains for the self-management strategies were identified: social, cognitive, behavioural and restorative. Interviewees reported using strategies across multiple domains, which included undertaking enjoyable, immersive activities, that provided relief from automatic negative thoughts and had a perceived cognitive benefit. Differences in the perceived sense of agency were noted around the self-regulation of mood, which indicated more explicit direction to patient-identified self-help management strategies by general practitioners for some may be of benefit in routine care. CONCLUSION: Some of the reported self-management strategies aligned with evidence-based approaches such as physical activity and mindfulness for mental health symptom management. These findings can inform low-intensity interventions within stepped care models for mental health in primary care, social prescribing models and, help to guide the management of patients by GPs for subthreshold depression.

What challenges did junior doctors face while working during the COVID-19 pandemic? A qualitative study.

OBJECTIVES: This paper reports findings exploring junior doctors' experiences of working during the COVID-19 pandemic in the UK. DESIGN: Qualitative study using in-depth interviews with 15 junior doctors. Interviews were audio-recorded, transcribed, anonymised and imported into NVivo V.12 to facilitate data management. Data were analysed using reflexive thematic analysis. SETTING: National Health Service (NHS) England. PARTICIPANTS: A purposive sample of 12 female and 3 male junior doctors who indicated severe depression and/or anxiety on the DASS-21 questionnaire or high suicidality on Paykel's measure were recruited. These doctors self-identified as having lived experience of distress due to their working conditions. RESULTS: We report three major themes. First, the challenges of working during the COVID-19 pandemic, which were both personal and organisational. Personal challenges were characterised by helplessness and included the trauma of seeing many patients dying, fears about safety and being powerless to switch off. Work-related challenges revolved around change and uncertainty and included increasing workloads, decreasing staff numbers and negative impacts on relationships with colleagues and patients. The second theme was strategies for coping with the impact of COVID-19 on work, which were also both personal and organisational. Personal coping strategies, which appeared limited in their usefulness, were problem and emotion focused. Several participants appeared to have moved from coping towards learnt helplessness. Some organisations reacted to COVID-19 collaboratively and flexibly. Third, participants reported a positive impact of the COVID-19 pandemic on working practices, which included simplified new ways of working-such as consistent teams and longer rotations-as well as increased camaraderie and support. CONCLUSIONS: The trauma that junior doctors experienced while working during COVID-19 led to powerlessness and a reduction in the benefit of individual coping strategies. This may have resulted in feelings of resignation. We recommend that, postpandemic, junior doctors are assigned to consistent teams and offered ongoing support.

'It's always in the back of my mind': understanding the psychological impact of recovery following pancreaticoduodenectomy for cancer: a qualitative study.

OBJECTIVES: Ten per cent of patients diagnosed with pancreatic cancer undergo pancreaticoduodenectomy. There is limited previous research focusing on psychological well-being; unmet support needs impact negatively on quality of life. This paper reports the psychological impact of a pancreatic cancer diagnosis and subsequent pancreaticoduodenectomy, exploring how patients' lives alter following surgery and how they seek support. DESIGN: Inductive qualitative study involving in-depth semistructured interviews with 20 participants who had undergone pancreaticoduodenectomy for pancreatic or distal biliary duct cancer. Interviews were audiorecorded, transcribed and anonymised, and thematic analysis used principles of constant comparison. SETTING: Single National Health Service Trust in Northwest England. PARTICIPANTS: Patients were eligible for inclusion if they had had pancreaticoduodenectomy for head of pancreas cancer, periampullary cancer or distal cholangiocarcinoma between 6 months and 6 years previously, and had completed adjuvant chemotherapy. RESULTS: Analysis identified the following main themes: diagnosis and decision making around surgery; recovery from surgery and chemotherapy; burden of monitoring and ongoing symptoms; adjusting to 'a new normal'; understanding around prognosis; support-seeking. Participants seized the chance to have surgery, often without seeming to absorb the risks or their prognosis. They perceived that they were unable to control their life trajectory and, although they valued close monitoring, experienced anxiety around their appointments. Participants expressed uncertainty about whether they would be able to return to their former activities. There were tensions in their comments about support-seeking, but most felt that emotional support should be offered proactively. CONCLUSIONS: Patients should be made aware of potential psychological sequelae, and that treatment completion may trigger the need for more support. Clinical nurse specialists (CNSs) were identified as key members of the team in proactively offering support; further training for CNSs should be encouraged. Understanding patients' experience of living with cancer and the impact of treatment is crucial in enabling the development of improved support interventions.

". . . The Forgotten Heroes": A Qualitative Study Exploring How Friends and Family Members of DV Survivors Use Domestic Violence Helplines.

Many women who experience domestic violence (DV) seek support from friends, relatives, colleagues, and neighbors. There are substantial knock-on effects for informal supporters, and they may seek help themselves. Tailored services for this group are rare, but DV helplines can provide listening and signposting support. The aim of this exploratory study was to understand which informal supporters contact DV helplines and what form these calls take. Three focus groups, following a topic guide, were conducted with staff and volunteers for DV helplines during autumn 2015. Discussions were digitally recorded, transcribed verbatim, and imported into NVivo10 software. Transcripts were coded line-by-line, and a thematic analysis carried out. All participants were female, aged between 22 and 54 years, with between 2 months' and 8 years' experience of taking helpline calls. Findings indicate that people with broad ranging connections to a survivor call a helpline. Calls can be triggered by disclosures, abuse escalation, witnessing incidents, feeling overwhelmed, and media highlighting of DV. Informal supporters respond to survivors, and experience impacts, in differing ways, often associated with their gender and their relationship with the survivor. Frequently, they feel a sense of responsibility and a desire to rescue the survivor, often calling a helpline to reduce feelings of helplessness and to seek a "magic" solution. Many people are concerned about the legitimacy of their involvement and seek reassurance about the validity of their own help-seeking. Helpline workers feel that informal supporters would benefit from opportunities to reduce isolation, have their predicament acknowledged, and learn from peers. DV helplines have an important role in helping informal supporters of survivors. The help requested is predominantly to equip and empower the informal supporter, so that they feel more adept at coping themselves and, are thus, better able to offer support to the survivor.

Accuracy of individual and combined risk-scale items in the prediction of repetition of self-harm: multicentre prospective cohort study.

BACKGROUND: Individuals attending emergency departments following self-harm have increased risks of future self-harm. Despite the common use of risk scales in self-harm assessment, there is growing evidence that combinations of risk factors do not accurately identify those at greatest risk of further self-harm and suicide. AIMS: To evaluate and compare predictive accuracy in prediction of repeat self-harm from clinician and patient ratings of risk, individual risk-scale items and a scale constructed with top-performing items. METHOD: We conducted secondary analysis of data from a five-hospital multicentre prospective cohort study of participants referred to psychiatric liaison services following self-harm. We tested predictive utility of items from five risk scales: Manchester Self-Harm Rule, ReACT Self-Harm Rule, SAD PERSONS, Modified SAD PERSONS, Barratt Impulsiveness Scale and clinician and patient risk estimates. Area under the curve (AUC), sensitivity, specificity, predictive values and likelihood ratios were used to evaluate predictive accuracy, with sensitivity analyses using classification-tree regression. RESULTS: A total of 483 self-harm episodes were included, and 145 (30%) were followed by a repeat presentation within 6 months. AUC of individual items ranged from 0.43-0.65. Combining best performing items resulted in an AUC of 0.56. Some individual items outperformed the scale they originated from; no items were superior to clinician or patient risk estimations. CONCLUSIONS: No individual or combination of items outperformed patients' or clinicians' ratings. This suggests there are limitations to combining risk factors to predict risk of self-harm repetition. Risk scales should have little role in the management of people who have self-harmed.

'We're all wounded healers': A qualitative study to explore the well-being and needs of helpline workers supporting survivors of domestic violence and abuse.

Domestic violence and abuse (DVA) can include physical, psychological, sexual, emotional or financial abuses, and is a globally widespread problem across all age groups, cultures and socioeconomic groups. Alongside the impacts of DVA experienced by survivors, there is a growing recognition that other people, who form the support network of survivors, may also be affected by the situation. Domestic violence organisations such as helplines are important third sector services supporting survivors. However, there has been little research into the impact on those providing the support. This qualitative study of domestic violence helpline workers explored their needs and well-being. We used qualitative methodology, conducting interviews with staff recruited from a selection of different helplines who all undertook direct client-focused work. The interviews used a semi-structured format and followed a topic guide covering the training received before commencing work, self-care strategies, the impact of work on their daily life and support offered by their employer. Ten helpline staff were interviewed, all female. Following analysis of the qualitative data, a number of themes emerged. Participants disclosed numerous ways in which their work challenged their well-being, including burnout, impact on personal relationships, and lack of training and support at work. Participants used some self-care strategies in order to "switch off" from work, but they also wanted clinical supervision to support them with the difficulties they experienced at work. This study suggests that helpline staff should receive more education about trauma triggers, and ongoing support to reduce the impact on their home and social life, thus improving mental well-being and job satisfaction. This work begins the debate on the well-being needs of frontline helpline workers, and whether better meeting these needs can facilitate the provision of better support.

How should we implement collaborative care for older people with depression? A qualitative study using normalisation process theory within the CASPER plus trial.

BACKGROUND: Depression in older people may have a prevalence as high as 20%, and is associated with physical co-morbidities, loss, and loneliness. It is associated with poorer health outcomes and reduced quality of life, and is under-diagnosed and under-treated. Older people may find it difficult to speak to their GPs about low mood, and GPs may avoid identifying depression due to limited consultation time and referral options for older patients. METHODS: A qualitative study nested within a randomised controlled trial for older people with moderate to severe depression: the CASPER plus Trial (Care for Screen Positive Elders). We interviewed patient participants, GPs, and case managers (CM) to explore patients' and professionals' views on collaborative care developed for older people, and how this model could be implemented at scale. Transcripts were analysed thematically using normalization process theory. RESULTS: Thirty-three interviews were conducted. Across the three data-sets, four main themes were identified based on the main principles of the Normalization Process Theory: understanding of collaborative care, interaction between patients and professionals, liaison between GPs and case managers, and the potential for implementation. CONCLUSIONS: A telephone-delivered intervention, incorporating behavioural activation, is acceptable to older people with depression, and is deliverable by case managers. The collaborative care framework makes sense to case managers and has the potential to optimize patient outcomes, but implementation requires integration in day to day general practice. Increasing GPs' understanding of collaborative care might improve liaison and collaboration with case managers, and facilitate the intervention through better support of patients. The CASPER plus model, delivering therapy to older adults with depression by telephone, offers the potential for implementation in a resource-poor health service.

What are the sources of stress and distress for general practitioners working in England? A qualitative study.

OBJECTIVES: This paper reports the sources of stress and distress experienced by general practitioners (GP) as part of a wider study exploring the barriers and facilitators to help-seeking for mental illness and burnout among this medical population. DESIGN: Qualitative study using in-depth interviews with 47 GP participants. The interviews were audio-recorded, transcribed, anonymised and imported into NVivo V.11 to facilitate data management. Data were analysed using a thematic analysis employing the constant comparative method. SETTING: England. PARTICIPANTS: A purposive sample of GP participants who self-identified as: (1) currently living with mental distress, (2) returning to work following treatment, (3) off sick or retired early as a result of mental distress or (4) without experience of mental distress. Interviews were conducted face-to-face or over the telephone. RESULTS: The key sources of stress/distress related to: (1) emotion work-the work invested and required in managing and responding to the psychosocial component of GPs' work, and dealing with abusive or confrontational patients; (2) practice culture-practice dynamics and collegial conflict, bullying, isolation and lack of support; (3) work role and demands-fear of making mistakes, complaints and inquests, revalidation, appraisal, inspections and financial worries. CONCLUSION: In addition to addressing escalating workloads through the provision of increased resources, addressing unhealthy practice cultures is paramount. Collegial support, a willingness to talk about vulnerability and illness, and having open channels of communication enable GPs to feel less isolated and better able to cope with the emotional and clinical demands of their work. Doctors, including GPs, are not invulnerable to the clinical and emotional demands of their work nor the effects of divisive work cultures-culture change and access to informal and formal support is therefore crucial in enabling GPs to do their job effectively and to stay well.

Barriers, facilitators, and survival strategies for GPs seeking treatment for distress: a qualitative study.

BACKGROUND: GPs are under increasing pressure due to a lack of resources, a diminishing workforce, and rising patient demand. As a result, they may feel stressed, burnt out, anxious, or depressed. AIM: To establish what might help or hinder GPs experiencing mental distress as they consider seeking help for their symptoms, and to explore potential survival strategies. DESIGN AND SETTING: The authors recruited 47 GP participants via e-mails to doctors attending a specialist service, adverts to local medical committees (LMCs) nationally and in GP publications, social media, and snowballing. Participants self-identified as either currently living with mental distress, returning to work following treatment, off sick or retired early as a result of mental distress, or without experience of mental distress. Interviews were conducted face to face or over the telephone. METHOD: Transcripts were uploaded to NVivo 11 and analysed using thematic analysis. RESULTS: Barriers and facilitators were related to work, stigma, and symptoms. Specifically, GPs discussed feeling a need to attend work, the stigma surrounding mental ill health, and issues around time, confidentiality, and privacy. Participants also reported difficulties accessing good-quality treatment. GPs also talked about cutting down or varying work content, or asserting boundaries to protect themselves. CONCLUSION: Systemic changes, such as further information about specialist services designed to help GPs, are needed to support individual GPs and protect the profession from further damage.