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The annual rate of outpatient mental health and substance use visits by Ontario doctors increased 27 per cent in the first year of the COVID-19 crisis, a new study suggests, raising concerns about the pandemic’s psychological toll across the medical profession.

A paper published in JAMA Network Open on Friday found there were 1,038 visits per 1,000 doctors from March 11, 2020, to March 10, 2021, up from 817 visits per 1,000 doctors over the same period before the pandemic.

The findings are based on an analysis that anonymously linked registration records for 34,055 practicing physicians in the province to administrative data collected under the Ontario Health Insurance Plan.

Lead author Dr. Daniel Myran, a public-health doctor and fellow at the Ottawa Hospital, said the ability to track population-level trends over time makes this “one of the first studies of its kind,” building on smaller self-reported surveys that offer a snapshot of how physicians have been handling the pandemic.

“What that allowed us to do was to study physicians as patients instead of providers, and to look at how their visits to another physician for mental health or substance use have changed,” said Dr. Myran, noting that numerous measures were taken to safeguard medical privacy.

“I am concerned that there was this large increase in outpatient visits related to mental health. It is very consistent with surveys from physicians saying they’ve been having a tough time.”

Researchers identified increases in both the number of doctors accessing mental-health services, and the number of physicians with repeat visits.

The proportion of physicians who booked at least one visit related to mental health and substance use within a year increased to 13.4 per cent from 12.3 per cent over the study period.

This relative rise was more pronounced among doctors without a prior history of seeking treatment for such concerns, said Dr. Myran.

“It really suggests that one of the effects of the pandemic is that it impacted the mental health of physicians who previously were resilient to these mental-health concerns,” he said.

While some reports have indicated that doctors providing acute care for COVID-19 patients have had a harder time than their colleagues in other specialties, Dr. Myran said his team found that the increase in visits didn’t vary much based on proximity to the pandemic’s front lines.

“COVID-19 has been very challenging for health care workers and physicians in a number of different roles,” he said. “We found that pretty universally, the pandemic seemed to be impacting all physicians.”

In addition to the society-wide burdens of living through a pandemic, Dr. Myran said, doctors are dealing with occupational stressors such as increased risk of contracting COVID-19 and spreading it to a loved one, and dealing with disruptions to the delivery of medicine that could be hampering their ability to care for patients.

Another potential factor contributing to the uptick in visits could be that the rise of virtual care has made it easier for physicians to access mental-health services by alleviating concerns about professional stigma and offering more scheduling flexibility, said Dr. Myran.

Existing literature suggests that the pandemic has exacerbated mental-health concerns among physicians that predate the pandemic, Dr. Myran said, pointing to an online survey of physicians by the Canadian Medical Association that found 30 per cent of respondents reported suffering from burnout in 2017.

He noted that the study only captures visits covered by the Ontario Health Insurance Plan, which would omit private mental-health services such as those provided by a psychologist, counsellor or social worker.

“There is a possibility that we’re underestimating the care-seeking behaviour of physicians during the pandemic because they increased their care-seeking behaviours through other avenues,” he said.

Canadian Medical Association president Dr. Katharine Smart said it’s promising to see that some doctors are seeking out help to cope with the stresses of the COVID-19 crisis.

But Dr. Smart said Friday’s study underscores the need to support doctors with more resources to take care of themselves, and by extension, provide better care for their patients.

“Mental health and physical health can no longer be viewed as two separate things. We need both aspects of our health to be on point to be healthy, and that’s true for physicians as well,” said Dr. Smart.

“What we need to do is to continue to recognize that physician wellness has to be part of patient safety.”

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