As Professor Debbie Cohen discusses work-related mental health issues among doctors, it's obvious that she feels there is much to be done, both in terms of what we do and how we do it. 'It's well reported that there are high levels of stress and distress in doctors and medical students across all grades, often related to the strains that the NHS is under,' she says. 'But I think we have to look carefully at this so that we can support people appropriately.'

This is something that Debbie is more than qualified to do. Based at the University of Cardiff's School of Medicine, she is an expert in mental ill health in the workplace, and physician health and received an OBE in 2012 for her services to occupational health.

Her recent research has examined topics such as the disparity between self-reporting of mental health issues and the results of clinical interviews. 'We know that in the general population the common mental health disorders like depression, anxiety and eating disorders are on the rise. But if you look specifically at doctors, the most recent data from 2008 is that 10%-20% of doctors will get depressed at some time. There are higher rates of suicide in doctors than in some other professions, and indeed it's higher than the general population.'

Debbie is adamant that the way we frame the discussions around work-related mental health is crucial - how we talk about occupational mental health issues in doctors is just as important as how we tackle them.

'We need to be careful about what we say and how we say it', she says. Taking burnout as an example, she describes it as a 'three-dimensional syndrome' related to the workplace that measures emotional exhaustion, depersonalisation and a lack of personal accomplishment. 'It's not a disease in itself,' she insists, 'but a syndrome that relates to workplace issues. This means if we want to tackle it and reduce the distress and ill health that can come from burnout we must tackle the workplace as well as supporting the individual. We mustn't stigmatise burnout but use it to look carefully at the causes as well as the consequences.'

Risks and reasons

In discussing the reasons behind the incidence of mental health issues in medicine, Debbie notes that there are lots of different factors to take into account and that different groups have different risks associated with them. For example, anaesthetists, psychiatrists and general practitioners have proportionally higher rates of suicide, 'which might relate to access to drugs along with other compounding issues like workload.'

Personality appears to be a factor as well. 'We tend to recruit into medicine neurotic perfectionists,' says Debbie respectfully, 'because that's what we need - we need people to be good, careful and cautious and to do their best. But what comes with that, as seen in the general population with neurotic perfectionist tendencies, is an increased risk of higher rates of common mental health problems.'

'There are also very clear issues that relate to doctors in terms of the demands placed on them,' Debbie continues, highlighting particular issues for junior doctors. 'Very often they have to move around the country, they lose that contact with family and friends, and they can't access support because they can't see their own GP. And because their rotas are so tight, they won't go to their own doctors because they don't want to let their colleagues down.'

Barriers to care

This perceived fear of failure is a recurring theme among doctors when talking about their health issues. Debbie's studies into the obstacles to doctors seeking support seem to chime with previous research, with stigma again being a key point. 'There's this notion that doctors feel they need to be invincible, so they don't disclose because they're worried about what other people will think of them.

'But there are still many myths about - if you have mental illness then you can't be a doctor, you'll get referred to fitness to practise, you'll be struck off.' Debbie cautions that while we think we're addressing these myths, 'our research shows it continues to be a problem.'

Confidentiality is another issue that comes up time and time again, and Debbie has found that some doctors are worried about what disclosure means in practice. 'If I tell somebody, what does that mean? Who finds out about my problem? We still don't make it explicit what confidentiality actually means.'

Diagnosis and disclosure

Debbie points out that disclosing about one's mental health to others is a very individual issue. She has found that while some doctors are happy to disclose that they're not well, they seem to be in the minority, and that many people are very cautious about disclosing. 'I think the importance of this, in really helping people to get disclosure right, is how we talk to people,' she says. 'It's very clear in our research what drives people to disclose and what stops them from disclosing. Often when someone has taken the plunge and talked to one person, they will then go on and disclose to others.'

In contrast, Debbie has found that a dismissive response to that initial disclosure can be extremely damaging. 'If someone reaches out and they get a bad response, you lose those people. They don't come back. They don't go on and then seek further help. Those initial meetings and discussions are the most important.'

An individually tailored approach is obviously difficult to implement, especially on a national level, but in Debbie's view it's not enough to simply offer a support service. 'We know that doctors will go to all sorts of different places for support,' she says, 'but in our survey, approximately 14% of respondents would go to their GP or support within the workplace, but only 6% would go to OHS [occupational health services]. In our UK survey not one trainee would go to their professional support unit. Now that doesn't at all mean those are bad services. But the way we advertise them, disseminate them and explain what they're there for - we obviously haven't got right.'

The way forward

Steps are now being taken to move support services in this direction. The end of January 2017 saw the launch of the NHS' GP Health Service, the first nationally-funded provision of its kind. Confidential and free to access, it offers GPs and trainees the opportunity to self-refer and connect in confidence. Crucially in Debbie's opinion, it is independent.

'Some other services are not seen as independent, and that's why doctors and medical students worry about confidentiality,' she says. 'In Wales we have HHP Wales [Health for Health Practitioners Wales], where any doctor in Wales can access eight sessions of CBT for free, and they can do so anonymously.

'I think there's sometimes a misunderstanding about what these services do and what it means if you disclose to these services,' she continues, emphasising again the importance of confidentiality. 'People want to go to someone they can trust. Different people go to different places, but at the heart of it, it's about confidentiality and feeling secure about what happens with their information.'

The new NHS service is a step in the right direction, but is there enough awareness of the help that is already available? Debbie is sceptical. 'We can offer a service to people but it's clearly not enough. Many are accessing the new services such as the GP health service and PHP in London and our service in Wales, and that's great. However many are still not coming forward early enough, we know that. We need to look internally, we need to look at ourselves and ask what we're doing that's not quite right or enough of. What can we do more of to raise awareness, to signpost more appropriately, to have less stigma and a better culture so people access help before they become desperate or too unwell?

'One of the things I particularly feel having talked to many doctors over the years, and also from our research, is that we need to be more compassionate and caring. If we can do that through providing better services, by talking about it more appropriately and putting more compassion and care into medical schools and at postgraduate level, then I think that will improve people accessing and seeking support. We label people; we see the press saying things like 'GPs are burnt out'. I don't think this is helpful, we need to rethink how we approach this.

'In Cardiff we're about to start a campaign called One Act of Kindness. We know from the research that simple acts of kindness make a big difference to people who are feeling low or distressed. If we can shift our culture by doing something very simple, like saying, 'you don't look too good, are you okay?' or 'Is there something I can do to help you?', that will go a long way to remove some of stigma and make a difference.'

Given her extensive study into this area, it's perhaps not surprising that Debbie is a strong advocate of further research, 'which we need to do before we can move forward and inform policy. We don't have enough data, and we've never had enough data on medical students and if they are different to other students, even other healthcare students. Do they have different needs, and if so, why? I'm very keen to do that area of work, because if we want to make a difference, we need to start early! When we have better research we can inform policy better, rather than doing so anecdotally.'

By providing a more informed and supportive environment, Debbie seems confident that the situation for doctors undergoing work-related mental health issues can be improved, but is clear that a nuanced and considered approach is needed. 'Going in early, doing it right, knowing where to go and how to support people; we can do that better,' she concludes. 'There's more we need to do.'