Prevalence and risk factors for psychiatric morbidity among tertiary hospital consultants in Nigeria

S A Kuranga, MB BS, FWACS, FICS Department of Surgery, College of Medicine, University of Ilorin, Nigeria The Nigerian health sector has recently been fraught with incessant crises occasioned by shortage of funds, poor remuneration, lack of job satisfaction, lack of state-of-theart equipment, and dearth of personnel. Therefore the working life of doctors in the country seems characterised by frustration, anxiety and anger, coupled with increasing patient load which inevitably translates to increased work demands. All these factors could impact on the psychological wellbeing of doctors.

Doctors especially have been reported to be susceptible to work-related distress and the accompanying psychological morbidity. 11Psychiatric morbidity among hospital workers and especially medical consultants calls for careful consideration as this may reflect personal suffering among doctors, and eventual threat to the quality of patient care and life expectancy of the doctors.
Previous studies have generally reported varying degrees of morbidity among medical personnel.In a study of New Zealand health professionals Downwell et al. 12 reported a morbidity level of 10%; in a study of teaching hospital consultants in Benin, Nigeria, Ofili et al. 1 reported a morbidity rate of 14%, while Grassi and Magnani 13 found morbidity levels of 20.3% and 24.6% among Italian general practitioners and hospital physicians respectively.In separate studies of different consultants Ramirez et al. 14 reported morbidity rates of 27% and 28%, while Catalan et al. 15 found a morbidity level of 33% among staff caring for people with HIV infection and cancer.A morbidity level as high as 47% among hospital consultants has also been documented. 11,16,17st studies on doctors have focused on junior doctors, with few studies focusing on senior doctors and specific subgroups of hospital consultants. 16,17Studies have identified that sources of stress among physicians include uncertainty of diagnosis, work overload and its effect on home life, feeling poorly managed and resourced, dealing with patient suffering, and long work hours.[19] However none or very few of these earlier studies investigated all the diverse groups of consultants at teaching hospital level to ascertain possible psychiatric morbidity among them, possible risk factors, and possible differential contribution, if any, of their areas of specialisation.Therefore, the need to know the prevalence of morbidity, and the possible sociodemographic and work-related risk factors in a group of tertiary hospital staff in the north-central zone of Nigeria prompted the present study in the hope of supplementing existing knowledge and assisting our health managers and health policy formulators to prevent increasing mental health problems in the health sector particularly, and by extension, in the other occupational sectors and the general population.At the time of the study the hospital had 82 consultants, 78 of whom were asked to respond to two questionnaires, one on sociodemographic and work-related factors, and the other the 30-item General Health Questionnaire (GHQ-30). 20 prevent biased responses to the screening instrument (the GHQ-30) by psychiatrists, being a psychiatrist was made an exclusion criterion for participation, and 4 consultants were therefore excluded.

Subjects
All the consultants were initially approached and told about the study.They were informed that similar studies were being conducted among the nursing staff, resident doctors and hospital administrators to ascertain how work conditions impacted on their psychological wellbeing.They were also informed that these studies constituted part of the hospital's strategic health plan which aimed to achieve quality service delivery, enhance staff-management co-operation, improve job satisfaction among all staff, and extend the ongoing national health reform.To ensure honest responses and to allay undue fear, they were further informed that the chief executive of the hospital was involved in the studies.Despite these assurances, however, the general negative attitude towards mental illness and the problem of stigmatisation still hindered the enthusiasm of some consulants with regard to participation.The majority expressed the fear of being labelled mentally ill.
Each consultant was provided with the questionnaires and an accompanying envelope in which to seal them once Consultants were reminded telephonically and by personal contact at the end of the first, second, third, and fourth weeks about the need to return the completed questionnaires.

Questionnaires
Each consultant was sent a questionnaire booklet that assessed: (i) sociodemographic and work-related characteristics; and (ii) psychiatric morbidity using the 30-item GHQ-30. 20e GHQ-30 is a self-administered screening instrument meant to detect current, diagnosable psychiatric disorders in general practice and in a community setting. 4,5,201,22 Therefore, any respondent with a GHQ-30 score of 4 or more was regarded as GHQ-positive, and therefore as having psychiatric morbidity.
All data were analysed using SPSS for Windows version 11.0. 23Frequency distributions and cross-tabulations were done, chi-square values were derived using Yates's correction where applicable, and the level of statistical significance was set at 5%.

Response rate
Fifty-four of the 78 consultants returned their questionnaires satisfactorily completed, giving a 69.2% response rate.
Fifty-two of the consultants (96.3%) had no degrees besides MB BS plus fellowship, and the majority (40, 74.1%) had practised for more than 10 years.Nineteen of 48 consultants (39.6%) had been promoted

Work-related characteristics (Table II)
3 -5 years previously, and 25/53 (47.2%) felt that their remuneration was not commensurate with their work.

Prevalence of psychiatric morbidity
Ten consultants (18.5%) scored 4 or more on the GHQ-30 and were therefore regarded as having morbidity.Forty-four scored less than 4 on the GHQ and were regarded as having no morbidity.

Sociodemographic factors (Table III)
As shown in Table III who preferred visiting friends/families had morbidity, while 1 (11.1%) who preferred outdoor games had morbidity (corrected x 2 = 0.17, p = 0.68).

Work-related factors (Table IV)
Table IV shows the work characteristics of the respondents.
Table IV also shows the work experience of the consultants.
It indicates that 6 consultants (60%) who had morbidity had more than 10 years' expertise, 4 (40%) with morbidity had between 5 and 10 years' expertise, while 4 (9.1%)without morbidity had less than 5 years' expertise (corrected x 2 = 1.76, p = 0.18).The effect of the consultants' work on their family is also shown in Table IV.Six consultants (60%) who had morbidity reported that their work had no adverse effects on their family, while 4 (40%) who had morbidity reported that their work had adverse effects on their family (corrected x 2 = 1.07, p = 0.30).

Morbidity prevalence
The finding of 18.5% morbidity is consistent with previous studies that reported morbidity of 17 -18% among bank employees in this locality 4,5 and factory workers in the more urban city of Lagos. 6][16][17]24 However, one study 12

Sociodemographic characteristics and morbidity
The absence of significant previous studies reporting such association.For instance, increased morbidity has been reported among younger consultants because it was believed that there was decreased level of distress with increasing medical seniority. 16,24milarly, in studies 4,5 of bankers in Ilorin, increased morbidity was reported in the younger age group (34 -44 years).This might also account for the absence of significant association between years of experience and psychiatric morbidity.
Some studies have reported increased psychological distress among female executives because of role conflict and role overload, 28 and among female doctors; 19,29,30 this has been reported to increase as women occupy a combination of roles.
Other studies 4,5,31 have reported comparatively more morbidity among male than female workers as a result of increased competitiveness.The present study showed no significant association between gender and morbidity, perhaps because of lack of differential exposure to environmental, professional and academic stress in the medical profession.However, the disproportionate gender distribution in this study prevented any definitive appraisal of this observation.
The observed lack of significant association between morbidity and the number of respondents' children differed from previous reports which noted significant association between morbidity and the increased demands of a large family and home-work conflict. 11,19,29,30,32The majority (51/54, 94.4%) of the respondents were male -in African culture men are expected to hold multiple roles outside the home-keeping and child-rearing prescribed for women.This may have strengthened the resolve of the male doctors to be less constrained by or concerned with childrearing and home-keeping, avoiding any conflict that could possibly arise therefrom.
The previous finding of Kask et al. 33 among consultant oncologists with regard to the mitigating influence of religion on morbidity was also not supported by this study.The finding was, however, similar to that previously reported among bank workers. 4,5This may further support the proposition that other intrinsic factors may be responsible for psychiatric morbidity among these consultants.There may be need for further research in this area.

Work characteristics and morbidity
The association between the doctors' workload and morbidity was not significant, and was therefore contrary to previous studies reporting such association among doctors and certain other occupational groups. 4,5,11,16,32,34,35One would have expected a significant association in view of the present increased work demands on these consultants consequent upon the shortage of resident doctors in the teaching hospital because of federal government embargo on employment.This had necessitated mobilisation of all consultants regardless of seniority in order to ensure ongoing clinical services.Perhaps because all doctors were invariably equally involved in patient care, years of experience was also not significantly associated with morbidity, in contrast to previous studies 16,24 that have reported reduced distress with increasing medical seniority.
Call duty that could translate to heavy workload on the doctors was also not significantly associated with morbidity, and was therefore inconsistent with previous findings of increased morbidity with both qualitative and quantitative work overloads. 28,31,36The accruable financial benefits (i.e.call duty allowances) might have mitigated the possible adverse psychological effects on the consultants.The participation of all consultants in patient care might also have lightened the workload of individual doctors and therefore lessened their potential physical or psychological distress.
The professional work demands of consultants fall into three fundamental categories in teaching hospitals, viz.clinical, academic (teaching), and administrative. 37It is thought that in the case of some consultants a combination of these demands may result in role conflict, possibly leading to psychological distress.This view was not supported by this study.It is possible that adjustment and development of adaptive coping strategies over time in this group of consultants may offset any perceived stressful conditions.
Contrary to the findings of some previous studies concerning morbidity and area of specialisation, 30,34,35 the present study did not show any significant association between morbidity and area of specialisation.This perhaps could be due to the multidisciplinary and collaborative approach being practised in the hospital which invariably still functions as both secondary and tertiary health institution.Therefore, all the consultants still interacted by way of consultation-liaison, articles assisting each other in proffering solutions to difficult clinical situations, and sharing one another's burdens and problems.
Poor interpersonal relations has been identified as a risk factor for poor psychological health. 6,28However absence of significant association between interpersonal relations and morbidity among the consultants in this study does not support these earlier reports.This may be because of people involved in co-operative efforts may be in a better position to combat stressful situations. 38muneration and promotion were not significantly associated with morbidity.This was in accord with the findings of Shankar and Famuyiwa, 6 but contrasted with some other research reports among other occupational groups. 11,18Perhaps because doctors see their service as being humanitarian and therefore attach less importance to the issue of personal convenience, they might have been less concerned about their personal comfort and therefore ready to sacrifice individual satisfaction for patient care and wellbeing.
Similarly, job satisfaction was not significantly associated with morbidity, contrary to previous reports 11,32 in which job satisfaction was identified as having a protective effect against the negative consequences of work stress.This is difficult to explain.However, the possibility of other inherent factors associated with morbidity among the consultants (outside the sociodemographic and work-related factors), which are beyond the scope of the present study, need to be investigated in future studies.

Limitation of the study
The fact that the study used information given by the consultants themselves was a limitation.Sole reliance on their reports may have influenced the results.

Conclusion
These consultants were as likely as any other occupational group to develop psychiatric morbidity, but it seems that the risk factors are more likely to be due to other inherent causal factors, such as personality characteristics and coping strategies. 11,28 advocate that the hospital management, in collaboration with the Department of Behavioural Sciences, organise regular stress management workshops and seminars for the consultants, as well as regular consultant-management interactive forums to deliberate jointly on issues concerning staff welfare and hospital policy.These are likely to eliminate resentment on the part of the consultants and to enhance their psychological wellbeing.

The
University of Ilorin Teaching Hospital is located in the north-central zone of Nigeria and serves as a referral centre for Kwara, Niger and Kogi states.It is a 450-bed hospital with 11 clinical departments comprising anaesthesia, behavioural sciences (psychiatry), epidemiology (public health), medicine (cardiology, endocrinology, dermatology, gastroenterology, nephrology and pulmonology), laboratory sciences (chemical pathology, haematology, histopathology and microbiology), obstetrics and gynaecology, ophthalmology, otorhinolaryngology, paediatrics, radiology, surgery (general surgery, orthopaedic surgery, neurosurgery, plastic surgery and urology).The ancillary departments include administration, medical records, nursing, pharmacy, security, and engineering (works).

articles Volume 12
No. 2 June 2006 -SAJP completed, and was assured of absolute confidentiality.
also reported a morbidity as low as 10% among health professionals.The similarity of morbidity between bank workers and hospital consultants could possibly be due to certain inherent factors common to both occupational groups, perhaps the stressful nature of the two occupations.While one takes charge of human economy, urbanised than the eastern part of the country where a lower morbidity was reported, possibly because of proximity to both Abuja (the federal capital) and Lagos (the former federal capital).

a s s o c i a t i o n b e t w e e
the friendship and partnership form of relationship found here, different from the supposedly traditional sour, envious relationships characterising health teams in most health institutions.The consultants may have developed coping strategies or the maturity to deal with these other members of health teams in order to forestall crisis.Possible attitudinal change of the consultants may have extended to patients and their relations, with consultants being more tolerant of any untoward behaviour of patients and their relations and adjusting healthily to clinical outcomes of medical or surgical interventions without undue emotional attachment.It has been reported that individual anxieties and conflicts are forgotten when people work together towards a common goal, and