Addiction (1993) 88, 655-663

RESEARCH REPORT

Doctors and substance misuse: types ofdoctors, types of problems

DEBORAH BROOKE, GRIFFITH EDWARDS & TOBY ANDREWSAddiction Research Unit, Institute of Psychiatry, National Addiction Centre, 4 Windsor Walk,London SE5 8AF, UK

AbstractThe casenotes of 144 doctors who had received treatmentfor substance misuse were analysed. There were nodifferences between general practitioners (n = 61) and hospital doctors (n - 58) in terms of their substancemisuse histories or the problems they incurred. Differences emerged between the consultant (n = 24) and thenon-consultant (n = 34) grades of hospital doctor. The consultants were older at onset of problematic use(42.6 8.6 vs. 29.9 9.8 years); they suffered fewer career problems and misused fewer substances. The mostfrequent pathways into substance use were personality difficulties (76 subjects, 52.8%) and anxiety ordepression (46 subjects, 31.9%). A history of depression (n = 36) was associated with perceived stress at work(p = 0.014), and at home (p - 0.06). Past neurotic disturbances (n = 20) were associated with personalitydifficulties (p - 0.035), anxiety or depression (p = 0.004), and with an earlier onset of problematic substanceuse (30.2 8.3 vs. 36.5 9.8 years, p 0.014). Principal components of possible antecedents yielded onemajor component on which all elements loaded; this was labelled the 'disturbance score'. This score showeda reduction with increasing age of onset of problematic substance use.

IntroductionIn a previous report,' we described the character-istics of 144 doctors with drug or alcoholproblems who were seen at the Bethlem andMaudsley hospitals between 1969 and 1988.The study was based on retrospective analysis ofcasenotes. These problems affected everyspeciality and all degrees of seniority. The meanage of presentation was 43 years; subjects hadexperienced problems with their substance mis-use on average for over 6 years. Alcohol was thecurrent problem for 42% and drug misuse for26%; 31% were misusing both alcohol and drugs

Correspondence to; Deborah Brooke, Depanment ofPsychiatry, Epsom General Hospital, Dorking Road, Epsom,Surrey KT18 7EG, UK.

at presentation. In the present study we take theanalysis further, looking at associations betweenvariables.

MethodThe sample comprised all doctors attending theMaudsley or Bethlem hospitals between 1969and 1988 who had received an ICD diagnosis ofalcohol dependence or drug dependence, orboth. Data were abstracted by D.B. and G.E.,using a structured schedule. The data dealt within the earlier paper comprised such variables asage, marital status, ethnic origin, place ofqualification, speciality and employment dura-tion, plus clinical details of drugs misused and

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their sources, and details of routes into treat-ment. In this paper, we present the findings forcertain additional areas:

Characteristics of the subject at key contact. Relat-ing to medical career and type of employment,and details of previous medical and psychiatricillness. (Within the UK, National Health Servicedoctors work in primary care as 'family doctors',i.e. general practitioners (36%) and general prac-titioner trainees (2%); as hospital doctorseither fully trained consultants (21%) or as non-consultants in training grades (33%) and inPublic and Community Health (5%). Percent-ages are based on British Medical Associationfigures for 1990; n = 88 191. Small categorieshave been excluded for clarity.)

Substance use characteristics at key contact andsubstance use history. Here such variables werecovered as age when drug and/or alcohol use firstbecame problematic and, where relevant, age atwhich drugs were first injected, and movementfrom alcohol to drugs or vice versa. Any treat-ments received and any self-help groupsattended were noted.

Pathways into substance misuse. This section ofthe schedule required the abstractor to make ajudgement as to the likely major aetiologicalfactors relating to the subject's misuse of alcoholor drugs. Given the nature of the case materialfirom which the information was being taken, itappeared better to code in terms of certainbroadly defined 'pathways', rather than employan extended check list of individual items wherethere might be missing information. One ormore of the following altemative pathways couldbe coded: personality problems; non-specificdrift into drinking; anxiety or depression; pain,injury or accident; stress at work; family stress;bereavement. To score positively on 'personalitydifficulties', evidence of long-standing relation-ship or occupational difficulties from earliestadulthood was needed, in the absence of con-comitant psychiatric problems and distinct fromconsequences of substance misuse.

Measures of impairment. Three scores werederived for each subject. These were (i) a scorefor number of substances ever misused, with onepoint given for misuse of a compound in each ofsix classes (alcohol; opiates; benzodiazepines and

barbiturates; cannabis, hallucinogens and sol-vents; stimulants; antidepressants and others),(ii) Score for substance-related problems in-curred at any time in each of seven defined areas(family relationships and financial difficulties;patient care; forensic involvement; drink-drivingcharges scored separately firom other forensiccontact; impaired personal health; suicide at-tempt; General Medical Council involvement),(iii) Score for detrimental effects of substancemisuse on career progression, with three gradesof severity: 'impaired', (for example, longperiods of unemployment or sickness absence);'chequered', (forced periods abroad or workingoutside own speciality); and 'blocked', (failure toprogress in preferred speciality).

ResultsThe frequency distribution for age of problemonset against type of substance misused is shownin Fig. 1. Alcohol problems developed in thisgroup across all age bands, but drug problemsdeclined in incidence with increasing age.

Exploratory correlation analysisInitially, we carried out an exploratory correla-tion analysis putting sex, ethnicity, generalpractice vs. hospital employment, and consultantvs. other hospital grades, against substance usecharacteristics, measures of impairment, andtreatments received. No significant differenceswere found between sex (124 men, 20 women),or between ethnic group (Caucasian 130, other14). Fifteen of 61 general practitioners as op-posed to 5 of 58 hospital doctors had attendedself-help groups (p = 0.02), but otherwise gen-eral practitioners and hospital staff showed nodifferences. When, however, a comparison wasmade between doctors of consultant and non-consultant grades, a number of findings emerged(Table 1).

Non-consultants had an earlier age of problemonset than consultants (non-consultants, n = 34,mean age of problem onset = 29.9 9.8 years,consultants, n = 24, mean age of problem on-set = 42.6 8.6, p = 0.000). With respect tochoice of substance, alcohol was the dominantsubstance of misuse among the consultants,while drugs and alcohol were equally representedamong the more junior doctors (p = 0.008).Junior staff had a higher mean drug score, that

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Figure 1. Age of problem onset by type of substance first misused (\3 % alcohol, 0 % drug(s); n = 133).

is, they had misused more substances (p = 0.04).They also showed a higher mean career handicapscore (p = 0,004). On the other hand, the con-sultants scored more highly on the problem score(p = 0.002).

The importance of past psychiatric problems. Thenumbers of subjects in the diagnostic categoriesof schizophrenia (n - 2), hypomania (n = 8) andbrain damage (w 3) were too small for statisti-cal analysis and these subjects were omitted.Data for other psychiatric problems are pre-sented in Table 2, The analysis for subjects witha past history of depression shows that they hada tendency to present with drug misuse ratherthan alcohol misuse, although this finding doesnot reach conventional levels of significance(p = 0,052). There were 20 subjects with a pasthistory of varieties of neurotic disturbance (ex-cluding depression). They developed problemswith substance misuse at a younger age(30.2 8.3 vs. 36.5 9.8 years, p - 0.014). Boththe group with past depression and the groupwith other neurotic disturbances hadsignificantly smaller problem scores (p = 0.05 ineach instance).

Continuity and change in choice of substance. Aseparate analysis (see Table 3) was carried outon the frequency with which subjects shiftedbetween a drug or alcohol problem.

Overalli there was continuity, but with sometendency to addition. Eighty-two subjects(56.9%) presented with problems related to their

originally problematic substance, while 43(29.9%) had added a drug to a pre-existingalcohol problem, or vice versa. This tendency toaddition was more marked within the group whostarted by misusing drugs. Some 45% of thesesubjects added an alcohol problem, while only25% of those whose initial difficulties were withalcohol went on to develop an additional drugproblem. Eight subjects (5.6%) substituted onecategory for the other.

Pathways leading into substance misuse. Themost frequently recorded pathways were person-ality difficulties (76 subjects, 52.8%) and anxietyor depression (46, 31.9%). Non-specific driftand family stress were each coded for 38 subjects(26.4%), and stress at work was coded for 33(22.9%). Pain and bereavement occurred in 14(9.7%) and 13 (9.0%) respectively. No pathwaywas cited for seven subjects (4.9%). More thanone pathway was cited for 72 subjects (50.0%).

As regards cross-tabulation of pathways withsubject characteristics, women (n = 20) weremore likely than men (n = 124) to be coded for'family stress' (45% vs. 23%, p = 0.04). Othersignificant findings emerged in relation to previ-ous experience of depression or other psychiatricillness, and here the relevant data are given inTable 4.

Those with a past history of depression(n = 36) were more likely than those withoutsuch a diagnosis (n = 93) to be coded for theanxiety and depression pathway (81% vs. 12%,p< 0.0001), for a pathway via bereavement

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Table 3 . Continuities in substances used between problem onset and index contact, numbers withpercentages of whole sample given in brackets (n = 144)

First problem Stayed same Added drugs Added alcohol SubstitutedAlcoholDrugsTotals

49 (34.0)33 (22.9)82 (56.9)

16 (11,1)27 (18.8)

43 (29.9)Information was incomplete on 11 subjects (7,6),

4 (2,8)4 (2,8)8 (5.6)

(19% VS. 3%, p - 0.005), for stress at work (39%vs. 18%, p = 0.014), or, at a marginal level ofsignificance, for stress in the family (36% vs.20%, p = 0.06). Conversely, they were less oftendiagnosed as having had a drift pathway (8% vs.35%, p = 0.002).

The subjects with a diagnosis of psychiatricillness (predominantly of a neurotic nature)other than depression (n = 20; n for those with-out this past diagnosis = 121), were also morelikely to have an anxiety and depression pathway(60% vs. 27%, p = 0.004) and this group con-tained more subjects coded for personalitydifficulties (75% vs. 50%, p = 0.04). In general,these findings appear to suggest that subjectswith a demonstrated psychiatric vulnerabilitymay be prone to finding pathways into substancemisuse which are characterised by mood dis-turbance or failure to find ways of coping withvarieties of stress.

Multivariate analysisPrincipal components analysis. Here we sought

to examine the postulate that two distinct typesof doctors with substance problems might beidentifiable. The two types were hypothesized interms of (i) younger doctors with greater evi-dence of psychiatric disturbance other thandepression, and with coding for personality oranxiety and depression pathways; (ii) older doc-tors, with contrasting characteristics on thesedimensions. Rather than using multiple vari-ables, we used a multivariate technique to detectunderlying trends: a principal components analy-sis of two pathways (anxiety/depression andpersonality difficulties) and a past history of neu-rotic disturbance (excluding depression) yieldedone major component on which all elementsloaded, and which accounted for 48% of thevariance, rather than there being two distinctcomponents. This component is a new variable,composed of the two pathways and the past

history, as above. We interpreted this variable asa 'disturbance score'. We concluded that thehypothesis that two distinct types of troubleddoctors could be identified was, in these terms,disconfirmed.

Analysis of variance. The disturbance scoreswere then entered into a univariate analysis ofvariance as dependent variables. Additional de-pendent variables were personality difficulties, apast history of neurotic disturbance and thehandicap score. The explanatory variables weresex, age of problem onset and type of problem(alcohol or drugs). The following conclusionscan be drawn:

(i) The personality difficulties pathway exertsa main effect upon age of problem onset: thiscoding was significantly more frequent atyounger ages (df = 5, F-3.8,p = 0.003).

(ii) There is an interaction between sex andage of problem onset for the disturbance score(df = 4, F = 2.85, p = 0.027). Thus disturbancescores showed a reduction with increasing age ofproblem onset, except for an increase amongmen in the 42-48 year group. The maximumdisturbance score among men was found inthose who presented at age 24 or younger, andthe maximum disturbance score among womenwas found in those who presented between theages of 24-30.

(iii) An interaction effect was demonstratedbetween age of problem onset, type of substanceproblem and handicap score (df=5, F = 2.56,p = 0.03). Those who present with a problemover the age of 48 have a greatly increased careerhandicap score. This is due to the small sub-group in this age bracket with drug problems(w = 4), rather than those with alcohol problems.

DiscussionWe wish to consider three issues. Firstly,

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whether sub-groups of doctors with substanceproblems can be identified; secondly, what mightbe the nature of factors that predispose to sub-stance misuse among doctors; and thirdly, thepolicy implications of our findings. There aremethodological limitations to our study. Thesubjects were limited to the sample of substance-misusing doctors who presented to apost-graduate teaching hospital over a 20-yearperiod. The sample is large in UK terms but thenumber is still small. There is no comparisongroup drawn from other occupations, or fromdoctors who do not misuse substances. The datawas collected retrospectively. Nonetheless, wehave explored some hypotheses, and this is thefirst time that multivariate techniques have beenused in this field. The results point to a series ofsignificant questions, which deserve further con-sideration.

The identification of sub-groupsAmong alcoholics in the general population,several authors have described a group with ayounger age of onset and a family history ofalcoholism, a more severe course and associatedpsychiatric problems or personality difficulties.^ '^A sub-group may be identified within the hospi-tal doctors, consisting of those below consultantgrade. This group is characterised by a youngerage at onset of substance problems, large num-bers of substances misused, a greater proportionmisusing drugs and experiencing markedly dis-advantageous effects on their careers. Those atconsultant grade have a later onset of problem-atic use, showing that they are not the cohort ofyoung, troubled doctors marched forward; theyaccumulate more substance-related problems,but their careers suffer less, except for those whodevelop a drug problem in later life. The highcareer handicap scores suffered by such individu-als in this study were due to taking earlyretirement, and it may have been that this coursewas infiuenced by the perceived illegality of illicitdrug use, as much as the health needs of thepractitioner. We hypothesized that these twoclusters might emerge on principal componentanalysis. However, principal component analysisof our data did not show two separate dimen-sions of older and younger subjects. It yielded aderived score of 'disturbance' for each subject.This derived score decreased with age, except foran increase in men in their forties. This finding

suggests a continuum of vulnerability to sub-stance misuse problems across all age groups; thecontribution made by personality difficulties inyounger substance misusers may inflate the dis-turbance score in the youngest age groups, butnot sufficiently to demonstrate a specific type.Doctors in all age groups continue to sufferdisturbance, and this data suggests that emo-tional problems are of major importance.

Pathways and past history: the nature of vulner-abilityThe genesis of an individual's substance misuseproblem cannot be reduced to a single factor andour concept of 'pathways' serves to draw atten-tion to premorbid individual susceptibilities. So,for example, over half of the subjects were codedpositively for personality difficulties. This is ahigh proportion with poor adult adjustment andlimited coping strategies. Furthermore, anxietyor depression had contributed to the develop-ment of substance misuse in about one-third.Whether anxiety and depression were experi-enced as a past event, or whether they were, inretrospect, a pathway into substance misuse,they emerge as frequent antecedents to sub-stance misuse at all ages.

It appears paradoxical, but both a past historyof depression and of other neurotic conditionswere associated with a lower problem score, pos-sibly because these subjects came to theattention of helping agents before they had timeto accumulate substance-related problems. Thegroup with other neurotic conditions was com-posed of a variety of diagnoses: seven hadsuffered from anxiety, five had sought help withrelationship difficulties and the remainder com-prised anorexia nervosa, conduct disorder,morbid jealousy or episodes of self-harm. Thisgroup had a younger age of onset of problematicsubstance use and some of these episodes ofpsychiatric illness may have been secondary tothe developing substance problem. Not all of oursubjects were considered to have a definablevulnerability; about one-quarter were thought tohave drifted into substance misuse.

Implications for policyThe detection and prevention of drug and alco-hol misuse at work is within the remit ofoccupational health services. Substance misuse

Doctors and substance misuse 663

by any member of an organization is damagingand wasteful of their training; it is entirely appro-priate that occupational health services prioritisethis issue. In addition to the increasing emphasison counselling and health promotion, occupa-tional health has an expanding role in theimplementation of UK and EEC regulationsgoveming conditions in the workplace. All ofthese demands have resource implications, butshort cuts in occupational health services arecostly in the long term. The hospital doctors intraining grades show a predilection to misuse avariety of drugs, in addition to alcohol. It is clearthat this is partly in response to personalitydifficulties, but also this group are known to besubject to a collection of stressors unique to thefirst years of qualification. The connections be-tween demoralisation and self-medication areunclear but failing to address misery due toorganizational deficiencies sets the scene for re-duced expectations and lack of motivation in thefuture. Strategies have been suggested both inthe UK^'' and the US^ to improve their experi-ences. As a preventive measure, the issue ofself-prescribing could be addressed via post-graduate education.

About 36% of Britain's doctors are self-employed general practitioners. They consulttheir own general practitioners (often a partnerin the practice) at about one-tenth the rate ofnon-general practitioner patients.' They fre-quently diagnose, treat and refer themselves,sometimes inappropriately. They have access tomood-altering drugs as a matter of routine, andmany of our subjects had attempted to alleviatedistress by misuse of self-prescribed medication.This is facilitated by a culture within the profes-sion that regards self-treatment as an appropriateinitial response to illness.*'' It has been suggestedthat a preferential health care system for doctorswould facilitate access to independent medicalcare.'"

Many subjects developed a substance misuseproblem in middle age, including one-quarter ofour number who were considered to have driftedinto substance misuse. This illustrates the needfor continuing interest by the profession in thewelfare of all its members. Concentrating on thetraining grades and the psychologically vulner-

able would fail to reach this group. They con-tribute to the numbers of undiagnosed addictdoctors. Not only missed, they are also misman-aged because of lack of awareness thatconfidential, expert and effective help is avail-able.""" Wider publicity for this help wouldencourage earlier entry into treatment and dispelthe aura of gloom that has imprisoned addicteddoctors by paralysing those around them.

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