Addiction (1993) 88, 655-663

RESEARCH REPORT

Doctors and substance misuse: types of

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

Abstract
The casenotes of 144 doctors who had received treatmentfor substance misuse were analysed. There were no
differences between general practitioners (n = 61) and hospital doctors (n - 58) in terms of their substance
misuse histories or the problems they incurred. Differences emerged between the consultant (n = 24) and the
non-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 most
frequent pathways into substance use were personality difficulties (76 subjects, 52.8%) and anxiety or
depression (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 personality
difficulties (p - 0.035), anxiety or depression (p = 0.004), and with an earlier onset of problematic substance
use (30.2 8.3 vs. 36.5 9.8 years, p 0.014). Principal components of possible antecedents yielded one
major component on which all elements loaded; this was labelled the 'disturbance score'. This score showed
a reduction with increasing age of onset of problematic substance use.

Introduction
In a previous report,' we described the characteristics of 144 doctors with drug or alcohol
problems who were seen at the Bethlem and
Maudsley hospitals between 1969 and 1988.
The study was based on retrospective analysis of
casenotes. These problems affected every
speciality and all degrees of seniority. The mean
age of presentation was 43 years; subjects had
experienced problems with their substance misuse on average for over 6 years. Alcohol was the
current problem for 42% and drug misuse for
26%; 31% were misusing both alcohol and drugs
Correspondence to; Deborah Brooke, Depanment of
Psychiatry, Epsom General Hospital, Dorking Road, Epsom,
Surrey KT18 7EG, UK.

at presentation. In the present study we take the

analysis further, looking at associations between
variables.
Method
The sample comprised all doctors attending the
Maudsley or Bethlem hospitals between 1969
and 1988 who had received an ICD diagnosis of
alcohol dependence or drug dependence, or
both. Data were abstracted by D.B. and G.E.,
using a structured schedule. The data dealt with
in the earlier paper comprised such variables as
age, marital status, ethnic origin, place of
qualification, speciality and employment duration, plus clinical details of drugs misused and

655

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Deborah Brooke et al.

their sources, and details of routes into treatment. In this paper, we present the findings for
certain additional areas:

barbiturates; cannabis, hallucinogens and solvents; stimulants; antidepressants and others),

(ii) Score for substance-related problems incurred at any time in each of seven defined areas
Characteristics of the subject at key contact. Relat(family relationships and financial difficulties;
ing to medical career and type of employment, patient care; forensic involvement; drink-driving
and details of previous medical and psychiatric charges scored separately firom other forensic
illness. (Within the UK, National Health Service contact; impaired personal health; suicide atdoctors work in primary care as 'family doctors', tempt; General Medical Council involvement),
i.e. general practitioners (36%) and general prac- (iii) Score for detrimental effects of substance
titioner trainees (2%); as hospital doctors misuse on career progression, with three grades
either fully trained consultants (21%) or as non- of severity: 'impaired', (for example, long
consultants in training grades (33%) and in periods of unemployment or sickness absence);
Public and Community Health (5%). Percent- 'chequered', (forced periods abroad or working
ages are based on British Medical Association outside own speciality); and 'blocked', (failure to
figures for 1990; n = 88 191. Small categories progress in preferred speciality).
have been excluded for clarity.)
Substance use characteristics at key contact and
Results
substance use history. Here such variables were The frequency distribution for age of problem
covered as age when drug and/or alcohol use first onset against type of substance misused is shown
became problematic and, where relevant, age at in Fig. 1. Alcohol problems developed in this
which drugs were first injected, and movement group across all age bands, but drug problems
from alcohol to drugs or vice versa. Any treat- declined in incidence with increasing age.
ments received and any self-help groups
attended were noted.
Exploratory correlation analysis
Pathways into substance misuse. This section ofInitially, we carried out an exploratory correlathe schedule required the abstractor to make a tion analysis putting sex, ethnicity, general
judgement as to the likely major aetiological practice vs. hospital employment, and consultant
factors relating to the subject's misuse of alcohol vs. other hospital grades, against substance use
or drugs. Given the nature of the case material characteristics, measures of impairment, and
firom which the information was being taken, it treatments received. No significant differences
appeared better to code in terms of certain were found between sex (124 men, 20 women),
broadly defined 'pathways', rather than employ or between ethnic group (Caucasian 130, other
an extended check list of individual items where 14). Fifteen of 61 general practitioners as opthere might be missing information. One or posed to 5 of 58 hospital doctors had attended
more of the following altemative pathways could self-help groups (p = 0.02), but otherwise genbe coded: personality problems; non-specific eral practitioners and hospital staff showed no
drift into drinking; anxiety or depression; pain, differences. When, however, a comparison was
injury or accident; stress at work; family stress; made between doctors of consultant and nonbereavement. To score positively on 'personality consultant grades, a number of findings emerged
difficulties', evidence of long-standing relation- (Table 1).
ship or occupational difficulties from earliest
Non-consultants had an earlier age of problem
adulthood was needed, in the absence of con- onset than consultants (non-consultants, n = 34,
comitant psychiatric problems and distinct from mean age of problem onset = 29.9 9.8 years,
consequences of substance misuse.
consultants, n = 24, mean age of problem onset = 42.6 8.6, p = 0.000). With respect to
Measures of impairment. Three scores were choice of substance, alcohol was the dominant
derived for each subject. These were (i) a score substance of misuse among the consultants,
for number of substances ever misused, with one while drugs and alcohol were equally represented
point given for misuse of a compound in each of among the more junior doctors (p = 0.008).
six classes (alcohol; opiates; benzodiazepines and Junior staff had a higher mean drug score, that

Doctors and substance misuse

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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 handicap
score (p = 0,004). On the other hand, the consultants scored more highly on the problem score
(p = 0.002).

originally problematic substance, while 43

(29.9%) had added a drug to a pre-existing
alcohol problem, or vice versa. This tendency to
addition was more marked within the group who
started by misusing drugs. Some 45% of these
subjects added an alcohol problem, while only
The importance of past psychiatric problems. The 25% of those whose initial difficulties were with
numbers of subjects in the diagnostic categories alcohol went on to develop an additional drug
of schizophrenia (n - 2), hypomania (n = 8) and problem. Eight subjects (5.6%) substituted one
brain damage (w 3) were too small for statisti- category for the other.
cal analysis and these subjects were omitted.
Data for other psychiatric problems are prePathways leading into substance misuse. The
sented in Table 2, The analysis for subjects with most frequently recorded pathways were persona past history of depression shows that they had ality difficulties (76 subjects, 52.8%) and anxiety
a tendency to present with drug misuse rather or depression (46, 31.9%). Non-specific drift
than alcohol misuse, although this finding does and family stress were each coded for 38 subjects
not reach conventional levels of significance (26.4%), and stress at work was coded for 33
(p = 0,052). There were 20 subjects with a past (22.9%). Pain and bereavement occurred in 14
history of varieties of neurotic disturbance (ex- (9.7%) and 13 (9.0%) respectively. No pathway
cluding depression). They developed problems was cited for seven subjects (4.9%). More than
with substance misuse at a younger age one pathway was cited for 72 subjects (50.0%).
(30.2 8.3 vs. 36.5 9.8 years, p - 0.014). Both
As regards cross-tabulation of pathways with
the group with past depression and the group subject characteristics, women (n = 20) were
with
other neurotic
disturbances
had more likely than men (n = 124) to be coded for
significantly smaller problem scores (p = 0.05 in 'family stress' (45% vs. 23%, p = 0.04). Other
each instance).
significant findings emerged in relation to previous experience of depression or other psychiatric
Continuity and change in choice of substance. A illness, and here the relevant data are given in
separate analysis (see Table 3) was carried out Table 4.
on the frequency with which subjects shifted
Those with a past history of depression
between a drug or alcohol problem.
(n = 36) were more likely than those without
Overalli there was continuity, but with some such a diagnosis (n = 93) to be coded for the
tendency to addition. Eighty-two subjects anxiety and depression pathway (81% vs. 12%,
(56.9%) presented with problems related to their 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 with
percentages of whole sample given in brackets (n = 144)

First problem
Alcohol
Drugs
Totals

Stayed same

Added drugs

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

16 (11,1)

Added alcohol

27 (18.8)
43 (29.9)

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

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

(19% VS. 3%, p - 0.005), for stress at work (39%

vs. 18%, p = 0.014), or, at a marginal level of
significance, for stress in the family (36% vs.
20%, p = 0.06). Conversely, they were less often
diagnosed as having had a drift pathway (8% vs.
35%, p = 0.002).
The subjects with a diagnosis of psychiatric
illness (predominantly of a neurotic nature)
other than depression (n = 20; n for those without this past diagnosis = 121), were also more
likely to have an anxiety and depression pathway
(60% vs. 27%, p = 0.004) and this group contained more subjects coded for personality
difficulties (75% vs. 50%, p = 0.04). In general,
these findings appear to suggest that subjects
with a demonstrated psychiatric vulnerability
may be prone to finding pathways into substance
misuse which are characterised by mood disturbance or failure to find ways of coping with
varieties of stress.

Multivariate analysis
Principal components analysis. Here we sought

to examine the postulate that two distinct types

of doctors with substance problems might be
identifiable. The two types were hypothesized in
terms of (i) younger doctors with greater evidence of psychiatric disturbance other than
depression, and with coding for personality or
anxiety and depression pathways; (ii) older doctors, with contrasting characteristics on these
dimensions. Rather than using multiple variables, we used a multivariate technique to detect
underlying trends: a principal components analysis of two pathways (anxiety/depression and
personality difficulties) and a past history of neurotic disturbance (excluding depression) yielded
one major component on which all elements
loaded, and which accounted for 48% of the
variance, rather than there being two distinct
components. This component is a new variable,
composed of the two pathways and the past

history, as above. We interpreted this variable as

a 'disturbance score'. We concluded that the
hypothesis that two distinct types of troubled
doctors could be identified was, in these terms,
disconfirmed.
Analysis of variance. The disturbance scores
were then entered into a univariate analysis of
variance as dependent variables. Additional dependent variables were personality difficulties, a
past history of neurotic disturbance and the
handicap score. The explanatory variables were
sex, age of problem onset and type of problem
(alcohol or drugs). The following conclusions
can be drawn:
(i) The personality difficulties pathway exerts
a main effect upon age of problem onset: this
coding was significantly more frequent at
younger ages (df = 5, F-3.8,p = 0.003).
(ii) There is an interaction between sex and
age of problem onset for the disturbance score
(df = 4, F = 2.85, p = 0.027). Thus disturbance
scores showed a reduction with increasing age of
problem onset, except for an increase among
men in the 42-48 year group. The maximum
disturbance score among men was found in
those who presented at age 24 or younger, and
the maximum disturbance score among women
was found in those who presented between the
ages of 24-30.
(iii) An interaction effect was demonstrated
between age of problem onset, type of substance
problem and handicap score (df=5, F = 2.56,
p = 0.03). Those who present with a problem
over the age of 48 have a greatly increased career
handicap score. This is due to the small subgroup in this age bracket with drug problems
(w = 4), rather than those with alcohol problems.

Discussion
We wish to consider three issues. Firstly,

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Deborah Brooke et al.

whether sub-groups of doctors with substance

problems can be identified; secondly, what might
be the nature of factors that predispose to substance misuse among doctors; and thirdly, the
policy implications of our findings. There are
methodological limitations to our study. The
subjects were limited to the sample of substancemisusing doctors who presented to a
post-graduate teaching hospital over a 20-year
period. The sample is large in UK terms but the
number is still small. There is no comparison
group drawn from other occupations, or from
doctors who do not misuse substances. The data
was collected retrospectively. Nonetheless, we
have explored some hypotheses, and this is the
first time that multivariate techniques have been
used in this field. The results point to a series of
significant questions, which deserve further consideration.

The identification of sub-groups

Among alcoholics in the general population,

several authors have described a group with a
younger age of onset and a family history of
alcoholism, a more severe course and associated
psychiatric problems or personality difficulties.^'^
A sub-group may be identified within the hospital doctors, consisting of those below consultant
grade. This group is characterised by a younger
age at onset of substance problems, large numbers of substances misused, a greater proportion
misusing drugs and experiencing markedly disadvantageous effects on their careers. Those at
consultant grade have a later onset of problematic use, showing that they are not the cohort of
young, troubled doctors marched forward; they
accumulate more substance-related problems,
but their careers suffer less, except for those who
develop a drug problem in later life. The high
career handicap scores suffered by such individuals in this study were due to taking early
retirement, and it may have been that this course
was infiuenced by the perceived illegality of illicit
drug use, as much as the health needs of the
practitioner. We hypothesized that these two
clusters might emerge on principal component
analysis. However, principal component analysis
of our data did not show two separate dimensions of older and younger subjects. It yielded a
derived score of 'disturbance' for each subject.
This derived score decreased with age, except for
an increase in men in their forties. This finding

suggests a continuum of vulnerability to substance misuse problems across all age groups; the
contribution made by personality difficulties in
younger substance misusers may inflate the disturbance score in the youngest age groups, but
not sufficiently to demonstrate a specific type.
Doctors in all age groups continue to suffer
disturbance, and this data suggests that emotional problems are of major importance.

Pathways and past history: the nature of vulnerability

The genesis of an individual's substance misuse

problem cannot be reduced to a single factor and
our concept of 'pathways' serves to draw attention to premorbid individual susceptibilities. So,
for example, over half of the subjects were coded
positively for personality difficulties. This is a
high proportion with poor adult adjustment and
limited coping strategies. Furthermore, anxiety
or depression had contributed to the development of substance misuse in about one-third.
Whether anxiety and depression were experienced as a past event, or whether they were, in
retrospect, a pathway into substance misuse,
they emerge as frequent antecedents to substance misuse at all ages.
It appears paradoxical, but both a past history
of depression and of other neurotic conditions
were associated with a lower problem score, possibly because these subjects came to the
attention of helping agents before they had time
to accumulate substance-related problems. The
group with other neurotic conditions was composed of a variety of diagnoses: seven had
suffered from anxiety, five had sought help with
relationship difficulties and the remainder comprised anorexia nervosa, conduct disorder,
morbid jealousy or episodes of self-harm. This
group had a younger age of onset of problematic
substance use and some of these episodes of
psychiatric illness may have been secondary to
the developing substance problem. Not all of our
subjects were considered to have a definable
vulnerability; about one-quarter were thought to
have drifted into substance misuse.
Implications for policy

The detection and prevention of drug and alcohol misuse at work is within the remit of
occupational health services. Substance misuse

Doctors and substance misuse

by any member of an organization is damaging

and wasteful of their training; it is entirely appropriate that occupational health services prioritise
this issue. In addition to the increasing emphasis
on counselling and health promotion, occupational health has an expanding role in the
implementation of UK and EEC regulations
goveming conditions in the workplace. All of
these demands have resource implications, but
short cuts in occupational health services are
costly in the long term. The hospital doctors in
training grades show a predilection to misuse a
variety of drugs, in addition to alcohol. It is clear
that this is partly in response to personality
difficulties, but also this group are known to be
subject to a collection of stressors unique to the
first years of qualification. The connections between demoralisation and self-medication are
unclear but failing to address misery due to
organizational deficiencies sets the scene for reduced expectations and lack of motivation in the
future. Strategies have been suggested both in
the UK^'' and the US^ to improve their experiences. As a preventive measure, the issue of
self-prescribing could be addressed via postgraduate education.
About 36% of Britain's doctors are selfemployed general practitioners. They consult
their own general practitioners (often a partner
in the practice) at about one-tenth the rate of
non-general practitioner patients.' They frequently diagnose, treat and refer themselves,
sometimes inappropriately. They have access to
mood-altering drugs as a matter of routine, and
many of our subjects had attempted to alleviate
distress by misuse of self-prescribed medication.
This is facilitated by a culture within the profession that regards self-treatment as an appropriate
initial response to illness.*'' It has been suggested
that a preferential health care system for doctors
would facilitate access to independent medical
care.'"
Many subjects developed a substance misuse
problem in middle age, including one-quarter of
our number who were considered to have drifted
into substance misuse. This illustrates the need
for continuing interest by the profession in the
welfare of all its members. Concentrating on the
training grades and the psychologically vulner-

663

able would fail to reach this group. They contribute to the numbers of undiagnosed addict
doctors. Not only missed, they are also mismanaged because of lack of awareness that
confidential, expert and effective help is available.""" Wider publicity for this help would
encourage earlier entry into treatment and dispel
the aura of gloom that has imprisoned addicted
doctors by paralysing those around them.

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