A recent study by Tejil Mora and Gemma Purbrick, published in this month’s SA Medical Journal, uncovers an alarmingly high prevalence of depression among community service doctors, with the two experts urging support for them to be tackled as a priority by national policy-makers.
They write that globally, depression among doctors – and its consequences on health systems and the patients they treat – has become an important area of research.
Junior doctors are particularly at risk for symptoms of depression as they transition from medical school into the working medical fraternity. In South Africa, Aljuwaiser et al reported a global pooled prevalence of depressive symptoms to be 43.1% to 51.0% among trainee doctors – significantly higher than the 5% global point prevalence of depressive disorders in adults reported in the 2022 World Mental Health Report.
In an SA context, Hain et al found that 33% of community service doctors (CSDs) in KwaZulu-Natal (KZN) screened positive for depression.
The aim of this study was to investigate possible depression among junior doctors in their community service year in SA, using an electronic REDCap survey to sample the CSDs, via the South African Medical Association (SAMA) and social media platforms (Facebook CSDs in SA group and WhatsApp).
Unsuccessful attempts were made to contact the Health Professions Council of South Africa (HPCSA) to assist with distribution of the survey.
The survey investigated sociodemographic variables, the Patient Health Questionnaire-9 (PHQ-9) was used to investigate possible depression, and the final section addressed potential associated factors based on a literature review.
Burnout
The descriptive cross-sectional study took place from October to December 2022, and formed part of a larger survey investigating burnout and associated factors among CSDs in SA, using the Maslach Burnout Inventory (MBI) to measure burnout
The total population of CSDs in SA each year varied between 1 057 and 1 308 in a 15-year review by Reid et al.
All SA doctors in their community service year who had access to the survey during the study period in 2022 were invited to participate. Using a population of 1 308 CSDs and an estimated prevalence of depressive symptoms of 33%, a sample of 217 provides a confidence level of 95%, and a margin of error of 5.72%.
The mean age of participants was 27.6 (1.95); 42.9% were white and 24.9% were black. Most were from Gauteng (27.7%) and then Western Cape and Mpumalanga (13.4% each). Most were outside metropolitan areas (49.1%).
Of the 217 participants, 96.3% screened positive for depression (mild, moderate or severe) with 51.15% screening positive for severe depression.
There were various predictors of higher PHQ-9 scores in the study. They included the following, with the increase in PHQ-9 scores noted in brackets: women (2.0), illicit drug use (6.4), feeling neutral (3.2) or disagreeing that one worked outside of normal working hours (2.2), working in KZN (3.7) or North West (4.2) provinces, emotional exhaustion on the MBI (0.2), working in orthopaedics (6.6), obstetrics and gynaecology (2.8) and the National Health Laboratory Service (10.8), getting one’s first choice of placement (2.1), current financial difficulties (2.5), and accessing mental health services (psychiatrist (4.3), psychologist (6.6) and counsellor (11.7)).
Triple the rate
The prevalence rate of depressive symptoms (96.3%) is extremely concerning, being more than triple the prevalence rate of depressive symptoms among the general population in SA (25.7%) observed by Craig et al.
It is also significantly higher than the global pooled prevalence of 20.5.% of depressive symptoms among medical doctors, and the global pooled prevalence of 43.1-51.0% for depressive symptoms among trainee doctors.
Nazeema et al also found the prevalence rate of depressive symptoms to be high (53.73%) among medical doctors of varying rank at an academic hospital in Johannesburg using a cut-off score of ≥8.
The significantly higher prevalence in our study may be attributable to various factors including that most participants were not in an academic setting, ours was a national study not restricted to an urban city, and the study focused on junior doctors, known to have higher rates of depressive symptoms.
Another consideration is the validity of the PHQ-9 among medical doctors.
While various studies have validated the PHQ-9 among the general population, including in low-middle income settings, few have focused on the validation of the tool in medical doctors specifically.
The PHQ-9 items pertaining to sleep, appetite and energy may overlap with the lifestyle of the medical profession (for example, shift work, high patient loads, long working hours and a lack of set lunch breaks).
However, without a screening tool for depression specifically developed for medical doctors, the PHQ-9 remains an important indicator that is widely used and generally accepted.
From an individual perspective, this and various other studies have highlighted that women in healthcare are at risk of depression compared with their male counterparts, while less work experience and a self-perception of incompetency have also been identified as potential predictive individual factors.
Respondents from KZN and North West had higher PHQ-9 scores than other provinces. In a multi-site study in KZN by Naidu et al in 2019, a prevalence rate of 21.3% for depressive symptoms using a PHQ-9 cutoff score of ≥10 was observed.
It was postulated by Naidu et al. that provincial financial and human resource challenges may play a role, with high HIV and TB rates adding considerably to workload. The highest prevalence rates of HIV in SA are in the northwestern parts of KZN. Working in those areas contributes to the development of mental health difficulties in doctors.
Respondents who admitted to illicit drug use had higher PHQ-9 scores by 6.4 points, with physicians being particularly vulnerable. Interestingly, alcohol use was predictive of a lower PHQ-9 score (-1.6), possibly indicating that respondents were self-medicating using alcohol.
PHQ-9 scores in those who had accessed mental healthcare were significantly higher. Those who sought help from counsellors had a score 11.68 points higher, which may indicate that doctors needing treatment for depression may find it easier to access counsellors initially.
From an organisation level, poor support and recognition by peers, supervisors and hospital leadership, as well as work location, have been noted to contribute.
On a systemic level, lack of recognition by government officials and policy makers of healthcare workers’ work conditions have been noted as contributors.
The government’s treatment of CSDs in SA has long been criticised, with some labelling these doctors as “slaves of the state” coerced into employment and not being able to practise as independent practitioners without completing their community service year.
Our study noted that not getting one’s first choice of placement or being placed in certain departments (perhaps involuntarily) were possible predictors of higher PHQ-9 scores.
Further research into practical and supportive interventions for CSDs to both prevent and screen for depressive symptoms should be considered, while investigating mental health-seeking behaviour of junior doctors is another potential topic for further research.
The study is an important one as it is the largest national study investigating depression in CSDs in SA, highlighting the extent of the problem. However, some limitations include the lack of a sampling frame, which could not be obtained from the HPCSA, possible respondent bias in that those with depression would be more likely to complete the survey, and the cross-sectional nature of the study making temporal inferences impossible.
CSDs in SA are a vulnerable population and such a high prevalence of depressive symptoms this early in their careers can have detrimental effects for their futures, as well as the future of our healthcare system.
Supporting these junior doctors at an individual, organisation and structural level should be a priority.
Study details
Depressive symptoms among community service doctors in South Africa
T Morar, G Purbrick.
Published in the SA Medical Journal in June 2026
Background
Medical doctors face occupational stressors threatening their mental health, particularly junior doctors in South Africa. There is a higher prevalence of depressive symptoms among medical doctors compared with the general population. The consequences of this to health systems and the patients doctors treat is a major public health concern. In South Africa, prevalence of depressive symptoms among community service doctors servicing public sector healthcare is largely unknown.
Objectives
To determine the prevalence of possible depression, and predictive factors thereof, among doctors in their community service year in South Africa.
Methods
A national descriptive cross-sectional survey was distributed electronically between October and December 2022. The Patient Health Questionnaire 9 (PHQ-9) was used to screen for depression. Demographic, occupational and individual characteristics were included as potential predictive factors
Results
A total of 217 participants were included in the analyses. Prevalence of depressive symptoms was 96.3% (standard error 0.13, 95% confidence interval 92.87 – 98.40%). Predictors of higher scores included: women, drug use, feeling neutral or disagreeing that one worked outside normal working hours, working in KwaZulu-Natal or North West, burnout (emotional exhaustion), working in orthopaedics, obstetrics and gynaecology departments or the National Health Laboratory Service, first choice of placement, financial difficulties, and accessing mental health services. Predictors of a lower score included: perceiving sufficient resources at work, using colleagues to cope, good work-life balance, and certain departments, particularly neurosurgery.
Conclusion
There is an extremely high prevalence of depressive symptoms among community service doctors. Supporting these doctors at an individual, organisational and structural level should be a priority for national policy-makers.
T Morar, MB ChB, DMH, FCPsych (SA), MMed Psych, PG Dip HSE, MRCPsych;
G M Purbrick, MB BCh, DipPEC, MMED (Psych), FCPsych (SA)
Department of Psychiatry, Faculty of Health Sciences, University of the Witwatersrand.
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