*3.1. Baseline Characteristics and Mental Health Experiences and Attitudes*

The study included a total of 483 FPs (398 females and 85 males), from which 95 (19.7%) were family medicine residents. The median age of the population was 47.0 (33.0–58.0) years, while data were collected mostly from urban areas of the country (N = 329, 68.1%). The highest percentage of the population disclosed a number of patients between 1500 and 2000 (N = 199, 41.2%), while 125 (25.9%) subjects were recovered from COVID-19 to date (Table 1).

Self-assessment analysis revealed that a total of 157 (32.5%) FPs disclosed confirmed diagnosis or confident subjective perception of MHD, from which 77 (49.0%) were newly diagnosed from the start of the COVID-19 pandemic emergence. Furthermore, when compared to the population without MHD, FPs with a positive MHD history have a significantly higher percentage of population with positive family MHD experience (53.5 vs. 23.5%, *p* < 0.001), as well as those with increased personal risk of COVID-19 adverse outcomes (47.1 vs. 33.4%, *p* = 0.004). Detailed information regarding baseline characteristics according to MHD history can be seen in Table 1.

Further analysis showed that the majority of the population with MHD history (N = 108, 68.7%) chose to use some form of help, including medications, psychotherapies or psychiatrist consultations. Furthermore, experiences from MHD positive FPs significantly differed from MHD negative population attitudes, in terms of higher medication use (60.5 vs. 46.3%, *p* = 0.003), and a lower percentage of consultations with psychiatrist (29.9 vs. 44.2 %, *p* = 0.003). In addition, the highest percentage of the total investigated population (51.8%) disclosed trying to solve the problem alone (Table 2). Lastly, analysis of the items perceived as best for acute mental health management showed that the majority of FPs (64.6%) perceive a long vacation as something best currently needed, without significant differences according to the MHD history (*p* = 0.272) (Table 2). Subgroup analysis of the experiences on mental health management of FPs with MHD history according to MHD

diagnostics (confirmed diagnosis vs. self-diagnosis) can be seen in Table S1, and according to the time of diagnosis (before COVID-19 pandemic vs. after COVID-19 pandemic) in Table S2.


**Table 1.** Baseline characteristics of study population according to mental health disorder medical history.

Data are presented as N (%) or median (interquartile range); MHD—mental health disorder; COVID-19 coronavirus disease 2019; \* chi-square test; ‡ Mann–Whitney U test; † confirmed MHD diagnosis or positive subjective perception; § increased self-assessed risk from COVID-19 adverse outcomes.

**Table 2.** Experiences and attitudes on mental health management according to MHD history.


Data are presented as N (%); MHD: mental health disorder; \* chi-square test or Fisher's exact test; † confirmed MHD diagnosis or positive subjective perception; ‡ population with MHD history disclosed experiences, while population without MHD history disclosed attitudes.

When asked about obstacles to seeking professional help for MHD, the most common answer overall was "no obstacles" (N = 273, 56.5%), with a significantly higher percentage in population without MHD history (62.0 vs. 45.2%, *p* < 0.001) in comparison to MHD negative FPs. Other chosen items were "no time" (N = 75, 15.5%), with significantly higher prevalence in the MHD positive population (22.9 vs. 12.0%, *p* = 0.002) and "fear of stigmatization" (N = 62, 12.8%), without significant differences between the groups (*p* = 0.964) (Figure 1).

**Figure 1.** Experiences and attitudes regarding obstacles in seeking help for mental health disturbance according to the history of mental health disorders §; MHD—mental health disorder; \* chi-square test, *p* < 0.001; ‡ chi-square test, *p* = 0.002; † confirmed MHD diagnosis or positive subjective perception, § population with MHD history disclosed experiences, while population without MHD history disclosed attitudes.

## *3.2. Stress-Coping Mechanisms and Current Mental Health Well-Being*

Analysis of stress-coping mechanisms revealed that the most commonly used ones were "spending time with family" (N = 234, 48.4%), and "working out" (N = 224, 46.4%), while according to MHD history, both of them were used significantly more in MHD negative population (53.1 vs. 38.9%, *p* = 0.003 and 49.7 vs. 39.5%, *p* = 0.035, respectively). Furthermore, FPs with MHD history used significantly more mechanisms such as "drinking alcoholic drinks" (10.8 vs. 4.9%, *p* = 0.016), "watching television" (43.9 vs. 34.0%, *p* = 0.035) and "eating food" (36.3 vs. 19.9%, *p* < 0.001). Detailed information on used stress-coping mechanisms according to MHD history can be found in Table 3.

In this study, multiple questionnaires were used in order to acquire information on FPs' mental health well-being. Analyses of the scales according to MHD history have shown that total scores that estimated resilience (BRS and BRCS), satisfaction with life and job (SWLS and WCW-JSS, respectively), and healthy lifestyle (FLQ) were higher in the MHD negative population, with robust significance levels (*p* < 0.001). Moreover, OBI scores that assessed burnout symptoms of exhaustion and disengagement, as well as cumulative score, were significantly lower in the same population of the MHD negative FPs, when compared to those with MHD history (*p* < 0.001) (Table 4). Subgroup analysis of mental health wellbeing questionnaire scores of FPs with MHD history according to MHD diagnostics can be seen in Table S1, and according to time of diagnosis in Table S2.


**Table 3.** Coping mechanisms for stress relief according to the history of mental health disorders in study population (N = 483).

Data are presented as N (%), MHD- mental health disorder, \* chi-square test; † confirmed MHD diagnosis or positive subjective perception.

**Table 4.** Total scores of used questionnaires investigating burnout levels, resilience, satisfaction with life and job, and healthy lifestyle in family physicians according to the history of mental health disorders.


Data are presented as median (interquartile range); MHD—mental health disorder; BRCS—Brief Resilient Coping Scale; BRS—Brief Resilience Scale; FLQ—Fantastic Lifestyle Questionnaire; OBI—Oldenburg Burnout Inventory; SWLS—Satisfaction with Life Scale; WCW-JSS—Warr-Cook-Wall Job Satisfaction Scale; \* Mann–Whitney U test; † confirmed MHD diagnosis or positive subjective perception.

Further analysis revealed that BRS and FLQ scores showed significant positive correlation between them, as well as with the SWLS and WCW-JSS score (*p* < 0.001), while significant negative correlation was found with age, work experience and OBI scores (*p* < 0.001). In addition, a cumulative OBI score showed significant positive correlation with age (*p* = 0.038) and work experience (*p* = 0.019), while robust negative correlation was presented with SWLS and WCW-JSS scores (*p* < 0.001) (Table S3).

Statistical analyses of total OBI score when divided into tertile groups have revealed that the third tertile group had significantly more women (*p* = 0.006) and FPs with increased risk of COVID-19 adverse outcomes (*p* < 0.001) when compared to second and first tertile groups, as well as significantly less FPs with satisfied/highly satisfied life (29.9 vs. 50.3 vs. 77.6%, *p* < 0.001). In addition, analysis of selected coping mechanisms according to burnout tertile groups showed that the third tertile group had significantly more FPs that used mechanisms such as "eating food" (29.9 vs. 29.0 vs. 17.8%, *p* = 0.018) and "watching television" (44.2 vs. 38.1 vs. 30.5%, *p* = 0.036), while it had significantly less of those who chose item "spending time with family" (37.0 vs. 48.4 vs. 58.6%, *p* < 0.001) (Table 5).


**Table 5.** OBI total score tertiles according to various relevant parameters in study population.

Data are presented as N (%) and median (IQR) where appropriate; COVID-19: coronavirus disease 2019; MHD: mental health disorder; \* chi-square test; ‡ Kruskall–Wallis test; † confirmed MHD diagnosis or positive subjective perception; § increased self-assessed risk from COVID-19 adverse outcomes.

Further analysis showed that the third OBI tertile group, in comparison with the other two, had significantly more participants with low resilience, according to the BRS scale (53.9 vs. 31.6 vs. 6.9%, *p* < 0.001) (Figure 2A), as well as significantly more of them in the fair lifestyle category (37.7 vs. 11.0 vs. 0.0%, *p* < 0.001) (Figure 2B).

**Figure 2.** Resilience categories according to BRS scale (**A**) and healthy lifestyle categories according to FLQ scale (**B**) in OBI total score tertiles in study population; BRS—Brief Resilience Scale; FLQ— Fantastic Lifestyle Questionnaire; OBI—Oldenburg Burnout Inventory; \* chi-square test.

Finally, the multiple linear regression model showed that the FLQ score (β = 0.03, SE = 0.003, *t*-value = 10.4, *p* < 0.001) was in significant association with the BRS score, set as dependent variable, when computed alongside baseline characteristics and SWLS score. Furthermore, a similar linear regression model that investigated independent predictors for

burnout levels, with OBI cumulative score set as dependent variable, determined the FLQ score (β= −0.35, SE = 0.03, *t*-value= −11.4, *p* < 0.001), and BRS score (β= −2.12, SE = 0.44, *t*-value= −4.87, *p* < 0.001) to be the significant correlates.

Additionally, multivariate logistic regression analysis was performed in order to determine independent predictors of positive MHD history status. Model analysis showed BRS score (OR = 0.387, 95% CI = 0.261–0.574, *p* < 0.001) and FLQ score (OR = 0.970, 95% CI = 0.945–0.995, *p* = 0.021) to be significant predictors of MHDs in our population (Table S4).

#### **4. Discussion**

In this survey study, we investigated the prevalence of self-reported MHD history in the nation-wide population sample of FPs, as well as their attitudes and experiences toward MHDs. Additionally, we further addressed FPs' well-being through assessment of burnout symptoms, job and life satisfaction, with analyzed connections to their resilience and healthy lifestyle following.

Results have shown than nearly one-third of the investigated population expressed a positive MHD history, from which 28% FPs had confirmed diagnosis. Furthermore, nearly 50% of MHD positive FPs developed these disturbances in the COVID-19 pandemic era. Moreover, the MHD positive group had a significantly larger percentage of FPs with an increased self-assessed risk of COVID-19 consequences when compared to the group without MHD history, that further attributes to the deleterious impact of the pandemic on mental health. Similar results were shown in a large cohort study of Australian frontline health workers, where 30% of the investigated population expressed a history of mental illness [61]. It can be argued that these results are in line with studies that confirmed the physician and FP population as susceptible to mental health disorders, especially in times of the COVID-19 pandemic [17–19]. However, according to the previous work on the similar FP population, there is a gap between percentages of anxiety, depression and PTSD symptoms based on validated questionnaires and the current self-report that expressed lower MHD prevalence [18]. This could be possible due to the different time period when the study has taken place, as well as possible self-perceived underestimation of low/moderate MHD symptoms that FPs could be used to and ignore.

Our results have shown that nearly 70% of FPs with MHD history actually had some form of professional help (medication, consultations, psychotherapies). This is a substantially larger percentage in comparison to the results of the studies conducted on medical workers in other countries during the pandemic [25,61,62]. These differences could be present due to several factors, including different cultural background, variability in formulated questions regarding help-seeking behavior, more recent timing in the pandemic in our study, differences in public health strategies, as well as the different population of healthcare workers. On the other hand, Muhamad Ramzi et al. conducted a study on a large cohort of physicians where obtained medical help for depression was around 60%, which is a similar result as in our study [63]. Although the current results imply that a favorable percentage of FPs actually took some form of mental health treatment, a large number of FPs still did not seek any kind of help. Additionally, the given percentage should be taken with caution due to the possibility of frequent self-medication in the physician population [64]. There is an interesting discrepancy between the attitudes in what MHD negative FPs think they would do if confronted with a disorder, and the actual history of actions of the MHD positive population. Taking medication was a more frequent answer in the MHD positive population, while consultation with a psychiatrist was a more common answer in the MHD negative population. It is possible that consultations are something that FPs would prefer to do in theory; however, due to the lack of available time, work overload or stigmatization, in the end, they put more effort into quicker solutions like medication.

Further analyses addressed attitudes on obstacles FPs face when seeking help for experienced MHD. The most commonly chosen answers were "no obstacles" and "no time"; however, again, there were significant differences on these attitudes according to the MHD history. FPs with a positive history had a lower answer rate on the "no obstacles" item, and a higher rate on the "no time" item. This is in line with the results of several other studies in which healthcare workers enclosed a lack of time as one of the most prominent reasons for not seeking mental health help [22,25]. These results are putting even more emphasis on the observation that FPs could change their attitudes when actually becoming unwell, and that they are indeed overwhelmed with work when they cannot find enough time to properly manage their mental health. These hypotheses are additionally supported with finding that most of the FPs believe a long vacation is the best thing to acutely tackle mental health state, regardless of MHD history.

Furthermore, the "fear of stigmatization" item was overall chosen in a somewhat lower percentage than expected (12.8%), when compared to other literature sources that addressed it as a major obstacle in seeking appropriate care [8,22,65]. Even though a systematic review by Clement et al., dating before the pandemic, associated a small to moderate cumulative negative effect of mental health stigma on help-seeking, it involved studies consisting of mixed population models [2]. Furthermore, it is possible that raising awareness about MHD in the pandemic time, encouraging the fight against stigmatization and severely deteriorating mental health well-being is facilitating favorable behaviors in the FP population, and reducing the effect of stigma. Nevertheless, mental health stigma still presents an important treatment obstacle in the physician population, and in these challenging times, it has never been more important to further raise awareness of mental health disturbances and to promote proper help seeking behaviors.

In order to assess the type of mechanisms by which FPs cope with daily stress, we offered them to choose from 11 different items, with the possible selection of multiple answers. Results have shown that the most commonly chosen mechanisms were working out (47%) and spending time with family (48%), which both can be considered as adaptive, positive coping mechanisms according to the available literature [40–42,66]. Moreover, these mechanisms were more represented in the group with a negative MHD history, and associated with lower burnout scores, which further emphasizes their commendatory, adaptive features. However, eating, watching television and drinking alcoholic drinks were moderately chosen mechanisms that were connected with a positive MHD history. Moreover, eating, watching television and smoking were represented more in higher burnout score groups. Studies have shown that the pandemic has had a negative effect on disordered eating behavior that could further be connected to increased psychological distress and job stress, which is in line with our observations [67]. When further comparing these results to other available similar studies, it can be observed that physical exercise is indeed one of most commonly used coping mechanisms in the healthcare population, while Smallwood et al. problematized increased alcohol use, which was connected to the history of poor mental health [38,61]. In addition, Wang et al. showed on a sample of Chinese physicians that those who had high perceived stress adopted more negative coping styles, which further led to higher levels of psychological distress [68]. According to all available information, it can be assumed that there is probable association between endured stress, MHDs and maladaptive coping skills. Healthy, positive coping mechanisms should be further promoted in the FP population in order to manage stress and possible MHD development more effectively [69].

Comprehensive evaluation of FPs' well-being with validated scales revealed moderate resilience, satisfaction with life and healthy lifestyle characteristics. Further analysis showed that the group with positive MHD history had lower scores on resilience, healthy lifestyle and satisfaction with life and work, while burnout scores were higher. Furthermore, correlation analysis determined robust positive association between life and work satisfaction, healthy lifestyle and resilience. Moreover, healthy lifestyle following retained a significant connection with resilience after adjustment in the multiple regression model. On the contrary, the burnout score had a clear negative association with all of the other questionnaire scores, including resilience and healthy lifestyle, which was further confirmed in the group analysis and regression model.

When comparing acquired results to other studies that investigated effects of resilience on physicians' burnout levels, similar associations were shown. In a study by Buck et al. conducted on family medicine residents and faculty members, regression models confirmed negative associations between depersonalization and emotional exhaustion with resilience, while corresponding results were shown in Australian general practice registrars, as well as the nurse population [33,70,71]. Similar conclusions were shown in the aforementioned studies despite the fact that burnout levels were measured via different scales. Considering the beneficial effects and importance of resilience, as well as the possibility of training it as an acquired skill [29], it is of utmost importance to learn more regarding factors that are positively influencing it. Moreover, literature has shown that physicians with higher resilience provide better quality of care for their patients, as well as reducing overall healthcare costs [72]. Hence, workplace intervention programs on healthcare workers have been described in the literature with some favorable findings; however, evidence is very limited and there is a need for more high-quality long-term studies [73,74].

It is interesting to notice healthy lifestyle as a factor between resilience and burnout, with significant connections to both. These results are in line with conclusions from recent investigations, which emphasized intensive healthy lifestyle as an important tool in burnout management and prevention, while it could be also seen as one of the fundamentals of resilience as a concept [28,31,34]. Our results further promote the idea of healthy lifestyle and resilience as key factors that could be used as a significant defense against work burnout in FP population. However, they could be strongly beneficial for overall mental health wellbeing as well, with results confirming both of them as significant independent predictors of MHD in a logistic regression model. It could be possible that individuals who demonstrate low resilience and live an unhealthy life are more susceptible in developing MHD; hence, these skills should be facilitated and worked on both personal and organizational levels. On the other hand, this may also be a two-way street, as FPs with MHDs may adopt an unhealthy lifestyle as a consequence of the mental disorder itself.

Several limitations of this study should be emphasized. With the cross-sectional investigation structure, causality between the acquired results cannot be assumed, while positive history of MHD in a family can be considered as a confounding factor. Furthermore, the history of MHD was based on a self-report by the investigated population, and not confirmed through official medical history records. In addition, specific medical diagnoses were not obtained and considered in the final analyses. Moreover, attitudes regarding specific mental health characteristics could be answered differently due to shame or perceived stigma. Hence, the number of the FPs with positive MHD history and results on MHD attitudes could be misinterpreted. However, as FPs are educated in recognizing relevant MHD symptoms and diseases, and with the anonymity guaranteed, it is safe to assume that answers were truthful and correct. Finally, much other collected information was based on a self-report as well, including the increased risk of COVID-19 adverse outcomes, practice localization and number of patients in practice, although we assume that FPs have enough knowledge to correctly answer these queries.

#### **5. Conclusions**

In conclusion, this study has shown that a relevant percentage of FPs experienced some form of mental health disturbances in their professional history, and that mental health severely deteriorated in the recent times of the COVID-19 pandemic. In addition, it is important to have in mind that a significant number of FPs still have obstacles that are preventing them from seeking adequate professional help. With the heavy burden they daily carry in the workplace, there is a strong need to continue raising awareness regarding MHD in this population, to encourage early help-seeking behavior, and to fight against stigmatization.

Furthermore, it is safe to assume that the FPs' comprehensive well-being and a possibility of developing MHD is connected to each distinctive feature assessed in the present study. Hence, promotion of positive stress-coping abilities, as well as introduction and

education regarding resilience and healthy lifestyle following should further be encouraged and investigated in order to improve overall health and to alleviate FPs from severe psychological distress. Finally, it is safe to assume that promotion of those characteristics can be expanded not only in the FP population, but to every patient in the clinical practice that is suffering from high work-related stress.

**Supplementary Materials:** The following are available online at https://www.mdpi.com/article/ 10.3390/jcm11020438/s1, Table S1: Experiences on mental health management and mental health well-being questionnaire scores according to diagnostics of MHD in a group of participants with positive MHD history (N = 157), Table S2: Experiences on mental health management and mental health well-being questionnaire scores according to time of diagnosis in a group of participants with positive MHD history (N = 157), Table S3: Correlation of resilience, burnout and healthy lifestyle questionnaire scores with other relevant parameters in the total study population (N = 483), Table S4: Multivariate logistic regression analysis of independent predictors for positive mental health disorder history status.

**Author Contributions:** Conceptualization, T.V., M.V. and M.T.; methodology, T.V., J.B., D.M. and S.Z.F.; software, M.V., D.R. and M.K.; validation, T.V., S.Z.F. and M.R.; formal analysis, T.V., D.R. and M.T.; investigation, T.V., S.Z.F., M.T. and M.R.; resources, T.V., J.B. and M.T.; data curation, T.V. and S.Z.F.; writing—original draft preparation, T.V. and M.V.; writing—review and editing, T.V., M.K., M.T., J.B. and D.M.; visualization, T.V.; supervision, M.T. and M.R.; project administration, T.V. and M.T.; funding acquisition, T.V., M.T. and J.B. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding.

**Institutional Review Board Statement:** The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Ethics Committee of University of Split School of Medicine (protocol code 2181-198-03-04-21-0027, 31 March 2021) and Ethics Committee of Health Centre of the Split-Dalmatia County (protocol code 2181-149/01-21/01, 18 March 2021).

**Informed Consent Statement:** Informed consent was obtained from all subjects involved in the study. Investigation was based on anonymous online survey, with explanations posted in accompanying mail and introduction section of the survey. All potential questions could be asked. Submitted response was considered as obtained informed consent, as it was stated to the participants as well.

**Data Availability Statement:** The data presented in this study are available on request from the corresponding author. The data are not publicly available due to ethical restrictions.

**Conflicts of Interest:** The authors declare no conflict of interest.

### **References**

