Docs have higher rates than general population.
Kate Spade. Anthony Bourdain. Two high profile individuals who recently took their own lives.
As physicians, we frequently care for individuals who demonstrate suicidal ideations. We also care for individuals who attempt suicidal acts, such as drug ingestions and other self-harm behaviors.
But are celebrities and our patients the only ones at risk for self-harm? Sadly, no. Physicians unfortunately have very high rates of suicide and in fact, much higher than the general population. As early as 1925, suicide was recognized as more common in physicians than the general population.(1, 2) More recently, in a study of United States male physician deaths between 1984 and 1995, suicide was found to comprise a much larger proportion of deaths versus other professionals. (3)
By 2004, a meta-analysis of 25 studies found that male and female physicians are 1.41 and 2.27 times more likely to commit suicide than those in the general population.(4) Certainly, this is a major issue and as of 2018, several articles continue to evaluate this problem.(5-7) What are the possible reasons behind this and are there any ways to mitigate physician suicide risk?
Physicians and our risk factors
Clinical depression is obviously a risk factor for suicide. While the estimated lifetime prevalence of depression in physicians has been found to be approximately the same as the general population8, the actual number is likely higher due to underreporting (9). Additionally, the prevalence of depression does seem to increase as one enters medical school and graduates from residency. (9-12) While the reasons behind this are largely unknown, it is speculated that large academic and clinical workloads, sleep deprivation, isolation and burnout are underlying factors.(12, 13)
Some consider the culture of medicine to be a significant factor that contributes toward higher levels of depression and suicide in physicians. The medical culture has continued to maintain a hierarchical structure that has been known to foster bullying and abuse.(14, 15) Over time, bullying and abuse can be detrimental to one’s self-esteem and mental health. (16, 17) In addition, the medical culture also does not tend to be particularly supportive or positive.
One article mentions that medical culture tends to have a “negativity bias,”18 where the focus is solely on the negative aspects (think morbidity and mortality conference, peer review and litigation), rather than more positive circumstances, such as the life-saving interventions that physicians perform every day. It has been demonstrated that the more negative events that occur, a negativity bias can develop and predispose to depression and anxiety.(19) Finally, physicians may also suffer when a medical error occurs. This is known as the “second victim” of medical error, which can lead to severe depression and anxiety.(20) Signs and symptoms of the second victim are similar to those in acute stress disorder including numbness, detachment and depersonalization. Shame, guilt, anger and self-doubt also may be present. Re-experiencing of the event, flashbacks and sleep disturbance may also be symptoms of the second victim.(20, 21) Suicide can also result.(22)
In terms of more intrinsic risk factors for depression and anxiety, physicians tend to have personality traits that reflect compulsivity and perfectionism. While it is true that these traits foster work toward comprehensive, methodical, and conscientious patient care, they can also lead physicians to feeling persistently overwhelmed and stressed.7 Being female, single and/or childless or having significant personal life stressors can all contribute to higher risk for depression and suicide.(4, 23, 24)
Are physicians getting help?
While many physicians may be willing to get help, others may fear letting others know due to shame and/or fear of losing one’s job. Many physicians worry that confidentiality will not be respected. It is common that a physician may be concerned that peers or office staff may learn about his or her diagnosis and that it will be reported to hospital credentialing boards.(25) Physicians may also worry that they will be denied health insurance, disability policies or malpractice insurance if they acknowledge a mental health problem.(25)
Thus, physicians may unfortunately not receive the proper care they need. Physicians also tend to self-diagnose and self-medicate, which can lead to inadequate treatment.(25) Additionally, the culture of medicine does not place physician health as a priority. This is despite evidence that physicians do suffer from mood disorders and increased risks of suicide.(8) Long work hours, sleep deprivation, lack of support at work and lack of autonomy at work are further evidence that physician health remains a low priority in the medical community. All of these factors have been associated with poor mental and physical health in physicians.(26-28)
What solutions do we have?
Physician depression and suicidality continues to be a widespread topic of discussion. Proposed solutions (8,13,29, 30, 31) for hospitals, administration and/or training programs include the following:
- Non-judgmental, non-punitive open discussions and protocols that address medical errors and difficult patient cases
- Reduce competitiveness in medical training
- Prevent burnout
- Encourage support from spouse/partner, family and friends and maintaining an individual life outside of medicine
- Initiate targeted educational campaigns
- Having leadership, including program directors, designated institutional officers, faculty and others who act as gatekeepers and encourage mental health and wellness among residents and medical students. This also includes devoting didactic time to educating students and residents about depression and suicidality in physicians.
- Ensure confidentiality
- Address any concerns regarding any potential ramifications of receiving mental health care on job security, regional licensure, malpractice, insurance and disability coverage.
- Consider screening for depression in trainees using validated scales
The above are simply suggestions for diagnosing and addressing this significant problem. All physicians should continue their own self-care, but also watch out for signs and symptoms in fellow colleagues. Anyone can be susceptible to depression.
Given our stressful work schedules and other reasons mentioned previously, physician self-care and camaraderie are lacking. Loneliness and lack of social support are highly correlated with depression (32-33) and physicians are not immune. Those physicians who work locums and/or are not a part of a large hospital, private or academic group are more at risk for loneliness and lack of support. These physicians should do their best to reach out and obtain support from families, friends and possibly other outside physicians.
We all should start discussing these concerning issues more, perhaps with peer support groups in non-judgmental, stress free environments. We need physicians to continue to help others, but if we are not healthy, then we cannot help our patients either.