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.
- Rose KD, Rosow I. Physicians who kill themselves. Arch Gen Psychiatry. 1973;29(6):800-5.
- Emerson H, Hughes HE. Death rates of male white physicians in the United States, by age and cause. Am J Public Health. 1926;16(11):1088-93.
- Frank E, Biola H, Burnett CA. Mortality rates and causes among US physicians. Am J Prev Med 2000;19(3):155-9
- Schernhammer ES, Colditz GA. Suicide rates among physicians: a quantitative and gender assessment (meta-analysis). Am J Psychiatry 2004;161(12):2295-302.
- Hoffman, M and Kunzmann K. Suffering in Silence: The Scourge of Physician Suicide. MD Magazine, Feb 8, 2018. Web. Accessed June 08, 2018. <http://www.mdmag.com/medical-news/suffering-in-silence-the-scourge-of-physician-suicide>
6. Anderson P. Doctors’ Suicide Rate Highest of Any Profession. WebMD, May 8, 2018. Web. Accessed June 08, 2018. <https://www.webmd.com/mental-health/news/20180508/doctors-suicide-rate-highest-of-any-profession#1>
- Brooks E, Gendel MH, Early SR, et al. When doctors struggle: current stressors and evaluation recommendations for physicians contemplating suicide. Arch Suicide Res 2018 Jan 4:1-0.
- Center C, Davis M, Detre T, et al. Confronting depression and suicide in physicians: a consensus statement. JAMA 2003; 289(23):3161-6.
- Bright RP, Krahn L. Depression and suicide among physicians. Curr Psychiatr 2011;10(4):16-7.
- Sen S, Kranzler HR, Krystal JH, et al. A prospective cohort study investigating factors associated with depression during medical internship. Arch Gen Psychiatry 2010;67(6):557-65.
- Rosal MC, Ockene IS, Ockene JK, et al. A longitudinal study of students’ depression at one medical school. Acad Med 1997;72(6):542-6.
- Dyrbye LN, Thomas MR, Shanafelt TD. Systematic review of depression, anxiety, and other indicators of psychological distress among US and Canadian medical students. Acad Med 2006;81(4):354-73.
- Goldman ML, Shah RN, Bernstein CA. Depression and suicide among physician trainees: recommendations for a national response. JAMA psychiatry 2015;72(5):411-2.
- Quine L. Workplace bullying in junior doctors: questionnaire survey. BMJ 2002;324(7342):878-9.
- Coverdale JH, Balon R, Roberts LW. Mistreatment of trainees: verbal abuse and other bullying behaviors. Acad Psychiatry 2009; 33 (4): 269-73.
- Schuchert MK. The relationship between verbal abuse of medical students and their confidence in their clinical abilities. Acad Med 1998;73(8):907-9.
- Verkuil B, Atasayi S, Molendijk ML. Workplace bullying and mental health: a meta-analysis on cross-sectional and longitudinal data. PloS one. 2015;10(8):e0135225.
- Haizlip J, May N, Schorling J, et al. Perspective: the negativity bias, medical education, and the culture of academic medicine: why culture change is hard. Acad Med 2012; 87(9):1205-9.
- Williams LM, Gatt JM, Schofield PR, et al. ‘Negativity bias’ in risk for depression and anxiety: Brain–body fear circuitry correlates, 5-HTT-LPR and early life stress. Neuroimage 2009;47(3):804-14.
- Wu, Albert W., and Steckelberg RC. Medical error, incident investigation and the second victim: doing better but feeling worse?; 2012: bmjqs-2011.
- Schwappach DL, Boluarte TA. The emotional impact of medical error involvement on physicians: a call for leadership and organisational accountability. Swiss Med Wkly 2009;139(1):9.
- Gazoni FM, Amato PE, Malik ZM, et al. The impact of perioperative catastrophes on anesthesiologists: results of a national survey. Anesth Analg 2012;114(3):596-603.
- Firth-Cozens J. Individual and organizational predictors of depression in general practitioners. Br J Gen Pract 1998;48(435):1647-51.
- Monroe SM, Slavich GM, Gotlib IH. Life stress and family history for depression: The moderating role of past depressive episodes. Journal of psychiatric research 2014;49:90-5.
- Caiati ME. Depression and suicide among physicians. News Colorado Phys Health Program. 2006;5(1).
- Fridner A, Belkić K, Minucci D, et al. Work environment and recent suicidal thoughts among male university hospital physicians in Sweden and Italy: the health and organization among university hospital physicians in Europe (HOUPE) study. Gend Med 2011;8(4):269-79.
- Williams ES, Konrad TR, Scheckler WE, et al. Understanding physicians: Intentions to withdraw from practice: The role of job satisfaction, job stress, mental and physical health. Adv Health Care Manag 2001: 243-262.
- Kalmbach DA, Arnedt JT, Song PX, et al. Sleep Disturbance and Short Sleep as Risk Factors for Depression and Perceived Medical Errors in First-Year Residents. Sleep 2017 ;40 (3).
- Christensen JF, Levinson W, Dunn PM. The heart of darkness: the impact of perceived mistakes on physicians. J Gen Intern Med 1992;7:424-31.
- Shanafelt TD. Enhancing meaning in work: a prescription for preventing physician burnout and promoting patient-centered care. JAMA 2009;302(12):1338-40.
- Weiner EL, Swain GR, Gottlieb M. Predictors of psychological well-being among physicians. Fam Syst Health 1998;16(4):419.
- Jaremka LM, Andridge RR, Fagundes CP, et al. Pain, depression, and fatigue: loneliness as a longitudinal risk factor. Health Psychol 2014 Sep;33(9):948.
- Ouellet R, Joshi P. Loneliness in relation to depression and self-esteem. Psychol Rep 1986; 58(3):821-2.