Like many others, I was distressed by the story of two resident physicians who died…
About 40,000 people in the U.S. kill themselves each year, and about 3 or 4 hundred of them are physicians. That’s about two medical school classes per year. Estimates of the relative risk of suicide in physicians compared to the general population range from 1.1 to 3.4 in male doctors and from 2.5 to almost 6 for female physicians. That is, suicide rates are about 70% higher for men and up to 400% higher for women who are physicians. This is surprising: those in high-status occupations like medicine tend to have lower suicide risk rates compared to others. But in a systematic review of 6 studies, comparing physicians to other professionals, rates of suicide in physicians remained elevated, 1.5 to 3.8 in males and 3.7 to 4.5 in females. Moreover, physicians have lower mortality rates from all causes except suicide. In a study by Torre et al., standardized mortality ratios for physicians compared to the general population show physicians are at a lower risk of death from cardiovascular disease, stroke, cancer, and respiratory diseases; but their risk of death by suicide is higher.
Recently, several physician-bloggers have been talking about physician suicide, as well as the question of the relationship between work dissatisfaction and physician suicide. But sometimes conversations like this can be polarizing or shrill. Sober attempts to discuss suicide are often undone by suicide’s inherent melodrama. We can all feel exhausted or overwhelmed by work, but most of us do not ever contemplate killing ourselves. Suicide is abrupt, unexpected, and final. As a result, it is difficult to process and comprehend. We all have felt distress, but most of us – living outside others’ subjective experience, as we do — can find it hard to understand the total blackness, pessimism, and hopelessness that the suicidal person feels. Most of us also find it difficult to imagine how a person could abandon a spouse, children, friends, patients, and colleagues in favor of self-annihilation. In these ways, suicide can feel extremely experience-distant. And, committing suicide can seem not only selfish but also weak – it can look like giving up – even though we understand intellectually that willpower does not cure depression. Suicide can elicit strong feelings of anger, worry, helplessness, or guilt, and it may therefore be easy to avoid thinking about it.
As far as we know, the risk factors for physician suicide are not different from the risk factors for other suicides: the presence of a major mood disorder, the use of substances, recent losses such as divorce or death of a loved one. Given that suicide rates are higher in physicians, are these risk factors more prevalent in physicians? Generally, no. Rates of depression in practicing physicians are similar to the general population. About 20% of female physicians and about 13% of male physicians report a history of depression, comparable to the general population. Rates of substance abuse are comparable or slightly higher than the general population.
One risk factor that is obviously elevated in physicians: access to means (and knowledge) to commit suicide. Many studies of several types suggest that when individuals’ access to lethal means increases, rates of suicide also increase. Physicians are 11 times as likely as others to die by overdose, perhaps because physicians understand and can access lethal doses of pills. Some have hypothesized that the gender disparity in suicide rates among physicians (i.e., that female physicians’ suicide rates are elevated more than male physicians’) may be attributable to women physicians’ access to lethal means. Since women attempt suicide more often than men, it may be that their rates of completed suicide rise disproportionately when lethal means are available.
But access to means is not a full explanation for elevated physician suicide. Suicidal ideation – not suicide attempts — appears to be unusually common in physicians. In a survey of over 7000 physicians and in a study of surgeons, about 6% reported recent suicidal ideation; this rate is about three times higher than in the general population. Suicidal attempts, on the other hand, may be less common among physicians compared to the general population. One study, using data from the Women Physicians’ Health Study, reported a lifetime history of suicide attempts of only 1.5% in women physicians compared to about 4% among women in the general population. Parsing these findings, though, is a bit presumptuous. Studies of physician suicide are not numerous, and almost all of them are based on self-report data. Self-report data have substantial limitations in the assessment of sensitive topics like suicidal ideation, depression, and suicide attempts.
That is, these data leave room for speculation. A study that looked at data from the U.S. National Violent Death Reporting System compared 203 physician suicide victims with non-physician suicide victims. The circumstances of physician suicide were, “substantially different from that of non-physician suicide.” Specifically, physician suicide victims were more likely to have had a recent job problem, less likely to have experienced a recent death, and less likely to have been taking an antidepressant. Overall, work-related distress (e.g., bereavement, burnout, second-victim experiences) appears likely to play a larger role in physician suicide than it might in others.
Another hypothesis: rates of suicide among physicians may be elevated not only because physicians have access to lethal means but also because they have developed the courage to use them. One could imagine that the routinization of intervention and physical intrusion that characterize physicians’ workaday activities inculcate a familiarity with the means of hastening death. This is obviously the precise opposite of our usual conceptualization of these interventions and intrusions – they are done to fight off death – but one could still wonder about the impact of physicians’ interventionist practices on those who are contemplating suicide.
In short, the picture of physician suicide is indistinct but some sharp outlines provide critical hints. More colleagues than we would like are at risk, and signs of depression or substance abuse need to be taken very seriously. Undoubtedly, the high rate of physician suicide reflects the fact that physicians are reluctant to seek mental health care when distressed. Despite their ability to care compassionately for others, physicians feel shame and stigma when in need themselves. They tend to want to go it alone. Yet physicians are in great trouble when they are unable to share their suffering with others and reluctant to lean on them for help.
Thank you to Arielle Lasky for research assistance
1. See the CDC’s webpage for statistics: http://www.cdc.gov/violenceprevention/suicide/statistics/reporting_system.html
2. Agerbo et al., Psychol Med, 2007; Lampert, Bourque & Kraus, Suic Life Thr Behav, 1984.
3. Lindeman et al., Brit Jo Psych, 1996.
4. Torre et al., Suic Life Thr Behav, 2005.
6. Two excellent accounts of this difficult subject are Edwin Shneidman’s Autopsy of a Suicidal Mind and Kay Redfield Jamison’s Night Falls Fast.
7. Robinson, Dep & Anxiety, 2003; Frank & Dingle, Am J Psychiatry, 1999.
8. Boone, Arch Int Med, 2012; Shanafelt et al., Ann Surg, 2011.
9. Frank & Dingle, Am J Psychiatry, 1999.
10. Gold, Sen & Schwenk, Gen Hosp Psych, 2012.