A Suicide per Day Keeps the Doctors Away: Depression and Suicide During Medical Training

Suicide Among Physicians

As a profession, doctors have known for more than 150 years that we are at an increased risk for depression and suicide. It was estimated in 1977 that on average, the United States loses the equivalent of at least one medical school class to suicide each year (Sargent, et al.,1977). Although it is nearly impossible to accurately calculate the cause of death for physicians and medical interns, the number most often cited for suicide among physicians is approximately 300 – 400 physicians per year, or one doctor per day.

As a group, physicians have lower mortality from cancer and heart disease compared to same age cohorts in the general population, yet they are at a significantly higher risk of dying from suicide. After adjusting for other variables, after accidents, the most common cause of death among medical students is suicide. In spite of this knowledge, training for medical students, interns and residence is often draconian.

Twenty-four hour work shifts are the norm, as is chronic sleep deprivation and witnessing more death and suffering in one week than a non-medical professional will see in their lifetime. Other factors include lack of social or professional support, plus chronic stress to compete, and high levels of anxiety and trepidation in regard to advancement.

Undertreated Mental Health Disorders

Suicidality is complicated and multifaceted, but invariably the result of untreated or under-treated depression, acute stress disorder or other psychiatric conditions including substance use disorder. The risk of death by suicide is associated with knowledge of, and access to, lethal means. This puts doctors, interns and residents at the top of the risk list. Yet depression is a highly treatable disease and suicide can be prevented.

In the simplest epidemiological terms of agent, host and environment, physicians, particularly during their training, endure or try to survive a toxic and often hostile environment that no other occupation, other than perhaps special operations training to become a Navy Seal or Army Ranger, must go through—except that medical training is much longer.

Depression among Physicians

A survey of American surgeons revealed that although 1 in 16 had experienced depressive symptoms and suicidal ideation in the past 12 months, only 26% had sought professional help. Moreover, at least 60% of those with suicidal ideation stated they were fearful to seek help because it could affect their medical license (Shanafelt, et al. 2011). Other studies (Gold, et al, 2016) confirmed that regulatory intervention is a major obstacle for physicians in crisis or considering how to find help for their stress and depression.

The insightful work by Mata, et al, entailed a systematic search of EMBASE, ERIC, MEDLINE, and PsycINFO for data on the prevalence of depressive symptoms or diagnosed depression, assessed by structured interview or validated instrument, among medical residents between January 1963 and September 2015. The overall pooled prevalence from over 17,000 individuals revealed the prevalence of depression or depressive symptoms was 28.8% (95% CI, 25.3%-32.5%). Prevalence of depression or depressive symptoms increased per calendar year in a secondary analysis of 7 longitudinal studies, the median absolute increase in depressive symptoms from the onset of residency training was 15.8% (range, 0.3%-26.3%; relative risk, 4.5%). This provides a good indication that environmental stressors are predictive of depression and suicidality. Certainly studies to determine phenotypical factors would be of great benefit, especially for prevention efforts. Lastly, other studies indicate that as many as one third of physicians have no regular source of medical care.

In my experience and research, it is clear that as a group physicians find it difficult to share their concerns, fears and symptoms regarding their mental health, largely because they believe that doing so could jeopardize their career and their social and professional standing among their peers. This partially explains why there is such scant published accounts of physician depression.

Joshua A. Gordon, the National Institute of Mental Health director explains some of the latest research surrounding physician suicide rates in the U.S.

  • Male anesthesiologists are at highest risk. Overdose is almost always their means.
  • Many doctors kill themselves in hospitals by jumping to their death, or killing themselves in the parking ramp. We think that these individuals want to die in the place where they’ve been emotionally invested and thus, emotionally wounded.
  • Many doctors who die by suicide often appear as the happiest, most well-adjusted people on the outside. But we know that doctors are masters of disguise. Even the fun-loving docs who crack jokes and make patients smile all day may be suffering in silence.
  • Family members of doctors who have killed themselves are also at high risk of suicide. Sometimes even by the same method. In one well documented case, a star third-year medical student chose suicide by helium inhalation; her mother, died by the same method. At the mother’s funeral, her husband said, “Medical school has killed half my family.”
  • Patient deaths hurt doctors. Even when there’s no medical error, some doctors may never forgive themselves for losing a patient. Suicide is the ultimate ­self-punishment. In several cases, the death of a patient seemed to be the key factor in pushing them over the edge.
  • Malpractice suits can be devastating. Humans make mistakes. Yet when doctors make mistakes, they’re publicly shamed in court, and in media, that now lives online forever. Many continue to suffer the agony of harming someone else — unintentionally — for the rest of our lives.
  • Academic distress kills medical students’ dreams. Doctors can be shattered if they fail to gain a residency. Before his suicide, a doctor who remained unmatched to residency, wrote a letter to medical officials and government leaders calling out a system that he said ruined his career.
  • Assembly-line medicine kills doctors. Brilliant, compassionate people can’t care for complex patients in 15-minute slots. When punished or fired by administrators for “inefficiency” or “low productivity,” doctors may become suicidal. Pressure from insurance companies and government mandates crush these talented people who just want to help patients. Many doctors cite inhumane working conditions in their suicide notes.
  • In medical training, bullying, hazing and sleep deprivation increase suicide risk.Medical training is rampant with deplorable conditions that are not permitted in other industries. Sleep deprived physicians report hallucinations or have life-threatening seizures. Depression and suicide are directly related to sleep deprivation and chronic stress.
  • Blaming doctors increases suicides. Medical institutions shift blame to doctors for their emotional distress to deflect attention from unsafe working conditions. When doctors are punished with loss of residency positions or hospital privileges for occupationally-induced mental health conditions, they can become even more hopeless and desperate.
  • Most doctors who need help don’t seek it because they fear that it won’t remain confidential. Many go out of town, pay cash and use fake names to hide from state medical boards, hospitals and insurance providers. Even if confidential care were available, physicians in training have little time to access care when working 80 to 100 or more hours per week.
  • Some doctors develop on-the-job post-traumatic stress disorder. This is especially true in emergency medicine. One day, they just snap — after a failed suicide attempt, an ER doctor stated: “My decision to end it all was 100 percent work-related.”

Ask The ExpertWhy Does This Matter?

Stress, burnout, substance abuse, depression and suicidality are established but seldom discussed occupational hazards for physicians. Columbia University’s, CASA report on Addiction Medicine, revealed that these issues are more prevalent among addiction medicine professionals. The severity of illness among the patient populations and the chronic turnover of peer and professional staff in this industry create a manpower shortage that increases work demands on the physicians, which in turn increases stress and burnout and depressive states.

Among all disciplines, anesthesiologists have the highest suicide rates and also the highest prevalence of Substance Use Disorders. We have hypothesized that passive exposure may contribute to the risk. Prevention and early intervention programs for higher risk specialties is an actionable intervention that could be employed systemically throughout medical training. These prevention programs have been used among other high risk professions, most notably among law enforcement professionals and other first responders.

This is just one example of the hundreds of modifiable risk factors that could be addressed. But institutional traditions and medical cultures are slow to change. But we can ill afford to lose any more of the best and brightest among us, who want to help others, when there are numerous things we can change to decrease these deplorable outcomes.

Reference:

Mata DA, Ramos MA, et al. Prevalence of Depression and Depressive Symptoms among Resident Physicians: A Systematic Review and Meta-analysis. JAMA. 2015 Dec 8;314(22):2373-83. doi: 10.1001/jama.2015.15845.