You are in: eMedicine Specialties > Emergency Medicine > PSYCHOSOCIAL Physician SuicideArticle Last Updated: Jul 10, 2008AUTHOR AND EDITOR INFORMATIONSection 1 of 7
  Author: Louise B Andrew, MD, JD, Medical-Legal, Risk Management and Trial Consultant, Litigation Stress Counselor Louise B Andrew is a member of the following medical societies: American Association of Women Emergency Physicians, American College of Emergency Physicians, and American Medical Association Editors: Dana A Stearns, MD, Assistant Director of Undergraduate Education, Department of Emergency Medicine, Massachusetts General Hospital; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Robert Harwood, MD, MPH, FACEP, FAAEM, Program Director, Department of Emergency Medicine, Advocate Christ Medical Center; Assistant Professor, Department of Emergency Medicine, University of Illinois at Chicago College of Medicine; John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center; Barry E Brenner, MD, PhD, FACEP, Program Director, Professor, Department of Emergency Medicine, Professor, Internal Medicine, University Hospitals, Case Western Reserve School of Medicine Author and Editor Disclosure Synonyms and related keywords: physician suicide, doctor suicide, medical student suicide, depressive illness, mood disorder, suicidal, suicidality, suicide ideation, suicide attempt, suicide attempts, self-destructive acts, self-murder, suicide gesture, major depressive disorder, MDD, bipolar affective disorder, BPD, unipolar depression, unipolar affective disorder, alcoholism, substance abuse, myocardial infarction risk, self treatment, VIP syndrome, physician health programs, medical licensure boards, medical license, licensure restriction, insurance discrimination, liability insurance denial, disability insurance denial, employment discrimination, litigation stress, malpractice associated stress, medical malpractice stress, malpractice stress syndrome, frivolous malpractice litigation, unethical expert witness, dishonest expert testimony, medical regulatory system, American Foundation for Suicide Prevention, Struggling in Silence, Physicians Who Kill Themselves INTRODUCTIONSection 2 of 7
  On average, the Sadly, physicians globally have a lower mortality risk from cancer and heart disease relative to the general population, presumably relating to self-care and early diagnosis; however, physicians have a significantly higher risk of dying from suicide. Depression is a leading risk factor for myocardial infarction in male physicians. Although, as a profession, physicians seem to have heeded their own advice about avoiding smoking and other common risk factors for early mortality, they are decidedly reluctant to address a significant risk of both morbidity and mortality that disproportionately affects them. In all populations, suicide is usually the result of untreated or inadequately treated depression coupled with knowledge and access to lethal means. Depression is at least as common in the medical profession as in the general population, affecting an estimated 12% of males and 18% of females. Depression is even more common in medical students and residents, with 15-30% screening positive for depressive symptoms. Self-reporting likely underestimates the prevalence of the disease in both populations. Perhaps due in part to knowledge of and ready access to lethal means, completed suicide is far more prevalent among physicians than the public, with the most reliable estimates ranging from 1.4-2.3 times the rate in the general population. More alarming is that, after accidents, suicide is the most common cause of death among medical students. Although female physicians attempt suicide far less often than their counterparts in the general population, completion rates equal those of male physicians and, thus, far exceed that of the general population (2.5-4 times the rate by some estimates). A reasonable assumption is that underreporting of suicide as the cause of death by sympathetic colleagues might well skew these statistics, so the real incidence of physician suicide is possibly somewhat higher. The most common psychiatric diagnoses among physicians who complete suicide are affective disorders (eg, depression and bipolar disease), alcoholism, and substance abuse. The most common means of suicide by physicians are lethal medication overdoses and firearms. DEPRESSION IN PHYSICIANSSection 3 of 7
Reticence to recognize physician depression is imposed by other physicians, who may be well intentioned, chronically emotionally distanced, and/or feeling temporarily vulnerable themselves. Physicians are notoriously reluctant to ask for help of any kind. When depressed and feeling less than adequate, asking for help is even more difficult, and sadly, sometimes remarkably difficult to actually obtain. Physicians are demonstrably poor at recognizing depression in patients let alone themselves. Furthermore, physicians are notoriously reluctant to seek treatment for any personal illness. Research suggests that 1 in 3 physicians has no regular source of medical care. Although everyone knows that "a doctor who treats (himself or) herself has a fool for a patient," we also know that most physicians treat themselves anyway, at least on occasion. This is especially likely when the physician believes that the consequences of seeking treatment might subject him or her to shame or worse (see Problems With Treatment in Physicians). Some physician reluctance to reach out is self-imposed. Physicians feel an obligation to appear healthy, perhaps as evidence of their ability to heal others. Inquiring about another physician's health can shatter this mutual myth of invulnerability. Volunteering assistance may seem like an affront to a colleague's self-sufficiency. Thus, the concerned partner may say nothing, while wondering privately if the colleague has become impaired. Unconsciously defending against this painful vulnerability, colleagues or partners may fail to notice significant depression or withdrawal, attributing behavioral changes to stress or overwork. Nearly every article or obituary about a physician's suicide contains a quotation from some close contact, occasionally a spouse, similar to "I never had any idea that he/she was suffering." Of course, many physician obituaries omit the fact that the "sudden death" was a completed suicide. Those physicians who do reach out may find limited understanding or sympathy demonstrated by colleagues. For many experiencing depression, the first symptoms experienced are physical. A physician unable to diagnose his or her own symptoms commonly feels incompetent. To admit inability to diagnose oneself to another colleague is an admission of failure. When this tacit confession is met with avoidance, disbelief, or derision, it can only reinforce feelings of worthlessness and hopelessness. Physicians find it painful to share their experience with others; therefore, published accounts are nearly impossible to find. However, in the author's experience, private consultations with a trusted counselor reveal that symptoms of depression among physicians are surprisingly common. Whether the incidence of divorce among physicians is higher than that in the general population is not known, but marital problems are common, perhaps in part due to the tendency of physicians to postpone addressing marital problems and a general conflict avoidance. Marital problems of course can contribute to depressive symptoms, which can increase the likelihood of suicidality if unaddressed. PROBLEMS WITH TREATMENT IN PHYSICIANSSection 4 of 7
Many clinicians are uncomfortable treating fellow physicians, especially in the realm of mental health. The "VIP syndrome" of well-intentioned but superficial or inadequate treatment based on collegiality and concerns about confidentiality can detract from the effectiveness of therapy. Mental health experts studying physician depression and suicide have stressed that immediate treatment and confidential hospitalization of suicidal physicians can be lifesaving more so than in other populations. Yet, this very specter is often the major impediment to a physician's reaching out in time of crisis. The fear of temporary withdrawal from practice, the lack of confidentiality and privacy in treatment, and the loss of respect in the community hampers physicians from seeking effective treatment. Physicians who have reported depressive symptoms (even those for which they are receiving effective treatment) to their licensing boards, potential employers, hospitals and other credentialing agencies have experienced a range of negative consequences, including repetitive and intrusive examinations, licensure restrictions, discriminatory employment decisions, practice restrictions, hospital privilege limitations, and increased supervision. Such discrimination can immediately and severely limit physicians' livelihoods as well as the financial stability of their families. For this reason, well-meaning colleagues or family members sometimes discourage physicians from seeking help. Regulations governing some state physician health programs allow a physician who is compliant with treatment to check "no" on the mental health questions on licensure applications, but this is not generally known by physicians who are contemplating or in need of treatment. Any lack of disclosure on an employment or credentialing application can be cited as grounds for termination or decredentialing. Discrimination in obtaining insurance coverage is a common but little publicized problem for physicians with mental illness. Health, disability, and liability insurance may all be denied to a physician who admits to depression. Even if disability insurance has previously been procured, its use may subject physicians to repetitive humiliating and invasive examinations by detached and dubious "independent medical examiners" for the insurer, whose motivation is to cut company losses. Many physicians affected by mental illness feel that insurers expect adherence by them to the standard prescription of "physician, heal thyself." Despite the protections offered by law to citizens and other professionals who have disabilities, the potentially devastating effects triggered by a physician's self-reporting of depression may delay or in effect preclude appropriate treatment. A depressed physician, whose thought processes are clouded because of the illness and the anticipated consequences of seeking treatment, may honestly believe that self-treatment is the only safe option. However, attempts at self-treatment are often unsuccessful. Failure to obtain consultation and treatment of depression significantly increases the risk of physician suicide. DEPRESSION IN MEDICAL TRAINEESSection 5 of 7
Prospective medical students and residents are unlikely to report a history of depression in selection interviews. The prevalence of depression in these populations and in medical student and postgraduate trainees is unknown, but it is estimated in the range of 15-30%. After accidents, suicide is the most common cause of death among medical students. A recent report has suggested that depression is not uncommon in pediatric residents (up to 20% self-reported in 3 programs). This preliminary study found that residents who experienced depression may be as much as 6 times more likely than nonaffected controls to make medication errors. EDUCATION AND RESOURCESSection 6 of 7
Depression, like substance abuse in physicians, is not only more common than in the general public, it usually is more readily treatable. This is because of the strong self-motivation to continue successful pursuit of a professional calling, which is an important source of a physician's self-esteem. More education is needed regarding this disease and its disproportionate and needless toll on the profession of medicine, beginning in the earliest stages of physician training. In addition, there is an urgent need to change the attitudes of those in health care, including those in the regulatory system, as well as the general public, toward mental illness. This might encourage physicians to be more receptive to a diagnosis of depression and enable them to feel free to seek treatment without the fear of repercussion. Physicians themselves need to be aware of the existence of Physician Health Programs in nearly every state and province, which allow a physician who is compliant with treatment to avoid disclosure of depression or other stable illness that does not interfere with ability to practice to licensing authorities. Please consult the American Foundation for Suicide Prevention available at www.afsp.org and www.physiciansuicide.com for further information and resources about physician depression and suicide. Litigation stress and related materials and resources can be found at www.mdmentor.com. REFERENCESSection 7 of 7
Article Last Updated: Jul 10, 2008 |
