Center C, Davis M, Detre T, Ford DE, Hansbrough W, Hendin H, Laszlo J, Litts DA, Mann J, Mansky PA, Michels R, Miles SH, Proujansky R, Reynolds III CF, Silverman MM. Confronting Depression and Suicide in PhysiciansA Consensus Statement. JAMA. 2003;289(23):3161-3166. doi:10.1001/jama.289.23.3161
Author Affiliations: Employment Law Center and the University of California, Hastings College of Law, San Francisco (Ms Center); George Washington University School of Public Health and Health Services, Washington, DC (Dr Davis); Department of Psychiatry, University of Pittsburgh Medical Center, Pittsburgh (Dr Detre); Departments of Medicine, Epidemiology, and Health Policy and Management, Johns Hopkins School of Medicine, Baltimore, Md (Dr Ford); Department of Education, Research, and Development, University of California Medical Center, San Diego (Ms Hansbrough); American Foundation for Suicide Prevention and Department of Psychiatry, New York Medical College, New York (Dr Hendin); American Cancer Society, Atlanta, Ga (Dr Laszlo); Office of the US Surgeon General, Washington, DC (Dr Litts); Division of Neuroscience, Department of Psychiatry, Columbia University Medical Center, New York, NY (Dr Mann); Committee for Physicians' Health, Medical Society of the State of New York, and Department of Psychopharmacology at Albany College of Union University, Albany (Dr Mansky); the Payne Whitney Clinic, Joan and Sanford I. Weill Medical College of Cornell University, New York, NY (Dr Michels); Department of Medicine and Geriatrics, University of Minnesota Medical School, Minneapolis (Dr Miles); Alfred I. duPont Hospital for Children, Wilmington, Del, and Jefferson Medical College, Philadelphia, Pa (Dr Proujansky); Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, Pittsburgh, Pa (Dr Reynolds); and National Suicide Prevention Resource Center, Newton, Mass, and Department of Psychiatry, University of Chicago Medical School, Chicago, Ill (Dr Silverman).
Objective To encourage treatment of depression and prevention of suicide in physicians
by calling for a shift in professional attitudes and institutional policies
to support physicians seeking help.
Participants An American Foundation for Suicide Prevention planning group invited
15 experts on the subject to evaluate the state of knowledge about physician
depression and suicide and barriers to treatment. The group assembled for
a workshop held October 6-7, 2002, in Philadelphia, Pa.
Evidence The planning group worked with each participant on a preworkshop literature
review in an assigned area. Abstracts of presentations and key publications
were distributed to participants before the workshop. After workshop presentations,
participants were assigned to 1 of 2 breakout groups: (1) physicians in their
role as patients and (2) medical institutions and professional organizations.
The groups identified areas that required further research, barriers to treatment,
and recommendations for reform.
Consensus Process This consensus statement emerged from a plenary session during which
each work group presented its recommendations. The consensus statement was
circulated to and approved by all participants.
Conclusions The culture of medicine accords low priority to physician mental health
despite evidence of untreated mood disorders and an increased burden of suicide.
Barriers to physicians' seeking help are often punitive, including discrimination
in medical licensing, hospital privileges, and professional advancement. This
consensus statement recommends transforming professional attitudes and changing
institutional policies to encourage physicians to seek help. As barriers are
removed and physicians confront depression and suicidality in their peers,
they are more likely to recognize and treat these conditions in patients,
including colleagues and medical students.
Attention to depression and suicide in physicians is long overdue. As
early as 1858, physicians in England observed that a higher suicide rate exists
among physicians than the general population.1 Since
the 1960s, research confirmed physicians' higher suicide rate and identified
depression as a major risk factor.2,3 Most
strikingly, suicide is a disproportionately high cause of mortality in physicians,4 with all published studies5,6 indicating
a particularly high suicide rate in female physicians.
Inattention to depression and suicide in physicians sharply contrasts
with heightened attention to physicians' smoking-related mortality. Since
the 1960s, declines of 40% to 60% have occurred in physicians' mortality rates
from smoking-related cancer, heart disease, and stroke.7,8 Physicians
now face lower mortality risks for cancer and heart disease relative to the
general population yet higher risk for suicide.9,10 During
the decades when physicians led the nation by heeding their own prevention
advice to patients regarding smoking, they neglected to seek help for depression
themselves and to diagnose it in their patients. This is alarming because
depression is a leading cause of disability.11 Even
though physicians have easier access to depression treatment than the general
public, they face more daunting regulatory and workplace barriers.
Addressing depression and suicidality in physicians more decisively
may have a multiplier effect for medical students, residents, and patients.
Treatment of mood disorders can lead to better physician mental health and
productivity,12 fewer suicides, and better
physical health. Depression is a leading risk factor for coronary artery disease
in male physicians.13 Because physicians' own
health habits affect their health and prevention counseling,14- 16 attention
to their depression and suicidality may improve their mentoring and training
of young physicians and may improve mental health care of patients. Conversely,
as physicians become more skillful at caring for their patients' depression
and suicidality, they are more likely to get care for themselves.
Depression is among the most common conditions in primary care patients,
yet studies17- 19 find
that physicians do not adequately detect or treat 40% to 60% of cases. Nearly
40% of those who die by suicide make contact with their primary care physician
within a month of suicide.20,21 During
that last contact, however, the question of suicide is raised infrequently.22- 24 Some physicians hold
unwarranted fears that asking patients about suicide will trigger suicidal
behavior.25 Some are unaware that suicidality
is both treatable and preventable through better detection of depression.25- 28 There
is a window of opportunity to prevent suicide because many patients are symptomatic
for several years before death.29,30 This
consensus statement was developed to encourage treatment of depression and
prevention of suicide in physicians by calling for a shift in professional
attitudes and institutional policies to support physicians who seek help.
The American Foundation for Suicide Prevention convened a workshop on
October 6-7, 2002, in Philadelphia, Pa, to develop a consensus statement to
evaluate what is known and to devise recommendations for treatment of depression
and prevention of suicide in physicians. The American Foundation for Suicide
Prevention invited 15 participants with expertise in physician health (D.E.F.,
J.L., P.A.M.), medical education (M.D., T.D., W.H., R.M.), licensing and credentialing
issues (C.C., S.H.M., R.P.), public health (D.E.F., D.A.L., M.M.S.), disability
law (C.C.), substance abuse (P.A.M.), depression (H.H., J.M., C.F.R., M.M.S.),
and suicidology (H.H., J.M., C.F.R., M.M.S.). The planning committee and the
participants conducted an extensive literature review. Key articles recommended
by participants were distributed in advance along with their presentation
abstracts. The workshop consisted of formal presentations by each participant,
and 2 breakout groups focused on overcoming barriers to care posed by physicians
in their role as patients and by medical institutions and professional organizations.
The groups reconvened in a plenary session to reach consensus on research
priorities and recommendations for reform. This consensus statement is intended
for physicians and institutions and organizations that train, license, accredit,
employ, and represent physicians.
Depression is as common in physicians as in the general population.
The lifetime prevalence is 12.8% for self-reported clinical depression in
a prospective study of more than 1300 male medical graduates from Johns Hopkins
University, who were enrolled between 1948 and 1964.13 This
rate is almost identical to the 12% lifetime prevalence of major depression
in US males (ages 45-54 years) in a nationally representative study.31 The only difference is in the later age of onset
in physicians. The lifetime prevalence is 19.5% for self-identified depression
in female physicians in the Women Physicians' Health Study (N = 4501), which
is a rate comparable with that in women in the general population and women
professionals.32 Rates of depression across
ethnic groups are similar, except for Asian female physicians, whose rates
are lower.32 Cross-sectional rates of depression
(15%-30%) are higher in medical students and residents than in the general
A systematic review of 14 international studies of suicide in physicians,
in articles published from 1963 to 1991, found higher rates of suicide in
physicians compared with the general population. The relative risks ranged
from 1.1 to 3.4 in male physicians and from 2.5 to 5.7 in female physicians.5 A subsequent large study6 from
England and Wales (1979-1995) confirmed elevated rates of suicide in female
but not in male physicians.
There have been no recent studies of suicide incidence rates for US
physicians. In their absence, studies of proportionate mortality (the percentage
of deaths in a group due to a particular cause) offer the next best approach.
The largest US study4 of white, male physician
deaths in 28 states during the years 1984 through 1995 found that, compared
with white, male professionals, physicians' proportionate mortality ratio
was higher for suicide than for all other leading causes of death (Figure 1).
In the general population, the male suicide rate is more than 4 times
higher than that in females, whereas in physicians the female rate is as high
as the male rate.3 Female physicians have lower
rates of suicide attempts than do other females in a nationally representative
study.32 A high ratio of suicide completions
to attempts may result from physicians' greater knowledge of toxicology and
access to lethal drugs,3 since overdoses of
medications, along with firearms, are the 2 most common methods of suicide.3,9 The literature suggesting that certain
specialists, such as psychiatrists and anesthesiologists, are at increased
suicide risk is beset by methodological limitations.3
Suicide results from a complex interplay of risk and protective factors
that are biological, psychological, and social in nature.25,36 The
major risk factors are mental disorders and substance use disorders. More
than 90% of those who die by suicide have at least one of these disorders,
most frequently depression (as major depressive disorder or bipolar disorder)
and/or alcohol abuse.25 The risk is much greater
when both are present. Since most people with these disorders do not die by
suicide, additional risk factors are also at play, including stressful events
and predisposing factors (eg, impulsivity). Protective factors include effective
treatment for mental and physical disorders, social and family support, resilience
and coping skills, religious faith, and restricted access to lethal means.25,36
Risk factors for completed suicide are typically examined by psychological
autopsy, a process that reconstructs factors that contribute to suicide via
semistructured interviews with key informants. Few psychological autopsy studies
have been undertaken for physician suicides. One such study37 in
Finland during a 12-month period found that all 7 physician suicides in the
database had a mood disorder, and 5 also had a disabling physical condition.
None had received adequate diagnosis or treatment for their mood disorder.
In the United States, the last psychological autopsy study of physicians was
conducted approximately 20 years ago.38 In
addition to mood and substance use problems, the study found greater likelihood
of personal and professional losses, financial problems, a tendency to overwork,
and career dissatisfaction (Box).2,3,38 Anecdotal evidence
suggests that even if physicians are treated for suicidality, the quality
of treatment, paradoxically, may be compromised because of collegial relationships
and deference from the treating clinician who may give more freedom to the
physician-patient to control the focus of therapy and to self-medicate.
Sex: Male or female
Age: 45 Years or older (woman); 50 years or
Marital status: Divorced, separated, single,
or currently having marital disruption
Risk factors: Depression, alcohol or other
drug abuse, workaholic, excessive risk taking (especially high-stakes gambler,
Medical status: Psychiatric symptoms or history
(especially depression, anxiety), physical symptoms (chronic pain, chronic
Professional: Change in status—threats
to status, autonomy, security, financial stability, recent losses, increased
Access to means: Access to legal medications,
access to firearms
Adapted from Silverman.3
Physician suicide has been correlated with personal, professional, and
financial stresses.38 However, a classic study,39 which followed up 47 physicians throughout 30 years,
concluded that long hours, demanding patients, and ready access to narcotics
were not problems for physicians who did not have preexisting psychological
difficulties evident at college entry. More recent studies40 found
that physicians experienced stress with a changing set of problems, in particular
paperwork and administrative hassles, loss of autonomy, and excessive professional
demands. Academic physicians have reported stressors such as long working
hours, little vacation time, and conflicts between work and personal life.41 Although stressors may be changing, there is no evidence
that links them to the elevated suicide rate among physicians. Nor is there
evidence that physicians are subject to more occupational stress than other
professionals. Rather, recent research indicates that stressful events thought
to precipitate suicide are themselves often precipitated by the behavior of
patients with affective disorders. Even when suicidal patients do not engender
stressful events, their experience of being intensely affected by them is
often a function of their preexisting depression.42
Thirty-five percent of physicians do not have a regular source of health
care, which is associated with less use of preventive medical services,43 supporting the observation that the medical profession
does not encourage physicians to admit health vulnerabilities or seek help.44 Physicians' use of mental health services also appears
low, but there is virtually no information on patterns of seeking help. Existing
data13 are outdated because they refer to treatment
from 1960-1980, and they do not differentiate self-treatment from treatment
by another clinician. More is known about medical students: they have low
rates of seeking help, with only 22% of those who had screened positive for
depression using mental health services.34 For
depressed students with suicidal ideation, only 42% received treatment. The
most frequently cited barriers to care included lack of time (48%), lack of
confidentiality (37%), stigma (30%), cost (28%), and fear of documentation
on academic record (24%). Although most of these barriers are reported by
the general population,18 concerns about confidentiality
and career prospects may weigh more heavily for young physicians,45,46 especially because student health
plans usually require care in the setting in which they are educated. One
study47 found that residency prospects were
reduced for otherwise qualified students with a history of psychological counseling.
Practicing physicians with psychiatric disorders often encounter overt
or covert discrimination in medical licensing, hospital privileges, health
insurance, and/or malpractice insurance. One of the authors (S.H.M.) drew
attention to the discriminatory policies of his state's licensing board, which
required submission of psychiatric records solely on the basis of his bipolar
diagnosis rather than on impaired professional abilities, which boards are
justified in inquiring about for protection of patients.48 The
physician refused access to his psychiatric records, arguing that he was receiving
effective treatment and was not impaired, that impairment cannot be inferred
from diagnosis alone, and that such policies are overly invasive and counterproductive
because they deter physicians from seeking help, thereby posing greater risks
to patient care from physicians' untreated illness. After a protracted standoff
and threats of legal action, the licensing board eventually changed its policy
to focus on impaired professional abilities rather than on diagnosis alone.
As early as 1983, the American Psychiatric Association expressed concern that
licensing board questions focused on diagnosis or treatment of mental illness
would deter physicians from seeking help.49
Most, but not all, state licensing boards have moved from questions
about diagnosis or treatment toward questions about impaired professional
performance at initial licensure and renewals according to surveys conducted
in 1993 and 1996.50 However, the time frame
of the mental health impairment questions in approximately half of surveyed
licensure applications is overly broad, ranging from "past 2 years" to "ever
impaired."51 Furthermore, it is not known whether
medical boards use the information to covertly discriminate against a physician
who was treated or previously impaired but does not report current impairment.
The Americans With Disabilities Act has been successfully deployed in
legal challenges to discriminatory policies by medical licensing boards.52 Some courts, however, have held that the Americans
With Disabilities Act does not apply to state licensing boards. Even if it
does, covert forms of discrimination may continue. Furthermore, many hospitals,
clinics, and malpractice insurance carriers continue to ask questions that
inappropriately focus on psychiatric diagnoses and require review of medical
records, but the extent of the problem is not known and deserves study.
It is reasonable to infer that physicians' concern about disclosure
of mental health records is widespread, although studies are lacking. Breaches
of confidentiality also are believed to harm openness between the physician
(as patient) and the treating clinician and may result in needless disclosures
to coworkers. Those concerns, coupled with professional attitudes that broadly
discourage admission of health vulnerabilities, are likely the driving forces
behind physicians' disinclination to seek mental health care.
Physician depression and suicidality have received scant research attention.
Most research is outdated, considering that the largest and most recent US
study of suicide risk factors in physicians was conducted 20 years ago. The
literature is also fraught with methodological problems, including case finding,
case definition, sampling bias, and statistical rigor.3 Depression
studies largely rely on self-reported diagnoses rather than clinical interviews
or validated questionnaires. There are few studies of protective factors for
practicing physicians with depression, including help-seeking patterns and
quality of care. We make the following recommendations for future research.
Investigate physician patterns of seeking help, barriers to treatment,
degree of impaired abilities, risk and protective factors for depression,
substance abuse, and suicidality, including the role of medical specialty
and personal or professional stressors.
Conduct a large psychological autopsy study of physician suicides
to determine risk and protective factors, patterns of seeking help, quality
of care, and adherence to treatment.
Determine the current incidence rate of completed suicide by US
physicians, including the effect of sex, ethnicity, and specialty.
We make the following recommendations for physicians:
Establish a regular source of health care and seek help for mood
disorders, substance abuse, and/or suicidality.
Learn to recognize depression and suicidality in themselves and
educate medical students and residents to do likewise.
Become informed about state and federal protections for confidentiality
of medical records and about legal protections for physicians and others with
disabilities. For physicians who are impaired, most commonly by substance
use disorders, all states should have physician health programs whose functions
include outreach, treatment, monitoring, and advocacy.53 However,
physicians should not be referred to physician health programs simply because
they have a psychiatric diagnosis or are receiving mental health treatment.
The American Foundation for Suicide Prevention is creating a Web site to inform
physicians about diagnosing depression in themselves and their legal rights
if in psychiatric treatment (http://www.afsp.org/physician).
Routinely screen all primary care patients for depression, as
recommended by the US Preventive Services Task Force.54 Depression
often coexists with medical illness particularly in patients older than 60
years, the group at highest risk for suicide. Screening for depression in
patients can help physicians recognize depression in themselves. Improved
depression screening also prevents suicide.26- 28 If
depression is suspected, ask patients about suicide. Only 58% of primary care
clinicians report questioning depressed patients about suicidal thoughts and
behavior, even though such questions are routine in a thorough depression
The institutions of medicine—medical schools, hospitals, and licensing
and accrediting bodies—minimize or disregard the mental health of physicians,
despite the high toll of depression and suicide on physicians, families, and
the profession. Medical institutions have lagged behind broader societal emphasis
on mental health,18,28,56 such
as a suicide prevention initiative by the leadership of the US Air Force.
That program motivates personnel to seek help and enhances protective factors
for a cluster of suicide-related risk factors.57 Compared
with the years before implementation, the program is associated with relative
risk reductions for suicide, fatal accidents, severe family violence, and
other outcomes (Kerry Knox, PhD, written communication, December 20, 2002).
The program provides a useful model for other communities, including schools,
universities, and medical schools. The medical profession can exert its leadership
via medical school deans and department chairs to create model programs that
simultaneously benefit the mental health of young physicians and the patients
they care for. The following are our recommendations for institutions.
Educate physicians, state licensing boards, hospitals, group practices,
and malpractice insurers about the public health benefits of encouraging physicians
to seek treatment for depression and suicidality. Consider developing model
regulations and policies for state licensing boards, hospitals, and malpractice
insurers that encourage physicians to seek help.
Provide boards with a model relicensure mailing that encourages
help seeking for all health conditions and asks screening questions about
depression and suicidality, along with other health questions (eg, have you
checked your blood pressure?). The answers should be solely for personal use
and should not be returned.
Ensure that licensure regulations, policies, and practices are
nondiscriminatory and require disclosure of misconduct, malpractice, or impaired
professional abilities rather than a diagnosis (mental or physical).
Encourage development of continuing medical education curricula
on physician depression, suicidality, and risk and protective factors.
The Liaison Committee on Medical Education and the Accreditation Committee
on Medical Education should mandate that medical schools educate medical students
and residents about depression and suicidality, encourage them to seek help,
and offer social support for any student or resident who seeks help.
Impose health system accountability through the Joint Commission on
Accreditation of Healthcare Organizations for detection and treatment of depression
in all primary care patients, in accordance with the recommendation of the
US Preventive Services Task Force.54
Hold a summit on physician mental health to foster a shift in the culture
of medicine to encourage physicians to seek help, treatment of depression
or other mental health problems and for prevention of suicide. Inculcate the
view that greater priority to mental health of physicians, medical students,
and residents serves as a model for patient care at a time of heightened public
health attention to depression and suicide.
The culture of medicine accords low priority to physician mental health
despite evidence of untreated mood disorders and an increased burden of suicide.
Barriers to physicians in seeking help are often punitive, including discrimination
in medical licensing, hospital privileges, and professional advancement. Professional
attitudes and institutional policies need to be changed to encourage physicians
with mental health problems to seek help. As barriers are removed and physicians
confront depression and suicidality in their peers, they are more likely to
recognize and treat these conditions in patients, including colleagues and