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Editorial
March 4, 2020

Physician Suicide—A Personal and Community Tragedy

Author Affiliations
  • 1Department of Family Medicine, University of Michigan, Ann Arbor
  • 2Institute for Health Care Policy and Innovation, University of Michigan, Ann Arbor
  • 3Depression Center, University of Michigan, Ann Arbor
  • 4School of Medicine, University of Nevada, Reno, Reno
JAMA Psychiatry. Published online March 4, 2020. doi:10.1001/jamapsychiatry.2020.0009

Physician suicide—its incidence, causes, and prevention—has been a subject of intense study, particularly since the landmark meta-analysis by Schernhammer.1 In this issue of JAMA Psychiatry, Duarte and colleagues2 provide a much-needed update on physician suicide rates in a meta-analysis of global studies. But ultimately, physician suicide is more than a matter of standardized mortality ratios; rather, it is a tragedy both personally and professionally. Any discussion of physician suicide deaths needs to recognize the far-reaching influence that even a single suicide has on the physician’s community.

Shortly after publishing a study of physician suicide, one of us received a phone call from an unknown, out-of-state number. The caller was a physician who asked several somewhat vague questions about the article and chatted amicably for several minutes. Eventually, the caller began to disclose serious, work-associated struggles that were potentially career threatening. While the reason for the call was not initially apparent, it gradually became more obvious that this was a physician in deep crisis. In fact, this physician was suicidal. Yes, there was a detailed plan. Yes, the plan included lethal and accessible means. No, the caller had not disclosed these suicidal thoughts with anyone. The fact that a physician with suicidal thoughts, with so many resources and likely excellent mental health care access, would reach out to an unknown physician who, almost by design, was geographically unavailable was an astonishing reflection of how isolated and frightened physicians with suicidal ideation can feel.

Last year, one of us gave a presentation to the medical staff of a hospital on the topic of physician mental health. A short time later, a local physician committed suicide. A recent follow-up visit to the hospital on the anniversary of the suicide showed not just patients or family but a much wider community still grieving, still confused, still guilty, and still angry, as is true in the aftermath of most suicides. Because physician relationships can touch hundreds of colleagues and thousands of patients and have widespread effects in a small community, the ripples of grief after a physician suicide stretch far.

The meta-analysis by Duarte and colleagues2 gives quantitative context to these qualitative outcomes of physician suicide. Suicide studies can be confusing, because they often use different outcomes and comparison groups, but this review addresses many of these shortcomings. The researchers collected enough data to compare a single consistent metric across studies, the standardized mortality ratios, and were able to compare physician suicide with suicides in the general population, rather than to just a working population or another professional group, such as dentists or nurses. The article restricted the studies to those with data from 1980 and later and provides an important update to the 1994 review by Schernhammer.1 Duarte et al2 carefully addressed the core statistical limitations that have long plagued this topic and provide sensitivity analyses that are as thoughtful as can possibly be undertaken using the existing studies. Yet many caveats still persist.

Suicide can be difficult to identify through death records (presumed unintentional deaths may not have a clear cause),3 and miscoding is thought to be more common for physicians than the general population,4 leading to wide-ranging estimates of physician suicide risk. The 32 studies in this analysis2 found suicide rates for physicians that were both higher and lower than those for the general population. The authors appropriately limited their meta-analysis to the 9 highest-quality studies, spanning 32 years and 8 countries, but the result was a sample of just 547 suicides by male physicians and 162 suicides by female physicians. A larger, more complete, detailed, and more accurate set of data is desperately needed.

Ideally, epidemiologic studies with detailed mental health and professional data would lead to the identification of clinical, professional, and structural risk factors that are subject to mitigation or elimination. The most prominent of those risk factors is the profound stigma felt by physicians with depression, which leads to isolation, loneliness, desperation and extraordinary efforts to hide the pain and misery. Physicians are generally likely to have better health insurance and financial resources, more access to mental health services, and more advanced professional knowledge of the benefits of treatment for depression, anxiety, and posttraumatic stress disorder than many of their own patients. But knowledge, resources, and access cannot always overcome the deep shame and inadequacy felt by physicians in crisis. This burden is worsened by fears of being seen as less capable,5 an educational system that stresses care for others over care for self, and licensing and credentialing requirements that often punish physicians who accurately report their diagnoses and treatments.6

Suicide prevention is a moral responsibility of the entire medical profession. Physician suicide spreads through the community in waves, each concentric circle with a slightly more muted effect but an expansion in size and the numbers of colleagues and patients affected. Immediate consequences for family members, patients, and staff are profound.7,8 The feelings of loss, shock, abandonment, betrayal, and confusion may weigh heavy. Colleagues may feel guilty that they did not stop the death.9 Students and trainees may see medicine as an unsustainable career that puts physicians at serious risk during and after a decade in training. Colleagues may question their own vulnerability and wonder if they are coping as well as they think.

As with most individuals experiencing suicidal ideation, the physician who called about our research article seemed relieved to share these feelings and ultimately agreed to disclose the suicidal thoughts to a close family member and seek immediate professional help near to home. A week later, this physician colleague was getting help and feeling safer. But the implications of this encounter are stunning. In what other profession besides medicine would a person with suicidal thoughts, in the depths of despair, feel so much stigma and shame that there was nowhere to go for help but PubMed?

Accurate estimates of the true rate of physician suicide may still be lacking, but the risk is not zero and the consequences loom large. The medical profession must address the root causes of physician distress. The profession must adopt, as a core professional value, a more sustainable approach to managing the burdens of medical practice. Educational and work environments are needed that support rather than stigmatize physicians who seek help. Barriers to accessing mental health care must be removed. Individual physicians, their colleagues and patients, and their communities deserve no less.

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Article Information

Corresponding Author: Katherine J. Gold, MD, MSW, MS, Department of Family Medicine, University of Michigan, 1018 Fuller St, Ann Arbor, MI 48104-1213 (ktgold@umich.edu).

Published Online: March 4, 2020. doi:10.1001/jamapsychiatry.2020.0009

Conflict of Interest Disclosures: None reported.

References
1.
Schernhammer  ES, Colditz  GA.  Suicide rates among physicians: a quantitative and gender assessment (meta-analysis).  Am J Psychiatry. 2004;161(12):2295-2302. doi:10.1176/appi.ajp.161.12.2295PubMedGoogle ScholarCrossref
2.
Duarte  D, El-Hagrassy  MM, Couto  TC, Gurgel  W, Fregni  F, Correa  H.  Male and female physician suicidality: a systematic review and meta-analysis  [published March 4, 2020].  JAMA Psychiatry. doi:10.1001/jamapsychiatry.2020.0011Google Scholar
3.
Tøllefsen  IM, Hem  E, Ekeberg  Ø.  The reliability of suicide statistics: a systematic review.  BMC Psychiatry. 2012;12:9. doi:10.1186/1471-244X-12-9PubMedGoogle ScholarCrossref
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Margolis  PM.  M.D. suicides: why?  Mich Med. 1968;67(9):589.PubMedGoogle Scholar
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Schwenk  TL, Davis  L, Wimsatt  LA.  Depression, stigma, and suicidal ideation in medical students.  JAMA. 2010;304(11):1181-1190. doi:10.1001/jama.2010.1300PubMedGoogle ScholarCrossref
6.
Gold  KJ, Andrew  LB, Goldman  EB, Schwenk  TL.  “I would never want to have a mental health diagnosis on my record”: a survey of female physicians on mental health diagnosis, treatment, and reporting.  Gen Hosp Psychiatry. 2016;43:51-57. doi:10.1016/j.genhosppsych.2016.09.004PubMedGoogle ScholarCrossref
7.
Maple  M, Cerel  J, Sanford  R, Pearce  T, Jordan  J.  Is exposure to suicide beyond kin associated with risk for suicidal behavior? a systematic review of the evidence.  Suicide Life Threat Behav. 2017;47(4):461-474. doi:10.1111/sltb.12308PubMedGoogle ScholarCrossref
8.
Cerel  J, Maple  M, van de Venne  J, Brown  M, Moore  M, Flaherty  C.  Suicide exposure in the population: perceptions of impact and closeness.  Suicide Life Threat Behav. 2017;47(6):696-708. doi:10.1111/sltb.12333PubMedGoogle ScholarCrossref
9.
Dickey  CC, Cannon  B.  When a resident or fellow dies.  J Grad Med Educ. 2018;10(4):387-391. doi:10.4300/JGME-D-17-00566.1PubMedGoogle ScholarCrossref
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