Care for caregivers: Proactive efforts to prevent physician, medical student and nurse suicide

Editor’s note: If you are in crisis, call the National Suicide Prevention Lifeline at 1-800-273-8255 or reach out to the Crisis Text Line by texting “Home” to 741741.

One doctor every day.

That’s the rate of physician suicide in the United States, as outlined at the 2018 annual meeting of the American Psychiatric Association — estimated to be the highest suicide rate of all professions in the country and more than twice the rate of the general population.

Those hundreds of lives — an estimated 300 to 400 per year, according to the American Foundation for Suicide Prevention1 — leave about half a million patients without their physician, and the effects carry over to family, friends and colleagues in the medical field.

Michael F. Myers, MD, professor of clinical psychiatry at SUNY Downstate Medical Center, Brooklyn, N.Y., notes that the majority of individuals who kill themselves suffer from a psychiatric illness at the time of death, and that many face multiple illnesses concurrently, such as depression, alcoholism or other substance abuse disorders.2

Many researchers point to many of these issues beginning in medical school or residency, when individuals push themselves to succeed, causing circadian rhythm changes and experiencing a loss of control over their schedule amid a highly competitive and focused system of assessment.

But for decades, Myers notes, “medical students and physicians who killed themselves were considered outliers, misfits or, even worse, individuals whose deaths sullied the profession.” Only in recent decades has focus shifted to recognizing the growing trend of stress and burnout for the nation’s healthcare providers.

One example: In 2007 the Mayo Clinic Department of Medicine developed a physician well-being program, recognizing “the daily work of physicians is critical to patient outcomes and cost of care” and that understanding and measuring factors influencing physician satisfaction and burnout help drive changes in organizational structure.

The Mayo program and work done by Myers seek to shift our understanding to evidence-based approaches about examining physician well-being, burnout and suicide. Take those last two components, for example: Myers writes that the concept of burnout may, in some cases, reflect a mood disorder. Depression is the most common psychiatric illness among physicians and can be difficult to treat, even if treatment is sought.

The dangers of stigma

Even if a healthcare provider recognizes factors associated with suicidality, a decision to seek treatment can be put off by worries about stigmas, both enacted and felt. As Myers writes, enacted stigma come from external sources, such as being discriminated against if a mental illness is known to colleagues. Felt stigma are primarily internal fears of enacted stigma or personal shame. Both can fuel “denial and the tendency to minimize the severity” of an illness, and that denial can exacerbate underlying issues, especially if a felt stigma prevents an individual from being forthcoming with a therapist or other mental healthcare professional treating them.

Identifying risk, offering help

The issues of suicide in healthcare organizations are, in no way, limited to physicians. Many of the same contributing factors are affecting nurses.
Judy E. Davidson, DNP, RN, FCCM, FAAN, nurse scientist at UC San Diego Health, helped pilot a nurse-specific version of the Healer Education, Assessment and Referral (HEAR) program to educate on risks of depression and suicide, as well as offer anonymous online PHQ-9 depression risk screening to help counselors evaluate nurses who may be at risk.

Results of the HEAR program found 43% of nurses were ranked as high risk and 55% were considered moderate risk. Twelve out of 172 individuals surveyed reported current active thoughts or actions of self-harm, and 19 reported previous suicide attempts. In total, 44 nurses received counseling, while 17 accepted referrals for ongoing treatment.
At the medical student level, similar best-practice programs are being promoted. The Accreditation Council for Graduate Medical Education (ACGME) has institutional requirements for their accredited programs so that residents have access to health services, “such as confidential counseling and behavioral health resources.”
Myers concludes that physician-patients — the doctors receiving treatment— require more education about mental health and recognizing “symptoms and signs of depression, obsessive-compulsive disorder, panic disorder and alcohol abuse,” and that state physician health programs often have valuable resources for them. Additionally, inviting guest speakers or organizing other mental health awareness opportunities through an organization’s wellness committee can offer positive messaging to educate and begin a meaningful conversation about these issues.
Above all, there is great value in stressing to at-risk individuals that there are others who care and are willing to engage them positively on what so many consider a secret that should be hidden from others.
“One of the hallmarks of suicidal despair is an intractable feeling of being friendless and all alone … Every suicidal physician I’ve treated who is now on the mend and regaining hope looks back and cannot believe how alone and estranged they felt at that point of desperation,” Myers writes. “It is like night and day.”

Notes:

1. Center C, Davis M, Detre T, et al. “Confronting depression and suicide in physicians: a consensus statement.” JAMA. 2003;289(23):3161-3166.
2. Myers M. Why physicians die by suicide: Lessons learned from their families and others who cared. 2017;3-5.