Preventing physician suicide

New efforts seek to reduce stigma among clinicians about mental illness and treatment.

In 2004, a medical resident at Oregon Health and Science University (OHSU) in Portland, Ore., died by suicide. In the ensuing months, resident and faculty leaders looked at what support systems were in place to help trainees get through several years marked by overwhelming pressure, and they found that there were some obstacles to accessing assistance.

Photo by Thinkstock
Photo by Thinkstock.

That same year, OHSU created a comprehensive wellness and suicide prevention program that now offers confidential, onsite care to residents, fellows, and full-time faculty. The Resident and Faculty Wellness Program, which serves about 23% of residents and 8% of faculty, is free for users, does not bill insurance, and stands completely separate from the institution's electronic health record (EHR) system—reducing physicians' concerns about confidentiality.

“We looked at the research about why physicians don't seek treatment and found that the stigma surrounding mental health treatment was one of their biggest concerns,” said Sydney Ey, PhD, professor of psychiatry at OHSU and associate director of the wellness program. “In addition, residents have limited time to go offsite and get care, so we created a program that's both easy to access and confidential.”

Compared with the general population, suicide rates are slightly higher among male physicians and significantly higher among female physicians, according to a frequently cited 2004 study published in the American Journal of Psychiatry. Mental illness is an important contributing risk factor, but the stigma surrounding treatment makes it difficult to assess its prevalence in the medical community.

A 2013 study that examined postmortem toxicology data on suicide victims from the U.S. National Violent Death Reporting System found that physicians were more likely than nonphysicians to have high levels of antipsychotics, benzodiazepines, and barbiturates in their blood, but not antidepressants, suggesting that many physician in distress do not seek treatment. The authors also reported that job stress was more likely to be a suicide risk factor for physicians than the general population.

“Physicians are more likely than others to see their job as integral to their identity,” said the study's lead author Katherine Gold, MD, MSW, a mental health researcher and assistant professor of family medicine and obstetrics and gynecology at the University of Michigan in Ann Arbor. “If something happens to threaten that identity, such as a mistake or a patient dying, they could be at risk for depression or suicidal ideation.”

Stigma begins in residency

The problem of physician suicide drew renewed national scrutiny in 2014 when two internal medicine residents in New York jumped to their deaths. More recently, a July 2017 study in Academic Medicine found that suicide is the second-leading cause of death among residents.

“Our study raises an alarming concern that the rate of suicide rises as physicians age and rises to levels that are significantly greater than both the general population and other professionals,” said the study's lead author, Thomas Nasca, MD, MACP, CEO of the Accreditation Council for Graduate Medical Education and professor of medicine and molecular physiology at Thomas Jefferson University in Philadelphia. “With the rates of burnout increasing, it's crucial that hospitals create an environment where physicians can easily and confidentially receive appropriate counseling and support.”

While most medical students begin their education psychologically healthy, by their third year and into residency, up to one-third are clinically depressed, more than half describe burnout symptoms, and between 6% and 12% report suicidal ideation, according to a study led by Dr. Ey and published in the Dec. 1, 2016, Journal of Graduate Medical Education. Despite having access to high-quality care and health insurance coverage, relatively few medical students and residents seek treatment.

Physicians are hard-wired as helpers and problem solvers and often have difficulty accepting that they might not be able to cope with difficult situations on their own, noted Christine Moutier, MD, chief medical officer for the American Foundation for Suicide Prevention (AFSP) in New York City.

“Compared with the general population, physicians tend to be perfectionists and achievement-oriented, with an exaggerated sense of responsibility and guilt,” she said. “Those traits are absolutely counter to getting help for oneself and knowing how to prevent a crisis.”

Historically, the requirements surrounding state licensing have presented a significant barrier to disclosing mental health problems or seeking treatment, said Dr. Gold. Evidence of previous diagnoses—even for very treatable conditions like depression or anxiety—can prompt requests for documentation of proof of fitness for practice or requests to appear before a state board of examiners, among other consequences.

Dr. Gold and colleagues recently examined whether such requirements influence female physicians' decisions about seeking help or treatment. For the study, published in General Hospital Psychiatry in 2016, they administered an online survey to a Facebook group made up of female physicians who were also mothers. They found that half of respondents had prior diagnoses or treatment of mental illnesses since medical school but that only 6% reported the information to their state boards.

In a separate study published in the June 2017 Family Medicine, Dr. Gold reports that, as of 2013, 43 states asked questions about mental health conditions on their licensing applications. Only 23 of those limited questions to disorders causing impairment, and just six focused on current problems.

“There is a general perception, partially rooted in truth, that it can be dangerous to reveal that you've had a mental illness,” said Dr. Gold. “That's particularly worrisome for women physicians, who have higher rates of suicide than their male counterparts and women in the general population.”

The findings also raise important questions about how state boards assess mental versus physical health and the ethics of requiring physicians to disclose past diagnoses or current conditions that are well controlled with treatment and have no obvious impact on practice, she said. Besides potentially violating the Americans with Disabilities Act, questions not related to current impairment have no clear relationship to protecting patient safety.

“In the past, if a physician disclosed that they sought treatment for substance abuse or even depression it wouldn't have been uncommon for a state board to demand access to their entire health history and to communicate with their psychiatrist—which would never have been done for a nonpsychiatric condition,” said Dr. Moutier. “That's been changing, but the majority of states still are not doing this in the most progressive way.”

Reforms may be in sight, however. In 2016, the American Medical Association's Council on Medical Education approved a policy recommending that state medical boards refrain from asking about history of mental illness and substance abuse. In addition, the Federation of State Medical Boards Workgroup on Physician Wellness and Burnout is discussing ways to reduce the stigma associated with seeking help.

Strategies for prevention

Individual hospitals can help prevent physician suicide by creating a culture that destigmatizes mental health changes and treatment, said Dr. Moutier. Targeted educational campaigns should cover things like burnout, depression, and addiction and raise awareness about their prevalence in the medical community.

Procedural or programmatic initiatives should be implemented in parallel with an educational campaign, she said. “Just telling people to get treatment does nothing—you have to engage them in the topic.”

For example, the Healer Education Assessment and Referral program or HEAR—co-developed and led by Dr. Moutier at UCSD—pairs an educational campaign with a free confidential assessment by a counselor and advice on how and where to seek treatment. Over the past nine years, HEAR has referred 320 practicing physicians and residents to mental health treatment, said Dr. Moutier.

Hospitals can take also practical steps to help people work more efficiently and increase job satisfaction, said Dr. Ey. Relatively simple changes can be meaningful, such as ensuring that clinicians have ready access to food and water or providing quiet workspaces with natural light where people can focus.

To truly change the culture around mental health care, hospitals must prioritize workforce well-being, said Dr. Ey. That means implementing systemic changes that allow physicians time for self-care, including regular exercise and adequate sleep.

In order to do that, hospitals must commit resources to removing some of the time-consuming administrative tasks that detract from physicians' job satisfaction, said Dr. Nasca.

“Administrative demands weigh heavily on physicians and keep them away from the bedside, which is the element of their professional lives that invigorates them,” he said. “Physicians are motivated by the urge to help others, and when they are inhibited from doing that, it detracts from their sense of accomplishment and overall sense of well-being.”

Physicians are particularly vulnerable to falling into depression following a tragic event or clinical error, noted Dr. Ey. Peer support can help them make it through painful situations and encourage them to seek professional help if needed.

“One of most devastating things that can happen to a physician is an adverse event with a patient, and they may be discouraged from talking about it for legal reasons,” she said. “Institutions need to be proactive with peer support programs, and individuals need to reach out to peers when they have a rough outcome.”

Several aspects of modern health care have weakened the sense of camaraderie on workforce teams, added Dr. Nasca. EHRs—while more convenient and efficient than manual systems—have reduced the need for face-to-face meetings, and an increasingly fast-paced work environment with higher productivity expectations has led many physicians to eat on the run, for example, instead of meeting colleagues in the hospital cafeteria.

“It's important for physicians to be observant of their colleagues and watch for signs of someone who may be slipping into clinical depression,” said Dr. Nasca. “Everyone should know what support systems and interventions are available in their own institutions.”