Suicide and role strain among physicians

Suicide in anaesthetists: a systematic review

Evidence suggests that healthcare professionals are at an increased risk of dying by suicide, with anaesthetists at particularly high risk. However, much of the data on which this is based are historical. With a focus on the epidemiology and methods used, we conducted a systematic review of evidence regarding suicide and suicidal behaviour among anaesthetists to provide a more contemporary summary. The systematic review process was adapted from a previous similar study in veterinary surgeons and was consistent with recommended guidance. We identified 54 articles published in or after 1990 that had anaesthetist-specific data and met the inclusion criteria. Seven of these reported epidemiological data, of which four were published after 2000. Although none of the more recent studies reported standardised mortality rates specific to suicide in anaesthetists, the proportion of anaesthetists dying by suicide was increased with respect to comparator groups, which is consistent with previous findings. Eleven studies that included information on suicidal behaviour reported suicidal ideation in 3.2-25% of individuals (six studies) and suicide attempts in 0.5-2% (four studies). Studies reporting methods of suicide highlighted the use of anaesthetic drugs, particularly propofol, supporting the suggestion that the increased risk of suicide in anaesthetists may be related to the availability of the means. We discuss our findings in relation to other recently published data and guidance concerning mental health problems in anaesthetists.

Suicide among physicians and health-care workers: A systematic review and meta-analysis

BACKGROUND

Medical-related professions are at high suicide risk. However, data are contradictory and comparisons were not made between gender, occupation and specialties, epochs of times. Thus, we conducted a systematic review and meta-analysis on suicide risk among health-care workers.

METHOD

The PubMed, Cochrane Library, Science Direct and Embase databases were searched without language restriction on April 2019, with the following keywords: suicide* AND (« health care worker* » OR physician* OR nurse*). When possible, we stratified results by gender, countries, time, and specialties. Estimates were pooled using random-effect meta-analysis. Differences by study-level characteristics were estimated using stratified meta-analysis and meta-regression. Suicides, suicidal attempts, and suicidal ideation were retrieved from national or local specific registers or case records. In addition, suicide attempts and suicidal ideation were also retrieved from questionnaires (paper or internet).

RESULTS

The overall SMR for suicide in physicians was 1.44 (95CI 1.16, 1.72) with an important heterogeneity (I2 = 93.9%, p<0.001). Female were at higher risk (SMR = 1.9; 95CI 1.49, 2.58; and ES = 0.67; 95CI 0.19, 1.14; p<0.001 compared to male). US physicians were at higher risk (ES = 1.34; 95CI 1.28, 1.55; p <0.001 vs Rest of the world). Suicide decreased over time, especially in Europe (ES = -0.18; 95CI -0.37, -0.01; p = 0.044). Some specialties might be at higher risk such as anesthesiologists, psychiatrists, general practitioners and general surgeons. There were 1.0% (95CI 1.0, 2.0; p<0.001) of suicide attempts and 17% (95CI 12, 21; p<0.001) of suicidal ideation in physicians. Insufficient data precluded meta-analysis on other health-care workers.

CONCLUSION

Physicians are an at-risk profession of suicide, with women particularly at risk. The rate of suicide in physicians decreased over time, especially in Europe. The high prevalence of physicians who committed suicide attempt as well as those with suicidal ideation should benefits for preventive strategies at the workplace. Finally, the lack of data on other health-care workers suggest to implement studies investigating those occupations.

A history of physician suicide in America

Over the course of the last century, physicians have written a number of articles about suicide among their own. These articles reveal how physicians have fundamentally conceived of themselves, how they have addressed vulnerability among their own, and how their self-identification has changed over time, due, in part, to larger historical changes in the profession, psychiatry, and suicidology. The suicidal physician of the Golden Age (1900-1970), an expendable deviant, represents the antithesis of that era's image of strength and invincibility. In contrast, the suicidal physician of the modern era (1970 onwards), a vulnerable human being deserving of support, reflects that era's frustration with bearing these unattainable ideals and its growing emphasis on physician health and well-being. Despite this key transition, specifically the acknowledgment of physicians' limitations, more recent articles about physician suicide indicate that Golden Age values have endured. These persistent emphases on perfection and discomfort with vulnerability have hindered a comprehensive consideration of physician suicide, despite one hundred years of dialogue in the medical literature.

Suicide compared to other causes of mortality in physicians

Physicians frequently are early adopters of healthy behaviors based on their knowledge and economic resources. The mortality patterns of physicians in the United States, particularly suicide, have not been rigorously described for over a decade. Previous studies have shown lower all-cause mortality among physicians yet reported conflicting results about cause-specific mortality such as suicide. In this study, we compared all-cause and cause-specific mortality in a sample of physicians to the age-gender matched general U.S. population from 1948 through 1998. We also compared the mortality experience across medical specialties. The risk of all-cause mortality was 56% lower than expected in men, and 26% lower in women, compared to the general population. Standardized mortality ratios (SMRs) were markedly lower for diseases strongly linked to smoking, e.g., cardiovascular diseases, respiratory diseases, and lung cancer. Suicide was the only cause of death where risk was greater than the general population. Overall, we found that physicians are at substantially lower risk of dying compared to the general population for all causes of death except suicide. The findings for suicide are strikingly different than other causes of death and should provide impetus for new research on the mental health of physicians.

Are anaesthetists prone to suicide? A review of rates and risk factors

Suicide represents a major source of mortality in Western countries. There is an emerging literature about suicide and the medical profession. The suicide of an anaesthetist represents a catastrophic event, with painful consequences for family, colleagues and the community at large. This review will examine the literature regarding suicide amongst anaesthetists and trainees in the field. It is presented in three sections. First, it provides an overview of existing epidemiological data, comparing rates in the general population, the medical profession, in general, and in anaesthesia, in particular. Second, risk factors that may account for differences in rates will be discussed. Finally, a series of recommendations has been formulated.

Psychological stress among hospital doctors caring for HIV patients in the late nineties

To assess stress and satisfaction related to HIV medical work and its impact on psychological wellbeing, a cross-sectional study was undertaken among the population of doctors caring for HIV/AIDS patients in French hospitals. They were sent a questionnaire on demographic and professional characteristics along with three additional scales: the Consultants Mental Health Questionnaire with three components - stress, satisfaction and responses to job stress; the Maslach Burnout Inventory; and the GHQ-12 (General Health Questionnaire). A total of 670 physicians responded anonymously (65.4% participation). For 45% of respondents, HIV/AIDS represented less than 25% of their activity. Three dimensions were extracted by multivariate analysis from the stress scale (overload, social relationships at work, patients/family distress) and four dimensions from the satisfaction scale (work content, patients/family, peer recognition, work environment). Length of time working in HIV/AIDS, and proportion of clinical work in HIV/AIDS were not related to either stress or satisfaction. Only participation in NGOs increased the level of stress. Stress was not related to time spent in clinical work, neither to HIV work. Satisfaction derived from work decreases with time in direct contact with patients and is mainly related to the position in hospital. Eleven per cent sought help from professionals for psychological problems. Stress derived from patients suffering was not related to any psychological outcomes. Work overload and stress derived from social relationships at work are the main predictors of psychological distress, emotional exhaustion and depersonalization, while the moderator effect of satisfaction is weak. In the late nineties, the amount of HIV work did not appear as a specific feature of hospital medical work.

When a Colleague Commits Suicide: How the Staff Reacts

1. A literature review on the subject of suicide by mental health professional indicates that research has been limited to family member survivors. There is some data on reactions to patient suicide by psychiatrists and psychologists. 2. The results of this study show that mental health professional survivors of peer suicide experience similar reactions to the studied groups. These include anger, guilt, loss of self-esteem, disruption of relationships, and concern about assessing for suicidality. 3. Subjects felt the victim did not reach out for help because she feared stigmatization; mental health professionals are not permitted to have serious problems. 4. The clinical nurse specialist can perform an important role by addressing this dynamic and working to provide a supportive and nonpunitive environment for mental health professionals experiencing problems.

Stress symptoms, burnout and suicidal thoughts in Finnish physicians

Stress symptoms, burnout and suicidal thoughts in Finnish physicians were studied using a questionnaire. The questionnaire, containing 99 questions or groups of questions, was mailed to 3,496 physicians representative, as regards age, sex, specialization and employment, of all active physicians in Finland. Altogether, 2,671 physicians (76%) responded. Stress symptoms in male physicians were similar to those in male managers. In female physicians they were slightly less than in female white-collar workers. In male specialists highest burnout indices were found in general practice and occupational health; psychiatry and child psychiatry; internal medicine, oncology, pulmonary diseases, and dermatology and venereology. In female specialists they occurred in general practice and occupational health; radiology; internal medicine, neurology, pulmonary diseases, and dermatology and venereology. Non-specialists had higher burnout scores than specialists for both sexes. Highest burnout scores in both men and women occurred in those working in municipal health centres. Lowest scores occurred in those working in private practice, universities, research institutes, and public offices and organizations. Suicidal intent tended to be commoner in physicians than in the general population. It was also commoner in female (26%) than in male (22%) physicians. The results indicate a polarization between "higher burnout specialities", often dealing with chronically ill, incurable or dying patients (e.g. specialties such as oncology, pulmonary diseases and psychiatry), on the one hand and "lower burnout specialties", often dealing with curable diseases and favourable prognoses (e.g. specialties such as obstetrics and gynaecology, otorhinolaryngology and ophthalmology), on the other.

The stereotype of the mad psychiatrist

The stereotype of the mad psychiatrist is examined. There is initial consideration of the "popular" model of madness. It is suggested that there is no firm evidence that psychiatrists suffer more frequently from "popular madness" than other medical practitioners. The paper subsequently explores the stereotype's functions, origins, means of propagation and range of effects. It emerges that members of "the first generation" of psychiatrists were labelled as mad. It is inferred that the stereotype may not be about to change. The paper invokes the conceptually closely-related literatures and attendant terminologies of stereotyping, mythology, labelling, deviance, prejudice and stigma.

Mental illness in doctors

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Mortality of medical practitioners in Japan: social class and the "healthy worker effect"

To assess patterns of mortality in Japanese medical practitioners, we compared the mortality of male physicians in a Japanese prefecture with that of eight major working populations, the nonworking population, and the general population of all Japan and of the prefecture. Standardized mortality ratios were calculated. All-causes mortality in medical practitioners aged 25-64 years was significantly higher than that of administrative and managing workers (standardized mortality ratio [SMR] = 228); it was significantly lower than that of the nonworking population (SMR = 23). Physicians were found to have higher cause-specific mortality for pneumonia and bronchitis and for ischemic heart disease than the total working population. These findings suggest that the previously reported low mortality of physicians reflects principally their high socioeconomic status; within the professional class, the mortality of medical practitioners compares unfavorably with that of other persons.

Death anxiety: comparison of psychiatrists, psychologists, suicidologists, and funeral directors

Death anxiety levels of 130 psychiatrists, 57 psychologists, 31 suicidologists, and 8 funeral directors in California were compared through a mail survey. The hypothesis that psychiatrists would have the highest death anxiety levels because their suicide rates are high was not supported. However, this study provides baseline data for levels of death anxiety for the four occupational groups; psychologists showed the highest levels of death anxiety.

The psychiatrist's role in behavioral pediatrics training programs

Behavioral pediatric fellowships are available in 15 major medical institutions in the United States. In general, these programs focus on the psychologic, social, and biologic determinants of behavior and learning disabilities in children. Child psychiatry's participation in the formulative stages of these programs is considered vital. The authors caution psychiatry to avoid concentrating its energies upon these socially and developmentally inclined behavioral pediatricians to the detriment of all pediatric house staff.

The suicide rate among psychiatrists revisited

A review of the literature which examined the suicide rate among psychiatrists and other doctors was made. Particular attention was given to statistical and methodological problems. Common problems include small research sampling, inappropriate comparisons, lack of controls for age, sex, or other relevant factors, interpolating rates from a level per 10,000 to a level per 100,000, and inclusion of a number of unwarranted assumptions. The review did not find evidence that the suicide rate among psychiatrists is higher compared to the population as a whole; nor is there any evidence that the rates of any medical specialty are above average, controlling for the relevant variables. The materials reviewed included all published studies. In order adequately to assess the suicide rate among psychiatrists, a systematic and extensive study must be made, controlling for the relevant methodological variables.

The physician's work and marriage

Medicine and personality characteristics of its practitioners pose for physicians unique hazards to emotional health and marital satisfaction. The attempt to meet too many emotional needs in work may preclude adequate attention to personal and family problems. The physician should be more aware of his own and his family's emotional needs, and be less threatened by less-than-perfect adjustment in himself or other family members. Suggestions include: teaching psychiatry on a developmental and adaptational model; offering marital groups in medical school; and encouraging the process of marital contracting and the use of marital therapy when emotional problems arise in either spouse. The understanding and resolution of emotional distress of one marital partner often requires the involvement of both, as people intimately attached to each other tend to have neither problems nor solutions in isolation.

Mortality among doctors in different occupations

A total of 20540 male doctors who replied to a questionnaire on their smoking habits that was sent to them on 1 November 1951, and who were aged 35 years and over, were classified according to their occupation as listed in the Medical Directory for 1952 and followed up until 1 November 1971. Examination of the mortality rates in 11 occupational groups showed gross heterogeneity for smoking-related diseases but not for all other diseases grouped together. On average, general practitioners smoked 37% more cigarettes than did hospital physicians and surgeons and the overall death rates among general practitioners were about 23% higher than among physicians and surgeons of similar ages. This excess death rate was chiefly accounted for by a 38% excess mortality from smoking-related diseases such as lung cancer, chronic bronchitis, and ischaemic and pulmonary heart disease. The few other statistically significant associations between occupation and disease were thought to be due either to chance or to the effect of the disease on the choice of specialty.

Suicide among physicians

A review of the international literature of the past 75 years of suicide among physicians indicates that (1) suicide among physicians is high, (2) suicide among female physicians is higher than among male physicians, (3) physician suicide varies from country to country, with the highest rate among the Danes, the next among British and the next among U.S.A. physicians, (4) there is a high incidence of psychiatric morbidity, alcoholism and drug addiction among physicians who suicide, (5) as in suicides among other groups, there are significant variable correlates of age, gender, medical school affiliation, geographic residence, type of medical practice and specialty, the state of physical and emotional health, the use of alcohol and drugs, and professional and psychosocial factors, and (6) preventive action is both possible and desirable.