From the Editor
It’s a demanding profession that can push us. Not surprisingly, there is some evidence that physicians may be at higher risk of completing suicide than the general population. But are we?
Hirsh Makhija (of the University of California, San Diego) and his co-authors attempt to answer this question in new JAMA Psychiatry study. Drawing on a US national database, they compared suicides among male and female physicians to the nonphysicians, over five years, finding that suicide rates for female physicians were 47% higher than for women in the general population. They also looked at mood, mental health, and other problems. “Comprehensive and multimodal suicide prevention strategies remain warranted for physicians, with proactive consideration for those experiencing mental health issues, job problems, legal issues, and diversion investigations.” We review the paper and its implications, and look at the accompanying Editorial.
In this week’s second selection, Ryan D. Assaf (of the University of California, San Francisco) and his co-authors report on homelessness and substance use. In a new paper for JAMA, they surveyed 3 200 people, finding that 37% reported using any illicit substance regularly (more than three times per week), most commonly crystal methamphetamine. “In a representative study of adults experiencing homelessness in California, there was a high proportion of current drug use, history of overdose, and unmet need for treatment.”
Note that there will be no Readings for the next two weeks.
DG
Selection 1: “National Incidence of Physician Suicide and Associated Features”
Hirsh Makhija, Judy E. Davidson, Kelly C. Lee, et al.
JAMA Psychiatry, 26 February 2025 Online First
Although the practice of medicine can be immensely rewarding, physicians are human above all, and as such, are subject to the immense stresses that accompany their profession – long work hours, the weight of regularly making life or death decisions, caring for patients in what is often the most challenging phase of their and their families’ lives, onerous health care system changes, lack of autonomy, and increased time spent on computers instead of with patients. It is not surprising that physicians experience high rates of dissatisfaction with life and career, burnout, depressive symptoms and major depressive disorder, substance use, and possibly suicide. Further, the prevalence of depression for resident physicians is estimated to be as high as 29%, with one survey showing rates of 19.1% to 38.5% for mild to severe depression symptoms across specialties. Adding to these longstanding occupational hazards, the COVID-19 pandemic has been associated with an increased prevalence of physician burnout…
Even before the COVID-19 pandemic, major medical organizations and institutions recognized the vulnerability of physicians to suicide and urged actions to prioritize physician wellness and suicide prevention. The most cited study on age-standardized physician suicide rates found elevated rates among both male and female physicians compared to gender-matched nonphysicians in the general population, but that meta-analysis included few studies from the US and a limited number of female physician suicides. Subsequent international meta-analyses have not consistently confirmed these earlier findings. The most recent of these concluded that female physicians were at greater risk of suicide than female nonphysicians, while male physicians had a risk similar to male nonphysicians. However, that study reported high heterogeneity based on time and place and did not include any US data beyond 2018.
So begins a paper by Makhija et al.
Here’s what they did:
- They conducted a retrospective cohort study investigating suicides among US physicians and nonphysicians aged 25 years and older.
- Data was drawn from January 2017 to December 2021.
- They used data from the National Violent Death Reporting System from 30 US states and Washington, DC. “This anonymous database draws information from death certificates, coroner and medical examiner reports, and law enforcement reports.”
- “Decedents with missing age or sex were excluded for incidence, and missing race, ethnicity, or marital status for further analyses.”
- Main outcome: “Suicide incidence rate ratios (IRRs) and odds ratios (aORs) adjusted by age, sex, race, ethnicity, and marital status were used to compare preceding circumstances, primary method, and substances.”
Here’s what they found:
- A total of 448 physician and 97 467 general suicides were identified.
- Demographics. Among physicians: 79% were male; mean age of 60. Among the general population: 79% were male; mean age of 51.
- Females. “Female physicians had higher rates of suicide than female nonphysicians in 2017 (IRR, 1.88…) and 2019 (IRR, 1.75…), with overall higher 2017 to 2021 suicide risk (IRR, 1.53…).”
- Males. “Male physicians had lower 2017 to 2021 suicide risk than male nonphysicians (IRR, 0.84…).”
- Problems. “Compared to the general population and including all available jurisdiction data, physicians had higher odds of depressed mood (aOR, 1.35…) as well as mental health (aOR, 1.66…), job (aOR, 2.66…), and legal (aOR, 1.40…) problems preceding suicide…”
A few thoughts:
1. This is a good study, drawing on an excellent dataset, published in a solid journal.
2. The main finding in two sentences: “Female physicians had a significantly higher suicide incidence per 100 000 person-years than the female general population in 2017 and 2019, with overall higher 2017 to 2021 suicide incidence. Male physicians had an overall significantly lower 2017 to 2021 suicide incidence than the male general population.”
3. Wow.
4. The study explored the circumstances preceding suicide.
To state the obvious: it’s striking that those in health care were more likely to have a mental health problem.
Are doctors concerned about the mandatory reporting of mental health problems to regulatory bodies – and thus hesitant on seeking care? On a positive note, more and more states are changing the rules around disclosures, as reported by The Washington Post: https://www.washingtonpost.com/health/2025/02/17/physician-suicide-mental-health-disclosure/
5. The paper is published with an Editorial, “Female Physician Suicide Compared to the General Population” by Elena Frank, Dr. Srijan Sen (both of the University of Michigan), and Dr. Constance Guille (of the University of South Carolina). This paper is excellent and worth exploring.
They put the study in a larger perspective. “Consistent with results of a recent international meta-analysis, Makhija and colleagues’ findings suggest that female physicians have higher rates of suicide than nonphysician female individuals in the general US population, while the same was not true for male physicians. Taken together with comparable data on female nurses and suicide risk, these findings suggest that there is something fundamentally different about the experience of female physicians in health care that disproportionately increases suicide risk compared to other work environments.”
They focus on work hours. “Differences in depressive symptoms – a major risk factor for suicide – between male and female physicians are primarily driven by increased work hours and, in particular, heightened work-family conflict. A 2023 study shows a decrease in work hours among physician-fathers over the past 2 decades, while physician-mothers’ work hours increased. At the same time, female physicians were more likely to be a part of a dual-career family and perform disproportionately more housework and caregiving duties than male physicians, resulting in a higher overall personal and professional workload.” They argue that the pandemic has only worsened things with physician-mothers being 30-fold more likely to manage childcare and schooling responsibilities compared to physician-fathers.”
Elena Frank
“Organizations must also create flexible practice environments that recognize that most physicians are in dual-career relationships with shared family duties, enabling physicians of all genders to meet their personal and professional obligations while minimizing risk of burnout, depression, or suicide.”
They make several suggestions.
- Childcare. They advocate for improved access to quality childcare options that “align with physicians’ work schedules and implementation of a formal coverage system for last-minute schedule changes could significantly reduce the burden on physician-mothers and their colleagues.” Also, they see a role for “services that can help reduce female physicians’ overall workload, such as meal delivery and home cleaning…”
- Parental leave. They argue for improved parental leave policies. “The American Academy of Pediatrics recommends at least 12 weeks paid leave for the benefit of the mother and child’s physical and mental health. However, according to a 2018 study, the average paid childbearing leave for US faculty physicians is only 8.6 weeks.”
- A culture shift. They advocate for a culture shift to “reduce fears around flexibility stigma (ie, a cultural bias that can make it difficult for people to utilize family-supportive policies for fear they will be seen as less committed or dedicated to their work)…” To do that, “leadership must not only enact supportive policies but also actively promote and model their use. For example, normalizing the use of parental and sick leave for male physicians and taking time off for caregiving needs more broadly can help challenge gendered parenting expectations within medicine and foster a more supportive culture wherein physicians of all genders feel they can take time off for caregiving needs without penalty.”
They also remind us that physicians are people, too – and would benefit from approaches proven to reduce suicide risk in the general population, including “ensuring accessing to timely care, means restrictions and safety planning for those at risk, as well as targeted efforts to mitigate work-family conflict.” (!)
The full Editorial can be found here:
https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2830402
6. Like all studies, there are limitations. The authors note several including some problems with the dataset that may underrepresent physicians in the sample.
7. Past Readings have looked at physician mental health. Earlier this year, we featured an interview with Dr. Joss Reimer, the president of the Canadian Medical Association. On physician suicide, she notes: “It’s something that as physicians, we don’t like to talk about. We don’t want to be vulnerable. We’re supposed to be the helpers…” That Reading can be found here:
The full JAMA Psych paper can be found here:
https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2830401
Selection 2: “Illicit Substance Use and Treatment Access Among Adults Experiencing Homelessness”
Ryan D. Assaf, Meghan D. Morris, Elana R. Straus, et al.
JAMA, 19 February 2025
In the US, more than 650 000 people experience homelessness nightly, of whom 181 000 live in California… Substance use disorders increase an individual’s risk of homelessness by interfering with legal, economic, and social functioning. People may use substances in response to trauma as a coping mechanism or strategy to protect themselves from violence. Homelessness creates competing priorities and decreases access to harm reduction and substance use treatment. Substance use contributes to morbidity, acute health care use, and mortality in homeless populations. Overdose is the leading cause of death among people experiencing homelessness.
There is a dearth of representative data on homelessness. Because most studies use convenience samples, samples from service settings, or mortality records with incomplete capture of homelessness, there is wide variability in estimates of substance use, which sampling bias may skew. The last representative sample of people experiencing homelessness, the National Survey of Homeless Assistance Providers and Clients (NSHAPC) in the 1990s, included only those who used homeless services. Since then, a higher proportion of people have experienced unsheltered homelessness and the population has aged. Additionally, drug use patterns in the general population have shifted (eg, increasing methamphetamines and fentanyl use, overdoses).
So begins a paper by Assaf et al.
Here’s what they did:
- They conducted a “representative survey study of adults experiencing homelessness from October 2021 to November 2022 in 8 California counties…”
- They used a “multistaged probability-based sampling and respondent-driven sampling.”
- Eligible individuals: those who were 18 years or older and met the federal definition of homelessness.
- Main outcome: “The primary outcome measures included lifetime and past–6-month illicit substance use and substance type (methamphetamine, nonprescription opioids, or cocaine). Lifetime and current substance use treatment, unmet treatment need, types of treatments received, nonfatal overdose (lifetime and current episode of homelessness), and current possession of naloxone were measured.”
Here’s what they found:
- 3 865 individuals were approached; 79% participated, as well as 158 participants were recruited through respondent-driven sampling.
- Demographics. The mean age was 46.1 years; 67.3% were male; participants were equally divided as self-identified Black, Hispanic, and White.
- Use. An estimated 65.3% of participants used illicit drugs regularly (that is, three times per week) in their lifetime; 41.6% (began using regularly before their first episode of homelessness and 23.2% began using regularly after). In the past 6 months, an estimated 37.1% of participants reported regular use of any drug. (!)
- Drugs. 33.1% reported use of methamphetamines; 10.4%, opioids; 3.2%, cocaine. In their lifetime, an estimated 25.6% injected drugs and 11.8% injected drugs in the past 6 months.
- Treatment. An estimated 6.7% of participants were currently receiving treatment for those with lifetime use. Of those with any regular use in the last 6 months, an estimated 21.2% reported currently “wanting but not receiving treatment.”
- Overdose. “An estimated 19.6%… of participants had a nonfatal overdose in their lifetime and 24.9%… currently possessed naloxone.”
A few thoughts:
1. This is an important study looking at a vulnerable population, published in a major journal.
2. The key findings: substance use was common (about a third had regular use the past six months); many wanted treatment but didn’t get it; 1 in 5 had had at least one overdose.
3. Ouch.
4. The authors see practical implications. “Expanding treatment access through outreach to places in which people experiencing homelessness are (including encampments, shelters, and emergency departments) could increase engagement.”
5. Like all studies, there are limitations. The authors note several, including some difficulties with sampling that may undersample transition-age youth.
6. Past Readings have looked at the mental health problems of those who are homeless. In May 2024, we considered a few papers, including an excellent review from Nature Mental Health by Kerman and Stergiopoulos. That Reading can be found here:
The full JAMA paper can be found here:
https://jamanetwork.com/journals/jama/article-abstract/2830616
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.
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