From the Editor
“‘I Couldn’t Do Anything’: The Virus and an E.R. Doctor’s Suicide.”
So headlines a long article on the life and death of a New York doctor who had excelled at medicine – Dr. Lorna Breen oversaw an ER department, and was studying in a dual degree master’s program at Cornell University – but died during the COVID-19 pandemic. The front-page story ran last weekend in The New York Times.
Physician suicide. It’s a weighty topic, one that typically wasn’t discussed much in the past, in part because of the reluctance of physicians to acknowledge their own problems. But how often does it occur and is there a gender gap?
This week, we consider a new paper by Dr. Dante Duarte (of Harvard Medical School) and his co-authors. While previous papers have been published in this area, Duarte et al. are ambitious: they do a systematic review and meta-analysis of studies published over the last four decades. In the JAMA Psychiatry paper, they find: “suicide standardized morality ratios were high in female physicians and low in male physicians after 1980…”
The paper runs with an editorial by Drs. Katherine J. Gold (of the University of Michigan) and Thomas L. Schwenk (of the University of Nevada). Putting the paper in a larger context, they write: “Suicide prevention is a moral responsibility of the entire medical profession.”
And a quick word of welcome to PGY1 residents who are joining us this week as part of our continued partnership with 12 Canadian residency programs from coast to coast to coast.
“Male and Female Physician Suicidality: A Systematic Review and Meta-analysis”
Dante Duarte, Mirret M. El-Hagrassy, Tiago Castro e Couto, Wagner Gurgel, Felipe Fregni, Humberto Correa
JAMA Psychiatry, June 2020
Suicide leads to more annual deaths globally than natural disasters, violence inflicted by others, war, and conflict combined. Suicide caused almost 800 000 deaths worldwide in 2016, down from nearly 850 000 suicide deaths in 2004. In 2016, the age-standardized suicide rates were 10.53 per 100 000 persons globally…
Suicide risk factors are male sex (for completed suicides), younger age, fewer years of formal education, unmarried status, and the presence of mental disorders. Occupational hazards are also associated with suicide risk; physicians typically have higher suicide rates than the general population, including the military. Overall, age-standardized suicide mortality ratios (SMRs) for physicians were significantly higher (ie, higher suicide rates in physicians compared with the general population) according to [an older] meta-analysis, including much higher findings for female physicians and moderately higher findings for male physicians. However, heterogeneity was considerable for the meta-analysis overall, and data quality was higher for the suicides of male physicians, possibly because the data ranged from 1910 to 1998 and multiple articles had no data on female physicians.
So opens a paper by Duarte et al.
Here’s what they did:
- They searched major databases for papers, including PubMed.
- Search terms included “suicide,” “self harm” and “doctors.”
- Inclusion criteria: papers published in English, Portuguese, Spanish, or French, and the cohort periods were from 1980 to present.
- Data was extracted.
- Different statistical analyses were done. “The calculation for SMRs of the period being studied was the male or female physician suicide mortality rate per 100 000 person-years, divided by the suicide mortality rate of male or female individuals in the general population per 100 000 persons per year.”
Here’s what they found:
- Of 7 877 search results, 32 articles were included in the systematic review; 9 articles, in the meta-analysis.
- Systematic review. On the characteristics of physicians: “Twenty-one articles showed significant differences between suicide rates in physicians and those of the general population; 11 articles showed none. Most articles separated physicians by sex, with 11 studies and 9 articles showing significantly higher suicide risk in female and male physicians, respectively, than the general population.” On comorbidities: “Psychiatric illnesses were reported as risk factors in only 4 articles…” On demographic factors: “Eight studies reported the most prominent demographic risk factors for suicide. These were sex (although results were mixed), followed by increasing age…”
- Meta-analysis: “SMR was significantly lower than the SMR of the general male population (ie, there were lower suicide rates in male physicians than men in general)…” “Female physicians’ SMR was significantly higher than the SMR of the general female population…” See figure below.
- “There was no evidence of publication bias in studies on male and female physician suicides…”
A few thoughts:
- This is a good paper.
- The authors find two big results. That is, “a significantly higher suicide SMR in female physicians compared with women in general” and “male and female physician SMRs significantly decreased after 1980 vs. before 1980…”
- Were physicians in certain specialties more at risk? “Psychiatry and anesthesiology were the top 2 specialties at risk in this review. However, we excluded studies analyzing only specialist data, some of which reported higher suicide rates for anesthesiologists, typically by drugs.”
- Limitations? They note: “A probable bias in physician suicidality studies is underreporting, because colleagues may be unwilling to classify deaths as suicides.” (!!)
- The authors do a comparison of physicians and non-physicians. Was the decline over time, then, a reflection on decreasing physician suicides or, say, increasing population suicides? “Our meta-regression suggested that the decrease in male physician suicide SMR over time was driven by the rate of physician suicides rather than population suicides. This may be because male physicians are relatively protected from workforce or unemployment factors affecting men of lower socioeconomic status, which may have obscured any burnout-associated outcomes.”
With regard to women: “Conversely, we could not make the same claim for female physicians vs. women in the general population, potentially because the pre-1980 data was underpowered. Yet the SMR for female physicians, while decreasing, was still high, implying that greater female representation in the physician workforce may not have overcome the magnitude of their increased risk compared with women in general. It also raises the question of a lag in improved workforce conditions compared with workforce numbers.”
- Picking up on that last point: the consideration of time is obviously interesting. Remember how much the gender composition of medical schools has changed in recent years; in the United States, for example, women went from 23% of graduates (1980) to 48% (2015).
- The authors are very ambitious, drawing on papers over decades, and including data from many different geographic locations (Estonia, England and Wales, Finland, Brazil, Australia, and the United States). Are the authors too ambitious?
The full paper can be found here:
“Physician Suicide – A Personal and Community Tragedy”
Katherine J. Gold and Thomas L. Schwenk
Physician suicide – its incidence, causes, and prevention – has been a subject of intense study, particularly since the landmark meta-analysis by Schernhammer. In this issue of JAMA Psychiatry, Duarte and colleagues 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.
Katherine J. Gold
So opens an editorial by Drs. Gold and Schwenk.
They discuss the paper, and note the inadequacies of the data. “A larger, more complete, detailed, and more accurate set of data is desperately needed.” Ultimately, they believe we need more than just some basic statistics on suicide completions: “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.”
They write: “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. The feelings of loss, shock, abandonment, betrayal, and confusion may weigh heavy. Colleagues may feel guilty that they did not stop the death. 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.
The authors call for educational environments that “support rather than stigmatize” and the elimination of barriers to health care.
A few thoughts:
- This is a good editorial.
- The authors do a nice job of discussing the study, and also putting it in a larger context.
- “Suicide prevention is a moral responsibility of the entire medical profession.” This comment is so important that I repeat it again.
- And the acknowledgement of stigma is important.
- We began this week’s Reading by mentioning the story of Dr. Lorna Breen. You can find the full NYT article here:
Her family, by the way, has established a fund to offer mental health support to health care providers.
- Of course, physicians do become ill with mental disorders – like everyone else. In a past Reading, we considered the decision of Dr. Adam Hill to speak out about his mental health problems; his New England Journal of Medicine essay was discussed. You can find it here:
Dr. Hill has now written a highly readable book about his journey, Long Walk Out of the Woods: A Physician’s Story of Addiction, Depression, Hope, and Recovery. Amazing.
The JAMA Psychiatry editorial can be found here:
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.