PHYSICIAN SUICIDE: THE SILENT EPIDEMIC

1. PHYSICIAN SUICIDE:THE SILENT EPIDEMIC Amanda Kingston, MD

2. OUTLINE • Background • Mental illness among physicians • Risk factors • Culture of medicine • Public policy • Second victim phenomenon • Prevention

4. SOME SCARY STATISTICS • Rate of suicide in general population – 12.3 per 100,0001 • Rate of suicide among all physicians – 28-40 per 100,0001 • That is 2-3 X the general population! • It would take the entire graduating class of University of Missouri – SOM to replace the physician lives lost to suicide each year. • Death due to other factors (heart disease, DM, etc) is lower in physicians than the general population2 • Suicide is one of the leading causes of death among medical students3

5. MORE SCARY STATISTICS • Women physicians are at especially high risk. Rate of suicide by female physicians is 4X the general population! • The rate for suicide attempts in the general population is females >> males, but among physicians females = males • The rate for suicide completion in the general population is males >> females, but among physicians males = females • The suicide rate for physicians has remained about the same for at least the past 40 years

6. IMPORTANT QUESTIONS • Do those more at risk self-select to enter medicine? • Do certain traits among physicians increase risk? • Do physicians tire from repeated patient contact and become depleted? • Do physicians have more difficulty trusting others and confiding in them? • Does being a doctor increase risk because physicians become more reluctant than others to seek help? • Do physicians have no one to talk to about their concerns? • Are they too proud?

7. CONTRIBUTIONS TO HIGHER RATE • Physicians use more deadly methods: poisoning, firearms, hanging • Overdoses are significantly more deadly as they possess knowledge of doses and types of medications needed to cause death • Theories suggest that women physicians attempt at a similar rate to the general population but complete suicide much more frequently • Incidence of mental health problems is higher among physicians • Use of mental health services is significantly lower than the general population

8. DEPRESSION • Higher rate than in the general population. • In PGY1 residents the rate of depression as rated by Feighner criteria were 27-30% 7 • 25% of those depressed endorsed suicidal ideations • Among female physicians the lifetime rate of depression was 51%8

9. SUBSTANCE ABUSE • Similar rates to the general population • Higher rate of prescription drug abuse than the general population9 • Wide availability to addictive medications to physicians is thought to play a role • Toxicology on autopsy has shown that 40% of physician suicides involve alcohol and 20% involved illicit or addictive prescription drugs • Significant stigma for physicians who seek substance abuse treatment • Many physicians may chose to treat themselves rather than seek treatment from their colleagues

10. THE EVIDENCE • Schernhammer Meta-analysis10 • Looked at 24 studies that included information about physician suicide and mental illness. • AFSP meeting of experts in 200511 • 35 experts met over 9 months • Discussed potential explanations and focused on prevention • Agerbo et al Study in Denmark12 • 496 suicides from 1981-1997 compared with 800 control cases

11. RISK FACTORS • Divorced, widowed, never married (Single)5 • Graduate of a high prestige school • Described as driven, competitive, compulsive, individualistic, ambitious • Never had children • Alcohol or drug use • Underlying medical illness (often seen as a flaw)6 • History of mental illness (depression, bipolar, etc) • Fewer friends and less social support • Previous suicide attempts • Family history of suicide attempts • Female • Early career physicians (first 7 years after training) or after retirement

12. THE THEMES • Women are at higher risk of depression and suicide • Physicians as a whole have a higher risk for mental health disorders and substance abuse and a higher rate of suicide • Physicians attempt suicide at a somewhat higher rate than the general population but are significantly more likely to complete suicide • Physicians have a lower incidence and risk of death from medical diseases but 2-3X higher risk of death by suicide. • Physicians (even if they know they have a mental health diagnosis) seek treatment less frequently. • The physicians at highest risk are female, single, competitive, driven psychiatrists who have a personal or family history of substance abuse or mental illness

13. CULTURE OF MEDICINE • Significant stigma on physicians for seeking help with mental illness and substance abuse • Some hesitation by psychiatrists to treat colleagues • Women feeling subject to gender or sexual harassment in the workplace • Emotionally difficult patients • High stress work environment • Training (SOM and residency) teaches an unhealthy lifestyle that many can not maintain throughout their careers • State medical licensing boards reporting guidelines • Doctor, heal thyself

15. MEDICAL BOARDS • 20 CSR 2150-2.015 Determination of Competency • “Mental incapacity”—suffering from a mental illness or disorder to such an extent that he or she lacks the capacity to practice his or her profession • Concern is brought to the board > board requires evaluation by one of their selected providers > practitioner meets with the board > board makes a decision about fitness for duty • Some are concerned that any mental illness could be construed as having a mental incapacity. There is some previous precedent for this.

16. JOINT COMMISSION

17. SECOND VICTIM • Second victim14 – healthcare providers who are involved in an unanticipated adverse patient event, in a medical error and/or a patient related injury and become victimized in the sense that the provider is traumatized by the event. Frequently, these individuals feel personally responsible for the patient outcome. Many feel as though they have failed the patient, second guessing their clinical skills and knowledge base. • “Human fallibility versus perfection is not deeply integrated within many health professional training programs, so preparation for medical error consequences is far from developed” 14 • Scott et al

18. SECOND VICTIM • High risk scenarios • Patient who “connects” to health care professional’s own family • Unanticipated clinical event involving a pediatric patient • Unexpected patient death • Preventable harm to patient • Multiple patients with bad outcomes within a short period of time within one clinical area • Long-term care relationship with patient death • Clinician experiencing his or her first patient death • Failure to detect patient deterioration in timely manner • Death in a young adult patient • Notification of pending litigation plans • Community high-profile patient or event • Health care professional who experienced needle stick exposure with high-risk patient • Death of a staff member or spouse of a staff member

19. SECOND VICTIM • Stages of Recovery • Stage 1 – Chaos and accident response • At the time of event the clinical has chaotic and confusing scenarios of what occurred. Period of rapid inquiry. Often remove themselves and transfer care to a colleague due to blaming themselves • Stage 2 – Intrusive reflections • Period of re-enactments with feelings of inadequacy and self-isolation. Repeatedly asks “what if” • Stage 3 – Restoring personal integrity • Seek support from someone they trust. Many will not do this for fear of what others will think or that others would no longer trust them. • Stage 4 – Enduring the inquisition • Concerns about how the institution will react and repercussions to them personally (job security, licensure, litigation) • Stage 5 – Obtaining emotional first aid • Seeking emotional support from someone they trust (most are unable to identify a person that can understand the event and be trusted) • Stage 6 – Moving on-dropping out, surviving, or thriving • Push from others to move on. Results in dropping out (changing professional role, leaving profession, or moving), surviving (performs as expected but continues to be plagued by the event), or thriving (made something good come from it).

22. PHYSICIAN IMPAIRMENT PROGRAMS • Missouri Physicians Health Program13 • 680 Craig Rd, Suite 308, St. Louis • (800) 958-7124, (800) 274-0933 • www.themphp.org • Operated by MSMA + MAOPS • Regional coordinators in Columbia, KC, Joplin, Poplar Bluff, and Springfield • Treat substance use disorders, process addictions (gambling), mental health problems, sexual misconduct and/or boundary violations, stress management, physical illness, cognitive issues, issues related to aging, and licensure issues • Cares for MDs, DOs, physician family members, medical students, and residents • It does cost a monthly fee while participating in services • NO reporting responsibility to MO Board, DEA, BNDD, etc

23. PREVENTION • Huge cultural shift and change in training • Work-life balance • De-stigmatize • Balint groups • Educate medical students and residents about mental health and suicide • Encouragement, financial assistance, and time allotted for trainees to receive primary care and mental health services.

24. CONSENSUS STATEMENT FROM AFSP • Hospitals and medical centers should be convinced to do yearly anonymous screenings. • Hospitals should implement programs that train medical students and physicians to recognize depression in themselves, colleagues, and patients. • Medical schools and hospitals should work with insurance companies to develop in-house consultation, referral, and treatment services for students and residents with mental health problems. • Data on treatment services offered to medical students and residents with mental health problems should be collected. • Decisions about physician licensing and credentials should be based on professional performance, not psychiatric treatment or diagnosis. • State wellness programs should address the needs of physicians who are depressed, but not necessarily abusing substances. • Physicians applying for insurance should be informed of their rights, privileges, and obligations regarding disclosure of a psychiatric diagnosis and/or treatment.

25. WHAT CAN WE DO? • Be aware of your and your peer’s mental health and the warning signs • Be open to consultation with medical students, peers, attendings, etc that seek out your help • Seek out furthering education on the topic • Get involved with peer support groups (ForYOU) • Educate other physicians • Advocate for change in public policy to increase access to mental health care and decrease stigma

26. RESOURCES FOR PHYSICIANS • The National Mental Health Association (http://www.nmha.org/index.cfm). This nonprofit organization addresses all aspects of mental health and mental illness, including advocacy, education, research and service. • The National Institute of Mental Health (http://www.nimh.nih.gov/). The mission of this government agency for research on mental and behavioral disorders, part of the National Institutes of Health, is to reduce the burden of mental illness and behavioral disorders through research on mind, brain, and behavior. • The American Psychiatric Association (http://www.psych.org/). This a medical specialty society that works to ensure humane care and effective treatment for all persons with mental disorders. Links to topics relating to physician suicide are provided. • The American Foundation for Suicide Prevention (http://www.afsp.org/). This nonprofit organization funds research, develops prevention initiatives, and offers educational programs and conferences for friends and family of individuals who died by suicide, mental health professionals, physicians, and the public. • The American Association of Suicidology (http://www.suicidology.org/). This nonprofit organization promotes research, public awareness programs, and education about suicide. • The Bazelon Center for Mental Health Law (http://www.bazelon.org/). This national legal advocate for individuals with mental disabilities works to advance and preserve the rights of individuals with mental illnesses and developmental disabilities.

27. TAKE HOME POINTS • Rate of suicide among physicians is 2-3 times higher than the general population • Suicide attempts are much more frequently lethal • Mental illness and substance abuse are significant risk factors • Complex problem with a lot of variables • Second victim phenomenon may play a large role • There is help with the MPHPand numerous agencies with resources. • It will require a large shift in the culture of medicine and medical training to effect significant change on this topic • If you are struggling with mental illness, substance abuse, or suicidal thoughts please reach out to colleagues, private psychiatrists, primary care, therapists, etc. • Do not suffer in silence!

28. REFERENCES • 1. Council on Scientific Affairs: Results and implications of the AMA-APA Physician Mortality Project, Stage II. JAMA 1987; 257:2949-2953 • 2. Samkoff JS, Hockenberry S, Simon LJ, et al: Mortality of young physicians in the United States, 1980-1988. Acad Med 1995; 70:242-244 • 3. Everson RB, Fraumeni JF: Mortality among medical students and young physicians. J Med Educ 1975; 50:809-811 • 4. Rich CL, Pitts FN: Suicide by psychiatrists: a study of medical specialists among 18,730 consecutive physician deaths during a five-year period, 1967-72. J Clin Psychiatry 1980; 41:261-263 • 5. Rose KD, Rosow I: Physicians who kill themselves. Arch Gen Psychiatry 1973; 29:800-805 • 6. Ross M: Suicide among physicians: a psychological study. Dis Nerv Syst 1973; 34:145-150 • 7. Valko RJ, Clayton PJ: Depression in the internship. Dis Nerv Syst 1975; 36:26-29 • 8. Welner A, Marten S, Wochnick E, et al: Psychiatric disorders among professional women. Arch Gen Psychiatry 1979; 36:169-173

29. REFERENCE • 9. O'Connor PG, Spickard A: Physician impairment by substance abuse. Med Clin North Am 1997; 81:1037-1052 • 10. Schernhammer E: Taking their own lives-The high rate of physician suicide. NEJM 2005; 352:2473-2476 • 11. Hampton T: Experts Address Risk of Physician Suicide. JAMA. 2005 ;294:1189-1191. • 12. Agerbo et al: Familial, psychiatric, and socioeconomic risk factors for suicide in young people: nested case-control study. BMJ. 2002 Jul 13;325(7355):74 • 13. www.themphp.org • 14. S D Scott, Office of Clinical Effectiveness, University of Missouri Health System, One Hospital Drive, 1W-29, DC 103.40, Columbia MO 65212, USA

30. Questions?

31. Suicide Prevention Hotline 1-800-273-8255 • Missouri Crisis Hotline (573) 445-5035