8
doc • Spring 2015
Kentucky
Clinical Perils
Suicide in Physicians
By Robert P. Granacher Jr., M.D.,
M.B.A.
Overview
Last fall a central Kentucky surgeon called
his family and then killed himself on the
roof of a small town surgery center parking
garage. Like many depressed patients who
complete suicide, he had seen a physician
or therapist shortly before his death. It has
been estimated recently that on average in
the United States, as many as 400 physicians die by suicide each year (the equivalent of at least one entire average medical
school class). Physicians globally have a
lower mortality risk from cancer and heart
disease relative to the general population,
however, they have a significantly higher
risk of dying from suicide. Even more
alarming for our future is that, after accidents, suicide is the most common cause of
death among medical students.
Statistically, physicians have a far higher
suicide completion rate than the general
public with male physicians dying at a rate
70% higher than the male rate in the general population. Moreover, female physicians
attempt suicide far less often than their
male counterparts, but their completion
rate exceeds female suicides in the general
population by 250 to 400%.
It is assumed by experts that suicide as a
cause of death in physicians is underreported. This is most likely due to sympathetic
colleagues who may skew the reporting,
and thus the real incidence of physician
suicide is probably higher than published
statistics. The most common psychiatric
diagnoses among physicians who complete
suicide are depression, bipolar disorder,
alcoholism and substance abuse, but physician rates of these diseases is much less
than in the general population while the
physician suicide rate is much higher. The
most common means of suicide by physicians is lethal medication overdose or use
of firearms. Thus, for we physicians as colleagues or as treaters of other physicians, it
must be remembered that suicide does not
occur in the absence of a cause or contributing factor.
Problems with Treating
Our Physician Colleagues
It is common among physicians who
attempt to treat physician colleagues to see
them as special patients, and thus the treatment develops into the “VIP syndrome.”
This is represented by superficial or inadequate treatment, excess concerns about
confidentiality and the suicidal physician’s
own concerns about medical licensure applications, renewed applications for licensure,
and other intrusive questions that may be
involved in the relicensure process. Most
states, including Kentucky, have physician
health programs that are advertised as independent of the medical licensing authority.
However, it is not unusual for a suicidal
physician, who is contemplating or in
need of psychiatric treatment, to be almost
universally unaware of these provisions or
to perceive a lack of confidentiality. Even
more extreme for the ill physician is the discrimination toward physicians with a mental
diagnosis. Health, disability, and liability
insurance have been, and may be, denied
to physicians who admit to depression, or
treatment for depression, particularly if they
have been suicidal. It is known that some
application processes require physicians
to answer intrusive questions about their
mental health history and diagnoses, and in
some cases these requirements may be out
of compliance with the provisions of the
Americans with Disabilities Act (ADA).
Those physicians treating medical colleagues for depression and suicidal ideation
or behavior, should be aware that many
physicians attempt to treat themselves. The
evaluation and history should include questions to determine whether this is occurring, as in Kentucky and many other states,
boards of medical licensure frown upon this
behavior and they may restrict or suspend
a physician’s license for engaging in such
behavior when depressed. It is not unusual
for physicians who are depressed and suicidal to be so concerned about the ramifications of treatment that they believe that selftreatment is their only personal-protective
alternative.
Prospective medical students and residents rarely will report a history of a prior
depression during the competitive selection
interviews for positions. The prevalence of
depression in these populations is unknown,
but it has been estimated to be 15 to 30
percent. Harassment and belittlement by
professors, higher-level residents or fellows,
and even nurses, contribute to the mental
distress of students and physicians in training, and aggravate depression. Job stress
has been found to be a major factor in high
rates of physician suicide (General Hospital
Psychiatry, published online, November 15,
2014). This study by Katherine Gold, M.D.,
noted that physicians who die by suicide are
much more likely than non-physician counterparts to have antipsychotics, benzodiazepines, and barbiturates found by postmortem toxicology, but not antidepressants. She
notes that there needs to be a much greater
effort to address the stigma of psychiatric illness and the under-diagnosis or treatment of
depression among physicians, and for greater understanding in how the stress related to
physician work can be modified or reduced.
Mental health treatment for physicians and
students must be made more available, safer
and more confidential.
The Culture of Physicians
as a Contributor to
Suicide Risk
What is it about physicians that can make
them their own worst enemy when suicidal
from depression or abusing substances? Dr.
Gary Carr, a Tennessee family physician
and addiction specialist has noted five cultural contributors to the risk of suicide and
avoidance of seeking help [ Journal of the
Mississippi Medical Association 2008:49
(10)]:
• Persons who choose medicine as a career
typically will not admit weakness or seek
help.
• Physicians see themselves as “care givers
not care receivers.”
• As a doctor, “I can’t have a problem; I’m
a doctor.”
• Physicians fear, often for good reason,
that acknowledging a substance use
disorder or a mental illness (e.g. depression) will adversely impact their career
or medical license.
• Mental illness