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Physician suicide too often “brushed under the rug”

Roger Collier | CMAJ | September 9, 2017

“We have a system where people fear punitive consequences if they get help,” said Dr. Christine Moutier.

When Dr. Christine Moutier worked for the University of California, San Diego, she was asked by the dean of medical education to find out the number of deaths by suicide among faculty physicians. She began looking at the previous 15 years, expecting to find they had lost four, perhaps five, doctors to suicide. To her surprise, and dismay, the number was actually 13.

“I would venture to guess that our experience of suicide loss is not necessarily different from other academic institutions,” said Moutier, now chief medical officer of the American Foundation for Suicide Prevention, during a session at the Canadian Conference on Physician Health in Ottawa.

In society in general, there is “change afoot” when it comes to talking about mental health and suicide, said Moutier. Young people discuss these topics more openly than previous generations, understanding it is part of navigating their lives. There has been some progress on addressing mental health issues in the medical profession as well, though not nearly enough, noted Moutier.

“We physicians have some catching up to do,” said Moutier. “Clinicians who protect their own health, including mental health, provide better care for others.”

Moutier presented data on the mental illness toll on doctors in the United States. Research shows that 39% of physicians have experienced depression, twice the rate of the general population. About 400 die by suicide every year.

“Part of the problem is that it does get brushed under the rug in many instances,” said Moutier, sharing the story of how the suicide of one physician at an academic institution was not even mentioned at a department meeting held soon after.

Too often in medical and academic institutions, lamented Moutier, the problem is not acknowledged, let alone addressed, until a prominent physician or beloved colleague dies from suicide. “We live with the status quo until we can’t any longer,” said Moutier. “When you lose somebody and it’s smack right in your face, you can no longer tolerate the status quo.”

In general, the culture of medicine has put a low priority on improving mental health among its practitioners, said Moutier. This is true despite general acceptance that people drawn to medicine tend to have traits that make them prone to potential problems — traits such as perfectionism, an exaggerated sense of responsibility, a compulsion for achievement, and difficulty asking for help.

“Some of these traits have set us up for higher rates of distress,” said Moutier.

When it comes to suicide, however, there are many other factors at play as well, stressed Moutier. There are aspects related to an individual doctor’s biology, psychology and work environment. The dynamic interplay between internal and external factors make it a challenging problem to understand and address.

“There are always multiple risk factors that have converged like a perfect storm,” said Moutier.

A psychological autopsy study found that physicians who died from suicide were 20–40 times more likely to have ingested benzodiazepines, barbiturates or antipsychotics prior to death than the general population, noted Moutier. They were also three times more likely to have been experiencing problems at work.

One particular troubling aspect of physician suicide is that medical expertise makes it far more likely that a suicide attempt will be successful. “We have knowledge that is specialized about life and death and lethality,” said Moutier.

A major barrier to addressing suicide and other mental health issues in the medical profession is the strong stigma that persists. Too often, a mental health problem is considered to imply automatically some form of impairment that inhibits effective medical practice. But that is simply not true, said Moutier. Stigma reduction is a core aspect of all successful suicide-prevention programs, she added.

Moutier cited a survey of 2100 female physicians in which one of three respondents reported receiving a formal mental health diagnosis since medical school. Most tried to manage the problem on their own, including writing their own prescriptions. Only 6% disclosed their diagnoses to state licensing boards.

“We have a system where people fear punitive consequences if they get help,” said Moutier.

To address this issue at the University of California, San Diego — after they discovered the extent of the problem — the medical school took a two-pronged approach. First, they launched an educational campaign that focused on destigmatizing suicide and promoting help-seeking and treatment. But education alone is “not quite enough to truly reach those in distress,” said Moutier.

So the university also created an online anonymous interactive screening program. Faculty physicians and medical students are able to complete questionnaires and engage in anonymous dialogs with counselors. It has resulted in a 40% increase of medical students seeking help and 230 referrals of doctors for treatment. Since the program began 11 years ago, there has been only one death by suicide among faculty physicians.

Photo credit: Mark Holleron/CMA



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