Preventing Physician Depression and Suicide

Preventing Physician Depression and Suicide

Department of Psychiatry UNMC

Top causes of death among residents

#1 Neoplastic

#2 Suicide

Higher rates of death early in residency (first two years)

Unchanged over the last 15 years

Yaghmour et al. Causes of Death of Residents in ACGME-Accredited Programs 2000 Through 2014: Implications for the Learning Environment. Acad Med. 2017 Jul;92(7):976-983

Suicides cluster at certain times of year

Higher in the first (July) and third quarters (after winter holidays) of academic year

Physician Suicide Is a
Multi-Faceted Problem

Individual factors

The training environment

Culture of medicine

An estimated 400 physicians die by suicide in the US per year

Center C, Davis M, Detre T, Ford DE, Hansbrough W, Hendin H, Laszlo J, Litts DA, Mann J, Mansky PA, Michels R, Miles SH, Proujansky R, Reynolds CF 3rd, Silverman M M (2003). Confronting Depression and Suicide in Physicians. JAMA, 289(23), 3161.

Risk Factors for Suicide (1/2)

Mental disorders (particularly depression)

Alcohol and/or other substance use disorders

Previous suicide attempt(s)

Family history of suicide

Impulsive or aggressive tendencies

Easy access to lethal means (e.g., firearms)

Losses and other events (e.g., the breakup of a relationship or a death, academic failures, legal difficulties, financial difficulties, or bullying)

Isolation, a feeling of being cut off from other people

Feelings of hopelessness

US Public Health Service, The Surgeon General's Call to Action to Prevent. Suicide. Washington, DC: 1999.

Risk Factors for Suicide (2/2)

Trauma or abuse history

Chronic physical illness, including chronic pain

Exposure to the suicidal behavior of others

Cultural and religious beliefs (e.g., belief that suicide is noble resolution of a personal dilemma)

Unwillingness to seek help because of the stigma attached to mental health and substance use disorders or to suicidal thoughts

Barriers to accessing mental health treatment

US Public Health Service, The Surgeon General's Call to Action to Prevent. Suicide. Washington, DC: 1999.

Suicide Warning Signs – Talk

A person who is considering suicide may talk or write about:

Killing themselves

Death or dying

Feeling hopeless, helpless or worthless

Having no reason to live

No sense of purpose in life

Being a burden to others

Feeling trapped

Unbearable pain

Suicide Warning Signs – Behavior

Concerning behaviors, especially if related to a painful event, loss or change:

Increased alcohol and/or drug misuse

Searching for a way to end their lives, e.g., searching online for materials or means

Withdrawing from activities

Isolating from family, friends and community

Reckless behavior or more risky activities, seemingly without thinking

Sleeping too much or too little

Tying up loose ends

Visiting or calling people to say “goodbye”

Giving away valued possessions to others

Aggression

Fatigue

Not making plans or looking forward to future events

Suicide Warning Signs – Mood

A person who is considering suicide may display one or more of the following:

Depression

Anxiety

Loss of interest

Dramatic mood changes

Irritability

Humiliation

Agitation

Rage

Sudden improvement in mood after he/she had appeared depressed for a while

Predictors of Depression in Physicians

Difficult relationships with senior doctors, staff, and/or patients

Lack of sleep

Dealing with death

Making mistakes

Loneliness

24-hour responsibility

Self-criticism

Bright RP, Krahn L. Depression and suicide among physicians. Current Psychiatry. 2011; 10(4):16-30.

Protective Factors Against Suicide

Effective clinical care for mental, physical and substance use disorders

Easy access to a variety of clinical interventions and support for help seeking

Connectedness– Strong connections to individuals, family, community and social institutions

Support from ongoing medical and mental health care relationships

Skills in problem solving, conflict resolution and nonviolent ways of handling disputes

Cultural and religious beliefs that discourage suicide and support instincts for self-preservation

US Public Health Service, The Surgeon General's Call to Action to Prevent. Suicide. Washington, DC: 1999.

Barriers to Treatment

Fear of recrimination by colleagues, facilities where they work, credentialers, or licensing boards

Perceived lack of confidentiality–

Fear that his/her illness will be documented in his/her academic record

Accessibility–

Difficulty finding a local provider who he/she trusts, but is not a colleague

Reluctance to seek treatment

Time constraints

Affordability

An attempt to diagnose and treat themselves

Seeking and receiving “VIP treatment” from other health care providers

Belief that treatment does not work

Bright RP, Krahn L. Depression and suicide among physicians. Current Psychiatry. 2011; 10(4):16-30.

Lack of Mental Health Treatment (1/2)

Fears about the potential for seeking mental health care to negatively impact one’s professional reputation, ability to get or maintain licensure, or malpractice insurance are largely unfounded

What is more likely to harm a physician’s reputation, licensure and insurance, are unaddressed and worsening mental health conditions

Gold KJ, Sen A, Schwenk TL. Details on suicide among US physicians: Data from the National Violent Death Reporting System. General Hospital Psychiatry. 2013; 35(1), 45-49.

Lack of Mental Health Treatment (2/2)

In cases where physicians died by suicide, depression is found to be a significant risk factor leading to their death at approximately the same rate as among non-physician suicide deaths

Physicians who took their lives were less likely to be receiving mental health treatment compared with non-physicians who took their lives

Gold K J, Sen A, & Schwenk T L. Details on suicide among US physicians: Data from the National Violent Death Reporting System. General Hospital Psychiatry. 2013; 35(1), 45-49.

Burnout

Emotional exhaustion–

Tired, nothing left to give, no pleasure

Depersonalization–

Cynicism, going through the motions, like a robot, automatic pilot

Decreased sense of accomplishment–

Never good enough, not worthwhile

Stress and Productivity

Approaching a Depressed Colleague

Take the lead and be gently assertive–

As a general rule, it is easier and safer for healers to be in the healing role and much harder to be in a position of vulnerabiReach out and do not wait for them to come to you

Normalize their experience–

Remind him/her of the difficult realities of medicine

Your training and your work is inherently stressful and challenging

Hence, feeling distressed or overwhelmed is natural at times

If you are comfortable, self-disclosure or sharing examples of others who have struggled can be powerfully validating

Be a good observer–

Do not tell someone how you think they may be feeling, as this could be experienced as either threatening or condescending

Rather, observe and reflect their behavior, and ask them to ascribe meaning (e.g., “I notice you have been late to clinic/class a lot lately. How are things going for you?”)

Be reassuring–

Even though depression and other emotional problems can impact work performance at times, it does not mean you are a bad physician

It means you need to take steps to take better care of yourself

Be willing to offer flexibility and space for the person to get the help they need–

All the compassionate listening and caring for our students, trainees and colleagues will not amount to much if we do not offer opportunities for them to avail themselves of the resources they need in times of emotional distress

Furthermore, individuals probably need to hear very clearly that there will be no negative repercussions for them seeking and receiving help in times of need

Speak clearly and directly–

Once the conversation is opened, do not be afraid to use words like “depression” or “suicide”

If people are struggling with these issues, it can a relief to have an opportunity to discuss them

Know your resources–

Be ready to offer real help in the form of information about how a person in your environment can get help quickly, if necessary

Please see “Suicide Prevention” Resource Document provided by the GME office.