Addressing doctors’ suicide and mental health in the world of medicine.
Suicide is not a subject that is talked about as openly or easily as it should be. It seems even more shrouded in the medical community, and a great deal of mystery still surrounds it.
Too often when this topic is brought up, an unsettling silence stifles it and many will simply continue about their day.
I recently completed my first year as a junior doctor and it has only increased my admiration for medicine. But I’d have to doubt the genuineness of that if I cannot also discuss what’s wrong in medical education and practise.
Why does mental health seem like an almost taboo topic to talk about in our ranks? How many of our colleagues should suffer, or commit suicide, before we realise its seriousness? As someone passionate about mental health (and an aspiring Psychiatrist), I find the scale of such silence worrisome and dangerous. If awareness is the first step in minimising these attitudes, then we must meet this subject head-on, with honesty and acceptance. Besides, it also makes me wonder how much of this negative perception gets reflected in the wider world when we deliver care or advocate for mental health.
An individual’s suffering is often difficult for others to understand, as is the grief of lost loved ones. But what about when the person is a doctor?
In this two-part series, I hope to address the extent of mental illness and suicide in doctors, and what perpetuates it from an individual and institutional perspective. In this first part, I will cover the individual — problems facing a doctor and what leads to their suicide.
Suicide ranks as a disproportionately high cause for death amongst doctors, with depression as a major risk factor. Reports show that doctors have higher rates of depression and anxiety compared to the general population and other professional groups. According to the American Foundation for Suicide Prevention, 300–400 doctors die by suicide every year in the U.S alone. In the U.K, one doctor dies every three to four weeks. In some other parts of the world, we believe the numbers are higher.
We began this century with the tragic suicide of Dr Daksha Emson in October 2000, a young psychiatrist in the U.K. The report published in the aftermath, which includes her last diary entry before her death, is heart-rending to read. How much have things really changed since then?
Dr Lauren Phillips, a 26-year-old Junior Doctor, 2019. Dr Louise Tebboth, a general practitioner, January 2015.
Dr Lorna M. Breen, a top E.R doctor in Manhattan, took her own life in April 2019. “She tried to do her job, and it killed her,” her father said.
Dr Poulami Saha, a young doctor in her internship year in Calcutta, Dr Kimoto Aya in Niigata.
There are so many more names that I could give you.
The problem is worldwide and affects all ages, genders, specialties and occurs regardless of seniority or rank.
What we know of suicide is that there isn’t just a single factor that makes someone suicidal. As described by Edwin Schneidman, suicide is a ‘multidimensional malaise’. It involves facets of neurobiology, psychiatry, psychology, phenomenology, sociology, and culture.
Despite an increase in mental health research and awareness in the last few decades, there are still several doctors who end up taking their lives every year.
Why?
At the level of the individual (the doctor as a patient):
The most commonly associated psychiatric disorders with doctor’s suicide are major depressive disorder, bipolar affective disorder, alcohol and other drug abuse, anxiety disorders, and borderline personality disorder.
Many doctors who live with mental health problems and/or substance misuse either treat themselves, remain untreated or are under-treated because they do not receive enough attention, or escape attention. Here are some reasons for that:
Fear — they may not be honest about their mental struggles because they are afraid of facing discrimination. When they finally open up, they may not disclose suicidal ideations, any previous suicide attempts or plans of inflicting injury to themself because they are terrified of being forced into a hospital against their wishes.
Stubbornness — many doctors prefer independence in their approach to work and often claim to know what is best for themselves. Should they fall ill, this may translate into a stubbornness to cooperate.
Trust — they may be less trusting of their therapist because of issues related to confidentiality, ensuing investigations by licensing boards/councils and the likely detrimental effects on their career.
Internalised stigma — clinicians who treat them may have negative attitudes to mental illness, too. This makes them avoid certain questions, assume too much and therefore misdiagnose. Ill doctors may not be managed with the same care and vigilance as other patients because of this.
The work of a doctor demands a certain level of meticulousness in order to be competent and safe, so perfectionism is common in doctors and medical students. But in stressful times, these features can become excessive and drive a doctor to be so unforgiving and rigid to themselves. Perfectionism is a multidimensional concept and illness because of it is not surprising. When it goes too far, it can lead to suicide.
Many doctors carry a lot of unresolved trauma they don’t know about or won’t admit to because of shame. They may silence or berate the part of them that aches for rest and help. Psychological defences are developed for the sake of surviving in medicine, some of which become hindrances to help-seeking in the long-run. It is important to point out that Post-Traumatic Stress Disorder (PTSD) is under-recognised in doctors, even though it may be more prevalent in them than the general population.
In his book ‘Why People Die By Suicide’, Thomas Joiner postulates that suicide has three most important components that can lead toward suicide.
Perceived burdensomeness
Perceived failed belonging
Learned fearlessness
These may help us understand suicide in doctors.
Perceived burdensomeness: An ill doctor may feel like they would become a liability to others if they disclosed their pain. For many doctors who have a saw-edged sense of individualism, this may intensify because they would not want to ‘bother’ anyone.
Perceived failed belonging: Many doctors seem to live and work their entire lives mostly or only within the confines of medicine. When these doctors suffer an illness and cannot return to practice, they may feel severely neglected from being a name in a valued field.
Learned fearlessness: As for this, Joiner places it in the chapter ‘The Capability to Enact Lethal Self-Injury Is Acquired.’ He calls it the ‘accrual of fearlessness about and the means for suicide’ or ‘accrued lethality.’
Doctors are trained to greet patient and colleague alike with a smile and so can be clever in masking their symptoms. You may see nothing but a smile. But it’s a misconception to think depression is always a sad, gloomy individual. The face of depression is often a smile.
It’s an irony that healers rarely take advantage of healing for themselves. Many doctors may rationalise their symptoms as by-products of their work. They may be bent on the notion that it is their only way out. But if more doctors demonstrate healthy expression of emotion and how to receive care, it may help ease the silence and stigma around it. It will encourage other doctors to engage in mental health-promoting behaviour.
Suicide is an illness, not a crime. Perhaps we can start with the emphasis on that. Convincing the individual alone, however, will not solve our problem. Even though we are in the 21st century, it’s quite shocking to think that mental health associated stigma remains a quiet, deadly serpent in the realm of medicine. Irrational fear and perceived stigma may (often because of mental illness impairing thoughts and perceptions) make the ailing doctor feel judged by their family and friends.
But there is another type of stigma that is at play — one alive in the institutions and their cultures.
In Part 2, I will discuss mental health-related issues at the level of the institution — from the culture of medicine to backward standards, under-funding and so on, and on working towards a better future.