February 18, 2009

Guess What Isn't The Cause Of Physician Suicide

Don't worry, the word narcissism does not appear in this post.

A review article in Psychiatry finds that the suicide rate among physicians is higher than the general population.  What's interesting about the article is what they don't find.

What they do find is that the male rate is lower than the general population, but the female physician rate is not only higher than the general population, it is even than the male rate.

Why?  Cultural bias might suggest women would be happy to have advanced to the level of doctors; though that same bias, read the other way, might suggest that the unrealistic expectations of how awesome it is to be a doctor meeting the reality might drive them to suicide.   Speculation, your Honor.

The article then explored causes for physician suicide, and this is where it got interesting.  The article cites a number of reasons: role conflicts, career dissatisfaction, personality stylings, morale-- all the possibilities even a layman might suggest.

But these aren't laymen, they're psychiatrists.  What the psychiatrists do not point to as a cause is psychiatric illness.

In any study about suicide, psychiatric illness, depression, bipolar, etc, is the main cause, if not the only cause, cited.  Axis I pathology is the framework for interpreting the rates, as well as deciding what to do about it.    Not "life got him depressed," but "he had depression."  Not "lifestyle modifications, religion, family" but "there are a number of treatments available."

But in this article, only one paragraph is given to Axis I disorders. 

As an example of the prevalence of depression among physicians, according to a 2006 survey by the American College of Physician Executives, over two-thirds of responding physicians reported burn-out and nearly a third acknowledged current depression.

Biologic predisposition need not be involved.

The only Axis I pathology noted with any assuredness is alcohol abuse, but not as an independent diathesis for abuse, but as an outward expression of the distress.

As with suicide in the general population, in addition to depression, alcohol and substance abuse are common factors associated with physician suicides.[16,23] Alcohol and/or substance usage affect anywhere from 20 to 40 percent of physician suicide completers.

The article cites the ten (1)  studies on this topic published since 1973.  None of them cite psychiatric illness as the major cause; social explanations figure more prominently than biologic ones.

Indeed, even the title of this study belittles a psychiatric or endogenous cause: "Physician Suicide: A Fleeting Moment of Despair."


I don't disagree with their analysis, but  it's funny/scary to see the very people who are biased towards the organic model basically disavow the link when it applies to themselves.

Given the current climate of healthcare and the seemingly unending stressors in the practice of medicine, we physicians must be mindful of ourselves and our colleagues. We need to be sensitive to psychological distress in ourselves and others and be willing to obtain and offer support when needed.
But what about an SSRI?  The need for an adjunctive "mood stabilization from below?"

In many cases, the suicidal impulse is a temporary phenomenon--one that will pass. We must be on guard not to lose ourselves or talented colleagues in a fleeting moment of despair.
When was the last time you heard a psychiatrist suggest that suicidality was temporary or transient?  Why assume our colleagues are talented? 

It appears to this blogger that when psychiatry has little direct information about the social factors impacting a group's lives-- for example, college students in China-- psychiatric explanations are held as paramount.  When they are intimately familiar with the group, they lose perspective. 

This is, essentially, the fundamental attribution error.  We interpret the behavior of other people as the result of something about them (jerk, meanie, idiot), but we'd interpret the exact same behavior of ourselves as the result of circumstance.

Psychiatrists are assuming doctors attempt suicide in reaction to situations; but assume that others that they don't really know attempt suicide as a result of something about them.

The key is the italicized part; the more you know of a person, the more likely you are to blame circumstance.  The less you know of a person, the more likely you are to blame them.   The question is which of those two is the error-- not knowing enough about another's circumstance, or not being able to step back and see ourselves from the outside, for who we are?

There's a term for the latter, but I cannot remember what it is.


1. Three examples of the cited studies:

Petersen's study (2008) of 1984 through 1992 from 26 states, and looking only at whites, finding 181 male and 22 female doctors/dentists who suicided, the word "depression" does not even appear at all.  Neither does Axis, etc.

Scherhammer's study of rates (2004): "depression" appears only twice.

Aasland's study (2001) found that being married is protective; but summarily dismissed the link to psychopathology with that depression and drug abuse are the most common psychiatric illnesses found in doctors, but that most people who are able to become doctors probably don't have serious psychopathology.  Ok-- so suicide isn't a marker for psychopathology?

In Hem's study (2005) only three sentences are given to the possibility of a psychiatric illness; and then it is explicitly minimized: "However, there may be specific reasons [why doctors commit suicide.]"  The study cites over a dozen: stress, long hours, access to lethal medications, etc.   

More than 60 different risk factors for suicide have been described. Thus, suicide is a multi-determined event, and the search for a single explanatory factor is too simplistic.


Basically, they're saying i... (Below threshold)

February 19, 2009 12:00 AM | Posted by Guffin Mopes: | Reply

Basically, they're saying it sorta makes sense?

Messsed up.

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looks to me like simple bia... (Below threshold)

February 19, 2009 12:05 AM | Posted by Aaron Davies: | Reply

looks to me like simple bias towards assuming they and their friends are sane. reminds me of a law review article showing how judges expand continually client-lawyer privilege while shrinking client-doctor (or anyone else) privilege.

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Your perspective on this ph... (Below threshold)

February 19, 2009 1:34 AM | Posted by ItsTheWooo: | Reply

Your perspective on this phenomenon is insightful and I do tend to agree, however I think there is another reason (besides being biased toward people you identify with).

From my own experience with mental health professionals, a diagnosis of insanity seems largely determined by functionality, which in turn is largely determined by being able to partake in employment or career consistently. Basically, crazy people can't function, which means they can't hold down a job and can't possibly have a consistent career. Being a physician suggests not only having stable employment, thus functionality, but it suggests SUPER functionality because of the fact that one is a physician is such a difficult to obtain career. Think about it, in order to become a physician one must possess the mental/emotional stability to make it through 4 yeras of college, and then 4 years of medical school, followed by 4 years of residency, and then all the years of practice (up until your suicide in this case). You've got to have your mind working right to do that. Crazy people can't do it, unless they are specifically doing things to control the crazy (e.g. meds) and very high functioning.

So, I don't know if it is an exclusive issue of blindness and double standards ... it's more to do with the fact that employment history and career is a big part about whether or not we consider someone to have a mental illness (and the assumption that people who are uncontrolled mentally ill cannot have stable employment and careers).

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This is an important piece... (Below threshold)

February 19, 2009 3:37 AM | Posted by Sally: | Reply

This is an important piece. A problem with psychiatry is that what is considered a symptom in one person is considered an understandable, reasonable response in someone else. This is what sets "psychiatry" apart from other fields of medicine. The etiology fight is pointless as one can always use the analogy that a bleeding would must be treated whether from a gun shot or a cut but "mental illness" is not always illness. A poor, lonely person might be labeled hypersexual for the exact same behavior that gets a psychiatrist a sly wink. A physician commits suicide and it's proof that the practice of medicine puts unfair stress on doctors, a homeless person does so and it's proof that untreated mental illness causes death...

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Dear Mr. Last Psychiatrist,... (Below threshold)

February 19, 2009 9:44 AM | Posted by jessa: | Reply

Dear Mr. Last Psychiatrist,

I love you.

This makes me so happy, your noting this double standard. It is one that I hadn't noticed, so it makes me even happier that someone within the field noticed it without having to have it beaten into him by someone from the outside. Although I probably didn't notice it because I have never seen these studies.

Dear Mr. (Ms.) ItsTheWooo,

I can see the point that stable employment can be seen as evidence that there isn't mental illness while unemployment can be seen as evidence of mental illness. However, this is not always the case. Consider me. I first showed up in the world of mental health care as a high school student and continued as a college student. A 4.0 GPA and good work ethic wasn't enough to show that I wasn't crazy. I don't know how they thought I managed that while I was supposedly so crazy, but they took it as perfectionism and workaholism, which is an entirely valid possibility. However, that entirely valid possibility is no less possible for their colleagues. Why assume that I manage to do so well in school because I am using it to cope with the out-of-controlness of the rest of my life but not allow that same possibility for the doctors? Or perhaps they do allow it as a way of coping, but for doctors it is a way of coping with stress and heartbreak, while for patients it is a way of coping with mental illness. Situations can cause just as much distress as mental illness and can be handled with the same coping mechanisms. So why assume that the doctor who presents this way is struggling situationally and the patient is ill? Your objection may hold some truth in that stable employment CAN be indicative of a lack of mental illness, but this is by no means a guarantee and still leaves that double standard intact.

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The word narcissism doesn't... (Below threshold)

February 19, 2009 10:13 AM | Posted by Nadia: | Reply

The word narcissism doesn't appear here, but of course my mind flew to it to check if this could be part of the problem. Physicians thinking they're above lowly mental illness? And propagating that image without any semblance of self-doubt?


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Great post. Clever insight.... (Below threshold)

February 19, 2009 10:31 AM | Posted by MedsVsTherapy: | Reply

Great post. Clever insight. Another hypothesis: there is growing awareness of the association between SSRI use and suicide. SSRI use, at least for some, or SSRI withdrawal, may provoke agressive impulsiveness (speculation, your honor). SSRI plus alcohol is even more risky.

If the use of SSRIs is sufficiently high in the psychiatrist trade, this could account for the observed rate.

Like I said, there is emerging epi type data on SSRIs and aggressive acts, incl. suicide, road rage, and killings.

Now, recently, the possible physiological connections are getting mapped out: nitric oxide in frontal lobe. NO as neurotransmitter is affeted by SSRIs. And NO variation may be assoc with aggressive impulsiveness:

Reif A, Jacob CP, Rujescu D, Herterich S, Lang S, Gutknecht L, Baehne CG, Strobel A, Freitag CM, Giegling I, Romanos M, Hartmann A, Rösler M, Renner TJ, Fallgatter AJ, Retz W, Ehlis AC, Lesch KP. Influence of functional variant of neuronal nitric oxide synthase on impulsive behaviors in humans. Arch Gen Psychiatry. 2009 Jan;66(1):41-50.

I believe there is a fair amount of psych med use among psychaitrists, from my biased sample of hearsay. Hey, I'm just sayin'. Something to think about.

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I did a quick research of d... (Below threshold)

February 19, 2009 11:49 AM | Posted by Dave Johnson: | Reply

I did a quick research of depression, substance abuse and doctors, looking for comparative studies. Very, very few.

You're on a roll ...

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neah, it's much simpler tha... (Below threshold)

February 19, 2009 2:14 PM | Posted by Trei: | Reply

neah, it's much simpler than that.
Doctors don't get sick. Plumber’s faucets never leak. Light-bulbs never flicker in an electrician’s house.Dentists aren't afraid of the drill. And so on.

It's a magical world out there.

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Ms ItsTheWooo :)Je... (Below threshold)

February 19, 2009 3:08 PM | Posted by ItsTheWooo: | Reply

Ms ItsTheWooo :)

Jessa, I would argue there is a big difference between being a super achieving student and a successful physician. The later requires obsessive focus, often shutting out the real world (other people especially) and indicates neuroticism at the very least. Being a physician requires some measure of balance between your mind and the outside world, because of how often you need to interact with others in addition to maintaining a high level of acheivement. Students with mental illness often become very high achievers in school as a way to deal with mental illness. I'm a perfect example of that; I went from being unable to go to school or leave my house, to being extremely obsessive and getting the best grades (that is to say, once I started leaving my house again). Certainly this is much preferred to previous behavior, but ultimately it was a sign of crazy (although admittedly a much higher functioning form than before).

The reason I thought of this is because I personally wanted to be a doctor when I was younger, but when I considered the confidence, stress and stability required of it, I realized it would not be possible for me. I expect others think along the same lines: crazy people can't be doctors. Or Lawyers. Or any stressful career.
"Physician" (or "lawyer" or "judge" or any profession) is includes being "high functioning" which translates into "not mentally ill".

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*the formerPlz excus... (Below threshold)

February 19, 2009 4:14 PM | Posted by ITW: | Reply

*the former
Plz excuse my writing, honestly english is my first language.

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"Physician" (or "lawyer" or... (Below threshold)

February 20, 2009 10:18 AM | Posted by dymphna: | Reply

"Physician" (or "lawyer" or "judge" or any profession) is includes being "high functioning" which translates into "not mentally ill".


Wow. Don't tell Kay Redfield Jamison.

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Ms. ITW, Yes, I do... (Below threshold)

February 20, 2009 10:41 AM | Posted by jessa: | Reply

Ms. ITW,

Yes, I do see your point, even that the stability required of a student is not necessarily equal to that required of a doctor, lawyer, whatever. Still, that may be a stereotype for a reason, because there really may be more people who are able to handle school while mentally ill than being a doctor while mentally ill, but it is still a stereotype and still not universally true. As soon as someone is labeled "patient," the perception of the cause of their problems seems to change immediately.

If we can determine that another profession, law for example, is really comparable to medicine in those stereotypical ways, perhaps we can test to see whether or not it is those attributes of supposed stability they are really relying on, or if it is, like Last posited, more about familiarity and implicating oneself. If I had to guess, I would say I think it is a little of each, but much more the latter than the former. (Pesky English skills again. :)

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Service workers all know th... (Below threshold)

February 20, 2009 5:15 PM | Posted by Anonymous: | Reply

Service workers all know that lawyers and doctors are keeeerazy.

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Denial of mental illness is... (Below threshold)

February 20, 2009 6:09 PM | Posted by beelicious: | Reply

Denial of mental illness is the cultural norm in medicine. Part of this is probably due to the "doctors make bad patients"/failure to recognize pathology in oneself factor. But fear also plays a role. Admitting being treated for a mental illness can trigger some really ridiculous and draconian requirements from some state medical boards. Thus, what axis I pathology there is among physicians often goes untreated.

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Dymphna - Kay Redfield Jami... (Below threshold)

February 21, 2009 12:38 AM | Posted by ITW: | Reply

Dymphna - Kay Redfield Jamison takes medication to control her bipolar disorder. She has a mental illness, but she is NOT mentally ill as she is very well controlled. Therefore, KRJ is not at risk for suicide. I'm sure there are many successful people who have mental illnesses, the key is that they are very well controlled.

It is assumed suicide as pertaining to mental illness is the result of unmedicated or poorly controlled mental illness, in which case it is impossible to be a physician in such a state.

Jessa - I agree it is probably a little bit of both, where we disagree is that I think it has more to do with the "professionals can't be crazy" assumption. I'm trying to imagine what doctors would think of an association between lawyers and suicide... I don't think they would come to the conclusion that the lawyers were mentally ill (bipolar, schizophrenic, major depression), I think they would think the lawyers were stressed out and had poor coping (in other words, the same conclusion reached about suicidal doctors).

Perhaps the real bias is the assumption that successful people can't be crazy. Crazy people are poor and uneducated and live in state hospitals slash the streets.

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I would like to see some ki... (Below threshold)

February 21, 2009 1:32 PM | Posted by Arlene : | Reply

I would like to see some kind of study (not sure how it would be done though) to see if there is a higher incidence/prevalence of depression among students entering medical school compared to the general population and, if so, why. Either there are more depressed people entering medicine or there's something about medicine that makes people depressed and ultimately end their life at a higher (and much higher in the case of women) rate than normal. I'm a physician who obviously hasn't ended my life because I'm writing this, but I've suffered from depression that my doctor and more than one therapist (not an M.D.) both diagnosed as situational and the result of YEARS of ridiculous amounts of stress throughout the training and practicing years. I'm now getting ready to leave the practice of medicine but it's not easy. There are so many factors that can make one feel trapped and that could lead some physicians to feel like there is no way out.

Anyway, in light of the scary percentages of doctors committing suicide, I think there has to be some work below the surface to try to see why this is the case and what can be done about it.

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I once read that physicians... (Below threshold)

February 23, 2009 9:45 AM | Posted by Jack Coupal: | Reply

I once read that physicians choose psychiatry as a calling, because they want to find out why their parents acted so weird.

Maybe as they practice psychiatry, physicians learn that the bizarre behavior of their parents has been incorporated into themselves to an unacceptable degree. And, they don't like the consequences.

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Is there a sane suicide? ye... (Below threshold)

February 23, 2009 8:36 PM | Posted by mark p.s.2: | Reply

Is there a sane suicide? yes when one has an unliveable medical condition.
Classic definition of insane is not knowing "wrong" from "right".
Dr's are never wrong therefore they can not be insane/mentally ill.
It's despair that killed them, not wrong thinking.

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I have noticed than my medi... (Below threshold)

February 24, 2009 1:06 PM | Posted by Phin: | Reply

I have noticed than my medical friends would rather write their own prescriptions for antidepressants than ever consult a psy - never mind admitting their depression to a general practitioner. A biochemist I know well, when I once mentioned to her I was in psychotherapy retorted "to each their own religion". Fear of being found out, fear of being judged by one's peers, or smugly sure that psychotherapy is not a science, but just another superstition, and therefore "beneath" them and yes, a certain fragile ego, I'd say, are all reasons I'd give to explain the above. The bottom line - doctors are the last population to look for help with their mental problems.

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This new scientist article ... (Below threshold)

March 4, 2009 10:42 AM | Posted by Leth: | Reply

This new scientist article is quite interesting, and relevant.

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I wonder if you are thinkin... (Below threshold)

March 14, 2009 1:43 PM | Posted by Hard Cheese: | Reply

I wonder if you are thinking about the fundamental attribution error at the end there.

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Itsthewooo: "high functioni... (Below threshold)

February 20, 2010 1:59 PM | Posted by JayEnn: | Reply

Itsthewooo: "high functioning" which translates into "not mentally ill"

Respectfully, I beg to differ. Why else would the phrase "high functioning autistic" be so commonly used...?

ITW: "She has a mental illness, but she is NOT mentally ill as she is very well controlled. Therefore, KRJ is not at risk for suicide."

This conclusion doesn't make sense to me. Having read some of her work, she explicitly states that one of the major reasons she must stay on top of her meds and therapy is precisely because she's never truly safe from the possibility of suicide.
Also, suicide is not purely the result of "uncontrolled mental illness". There are many cultural/socioeconomic/religious/circumstantial instances where suicide is honestly seen as the only "sane" or "honorable" way out of a certain situation. This does not indicate that said culture or religion is inherently mentally ill.

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This doesn't surprise me at... (Below threshold)

March 26, 2012 10:09 AM | Posted by Anonymous: | Reply

This doesn't surprise me at all. The difference between us and them that physicians carry around in their heads is appalling, kind of reminds me of why the Hippocratic oath has been discontinued in some schools.

It's also strange to read magazines that are written for physicians. I read an article on drug-seeking once, I picked up the magazine at the hospital where i worked. I'd gone to ER in excruciating pain and been denied a bubble pack of vicodin or percocet---we're talking a mere four pills (I think) to help until the medication for multiple infections kicked in. The doctor had charted history of suicidal ideation and thus denied the tiny bubble pack. Uh, yeah--- I had no drug abuse history and tried to kill myself many years prior with antifreeze. They had all my scripts on computer because it was all one big doctor group and and there were no pain killers, no narcotics, just antibiotics and neuroleptics, no indications of current lethality. So I brought the magazine home and basically read that if you know a lot about pain meds, you're a drug seeker. If you claim to know very little, you're a drug seeker. If you have back pain or abdominal pain, you're a drug seeker. If you lose your meds or are from out of town you're a drug seeker. It went on and on; basically, in the end, if you seek pain relief, you are a drug seeker.
The one example they used of the possibility of abuse was a suicidal man under psychiatric care who saved up his pain meds for a year and then OD'd. His family, probably to deflect their own guilt, sued the prescribing doctor for prescribing the meds in the first place, and won. And won!!! This should not be allowed to happen. If someone has some idea of why they won please tell me- I find it absurd. So now someone in legitimate pan goes to ER and has to suffer.
Which is why, unless someone screws up royally and practically laughs about it to my face, I won't sue. Ever.

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