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.