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Study Authors: Yisi D. Ji, Faith C. Robertson, et al.; Suzanne C. Danhauer, Katherine Files, Julie Ann Freischlag

Target Audience and Goal Statement: Hospitalists, practice managers, primary care physicians, psychiatrists, public health and policy makers, surgeons

The goal of this study was to assess risk factors for suicide among healthcare professionals (surgeons, nonsurgeon physicians, and dentists) compared with the general population.

Question Addressed:

Are there differences in risk factors for suicide among healthcare professionals compared with the general population?

Study Synopsis and Perspective:

Healthcare professionals have long been known to suffer -- defined as emotional exhaustion, depersonalization, and feelings of inefficacy resulting from chronic work-related stress. From 2011 to 2014, the rate of physician burnout increased from 46% to 54%, according to one national survey of the U.S. working population.

Among healthcare professionals, burnout may be driven by workload, work inefficiency, lack of autonomy and meaning in work, and work-home conflict.

Despite experiencing significant levels of psychological distress, physicians are less likely than the general population to seek mental health treatment. Barriers reported include time constraints, reluctance to draw attention to self-perceived weakness, and concerns about their reputation and confidentiality.

In addition, physicians with unaddressed mental health problems may turn to self-medication, mainly with prescription medications, to manage anxiety, insomnia, or other distressing symptoms, according to the .

A large body of research has highlighted that, along with evidence of increased risks of burnout and depression, physicians have been shown to than the general population. And mental health issues are on the rise among healthcare professionals on the frontlines of the COVID-19 pandemic.

A recent of frontline healthcare workers at the epicenter of the COVID-19 outbreak in China found that over half suffered psychological effects, including depression, insomnia, and distress.

The suicide of New York City emergency room physician Lorna Breen, MD, on April 26, after months of fighting valiantly to care for her patients, support her fellow clinicians, and regain her own health after developing COVID-19, brings home the extreme mental health burden that physicians face in caring for patients with this disease.

A recent study published in identified several risk factors for suicide among healthcare professionals, which may help the medical community prepare for the mental health crisis emerging from COVID-19.

Compared with the general population, an increased risk of suicide was observed among surgeons, nonsurgeon physicians, and dentists who had job problems like conflicts with superiors (OR 1.79, 95% CI 1.49-2.17, P<0.001), legal problems (OR 1.61, 95% CI 1.15-2.26, P=0.006), or physical health problems (OR 1.40, 95% CI 1.19-1.64, P<0.001), reported Yisi D. Ji, DMD, of Harvard Medical School in Boston, and colleagues.

Healthcare workers who died by suicide were also substantially older than those who died by suicide in the general population, and this was identified as a risk factor across all specialties as well (59.6 vs 46.8 years), the researchers wrote.

For the study, Ji and colleagues retrospectively looked at death records from 2003-2016 from 32 states. During that time period, 170,030 individuals who died by suicide were reported in the database.

Among healthcare professionals in the study, 767 suicide deaths occurred, which was just 0.5% of the total number of suicides recorded in the NVDRS.

The majority of the healthcare professionals to die across the study period were men (88%) and white (89.7%). About two-thirds (63.2%) were nonsurgeon physicians, 23.3% were dentists, and 13.4% were surgeons.

Compared with the general population, healthcare professionals were also at an increased risk of suicide if they had mental illness (OR 1.45, 95% CI 1.24-1.69, P<0.001) or were of Asian or Pacific Islander descent (OR 2.80, 95% CI 1.96-3.99, P<0.001).

However, healthcare professionals were at a lower risk of suicide versus the general population if they had intimate partner problems, alcohol use issues, were black, female, or unmarried.

Ji and team did not find an association between suicide death among healthcare professionals and physician suicide risk factors of substance use (e.g., antipsychotic, opioid, benzodiazepine, barbiturate, and antidepressant medications, as well as cocaine and marijuana) in comparison with the general population.

Compared with other specialties, surgeons had a higher risk of suicide if they were older (OR 1.003 per year, 95% CI 1.002-1.004, P<0.001) or had mental illness (OR 1.32, 95% CI 1.09-1.61, P=0.005).

An increased risk was also observed among surgeons compared with other specialties for doctors with civil legal problems (OR 1.80, 95% CI 1.19-2.71, P=0.006); job problems such as poor performance, work pressure, fear of being fired or demoted, conflict with colleagues or superiors, or joblessness (OR 1.72, 95% CI 1.35-2.20, P<0.001); or physical health problems (OR 1.53, 95% CI 1.25-1.87, P<0.001).

"The prevailing belief is that medical residents have a greater risk of suicide owing to difficulty associated with the high number of training hours required," Ji and co-authors wrote. "Our results suggest that, in addition to reports describing trainee burnout, another population comprising older surgeons and nonsurgeon physicians may also be at risk of suicide."

Searching for surgeons by occupation may not be precise because they may also be listed as physicians, which is a limitation, the researchers noted, adding that they were also unable to assess suicide rates over time due to the nature of the database.

Source References: 2020; DOI: 10.1001/jamasurg.2020.1338

Editorial: 2020; DOI: 10.1001/jamasurg.2020.1345

Study Highlights and Explanation of Findings:

Given the observed association of healthcare professionals' job problems and civil legal problems with a significantly higher risk of suicide, institutions can aim to ensure sufficient human resource and legal support for professionals experiencing litigation, wrote Julie Ann Freischlag, MD, of Wake Forest Baptist Health in Salem, North Carolina, and colleagues, in an .

Notably, physicians experiencing burnout have poorer patient safety outcomes and lower patient satisfaction scores, and are at greater risk of unprofessional behavior, making unaddressed mental health concerns likely to be a detriment to a physician's professional reputation and medical practice.

Additionally, the association between age and suicide risk is "worrisome," as surgeons have been known to report being satisfied with their careers and feeling respected in their communities, noted Freischlag and co-authors.

This "may be associated with working longer before retirement," they wrote. "Loss of connection with colleagues during retirement and a perceived loss of relevance after a satisfying career could be factors in surgeons' high levels of distress."

Indeed, is central to preventing burnout and suicidality, as is web-based cognitive behavioral therapy (CBT), which was shown to in interns who completed four sessions.

A recent on preventing a mental health crisis among clinicians dealing with COVID-19-related trauma refers to "the value of finding meaning in times of intense grief and sorrow" and offers guidance on building internal support for the trauma caused by the pandemic.

Likewise, the editorialists pointed to the importance of building resilience in the medical community and moving towards a culture of empathy and support in the midst of professional and personal stressors. Freischlag and co-authors recommended increasing access to on-site mental health services, implementing systemic changes that reduce burnout, and promoting programs that offer a sense of community to healthcare workers.

"Through such approaches, which are focused on resilience and relevance, we can better recognize warning signs of distress, and even prevent them from occurring, as we encourage all health care professionals to care for their patients and themselves," they concluded.

While the ongoing pandemic brings urgency to the need for greater vigilance and support of clinicians on the frontlines, strategies to identify burnout, such as the , and to its effects should be targeted to all physicians.

If you or someone you know is considering suicide, call the at 1-800-273-8255.