Break the Silence: Physician Suicide in the Time of COVID-19

Abstract

The rates of physician burnout, depression, and suicide have been on the rise over the past 50 years. Despite increased attention to these topics over the past decade these numbers have remained steady. In the age of SARS-Cov-2 and COVID-19 these numbers are predicted to show a steep increase due to the increased work demands, social isolation, decreased self-care, and increased exposure to emotionally traumatic events at work and home. The potential solutions to these issues generally remain the same; however, we are now in an environment with even more barriers to those solutions.

Introduction

The increased rate of suicide among physicians has been known since 1858;¹ however, physician suicide has remained a silent epidemic for the past 150 years. Over the past few years there has been growing attention on this topic in the age of increased rates of physician burnout² and mental health diagnoses among physician populations. In recent years, the American Medical Association³ and the Association of American Medical Colleges⁴ have launched campaigns to identify, educate, and guide physicians on burnout. Now, amidst the COVID-19 pandemic, there has been increased media attention to burnout, mental health diagnoses, and suicides attributed to the stress and workload of being a physician during this unprecedented time in medicine. With the spotlight being directed toward this once silent issue, there has been an increased focus on the stresses of working in healthcare. This highlights the longstanding issue of physicians struggling with mental health issues including depression, anxiety, and substance abuse. These issues once kept in the dark, are now front and center of the national discussion regarding COVID-19 and the healthcare workers treating these patients.

Characteristics of Physician Suicide

Factors that have been identified which lead to increased risk of depression and suicide in physicians includes female gender, personal history of mental illness, family history of mental illness, lack of social support, and substance use or abuse. Similar to the general population, the biggest predictor of future suicidal thoughts or attempts is a personal history of a suicide attempt.⁵

There are several factors that contribute to the higher rates of suicide seen among physicians. Physicians have extensive knowledge of pharmacology including the lethal doses of medications which makes suicides by overdose more frequently lethal than in the general population. Physicians also have increased access to potentially lethal medications within hospital and clinic settings. Physicians tend to use suicide methods of higher lethality including firearms and hanging.⁵ This increased knowledge and use of highly lethal means equates to a higher percentage of suicide attempts by physicians being lethal.

Survey-based studies show that the rates of mental illnesses, primarily depression and anxiety disorders, are higher among physicians; however, physicians seek care for mental health diagnosis much less frequently than the general population.⁶ There is significant societal stigma related to mental illnesses and this extends and is amplified among physicians. Many physicians fear repercussions from state medical boards or employers if their mental health diagnoses are learned. This culture of stigma leads many physicians to attempt to treat their own mental health issues with prescription medications or self-help style therapies. This idea of “physician, heal thyself ” has proven to be grossly inadequate.

Physician suicide has a double peak with the highest incidence occurring in late-middle age and the second peak during the training years of residency and fellowship.⁷ The peak during training is often attributed to the intense and stressful time of training with working long hours, risk of medical errors, and balancing work and family obligations. The higher peak later in life has been attributed to physicians’ loss of identity either by retirement or deterioration of their own physical health.

Mental Health Diagnoses

The most common mental health diagnoses of physicians mirrors that of the general population; however, the rates of these diagnoses are much higher and as noted above, physician engagement in treatment is much lower. The most common mental health issues include depressive disorders, anxiety disorders, and substance use and abuse. Rates of depression among physicians have been estimated at 19%⁸ and 28.8% among resident physicians⁹ compared to 7.1% in the general population.¹⁰ The incidence depression increases rapidly in medical training, increasing four-fold in the first four months of the internship year.¹¹ This increased rate is often attributed to the high stress culture of medicine, long work hours, relative neglect of self-care, less time with family and friends, financial stresses of medical education, and perceptions of inadequacy.⁸

Anxiety disorders also have higher incidence among physicians. The field of medicine likely selects for individuals at high risk for anxiety disorder due to the coveting of perfectionistic traits. Anxiety and depressive disorder are highly comorbid and intertwined which increases risk for physician burnout and suicidal thoughts. With physicians seeking care from their own primary care physicians or mental health professionals much less frequently, they may also turn to other ways to self-medicate either by self-prescribing or the use or abuse of alcohol or illicit drugs.

Substance Abuse

Substance abuse is independently a risk factor for suicide with more than 50% of all suicides involving alcohol or drugs.¹² Substance abuse is particularly prevalent among physicians with the highest rates effecting anesthesiology, psychiatry, and emergency medicine.¹³ Prescription drug abuse is significantly higher in physician populations likely due to the increased access to addictive medications. However, female physicians also have increased rates of alcohol abuse and dependence compared to females in the general population. These increased rates of substance abuse combined with increased access and knowledge of pharmacology and underlying psychiatric illness can be a very dangerous recipe and likely contributes to the increased rates of suicide completion within the physician population.

Physician Burnout

Burnout is a long-term stress reaction marked by emotional exhaustion, depersonalization, and a lack of sense of personal accomplishment.² Approximately 50% of physicians in the United States will report symptoms consistent with burnout at some point in their career.¹⁴ Rates of burnout are climbing which is attributed to increased bureaucratic oversight, loss of physician autonomy, increased documentation requirements, increased administrative burden, and decreased time spent with patients. Many hospital systems and professional organizations have created and instituted educational curriculum and self-care programs which have shown some improvement in some areas of burnout but have generally not reversed the trend of increasing physician burnout.

Potential Solutions

Particularly in the past 10 years, there have been increased efforts to treat these alarming trends of burnout, depression, and suicide among physicians. These solutions have included initiatives such as physician wellness programs, state physician health programs such as the Missouri Physician Health Program, increased education during training years, increased screening measures, and increased access to treatment resources including therapy and psychiatry referrals for physicians who are struggling.¹⁵ Data showing the efficacy of these initiatives is not robust but generally has not demonstrated significant improvement in outcomes.¹⁶ In this time of COVID-19 we are in uncharted territory and although these same solutions may prove to be effective, the new realities of fighting this pandemic present new barriers. These barriers include decreased time away from work for physicians to seek care, reduction of onsite staff and personal to perform screenings and treatment, deferral of all non-emergent medical and psychiatric care, and increased stigma for physicians taking time off from work to address personal care and medical appointments.

Impact of COVID-19

With the coming of SARS-Cov-2 in 2020 the rates of physician burnout have climbed due to increased emotional demands including increased patient deaths, lack of feelings of control, personal blame for inability to do more for patients, increased work hours, and increased emotional stress within their support system.¹⁷ Increased rates of burnout, symptoms of depression and anxiety, and increased social isolation suicide rates are also predicted to climb both in the general population and within the population of U.S. physicians.

At this point, large data sets regarding the impact of COVID-19 on physician mental health and suicide are not available. However, the stories published in the press regarding suicide by health professionals paints a grim picture. The story of Dr. Laura Breen, and ER physician who contracted COVID-19 and then later died by suicide¹⁸ illustrates not only the physical toll of this pandemic, but the intense emotional toll to those who are working on the frontlines. There are also stories of paramedics, nurses, techs, and other workers in the medical field who have died by suicide during this incredibly difficult time. These few stories which reach the press are likely only a small fraction of the true loss of life during this time as much of the airtime is devoted to those dying from the infection itself rather than the emotional and mental consequences of fighting it.

Future Directions

As we move forward as a country and profession from this pandemic and all that it has changed in our daily lives, it will be vital to track the rates of burnout, depression, anxiety, suicide, and substance abuse and intervene early. All of us are working long hours, picking up extra shifts, and putting our own self-care last during this pandemic which will have dire consequences if gone unchecked. We know from previous research that physicians are a vulnerable group for depression and suicide and hesitant to seek care in the best of circumstances. With these new demands and shifts in work responsibilities we must not lose sight of these underlying facts. This is a marathon, not a sprint; we must continue to take care of our physicians so that they can continue to care for those who need them most.