'Something needs to change': Women physicians face sharply higher suicide risk than public
Key takeaways:
- Compared with the general population, physicians are more likely to have worse mental health, job issues, legal issues and more before dying by suicide.
- The risk is particularly significant for women physicians.
Physician suicide is a pervasive issue in the medical field, especially among women, according to the results of nationwide cohort study.
In a recent JAMA Psychiatry article, Hirsh Makhija, MS, a postgraduate researcher at the University of California San Diego, and colleagues detailed troubling evidence of worsened mental health among physicians compared with the general population.
As physicians care for others, their own well-being is “often overlooked,” Makhija told Healio.
“Stigma surrounding mental health care, along with fears of jeopardizing their licensure, further discourages them from seeking help. This is also seen through the high prevalence of burnout and depression within the occupation,” Makhija said. “I believe studies like ours are critical to the well-being of physicians as they give data-driven evidence that something needs to change — for example, added multimodal suicide prevention — and starts to deconstruct some of that stigma still within the occupation.”
For the retrospective study, Makhija and colleagues analyzed 448 physician suicides (79% of which occurred in men) and 97,467 suicides among members of the general population (again, 79% of whom were men) from January 2017 to December 2021.
The researchers found that, compared with the general population, being a physician corresponded with:
- more mental health issues (adjusted OR = 1.66; 95% CI, 1.39-1.97), legal issues (aOR = 1.4; 95% CI, 1.06-1.84), job issues (aOR = 2.66; 95% CI, 2.11-3.35) and depressed mood (aOR = 1.35; 95% CI, 1.14-1.61) before suicide;
- higher odds of using sharp instruments (aOR = 4.58; 95% CI, 3.47;6.06) and poisoning (aOR = 1.85; 95% CI, 1.5-2.3) — a finding that Makhija said has also previously been seen among nurses; and
- higher odds of positive toxicology results for poison, caffeine, drugs not prescribed for home use (Makhija said these were likely diverted from hospitals), anxiolytics, cardiovascular agents, benzodiazepines, hypnotics and nonbenzodiazepines.
Margot L. Savoy, MD, MPH, FAAFP, senior vice president of education, inclusiveness and physician well-being for the American Academy of Family Physicians, said she has “repeatedly heard the heartbreaking stories” of her peers who are “struggling to navigate the daily challenges of their professional and personal lives in a career where having a bad day or making a mistake is simply not tolerated.”
“So many aspects of the physician journey feel high stakes — from getting into medical school to matching to a residency to practicing medicine — that it is unrealistic to expect humans to navigate through it all without the benefit of some emotional or mental health support,” Savoy said. “Yet, for physicians, not only are you worried about being considered weak for asking for help, but the very real threat of losing professional credibility or your medical license immediately dashes any desire to be vulnerable or seek mental health care, even when it could save your life.”
“That is a travesty and must be changed,” she continued.
Each physician suicide is a “societal loss,” according to Robert Piccinini, DO, D.FACN, president-elect of the American Osteopathic Association.
“The tragedy of physician suicide not only devastates those around the physician, but the greater impact to their patient population is tremendous,” Piccinini, who is also an osteopathic physician specializing in psychiatry, told Healio. “Unfortunately, there are significant burdens such as financial debt, regulatory stressors and the lack of appreciation and respect physicians have been encountering during the last several years.”
Disparities
Makhija and colleagues found that, compared with women in the general population, women physicians faced an overall higher suicide risk (suicide incidence rate ratio [IRR] = 1.53; 95% CI, 1.23-1.87) throughout the entire study period from 2017 to 2021. Women physicians had significantly higher rates of suicide in both 2017 (IRR = 1.88; 95% CI, 1.19-2.83) and 2019 (IRR = 1.75; 95% CI, 1.09-2.65).
In other words, compared with women in the general population, women physicians overall had up to a 53% higher suicide risk for the entire study period, with peaks at 88% in 2017 and 75% in 2019.
In contrast, when compared with men in the general population, men physicians had lower suicide risk (IRR = 0.84; 95% CI, 0.75-0.93) across the entire study period.
“Although our physician suicide dataset comprised 80% men, it was very eye opening to see that female physicians had higher [incidence] rates than the female general population, while the same was not true for male physicians,” Makhija said. “However, this finding was not surprising as several international meta-analyses and systematic reviews had been pointing to this result.”
Savoy said she was saddened but unsurprised by these findings.
“Before the COVID-19 pandemic, women physicians were barely managing the complex societal expectations of being the primary caregiver at home in addition to navigating a career in medicine,” she said. “This constant tension drives burnout and mental health issues such as depression and anxiety. The pressure appeared to increase exponentially during the pandemic when external support structures became less available almost overnight, leaving women physicians to carry a disproportionate burden of the household responsibilities and child care.”
If a woman physician feels like they are failing in both their professional and personal lives, “the feeling of devastation can be profound,” Savoy said.
“Even without children, women physicians remain subject to striking differences in pay, promotion opportunities, higher expectations from patients, colleagues and partners, all compounded with macro and microaggressions,” she said. “For women physicians who also identify with another intersectional identity, these experiences are amplified.”
Based on their data alone, Makhija said the researchers could not confirm why this sex-based difference exists.
“Female physicians having higher rates of suicide is a similar finding to what we found for female nurses [in a previous study], and we believe possible contributors to this situation include under-recognition for similar work and achievements, inequitable pay and opportunities for promotion, greater domestic responsibilities leading to work-life imbalance and risk of sexual harassment,” Makhija said.
Solutions
The potential solutions here are complex, Makhija said, but an attitude shift and a few concrete interventions could make a difference.
“We need added multimodal and comprehensive suicide prevention,” he said. “With depressed mood, mental health issues and job problems all associated with physician suicides, there is a need for proactive mental health screening and treatment specific for physicians.”
But before anything else, stigma reduction is key, Makhija said.
“Many in the health care space are discouraged from seeking mental health resources due to perceived stigma, as well as potential effects on licensure,” he said. “Both from an individual and community perspective, we must deconstruct this stigma and promote positivity, wellness and knowledge in accessing and using mental health resources.”
Savoy and Piccinini said they have also seen how harmful stigma can be to physicians’ well-being.
“When I have spoken to families of physicians who have committed suicide, they talk about that physician’s intense feeling of isolation, that they experienced a feeling of shame in disclosing their struggles,” Piccinini said.
It is important to “normalize being available for your fellow physicians, especially if they are in crisis,” Savoy added.
“Often doctors report not wanting to bother others or believing others are too busy to deal with their distress. That simply isn’t true,” she said. “Tell the physicians in your circle that they can call you at 3 a.m. and you would pick up the phone.”
Savoy also stressed that all people should have access to mental health care regardless of their career and without fear of losing their jobs.
“I really hope that the message that physicians are humans, too, is heard,” she said. “Take your health seriously and seek help if you need it. From employee assistance programs to peer groups and even the national 988 hotline, there are so many supports available. You are allowed to be human and deserve the same love and support you would give your patients.”
Screening and access to physician-specific mental health resources would also be helpful, Makhija said, but he acknowledged that physician wellness initiatives require much more effort and policy change to achieve tangible effects.
“There is a need for proactive and anonymous mental health screening, along with targeted treatments specifically for health care workers,” he said. “Like the goal of stigma reduction, we need to connect physicians who need help with mental health resources that are made for them.”
Other options for suicide prevention interventions, he said, can include large institution programs, “limiting access to lethal means and changing how licensure asks intrusive questions to physicians.”
Specifically for physicians who are in mentorship positions, advocating for mentees can play a major role in their well-being, Makhija said. This can look like:
- linking professionalism and self-care;
- demonstrating a growth mindset by modeling how to take care of yourself and those around you; and
- identifying supportive and unsupportive policies.
There is no one-size-fits-all approach to physician suicide prevention, but “improving the colleague mentoring of physicians to help level their worries and anxieties,” as well as regulatory improvement, would “go a long way in reducing stress and potential suicidal thoughts,” Piccinini said.
“The cost to society is much greater than recognized when a physician commits suicide. The impact on friends, family and colleagues are significant,” he added. “The approach to correcting the problems must have enough flexibility and be individualized to each situation.”
Anyone in crisis can contact the 988 Suicide & Crisis Lifeline by texting or calling 988 or reaching out online at 988lifeline.org.