Why Are Doctors at Higher Risk of Suicide?

Stethoscope on x-rayThose familiar with research on depression and suicide have stumbled across a curious and disturbing pattern, one that many medical professionals have been aware of for more than a decade: The rate of suicide among physicians is higher than among the general population. What accounts for this, and what can be done about it?

More than 800,000 people die by suicide every year. The rate of suicide in the United States is about 13 people per 100,000, according to the World Health Organization. The numbers are even more alarming for physicians. Data collected by suicide researcher Keith Hawton shows that doctors commit suicide at a rate that is 1.5 to three times higher for men and three to five times higher for women.

To make sense of this, we need a better understanding of suicide itself.

What leads to death by suicide?

In 2005, psychologist Thomas Joiner published the interpersonal-psychological theory of why people die by suicide in an attempt to answer that very question. To summarize this theory, suicide occurs when two criteria are met: the desire for death and the capability to enact lethal self-injury. This means the desire for death and the ability to carry out lethal self-injury are both acquired and required, simultaneously, in order for a suicide death to occur.

Going deeper, the desire for death and the capability of lethal self-injury are facilitated by three core components: thwarted belongingness, perceived burdensomeness, and impulsivity/habituation. (Pay attention to that latter component; it’s going to play a big part later on.) Joiner’s theory holds that only when levels of all three components are high is suicide possible.

Thwarted belongingness can be viewed as a lack of connection or lack of meaningful connections in a person’s life. Someone with thwarted belongingness might feel like he or she has no place in the world, even if surrounded by family or friends.

Perceived burdensomeness can be thought of both as being a burden on others or lacking utility. Someone with high perceived burdensomeness may feel like his or her very existence makes life more difficult for others (i.e., his or her death would have more value than his or her life), or that he or she is useless in a role that has high personal meaning (for example, as a parent, as a spouse, in the workplace, or in the world in general). Thwarted belongingness and perceived burdensomeness together may contribute to a desire for death.

Doctors, as a part of their work, are inherently high on the impulsivity/habituation scale. They not only come into contact with individuals with significant injuries, they are near when families are frightened, grieving, and wanting answers, and often literally hold a person’s life in their hands.

Impulsivity/habituation contributes to the capacity to attempt and die of suicide. While any number of people who die of suicide each year is too many, the vast majority of individuals who think about and consider suicide do not die of suicide. (If you have 240 friends on Facebook, statistically, about 15 have considered suicide at some point, according to the American Association of Suicidology.) Why is this? Well, although these people may be in immense pain and may desire death (they are likely high on the thwarted belongingness and perceived burdensomeness scales), their level of impulsivity/habituation is low.

What we see in those who have attempted suicide multiple times is that people often work up to lethal self-injury. In other words, it doesn’t just happen out of the blue. They may attempt suicide using methods of increasing levels of potential lethality before finally dying, or habituate in nonlethal ways. Substance abuse, nonsuicidal self-injury, impulsive or reckless behavior, or physical or sexual abuse (as perpetrator or victim) are all ways a person may habituate to pain, fear, trauma, and injury. (This list is not exhaustive.)

What does all this have to do with doctors? Just as it is possible to habituate to personal bodily harm, it is possible to habituate “by association,” by being near experiences of pain, fear, trauma, and injury—say, for instance, in a combat zone, as a police officer, or, you guessed it, in a medical environment.

Doctors, as a part of their work, are inherently high on the impulsivity/habituation scale. They not only come into contact with individuals with significant injuries, they are near when families are frightened, grieving, and wanting answers, and often literally hold a person’s life in their hands. In addition to the habituation to these experiences, doctors by training would know a fair amount about what injuries would be most lethal, contributing not only to their capability for lethal self-injury but their competency for lethal self-injury.

If thwarted belongingness, perceived burdensomeness, and impulsivity/habituation were barriers that needed to be pushed through in order for death by suicide to be possible, the impulsivity/habituation barrier would be weakened for doctors as compared to the average person, leaving the former two components as the only potential stopgaps.

Suppose, then, that a doctor felt disconnected from others in his or her personal life (many work long, tiring, stressful hours, which can be challenging for relationships). Suppose, also, that this doctor made a mistake that cost someone his or her health or even life (or at least perceived himself or herself as having made such an error). It’s easy to imagine the affront to the self-concept of being a helper or healer that someone in that situation might feel. It’s also easy to imagine what might come next if this doctor’s pain became unbearable.

So what can be done?

When looking at the underlying mechanisms of suicide through the lens of this model, prevention strategies become a little clearer. Instead of focusing vaguely on reducing depression among medical professionals, we can see that the only two factors that are easily workable are belongingness and burdensomeness. Perhaps one key to reducing the suicide rate among doctors is to strategically identify those who are at higher risk (Hawton’s research suggests doctors facing disciplinary action are more likely to die of suicide, lending support to the affect of perceived burdensomeness) and increase the support they receive. Also, just as stigma is a frequent barrier to help for the general population, it surely plays a role in the medical profession; doctors may not seek the help they need for fear of career ramifications. Access to mental health treatment must improve, and utilization of such resources should be both encouraged and anonymous, as it is for everyone else.

Undoubtedly, there are many creative ideas worth considering, and I’m sure the ones most beneficial to prevention efforts will come from those who are most familiar with these environments—physicians themselves.

What ideas do you have?

References:

  1. American Association of Suicidology. Facebook Infographic. Retrieved from http://www.suicidology.org/resources/infographics/facebook
  2. Hawton, K., Agerbo, E., Simkin, S., Platt, B., & Mellanby, R. J. (2011). Risk of suicide in medical and related occupational groups: a national study based on Danish case population-based registers. Journal of Affective Disorders, 134(1-3), 320-326. doi:10.1016/j.jad.2011.05.044
  3. Hawton, K., Malmberg, A., & Simkin, S. (2004). Suicide in doctors: a psychological autopsy study. Journal of Psychosomatic Research, 57(01), 1-4. doi:10.1016/S0022-3999(03)00372-6
  4. Joiner, T. (2005). Why people die by suicide. Cambridge, Mass.: Harvard University Press.
  5. World Health Organization. Suicide data. WHO Suicide Data. Retrieved from http://www.who.int/mental_health/prevention/suicide/suicideprevent/en/

© Copyright 2015 GoodTherapy.org. All rights reserved. Permission to publish granted by Jacob Martinez, MA, LPC Intern, therapist in San Antonio, Texas

The preceding article was solely written by the author named above. Any views and opinions expressed are not necessarily shared by GoodTherapy.org. Questions or concerns about the preceding article can be directed to the author or posted as a comment below.

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  • Marcella

    Marcella

    May 11th, 2015 at 10:14 AM

    If I had to spend my life trying to save others and not being successful at it all of the time, you can see how this would easily lead to depression for so many. Another thing is that I think we don’t think of the financial difficulties that so many people in this profession have to live with, there is an awful lot of pressure to look one way and then it can get hard always trying to keep up with that if the money isn’t there. Anyway, I am sure that there are a lot of other factors, these are just the ones that popped into my head.

  • Tom

    Tom

    May 11th, 2015 at 1:50 PM

    Wonder if this could be put down to ‘carers fatigue’? I was involved in caring for several elderly people over the past few years and noticed I often felt depressed. I stopped doing that and instead became involved in tutoring young adults–overnight my depression lifted. Since then Having talked to othets who have been in the same position I found the peonomena is more common than I suspectef.

    Physicians are perhaps unable to change their line of work so easily as they are highly-invested in a great many ways & admiring to depression might be career limiting since it still holds a stigma?

  • Carson

    Carson

    May 11th, 2015 at 3:09 PM

    So who is supposed to monitor these providers and say who is at high risk and who isn’t? That gets into some pretty tricky territory if you ask me.

  • Margo

    Margo

    May 12th, 2015 at 10:48 AM

    Have you seen insurance rates lately?
    And how they are the ones calling all the shots today and not the doctors?
    Think that having this independence and autonomy taken away from this once respected profession could have a great deal to do with the rise in these numbers.

  • Kelly

    Kelly

    May 12th, 2015 at 8:00 PM

    I wondered if control over one’s own life factored into this at all. More specifically, after seeing so many people go through various stages of diseases and dying, often entirely out of that person’s control, would there be a desire to have some control over the end instead of waiting for it? Just a thought I had.

  • Delia

    Delia

    May 13th, 2015 at 9:37 AM

    I feel that there are so many resources available but that this is a demographic who may be less that easily convinced to seek those out. They are so busy thinking about the care that they give to others that they fail to consider taking care of themselves as well.

  • js

    js

    May 15th, 2015 at 1:51 PM

    could it also be that this is a profession where the numbers are reported more frequently than in other professions?

  • Nanete

    Nanete

    May 16th, 2015 at 3:56 PM

    There isn’t a harder position out there than doctors. Think of how they must feel when day in and day out people are not only telling them that they make too much money etc but they also have to deal with loss when they know that they can no longer help a patient. That is a lot of pressure for one person to deal with and yet this is what we ask for from our medical team and staff.

  • lorna

    lorna

    May 18th, 2015 at 10:21 AM

    I know that they chose this job, but you have to imagine that there is so much more that goes into it than what most of us know or understand. There are things that they have to deal with on a daily basis that could make even the sanest of people question their decisions, and so I would think that this could play a very large role in the number of suicides that you will find.

  • Alisa

    Alisa

    March 30th, 2017 at 11:14 PM

    My husband was a brilliant ER doctor. He just became a work-A-Holic. He committed suicide.

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