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Two more and counting: Suicide in medical trainees
Like everyone in the arc of social media impact, I was shocked and terribly saddened by the recent suicides of two New York women in medicine – a final-year medical student on May 1 and a second-year resident on May 5. As a specialist in physician health, a former training director, a long-standing member of our institution’s medical student admissions committee, and the ombudsman for our medical students, I am finding these tragedies harder and harder to reconcile. Something isn’t working. But before I get to that, what follows is a bulleted list of some events of the past couple of weeks that may give a context for my statements and have informed my two recommendations.
- May 3, 2018: I give an invited GI grand rounds on stress, burnout, depression, and suicide in physicians. The residents are quiet and say nothing. Faculty members seem only concerned about preventing and eradicating burnout – and not that interested in anything more severe.
- May 5: A psychiatry resident from Melbourne arrives to spend 10 days with me to do an elective in physician health. As in the United States, there is a significant suicide death rate in medical students and residents Down Under. In the afternoon, I present a paper at the annual meeting of the American Academy of Psychodynamic Psychiatry and Psychoanalysis on the use of psychotherapy in treatment-resistant suicidal depression in physicians. There is increasing hope that this essential modality of care will return to the contemporary psychiatrist’s toolbox.
- May 6: At the annual meeting of the American Psychiatric Association in New York, I’m the discussant for powerful heartfelt papers of five psychiatrists (mostly early career psychiatrists and one resident) that talked about living with a psychiatric illness. The audience is huge, and we hear narratives about internal stigma, self-disclosure, external stigma, shunning, bullying, acceptance, rejection, alienation, connection, and love by peers and family. The authenticity and valor of the speakers create an atmosphere of safety, which enables psychiatrists in attendance from all over the world to share their personal stories – some at the microphone, some privately.
- May 7: Again at the APA, I chair and facilitate a workshop on physician suicide. We hear from four speakers, all women, who have lost a loved one to suicide – a husband, a father, a brother, a son – all doctors. Two of the speakers are psychiatrists. The stories are gripping, detailed, and tender. Yes, the atmosphere is very sad, but there is not a pall. We learn how these doctors lived, not just how they died. They all loved medicine; they were creative; they cared deeply; they suffered silently; and with shame, they lost hope. Again, a big audience of psychiatrists, many of whom share their own stories, that they, too, had lost a physician son, wife, or mother to suicide. Some of their deceased family members fell through the cracks and did not receive the life-saving care they deserved; some, fearing assaults to their medical license, hospital privileges, or insurance, refused to see anyone. They died untreated.
- May 8: Still at the APA, a psychiatrist colleague and I collaborate on a clinical case conference. Each of us describes losing a physician patient to suicide. We walk the attendees through the clinical details of assessment, treatment, and the aftermath of their deaths. We talk openly and frankly about our feelings, grief, outreach to colleagues and the family, and our own personal journeys of learning, growth, and healing. The clinician audience members give constructive feedback, and some share their own stories of losing patients to suicide. Like the day before, some psychiatrists are grieving the loss of a physician son or sibling to suicide. As mental health professionals, they suffer from an additional layer of failure and guilt that a loved one died “under their watch.”
- May 8: I rush across the Javits Center to catch the discussant for a concurrent symposium on physician burnout and depression. She foregoes any prepared remarks to share her previous 48 hours with the audience. She is the training director of the program that lost the second-year resident on May 5. She did not learn of the death until 24 hours later. We are all on the edge of our seats as we listen to this grieving, courageous woman, a seasoned psychiatrist and educator, who has been blindsided by this tragedy. She has not slept. She called all of her residents and broke the news personally as best she could. Aided by “After A Suicide: A Toolkit for Residency/Fellowship Programs” (American Foundation for Suicide Prevention), she and her colleagues instituted a plan of action and worked with administration and faculty. Her strength and commitment to the well-being of her trainees is palpable and magnanimous. When the session ends, many of us stand in line to give her a hug. It is a stark reminder of how many lives are affected when someone you know or care about takes his/her own life – and how, in the house of medicine, medical students and residents really are part of an institutional family.
- May 10: I facilitate a meeting of our 12 second-year residents, many of whom knew of or had met the resident who died. Almost everyone speaks, shares their feelings, poses questions, and calls for answers and change. There is disbelief, sadness, confusion, some guilt, and lots of anger. Also a feeling of disillusionment or paradox about the field of psychiatry: “Of all branches of medicine, shouldn’t residents who are struggling with psychiatric issues feel safe, protected, cared for in psychiatry?” There is also a feeling of lip service being paid to personal treatment, as in quoted statements: “By all means, get treatment for your issues, but don’t let it encroach on your duty hours” or “It’s good you’re getting help, but do you still have to go weekly?”
In the immediate aftermath of suicide, feelings run high, as they should. But rather than wait it out – and fearing a return to “business as usual” – let me make only two suggestions:
2. In psychiatry, we need to redouble our efforts in fighting the stigma attached to psychiatric illness in trainees. It is unconscionable that medical students and residents are dying of treatable disorders (I’ve never heard of a doctor dying of cancer who didn’t go to an oncologist at least once), yet too many are not availing themselves of services we provide – even when they’re free of charge or covered by insurance. And are we certain that, when they knock on our doors, we are providing them with state-of-the-art care? Is it possible that unrecognized internal stigma and shame deep within us might make us hesitant to help our trainees in their hour of need? Or cut corners? Or not get a second opinion? Very few psychiatrists on faculty of our medical schools divulge their personal experiences of depression, posttraumatic stress disorders, substance use disorders, and more (with the exception of being in therapy during residency, which is normative and isn’t stigmatized). Coming out is leveling, humane, and respectful – and it shrinks the power differential in the teaching dyad. It might even save a life.
Dr. Myers is a professor of clinical psychiatry at State University of New York, Brooklyn, and the author of “Why Physicians Die by Suicide: Lessons Learned From Their Families and Others Who Cared.”
Like everyone in the arc of social media impact, I was shocked and terribly saddened by the recent suicides of two New York women in medicine – a final-year medical student on May 1 and a second-year resident on May 5. As a specialist in physician health, a former training director, a long-standing member of our institution’s medical student admissions committee, and the ombudsman for our medical students, I am finding these tragedies harder and harder to reconcile. Something isn’t working. But before I get to that, what follows is a bulleted list of some events of the past couple of weeks that may give a context for my statements and have informed my two recommendations.
- May 3, 2018: I give an invited GI grand rounds on stress, burnout, depression, and suicide in physicians. The residents are quiet and say nothing. Faculty members seem only concerned about preventing and eradicating burnout – and not that interested in anything more severe.
- May 5: A psychiatry resident from Melbourne arrives to spend 10 days with me to do an elective in physician health. As in the United States, there is a significant suicide death rate in medical students and residents Down Under. In the afternoon, I present a paper at the annual meeting of the American Academy of Psychodynamic Psychiatry and Psychoanalysis on the use of psychotherapy in treatment-resistant suicidal depression in physicians. There is increasing hope that this essential modality of care will return to the contemporary psychiatrist’s toolbox.
- May 6: At the annual meeting of the American Psychiatric Association in New York, I’m the discussant for powerful heartfelt papers of five psychiatrists (mostly early career psychiatrists and one resident) that talked about living with a psychiatric illness. The audience is huge, and we hear narratives about internal stigma, self-disclosure, external stigma, shunning, bullying, acceptance, rejection, alienation, connection, and love by peers and family. The authenticity and valor of the speakers create an atmosphere of safety, which enables psychiatrists in attendance from all over the world to share their personal stories – some at the microphone, some privately.
- May 7: Again at the APA, I chair and facilitate a workshop on physician suicide. We hear from four speakers, all women, who have lost a loved one to suicide – a husband, a father, a brother, a son – all doctors. Two of the speakers are psychiatrists. The stories are gripping, detailed, and tender. Yes, the atmosphere is very sad, but there is not a pall. We learn how these doctors lived, not just how they died. They all loved medicine; they were creative; they cared deeply; they suffered silently; and with shame, they lost hope. Again, a big audience of psychiatrists, many of whom share their own stories, that they, too, had lost a physician son, wife, or mother to suicide. Some of their deceased family members fell through the cracks and did not receive the life-saving care they deserved; some, fearing assaults to their medical license, hospital privileges, or insurance, refused to see anyone. They died untreated.
- May 8: Still at the APA, a psychiatrist colleague and I collaborate on a clinical case conference. Each of us describes losing a physician patient to suicide. We walk the attendees through the clinical details of assessment, treatment, and the aftermath of their deaths. We talk openly and frankly about our feelings, grief, outreach to colleagues and the family, and our own personal journeys of learning, growth, and healing. The clinician audience members give constructive feedback, and some share their own stories of losing patients to suicide. Like the day before, some psychiatrists are grieving the loss of a physician son or sibling to suicide. As mental health professionals, they suffer from an additional layer of failure and guilt that a loved one died “under their watch.”
- May 8: I rush across the Javits Center to catch the discussant for a concurrent symposium on physician burnout and depression. She foregoes any prepared remarks to share her previous 48 hours with the audience. She is the training director of the program that lost the second-year resident on May 5. She did not learn of the death until 24 hours later. We are all on the edge of our seats as we listen to this grieving, courageous woman, a seasoned psychiatrist and educator, who has been blindsided by this tragedy. She has not slept. She called all of her residents and broke the news personally as best she could. Aided by “After A Suicide: A Toolkit for Residency/Fellowship Programs” (American Foundation for Suicide Prevention), she and her colleagues instituted a plan of action and worked with administration and faculty. Her strength and commitment to the well-being of her trainees is palpable and magnanimous. When the session ends, many of us stand in line to give her a hug. It is a stark reminder of how many lives are affected when someone you know or care about takes his/her own life – and how, in the house of medicine, medical students and residents really are part of an institutional family.
- May 10: I facilitate a meeting of our 12 second-year residents, many of whom knew of or had met the resident who died. Almost everyone speaks, shares their feelings, poses questions, and calls for answers and change. There is disbelief, sadness, confusion, some guilt, and lots of anger. Also a feeling of disillusionment or paradox about the field of psychiatry: “Of all branches of medicine, shouldn’t residents who are struggling with psychiatric issues feel safe, protected, cared for in psychiatry?” There is also a feeling of lip service being paid to personal treatment, as in quoted statements: “By all means, get treatment for your issues, but don’t let it encroach on your duty hours” or “It’s good you’re getting help, but do you still have to go weekly?”
In the immediate aftermath of suicide, feelings run high, as they should. But rather than wait it out – and fearing a return to “business as usual” – let me make only two suggestions:
2. In psychiatry, we need to redouble our efforts in fighting the stigma attached to psychiatric illness in trainees. It is unconscionable that medical students and residents are dying of treatable disorders (I’ve never heard of a doctor dying of cancer who didn’t go to an oncologist at least once), yet too many are not availing themselves of services we provide – even when they’re free of charge or covered by insurance. And are we certain that, when they knock on our doors, we are providing them with state-of-the-art care? Is it possible that unrecognized internal stigma and shame deep within us might make us hesitant to help our trainees in their hour of need? Or cut corners? Or not get a second opinion? Very few psychiatrists on faculty of our medical schools divulge their personal experiences of depression, posttraumatic stress disorders, substance use disorders, and more (with the exception of being in therapy during residency, which is normative and isn’t stigmatized). Coming out is leveling, humane, and respectful – and it shrinks the power differential in the teaching dyad. It might even save a life.
Dr. Myers is a professor of clinical psychiatry at State University of New York, Brooklyn, and the author of “Why Physicians Die by Suicide: Lessons Learned From Their Families and Others Who Cared.”
Like everyone in the arc of social media impact, I was shocked and terribly saddened by the recent suicides of two New York women in medicine – a final-year medical student on May 1 and a second-year resident on May 5. As a specialist in physician health, a former training director, a long-standing member of our institution’s medical student admissions committee, and the ombudsman for our medical students, I am finding these tragedies harder and harder to reconcile. Something isn’t working. But before I get to that, what follows is a bulleted list of some events of the past couple of weeks that may give a context for my statements and have informed my two recommendations.
- May 3, 2018: I give an invited GI grand rounds on stress, burnout, depression, and suicide in physicians. The residents are quiet and say nothing. Faculty members seem only concerned about preventing and eradicating burnout – and not that interested in anything more severe.
- May 5: A psychiatry resident from Melbourne arrives to spend 10 days with me to do an elective in physician health. As in the United States, there is a significant suicide death rate in medical students and residents Down Under. In the afternoon, I present a paper at the annual meeting of the American Academy of Psychodynamic Psychiatry and Psychoanalysis on the use of psychotherapy in treatment-resistant suicidal depression in physicians. There is increasing hope that this essential modality of care will return to the contemporary psychiatrist’s toolbox.
- May 6: At the annual meeting of the American Psychiatric Association in New York, I’m the discussant for powerful heartfelt papers of five psychiatrists (mostly early career psychiatrists and one resident) that talked about living with a psychiatric illness. The audience is huge, and we hear narratives about internal stigma, self-disclosure, external stigma, shunning, bullying, acceptance, rejection, alienation, connection, and love by peers and family. The authenticity and valor of the speakers create an atmosphere of safety, which enables psychiatrists in attendance from all over the world to share their personal stories – some at the microphone, some privately.
- May 7: Again at the APA, I chair and facilitate a workshop on physician suicide. We hear from four speakers, all women, who have lost a loved one to suicide – a husband, a father, a brother, a son – all doctors. Two of the speakers are psychiatrists. The stories are gripping, detailed, and tender. Yes, the atmosphere is very sad, but there is not a pall. We learn how these doctors lived, not just how they died. They all loved medicine; they were creative; they cared deeply; they suffered silently; and with shame, they lost hope. Again, a big audience of psychiatrists, many of whom share their own stories, that they, too, had lost a physician son, wife, or mother to suicide. Some of their deceased family members fell through the cracks and did not receive the life-saving care they deserved; some, fearing assaults to their medical license, hospital privileges, or insurance, refused to see anyone. They died untreated.
- May 8: Still at the APA, a psychiatrist colleague and I collaborate on a clinical case conference. Each of us describes losing a physician patient to suicide. We walk the attendees through the clinical details of assessment, treatment, and the aftermath of their deaths. We talk openly and frankly about our feelings, grief, outreach to colleagues and the family, and our own personal journeys of learning, growth, and healing. The clinician audience members give constructive feedback, and some share their own stories of losing patients to suicide. Like the day before, some psychiatrists are grieving the loss of a physician son or sibling to suicide. As mental health professionals, they suffer from an additional layer of failure and guilt that a loved one died “under their watch.”
- May 8: I rush across the Javits Center to catch the discussant for a concurrent symposium on physician burnout and depression. She foregoes any prepared remarks to share her previous 48 hours with the audience. She is the training director of the program that lost the second-year resident on May 5. She did not learn of the death until 24 hours later. We are all on the edge of our seats as we listen to this grieving, courageous woman, a seasoned psychiatrist and educator, who has been blindsided by this tragedy. She has not slept. She called all of her residents and broke the news personally as best she could. Aided by “After A Suicide: A Toolkit for Residency/Fellowship Programs” (American Foundation for Suicide Prevention), she and her colleagues instituted a plan of action and worked with administration and faculty. Her strength and commitment to the well-being of her trainees is palpable and magnanimous. When the session ends, many of us stand in line to give her a hug. It is a stark reminder of how many lives are affected when someone you know or care about takes his/her own life – and how, in the house of medicine, medical students and residents really are part of an institutional family.
- May 10: I facilitate a meeting of our 12 second-year residents, many of whom knew of or had met the resident who died. Almost everyone speaks, shares their feelings, poses questions, and calls for answers and change. There is disbelief, sadness, confusion, some guilt, and lots of anger. Also a feeling of disillusionment or paradox about the field of psychiatry: “Of all branches of medicine, shouldn’t residents who are struggling with psychiatric issues feel safe, protected, cared for in psychiatry?” There is also a feeling of lip service being paid to personal treatment, as in quoted statements: “By all means, get treatment for your issues, but don’t let it encroach on your duty hours” or “It’s good you’re getting help, but do you still have to go weekly?”
In the immediate aftermath of suicide, feelings run high, as they should. But rather than wait it out – and fearing a return to “business as usual” – let me make only two suggestions:
2. In psychiatry, we need to redouble our efforts in fighting the stigma attached to psychiatric illness in trainees. It is unconscionable that medical students and residents are dying of treatable disorders (I’ve never heard of a doctor dying of cancer who didn’t go to an oncologist at least once), yet too many are not availing themselves of services we provide – even when they’re free of charge or covered by insurance. And are we certain that, when they knock on our doors, we are providing them with state-of-the-art care? Is it possible that unrecognized internal stigma and shame deep within us might make us hesitant to help our trainees in their hour of need? Or cut corners? Or not get a second opinion? Very few psychiatrists on faculty of our medical schools divulge their personal experiences of depression, posttraumatic stress disorders, substance use disorders, and more (with the exception of being in therapy during residency, which is normative and isn’t stigmatized). Coming out is leveling, humane, and respectful – and it shrinks the power differential in the teaching dyad. It might even save a life.
Dr. Myers is a professor of clinical psychiatry at State University of New York, Brooklyn, and the author of “Why Physicians Die by Suicide: Lessons Learned From Their Families and Others Who Cared.”
When Psychiatrists Die by Suicide
"You’re joking, right?" Even as I reflexively uttered these few words, I knew that my friend was not kidding around. Yes, it was true; Jim Steele (not his real name), whom I had trained with many years ago, had killed himself. "Gunshot wound to the head" was offered next. I realize now that my friend, another physician, was using clinical jargon to protect himself from the horror and the deeply personal nature of the act of self-destruction. "You’re joking, right?" conveys my shock and disbelief. But why are we stunned like this in the face of suicide? Would I have used these words if Jim had died of a coronary or cancer?
Physicians have long been known to have significant rates of suicide. The most common underlying psychiatric illnesses are mood disorders, substance use disorders, dual diagnoses, and personality traits and disorders (borderline, narcissistic, antisocial). Psychiatry is one of the vulnerable branches of medicine. For some observers, this is a paradox – wouldn’t specialists in diseases of the mind be able to recognize illness in themselves and seek appropriate treatment? For others, the cynics who have always deemed psychiatrists somewhat unstable and "less than," suicide is no surprise at all. If they weren’t already a bit off before specializing, then looking after mentally ill patients day after day could drive them to suicide.
What do we know about physician suicide, and in particular, psychiatrist suicide?
It is believed that 85%-90% of people who kill themselves have been living with a psychiatric illness, whether diagnosed or treated or not. Doctors are no exception. As a specialist in physician health, most of the doctor patients I have lost to suicide have been in this cohort. They are individuals who have died of their diseases, often after a long courageous battle. They have been poorly responsive to medications and various psychotherapies; they have had repeated hospitalizations, including courses of ECT, and their losses have been phenomenal – loss of career trajectory, loss of income, loss of marital and family stability, and loss of social supports.
Another group of physicians who take their own lives are doctors living with chronic, persistent, and progressive medically debilitating disorders. The loss of robust health and functioning, a medical vision of what lies ahead, and a need for autonomy and control over one’s destiny may drive the decision to die by suicide.
Given their medical training and knowledge, doctors know how to kill themselves. Access to lethal drugs (barbiturates, opiates, tricyclic antidepressants, insulin, potassium chloride) contributes to suicide risk. When exploring suicidality in my physician patients, I have been struck by the elaborate research and planning that underlie the suicide plans of physicians. It is embodied in statements like: "I want to do it right, absolutely foolproof; I’ve looked after too many botched suicide attempts in my work as a physician."
Stigma attached to psychiatric illness is still with us in the house of medicine. Stigma drives denial of symptoms, increases refractoriness, contributes to self-medicating, delays seeking help, and contributes to poor treatment adherence. In fact, many psychiatrists live with internalized stigma when they fall ill. They are ashamed to seek help and sometimes feel fraudulent, fearing that their talent and credibility as a competent physician are sullied by becoming a patient. They are tempted to prescribe for themselves and eschew reaching out to other psychiatrists for treatment. This is dangerous and puts psychiatrists at risk for suicide.
Psychiatrists probably have a higher incidence of mood disorders than those in other branches of medicine. This may be due to self-selection and choosing a field that is accepting of mental illness in its practitioners. It is not by accident that a medical student is attracted to psychiatry in part because of a bout of mental illness (eating disorder, anxiety, or mood disorder) and successful treatment during high school or college. Studies of addictive diseases in doctors have also found psychiatrists to be at risk. Mood disorders and chemical dependency – alone or in combination – contribute to suicide in psychiatrists.
There is much that we can do to avert these tragedies. Awareness is central. All of us need to fight stigma – both in our words and deeds. We need to take care of ourselves and embrace the notion of wellness. We need to be our brother’s and sister’s keeper, to reach out to colleagues we think are struggling and help them get appropriate, state-of-the art treatment. And should we lose colleagues to suicide, let’s remember them for how they lived, not just how they died. This is respectful and compassionate. We will honor their memory and their family members left behind.
Dr. Myers is a professor of clinical psychiatry, vice chair of education, and director of training at SUNY Downstate Medical Center, Brooklyn, N.Y. He is the coauthor (with Dr. Glen O. Gabbard) of "The Physician as Patient: A Clinical Handbook for Mental Health Professionals" (Washington: American Psychiatric Publishing, 2008) and (with Carla Fine) of "Touched by Suicide: Hope and Healing After Loss" (New York: Gotham Books, 2006). E-mail him.
"You’re joking, right?" Even as I reflexively uttered these few words, I knew that my friend was not kidding around. Yes, it was true; Jim Steele (not his real name), whom I had trained with many years ago, had killed himself. "Gunshot wound to the head" was offered next. I realize now that my friend, another physician, was using clinical jargon to protect himself from the horror and the deeply personal nature of the act of self-destruction. "You’re joking, right?" conveys my shock and disbelief. But why are we stunned like this in the face of suicide? Would I have used these words if Jim had died of a coronary or cancer?
Physicians have long been known to have significant rates of suicide. The most common underlying psychiatric illnesses are mood disorders, substance use disorders, dual diagnoses, and personality traits and disorders (borderline, narcissistic, antisocial). Psychiatry is one of the vulnerable branches of medicine. For some observers, this is a paradox – wouldn’t specialists in diseases of the mind be able to recognize illness in themselves and seek appropriate treatment? For others, the cynics who have always deemed psychiatrists somewhat unstable and "less than," suicide is no surprise at all. If they weren’t already a bit off before specializing, then looking after mentally ill patients day after day could drive them to suicide.
What do we know about physician suicide, and in particular, psychiatrist suicide?
It is believed that 85%-90% of people who kill themselves have been living with a psychiatric illness, whether diagnosed or treated or not. Doctors are no exception. As a specialist in physician health, most of the doctor patients I have lost to suicide have been in this cohort. They are individuals who have died of their diseases, often after a long courageous battle. They have been poorly responsive to medications and various psychotherapies; they have had repeated hospitalizations, including courses of ECT, and their losses have been phenomenal – loss of career trajectory, loss of income, loss of marital and family stability, and loss of social supports.
Another group of physicians who take their own lives are doctors living with chronic, persistent, and progressive medically debilitating disorders. The loss of robust health and functioning, a medical vision of what lies ahead, and a need for autonomy and control over one’s destiny may drive the decision to die by suicide.
Given their medical training and knowledge, doctors know how to kill themselves. Access to lethal drugs (barbiturates, opiates, tricyclic antidepressants, insulin, potassium chloride) contributes to suicide risk. When exploring suicidality in my physician patients, I have been struck by the elaborate research and planning that underlie the suicide plans of physicians. It is embodied in statements like: "I want to do it right, absolutely foolproof; I’ve looked after too many botched suicide attempts in my work as a physician."
Stigma attached to psychiatric illness is still with us in the house of medicine. Stigma drives denial of symptoms, increases refractoriness, contributes to self-medicating, delays seeking help, and contributes to poor treatment adherence. In fact, many psychiatrists live with internalized stigma when they fall ill. They are ashamed to seek help and sometimes feel fraudulent, fearing that their talent and credibility as a competent physician are sullied by becoming a patient. They are tempted to prescribe for themselves and eschew reaching out to other psychiatrists for treatment. This is dangerous and puts psychiatrists at risk for suicide.
Psychiatrists probably have a higher incidence of mood disorders than those in other branches of medicine. This may be due to self-selection and choosing a field that is accepting of mental illness in its practitioners. It is not by accident that a medical student is attracted to psychiatry in part because of a bout of mental illness (eating disorder, anxiety, or mood disorder) and successful treatment during high school or college. Studies of addictive diseases in doctors have also found psychiatrists to be at risk. Mood disorders and chemical dependency – alone or in combination – contribute to suicide in psychiatrists.
There is much that we can do to avert these tragedies. Awareness is central. All of us need to fight stigma – both in our words and deeds. We need to take care of ourselves and embrace the notion of wellness. We need to be our brother’s and sister’s keeper, to reach out to colleagues we think are struggling and help them get appropriate, state-of-the art treatment. And should we lose colleagues to suicide, let’s remember them for how they lived, not just how they died. This is respectful and compassionate. We will honor their memory and their family members left behind.
Dr. Myers is a professor of clinical psychiatry, vice chair of education, and director of training at SUNY Downstate Medical Center, Brooklyn, N.Y. He is the coauthor (with Dr. Glen O. Gabbard) of "The Physician as Patient: A Clinical Handbook for Mental Health Professionals" (Washington: American Psychiatric Publishing, 2008) and (with Carla Fine) of "Touched by Suicide: Hope and Healing After Loss" (New York: Gotham Books, 2006). E-mail him.
"You’re joking, right?" Even as I reflexively uttered these few words, I knew that my friend was not kidding around. Yes, it was true; Jim Steele (not his real name), whom I had trained with many years ago, had killed himself. "Gunshot wound to the head" was offered next. I realize now that my friend, another physician, was using clinical jargon to protect himself from the horror and the deeply personal nature of the act of self-destruction. "You’re joking, right?" conveys my shock and disbelief. But why are we stunned like this in the face of suicide? Would I have used these words if Jim had died of a coronary or cancer?
Physicians have long been known to have significant rates of suicide. The most common underlying psychiatric illnesses are mood disorders, substance use disorders, dual diagnoses, and personality traits and disorders (borderline, narcissistic, antisocial). Psychiatry is one of the vulnerable branches of medicine. For some observers, this is a paradox – wouldn’t specialists in diseases of the mind be able to recognize illness in themselves and seek appropriate treatment? For others, the cynics who have always deemed psychiatrists somewhat unstable and "less than," suicide is no surprise at all. If they weren’t already a bit off before specializing, then looking after mentally ill patients day after day could drive them to suicide.
What do we know about physician suicide, and in particular, psychiatrist suicide?
It is believed that 85%-90% of people who kill themselves have been living with a psychiatric illness, whether diagnosed or treated or not. Doctors are no exception. As a specialist in physician health, most of the doctor patients I have lost to suicide have been in this cohort. They are individuals who have died of their diseases, often after a long courageous battle. They have been poorly responsive to medications and various psychotherapies; they have had repeated hospitalizations, including courses of ECT, and their losses have been phenomenal – loss of career trajectory, loss of income, loss of marital and family stability, and loss of social supports.
Another group of physicians who take their own lives are doctors living with chronic, persistent, and progressive medically debilitating disorders. The loss of robust health and functioning, a medical vision of what lies ahead, and a need for autonomy and control over one’s destiny may drive the decision to die by suicide.
Given their medical training and knowledge, doctors know how to kill themselves. Access to lethal drugs (barbiturates, opiates, tricyclic antidepressants, insulin, potassium chloride) contributes to suicide risk. When exploring suicidality in my physician patients, I have been struck by the elaborate research and planning that underlie the suicide plans of physicians. It is embodied in statements like: "I want to do it right, absolutely foolproof; I’ve looked after too many botched suicide attempts in my work as a physician."
Stigma attached to psychiatric illness is still with us in the house of medicine. Stigma drives denial of symptoms, increases refractoriness, contributes to self-medicating, delays seeking help, and contributes to poor treatment adherence. In fact, many psychiatrists live with internalized stigma when they fall ill. They are ashamed to seek help and sometimes feel fraudulent, fearing that their talent and credibility as a competent physician are sullied by becoming a patient. They are tempted to prescribe for themselves and eschew reaching out to other psychiatrists for treatment. This is dangerous and puts psychiatrists at risk for suicide.
Psychiatrists probably have a higher incidence of mood disorders than those in other branches of medicine. This may be due to self-selection and choosing a field that is accepting of mental illness in its practitioners. It is not by accident that a medical student is attracted to psychiatry in part because of a bout of mental illness (eating disorder, anxiety, or mood disorder) and successful treatment during high school or college. Studies of addictive diseases in doctors have also found psychiatrists to be at risk. Mood disorders and chemical dependency – alone or in combination – contribute to suicide in psychiatrists.
There is much that we can do to avert these tragedies. Awareness is central. All of us need to fight stigma – both in our words and deeds. We need to take care of ourselves and embrace the notion of wellness. We need to be our brother’s and sister’s keeper, to reach out to colleagues we think are struggling and help them get appropriate, state-of-the art treatment. And should we lose colleagues to suicide, let’s remember them for how they lived, not just how they died. This is respectful and compassionate. We will honor their memory and their family members left behind.
Dr. Myers is a professor of clinical psychiatry, vice chair of education, and director of training at SUNY Downstate Medical Center, Brooklyn, N.Y. He is the coauthor (with Dr. Glen O. Gabbard) of "The Physician as Patient: A Clinical Handbook for Mental Health Professionals" (Washington: American Psychiatric Publishing, 2008) and (with Carla Fine) of "Touched by Suicide: Hope and Healing After Loss" (New York: Gotham Books, 2006). E-mail him.