Incidence of suicide among medical professionals (students as well as doctors) is showing an alarming upward trend. What is worrying is the rather high and increasing rate of attrition among the young professionals. As high as 37.8 per cent of suicides in India are in the age bracket of 15 to 29 years and 51 per cent of the total suicide victims are graduates, college students or younger — the most productive and promising segment on which depends the economy, the future, and all the hopes of the nation.
Suicide has become a major public health problem worldwide. Nearly 1 million people worldwide commit suicide and 10 million to 20 million people attempt suicide every year. The United States alone has a high incidence of more than 32,000 suicides each year. It is the 3rd leading cause of death in 10-24 years age group in the US.
Incidence of suicide in India (as per a Lancet study) is the highest in the world. Twenty per cent of the total suicides of the world occur in India. In the last two decades, the incidence increased from 7.9 to 10.3 per 100,000 population. By 2010 the figure had reached 187,000 (with 40% adolescents). It is increasing further and threatens to become the No.1 killer in India.
Suicide among Medical Professionals
Doctors have the highest rate of suicide among all the professions. In the US every year, between 300 and 400 physicians take their own lives. And, in sharp contrast to the general population, where male suicides outnumber female suicides four to one, the suicide rate among male and female doctors is the same.
The rate of suicidal deaths among doctors is 2-4 per cent as against only about 1-2 per cent among general population. Male physicians have a 70 per cent higher suicide rate than males in other professions; and female physicians have a 400 per cent higher rate than females in other professions.
Suicide is usually the result of untreated or inadequately treated depression, coupled with knowledge of and access to lethal means. In medical profession, an estimated 12 per cent of males and 18 per cent of females suffer from depression. The higher rate of depression and suicide among female doctors can be explained. In addition to the stress and strain of being a doctor they also have to cope with the extra stresses of managing the household as well as their role as a wife, mother, and daughter-in-law. All that leaves little time for oneself, leads to inadequate rest and sleep, and social isolation and depression. Sexual harassment at work is another factor for higher incidence of suicide among female doctors.
Unfortunately, physicians who diagnose the ailments of mankind, frequently fail to recognize their own depression and that of their colleagues. Even when they do recognize that they are depressed, many physicians are reluctant to get effective treatment for their problems because of stigma attached to mental disorders and fear of loss of reputation and business, should the word get around. They tend to resort to self-medication with alcohol or prescription drugs, increasing their risk of drug addiction and depression resulting sometimes tragically into suicide. The most common psychiatric diagnoses among physicians with successful suicides are alleged to be affective disorders (e.g., depression and bipolar disease), alcoholism, and substance abuse.
Suicide among Medical Residents
Medical students and residents are even more vulnerable as 15-30 per cent of them are screened positive for depressive symptoms. Another study has reported that no fewer than one in five trainees suffered from clinically significant levels of depression, and 1 in 16 reported suicidal ideation (thoughts about or an unusual preoccupation with suicide). In episodes of depression, the trainees, having both the knowledge and access to dangerous drugs, may get driven to use them and commit suicide in their week moments.
Burnout, Depression and Suicide among Medical Students
Medical training can be very stressful. Many students having been toppers in their school, get a shock finding themselves in the middle or even at the bottom of the class in the medical college. Many of them do not have the requisite intelligence, competence or the aptitude to meet the tough demands of medical studies. Long study hours, inadequate sleep and standing for hours learning the clinical skills may lead to social isolation, mental fatigue and depression. Almost half of the medical students have symptoms of “burnout”. An estimated 15 to 30 per cent of medical students and residents suffer from depression. Even more frightening, 11 per cent of medical students have reported suicidal ideation within the past year. After accidents, suicide remains the most common cause of death among medical students in the United States.
A study by Abhinav Goyal et al (Journal of Mental Health and Human Behaviour, 2012) on 265 undergraduate students of a medical college in Delhi reported an association as high as 53.6 per cent with suicidal ideation. Suicidal ideation was highest in first professional year (64.4%) and lowest in third professional year (40.4%). About 4.9 per cent students seriously contemplated suicide and 2.6 per cent attempted suicide at least once in their life.
Habitual use of non-prescription drug is another predisposing factor. In a study by Divin and Zullig (2008) involving 26,600 randomly selected college students from 40 campuses in the US, 13 per cent of the respondents reported non-medical prescription drug use, and a significant percentage of them were those feeling hopeless, sad, depressed or having considered suicide, especially the females using painkillers.
In spite of the serious level of affliction, students avoid reporting their symptoms for fear of appearing weak in front of their peers, or because of adverse effect on their carrier. Lack of time or money for treatment, concern for confidentiality, could be other significant factors.
Risk Factors for Suicide
The common risk factors predisposing individuals to this extreme madness are:
• Mental illness (depression, manic depression, schizophrenia, substance abuse, severe anxiety and a past history / family history of suicide / attempted suicide). Nine out of 10 people who commit suicide have a diagnosable mental-health problem.
• History of physical/sexual abuse, access to firearms.
• Violent behaviour. There is a strong correlation (64%) between domestic violence on women and suicidal ideation / suicide among women.
• Real or imagined losses, like the breakup of a romantic relationship.
• Males (especially those unemployed, low income, singles/divorcees) are more likely than females to commit suicide, although attempts are more common among females.
• Sense of unbearable shame, loss of honour, or extreme poverty.
• In children and adolescents, particularly male teens, bullying and being bullied and loss of some loved one due to suicide.
Risk Factors Specific to Medical Professionals
• Among students, the reasons for suicide may be — lack of competence, frustration and depression because of poor performance and repeated failure in the examinations, problems with English language — the study medium, inability to cope with work related stress, use of drugs/alcohol.
• Among residents, stress and strain of long working hours during residency, harassment by seniors, failure to get speciality of choice, use of drugs/painkillers/alcohol, early burnout, knowledge about and easy access to lethal drugs.
• Among senior doctors, continuous long exposure to professional stress and strain, loss of professional reputation, failure to recognise depression and resorting to self-medication, overindulgence with drugs/alcohol.
As many as 75 per cent of suicide victims display some warning signs or symptoms such as given below, which if recognised early, a timely action can be taken for treatment and prevention of suicide.
• Severe anxiety or depression, symptoms of which may include insomnia, agitation, loss of interest in activities they used to enjoy (anhedonia), hopelessness and persistent thoughts about the possibility of something bad happening, alcohol abuse.
• A feeling of worthlessness, isolation, self-criticism, self-hatred, despair and loss of desire to live.
• Sudden indulgence in activities such as making a will, getting his/her affairs in order, suddenly visiting friends or family members (one last time), buying instruments of suicide like a gun, hose, rope, pills, other forms of medications, a sudden and significant decline or improvement in mood, or writing a suicide note.
Measures for Preventing Suicide among Medical Professionals
What is needed is a comprehensive programme addressing all the important factors and laying adequate emphasis on preventive as well as curative aspects, on the following lines.
1. Assessment of Competence: To prevent a mismatch between the student’s competence and the requisite competence, there should be a system of assessing the academic as well as psychological suitability of the student at the time of admission. A low calibre or emotionally fragile student, in any case would be no good for the patients, even if he does become a doctor.
2. Provision for Physical/Mental Rest and Recreation: One reason for undue stress and burnout is overwork (and no rest) in long 12 to 24 hour shifts. In some specialties in some (poorly staffed) hospitals, the residents may be forced to continue round the clock, for a full week without a break. A long stretch of gross overwork for months together is bound to cause attrition, physical as well as mental, sooner or later. The authorities must ensure that the hospitals employ adequate manpower as per the norms so that no resident is grossly overworked. Deficiency in manpower, in any case, is considered as deficiency in service, under the Consumer Protection Act, 1986.
3. Prevention of Burn out by officially organising Stress Busting Activities:
• Physical exercises / sports (often neglected) can be very effective in improving mood.
• Organised recreational activities to break the monotony.
• Stress-busting measures such as meditation, yoga, relaxation techniques, and hobbies.
• Social support from peers, friends and family is crucial to maintaining good mental health.
• In case of serious depression, especially with past history / family history of depression, one must seek professional treatment.
4. Faculty Members adopting groups of students to keep a finger on their pulse and providing social psychological support and guidance. In my medical college there used to be a system of Friday Groups. All students and faculty members were made members of some or the other group. Faculty members, on turn, would organise group meetings at their residences on Friday evenings, where snacks/refreshments, recreational activities and free interactions between juniors, seniors and the faculty members would provide an excellent opportunity to mix around, enjoy and take a break from work fatigue.
5. Suicide Hotline / Counselling Services: Availability of timely help/counselling from agencies such as Support Centres, Suicide Prevention hotline can prevent many suicides.
6. Resolution of Grief: Techniques for coping with the grief (due to suicide of a loved one or failure in the exam) include extra rest, nutritious eating, writing about their emotions, talking to others about the experience and thinking of ways to handle painful memories. Participation in school, social, and extracurricular activities is necessary to a successful resolution of grief.
7. A Programme of Prevention of Depression and Suicide among medical professionals may be organised in every medical college / medium/large sized hospital.
• The programme must include deliberate efforts to educate the students and residents about the problem of burnout and depression and the ways and means of preventing/coping with it in a healthy manner.
• It should aim at removing the stigma and other barriers to reporting and treating depression and encourage the students to come forward and seek timely counselling and help.
• It may include a programme of discrete monitoring of behaviour of students and residents by the faculty as well as peers, so as to detect and render help at early stages.
• Use of prescription drugs — particularly painkillers, is related to depressive symptoms and suicidal thoughts and behaviour in college students. The programme may include a system of monitoring by the faculty, the use of such drugs by the students/residents.
• Starting websites that allow students to screen themselves anonymously for depression and taking help of counsellors who may encourage them to come in for evaluation/treatment, observing full confidentiality.
• The programme should include a change in the culture of medicine that contributes to and/or stigmatizes depression among its members.
8. Students and residents should be made to realistically understand the level of their competence and the pace at which they can progress. Unnecessary competition with the better ones only leads to tension, disappointments and depression and may best be avoided.
Management of Depression and Suicide
Assessment of suicide risk in an individual and its management are in the domain of experts and should best be handled by them without any delay.
1. Comprehensive risk assessment for suicidal thoughts and behaviour, performed by mental-health professionals, would include:
• An evaluation of the presence, severity, and duration of suicidal feelings in the individual, family mental-health history, symptoms of emotional problems (anxiety, depression, mood swings, bizarre thoughts, substance abuse, eating disorders, history of being traumatized), violent behaviour, any past or present suicidal thoughts/dreams/intent/plans or suicidal attempts in the past, the circumstances, the level of dangerousness of the method and the outcome of the attempt;
• The person’s current circumstances, recent stressors (e.g., end of a relationship, family problems), sources of social support, accessibility of weapons, the treatment being availed and the response.
2. Assessment of suicide risk can also be done by using an assessment scale such as the SAD PERSONS scale, which identifies risk factors for suicide as follows:
• Sex (male)
• Age younger than 19 or older than 45 years of age
• Depression (severe enough to be considered clinically significant)
• Previous suicide attempt or received mental-health services of any kind
• Excessive alcohol or other drug use
• Rational thinking lost
• Separated, divorced, or widowed (or ending of other significant relationship)
• Organized suicide plan or serious attempt
• No or little social support
• Sickness or chronic medical illness
In the effort to cope with suicidal thoughts, silence is the enemy. Suggestions for helping people survive suicidal thinking, include engaging the help of a doctor or other health professional, a spiritual advisor, or by immediately calling a suicide hotline or going to the closest emergency room or mental-health crisis centre or by keeping a written or mental list of people to call in the event of suicidal thoughts coming back.
3. Timely treatment of suicidal thinking or attempt as deemed appropriate by the specialists on inpatient/outpatient basis, in the form of psychotherapy, drug therapy (antidepressants, mood stabilisers, anxiolytics etc) or a combination of both. ‘Talk therapy’ that focuses on helping the person understand how their thoughts and behaviour affect each other (cognitive behavioural therapy) has been found to be an effective treatment for many people who struggle with thoughts of harming themselves.
4. Since suicidal behaviour is often quite impulsive, removing the guns, knives, sharp objects and potentially lethal medications from the immediate environment can allow the individual time to think more clearly and perhaps choose a more rational way of coping with their depression/pain.
Dr S K Joshi (MBBS, MHA, DNB, QMAHO, MIPHA, MAHA) is a Hospital Administrator and author of books (‘Quality Management in Hospitals’, ‘Law and The Practice of Medicine’ and ‘Safety Management in Hospitals’), and many articles on professional issues. He is an Assessor for NABH Accreditation of Hospitals. Presently, he is working as a Consultant and a Visiting Faculty for PG courses in Hospital Management and Quality Management in Hospitals. Email: email@example.com Mobile: 9871582005