Physician Suicide and Organizational Justice: The Role of Hopelessness, Helplessness and Defeat
Michael Langan, M.D.
They can be a terror to your mind and show you how to hold your tongue
They got mystery written all over their forehead
They kill babies in the crib and say only the good die young
They don’t believe in mercy
Judgement on them is something that you’ll never see
They can exalt you up or bring you down main route
Turn you into anything that they want you to be–Bob Dylan, Foot of Pride
In F. Scott Fitzgerald’s The Great Gatsby, Nick Carraway observes that “the loneliest moment in someone’s life is when they are watching their whole world fall apart, and all they can do is stare blankly” In 1896 Émile Durkheim described “melancholy suicide” as being “connected with a general state of extreme depression and exaggerated sadness, causing the patient no longer to realize sanely the bonds which connect him with people and things about him. Pleasures no longer attract.” Heightened perceptions of defeat and entrapment are known to be powerful predictors of suicide. According to the “Cry of Pain” model people are particularly prone to suicide when life experiences are interpreted as signaling defeat, defined as a sense of a “failed struggle.” Unable to find some sort of resolution to a defeating situation, a sense of entrapment proliferates and the perception of no way out provides the central impetus for ending one’s life.
Although no reliable statistics yet exist, anecdotal reports suggest a marked rise in physician suicide in recent years. From the reports I am receiving it is a lot more than the oft cited “medical school class” of 400 per year.
This necessitates an evaluation of predisposing risk factors such as substance abuse and depression, but also requires a critical examination of what external forces may be involved. What acute and cumulative situational and psychosocial factors are involved in the descent from suicidal ideation to planning to completion? What makes suicide a potential option for doctors and what acute events precipitate and trigger the final act?
Depression and Substance Abuse no Different from General Population
The prevalence of depression in physicians is close to that of the general population1,2 and, if one looks critically at the evidence based literature, substance abuse in medical professionals approximates that of the general population. Controlled studies using DSM diagnostic criteria indicate that physicians have the same rates (8-14%) of substance abuse and dependence as the general population,3 and slightly lower rates compared to other occupations.4,5 Epidemiological surveys reveal the same. Hughes, et al.6 reported a lifetime prevalence of drug or alcohol abuse or dependence in physicians of 7.9%, markedly less than the 14.6% prevalence reported in the general population by Kessler.7
Job Stress and Untreated Mental Illness Risk Factors
Job stress coupled with inadequate treatment for mental illness may be factors contributing to physician suicide according to one recent study. Using data from the National Violent Death Reporting System, Gold, Sen, & Schwenk, 2013 8 compared 203 physicians who had committed suicide to more than 31,000 non-physicians and found that having a known mental health disorder or a job problem that contributed to the suicide significantly predicted being a physician.
Physicians were 3.12 times more likely to have a job problem as a contributing factor. In addition, toxicology testing showed low rates of medication treatment. The authors concluded that inadequate treatment and increased problems related to job stress are potentially modifiable risk factors to reduce suicidal death among physicians. They also warned that the database used likely underestimated physician suicides because of “underreporting and even deliberate miscoding because of the stigma attached.”8
Few studies have evaluated the psychosocial stressors surrounding physician suicide but there is no reason to believe they are any different from the rest of the population. Although the triggering life events and specific stressors may vary outside, the inner psyche and undercurrent of thoughts and feelings should remains the same. Perhaps the same drivers of suicide identified in other populations are contributing to physician suicide.