The COVID-19 outbreak has caused a stress on the health care system never before seen in our lifetime. It has caused unprecedented resource utilization in our emergency departments, ICU, and inpatient services. At the same time, it has completely shut down elective surgeries and non-urgent outpatient visits. Primary care physicians and outpatient doctors are shuttering their offices in favor of phone calls and visits through electronic means. While some of us are busier than we have ever been, others are sitting at home worried about their career. In this period of uncertainty, the risk of suicide among physicians is higher than it has been. We cannot care for our patients if we lose increasing numbers of physicians to suicide.
In our modern era, there is precious little information about the effects of a pandemic on suicide. During the SARS outbreak of 2003, Hong Kong saw an increase in suicides among those over 65 from 28.44 per 100,000 to 37.46 per 100,000 in one year. When graphed by month, the rates rose and fell with SARS incident cases. These increased rates sustained to 2004, a year after the SARS outbreak was over.
Physicians who die by suicide differ from the general population in a few key areas. They are less likely to die after the death of a friend or family member and less likely to die after a personal crisis in the last two weeks but are 3.12 times more likely to die after job-related issues. This reflects the resilience of physicians when dealing with stressors in their personal life. Similarly, this shows their tenuous resiliency to threats of professional identity due to how intertwined their professional and personal identities are. During the time of COVID-19, many physicians are undergoing incredible stress over their job-related issues. Whether it is a lack of PPE or concerns over their future as their clinics and offices close, these issues hang heavy over many of our colleagues. The most at-risk are females above 45 and males above 50. Males are at a higher risk than females, and whites are at higher risk than other races. At increased risk are those that are divorced, separated, or experiencing a marital disruption, who have depression or substance use disorder, and those who have access to firearms or medications.
Given all that is known about suicide prevention, there is a paucity of organized prevention strategies on a national scale for physicians. There have been successful programs implementing global suicide prevention strategies in specific occupations, most prominently the US Air Force. After implementation, there was a 33% relative decrease in suicide, a 51% decrease in homicide, and an 18% decrease in accidental death. These interventions share many common strategies. Gatekeeper training teaches individuals how to recognize at-risk individuals and how to intervene. Addressing the stigma of suicide is important. Having members of leadership openly discuss the importance of help-seeking behavior works, along with having open and candid conversations about suicide. Decreasing barriers to help is an effective strategy, as is suicide-screening for those facing legal problems. Survival stories can give those in crisis hope, but there are minimal first-hand accounts of survival among physicians. Safety planning is an effective tool for mitigating suicide risk. A simple one-page sheet can help individuals recognize their triggers and use customized interventions. Web-based interventions using cognitive behavioral therapy can mitigate suicidal ideation among physicians.
On a flight, you are reminded by a flight attendant to put on your mask before you assist someone else. The logic being if you are incapacitated, then you are unable to help those that cannot help themselves. In the COVID-19 epidemic, physicians are asked to step up to help others; doctors are a precious limited resource. We must first ensure our oxygen masks are on before we can help patients. Now more than ever, we must break through the stigma of suicide among doctors and reach out to those around us. As a nation and a profession, we must stand up and demand common sense suicide prevention strategies for our doctors. Let us all take a moment and ask, “Are you OK?” That simple gesture may save a life who, in turn, can save thousands more.
Perry Lin is the current Co-Chair Physician Suicide Awareness Committee, American Association for Suicidology and Assistant Program Director, Internal Medicine, Mount Carmel Health System. He has presented nationally on physician suicide and physician suicide prevention.
Illustration by Jennifer Bogartz