by James S. Harrop, MD; Isabelle M. Germano, MD, MBA; Ann R. Stroink, MD, FAANS
The word suicide is one we do not think of often as neurological surgeons. Its definition, according to the Merriam-Webster dictionary, is “the act or an instance of taking one’s own life, voluntarily and intentionally.” I recently was asked to provide a talk on physician suicide at the last AANS meeting. I must confess I did not have much insight or experience with the topic. However, I did have a close friend who unfortunately was heading down this path; with the support of his physician wife, this catastrophe was avoided. In retrospect, he and I discussed how I could be so myopic and have missed his depression and anhedonia. His response to me was surprising in that he acknowledged there were no signs, since he did everything possible to let people know. He described his experience as a weight or constriction on all his abilities similar to being confined in a straight jacket. Unfortunately, he is not alone, and others are not as fortunate.
As I talked to more experts in this field, I realized that my misconception that only depressed people commit suicide is incorrect. This is exemplified in the case of Lorna Breen, New York City emergency room physician who dedicated enormous energy to the Covid pandemic. She had no prior mental health history issues nor any history of depression or anxiety. Despite this, on October 9, 2020, she ended her life. The family has set up a foundation in her name that is an excellent resource and can be found at https://drlornabreen.org/. Mark Goulston, a physician and psychiatrist who studied this issue, noted “when people feel powerless and helpless and trapped, and they’re looking for relief, suicide is a permanent solution to a temporary problem.” We can all reflect on several individuals we know affected by suicide.
Over the five-year period of 2017 to 2021, almost a quarter of a million Americans died by suicide. Since 1995, it’s incidence has been on the rise as a leading cause of death, and now is the second most common cause of death for individuals less than 45 years of age. These figures probably underestimate the true incidence of suicide due to how deaths are reported and society’s unwillingness to accept mortality due to suicide. Recently, politicians and newscasters have reported the concern for increased crime rates and risk of homicide. However, Americans are almost three times more likely to die from suicide rather than homicide. Suicide affects us all and after the age of 18 years old, it appears all age groups have a similar incidence. Suicide does not discriminate; all ethnic groups are affected with a higher incidence in white and Native Americans. Males have significantly higher risk than females, but this ratio is decreasing. In fact, female physicians are at a greater risk, twice that of males, compared to the general population.
As physicians, we need to be educated about this disorder in order to help our patients. However, we are not immune to the disease. In fact, health care workers and physicians have the greatest incidence of suicide. The number is staggering: approximately 300 to 400 physicians die by suicide each year. Stop and reflect back on sitting in that medical school auditorium. In a single year, one and a half to two times the number of physicians of your entire medical school class are dying due to suicide.
In 2001, Stack published an interesting article analyzing 32 professions and calculating the incidence of suicide for each group (Stack S. Social Science Quarterly. Vol 82(2) Jun 2001. p221-431) in an attempt to determine if high risk professions had increased suicide risk because of occupational stress or because of their inherent demographic composition. Health-related occupations had the highest incidence even after controls were included for demographic covariates. It would appear that the health-related occupations contain many variables that may affect the suicide rate. Hopefully, with better physician education, we can improve.
Why physicians? There are numerous factors at play here, and they affect each of us and in different ways. This high stress environment is further intensified with long work hours, delayed gratification, difficulty balancing work and home life, lawsuits, patient management issues, changing health care environments and burn out. In addition, physicians are known to be poor patients deferring the utilization of health care resources. This, combined with the culture and negative stigma deter us from seeking help. We are poor allocators of our time and prioritize patients above all else. Lack of time was noted as the largest barrier of physicians seeking medical attention. Unfortunately, we must also acknowledge that we are a unique profession that has the ability to prescribe and obtain lethal drugs. Physicians are five times greater users of sedatives and tranquilizers without direct medical supervision. The availability of these “medications” has been directly linked to higher suicide rates.
This affects all facets of physicians including our medical trainees (medical students, interns and residents). When entering med school, our students have a slightly higher baseline rate of depression compared to other graduate students. However, as they go through internship and residency, there appears to be a significant increase in depression. Unfortunately, there does appear to be a direct correlation to depression and medical errors. It has been documented that medical professions, including trainees with depression, are at a significantly increased risk to make medical errors. What is exceedingly worrisome is that individuals that had a medical error have been shown to have an increased prevalence for depression. Hence, a vicious cycle is set up.
What can we do? The first thing we must do with any problem is to acknowledge it exists and destigmatize the issue of mental health. Although we tend to try and avoid this issue, the data clearly tells us there is a serious problem. Stop and think about how many physicians you know with these issues. We need to discuss it openly and, hence, this is my rationale for this article. Once we acknowledge these difficulties, we can develop solutions. Medicine can do better; other professions have been successful in reducing their suicide rates. Three steps to reduce suicide: 1) education on this topic for awareness and prevention 2) screening for depression and substance abuse, annual suicide prevention awareness and 3) access to treatment. In addition, medicine needs to fund research, identify the underlying causes and advocate for systemic changes in the health care system to prevent suicide.
James S. Harrop MD, is a neurosurgeon and professor, Departments of Neurological and Orthopedic Surgery at Thomas Jefferson University in Philadelphia, PA. Furthermore, he is the chief of the Division of Spine and Peripheral Nerve Surgery and neurosurgery director of Delaware Valley Spinal Cord Injury Center and director for Adult Reconstructive Spine. As well has a professorship appointment in Jefferson College of Population Health.
Ann R. Stroink, MD, FAANS, is a board-certified neurosurgeon and manages a full neurosurgery practice for Carle Health. She trained in general neurosurgery at the Mayo Clinic in Rochester, Minn., under the supervision of Thoralf M. Sundt, MD, and fellowed in pediatric neurosurgery at the Hospital for Sick Children at the University of Toronto.
Isabelle M. Germano, MD, MBA, FAANS, is a tenured professor of Neurosurgery, Neurology Oncological Sciences and Global health at the Icahn School of Medicine at Mount Sinai in New York City. She serves as director of the Comprehensive Brain Tumor Program at The Mount Sinai Hospital in New York City and Chair of the AANS Global Neurosurgery Committee (2023-2027) and immediate past-chair of the AANS/CNS Section on Tumor Chair (2022-2024).
