Out of the Silence:

Medical Student Depression and

Suicide
A Companion Presentation
Paula J. Clayton, M.D.
Charles F. Reynolds III, M.D.
Sid Zisook, M.D.

Suicide and Other

Illness Rates Among Physicians

Suicide

Little attention to problem

Suicide rate is higher than

among the general
population, especially
among women physicians

Suicide rates in physicians

are not changing

Depression is a major risk

factor

Smoking

Heightened attention to
problem

Mortality rates from

smoking-related cancer,
heart disease and stroke are
lower than for the general
population

Smoking-related deaths
have declined 40%60%
since 1960
2

Suicide Rates Among

Physicians
Standardized Mortality Rate
Actual/Expected

Male physicians/age matched males in the general population

1.41

Female physicians/age matched females in the general population

2.27

Schernhammer E, Colditz G, Am J Psych, 2004

Schernhammer E, NEJM, 2005

Schernhammer E, Colditz G, Am J Psych, 2004

Schernhammer E, Colditz G, Am J Psych, 2004

Suicide and Occupation

Study in Denmark
Methods

Subjects who died by suicide from 19911997 while aged 2560 and
for each, 25 controls of same gender who were born in the same
year: 3,195 suicides (898 females), 63,900 controls

Results

RR
Highest risk of suicide is among medical doctors

Higher risk of suicide by poisoning in physicians

Higher risk in females working in male-dominated occupations

Particularly high-risk in doctors who have been admitted to the

hospital with a psychiatric disorder

Agerbo et al., Psych Med, 2007

2.73

Suicide and Occupation

Study in Denmark
Suicide, five highest occupational rate ratios:
Occupation
CI)

DISCO-88*

RR (95%

Highest
Medical doctors
2221
4.22)
A residual group without occupation
9999
(1.873.28)
Nursing associate professionals
3231
3.11)
Elementary occupations
(largely unskilled manual workers)
9
(1.472.68)
Plant and machine operators and assemblers
8
(1.222.76)
7

2.73 (1.77
2.47
2.04 (1.34
1.99
1.84

Additional Facts

In the general population, the male suicide rate is four times

that of females; in physicians the rates are equal

Physicians have higher rates of completion to attempts

which may result from greater knowledge of lethality of
drugs and easy access to means

Nordentoft M, Laegeforeningens Forlag Kobenhavn 2007, pp. 22

Risk Factors For Suicide

Major risk factors include mental disorders:

Major depressive disorder

Bipolar disorder, depression
Alcohol abuse
Drug abuse
Other disorders

Epidemiology of
Depression in Physicians

Lifetime rates of depression in women physicians were 39

percent compared to 30 percent in age matched women
with PhDs, both being higher than the general population
figures

Lifetime rates of depression in male physicians (13%) may

be similar to rates of depression in men in the general
population, or they may be elevated. Data from Denmark
using population-based case controls and hospital or
outpatient care for a first-time ever diagnosis of depression
(broadly define) show that male physicians have elevated
rates of care

Rates of depression are higher in medical students (15%

30%), interns (30%), and residents than in the general
population

Welner et al., Arch Gen Psych, 1979

Clayton et al., J Ad Dis, 1980
Frank & Dingle, Am J Psych, 1999
Wieclaw et al., Occup Environ Med, 2006

10

Depression in Medical
Faculty

A survey of physician well-being and health behaviors at an

academic health center found that nearly 30 percent of
respondents (attendings and house staff) reported past or
present depressive symptoms. This correlated with female
gender, younger age, living alone, and not having a primary
care physician

Reinhardt et al., Med Educ Online, 2005

11

Women Physicians and

Addiction

969 impaired physicians from 4 state physician health

programs
Female: 125
Male: 844
Alcohol was primary abused substance for all

Age, average

Women
39.9

Men
43.7

p < 0.0001

OR*
Med for psych problem
76.5
64.0 1.84
Past suicidal ideation
52.0
30.0 2.51
Current suicidal ideation
11.47
4.8 2.54
Made attempt under influence
20.0
5.1 4.64
Made attempt not under influence
14.0
1.7
Abused sedatives
11.4
6.4 1.87
*OR (odds ratio) >1.5 = statistically significant results
12

Wunsch et al., J Add Dis, 2007

9.67

Another Risk Factor:

Family History of Mood Disorders

Several of the studies with interns and physicians indicate

that depressed physicians, compared to appropriate
controls, had positive family histories of depression and
more previous depressions

Waterman, Jt Comm J Qual Patient Saf, 2007

Clayton et al., JAD, 1980
Valco & Clayton, Am J Psych, 1975
The Pharos, Winter 2008
13

Another Important Issue

There is no evidence that stressors in general are linked to

elevated rates of suicide in physicians

Gross et al., Arch Intern Med, 2000

14

Access of Care
and Barriers to Care

35 percent of physicians do not have a regular source of

health care

Low rates of seeking help among medical students:

Only 22 percent of those screening positive for
depression used mental health services
Only 42 percent of those with suicidal ideation received
treatment

Reasons:
lack of time (48%)
lack of confidentiality (37%)
stigma (30%)
cost (28%)
fear of documentation on academic record (24%)

Gross et al., Arch Intern Med, 2000

15

Access of Care
and Barriers to Care cont.

Among practicing physicians, barriers to mental health care

include:
discrimination in medical licensing
hospital privileges
health insurance
malpractice insurance

Miles SH, JAMA, 1998

APA, Am J Psych, 1984
16

Additional Barriers to
Adequate Mental Health
Care for Physicians

Professional attitudes that broadly discourage admission of

health vulnerabilities

Professional attitudes and lack of knowledge about

psychiatric illnesses

Physician-patients concerns about breaches of

confidentiality by the treating clinician

Compromised treatment due to collegial relationships;

deference from the treating clinician may give more freedom
to the physician-patient to control the focus of therapy and
to self-medicate

17

Licensing and Physician

Mental Health

Invited analysis of all State Medical Boards on policies

regarding mental illness

35/50 responded

37 percent indicated that a diagnosis of mental illness was

sufficient for sanctioning (although only 69% of these asked
about it)

40 percent indicated that the diagnosis of substance abuse

was sufficient for sanctioning and the majority had questions
about it

Survey urged that sanctioning be on basis of impairment for

physical or psychiatric illness

Arkansas and 18 other states focus on impairment

18

Hendin et al., Fed Bull, 2007

Suicide Inquiry in Primary Care

Using standardized depressed patients with 154 participating
physicians.
In 36 percent of 298 encounters, suicide was explored. It was
significantly more likely to happen when:

the patient portrayed major depression

if the patient made a request for an antidepressant
in an academic setting
among physicians with personal experience with
depression

19

Feldman et al., Annuals of Family Med, 2007

Patient Vignette:
A Depressed Medical Student
Patient: Blanca
Blanca is a first-year medical student at a large West Coast
university. Having always been an outstanding student, Blanca
was
overwhelmed with anxiety when struggling with her academics
for the
first time. She recalls feeling both distracted by her sadness
and
hampered by her anxiety while attempting to study for exams.
Yet, like
many others, Blanca did not recognize her feelings as being
symptoms
of depression and anxiety. Initially, Blancas fear that therapy
would be
20
just another stressor in her already-packed schedule
prevented
her from

Patient Vignette:
A Depressed Medical Student cont.
school psychologist. Blanca admits that upon hearing of her
diagnoses
major depression and generalized anxiety disorder she
was taken
by surprise. Indeed, her reaction typifies that of many newly
diagnosed
individuals: It was hard to take. Because theres always the
sense of
thats never me. Thats never going to be me. But it was.
Though
Blanca recognizes that receiving treatment does not lighten the
work
load of medical school, she does feel very strongly that the
combination
of medication and therapy has helped her to handle
her work,
21
and her

Patient Vignette:
A Depressed Surgeon
Patient: Robert
Robert is a plastic surgeon who practices in the Midwest. Like
so many
others, he did not consider the possibility that he was
depressed until
someone else suggested it to him. He recalls having a professor
in
medical school tell him that he needed to get over being
depressed if
he wanted to go on to become a doctor, a reflection of the
attitudes
held toward medical students and doctors seeking treatment
for mood
disorders. Though many, and indeed perhaps most, depressed
people
22
find it nearly impossible to be productive at work, Robert found

Patient Vignette:
A Depressed Surgeon
Despite his unhappiness, Robert was reluctant to seek
treatment, mainly
due to concerns over stigma. The stigma attached to a
physician
receiving psychiatric services has the potential to affect many
aspects of
his career, including his referral base, his reputation as a
competent
physician, both among colleagues and patients, and even his
license to
practice medicine. Once he finally did enter treatment, Robert
was
happy to learn that his concerns were unfounded, and his
career and
his life only benefited from his decision to get treatment.
His
23
only

Patient Vignette:
A Bipolar Physician
Patient: Alice
Alice is a neurologist specializing in movement disorders at a
prestigious
hospital in the Northeast. She began experiencing intense
feelings of
sadness after delivering stillborn twins, which she attributed to
the
grieving process. She dismissed others comments that she
seemed
withdrawn and depressed. In fact, Alice did not begin to
recognize
anything unusual within herself until she began experiencing
what she
calls extreme agitation wherein she felt that her mind was
overwhelmed with ideas. Wanting to keep track of24 this constant
flow of

Patient Vignette:
A Bipolar Physician cont.
urge to write. Indeed, she says it felt like I was doing work.
Alice also
recalls that she felt no need to see a psychiatrist, and only
relented once
her Chairman suggested she should. Once her treatment
began, Alice
received what she calls significant medication therapy and
participated
in psychotherapy (talk therapy). While she feels that the
majority of
her psychological improvement came from the medication, she
also
acknowledges that the psychotherapy helped her to deal with
her
feelings more adequately. As she learned more about the mania
that
enveloped her, Alices scientific curiosity was piqued.
Eventually Alice felt
25
compelled to write a book, The Midnight Disease, that
combined her

Discussion Questions
1.

What are your first thoughts after seeing this video?

2.

How many of you DO NOT have a close friend or relative

who has had a major depressive episode? For those who
haven't, are you surprised that you are in the minority on
this?

3.

How many of you DO NOT have a close friend, relative or

classmate (that you know of) on a SSRI?

4.

How many of you have had a close friend, relative or

classmate who has taken their own life? Are any of you
surprised at the high number? Were you aware before this
morning that the suicide rates are higher among medical
students and physicians than our non-medical
counterparts?
26

Discussion Questions
cont.
5.

If medical students tend to be smarter than average,

relatively healthy, have excellent resources available to
them and know more about health promoting behaviors
than most, wouldnt you expect the rate of depression to
be lower than in the general population for young adults?
Is it? Why Not?How do you explain the "paradox"?

6.

Some studies have found higher than expected rates of

suicide among medical students. Do you have any ideas
why that might be the case?Any other ideas?

7.

In the general population, men have higher rates of

suicide than women. Among physicians, however, women
physicians have rates equal to male physicians. Do you
have any ideas why that might be the case?

8.

What should we as a medical profession be doing about

it?
27

Discussion Questions
cont.
9.

In the video, could Blanca just as easily have been a

man? Would her story and treatment be as believable?
Would she be as open to being taped?

10.

In what ways do you identify with the feelings expressed

in the video about the White Coat ceremony?About what
happens in the way you feel about yourselves in the
ensuing months?

11.

At least 3/4 of you are no longer in the upper 1/4 of

everything you do.Is anyone willing to comment on what
that feels like? What are some of the other stresses
unique to being a medical student? Which of those do you
think can be remedied by feasible coping strategies?
Any examples of some of those strategies that have
worked?
28

Discussion Questions
cont.
12.

The video talked about stigma and other roadblocks to

care. Is any of that true at our school?Do any of you have
any ideas what we can do about it?

13.

In you heart of hearts, do you see major depression as an

illness?Is it something like laziness or self-pity that you
can will yourself out of; is it more like diabetes that
happens to us, but that we can do a lot regarding lifestyle
changes to control; or is more like a developmental
disorder that is pretty much out of our control? How do
you think most psychiatrists would answer that
question?What about most orthopedic surgeons?Most
medical school deans? Your classmates? Your
parents?Your future patients?

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