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Professional Adversities and Protective Factors Associated with Suicidal Ideation in Mexican Psychiatrists
Archives of Medical Research 50 (2019) 484e489
ORIGINAL ARTICLE
Professional Adversities and Protective Factors Associated with Suicidal Ideation in Mexican Psychiatrists Ana Fresan,a Marıa Yoldi-Negrete,b Rebeca Robles-Garcıa,c Carlos-Alfonso Tovilla-Zarate,d and Aldo Suarez-Mendozae a Subdirecci on de Investigaciones Clınicas, Instituto Nacional de Psiquiatrıa Ramon de la Fuente Mu~nız, Ciudad de Mexico, Mexico Consejo Nacional de Ciencia y Tecnologıa, Instituto Nacional de Psiquiatrıa Ramon de la Fuente Mu~nız, Ciudad de Mexico, Mexico c Centro de Investigacion en Salud Mental Global. Instituto Nacional de Psiquiatrıa Ramon de la Fuente Mu~nız, Ciudad de Mexico, Mexico d Divisi on Academica Multidisciplinaria de Comalcalco, Universidad Juarez Autonoma de Tabasco, Rancherıa Sur, Cuarta Seccion, Comalcalco, Tabasco, Mexico e Asociacion Psiqui atrica Mexicana, Ciudad de Mexico, Mexico b
Received for publication March 5, 2019; accepted November 20, 2019 (ARCMED_2019_195)..
Background. Psychiatrists may be at an increased risk of suicide, since they encounter stressful factors in their everyday activities in addition to the sociodemographic factors for suicidal ideation reported for Mexican population. Aim of the study. To determine whether experiences inherent to the profession were related to the self-report of suicidal ideation among Mexican psychiatrists or could be attributed to factors previously reported in the general population (age, marital status, presence of a mental disorder and not having received specialized treatment). Methods. This was a cross-sectional retrospective study with 288 psychiatrists from Mexico who participated through an online survey where current working activities, self-reported mental health conditions (major depression, anxiety, burnout and suicidal ideation) and professional adversities (assaults, lawsuits, patients with suicidal ideation or who had committed suicide, perceived discrimination and social support) throughout the professional lifespan were evaluated. Results. Twenty-two psychiatrists (7.6%) reported having had suicidal ideation at some point in their training in psychiatry or their professional lives as psychiatrists. Depression and burnout were the most important predictors for suicidal ideation while greater satisfaction with social support was the most important protector, followed by being married/ living together and having other physicians in the family. Conclusions. Psychiatrist represent a risk population for suicidal ideation. As such, detection and attention are essential. Psychiatrists need to be encouraged to pursue healthy, lasting interpersonal relationships and seek professional help when required. Ó 2019 IMSS. Published by Elsevier Inc. Key Words: Suicidal ideation, Psychiatrist, Mental health, Mexico.
Introduction Suicides and suicide attempts are preventable tragedies, yet they occur at all ages, in every region of the world and represent the second leading cause of death among people
Address reprint requests to: Ana Fresan, PsyD, PhD, Instituto Nacional de Psiquiatrıa Ram on de la Fuente Mu~nız, Calz. Mexico-Xochimilco 101, Ciudad de Mexico, 14370, Mexico; Phone: (þ52) (55) 41605069; FAX: (þ52) (55) 56550411; E-mail: [email protected]
ages 15e29. The impact of a single suicide is long lasting and devastating for families, friends, communities and the health care system (1). The taboo and stigma surrounding suicide that prevents people from seeking help or receiving it in a timely and efficient manner (1) is also present among health-care workers. Physicians have been found to have higher suicide rates than the general population (2). This difference, observed as early as in medical school (3,4), has been hypothesized to be associated with personality traits
0188-4409/$ - see front matter. Copyright Ó 2019 IMSS. Published by Elsevier Inc. https://doi.org/10.1016/j.arcmed.2019.11.010
Suicidal Ideation in Psychiatrists
characterized by a deep sense of responsibility, leading to reluctance to take vacations, long working hours, difficulty balancing work-family priorities and a general sense of the need to do more. As expected, these traits are associated with depression, anxiety, burnout and hopelessnesseall linked to suicide (5,6). Physicians’ negative attitude and rejection of their own illnesses and that of colleagues is also thought to be a risk factor, especially as regards mental disease (2,7e9) and psychiatrists are no exception. As mentioned by Kosulwit (10) ‘‘Society expects psychiatrists to have good mental health because they have to serve the mentally ill’’. Indeed, psychiatric disorders continue to be perceived as diseases in which voluntary control plays a major role, therefore holding the patient responsible, much like the stigma surrounding obesity (11) or lung cancer (12). This oversimplification of the causes underlying mental illness puts great pressure on clinicians, making help-seeking a difficult task: fear of nonconfidentiality and the possible impact on professional career are among the main factors why psychiatrists do not seek help (13,14). Balon R. and colleagues (14) found that of 830 Michigan psychiatrists, up to 50% revealed they chose to treat themselves even if they had suicidal thoughts. This is particularly disturbing, as mental health professionals deal with situations which are known to have a significant emotional impact, such as treating patients with suicide attempts or completed suicides (15e17), and are faced with demands inherent to psychiatry practice such as demanding patients, threats of violence or stalking (18), highlighting the need for support. The small number of mental health specialists in the country also results in a work overload for existing psychiatrists (19), and stigma in this profession is another stressful factor (18). In addition to the stressful factors surrounding the everyday activities of psychiatrists, we cannot ignore the risk factors related to the Mexican population associated with suicidal ideation and suicide in the general population, since they could further increase the risk in psychiatrists. Approximately three out of every four suicides occur in low and middleincome countries (20). While the difference in suicide death rates between 2000 and 2012 showed a 26% decrease internationally, the panorama in Mexico worsened, with an increase of 17.1% during the same period (1). Being a woman, not being in a relationship, unemployment, a younger age and living in the southeast of the country were found to be sociodemographic risk factors for suicidal ideation, planned suicide and attempted suicide in Mexicans (21). As psychiatrists may be at an increased risk of suicide (22,23) and suicidal ideation precedes and amplifies the risk of death by suicide, the study of suicidal ideation of psychiatrists in Mexico is a priority for the health system, individual well-being and life itself. Accordingly, the purpose of this study was to examine whether experiences related to the profession, such as having a family member who is a psychiatrist, working hours, assaults experienced, lawsuits, patients with
485
suicidal ideation or who have committed suicide, perceived discrimination as a psychiatrist or lack of social support were related to the self-report of suicidal ideation among Mexican psychiatrists; or whether suicidal ideation could be attributed to the same factors previously reported in the general population such as age, marital status and having had a mental disorder (depression, anxiety or burnout) and not having received specialized treatment. The study was conducted among a sample of psychiatrists in Mexico.
Materials and Method The present study was approved by the Ethics and Research Committees of the Ramon de la Fuente Mu~nız National Institute of Psychiatry, Secretariat of Health, Mexico No. 09-CEI-010-20170316. Study Design and Participants This was a cross-sectional retrospective study of Mexican psychiatrists. Recruitment was performed by a convenience sample approach with psychiatrists in the country who were willing and able to participate through an online survey. The nature of the study was explained to participants at the beginning of the electronic interview where anonymity was preserved; those who agreed to participate proceeded to complete the interview. Recruitment was performed from January 2018eDecember 2018. Assessment Procedure The interview was conducted in Spanish. Prior to its application, a pilot version was conducted among 10 volunteer psychiatrists to adjust questions with confusing language and terminology. The first section of the interview included questions related to demographic variables: age, sex, marital status, postgraduate studies in addition to the specialty in psychiatry, current working activities, maximum working hours per day and whether or not there were other physicians and psychiatrists in the family. The second section of the interview included questions about mental health conditions. Psychiatrists were asked about the presence of major depression, anxiety disorders or burnout throughout their professional lifespan and whether they had received specialized treatment for these conditions. Suicidal ideation was included in this section, and was used to divide the sample in those who reported having had suicidal ideation at some point in their professional life and those who did not. The third and final section of the interview included questions about professional adversities: assaults received, lawsuits, patients with suicidal ideation or who had committed suicide, perceived discrimination as a psychiatrist and social support. Perceived discrimination was assessed through an adaptation of the Spanish version of King’s Internalized Stigma ScaleeDiscrimination dimension (24,25), which is composed
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Fresan et al./ Archives of Medical Research 50 (2019) 484e489
of 13 items scored on a five-point Likert agreement scale. Items are designed to evaluate the perception of negative reactions of other people toward being a psychiatrist. The Social Support Questionnaire (SSQ-6) (26) was used to evaluate satisfaction with the social support that the individual receives using the mean score obtained from the six items in the instrument rated on a six-point Likert satisfaction scale. Psychiatrists known to the researchers responsible for the study were invited to participate by email. This email included a link for the electronic interview, and they were asked to send this email to other colleagues in the country. Moreover, the Mexican Psychiatric Association disseminated the interview link through its website. Statistical Analyses First, descriptive information was determined by frequencies and percentages for categorical variables and means and standard deviations (S.D.) for continuous variables. The comparison of variables between psychiatrists having had suicidal ideation and those who did not, was performed with contingency table c2 tests with an estimated odds ratio (95% C.I.) for categorical variables; independent samples t-tests were used for continuous variables. Variables with significant differences between groups were included in multivariate logistic regression analyses to determine which variables predicted suicidal ideation among Mexican psychiatrists. The Akaike Information Criterion (AIC) was used to determine which of the logistic regression models best approximated the data. Significance was established at p #0.05 for all analyses performed using the SPSS version 21 for Windows, PC.
Results Demographic Variables The present analysis was based on a sample of 288 psychiatrists from 27 states in Mexico who completed the interview. A similar proportion of men (49%, n 5 101) and women (51%, n 5 147) were included in the study. The mean age of the sample was 43.7 years (S.D. 5 11.3, range 28e74). Most psychiatrists are married (64.6%, n 5 186) or partnered (24.3%, n 5 70) and have children (58.7%, n 5 169). Over half the participants (62.2%, n 5 179) had additional postgraduate studies (subspecialty, masters and/or doctorate studies) in addition to the specialty in psychiatry and currently have various work activities, mainly involving clinical consultation (93.4%, n 5 269) and teaching (53.8%, n 5 155). The maximum continuous workinghours reported were 13.8 hours (S.D. 5 4.7, range 6e36). Other physicians in the family were reported by 53.5% (n 5 154) and only 17.7% (n 5 51) reported having relatives who were psychiatrists.
Twenty-two psychiatrists (7.6%) reported having had suicidal ideation at some point in their training in psychiatry or their professional lives as psychiatrists. Demographic features according to the report of suicidal ideation are shown in Table 1. As shown in Table 1, psychiatrists without suicidal ideation were older, more frequently married/partnered (OR 5 0.34, 95% C.I. 5 0.14e0.84), with children (OR 5 0.37, 95% C.I. 5 0.15e0.91) and with more physicians in the family (OR 5 0.37, 95% C.I. 5 0.14e0.95) than their counterparts with a history of suicidal ideation. Postgraduate studies and work-related activities were similar among the groups (Table 1). Mental Health and Specialized Treatment Nearly three-quarters of the psychiatrists (71.9%, n 5 207) reported having had a mental health problem throughout their professional lifespan. Depression was the most frequent disorder (50.3%, n 5 145) followed by anxiety (42.0%, n 5 121) and burnout (30.2%, n 5 87). Of the participants affected by any of these disorders, 81.2% (n 5 168 from the 207 affected psychiatrists) were receiving specialized treatment: 66.7% (n 5 138) were undergoing psychotherapeutic interventions and 71.0% (n 5 147) were being given pharmacological treatment, of which 43.5% (n 5 64 of 147 who received specialized treatment) was by selfprescription. Mental health disorders were significantly more common in psychiatrists with a history of suicidal ideation (depression OR 5 11.2, 95% C.I. 5 2.5e49.2; anxiety OR 5 11.2, 95% C.I. 5 2.5e49.2; burnout OR 5 4.6, 95% C.I. 5 1.8e11.4). Nevertheless, specialized treatment for these disorders did not differ between psychiatrists with and without suicidal ideation (Table 1). Professional Adversities Professional adversities were reported by almost all the psychiatrists (97.9%, n 5 282). The most common adversities were having patients with severe suicidal ideation (94.3%, n 5 266), assaults (89.4%, n 5 253), having had patients who had committed suicide (47.9%, n 5 135) and lawsuits (17.7%, n 5 50). Assaults were mainly verbal (85%, n 5 215 from those who reported assaults) and physical (43.5%, n 5 110) and committed by patients (76.7%, n 5 194) or patients’ relatives (53.4%, n 5 135). None of the adversities differed between groups. Nevertheless, whereas perceived discrimination assessed with the King’s Internalized Stigma Scale can be considered as low/moderate (mean score 18.4, S.D. 5 18.4, range 0e46) and general satisfaction with social support was high (SSQ-6 mean score 5.0, S.D. 5 1.1, range 1e6), psychiatrists with suicidal ideation perceived more discrimination and reported less satisfaction with social support than those without suicidal ideation (Table 1).
Suicidal Ideation in Psychiatrists
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Table 1. Demographic variables, mental health disorders and professional adversities in psychiatrists with and without suicidal ideation Total n [ 288 n Demographics Sex-Women Age (mean; S.D.; range) Marital status-Married Children-Yes Postgraduate studies-Yes Physicians in family-Yes Psychiatrists in family-Yes Current work-activities Clinical consultation-Yes Teaching-Yes Research-Yes Administrative-Yes Maximum working-hours (mean; S.D.; range) Mental Health and specialized treatment Depression e Yes Anxiety e Yes Burnout-Yes Specialized treatment e Yesa Psychotherapy e Yesa Pharmacological e Yesa Medication self-prescription e Yesb Professional adversities Any professional adversity-Yes Lawsuits-Yesc Patients with suicidal ideation-Yesc Patients who committed suicide-Yesc Assaultsc Physical-Yesd Verbal-Yesd Psychological-Yesd By patients-Yesd By patients’ relatives-Yesd By colleagues-Yesd Perceived discrimination (mean; S.D.; range) Satisfaction with social support (mean; S.D.; range)
Without suicidal ideation n [ 266
With suicidal ideation n [ 22
n
n
%
%
%
147 51.0 43.7 (11.3; 28e74)
133 50.0 44.1 (11.4; 28e74)
14 63.6 38.2 (6.6; 29e55)
186 169 179 154 51
177 161 166 147 49
9 8 13 7 2
64.6 58.7 62.2 53.5 17.7
66.5 60.5 62.4 55.3 18.4
40.9 36.4 59.1 31.8 9.1
Statistics Fisher 5 0.27 t 5 3.7, p 5 0.001 Fisher 5 0.02 Fisher 5 0.04 Fisher 5 0.82 Fisher 5 0.04 Fisher 5 0.38
269 93.4 155 53.8 59 20.5 50 17.4 13.8 (4.7; 6e36)
248 93.2 144 54.1 53 19.9 45 16.9 13.6 (4.4; 6e32)
21 95.5 11 50.0 6 27.3 5 22.7 16.2 (7.0; 8e36)
Fisher 5 1.00 Fisher 5 0.82 Fisher 5 0.41 Fisher 5 0.55 t 5 -1.3, p 5 0.19
145 121 87 168 138 147 64
125 104 73 149 121 128 55
20 17 14 19 17 19 9
Fisher Fisher Fisher Fisher Fisher Fisher Fisher
50.3 42.0 30.2 82.1 66.7 71.0 43.5
47.0 39.1 27.4 80.5 65.4 69.2 43.0
90.9 77.3 63.6 86.4 77.3 86.4 47.4
282 97.9 50 17.7 266 94.3 135 47.9 253 89.7 110 43.5 215 85.0 92 36.4 194 76.7 135 53.4 36 14.2 18.4 (10.0; 0e46)
260 97.7 50 19.2 247 95.0 125 48.1 233 89.6 105 45.1 198 85.0 84 36.1 182 78.1 121 51.9 33 14.2 18.0 (10.0; 0e46)
22 100.0 19 86.4 10 45.5 20 90.9 5 25.0 17 85.0 8 40.0 12 60.0 14 70.0 3 15.0 23.0 (9.2; 10e41)
5.0 (1.1; 1e69)
5.0 (1.1; 1e6)
4.2; 1.3; 1-6
!0.001 5 0.001 5 0.001 5 0.77 5 0.34 5 0.09 5 0.80
Fisher 5 1.00 Fisher 5 0.11 Fisher 5 0.82 Fisher 5 1.00 Fisher 5 0.10 Fisher 5 1.00 Fisher 5 0.81 Fisher 5 0.09 Fisher 5 0.16 Fisher 5 1.00 t 5 ‒2.2, p 5 0.02 t 5 3.2, p 5 0.001
n 5 207 from psychiatrists who reported mental health disorders. n 5 147 from those who received pharmacological treatment. c n 5 282 from those who reported professional adversities. d n 5 253 from those who reported assaults. a
b
Prediction of Suicidal Ideation in Mexican Psychiatrists A series of multivariate logistic regressions were conducted to examine predictors of suicidal ideation among psychiatrists. The initial regression model included variables where significant differences arise in the comparative analyses: age, marital status, having children and other physicians in the family in the demographic variables; selfreported depression, anxiety and burnout from mental health variables and perceived discrimination and satisfaction with social support in the professional adversities
variables. The initial and final models are shown in Table 2. The final logistic regression equation was significant for the present sample according to the Hosmer and Lemeshaw statistical value ( p 5 0.98) with improvements in the model fit evident from the reduction in AIC values. Depression and burnout were the most important predictors for suicidal ideation in Mexican psychiatrists, while having higher satisfaction with social support was the most important protector, followed by being married/partnered and having other physicians in the family.
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Fresan et al./ Archives of Medical Research 50 (2019) 484e489
Table 2. Logistic regression models for the prediction of suicidal ideation in Mexican psychiatrists
Initial Model: AIC value 244.02 Marital status e Married/partnered Current age Children-Yes Other physicians in the family-Yes Depression-Yes Anxiety-Yes Burnout-Yes Perceived discrimination Satisfaction with social support Final Model: AIC value 131.80 Marital status-Married/partnered Other physicians in the family-Yes Depression-Yes Burnout-Yes Satisfaction with social support
b
OR
95% C.I.
p
‒1.20 ‒0.04 ‒0.11 ‒1.34 1.84 0.83 0.80 0.002 ‒0.49
0.29 0.95 0.89 0.26 6.33 2.31 2.24 1.00 0.61
0.09e0.91 0.89e1.02 0.27e2.91 0.08e0.76 1.33e30.0 0.71e7.52 0.76e6.57 0.94e1.06 0.41e0.90
0.03 0.18 0.85 0.01 0.02 0.16 0.14 0.93 0.01
‒1.20 ‒1.31 2.19 1.09 ‒0.48
0.29 0.26 8.99 2.99 0.61
0.11e0.80 0.09e0.76 1.93e41.79 1.09e8.19 0.42e0.89
0.01 0.01 0.005 0.03 0.01
Discussion The aim of the present study was to determine whether the self-report of suicidal ideation among Mexican psychiatrists was associated with factors inherent to psychiatry as a profession or to factors reported in the general population. Our main findings show that depression and burnout were the most important predictors of a history of suicidal ideation while satisfactory social support, being in a relationship and having physicians in the family were the most important protectors. According to 2016 National Survey on Drug, Alcohol and Tobacco Use (Encuesta Nacional de Consumo de Drogas, Alcohol y TabacoeENCODAT 2016), the prevalence of suicidal ideation among Mexican population over 18 years old is 2.3% (27). The prevalence among Mexican psychiatrists was 7.6%, three times higher than that observed in the general population. This supports previous reports showing that psychiatrists are at an increased risk for suicide (28,29). Although to our knowledge, there are no studies exploring the prevalence of burnout in Mexican psychiatrists, this condition has been found to be higher among psychiatrists than among other medical specialties in a number of studies (30). There is no reason to believe this would be different in our country, given the low rate of psychiatrists per 100 000 inhabitants (Heinze et al reported 3.68 per 100 000 inhabitants in 2016) and the poor distribution in the country: 60% practice in one of the three major Mexican cities (19). Long working hours are likely to be common and a lack of resources highly probable. Burnout has also been found to be a risk factor for suicidal ideation in other studies (31). Depression and especially severe depressive symptomatology is a well-known risk factor for suicidal ideation and suicide (32). What is especially relevant is that it is also known that suicidal ideation declines with the improvement
of depressive symptoms, especially subjective symptoms (33). The paradox is that psychiatrists face a potential deadly effect of self-treating their own depression (suicide) (14) and need access to professional treatment. Our results show that only 81.2% of psychiatrists with a mental disorder received specialized treatment and 43.5% selfprescribed that treatment. Although psychiatrists specialize in diagnosing and treating these disorders, the practice of self-treatment of depression and other mental health conditions should be considered unacceptable (14), as clinical judgement may be altered by symptoms, which could result in errors in treatment choices that can be potentially dangerous. Being in a relationship was found to be a protective factor for suicidal ideation in the present study together with higher satisfaction with social support. Strong social support rather than marriage/living together has systematically been found to be a protective factor for suicide and suicidal behavior, while its counterpart, living alone, has been identified as a risk factor in the general population (34,35). This has also been found in physicians (5). Closely related to the previous result of social support, having another physician in the family was a protective factor for suicidal ideation in Mexican psychiatrists. To our knowledge, this has not been previously explored among physicians, although it seems reasonable to conceive that physicians may experience less stigma towards mental illness and therefore support their relatives who are also physicians or psychiatrists. Also, the understanding of work-related stressors by this additional physician in the family might improve the quality of familial support provided, as the efficacy of support has been found to be related to the degree of similarity between people (36). This study has some limitations that should be considered in the interpretation of our results. The first limitation is related to possible sampling and evaluation biases. We should consider the fact that psychiatrists with suicidal ideation may be less likely to answer the survey due to concerns about being identified (even though confidentiality was guaranteed) or possible self-stigmatizing attitudes. Second, suicidal ideation was explored as a past event, and current living circumstances may not reflect those present at the time of active suicidal ideation. History of psychiatric disorders was not externally confirmed and relied on self-report. Although psychiatrists may be specialists in these disorders, self-diagnosis could bias their accuracy. Despite these limitations, this study represents the first large-scale research project on suicidal ideation among Mexican psychiatrists. The information provided is urgently needed as the demand for mental health professionals is increasing due to the rise in depression, drug misuse and suicide in the general population, together with the evidence of the effectiveness of psychopharmacological treatment for these conditions.
Suicidal Ideation in Psychiatrists
Mental health professionals are not immune to psychiatric illnesses although they are further from help than the general population. Psychiatrists must be encouraged to pursue healthy, lasting interpersonal relationships and seek professional help when needed.
Conclusion Since there is, ‘‘No health without mental health’’ (37), the mental health care of psychiatrists must be one of the main objectives of health systems, since these professionals are responsible for the care and monitoring of the mental health of thousands of people around the country.
Acknowledgments To all psychiatrists who participated in the present survey. Special thanks are due to Yolanda Pica, MD and Hector Esquivias MD for their valuable support in the promotion of the survey.
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ORIGINAL ARTICLE
Professional Adversities and Protective Factors Associated with Suicidal Ideation in Mexican Psychiatrists Ana Fresan,a Marıa Yoldi-Negrete,b Rebeca Robles-Garcıa,c Carlos-Alfonso Tovilla-Zarate,d and Aldo Suarez-Mendozae a Subdirecci on de Investigaciones Clınicas, Instituto Nacional de Psiquiatrıa Ramon de la Fuente Mu~nız, Ciudad de Mexico, Mexico Consejo Nacional de Ciencia y Tecnologıa, Instituto Nacional de Psiquiatrıa Ramon de la Fuente Mu~nız, Ciudad de Mexico, Mexico c Centro de Investigacion en Salud Mental Global. Instituto Nacional de Psiquiatrıa Ramon de la Fuente Mu~nız, Ciudad de Mexico, Mexico d Divisi on Academica Multidisciplinaria de Comalcalco, Universidad Juarez Autonoma de Tabasco, Rancherıa Sur, Cuarta Seccion, Comalcalco, Tabasco, Mexico e Asociacion Psiqui atrica Mexicana, Ciudad de Mexico, Mexico b
Received for publication March 5, 2019; accepted November 20, 2019 (ARCMED_2019_195)..
Background. Psychiatrists may be at an increased risk of suicide, since they encounter stressful factors in their everyday activities in addition to the sociodemographic factors for suicidal ideation reported for Mexican population. Aim of the study. To determine whether experiences inherent to the profession were related to the self-report of suicidal ideation among Mexican psychiatrists or could be attributed to factors previously reported in the general population (age, marital status, presence of a mental disorder and not having received specialized treatment). Methods. This was a cross-sectional retrospective study with 288 psychiatrists from Mexico who participated through an online survey where current working activities, self-reported mental health conditions (major depression, anxiety, burnout and suicidal ideation) and professional adversities (assaults, lawsuits, patients with suicidal ideation or who had committed suicide, perceived discrimination and social support) throughout the professional lifespan were evaluated. Results. Twenty-two psychiatrists (7.6%) reported having had suicidal ideation at some point in their training in psychiatry or their professional lives as psychiatrists. Depression and burnout were the most important predictors for suicidal ideation while greater satisfaction with social support was the most important protector, followed by being married/ living together and having other physicians in the family. Conclusions. Psychiatrist represent a risk population for suicidal ideation. As such, detection and attention are essential. Psychiatrists need to be encouraged to pursue healthy, lasting interpersonal relationships and seek professional help when required. Ó 2019 IMSS. Published by Elsevier Inc. Key Words: Suicidal ideation, Psychiatrist, Mental health, Mexico.
Introduction Suicides and suicide attempts are preventable tragedies, yet they occur at all ages, in every region of the world and represent the second leading cause of death among people
Address reprint requests to: Ana Fresan, PsyD, PhD, Instituto Nacional de Psiquiatrıa Ram on de la Fuente Mu~nız, Calz. Mexico-Xochimilco 101, Ciudad de Mexico, 14370, Mexico; Phone: (þ52) (55) 41605069; FAX: (þ52) (55) 56550411; E-mail: [email protected]
ages 15e29. The impact of a single suicide is long lasting and devastating for families, friends, communities and the health care system (1). The taboo and stigma surrounding suicide that prevents people from seeking help or receiving it in a timely and efficient manner (1) is also present among health-care workers. Physicians have been found to have higher suicide rates than the general population (2). This difference, observed as early as in medical school (3,4), has been hypothesized to be associated with personality traits
0188-4409/$ - see front matter. Copyright Ó 2019 IMSS. Published by Elsevier Inc. https://doi.org/10.1016/j.arcmed.2019.11.010
Suicidal Ideation in Psychiatrists
characterized by a deep sense of responsibility, leading to reluctance to take vacations, long working hours, difficulty balancing work-family priorities and a general sense of the need to do more. As expected, these traits are associated with depression, anxiety, burnout and hopelessnesseall linked to suicide (5,6). Physicians’ negative attitude and rejection of their own illnesses and that of colleagues is also thought to be a risk factor, especially as regards mental disease (2,7e9) and psychiatrists are no exception. As mentioned by Kosulwit (10) ‘‘Society expects psychiatrists to have good mental health because they have to serve the mentally ill’’. Indeed, psychiatric disorders continue to be perceived as diseases in which voluntary control plays a major role, therefore holding the patient responsible, much like the stigma surrounding obesity (11) or lung cancer (12). This oversimplification of the causes underlying mental illness puts great pressure on clinicians, making help-seeking a difficult task: fear of nonconfidentiality and the possible impact on professional career are among the main factors why psychiatrists do not seek help (13,14). Balon R. and colleagues (14) found that of 830 Michigan psychiatrists, up to 50% revealed they chose to treat themselves even if they had suicidal thoughts. This is particularly disturbing, as mental health professionals deal with situations which are known to have a significant emotional impact, such as treating patients with suicide attempts or completed suicides (15e17), and are faced with demands inherent to psychiatry practice such as demanding patients, threats of violence or stalking (18), highlighting the need for support. The small number of mental health specialists in the country also results in a work overload for existing psychiatrists (19), and stigma in this profession is another stressful factor (18). In addition to the stressful factors surrounding the everyday activities of psychiatrists, we cannot ignore the risk factors related to the Mexican population associated with suicidal ideation and suicide in the general population, since they could further increase the risk in psychiatrists. Approximately three out of every four suicides occur in low and middleincome countries (20). While the difference in suicide death rates between 2000 and 2012 showed a 26% decrease internationally, the panorama in Mexico worsened, with an increase of 17.1% during the same period (1). Being a woman, not being in a relationship, unemployment, a younger age and living in the southeast of the country were found to be sociodemographic risk factors for suicidal ideation, planned suicide and attempted suicide in Mexicans (21). As psychiatrists may be at an increased risk of suicide (22,23) and suicidal ideation precedes and amplifies the risk of death by suicide, the study of suicidal ideation of psychiatrists in Mexico is a priority for the health system, individual well-being and life itself. Accordingly, the purpose of this study was to examine whether experiences related to the profession, such as having a family member who is a psychiatrist, working hours, assaults experienced, lawsuits, patients with
485
suicidal ideation or who have committed suicide, perceived discrimination as a psychiatrist or lack of social support were related to the self-report of suicidal ideation among Mexican psychiatrists; or whether suicidal ideation could be attributed to the same factors previously reported in the general population such as age, marital status and having had a mental disorder (depression, anxiety or burnout) and not having received specialized treatment. The study was conducted among a sample of psychiatrists in Mexico.
Materials and Method The present study was approved by the Ethics and Research Committees of the Ramon de la Fuente Mu~nız National Institute of Psychiatry, Secretariat of Health, Mexico No. 09-CEI-010-20170316. Study Design and Participants This was a cross-sectional retrospective study of Mexican psychiatrists. Recruitment was performed by a convenience sample approach with psychiatrists in the country who were willing and able to participate through an online survey. The nature of the study was explained to participants at the beginning of the electronic interview where anonymity was preserved; those who agreed to participate proceeded to complete the interview. Recruitment was performed from January 2018eDecember 2018. Assessment Procedure The interview was conducted in Spanish. Prior to its application, a pilot version was conducted among 10 volunteer psychiatrists to adjust questions with confusing language and terminology. The first section of the interview included questions related to demographic variables: age, sex, marital status, postgraduate studies in addition to the specialty in psychiatry, current working activities, maximum working hours per day and whether or not there were other physicians and psychiatrists in the family. The second section of the interview included questions about mental health conditions. Psychiatrists were asked about the presence of major depression, anxiety disorders or burnout throughout their professional lifespan and whether they had received specialized treatment for these conditions. Suicidal ideation was included in this section, and was used to divide the sample in those who reported having had suicidal ideation at some point in their professional life and those who did not. The third and final section of the interview included questions about professional adversities: assaults received, lawsuits, patients with suicidal ideation or who had committed suicide, perceived discrimination as a psychiatrist and social support. Perceived discrimination was assessed through an adaptation of the Spanish version of King’s Internalized Stigma ScaleeDiscrimination dimension (24,25), which is composed
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of 13 items scored on a five-point Likert agreement scale. Items are designed to evaluate the perception of negative reactions of other people toward being a psychiatrist. The Social Support Questionnaire (SSQ-6) (26) was used to evaluate satisfaction with the social support that the individual receives using the mean score obtained from the six items in the instrument rated on a six-point Likert satisfaction scale. Psychiatrists known to the researchers responsible for the study were invited to participate by email. This email included a link for the electronic interview, and they were asked to send this email to other colleagues in the country. Moreover, the Mexican Psychiatric Association disseminated the interview link through its website. Statistical Analyses First, descriptive information was determined by frequencies and percentages for categorical variables and means and standard deviations (S.D.) for continuous variables. The comparison of variables between psychiatrists having had suicidal ideation and those who did not, was performed with contingency table c2 tests with an estimated odds ratio (95% C.I.) for categorical variables; independent samples t-tests were used for continuous variables. Variables with significant differences between groups were included in multivariate logistic regression analyses to determine which variables predicted suicidal ideation among Mexican psychiatrists. The Akaike Information Criterion (AIC) was used to determine which of the logistic regression models best approximated the data. Significance was established at p #0.05 for all analyses performed using the SPSS version 21 for Windows, PC.
Results Demographic Variables The present analysis was based on a sample of 288 psychiatrists from 27 states in Mexico who completed the interview. A similar proportion of men (49%, n 5 101) and women (51%, n 5 147) were included in the study. The mean age of the sample was 43.7 years (S.D. 5 11.3, range 28e74). Most psychiatrists are married (64.6%, n 5 186) or partnered (24.3%, n 5 70) and have children (58.7%, n 5 169). Over half the participants (62.2%, n 5 179) had additional postgraduate studies (subspecialty, masters and/or doctorate studies) in addition to the specialty in psychiatry and currently have various work activities, mainly involving clinical consultation (93.4%, n 5 269) and teaching (53.8%, n 5 155). The maximum continuous workinghours reported were 13.8 hours (S.D. 5 4.7, range 6e36). Other physicians in the family were reported by 53.5% (n 5 154) and only 17.7% (n 5 51) reported having relatives who were psychiatrists.
Twenty-two psychiatrists (7.6%) reported having had suicidal ideation at some point in their training in psychiatry or their professional lives as psychiatrists. Demographic features according to the report of suicidal ideation are shown in Table 1. As shown in Table 1, psychiatrists without suicidal ideation were older, more frequently married/partnered (OR 5 0.34, 95% C.I. 5 0.14e0.84), with children (OR 5 0.37, 95% C.I. 5 0.15e0.91) and with more physicians in the family (OR 5 0.37, 95% C.I. 5 0.14e0.95) than their counterparts with a history of suicidal ideation. Postgraduate studies and work-related activities were similar among the groups (Table 1). Mental Health and Specialized Treatment Nearly three-quarters of the psychiatrists (71.9%, n 5 207) reported having had a mental health problem throughout their professional lifespan. Depression was the most frequent disorder (50.3%, n 5 145) followed by anxiety (42.0%, n 5 121) and burnout (30.2%, n 5 87). Of the participants affected by any of these disorders, 81.2% (n 5 168 from the 207 affected psychiatrists) were receiving specialized treatment: 66.7% (n 5 138) were undergoing psychotherapeutic interventions and 71.0% (n 5 147) were being given pharmacological treatment, of which 43.5% (n 5 64 of 147 who received specialized treatment) was by selfprescription. Mental health disorders were significantly more common in psychiatrists with a history of suicidal ideation (depression OR 5 11.2, 95% C.I. 5 2.5e49.2; anxiety OR 5 11.2, 95% C.I. 5 2.5e49.2; burnout OR 5 4.6, 95% C.I. 5 1.8e11.4). Nevertheless, specialized treatment for these disorders did not differ between psychiatrists with and without suicidal ideation (Table 1). Professional Adversities Professional adversities were reported by almost all the psychiatrists (97.9%, n 5 282). The most common adversities were having patients with severe suicidal ideation (94.3%, n 5 266), assaults (89.4%, n 5 253), having had patients who had committed suicide (47.9%, n 5 135) and lawsuits (17.7%, n 5 50). Assaults were mainly verbal (85%, n 5 215 from those who reported assaults) and physical (43.5%, n 5 110) and committed by patients (76.7%, n 5 194) or patients’ relatives (53.4%, n 5 135). None of the adversities differed between groups. Nevertheless, whereas perceived discrimination assessed with the King’s Internalized Stigma Scale can be considered as low/moderate (mean score 18.4, S.D. 5 18.4, range 0e46) and general satisfaction with social support was high (SSQ-6 mean score 5.0, S.D. 5 1.1, range 1e6), psychiatrists with suicidal ideation perceived more discrimination and reported less satisfaction with social support than those without suicidal ideation (Table 1).
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Table 1. Demographic variables, mental health disorders and professional adversities in psychiatrists with and without suicidal ideation Total n [ 288 n Demographics Sex-Women Age (mean; S.D.; range) Marital status-Married Children-Yes Postgraduate studies-Yes Physicians in family-Yes Psychiatrists in family-Yes Current work-activities Clinical consultation-Yes Teaching-Yes Research-Yes Administrative-Yes Maximum working-hours (mean; S.D.; range) Mental Health and specialized treatment Depression e Yes Anxiety e Yes Burnout-Yes Specialized treatment e Yesa Psychotherapy e Yesa Pharmacological e Yesa Medication self-prescription e Yesb Professional adversities Any professional adversity-Yes Lawsuits-Yesc Patients with suicidal ideation-Yesc Patients who committed suicide-Yesc Assaultsc Physical-Yesd Verbal-Yesd Psychological-Yesd By patients-Yesd By patients’ relatives-Yesd By colleagues-Yesd Perceived discrimination (mean; S.D.; range) Satisfaction with social support (mean; S.D.; range)
Without suicidal ideation n [ 266
With suicidal ideation n [ 22
n
n
%
%
%
147 51.0 43.7 (11.3; 28e74)
133 50.0 44.1 (11.4; 28e74)
14 63.6 38.2 (6.6; 29e55)
186 169 179 154 51
177 161 166 147 49
9 8 13 7 2
64.6 58.7 62.2 53.5 17.7
66.5 60.5 62.4 55.3 18.4
40.9 36.4 59.1 31.8 9.1
Statistics Fisher 5 0.27 t 5 3.7, p 5 0.001 Fisher 5 0.02 Fisher 5 0.04 Fisher 5 0.82 Fisher 5 0.04 Fisher 5 0.38
269 93.4 155 53.8 59 20.5 50 17.4 13.8 (4.7; 6e36)
248 93.2 144 54.1 53 19.9 45 16.9 13.6 (4.4; 6e32)
21 95.5 11 50.0 6 27.3 5 22.7 16.2 (7.0; 8e36)
Fisher 5 1.00 Fisher 5 0.82 Fisher 5 0.41 Fisher 5 0.55 t 5 -1.3, p 5 0.19
145 121 87 168 138 147 64
125 104 73 149 121 128 55
20 17 14 19 17 19 9
Fisher Fisher Fisher Fisher Fisher Fisher Fisher
50.3 42.0 30.2 82.1 66.7 71.0 43.5
47.0 39.1 27.4 80.5 65.4 69.2 43.0
90.9 77.3 63.6 86.4 77.3 86.4 47.4
282 97.9 50 17.7 266 94.3 135 47.9 253 89.7 110 43.5 215 85.0 92 36.4 194 76.7 135 53.4 36 14.2 18.4 (10.0; 0e46)
260 97.7 50 19.2 247 95.0 125 48.1 233 89.6 105 45.1 198 85.0 84 36.1 182 78.1 121 51.9 33 14.2 18.0 (10.0; 0e46)
22 100.0 19 86.4 10 45.5 20 90.9 5 25.0 17 85.0 8 40.0 12 60.0 14 70.0 3 15.0 23.0 (9.2; 10e41)
5.0 (1.1; 1e69)
5.0 (1.1; 1e6)
4.2; 1.3; 1-6
!0.001 5 0.001 5 0.001 5 0.77 5 0.34 5 0.09 5 0.80
Fisher 5 1.00 Fisher 5 0.11 Fisher 5 0.82 Fisher 5 1.00 Fisher 5 0.10 Fisher 5 1.00 Fisher 5 0.81 Fisher 5 0.09 Fisher 5 0.16 Fisher 5 1.00 t 5 ‒2.2, p 5 0.02 t 5 3.2, p 5 0.001
n 5 207 from psychiatrists who reported mental health disorders. n 5 147 from those who received pharmacological treatment. c n 5 282 from those who reported professional adversities. d n 5 253 from those who reported assaults. a
b
Prediction of Suicidal Ideation in Mexican Psychiatrists A series of multivariate logistic regressions were conducted to examine predictors of suicidal ideation among psychiatrists. The initial regression model included variables where significant differences arise in the comparative analyses: age, marital status, having children and other physicians in the family in the demographic variables; selfreported depression, anxiety and burnout from mental health variables and perceived discrimination and satisfaction with social support in the professional adversities
variables. The initial and final models are shown in Table 2. The final logistic regression equation was significant for the present sample according to the Hosmer and Lemeshaw statistical value ( p 5 0.98) with improvements in the model fit evident from the reduction in AIC values. Depression and burnout were the most important predictors for suicidal ideation in Mexican psychiatrists, while having higher satisfaction with social support was the most important protector, followed by being married/partnered and having other physicians in the family.
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Fresan et al./ Archives of Medical Research 50 (2019) 484e489
Table 2. Logistic regression models for the prediction of suicidal ideation in Mexican psychiatrists
Initial Model: AIC value 244.02 Marital status e Married/partnered Current age Children-Yes Other physicians in the family-Yes Depression-Yes Anxiety-Yes Burnout-Yes Perceived discrimination Satisfaction with social support Final Model: AIC value 131.80 Marital status-Married/partnered Other physicians in the family-Yes Depression-Yes Burnout-Yes Satisfaction with social support
b
OR
95% C.I.
p
‒1.20 ‒0.04 ‒0.11 ‒1.34 1.84 0.83 0.80 0.002 ‒0.49
0.29 0.95 0.89 0.26 6.33 2.31 2.24 1.00 0.61
0.09e0.91 0.89e1.02 0.27e2.91 0.08e0.76 1.33e30.0 0.71e7.52 0.76e6.57 0.94e1.06 0.41e0.90
0.03 0.18 0.85 0.01 0.02 0.16 0.14 0.93 0.01
‒1.20 ‒1.31 2.19 1.09 ‒0.48
0.29 0.26 8.99 2.99 0.61
0.11e0.80 0.09e0.76 1.93e41.79 1.09e8.19 0.42e0.89
0.01 0.01 0.005 0.03 0.01
Discussion The aim of the present study was to determine whether the self-report of suicidal ideation among Mexican psychiatrists was associated with factors inherent to psychiatry as a profession or to factors reported in the general population. Our main findings show that depression and burnout were the most important predictors of a history of suicidal ideation while satisfactory social support, being in a relationship and having physicians in the family were the most important protectors. According to 2016 National Survey on Drug, Alcohol and Tobacco Use (Encuesta Nacional de Consumo de Drogas, Alcohol y TabacoeENCODAT 2016), the prevalence of suicidal ideation among Mexican population over 18 years old is 2.3% (27). The prevalence among Mexican psychiatrists was 7.6%, three times higher than that observed in the general population. This supports previous reports showing that psychiatrists are at an increased risk for suicide (28,29). Although to our knowledge, there are no studies exploring the prevalence of burnout in Mexican psychiatrists, this condition has been found to be higher among psychiatrists than among other medical specialties in a number of studies (30). There is no reason to believe this would be different in our country, given the low rate of psychiatrists per 100 000 inhabitants (Heinze et al reported 3.68 per 100 000 inhabitants in 2016) and the poor distribution in the country: 60% practice in one of the three major Mexican cities (19). Long working hours are likely to be common and a lack of resources highly probable. Burnout has also been found to be a risk factor for suicidal ideation in other studies (31). Depression and especially severe depressive symptomatology is a well-known risk factor for suicidal ideation and suicide (32). What is especially relevant is that it is also known that suicidal ideation declines with the improvement
of depressive symptoms, especially subjective symptoms (33). The paradox is that psychiatrists face a potential deadly effect of self-treating their own depression (suicide) (14) and need access to professional treatment. Our results show that only 81.2% of psychiatrists with a mental disorder received specialized treatment and 43.5% selfprescribed that treatment. Although psychiatrists specialize in diagnosing and treating these disorders, the practice of self-treatment of depression and other mental health conditions should be considered unacceptable (14), as clinical judgement may be altered by symptoms, which could result in errors in treatment choices that can be potentially dangerous. Being in a relationship was found to be a protective factor for suicidal ideation in the present study together with higher satisfaction with social support. Strong social support rather than marriage/living together has systematically been found to be a protective factor for suicide and suicidal behavior, while its counterpart, living alone, has been identified as a risk factor in the general population (34,35). This has also been found in physicians (5). Closely related to the previous result of social support, having another physician in the family was a protective factor for suicidal ideation in Mexican psychiatrists. To our knowledge, this has not been previously explored among physicians, although it seems reasonable to conceive that physicians may experience less stigma towards mental illness and therefore support their relatives who are also physicians or psychiatrists. Also, the understanding of work-related stressors by this additional physician in the family might improve the quality of familial support provided, as the efficacy of support has been found to be related to the degree of similarity between people (36). This study has some limitations that should be considered in the interpretation of our results. The first limitation is related to possible sampling and evaluation biases. We should consider the fact that psychiatrists with suicidal ideation may be less likely to answer the survey due to concerns about being identified (even though confidentiality was guaranteed) or possible self-stigmatizing attitudes. Second, suicidal ideation was explored as a past event, and current living circumstances may not reflect those present at the time of active suicidal ideation. History of psychiatric disorders was not externally confirmed and relied on self-report. Although psychiatrists may be specialists in these disorders, self-diagnosis could bias their accuracy. Despite these limitations, this study represents the first large-scale research project on suicidal ideation among Mexican psychiatrists. The information provided is urgently needed as the demand for mental health professionals is increasing due to the rise in depression, drug misuse and suicide in the general population, together with the evidence of the effectiveness of psychopharmacological treatment for these conditions.
Suicidal Ideation in Psychiatrists
Mental health professionals are not immune to psychiatric illnesses although they are further from help than the general population. Psychiatrists must be encouraged to pursue healthy, lasting interpersonal relationships and seek professional help when needed.
Conclusion Since there is, ‘‘No health without mental health’’ (37), the mental health care of psychiatrists must be one of the main objectives of health systems, since these professionals are responsible for the care and monitoring of the mental health of thousands of people around the country.
Acknowledgments To all psychiatrists who participated in the present survey. Special thanks are due to Yolanda Pica, MD and Hector Esquivias MD for their valuable support in the promotion of the survey.
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