- Email: [email protected]
Suicide in physicians and veterinarians: risk factors and theories
Accepted Manuscript Title: Suicide in Physicians and Veterinarians: Risk Factors and Theories Author: Erin L. Fink-Miller Lisa M. Nestler PII: DOI: Reference:
S2352-250X(17)30188-4 http://dx.doi.org/doi:10.1016/j.copsyc.2017.07.019 COPSYC 502
To appear in: Received date: Revised date: Accepted date:
30-6-2017 11-7-2017 17-7-2017
Please cite this article as: E.L. Fink-Miller, L.M. Nestler, Suicide in Physicians and Veterinarians: Risk Factors and Theories, COPSYC (2017), http://dx.doi.org/10.1016/j.copsyc.2017.07.019 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Suicide in Physicians and Veterinarians: Risk Factors and Theories
ip t
Erin L. Fink-Miller
Ac ce p
te
d
M
an
us
cr
Lisa M. Nestler
Address a
Department of Psychology, Penn State Harrisburg W311 Olmsted, 777 West Harrisburg Pike Middletown, PA 17057, USA Corresponding author: Fink-Miller, Erin ([email protected])
Page 1 of 15
Introduction In 2015, suicide was the 10th leading cause of death in the U.S. [1]. In 2012, it was estimated that 804,000 suicides occurred globally [2]. The U.S. Department of Health and Human Services
ip t
(2014) reports a crude suicide rate of 12.4 per 100,000. Men die by suicide nearly four times as frequently as women, although women attempt suicide more often [3]. Additionally, research has
cr
suggested an elevated risk in certain occupations. Physicians and veterinarians, in particular,
us
have demonstrated an increased risk of suicide compared to the general population [4, 5, 6, 7**]. Although risk in these occupations is well-documented, less is understand about potential causes.
an
This review discusses rates of suicide in these occupations, as well as risk factors and theories of suicide, and treatment barriers.
M
Rates of Suicide
d
Hawton, and colleagues [8] reported a 1.87 relative risk for suicide in physicians compared to
te
1.25 in the general population. Using data from the 1990 National Mortality Detail Files, Stack [9] found that 8.04% of physicians died by suicide, compared to 4.3% of the rest of the labor
Ac ce p
force. This risk appears especially salient for female physicians [7**, 10, 11, 12]. Research by Milner and colleagues [13**] established that the suicide rate for women in the medical field is markedly higher than their non-healthcare counterparts. Specifically, suicide in female physicians is consistently reported to be four times that of females in the general population. [14, 15, 16].
Similarly, several reviews have indicated that suicide risk appears to be increased in veterinarians, with some estimates suggesting that the risk for suicide in this profession may be three times that of the general population [17, 18]. In a survey conducted in 2014, Nett and colleagues found that 1 in 6 veterinarians had experienced suicidal ideation since veterinary
Page 2 of 15
school graduation. [19]. The proportional mortality ratio, or PMR, is a statistic that allows comparison of incidence of suicide between groups, and is an expression of observed suicides in a group, divided by the expected number of suicides in a group. Data collected from the Office
ip t
for National Statistics in England and Wales indicated a PMR of 361 for male veterinarians, and 414 for female veterinarians when compared to the general population. This translates to a risk
cr
approximately 3-4 times that which would be expected in the population at large, and is similar
us
to the pattern observed in physicians [20]. Notably, risk for mental health issues and suicidal ideation in veterinarians appears to be particularly pertinent to those who are female, and of a
an
younger age [17]. Fritschi and colleagues [18] hypothesized that this may be due to the propensity of females to experience more symptoms of anxiety and depression than males. They
M
also suggest that more experienced veterinarians have had time to develop adaptive coping
te
Risk Factors
d
mechanisms for the occupational stressors they encounter.
Efforts aimed at identifying those at risk, and implementing prevention and treatment are
Ac ce p
hindered by the lack of a cohesive framework for understanding risk for suicide. A wide array of risk factors for suicide have been put forth, with one frequently cited risk factor in both occupations being job stress. Gold and colleagues [5] analyzed post-mortem data comparing physician suicide to non-physician suicide, and found that job stressors contributing to suicide were more prevalent in physicians compared to their non-physician counterparts. Bartram and Baldwin [22] discuss a plethora of work-related stressors commonly experienced by veterinarians, including long hours, social isolation, feelings of incompetence, and mistakes during practice that can lead to significant psychological distress for the practitioner.
Page 3 of 15
On the other hand, some researchers have suggested personality variables common among physicians and veterinarians that may render them more susceptible to suicidal behavior. For example, Fink-Miller [23*] suggested that personality variables—such as sensation-
ip t
seeking—may draw some physicians to pursue a career that tends to be fast-paced and
provocative, such as medicine. Similar personality patterns have been described among
cr
veterinarians. In their review, Bartram and Baldwin [22] discuss that traits such as perfectionism,
us
high achievement orientation, a predisposition for anxiety, and a preference for interactions with animals rather than humans may be common to veterinarians, and also associated with increased
an
risk for suicide.
In addition to personality traits, some argue that unique aspects of practicing medicine,
M
and veterinary medicine—such as exposure to illness and death in humans and animals, as well
d
as access to lethal medications—may partially explain the observed rates of suicide. Both
te
physicians and veterinarians have ready access to lethal drugs, including barbiturates, as well as a working knowledge of lethal dosing. Hawton and colleagues [24] assessed death records in
Ac ce p
England and Wales between 1979 and 1995 and compared methods of suicide in physicians versus non-physicians. Results indicated that poisoning was significantly more common in both male and female physicians, and the most commonly used agent was barbiturates. A follow-up study in the years 1991-1993 revealed a similar pattern, in that self-poisoning was the most common method used by physicians [25]. Additionally, it was noted that the majority of drugs (69.2%) had been obtained at the workplace. Agerbo and colleagues [4] similarly noted that suicide by poisoning was more common among physicians, as compared to those in other occupations when examining records from the Danish Medical Register on Vital Statistics. Gold and colleagues [5] utilized data from the United States National Violent Death Reporting System
Page 4 of 15
to compare physician and non-physician suicides, and found that self-poisoning was a less commonly used method (23.5%) than firearms (48%); however, physicians were more likely to have had barbiturates, benzodiazepines, or antipsychotics in their system than non-physicians.
ip t
Similar findings have been noted for veterinarians. Seven of nine veterinarians in the United Kingdom who were interviewed by Platt and colleagues [26] and indicated prior suicide
cr
attempts reported using self-poisoning, frequently with drugs obtained at work. Further, for
us
veterinarians who reported suicidal ideation and had identified a method they would likely use, self-poisoning was again the most common. A retrospective investigation of data obtained from
an
the Australian National Coroners Information System (2001-2012) suggested a similar pattern, in that 80% of veterinary surgeon and nurse suicides involved the use of pentobarbital—a common
M
drug of euthanasia for animals [7**]. Taken together, these findings suggest that ready access to
te
Theories of Suicidal Behavior
d
lethal means is a potent risk factor for suicide in veterinary workers [19, 22, 27].
While the factors above inform a better understanding of why physicians and veterinarians are at
Ac ce p
increased risk for suicide, it is unclear why some individuals with these risk factors make a lethal attempt, while others do not. In other words, there is a lack of specificity and precision in identifying those at risk, both in these occupations, and in the population at large. Recently, the interpersonal psychological theory of suicidal behavior (IPTS) has been put forth as a promising means of more accurately identifying those at risk [28]. The IPTS posits three necessary and sufficient precursors to death by suicide: perceived burdensomeness, thwarted belongingness, and capability for suicide. Perceived burdensomeness is an individual’s perception that their death would be more beneficial to others than their continued life. Thwarted belongingness is a sense of disconnection
Page 5 of 15
and isolation from others. The continued experience of both perceived burdensomeness and thwarted belongingness—as well as a sense of hopelessness—may lead to suicidal ideation. Capability for suicide refers to the physical capacity to inflict lethal self-harm, and a fearlessness
ip t
of death. Capability is an evolving construct, with recent research suggesting that capability may be broken into three distinct components: dispositional (inherited), acquired (obtained over
cr
time), and practical (e.g., ready access to lethal means) [29]. The IPTS has been widely
us
supported in a variety of populations [30, 31], and may be useful in understanding suicide in both physicians and veterinarians.
an
Cornette and colleagues [32] initially suggested that the IPTS may be utilized to better understand physician suicide. The authors drew parallels between common physician
M
experiences and components of the IPTS. For example, debts accrued in graduate school may
d
cause physicians to feel a sense of burdensomeness. Fink-Miller [33**] expanded upon this
te
research by assessing physicians on components of the IPTS. In a sample of 419 physicians, the author found that perceived burdensomeness predicted suicidal ideation, while thwarted
Ac ce p
belongingness predicted prior suicide attempts. Further, physicians displayed capability similar to those who had attempted suicide once—a population that has been shown to display elevated capability for suicide [34]. A follow-up study assessed provocative experiences that physicians commonly encounter at work (e.g., withdrawing life support, witnessing a patient death), to determine whether frequency of these events predicted capability for suicide. Results indicated that provocative work experiences predicted scores on capability, even while controlling for painful and provocative experiences occurring outside the workplace. These findings suggest that unique occupational experiences of physicians could potentially serve to increase the capacity for suicide [23*].
Page 6 of 15
Similar parallels have been drawn between the IPTS and suicide in veterinarians, although IPTS constructs have not, to our knowledge, directly been measured in veterinarians. One exception to this is a study completed by Witte and colleagues [35]. The authors measured a
ip t
host of variables in 130 veterinary students, including one specific component of the IPTS: fearlessness about death—a subscale of the Acquired Capability for Suicide Scale [36].
cr
Additional variables of study included exposure to euthanasia, necropsy, and surgery, and
us
emotional distress regarding euthanasia. Results suggested that experiences with euthanasia were associated with decreased fear of one’s own death. Interestingly, similar relationships were not
an
observed among exposure to necropsy, surgery, and fearlessness regarding death, which suggests a specific impact of euthanasia on capability for suicide. This research further clarifies how
M
repeated engagement with provocative events via occupation may contribute to increased risk.
d
Barriers to Treatment
te
While the research discussed above provides promise in understanding, treating, and preventing suicidal behavior in physicians and veterinarians, significant barriers remain. Stigmas
Ac ce p
surrounding mental health persist, and may be even more salient in certain occupations. Gold and colleagues [5] found no significant differences on current mental health diagnoses between physicians and non-physicians who had died by suicide, suggesting that physicians experience similar mental health issues as those in the general population. However, it is likely the case the physicians avoid seeking treatment for mental health issues for various reasons. Sadly, studies that have assessed barriers to treatment appear to confirm this hypothesis. Schwenk and colleagues [37] reported that physicians who were moderately or severely depressed endorsed several disturbing trends, in that they were more likely to self-prescribe antidepressants, and less likely to seek mental health treatment than their mildly depressed
Page 7 of 15
colleagues. Similar patterns have been found in medical students: those who do endorse moderate to severe depression feel that depressive symptoms may cause them to endanger patients, be unable to handle work responsibilities, and be viewed as less competent [38].
ip t
In their review, Bartram and Baldwin [22] suggest that this stigma is salient in veterinary medicine as well, and may discourage veterinarians from obtaining adequate mental healthcare.
cr
Instead, veterinarians under distress may opt to use informal supports (e.g., friends and family)
us
rather than seeking professional help [17, 39]. In their review of suicidality in veterinarians, Platt and colleagues also note that veterinarians may be more likely than physicians to use drugs as a
an
coping mechanism, particularly those not prescribed to them [17]. These findings reiterate the role that access to lethal means may have in suicide.
M
Conclusions
d
Suicide risk in physicians and veterinarians has been widely documented. Many risk factors have
te
been suggested to explain why members of these occupations are at risk. It may be that psychosocial stressors, provocative work experiences (including witnessing or contributing to the
Ac ce p
deaths of both human and animal patients) and access to lethal means contribute to suicide in these groups. Physicians and veterinarians are not impervious to psychological disorders, but may experience stigma (real or perceived) when accessing mental health care. It is imperative that these professionals are encouraged to utilize appropriate treatment when needed. Of similar importance is the need to restrict access to lethal drugs when individuals are at increased risk.
Page 8 of 15
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ip t
(2016). U.S.A. suicide 2015: Official final data. Washington, DC: American Association of Suicidology, dated December 23, 2016, downloaded from http://www.suicidology.org. World Health Organization. (2014). Preventing suicide, a global imperative. Geneva,
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Milner A, Niven H, Page K, LaMontagne A: Suicide in veterinarians and veterinary nurses in Australia: 2001–2012. Aust Vet J. 2015, 93: 308-310. **This paper compared death records of veterinarians and veterinary nurses with those in the general population over a decade. The authors concluded that veterinarians and
Page 9 of 15
veterinary nurses displayed elevated rates of suicide compared to the general population, and most commonly overdosed on drugs common to veterinary medicine. Hawton K, Agerbo E, Simkin S, Platt B, Mellanby RJ: Risk of suicide in medical and
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among physicians related to other academics as well as to the general population. Results from a national long-term prospective study and a retrospective study. Acta
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of risk according to gender, seniority and specialty in medical practitioners in England and Wales, 1979-1995. J Epidemiol Community Health. 2001, 55: 296-300. 12.
Schernhammer ES, Colditz GA: Suicide rates among physicians: A quantitative and gender assessment (meta-analysis). Am J Psychiatry. 2004, 161: 2295-2302.
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Milner AJ, Maheen H, Bismark MM, Spittal MJ: Suicide by health professionals: a retrospective mortality study in Australia, 2001-2012. Med J Aust. 2016, 205: 260265. **This paper compared suicide rates of health professionals to those of the general
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population across a decade. Rates of suicide were higher in female health professionals and males in nursing and midwivery compared to those in other occupations. Suicide by
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poisoning was the most common method. Alexander RE: Stress-related suicide by dentists and other health care workers: Fact
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recent suicidal ideation among female university hospital physicians in Sweden and
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Italy (the HOUPE study): Cross-sectional associations with work stressors. Gend
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Med. 2009, 6: 314-328.
Pitts FN, Schuller AB, Rich CL, Pitts AF: Suicide among U.S. women physicians,
Platt B, Hawton K, Simkin S, Mellanby RJ: Suicidal behaviour and psychosocial
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1967-1972. Am J Psychiatry. 1979, 136: 694-696.
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problems in veterinary surgeons: a systematic review. Soc Psychiatry Psychiatr Epidemiol. 2012, 47: 223-240. 18.
Fritschi L, Morrison D, Shirangi A, Day L: Psychological well-being of Australian veterinarians. Aust Vet J. 2009, 87: 76-81.
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Platt B, Hawton K, Simkin S, Mellanby RJ: Systematic review of the prevalence of suicide in veterinary surgeons. Occ Med. 2010, 60: 436-446.
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Nett RJ, Witte TK, Holzbauer SM, Elchos BL, Campagnolo ER, Musgrave KJ, Carter KK, Kurkjian KM, Vanicek C, O’Leary, DR, Pride, KR, Funk RH: Prevalence of risk
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factors for suicide among veterinarians - United States, 2014. Morb Mortal Wkly Rep. 2015, 64: 131-132. Mellanby RJ: Incidence of suicide in the veterinary profession in England and Wales.
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Vet Rec. 2005, 157: 415-417.
Bartram DJ, Baldwin DS: Veterinary surgeons and suicide: A structured review of
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Fink-Miller EL: Provocative work experiences predict the acquired capability for
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possible influences on increased risk. Vet Rec. 2010, 166: 388-397.
suicide in physicians. Psychiatry Res. 2015, 229:143-147.
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*This paper explored whether certain work experiences unique to medicine would be associated with increased capability for suicide in practicing physicians. Results indicated
d
that continued participation in such work experiences predicted acquired capability even
Hawton K, Clements A, Simkin S, Malmberg A: Doctors who kill themselves: a study
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while accounting for provocative experiences outside of work.
of the methods used for suicide. QJM. 2000, 93: 351-357. 25.
Hawton K, Malmberg A, Simkin S: Suicide in doctors. A psychological autopsy study. J Psychosom Res. 2004, 57: 1-4.
26.
Platt B, Hawton K, Simkin S, Dean R, Mellanby RJ: Suicidality in the veterinary profession: Interview study of veterinarians with a history of suicidal ideation or behavior. Crisis. 2012, 33: 280-289.
27.
Jones-Fairnie H, Ferroni P, Silburn S, Lawrence D: Suicide in Australian veterinarians.
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Aust Vet J. 2008, 86: 114-116. Joiner TE: Why People Die by Suicide. Harvard University Press; 2005.
29.
Konsky E, May AM: The Three-Step Theory (3ST): a new theory of suicide rooted in
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28.
30.
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the “ideation-to-action” framework. Int J Cogn Ther. 2015, 8: 114-129.
Van Orden KA, Witte TK, Gordon KH, Bender TW, Joiner TE: Suicidal desire and the
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capability for suicide: Tests of the interpersonal-psychological theory of suicidal
31.
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behavior among adults. J Consult Clin Psychol. 2008, 76: 72-83.
Bryan CJ, Morrow CE, Anestis MD, Joiner TE.: A preliminary test of the
Cornette MM, DeRoon-Cassini TA, Fosco GM, Holloway RL, Clark DC, Joiner TE:
te
32.
d
Individ Dif. 2010, 48: 347-350.
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interpersonal-psychological theory of suicidal behavior in a military sample. Pers
Application of an interpersonal-psychology model of suicidal behavior to physicians
33.
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and medical trainees. Arch Suicide Res. 2009, 13: 1-14. Fink-Miller E: An examination of the interpersonal psychological theory of suicidal behavior in physicians. Suicide Life Threat Behav. 2015, 45: 488-494. **This paper applied the interpersonal psychological theory of suicidal behavior to currently practicing physicians. Results indicated that perceived burdensomeness was associated with suicidal ideation, while thwarted belongingness was associated with past suicide attempts. 34.
Anestis MD, Joiner TE: Examining the role of emotion in suicidality: Negative
Page 13 of 15
urgency as an amplifier of the relationship between components of the interpersonal-psychological theory of suicidal behavior and lifetime number of
35.
ip t
suicide attempts. J Affect Disord. 2011, 129: 261-269. Witte TK, Correia CJ, Angarano D: Experience with euthanasia is associated with
cr
fearlessness about death in veterinary students. Suicide Life Threat Behav. 2013, 43:
36.
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125-138.
Ribeiro JD, Witte TK, Van Orden KA, Selby EA, Gordon KH, Bender TW, Joiner TE:
an
Fearlessness about death: the psychometric properties and construct validity of the revision to the Acquired Capability for Suicide Scale. Psychol Assess. 2014, 26: 115-
Schwenk TL, Gorenflo DW, Leja LM: A survey on the impact of being depressed on
d
37.
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126.
38.
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69: 617-620.
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the professional status and mental health care of physicians. J Clin Psychiatry. 2008,
Schwenk TL, Davis L, Wimsatt LA: Depression, stigma, and suicidal ideation in medical students. JAMA. 2010, 304: 1181-1190.
39.
Gardner DH, Hini D: Work-related stress in the veterinary profession in New Zealand. N Z Vet J. 2006, 54: 119-124.
Page 14 of 15
Highlights Risk for suicide is elevated in physicians and veterinarians. Job stress, personality, access to means, and work experiences are risk factors. The IPTS has garnered support in explaining physician and veterinarian suicide. Continued barriers may prevent physicians and veterinarians from seeking therapy.
cr
ip t
• • • •
Ac ce p
te
d
M
an
us
COI: The authors declare no conflicts of interest.
Page 15 of 15
S2352-250X(17)30188-4 http://dx.doi.org/doi:10.1016/j.copsyc.2017.07.019 COPSYC 502
To appear in: Received date: Revised date: Accepted date:
30-6-2017 11-7-2017 17-7-2017
Please cite this article as: E.L. Fink-Miller, L.M. Nestler, Suicide in Physicians and Veterinarians: Risk Factors and Theories, COPSYC (2017), http://dx.doi.org/10.1016/j.copsyc.2017.07.019 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Suicide in Physicians and Veterinarians: Risk Factors and Theories
ip t
Erin L. Fink-Miller
Ac ce p
te
d
M
an
us
cr
Lisa M. Nestler
Address a
Department of Psychology, Penn State Harrisburg W311 Olmsted, 777 West Harrisburg Pike Middletown, PA 17057, USA Corresponding author: Fink-Miller, Erin ([email protected])
Page 1 of 15
Introduction In 2015, suicide was the 10th leading cause of death in the U.S. [1]. In 2012, it was estimated that 804,000 suicides occurred globally [2]. The U.S. Department of Health and Human Services
ip t
(2014) reports a crude suicide rate of 12.4 per 100,000. Men die by suicide nearly four times as frequently as women, although women attempt suicide more often [3]. Additionally, research has
cr
suggested an elevated risk in certain occupations. Physicians and veterinarians, in particular,
us
have demonstrated an increased risk of suicide compared to the general population [4, 5, 6, 7**]. Although risk in these occupations is well-documented, less is understand about potential causes.
an
This review discusses rates of suicide in these occupations, as well as risk factors and theories of suicide, and treatment barriers.
M
Rates of Suicide
d
Hawton, and colleagues [8] reported a 1.87 relative risk for suicide in physicians compared to
te
1.25 in the general population. Using data from the 1990 National Mortality Detail Files, Stack [9] found that 8.04% of physicians died by suicide, compared to 4.3% of the rest of the labor
Ac ce p
force. This risk appears especially salient for female physicians [7**, 10, 11, 12]. Research by Milner and colleagues [13**] established that the suicide rate for women in the medical field is markedly higher than their non-healthcare counterparts. Specifically, suicide in female physicians is consistently reported to be four times that of females in the general population. [14, 15, 16].
Similarly, several reviews have indicated that suicide risk appears to be increased in veterinarians, with some estimates suggesting that the risk for suicide in this profession may be three times that of the general population [17, 18]. In a survey conducted in 2014, Nett and colleagues found that 1 in 6 veterinarians had experienced suicidal ideation since veterinary
Page 2 of 15
school graduation. [19]. The proportional mortality ratio, or PMR, is a statistic that allows comparison of incidence of suicide between groups, and is an expression of observed suicides in a group, divided by the expected number of suicides in a group. Data collected from the Office
ip t
for National Statistics in England and Wales indicated a PMR of 361 for male veterinarians, and 414 for female veterinarians when compared to the general population. This translates to a risk
cr
approximately 3-4 times that which would be expected in the population at large, and is similar
us
to the pattern observed in physicians [20]. Notably, risk for mental health issues and suicidal ideation in veterinarians appears to be particularly pertinent to those who are female, and of a
an
younger age [17]. Fritschi and colleagues [18] hypothesized that this may be due to the propensity of females to experience more symptoms of anxiety and depression than males. They
M
also suggest that more experienced veterinarians have had time to develop adaptive coping
te
Risk Factors
d
mechanisms for the occupational stressors they encounter.
Efforts aimed at identifying those at risk, and implementing prevention and treatment are
Ac ce p
hindered by the lack of a cohesive framework for understanding risk for suicide. A wide array of risk factors for suicide have been put forth, with one frequently cited risk factor in both occupations being job stress. Gold and colleagues [5] analyzed post-mortem data comparing physician suicide to non-physician suicide, and found that job stressors contributing to suicide were more prevalent in physicians compared to their non-physician counterparts. Bartram and Baldwin [22] discuss a plethora of work-related stressors commonly experienced by veterinarians, including long hours, social isolation, feelings of incompetence, and mistakes during practice that can lead to significant psychological distress for the practitioner.
Page 3 of 15
On the other hand, some researchers have suggested personality variables common among physicians and veterinarians that may render them more susceptible to suicidal behavior. For example, Fink-Miller [23*] suggested that personality variables—such as sensation-
ip t
seeking—may draw some physicians to pursue a career that tends to be fast-paced and
provocative, such as medicine. Similar personality patterns have been described among
cr
veterinarians. In their review, Bartram and Baldwin [22] discuss that traits such as perfectionism,
us
high achievement orientation, a predisposition for anxiety, and a preference for interactions with animals rather than humans may be common to veterinarians, and also associated with increased
an
risk for suicide.
In addition to personality traits, some argue that unique aspects of practicing medicine,
M
and veterinary medicine—such as exposure to illness and death in humans and animals, as well
d
as access to lethal medications—may partially explain the observed rates of suicide. Both
te
physicians and veterinarians have ready access to lethal drugs, including barbiturates, as well as a working knowledge of lethal dosing. Hawton and colleagues [24] assessed death records in
Ac ce p
England and Wales between 1979 and 1995 and compared methods of suicide in physicians versus non-physicians. Results indicated that poisoning was significantly more common in both male and female physicians, and the most commonly used agent was barbiturates. A follow-up study in the years 1991-1993 revealed a similar pattern, in that self-poisoning was the most common method used by physicians [25]. Additionally, it was noted that the majority of drugs (69.2%) had been obtained at the workplace. Agerbo and colleagues [4] similarly noted that suicide by poisoning was more common among physicians, as compared to those in other occupations when examining records from the Danish Medical Register on Vital Statistics. Gold and colleagues [5] utilized data from the United States National Violent Death Reporting System
Page 4 of 15
to compare physician and non-physician suicides, and found that self-poisoning was a less commonly used method (23.5%) than firearms (48%); however, physicians were more likely to have had barbiturates, benzodiazepines, or antipsychotics in their system than non-physicians.
ip t
Similar findings have been noted for veterinarians. Seven of nine veterinarians in the United Kingdom who were interviewed by Platt and colleagues [26] and indicated prior suicide
cr
attempts reported using self-poisoning, frequently with drugs obtained at work. Further, for
us
veterinarians who reported suicidal ideation and had identified a method they would likely use, self-poisoning was again the most common. A retrospective investigation of data obtained from
an
the Australian National Coroners Information System (2001-2012) suggested a similar pattern, in that 80% of veterinary surgeon and nurse suicides involved the use of pentobarbital—a common
M
drug of euthanasia for animals [7**]. Taken together, these findings suggest that ready access to
te
Theories of Suicidal Behavior
d
lethal means is a potent risk factor for suicide in veterinary workers [19, 22, 27].
While the factors above inform a better understanding of why physicians and veterinarians are at
Ac ce p
increased risk for suicide, it is unclear why some individuals with these risk factors make a lethal attempt, while others do not. In other words, there is a lack of specificity and precision in identifying those at risk, both in these occupations, and in the population at large. Recently, the interpersonal psychological theory of suicidal behavior (IPTS) has been put forth as a promising means of more accurately identifying those at risk [28]. The IPTS posits three necessary and sufficient precursors to death by suicide: perceived burdensomeness, thwarted belongingness, and capability for suicide. Perceived burdensomeness is an individual’s perception that their death would be more beneficial to others than their continued life. Thwarted belongingness is a sense of disconnection
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and isolation from others. The continued experience of both perceived burdensomeness and thwarted belongingness—as well as a sense of hopelessness—may lead to suicidal ideation. Capability for suicide refers to the physical capacity to inflict lethal self-harm, and a fearlessness
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of death. Capability is an evolving construct, with recent research suggesting that capability may be broken into three distinct components: dispositional (inherited), acquired (obtained over
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time), and practical (e.g., ready access to lethal means) [29]. The IPTS has been widely
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supported in a variety of populations [30, 31], and may be useful in understanding suicide in both physicians and veterinarians.
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Cornette and colleagues [32] initially suggested that the IPTS may be utilized to better understand physician suicide. The authors drew parallels between common physician
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experiences and components of the IPTS. For example, debts accrued in graduate school may
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cause physicians to feel a sense of burdensomeness. Fink-Miller [33**] expanded upon this
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research by assessing physicians on components of the IPTS. In a sample of 419 physicians, the author found that perceived burdensomeness predicted suicidal ideation, while thwarted
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belongingness predicted prior suicide attempts. Further, physicians displayed capability similar to those who had attempted suicide once—a population that has been shown to display elevated capability for suicide [34]. A follow-up study assessed provocative experiences that physicians commonly encounter at work (e.g., withdrawing life support, witnessing a patient death), to determine whether frequency of these events predicted capability for suicide. Results indicated that provocative work experiences predicted scores on capability, even while controlling for painful and provocative experiences occurring outside the workplace. These findings suggest that unique occupational experiences of physicians could potentially serve to increase the capacity for suicide [23*].
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Similar parallels have been drawn between the IPTS and suicide in veterinarians, although IPTS constructs have not, to our knowledge, directly been measured in veterinarians. One exception to this is a study completed by Witte and colleagues [35]. The authors measured a
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host of variables in 130 veterinary students, including one specific component of the IPTS: fearlessness about death—a subscale of the Acquired Capability for Suicide Scale [36].
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Additional variables of study included exposure to euthanasia, necropsy, and surgery, and
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emotional distress regarding euthanasia. Results suggested that experiences with euthanasia were associated with decreased fear of one’s own death. Interestingly, similar relationships were not
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observed among exposure to necropsy, surgery, and fearlessness regarding death, which suggests a specific impact of euthanasia on capability for suicide. This research further clarifies how
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repeated engagement with provocative events via occupation may contribute to increased risk.
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Barriers to Treatment
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While the research discussed above provides promise in understanding, treating, and preventing suicidal behavior in physicians and veterinarians, significant barriers remain. Stigmas
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surrounding mental health persist, and may be even more salient in certain occupations. Gold and colleagues [5] found no significant differences on current mental health diagnoses between physicians and non-physicians who had died by suicide, suggesting that physicians experience similar mental health issues as those in the general population. However, it is likely the case the physicians avoid seeking treatment for mental health issues for various reasons. Sadly, studies that have assessed barriers to treatment appear to confirm this hypothesis. Schwenk and colleagues [37] reported that physicians who were moderately or severely depressed endorsed several disturbing trends, in that they were more likely to self-prescribe antidepressants, and less likely to seek mental health treatment than their mildly depressed
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colleagues. Similar patterns have been found in medical students: those who do endorse moderate to severe depression feel that depressive symptoms may cause them to endanger patients, be unable to handle work responsibilities, and be viewed as less competent [38].
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In their review, Bartram and Baldwin [22] suggest that this stigma is salient in veterinary medicine as well, and may discourage veterinarians from obtaining adequate mental healthcare.
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Instead, veterinarians under distress may opt to use informal supports (e.g., friends and family)
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rather than seeking professional help [17, 39]. In their review of suicidality in veterinarians, Platt and colleagues also note that veterinarians may be more likely than physicians to use drugs as a
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coping mechanism, particularly those not prescribed to them [17]. These findings reiterate the role that access to lethal means may have in suicide.
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Conclusions
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Suicide risk in physicians and veterinarians has been widely documented. Many risk factors have
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been suggested to explain why members of these occupations are at risk. It may be that psychosocial stressors, provocative work experiences (including witnessing or contributing to the
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deaths of both human and animal patients) and access to lethal means contribute to suicide in these groups. Physicians and veterinarians are not impervious to psychological disorders, but may experience stigma (real or perceived) when accessing mental health care. It is imperative that these professionals are encouraged to utilize appropriate treatment when needed. Of similar importance is the need to restrict access to lethal drugs when individuals are at increased risk.
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Highlights Risk for suicide is elevated in physicians and veterinarians. Job stress, personality, access to means, and work experiences are risk factors. The IPTS has garnered support in explaining physician and veterinarian suicide. Continued barriers may prevent physicians and veterinarians from seeking therapy.
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COI: The authors declare no conflicts of interest.
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