Thet George Duchi MPH in Global Health Leadership and Administration Integrative Learning Experience

Thet George Duchi
MPH in Global Health Leadership and Administration
Integrative Learning Experience (Capstone)
Physician Suicide Rate: Suffering in Silence
Prof. Manfred Green
Prof. Richard Schuster
August 22, 2018

OUTLINE
Abstract
Introduction
Reasons for Physician Suicide
Burnout in Physicians
Signs and Symptoms of Burnout
Main causes of Burnout in Physicians
Medical specialties with the highest burnout rate
Tactics to reduce burnout
Physician Suicide by Specialty
Depression in Physicians
Signs of Depression
Risk Factors for Depression
Physician Depression Questionnaire
Chosen Methods for committing Suicide
Ways to Combat Physician Suicide.
Public Health Model for Suicide Prevention
References
ABSTRACT
Suicide Doctor. The Ultimate Oxymoron. It is unclear why someone whose job is to preserve life decide to do the reverse by taking theirs. Suicide amongst physicians is an unrecognized public health problem. It is considered as one of medicine’s grubby secrets. It is rarely discussed and not a lot of light has been shed on this topic. A review of international literature over the past 75 years indicates that:
Suicide among physicians is high.

Physician suicide differs from country to country, with the highest rate being among the Danes, the next amongst the British and the next amongst U.S.A. physicians.

There is a high incidence of psychiatric morbidity, alcoholism and drug addiction among physicians who suicide.

Social, psychological, cultural and other factors can interact to lead a person to suicidal behavior, but the stigma attached to mental disorders and suicide means that many people feel unable to seek help.

As in suicides among other groups, there are significant variable correlates of age, gender, medical school affiliation, geographic residence, type of medical practice and specialty, the state of physical and emotional health, the use of alcohol and drugs, and professional and psychosocial factors.

Preventive action is both possible and desirable.

INTRODUCTION
Suicide can be defined as “when people direct violence at themselves with the intent to end their lives, and they die because of their actions.” A suicide attempt is when people harm themselves with the intent to end their lives, but they do not die because of their actions. The World Health Organization (WHO) estimates that each year approximately one million people die from suicide, which represents a global mortality rate of 16 people per 100,000. 1
Compared with the general population, physicians are nearly twice as likely to commit suicide. Amongst white male physicians, the rate is 1.87 times higher than the average American, according to findings from 1 study. Among white women, the rate is 2.78 times higher. 2
But what are the risks associated with suicide: The main risk factors associated with suicide include: a prior suicide attempt, depression and other mental health disorders, substance abuse disorders, medical illness, family history of suicide, family violence, medical illness, being between the ages of 15- 24, and over 60 years.
Suicide does not discriminate and is not limited by age, sex, or education. It knows no boundaries. People who decide to terminate their lives pursue the aim in spite of any external interventions. The victims of suicide are not only the people who take their own lives but also include family, friends and colleagues who might never recover from the loss of loved one
Health care professionals have major performance expectations from both the public and themselves. Individuals who work in these fields are exposed to an immense amount of stress. Physicians are more likely to commit suicide than individuals in any other profession. But does this come as a surprise and does this occur because doctors are continually being exposed to their patient’s problems?
Numerous global studies involving every medical and surgical specialty indicate that approximately 1 in 3 physicians is experiencing burnout at any given time (Medical students appear to be at an equal or higher risk of burnout, depression, substance abuse, and suicide.

This cycle of health care abuse is a global phenomenon. What can we do to end the cycle of institutional abuse? Do we introduce physician suicide hotlines inside hospitals or provide resilience training for wiped-out doctors, meditation classes for medical student or even advocacy centers for mistreated patients? Some educational and institutional reform is gravely needed to curb the dire situation.
The purpose of this paper is to shine a spotlight on this culture of silence, to understand the scope and complexity of the underlying issues, and to drive changes to deliver individual, organizational, and societal interventions that preserve and promote the physical and emotional health of care givers.

The fear of stigma is strong and, although many physicians admit struggling with mental health issues, including depression, they are unlikely to seek treatment due to fear of humiliation by those within the medical community. Due to the perceived and real risks associated with seeking help for such problems, many students, trainees, and doctors, and health care organizations fail to recognize report, discuss, or pursue treatment for these conditions.

REASONS FOR PHYSICIAN SUICIDE
Why do physicians commit suicide? There are various reasons which physicians commit suicide which include:
Burnout
Depression
Substance Abuse and Alcoholism
Malpractice suits
Hazing, Bulling and Name calling
Doctors without residencies
Academic Distress in students
Barriers to mental health treatment
BURNOUT IN PHYSICIANS
Burnout can be defined as a “state of emotional, physical, and mental exhaustion caused by excessive and prolonged stress.”3 Burnout is an occupational-related clinical syndrome that manifests as chronic occupational and interpersonal pressures that persevere over time. 
SIGNS AND SYMPTOMS OF BURNOUT
The accepted standard for burnout diagnosis is the Maslach Burnout Inventory, developed by Christina Maslach and her colleagues at the University of San Francisco in the 1970s. She later described burnout as “an erosion of the soul caused by a deterioration of one’s values, dignity, spirit, and will.4 Symptoms of burnout include:
Exhaustion: Physical and emotional energy levels are low
Lack of efficacy: Healthcare professionals begin to doubt the meaning and quality of their work. They are bothered about mistakes.
Depersonalization: characterized by sarcasm and cynicism. The physician is not emotionally available to his patients and complains about their job.
Burnout can have a set of undesirable consequences such as:
Lower patient satisfaction and care quality,
Higher medical error rates and malpractice risk,
Higher physician and staff turnover,
Physician alcohol and drug abuse and addiction,
Physician suicide.

MAIN CAUSES OF BURNOUT IN PHYSICIANS
The practice of clinical medicine: Stress is a fundamental feature of the medical profession. Physicians have to attend to people who are sick and scared of dying; together with their family members. The medical practice is the classic high-stress combination of great responsibility and little control.
Your specific job: Each specific job has its own set of responsibilities and a set of unique stresses. They include the hassles of your personal call rotation, your compensation formula, the local health care politics associated with the hospital, the personality clashes in your department or clinic, your leadership, your personal work team etc.
Having a life: Physicians are not taught to balance skills during medical education. Residency training teaches the opposite and how to multi task. They learn and practice ignoring their physical, emotional, and spiritual needs to unhealthy levels and then carry these negative habits into their career.
The conditioning of medical education: Several important character traits essential to graduating from medical school and residency emerge during the premed years. Over the seven-plus years medical education, they become hard wired into day-to-day physician persona, creating a double-edged sword. The same traits responsible for their success as physicians simultaneously set them up for burnout down the road.

The leadership skills of your immediate supervisors. It is a significant source of stress for many employed physicians. Some supervisors lack the skillset and can be a significant burden.
Medical Specialties with the highest burnout rate
Physician burnout experts at the AMA and the Mayo Clinic conducted a survey of 6,880 physicians to “evaluate the prevalence of burnout and physicians’ satisfaction with work-life balance compared to the general U.S. population relative to 2011 and 2014,” according to the study, which was recently published in Mayo Clinic Proceedings.

Compared to 2011, burnout rates were higher for all specialties in 2014. In fact, nearly a dozen specialties experienced more than a 10 percent increase in burnout over those three years:
3750945-76200Family medicine (51.3 percent of physicians reported burnout in 2011 versus 63.0 percent in 2014)
General pediatrics (35.3 percent versus 46.3 percent)
Urology (41.2 percent versus 63.6 percent)
Orthopedic surgery (48.3 percent versus 59.6 percent)
Dermatology (31.8 percent versus 56.5 percent)
Physical medicine and rehabilitation (47.4 percent versus 63.3 percent)
Pathology (37.6 percent versus 52.5 percent)
Radiology (47.7 percent versus 61.4 percent)
General surgery subspecialties (42.4 percent versus 52.7 percent).

Tactics to reduce burnout (For use in practice setting)
To improve feelings of control and/or reduce feelings of chaos:
Provide flexible scheduling options for providers, such as:
More part-time options
Seven days on, seven days off for ambulatory practices
Flexible scheduling at the beginning and end of the day for clinicians who are parents
Consistently schedule support staff (e.g., MAs, RNs, etc.) with the same providers.
Outsource time-consuming tasks, such as coding, to other departments or other staff members in the organization.
Pilot a call “cap and trade program” in which providers are compensated more if they are willing to take more call time. This may relieve the burden on providers who find it difficult to take call shifts because of personal obligations.

To improve team spirit and teamwork:
Work with occupational health or organizational development departments to hold training sessions on building trust and respect within the team.

Recognize accomplishments of providers at staff meetings or through one-on-one recognition.

To improve communication:
Provide a mechanism for providers to give ongoing feedback, such as:
Setting aside dedicated time at staff meetings to share concerns
Holding office hours with leader
Putting out a comment box
Begin meetings by sharing patient case studies.
Distribute agendas before meetings and provide minutes shortly after to recap discussions. Ask providers for their input on the minutes.

To learn more about stress and burnout results from the Mini Z(Zero Burnout Program (e.g., in departments or clinics with challenges):
Administer a longer survey instrument at clinic or department meetings.
Seek insight on specific challenges by scheduling one-on-one meetings with providers whenever possible. Be supportive and earnest during the meeting
DEPRESSION IN PHYSICIANS
Physicians find it difficult to recognize depression in patients, let alone themselves. Furthermore, they are notoriously reluctant to seek treatment for any personal illness. A survey of American surgeons revealed that although 1 in 16 had experienced suicidal ideation in the past 12 months, only 26% had sought psychiatric or psychological help. There was a strong correlation between depressive symptoms, as well as indicators of burnout, with the incidence of suicidal ideation. More than 60% of those with suicidal ideation indicated they were reluctant to seek help due to concern that it could affect their medical license.5
Even when healthy, physicians find it difficult to ask for help of any kind. When they are depressed and feeling less than adequate, they find it even more difficult—and when they can bring themselves to ask, they sometimes find that the help they need is remarkably difficult to obtain.

To some extent, however, physicians’ reluctance to reach out is self-imposed. They may feel an obligation to appear healthy, perhaps as evidence of their ability to heal others. Inquiring about another physician’s health may shatter this mutual myth of invulnerability, and volunteering support or assistance unasked may seem like an affront to a colleague’s self-sufficiency. Thus, the concerned colleague or partner may say nothing, while wondering privately if the colleague has become impaired.

Unconsciously defending against this painful vulnerability, partners or significant others may also fail to notice significant depression or withdrawal, attributing behavioral changes instead to stress or overwork. Nearly every article about a physician’s suicide contains a quotation from some close contact, occasionally a spouse, saying something like, “I never had any idea that he/she was suffering.” 6 Of course, many physician obituaries omit the fact that the “sudden death” was a completed suicide.

Depressed physicians who do reach out may find that they receive only limited understanding or sympathy from colleagues
For many experiencing depression, the early symptoms are physical. A physician inability to diagnose his or her own symptoms makes them feel incompetent. To admit one’s inability to diagnose oneself to another colleague is to admit failure. When this admission is met with avoidance, disbelief, or derision by a reluctant treating physician, it can only reinforce a depressed physician’s feelings of worthlessness and hopelessness.

Physicians are a “high control” population and situations that decrease physicians’ ability to control their environment, workplace, or employment conditions predictably play a higher role in physician suicide than they do in lower control populations.

The massive changes that have taken place in medicine in the past several decades, leading to increased workloads and regulatory requirements coupled with decreased ability to control income and patient safety and liability concerns also predictably lead to higher levels of stress, job dissatisfaction, burnout, and depression in physicians.

Some physicians have contemplated suicide upon first receipt of malpractice claims, after judgments against them in court, or after financially motivated settlements foisted upon them by a malpractice insurer solely in order to cut the insurer’s losses.

Physicians who have reported depressive symptoms (even those for which they are receiving effective treatment) to their licensing boards, potential employers, hospitals, and other credentialing agencies have experienced a range of negative consequences, including loss of their medical privacy and autonomy, repetitive and intrusive examinations, licensure restrictions, discriminatory employment decisions, practice restrictions, hospital privilege limitations, and increased supervision.

Such discrimination can immediately and severely limit physicians’ livelihoods as well as the financial stability of their families. For this reason, well-meaning colleagues or family members who are aware of the depression sometimes discourage physicians from seeking help.

Insurance concerns
Physicians with mental illness face discrimination in obtaining insurance coverage. Health, disability, life, and liability insurance may all be denied to a physician who admits to depression.Even if disability insurance has previously been procured, its use may subject physicians to repeat humiliating and invasive examinations by detached and dubious “independent medical examiners” for the insurer, whose motivation is to cut company losses. Many physicians affected by mental illness feel that insurers expect them to adhere to the standard prescription “physician, heal thyself.”
Self-treatment
Despite the protections afforded by law to citizens and other professionals who have disabilities, the potentially devastating effects triggered by a physician’s self-reporting of depression may delay or, in effect, preclude appropriate treatment.

Although everyone knows that a doctor who treats himself or herself “has a fool for a patient,” we also know that most physicians treat themselves anyway, at least on occasion. This is especially likely when the physician believes that the consequences of seeking treatment may subject him or her to stigma, shame, or worse.

Because many states in the US require reporting by other licensed physicians of a physician who may be suffering from a potentially impairing condition, physicians can be reluctant to seek treatment from colleagues, or from utilizing their insurance coverage, or even from using their own names when seeking treatment. A physician whose thought processes are clouded by depression and the anticipated consequences of seeking treatment for it may honestly believe that self-treatment is the only safe option. One analysis of physician suicide data relative to non-physician victims revealed a much lower prevalence of antidepressant medication in the blood of physician victims, which is an objective indication of the truth that physicians do not receive mental health care in proportion to their need. Too often, however, attempts at self-treatment are unsuccessful. Failure to obtain consultation and treatment for depression needlessly and significantly increases the risk of physician suicide.

Depression in Medical Trainees
Prospective medical students and residents are extremely unlikely to report a history of depression during highly competitive selection interviews. The prevalence of depression in these populations and in medical student and postgraduate trainees is unknown, but it is estimated to range from 15-30%. A recent meta-analysis found that depressive symptoms and suicidal ideation are common among medical students. 7 However, the epidemiology of suicide deaths among medical students has been relatively underreported.

Other studies have confirmed the association of depression with self-perceived medication and other errors.

Stressful aspects of physician training—such as long hours, having to make difficult decisions while being at risk for errors due to inexperience, learning to deal with death and dying, frequent shifts in workplace, and estrangement from supportive networks, such as family—could add to the tendency toward depressive symptoms in trainees.

Harassment and belittlement by professors, higher-level trainees, and even nurses contribute to mental distress of students and development of depression in some.

SIGNS OF DEPRESSION
Characterized by a set of symptoms lasting at least two weeks and causing a change from the patients previous functioning.
The classic diagnostic criteria for a major depressive episode are:
Pervasive sadness/lack or interest or pleasure of activities normally found pleasurable
Four of the following signs:
Significant loss of appetite
Insomnia
Psychomotor agitation
Significant fatigue
Diminished ability to concentrate
Feeling of despair
Feeling of guilt
Thoughts of death.
Risk Factors for Depression
Chronic medical illness
Chronic minor daily stress
Chronic pain syndrome
Family history of depression
Female sex
Low income/job loss
Low self-esteem
Low social support
Prior depression
Single/divorced/widowed
Traumatic brain injury
Younger age
Physician Depression Questionnaire PDQ-9
Instructions: This questionnaire consists of several statements. Read each statement carefully, then pick the number that best describes the way you have been feeling during the past two weeks, including today. See the Table below for interpreting your score.
Over the last 2 weeks, how often have you been bothered by any of the following problems? 0 – Not at all 1 – Several days2 – More than half the days 3 – Nearly every day 1. Little interest or pleasure in doing things2. Feeling down or depressed3. Trouble falling or staying asleep, or sleeping too much4. Feeling tired or having little energy5. Poor appetite or overeating6. Feeling bad about yourself – or that you are a failure or have let yourself or your family down7. Trouble concentrating on things, such as reading the newspaper or watching television 8. Moving or speaking so slowly that other people could have noticed? Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual9. Thoughts that you would be better off dead or of hurting yourself in some way______ Total Score
Interpreting PDQ-9 Scores: This questionnaire estimates the overall severity of depression experienced by the patient according to the categories shown in the table below. If you scored in the 10-14 range, you should probably seek treatment. If you scored a 15 or higher, seeking treatment is strongly recommended.
Raw score Range of severity 0-5 Not Present5-9 Minimal symptoms of depression reported10-14 Moderate symptoms of depression reported 15-19 Moderately Severe symptoms of depression reported 20-27 Severe symptoms of depression reported
10 Facts about Physician Suicide and Mental Health in the US
1. Suicide is generally caused by the convergence of multiple risk factors, the most common being untreated or inadequately managed mental health conditions.

2. An estimated 300 physicians die by suicide in the U.S. per year.8
3. In cases where physicians died by suicide, depression is found to be a significant risk factor leading to their death.at approximately the same rate as among non-physician suicide deaths; but physicians who took their lives were less likely to be receiving mental health treatment compared with non-physicians who took their lives.9
4. The suicide rate among male physicians is 1.41 times higher than the general male population. And among female physicians the relative risk is even more pronounced — 2.27x greater than the general female population.10
5. Suicide is the second leading cause of death in the 24-34 age range (accidents are the first).11
6. The prevalence of depression among residents is higher than in similarly aged individuals in the general U.S.population — 28 percent of residents experience a major depressive episode during training versus the general population rate of 7-8 percent.12
7. Among physicians, risk for suicide increases when mental health conditions go unaddressed and when self-medication occurs as a way to address anxiety, insomnia, or other distressing symptoms. Although self-medicating may reduce some symptoms, the underlying health problem is not effectively treated and this can lead to a tragic outcome.

8. In one prospective study, 23 percent of interns had suicidal thoughts, but among those interns who completed four sessions of web-based Cognitive Behavior Therapy nearly 50 percent fewer had suicidal ideation.13
9. Drivers of burnout include work load, work inefficiency, lack of autonomy and meaning in work, and work-home conflict.

10. Unaddressed mental health conditions are, in the long run, more likely to negatively impact one’s professional reputation and practice than reaching out for help early.

Methods used for committing suicide
Suicide risk appears to be elevated in medical practitioners. The methods used by doctors for committing suicide were classified as self?poisoning (including carbon monoxide), self?injury or both. The methods of self?poisoning by drugs were subdivided into categories which reflected the important classes of drugs likely to be used by doctors (e.g. anaesthetic agents, analgesics, barbiturates), rather than the broad ICD groupings. Some doctors would prefer to use fire arms, and jumping from various locations, hanging.
Difference between doctors’ suicides and those in the general population
There are marked differences in the methods used for suicide by doctors and those in the population. Most doctors have usually died from drug overdoses. The excess of self?poisoning deaths in the doctors compared with suicides in the general population was somewhat more marked in males than females, although self?poisoning was generally more common in females, both in doctors and the general population.
There are at least two factors which may contribute to the greater use of self?poisoning as a method of suicide in doctors. The first is the ready availability of medicinal drugs to most working doctors. The second is the specific knowledge doctors have about the dangers of drugs, and hence which drugs and what doses are most likely to cause death. It also seems likely, but cannot be proven from our findings, that these factors contribute to the relatively high risk of suicide in doctors.

Of the methods used less often in doctors’ suicides compared to suicides in the general population (hanging, strangulation and suffocation, gas, including carbon monoxide, drowning, jumping from a height), all would have been equally available to both groups (except perhaps cars, which would be owned by nearly all doctors). On the other hand it might be argued that doctors would have greater knowledge of how to ensure death by cutting and that this might explain why more doctors used this method, although the numbers involved were relatively small.

Retired doctors who committed suicide also tended to use medicinal drugs suggests that having been a doctor may also serve to model this method of suicide for some individuals, although continuing access to medication might be a further factor.

The influence of specialty
The role of availability in determining methods used for suicide is strikingly illustrated by the fact that half of the anesthetists who committed suicide used anesthetic agents in these acts.

Several studies have demonstrated that general practitioners tend to favor the use of barbiturates and opiates whilst few psychiatrists who died overdosed on psychotropic agents.
This might reflect the fact that psychiatrists rarely have direct contact with the drugs they prescribe, but is perhaps more likely to be due to the psychiatrists being aware that many psychotropic agents are less dangerous in overdose than other drugs. The greater use of opiates for self?poisoning by male doctors compared to female doctors may be due to a higher incidence of substance misuse among male doctors.

PUBLIC HEALTH MODEL FOR SUICIDE PREVENTION
Applying the Public Health Approach to Suicide Prevention
1. Define the problem: Surveillance
Suicide Surveillance – Collecting information about the rates of suicidal behaviors. This can include the collection of information about individuals (physicians) who attempt or die by suicide, their circumstances, and the effects on others
2. Identify Causes:
Suicide is best understood as a very complex human behavior, with no single determining cause. The factors that affect the likelihood of a person attempting or completing suicide are known as Risk or protective factors, depending on whether they raise or lower the likelihood of suicidal behavior. Risk factors include mental illness and loss of a loved one. Protective factors include support networks and access to mental health care.

While physicians who attempt or complete suicide typically experience a combination of risk factors, there is often one precipitating factor that leads the person to attempt suicide. However, a person with many risk factors may not attempt to commit suicide if his or her risk factors are balanced by protective factors.

3. Develop and test interventions
Interventions might attempt to influence some combination of psychological state, physical environment, and cultural conditions. It is important to test intervention methods to ensure that they are safe, ethical, and feasible. Interventions that are successful in one setting may not be universally applicable. Comprehensive suicide prevention programs are believed to have a greater likelihood of reducing the suicide rate than are interventions that address only one risk or protective factor. Collaboration between community leaders and coalitions that cut across traditionally separate sectors can increase effectiveness.

Formative evaluation, including pre-testing, permits necessary revisions before the full effort goes forward. Its purpose is to maximize success of the program prior to implementation. Thorough consideration needs to be given to the possibility of increase in demand for services that do not exist in the community.

4. Implement Interventions
Fidelity, which means implementing the entire program as it was designed and tested, is of key importance in the implementation phase. The principles of the program should remain intact even as minor adaptations for community or cultural needs are made. Consistency of design is the primary means of ensuring success as programs are disseminated.

Despite having a sound implementation plan, unanticipated problems often arise. Evaluation must be incorporated into a project right from its planning stages.

5. Evaluate effectiveness
Evaluation involves setting realistic goals and objectives, and must be incorporated into a program from its inception. (Information on incorporating evaluation into program planning can be found in Suicide Prevention: Prevention Effectiveness and Evaluation by SPAN USA, Inc. (2001).

Objectives must be specific, measurable, attainable, relevant, and time-based. An ideal, evidence-based intervention is one that has been evaluated and found to be safe, ethical, and feasible, as well as effective. Determination of cost effectiveness is another important aspect of evaluation.

Most interventions that are presumed to prevent suicide, including some that have been widely implemented, have not yet been evaluated. Evaluation can help determine for whom a particular suicide prevention strategy is best fitted or how it should be modified in order to achieve maximum effectiveness. Evaluation does not need to be expensive or require expertise in biostatistics. As seen in the previous steps, evaluation can easily be integrated into the different phases of a project, making the project an evidence-based practice.

Risk prevention strategies
Prevention strategies to counteract these risk factors may be grouped along three levels. Universal prevention strategies are designed to reach an entire population. These strategies promote access to health care, encourage approaches to prevent mental health issues (such as reducing the harmful use of alcohol), limit access to the means of suicide, and promote responsible reporting by the media.

Selective prevention strategies target vulnerable groups that are at higher risk of suicide than the general population, such as people who have suffered trauma or abuse, victims of war or disaster, refugees and migrants, and the relatives of people who have committed suicide. These activities are conducted, for example, by “gatekeepers” trained to provide support and services such as telephone help lines.

Finally, indicated prevention strategies target individuals with specific vulnerabilities specifically, people who have been discharged from psychiatric institutions or have attempted suicide. The intervention activities vary and include follow-up by general health workers or specialists or better identification and management of mental or substance use disorders.

Primary prevention that reinforces protective factors such as close personal relationships, a personal belief system, and strategies for coping with stressful situations may also be employed.

STRATEGIES TO PREVENT SUICIDE IN PHYSICIANS
Four steps to identifying at-risk physicians and facilitating access to appropriate care.

Talk about the risk factors and warning signs of suicide.

Take steps to standardize care seeking in your organization
Make it easy to find help
Consider creating a support system for physicians in your organization.
Take steps to standardize care seeking in your organization
Recognize the importance of modeling self-care and encouraging others to do the same. Start by taking steps to maintain health.

Allow the doctors to recharge. To take personal time off and make time for relaxation with friends and family members.

Physicians should talk to their colleagues about their own stress.
Opening up to co-workers about you’re their anxieties and stress shows others that they are not alone. The support of colleagues can be a great source of comfort during difficult circumstances.

Learn to say “no.” Many physicians have difficulty turning down requests from work and the community. Sometimes saying no is the best medical care for both the patient and the doctor.

Learn to recognize the signs of stress, depression and burnout in themselves. Most importantly, they feel that you too would benefit from assistance, reach out to colleagues. You will find that you are not alone. Sharing your experiences with colleagues may help others in similar situations.

Follow basic health rules for staying healthy! Get enough sleep, eat nutritiously and exercise regularly.

Make it easy to find help
The leadership should keep updated referral lists for resources inside and outside your organization and make them readily available to staff. Be sure to house these resources in a highly visible location that does not require a password and assure users that there is no tracing of page visits or downloads.

Many confidential resources are available to help physicians in distress or at risk for suicide. .There are Physician Health Programs. Although programs vary, PHPs provide or facilitate in-depth evaluations, appropriate treatment referrals, and if necessary, monitoring for residents, physicians and sometimes medical students. Because PHPs are not affiliated with clinical practices or hospitals, they allow physicians to access private and confidential care.
Identify policy barriers to care-seeking in your organization and take steps to minimize them. Work with leadership to examine and modify (if necessary) your internal policies to encourage care-seeking by physicians. In this review they should ask yourself:
Can physicians receive care confidentially?
What type of information is recorded when physicians seek treatment?
If a physician receives care internally, are the records private? Is access to these records controlled?
Are physicians’ jobs secure if they seek extensive care for mental health treatment? If so, is this job security widely known by physicians within your organization?
Do physicians have the flexibility and time in their schedules to seek care if they need it?
Is personal time off encouraged in the organization?
Is access to mental health care on par with access to other forms of health care?
Are physicians in the state or county required to report mental health treatment when applying for renewal of their medical licenses?
Are your policies visibly posted (online and/or in print) and easily accessible for physicians in your organization to review?
Consider creating a support system for physicians in your organization
Creating a supportive atmosphere in the workplace can be instrumental to addressing physician distress.

Forms of support include:
Encouraging physicians to establish and use a regular source of health care
Reducing the physician’s patient caseload in the short term
Developing internal peer network programs and opportunities
Offering regular screenings for depression, distress and burnout
Identifying and adapting approaches used by external suicide prevention programs to your organization.
NATIONAL STRATEGIES
A national strategy reflects the clear commitment of a government to address the issue. National strategies generally include prevention measures, such as surveillance, restriction of access to the means of suicide, guidelines for the media, stigma reduction, and public awareness, as well as training health workers, educators, the police, and other “gatekeepers.” As a rule, these strategies also include crisis intervention and post-intervention services. A comprehensive suicide prevention strategy may involve multiple actors.

For a national suicide prevention strategy, it is essential that governments exercise leadership and call on multiple stakeholders who might not otherwise coordinate their actions. Governments are also in a unique position to develop and strengthen surveillance and to provide and disseminate the data necessary to inform action.

Strategies to prevent it require tailoring measures to the cultural and social context of each country and the inclusion of evidence-based best practices and interventions with a comprehensive approach. Resources should be allocated to meet short-, medium-, and long term objectives, and effective planning is a must.

The strategy should be evaluated periodically and the findings used for future planning. However, lack of a fully developed comprehensive national strategy should not hinder the execution of less comprehensive suicide prevention programs, as these may contribute to the formulation of a national response. Some of these programs may be used to identify vulnerable groups at risk of suicide and increase their access to services and resources.

The development and putting in place of a national suicide prevention strategy requires:
Recognition that suicidal behavior is a public health problem;
An indication of government commitment to address the problem;
Recommendation of a structural framework incorporating various aspects of suicide prevention;
Guidance on suicide prevention based on key information—that is, identifying what has worked and what has not
Identification of the main parties and stakeholders accountable for specific tasks, outlining ways for them to coordinate;
Identification of critical gaps in legislation, service delivery, and data collection;
Allocation of the human and financial resources necessary for the interventions;
Media efforts to raise public awareness;
Adequate surveillance and an appropriate assessment framework requires inculcating a sense of responsibility among those responsible for the interventions to ensure that the necessary data are recorded reliably; and
Creation of an environment for a research agenda on suicidal behavior.

Development areas for strategic action
Strategic action implies:
Engaging appropriate direct stakeholders and actors who can work within their own sectors or across sectors to reduce suicide rates;
Making efforts to reduce access to the means of completing suicide;
Improving the systematic collection of surveillance data to understand trends in suicide;
Monitoring the effects of prevention efforts over time;
Conducting efforts to debunk myths and raise awareness that suicide is a preventable public health problem; and
Mobilizing the health system.

Areas of strategic
action Lead stakeholders No activity (currently
there is
no suicide prevention
response at national
or local level) Some activity
(some work has
begun in suicide
prevention in priority
areas at either
national or local level) Established suicide
prevention strategy
exists at national level
Engage key
stakeholders Ministry of Health
as lead, or other
coordinating health
body Begin planning and implementing care for people who attempt suicide, and train health workers. Initiate identification
of and engagement
with key stakeholders
on country priorities,
or where activities already exist. Assess the roles,
responsibilities,
and activities of all
key stakeholders
on a regular basis.

Use the results
to expand sector
participation and
increase stakeholder involvement.

Reduce access to
means Legal and judicial system, policy-makers, agriculture,
transportation Begin efforts to reduce access to means of suicide through community interventions. Coordinate and
expand existing efforts
to reduce access to
the means of suicide
(including laws,
policies and practices
at national level). Evaluate efforts to
reduce access to the
means of suicide.

Use the evaluation
results to make
improvements.

Conduct surveillance
and improve data
quality Ministry of Health,
Bureau of Statistics,
all other stakeholders,
and particularly the
formal and informal
health systems to
collect data Begin surveillance,
prioritizing mortality
data, with core
information on age,
sex and methods
of suicide. Begin
identification of
representative
locations for
development of
models. Put a surveillance
system in place to
monitor suicide and
suicide attempts
at national level
(including additional
disaggregation) and
ensure the data is
reliable, valid and
publicly available.

Establish feasible
data models that are
effective and can be
scaled up. Monitor key attributes
such as quality,
representative- ness,
timeliness, usefulness
and costs of the
surveillance system in
a timely manner. Use
the results to improve
the system. Scale up
effective models for
comprehensive data
coverage and quality
Raise awareness All sectors, with
leadership from the
Ministry of Health and
the media Organize activities
to raise awareness
that suicides are
preventable. Ensure
that messages reach
some of the regions or
populations targeted
and are delivered
through at least one
widely accessed
channel. Develop strategic
public awareness
campaigns and
implement them
using evidence-based
information at national
level. Use methods
and messages that
are tailored to target
populations. Evaluate the
effectiveness of public
awareness campaign
(s). Use the results
to improve future
campaigns.

Engage the media Media and Ministry of
Health in partnership Begin dialogue
with the media on
responsible reporting
of suicide. Approach major
media organizations
within the country
to support the
development of their
own standards and
practices to ensure
responsible reporting
on suicide. Work with
media stakeholders to
promote prevention
resources and
appropriate referrals Evaluate media
reporting of suicide
events. Engage
and train all media
about responsible
reporting. Establish
timely training for new
workers in the media.

Change attitudes and
beliefs Media, health services
sector, education
sector, community
organizations Begin implementation
of activities to reduce
stigma associated
with seeking help for
suicide. Increase helpseeking
behaviour. Change attitudes
towards the use
of mental health
services, and reduce
discrimina- tion
against users of these
services. Conduct periodic
evaluations to monitor
changes in public
attitudes and beliefs
about suicide, mental
and substance use
disorders and
help-seeking.

Conduct evaluation
and research Relevant community
health services,
education sector and
Ministry of Health Begin planning
and prioritizing the
required suicide
prevention research,
and collate the
existing data (e.g.

suicide deaths). Expand existing
research, assigning
resources to inform
and evaluate efforts
to prevent suicide
at regional and/or
national level. Conduct periodic
assessment of the
portfolio of research
to monitor scientific
progress and identify
knowledge gaps.

Redirect resources
on the basis of the
evaluation.

Develop and
implement a
comprehensive
national suicide
prevention strategy Ministry of Health Begin to develop
a national suicide
prevention strategy
to serve as a rallying
point, even if data and
resources are not yet
available. Continue to develop
the national strategy
to ensure it is
comprehensive,
multisectoral and
covers all gaps
in service and
implementation. Evaluate and
monitor strategy
implementation and
outcomes in order
to identify the most
effective components.

Use the results to
update the strategy
continuous

CONCLUSION
Prevention-focused approaches in mental health are more cost effective than treatment approaches, not to mention the fact the growing burden of mental ill health cannot reasonably be.

There is a need to recognize suicide prevention and mental health as a part of the larger employee wellness program. At the same time, it is also essential to recognize suicide as an issue, assess its impact on an organization, and create a structured plan to deal with it.

Why is it important to have a suicide prevention program?
ADVANTAGES
Improving employee health and wellness
Identify those at risk of developing a mental health disorder (and offer support to them)
Identify those who are in critical situations (i.e. employees who have attempted suicide, or are contemplating it), offer them timely support and follow-up services.

Improve the quality of life for those who are affected by mental health issues or suicidal thoughts, and support them in returning to productivity.

From the employer’s point of view, having a proactive suicide prevention program ensures that the employees are mentally healthy. If an employee has suicidal thoughts, they can receive support, which helps them cope better with work, and improves their level of productivity. An outreach program gives the employees a sense of being taken care of, and improves their comfort level. Overall, the organization benefits by having a more mentally healthy and productive workforce.

For the employee, the existence of a mental health and suicide prevention program tells them that the organization is interested in their health and welfare; this can increase their confidence in the management. The employee also benefits from the opportunity to discuss their challenges with a dedicated team of experts – they can receive help for themselves, or seek it on behalf of their colleagues or family. This access is a crucial element in the prevention of suicide. A person who has access to help and is able to tackle their problems with professional support is likely to come out of the suicidal ideation phase.

In short, having an effective mental health and suicide prevention program benefits both the employer as well as the employee.

There are two ways in which an organization can take a proactive approach to preventing employee suicide:
By having an overall mental health program that addresses common mental health disorders such as depression, anxiety and substance use. By having a suicide prevention program independent or as part of the workplace program on mental health.

Restrict Access to the site and the means of suicide
Close all or part the site
PROS
evidence of effectiveness
restricts access to a drop or path of moving object
CONS
may limit rights and enjoyment of non-suicidal persons
Install physical barriers to prevent jumping
PROS
evidence of effectiveness
restricts access to a drop or path of moving object
increases chances of human intervention by delaying the jump
recommended by survivors of suicidal jumps
may prevent other acts of vandalism that endanger the public, for example throwing things from bridges or onto rail tracks
CONS
method specific, that is only prevents suicide by jumping
high cost
permanent
may pose engineering challenges,
especially if being added to an existing structure
Introduce other deterrents, for example boundary markers or lighting
PROS
eliminates hiding places; makes suicidal individuals
conspicuous increases chances of human intervention
not method-specific
may improve public safety generally
CONS
Not tested
Increase opportunity and capacity for human intervention
Improve surveillance using CCTV, thermal imaging and other technologies; increase staffing or foot patrols
PROS
risk of being seen may deter suicidal individual from entering site
increases chances of human intervention and reduces response time
not method-specific
CONS
no evidence of effectiveness for surveillance alone
CCTV no use without permanent
monitoring by sufficiently skilled and confident staff
Increase opportunities for help seeking by the suicidal individual
Install Samaritans signs and/or free emergency telephones
PROS
limited evidence of effectiveness for signs
alone evidence of effectiveness for telephones
not method-specific
CONS
may advertise potential lethality of a site
signs and telephones rely on Suicidal individual to make the call
signs without telephones require adequate mobile phone signal
Provide a staffed sanctuary, or signpost people to a nearby onePROS
human contact is the best defense against isolation and hopelessness
not method-specific
CONS
not yet tested
Change the public image of the site
Restrict media reporting of suicidal acts
PROS
evidence of effectiveness
prevents’ effectiveness’ of location or method
being advertised to other vulnerable individuals
suicide prevention ‘is everybody’s business’
not method-specific
CONS
none identified
Discourage flora tributes and personal memorials at the site
PROS
not method-specific
may prevent ‘effectiveness’ of site
being advertised to other vulnerable individuals
CONS
not tested
risk of adverse publicity and causing distress to the bereaved
needs to be handled sensitive
Introduce new amenities or activities; consider re-naming and re-marketing the location
PROS
may help to dispel image of site as a’suicide spot’
may increase footfall and chances of intervention
may improve health and emotional
wellbeing of whole community
CONS
NOT tested.

REFERENCES
World Health Organization (2014) Preventing suicide: A global imperative.

Highest suicide rate by profession. New Health Guide website. newhealthguide.org/Highest-Suicide-Rate-By-Profession.html. Updated February 2, 2018. Accessed February 1, 2018.

https://www.helpguide.org/articles/stress/burnout-prevention-and-recovery.htmMaslach C, Leiter MP. The Truth About Burnout: How Organizations Cause Personal Stress and What to Do About It. San Francisco: Jossey-Bass; 1997.

https://wire.ama-assn.org/life-career/medical-specialties-highest-burnout-rates
Shanafelt TD, Balch CM, Dyrbye L, Bechamps G, Russell T, Satele D, et al. Special report: suicidal ideation among American surgeons. Arch Surg. 2011 Jan. 146(1):54-62. Medline.

Moutier C, Norcross W, Jong P, et al. The suicide prevention and depression awareness program at the University of California, San Diego School of Medicine. Acad Med. 2012;87:320-326
Goebert D, Thompson D, Takeshita J, Beach C, Bryson P, Ephgrave K, et al. Depressive symptoms in medical students and residents: a multischool study. Acad Med. 2009 Feb. 84 (2):236-41. Medline.

https://www.aafp.org/afp/2012/0115/p139.htmlCenter, C., Davis, M., Detre, T., Ford, D. E., Hansbrough, W., Hendin, H., Laszlo, J., Litts, D.A., Mann, J., Mansky, P.A., Michels, R., Miles, S.H., Proujansky, R., Reynolds, C.F. 3rd, Silverman, M. M. (2003). Confronting Depression and Suicide in Physicians. JAMA, 289(23), 3161. doi:10.1001/jama.289.23.3161
Gold, K. J., Sen, A., ; Schwenk, T. L. (2013). Details on suicide among US physicians: Data from the National Violent Death Reporting System. General Hospital Psychiatry, 35(1), 45-49. doi:10.1016/j.genhosppsych.2012.08.005
Schernhammer, E. S., ; Colditz, G. A. (2004). Suicide Rates Among Physicians: A Quantitative and Gender Assessment (Meta-Analysis). American Journal of Psychiatry AJP, 161(12), 2295-2302.doi:10.1176/appi.ajp.161.12.2295
CDC National Center for Injury Prevention and Control. (2015). 10 Leading Causes of Death by Age Group, United States – 2014 Retrieved from http://www.cdc.gov/injury/images/lc-charts/ leading_causes_of_death_age_group_2014_1050w760h.gif
Mata, D. A., Ramos, M. A., Bansal, N., Khan, R., Guille, C., Angelantonio, E. D., ; Sen, S. (2015). Prevalence of Depression and Depressive Symptoms among Resident Physicians. JAMA, 314(22), 2373. doi:10.1001/jama.2015.15845
Guille, C., Zhao, Z., Krystal, J., Nichols, B., Brady, K., ; Sen, S. (2015). Web-Based Cognitive Behavioral Therapy Intervention for the Prevention of Suicidal Ideation in Medical Interns. JAMA Psychiatry, 72(12), 1192. doi:10.1001/jamapsychiatry.2015.1880
STEPS optional module: mental health/suicide. Geneva: World HealthOrganization; 2014 (http://www.who.int/chp/steps/riskfactor/modules/en/, accessed 15 May 2014).

Preventing suicide: a resource for suicide case registration. Geneva: World HealthOrganization; 2011
Cho J, Lee WJ, Moon KT, Suh M, Sohn J, Ha KH et al. Medical care utilization during 1 year prior to death in suicides motivated by physical illnesses. J Prev Med
Public Health. 2013;46(3):147?54.

Health literacy: the solid facts. Copenhagen: World Health Organization Regional
OfficeforEurope;2013(http://www.euro.who.int/__data/assets/pdf_file/0008/190655/e96854.pdf, accessed 23 April 2014).

Niederkrotenthaler T, Fu KW, Yip PS, Fong DY, Stack S, Cheng Q et al. Changes
in suicide rates following media reports on celebrity suicide: a meta-analysis. JEpidemiol Community Health. 2012;66(11):1037?42.

Sisask M, Värnik A. Media roles in suicide prevention: a systematic review. Int J
111Environ Res Public Health. 2012;9:123?38.

Daine K, Hawton K, Singaravelu V, Stewart A, Simkin S, Montgomery P. The power
of the web: a systematic review of studies of the influence of the internet on self-harmand suicide in young people. PloS ONE. 2013;8(10):e77555.