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. 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.
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