Today I’m Grieving a Physician Suicide

Over the past twenty years, our physician health program in Washington state has monitored nearly 800 physicians with potentially impairing conditions. In the past four years, we have seen a tremendous spike in the incidence of mood disorders and are currently monitoring several physicians (20) following their near-lethal suicide attempts. Most of these fellow physicians had never received treatment for a mood disorder and had no idea of the severity of their episode. For the most part, they were self-diagnosed and self-treated. With two exceptions they were working in the 24 hours preceding their attempt.

Several excellent educational resources have been developed since the JAMA consensus panel in 2003. Examples are the "Struggling in Silence" DVD by the American Foundation for Suicide Prevention and the excellent book on "The Physician as Patient" by Drs. Myers and Gabbard.

From our experience, we have come to believe that physicians will be more inclined to take advantage of these resources if they become aware of their own vulnerability for the development of a mood disorder. Accordingly, we are developing a confidential online self-assessment survey of at-risk behavior which will give instant feedback to the physicians who are taking the survey and link them to both the educational resources and the clinical resources available in their community.

Congratulations to Dr. Middleton for her powerful and poignant essay which leaves us with the compelling realization that we are our brothers' and sisters' keeper!

Competing interests:   None declared

I believe that I am the visiting professor to which Dr. Middleton refers in her important and well-written essay. Her personal reactions and observations highlight the very special, very powerful, and potentially very tragic nature of depression and suicide in physicians.

The issues surrounding the physician who is also a patient (or the patient who is also a physician, as you choose to see it) are increased in both complexity and intensity when the medical issue is depression. We have recently published a survey of physician experiences with depression relative to medical staff and medical licensure sanctions (Schwenk TL, Gorenflo DW, Leja LM. The impact of depression on the professional status and mental health care of physicians. J Clin Psych, 2008;69:617-620.) It is clear that however much we have reduced stigma with regard to patients who are depressed, physicians who are depressed are still viewed differently than are physicians with other chronic medical illness. This stigmatization leads to inappropriate and dangerous behaviors up to and including self-prescription of antidepressants.

We have a significant, and to date mostly unmet, responsibility to our profession, our patients, our colleagues, and ourselves, to address the issue of stigma in physicians who are depressed, so as to improve the quality of care and clinical outcomes, in particular reducing the likelihood of the type of tragedy described so well by Dr. Middleton.

Competing interests:   None declared

I thank Dr. Peschke for his response. I agree that I am certainly often guilty of assigning myself more control over others' outcomes than I actually have. In light of information I learned after my colleague's death (was seeking treatment for depression, as I alluded to in the piece), though, I respectfully reject the suggestion that my colleague may have committed suicide as a rational and non-illness-related act. I prefer to leave the debate over the existence of the "rational suicide" to others; we should focus our energies instead on providing high-quality, non- stigmatized mental health care for our professional colleagues, which is a need I hope we all can agree on. I concede that all suicide may not be depression, but that does not allow us to abrogate our responsibility to our suffering peers.

Competing interests:   None declared

It is natural for physicians to ask themselves; "Is there anything I could have done to prevent this suicide?". Perhaps this was the deep desire of the physician, which if known to us, we would have done everything in our power to stop, even against their wishes. Some people subtly commit suicide when they smoke, drink and drive, or make other poor lifestyle choices. There may also a conscious choice some people make, like the old eskimo walking out into the snowstorm when food is becoming scarce, allowing the younger family members to survive. For some people it is a relief to get their affairs in order, provide for their familiy and make an informed decision for death, especially if they percieve a future which is not a life which they would want to lead. This certainly becomes more ethically challenging when a patient asks a physician to become involved in their death process whatever form it takes. I think that sometimes we do a disservice to our patients by not being able to assist, and thereby hasten their suicide, while they still are able to do so "by their own hands". Physicians certainly have the capability to be more effective than most, even without assistance. We assume that no one can wish for death like a "Catch 22" scenario; To wish for death means one is depressed and therefore not rational. As physicians we are trained to feel as though we are responsible, which although it is noble, it is also controling. Control is an illusion, and death is inevitable, the rest is all about timing.

Competing interests:   None declared