Rates of Suicidal Ideation Among US Surgeons 'Very Concerning'

Megan Brooks

January 17, 2011

January 17, 2011 — An anonymous survey of US surgeons finds that about 1 in 16 had suicidal thoughts in the past year, yet few sought help from a mental health professional.

"The fact that 6% of US surgeons thought of killing themselves in the last 12 months is certainly very concerning," Tait D. Shanafelt, MD, director of the Mayo Clinic Department of Medicine Program on Physician Well-Being, Rochester, Minnesota, told Medscape Medical News.

Dr. Tait Shanafelt

Among surgeons age 45 years and older, the prevalence of suicidal thoughts was 1.5 to 3.0 times more common than in the US general population (P < .02).

This finding, Dr. Shanafelt said, is "even more striking considering that surgeons are highly educated, nearly universally employed, and overwhelmingly (88%) married — all factors known to reduce risk of suicide in the general population."

The findings are even more striking considering that surgeons are highly educated, nearly universally employed, and overwhelmingly (88%) married — all factors known to reduce risk of suicide in the general population.

The survey results are published in the January issue of Archives of Surgery.

In June 2008, 24,922 members of the American College of Surgeons received the survey in the mail. It included questions on suicidal ideation and use of mental health resources, a validated depression screening tool, and standardized assessments to gauge burnout and quality of life.

Among 7905 surgeons who completed the survey (a response rate of 31.7%), 501 (6.3%) reported thoughts of suicide in the prior year.

The prevalence of suicidal ideation among surgeons was similar to that in the general population for those 25 to 34 years old (7.3% vs 6.7%; P = .85) and those 35 to 44 years old (6.3% vs 6.8%; P = .21).

However, rates were substantially higher among surgeons age 45 to 54 years (7.6% vs 5.0%; P = .008), 55 to 64 years old (6.9% vs 2.3%; P < .001), and 65 years or older (2.7% vs 1.2%; P = .02).

It is "notable," said Dr. Shanafelt, "that although individuals age 45 to 54 in the general population have a lower risk of suicidal ideation than younger individuals, the reverse appears to be true for surgeons."

Being married and having children lowered the likelihood of suicidal ideation; being divorced raised it. Rates of suicidal ideation among surgeons did not vary by sex.

Error Risk

In addition to some of the traditional risk factors for suicidal thoughts, such as depression (odds ratio [OR], 7.0; P < .001), the researchers found that occupational risks, including surgeon burnout (OR, 1.9; P < .001) and having made a recent major medical error (OR, 1.8; P < .001), were independent risk factors for suicidal thoughts among surgeons.

Suicidal thoughts were also strongly associated with distress, depression, and all 3 domains of burnout: emotional exhaustion, depersonalization, and low personal accomplishment.

"This is concerning," Dr. Shanafelt said, "because we previously found that surgeon burnout is associated with an increased risk of medical errors."

The perception of having made a major mistake in the previous 3 months was associated with a 3-fold increased risk for suicidal ideation; 16.2% of surgeons who reported a recent major error reported suicidal ideation compared with 5.4% of those who did not report an error.

This finding, the investigators say, highlights the "personal consequences" medical errors have on physicians.

Of the 501 surgeons who reported past year suicidal thoughts, only 130 (26%) sought help from a psychiatrist or psychologist, a rate substantially lower than the rate of 44% for individuals in the general population with suicidal thoughts.

Surgeons with suicidal ideation were more likely to have used antidepressant medication in the past year (21.8% vs 4.8%; P < .001) and to have self-prescribed the medication (15.7% vs 6.9%; P = .006).

More than one third of surgeons overall and more than 60% of those with suicidal ideation indicated that they would be reluctant to seek professional help for mental health problems out of concern that it might affect their license to practice medicine.

"Although this study was limited to approximately 7900 US surgeons, I suspect many of the findings apply to US physicians in general," said Dr. Shanafelt. "Burnout is a major problem for US physicians in general, and the rates of burnout among surgeons are similar to those observed in other specialties."

Findings "Resonate"

In a critique published with the study, Kelly L. McCoy, MD, and Sally E. Carty, MD, from the Department of Surgery, University of Pittsburgh School of Medicine in Pennsylvania, say the findings in this survey "sadly resonate with experience."

It is a subject "too often ignored," they write, and they say that "more research on the realities of surgical practice today" is needed.

Dr. McCoy and Dr. Carty also point out that 92% of surgeons surveyed reported working 40 hours per week or longer and that their irregular hours and ultimate accountability for immediate life-and-death situations compound job stress.

Surgeons also exist in a culture that, like it or not, honors self-denial, prizes impervious resilience, and tends to interpret imperfection as failure.

"Surgeons also exist in a culture that, like it or not, honors self-denial, prizes impervious resilience, and tends to interpret imperfection as failure. Together we need to better recognize stress and depression and encourage acceptance for those who seek to better their mental health for themselves, their families and their patients," Dr. McCoy and Dr. Carty write.

Funding for the survey was provided by the American College of Surgeons. The authors of the study and the invited critique have disclosed no relevant financial relationships.

Arch Surg. 2011;146:54-62. Abstract

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