New Text Tackles the Occupational Hazard of Physician Suicide

Deborah Brauser

August 14, 2018

As the US "epidemic" of physician suicide continues, the American Psychiatric Association (APA) has developed a new textbook designed to help medical trainees and established practitioners alike reduce their risk for what is fast becoming an occupational hazard.

Dr Peter Yellowlees

The Centers for Disease Control and Prevention reports that the US suicide rate has increased almost 30% since 1999. In addition, a systematic literature review presented at the APA's 2018 annual meeting shows that US physicians have the highest suicide rate of any profession — 28 to 40 per 100,000 — which is more than double that of the general population.

In the newly published Physician Suicide: Cases and Commentaries, author Peter Yellowlees, MD, professor of psychiatry at the University of California, Davis, discusses risk factors for burnout, depressive symptoms, and suicide in a literature review and series of fictionalized case studies.

Although designed as a textbook, Yellowlees told Medscape Medical News the book is intended to educate and help physicians at any point in their career.

"This is important not just to the area of mental health but to the whole area of medicine, and potentially to the public. The book talks about physician suicide itself, but also about the causes of it," he said.

"One of the reasons I wrote this is because I strongly believe the whole culture of medicine needs to change. In the face of all of these pressures that physicians now have to deal with, they need to learn how to respond better and how they can look after themselves," Yellowlees added.

Tip of the Iceberg?

He noted that physician suicide is really "the tip of the iceberg" that also includes stress, burnout, and dissatisfaction.

"It's pretty clear in the work that Medscape has done and other people have done that most of the causes of burnout are essentially organizational or systems-type issues," said Yellowlees.

"It's physicians feeling more squeezed and more under pressure from multiple sources of people requiring their time, information, data, etc. There's no question that all of that has dramatically increased, and I think it's likely that that's led to the increase in suicide rate, as well as the increase in [physician] stress, burnout, and depression rates," Yellowlees added.

Earlier this summer, the American Medical Association adopted a new policy to increase training about the issue of physician suicide. This is especially important because, as reported in previous research, physicians often don't seek professional help, owing in large part to fear of career repercussions and damage to their professional reputation.

"A big message in my book is that if you see a colleague who is clearly distressed or unwell, you should approach them. The current culture of medicine is that we're trained to be highly independent and not show any weakness — to our patients and to the world at large. But this often stops [us] from getting care, especially for mental health issues," said Yellowlees.

In an excerpted review published on the book's website, immediate past president of the APA Anita Everett, MD, chief medical officer at the Substance Abuse and Mental Health Services Administration, noted that Yellowlees' work "will go a long way" toward increasing awareness of these issues — and reducing the stigma that often accompanies them.

"Physician burnout and risk for suicide is an issue of our time," said Everett. "Suicidal ideation is often a treatable condition, and we cannot afford to lose one more physician."

Dr Michael Myers

On the same website, Michael Myers, MD, professor of clinical psychiatry at SUNY Downstate Medical Center, New York City, said that the book is "full of sage advice" for physicians, as well as for their families and those who treat them.

"Dr Yellowlees...has created a unique book on a difficult subject," said Myers, who previously authored his own book on this topic in 2017, entitled Why Physicians Die By Suicide: Lessons Learned From Their Families and Others Who Cared.

Asked for further comment by Medscape Medical News, Myers, a past member of the editorial board for APA Publishing, said that this is the right book at the right time for a wide range of mental health professionals.

"To me, this book will be of great value to psychologists, to nurse practitioners, to the clergy, to clinical social workers, to physician health programs across the continent, and even to international readers," he said.

Homage to Oliver Sacks

Yellowlees said he was inspired by the late Oliver Sacks, MD, who wrote the seminal book The Man Who Mistook His Wife for a Hat and Other Clinical Tales, when organizing his own 10-chapter book — although Yellowlees' case studies are fictionalized.

"I deliberately modeled after his book, with each chapter focusing on a specific topic about physician health. One is about suicide, another is about burnout, another about alcohol abuse, and so on. Two thirds of these chapters are essentially a fictional, detailed, but short story about a physician who is affected by the chapter's topic. All are realistic and taken from my own or others' experiences," he said.

"I tried to show what it's like to get in the mind of the physician to show what their daily life is really like. Then the last third of the chapter is basically an editorial that covers the literature, looks at the major issues that were brought up, and gives an opinion on how we could change and improve things and what works and what doesn't," said Yellowlees.

For example, the first chapter is about a psychiatrist who had a physician patient who died by suicide. "And that's a common scenario. Most psychiatrists will have, on average, at least two patients during their careers who will suicide," he said. "There's very little written about how to feel and react during that situation."

Another chapter focuses on a psychiatrist who is treating another doctor who has a bipolar disorder. "How do you treat doctors? How do you effectively treat VIP patients? Corners are often cut with VIPs, they don't do the normal screenings, and it's assumed that VIPs know more about what's going on. So the chapter focuses on how psychiatrists can provide better treatment," Yellowlees said.

Other chapters deal with primary care and other specialties.

Myers noted in his review blurb that Sacks would be proud of Yellowlees' book and the way it presents these fictionalized stories.

"Dr Sacks was a great mentor of mine. And these case studies are written beautifully. They're very engaging," he added in his interview with Medscape Medical News.

Difficult Topic

Myers, who did not know Yellowlees prior to being asked by the publisher to review the new book, is now working with the author to jointly present a workshop about physician suicide at the International Conference on Physician Health in Toronto, Canada, in October.

"This is not an easy subject, and there are a lot of people who would rather it just go away. But it doesn't go away. Instead, we continue to learn about another physician who has taken his or her life. And at that medical center they wonder: what are the next steps? What do we do in terms of a crisis like this? There are some good material, at least for the immediate aftermath," said Myers.

He noted that two versions of a toolkit, put together by the Mayo Clinic Center for Physician Health, are available on the website of the American Foundation for Suicide Prevention. One focuses on medical students and the other on residents.

Myers added that all of these resources work well together in a personal library for use by those interested in taking care of physician colleagues — and themselves.

Physicians who are having thoughts of suicide need to take those thoughts very seriously, said Myers.

"Sometimes physicians will almost 'normalize' having thoughts of suicide, as a reaction to the work being so hard and being tired all of the time. But that's not a normal feeling, and it's something we need to talk about," he said.

"I've found in my clinical experience that physicians feel so relieved when they're able to share their kind of dark thoughts and secrets. Unless it's an emergency, when they're able to share with someone who is listening carefully without 'freaking out,' that can be a great comfort. They find out that these thoughts can be dealt with, treated, and then go away," he added.

Dr Yellowlees consults for Medscape Medical News by providing monthly video commentaries on psychiatric issues.

Follow Deborah Brauser on Twitter: @MedscapeDeb.

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