Medical School a Risk Factor for Suicide?

Although limited research shows "no consensus" on whether suicide rates in medical students are higher or lower than in the overall population, there is increasing awareness that some early-career physicians are at risk.

In a systematic review of seven studies from the United States, Austria, and Brazil, which tracked medical student data between 1879 and 2011, suicide rates ranged between zero and 39.6 per 100,000 students. In three studies that distinguished between data from male and female students, the rates ranged from 2.96 to 15.6 per 100,000 and 1.63 to 18.9 per 100,000, respectively.

In the six studies that compared medical students to an age-matched population sample, two showed that suicide rates were lower for the medical students, three found the rates to be higher, and one found the rates to be comparable.

Lead author Rebecca M. Zivanovic, MD, resident at the University of British Columbia, Vancouver, Canada, noted that "it's likely impossible" to find a true control group to measure this outcome.

"How do we take out confounding data? Or is this enough to tell us that we should at least consider that medical training is a risk factor for death by suicide? If so, we need to be working toward making something happen," she said.


"We were interested in finding out if the suicide rate was higher than expected in medical students. But no matter what, even one outcome is a bad outcome," said Dr Zivanovic, who presented her findings here at the American Psychiatric Association (APA) 2017 Annual Meeting.

Growing Awareness

Suicide is the ninth leading cause of death in Canada and the tenth leading cause in the United States.

In a review of 37 studies published in 2015, the prevalence of depression in medical students ranged from 2.9% to 38.2%, suicidal ideation ranged from 4.4% to 23.1%, and self-reported suicide attempts ranged from zero to 6.4%.

However, "no systematic review has been conducted analyzing the rate of completed suicide in this unique population," Dr Zivanovic and colleagues write.

"At the Canadian Psychiatric Association Conference last fall, suicide was a huge topic, especially suicide in our colleagues and peers, and they included a suicide prevention plenary for trainees," said Dr Zivanovic. "Awareness is gaining traction, and we just wanted to provide a little more background literature, including how it's been reported in the past."

After a search through databases that included Medline, Cochrane, and PsycINFO, the investigators included seven studies in their analysis, all of which reported medical student suicide rates.

Decreasing Rates?

Of the studies, five were from the United States, of which four included mailed questionnaires or telephone/electronic surveys sent to deans of student affairs at almost 450 medical schools.

Interestingly, the overall suicide rate from these data appeared to decline over time. In the study conducted between 1947 and 1967, the rate was 33 per 100,000 medical students. The rate was 18.4 and 5.8 per 100,000 for the studies conducted in the 1970s and early 1990s, respectively. And it was 2.3 per 100,000 for the study conducted between 2006 and 2011.


The fifth US study was a retrospective file review of nearly 21,000 medical students in Arkansas between 1879 and 1976. It showed a suicide rate of 0 per 100,000 students. This was the only study that did not compare its data to a population control group.


The other two studies in the current meta-analysis were a retrospective review of more than 20,000 medical students at the University of São Paulo, Brazil, between 1965 and 1985 and a literature search of 2800 medical students at Innsbruck Medical University in Austria conducted between 2007 and 2012. The suicide rates were 39.6 and 36 per 100,000 students, respectively.


The only studies that had a higher rate of suicide among medical students compared with population-based control groups were the ones from Brazil and Austria and the one from the United States that was conducted between 1947 and 1967. The US study that was conducted in the 1970s had a rate comparable to its control group.


Limitations and possible bias were found in all of the included studies. Most of the studies depended on volunteered information from the schools, which may have been influenced by stigma. There was also no clear information on psychiatric comorbidities.


"Further prospective research is needed into current rates of medical student suicide and the predisposing factors that may be contributing to cases where deaths do occur if we are to implement meaningful suicide prevention strategies," write the investigators.


Personal Story of Loss

Dr Zivanovic noted that medical students are driven to be perfect and are not used to failure and that these factors are a big part of what led them to medical school. However, for some individuals, when things feel out of control, emotions start to snowball.


Matthew L. Goldman, MD, resident in the Department of Psychiatry at Columbia University, New York City, told Medscape Medical News that he's heard this narrative before.


"It's a feeling of, 'We've done so much, but now it's overwhelming. Do we have the resiliency or coping skills to be able to tolerate all of the difficulties in these situations?' " said Dr Goldman.


"It's part of the culture in our field that there's not often a time where you can share all of your vulnerabilities in a safe way. And that is very much a focus of what we're recommending for an intervention: creating those spaces for sharing experiences or communicating about the difficulties of residency."


Dr Goldman was a first-year medical student when he lost a friend and fellow student to an apparent suicide. "It was an incredibly painful experience. In my own way of processing those feelings, I decided to do something, which took the form of writing, teaching, and advocating."


He is currently on the APA's work group for well-being and burnout, and he coauthored an action paper approved by the APA General Assembly entitled "Addressing Physician Burnout, Depression, and Suicide – Within Psychiatry and Beyond." He also started a forum at Columbia where residents can get together and talk freely.


"It's becoming more normalized to have the hard conversations. That doesn't mean it's easy, so it's important to continue to be encouraging. All of these efforts address stigma within our field."


"Go There"

Commenting on the findings for Medscape Medical News, Michael F. Myers, MD, professor of clinical psychiatry at SUNY Downstate Medical Center in New York City, noted that physicians should step in when they see something wrong with a colleague.

"Physicians need to be their brothers' and sisters' keepers by helping each other," said Dr Myers, who is immediate past president of the New York City chapter of the American Foundation for Suicide Prevention.


"Most doctors will be quite frank with you about the thoughts they're having. And by going there, that's how you can help them."


Like Dr Goldman, when Dr Myers was 19 years old, a fellow medical student took his own life. Dr Myers has devoted his career to studying suicide among physicians, which he says affects 300 to 400 physicians every year.


While working on his recent book on physician suicide, he discovered that 10% to 15% of the 50 physicians he was researching did not reach out for help beforehand.


"For too long, medical students and physicians who killed themselves were considered outliers, misfits, or, even worse, individuals whose deaths sullied the profession and who should never have been admitted into the medical field in the first place," said Dr Myers in a release.


"The culture of medicine has to change. Physicians deserve support, respect, and state-of-the-art treatment like their patients."


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