The relative rate of suicide among medical specialties is unknown. Studies had indicated higher rates of suicide among psychiatrists and anesthesiologists, but these trials were methodologically flawed.12
Silverman12 developed a profile of the physician at high risk for suicide: a workaholic white male age ≥50 or female age ≥45 who is divorced, single, or currently experiencing marital disruption and is suffering from depression. He or she has a substance abuse problem and a history of risk-taking (high-stakes gambling, etc.). Physicians with chronic pain or illness or with a recent change in occupational or financial status also are at risk. Recent increased work demands, personal losses, diminished autonomy, and access to lethal means (medications, firearms) complete the profile.
Protective factors that lower the risk of completed suicide include effective treatment, social and family support, resilience and coping skills, religious faith, and restricted access to lethal means.13,14
Barriers to treatment
Physicians often are hesitant to seek mental health treatment.15 They may fear social stigma and could have trouble finding a local provider who they trust but is not a colleague. Physicians might be concerned about confidentiality and fear recrimination by colleagues, facilities where they work, or licensing boards.16 Givens and Tjia3 found that only 22% of medical students who screened positive for depression sought help and only 42% of students with suicidal ideation received treatment. These students reported that time constraints, confidentiality concerns, stigma, cost, and fear that their illness will be documented on their academic record were major barriers to seeking mental health care.
Licensing concerns. Physicians may be required to disclose a mental health diagnosis or treatment history when applying for or renewing their medical license. Increasingly, medical boards are asking applicants if they have been treated for bipolar disorder, schizophrenia, paranoia, or other disorders.17 Credentialing bodies, clinics, and hospitals may make similar queries.
In an analysis of 51 medical licensing applications (50 states and the District of Columbia), Schroeder et al17 determined that 69% contained at least 1 question that was “likely impermissible” or “impermissible” in terms of compliance with the Americans with Disabilities Act (ADA). In 1993, a U.S. District Court found that the New Jersey State Board of Medical Examiners was in violation of the ADA because licensure application questions did not focus on current fitness to practice medicine but rather on information about a candidate’s status as a person with a disability (illness or diagnosis).18
In Alexander v Margolis,19 however, the court found that because patient safety is in question, medical licensing boards and credentialing bodies can solicit information about serious mental illness that could lead to impaired performance. Courts have ruled that questions regarding a history of treatment or hospitalization for bipolar disorder or schizophrenia and other psychotic disorders are permissible because they are considered “serious disorders” likely to interfere with a physician’s current ability to practice.20 In a 2008 review of all U.S. -affiliated medical licensing boards (N=54), Polfliet21 found that 7 specifically asked applicants about a history of bipolar disorder or schizophrenia, paranoia, and other psychotic disorders. Polfliet21 also found that state medical boards’ compliance with ADA guidelines was not uniform and some questions were “just as broad, and potentially discriminatory, as they were before enactment of the ADA.”
Worley22 reported a successful appeal to the Arkansas State Medical Board to revise its licensure questions following a cluster of medical student and physician suicides. The Board changed the question “Have you ever, or are you presently, being treated for a mental health condition?” to “Have you ever been advised or required by any licensing or privileging body to seek treatment for a physical or mental health condition?”
Providing inaccurate information on a medical licensure application may result in denial or revocation,23 but acknowledging a history of mental health or substance abuse treatment triggers a more in-depth inquiry by the medical board. The lack of distinction between diagnosis and impairment further stigmatizes physicians who seek care and impedes treatment.
Bipolar disorder. The trend in psychiatry toward diagnosing bipolar II disorder and “soft bipolarity” in patients previously diagnosed with and treated for major depression presents a new challenge. Despite no change in their history or functioning, a physician whose diagnosis is changed from depression to bipolar II disorder might be moved from a non-reportable to a board-reportable diagnostic category. With the evolving understanding of bipolar spectrum disorders, medical boards may need to revise their screening questions to ensure that they are seeking information about impairment, not simply the presence of a medical disorder.