Physicians & suicide: Speaking out, preventive action, and Dr Cunningham's example

An influential physician spoke openly about her mental health struggles. She hopes to change attitudes and prevent suicide among colleagues.

Translated from the original French version.

Dr. Carrie Cunningham's speech

Dr. Carrie Cunningham's speech in 2023¹ is a profoundly powerful exposé. President of the Association for Academic Surgery, former tennis professional, mother of two, she is a model of success. And yet she is not. Like so many people, she struggles with chronic depression and addiction. Normally, she would be well advised not to talk about it. But she decided to share her experiences because she wants to change people's attitudes. It is crucial that the culture and institutions change so that doctors' mental health problems are no longer stigmatised. They need to be able to get help, without having to fear negative consequences for their careers.

The mental distress of doctors

Confronted daily with death and illness, exhausted by their working conditions, victims of imposter syndrome, or feeling that they never do enough for their patients, doctors have more than one reason for developing depressive or anxiety disorders. As Dr Cunningham reminds us, they are also quite simply men and women, with a personal life that is sometimes difficult to manage alongside their work.

Yet, according to her account, it is very difficult for them to seek help when they need it. This can lead to extremes: the suicide rate among doctors is estimated to be at least 2.5 times higher than that of the rest of the population (in both the United States and France)². It should be noted, however, that it is impossible to obtain exact figures for depressive or anxiety disorders, burn-outs, or suicide among doctors, which helps to minimise their importance³.

There are several explanations for the lack of research on self care:

The pressure to maintain an image of unshakeable competence often prevents doctors from recognising their own vulnerabilities. They try to hide their weaknesses, because they operate in a system where it is up to them to provide help, not the other way round. Many are very afraid of the negative consequences such an admission could have for their career. They are afraid that they will be judged unfit to do their job, and that suspicion of their abilities will wipe out all the sacrifices they have made to get where they are.

The category most affected is that of interns. As Dr Cunningham explains, unlike their older colleagues, they don't have the financial resources, the time, or the perspective to seek treatment. Among medical students, the risk of suicidal ideation is estimated at 23%⁴.

A set of recommendations to prevent suicide among doctors

In an article in the Psychiatrics Times⁵, Dr Cunningham and his colleagues put forward a series of recommendations which, if implemented, would help to prevent suicide among doctors. The authors base their recommendations on current literature and envisage prevention as early as the training stage.

Evidence-based recommendations

Train primary care physicians to recognise and treat depression.
Actively manage psychiatric patients after discharge or following a suicidal crisis.
Ensure effective treatment of depression and other conditions associated with suicide risk. This is particularly effective when combined with prevention strategies.
Many studies encourage the use of clozapine for patients with schizophrenia or schizoaffective disorder, and lithium for patients with mood disorders.
Ketamine reduces suicidal ideation within a few hours but has not been tested for long-term prevention or prevention of suicidal behaviour.
Suicide-focused psychotherapies prevent suicidal behaviour in at-risk populations.
Restriction of means, including firearms, prevents suicide. In the United States, this is rarely applied, even though firearms are used in half of all suicides.

Actions that can be taken on an individual basis

Take care of yourself every day. Observe which activities are particularly good for you.
Understand that you can influence your health in general and your mental health too, for example by taking the right treatment.
Pay attention to your colleagues. Bear in mind that subtle changes in their behaviour may conceal major problems.
Don't assume that your particularly brilliant colleagues have everything under control, that they aren't fighting their inner demons.
Learn to have caring conversations with your colleagues to encourage them to really open up.
When you talk to a colleague in distress, remember that negative cognitive distortions accompany that distress. It is therefore essential to remind them of the obvious, such as the fact that you respect and appreciate them. That you are ready to help him find the right treatment and that you will continue to be there for him.
If you've experienced difficulties yourself, you may have particular empathy. Use it to help colleagues who need to understand that they are not alone.

Measures for institution managers

Ensure that students / trainees have access to mentors, support and mental health care without any punitive or negative consequences. This includes, for example, debriefing after critical incidents, encouraging therapy to optimise resilience, allowing access to treatment inside and outside the institution free of charge or at an affordable cost.
Be transparent. Communicate clearly and widely about how mental health challenges are managed by your institution.
Provide ongoing information on how students can access mental health support, advice and treatment. List resources on the back of student cards and on programme websites.
Prioritise and promote a constructive approach. For example: "Every clinician encounters difficulties from time to time. It's a sign of strength to face them, and it's commendable not to wait until the crisis point to seek help".
Introduce self-care early in the curriculum. Introduce it as a practice linked to professionalism that can be cultivated throughout a career.
Lead by example, by disclosing personal struggles where appropriate and explaining that everyone needs to lean on others for support or treatment.
Provide storytelling opportunities to set new standards with stories of hope.
Reinforce peer support by teaching trainees how to reach out and respond to colleagues in distress. Cultivate active listening skills and use available resources for support.
Survey trainees and staff to identify specific barriers to seeking support and treatment.
Form a working group to plan suicide prevention and wellness initiatives, including members at all levels of seniority and from all backgrounds.
Incorporate self-care issues into certification and continuing education to emphasise that, alongside medical knowledge, technical skills and empathy, the ability to optimise one's own mental health is an essential part of professional responsibility.

We invite you to check another article on phyisicians' mental health, by Professor Nicolas Peschanski: Burnout in the ER: when the tank is empty, everyone suffers

Sources

2023 AAS Presidential Address- Removing the Mask, Video of Dr Carrie Cunningham's speech, 3 March 2023
[Only in French] Doctors in pain, Ordre des médecins du Nord, 25 November 2020
[Only in French] Les chiffres introuvables du suicide des médecins français, Adrien Renaud for What'up doc, 18 June 2020
[Only in French] Suicide des médecins : quels messages faire passer en attendant des chiffres officiels, Véronique Duqueroy for Medscape France, 25 November 2020.
Preventing Clinician Suicide, Dr Cunningham, MD, Dr Moutier & Dr Zisook for Psychiatric Times Vol 41, Issue 4, 10 April 2024