OBJECTIVES: Examine the history of suicide in the medical professional and how that differs from other groups Look at variables which contribute to physician burn out Describe and Discuss Depression, Stress and Anxiety in the Medical Community Describe how Addiction, Depression and Anxiety and Suicide Effect Families

1. Suicide Amongst Professionals
Louise Stanger Ed.d, LCSW, CDWF
2019

2. Name Commercial
Interests
Relevant
Financial
Relationships:
What Was
Received
Relevant
Financial
Relationships:
For What Role
No Relevant
Financial
Relationships
with Any
Commercial
Interests
Louise Stanger None None None None
CONFLICT OF INTEREST / DISCLOSURES
1

3. ABOUT DR. WALTON
KUDOS AND THANK YOU
▸ Lauren Walton MD, ASAM, APA
▸ President Los Angeles American
Society of Suicide and
Prevention
▸ Head of Addiction Medicine
Kaiser-Downey, Ca
▸ “You inspire me daily with your
goodness”LAS

4. ABOUT DR. LOUISE
▸ Clinician-Educator- Speaker
▸ Author, Falling Up!A Memoir of Renewal
▸ Author- The Definitive Guide to Addiction Intervention-Routledge 2018
▸ 2019 “ Interventionist of the Year”DB Resources London and McLean Hospital, an
affiliate of Harvard University
▸ Widow-Wife-Mother-Grandmother- Suicide Survivor
▸ Adventurer
▸ email -DrStanger@allaboutinterventions.com
▸ www.allaboutinterventions.com-
▸ 619-507-1699

6. OBJECTIVES
▸ Examine the history of suicide in the medical professional
and how that differs from other groups
▸ Look at variables which contribute to physician burn out
▸ Describe and Discuss Depression, Stress and Anxiety in
the Medical Community
▸ Describe how Addiction, Depression and Anxiety and
Suicide Effect Families

7. OBJECTIVES
▸ State statistics as it relates to physicians and suicide including the
“July’ Effect
▸ Explain the correlation between depression and addiction as it
manifests itself in this population
▸ Demonstrate the efficacy of a robust bio-psycho-social and
questions
▸ Recommend strategies within medical practices and hospitals to
reduce risk
▸ Discuss Effects of Suicide on Family, Friends, Co-workers etc

9. WHY DO YOU VISIT YOUR DOCTOR??
WHAT DO YOU THINK ABOUT?
▸ You are going because :
▸ You need a check up
▸ Something Is bothering
▸ You expect an exam, your vitals
checked , sample of blood, tests
run
▸ But do you ever think about what’s
going on with your doctor?

10. DOCTOR SUICIDE-
THE ELEPHANT IN
THE MIDDLE OF THE
EXAMINING ROOM

11. LEGHA, R. A HISTORY OF PHYSICAL SUICIDE IN AMERICA, 2012
HISTORY OF PHYSICIAN SUICIDE
▸ 1897 Philadelphia Medical Surgical
Reporter published first article
▸ 1900-1970- physicals were viewed as
“expendable deviants”
▸ Physical suicide “would go from a
forgivable mister committed by
downtrodden people to a reprehensible
crime committed by those society
consider the best and the brightest “.
▸ 1970s and beyond (Doctors vulnerable
human beings deserving of respect)

12. HISTORY OF SUICIDE
GOLDEN AGE AND BEYOND
▸ 1900-1950- thought suicide was a
complicated thought driven from within
▸ 1960- was viewed as individual pathology
▸ 1970s -1980s saw replacement of
physical leadership to corporate
leadership
▸ Psychiatry became more mainstream and
medical profession was able to
acknowledge mental illness on its own
▸ 1987 The American Suicide Foundation
was founded

13. TEXT
HISTORY OF SUICIDE
▸ 1999 US Surgeon General “Call to
Action to Prevent Suicide”
▸ Paucity of knowledge -growing
body of knowledge on physicians
and addiction
▸ Caregiver failing to care for himself
▸ Environmental factors- Pathological
Nature of the Profession
▸ Punishment not treatment

14. HISTORY OF SUICIDE
SUICIDE AND PHYSICIANS
▸ 1980 Sakinosky- Doctors wives have higher rate
of suicide in comparison with other professionals
▸ AMA 1982 demanded better care of its own-how
to reconcile personal stress with professional
demands
▸ 2002 AMA issued a consensus statement
“Confronting Suicide in Physicians
▸ “Problem of Physical suicide is not solely a matter
of whether it takes place or not at a higher rate
than the general public. That a professional
caregiver can fall ill and not receive adequate
care and support demand careful assessment
what it happens at all.”

17. DID YOU KNOW ?
▸ More then 920,000 Americans lose
their doctors to suicide each year
▸ Approximately 400 doctors
commit suicide each year
▸ Physicians are more then twice
likely to commit suicide then non-
physicians
▸ Female physicians three times
more likely then their male
counterpart to complete

18. STATISTICS
DID YOU KNOW ?
▸ Female completion rate is higher then
male physicians and exceeds general
population by 4 times the rate
▸ After accidents suicide is the most
common form of death amongst
medical students
▸ Common psychiatric diagnoses are
depression, anxiety , bipolar disease
and other untreated mental illness
▸ Substance misuse and abuse
▸ Also easy access to lethal means

19. ▸ In every population suicide is the
result of untreated or inadequately
treated depression
▸ Depression is as common amongst
physicians as the general
population-12%
▸ More common in residents 15%
▸ This is a global phenomena _Finland,
Norway, Australia, Singapore, China ,
Taiwan, SirLanka , Australia etc .
U.S .LOSES THE EQUIVALENT OF ONE SMALL MEDICAL SCHOOL TO SUICIDE
EACH YEAR OR ONE LARGE MEDICAL SCHOOL CLASS
DID YOU KNOW?

20. PHYSICIAN BURNOUT RATES- MAYO CLINIC PROCEEDINGS
MALASH BURNOUT INVENTORY
▸ Emergency Medicine
▸ Family Medicine
▸ General Pediatrics
▸ Urology
▸ Orthopedic Surgery
▸ Physical Medicine & Rehabilitation
▸ Pathology
▸ Radiation
▸ General Surgery Subspecialties

21. A CONFLUENCE OF ISSUES
▸ Educational Demand
▸ Extended Workdays
▸ Increasing Computerization Of Practice
▸ Chronic Stress
▸ Lack of Institutional Support
▸ Income not High Enough
▸ Feeling Like a Cog in a wheel
▸ Too Many Difficult Patients

22. CONFLUENCE OF ISSUES
▸Lack of Institutional Support
▸Availability of Addictive Substances
▸“Conspiracy of Silence”
▸Underreporting when a Physician is in Trouble
▸A Spiderweb of Silence
▸Perfectionism
▸Family Issues
▸Conflicting Societal Messages
▸Stigma

23. NURSES 3.4 MILLION PRACTICING NURSES
UNDER THE RADAR
▸ Stigma not mental health
▸ No Procedures
▸ Second Victim Trauma
▸ Few Statistics , Little Literature
▸ UCSD Healer Education and
Assessment Program -identifies
high risk nurses
https://nam.edu/nurse-suicide-breaking-the-silence/

24. RISK FACTORS INCLUDE-PAST HISTORY OF
SUICIDE ATTEMPT, SUICIDAL IDEATION , PAST
OR PRESENT SERIOUS MENTAL ILLNESS SUCH
AS DEPRESSION OR BI-POLAR..NURSES ARE
NO LESS IMMUNE THEN ANY ONE ELSE
Sidney Ziook MD UCSD
NURSES AND OTHER MEDICAL PERSONAL

28. MEDICAL SCHOOL CULTURE-“HAZING ,
BULLYING, & NAME CALLING THAT
RESULTS IN “OCCUPATIONAL
DEPRESSION & POORER HEALTH CARE”
Pamela Wible MD ,”Why Doctors Kill Themselves”

29. AMERICAN FOUNDATION SUICIDE PREVENTION
▸ DRIVERS OF BURNOUT :
▸ WORKLOAD INEFFICIENCY
▸ LACK OF AUTONOMY
▸ LACK OF MEANING IN
WORK
▸ WORK-HOME CONFLICT

30. “THERE IS A STRANGE MACHISMO …
DRS LIKE ME,FEEL PRESSURE TO
PROJECT INTELLECTUAL PROWESS…
OUR EXPECTATIONS SKYROCKET AS
IF THE CONFERRAL OF A DEGREE
WERE AN ENCHANTMENT OF
INFALLIBILITY .. LITTLE CHANGES ,
APART FROM OUR LEGAL ABILITY
TO WRITE A PRESCRIPTION
Pranay Sinah MD, NY Times

31. UNPACKING DEPRESSION IN RESIDENTS DOCTORS
▸ Under reported -Under recognized &
Untreated :
▸ Drs may be reluctant to seek treatment
▸ Have no time to seek treatment because of
grueling work weeks
▸ Easy access to prescription drugs
▸ Fearful of stigma
▸ Relational Issues
▸ Doctors if they do seek treatment get VIP
treatment feeding into Narcissistic
tendencies
▸ Prevalence of depression higher in residents then general population

32. ASSESSMENT QUESTIONS
BIO-PSYCH0
▸ Is their Family History MH ?
▸ Is there FH of Suicide?
▸ Has there been previous episode of
depression?
▸ Is there FH process disorder or
addiction?
▸ FH- sudden death, abuse, multiple
moves, et?
▸ Does Dr have hx. of substance misuse?

33. TEXT
MORE QUESTIONS
▸ Past experience with prescription & non
prescription drugs ?
▸ Been treated for any disease per ASAM
2011 Criteria for addiction
▸ Any treatment for anxiety or insomnia ?
▸ Any Learning difficulties?
▸ Current Relationships
▸ What are views on getting and seeking
help? Self & Families
▸ Cultural and Religious view on MH,
Association, Suicide etc

34. RATES OF DEPRESSION -BRIGHT AND KAHN MAYO CLINIC
PREDICTORS OF DEPRESSION
▸ Relational Difficulties withdrs, staff
or parents
▸ Lack of Sleep
▸ Making Mistakes
▸ Loneliness
▸ 24 hour responsibility
▸ Self-Criticism

36. THE NEW C0HORT OF RESIDENTS 36,000
THE JULY EFFECT

42. IN HOSPITALS AND PRIVATE PRACTICE
POLICIES & PRACTICES HR & WELL BEING
▸ HR Policies on Substance Misuse ,
Depression, Anxiety and Action
▸ Review of Work Hours
▸ Education & Resources about
Impairments common to medical
community
▸ Self-Referral Processes for Help
▸ Confidential Referral Process

43. GOAL OF WORKPLACE WELLNESS
▸ Healthy Behaviors are promoted,
encouraged and Supported
▸ Employees have easy access to help
them make better life style choices
▸ Employees have opportunity to
practice healthy lifestyle behaviors
▸ organizational Programs must ensure
that leadership, policies , practices &
the physical environment are
supportive & conducive to healthy
behavior changes

47. CENTER FOR PROFESSIONAL RECOVERY
WELL BEING COMMITTEES
▸ Evaluation of complaints or
allegations to determine validity
▸ Monitoring of professional to protect
safety of patients until rehabilitation is
completed
▸ Proper reporting to appropriate
leadership when patient safety might
be compromised
▸ Initiating proper protocols if impaired
physician fails to complete prescribe
rehabilitation program

48. CENTE FOR PROFESSIONAL PROGRAMS
DIVERSION PROGRAMS-PHP
▸ Referral of Individual by patient, partner or
family
Evaluation of initial referral
▸ Notification is given to MD with option to
enter treatment & monitoring
▸ Comprehensive assessment
▸ Referral to Appropriate Treatment center
▸ Referral to Counselor
▸ AfterCare that includes ongoing counseling,
drug testing etc
▸ Involvement of Family in Treatment process

50. TEXT
CONTINUING CARE PHP
▸ After Care Programming -PHP-IOP
▸ Long Term Monitoring- Including Counseling and Drug Testing
▸ Family , Friends & Medical Team Counseling
▸ Routine Reports To Medical Board
▸ Reassessments and Evaluations
▸ Lifestyle Coaching & Trigger (Relapse) Prevention
▸ Finding Joy

51. EFFECTS OF SUICIDE

52. EFFECTS OF SUICIDE
HAVE YOU EVER FELT
▸ If only I could of
▸ Confusion
▸ Guilt

54. Humiliation- Embarrassment
The Act of Making
Someone Inferior or
Foolish
“ Your Father Committed
Suicide!”

56. Anxiety and Depression
Grief and Loss

59. Creating Services For All
Prevention
Intervention
Treatment

63. RESOURCES
DR. LOUISE STANGER
▸ Doctor Suicide The Elephant in the Middle
of The Examining Roomhttps://
www.huffingtonpost.com/entry/doctor-
suicide-the-elephant-in-the-examining-
room_us_596d04c4e4b05561da5a5992
▸ All About Interventions
www.allaboutinterventions.com
▸ Thrive Global Louise https://
www.thriveglobal.com/authors/3258-louise-
stanger-ed-d-lcsw-cdwf-cip-roger-porter
▸ Huffington Post https://
www.huffingtonpost.com/author/louise-
stanger-edd-lcsw-bri-ii-cip

65. Sept. 16, 2019

66. RESOURCES
▸ Details on Suicide among Us Physicians: Data from the National Violent Death
Reporting System, Gold MD, Sen, PHD, Schwenk, MD . General Hospital Psychiatry
▸ Physical Mental Health-An Evidenced Based Approach to Change. Moutier, MD.
Journal of Medical Regulation. Vol 104, No.2/7
▸ Wellness Committee Guide http://www.shawhankins.com/wp-content/uploads/
2014/11/Wellness-Committee-Guide-2-1.pdf
▸ Creating A WorkPlace Wellness Committee A Toolkit for Employers https://
msdh.ms.gov/msdhsite/_static/resources/6663.pdf
▸ Wellness Tool Kit https://www.cigna.com/assets/docs/wht/wellness-committee-
toolkit.pdf
▸ Center for Professional Recovery https://www.centerforprofessionalrecovery.com/?
gclid=EAIaIQobChMI5rb9gL3J2gIVi8pkCh2nagIkEAAYASAAEgJHMvD_BwE

67. RESOURCES
▸ Physician Suicide Letters, Pamela Wible https://www.amazon.com/
Physician-Suicide-Letters-Answered-Pamela/dp/0985710322
▸ Match Day 2017 https://www.statnews.com/2017/03/17/match-
day-residency-international/
▸ Match dayhttp://www.nrmp.org/main-residency-match-data/
▸ Headed to the Hospital? Beware the July Effect https://
health.usnews.com/health-news/patient-advice/articles/
2014/07/21/headed-to-the-hospital-beware-the-july-effect
▸

68. RESOURCES
▸ The Tennis Partner, Abraham Verghese https://www.amazon.com/Tennis-Partner-
Abraham-Verghese/dp/0062116398
▸ A History of Physical Suicide in America, Legha, J Med Humanit (2013 33:219-244
▸ Hidden Epidemic Of Doctor Suicide https://www.fastcompany.com/3056015/the-
hidden-epidemic-of-doctor-suicides
▸ Why Do Doctors Commit Suicide ? Pranay sinhahttps://www.nytimes.com/
2014/09/05/opinion/why-do-doctors-commit-suicide.html?_r=0
▸ Kahn on Depression https://www.khanacademy.org/test-prep/mcat/behavior/
psychological-disorders/v/depression-and-major-depressive-disorder
▸ https://www.mdedge.com/psychiatry/article/64274/depression/depression-and-
suicide-among-physicians

69. RESOURCES
▸ American Foundation for Suicide Preventionhttps://
afsp.org/our-work/education/healthcare-professional-
burnout-depression-suicide-prevention/

70. Resources for healthcare professionals and medical educators
Accreditation Council for Graduate Medical Education (ACGME) Resources – Resources to share with programs, institutions, residents, and
fellows that promote a culture of physician well-being and provide support in the case of burnout, depression, or suicide.
Breaking the Culture of Silence on Physician Suicide – A sharable graphic and information about physician suicide from the National Academy
of Medicine.
Creating a Safety Net: Preventing Physician Suicide – An article by AFSP Chief Medical Officer Christine Moutier, M.D., for the Association of
American Medical Colleges’ AAMC News.
Reducing the Stigma: Faculty Speak Out About Suicide Rates Among Medical Students, Physicians – An article by Dana Cook Grossman, for
the Association of American Medical Colleges’ AAMC News.
Preventing Suicide in Physicians, Residents and Medical Students (Video) – Dr. Christine Moutier addresses the American Psychiatric
Association, May 20, 2016.
Symposium on Physician Well-Being – A symposium held on November 17-18, 2015 by The Accreditation Council for Graduate Medical
Education (ACGME).
Leaders in Academic Medicine Address Physician Well-being and Resilience – A news release from the Association of American Medical
Colleges.
Preventing Physician Distress and Suicide – Tools for identifying at-risk physicians and facilitating access to care from the American Medical
Association.
Make the Difference: Preventing Medical Trainee Suicide (Video) – A 4-minute PSA from Mayo Clinic and the American Foundation for Suicide
Prevention that explains how everyone can help prevent suicide by being alert for the signs of depression and escaping stress and how to be
most helpful. This film can be used in medical school physician wellness, humanism and professionalism curricula. Featured at top of this
page.
Why Physicians Die by Suicide – Dr. Michael Myers guides readers through the variety of factors that contribute to physician suicide. He then
makes practical, across-the-board recommendations in an effort to prevent this tragedy, arriving at the encouraging conclusion that everyone
has a role to play in saving a doctor’s life.
Struggling in Silence: Physician Depression and Suicide (DVD) – An award-winning, one-hour documentary from AFSP, that sheds light on the
topic of physician mental health and suicide prevention, featured on public television stations nationwide. This film can be used in medical
school physician wellness, humanism and professionalism curricula.

71. Make the Difference: Preventing Medical Trainee Suicide (Video) – A 4-minute PSA from Mayo Clinic and the American Foundation for Suicid
Prevention that explains how everyone can help prevent suicide by being alert for the signs of depression and escaping stress and how to be
most helpful. This film can be used in medical school physician wellness, humanism and professionalism curricula. Featured at top of this
page.
Why Physicians Die by Suicide – Dr. Michael Myers guides readers through the variety of factors that contribute to physician suicide. He then
makes practical, across-the-board recommendations in an effort to prevent this tragedy, arriving at the encouraging conclusion that everyone
has a role to play in saving a doctor’s life.
Struggling in Silence: Physician Depression and Suicide (DVD) – An award-winning, one-hour documentary from AFSP, that sheds light on th
topic of physician mental health and suicide prevention, featured on public television stations nationwide. This film can be used in medical
school physician wellness, humanism and professionalism curricula.
Collateral Damage: The Impact of Patient Suicide on the Physician, a DVD film of several physicians speaking about their experience of patient
loss to suicide, and group discussion. Psychiatrists featured in this educational film include Drs. Glen Gabbard, Sidney Zisook, and Jim Lomax.
This resource can be used to facilitate an educational session for physicians, psychologists, residents or other trainees. Please contact
education@afsp.org to request the DVD.
American Medical Student Association – The oldest and largest independent association of physicians-in-training in the United States.
Suicide Risk in Physicians – Emergency Physician Dr. Mel Herbert produces a popular podcast called EMRAP for healthcare professionals in
Emergency Medicine. In this 26-minute podcast he speaks with Dr. Christine Moutier about suicide risk and prevention for physicians and
trainees.
Nurse Suicide: Breaking the Silence – The National Academy of Medicine released a landmark paper in 2018 as a call for action regarding
nurse suicide.

72. Prevention programs
Interactive Screening Program (ISP) – AFSP’s signature intervention program, the ISP is an online tool used by medical schools across the
country as a method of connecting to students, residents and faculty, and encouraging them to utilize available mental health services before
crises emerge. ISP is listed as a Best Practice for Suicide Prevention and is an integral part of a comprehensive suicide prevention and mental
health promotion strategy.1, 2, 3, 4
Web-Based Cognitive Behavioral Therapy for Medical Trainees (Guille, C., et al., JAMA Psychiatry, 2015)
Intervention to Promote Physician Well-being (West, C.P., et al. JAMA Intern Med., 2014)
Stanford’s Burnout Prevention Approach (Schulte, B., Washington Post, 2015)

73. DOCTOR SUICIDE-
THE ELEPHANT IN
THE EXAMINING
ROOM
Louise Stanger
Ed.D,LCSW,CDWF,CIP