Challenges and potential solutions for physician suicide risk factors in the COVID-19 era: psychiatric comorbidities, judicialization of medicine, and burnout

Abstract Introduction Suicide among physicians constitutes a public health problem that deserves more consideration. A recently performed meta-analysis and systematic review evaluated suicide mortality in physicians by gender and investigated several related risk factors. It showed that the post-1980 suicide mortality was 46% higher in female physicians than among women in the general population, while the risk in male physicians was 33% lower than among men in general, despite an overall contraction in physician mortality rates in both genders. Methods This narrative review was conducted by searching and analyzing articles/databases that were relevant to addressing questions raised by a prior meta-analysis and how they might be affected by COVID-19. This process included unstructured searches on Pubmed for physician suicide, burnout, judicialization of medicine, healthcare organizations, and COVID-19, and Google searches for relevant databases and medical society, expert, and media commentaries on these topics. We focus on three factors critical to addressing physician suicides: epidemiological data limitations, psychiatric comorbidities, and professional overload. Results We found relevant articles on suicide reporting, physician mental health, the effects of healthcare judicialization, and organizational involvement on physician and patient health, and how COVID-19 may impact such factors. This review addresses information sources, underreporting/misreporting of physician suicide rates, inadequate diagnosis and management of psychiatric comorbidities and the chronic effects on physicians’ work capacity, and, finally, judicialization of medicine and organizational failures increasing physician burnout. We discuss these factors in general and in relation to the COVID-19 pandemic. Conclusions We present an overview of the above factors, discuss possible solutions, and specifically address how COVID-19 may impact such factors.


Introduction
Suicide is among the leading causes of mortality worldwide 1 and the US age-adjusted suicide rate in 2018 was the highest since 1941. 2 Suicide among physicians constitutes a public health problem and modifiable risk factors play a clear moderating role. We recently performed a meta-analysis and systematic review evaluating suicide mortality in physicians by gender and investigating several relevant risk factors. Our results showed that the post-1980 suicide mortality was 46% higher in female physicians than among women in the general population, while the risk in male physicians was 33% lower than among men in the general population. 3 Psychiatric comorbidities were one of the physician suicide risk factors identified in our systematic review 3 and need further consideration, as do certain factors that were not addressed: judicialization of medicine, organizational oversight, and burnout. Moreover, the COVID-19 pandemic ravaging the world has had harmful effects on the mental health of physicians, especially frontline physicians. 4 For instance, China was the first country hit by the pandemic and we found that rates of depression and anxiety symptoms were as high as 50% in 1,257 physicians and healthcare workers in China, while 70% were in distress. 5 A similar trend was observed in Italy, which was one of the most affected countries in Europe, where nearly 50% of 1,379 healthcare workers reported posttraumatic stress symptoms and almost 30% reported symptoms of depression and anxiety. 6 In this narrative review, we therefore searched and analyzed databases for relevant articles with the intention of addressing these risk factors, by investigating their main issues and potential solutions.
We then presented these risk factors considering the current COVID-19 pandemic and how it may impact the likelihood of physician death by suicide.
This process included unstructured searches on Pubmed for physician suicide, judicialization of medicine, healthcare organization oversight, burnout, and COVID-19 and Google searches for relevant databases as well as medical society, expert, and media commentaries on these topics. We postulated that these factors may have been worsened by the impact of the COVID-19 pandemic on physician workforces and wellbeing.

Psychiatric comorbidities
Most patients who die by suicide suffer from psychiatric comorbidities. 7,8 Physicians, in particular, often have unmanaged (undiagnosed or untreated) psychiatric disorders, primarily depression and substance abuse (alcohol and drugs). 9 At early stages of their careers, medical practitioners already have higher levels of depression than the general population. 10,11 A series of recent meta-analyses estimated the prevalence of depression at 27.2% in medical students and 28.8% in resident physicians, ranging from 9.3% to 55.9% and 20.9% to 43.2%, respectively, depending on the instrument used. 10,11 Moreover, depression prevalence rates in resident physicians increased by calendar year (0.5% increase per year). 11 If not properly treated, these psychiatric conditions become chronic, with potential for significant harm to physicians' practices and reputations and to patient safety. 12 Nevertheless, we could not find any meta-analyses investigating practicing physicians' depression symptoms or disorders.

The American Foundation for Suicide Prevention (AFSP) published Facts about Mental Health and Suicide
Among Physicians. 9 One of the facts listed is that among people whose death was by suicide, physicians were less likely to have been receiving mental health treatment than non-physicians, despite similar rates of depression. 13 The same problem was observed in medical students. 10  The prevalence of physician alcohol and drug abuse may relate to self-medicating symptoms of depression, anxiety, and insomnia, although attempted cognitive enhancement through psychostimulants is also common among medical students and physicians. 15,16 A Swiss study found that regular use of hypnotics and sedatives (mainly benzodiazepines) was significantly higher among doctors than in the general population. 17 Psychiatry is the specialty with the highest percentage of daily use of such medications. 11 In random US samples of physicians and students, 10% of 337 physicians and 16% of 381 medical students reported psychoactive drug use once a month or more. 18 Despite substantial psychiatric comorbidities, physicians tend not to seek care for their own health: nearly 40% of 5,829 surveyed physicians reported reluctance to seek formal mental healthcare due to "concerns about repercussions to their medical licensure"; the study found that medical licensure application questions regarding psychiatric conditions were a barrier to physicians seeking help. 19 Meanwhile, people close to physicians who died of suicide were often unaware of their suffering, possibly due to physicians' pretense of being well-adjusted. 20 Physician personality factors (or fear of being reported as "impaired" by colleagues) may prevent a "cry for help." Furthermore, loved ones often attribute behavioral changes to work-related stress. 21 Many suicides result from acute events aggravating undiagnosed longstanding psychiatric illnesses, highlighting the need to systematically protect physicians from acting on transient suicidal impulses such as those relating to work or life events. 22 Medicine judicialization and organizational oversight Physicians are exposed to an array of stressors relating to judicialization of medicine and organizational oversight that go beyond the complexity of diseases and clinical cases. 23 The interaction between the judicialization of medicine and organizations (e.g., federal/state levels, medical boards/oversight agencies, etc.) has a negative feedback loop on physician and patient health. [24][25][26] Judicialization tends to raise costs and patient risk without improving health outcomes and leads to physicians dropping out of the system, sometimes due to suicide. 24  in those states, 19,31 and most at-risk physicians are unaware of "safe harbor" provisions. 35 Indeed, job- factors -e.g., how supportive a spouse may be of long work hours, stressors due to lack of organizational support for family leave/time off, particularly for women whose spouses/families expect them to bear the burden of child and homecare, and stressors to male physicians who want to work fewer hours or whose work hours may be limited by psychiatric comorbidities or other factors.

Burnout
Burnout affects 50% of physicians (being most prevalent in emergency medicine, which has been compared to a warzone), 36 and is a risk factor for medical error and suicide. 37 Under-recognition of physician needs and challenges by non-clinician administrators leads to systematic stressors, including excessive/misdirected regulations culminating in a "burnout crisis." 36 The NEJM Catalyst survey highlights the disconnect between healthcare executives and clinicians. 37  Notably, while physician burnout is increasingly addressed in national and regional professional meetings, physician suicides are seldom brought up by professional associations, despite receiving some media attention. 20

Psychiatric comorbidities
The critical issue is early detection of psychiatric self-treatment and allowing appropriate treatment.

Recommendations made after the General Medical
Council investigation included reducing health examiner assessments, making physicians feel "innocent until proven guilty," exposing investigational staff to frontline clinical practice, and establishing a National Support Service for physicians. 34 The US FSMB adopted as policy the Report and Recommendations of the Workgroup on Physician Wellness and Burnout. 57 However, there is a need for greater legal, 31 legislative, and organizational advocacy led by physicians to protect physician rights and privacy, to enforce existing laws (e.g., ADA), and to create a culture of trust and transparency between healthcare workers, patients, and boards/oversight organizations.
It will be essential to reduce financial incentives for frivolous malpractice lawsuits (e.g., malpractice caps in Texas), 58   Finally, mental health consequences are likely to be present for more extended durations and peak later than the actual pandemic. 50

Limitations
Suicide reports vary by country and location for various reasons. 3,4,77 One reason is that suicide data is collated from multiple incomplete and even overlapping sources. 3,4 Different locations and organizations may face challenges in reporting or identifying suicides, may lack the resources to collect information, or data may not be collected systematically and reliably. 78 These data may be incorrectly coded, whether due to lack of information availability (e.g., death of unclear The pandemic has uncovered a significant capacity for change, and we should use this chance to heal the system and its most skilled workers: physicians.

Disclosure
No conflicts of interest declared concerning the publication of this article.