Jagdip Sidhu, a consultant cardiologist, died in 2018, having taken his own life. Work became impossible, and the shame of failing in his vocation was too much for him. Writing about this death, his brother Amandip said he believed that he misinterpreted being signed off sick as a punishment (McGuinness, 2023). Jagdip is sadly not the only doctor to have taken his own life due to work-related pressures. It has been estimated that in the United States, a doctor dies by suicide every day (Center et al., 2003), and in the United Kingdom, one dies every two weeks or so.

Studies have tried to establish whether the rate of suicide is higher among doctors and whether medicine, as studies have suggested, is an occupational hazard. This blog (published today on World Mental Health Day, which this year has the theme ‘It is Time to Prioritise Mental Health in the Workplace’) explores the latest meta-analysis, based on studies published since 1960, on doctors and suicide.

Methods

The latest meta-analysis on suicide among doctors was published in 2024 by Austrian researchers (Zimmermann et al., 2024). Researchers searched for papers published between 1960 and March 2024 in Medline, PsycINFO and Embase. The study included only research with rate-based outcomes comparing physician suicide mortality to a reference population, such as standardised mortality ratios (SMR) or rate ratios. Studies focused on non-fatal suicidal behaviour, specific methods, mental health, conference materials, or those with overlapping data or insufficient detail (e.g., lacking gender-stratified ratios) were excluded. Odds ratios, relative risk calculations, and proportionate mortality ratios were also excluded. Risk of bias was assessed using the JBI checklist for prevalence studies (Munn et al., 2017). The authors compared the suicide rates of male and female doctors to those of the general population and, additionally, to those from similar socio-economic non-medical occupations.

Results

In total, 38 studies on male doctors and 26 on females met the criteria for the meta-analysis. The analysis included studies from 20 countries, mainly the United States, Australasia, and Europe. A total of 3,303 male and 587 female suicides were included in these studies, dating back to 1935. Because a few studies provided more than one effect estimate, forty-two datasets (male doctors) and 27 (female) were used for meta-analysis. Across all studies, the suicide rate ratio for male doctors was 1.05 (95% confidence interval 0.90 to 1.22). For females, the rate ratio was significantly higher at 1.76 (1.40 to 2.21).

The authors identified eight studies that compared male doctors with a reference group of other academics, professionals, or members of similar social classes. The pooled effect estimate was significantly increased to 1.81 (95% CI 1.55 to 2.12). Five studies on female doctors were identified, and the results of these appeared to be the same as for male doctors. However, the authors considered further analysis impossible due to the few eligible studies.

When looking at the ten most recent studies, the authors found that the suicide rate for both men and women has declined over the years. However, the rate for women was still significantly higher (24%) than the general population.

Zimmerman and colleagues also looked for geographical variation. They found lower overall suicide rates for male doctors in the Western Pacific Region of 0.61 (95% CI 0.35 to 1.04), or similarly, for studies outside of Europe and the US with 0.69 (0.45 to 1.06). This pattern was not observed for female doctors, although the suicide rate ratio for the Western Pacific Region was also the lowest compared with all other subgroups.

Conclusions

There are variations in not just the gender but also the location and speciality of those who die by suicide. Higher rates of suicide among female doctors suggest they face additional problems, including barriers hindering their career advancement and extra roles at home.

Strengths and limitations

This was a good study with a sound methodology that adhered to good academic practices when conducting a meta-analysis. However, studies examining suicide, whether in doctors or the general population, face the issue of underreporting suicide as a cause of death. This bias is more likely against doctors than the general population, leading to a higher suicide rate among doctors due to the stigma associated with recording suicide as a cause of death. The recording of suicides may also be influenced by generational factors, with them being less likely to be recorded earlier in the century than in more modern times, for example.

Implications for practice

If we are to reduce the rate of suicide amongst health professionals, this has to start with reducing the factors that correlate with higher rates. These factors, as in the general population, are linked to mental illness and drug and alcohol misuse (Beghi et al., 2013; Brådvik, 2018; Chesney et al., 2014). However, for doctors, there are additional risks associated with medicine (Rátiva Hernández et al., 2023). The factors contributing to suicide are complex and often interconnected. Physicians face numerous stressors in their daily lives, such as long work hours, heavy workloads, burnout, and frequent exposure to traumatic events. These challenges can lead to mental health issues, including depression, anxiety, and substance use disorders, which may elevate the risk of suicide (Imo, 2017). From work-related pressures, personal difficulties like relationship problems, financial stress, and a history of mental health issues can also elevate suicide risk.

Furthermore, the stigma and shame connected to seeking help for mental health concerns might discourage physicians from seeking treatment, exacerbating the situation. Concerning female doctors, given the constantly higher rate than their age-matched peers, it is even more urgent to understand and address the additional pressures and barriers to care that this group have. These may be understanding the role of bullying in the workplace, discrimination leading to poor work progression and out-of-work pressures (Gerada et al., 2014; Pitts et al., 1979; Rimmer, 2021).

Suicide is a particular risk for doctors undergoing any disciplinary investigation. Tom Bourne and colleagues (Bourne et al., 2016) looked at the impact of complaints and the risk of suicide on doctors. Doctors who had recently received a complaint of any kind were found to be 77% more likely to suffer from moderate to severe depression than those who had never had a complaint. They were also found to have an increased number of suicidal thoughts, sleep difficulties, relationship problems, and a host of physical health problems compared to doctors who had not been through a complaints process. Those without a complaint had suicidal thoughts at around 2.5%, which increased to around nine per cent for those with a current or recent complaint and 13% for those with a past complaint. Poorly handled complaints often result in dysfunctional behaviours, such as failure to disclose all events, blaming of self and others, and arguments, which can contribute to doctors attempting suicide (Verhoef et al., 2015). A serious complaint can take years to pass through the various processes, and multiple jeopardy is common.

Finally, it is essential to remember that most doctors do not die by suicide. Most thrive in their working environment. However, each death has repercussions for the profession, posing the risk of creating contagion. In the future, we must halt the decline in morale among doctors. This will mean addressing many systemic issues creating unhappiness: Tackling the culture of naming, blaming and shaming; allowing doctors to maintain a sensible work-life balance and paying attention to the basic needs of staff who give their all to patients.

Statement of interests

CG is a Patron of the Charity Doctors in Distress.

CG was the medical lead for NHS Practitioner Health.

Primary paper

Zimmermann, C., Strohmaier, S., Herkner, H., Niederkrotenthaler, T., & Schernhammer, E. (2024). Suicide rates among physicians compared with the general population in studies from 20 countries: Gender-stratified systematic review and meta-analysis. BMJ, 386, e078964. https://doi.org/10.1136/bmj-2023-078964

Other references

Beghi, M., Rosenbaum, J. F., Cerri, C., & Cornaggia, C. M. (2013). Risk factors for fatal and nonfatal repetition of suicide attempts: A literature review. Neuropsychiatric Disease and Treatment, 9, 1725–1736. https://doi.org/10.2147/NDT.S40213

Bourne, T., Vanderhaegen, J., Vranken, R., Wynants, L., De Cock, B., Peters, M., Timmerman, D., Van Calster, B., Jalmbrant, M., & Van Audenhove, C. (2016). Doctors’ experiences and their perception of the most stressful aspects of complaints processes in the UK: An analysis of qualitative survey data. BMJ Open, 6(7), e011711. https://doi.org/10.1136/bmjopen-2016-011711

Brådvik, L. (2018). Suicide Risk and Mental Disorders. International Journal of Environmental Research and Public Health, 15(9), 2028. https://doi.org/10.3390/ijerph15092028

Center, C., Davis, M., Detre, T., Ford, D. E., Hansbrough, W., Hendin, H., Laszlo, J., Litts, D. A., Mann, J., Mansky, P. A., Michels, R., Miles, S. H., Proujansky, R., Reynolds, C. F., & Silverman, M. M. (2003). Confronting depression and suicide in physicians: A consensus statement. JAMA, 289(23), 3161–3166. https://doi.org/10.1001/jama.289.23.3161

Chesney, E., Goodwin, G. M., & Fazel, S. (2014). Risks of all-cause and suicide mortality in mental disorders: A meta-review. World Psychiatry: Official Journal of the World Psychiatric Association (WPA), 13(2), 153–160. https://doi.org/10.1002/wps.20128

Gerada, C., Jones, R., & Wessely, A. (2014). Young female doctors, mental health, and the NHS working environment. BMJ, 348, g1. https://doi.org/10.1136/bmj.g1

Imo, U. O. (2017). Burnout and psychiatric morbidity among doctors in the UK: A systematic literature review of prevalence and associated factors. BJPsych Bulletin, 41(4), 197–204. https://doi.org/10.1192/pb.bp.116.054247

McGuinness, F. (2023, October 7). Doctor’s brother’s death pushes Watford NHS suicide campaigner. Watford Observer.

Munn, Z., Moola, S., Lisy, K., Riitano, D., & Tufanaru, C. (2017). Systematic reviews of prevalence and incidence. Joanna Briggs Institute reviewer’s manual Adelaide, South Australia: The Joanna Briggs Institute, 5, 1-5.

Pitts, F. N., Schuller, A. B., Rich, C. L., & Pitts, A. F. (1979). Suicide among U.S. women physicians, 1967-1972. The American Journal of Psychiatry, 136(5), 694–696. https://doi.org/10.1176/ajp.136.5.694

Rátiva Hernández, N. K., Carrero-Barragán, T. Y., Ardila, A. F., Rodríguez-Salazar, J. D., Lozada-Martinez, I. D., Velez-Jaramillo, E., Ortega Delgado, D. A., Fiorillo Moreno, O., & Navarro Quiroz, E. (2023). Factors associated with suicide in physicians: A silent stigma and public health problem that has not been studied in depth. Frontiers in Psychiatry, 14, 1222972. https://doi.org/10.3389/fpsyt.2023.1222972

Rimmer, A. (2021). Nine in 10 female doctors in UK have experienced sexism at work, says BMA. BMJ, 374, n2123. https://doi.org/10.1136/bmj.n2123

Verhoef, L. M., Weenink, J.-W., Winters, S., Robben, P. B. M., Westert, G. P., & Kool, R. B. (2015). The disciplined healthcare professional: A qualitative interview study on the impact of the disciplinary process and imposed measures in the Netherlands. BMJ Open, 5(11), e009275. https://doi.org/10.1136/bmjopen-2015-009275

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