Anthony Bourdain, American chef and TV personality; Kate Spade, fashion mogul;
Robin Williams, actor and comedian; Ernest Hemingway, writer; Vincent Van Gogh, painter.

What did they have in common? Fame and death by suicide.

Deelshad Joomun, attending nephrologist; Kathryn Stascavage, medical student; Dean Lorich, orthopedic surgeon; Gabriel Goodwin, anesthesiologist.

What did they have in common? Health care providers and death by suicide.

Eight hundred thousand people in the world, from all countries, all backgrounds, all cultures.
What did they have in common? Death by suicide.

Suicide FACTS in the United States:
• 2013 CDC report: suicide accounted for $50.8 billion (24%) of the fatal injury cost
• 2016 CDC report: nearly 45,000 people age 10 or older died by suicide
• Suicide: the 10th leading cause of death overall

Beyond statistics and numbers each suicide is a human being. Someone’s mother, father, child, uncle, grandmother, friend, co-worker.

What makes someone take their own life?

There is no single cause for suicide as it has a multidimensional basis. All health care professionals are expected to screen for suicidal thoughts, “Have you ever thought of ending your life?” And, if positive, they are expected to refer to mental health professionals who in turn are expected to assess the identified risk for suicide using these comprehensive assessments:

• review risk factors (past suicidal attempts; psychiatric diagnoses; history of suicide in the family; substance abuse; history of abuse)
• review protective factors (reasons for living; existence of children; cultural and religious believes related to suicide)
• identify modifiable risk factors with interventions
• make recommendations on managing the risk for suicide.

When “famous” people commit suicide we ask ourselves: why HE who had money and fame? Why SHE who had admirers and followers? It is the seemingly “unexplained” suicide that captures the attention, raises questions and seeks to find answers.

We think we know these individuals and we imagine they have it ALL. We ignore they are human beings with their failings, sufferings, disappointments and heartaches. We fantasize glamour and money offer solutions to all problems, but we forget mental illness can affect ANYONE. Fear of stigma makes people of any status hide the depression they experience, the abuse of drugs, the highs and lows they feel.

In an attempt to explain WHY, social media, journalists and investigators start searching for reasons. Many times, these searches bring speculation and pain to the surviving family and anxiety and more questions to the public. As laymen, we might think:

• Didn’t it have to be severe depression that made this person hopeless and helpless?
• Did a borderline personality disorder make someone suicidal on the brink of the moment (as associated by low self-esteem and mood swings)?
• Did they overdose with drugs?
• Were there flashbacks/nightmares about the traumatic events they witnessed or suffered?
• Did they face a terminal illness? Or chronic, unrelenting pain?
• Was there a loss (of a close person, a job, social status, freedom)?

Physician Suicide

Most concerning, frightening and alarming is the suicide of medical professionals. Why do medical students, trainees, physicians kill themselves? Is it the intensity, the hardship of the work they do? Is it the suffering they witness every day?

Here are facts about physician suicide in the United States:
• Annually 400 physician suicides translate to more than 1 million patients losing their doctors to suicide each year.
• The suicide rate among doctors is between 28 to 40 per 100,000 – more than twice than in the overall population.
• The suicide ratio for physicians compared with age-matched controls in the general population is 1.41 times higher for men and 2.27 times higher for women.
• The mean cost of replacing a physician is $500,000 to $1,000,000.

When doctors kill themselves the question “why” becomes more intense. Why the people who are supposed to help and heal? Why the people who know about depression and anxiety and substance abuse? Why the ones who have the most well-informed access to resources?

In “What I’ve learned from my tally of 757 doctor suicides,” an article that appeared earlier this year in The Washington Post, Pamela Wible provides a list of potential reasons: burnout; patients’ death and medical errors; malpractice suits; sleep deprivation; and loss of status or affiliation in addition to such personal factors as divorce, death, illness.

Stigma is again the main obstacle in seeking treatment. Physicians worry their report of depressive symptoms or other mental health symptoms can impact licensure, employment or hospital privileges.

After reading this article and many more, we are left with more questions: Can it happen to the mother who feels depressed? Or to the spouse who drinks heavily to alleviate pain? Or the next-door neighbor who is always apparently happy?

Suicide can be preventable by raising awareness, improving and encouraging access to mental health care, mobilizing resources and fighting stigma. There are multiple venues:

• World Suicide Prevention Day, organized by the International Association for Suicide Prevention, is observed worldwide on September 10.
• National Physician Suicide Awareness Day, organized by the Council of Emergency Medicine Residency Directors (CORD), in collaboration with other agencies, is observed on the third Monday in September.
• On September 10, 2018, the World Health Organization released WHO’s preventing suicide: a community engagement toolkit, a step-by-step guide for people who would like to initiate suicide prevention activities in their community.
• The CDC encourages everyone to learn the warning signs of suicide, to identify and to appropriately respond to people at risk by visiting the National Suicide Prevention Lifeline website and learning about #BeThe1To movement

Five Action Steps for Helping Someone in Emotional Pain

1. Ask them: “Are you thinking about killing yourself?”
2. Keep them safe: Reducing a suicidal person’s access to highly lethal items or places is an important part of suicide prevention.
3. Be there: Listen carefully and learn what the individual is thinking and feeling.
4. Help them connect: Save the National Suicide Prevention Lifeline’s number in your phone so it’s there when you need it: 1-800-273-TALK (8255).
5. Stay Connected: Staying in touch after a crisis or after being discharged from care can make a difference.

Dr. Lizica Troneci, MD, Chair, Department of Psychiatry at SBH