New research published in BMJ details a systematic review and meta-analysis of global clinical studies on suicide rates comparing physicians versus the general population over several decades.
Give me some background.
The number of suicides recorded across the globe clocked in at 700,00 in 2019—translating to more than one in 100 deaths, or 1.3%, for that year alone, according to the World Health Organization (WHO).
- To note: This number varied greatly among regions, countries, and genders.
Additional stats:
- Male suicide rates are higher in higher-income countries, while female rates are highest in lower-middle-income countries (LMIC).
- 16.5 per 100,000 vs 7.1 per 100,000, respectively
- More than twice as many males as females are more likely to commit suicide
- 12.6 per 100,000 vs 5.4 per 100,000, respectively
How have rates changed over the last two decades?
In general, the global rate decreased from 2000 to 2019 by 36%—with 17% in the Eastern Mediterranean region, 47% in the European Mediterranean regions, and 49% in the Western Pacific.
- In the Americas, however: The rates actually increased by 17%.
And for physicians?
In the United States, an estimated 300 to 400 physicians die by suicide each year, according to The American Foundation for Suicide Prevention.
- Among females: Prior findings have found suicide deaths among female physicians to be 250% to 400% higher than females in other professionals (and at a rate equal to male physicians).
Talk about depression for a moment.
Depression is noted as a major risk factor for suicide among medical students, with rates reportedly 15% to 30% higher than the general population.
Among physicians, previous research has suggested the lifetime risk of depression to be 15% for males and 20% to 30% for females—compared to 9% and 15% among the general population, respectively.
- See the top 10 specialties with the highest rates of mild to severe depression symptoms.
- Notably, ophthalmology recorded the lowest rate (19.1%)
Alrighty, now let’s dive into this research.
Investigators conducted a systematic review of observational studies (with no language restrictions) published between 1960 and March 31, 2024, that were collected from three databases:
- Embase
- Medline
- PsycINFO
And the criteria for these studies?
Included studies were those with:
- Directly or indirectly age-standardized mortality ratios for physician deaths by suicide, or
- Suicide rates per 100,000 person years of physicians and a reference group similar to the general population, or
- Extractable data on physician deaths by suicide (appropriate for ratio calculations)
To note: Two independent reviewers screened all selected literature.
- At this time, investigators determined to use only studies with rate-based outcome measures comparing suicide mortality among physicians vs the general population.
Any overlaps?
While the investigators avoided most studies with overlapping time periods of the same geographical regions—so any physician suicide would be counted only once—in the instances where overlaps did occur, only one study was included.
This determination was based on:
- Sample size (highest number of observed suicides)
- Lowest risk of bias (based on the Joanna Briggs Institute checklist)
- Recentness (ideally, a more recent midpoint of the observation period)
The following data was also extracted: geographical location, observation period, age range, level of age standardization, suicide classification, study design, and reference group.
So how was this data analyzed?
Separate meta-analyses were performed on suicide rate ratios for both genders of physicians, as well as:
- Sensitivity analyses using meta-regression
- Meta-regressions for length of observation period and number of suicides
- Subgroup analyses for geographic differences as well as to calculate mean effects estimated in older/more recent studies
- Secondary meta-analyses on suicide rates in physicians vs a reference group similar to the general population (for socioeconomic status)
And how many studies were actually included in the analysis?
Out of 23,458 studies and 786 articles initially selected, the study authors performed additional full-text screenings and analyses to result in the final tally of 39 studies:
- 38 eligible studies for male physicians
- 26 eligible studies for female physicians
Geographic regions included: Primarily Europe, the United States, and Australia.
And the total number of suicides?
- 3,303 among male physicians
- Observation (note: different from study publication date) period: 1935 - 2020
- 587 among female physicians
- Observation period: 1960 - 2020
So what was the rate ratio?
Starting with male physicians, the suicide rate ratio across all studies was 1.05 (95% confidence interval [CI] 0.90 to 1.22).
- Based on data from all included studies, the researchers “found no overall increase in suicide risk for male doctors compared with the general population,” according to BMJ.
Interestingly: The rate ratio for male physicians versus other professions was 1.81 (1.55 to 2.12).
And for females?
For females: 1.76 (1.40 to 2.21).
- Meaning: Among female physicians, “suicide risk was significantly higher (76%) than the general population.
In context: In the U.S., the number of female physicians has been on a steady incline over the last two decades, increasing by 97% from 2004 to 2022.
- On a global scale: Women now account for 67% of the global health and social care workforce.
Any similarities between the two?
While female physicians’ rate ratio was significantly higher than males’, heterogeneity was high for both analyses (males and females).
Meaning: This may suggest that physician suicide risk isn’t consistent across different populations and demographics—likely due to training/work environments and differing attitudes or stigma on mental health and suicide.
- Case in point: A propensity for burnout has been known to be high among physicians.
And in terms of recent vs. older studies?
BMJ noted that, based on an analysis of the 10 most recent and older studies, a decline over time was noted among suicide rates for both physician genders— “although the rate for female physicians remained significantly elevated” versus the general population (at 24%).
- The authors’ input on this: While an exact cause for this decline isn’t known, the implementation of more physician-targeted mental health awareness and workplace support in recent years may be a contributing factor.
Any notable limitations to this analysis?
The authors noted the potential for:
- Underreporting of suicide deaths for physicians (vs general population), which could have influenced the ratios between the two populations
- Despite the inclusion of 20+ countries in the analysis, several geographical regions were still underrepresented, which may have limited the generalization of the findings
Glance note: The most recent of those studies analyzed concluded prior to the start of the COVID-19 pandemic—which, since then, has since played a significant role in increasing physicians’ rates of burnout, depression and anxiety, and suicide rates.
- As such: The effect of this global event was not taken into consideration for this analysis.
And overall?
On a broader scale, these findings indicate that the suicide risk is decreasing across varying physician populations in comparison to the general population—with female physicians being a notable exception.
The authors also emphasized that there is still a “partly unexplained” reason for why “considerable heterogeneity exists” in the risk for suicide among varying physician populations, with training/work environments and societal influences likely playing roles.
What about for the future?
The authors stated that, with an increase in suicide rates among female physicians, the study “highlights the ongoing need for suicide prevention measures among physicians.”
They also recommended that future research include studies from additional countries, as well as a systemic look at other factors beyond study characteristics that may explain the heterogeneity in suicide risk among physicians.