Editor’s Note: The following article contains potentially sensitive content about suicide.

Death by suicide has been a widespread occurrence in antiquity across cultures. Physicians are not spared from this tragic end, with the first reported opinion in 1858 (A Manual of Psychological Medicine. 1858). This unfortunate problem has been studied for over 150 years, and these studies have at times revealed conflicting findings. While significant reductions in the incidence of death by suicide among physicians were seen in Europe through the early 21st century, the United States unfortunately continued to see high rates of death due to suicide (PLoS One 2019;14:e0226361). Whether practicing physicians have a higher rate of death by suicide than the general population remains a subject of considerable debate. A 2004 meta-analysis by Shernhammer et al. of 25 studies determined that male physicians had a rate of death by suicide 1.47-times that of the general population, while female physicians were subject to more than double the risk (Am J Psychiatry 2004;161:2295-302). Dutheil performed a meta-analysis in 2019 and published similar findings, while also noting that 1% of physicians attempted death by suicide and 17% acknowledged suicidal ideation (PLoS One 2019;14:e0226361). Duarte et al. confirmed the higher incidence of death by suicide among female physicians but found that male physicians experienced a lower rate than the general population (JAMA Psychiatry 2020;77:587-97).

The incidence of death by suicide among anesthesiologists compared with the general population and other physicians is unclear, although it appears that we are at higher risk. A 1968 study of causes of death among anesthesiologists indicated that the risk of death by suicide for anesthesiologists was 1.5-times the general population (Anesthesiology 1968;29:565-9). A follow-up study completed in 1974 comparing anesthesiologists with male standard policy life insurance holders also revealed that death by suicide was the only area where this cause of death exceeded that of general policyholders (Anesthesiology 1974;41:71-4). Alexander’s often-quoted 2000 study of cause-specific mortality of anesthesiologists found that anesthesiologists have higher rates of early death due to suicide, substance use disorders, and other external causes when compared with internists (Anesthesiology 2000;93:922-30). Higher risks of death by suicide have been suggested among anesthesiologists and psychiatrists, but other studies have not confirmed this (JAMA Psychiatry 2020;77:587-97). Plunkett’s 2021 systematic review revealed that the proportion of anesthesiologists dying by suicide was increased in relation to comparator groups and that suicidal ideation was present in 3.2%-25% of individuals and attempts in 0.5%-2% of individuals (Anaesthesia 2021;76:1392-403).

Multiple factors contribute to the inconsistent findings in studies of death by suicide among anesthesiologists and other physicians. Anesthesiologists may have higher rates of death due to accidental overdose than other specialties, and it is often difficult to determine whether fatal overdose is accidental or intentional. Overdose has been referred to as a “silent contributor” to opioid deaths (N Eng J Med 2018;378:1567-9). When individuals die alone, the cause of death is inferred from findings at the scene and is subject to the bias of the investigator (N Engl J Med 2018;378:1567-9). Terminology, fears of litigation, and state-level factors may influence the ultimate finding of the cause of death (N Engl J Med 2018;378:1567-9). The stigma associated with death by suicide as well as attitudes toward psychiatric illness may result in nondisclosure of the nature of the event (Anaesth Intensive Care 2003;31:434-45). The other factor is that surveys of death by suicide are retrospective by nature and largely rely upon individual and institutional recall, an inaccurate method to collect critical data. Factors that may contribute to this tragic ending, such as social isolation, may further cloud memories of the individual. Perhaps the study of death by suicide requires a different approach.

No medical specialty has established a formal means to routinely track the incidence of death by suicide. Federal agencies such as the Centers for Disease Control and Prevention, Veterans Administration, and Federal Bureau of Investigation collect information for reporting purposes. Agency data are primarily objective and generally collected from sources such as the National Death Index. These databases serve a valuable purpose but are not specific for anesthesiology or other specialties and lack detail about factors that could potentially identify individuals who are at high risk beyond mere membership in a high-risk demographic group. The authors implemented a new method to track death by suicide among anesthesiologists – a confidential collection mechanism called the Anesthesiologist Database on Death by Suicide (ADDS). The project originated within the ASA Working Group on Mental Health and Suicide Prevention, which reports to the Committee on Physician Well-Being.

The purpose the ADDS is to formalize the reporting of routine as well as detailed demographic and situational data related to anesthesiologist deaths by suicide as early after the event as possible. This strategy is consistent with the recommendation of the Association of Anaesthetists that documentation of physician suicide by specialty be improved (Anaesthesia 2020;75:96-108). Early collection may minimize errors associated with periodic surveys, including errant recall. We expect the database will facilitate better insight into factors that can potentially lead to suicidal ideation and death as well as warning signs that are often ignored or minimized. These factors may be identified in the period after an event but are often lost to memory at the time a survey is performed. The database is designed so that any anesthesiologist may submit information. Duplicate submissions are reviewed to establish a more complete picture of any individual event. Collected data include primary objective demographic identifiers such as age, gender, ethnic group, status as a trainee or attending, and years in the position. Other factors commonly identified as risk factors for death by suicide are also included, such as work-related problems, litigation, prior substance use disorders, legal issues, negative childhood experiences, and physical and mental health problems. The Massachusetts General Hospital Institutional Review Board approved the database.

The database entry process was initially distributed to ASA leadership, society committees, and the House of Delegates. Data on 56 deaths (F=18, M=38) have been submitted to date. The data include 13 resident physicians. This limited sample size precludes definite conclusions or recommendations, but early findings indicate that women who die by suicide are far younger than their male colleagues (average 36 years versus 46 years, respectively).

The ADDS is a worthwhile, dynamic initiative that will further characterize factors that contribute to death by suicide for years to come. It is endorsed by ASA leaders. Much like the Closed Claims Database, data derived from the collection of additional information about anesthesiologist suicides in a confidential, secure manner can be used to educate the anesthesiology community about the risk factors and early warning signs of death by suicide. The survey is now being shared with the general ASA membership with the hope that additional submissions, now and going forward, will help anesthesiology practices and organizations to develop strategies for early intervention, appropriate treatment, and, ideally, return to successful careers. ASA members can enter information into the database through redcap.link/anes_suicide. Additional resources for suicide prevention strategies can be found at asahq.org/advocating-for-you/suicide-prevention, which is curated by the ASA Committee on Physician Well-Being. Readers will soon have the option to access the survey on the site.

  • If you or a colleague are suicidal and need emergency help, contact:
    • 911 immediately or
    • The National Suicide Prevention Lifeline at 988 or
    • Crisis Text Line by texting HOME to 741741.
  • The National Suicide Prevention Lifeline also published a resource, Suggestions to Help Someone Else: “Do They Need Your Help? How Can You Help Them?” (988lifeline.org/help-someone-else).