COVID-19: suicide rates notably high among physicians and nurses

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The pandemic put a spotlight on mental health and burnout within health care professions, but emerging research reveals these issues have been affecting health care workers for years, with suicide rates notably high among physicians and nurses.

But until now, less was known about the mental health of pharmacists.

In the first study to report pharmacist suicide rates in the United States, researchers from Skaggs School of Pharmacy and Pharmaceutical Sciences at University of California and UC San Diego School of Medicine found that suicide rates are higher among pharmacists compared to the general population, at an approximate rate of 20 per 100,000 pharmacists compared to 12 per 100,000 in the general population. Results of the longitudinal study published May 13, 2022 in Journal of the American Pharmacists Association.

The figures are based on data from 2003 through 2018, collected by the Centers for Disease Control and Prevention’s National Violent Death Reporting System. Study authors expect numbers to be even higher in subsequent years due to the additional stressors of the pandemic, and are currently evaluating more recent data.

“If we learned anything from the pandemic, it’s that there is a breaking point for health professionals,” said corresponding author Kelly C. Lee, PharmD, professor of clinical pharmacy at UC San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences.

The study identified the most common means of suicide in this population, with 49.8 percent of cases involving firearms, 29.4 percent involving poisoning and 13 percent involving suffocation. The use of firearms was similar between pharmacists and the general population, but poisoning via benzodiazepines, antidepressants and opioids was more frequent among pharmacists.

The data also provide some insight into contributing factors, including a history of mental illness and a high prevalence of job problems. Job problems are the most common feature of suicides across health care professions.

For pharmacists, Lee said job problems reflect significant changes in the industry in recent years, with more pharmacists employed by hospitals and chain retailers than small, private pharmacies more common in the past. The responsibilities of a pharmacist have also grown considerably, with larger volumes of pharmaceuticals to dispense and increasing demands to administer vaccines and other health care services.

“Pharmacists have many more responsibilities now, but are expected to do them with the same resources and compensation they had 20 years ago,” said Lee. “And with strict monitoring from state and federal regulatory boards, pharmacists are expected to perform in a fast-paced environment with perfect accuracy. It’s difficult for any human to keep up with that pressure.”

Future research will further evaluate which job problems have the biggest impact and how the field can better respond. In the meantime, Lee advised pharmacists to encourage help-seeking behaviors amongst themselves and their colleagues.

“Mental health is still highly stigmatized, and often even more so among health professionals,” said Lee. “Even though we should know better, there is such an expectation to appear strong, capable and reliable in our roles that we struggle to admit any vulnerabilities. It’s time to take a look at what our jobs are doing to us and how we can better support each other, or we are going to lose our best pharmacists.”


Work Associated Factors For Suicide

Since hospital working conditions vary between and within regions, differences are expected in healthcare workers’ mental health and suicide rates. Burnout is a psychological condition that develops when people are exposed to a stressful work environment with high job demands and limited resources (19, 20). Suicidal ideation was found to be higher among those with burnout than those without it, according to a cross-sectional survey of 2,734 female nurses working in Taiwanese hospitals. Similarly, burnout was predictive of suicidal ideation in a longitudinal study of U.S. medical students, even when depressive symptoms were not present (21, 22).

To avoid the unanticipated effects of exhaustion and burnout, it is critical to strike a balance between appropriate working hours for health care workers, including surgical trainees, physician assistants, psychiatrists, and nurses, while maintaining high-quality patient care. A study conducted in Taiwan has shown that the prevalence of high work-related burnout from highest to lowest was nurses (66%), physician assistants (61.8%), physicians (38.6%), administrative staff (36.1%), and medical technicians (31.9%), respectively (23).

Residents, in particular, have been reported to be at a higher risk of depression as a result of a transition in their job capacity from a medical student to a trainee, which now includes intensive training hours along with studies and research (24, 25). This is compounded by characteristics such as early employment uncertainty, competitive work environment, and being younger, all of which are risk factors for emotional distress and ultimately suicidal thoughts. (26) reported that working in a training set for more than 80 h per week considerably increases the resident’s depressive symptoms. Another study of first-year Japanese residents has found that 22.6 percent of residents had newly developed depressive symptoms after three months of residency (27).

Some places, particularly in the developed Western world, recognize and address the need to promote a better work environment by reducing working hours for doctors. The European Working Time Directive (EWTD) is one such initiative that has had a significant impact on training and work schedules in countries such as New Zealand and Australia. For example, an agreement in New Zealand specifies regular working hours for surgical trainees as 40 h per week and no more than 8 h per day, with overtime permitted and compensation (28). The impact of such reforms can be seen in a meta-analysis that identified a higher incidence of physician suicide in North America than in Australia, New Zealand, and the Pacific, and that suicide has declined over time, particularly in Europe (18).

It is important to note that job uncertainty and a shorter duration of employment are associated with a higher risk of suicide among healthcare professionals. This correlation was discovered among diagnostic medical radiation workers in South Korea, who had a 2.74 and 4.66 times greater risk of suicide among male and female workers with < one year of employment, respectively, than those with more than 10 years of employment (29).

As a result, it appears that the healthcare workers with short-term jobs are a vulnerable population who should be given enough assistance and a better working environment (29). In addition, factors such as limited resources, an insufficient workforce, and high job expectations contribute to suicide risk among HCWs, especially in developing countries. This issue is more pronounced among nurses, one of the most undervalued groups, even though they are the backbone of every healthcare system. Nurses’ suicide rates have gone unnoticed for years, and there are several underlying contributing factors, including long working hours, being the primary caregiver for patients, such as in the ICU, and a lack of professional autonomy (30).

Furthermore, female nurses who form the majority of the workforce have dual profession and home responsibilities. Davis et al. reported that the suicide incidence among nurses was 17.1 per 1,00,000, compared to 8.6 per 1,00,000 among women in the general population, representing a doubling of risk (31). In addition, the increased rate of substance abuse, such as antidepressants, opiates, and amphetamines, which have been discovered to be more commonly used as poisoning methods for suicide attempts among this demographic, is an important issue to highlight (31, 32).

Mental Health Challenges Faced by Healthcare Workers

Literature regarding the mental well-being of healthcare workers was limited until 2016 (33); however, recent studies have started focusing on the challenges faced by healthcare workers. It has been noticed that constant amounts of stress negatively impact healthcare workers. Acute signs of anxiety, depression, and burnout have been noticed at all levels of training in the medical profession.

According to a report from 2014, symptoms specific to depression have been noticed in medical students, whereas signs of burnout are highly probable amongst residents during their training (33). Seventy four percent of residents have reported signs of exhaustion in a study from 2015, thus highlighting the burnout epidemic in the medical community. It is described as a feeling of inefficacy, depersonalization coupled with signs of emotional exhaustion in the workplace (34). Another study has reported that constant exposure to intense and unpredictable working hours could lead to fatigue during training years, causing multiple mental health issues amongst health care workers (35).

Specific categories of physicians affected by PTSD include emergency physicians, medical personnel working in remote areas or warzones, physicians in training, those indirectly exposed to trauma, and malpractice litigation (36). The frequency of dealing with a higher burden of death in trauma care puts them at a higher risk for developing these symptoms. High-risk groups for suicide are often those with either a previous history of such instances or those with Post-traumatic stress disorder (PTSD).

PTSD symptoms have been observed in 30% of the residents working in the emergency room, with symptoms increasing with training (37). A 4-factor model suggests association patterns between suicidal ideation and symptoms of PTSD, which include re-experiencing feelings, negative alterations in cognition and mood, and hyperarousal. A similar study has suggested a 7-factor model correlating PTSD and an increased risk for suicide (17). Exposure to critically ill patients also poses a higher risk of developing depression amongst residents (33). Similarly, nurses and staff from the emergency room have a higher risk of experiencing suicidal ideation due to the nature of cases they consult daily.

Work-related changes are believed to play a significant role in developing mental health issues in physicians. In a study conducted among intensive care unit staff, almost half reported symptoms consistent with a probable diagnosis of post-traumatic stress disorder, severe depression or anxiety, or problem drinking. In the previous two weeks, 13% of respondents reported having recurring thoughts of being better off dead or injuring themselves (38).

According to studies conducted in the United States, 10–15% of HCPs will misuse substances at some point in their careers, and prescription drug abuse and addiction rates are five times higher among physicians than in the general population benzodiazepine opioid abuse have exceptionally high rates (39). According to a 2010 inquiry into the Texas Board of Nursing, around a third of all disciplinary actions against nurses were related to drugs or alcohol (39). Many healthcare personnel uses these medicines to relieve stress, depression, and pain symptoms and improve their general work performance. However, these seemingly harmless medications frequently become a source of dependence or addiction in the user over time.

Impact of the Covid-19 Pandemic on Healthcare Workers’ Mental Health

As the world and healthcare institutions deal with the fallout from the 2019 Coronavirus pandemic, we are likely to see the impact on the mental health of all healthcare professionals who are facing the reality of constrained resources and unthinkable choices, working to exhaustion, and caring for patients while being at significant personal risk.

Fear and uncertainty about the new virus, its devastating repercussions, exhausting working hours in the hospital, countless deaths, and shortage of PPE’s have all been significant setbacks for the healthcare system and have led to emotional stress and depressive symptoms among HCWs during the early stages of the pandemic (40). Coping with the COVID-19 pandemic has exacerbated HCWS’s already-existing mental health issues and has placed extra strains on their well-being. Inevitably, this is bound to have a negative impact on the mental health of healthcare personnel, with long-term consequences.

Previous research has also shown that healthcare workers’ mental health consequences of an epidemic or pandemic is long-term. Healthcare workers reported extreme emotional and traumatic stress and burnout, anxiety, and depressive symptoms during the SARS pandemic in 2003 and the MERS outbreak in 2015 (41, 42). Due to the nature of their job during the pandemic, HCWs, including nurses, emergency department staff, intensivists, and physicians, are among the most vulnerable groups to experience stressful events that can trigger a suicidal crisis (9). These individuals are already at risk for mental health issues such as post-traumatic stress disorder (PTSD), common among emergency room residents, intensivists, and surgeons (43).

According to studies, the COVID-19 epidemic has significantly increased stress, anxiety, depression, and insomnia among HCWs. The lack of standard treatment protocols or vaccines, work-related stress, the rapid spread of the virus, and fear of COVID-19 infection and transmission are major contributing factors leading to mental health disorders (44, 45).

According to a study conducted among Malaysian HCWs, clinical depression has been the most significant predictor of present suicidal ideation, followed by mild (subthreshold) depression (46). Furthermore, it should be highlighted that female HCWs have appeared to be at a higher risk of suicidal behavior than their male counterparts during the current pandemic (47).

It concerns that a total of 26 worldwide COVID-19-related suicide cases among HCWs have been reported in a recent study; the affected persons consisted primarily of doctors, nurses, and paramedics, with more than half of them being female from India (45). In a similar report, multiple COVID-19-related suicides have been reported among nurses who have been on the frontlines caring for COVID-19 patients (48).

This emphasizes the importance of creating a supportive workplace environment for HCWs to maintain their mental well-being. It is critical to create less stressful schedules for HCWs in order to give them time to process and recover from their experiences, to recognize their vital contributions during this intense medical crisis, to remove the stigma around seeking help, and to provide timely and free psychological support to all HCWs.

reference link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8850721/


More information: Kelly C. Lee et al, Longitudinal analysis of suicides among pharmacists during 2003-2018, Journal of the American Pharmacists Association (2022). DOI: 10.1016/j.japh.2022.04.013

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