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Taking Their Own Lives — The High Rate of Physician Suicide

n engl j med
352;24 june
16, 2005
tianity. This long-standing religious presence has
made atheists, agnostics, and members of minority
religions view themselves as oppressed, but recent
efforts to purge the public square of religion have
left conservative Christians also feeling subjugated
and suppressed. In this culture war, both sides claim
the mantle of victimhood — which is why health
care professionals can claim the right of conscience
as necessary to the nondiscriminatory practice of
their religion, even as frustrated patients view con-
science clauses as legalizing discrimination against
them when they practice their own religion.
For health care professionals, the question be-
comes: What does it mean to be a professional in
the United States? Does professionalism include
the rather old-fashioned notion of putting others
before oneself ? Should professionals avoid ex-
ploiting their positions to pursue an agenda sepa-
rate from that of their profession? And perhaps
most crucial, to what extent do professionals have
a collective duty to ensure that their profession pro-
vides nondiscriminatory access to all professional
Some health care providers would counter that
they distinguish between medical care and nonmed-
ical care that uses medical services. In this way, they
justify their willingness to bind the wounds of the
criminal before sending him back to the street or to
set the bones of a battering husband that were bro-
ken when he struck his wife. Birth control, abortion,
and in vitro fertilization, they say, are lifestyle choic-
es, not treatments for diseases.
And it is here that licensing systems complicate
the equation: such a claim would be easier to make
if the states did not give these professionals the ex-
clusive right to offer such services. By granting a
monopoly, they turn the profession into a kind of
public utility, obligated to provide service to all who
seek it. Claiming an unfettered right to personal
autonomy while holding monopolistic control over
a public good constitutes an abuse of the public
trust — all the worse if it is not in fact a personal act
of conscience but, rather, an attempt at cultural
Accepting a collective obligation does not mean
that all members of the profession are forced to vi-
olate their own consciences. It does, however, ne-
cessitate ensuring that a genuine system for coun-
seling and referring patients is in place, so that every
patient can act according to his or her own con-
science just as readily as the professional can. This
goal is not simple to achieve, but it does represent
the best effort to accommodate everyone and is the
approach taken by virtually all the major medical,
nursing, and pharmacy societies. It is also the ap-
proach taken by the governor of Illinois, who is im-
posing an obligation on pharmacies, rather than on
individual pharmacists, to ensure access to services
for all patients.
Conscience is a tricky business. Some interpret
its personal beacon as the guide to universal truth.
But the assumption that one’s own conscience is the
conscience of the world is fraught with dangers. As
C.S. Lewis wrote, “Of all tyrannies, a tyranny sin-
cerely exercised for the good of its victims may be
the most oppressive. It would be better to live under
robber barons than under omnipotent moral busy-
bodies. The robber baron’s cruelty may sometimes
sleep, his cupidity may at some point be satiated; but
those who torment us for our own good will torment
us without end for they do so with the approval of
their own conscience.”
When I was an oncology fellow in Vienna, a col-
league who had attended rounds with me on the
ward went home afterward and strangled herself.
Only later was it learned that she had suffered from
depression. In the course of that same year, three
more physicians in my immediate circle — two res-
idents and a department head — took their own
lives. This stunning series was my first encounter
with physician suicide, and it left many of us doc-
tors with an important message: we must care not
only for our patients but also for ourselves. In an ef-
fort to prevent further such tragedies, a program
Taking Their Own Lives — The High Rate of Physician Suicide
Eva Schernhammer, M.D., Dr.P.H.
The Celestial Fire of Conscience — Refusing to Deliver Medical Care
Dr. Schernhammer is an instructor in medicine at Har-
vard Medical School and Brigham and Women’s Hospi-
tal, both in Boston.
n engl j med
352;24 june
16, 2005
was launched at the hospital to help physicians and
nurses grapple with the emotional effects of caring
for the chronically ill. But the suicides that had al-
ready occurred were never discussed openly, no one
undertook a publicly acknowledged serious analysis
of the causes, and no other clear safeguards were
put into place. The deaths were simply accepted as
a fact of medical life.
Although physicians tend to have healthier life-
styles than those of the general public and thus to
live longer, it has been known for some time that
suicide rates among doctors are higher than those
in the general population (see graphs). And when
these tragic events make it into the headlines, as did
the recent suicide of gifted heart surgeon Jonathan
Drummond-Webb, we begin to wonder why these
healers apparently cannot heal the hurt in their
own lives.
The gap in suicide rates evidently begins as early
as medical school, where overall suicide rates are
higher than in the age-matched population. This
increased rate of suicide is driven largely by higher
rates among women: female medical students com-
mit suicide at the same rate as male medical stu-
whereas in the United States in general, sui-
cide rates are much higher among men. Evidence
from a large study of physician suicide indicates that
female doctors, in particular, are much more likely
than other women to take their own lives. The com-
bined results of 25 studies suggest that the suicide
rate among male doctors is 40 percent higher than
that among men in general, whereas the rate among
female doctors is 130 percent higher than that
among women in general.
Several factors that may contribute to the suicide
of physicians, especially female physicians, deserve
closer examination. Physicians may have a higher
prevalence of depression than nonphysicians, and
depression is clearly an important risk factor for
suicide; among female physicians, the risk may be
exacerbated by sexual harassment; and when they
become suicidal, physicians generally choose effec-
tive suicide methods.
A prevalent view is that both biologic and psy-
chosocial factors play a role —and interact — in
the decision to commit suicide. There is a higher
prevalence of psychiatric disorders among physi-
cians than in the general population. Some 30 to 70
percent of all persons who attempt suicide appar-
ently have an affective disorder (generally depres-
sion), a substance-use–related disorder, or schizo-
Evidence further suggests that drug abuse
and alcoholism, possibly under circumstances of
heightened stress or depression, are often associ-
ated with the suicides of physicians. Female phy-
sicians, in particular, have been shown to have a
higher frequency of alcoholism than women in the
general population. Drug abuse is also related to
specialty, being particularly prevalent among psy-
chiatrists, anesthesiologists, and emergency physi-
cians. Recent reports emphasize that the exposure
that anesthesiologists have to drugs as they work
represents a risk factor for drug addiction and pos-
sibly suicide, indicating that access to drugs may
support higher suicide rates among physicians by a
variety of pathways. In the general population, ac-
cording to autopsy studies and other evidence, as
many as 25 percent of all persons who commit sui-
cide are drunk at the time of their deaths.
Another way to view the problem is that the pro-
fessional burden carried by doctors leads to social
isolation and an increased probability of undergo-
ing phases of disturbances in their social networks.
It has also been noted that physicians tend to ne-
glect their own need for psychiatric, emotional, or
medical help and are more critical than most peo-
ple of both others and themselves. They are more
likely to blame themselves for their own illnesses.
And they are apparently more susceptible to depres-
sion caused by adverse life events, such as the death
of a relative, divorce, or the loss of a job.
Being single and not having children have also
been linked to an increased risk of suicide, and more
female than male physicians are single or childless.
Some studies of coping have emphasized that wom-
en in general are subject to a double burden — being
vulnerable to pressures of both family life and work
life. Stress and burnout may be added risk factors for
all physicians, and female doctors may feel more
stress than their male counterparts because of the
difficulty of succeeding in a male-dominated pro-
They may also be the targets of sex-based or sex-
ual harassment, which may, in turn, lead to depres-
sion and suicidality. In a study by Frank et al., 48
percent of female physicians reported having expe-
rienced sex-based (“gender-based,” per study ques-
tionnaire) harassment at least once, and 37 percent
reported sexual harassment.
Moreover, the study
established a link between higher rates of harass-
ment and a history of depression or suicide at-
tempts, showing an association between the sever-
Taking Their Own Lives — The High Rate of Physician Suicide
n engl j med
352;24 june
16, 2005
ity of harassment and the likelihood of depression.
Sex-based harassment and sexual harassment are
more common in historically male-dominated spe-
cialties, such as surgery and emergency medicine.
According to unpublished data from a recent U.S.
study by Straehley and Longo of the difficulties
women face when entering the field of medicine,
more than 75 percent of interviewed female sur-
geons said that they had been harassed. Moreover,
according to Frank et al., whose study results con-
curred with these findings, harassment rates are not
It has been argued that the reinforcing
of sex stereotypes through the promulgation of the
belief that women are innately inferior to men in
science may well contribute to the ongoing harass-
ment of female physicians.
Finally, physicians who make suicide attempts
are much more likely than nonphysicians to suc-
ceed. Among physicians in this country, in fact,
there are fewer unsuccessful suicide attempts than
completed suicides — a stark contrast to the data
for U.S. women in general, for instance, among
whom the ratio of unsuccessful attempts to com-
pleted suicides is between 10:1 and 15:1.
Not surprisingly, the method chosen predicts
the likelihood of success. Women in the general
population make more unsuccessful suicide at-
tempts than men, in large part because they prefer
Suicide Rates among Male Physicians (Panel A) and Female Physicians (Panel B) in Relation to the Rates in the General Population
of the Same Sex.
The size of each box represents the relative size of the study sample, and the horizontal line that intersects the box indicates the 95 percent
confidence interval. The dashed red line in each panel indicates the combined estimate. The diamond-shaped box represents the confidence
interval. The data are from a meta-analysis by Schernhammer and Colditz.
0.23 1.00 1.41 26.40
Individual Studies of Physician Suicide
Ratio of Suicide Rate among Male Physicians
to Rate among Men in General Population
0.23 1.00 2.27 26.40
Individual Studies of Physician Suicide
Ratio of Suicide Rate among Female Physicians
to Rate among Women in General Population
Taking Their Own Lives — The High Rate of Physician Suicide
n engl j med
352;24 june
16, 2005
methods that are typically less deadly than those —
such as the use of firearms — favored by men. It is
possible, therefore, that the higher suicide rate
among female physicians simply reflects a combi-
nation of the sex difference in the rate of suicide at-
tempts and a higher rate of completion inside the
medical profession than outside it.
According to a recent study, doctors most com-
monly take their own lives by poisoning themselves,
often with drugs taken from their offices or labora-
tories. The fact that greater access to drugs leads to
higher suicide rates has long been known — for ex-
ample, in Australia, an increase in suicides among
women coincided with the implementation of a law
that made it easier to obtain barbiturates. It seems
likely that the higher suicide rate among physicians
is related to both their relatively free access to drugs
and their medical knowledge, which enhances their
ability to use such methods successfully.
There are few interventions in place to help pre-
vent suicide among physicians. Such safeguards
might include the provision of discreet and confi-
dential access to psychotherapy and open discussion
of the stress encountered in a medical career. The
barriers that may prevent physicians from seeking
help for mental disorders (such as the threat of los-
ing their medical licenses) must also be addressed.
Part of the solution for female doctors must ulti-
mately be to equalize professional conditions in or-
der to reduce stress. In time, perhaps these and oth-
er measures will help doctors to do what they do
best: save lives, beginning with their own.
Schernhammer ES, Colditz GA. Suicide rates among physi-
cians: a quantitative and gender assessment (meta-analysis).
Am J Psychiatry 2004;161:2295-302.
Pepitone-Arreola-Rockwell F, Rockwell D, Core N. Fifty-two
medical student suicides. Am J Psychiatry 1981;138:198-201.
Litman RE. Mental disorders and suicidal intention. Suicide
Life Threat Behav 1987;17:85-92.
Kirsling RA, Kochar MS. Suicide and the stress of residency
training: a case report and review of the literature. Psychol Rep
Frank E, Brogan D, Schiffman M. Prevalence and correlates
of harassment among US women physicians. Arch Intern Med
Taking Their Own Lives — The High Rate of Physician Suicide
... A link exists between substance abuse and high stress. Substance abuse, associated with stress or depression, is associated with physician suicide [40][41][42]. Poor wellbeing, including depression, anxiety, poor quality of life, stress and high level of burnout, are associated with more self-reported errors [23] as well as decreased quality of patients' care, malpractice risk and early retirement [6,14,24]. Table 2 presents intellectual and physical wellness survey results. ...
... ⇒ Embedding a complex intervention at hospital-level takes time and any effect might become apparent only after the study ends. Open access impacts on those experiencing it, leading to depression, substance abuse and even suicide [11][12][13][14][15] but is also associated with worse patient outcomes, lower patient satisfaction, 6 medical errors, 16 reduced quality and safety 17 and reduced efficiency of hospitals. 18 The resulting lost productivity, combined with current recruitment challenges, further threatens the already overstretched health workforce, widening the gap between provision of health services and population needs. ...
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Introduction The increasing burden of mental distress reported by healthcare professionals is a matter of serious concern and there is a growing recognition of the role of the workplace in creating this problem. Magnet hospitals, a model shown to attract and retain staff in US research, creates positive work environments that aim to support the well-being of healthcare professionals. Methods and analysis Magnet4Europe is a cluster randomised controlled trial, with wait list controls, designed to evaluate the effects of organisational redesign, based on the Magnet model, on nurses’ and physicians’ well-being in general acute care hospitals, using a multicomponent implementation strategy. The study will be conducted in more than 60 general acute care hospitals in Belgium, England, Germany, Ireland, Norway and Sweden. The primary outcome is burnout among nurses and physicians, assessed in longitudinal surveys of nurses and physicians at participating hospitals. Additional data will be collected from them on perceived work environments, patient safety and patient quality of care and will be triangulated with data from medical records, including case mix-adjusted in-hospital mortality. The process of implementation will be evaluated using qualitative data from focus group and key informant interviews. Ethics and dissemination This study was approved by the Ethics Committee Research UZ/KU Leuven, Belgium; additionally, ethics approval is obtained in all other participating countries either through a central or decentral authority. Findings will be disseminated at conferences, through peer-reviewed manuscripts and via social media. Trial registration number ISRCTN10196901 .
... Resident physicians across specialties seem to struggle to stay mentally healthy and further increases in depressive symptoms occur with the onset of residency training [20]. The suicide rates in male and female physicians are increased with 40 and 130% respectively compared to the general population [21], a trend starting already in medical school [22]. ...
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Background: Medical students have a higher risk for depression, anxiety, stress-related symptoms, burnout, and suicide, and more rarely seek professional help or treatment than the general population. Appeals are being made to address the mental health and resilience of physicians-to-be. The novel program Training for Awareness, Resilience, and Action (TARA) was originally developed to treat depressed adolescents, targeting specific neuroscientific find- ings in this population. TARA has shown feasibility and preliminary efficacy in clinically depressed adolescents and corresponding brain-changes in mixed community adolescent samples. The present study investigated the feasibility and acceptability of TARA as a potential indicated prevention program for symptoms of depression, anxiety, stress and burnout in Swedish medical students. Methods: We conducted a single-arm trial with 23 self-selected students in their early semesters of medical school (mean age 25.38 years, 5 males and 18 females), with or without mental disorders. All participants received TARA. Self- reported symptoms of depression, anxiety, perceived stress and psychological inflexibility were collected before (T0) and after the intervention (T1). Qualitative data on the participants’ experiences of TARA were collected in focus-group interviews conducted halfway through the program and upon completion of the program. Individual interviews were also conducted 2 years later. Qualitative content analysis was performed. Results: The mean attendance rate was 61.22% and the dropout rate was 17.40%. The Child Session Rating Scale administered after every session reflected an overall acceptable content, mean total score 34.99 out of 40.00. Trends towards improvement were seen across all outcome measures, including the Hospital Anxiety and Depression Scale Anxiety (t = 1.13, p = 0.29) and Depression (t = 1.71, p = 0.11) subscales, Perceived Stress Scale (t = 0.67, p = 0.51) and Avoidance and Fusion Questionnaire for youth (t = 1.64, p = 0.10). None of the participants deteriorated markedly during the intervention. Qualitative content analysis resulted in a main theme labeled: “An uncommon meeting-ground for personal empowerment”, with 4 themes; “Acknowledging unmet needs”, “Entering a free zone”, “Feeling connected to oneself and others” and “Expanding self-efficacy”. Conclusion: TARA is feasible and acceptable in a mixed sample of Swedish medical students. The students’ reports of entering an uncommon meeting-ground for personal empowerment supports effectiveness studies of TARA in this context.
Objective Burnout among general surgery residents is prevalent. Guidance on how program directors (PDs) can effectively intervene on general surgery resident wellness is lacking. In this study, we explore how PDs learn about burnout among their residents and support their well-being. Design Semi-structured interviews were conducted with PDs. Interviews were transcribed and coded by study team dyads who utilized an inductive coding approach, and then reconciled via consensus. Interpretive description was the qualitative analytical method. Setting Program tours to 15 general surgery programs during the exploratory phase of the SECOND Trial. Participants Fifteen general surgery PDs. Results PDs identified the utility of contextual information in understanding resident wellness and implementing program-specific resident wellness initiatives. Three themes relating to PD awareness of resident burnout and well-being were identified: (1) PDs used conventional and novel methods to collect data from multiple information sources, including residents, faculty, staff, institutional representatives, and anonymous parties. (2) These contextualized data inspired the development of responsive strategies to effect programmatic changes that improved education and wellness. (3) Barriers to acquiring and utilizing information exist, requiring careful analysis, creative problem solving, as well as persistence and dedication to resident wellness. Conclusions Qualitative analysis of general surgery residency PDs yielded insightful knowledge about gathering and responding to information to support resident wellness, including successful strategies and areas of caution. The experience of these PDs can guide others in evaluating their wellness goals and initiatives for their own residents.
Kopfverletzungen können, wie es dieser Fall zeigt, sehr schnell sehr dramatisch ausfallen, vor allem, wenn „schwere Maschinen“ zum Einsatz kommen. Der vorliegende Fall zeigt zudem, dass man im Notarztdienst nicht davor gefeit ist, auch schreckliche Situationen, denen man eine Einmaligkeit unterstellt, ein weiteres Mal zu durchleben.
Das Studium der Humanmedizin ist, wie viele andere Studiengänge auch, eine große Herausforderung für die studierenden jungen Menschen. Der vorliegende Fall geht darauf ein, dass diese Herausforderung ohne Unterstützung und Begleitung nicht für jeden zu meistern ist und zur Überforderung werden kann.
Wellbeing is an ever-changing aspect of life that varies by individual and requires active awareness, acceptance, and commitment. Women in pediatrics must nurture each dimension of wellbeing in order to live fully. When wellbeing is neglected, a variety of stressors arise that can lead to burnout. Professional/personal burnout can be costly and lead to tragic consequences that impact doctors, patients, families, medical organizations, and the broader community. Drivers of burnout are encompassed within seven dimensions: workload and job demands, efficiency and resources, meaning in work, culture and values, control and flexibility, social support and community at work, and work-life integration. Within these dimensions, there are a multitude of gender disparities that leave women in pediatrics more susceptible to burnout than men. To prevent burnout among women pediatricians, major systemic changes targeting these gender differences must be designed, implemented effectively, and continuously evaluated for efficacy. Additionally, the overall culture in medicine must shift to enable and encourage women to develop and practice individual skills and strategies that help prevent or mitigate burnout. Only then will women enjoy lasting meaning and purpose in both their work and personal lives.
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Mental illness stigma is a complex public health issue that creates barriers for clients needing access to quality mental health services. Most research focuses on interpersonal stigma with emerging research examining intrapersonal and structural stigma in the healthcare setting. This commentary focuses on how to address the gaps in the existing research to elicit greater organizational/structural change in healthcare systems and positive health outcomes. It describes key components of a 5-year multiphase study that aims to explore and address multiple levels of stigma holistically among stakeholders including physicians, nurses, protective services staff, and patients/families in an emergency department setting. Unique to this study is the inclusion of a patient research partner who will be positioned as a co-designer throughout the project. The goal of this study will be to explore, address, understand, and evaluate interventions that mitigate stigma in healthcare at both the individual and structural/organizational levels.
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Objective: Physicians ' suicide rates have repeatedly been reported to be higher than those of the general population or other academics, but uncertainty remains. In this study, physicians ' suicide rate ratios were estimated with a meta - analysis and systematic quality ...
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Despite concerns about its prevalence and ramifications, harassment has not been well quantified among physicians. Previous published studies have been small, have surveyed only 1 site or a convenience sample, and have suffered from selection bias. Our database is the Women Physicians' Health Study, a large (4501 respondents; response rate, 59%), nationally distributed questionnaire study. We analyzed responses concerning gender-based and sexual harassment. Overall, 47.7% of women physicians reported ever experiencing gender-based harassment, and 36.9% reported sexual harassment. Harassment was more common while in medical school (31% of gender-based and 20% for sexual harassment) or during internship, residency, or fellowship (29% for gender-based and 19% for sexual harassment) than in practice (25% for gender-based and 11% for sexual harassment). Respondents more likely to report gender-based harassment were physicians who were now divorced or separated and those specializing in historically male specialties, whereas those of Asian and other (nonwhite, nonblack, non-Asian, non-Hispanic) ethnicity, those living in the East, and those self-characterized as politically very conservative were less likely to report gender-based harassment. Being younger, born in the United States, or divorced or separated were correlated with reporting ever experiencing sexual harassment; those who were Asian or who were currently working in group or government settings were less likely to report it. Those who felt in control of their work environments, were satisfied with their careers, and would choose again to become physicians reported lower prevalences of ever experiencing harassment. Those with histories of depression or suicide attempts were more likely to report ever having been harassed. Women physicians commonly perceive that they have been harassed. Experiences of and sensitivity to harassment differ among individuals, and there may be substantial professional and personal consequences of harassment. Since reported rates of sexual harassment are higher among younger physicians, the situation may not be improving.
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Physicians' suicide rates have repeatedly been reported to be higher than those of the general population or other academics, but uncertainty remains. In this study, physicians' suicide rate ratios were estimated with a meta-analysis and systematic quality assessment of recent studies. Studies of physicians' suicide rates were located in MEDLINE, PsycINFO, AARP Ageline, and the EBM Reviews: Cochrane Database of Systematic Reviews with the terms "physicians," "doctors," "suicide," and "mortality." Studies were included if they were published in or after 1960 and gave estimates of age-standardized suicide rates of physicians and their reference population or reported extractable data on physicians' suicide; 25 studies met the criteria. Reviewers extracted data and scored each study for quality. The studies were tested for heterogeneity and publication bias and were stratified by publication year, follow-up, and study quality. Effect sizes were pooled by using fixed-effects (women) and random-effects (men) models. The aggregate suicide rate ratio for male physicians, compared to the general population, was 1.41, with a 95% confidence interval (CI) of 1.21-1.65. For female physicians the ratio was 2.27 (95% CI=1.90-2.73). Visual inspection of funnel plots from tests of publication bias revealed randomness for men but some indication of bias for women, with a relative, nonsignificant lack of studies in the lower right quadrant. Studies on physicians' suicide collectively show modestly (men) to highly (women) elevated suicide rate ratios. Larger studies should help clarify whether female physicians' suicide rate is truly elevated or can be explained by publication bias.
Suicide rates among physicians have been reported to be twice that of the general adult population. Few data are available, however, regarding suicide among resident physicians. A case study of the suicide of a male intern is discussed. The literature is reviewed to elucidate potential contributory factors including reported causes and manifestations of stress among resident physicians, suicide rates among physicians including house staff with considerations of sex, and common personality characteristics of physicians and medical students. Recommendations are extended which may assist in early recognition and treatment of individuals at risk of impairment and suicide.
This paper continues a previous report (Litman, 1984) in exploring the use of psychological autopsies to clarify intention in suicide; clinical experience is compared with courtroom experience. The certification of suicide requires a judgment that the deceased intended to use his or her own death to resolve his or her problems of living, as demonstrated by a preponderance of the evidence. Now that suicide has been decriminalized, the issue of "sane or insane" in insurance contracts has probably become irrelevant. Mental disorders are important as part of the suicide constellation, as one element of many interacting factors. The capacity to have the intent to commit suicide--that is, to understand the physical nature of one's own death--is lost due to mental disorders only under special and unique circumstances.
The authors surveyed all U.S. medical schools to ascertain the frequency with which medical students attempt suicide, complete suicide, and seek psychiatric treatment. In the classes of 1974-1981 the annual suicide rate for male students was 15.6 per 100,000, which is comparable to their agemates in the national population. The rate for female students equaled that of the male students but was three to four times that of their agemates. Seventy-six percent of the suicides were committed by sophomore and junior students, and 50% were committed in November, December, or January. The authors discuss four steps schools can take in suicidal prevention.