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Taking Their Own Lives — The High Rate of Physician Suicide

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n engl j med
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PERSPECTIVE
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
services?
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
conquest.
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.
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PERSPECTIVE
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-
dents,
2
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.
1
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-
phrenia.
3
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.
4
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-
fession.
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.
5
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
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PERSPECTIVE
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
declining.
5
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.
1
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
BA
Taking Their Own Lives — The High Rate of Physician Suicide
n engl j med
352;24
www.nejm.org june
16, 2005
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PERSPECTIVE
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.
1.
Schernhammer ES, Colditz GA. Suicide rates among physi-
cians: a quantitative and gender assessment (meta-analysis).
Am J Psychiatry 2004;161:2295-302.
2.
Pepitone-Arreola-Rockwell F, Rockwell D, Core N. Fifty-two
medical student suicides. Am J Psychiatry 1981;138:198-201.
3.
Litman RE. Mental disorders and suicidal intention. Suicide
Life Threat Behav 1987;17:85-92.
4.
Kirsling RA, Kochar MS. Suicide and the stress of residency
training: a case report and review of the literature. Psychol Rep
1989;64:951-9.
5.
Frank E, Brogan D, Schiffman M. Prevalence and correlates
of harassment among US women physicians. Arch Intern Med
1998;158:352-8.
Taking Their Own Lives — The High Rate of Physician Suicide
... Healthcare providers are of these high-risk populations, and pharmacists, dentists, and doctors are among the high-risk occupations for suicide [17]. Studies on the prevalence of suicidal ideation and suicide risk among medical doctors of different countries have indicated a higher risk of suicide in this population compared to the general population [18][19][20][21][22][23][24]. In their first year at medical school, the prevalence of psychological issues, which are the main risk factors for suicidal ideation, in medical students is not significantly different from those of the same age [25][26][27]. ...
... However, the situation worsens during medical school education. In the later years of education, the prevalence of suicidal ideation increases in medical students, which may be a reason for the higher risk of suicidal ideation among doctors [23,28]. Many studies have evaluated suicidal ideation and its possible risk factors among medical students. ...
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Objectives. This study is aimed at comparing the prevalence of suicidal ideation among Iranian medical, dental, and pharmacy students and determining the demographic and basic characteristics and mental and psychological issues associated with suicidal ideation in these students. Methods. This cross-sectional online survey was conducted during the 2020-2021 academic year on medical, dental, and pharmacy students studying at the Tehran University of Medical Sciences (TUMS). The questionnaire consisted of six sections: Beck Hopelessness Scale (BHS), General Health Questionnaire (GHQ), Perceived Stress Scale (PSS), UCLA loneliness scale, Maslach Burnout Inventory-Student Survey (MBI-SS), and a questionnaire that was designed to evaluate students’ family history, current psychological status, and basic and demographic characteristics. Results. In total, 419 students participated in our study, with 133 (31.7%) being medical students, 85 (20.3%) being pharmacy students, and 201 (48%) being dental students. In our study, the prevalence of suicidal ideation was 32%. Family history of psychological issues ( OR = 2.186 , P =0.012), current or past smoking ( OR = 2.155 , P = 0.01 ), parents not living together ( OR = 2.512 , P = 0.046 ), and satisfaction with the current field ( OR = 0.51 , P < 0.001 ) were all independently associated with the presence of suicidal ideation. Also, higher scores in BHS ( OR = 1.167 , P < 0.001 ), PSS ( OR = 1.081 , P = 0.001 ), and UCLA loneliness scale ( OR = 1.057 , P < 0.001 ) were independently associated with a higher risk of suicidal ideation. Conclusion. The prevalence of suicidal ideation among Iranian medical, dental, and pharmacy students is relatively high and has increased during recent years, which needs emergent action.
... Public safety personnel (PSP) and healthcare workers (HCWs) are exposed to potentially traumatic events in the line of duty, including routine exposure to human suffering. This puts them at high risk for negative mental health outcomes such as posttraumatic stress injury/disorder, compassion fatigue, and burnout [1][2][3][4][5][6][7]. This paper reports on the findings of a narrative literature review that framed the development of a novel wellness program for public safety personnel (PSP) and healthcare workers (HCWs), and details the components of the program. ...
... A 2003 study revealed that 45% of Canadian physicians report advanced states of burnout [33]; this longstanding issue has only been exacerbated by the COVID-19 pandemic [34][35][36]. Depression, PTSI, substance use, and suicide are also more common in HCWs than in the general population, with an even higher risk following adverse events, critical incidents, and disasters (e.g., pandemics) [4,7,32,[37][38][39][40][41][42][43][44][45][46][47][48]. In one study, 33% of Canadian nurses reported thoughts of suicide, and 8% had attempted suicide. ...
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Public safety personnel (PSP) and healthcare workers (HCWs) are frequently exposed to traumatic events and experience an increased rate of adverse mental health outcomes compared to the public. Some organizations have implemented wellness programming to mitigate this issue. To our knowledge, no programs were developed collaboratively by researchers and knowledge users considering knowledge translation and implementation science frameworks to include all evidence-informed elements of posttraumatic stress prevention. The Social Support, Tracking Distress, Education, and Discussion Community (STEADY) Program was developed to fill this gap. It includes (1) peer partnering; (2) distress tracking; (3) psychoeducation; (4) peer support groups and voluntary psychological debriefing following critical incidents; (5) community-building activities. This paper reports on the narrative literature review that framed the development of the STEADY framework and introduces its key elements. If successful, STEADY has the potential to improve the mental well-being of PSP and HCWs across Canada and internationally.
... In comparison to the general population, HCPs have some of the highest rates of work-related mental health issues [5,8,9] and the highest suicide rates of any occupational group in England and Wales [10]. This has been estimated to be two to five times that of the general population [11,12]. ...
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Background The mental health of healthcare professionals is reaching a breaking point, and the COVID-19 pandemic has exacerbated current mental health issues to unprecedented levels. Whilst some research has been carried out on the barriers that doctors face when seeking mental health help, there is little research into factors which may facilitate seeking help. We aimed to expand the research base on factors which act as barriers to seeking help, as well as gain insight into facilitators of help-seeking behaviour for mental health in NHS doctors. Methods We conducted a systematic literature review which identified the barriers and facilitators to seeking help for mental health in healthcare professionals. Following this, we conducted semi-structured interviews with 31 NHS doctors about their experiences with mental health services. Finally, through thematic analysis, key themes were synthesised from the data. Results Our systematic literature review uncovered barriers and facilitators from pre-existing literature, of which the barriers were: preventing actions, self-stigma, perceived stigma, costs of seeking treatment, lack of awareness and availability of support, negative career implications, confidentiality concerns and a lack of time to seek help. Only two facilitators were found in the pre-existing literature, a positive work environment and availability of support services. Our qualitative study uncovered additional barriers and facilitators, of which the identified barriers include: a negative workplace culture, lack of openness, expectations of doctors and generational differences. The facilitators include positive views about mental health, external confidential service, better patient outcomes, protected time, greater awareness and accessibility, open culture and supportive supervisors. Conclusion Our study began by identifying barriers and facilitators to seeking mental health help in healthcare workers, through our systematic literature review. We contributed to these findings by identifying themes in qualitative data.. Our findings are crucial to identify factors preventing NHS doctors from seeking help for their mental health so that more can be done on a national, trust-wide and personal level to overcome these barriers. Likewise, further research into facilitators is key to encourage doctors to reach out and seek help for their mental health.
... A taxa de suicídio entre os médicos do sexo masculino é cerca de 40% maior quando comparada aos homens na população geral, enquanto o sexo feminino apresenta 130% a mais de risco em relação às mulheres da população geral 8,9 . Esse aumento da taxa de suicídio entre os médicos pode começar -inclusivedurante a faculdade de Medicina 10 . ...
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... ⇒ 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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“The disruptive surgeon” is a phrase we have all heard. Some of us may have been labeled as “a disruptive surgeon” ourselves. The disruptive surgeon is a definite threat to quality, outcomes, and safety in the operating room and beyond. Disruptive behavior is driven by multiple factors. Nearly 70% of sentinel events can be traced back to a problem with communication. Disruptive behavior can cause significant psychologic and behavioral disturbances that can have a critical effect on focus, concentration, collaboration, communication, and information transfer, which can lead to potentially preventable adverse events, errors, compromises in safety and quality, and patient mortality. These adverse events or patient mortality can lead to a decline in physician wellness, which can worsen the cycle of disruptive behavior. Disruptive behavior undermines teamwork and collegiality, which can lead to medical errors. Healthcare leaders and institutions must set expectations for professional behavior, enforce policies, and invest resources in programs to help distressed and disruptive physicians. The ideal solution would aim to prevent the disruptive behavior before it starts and focus on early identification and remediation. It is crucial to point out that while much of the literature focuses on the disruptive physician, disruptive behavior is not limited to physicians or surgeons. Disruptive behavior in other members of the healthcare team can equally impact patient safety and outcomes.KeywordsDisruptive behaviorDisruptive surgeon
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Objective: Physicians &apos; 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 &apos; 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.
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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.
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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.
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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.