Suicide among doctors: risks and barriers to care

A colleague stops showing up at meetings, answers messages late and seems more irritable on shifts. Someone comments that he has been tired, another says it is just a phase. Nobody asks him directly how he is doing. Doctors know how to recognize depression in patients, but often do not recognize it in colleagues, nor in themselves.

Suicide among doctors is a difficult topic, surrounded by silence. Studies show that doctors are not immune to mental illness and that some features of training and work increase the risk. They also show that many take a long time to ask for help, out of fear, shame or lack of time.

This text reviews what is known about the risk of suicide among doctors and medical students, the associated factors, the barriers to care and what colleagues, schools and services can do. If you are thinking about taking your own life, seek an emergency service now, an emotional support service in your region or someone you trust.

Key points

• Doctors are not immune to mental illness, and female doctors have a higher risk of suicide than women in the general population.
• The risk among male doctors has decreased over the decades, but it remains high compared with other professions.
• Depression and burnout are the strongest factors for suicidal ideation in medical students.
• Fear of breach of confidentiality, of harm to the career and stigma keep doctors away from care.
• Fear of asking for help keeps doctors away from care; positive working relationships and services the doctor trusts help reduce stigma (Carrieri and colleagues, 2020).
• Asking directly about suicidal thoughts did not increase suicidal ideation in the reviewed studies (Dazzi and colleagues, 2014).

What the numbers show

A review published in 2021 gathered the literature on mental illness and suicide among doctors (Harvey and colleagues, 2021). It shows that, despite what training may suggest, doctors are not immune to mental illness: between a quarter and a third report an increase in symptoms. Doctors, especially female doctors, have an increased risk of suicide.

A 2019 meta-analysis calculated a standardized mortality ratio of 1.44 for suicide among doctors, with a confidence interval of 1.16 to 1.72 (Dutheil and colleagues, 2019). This means more deaths by suicide than expected for the general population. Women had a higher risk, with a ratio of 1.9. The risk decreased over time, especially in Europe, and the heterogeneity between studies was high.

The same meta-analysis estimated that 17 out of every 100 doctors reported suicidal ideation, with an interval of 12 to 21 (Dutheil and colleagues, 2019). Some specialties may have a higher risk, such as anesthesiology, psychiatry, family medicine and general surgery. The authors conclude that prevention in the workplace should be a priority.

It is worth remembering what these numbers measure. The standardized mortality ratio compares the deaths observed among doctors with those expected for people of the same age and sex in the general population. A value above 1 indicates excess deaths. Because the studies come from different countries, periods and recording systems, the final estimate is an average with a lot of variation behind it.

Men and women

A more recent meta-analysis, from 2024, gathered 39 studies from 20 countries, with 3303 suicides in male doctors and 587 in female doctors, over observation periods ranging from 1935 to 2020 (Zimmermann and colleagues, 2024). For men, the rate ratio compared with the general population was 1.05, with an interval of 0.90 to 1.22, that is, with no significant difference. For women, the ratio was 1.76, with an interval of 1.40 to 2.21.

The study showed that the ratios decreased over time for both sexes (Zimmermann and colleagues, 2024). But when compared with other professions, and not with the general population, male doctors had a ratio of 1.81, with an interval of 1.55 to 2.12. The authors point out that studies from regions outside Europe, the United States and Australasia are lacking, which includes Brazil.

These numbers help to overturn two opposing ideas. The first is that physicians, because they have job security and prestige, would be protected. The second is that every physician runs a much higher risk than the rest of the population. Reality lies in between: the risk exists, it is higher among female physicians and it deserves specific prevention.

An editorial on physician suicide during the pandemic recalls that the rate of suicidal ideation among physicians is nearly twice that of the general population (Laboe et al., 2021). The authors link this picture to burnout, tied to increased workload, bureaucracy and time spent on the electronic health record.

For Brazil, the main lesson is the gap. Without good-quality local data, it is impossible to know whether the pattern seen in Europe, the United States and Australasia repeats here (Zimmermann et al., 2024). This does not lessen the urgency of prevention, but it calls for caution with imported numbers and for support of national research.

Risk factors

The reasons for suicide are many and intertwined. A narrative review divides them into three broad groups (Ventriglio et al., 2020). The first gathers personal reasons, such as psychiatric disorders, lack of support at work, exposure to trauma and a sense of losing control. The second gathers structural reasons, such as excessive management, the electronic health record, bureaucracy and rushed consultations. The third gathers sociocultural factors, such as the difficulty of taking time off, resting and finding safe spaces to talk.

A physician who runs a confidential service for physicians in the United Kingdom describes risk factors specific to the profession (Gerada, 2018). Physicians are selected for traits that predict good performance, such as perfectionism, obsessiveness and even elements of self-sacrifice, and these traits can turn against them. Under stress, competitiveness and individualism become excessive, and the physician blames themselves for failing to deliver the care they think the patient deserves.

The same author recalls that physicians are as exposed as anyone to genetic predisposition, childhood trauma, bereavement, illness and separations (Gerada, 2018). Of the roughly 3500 physicians seen by the service between 2008 and 2017, 80 in every 100 sought help for mental health problems, especially depression, anxiety and symptoms resembling post-traumatic stress.

A review of factors associated with suicide in physicians highlights long shifts, high workload, burnout and exposure to traumatic events (Rátiva Hernández et al., 2023). These stressors can lead to depression, anxiety and substance use, which raise the risk. Relationship problems, financial difficulties and a previous history of mental illness also contribute.

Anhedonia and dissatisfaction

A study of 557 physicians in Belgium investigated the relationship between anhedonia, the loss of the ability to feel pleasure, and suicidal behavior (Loas et al., 2018). Anhedonia had a significant relationship with suicidal ideation and attempts, even after accounting for depressive symptoms. It also mediated the relationship between suicidal ideation and the feeling of being a burden to others or of not belonging.

Among the components of anhedonia, dissatisfaction was related to suicidal ideation (Loas et al., 2018). The authors suggest that dissatisfaction, especially at work, be explored as an important predictor of suicidal ideation in physicians. In practice, a colleague who has lost the taste for what they did deserves attention, and not just advice to take a vacation.

The 2021 review also points out that part of the risk may be linked to access to highly lethal means, since other professionals with similar access, such as nurses, dentists and pharmacists, also have high rates (Harvey et al., 2021). Restricting access to lethal means is one of the prevention strategies with the best evidence in the general population (Mann et al., 2021).

In the case of anesthesiologists, the review notes that the apparent risk seems to result from the combination of more psychological distress with access to lethal means (Harvey et al., 2021). It is still unclear whether the pattern by specialty is due to more illness, more access to means, more barriers to care or a combination of these factors.

Medical students

The risk begins before graduation. A narrative review on suicide in medical students points to structural factors, such as curriculum, housing, social support and academic pressure (Watson et al., 2020). Among the interpersonal factors are isolation, competitiveness and leaving home early. There are also factors specific to training, such as working with cadavers and exposure to trauma during clerkships.

A meta-analysis gathered 25 studies, out of 4053 articles found, on risk factors for suicidal ideation and attempts in medical students (Seo et al., 2021). Depression was the strongest factor, with an odds ratio of 6.87 for ideation (range 4.80 to 9.82) and 9.34 for attempts (range 4.18 to 20.90). Burnout had an odds ratio of 6.29 for ideation (range 2.05 to 19.30).

Associated mental illness and stress were also associated with ideation (Seo et al., 2021). These data reinforce the importance of recognizing burnout in medical school early, before it adds to other factors. The narrative review also notes that rates seem higher among female students, which raises questions about gender expectations in medicine (Watson et al., 2020).

Why doctors take a long time to ask for help

The few published studies estimate that only 13 to 36 out of every 100 doctors with mental disorders seek help (Harvey et al., 2021). The main barriers are fear of breach of confidentiality, consequences for career and professional registration, lack of time and the belief that they can handle symptoms alone. Qualitative studies show frequent self-stigma, fed by the idea that a doctor must be invincible.

A narrative review sums up the problem in a few lines (Ventriglio et al., 2020). First, stigma against mental illness. Second, the perception that doctors should take care of themselves and that asking for help is a sign of weakness. Third, the lack of formal processes that encourage seeking help, together with concern about confidentiality and about the involvement of regulatory bodies.

What doctors report

A study in Australia interviewed 15 doctors in their second year after graduation, at three teaching hospitals (Forbes et al., 2019). They described embarrassment at being seen by another doctor, the tendency to minimize their own illness, the convenience of corridor consultations with colleagues and the lack of time to book an appointment. They also spoke of fear of losing confidentiality and the difficulty of finding a doctor unconnected to their own work environment.

The authors conclude that system and culture factors affect the health of young doctors, and that self-stigma weighs especially on this group (Forbes et al., 2019). The same study identified experiences of harassment and intimidation among the central themes linked to well-being.

A British realist review gathered 179 studies on mental illness among doctors and medical students (Carrieri et al., 2020). The analysis showed that doctors become ill more often when they feel isolated, when they cannot do the work they trained for and when they fear the consequences of asking for help. In a culture where becoming ill is seen as a lack of professionalism, doctors feel shame or fear and start hiding their difficulties from themselves and from colleagues. Even when there is a support service, those who know the system and know that confidentiality is hard to guarantee may fear harm to their career and prefer to hide their suffering.

The same review pointed out what helps (Carrieri et al., 2020). Positive working relationships and well-functioning groups make vulnerability more acceptable and reduce stigma. Support offered at the right moment, for example after a suicide attempt or the death of a colleague, can lessen the intensity of illness. And physicians only trust a service when it has leadership support, is run by professionals prepared to care for physicians, and includes physicians themselves in its design. These are points where services and schools can act.

What works in prevention

A systematic review of suicide prevention strategies in the general population offers useful lessons for those treating patients and for those caring for colleagues (Mann et al., 2021). Primary care and other non-psychiatric physicians see 45 out of every 100 people who die by suicide in the 30 days before death, and 77 out of every 100 in the 12 months before.

That is why training non-psychiatric physicians to recognize and treat depression reduced suicide rates in several studies (Mann et al., 2021). Active follow-up of patients after discharge or a suicidal crisis also prevented suicidal behavior, as did restricting access to lethal means and some psychotherapies. The text on suicide risk details what clinical assessment can capture.

These strategies were studied in patients, but the logic holds for physicians. A physician in distress is also someone's patient, and the colleague caring for them needs to recognize depression, ask about thoughts of death and ensure follow-up. The fact that the patient is a physician should not shorten the consultation or lead to skipping difficult questions.

A model at several levels

The 2021 review proposes an integrated model of individual and organizational interventions, applied in medical schools, health services and among colleagues (Harvey et al., 2021). The authors highlight the urgent need for interventions at the organizational level. They recall a particularity: many physicians do not have a single direct boss, because they answer to a service, a training institution and a regulatory body at the same time.

Residents also change colleagues, supervisors and workplaces frequently (Harvey et al., 2021). This makes it harder for anyone to notice behavior changes over time. Prevention programs need to take this fragmentation into account and create stable points of contact.

The model described in the review goes from prevention to recovery and return to work (Harvey et al., 2021). That last point is often forgotten. Returning to shifts after leave for mental illness requires planning, workload adjustment and follow-up, and the way the team receives the colleague weighs on recovery.

The narrative review on suicide among physicians concludes that changes must be both systemic and individual (Ventriglio et al., 2020). Workplace culture and social expectations must change, and clinical, educational and managerial support must be available. Self-care and support among colleagues help, but they do not replace structures that deal with stress and its causes.

What to do in practice

For physicians who are suffering, the most important step is to tell someone. It can be a trusted colleague, a family physician with no connection to their work, a mental health service or an emotional support service. Fear that confidentiality will not be respected keeps many physicians away from care, and that is why trust in the chosen service matters (Carrieri et al., 2020).

For anyone who notices a colleague in distress, it is worth asking directly. Changes in behavior, isolation, irritability, loss of interest in work and comments about being a burden are signs that deserve a conversation (Loas et al., 2018). A review of 13 studies with adolescents and adults, from the general population and from risk groups, found no significant increase in suicidal ideation among those who were asked about these thoughts, and suggests that talking about the subject may even reduce it (Dazzi et al., 2014). If there is immediate risk, the person should not be left alone and needs urgent assessment.

It is also worth looking at your own sleep, workload and alcohol use. No one needs to wait until reaching the limit to talk to a professional.

For schools and services, measures include protected time for appointments, confidential access to mental health care, supervisors trained to recognize signs and a culture that treats illness as a health issue, not a matter of character (Harvey et al., 2021; Carrieri et al., 2020). After a mistake, support for the second victim is also part of prevention.

Level	Common barrier	What helps
Individual	Self-stigma and the belief that one must solve it alone	Talk to someone you trust, see a doctor with no connection to work
Colleagues	Silence and fear of invading privacy	Ask directly, listen without judging, follow through to care
Medical school	Competition, isolation and academic pressure	Social support, screening for depression and burnout, accessible services
Health service	Lack of time, fear of harm to career	Protected time, confidential care, supportive supervisors
System	Bureaucracy, excessive workload and a culture of invincibility	Organizational changes and open culture about mental health

Mistakes that repeat

The first mistake is thinking that doctors are protected by knowledge. Knowing how to recognize depression in patients does not prevent illness, and self-stigma can delay the diagnosis in oneself (Harvey et al., 2021).

The second mistake is treating distress as weakness. The idea that asking for help is a sign of weakness appears in several studies as a central barrier (Ventriglio et al., 2020; Forbes et al., 2019).

The third mistake is relying only on individual resilience. The studies call for changes in the organization of work, not just self-care programs (Harvey et al., 2021; Ventriglio et al., 2020).

The fourth mistake is forgetting students. Depression and burnout already appear as strong factors for suicidal ideation during medical school (Seo et al., 2021).

How NEXO helps train this reasoning

In NEXO, the case of the day is fictional, with a real clinical presentation and up to six progressive clues, and you propose the diagnosis by searching for the ICD-10 code.

The limits of using the game are described on the NEXO economy page. If you research the teaching of clinical reasoning, the page for researchers explains how to get in touch. Professionals who write or review cases find information on curation and on creators, and institutions can learn about the proposal on the partnerships page. Training differential diagnosis with clues and searching for the right ICD-10 code complete this practice.

Frequently asked questions

Do doctors have a higher suicide risk than the general population?

Female doctors do, with a clearly higher risk than that of women in the general population. Among men, the most recent meta-analyses show rates close to those of the general population, but higher than those of other professions. The risk has decreased over the decades.

Why do doctors take so long to ask for help?

For fear of breach of confidentiality, of harm to career and license, lack of time, self-stigma and the belief that they can solve it alone. The culture of invincibility in medicine reinforces these barriers.

Are medical students also at risk?

Yes. Depression and burnout are the strongest factors for suicidal ideation in medical students, and factors from training, such as competition and isolation, contribute.

Can asking about suicide make the situation worse?

The reviewed studies indicate not. None of the 13 studies gathered in a review found a significant increase in suicidal ideation after the question, and talking about the subject may even reduce it (Dazzi et al., 2014).

What should I do if I am thinking about suicide?

Seek help now: an emergency service, an emotional support service in your region, your doctor or someone you trust. You do not have to face this alone.

Take-home messages

• Doctors are not immune to mental illness, and female doctors have an increased risk of suicide.
• The risk among male doctors has fallen over time, but it remains higher than that of other professions.
• Depression and burnout are strong factors for suicidal ideation as early as medical school.
• Stigma, fear of harm to one's career and lack of time keep doctors away from care.
• Positive working relationships, support at the right moment and services the doctor trusts help reduce illness (Carrieri et al., 2020).
• Prevention requires changes in the organization, not only individual resilience.

References

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