Acad Psychiatry DOI 10.1007/s40596-014-0075-1
EMPIRICAL REPORT
A National Survey of Medical Student Suicides Jacklyn Cheng & Shelley Kumar & Elizabeth Nelson & Toi Harris & John Coverdale
Received: 7 March 2013 / Accepted: 2 July 2013 # Academic Psychiatry 2014
Abstract Objective Because there is no current information on medical student suicides, the authors surveyed US medical schools about deaths by suicide of medical students from June 2006 to July 2011. Methods In spring through summer of 2012, the authors sent electronic surveys to the 133 accredited US allopathic medical schools at the time, excluding Puerto Rican schools. The 15item survey included questions about deaths by suicide and deaths by means other than suicide. In the case of a reported suicide, the survey obtained information regarding demographic characteristics and method of suicide. Results The 90 responding schools (response rate 69 %) reported a total of six suicides (four males, two females; five Caucasians, one Asian) from July 2006 to June 2011. Two deaths by suicide occurred in first year, two in second year, and two in third year. Two of the suicides occurred by gunshot, two by hanging, one by overdose, and for one, the cause of death was unknown. Three of the six students left a suicide note. Conclusion Although the number and rate of suicides among medical students may be lower than a prior survey that was conducted more than 15 years ago, these data affirm the importance of suicide prevention programs for medical students. Keywords Medical students . Suicide . Medical schools In 2010, suicide was the tenth leading cause of death in the USA with 37,793 attributed deaths [1]. It is the second leading cause of death for the 25–34 age group (second to J. Cheng : S. Kumar : E. Nelson : T. Harris : J. Coverdale (*) Baylor College of Medicine, Houston, TX, USA e-mail: [email protected] J. Cheng e-mail: [email protected]
unintentional injuries) with 5,735 attributable deaths and the third leading cause of death for 15–24 age group with 4,600 attributable deaths in 2010 [2]. Substantial numbers of medical students experience depression and suicidal ideation in the USA [3–7] and other countries [8–11]. There is also a higher prevalence of psychological distress among medical students compared to the general population and age-matched peers [3, 12]. Suicidal ideation is one possible consequence of psychological stress and burnout in medical students [5], and the presence of depression and suicidal ideation increases the risk for suicidal behavior [13–18]. Despite the importance of enumerating deaths by suicide of medical students, only four previous national surveys with such data have been conducted in the USA. Simon et al. found that of 163 medical student deaths that occurred in 1947 through 1967, 31 were suicides (19 %) and suicide was the second most common cause of deaths after accidental deaths [19]. A subsequent study by Everson et al. conducted in 1967 through 1971 found that of 55 total reported medical student deaths, only 26 were specified of which five were suicides [20]. In a third study by Pepitone-Arreola-Rockwell et al. conducted in 1974 through 1981, 88 responding medical schools reported 52 medical student suicides [21]. The last survey of medical school student suicides in the USA was performed in 1989 through 1994. The 101 responding medical schools of 126 total US medical schools reported 15 suicides from August 1989 through May 1994, 14 of which were by men [22]. In addition, while previous randomized controlled and controlled nonrandomized trials have sought to measure the impact of stress reduction programs in medical schools [23–34] and found reductions in stress and anxiety with several types of interventions [24, 29–35], to date, there are no surveys about medical school programs specifically designed to prevent suicide or made in response to deaths by suicide. Because the last formal national study on medical student suicide was published more than 15 years ago, we surveyed
Acad Psychiatry
US medical schools about recent deaths by suicide. We surveyed schools about suicides that had occurred within the time period of June 2006 to July 2011 in order to provide current data and to assess for changes in the frequency of deaths by suicide of medical students since the last completed survey conducted more than 15 years ago.
Methods Participants and Data Collection We conducted a cross-sectional survey of the 133 accredited US medical schools, excluding Puerto Rican schools, from spring to summer of 2012. After approval from the institutional review board of Baylor College of Medicine, we contacted one representative from each accredited school who was usually the dean of student affairs by electronic mail (email) with an explanation of the purpose and background of the research project. The survey invited them to answer an electronic survey of questions regarding knowledge of deaths by suicide of medical students between July 1, 2006 and June 30, 2011. Participation was voluntary, and we informed participants that all reported data would be anonymous. We sent reminder emails at subsequent 4-week intervals for 3 months to nonrespondents. In order to reach a higher response rate, we contacted individuals from medical schools who had not yet completed the survey by telephone after 3 months. Participants returned surveys electronically. Data collected from the questionnaires were stored electronically and were password protected for confidentiality. The identification of the schools with completed surveys was kept only for the purpose of tracking response status and was limited to the investigators of the research project. Survey Measures For purposes of analyzing changes since the last national survey of completed medical students, questions of the survey were based on reported data of the study by Hays and Patel Table 1 Suicides among medical students for each academic year from 2006 to 2011
Data on number of medical students in reporting schools compiled from “AAMC FACTS: total enrollment by US medical school and sex” [37]
Academic year
[22]. The survey asked respondents questions concerning deaths by suicides of medical students and medical student deaths by other means during the last five academic years, July 2006 to June 2011. The survey gathered additional information about demographic characteristics of those individuals who died by suicide or had died by other means during the time period. The survey also asked respondents to report any known psychiatric history of individuals who had died by suicide. In addition to questions based on the Hays and Patel study, the survey also asked respondents about current stress reduction programs, programs designed to prevent suicide, and responses taken by schools that experienced one or more medical student suicides.
Results We obtained responses from 90 of 133 US accredited medical schools. Two schools explicitly refused to participate in the study, three schools were new and therefore could not provide any data, and the other nonparticipating schools did not respond to the several email reminders. Excluding the three new schools that could not provide any data, the overall response rate was therefore 69.2 % (90/130). The 90 responding schools reported a total of six suicides from July 2006 to June 2011 (Table 1). The overall rate of suicides was 2.3 per 100,000 enrolled medical students. Four of these reported suicides were by men (mean age = 25.3 years), age range 22–29 years. Two of these reported suicides were by women (mean age=26.5 years). Of the four reported male suicides, three students were Caucasian and one was Asian. Both the female students who died by suicide were Caucasian. The rate of female medical student suicides per 100,000 for the 5-year period was 1.63, and the rate of male medical student suicides per 100,000 for the 5-year period was 2.96. Two deaths by suicide occurred in first year, two in second year, and two in third year. One death by suicide occurred while a third year student was on leave from school. Two of the suicides occurred by gunshot, two by hanging, and
Number of medical students in reporting schools
Number of suicides among women
Number of suicides among men
Total
Women
Men
Total
Per 100,000
Total
Per 100,000
2006–2007
49,690
23,961
25,729
0
0
0
0
2007–2008 2008–2009 2009–2010 2010–2011
50,633 51,574 52,698 53,568
24,244 24,533 24,986 25,197
26,389 27,041 27,712 28,371
0 0 2 0
0 0.0 8.0 0.0
1 1 1 1
3.8 3.7 3.6 3.5
Acad Psychiatry Table 2 2006–2010 suicide rates for 20–24-, 25–29-, and 30–34year-olds in the USA by sex and race
Data from “Underlying cause of death 1999–2010” on CDC Wonder online database [2]
Age (years)
20–24 25–29 30–34
Number of suicides per 100,000 population in 2006–2010 Total
White men
White women
Black men
Black women
Asian men
Asian women
12.8 13.2 13.1
22.6 23.2 23.5
4.2 5.3 6.0
15.4 15.7 14.9
2.6 2.7 2.2
12.4 10.1 9.1
4.4 4.2 4.1
one by overdose. For one, the cause of death was unknown. Three of these six students left a suicide note (in the remaining three cases, information was not available about the presence of suicide note). Three of these six reported suicides had a reported presence of psychiatric morbidity (there was no information about psychiatric morbidity in one case). Two students were reported to have major depression. There were no reported cases of substance/alcohol abuse in all the six deaths. None of the six students were married. The 90 responding schools reported 40 deaths due to causes other than suicide, 21 of whom were male. Seventeen of the 40 students died because of unintentional injuries (motor vehicle accidents, drowning, caving, and other accidents), 10 from cancer, and 1 individual each from cardiac arrest, neurological disorder, pulmonary embolism, seizure, homicide, and heart defect. The vast majority of the responding schools (n=83, 92 %) reported that they provided formal stress reduction programs for medical students. At least seven schools reported no formal stress reduction programs. Several schools discussed actions taken in response to medical student suicide including a review and revision of “university procedures in response to death of student protocol.” One school reported that representatives from the university counseling center and employee assistance program (EAP) met with students and faculty as a group and individually and “intensified suicide risk and QPR [Question, Persuade, and Refer] training” for students. Taking into consideration that the suicide occurred in association with the receipt of a board score, the same school also “modified notification procedures” and made “recommendations for notification changes to the NRMP [National Resident Matching Program].” Another school responded to a suicide with “intensive support sessions” for students, as well as by increasing the advertising of the counseling services and by increasing the availability of stress reduction programs.
Discussion Six medical student deaths by suicide were reported over the 5-year period from 2006 to 2011, including four men, five Caucasians, and one Asian. In keeping with national data on leading causes of death for persons of comparable
ages (Tables 2 and 3), many more medical students died of unintentional injuries including one homicide within the period of study. Although our study used the same methodology (except the method of survey) and many of the same questions as the study conducted during the 1989 to 1994 period [22], and obtained a very adequate response rate of 69 %, nine fewer medical student suicides were reported. The rate of medical student suicides per 100,000 for this 5-year period was 2.3 which compared to a rate of 5.9 for the earlier study [22]. However, the rate of female medical student suicides per 100,000 for the 5-year period Table 3 Leading causes of death for 20–24-, 25–29-, and 30–34-yearolds in the USA in 2006–2010 Number of deaths per 100,000 population Total
Men
Women
20–24 years Total Unintentional injury Homicide Suicide Cancer Heart disease
93.3 40.4 14.8 12.8 4.6 3.3
61.4 25.2 21.2 5.6 4.4
18.5 4.1 3.9 3.6 2.2
25–29 years Total Unintentional injury Suicide Homicide Cancer Heart disease
99.8 37.9 13.2 12.5 6.7 5.9
57.8 21.3 21.0 7.2 7.9
17.7 4.9 3.9 6.2 3.8
30–34 years Total Unintentional injury Suicide Cancer Heart disease Homicide
112.0 34.8 13.3 11.3 10.4 9.9
51.7 21.4 10.4 14.2 16.4
17.7 5.2 12.1 6.6 3.3
Data from “Underlying cause of death 1999–2010” on CDC Wonder online database by age and cause of death [2]
Acad Psychiatry
of 1.63 was higher than the rate of 1.03 in the previous study, while the rate of male medical student suicides per 100,000 for the 5-year period of 2.96 was lower than the rate of 8.80 in the previous study. Nevertheless, the suicide rates for all medical students, female medical students, and male medical students were all less than those calculated for White men and women, Black men, and Asian men and women in the age range brackets of 20–24, 25–29, and 30– 34 in 2006–2010 (Table 2) [2]. There are several possible explanations for the finding of a relative reduction in rate in medical student suicides between the two time periods. First, although we lack comparative data, it is possible that the experience of stress and the prevalence of mental disorders in medical student cohorts are becoming less over time. It is also possible that medical students are more resilient to stress compared to previous cohorts. Third, the higher proportion of female medical students now compared to 15 years ago may contribute to the lower suicide rates. Fourth, our response rate was more modest than the earlier survey [22], and our methodology was different in that we used a web-based survey. Changes in medical school demographics, health service availability, or attempts to destigmatize mental illness and its treatment may also play a role. Moreover, early identification and treatment of mental illness may conceivably play a role, and stress reduction programs and formal mental health treatment options for medical students may have become more available. However, it is difficult to judge the efficacy of stress reduction programs in terms of suicide prevention, because suicide assessment scales have not been routinely utilized as an outcome measure [35]. Of interest, firearms were used in two of the suicides. Firearms constitute the mode of about 50 % of deaths by suicide in the USA [36] and potentially contribute to suicide in circumstances of precipitous decision-making. Two of the students reportedly suffered from major depression, and a third had some unspecified mental disability. Alcohol or substance abuse was not implicated in any of the deaths by suicide. Limitations of our data include that around 31 % of the medical schools did not participate. Even though it was made clear that the data were to be handled anonymously, it is possible that some schools did not participate because of the sensitivity of the information and because of concern about possible stigma. While the number of suicides may be lower than previously reported, this may be accounted for, in part, by the methods employed (web-based survey) and the modest participation rate. Suicide rates comparing medical students with the general population were not conducted by individual year of age, race, and gender, but by relatively narrow age ranges relevant to the age ranges of medical students. Furthermore, final data on deaths by suicide in the general population for 2011 was not available at the time of the study. Because
every medical student death attributable to suicide represents a tragic and unacceptable loss, the profession should continue to strive to successfully identify and treat mental disorders in this population. Implications for Educators & The six medical student suicides affirm the importance of suicide prevention in this population. & Educator awareness and identification of signs of stress and mental illness may be an important component of medical student suicide prevention. & Educators should contribute to developing and advertising stress reduction programs.
Implications for Academic Leaders & Because every medical student death by suicide is a tragic and unacceptable loss, academic leaders should continue to strive to develop ways to successfully identify and treat mental disorders in the medical student population. & Because firearms played a role in two of the suicides and because they potentially contribute to suicide in circumstances of precipitous decision-making, academic leaders should provide counsel on access to firearms. & Academic leaders should advertise and routinely evaluate stress reduction and formal mental health treatment programs for medical students.
Acknowledgments The authors wish to thank Nancy Searle, Ed.D., who assisted in the early stages of this project. Disclosure On behalf of all the authors, the corresponding author states that there are no conflicts of interest to disclose.
References 1. Murphy SL, Xu J, Kochanek KD: Deaths: preliminary data for 2010. National Vital Statistics Reports 2012; 60 2. Centers for Disease Control and Prevention, National Center for Health Statistics: Underlying cause of death 1999–2010 on CDC WONDER online database, 2012; available at http://wonder.cdc. gov/ucd-icd10.html. accessed January 9, 2013 3. Compton MT, Carrera J, Frank E. Stress and depressive symptoms/ dysphoria among US medical students: results from a large, nationally representative survey. J Nerv Ment Dis. 2008;196:891–7. 4. Dyrbye LN, Harper W, Durning SJ, et al. Patterns of distress in US medical students. Med Teach. 2011;33:834–9. 5. Dyrbye LN, Thomas MR, Massie FS, et al. Burnout and suicidal ideation among U.S. medical students. Ann Intern Med. 2008;149: 334–41. 6. Goebert D, Thompson D, Takeshita J, et al. Depressive symptoms in medical students and residents: a multischool study. Acad Med. 2009;84:236. 7. Schwenk TL, Davis L, Wimsatt LA. Depression, stigma, and suicidal ideation in medical students. JAMA. 2010;304:1181–90.
Acad Psychiatry 8. Alexandrino-Silva C, Pereira ML, Bustamante C, et al. Suicidal ideation among students enrolled in healthcare training programs: a cross-sectional study. Rev Bras Psiquiatr. 2009;31:338–44. 9. Curran TA, Gawley E, Casey P, Gill M, Crumlish N. Depression, suicidality and alcohol abuse among medical and business students. Ir Med J. 2009;102:249–52. 10. Eskin M, Voracek M, Stieger S, Altinyazar V. A cross-cultural investigation of suicidal behavior and attitudes in Austrian and Turkish medical students. Soc Psychiatry Psychiatr Epidemiol. 2011;46:813–23. 11. Tyssen R, Vaglum P, Gronvold NT, Ekeberg O. Suicidal ideation among medical students and young physicians: a nationwide and prospective study of prevalence and predictors. J Affect Disord. 2001;64:69–79. 12. Dyrbye LN, Thomas MR, Shanafelt TD. Systematic review of depression, anxiety, and other indicators of psychological distress among US and Canadian medical students. Acad Med. 2006;81: 354–73. 13. Baca-Garcia E, Perez-Rodriguez MM, Oquendo MA, et al. Estimating risk for suicide attempt: are we asking the right questions? Passive suicidal ideation as a marker for suicidal behavior. J Affect Disord. 2011;134:327–32. 14. Beck AT, Brown GK, Steer RA, Dahlsgaard KK, Grisham JR. Suicide ideation at its worst point: a predictor of eventual suicide in psychiatric outpatients. Suicide and Life-Threatening Behav. 1999;29:1–9. 15. Blair-West GW, Cantor CH, Mellsop GW, Eyeson-Annan ML. Lifetime suicide risk in major depression: sex and age determinants. J Affect Disord. 1999;55:171–8. 16. Bulik CM, Carpenter LL, Kupfer DJ, Frank E. Features associated with suicide attempts in recurrent major depression. J Affect Disord. 1990;18:29–37. 17. Gould MS, King R, Greenwald S, et al. Psychopathology associated with suicidal ideation and attempts among children and adolescents. J Am Acad Child Adolesc Psychiatry. 1998;37:915–23. 18. Malone KM, Haas GL, Sweeney JA, Mann JJ. Major depression and the risk of attempted suicide. J Affect Disord. 1995;34:173–85. 19. Simon HJ. Mortality among medical students, 1947–1967. J Med Educ. 1968;43:1175–82. 20. Everson RB, Fraumeni Jr JF. Mortality among medical students and young physicians. J Med Educ. 1975;50:809–11. 21. Pepitone-Arreola-Rockwell F, Rockwell D, Core N. Fifty-two medical student suicides. Am J Psychiatry. 1981;138:198–201. 22. Hays LR, Cheever T, Patel P. Medical student suicide, 1989–1994. Am J Psychiatry. 1996;153:553–5. 23. Austenfeld JL, Paolo AM, Stanton AL. Effects of writing about emotions versus goals on psychological and physical health among third-year medical students. J Pers. 2006;74:267–86.
24. Bloodgood RA, Short JG, Jackson JM, Martindale JR. A change to pass/fail grading in the first two years at one medical school results in improved psychological well-being. Acad Med. 2009;84:655–62. 25. Dare AJ, Petrie KJ, Bagg W. Prepared for practice? Medical students’ perceptions of a shortened final year medical programme. N Z Med J. 2009;122:32–43. 26. Finkelstein C, Brownstein A, Scott C, Lan YL. Anxiety and stress reduction in medical education: an intervention. Med Educ. 2007;41: 258–64. 27. Guthrie E, Black D, Shaw C, Hamilton J, Creed F, Tomenson B. Psychological stress in medical students: a comparison of two very different university courses. Stress Med. 1998;13:179–84. 28. Kiessling C, Schubert B, Scheffner D, Burger W. First year medical students’ perceptions of stress and support: a comparison between reformed and traditional track curricula. Med Educ. 2004;38:504–9. 29. Reed DA, Shanafelt TD, Satele DW, et al. Relationship of pass/fail grading and curriculum structure with well-being among preclinical medical students: a multi-institutional study. Acad Med. 2011;86: 1367–73. 30. Rohe DE, Barrier PA, Clark MM, Cook DA, Vickers KS, Decker PA. The benefits of pass-fail grading on stress, mood, and group cohesion in medical students. Mayo Clin Proc. 2006;81:1443–8. 31. Rosenzweig S, Reibel DK, Greeson JM, Brainard GC, Hojat M. Mindfulness-based stress reduction lowers psychological distress in medical students. Teach Learn Med. 2003;15:88–92. 32. Shapiro SL, Schwartz GE, Bonner G. Effects of mindfulness-based stress reduction on medical and premedical students. J Behav Med. 1998;21:581–99. 33. Warnecke E, Quinn S, Ogden K, Towle N, Nelson MR. A randomised controlled trial of the effects of mindfulness practice on medical student stress levels. Med Educ. 2011;45:381–8. 34. Whitehouse WG, Dinges DF, Orne EC, et al. Psychosocial and immune effects of self-hypnosis training for stress management throughout the first semester of medical school. Psychosom Med. 1996;58:249–63. 35. Shiralkar M, Harris TB, Eddins-Folensbee FF, Coverdale JH: A systematic review of stress-management programs for medical students. Acad Psychiatry. [In Press]. 36. Centers for Disease Control and Prevention: Suicide and self-inflicted injury, 2012; available at http://www.cdc.gov/nchs/fastats/suicide. htm. accessed January 17, 2013. 37. Association of American Medical Colleges. AAMC FACTS: total enrollment by U.S. medical school and sex, 2012; available at https:// www.aamc.org/data/facts/enrollmentgraduate/158808/totalenrollment-by-medical-school-by-sex.html. accessed January 7, 2013.
EMPIRICAL REPORT
A National Survey of Medical Student Suicides Jacklyn Cheng & Shelley Kumar & Elizabeth Nelson & Toi Harris & John Coverdale
Received: 7 March 2013 / Accepted: 2 July 2013 # Academic Psychiatry 2014
Abstract Objective Because there is no current information on medical student suicides, the authors surveyed US medical schools about deaths by suicide of medical students from June 2006 to July 2011. Methods In spring through summer of 2012, the authors sent electronic surveys to the 133 accredited US allopathic medical schools at the time, excluding Puerto Rican schools. The 15item survey included questions about deaths by suicide and deaths by means other than suicide. In the case of a reported suicide, the survey obtained information regarding demographic characteristics and method of suicide. Results The 90 responding schools (response rate 69 %) reported a total of six suicides (four males, two females; five Caucasians, one Asian) from July 2006 to June 2011. Two deaths by suicide occurred in first year, two in second year, and two in third year. Two of the suicides occurred by gunshot, two by hanging, one by overdose, and for one, the cause of death was unknown. Three of the six students left a suicide note. Conclusion Although the number and rate of suicides among medical students may be lower than a prior survey that was conducted more than 15 years ago, these data affirm the importance of suicide prevention programs for medical students. Keywords Medical students . Suicide . Medical schools In 2010, suicide was the tenth leading cause of death in the USA with 37,793 attributed deaths [1]. It is the second leading cause of death for the 25–34 age group (second to J. Cheng : S. Kumar : E. Nelson : T. Harris : J. Coverdale (*) Baylor College of Medicine, Houston, TX, USA e-mail: [email protected] J. Cheng e-mail: [email protected]
unintentional injuries) with 5,735 attributable deaths and the third leading cause of death for 15–24 age group with 4,600 attributable deaths in 2010 [2]. Substantial numbers of medical students experience depression and suicidal ideation in the USA [3–7] and other countries [8–11]. There is also a higher prevalence of psychological distress among medical students compared to the general population and age-matched peers [3, 12]. Suicidal ideation is one possible consequence of psychological stress and burnout in medical students [5], and the presence of depression and suicidal ideation increases the risk for suicidal behavior [13–18]. Despite the importance of enumerating deaths by suicide of medical students, only four previous national surveys with such data have been conducted in the USA. Simon et al. found that of 163 medical student deaths that occurred in 1947 through 1967, 31 were suicides (19 %) and suicide was the second most common cause of deaths after accidental deaths [19]. A subsequent study by Everson et al. conducted in 1967 through 1971 found that of 55 total reported medical student deaths, only 26 were specified of which five were suicides [20]. In a third study by Pepitone-Arreola-Rockwell et al. conducted in 1974 through 1981, 88 responding medical schools reported 52 medical student suicides [21]. The last survey of medical school student suicides in the USA was performed in 1989 through 1994. The 101 responding medical schools of 126 total US medical schools reported 15 suicides from August 1989 through May 1994, 14 of which were by men [22]. In addition, while previous randomized controlled and controlled nonrandomized trials have sought to measure the impact of stress reduction programs in medical schools [23–34] and found reductions in stress and anxiety with several types of interventions [24, 29–35], to date, there are no surveys about medical school programs specifically designed to prevent suicide or made in response to deaths by suicide. Because the last formal national study on medical student suicide was published more than 15 years ago, we surveyed
Acad Psychiatry
US medical schools about recent deaths by suicide. We surveyed schools about suicides that had occurred within the time period of June 2006 to July 2011 in order to provide current data and to assess for changes in the frequency of deaths by suicide of medical students since the last completed survey conducted more than 15 years ago.
Methods Participants and Data Collection We conducted a cross-sectional survey of the 133 accredited US medical schools, excluding Puerto Rican schools, from spring to summer of 2012. After approval from the institutional review board of Baylor College of Medicine, we contacted one representative from each accredited school who was usually the dean of student affairs by electronic mail (email) with an explanation of the purpose and background of the research project. The survey invited them to answer an electronic survey of questions regarding knowledge of deaths by suicide of medical students between July 1, 2006 and June 30, 2011. Participation was voluntary, and we informed participants that all reported data would be anonymous. We sent reminder emails at subsequent 4-week intervals for 3 months to nonrespondents. In order to reach a higher response rate, we contacted individuals from medical schools who had not yet completed the survey by telephone after 3 months. Participants returned surveys electronically. Data collected from the questionnaires were stored electronically and were password protected for confidentiality. The identification of the schools with completed surveys was kept only for the purpose of tracking response status and was limited to the investigators of the research project. Survey Measures For purposes of analyzing changes since the last national survey of completed medical students, questions of the survey were based on reported data of the study by Hays and Patel Table 1 Suicides among medical students for each academic year from 2006 to 2011
Data on number of medical students in reporting schools compiled from “AAMC FACTS: total enrollment by US medical school and sex” [37]
Academic year
[22]. The survey asked respondents questions concerning deaths by suicides of medical students and medical student deaths by other means during the last five academic years, July 2006 to June 2011. The survey gathered additional information about demographic characteristics of those individuals who died by suicide or had died by other means during the time period. The survey also asked respondents to report any known psychiatric history of individuals who had died by suicide. In addition to questions based on the Hays and Patel study, the survey also asked respondents about current stress reduction programs, programs designed to prevent suicide, and responses taken by schools that experienced one or more medical student suicides.
Results We obtained responses from 90 of 133 US accredited medical schools. Two schools explicitly refused to participate in the study, three schools were new and therefore could not provide any data, and the other nonparticipating schools did not respond to the several email reminders. Excluding the three new schools that could not provide any data, the overall response rate was therefore 69.2 % (90/130). The 90 responding schools reported a total of six suicides from July 2006 to June 2011 (Table 1). The overall rate of suicides was 2.3 per 100,000 enrolled medical students. Four of these reported suicides were by men (mean age = 25.3 years), age range 22–29 years. Two of these reported suicides were by women (mean age=26.5 years). Of the four reported male suicides, three students were Caucasian and one was Asian. Both the female students who died by suicide were Caucasian. The rate of female medical student suicides per 100,000 for the 5-year period was 1.63, and the rate of male medical student suicides per 100,000 for the 5-year period was 2.96. Two deaths by suicide occurred in first year, two in second year, and two in third year. One death by suicide occurred while a third year student was on leave from school. Two of the suicides occurred by gunshot, two by hanging, and
Number of medical students in reporting schools
Number of suicides among women
Number of suicides among men
Total
Women
Men
Total
Per 100,000
Total
Per 100,000
2006–2007
49,690
23,961
25,729
0
0
0
0
2007–2008 2008–2009 2009–2010 2010–2011
50,633 51,574 52,698 53,568
24,244 24,533 24,986 25,197
26,389 27,041 27,712 28,371
0 0 2 0
0 0.0 8.0 0.0
1 1 1 1
3.8 3.7 3.6 3.5
Acad Psychiatry Table 2 2006–2010 suicide rates for 20–24-, 25–29-, and 30–34year-olds in the USA by sex and race
Data from “Underlying cause of death 1999–2010” on CDC Wonder online database [2]
Age (years)
20–24 25–29 30–34
Number of suicides per 100,000 population in 2006–2010 Total
White men
White women
Black men
Black women
Asian men
Asian women
12.8 13.2 13.1
22.6 23.2 23.5
4.2 5.3 6.0
15.4 15.7 14.9
2.6 2.7 2.2
12.4 10.1 9.1
4.4 4.2 4.1
one by overdose. For one, the cause of death was unknown. Three of these six students left a suicide note (in the remaining three cases, information was not available about the presence of suicide note). Three of these six reported suicides had a reported presence of psychiatric morbidity (there was no information about psychiatric morbidity in one case). Two students were reported to have major depression. There were no reported cases of substance/alcohol abuse in all the six deaths. None of the six students were married. The 90 responding schools reported 40 deaths due to causes other than suicide, 21 of whom were male. Seventeen of the 40 students died because of unintentional injuries (motor vehicle accidents, drowning, caving, and other accidents), 10 from cancer, and 1 individual each from cardiac arrest, neurological disorder, pulmonary embolism, seizure, homicide, and heart defect. The vast majority of the responding schools (n=83, 92 %) reported that they provided formal stress reduction programs for medical students. At least seven schools reported no formal stress reduction programs. Several schools discussed actions taken in response to medical student suicide including a review and revision of “university procedures in response to death of student protocol.” One school reported that representatives from the university counseling center and employee assistance program (EAP) met with students and faculty as a group and individually and “intensified suicide risk and QPR [Question, Persuade, and Refer] training” for students. Taking into consideration that the suicide occurred in association with the receipt of a board score, the same school also “modified notification procedures” and made “recommendations for notification changes to the NRMP [National Resident Matching Program].” Another school responded to a suicide with “intensive support sessions” for students, as well as by increasing the advertising of the counseling services and by increasing the availability of stress reduction programs.
Discussion Six medical student deaths by suicide were reported over the 5-year period from 2006 to 2011, including four men, five Caucasians, and one Asian. In keeping with national data on leading causes of death for persons of comparable
ages (Tables 2 and 3), many more medical students died of unintentional injuries including one homicide within the period of study. Although our study used the same methodology (except the method of survey) and many of the same questions as the study conducted during the 1989 to 1994 period [22], and obtained a very adequate response rate of 69 %, nine fewer medical student suicides were reported. The rate of medical student suicides per 100,000 for this 5-year period was 2.3 which compared to a rate of 5.9 for the earlier study [22]. However, the rate of female medical student suicides per 100,000 for the 5-year period Table 3 Leading causes of death for 20–24-, 25–29-, and 30–34-yearolds in the USA in 2006–2010 Number of deaths per 100,000 population Total
Men
Women
20–24 years Total Unintentional injury Homicide Suicide Cancer Heart disease
93.3 40.4 14.8 12.8 4.6 3.3
61.4 25.2 21.2 5.6 4.4
18.5 4.1 3.9 3.6 2.2
25–29 years Total Unintentional injury Suicide Homicide Cancer Heart disease
99.8 37.9 13.2 12.5 6.7 5.9
57.8 21.3 21.0 7.2 7.9
17.7 4.9 3.9 6.2 3.8
30–34 years Total Unintentional injury Suicide Cancer Heart disease Homicide
112.0 34.8 13.3 11.3 10.4 9.9
51.7 21.4 10.4 14.2 16.4
17.7 5.2 12.1 6.6 3.3
Data from “Underlying cause of death 1999–2010” on CDC Wonder online database by age and cause of death [2]
Acad Psychiatry
of 1.63 was higher than the rate of 1.03 in the previous study, while the rate of male medical student suicides per 100,000 for the 5-year period of 2.96 was lower than the rate of 8.80 in the previous study. Nevertheless, the suicide rates for all medical students, female medical students, and male medical students were all less than those calculated for White men and women, Black men, and Asian men and women in the age range brackets of 20–24, 25–29, and 30– 34 in 2006–2010 (Table 2) [2]. There are several possible explanations for the finding of a relative reduction in rate in medical student suicides between the two time periods. First, although we lack comparative data, it is possible that the experience of stress and the prevalence of mental disorders in medical student cohorts are becoming less over time. It is also possible that medical students are more resilient to stress compared to previous cohorts. Third, the higher proportion of female medical students now compared to 15 years ago may contribute to the lower suicide rates. Fourth, our response rate was more modest than the earlier survey [22], and our methodology was different in that we used a web-based survey. Changes in medical school demographics, health service availability, or attempts to destigmatize mental illness and its treatment may also play a role. Moreover, early identification and treatment of mental illness may conceivably play a role, and stress reduction programs and formal mental health treatment options for medical students may have become more available. However, it is difficult to judge the efficacy of stress reduction programs in terms of suicide prevention, because suicide assessment scales have not been routinely utilized as an outcome measure [35]. Of interest, firearms were used in two of the suicides. Firearms constitute the mode of about 50 % of deaths by suicide in the USA [36] and potentially contribute to suicide in circumstances of precipitous decision-making. Two of the students reportedly suffered from major depression, and a third had some unspecified mental disability. Alcohol or substance abuse was not implicated in any of the deaths by suicide. Limitations of our data include that around 31 % of the medical schools did not participate. Even though it was made clear that the data were to be handled anonymously, it is possible that some schools did not participate because of the sensitivity of the information and because of concern about possible stigma. While the number of suicides may be lower than previously reported, this may be accounted for, in part, by the methods employed (web-based survey) and the modest participation rate. Suicide rates comparing medical students with the general population were not conducted by individual year of age, race, and gender, but by relatively narrow age ranges relevant to the age ranges of medical students. Furthermore, final data on deaths by suicide in the general population for 2011 was not available at the time of the study. Because
every medical student death attributable to suicide represents a tragic and unacceptable loss, the profession should continue to strive to successfully identify and treat mental disorders in this population. Implications for Educators & The six medical student suicides affirm the importance of suicide prevention in this population. & Educator awareness and identification of signs of stress and mental illness may be an important component of medical student suicide prevention. & Educators should contribute to developing and advertising stress reduction programs.
Implications for Academic Leaders & Because every medical student death by suicide is a tragic and unacceptable loss, academic leaders should continue to strive to develop ways to successfully identify and treat mental disorders in the medical student population. & Because firearms played a role in two of the suicides and because they potentially contribute to suicide in circumstances of precipitous decision-making, academic leaders should provide counsel on access to firearms. & Academic leaders should advertise and routinely evaluate stress reduction and formal mental health treatment programs for medical students.
Acknowledgments The authors wish to thank Nancy Searle, Ed.D., who assisted in the early stages of this project. Disclosure On behalf of all the authors, the corresponding author states that there are no conflicts of interest to disclose.
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