Suicide In Medical Students: Need For A National Commission

Abstract

Suicide among medical students and physicians remains a global crisis, often linked to untreated depression, academic pressure and systemic failures. Despite longstanding awareness, preventive measures remain inadequate. This column emphasizes the urgent need for psychiatric crisis intervention services and advocates for a National Commission to address suicides in India’s medical community.

“Far too many doctors, many of them excellent physicians, commit suicide each year; one recent study concluded that, until quite recently, the United States lost annually the equivalent of a medium-sized medical school class from suicide alone. Most physician suicides are due to depression or manic-depressive illness, both of which are eminently treatable. Physicians, unfortunately, not only suffer from a higher rate of mood disorders than the general population, they also have greater access to very effective means of suicide.”

― Kay Redfield Jamison

Introduction

Kay Redfield Jamison, now an internationally feted author cum behavioural scientist and her husband, late Dick Wyatt were colleagues. In fact, Dick was a frequent visitor to my research laboratory in London and both he and Kay made stellar contributions to the field of behavioural science. However, Kay only became an international celebrity when she published her bestseller “An Unquiet Mind: A Memoir of Moods and Madness”, which most succinctly elaborates on her own battle with psychiatric illness and it is she who should get a large share of credit as to why people are more open to discussions about psychiatric illnesses, which has served to minimize the stigma that inevitably the diagnosis entertains.

She is bang on! Completed suicides and attempted suicides are very common among the medical community, not just in the United States but worldwide. I recall during my medical school days, almost 55 years ago, there were at least three completed and innumerable attempted suicides and there was absolutely no attempt to look into the reasons and institute ameliorative measures.

Personal anecdotes

One of my immediate juniors, a young boy of very cheerful disposition and a very talented guitarist, attempted suicide twice by overdosing and survived. There was absolutely no attempt either by the faculty or his parents to seek psychiatric assistance. A few months later, he hanged himself in his hostel room. I was among the first to discover the tragedy and I would be inveracious if I were to claim that the incident does not haunt me from time to time-even to this day!

I recall a batchmate of mine- an anesthesia resident whose body was found in the drain outside the hospital. He had fatally injected himself. Almost a decade later, when I was working in North America, I came to know of another heart wrenching incident. A brilliant resident in orthopedic surgery fatally injected himself after doing the same with his recently married young wife. It so transpired that one of the faculty members in his department had made some very lewd remarks to his wife to which she had objected. The then head of the orthopedic department, a thoroughly unpleasant character, had informed this young boy that unless there was an apology extended to his faculty colleague, this boy would never be able to pass the exams.

I can enumerate countless other cases from the 10 countries that I have worked in which just goes on to establish that this is truly a global problem and a concerted effort needs to be made to contain this most distressing phenomenon. We simply cannot allow this to go unchecked. Very recently, the Supreme Court of India has taken cognizance and I sincerely hope the powers that be start paying attention.

After my own relocation to India, I had myself written an open letter to Prime Minister Modi requesting him to:

1. Consider appointing a mental health ombudsman.
2. To constitute a National Commission to investigate suicide among medical students.

Needless to say, nothing has happened as yet but I sincerely hope that the Supreme Court intervention would prompt the government to take a few steps in this direction.

There has been a very distressing case of a suicide by an anesthesia resident in my own mofussil town a few days ago. He leaves behind a young wife and a six-month old daughter.

Current scenario

It has been known for almost 150 years that physicians have an increased propensity to die by suicide compared with the general population. Exact numbers are not known. Although it is impossible to estimate with any precision because of inaccurate cause of death reporting and coding, an estimate often used is approximately 300 – 400 physicians/year or perhaps loss of one doctor a day to suicide in the United States. I would be surprised if the situation is any different in India. However, because of the stigma plus the fact that until very recently attempted suicide was recognized as a crime under the now defunct Indian Penal Act, it was rarely, if ever, reported. Although none of available figures can be proven conclusively, it is believed that the medical profession consistently hovers near the top of occupations with the highest risk of death by suicide. Considering the investment made in and by those who choose and the motivations that young people have for entering the profession of medicine, any figure is too high.

Sadly, although physicians globally have a lower mortality risk from other common causes such as cancer and heart disease relative to the general population (presumably related to knowledge of self-care, awareness of symptoms and access to early diagnosis), it is believed they have a significantly higher risk of dying from suicide, the end stage of an eminently treatable disease process, depression. Perhaps even more alarming is that, after accidents, suicide is the most common cause of death among medical students and male resident physicians. It is the second most common cause of death in residents overall ⁽¹⁾.

Understanding the Psychology

In every population, suicide is almost invariably the result of untreated or inadequately treated depression or other mental illness (that may or may not include substance or alcohol abuse), coupled with knowledge of and access to lethal means. Depression is at least as common in the medical profession as in the general population, affecting an estimated 12% of males and up to 19.5% of females ⁽²⁾. Depression is even more common in medical students and residents, with 15–30% of them screening positive for depressive symptoms ⁽³⁾. This is a worldwide problem. Studies from Finland, Norway, Australia, Singapore, China, Taiwan, Sri Lanka, UK, Nigeria and others have shown increased prevalence of anxiety, depression and suicidality among students and practitioners of medicine.

Because of their greater knowledge of and better access to lethal means, physicians not surprisingly have a higher suicide completion rate than the general public. Estimates of successful completion of suicide by physicians range from 1.4 to 2.3 times the rate achieved in the general population. Although female physicians attempt suicide far less often than their counterparts in the general population, their completion rate equals that of male physicians and thus, greatly exceeds that of females in the general population (2.5 – 4.1 times the rate by some estimates ⁽²⁾. A reasonable assumption is that underreporting of suicide as the cause of death by sympathetic colleagues certifying death may well skew these statistics. Most probably, the real incidence of physician suicide is somewhat higher than the prevailing estimate.

French sociologist, Emile Durkheim had conducted some pioneering work on suicidology, the concepts of which are still very much in fashion whenever we try to make sense of this very distressing phenomenon. He was the first to declare that suicide should not be seen as a homogenous entity; there are according to him 4 types of suicides ⁽⁴⁾:

a. Egoistic suicide: A prolonged sense of not belonging, of not being integrated in a community, an experience of not having a tether, an absence that can give rise to meaninglessness, apathy, melancholy and depression. He referred to this type of suicide as the result of “excessive individuation” – where the individual becomes increasingly detached from other members of his community.  These individuals are essentially loners, not bound to any social group and have no adherence to traditions and goals.

b. Altruistic suicide: Where the individual is overwhelmed by the group’s goals and beliefs. Individual interest and goals take a tertiary position. Hunger strikers who starve themselves to death fall into this category. I recall how upset my senior colleague and a pioneer in epidemiological psychiatry, Dr. Krietman was when I referred to the Irish Republican Army hunger striker Bobby Sands who died as an example of “altruistic suicide”. Perhaps because the word altruistic has a very positive connotation. Suicide bombers would also fall into this category. If I recall correctly, the only exception Durkheim makes in his book is the death in a military war.

c. Anomic suicide:  Moral confusion and lack of social direction, which is related to dramatic social and economic upheaval and lack of definition of legitimate aspirations through a restraining social ethic, which could impose meaning and order on the individual conscience.  People do not know where they fit in within their societies. This leads to a perpetual state of dejection. A major social upheaval in society leads to “anomie”, which if unchecked can lead to multiple suicides.

d. Fatalistic suicide:  Which is just the reverse of “anomic suicide”. Here the individual suffers from excessive regulation.

These four types of suicide are based on the imbalance of two social forces: social integration and moral regulation. Durkheim noted the effects of various crises on social aggregates – war, for example, leading to an increase in altruism, economic boom or disaster contributing to “anomie”.

As is evident from the instances of medical suicides I have cited, the apparent reasons vary from case to case. One of the suicides was probably due to depression which was not quite obvious to his peers, one of the others was because the person was persecuted by those in authority. But in all these cases the fundamental driving force was identical i.e. imbalance between social integration and moral regulation which had led to a feeling of ‘hopelessness’ with no light at the end of the tunnel. It has also been demonstrated that 90 percent of those who complete suicide usually convey a message that is mostly cryptic and more often than not, misunderstood by their peers.

With such a high incidence of suicide in a particular group, it is surprising that no effective ameliorative measures have been instituted as yet. While there is a National Helpline, the sad fact is that it is grossly underused probably because most people are unaware of it. In Western countries, there are Samaritan Voluntary Helplines which perform a very useful function. Unfortunately, because of the inherent structure in our society, I am not very optimistic on its efficacy within our social structure.

In addition to the ready availability of psychiatrists and psychotherapists, I firmly believe that a psychiatric crisis intervention service is badly needed not just in the main metropolitan cities but also in mofussil towns. Crisis intervention in psychiatry is a time-limited, urgent approach to help individuals experiencing a mental health crisis stabilize and return to their previous level of functioning. It involves immediate support, assessment and action planning to address the crisis and prevent potential negative impacts.

Key Aspects of Crisis Intervention in Psychiatry:

• Immediate Support: Providing emotional support, active listening and a safe space for individuals to express their feelings and experiences.
• Assessment: Evaluating the individual’s situation, including the nature of the crisis, their current level of functioning and potential risks
• Action Planning: Collaborating with the individual to develop a plan to address the immediate crisis, including coping strategies, safety measures and referrals for further support.
• Follow-up: Ensuring individuals receive appropriate ongoing care and support to facilitate their recovery and prevent future crises.

Types of Crisis Intervention

• Individual Crisis Intervention: Focuses on one-on-one support and guidance for individuals in crisis.
• Family Crisis Intervention: Addresses the needs of families experiencing a crisis, providing support and guidance to help them navigate the situation.
• Group Crisis Intervention: Offers support and coping strategies in a group setting, allowing individuals to connect with others who have similar experiences.
• Mobile Crisis Services: Provide on-site support and assessment in the community, often responding to calls for assistance.
• Crisis Hotlines: Offer immediate support and guidance over the phone, providing a safe space for individuals to talk and receive information.

Conclusion

The 10^th of September is observed as World Suicide Prevention Day. An individual expressing suicidal thoughts may be assessed for risk and provided with a safety plan involving a support system and mental health services.

Crisis intervention is not a replacement for ongoing therapy or treatment, but rather a crucial first step in managing a mental health crisis. It is essential to have trained professionals, such as mental health specialists, crisis counselors and mobile crisis teams, to provide effective crisis intervention services. Crisis intervention can be provided in various settings, including hospitals, clinics, community centers and even over the phone. These measures can assist a person navigate a crisis. However, I firmly maintain that a long-term solution to this most distressing of all problems can only be found after a thorough deliberation for which I believe a National Commission is necessary.

References and Further Reading

1. Schwenk TL: Resident Depression; The Tip of Medical Education Iceberg: JAMA (2015); 314 (22) 2357-2358.
2. FrankE, AD Dingle; Self reported attempted suicides; AmJ Psychiat.; (1999) 156(12);1887-1894.
3. Hope V, M Henderson; Medical Student Depression, Anxiety and Distress outside North America: Med.Educ. (2014),48(10),963-979.
4. W. S. F. Pickering; Geoffrey Walford; British Centre for Durkheimian Studies (2000). Durkheim’s Suicide: a century of research and debate. Psychology Press. p. 25. ISBN 978-0-415-20582-5. Retrieved 12th Aug 2025.
5. Kishor M, Chandran S, Vinay HR, Ram D. Suicide among Indian doctors. Indian J Psychiatry. 2021 May-Jun;63(3):279-284.