By Dr Tommaso Gasparello
A 45-year-old anaesthetist was found dead in the doctor’s room of his hospital after being on call the night before. An empty syringe was found next to him, and the toxicological analysis detected the presence of laudanosine (a metabolite of atracurium) both in the syringe and in samples collected from his body. The anaesthetist was on venlafaxine for depression. Based on the results of the autopsy, case history, and toxicology, the forensic pathologist ruled that the cause of death was an overdose of atracurium, and the manner of death was suicide [1].
The findings of this case report are not isolated, but part of a wider body of evidence suggesting that anaesthetists might be at increased risk of suicide when compared both to the general population and to doctors working in other specialties. However, data on this topic are often historical, and many studies report contradictory results. So, what does the latest evidence tell us about the incidence of suicide amongst anaesthetists and which could be the main reasons for the increased susceptibility?
Firstly, it is important to note that a recent meta-analysis has shown that physicians in general are more prone to suicide when compared to the general population, even though all-cause mortality is lower amongst medical practitioners [2]. The Standardised Mortality Rate (SMR i.e., the ratio of the mortality rate of the exposed cohort to the mortality rate of an unexposed control group) for physicians was 1.44 (95%CI 1.16, 1.72), with higher risk reported for female doctors (opposite to the general population) and for those practicing in the US [3].
According to the same meta-analysis, some specialties are at higher risk of suicide [3], and these include Anaesthesia, GP, Psychiatry and General Surgery. When interpreting these data, however, it should be noted that these analyses are prone to bias due to the different number of physicians within each specialty (with Anaesthetists usually representing the largest group of consultants in the hospital and GP being the most represented specialty of all). Furthermore, the studies included in this meta-analysis are all retrospective and based on health registries or self-report questionnaire [3], which rank very low in the hierarchy of evidence for clinical research.
The conversation on potentially elevated suicide rates in anaesthesia started way before the results of this meta-analysis. The first few studies on this topic were published in the ‘60s and ‘70s and reported inconclusive and contradictory results [4], [5]. The latest review addressing suicide rates specifically in Anaesthesia was published in 2021 and reported findings from 54 studies conducted after 1990 [6]. Seven studies included epidemiological data, three of which showed an increase age adjusted SMR for female anaesthesiologists but not for their male counterpart. The more recent papers included in this analysis, with data from Finland and the Netherlands, reported the proportions of anaesthetists’ deaths that were due to suicide, which ranged from 7.2% to 17%, and were noted to be higher than the proportions historically observed in the general population (which is around 2–4%) [7], [8], [9]. The largest study included in this meta-analysis comes from the US, and it analysed the causes of death of more than 40 000 anaesthetists between 1979 and 1995. The main findings are a Rate Ratio (RR) for suicide of 1.45 (95% CI 1.07-1.97, P = 0.016) when comparing anaesthetists to internists, and an even higher RR of drug-related suicide (RR 2.21,95% CI 1.33-3.66, P=0.002). As observed in the general population, suicide rates were shown to increase over time after graduation from medical school [10].
Heavy workload, unpredictable hours, having to deal with life-or-death situations, and ease of access to potentially lethal medications are the most common reasons presented to explain increase suicide rates among doctors in general [3]. Furthermore, certain personality traits common amongst physician (such as conscientiousness, commitment, and perfectionism) may contribute to this phenomenon [11], [12]. Data from the studies presented so far suggest that ease of access to potentially lethal medications might represent the main cause of the particularly elevated risk of suicide among anaesthetists. Plunkett et al. reviewed five studies with data coming from Germany, the UK, Australia, Japan, and China, which found a correlation between mode of death and specialty [6]. In particular, the Odds Ratio (OR) for overdose with an anaesthetic drug for anaesthetists was 21.30 (95%CI 6.47–72.77) when compared to doctors of other specialties [13]. The Japanese study reported that 80% of suicides amongst Japanese anaesthetists occur by poisoning, whereas this modality accounts for only 5% of suicides in the general population [14]. These results are in keeping with those included in the study by Alexander et al., which reported a RR of 2.21 for drug-related suicide among anaesthesiologists, and another study which demonstrated that half of all suicide deaths in Anaesthesia results from anaesthetic agents [13]. Furthermore, twelve case reports of suicide or suicidal attempts of fourteen Anaesthesia providers were included in the study by Dutheil et al., all of which involved IV injection of drugs commonly (and even exclusively) used in Anaesthesia. The drugs most commonly featured in these case reports are neuromuscular blocking agents and drugs used for induction, with another study reporting data from autopsies performed in Germany, Austria and Switzerland that confirmed a central role of propofol in suspected suicide cases amongst personnel working in Anaesthesia [15]. Lastly, the study by Hawton et al. added barbiturates, opioids, and the combination of paracetamol with dextropropoxyphene to the list of drugs most used for suicidal purposes.
In summary, the latest evidence supports the hypothesis that anaesthetists might be at increased risk of suicide, even though most of the studies on this topic were conducted decades ago and suffer from many methodological limitations. What seems to emerge more clearly from the data, though, is that the main reason underpinning the excess of suicides seems to be ease of access to potentially lethal medications, which are routinely used in Anaesthesia.
On a more hopeful note, over the last few years there has been a marked increase in resources available to tackle mental health issues, and the UK Association of Anaesthetists produced a guidance specifically aimed at anaesthesia departments and health care workers regarding suicide prevention and how to deal with the death of a colleague [16]. The main recommendations included in this document are:
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improving the recording and reporting of suicide as a cause of death amongst doctors,
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identifying an individual in each anaesthetic department with a lead role in supporting the mental health of the staff,
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providing ongoing education within departments and organisations about suicide,
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early involvement of specialist medical input (GP, psychiatry, occupational health) where appropriate,
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the creation of a ”safety plan” for high-risk individuals and a plan for staff-related crisis (including suicide) [16].
Where available, these recommendations are based on evidence, but for the most part they are the result of expert opinion and current “best” practice [16]. The presence of guidelines from such a respected organisation is for sure a good starting point to raise awareness on the issue of suicide amongst anaesthetists, but more studies will need to be conducted in the next few years to understand the impact of these recommendations on suicide rates and modalities amongst anaesthesia professionals.
References:
[1] M. A. Martinez, S. Ballesteros, and E. Almarza, ‘Anesthesiologist Suicide with Atracurium’, J. Anal. Toxicol., vol. 30, no. 2, pp. 120–124, Mar. 2006, doi: 10.1093/jat/30.2.120.
[2] S. P. Swanson, L. J. Roberts, and M. D. Chapman, ‘Are Anaesthetists Prone to Suicide? A Review of Rates and Risk Factors’, Anaesth. Intensive Care, vol. 31, no. 4, pp. 434–445, Aug. 2003, doi: 10.1177/0310057X0303100413.
[3] F. Dutheil et al., ‘Suicide among physicians and health-care workers: A systematic review and meta-analysis’, PLOS ONE, vol. 14, no. 12, p. e0226361, Dec. 2019, doi: 10.1371/journal.pone.0226361.
[4] H. A. Neil, J. G. Fairer, M. P. Coleman, A. Thurston, and M. P. Vessey, ‘Mortality among male anaesthetists in the United Kingdom, 1957-83.’, BMJ, vol. 295, no. 6594, pp. 360–362, Aug. 1987, doi: 10.1136/bmj.295.6594.360.
[5] D. L. Bruce, K. A. Eide, N. J. Smith, F. Seltzer, and M. H. M. Dykes, ‘A Prospective Survey of Anesthesiologist Mortality, 1967–1971’, Anesthesiology, vol. 41, no. 1, pp. 71–74, Jul. 1974, doi: 10.1097/00000542-197407000-00017.
[6] E. Plunkett, A. Costello, S. M. Yentis, and K. Hawton, ‘Suicide in anaesthetists: a systematic review’, Anaesthesia, vol. 76, no. 10, pp. 1392–1403, Oct. 2021, doi: 10.1111/anae.15514.
[7] P. Ohtonen and S. Alahuhta, ‘Mortality among Finnish anesthesiologists from 1984-2000: Mortality among Finnish anesthesiologists’, Acta Anaesthesiol. Scand., vol. 46, no. 10, pp. 1196–1199, Nov. 2002, doi: 10.1034/j.1399-6576.2002.461004.x.
[8] P. Ohtonen and S. Alahuhta, ‘Mortality rates for Finnish anaesthesiologists and paediatricians are lower than those for the general population’, Acta Anaesthesiol. Scand., vol. 61, no. 8, pp. 880–884, Sep. 2017, doi: 10.1111/aas.12936.
[9] M. Liem, L. Liem, E. P. A. van Dongen, I. C. Carels, M. van Egmond, and A. J. F. M. Kerkhof, ‘Suicide Mortality, Suicidal Ideation and Psychological Problems inDutch Anaesthesiologists’, Suicide Mortal. Suicidal Ideation Psychol. Probl. InDutch Anaesthesiol., vol. 6, no. Suicidology Online 2015, [Online]. Available: https://hdl.handle.net/1887/46948
[10] B. H. Alexander, H. Checkoway, S. I. Nagahama, and K. B. Domino, ‘Cause-specific Mortality Risks of Anesthesiologists’, Anesthesiology, vol. 93, no. 4, pp. 922–930, Oct. 2000, doi: 10.1097/00000542-200010000-00008.
[11] B. Bressler, ‘Suicide and drug abuse in the medical community’, Suicide Life. Threat. Behav., vol. 6, no. 3, pp. 169–178, 1976.
[12] G. D. Carr, ‘Physician suicide–a problem for our time’, J. Miss. State Med. Assoc., vol. 49, no. 10, pp. 308–312, Oct. 2008.
[13] K. Hawton, ‘Doctors who kill themselves: a study of the methods used for suicide’, QJM, vol. 93, no. 6, pp. 351–357, Jun. 2000, doi: 10.1093/qjmed/93.6.351.
[14] W. Hikiji and T. Fukunaga, ‘Suicide of physicians in the special wards of Tokyo Metropolitan area’, J. Forensic Leg. Med., vol. 22, pp. 37–40, Feb. 2014, doi: 10.1016/j.jflm.2013.12.022.
[15] C. Maier, J. Iwunna, M. Tsokos, and F. Mußhoff, ‘Todesfälle durch Propofolmissbrauch: Befragung in rechtsmedizinischen Instituten in Deutschland, Österreich und der Schweiz’, Anaesthesist, vol. 66, no. 2, pp. 109–114, Feb. 2017, doi: 10.1007/s00101-016-0260-6.
[16] Shinde, S., Yentis, S. M., Asanati, K., Coetzee, R. H., Cole‐King, A., Gerada, C., … & Rowland, A. (2020). Guidelines on suicide amongst anaesthetists 2019. Anaesthesia, 75(1), 96-108.
