This paper contains information about suicide and/or self-harm. Please take a moment to reflect before and after reading this for your well-being.
Suicide is a major challenge to public health in the United States (U.S.) and the world (Stone & Crosby, 2014). Suicide is the leading cause of death in the U.S., with an average of 48,344 suicide deaths in 2018, and it is one of the leading causes of mortality among young people aged 15–24 globally (Michail et al., 2023; Man et al., 2021). International data indicates that the U.S. is among the countries with the highest rates of both suicide mortality and ideation, and this rate continues to rise (Davis et al., 2021). Additionally, an individual’s occupation can impose specific stressors that place them at higher risk of suicide such as in the case of healthcare workers (HCWs), which has created unprecedented consequences for both the health system as well as the public (Davis et al., 2021).
Healthcare professionals’ suicide risk can be tied to occupation-specific matters such as their highly stressful work environment, and public perception that subjects them to high levels of stress, anxiety, and depression (Garcia-Iglesias et al., 2022). In their cohort study of suicides in the US, Davis et al. (2021) found that in the year 2017-2018 nurses were 18% more likely than the general population to die by suicide. This disparity in this year was even more stark for female nurses, who were more than twice as likely to die by suicide than women in the general population (Davis et al., 2021).
From 2017-2018, an estimated 729 American nurses died by suicide, the highest number in the decade of their cohort study, and a number that would be likely to significantly increase due to the traumatic stress experienced during the COVID-19 pandemic (Davis, et al., 2021; Lee & Friese, 2021). During the pandemic many HCWs dealt with fears of infecting their loved ones, fear of the disease, felt stigmatized and isolated, suffered traumatic experiences, and faced ethical dilemmas with limited resources (Garcia-Iglesias et al., 2022). Additionally, due to the lack of available resources at the start of the pandemic many HCW’s lacked personal protective equipment (PPE), dealt with excessive patient loads coupled with difficult decision making, and witnessed high levels of patient deaths under their care (Garcia-Iglesias et al., 2022).
The mental duress many faced during this period of isolation and the intense stress experienced by healthcare workers likely contributed to the rise in suicidal ideation in HCWs in recent years. A study in Bangladesh uncovered that from April 2020 to July 2020, the prevalence of suicidal ideation increased from 5% to 19%, and overall suicidal thoughts had a prevalence of 11% among HCWs, compared to 6% in the general population (Garcia-Iglesias et al., 2022). The consequences of suicidal ideation are far reaching as they can lead to suicide attempts, or even a completion of suicide (Garcia-Iglesias et al., 2022). Additionally, such thoughts can affect professional performance due to their impact on an individual’s ability to demonstrate empathy, compassion, and active listening skills, all of which are fundamental to the quality of care provided to patients (Garcia-Iglesias et al., 2022). The psychological impact COVID-19 had on HCWs cannot be understated; the estimated prevalence of depression, anxiety, and PTSD amongst HCWs globally during 2020 was 21.7%, 22.6%, and 21.5% respectively (Li et al., 2021). Compare this to estimates from the general population: 4.4% for depression and 3.6% for anxiety disorders (including PTSD) (Li et al., 2021). This significant difference further substantiates the impact of COVID-19 on the psychological wellbeing of health care workers (Li et al., 2021).
The devastion that the early death of an indvidual by suicide has on society cannot be measured in numbers alone, yet the statistics depict a horrendous loss of life triggered by mental exhaustion. Currently, as compared to other U.S. workers, nurses are at higher risk for suicidal ideation and are less likely to seek assistance (Davis et al., 2021). The battle against suicide is not fought only on the nursing front, but a battle that physicians have struggled to overcome. An astonishing record of over 300 physicians attempt suicide every year (Kane, 2021). In a survey conducted in 2020 out of 12,339 physician respondents, 123 reported attempting suicide, and 1604 reported suicidal ideation (Kane, 2021). Currently, more than 70% of HCWs in the country have displayed symptoms of anxiety and depression, whereas within the general population the rates are much lower, at around 8% (Kane, 2021). In addition to the 38% suffering from symptoms of post-traumatic stress disorder, an additional 15% reported having had recent thoughts of suicide/self-harm (Hendrickson et al., 2022; Li et al., 2021). This has been exacerbated by medical burnout, a feeling of emotional distress, turmoil, and exhaustion related to the care they provide patients.
HCWs have long been at risk of burnout due to a number of factors within our healthcare system. The pandemic has only exacerbated these existing reasons for provider burnout: working long hours, demanding workload, inadequate staffing, emotional strain of caring for sick and dying patients, lack of support from leadership, poor collaboration/communication within the healthcare team, and emotional exhaustion (Mensik, 2021 & Shah et al., 2021). Despite being health professionals who have the amassed knowledge to diagnose and manage these conditions and stressors in their patients, the same care is often lost to themselves. Kane (2021) attributes this dichotomy to a myriad of different barriers such as: stigma around seeking mental health treatment, fear of being reported to the medical board, fear of being outed to colleagues, fear of having their illness dismissed, and lack of self awareness. A vicious cycle that has stretched the mental psyche of our health professionals and risks collapsing the most important sector of society's well-being.
In 2020, Dr. Lorna Breen, an emergency medicine physician at New York-Presbyterian Allen Hospital succumbed to the stressors of COVID-19 and died by suicide. As a result of this insurmountable loss to the medical community, the Lorna Breen Act was passed into law in 2022 establishing policies to protect the well-being of providers. The act included: grants for training HCWs and evidence-informed strategies to reduce suicide and mental health conditions, identifying and disseminating evidence-informed best practices for reducing and preventing suicide and promoting improved mental health. Additionally, it establishes a national education and awareness campaign to encourage HCWs to seek mental health treatment if needed, grants for education, peer-support programming, treatment in COVID-19 hotspots, and a comprehensive study on HCW’s mental health (The legislation - Dr. Lorna Breen Heroes Foundation, 2023). There is a need for a referendum of change within our healthcare systems to protect HCWs and prevent mental health crises, as well as substantive research into these protective factors to create a push for institutions to implement these changes.
When healthcare workers take the sacred hippocratic oath, it is a testament to do no harm and protect their patients' lives. Now they are the ones in need of the same oath from the public, protecting their mental health and creating a toxic-free work environment where they can provide safe and effective care. As the physical and psychological long-term implications of the pandemic are being studied, it is imperative to design and implement strategies that best support HCWs during crisis events. These interventions must be pragmatic, dynamic, and tailored according to individual needs. In addition, early prevention strategies, identification of at-risk individuals, and supportive workplace culture are essential to tackle the increased incidence of suicide among healthcare professionals to address current and potential future needs (Awan et al., 2022).
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