• Study confirms most frequent method of self-murcer among health professionals is self-poisoning

By Azoma Chikwe

Several studies have indicated to an elevated risk of suicide for medical occupations such as physicians, dentists, veterinarians, and nurses compared to the general population and to other academic occupations such as education professionals. (Platt et al. 2010;
chernhammer and Colditz, 2004; Agerbo et al., 2007; Hawton et al., 2011).
In a British study of high-risk occupations for suicide, medical occupations had the highest suicide rates (per 100 000 population), including veterinarians (ranked first), pharmacists (fourth), dentists (sixth) and doctors (tenth) They had easy occupational access to a method of suicide (pharmaceuticals or guns).
In a retrospective study of suicides by health professionals in Austrialia, Alison et al (2016) found that; suicide rates for female health professionals were higher than for women in other occupations. Suicide rates for male medical practitioners were not significantly higher than for other occupations, but the suicide rate for male nurses and midwives was significantly higher than for men working outside the health professions.
The suicide rate for health professionals with ready access to prescription medications was
higher than for those in health professions without such access or in non-health professional occupations. The most frequent method of suicide used by health professionals was self-poisoning.
Today, our community is confronted with spate of unpleasant news of men and women mostly young, who end their lives in quick succession in a way that is unprecedented at least in our recent history.
Health professionals, especially doctors, are not immune to this scourge that is ravaging the
Society, further depleting the already limited number of health personnel, leaving its tolls on
families, colleagues and patients and ultimately the health of the nation.

Suicide behaviours
Suicide is the act of deliberately killing oneself.according to World Health Organisation(WHO). Derived from the Latin word for self-murder.. It is also defined as an act with fatal outcome that is deliberately initiated and performed by the person in the knowledge or expectation of its fatal outcome..
Consultant Psychiatrist, Neuropsychiatric Hospital, Aro, Abeokuta, Ogun State, Dr Oluyinka Emmanuel Majekodunmi, described suicidal behaviours as a complex process that can range from
suicidal ideation, which can be communicated through verbal or non-verbal means, to
planning, attempting and in the worst case, suicide. Influenced by interacting biological, genetic, psychological, social, environmental and situational factors.

Epidemiology
Every 40 seconds a person dies by suicide somewhere in the world. In 2012, an estimated 804 000 suicide deaths occurred worldwide, representing an annual global age-standardised suicide rate of 11.4 per 100 000 population (15.0 for males and 8.0 for females).
Nigeria’s WHO 2012 suicide rate was 6.5 deaths per 100,000 population but in 2015 the figure rose to 9.3. Estimated numbers and rates of suicide by region and the world, 2012 ,in resource rich countries, three times as many men die of suicide than women, but in
low- and middle-income countries the male-to-female ratio is much lower at 1.5 men to each woman.
On a global scale it accounts for 50 per cent of all violent deaths in men and 71 per cent in women. Rates are higher in the unemployed compared to the employed. “Rates increases during economic recessions and depressions and decreases during times of high unemployment and during wars. Suicide rates among Roman Catholic populations have been known to be lower than rates among Protestants and Jews.
“Highest rate is found among the social class 5 (unskilled workers) followed by social class I
(professionals). Among professionals, physicians are considered to be at greatest risk with higher rates among female. Other high risk occupations include law enforcement, dentists, artists, mechanics, farmers, lawyers and insurance agents,” he said.

Increased rates in Nigeria
In Nigeria, rate of suicide has been on the increase especially following the official declaration of recession. Last year August, as at September 2016, 7 out of the 36 states of
the federation recorded over 62 cases of suicide according to statistics from the Police commands. Ogun had the highest no of cases 25, followed by Lagos with 12 cases and 5 attempts, followed by Ebonyi, Delta, Oyo, Ondo and Kano.
Majekodunmi said, “Suicide is often committed by people suffering from mental disorder, and for this reason it can be an index of mental ill-health in a community. The earliest study of suicide in Nigeria was by Asuni etal.This study was based on coroners’ reports over a
four year period (1957-60) in the Western Region of Nigeria, with a population of 61 million
“Rates are higher in the unemployed compared to the employed.. rates increases during economic recessions and depressions and decreases during times of high unemployment and during wars. Suicides in Ile-Ife in 2001 was found to be 0.4 per 100,000 population with a higher incidence in males with a ratio 3.6 to 1. The majority of the victims were in the third
decade of life. Gammalin 20 and local Dane gun were the commonest means

Studies of Suicidal Behaviour
“Out of a total of 1429 adolescents screened for suicidal behaviour, over 20% reported suicidal ideation and approximately 12% reported that they had attempted suicide in the last year. Adolescents living in urban areas, from polygamous or disrupted families, had higher rates of suicidal behaviour.”
The Lagos State Mental Health Survey found a prevalence of current suicidal ideation to be 7.28 per cent. Associated factors were older age, being female, not married, low occupational group, depression, anxiety, somatic symptoms and disability. According to a report in 2016.

Suicides among Nurses
An integrative review in 2015 revealed that nursing professionals are vulnerable to
depression when young, married, performing night work and having several jobs,
and when they have a high level of education, low family income, work overload,
high stress, insufficient autonomy and a sense of professional insecurity and
conflict in the family and work relationship..

Physician suicide
Physician suicides evoke more public interest than most other suicides. Is this because physicians are expected to be superhuman, impeccable and flawless? Do some patients perceive a physician suicide as the ultimate proof of total sacrifice and devotion? Or Could it be because physicians are in charge of hospital psychiatry ?

Suicide in medical trainees
He said, “Medical training involves numerous risk factors for mental illness, such as role transition, decreased sleep, relocation resulting in fewer, available support systems, and feelings of isolation, difficulty in getting placement for rotation in some specialty.
“Inadequate job opportunity for post part II residents is a consideration. Depression is more common in medical students and residents.”
A prospective cohort study of 740 interns across 13 US hospitals found that the incidence of depression increased from 3.9% to 27.1% in the first 3 months of their intern year and their thoughts of death increased by 370%. (Sen et al. 2010)
“Among physicians, psychiatrists are considered to be at greatest risk, followed by ophthalmologists and anesthesiologists. Most common psychiatric diagnosis among those physicians that complete suicide are: depression and bipolar disorder, alcohol dependence and other substance abuse and dependence.”

Many reasons

Many reasons had been adduced for increaased suicide in physicians: ready availability of drugs, increased rate of alcohol and other psychoactive substance dependence, stresses related to work, reluctance to seek treatment for depressive disorder and other psychiatric disorders and selection into the medical profession of predisposed personalities.
Studies have also identified problem at work and financial difficulty as contributory factors marital problems, litigation Issues are common precipitants of depression.
Consultant Psychiatrist, Lagos University Teaching Hospital, LUTH, Dr Raphael Emeka Ogbolu, said, “Physicians commit suicide significantly more often by substance overdoses and less often by firearms than persons in the general population; drug availability and knowledge about toxicity are important factors .”
A review on Health problems and the use of health services among physicians with particular emphasis on Norwegian studies by Tyssen, in 2007 suggests that physicians’ physical health is similar to the general population, although female physicians tend to be in better health than other women.
Ogbolu said,“Some mental disorders such as depression and suicide appear to be more prevalent. Mental health problems are known to be associated with low work control (autonomy), time pressure and demanding patients. There is little difference between the genders early in their career, but more female than male physicians seem to experience problems later on.
“Physicians seldom take sick leave or vacation, and tend to make less use of primary health care and some screening facilities. Self-treatment is common – even for mental problems. Barriers to physician seeking help are often punitive including discrimination in medical licensing, hospital privileges and professional advancement.
“Self-treatment is common – even for mental problems. Barriers to physician seeking help are often punitive including discrimination in medical licensing, hospital privileges andprofessional advancement. Many clinicians are uncomfortable in treating fellow physicians in general, especially for mental health issues. Many times the first signs are physical /somatic complaints making depression harder to diagnosis.
“Medical licensure applications and renewal applications frequently require answering
questions regarding the physicians mental health history “

Survivors
Survivors are those who have lost someone to suicide. This could include immediate family members, close friends, co-workers or classmates or professional colleagues. Reaching out to this vulnerable group is crucial, as they can be prone to depression and suicidal behaviours
.
This process, known as postvention not only offers timely support to the bereaved through grieving process, but also becomes a method of suicide prevention in itself.

 

Presence or absence of suicidal tendency
Majekodunmi said, “Address the patients feelings about living with questions such as: how does life seem to you at this point? Or have you ever felt that life was not worth living? Did you ever wish you could go to sleep and just not wake up?
“Follow up with specific questions that ask about thoughts of death, self-harm, or
suicide: Is death something you’ve thought about recently? Have things ever reached the point that you’ve thought of harming yourself?
“For individuals who have thoughts of self-harm or suicide, ask: how often have those thoughts occurred (including frequency, obsessional quality, controllability)? How likely do you think it is that you will act on them in the future?
“What do you envision happening if you actually killed yourself (e.g., escape, reunion with significant other, rebirth, reactions of others)? Have you made a specific plan to harm or kill yourself? (If so, what does the plan include?)
“For individuals who have attempted suicide or engaged in self-damaging action(s), Additional questions may include:Can you describe what happened (e.g., circumstances, precipitants, view of future, use of alcohol or other substances, method, intent, seriousness of injury)?
“What did you think would happen (e.g., going to sleep versus injury versus dying, getting a reaction out of a particular person)? Did you receive treatment afterward (e.g., medical versus psychiatric, emergency department versus inpatient versus outpatient)?
“For individuals with repeated suicidal thoughts or attempts, ask: About how often have you tried to harm (or kill) yourself? When was the most recent time? Can you describe your thoughts at the time that you were thinking most seriously about suicide?
“For individuals with psychosis, ask specifically about hallucinations and delusions: Have you ever done what the voices ask you to do? (What led you to obey the voices? If you tried to resist them, what made it difficult?) Have there been times when the voices told you to hurt or kill yourself? (How often? What happened?) Are there things that you’ve been feeling guilty about or blaming yourself for? Consider assessing the patients potential to harm others in addition to him- or herself:
“Are there others who you think may be responsible for what you’re experiencing (e.g.,
persecutory ideas, passivity experiences)? Are you having any thoughts of harming them?
Are there other people you would want to die with you? Are there others who you think would be unable to go on without you? “

Recommendations
Majekodunmi recommended, “health professionals should establish regular source of health care and seek help for mood disorders, substance abuse and or suicidality. Medical and training institutions should provide adequate, prompt and accessible treatment and preventive services and support for health professionals with mental and substance use disorders and suicidality
“For individuals with psychosis, ask specifically about hallucinations and delusions: Have you ever done what the voices ask you to do? (What led you to obey the voices? If you tried to resist them, what made it difficult? Have there been times when the voices told you to hurt or kill yourself? (How often? What happened?) Are there things that you’ve been feeling guilty about or blaming yourself for? Consider assessing the patient’s potential to harm others in addition to him- or herself:”

There is need for advocacy
Suicide occur in every region of the world and throughout the lifespan impacting the most vulnerable world’s population and mostly prevalent in low- and medium- income countries like Nigeria where resources and services are scarce with far-reaching consequences on the society, family and significant others.
Increase vulnerability of physician and other health professionals for depressive disorders and suicides, being influenced by alcohol and substance use dependence as well as other psychosocial factors is increasingly being recognized. “For individuals with psychosis, ask specifically about hallucinations and delusions,” Majekodunmi said.