Dr. Lorna M. Breen was the medical director of the emergency department at a hospital in New York. While caring for patients, she contracted Covid-19. She recovered and returned to work caring for patients. Then, on a brief vacation in April at home, Breen took her own life. Her colleagues describe her as a fun-loving and energetic servant leader dedicated to her community. Now, Breen is another tragic victim of physician suicide.

Pediatric resident Dr. Poulami Saha suffered from depression. In May, She jumped off the 11th floor of her hospital in Calcutta. In March, Daniela Trezzi, an ICU nurse in the hard-hit Lombardy region of Italy, took her own life. Reports indicate she could not move on from the fear that she may have infected patients under her care.

As National Suicide Prevention Awareness Month comes to a close in the midst of a global pandemic, a focus on the health needs of medical professionals (often a taboo subject) feels overdue. As the leader of a large OB-GYN practice in Texas, I see the mental health impact on doctors, nurses, and other health care workers every day.

A crisis intensified

Suicide is the 10th leading cause of death in the United States. Health care providers are not immune. In fact, physicians take their own lives at twice the rate of the general population. One doctor per day dies by suicide in the United States. Long before the pandemic, stressful working conditions, excessively long hours, and sleep deprivation led to a surge in physician burnout. Pandemic stress puts health care providers at an even higher risk of despair.

Quarantines, school closings, social isolation, and shelter-in-place orders have changed the way we live. Frontline health workers in hard-hit areas are exhausted and often traumatized from treating Covid-19. But health care providers in all areas struggle to cope with the complicated politics that now surround the pandemic and the lack of a national, strategic plan to fight it.

While my city is not experiencing an overwhelmed hospital capacity, I understand what Breen, Saha, Trezzi, and other providers must have felt. With empathy, I recognize the feelings of hopelessness that can lead one to think the only way to make the pain stop is to die.

Not only does the incidence of suicide signal unbearable conditions for doctors and health care workers, but when suicide happens in the industry, it creates a new layer of trauma and stress for everyone in medicine. Our colleagues’ suicide stories place us at increased risk of post-traumatic stress, anxiety, depression, and insomnia.

Physicians take their own lives at twice the rate of the general population.

In March, JAMA published a study evaluating the pandemic effects on health providers’ mental health in Wuhan, China. In this cross-sectional study of 1,257 health care workers, investigators demonstrated the high incidence of depression, anxiety, insomnia, and distress in frontline health care workers. Early in the pandemic, many health care workers around the world felt betrayed by the lack of PPE, ventilators, and ICU capacity. As Covid-19 drags on, physician workloads have increased, and general hospital morale has plummeted. Health providers worry about catching the coronavirus but also live in fear of infecting their families.

Health care workers and those who love them must be aware of the factors increasing the risk of suicide. Hopefully, improving our risk factor awareness will increase our capacity for recognition, early intervention, and prevention.

According to the National Alliance on Mental illness, risk factors for suicide include:

1. Mental health condition. Forty-six percent of suicide victims had a known mental health condition such as depression, anxiety, insomnia, or substance abuse.
2. Family history of suicide.
3. Substance use.
4. Intoxication. More than one in three people who die from suicide are under the influence of alcohol at the time of death.
5. Access to firearms.
6. A serious or chronic medical illness.
7. Gender. Women are more at risk of attempting suicide, while men are nearly four times more likely to succeed.
8. A history of trauma or abuse.
9. Prolonged stress.
10. A recent tragedy or loss.

The Covid-19 pandemic pushes health care workers to operate at peak performance levels. Patients are sicker, which requires a higher level of care. Covid-19 management guidelines are changing at a rapid pace. While the mortality rate is decreasing, physician workload is increasing.

The constant barrage of bad news, political turmoil, mask noncompliance, and social media toxicity strains our ability to get through each day.

I see firsthand how we are pushing ourselves to serve our patients better, and yet we are of no use to others if we do not first take care of ourselves. We all need a mental break, some moments of peace and tranquility — which can be challenging to come by in a time marked by paramount hardship.The National Alliance on Mental Illness offers the following five warning signs to look out for, as signals of the need for professional guidance and support:

1. Increased alcohol and drug use.
2. Aggressive behavior.
3. Withdrawal from friends, family, and community.
4. Dramatic mood swings.
5. Impulsive or reckless behavior.

The National Institute of Health offers a more extensive list of behavioral changes indicating someone may be thinking about suicide. Some people considering suicide may express their intent directly by talking about wanting to die or wanting to take their own lives. They may give away possessions, say goodbye to friends and family, or put affairs in order in the shape of a will.

Other at-risk individuals may express feelings of guilt, emptiness, or hopelessness. Some talk about feeling trapped or being a burden to loved ones. Anxiety and depression may lead to mood swings, agitation, and even rage.

Some people change their behavior by withdrawing from family and friends, drinking alcohol, using drugs or medications, or changing their eating and sleeping habits.

Not only does the incidence of suicide signal unbearable conditions for doctors and health care workers, but when suicide happens in the industry, it creates a new layer of trauma and stress for everyone in medicine.

Caring for health care workers

If you recognize any of these signs or symptoms in a friend, colleague, or family member, it is critical (and potentially life-saving) to reach out with compassion and empathy. Active listening techniques can help someone struggling with suicidal ideas to feel heard and not worry that their feelings are wrong.

If you recognize any of these signs or symptoms in yourself, please know it is safe to reach out and speak up. Schedule a telehealth visit. Reach out to a doctor, a colleague, or a friend.

If you are struggling with thoughts of self-harm or suicide, please do not hesitate to contact the National Suicide Prevention Lifeline at 1-800-273-TALK (8255). This is a free 24/7 confidential service that can provide people in suicidal crisis or emotional distress, or those around them, with support, information, and local resources. For more information, call or visit SuicidePreventionHotline.org.