PPE gear used by employees at a hotel for sanitising rooms is left out to dry on a rooftop, during a COVID-19 outbreak in Bhagalpur, Bihar. July 27, 2020. Photo: Reuters/Danish Siddiqui.
Trigger warning: Suicide
Bengaluru: As India groans under the weight of COVID-19, another underreported crisis has come to the fore.
In the last two months, nearly ten doctors have reportedly died by suicide in different institutions across the country. Most of them were younger than 30 years. The latest addition to this unfortunate list was Mohit Singhla, a research officer in the paediatrics department of the All India Institute of Medical Sciences (AIIMS), New Delhi – the third doctor to have died thus at this hospital in this period.
Suicide among doctors is a complex, multi-factoral issue that has been plaguing the country for decades now. Studies from across the world indicate that suicide rates among doctors are higher than in the general population. According to the 2019 World Health Statistics, there are 10.6 suicides per one lakh people every year, although in India there are 16.3. And while studies that compare suicide rates among doctors with that of the general population in India are lacking, “there is no reason why it should be any different,” Soumitra Pathare, director of the Centre for Mental Health Law and Policy, Pune, told The Wire Science.
“When I went to medical school in Mumbai in the 1980s, each batch would graduate with one or two student suicides during the five-year course. Very exceptional batches, maybe one in five or six batches, would have no suicides,” he added. Now, at least one or two suicides are reported each year in most medical colleges. “That’s a very high rate compared to the general population.”
After six doctors in AIIMS checked into the psychiatric ward for treatment in March 2018, the Indian Medical Association (IMA) told The Hindu that suicide among physicians was a “public health crisis” to be “tackled before it was too late”. A study at the Postgraduate Institute of Medical Education and Research, Chandigarh, and published in 2018, concluded that 30% of the 445 doctors who participated were depressed and about 17% had thought about ending their lives.
Earlier this month, The Wire Science informally polled 45 doctors and medical students from across the country about suicides among doctors. Over 62% of them said it is a longstanding problem that is only being reported better now.*
Pathare agreed: “There seem to be more doctor suicides being reported now – but that may be a reporting issue – as in, due to the pandemic and heightened interest among journalists, more of these doctor suicides are getting reported prominently now, as compared to the past.”
Suicide rates are high (relative to the general population) in many of India’ medical colleges as well, but only a few cases from the more prominent institutions are even reported. “While the risk may be higher in some institutes because of the work environment, it is a countrywide problem that is not limited to a few institutions,” Shankul Dwivedi, former president of the IMA-Medical Students Network, Madhya Pradesh chapter, said.
Many personal and systemic factors contribute to this problem. Doctors face different struggles at different stages of their career that affect their mental health and cause some to kill themselves. Medical students and interns face examination-related stresses, sleep deprivation, poor living conditions and competition from peers. “Many suicides would take place during exam times,” Dwivedi said.
Caste-based discrimination and regionalism are other important factors. The Sukhdeo Thorat committee, set up in 2007 to look into caste discrimination at higher education institutions, found in its report that 85% of Adivasi and Dalit students at AIIMS felt that internal examiners had discriminated against them when awarding grades.
Toxic work environments, long working hours, bad living conditions and violence against doctors are a few of the many challenges resident doctors face. And most doctors The Wire Science spoke to agreed that interns and residents had the highest suicide rates among doctors.
At this juncture, the tragic case of Payal Tadvi‘s suicide comes to mind. Tadvi, a resident doctor at BYL Nair Hospital, Mumbai, hung herself to death on May 22, 2019. She belonged to the Tadvi Bhil community, a scheduled tribe. In her suicide note, she blamed three senior doctors for her plight.
Two separate committees, constituted by the BYL Nair Hospital and the government of Maharashtra, reported that the accused had harassed and publicly shamed her on multiple occasions. The Maharashtra Medical Council temporarily suspended the three’s medical licences before restoring two of them last month.
Arpitha Rath, a Bhubaneshwar-based intern, had anxiety issues and panic attacks in the first few semesters of her MBBS training. They subsided before intensifying and becoming more frequent over the last few months, with tremors, psychogenic vomiting and a choking sensation as well. “I have been on medication for anxiety disorder for about two months now,” she said.
“The medical field, especially the residency period, is mentally and physically demanding,” Nisha Pandey, a doctor in Bareilly, told The Wire Science. “You get less time to spend with family, long duty hours, the life of a patient at stake – all these stressors can cause mental distress, and sometimes lead to suicide.” Senior doctors also attributed suicide among their peers to toxic work environments and violence against doctors.
COVID-19, a new stressor?
Although these issues have led many doctors to take their lives even before the pandemic hit, the recent spate of suicides has raised many eyebrows and prompted many to wonder whether COVID-19 and the attendant changes in healthcare and governance have increased the suicide rate.
Studies have found that COVID-19 and the consequent lockdown have increased suicidal and self-harm tendencies among the general populace in the country, but there is no data on how they have affected the mental health of doctors. Significantly, around 42% of doctors The Wire Science polled thought that COVID-19 and the related work stress have increased suicide rates among doctors. An online survey conducted between March 28 and April 6 this year, in which 152 doctors responded, found that about 35% were depressed, 40% had anxiety and 33% were stressed.
Dwivedi said concerns regarding PPE availability and quality, uncertainties about the extent of support from their institution, long working hours, delayed salaries, unhygienic quarantine facilities, separation from families and several incidents of violence against doctors have added to the existing pressure, and exacerbating the sense of the crisis.
However, the lack of appropriate data on suicides among doctors has made evaluating the pandemic’s effects on the trends difficult. The annual record of accidental deaths and suicides in India, published by the National Crime Records Bureau (NCRB), is the only national-level data available on suicides – “but the NCRB does not release the entire data set and publishes a snapshot of some of the variables in their annual reports, which also tend to be delayed and come out 12-18 months after the end of the year,” Pathare said.
Preventing the problem
Associations like the IMA have taken some steps to ensure doctors are mentally healthy; through its Doctors for Doctors, or D4D, programme, IMA organises self-help and awareness workshops. In 2019, the association released a mental health guideline for medical students, and more recently a book entitled Surviving COVID-19 as a Medical Student. Earlier this year, IMA also initiated a 24/7 helpline for doctors in mental distress.
Experts say that in addition to these initiatives, other stakeholders – governments, hospitals, the medical community, the press and the people – must engage if we are to surmount this crisis.
“The Centre for Mental Health Law and Policy is exploring the possibility of launching a suicide prevention programme targeted at medical students and doctors,” Pathare said.
Pathare and Dwivedi also noted that governments must improve the working conditions for resident doctors, design the university curriculum keeping this problem in mind, and keep a proper record of mortality among doctors and medical students. Institutions should take necessary steps to combat bullying, provide psychosocial support, tackle alcohol and substance abuse, look into the way examinations are conducted, and provide good living conditions (e.g. hostels) for students.
The medical fraternity must take active steps to destigmatise mental illness. “Ironically, the stigma associated with mental illness is magnified in the medical profession,” Dwivedi said.
Many doctors fear that seeking help could adversely affect their careers and personal lives. A study conducted among female physicians in the US found that 50% of them believed they had mental illness – but did not seek help. In 2017, Suhas Chandran and Kishor M., two psychiatrists with the J.S.S. Medical College and Hospital, Mysuru, wrote that too many doctors suffered depression in silence, afraid to seek help because they feared penalties at work and in some cases being judged in their personal lives as well.
Dwivedi added that journalists ought to report suicide responsibly as well, without sensationalising it or fixating on the methods. However, Usha Raman, a professor of communication at Hyderabad Central University, was skeptical – although she did agree sensitive reporting “can certainly help the broader societal understanding of suicide and its underlying contexts.”
She said she believed that the print media by and large exercises restraint when reporting on suicide, but that audio-visual news publications tend to sensationalise the act and delve into the details. “Responsible reporting could be characterised by empathetic handling of sources, avoiding conclusive statements about causes and effects, and perhaps talking about broader contextual issues, rather than making it an individual story,” Raman said.
Then there’s the issue of violence against doctors. “This just adds to [the stress of] already stressed out doctors who are working in difficult situations with little resources and which they have no control over,” Pathare said.
“These systemic and individualistic changes can prevent suicides among doctors in India,” Dwivedi added.
* For the survey, the correspondent circulated a Google form through professional connections via email and WhatsApp groups and collected responses on August 16 and 17, 2020. The form covered four broad questions: (i) Are suicides among doctors in India a prevailing problem being reported better now? (ii) Could COVID-19 and the related work stress have increased suicide rates among doctors in India? (iii) At which stage of the professional medical career do doctors face the highest risk of suicide? (iv) What are the major reasons for high suicide rates among doctors? The survey also accepted suggestions on ways to improve mental health and prevent suicides among doctors.
If you know someone – friend or family member – at risk of suicide, please reach out to them. The Suicide Prevention India Foundation maintains a list of telephone numbers (www.spif.in/seek-help/) they can call to speak in confidence. You could also refer them to the nearest hospital.
Joel P. Joseph is a science writer.