Suicide deaths among medical students,residents and physicians in India spanning a decade (2010–2019): An exploratory study using on line news portals and Google database

Abstract

Background:

Despite having one of the world’s largest medical education consortium, India lacks a comprehensive and nationally representative data on suicide deaths among medical students and physicians unlike the one found in most of the developed nations of the world.

Aim:

We aimed to explore the different characteristics of suicide deaths among medical students, residents and physicians in India over a decade (2010–2019).

Methods:

Content analysis of all suicide death reports among medical students, residents and physicians available from online news portals and other publicly available sites was done. Search was done retrospectively using pertinent search words individually or in combination with language restricted to Hindi and English and timed from January 2010 to December 2019. Reports on completed suicide by allopathic medical students, residents and physicians from India were included. Socio-demographic and suicidological variables were analysed using R software.

Results:

A total of 358 suicide deaths among medical students (125), residents (105) and physicians (128) were reported between 2010 and 2019. Around 7 out of 10 suicides happened before the age of 30 and had mean age 29.9 (±12.2) years. Female residents and physicians were younger than their male counterparts at the time of suicide. Overall maximum suicide deaths were concentrated in South India except the state of Kerala. The specialty of anesthesiology (22.4%) followed by obstetrics-gynaecology (16.0%) had the highest suicide deaths. Violent suicide methods were more commonly used by all, with hanging being the most common mean of suicide. Academic stress among medical students (45.2%) and residents (23.1%), and marital discord among physicians (26.7%) were the most noticeable reasons for suicide. Mental health problems were the next most common reason in medical students (24%) and physicians (20%) while harassment (20.5%) was in residents. Twenty six percent had exhibited suicide warning signs and only 13% had ever sought psychiatric help before ending their lives. A total of nine reports of suicide pact were found with the average deaths per pact being 2.4 and predominantly driven by financial reasons.

Conclusion:

Academic stress among medical students and residents, and marital discord in physicians emerged as the key reasons for suicide. However, this preventable domain should be further explored through focused research. This is the first of its kind study from India which attempted to explore this vital yet neglected public health issue using the most feasible and practical method of online news content-based analysis.

Keywords

Suicide physicians doctors residents medical students India

Introduction

As per the 2016 report of World Health Organization (WHO), India’s suicide rate stood at 16.5 per 100,000 people; much higher than the global average suicide death rate of 10.6 per 100,000 population (WHO, 2016). India also had the highest suicide rate for females (14.5) and third highest suicide rate for males (18.5) in the South-East Asian region (India State-Level Disease Burden Initiative Suicide Collaborators, 2018). Literature reflects that medical students and physicians are at a higher risk of suicide than the general population (Duarte et al., 2020) and other academic groups or professions attributable to academic pressure, work stress, burnout, depression especially in younger physicians along with constant hassle of juggling between professional, family and financial problems (Ventriglio et al., 2020). Though generous data exists on the prevalence of depression or suicidal ideation among medical students (Mata et al., 2015; Rotenstein et al., 2016); completed suicides among them, however, have sparsely been explored even in international literature with only a few countries publishing a periodic data of the same (Kamski et al., 2012). Studies from United States (2006–2011), Austria (2007–2012) and Canada (2006–2016) have reported a total of six suicide deaths each among medical students (Cheng et al., 2014; Kamski et al., 2012; Zivanovic et al., 2018). Likewise limited data on suicide deaths among physicians is available internationally (Gold et al., 2013; Palhares-Alves et al., 2015). In Sao Paulo, Brazil (2000–2009) suicide accounted for 1.7% of all causes of physicians’ deaths and Gold et al. identified 203 physicians’ suicide from National Violent Death Reporting System (2003–2008) of United states (Gold et al., 2013; Palhares-Alves et al., 2015).

Though nationally representative suicide data of India can be drawn from National Crime Record Bureau (NCRB) and Global Burden of Disease Study (GBD 1990–2016), however, there is no data available in relation to the suicide deaths among medical students or physicians in the country (National Crime Records Bureau, 2015; WHO, 2016.). Though India houses one of the world’s largest medical education consortium with the highest number of medical colleges in the world yet it struggles with low doctor population ratio (Supe & Burdick, 2006). Further, the life expectancy of doctors is 59 years as compared to 67.9 years of general population in India (https://timesofindia.indiatimes.com/city/kochi/docs-die-early-than-gen-public-study/articleshow/61716443.cms; Pandey & Sharma, 2019). To add fuel to the fire, a considerable number of medical students and doctors in India suffer from depression or have suicidal ideation and many prospective or current doctors lose their lives to suicides (Goyal et al., 2012). Prevention of suicide among medical students and physicians can go a long way to compensate for the existing manpower shortage in the health sector of the country. Further, the Sustainable Development Goal of one-third reduction in suicide death rate from 2015 to 2030 seems far-fetched in absence of focused, thorough and well-timed recognition and prevention of suicides among medical students and physicians (UN Department of Economic and Social Affairs, 2017). Since suicide among medical students and physicians has remained an unexplored issue in India till date, hence, the present study was undertaken with an aim to explore the different characteristics of suicide deaths among medical students, residents and physicians in India over a decade (2010–2019).

Methods

India has the limitation of poor-quality death registration attributable to incompleteness and inadequacy of data specifically with regard to cause of death which is often either missing or is inaccurate unlike developed countries (Kumar et al., 2019). It is not possible to extract suicide statistics on medical students and physicians from NCRB due to the use of broad category descriptors in the NCRB data (National Crime Records Bureau, 2015). Moreover, NCRB data is based on passive surveillance of information gathered as hard copy of First Information Report (FIR) from the police rather than the use of systematic verbal autopsy (Behere et al., 2015; Dandona et al., 2017). Suicide death reporting among medical fraternity is further constrained in NCRB in the sense that information pertaining many of the crucial variables like medical speciality, academic year, reasons behind suicide and presence of suicide warning signs is often missing. Since literature search has also mentioned about use of newspaper reporting and coverage to study particular aspects of suicide clustering and suicide methods, therefore, the use of online news portals seemed to be the only feasible alternative to achieve the aim of the study (Chen et al., 2016; Gould et al., 2014).

Information sources and search query

The present study is an exploratory study based on retrospective news content analysis. Reports of suicide deaths from January 2010 to December 2019 among medical students, residents and physicians available on leading online news portals and other publicly available sites were selected as the primary sources of data collection in the current study. News published only in Hindi and English were selected for this study. Search words and search query were developed for data collection (Supplemental material 1).

Eligibility criteria

The inclusion criteria were reports of completed suicide by medical students {students pursuing MBBS (Bachelor of Medicine, Bachelor of Surgery)}, residents {interns, house physicians, Junior Residents pursuing MD (Doctor of Medicine)/MS (Master of Surgery)/DNB (Diplomate of National Board)/Diploma (2 years post-graduation course), Senior Residents, those pursuing advanced qualification in medicine (DM) and surgery (MCH)/fellowships and physicians (post-graduation medical aspirants), any other practicing or non-practicing allopathic doctors}. All should be citizens of India and either pursuing medical education in Indian medical colleges or working in India.

Study excluded reports of attempted suicide, suicide by dentists and physicians of alternative systems of medicine (Ayurveda, Homeopathy, Unani, Naturopathy, Siddha etc.), suicide by physicians serving in armed forces institutions, autopsy ruling out suicide, dubious cases where suicide, homicide or accident was not clear, Non-Resident Indian (NRI) physicians, Indian medical students pursuing medical education outside India and Indian physicians serving any country other than India.

Search strategy

A list of all leading Indian online news portals (Supplemental material 2) in English and Hindi language was prepared and each of them was thoroughly searched for news of suicides among medical students, residents and physicians retrospectively using search query. To find additional cases, news pertaining to suicide among medical students, residents and physician was searched on Google database individually for each medical college and each states/Union territory of India using search query. The detailed list of all Indian medical colleges and states/Union territory was obtained from the site of Medical council of India and Government of India (National Medical Commission of India, 2019; Government of India, 2019). Two authors (CS, NA) independently searched for data, so that maximum cases could be searched. Links of all news were saved for later on retrospective analysis.

Data extraction

Two authors (CS, NA) individually extracted the data from links. All news links were screened for eligibility criteria. A thorough content analysis of each suicide report was done. Information taken from each report were collected based on the several parameters: socio-demographic variables like age, sex, marital status, professional variables like designation, rank, professional year, nature of workplace etc. and suicidological variables like place, method and alleged reason for suicide, suicide warning signs or special suicide patterns like extended suicide or suicide pact etc.

Duplications (report of same suicide in different news portals) in the search were identified by using socio-demographic variables like name, father’s name, place of suicide, name of medical college etc. Data deduplication was done by matching these variables. However, for the purpose of validation of news and extraction of extra details pertaining to a particular report, multiple newspapers were explored for a suicide report. One link was saved for one victim and duplication was ignored for victims of suicide pact & multiple victims from same medical college. In case of disagreement between two authors (CS, NA), arbitration was done by other authors (GN and ND).

Statistical analysis

We compiled the data in Microsoft excel 2007 and analysed data with R software version 3.6.1. Percentages, mean and standard deviation (SD) were calculated, Pearson’s Chi-square test was used. The level of significance was fixed at <0.05 at 95% confidence interval. Missing variables were excluded during analysis.

Results

Total 2081 links were saved after exploring the online news portal and Google database. After removing duplications, a total of 358 suicide death reports with maximum information served as the primary link for information. Another 285 links served as channel for additional information to the primary link in the study (Figure 1) (Supplemental material 3).

Figure 1.

Flowchart of selection of Links.

Distribution and demographics of the participants

A total of 358 suicide deaths among medical students, residents and physicians were reported between 2010 and 2019. Medical students, resident and physicians constituted 34.9% (125), 29.3% (105) and 35.8% (128) of study group respectively. As the study was based on content analysis of online news, some of the variables of a particular case were missing.

There was a higher male to female ratio (1.7:1) for suicide deaths except among residents where females outnumbered their male counterparts. Female residents and physicians were significantly younger (p < 0.05) than their male counterparts at the time of suicide. Around 7 out of 10 suicides happened before the age of 30 and had mean age 29.9 (±12.2) years. Only 2 (1.6%) medical students, 18 (17.5%) residents and 84 (68.9%) were married at the time of committing suicide. More suicides happened in physicians running their own clinics or hospitals or working in private setting while it was otherwise for medical students and residents where more suicides were reported from government medical colleges (Table 1).

Table 1.

Socio-demographic characteristics of suicide deaths among medical students, residents and physicians in India (2010–2019).

Characteristics	Medical students	Residents	Physicians	Total	χ^2;; p value
Sex, n (%)^$
Male	78 (62.4)	47 (44.8)	81 (63.3)	206 (57.5)	9.953; 0.007
Female	47 (37.6)	58 (55.2)	47 (36.7)	152 (42.5)	9.953; 0.007
Mean age (standard deviation)*
Male	21.2 (±2.3)	27.9 (±3.6)	43.5 (±15.5)	31.4 (±14.0)
Female	21.1 (±2.2)	27.0 (±2.5)	37 (±11.3)	27.9 (±8.8)
Age categories* n (%)
17–29 years	110 (100)	70 (76.1)	30 (28.3)	210 (68.2)	130.404; <0.001
⩾30 years	0 (0.0)	22 (23.9)	76 (71.7)	98 (31.8)	130.404; <0.001
Type of Institute** n (%)
Government	67 (54.0)	70 (69.3)	44 (41.5)	181 (54.7)	43.064; <0.001
Private	57 (46.0)	31 (30.7)	62 (58.5)	150 (45.3)	43.064; <0.001

indicates zero missing values.

indicates 50 missing values.

indicates 27 missing values.

Overall maximum suicide deaths were reported in South India with the state of Kerala being an exception. North India except the state of Uttar Pradesh had relatively lower suicide deaths compared to South India. Eastern and North Eastern zones of the country had the least suicide deaths reported so far. Andhra Pradesh gained the notoriety of being the state with the highest reported suicide deaths among medical students. While among residents’ maximum suicides were reported from Delhi followed by Maharashtra. Among physicians, a trio of Uttar Pradesh, Maharashtra and Tamil Nadu was reported having highest suicide deaths (Figure 2).

Figure 2.

State wise distribution of overall suicide deaths among medical students, residents and physicians in India, 2010 to 2019.

Speciality wise distribution of suicide deaths

Of all the medical specialities, anaesthesiology (22.4%) followed by obstetrics-gynaecology (16.0%) had the highest suicide figures (Table 2) (Supplemental material 4).

Table 2.

Speciality wise distribution of suicide deaths among residents and physicians in India, 2010 to 2019.

Speciality	Residents	Physicians	Total
Speciality	n = 74 (%, M:F)	n = 51 (%, M:F)	n = 125 (%, M:F)
Anesthesiology	20 (27.0, 0.33:1)	8 (15.7, 1.66:1)	28 (22.4, 0.56:1)
Obstetrics- Gynaecology	10 (13.5, 0.11:1)	10 (19.6, 0.11:1)	20 (16.0, 0.11:1)
Paediatrics	8 (10.8, 1:1)	3 (5.9, 3:0)	11 (8.8, 1.75:1)
General surgery	6 (8.1, 2:1)	2 (3.9, 2:0)	8 (6.4, 3:1)
Orthopaedics	5 (6.8, 4:1)	2 (3.9, 2:0)	7 (5.6, 6:1)
General medicine	3 (4.1, 2:1)	3 (5.9, 2:1)	6 (4.8, 2:1)
Ophthalmology	2 (2.7, 0:2)	4 (7.8, 1:1)	6 (4.8, 0.5:1)
Radio-diagnosis	3 (4.1, 2:1)	3 (5.9, 2:1)	6 (4.8, 2:1)
Other specialities	17 (23.0, 0:0.89)	16 (31.4, 4.33:1)	33 (26.4, 1.75:1)

M:F indicate Male:Female

Means of suicide

Hanging emerged as the most commonly adopted mean to end life among all groups. Use of gunshot to commit suicide was mainly found among physicians (7%) and only sparingly by residents (1.0%) (Figure 3). Use of non-violent methods (poisoning) compared to violent methods (hanging, jumping from height or in front of running train, drowning, slitting throat or wrist, self-immolation, gunshot) was found significantly (χ² = 35.234; p < 0.001) more among residents (40.0%) and physicians (36.7%) as compared to medical students (8.8%).

Figure 3.

Means of suicide adopted in suicide deaths by medical students, residents and physicians in India, 2010 to 2019.

No significant difference (χ² = 7.571; p = 0.109) was noticed in method of suicide with respect to gender. Maximum number of anaesthetists (85.1%; 23 out of 28) resorted to intentional poisoning to commit suicide. Intravenous anaesthetic drugs were used in 42.9 % (12 out of 28) cases. Insulin, cardiac drugs, Aluminium Phosphide and sedative hypnotics were some of the drugs other than anaesthetics used for suicide.

Putative reasons for suicide

Academic stress emerged to be the most important reason for suicide deaths among medical students (45.2%) and residents (23.1%). Maximum suicides among physicians were attributed to marital discord (26.7%). Mental health problems were the second most common reason of suicide among medical students (24%) and physicians (20%) but Harassment (20.5%) was second important reason for suicide deaths among residents. More than one reason behind suicide coexisted in 30 (10.4%) of the suicide victims Males outnumber the females in mental health problems while females outnumbered the males in marital discord (Table 3).

Table 3.

Apparent reasons for suicide among medical students, residents and physicians in India, 2010 to 2019.

Apparent reasons	Students	Residents	Physicians	Total
Apparent reasons	n = 104 (%, M:F)	n = 78 (%, M:F)	n = 105 (%, M:F)	n = 287 (%, M:F)
Academic stress	47 (45.2, 1.35:1)	18 (23.1, 0.64:1)	3 (2.9, 0.5:1)	68 (23.7, 1.06:1)
Marital discord	1 (1.0, 0:1)	8 (10.3, 0.33:1)	28 (26.7, 0.87:1)	37 (12.9, 0.68:1)
Harassment/Humiliation	18 (17.3, 2.6:1)	16 (20.5, 0.6:1)	7 (6.7, 2.5:1)	41 (14.3, 1.41:1)
Mental health problems	25 (24.0, 1.78:1)	14 (18.0, 1.8:1)	21 (20, 1.63:1)	60 (20.9, 1.73:1)
Failed or Troubled Love affair	13 (12.5, 0.63:1)	15 (19.2, 1.14:1)	6 (5.7, 1:1)	34 (11.8, 0.89:1)
Family problems	4 (3.8, 1:1)	4 (5.1, 0.33:1)	14 (13.3, 2.5:1)	22 (7.7, 1.4:1)
Financial stress	2 (1.9, 2:0)	0.0	12 (11.4, 5:1)	14 (4.9, 6:1)
Physical illnesses	1 (1.0, 1:0)	3 (3.8, 0.5:1)	9 (8.6, 3.5:1)	13 (4.5, 2.25:1)
Work stress	0.0	9 (11.5, 2:1)	2 (1.9, 2:0)	11 (3.8, 2.67:1)
Legal Issues	2 (1.9, 2:0)	2 (2.6, 1:1)	8 (7.6, 7:1)	12 (4.2, 5:1)
Recent death of close one	1 (1.0, 1:0)	3 (3.8, 0.5:1)	5 (4.8, 4:1)	9 (3.1, 2:1)
More than one reason	9 (8.7, 2:1)	11 (14.1, 1.2:1)	10 (9.5, 4:1)	30 (10.4,1.8:1)

M:F indicate Male:Female

Suicide warning signs

Out of 358, ninety-three had exhibited warning signs before committing suicide. Around 6% had a past suicide attempt; one of the most important variables predicting completed suicide (Table 4).

Table 4.

Suicide warning signs in medical students, resident and physicians committing suicide in India, 2010 to 2019.

Suicide warning signs	Medical students	Resident	Physicians	Total
Suicide warning signs	n = 35 (%, M:F)	n = 27 (%, M:F)	n = 31 (%, M:F)	n = 93 (%, M:F)
Recent change in behaviour or mood	19 (54.3, 1.71:1)	16 (59.3, 1.67:1)	15 (48.4, 2:1)	50 (53.8, 1.78:1)
Past suicide attempt	7 (20.0, 7:0)	5 (18.5, 1.5:1)	10 (32.3, 0.67:1)	22 (23.7, 1.75:1)
Verbal/Written communication about Suicidal intent	6 (17.1, 1:1)	6 (22.2, 0.5:1)	6 (19.4, 2:1)	18 (19.4, 1:1)
Absenteeism from Work/Classes	9 (25.7, 8:1)	3 (11.1, 2:1)	1 (3.2, 1:0)	13 (14.0, 5.5:1)
More than one warning sign	6 (17.1, 6:0)	2 (7.4, 1:1)	1 (3.2, 1:0)	9 (9.7, 8:1)

M:F indicate Male:Female

Suicide note and special suicide patterns

Suicide note could be traced in 32.1% of the total suicide deaths. Only 14 (11.2%), 21 (20%) and 12 (9.4%) of the medical students, residents and physicians respectively had ever sought psychiatric help before ending their lives. A total of nine reports of suicide pact were found with the average deaths per pact being 2.4 and predominantly driven by financial reasons. Three reports of extended suicide were found in which the average number of homicides before committing suicide was 1.3.

Discussion

Suicide among medical students and physicians is a largely unacknowledged, though, preventable crisis gripping medicine. The current study has been undertaken with the purpose of presenting information as available from online news portals and Google database search that will serve as reference to draw the collective attention of medical fraternity, stakeholders and policy makers towards this vital yet neglected and underexplored issue of high public health significance. Our study has reported death by suicide of 125 medical students in last decade (2010–2019) which is remarkably higher than six suicide deaths found each in United State medical schools survey over a period of 5 years (2006–2011) and a national survey-based study of suicide deaths among Canadian medical students over a period of 10 years (2006–2016) (Cheng et al., 2014; Zivanovic et al., 2018).

Indian Medical Association of Kerala interviewed 10,000 doctors over 10 years, during the study, 282 doctors died, out of which 1% committed suicide (City News & Kochi News, 2017). Jin et al. reported a total of only 51 cases of doctor suicides from Mainland China over a period of 8 years (2008–2016) which is much less compared to 233 cases of physician suicides (inclusive of residents) from India over a decade (2010–2019) in our study (Jin & Guo, 2018). This, however, is comparable with the report of 203 physician suicide cases from United States (National Violent Death Reporting System 2003–2008) (Gold et al., 2013).

Our study sample had a higher male to female ratio (1.7:1) for reported suicide deaths among medical students and physicians reflecting the global suicide trends of the general population where completed suicide is more prevalent among males. This finding is also in line with some of the previous international studies on suicide among physicians (Gagné et al., 2011; Hawton et al., 2001). More males than females entering medical profession could be one possible explanation for this. However, overrepresentation of suicide deaths among females in the resident group was a noteworthy finding in the study which further raises discussion on the nature of gender roles and gender role expectations within medicine (Watson et al., 2020). Entering into the specialities of predominantly male domain, added stress of balancing academic, professional and family life particularly inescapable responsibilities of housework and raising children, high propensity of perceiving humiliating experience as distressing, vulnerability to sexual harassment being fairer sex are some of the factors exclusively applicable to females thus explaining higher suicide figures among them (Siller et al., 2017). More marital discord in females as compared to males was also reflected in the study.

Analysis of study sample characteristics revealed that about 70% of the suicide victims were less than 30 years of age with mean age 29.9 (±12.2) years which signifies early loss of productive lives and ultimately a loss to the economy, nation and mankind at large. It could be because of the inclusion of young population of medical students and residents in the analysis which constituted nearly two third of the study population. Young age is, otherwise also, an established risk factor for suicide (Cheng et al., 2014). Females physician and resident, were significantly younger than their male counterparts at the time of committing suicide. This mirrors the finding of suicide among Quebec physicians (Siller et al., 2017).

Relationship status of being single could not be determined with absolute certainty from on line news portal, so this variable was excluded from final analysis. More reports of suicide among medical students and residents of government medical colleges were retrieved which could be attributable to higher magnitude of academic stress among students of government compared to private medical college as also reflected in one of the studies conducted in Bangladesh, where medical education system is similar to ours (Eva et al., 2015). Similar finding among residents is probably linked to the voluminous and unmanageable inflow of patients in government colleges and hospitals (Bajpai, 2014). The residents, who carry the larger share of the work pressure, bear the biggest brunt. On the contrary, more suicides were reported among physicians running their own clinics/hospitals or working in private set up which could possibly be related to financial hardships faced particularly heavy debts.

There was a regional skew in the study sample with maximum reports of suicide deaths concentrated in South India which tallies with suicide trends in general population of India as per NCRB data wherein more southerners compared to northerners commit suicide (National Crime Records Bureau, 2015). This could be because the four southern states account for more than 41% of the medical colleges in the country (https://www.mciindia.org/CMS/information-desk/for-students-to-study-in-india/list-of-college-teaching-mbbs.). Manoranjitham et al. (2010) found psychosocial stress and social isolation as a suicidal risk factor in south Indian. Surprisingly, Uttar Pradesh, a state from North India, had the highest reported suicide deaths among physicians in the study sample. Being the most populous state and having extensive news coverage especially in local Hindi newspapers (study bias) compared to Southern or Western states could have resulted in picking maximum cases from here. Among Union territories, Puducherry in South India had highest reported suicides among medical students and physicians which again concords with NCRB data (National Crime Records Bureau, 2015). While among residents, maximum suicides were reported from Delhi and Maharashtra; one of the states with highest number of medical colleges in India. It is also in agreement with the high suicide rate observed in the general population of Maharashtra as per NCRB data (National Crime Records Bureau, 2015).

The analysis of suicide deaths by medical speciality reflected that highest suicides were found among anaesthesiologists in our study sample. Similar findings have been confirmed in some previous studies as well (Dutheil et al., 2019). Having knowledge and ready access to potentially lethal drugs might account for higher rate of suicide completion in anaesthetists. Another notable finding was high risk of suicide mortality found among obstetrician-gynaecologists compared to physicians majoring in other specialities. Tremendous work pressure, gruelling hours of clinical work, large patient to physician ratio, substantial number of emergencies to be dealt with, pressure of balancing demands of professional and family life particularly for female residents and physicians might be contributing to higher suicide deaths in the speciality of obstetrics-gynaecology. Contrary to the findings of previous studies, psychiatrists in our study did not seem to have high risk of deaths by suicide (Dutheil et al., 2019).

In line with many previous findings, hanging was reported to be most commonly adopted method of suicide in the study sample among all categories viz medical students, residents and physicians This was, however, in contrast with the suicide methods chosen by physicians from European nations and United States where self-poisoning with drugs and firearms were the most commonly employed methods respectively (Gagné et al., 2011; Gold et al., 2013). Interestingly intentional poisoning with drugs was higher among residents and physicians compared to medical students. This could be attributable to easy access as well as better knowledge of lethal drugs and their doses. The most striking finding for speciality –wise suicide method chosen was that the use of intravenous anaesthetic drugs to end life was found among 42.9% of the anaesthetists (85.1% used poisoning) which is in sheer concordance with the reports of Hikiji and Fukunaga (2014). In contrast to some of the previous studies, use of violent methods of suicide compared to non-violent methods like poisoning was more commonly found among all categories in our study (Hawton et al., 2000).

Academic stress was the most putative reason for suicide among medical students and resident thus emphasizing that medical institutes themselves are boiling pots of stress and suicidality. This finds support in another study by Supe et al. that stress in medical student is process oriented not trait oriented (Supe & Burdick, 2006). Vastness of medical syllabus, traditional teaching methods, poor academic performance, anticipation of failure, repeated failure in examinations, problems with English language as study medium tend to contribute to academic stress among medical students (Gupta et al., 2015).

Harassment was second important reason behind suicide deaths among residents. Extremely competitive work culture, high degree of commitment to work and personal scarifies may, at times, make residents feel harassed by colleagues or seniors (Foster et al., 2000). Physician suicides in our study were mainly found to have been linked to marital discord and mental health problems which are resonant with the findings of study by Gagné et al. (2011) and Gold et al. (2013). Four out of nine suicide pacts in the study were driven by financial reasons particularly heavy debts.

Only one-fourth of the medical students and physicians had issued a suicide warning. Similar finding has been reported by Gagné et al. in his study on suicide among Quebec physicians (Gagné et al., 2011). Committing suicides shortly after issuing a verbal or written warning about suicidal intent before the close ones could intervene and previous suicide attempts in only 6.1% of the study sample makes enough case for impulsive suicides rather than contemplated suicides Resonant with the findings of suicide among Quebec physicians, only 32% of the suicide victims included in the study had left behind an explicative suicide note which further raises the question of impulsivity behind suicide deaths (Gagné et al., 2011).

Even though, poor mental health, a modifiable risk factor, was the second most important reason for suicide deaths; still only 13% of the medical students and physicians included in the study had evidence of seeking psychiatric help ever before ending their lives. This may be explained by barrier of stigma associated with mental health which is ironically magnified in medical profession (Gerada, 2018), reluctance in expressing their issues to colleagues, fear of appearing weak in front of their peers, tendency to hide their condition to protect their career, lack of time or money for treatment, concerns about confidentiality and endorsing false beliefs of self-treatment (Guille et al., 2010).

This online news portal based exploratory study on the suicide deaths among medical students, residents and physicians is the first of its kind from India with an coverage of the suicide deaths among medical students, residents and physicians. This is a fair attempt by the authors to enhance the understanding of socio-demographic and professional correlates of suicide deaths in this population. Our results may also be applicable to medical students and physicians of other developing nations having same medical curricula, less doctor population ratio, similar cultural characteristics and health care system. This study also calls out for an accelerated development of a mandatory well systematized centralized suicide reporting system for medical professionals, serious amendments in existing civil registration system, improvisations in NCRB data reporting, reformation in medical education system, and national guidelines for screening, prevention and control of suicides among medical professionals.

Limitations

However, the grim tally of suicides in our study is still probably an undercount since the possibility of suicides remaining totally unreported or being reported only in less circulated local newspapers with no online coverage or in languages other than Hindi or English cannot be completely denied. Many of the news reports wherein the suicide attempter was in critical condition with meagre chances of survival were not updated of the ultimate outcome and hence were dropped from the study. Even the errors in reporting of suicide deaths or few of the variables cannot be completely denied. But that is the case with all the sources of suicide statistics including the one from National Crime Records Bureau which could be inaccurate, incomplete or inconsistent and Global burden of disease (1990–2016) (The Global Burden of Disease Study 1990–2016, 2018; Kumar et al., 2019). It was very hard to get strictly scientific information about completed suicides from media reports as these reports were mostly based on circumstantial information and personal testimony. Non-inclusion of toxicology, autopsy reports and media bias is another limitation of the study. The authors and medical research experts do not deny that news do, sometimes, report in sensational manner and on occasions, suicide might actually turn out to be a case of homicide in follow up investigation. However, authors have made their best efforts to tackle these limitations as suicides were further followed up in many newspapers as well as dubious and mysterious suicide reports were deleted from final analysis as shown in Figure 1.

Conclusion

This is the first of its kind study from India which has exhaustively attempted to elucidate maximum and authentic information for gaining better insights into this important public health issue of concern using the most feasible and practical method of online news content analysis. In conclusion, academic stress among medical students and residents, and marital discord in physicians appeared to be important reasons for suicide. Anaesthesiology followed by obstetrics-gynaecology had the highest suicide figures among medical specialities. Hanging emerged as the most commonly adopted mean to end life among all groups but poisoning was found significantly more among residents and physicians as compared to medical students.

However, this preventable domain should be further explored through focused research. A national suicide prevention strategy needs to be formulated to serve as a guide to reduce the burden of suicide deaths in medical students and physicians in India. There should be mandatory notification of suicide deaths by medical students and physicians to a designated centralized medical education or health authority in the country in order to generate complete and authentic data for national policy making and designing effective preventive strategies. Appropriate measures should be taken to minimize academic stress and harassment among medical students and residents. Medical students and physicians need to be sensitized about recognition of suicide warning signs as well as symptoms of mental health problems in self and colleagues and should be treated with utmost importance and seriousness. They should be regularly encouraged to reach out for assistance instead of self-treatment. There should be a strict system that monitors the usage of lethal drugs to prevent their misuse.

Supplemental Material

sj-pdf-1-isp-10.1177_00207640211011365 – Supplemental material for Suicide deaths among medical students, residents and physicians in India spanning a decade (2010–2019): An exploratory study using on line news portals and Google database

Supplemental material, sj-pdf-1-isp-10.1177_00207640211011365 for Suicide deaths among medical students, residents and physicians in India spanning a decade (2010–2019): An exploratory study using on line news portals and Google database by Savita Chahal, Anuradha Nadda, Nikhil Govil, Nishu Gupta, Diviyanshu Nadda, Kapil Goel and Priyamadhaba Behra in International Journal of Social Psychiatry

Footnotes

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethics approval and consent to participate

Ethical approval is not required as it used the data available from published findings.

Availability of data and materials

The dataset is available with corresponding authors and can be availed on request. This is not in the public domain due to author’s perception that it is unethical to share the data in public domain because it might hurt sentiments of victim’s family.

Authors’ contributions

Conceived and designed the experiments: SC, NA. Performed the experiments: SC, NA, GN, GN, ND. Data analysis: SC, NA, ND and GN. Data interpretation: SC, NA, GN, GN, ND and GK. Writing the original draft: SC, NA, GN, ND, GN. Critical revision to the manuscript: SC, NA, GN, GN, ND, BP, and GK. All authors have read and approved the final manuscript.

Supplemental material

Supplemental material for this article is available online.

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