Research report
The process of suicidal planning among medical doctors: predictors in a longitudinal Norwegian sample

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Abstract

Background: The suicidal process is a common underlying perspective on suicidal behaviour, but the process has hardly been empirically studied. This study investigates the process from suicidal thoughts to suicidal planning among physicians; an occupational group with a raised risk of suicide. The process is studied in two ways: First, predictors at medical school of postgraduate suicidal planning are identified. Second, the transition from suicidal thoughts to planning over three to four years is explored. Methods: A nationwide cohort of Norwegian medical students (N=631) were approached initially in their final semester (T1), and then again in the first (T2) and fourth (T3) postgraduate years. The average observation time was 3.6 years. Results: Twenty-eight participants (6%) reported suicidal planning in the postgraduate years. Adjusted predictors at T1 were vulnerability trait (neuroticism), severe depressive symptoms, and negative life events. Among those with previous suicidal thoughts at T1, 13 (8%) reported suicidal planning at T2 or T3. Adjusted predictors of transition from thoughts to planning were reality weakness trait, severe depressive symptoms, and a low level of perceived medical school stress. A minority of the postgraduate planners had sought professional care. Limitations: The effect of severe depressive symptoms may be overestimated, and the sample size is relatively small. Conclusions: Common predictors for both postgraduate suicidal planning and transition from thoughts to planning were depressive symptoms and personality traits. Reality weakness was the most decisive trait for aggravation in suicidal ideation, and this personality trait needs further study in suicidal research and clinical awareness.

Introduction

Physicians have an increased risk of committing suicide (Lindeman et al., 1996, Aasland et al., 2001, Hawton et al., 2001). Suicidal planning is a well-known risk factor for suicide attempts (Kessler et al., 1999) and suicide (Beck et al., 1985), and it is prevalent among medical students (Tyssen et al., 2001a) and physicians (Hem et al., 2000). Thus, it would be desirable to identify predictors of such planning in medical school.

The suicidal process describes suicidal behaviour as a continuum of gradually increasing seriousness: feelings that life is not worth living, thoughts of taking one’s life, seriously considering suicide, suicidal planning, and suicidal attempt. This process is a common underlying perspective on suicidal behaviour. However, surprisingly few papers have focused on the process aspect (Runeson et al., 1996, Vilhjalmsson et al., 1998). A literature search in the Medline and PsycInfo databases (1966–2002) identified only 25 papers discussing this process, most of them from a theoretical point of view. The lack of empirical studies may be due to a relative scarcity of longitudinal studies.

This prospective study includes a nationwide representative sample of medical students, approached initially during their final term of medical school, secondly at the end of the first postgraduate (internship) year, and finally in their third or fourth postgraduate year. Our previous study on this cohort (Tyssen et al., 2001a) did not investigate the development of suicidal planning in the postgraduate years.

The aim of the present study is to identify: (1) predictors at the student level of suicidal planning in the first postgraduate years; and (2) predictors that promote the transition from more vague thoughts to suicidal planning over the first postgraduate years. Such suicidal planning is of more clinical importance than suicidal thoughts, that are relatively common in this group, with a lifetime prevalence above 40% (Tyssen et al., 2001a).

Section snippets

Participants

The study cohort consisted of students graduating in 1993 and 1994 from all four medical schools in Norway (N=631). They received postal questionnaires in their last term of medical school (T1), at the end of the internship year (T2), and 2–3 years later (T3). To ensure confidentiality, the questionnaire was answered with the identity of respondents remaining anonymous to the researchers, while the name and address codes were kept in the Central Bureau of Statistics of Norway. The project was

Postgraduate suicidal planning

Twenty-eight participants (6.4%, 28/439) reported postgraduate suicidal planning, 15 (5.9%) among the women, and 13 (7.0%) among the men (n.s.). The predictors are shown in Table 1. All independent variables were entered in a logistic regression analysis to predict suicidal planning. Adjusted predictors were negative life events, vulnerability, and severe depressive symptoms. Additional analysis of life events showed that the following were linked to postgraduate planning:

Discussion

A prevalence rate of 6.4% of postgraduate suicidal planning is relatively high, particularly at this age (29–31 years). In a US study (Crosby et al., 1999), the 1-year prevalence of suicidal planning was 2.8% in the age group 25–34 years, while the lifetime prevalence of suicidal plans in the National Comorbidity Survey was 3.9% (Kessler et al., 1999). Among Finnish physicians, only 1% had ever seriously planned suicide (Olkinuora et al., 1990). In a study of Norwegian physicians, the lifetime

Acknowledgements

The Research Council of Norway, the Norwegian Foundation for Health and Rehabilitation, and the Norwegian Medical Association are greatly acknowledged for funding this research.

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