It’s no secret that pharmacists have work stress. What you may not know is the truth about pharmacist suicide risk.
Anecdotally, I hear pharmacists saying, “burnout runs rampant through the pharmacy industry,” just as it does through other healthcare professions. Because pharmacists face issues like unrealistic metric goals from management, odd shifts, increased workload, decreased support staff, unachievable expectations from the public (i.e., never make a mistake), our industry is ripe for mental health trouble.
Coupled with the high-stress environment and the fact that pharmacists often work in isolation, it should come as no surprise that pharmacists are more likely to struggle with mental health issues and burnout, and face a greater suicide risk than many other occupations, as this article aims to prove.
However, the data reported in the literature and other sources are scant and sorely outdated (or inaccurate).
Why pharmacist burnout risk matters
Burnout left unchecked makes its mark on those who suffer from it: exhaustion, chronic fatigue, alienation, insomnia, loss of appetite and a higher risk of suicide. One study found a higher risk of suicide in physicians who scored higher on the Oldenburg Burnout Inventory and Beck’s Hopelessness Scale.
For those in the healthcare profession, burnout manifests as a lack of compassion for patients and coworkers and a loss of interest in things they once enjoyed. It can ultimately lead to, as one review put it, “depression; anxiety; sleep disturbances; fatigue; alcohol and drug misuse; marital dysfunction; premature retirement and perhaps most seriously suicide.
Burned out employees must address the physical and psychological components or face dire consequences.
Data on pharmacy burnout is sparse. The majority of studies listed on PubMed are related to physicians. One would think that research would be plentiful on such a perverse problem.
From the corporate perspective, there’s a tangible cost for high pharmacist turnover, a likely outcome from high burnout. Conservative estimates suggest that the cost of losing an employee is 1.5 – 2.0 times the employee’s annual salary. When you consider the costs to hire, onboard, and train employees, the pharmacist’s salary in addition to the loss of productivity, the cost of turnover is incredibly high.
Burnout is a predictor for poor mental health, which, in turn, can lead to suicide. It’s not a stretch to suggest that the increased incidence of burnout could account for pharmacy’s 20% higher than average substance abuse rate or its 1.29 odds ratio for pharmacist suicide according to an excessively linked article, a calculation which the author could not determine.
It’s time for an update on what we know about pharmacist suicide risk.
Evaluating pharmacist suicide risk (Methods)
To determine just how severe the problem is, I worked with Syed Haider, PharmD to review the Center for Disease Control and Prevention (CDC) publically available data from the National Occupational Mortality Surveillance (NOMS). Occupational mortality surveillance identifies trends in work-related deaths to identify jobs and work environments that present increased hazards for the people who work there. Think of NOMS as the first line of defense noticing alarming trends in occupations. The data is somewhat helpful, but the results are not as useful as data from a double-blind placebo-controlled trial.
NOMS is a CDC partnership that monitors changes in cause of death by industry and seeks to protect workers by identifying patterns and emerging risks as well as suggesting interventions to prevent them. The program is voluntary. States send in death certificate reports to NOMS. NOMS analysts have to analyze about 15% (as of 2018) of the data as free text, thus indicating a potential point for errors. Additionally, a death certificate may report multiple death causes. For the sake of brevity (even though this article is longer than average), we eliminated reviewing other causes of death. In the future, I hope to discuss other stress-related deaths.
The database allows querying the system by Industry or Occupation. Our results below were searched by the “Pharmacist” occupation. You can query the database found here.
The database is split into two time-bound categories:
Dataset 1: 1985-1998
Dataset 2: 1999, 2003-2004, 2007-2012
The time-bound databases will be referred to as dataset 1 (1985-1998) and dataset 2 (1999, 2003-2004, 2007-2012). Dataset 2 has multiple missing years of data.
Only 26 states submitted data for the first database (1985-1998), whereas 24 states in the USA submitted information in the second database (1999, 2003-2004, 2007-2012). The data sets do not have the same states reporting data, therefore, we are not comparing apples to apples. Thus we cannot make comparisons over time as the authors originally intended. NOMS is a Surveillance System, not a research outlet.
NOMS reports the number of deaths and the proportionate mortality ratio, or PMR. NOMS calculates the PMR using data related to the cause of death, occupation, industry, age, race (only white or black reported), and gender.
Proportionate Mortality Ratio: Number of deaths within a population due to a specific disease or cause divided by the total number of deaths in the breadth during a period such as a year.
PMR is calculated by dividing the proportion of deaths in population A by the proportion of deaths in the total population, then multiplying by 100.
From the CDC, “A PMR greater than 100 indicates that a particular cause accounts for a greater proportion of deaths in the population of interest than you might expect.”
Thus, a value of 200 means the given occupation has double the proportion of all deaths certified as suicide than would be expected from the proportion of the general population.
I spoke with CDC epidemiologist Andrea Steege Ph.D. MPH, about the NOMS program. When asked about how to discuss PMR data, she concluded that one could say,
“When compared to the general public, a higher PMR indicates a higher risk.”
The PMR is problematic with a few limitations. For example, we can’t claim that all pharmacists have a higher odds of suicide based on the data. Thus, the data does not support calculating a suicide odds risk of 1.29 (which the article mentioned above claims to cite). We can say there is a higher or lower risk of suicide based on the PMR.
The CDC NOMS data reviewed by “intentional self-harm” on death certificates. Only intentional self-harm data was reviewed due to the breadth of data needed to be reviewed for future articles.
Age is separated into three groups: 18-64, 65-90, or 18-90. Our data only examined ages 18-64, as this is the most likely age for an active working pharmacist. While pharmacists often work beyond the age of 65, they are less likely to be working full time.
Intentional Self Harm or suicide is defined as the taking of one’s own life voluntarily and intentionally.
We excluded the following causes of death, but do feel like a full examination of these deaths in pharmacists is worth examining in the future:
- mental disorders, mental disorders related to substance abuse, mental disorders related to alcohol abuse, drug-related deaths, alcoholism, mental disorders excluding schizophrenia and retardation, and potentially other deaths related to stress such as cardiovascular death
For our purposes, PMR could not be calculated for datasets with less than five deaths, and thus were not evaluated
Beyond the CDC data, little information exists about pharmacists and suicide. No article was found assessing NOMS pharmacist suicide data or from any other source.
Evidence of pharmacist suicide
First, let’s compare pharmacists to the 481 listed occupations in the USA.
Using the NOMS dataset 2, when combining all ages (18-64), races (black and white), and genders, the pharmacist PMR for intentional self-harm was number 14. Out of 482 list occupations in the USA, pharmacists have the 14th highest intentional self-harm PMR (PMR = 198, p <0.01; CI: 159-244)
|#||Occupation||PMR||Deaths||Significance level||Lower 95% CI||Upper 95% CI|
|4||HAND ENGRAVING & PRINTING OCCUPATIONS||269||11||p<0.01||134||482|
|6||CONTROL & VALVE INSTALLER REPAIRERS||241||11||p<0.05||121||432|
|7||BIOLOGICAL, LIFE, & MEDICAL SCIENTISTS||220||72||p<0.01||172||277|
|9||LAWYERS & JUDGES||217||331||p<0.01||195||242|
|10||ELEVATOR INSTALLERS & REPAIRERS||208||28||p<0.01||138||301|
|11||TOOL GRINDERS, FITTERS, & SHARPENERS||205||7||82||422|
|12||SECURITIES & FINANCIAL SERVICES SALES OCCUPATIONS||204||149||p<0.01||173||240|
|15||MARINE ENGINEERS & NAVAL ARCHITECTS||196||12||p<0.05||102||343|
|16||PHYSICISTS & ASTRONOMERS||196||9||90||372|
|18||ENVIRONMENTAL & GEOSCIENTISTS||192||73||p<0.01||150||241|
|19||AGRICULTURAL & FOOD SCIENCE TECH||191||20||p<0.05||117||295|
Dataset 2 (1999, 2003-2004, 2007-2012) suggests the risk of suicides as a cause of death in pharmacist is twice (PMR: 198 p<0.01; CI: 159-244) the general population of workers.
The dataset 2 intentional self-harm PMR was higher for all races/genders combined when compared to dataset 1, from PMR 198 to 182, respectively. However, as stated before, different states reported death information between dataset 1 and 2. The number of deaths was lower, from 119 to 88 due to suicide. However, the second dataset is from 8 years while the first dataset is over 13 years.