When a JAMA Network Open study reported earlier this year that suicide remains the leading cause of death among medical residents, many experts were saddened but unsurprised.

“It signals that there are underlying problems that we should solve,” said Srijan Sen, MD, PhD, director of the Frances and Kenneth Eisenberg and Family Depression Center and professor of depression and neurosciences at the University of Michigan, Ann Arbor, Michigan.

Aditee Narayan, MD, MPH, pointed to the challenges that exist in today’s healthcare system for all physicians, including residents.

“This system may escalate moral injury among our residents — they want to do more for our patients but are limited to what is available for them,” said Narayan, vice dean for Medical and Health Professions Education at the Duke University School of Medicine in Durham, North Carolina.

According to the JAMA Network Open study, the actual incidence of suicide, while higher from 2000 to 2014 than from 2015 to 2021, was still relatively rare. In fact, the study noted that the suicide rate in the 30- to 34-year-old age group was 70% lower than in the same age group in the general population.

That doesn’t mean that it should be ignored or dismissed, said Christine Moutier, MD, chief medical officer of the American Foundation for Suicide Prevention.

Christine Moutier, MD

“My hope is that we would not be inured to this tragic public health concern,” she said.

Instead, efforts to address mental health among residents should be intentional and proactive, she said.

Intentional Efforts to Address Mental Health

Stress can push even well-adjusted people to the limit, and plenty of stress exists in the life of most medical residents. However, there are a number of perceived barriers to accessing care, including lack of time, concerns over confidentiality, stigma, uncertainty about where to access care, cost, a preference to receive care outside their own organization, and others, according to research.

As a result, despite the high-pressure environments in which they work and high stress levels, residents report a low use of mental health services, according to a 2024 study in the Journal of Graduate Medical Education.

In response, a growing number of programs are not waiting for their residents to reach a crisis point.

Aditee Narayan, MD, MPH

Some programs have experimented with opt-out programs for mental health support for residents to reduce barriers to accessing care and to minimize stigma. For example, Riverside Community Hospital, a clinical rotation site for the University of California, Riverside School of Medicine in Southern California, found that residents were more likely to access free, confidential teletherapy sessions when the initial appointment was already scheduled for them.

At the University of Texas Health Science Center at San Antonio, new residents are asked to voluntarily complete a form that helps assess their risk for factors that could take a toll on their psychological health and well-being: the Transition to Residency Risk Index. Their score shows whether they are low, medium, or high risk, and resources are made available to them.

Jon Alan Courand, MD, who created the index, said the first few months of the postgraduate year 1 are considered the highest risk period, according to the latest research.

“There’s a lot of turmoil that happens in these transitions,” said Courand, professor of pediatrics and the assistant dean for Wellbeing for Graduate Medical Education at the University of Texas Health Science Center at San Antonio.

Making sure that residents know that multiple kinds of support are available is also crucial. The program has recently added an opt-out program for incoming residents called Circle of Care as another possible way to reach them and offer support.

“We might be preventing one very negative outcome, and that might be enough to justify everything else that we’re doing,” said Adriana Dyurich, PhD, LPC, who helped edit and validate the risk index. “We don’t have to look for super high numbers because the meaning of one or two suicides is devastating for institutions, for programs, for everyone that is around.”

Case Study: Columbia

As soon as interns begin their training at Columbia University Irving Medical Center, New York City, they encounter Laurel Mayer, MD. Mayer, a professor of psychiatry, is a faculty member for the CopeColumbia program, and she talks to all the new interns during orientation about stress, burnout, and risk factors for suicide. She shows them statistics.

“If you take care of yourself, and you are working as your best self, you will take better care of your patients,” she tells them.

Then she tells them to call her. In fact, she encourages them to put her phone number into their phones so they don’t have to ask anyone how to contact her if they need help.

“I’ve actually had a number of residents call me,” said Mayer. “Not even just internship year, but later. They say, ‘I had your information in my phone.’”

Jon Alan Courand, MD

Mayer can help connect residents with therapists, and she and her team make sure that the providers are educated about the unique issues associated with caring for physicians in training. She’s also working to address cost and confidentiality concerns: Through the organization’s Cope GME program, residents can receive eight therapy sessions per year at no charge. Beyond that, Mayer works to make sure that residents are connected with providers who accept their insurance. While care may be documented in the resident’s own electronic medical record, the information is flagged and protected for privacy.

They’re also piloting a new opt-out program based on a series of one-on-one check-ins, where everyone gets a 30-minute session with someone on her team. It’s not a psychiatric evaluation — just time to talk.

“We have data that 96% of the residents, at the end of that check-in, thought it was helpful and thought it should become part of the residency curriculum,” Mayer said, noting that her team is now evaluating if those check-ins facilitate access to mental health treatment.

Additional Resources and Strategies

The Accreditation Council for Graduate Medical Education (ACGME) offers a Mental Health and Well-Being During Transitions tool kit, among other resources, to help programs start new or bolster existing efforts to address the mental health and well-being of their resident workforce.

Nicholas Yaghmour, MPP, director of the Resident Experience, Well-Being, and Milestones Research at the ACGME, suggested that residency programs also consider providing annual physicals to their residents. Yaghmour was also the leading author of the JAMA Network Open study.

“We may be able to catch more undiagnosed mental health problems like depression and anxiety,” he said. “We also may prevent the other causes of death and disease, such as neoplastic diseases and infectious diseases.”

Adriana Dyurich, PhD, LPC

Individuals in training program leadership roles who commit to setting positive examples can also be a part of suicide prevention efforts, according to Mark Olfson, MD, PhD, professor of epidemiology and professor of psychiatry, medicine, and law at Columbia University Medical School in New York City.

“We need to set examples, if we’re involved with training physicians, to normalize stress and acknowledge when it occurs and talk about it openly, to help set up a culture that lowers the stigma around behavioral healthcare services among medical trainees,” said Olfson, whose research includes a focus on suicide prevention.

Plus, it may also encourage other physicians to access care when they need it.

“The more we can normalize physicians at all professional stages reaching out for mental health care and for emergency support when they feel they are in crisis, the better we can be as a field in preventing deaths by suicide,” said Yaghmour.