A review found that male physicians are 40 per cent more likely than non-physicians to die by self-harm. Now, an article published today in the Canadian Medical Association Journal paints a disturbing picture of the implications for physicians' families, and their patients, when a doctor dies by suicide.

Suicide is the only cause of death that is higher in physicians than in non-physicians. Not only are male physicians 40 per cent more likely that non-physicians to attempt self-harm, but the risk among female physicians has more than doubled as well.

In the U.S., there are estimates that approximately 400 doctors die in this manner in the United States each year. That's roughly the equivalent to an entire medical school (freshman through senior year).

Physicians have the highest suicide rate of any profession. But we aren't just talking about doctors. Nurses are also at increased risk of self-harm. Physicians and nurses complete suicide more often than do Americans in the general population, and rates are even higher for women in both professions. Pharmacists and dentists also have a higher risk of suicide than non-health professionals.

In their CMAJ article, Drs. Joy Albuquerque and Sarah Tulk pointed out that the most common means of self-harm include firearms, poisoning and blunt force trauma such as resulting from a fall from a height. Firearms are common among health professionals and the general population. However, medical personnel are more likely than people outside the health professions to complete suicide via an overdose. A study involving physicians concluded that they were more likely than non-physicians to have access to medications such as benzodiazepines (for example, Valium), barbiturates and anti-psychotic medications. Pharmacists have access to medications and the knowledge on how to use them.

There are some unique reasons why health professionals are at increased risk of self-harm. A patient complaint to the doctor's licensing body may be the trigger to self-harm. A survey of nearly 8,000 physicians in the United Kingdom found that 9.3 per cent who had a recent complaint to the licensing authority had thoughts of self-harm, compared to just 2.5 per cent of physicians not the subject of a complaint. Medical errors can trigger thoughts of suicide.

A 2016 meta-analysis indicated that suicidal ideation often begins in medical school. A study linked burnout to thoughts of self-harm among medical residents.

Some have linked suicidal thoughts to on-the-job stress and high expectations at work. I suspect that health professionals who have perfectionistic tendencies may feel they can never live up to their own standards. Suicide death through opioid overdose has been documented. It would not be a stretch to speculate that rising rates of opioid use among health professionals might be also be a factor.

Self-harm has an impact on patients and the health-care system. Physicians who die by suicide leave patients without medical care. This can be particularly acute for patients waiting for a surgical procedure when the surgeon dies by suicide. The emotional fallout among colleagues and allied health professionals can be enormous.

Experts say more needs to be done to address the roots of the problem. Increased recognition is a start. There are teaching programs that train young physicians to help colleagues.

Suicide by health professionals is a problem that must be confronted. Barriers to timely treatment need to come down. Health professionals fear that their mental health challenges will be discovered by colleagues and that they'll face threats to their hospital privileges and professional licenses. Society tends to stigmatize people who seek treatment for mental health challenges. If anything, the stigma is even greater among health professionals.

Anything that reduces stigma will increase the likelihood that health professionals seek treatment.

Canada Suicide Prevention Service: 1-833-456-4566 (Phone) | 45645 (Text) | crisisservicescanada.ca (Chat)

In Quebec (French): Association québécoise de prévention du suicide: 1-866-APPELLE (1-866-277-3553)

Kids Help Phone: 1-800-668-6868 (Phone), Live Chat counselling at www.kidshelpphone.ca

Canadian Association for Suicide Prevention: Find a 24-hour crisis centre

If you're worried someone you know may be at risk of suicide, you should talk to them about it, says the Canadian Association for Suicide Prevention. Here are some warning signs:

Suicidal thoughts.Substance abuse.Purposelessness.Anxiety.Feeling trapped.Hopelessness and helplessness.Withdrawal.Anger.Recklessness.Mood changes.