42 After a Suicide | A Toolkit for Physician Residency/Fellowship Programs • Successful suicide prevention programs utilize stigma reduction, education, and policy to increase healthy behaviors and access to mental health services4 Suicidal Ideation • In surveys of students, house staff and faculty 10-12 percent report suicidal ideation12, 13 • In one prospective study, 23 percent of interns had suicidal thoughts, but among those interns who completed four sessions of web-based Cognitive Behavior Therapy nearly 50 percent fewer had SI14 • Burnout has been found to be an independent risk factor for suicidal ideation12 Alcohol Use • Alcohol misuse is a common response to unmanageable stress • Alcohol increases impulsivity and the risk of a suicide attempt Stressors • The experience of becoming depressed is in itself tremendously stressful; while fewer than 25 percent will suffer from depression or significant depressive symptoms during their intern year; interns are under tremendous stress and have little time to rest15, 16 • Drivers of burnout include work load, work inefficiency, lack of autonomy and meaning in work, and work-home conflict • Feeling like a failure or making a medical mistake often leads to severe distress17 • Impostor syndrome: despite countless successes, when confronted with their internship, residents may start feeling like they don’t really belong here; the worry about being “exposed” or “failing” may be intolerable Stigma • Perfectionism, self-perceived identity as a caregiver to others, and lack of practice seeking help for oneself are all common among physicians, making it hard for residents to recognize and accept their need for mental health care; there is also concern about being “found out” by their peers or supervisors • Residents often mask symptoms of depression or other mental health problems, leading at least some suicides to appear shocking or seem to come out of the blue