Until Harry Reiss, M.D., a urologist in New York committed suicide in 1989, no one, including his wife, knew that he was severely depressed. He never talked about it and saw patients until the day he ended his life with a lethal dose of pentobarbital.

His widow, Carla Fine, who has remarried, said via a video presentation on survivors of suicide at the Canadian Psychiatric Association (CPA) annual meeting last month in Victoria, British Columbia, "Until someone crosses that line, you don’t believe the person has the capacity to take his or her own life. The tragedy is that Harry’s death could have been prevented if he had gotten the right help." Fine is the author of No Time to Say Goodbye, published by Mainstreet Books/Doubleday in 1997.

Because society views physicians as healers who are invulnerable, their suicides are particularly unsettling.

Fine said that soon after her late husband’s suicide, she wondered: "If Harry, who was is in the business of sustaining life, gave up, what does that mean for the rest of us?"

People are often more puzzled when a psychiatrist, who is trained to recognize depression attempts or commits suicide. Psychiatrists may slip into a depression without realizing it, explained Michael Myers, M.D., the CPA president. Myers, who is also clinical professor of psychiatry at the University of British Columbia and chair of the Psychiatric News Editorial Advisory Board, produced the videotape, "When Physicians Commit Suicide: Reflections of Those They Leave Behind," which won the 1999 Psychiatric Services Award.

He mentioned the suicide attempt in August by Toronto psychiatrist Suzanne Killinger-Johnson, M.D., who made headlines after she jumped in front of an oncoming subway train while holding her 6-month-old baby. Although she survived, her baby died immediately on impact, according to the August 15 Toronto Star.

Because physicians are hard driving and perfectionists, "they tend to deny or minimize their symptoms even when they are severely depressed," said Myers.

The stigma surrounding mental illness within the medical profession reinforces physicians’ feelings of failure and concerns that disclosure will damage their careers, added Myers.

William Ashdown, president of the Canadian Mood Disorders Association, said at the CPA meeting, "Once it is known that a physician has a mental illness, the individual is suspect. I know of two cases where senior doctors were removed from their practices because of the perception they were crazy."

Psychiatrists should not underestimate the severity of depression in physicians who sound apologetic and tentative about whether they need to see a psychiatrist. "It’s critical to make time for them because they are already reluctant to get help," said Myers.

He also warned against sacrificing a thorough assessment for suicide risk because the physicians are minimizing their symptoms or are concerned about their reputation.

"Do not also sacrifice hospitalization, whether voluntary or involuntary, but try to maintain the physician’s anonymity and privacy," said Myers.

He also recommended that severely depressed physicians be placed on medical leave and not allowed to return to work prematurely.

When they do return to work, "they should only work part time; have lighter duties; no on-call, which disrupts their sleep cycle; and not be isolated at work at first," he added. These physicians should also be closely monitored during the first and second weeks back to work.

Psychiatrists treating physicians should be aware of the potential for heightened countertransference. "We may identify more with physicians and find ourselves thinking this could happen to me, which is frightening," he explained.

For example, when Myers treated a physician whose 24-year-old son had recently committed suicide, he showed Myers a picture of him. "I was immediately struck by how much he looked like my son Zachary, who is the same age."

The physician told Myers he was having painful flashbacks of the image of his son hanging on a crossbeam on the deck of his apartment. "I sat there quietly and listened to the father say that he cut his son’s body down and administered CPR to no avail. The father then cradled his son and sang him a lullaby."

Myers added, "I would not have been able to deal with my feelings of vulnerability had I been five years out of residency. I would have cut him off by saying something like, ‘Intrusive flashbacks are common in depression,’ and asked him about medications.

"We can honor our colleagues who have died by suicide by applying this advice from Holocaust survivor Elie Wiesel to our work. ‘Memories, even pain- ful ones, are all we have. In fact, they are the only thing we are. So we must take very good care of them.’ "