An estimated 300 to 400 U.S. doctors kill themselves each year - a suicide rate thought to be higher than in the general population, although exact figures are hard to come by.
Some doctors believe the stigma of mental illness is magnified in a profession that prides itself on stoicism and bravado. Many fear admitting psychiatric problems could be fatal to their careers, so they suffer in silence.
And when the pain is too much, doctors have easy access to prescription drugs and a precise knowledge of both how the body works and the amount of a drug needed for an overdose to stop breathing and halt the heart.
"All physicians have access to neat, clean ways to commit suicide," said Dr. Robert Lehmberg, a Little Rock, Ark., surgeon who has battled depression and long considered suicide "an exit strategy if absolutely necessary."
The American Medical Association has called physician suicide "an endemic catastrophe," and pledged two years ago to work to prevent the problem.
But the suicides have persisted. So the American Foundation for Suicide Prevention has launched an educational campaign in hopes of making troubled doctors more willing to seek help.
The foundation, the American College of Psychiatrists and Wyeth Pharmaceuticals, a maker of antidepressant pills, paid for the program. It includes a documentary titled "Struggling in Silence" that begins airing on public television stations this week.
"It really has been swept under the carpet," said Dr. Paula Clayton, the suicide foundation's medical director.
The foundation says 300 to 400 doctors commit suicide each year, based on estimates from research, but that more studies are needed to get a more precise count.
Another estimate of 250 yearly comes from an online article by Dr. Louise Andrew and in American Medical News, an AMA publication. But a spokesman said the AMA doesn't track doctor suicides because accurate numbers aren't available.
Suicide figures in broader society are not completely reliable because suicide is often not given as the cause of death.
The overall U.S. suicide rate among men is four times higher than in women - about 23 per 100,000 versus about 6 per 100,000 in women, according to the most recent government data.
But among doctors, suicide rates are about equal for men and women.
A 28-state study from 1984-95 found women doctors were more than twice as likely as women in the general population to kill themselves. Men were more than 70 percent more likely inside the medical profession than overall to commit suicide.
One explanation is that most suicide attempts in the broader population are unsuccessful, while doctors know how to successfully commit suicide, said Dr. Erika Frank, who specializes in research on physician health.
Depression is often the problem.
Depressed doctors frequently decide to self-medicate but don't seek psychotherapy that could help them deal with underlying issues, said Dr. Glenn Siegel, who runs a suburban Chicago program that treats doctors with drug abuse, depression and other psychiatric problems.
"It's not a safe topic to be as open about in that profession because you're responsible for the well-being of others," Siegel said. "If you're admitting something like that, you're saying maybe you're not fit to do your job."
Adds Lehmberg, the Arkansas surgeon, who is featured in the documentary: "You just would rather take a risk with your health than your career. It's not like you get a second chance with it."
A psychiatrist in the New York area who asked to remain unidentified said he had suicidal thoughts every day for several years. But in medical school in the 1980s, he said he was so embarrassed about seeking help for depression that he went to a pay phone instead of his dorm to call a therapist.
Since then, some schools have begun teaching medical students about depression among doctors, but, he said in an interview, "so much more needs to be done."
Because the stigma persists, he said he didn't want his name used to avoid hurting his family and relationships with colleagues and patients.
Some studies have suggested depression is more common among doctors, especially women physicians, and that the high demands of a job dealing with life-and-death issues makes them prone.
But Frank questions that and said she worries that singling out physicians risks "pathologizing" a profession whose members generally "have it awfully good."
"I think the situation gets portrayed as far more grave than it really is for physicians compared to anyone else in the world," Frank said.
There could be reasons why the stigma would be worse for doctors, "but you can come up with just as many reasons why physicians would be better equipped to acknowledge" mental illness, she said.
"We've all done psychiatric training. We all know bad mental health outcomes happen to good people," she said.
A study in Denmark, published last year, found more suicides in doctors than among more than 20 other professions, including nurses, factory workers, elementary school teachers, corporate managers and architects.
But there are few comprehensive studies on suicides among U.S. doctors.
Some have been based on newspaper obituaries, which are "flawed at best" because suicide often isn't listed as a cause of death, said Dr. Morton Silverman, a University of Chicago suicide expert.
New Jersey physician Ron Brown suffered from depression and killed himself in 2002. His widow, Mumtaz Bari-Brown, said she believes the stigma kept her husband from getting help in time to save his life.
As a boy, Brown had been told his father died of a heart attack, not the real cause of suicide, the widow said.
"We have to stop the hiding and the ignorance and recognize it as a disease like high blood pressure or diabetes," said Bari-Brown, who also is featured in the new documentary.
Dr. G. Richard Smith, Lehmberg's doctor and director of the University of Arkansas for Medical Sciences' psychiatric research institute, said doctors need assurance they won't risk their jobs if they seek psychiatric help.
Smith succeeded in getting changes to questions on medical license applications in Arkansas that he believes will help. The old application asked doctors if they were being treated for mental illness or ever had been. A "yes" answer required a psychiatrist's note declaring they were fit to practice medicine. Now, they need only disclose mental health treatment that was advised or required by medical authorities.
The previous form didn't keep doctors with psychiatric problems from practicing, Smith said. But it did keep "doctors who needed treatment from getting the treatment that they needed."