The numbers cited in the commentary are striking, even if they come from studies with different methods and samples rather than standardized national estimates. A cross-sectional survey of medical residents in Tehran found that 34.3 percent had experienced suicidal ideation. A meta-analysis estimated the prevalence of occupational stress among Iranian physicians at 70.1 percent. In a sample of 204 residents at a tertiary teaching hospital in Tehran, burnout was reported in 92.2 percent, typically in the context of long working hours and relentless clinical duties. Depression was observed in 43 percent of Iranian medical students and resident physicians in a cross-sectional study. Among emergency medicine residents, 90.7 percent reported verbal abuse in the workplace. Taken together, these figures suggest that psychological distress is not an anomaly in Iranian medicine but, in many settings, close to the norm.

The IMV model, developed by Rory O’Connor and Olivia Kirtley, describes suicidality as unfolding across three phases. The pre-motivational phase encompasses background vulnerabilities and the environmental context in which a person lives and works. The motivational phase centers on the emergence of feelings of defeat and entrapment, which can give rise to suicidal ideation. The volitional phase addresses the factors that determine whether ideation progresses to behavior, including impulsivity, access to lethal means, and prior exposure to self-harm or suicide. A key strength of the model is that it separates the emergence of suicidal thoughts from the transition to suicidal action, allowing researchers and prevention planners to identify distinct intervention points along a continuum rather than treating suicidality as a single undifferentiated phenomenon.

Applied to Iranian medicine, the pre-motivational phase is populated by structural stressors that vary with career stage. Interns face sudden immersion into rigid hospital hierarchies, sleep deprivation during clinical rotations, high responsibility paired with little authority, and repeated exposure to criticism or humiliation. The authors describe an identity threat in this stage: the gap between the expected image of the competent, resilient physician and the lived experience of vulnerability, fear of error, and dependence on senior staff. Residents encounter a different configuration of pressures, including long working hours, financial instability, absence of control over their training, fear of repercussions, and limited opportunities to leave or transfer from a program. Practicing physicians face yet another pathway involving medicolegal pressure, economic uncertainty, reduced professional autonomy, public mistrust, and gender-related vulnerabilities, although the authors caution that these latter pathways require further dedicated study in the Iranian context.

The analytical power of the IMV framework lies in its treatment of these factors as cumulative and interactive rather than parallel and independent. A single long shift or a single humiliating encounter is unlikely to produce suicidal ideation. But when excessive workload, financial insecurity, compulsory service placements, sleep deprivation, and fear of disclosure occur together and persist over years, they can create a professional environment in which distress becomes normalized and escape becomes difficult to imagine. Mandatory service in remote areas adds isolation and overload. Socially prescribed perfectionism, common among high-achieving medical students and professionals, heightens vulnerability to criticism and perceived failure. Social expectations that physicians remain competent, self-sacrificing, and emotionally controlled mean that distress is often experienced not merely as exhaustion but as personal failure and shame, deepening the psychological wound that institutional arrangements have produced.

The motivational phase of the model explains how this accumulated adversity converts into defeat and entrapment, the psychological states most closely linked to suicidal ideation. In Iranian hospitals and training institutions, the authors point to authoritarian and hierarchical workplace cultures in which physicians feel mistreated by superiors, and in which enduring suffering is equated with professionalism. Complaining about mistreatment is framed as a lack of resilience, discouraging trainees from seeking help. Entrapment is reinforced by structural constraints: until recently, entering a residency program often required substantial financial guarantees that made withdrawal extremely difficult even amid severe distress. Although those requirements were largely rescinded following multiple high-profile suicides, their legacy may continue to shape trainees’ perceptions of inescapability. The supervisor’s control over evaluation, referral, and career progression compounds the problem, because the institution that generates the stress also controls every avenue of escape from it, making reporting abuse a professionally dangerous act.

The volitional phase addresses the most lethal question: why do some physicians with suicidal thoughts act on them? The commentary identifies several occupationally specific moderators. Physicians have ready access to prescription medications and possess detailed medical knowledge that reduces fear of medical procedures. Emotional exhaustion and perceived entrapment can interact with this access in ways that raise risk beyond what ideation alone would predict. Exposure to a colleague’s suicide within closely connected professional networks may heighten vulnerability, operating through identification with the deceased, perception of shared working conditions, and the normalization of suicide as an exit from an intolerable situation, though the authors stress this process is psychologically complex and should not be reduced to simple imitation. They also warn that sensational or romanticized media coverage of physician suicides could exacerbate the problem, while responsible reporting could aid prevention.

Crucially, the IMV model does more than explain; it prescribes. Interventions targeting the pre-motivational phase should attack the structural production of distress by limiting excessive consecutive working hours, guaranteeing rest periods, paying salaries and overtime on time, improving protection against workplace violence, and removing unnecessary financial obligations attached to training. Strategies for the motivational phase would weaken defeat and entrapment: an independent complaints system for humiliation, harassment, and abuse; mentorship programs operating outside the hierarchical evaluative relationship; and the freedom for residents to discuss problems or explore leaving a program without punishment. Volitional-phase strategies include confidential suicide risk assessment and safety planning, restriction of access to lethal means, responsible media reporting, and postvention support for colleagues after a suicide or attempt. Each measure is designed to interrupt a specific pathway identified by the model, from background stressor to entrapment to action.

The commentary’s central implication is that these pressures become most dangerous when they converge: when professional identity is repeatedly damaged, exit options are restricted, confidential support is unavailable, and access to lethal means or exposure to colleague suicide raises the probability that ideation becomes behavior. The authors argue that prevention must therefore move beyond calls for individual resilience and toward institutional responsibility, proposing confidential screening for depression, burnout, and suicidal thoughts whose results are never shared with a resident’s direct supervisor, anonymous reporting systems for mistreatment and bullying, faculty mentoring outside the hierarchy, working-hour restrictions, hospital committees on workplace violence, and formal postvention procedures. Framed by the recent tragedy that prompted its writing, the analysis insists that the structure of risk revealed by the literature, not any single loss, is what demands urgent reform of how Iran trains, pays, protects, and supports its physicians.

Subject of Research: Suicide risk and suicidal ideation among physicians in Iran analyzed through the integrated motivational–volitional model

Article Title: Suicide risk and suicidal ideation among physicians in Iran from an integrated motivational volitional perspective

Article References: Msohfeghinia, R., Ghorbanpour, A., Mani, A., Rezaeian, M., & Molavi Vardanjani, H. (2026). Suicide risk and suicidal ideation among physicians in Iran from an integrated motivational volitional perspective. Discover Mental Health, 6(1), Article 189. https://doi.org/10.1007/s44192-026-00604-3

Image Credits: AI Generated

DOI: 10.1007/s44192-026-00604-3

Keywords: suicide risk, physician mental health, Iran, integrated motivational-volitional model, burnout, suicidal ideation, medical residents, occupational stress, entrapment, workplace violence, suicide prevention, medical education