New England Journal of Medicine
January 24, 2019 Dinah Miller, M.D.
We talk about the toll suicide takes on families and the tragedy for the people who’ve died. What we don’t openly talk about is suicide’s toll on the doctors who have treated these patients. But when a patient dies by suicide, it leaves us profoundly changed.
The news came by text as we drove home from brunch. My patient had died that morning by suicide. I read the text and wailed. My husband was driving, and our adult children happened to be away, traveling together on an exotic journey. I struggled to gather words, and my husband held control of the car through those excruciating moments when he thought something horrible had happened to our kids. I calmed down enough to tell him that the tragedy involved a patient. He was relieved. I was not.
U.S. suicide rates increased by 25.4% between 1999 and 2016.1 It’s been estimated that at least half of psychiatrists will lose at least one patient to suicide during their career.2 There are no estimates on how many primary care physicians will have the same experience, though they often treat psychiatric disorders. Among people who complete suicide in the United States, 46% have been diagnosed with a mental health condition, and many more people have undiagnosed mental illness.
We talk about the toll suicide takes on families. They experience grief, guilt, regret, anguish, anger, and stigma, and they often face significant financial and logistic consequences. We talk about the tragedy for the people who’ve died — the years of life lost, the graduations and weddings they won’t attend, the grandchildren they’ll never hold. Since suicide is considered preventable, these deaths inflict an added injury on the survivors, who may face the lingering pain of believing that there was something more they might have done.
What we don’t openly talk about is suicide’s toll on the doctors who have treated these patients. Death is part of life, and for many physicians it becomes a routine element of the job. Oncology patients die, trauma patients die, geriatric patients die — indeed, everybody eventually dies. In psychiatry, however, death is not a usual or expected outcome, and suicide induces the sharpest feelings of failure. We may grieve the loss of patients when they die of cancer, but when they die by suicide, it leaves us changed, sometimes even devastated.
Psychiatrists are considered the experts on suicide. After all, many people with major depression have feelings of hopelessness and thoughts of ending their own lives. In an outpatient psychiatry practice, it’s not uncommon for several patients a week to talk about psychic demons, dark thoughts, or the wish to simply not wake up, but such thoughts rarely crescendo to a suicide attempt, and much less often to a completed suicide.
A suicide plan with stated or presumed intent generally triggers hospitalization, and suicide risk is part of the daily landscape for inpatient psychiatrists. Insurers often require that patients be a danger to themselves or others as the standard for admission, making psychiatry the only specialty in which an illness must be deemed life-threatening for the patient to obtain hospital care. Yet the ongoing shortage of psychiatric beds makes it difficult for all but the sickest of patients to be admitted, and in rural areas the nearest facility may be hours away. A few states rely on the unconscionable practice of holding ill patients in jail until psychiatric beds become available. When depressed patients deny having any intention of harming themselves, inpatient options are rarely used. Moreover, even when patients are admitted, the average length of stay is only days, although medications for depression take weeks to begin working.
Suicide is often an impulsive act — it is not always planned, and patients don’t always share their intentions. Most psychiatrists care for many patients they deem “at risk” for suicide, but even if we are the experts on suicidal thinking and behavior, we’re generally fortunate enough not to be experts on completed suicide.
When my patient died, I told a few colleagues who are also my friends. All were sympathetic, but some could tolerate listening to my ruminations for only so long. Suicide is a topic that makes us all uneasy. It’s the psychiatrist’s biggest professional fear and failure, and on top of our own loss, self-recrimination, and regret, we may fear a lawsuit or feel defensive and anxious. I had worried about this patient and had carefully considered the care I provided. There had been numerous hurdles to optimal treatment, and looking back, I could see no obvious breaches of the standard of care. Still, for months afterward, my thoughts kept looping back to what else I might have tried. Yet all my mental machinations won’t bring the patient back to life. A patient suicide can fill us with shame, and we worry that our colleagues will judge us to be inadequate. The stigma associated with suicide attaches to the patient, the family, and also the doctor. At times, I’ve felt this suicide was my professional burden to bear alone.
Colleagues who have experienced a suicide told me that attending the funeral and meeting with the family was helpful. But we have no systematized way of coming together to learn from these cases, and no set rituals of our own to mark a death and find a path toward healing.
Days after the death, I attended a professional event and felt disingenuous as I made small talk, never mentioning the recent cataclysmic event in my professional life. It took some time and distance before I could tell my colleagues that this tragedy had transpired. With some trepidation, I mentioned a “bad outcome” to a couple of distressed patients as part of my plea that they relinquish possession of firearms until their mood improved. It felt unconventional, but I found that “Please do it for me” held some power and shifted the dialogue away from the question of my willingness to trust them.
I am still figuring out how to quiet my haunting emotions. For quite some time, I would wake up with my dead patient front and center in my mind, and we traveled together through the days. My sadness for the family remains immense. My feelings as a doctor are complicated by the fact that this particular patient had not followed my treatment recommendations and so my sadness is mixed with anger — yet somehow it feels wrong to be angry with a dead person who had suffered so deeply.
I am working my way back to being the psychiatrist I was before. At first, I felt anxious about taking on new patients and about ongoing treatment with my high-risk patients. Psychiatry is a gratifying specialty, and it’s not unusual for patients to verbalize their appreciation for the care they have received. After the suicide, I found such exchanges difficult; after all, keeping people alive had always been key to my understanding of what it is to be a good doctor, and every time a patient expressed gratitude I thought of my patient who died. I am left with the nagging questions of whether I can trust my own intuition about when a patient is safe and whether I can trust my patients to be forthcoming. I had treated this patient for only a short time; I can’t imagine the intensity of the grief I would feel if a patient I’d cared for for years were to lose this battle.
After a celebrity suicide, the media tends to reduce the solution to a singular message: Get help. But sometimes getting help and being identified as a person at risk are simply not enough. Sometimes we do everything possible and patients still choose to end their lives.
Suicide affects not just psychiatrists but also physicians in all specialties. As we tackle a tragedy that touches so many, I hope we can also lift the barriers that keep us from addressing our own anguish.
From the Johns Hopkins School of Medicine, Baltimore.