From the Editor
It’s the phone call that we all dread – the call from the family or the coroner, explaining that your patient has died, likely by suicide.
At some point, we all receive that call.
Obviously, we think about the impact of suicide on families. But what impact does suicide have on us clinicians? In this week’s Reading, we consider the new BJP Bulletin paper on suicide and psychiatrists. Dr. Rachel Gibbons, an English psychiatrist, and her co-authors try to answer this question with a survey. Among their findings: a quarter of psychiatrist has considered a career change after a patient’s suicide.
In this week’s other selection, in a Lancet Psychiatry paper, Dr. Alex Langford, also an English psychiatrist, talks about the impact that suicide has had on his life.
Suicide and Providers
“Effects of patient suicide on psychiatrists: survey of experiences and support required”
Rachel Gibbons, Fiona Brand, Anne Carbonnier, Alison Croft, Karen Lascelles, Gislene Wolfart, and Keith Hawton
BJPsych Bulletin, 11 April 2019, FirstView Open Access
The death of patients by suicide has profound effects on the personal and professional life of many psychiatrists. Patient suicide can have an influence on staff recruitment and retention, quality of professional life, patient care and professional well-being. Currently there is limited and idiosyncratic support for clinicians who experience patient suicide. This important issue has not been well examined.
The majority of psychiatrists experience the death of a patient by suicide such at least once during their career, with many experiencing this more often. In one study, 53% of psychiatrists reported stress levels in the weeks following a suicide comparable to those reported in studies of people seeking treatment after the death of a parent. The intensity of this experience can result in a combination of symptoms of post-traumatic stress disorder, shame, guilt, anger, isolation, and fear of litigation and of retribution from the psychiatric community. The stress following a patient suicide can be exacerbated by organisational responses, including serious incident enquiries, and the pressure of attending the coroner’s court. The result can be increased anxiety in clinical situations and changes in practice. In those suffering a severe stress reaction, retirement and change in career are often considered.
So begins a paper by Dr. Gibbons et al. seeking to look at the emotional and clinical effects of suicide on psychiatrists, as well as the resources that would be helpful.
Here’s what they did:
- They drew data from “[a] web-based survey was designed by a multidisciplinary team of clinicians experienced in this area and informed by past research.”
- Participants were psychiatrists in active practices from four NHS Trusts (two from London, two from south-east England).
- The survey consisted of 42 questions.
- Statistical analyses were done, including t-tests; thematic analysis was also done.
Here’s what they found:
- “The survey was circulated to 520 psychiatrists, of whom 174 responded (34%).”
- “Of the 140 respondents who had experienced death of a patient by suicide, 100 (72%) had experienced more than one, 18 (15%) had experienced more than six, and (3%) five had experienced more than ten.” The average was 4.
- Respondents tended to be in general and geriatric psychiatry (30% and 20%, respectively), female (52%), and mid career (43%).
- Change in career path. “33 professionals (27%) noted in the free text that they had considered a change in their career path as a result of the suicide of their patient.” Also, with the most impactful suicide often occurring early in career (according to the data), 39% were not working in the same area at the time of this survey, indicating a possible post-suicide shift.
- Effects on emotional well-being. “Respondents were asked to rate the effect of the death on their emotional well-being on a Likert scale, where 0 = ‘no effect’, 50 = ‘some’ and 100 = ‘a very severe response’. Most (N= 105, 92%) rated their experience above 50, with an average rating of 66 out of 100. Only nine (8%) felt that their symptoms had met a clinical threshold for diagnosis of a psychiatric disorder at any time, although 15 (12%) were uncertain. Six (5%) had taken time off work.”
- Effect on clinical duties. “One hundred and fifteen (98%) reported a detrimental effect on clinical practice in the period after the death, with women (mean Likert scale score = 48) affected more than men (mean = 35; P= 0.01).”
- Factors that influenced psychiatrists’ experiences following the death. Respondents found support from a colleague with a similar experience to be helpful (48%); a persecutory or insensitive incident process, not so much (19%).
- Support wanted after a patient suicide. Psychiatrists favoured “a senior clinician with a role as a suicide lead to give confidential advice and support” (75%) and “support for the formal processes following a patient’s suicide” (70%).
- Responsibility for the death. Psychiatrists felt partially responsible for the death, but “thesense of responsibility decreased with time…”
The survey also allowed psychiatrists to make comments, organized by themes. I highlight:
It is a very frightening world where one professional group is given an impossible task and then censured by society (and themselves) for failing to achieve it.
Shame, guilt, it kept me awake at night. It affected subsequent career choices. It affected my capacity to work.
The authors conclude:
Respondents to this survey confirmed that the death of a patient by suicide can have very strong emotional effects on psychiatrists. Their clinical practice was often negatively affected for a period of time, and over a quarter considered a change of career path as a result.
A few thoughts:
- This is an interesting paper.
- The paper sheds light on an important issue.
- There are limitations: the data was drawn from self reporting, and the people surveyed were all from southern England. And the response rate was good but not amazing (34%). Still, despite the relatively common occurrence – a catastrophic event that the vast majority of us experience at least once – the data is fresh and new.
- Some of the results aren’t so surprising. For instance, the finding that psychiatrists were deeply affected by suicide.
- Other results seem a bit surprising – for example, the type of support found helpful after a patient’s suicide. Many favoured such support from “a senior clinician with a role as a suicide lead to give confidential advice and support” (75%); in contrast, “therapy and support” wasn’t a popular choice (23%), nor was “a workshop” (33%).
Suicide and Its Effects
The Lancet Psychiatry, 8 May 2019
You could be forgiven for thinking of every suicide as a lightning strike: an unpredictable flash of tragedy with shocking but isolated damage. In reality, however, suicides have more in common with earthquakes. Their effects reverberate far beyond an epicentre of devastation. Around 60 people are intimately affected by each of the 800 000 annual global suicides, bereaving an estimated 48 million to 500 million people a year. These survivors are exposed to an increased risk of suicide and mental illness themselves, and experience stigma, rejection, and shame. To maintain the analogy, most people will have their psychological foundations rocked again and again by suicide over the course of their lives.
I was one of those millions of people before I had even left primary school. My memories of that time are few, but enduring. The damage was not appreciable to me as a child, and my childhood was largely safe and enviable, but those thin cracks in my psychosocial stability widened with time. I grew into a young adult who was academically able to get into medical school, but personally nearly unable to cope away from home.
So begins a short essay by Dr. Alex Langford that doesn’t require much of a summary here.
Shortly after starting work, I collapsed completely. I was far from the only one.
If the experience has been deeply personal, so has his decision to do something larger:
As well as my work, I run. This spring and summer, I am running four marathons and three ultramarathons in aid of Papyrus, and, over thousands of training miles, I have dwelt on why I chose this challenge. I suspect it is a dual process: an exposure to enduring pain as a reminder that I have overcome it, and so that others never have to. Step by step, together, we will overcome suicide.
A few thoughts:
- This is a moving essay.
- The global statistics are stunning. To repeat: “Around 60 people are intimately affected by each of the 800 000 annual global suicides, bereaving an estimated 48 million to 500 million people a year.”
- Dr. Langford provides updates on his training, as well as information on how to support Papyrus, the suicide prevention charity he is running for, on Twitter. See: https://twitter.com/psychiatrysho?lang=en.
- Further reading? Dr. Dinah Miller, a psychiatrist affiliated with Johns Hopkins Medicine, wrote about her reaction to a patient’s suicide.
On the topic of global psychiatry, I recently interviewed Dr. Vikram Patel of Harvard University.
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.