From the Editor

It’s the call we dread, perhaps from a relative or the family doctor. The news catches us by surprise: the patient has died and suicide is suspected.

In the first selection from The Canadian Journal of Psychiatry, Dr. Zainab Furqan (of the University of Toronto) and her co-authors consider psychiatrists’ experiences with patients who die by suicide. In this qualitative analysis drawing on 17 interviews, they explore the emotional response. They conclude: “patient suicide is often associated with grief, shock, anxiety and guilt; emotions which are mediated by physician, patient, relational and institutional factors and have important ramifications on psychiatrists’ well-being and clinical practice.” We consider the paper and its implications.

In this week’s second selection, Anna Wexler and Dominic Sisti (both of the University of Pennsylvania) write about the potential and problems of off-label use for psychedelic drugs in light of likely FDA approval. In a JAMA PsychiatryViewpoint, they note: “With high public enthusiasm, extremely bullish investors, and hundreds of newly established brain wellness clinics, all the pieces are now in place for expansive off-label promotion and use of psychedelics to quickly mushroom beyond what is safe.”

Finally, in the third selection from The New England Journal of Medicine, Dr. Shireen N. Heidari (of Stanford University) notes the incredible challenges of working during the pandemic – and the psychological toll. She describes her decision to seek care and her own recovery: “A year after making the decision to talk to my family and my doctor, I know that advocating for my own mental health was the best decision I could have made.”

DG

Selection 1: “‘I was Close to Helping him but Couldn’t Quite get There’: Psychiatrists’ Experiences of a Patient’s Death by Suicide”

Zainab Furqan, Rachel Beth Cooper, Andrew Lustig, et al. 

The Canadian Journal of Psychiatry, 19 September 2022  Online First

Suicide is among the top 10 causes of death in North America and one of the most common causes of death among psychiatric patients. Approximately 33% to 80% of psychiatrists experience the death of a patient by suicide. However, our knowledge about the impact of a patient’s suicide on psychiatrists’ emotional well-being and clinical practice is limited to a few survey studies and minimal qualitative data.

Survey studies have indicated that psychiatrists experience strong emotional reactions to a patient dying by suicide. Reactions include disbelief, self-doubt, embarrassment, guilt, self-blame, anger, and shock, as well as fear and anxiety over personal or legal repercussions. Many also experience low mood, irritability and poor sleep.

So begins a paper by Furqan et al.

Here’s what they did:

“Eighteen psychiatrists were recruited using snowball sampling and interviewed to collect demographic data, followed by an in-depth exploration of their experiences of patient suicide. Interviews were then transcribed verbatim and analysed using constructivist grounded theory.”

Here’s what they found:

  • The sample initially included 18 psychiatrists, though only 17 interviews were available for qualitative analysis.
  • Demographics. Most were female (11), White (12) and working in general psychiatry. The mean age was 46.1; years in practice: 13.8.

The paper notes emotional responses:

Grief and sadness

“Fifteen out of the 17 psychiatrists expressed grief and sadness after the death of a patient to suicide. Participants spoke about the loss of their patient as a loss of a human being, one with unique qualities… ‘I was really disturbed by the loss. That was my first. Just the loss of like a person who I cared about. And a person with whom I had a relationship. So that was first.’”

Shock

“Twelve participants described shock upon hearing the news that a patient had died by suicide. Manifestations of shock differed among participants; some cried, while others felt ‘numb.’”

Anxiety

“Twelve participants experienced anxiety, often in multiple domains after the patient’s death. Anxiety-inducing domains included (a) fear of future patient suicides, (b) anxiety about speaking to patient families, and (c) anxiety about anticipated incident reviews and possible medico-legal repercussions. Highlighting the fear around future patient suicides, one participant articulated,

Well, number one I think I have a sinking feeling anytime now someone doesn’t come back from pass as expected.’”

Adding to the anxiety: “Many participants explained that they had not received any type of training about speaking to families after a patient’s suicide.”

The paper also notes factors that help mediate emotional response – patient, relational, physician factors, as well as institutional responses and non-institutional sources of support. We focus here on institutional responses: 

“Thirteen participants endorsed distress or discomfort around the way their institutions responded to at least one of the patient suicides that they had experienced. The most common reason that was cited for this distress was the perception of being unfairly blamed or scrutinized. Encounters that were experienced as guilt-inducing were the most difficult. This was captured by one participant who stated: ‘She was on her computer, kind of not making eye contact, and just asking me a lot of questions that just felt like, like I was on trial.’” 

That said, participants were also able to identify positive responses, including the creation of safe spaces (independent of debriefing).

A few thoughts:

1. This is a good paper.

2. Though so many of us have lost patients to suicide, the field is under-studied. This paper is thus relevant, timely, and – yes – overdue. 

3. The implications? The authors put forward a list of suggestions for institutional responses. Among them: better training during residency and regular check-ins after a physician has lost a patient. They suggest that institutions: “Consider separating team debriefs and formal incident reviews, with the former reserved for emotional support.” Thoughtful.

4. Like all papers, there are limitations. The authors note several including: “Eighteen psychiatrists were interviewed for this study, and while this is robust sample size for a qualitative study, it limits the generalizability of the findings.”

The full CJP paper can be found here:

https://journals.sagepub.com/doi/10.1177/07067437221125300

Selection 2: “Brain Wellness ‘Spas’–Anticipating the Off-label Promotion of Psychedelics”

Anna Wexler and Dominic Sisti

JAMA Psychiatry, August 2022

Psychedelic drugs have reemerged as a promising adjunct to psychotherapy for a variety of mental health indications. Recent phase 3 clinical studies indicate 3,4-methylenedioxymethamphetamine (MDMA) is both efficacious and well tolerated in the treatment of posttraumatic stress disorder. Psilocybin – naturally found in mushrooms – appears in phase 2 studies to be efficacious in treating depression. The US Food and Drug Administration (FDA) has designated both as breakthrough therapies, fast-tracking them for approval…

If and when psychedelics are approved by the FDA, they will almost certainly be used not just for their approved indication(s) but for off-label ones as well.

So begins a paper by Wexler and Sisti.

They write: “Any approval of psychedelic treatments will come against the background of an already-burgeoning landscape of private neurotherapy and brain wellness clinics that promote the off-label use of psychiatric drugs and medical devices.” They give examples:

  • “[M]ore than 100 clinics in the US advertise the use of transcranial magnetic stimulation for off-label indications; some of the advertised indications have a weaker body of evidence supporting efficacy than others.” 
  • “Hundreds of other clinics offer alternative neurotherapies that lack a strong evidence base, such as neurofeedback, for both clinical indications as well as for ‘cognitive enhancement.’”

They argue that there are three ethical issues with the approval of MDMA and/or psilocybin.

History has shown that clinics will likely overhype the use of the drugs and advertise that psychedelics can effectively treat certain indications even in the absence of scientific evidence. 

“These claims can be misleading for patients, which is especially ethically concerning for vulnerable populations who may be paying significant costs out of pocket.”

While physicians can legally offer off-label treatments, any ethical administration of a treatment requires health care professionals to have competency, not just relevant credentials. 

“Physicians without relevant training may not be able to competently treat patients with serious conditions, such as bipolar disorder or posttraumatic stress disorder. Related concerns include that those without any medical training may offer psychedelic treatments for mental health…”

There will likely be significant variation in terms of off-label protocols and dosing practices, which will complicate attempts to assess the efficacy of MDMA and psilocybin for nonapproved indications. 

“Unlike pharmacological drugs, the administration of psychedelics does not just involve a dose to be taken at home, but the evidence base is built on protocols that typically include a psychotherapy session usually provided by highly specialized clinicians, along with a series of preexperience and postexperience sessions. Because those interested in obtaining psychedelics may opt to receive them at an off-label clinic rather than through a clinical trial where they might receive a placebo, efforts at assessing efficacy for a broader array of indications will be dampened.”

They argue that Oregon has taken a good first step: “the Oregon Health Authority has established the Oregon Psilocybin Services Section, carving a pathway for the provision of mushrooms by licensed facilitators who will be required to undergo a minimum amount of training.” 

They close on a cautionary note: “While off-label use may be a useful way to provide access to promising treatments, it must be done responsibly and with an eye toward future evidence-based advancements in medical science; regulators, policy makers, and health authorities must carefully examine and create guardrails for the promotion and off-label use of psychedelics.”

A few thoughts:

1. This essay is written by Americans with an eye on US regulations and approval. That said, it is relevant in Canada (and, for that matter, in the UK and Europe).

2. They make good arguments. The regulatory framework of Oregon is interesting.

3. Would private industry (over)promote psychedelics? The experience with cannabis legalization in Canada and in many US states suggests caution is appropriate.

The full JAMA Psychiatry paper can be found here:

https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2793902



Selection 3: “Finding a New Mantra”

Shireen N. Heidari

The New England Journal of Medicine, 15 September 2022

I know the exact day that broke me. In January 2021, I was working on the inpatient palliative care team and had spent most of a long day in the ICU. The patient in the room across the hall was struggling to breathe. He had been clear: yes to oxygen, but no breathing tube. The oxygen was already cranked as high as it could go. I watched him through the glass, heaving the muscles of his chest higher, trying desperately to catch more air. He wouldn’t be able to keep going much longer. How many more times would we watch a scene like this play out? I could see similar emotions on everyone’s faces: I don’t know if I can lose another patient today. I looked down at my gray tennis shoes: one of the laces was coming loose again. I really wanted to go home.

So begins a paper by Dr. Heidari.

She talks about a childhood memory of her mother reassuring her after a near car accident by telling her that everything was okay. As a physician working through the pandemic, she writes: “I learned to pretend that I was OK in a crisis because it was an essential skill in health care… I needed to believe that mantra.”

She talks of the strain at home: “I never expected that 7 months into my marriage, I’d be asking, each time I was exposed to a deadly disease at work, whether I should come home. Working in palliative care had always involved being present in crisis, sitting with grief, but the depth of human loss was devastating in a way I had never experienced, and I had very little left to give when I came home.”

She describes the deterioration of her mental health: “I wasn’t sleeping. I didn’t have the time or energy to do things I loved – reading, playing music, being outside, chasing my dog – I couldn’t remember the last time I felt like myself. I was terrified I would get my family sick. For months I could focus on only one or two steps ahead. I’d been trained to subordinate my own physical and emotional needs to what was needed of me.”

And she describes the decision to get care: “I wanted to start taking an antidepressant. I wanted to feel like myself again, and it was time to stop being afraid of an option that could help.”

“[A] few months after starting medication, I felt like myself for the first time in more than a year. I no longer feel like I’m staring at the headlights coming toward me. I come home from the hospital with energy left for myself and my family.”

She closes: “I have a new mantra now, etched on a bracelet around my wrist: I am human.”

A few thoughts:

1. This is good paper.

2. Her writing is raw.

3. Dr. Heidari finds fault with medical culture itself. “We get so many messages in medicine that we should tough it out, push through.” She notes, as an example: “Licensing and credentialing forms often inappropriately ask if we’ve ever sought treatment for our mental health.” Relevant. 

The full NEJM paper can be found here:

https://www.nejm.org/doi/full/10.1056/NEJMp2206851

Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.