If you've been distressed by the loss of a patient to suicide, I hope my story will provide a moment of relief as you begin the process of healing; I hope that you may feel less alone.
Lifelong Learning in Clinical Excellence | February 19, 2019 | 4 min read
By Dinah Miller, MD, Johns Hopkins University School of Medicine
I have spent all thirty years of my career as a psychiatrist worrying about suicide. In my efforts to prevent this tragic outcome I have involved family, I have called the police and asked them to check on people, on rare occasions I have hospitalized patients, and I have often changed, started, or stopped medications in an effort to lift someone’s mood away from that terrifying ledge. I don’t think I am alone; the fact is that suicide is a chronic worry in psychiatric practice. Depression is the most common condition I treat, and part of depression is a change in cognition: nearly everyone who is affected by it has some dark thoughts – if not explicit thoughts of suicide, then vague thoughts that it might be welcome to just not wake up, or that things might be easier if they weren’t here. At any given time, there are one or two patients I am worried about, who seep past their appointed hour and into my psyche on nights and on weekends. I often ask these patients to touch base with me every day until their distress and my worry subside.
Last year, my worst fear came true and a patient died of suicide.
This was someone I worried about, someone who assured me – like so many others – that they would never do this to their family. I had come to believe that a caring family was protective and that a patient’s stated intentions (or lack thereof) were meaningful predictors of the unpredictable. It’s part of the job of being a psychiatrist, you might think, but really, it’s not. Really, it’s just horrible.
Everyone needs a release for their internal struggles, and I have found mine through writing.
Early on, I wrote a pages-long account of what happened and I showed it to no one. Time ticked by and my sadness continued. I talked to my colleagues, many of whom had had patients die of suicide, and I discovered that others shared my experience. The emotional fallout of suicide lingers for the doctor and little is written about this. Suicide leads to shame for those of us who failed to prevent this tragic outcome, and perhaps there is some guilt to feeling so badly when another person has lost their life and a family remains who are the true owners of the grief. I returned again to Microsoft Word, this time to write a much shorter account, focusing on my own feelings and not the details of the case. I sent the essay to the New England Journal of Medicine and they ran it as a Perspective selection at the end of January.
I’ve written a lot over the years. For twelve years, I had a psychiatry blog with two other psychiatrists, I’ve co-authored two books, and I’ve written a column for Clinical Psychiatry News since 2011. I’ve come to appreciate how important it is to find others who have shared an experience. People value reading about emotions that resonate for them and it provides a sense of relief from our all-too-human aloneness in our world of Instagram cats, designer dinner entrees, and smiles from beautiful beaches. I hoped we might open a discussion about our own emotions as physicians in all specialties as we linger against rising suicide rates that seem to defy all the treatments we have to offer.
Several people have commented that my essay was “brave,” including one of the reviewers for the New England Journal. I will tell you that it did not feel brave. I am accustomed to writing about my internal world and I did not see any risk to making myself just a little bit vulnerable. My family will still love me (I hope), my friends will still invite me to their parties, I don’t foresee patients leaving in hoards. It’s unfortunate that when physicians write about their feelings or their failures, it is considered an act of bravery. When I pressed myself to think more honestly about this, however, I realized there is a limit. If this suicide had happened earlier in my career, if I had felt that there was an obvious breach in the standard of care, if I had felt it was my “fault,” or if there had been more than a single completed suicide in my career-to-date, I would not have written this essay. As it turns out, I’m not particularly brave.
I wish I could tell you that something good has come of all this. I was always a worrier and now I worry even more. I’ve come to appreciate that my predictive powers are limited, that I must practice with the knowledge that patients may do what they will and my ability to impact their decisions may or may not work; there are forces that influence outcome in addition to my own efforts.
If you’ve been distressed by the loss of a patient to suicide, then I hope my story will provide a moment of relief as you begin the process of healing, or the response that one young psychologist wrote “…you made me feel less alone.”