Hero

Videos

Slideshows

Articles

Podcasts

Poll

September is National Suicide Prevention Month. Christine Moutier, MD, Chief Medical Officer for the American Foundation for Suicide Prevention, shared recent survey data and the latest suicide prevention techniques with 

Psychiatric Times: Youth suicide has been getting a lot of media attention lately. As the Chief Medical Officer for the American Foundation for Suicide Prevention, would you say youth suicide is increasing? Why or why not?

 from the Centers for Disease Control and Prevention (CDC), youth suicide rates had been rising from 2007 through 2018. In 2019, we saw the first decreases in rates in over a decade, when youth rates decreased by 5.2% from 2018 to 2019. And then for 2020, during the pandemic, although we do not yet have finalized 2020 suicide data from the CDC, preliminary numbers on the total US suicides (across all age groups) show a further decrease by 5.6% when compared to 2019. However, certain populations (ie, youth and young adults, as well as historically marginalized communities) may be disproportionately impacted by the pandemic and may be experiencing different suicide-related trends than the general population. We need more data to identify trends among youth suicide mortality during the pandemic. It is also worth noting there are fluctuations in suicide rates of all age groups over time.

PT: According to reports, the proportion of mental health–related emergency department (ED) visits among adolescents aged 12 to 17 years increased 31% in 2020 compared with that during 2019. Do you expect to see another rise in the coming years?

 looked at trends in emergency department visits for suspected suicide attempts by age group and sex during 3 time periods during the COVID-19 pandemic. Key findings included:

- During February and March 2021, when compared to the same time period in 2019, there was a 39% increase in ED visits for suspected suicide related concerns among youth aged 12 to 17 years.

- The increase for females aged 12 to 17 years was 51%.

- The increase for males aged 12 to 17 years was 4%.

- Young individuals (aged 18 to 24 years) did not see a similar increase as adolescents.

It is important to note these are not mortality data, but rather ED presentations for “suspected suicide attempts,” meaning likely self-harm (some of which is nonsuicidal), suicidal ideation, and suicide attempts. In general, many suicide attempts never come to medical attention, and some are never disclosed even to peers or parents.

It is also relevant that suicidal behavior is generally more prevalent among girls than boys, while boys suicide death rates are higher than girls. Presenting to the ED for suicidal concerns could be reflective of both higher rates of distress among the 12- to 17-year-old girl population but also could also be a measure of increased help seeking behavior. Average ED visit rates for mental health concerns and/or risk factors for suicide attempts could have potentially increased as adolescent females have been spending more time at home due to physical distancing and remote schooling, allowing them to express mental health distress and talk more about suicidal thoughts and behaviors than ever before, prompting adult figures in their lives to take them to the ED. When help seeking behaviors increase, suicide risk is generally mitigated.

Again, this data does not mean there was an increase in suicide deaths. The takeaway from this finding is that we need to pay attention to our youth regardless of age, gender, race, or ethnicity. We know some youth have higher rates of suicidal thoughts and behaviors (prepandemic), (eg, LGBTQ youth, youth who engage in bullying behaviors, and concerning trends in Black and Latinx youth) and so keeping in mind that there are known higher risk factors that were present before the pandemic is an important consideration.

If there is a young individual in your life and/or if you have pediatric/adolescent patients, now is the time to engage them in open, authentic conversations to understand where a child is with their mental health, and—if necessary—help them get support or treatment customized to their needs. It may be reasonable to utilize mental health services at an earlier stage of symptoms or concern, given the protective effect for suicide risk that mental health treatment and support affords.

PT: Girls aged 12 to 17 are especially at risk, with suspected suicide attempt ED visits 50.6% higher in early 2021. What advice would you give to mental health professionals treating girls in this age group?

 The difference in suspected suicide attempts between adolescent males and females could be attributed to the possibility that adolescent females disclose suicidal ideation or behavior more than adolescent males. It is also possible that there are differences between the pandemic’s impacts on mental health and suicide risk between the genders. The pandemic’s potential impact on family and parental stress, coping and mental health, social distancing, remote schooling, and other factors may be impacting girls in some unique or disproportionate ways compared with boys. This could relate to how boys and girls are socialized differently, possible differences in baseline social dynamics between girls and boys’ social networks, possible differences in how screen time, social media and video game engagement impacts youth, and their developmental needs being differently disrupted in some way.

PT: How would you like to see emergency psychiatric care evolve in the future to cope with the problem of youth suicide?

 The CDC’s data from syndromic ED surveillance speaks to the importance of improving suicide preventive care both during and after ED visits. There are evidence-based steps and tools for clinicians and health systems, detailed in the National Action Alliance for Suicide Prevention’s 

Recommended Standard Care for People with Suicide Risk

, that can be implemented in routine medical care for patients, including universal screening for suicide risk, safety planning, lethal means counseling, and providing caring communications that bridge transitions in care.

 All of these steps are included in an app called 

 codeveloped by AFSP and the American College of Emergency Physicians (ACEP).

It is critical to strengthen care transitions so once individuals leave the ED they do not fall through the cracks, but instead have a seamless transition that keeps them safely recovering well after the suicide attempt or suicidal crisis. It has been shown that caring contacts and follow up with patients after their visit to the emergency department, including 6 to 12 communications over the course of 18 months in addition to treatment as usual, can reduce subsequent suicide attempts by 40% to 60%.

 Key resources to assist in strengthening care transitions include 

Best Practices in Care Transitions for Individuals with Suicide Risk: Inpatient Care to Outpatient Care

Suicide is a complex public health problem so we must ensure 

suicide prevention is infused into community-based settings

 as well as health systems to carry out prevention activities and interventions that are effective and culturally appropriate.

PT: What are some of the myths surrounding youth suicide?

 For many complex health issues throughout history, misinformed views tend to promulgate, leading to a multitude of negative effects, deeply stigmatizing the experiences where these health issues are involved. Without science, untruths and stigma continue to thrive.

In the past, before a body of scientific research led to an understanding of what drives suicide risk, many myths prevailed about suicide. These myths not only shaped stigmatized and erroneous views of suicidal behavior but resulted in harshly punitive ideas and judgment of those who experience suicidal thoughts, who attempt, or who ultimately lose their lives to suicide. Now that a multidisciplinary group of scientific fields are shedding tremendous light on the actual drivers of suicide risk, cultural views are changing, bringing an understanding that, while complex, suicide is a health issue.

One myth that may still have echoes in the current day is the erroneous idea that certain individuals are bent on suicide, and therefore very little can be done to change course once someone becomes suicidal. Today, scientific research in a broad range of domains—from neuroscience to clinical research to epidemiology and community/public health interventions—shows that despite its complexity, suicide is 1) a health-related outcome and 2) can be preventable.

Another common misunderstanding might be related to conflation between suicide contagion and asking about suicidal thoughts. One might think if “I ask if someone if they are suicidal, I will put the thought in their head” or “I am going to increase risk,” because they have heard of the concept of suicide contagion, but asking in an open, caring manner will not increase risk. When you ask someone about suicidal thoughts directly, it provides them with the opportunity to share what may have been not disclosed and therefore not been addressed. Whereas suicide contagion stems from unsafe messaging that sensationalizes suicide and details suicide methods through media, social media, or other key moments of messaging, such as during the postvention period after a suicide has occurred.

PT: You recently participated in a World Suicide Prevention Day Facebook Live Event. Can you share with us what you thought were some of the most important discussions of the day?

 for World Suicide Prevention Day on September 10, and we heard from musicians, celebrities, and experts that elevated the conversation about supporting one another; the power of safe, effective self-disclosure by a number of influencers; and about some important initiatives going on in suicide prevention. For example, a conversation between AFSP’s CEO Bob Gebbia and policy makers highlighted the important opportunity for transforming our national crisis response system with the implementation of 988, which will go live July 2022. I spoke with our partners at the American Academy of Pediatrics and the National Institute of Mental Health about our national youth suicide prevention blueprint, which will be released in early 2022. It will engage pediatricians in the important role they have to play in preventing youth suicide.

PT: One of the other panels you attended was on music and mental health. Do you think music is integral in mental health care, and why? How can psychiatrists leverage the powerful effects of music to help their patients?

 The music industry is engaging with the topic of mental health and suicide prevention in some very positive ways. For example, AFSP has partnerships with Audacy, a global radio network, as well as Universal Music Group, which is hosting opportunities for musicians to discuss mental health and coping as a way to inspire their followers to become more proactive about their own mental health. Music can also be a beneficial outlet for individuals who are experiencing depression or struggling with their mental health, as it provides an opportunity to process overwhelming emotions as well as communicate how they are feeling through safe and creative expression. Sometimes music resonates with listeners, lets them know that they are not alone in how they are feeling, or alone in what they are going through. That can provide immense comfort.

Music is a fantastic tool for improving patient outcomes, and research has shown us it can be extremely beneficial in treating mental health conditions like depression. Psychiatrists should consider incorporating music as a topic for example related to a patient’s Safety Plan for internal coping, as a way to distract from suicidal thoughts, and to tap into healthier coping strategies.

PT: The Netflix drama “13 Reasons Why” put the spotlight on youth suicide in the media. Do you think shows like that help youth recognize they are not alone and should seek help?

 The portrayal of suicidal struggles and suicide is complex, and research shows that viewers respond to entertainment content in a variety of different ways. The same content that can lead to increased awareness and interest, and even empathy in many, can also lead to worsening of mood, anxiety, or self-image, or even increased suicide risk for others who are vulnerable or struggling. Research also shows that for individuals who have certain vulnerabilities—either related to their present mental health, or past experiences, especially trauma—some of those individuals have a special susceptibility to identification with others they see struggling in similar ways. If the vulnerable individual sees a fictional character struggling and then dying by suicide, especially when portrayed graphically or in a manner that glorifies the death or the decedent, the vulnerable viewer can become more at risk of imitating this suicidal behavior.

The Annenberg Inclusion Initiative, in collaboration with AFSP, released 

a study in 2019 on the portrayal of mental health

 and suicide in film and television, which found that it is sparse (1.7% of speaking roles appearing in film and 7.1% on television, versus 20% of the American public who we know have a diagnosable mental health condition), and portrayals tend to be extremely distorted, showing a grave misunderstanding of mental health and the experiences patients have living with psychiatric illnesses. This misrepresentation includes frequent derogatory name calling, inaccurate linkage to violent behavior, and an overall lack of understanding about the experiences of individuals with mental health conditions. We know most people with mental health conditions live full lives, but this is not shown in most television programs or in movies.

PT: If a patient starts discussing shows, music, or other media around suicide, should clinicians consider that a warning sign?

 Absolutely, I would hone in and explore that further. It is possible that it is an avenue for them to begin discussing their own suicide risk factors such as past trauma, family history of suicide, or prior suicidal thoughts or attempt. Exposure to another’s suicide or to graphic or sensationalized accounts of suicide is a risk factor too. If a patient starts discussing their exposure or accounts of suicide in shows, music, or other media, I would encourage asking about their connection to the content or artist and probing for possible suicide risk factors. Consider it an appropriate time for a reassessment and formulation of suicide risk. To learn more about how to do that, Drs Pisani, Stahl, and I cover that in our recently released clinical handbook, 

PT: September is National Suicide Prevention Month. What are some ways people psychiatrists and other mental health clinicians can get involved this month to help put a stop to suicide?

 In observance of National Suicide Prevention Month, there are a multitude of ways everyone including psychiatrists and other mental health clinicians can help prevent suicide, including:

- Adding crisis resource numbers to your patient resources, to you own cell phone, and encouraging loved ones to do the same, so that it is ready when/if you need it.

- Considering additional training in Safety Planning, Lethal Means Counseling, and other brief risk reducing interventions.

- Encouraging your health system’s leadership to engage in system-wide suicide prevention policies and practices.

- Advocating for mental health and suicide prevention policies at the national, state, or local levels that ensure everyone in your community has access to mental health care, suicide prevention training, and funding for local crisis resources.

- Getting involved with your local AFSP chapter and helping transform your community into one that is smart about mental health, where everyone has support when they need it.

Additionally, AFSP provides opportunities for everyone to get involved with the organization and raise awareness for suicide prevention within their community, including 

creating a suicide prevention awareness and fundraising event

To see more of Dr Moutier’s thoughts on suicide, watch 

is Chief Medical Officer, American Foundation for Suicide Prevention, New York, NY.

2. Luxton DD, June JD, Comtois KA. Can post discharge follow-up contacts prevent suicide and suicidal behavior? A review of the evidence. 

The Chief Medical Officer for the American Foundation for Suicide Prevention sat down to talk with Psychiatric Times about a number of important topics in suicide. 

Suicide: Myths, Media, and Difficult Discussions

H. Steven Moffic, MD, discusses the risk of Muslim patients committing suicide, and also how 'suicide bombings' might be a misnomer. 

is an award-winning psychiatrist who has specialized in the cultural and ethical aspects of psychiatry. A prolific writer and speaker, he received the one-time designation of Hero of Public Psychiatry from the Assembly of the American Psychiatric Association in 2002. He is an advocate for mental health issues relate to climate instability, burnout, Islamophobia, and anti-Semitism for a better world. He serves on the Editorial Board of

The term 'suicidal bombings' should perhaps be renamed 'homicidal bombings.' Here's why. 

When Suicide Is Not a Suicide: An Epilogue

In this Mental Health Minute, Chad Moses talks about rising suicide rates and how we as a community can help. 

5 Studies Aimed at Reducing Suicide Among Teens

is the Director of Outreach and Experience at 

, a nonprofit movement dedicated to presenting hope and finding help for people struggling with depression, addiction, self-injury, and suicide.

There's 1 suicide death every 45 seconds... every community has a suicide story, but we can help. 

Hopelessness to Help

Let me tell you an old joke, the kind of humor that might have resonated with my immigrant grandparents: “A Jewish mother is with her son at the beach after he recently passed his medical licensing exams. He goes for a swim, but suddenly gets pulled under a large wave. Trying to get assistance, she shouts, ‘Help, help! My son the doctor is drowning!’”

That is a fitting allegory for the experience of young doctors today, who are publicly applauded for their professional skills and accomplishments, but continue, metaphorically speaking, to drown.

In ideal circumstances, a doctor’s professional identity centers around not only using one’s knowledge of medicine to educate and help individuals who are suffering from illnesses, but also exercising compassion and earning respect through competence, ingenuity, and fortitude. However, the unfortunate reality is that modern medicine is practiced within an increasingly inefficient, dysfunctional, and bureaucratic health care system that limits our ability to live up to this standard. In other words, the problem we are facing in residency is that medicine has changed, but medical training has not.

Facing the Alarming, Blunt Facts About Burnout and Stress

I was actually warned about the growing mental health crisis among doctors in training 3 years ago on my first day of hospital orientation when the director of our house staff mental health service told us the facts bluntly. About 

 would develop burnout during our residency training, and a quarter would develop clinical depression, a rate that has been estimated by the American Foundation for Suicide Prevention to be 3 to 4 times that of similarly aged peers in other professions.

 Because many of us would be repeatedly exposed to medical emergencies and traumatic stress, we would be more likely to develop 

 Most alarming, we would be at increased risk of suicide. One study from 

 found that 23% of first-year residents had had suicidal thoughts during the previous year.

 Suicide is the second leading cause of death among residents, and the leading cause among male residents.

These are not mere statistics. I have completed my final year of residency training in psychiatry, and every year since that orientation lecture, in what has become a disturbingly routine ritual, I have gathered informally with my department after learning of a colleague’s suicide.

Residency: Training Program or Hazing Ritual?

It is impossible to discuss the current burnout and mental health crisis among residents without considering the historically demanding nature of residency training. Equal parts training program and hazing ritual, residency is a modern, systematized form of apprenticeship; it is a rite of passage that initiates young doctors into the practice of medicine. Formal residency programs have been in place in the United States for more than 100 years, and their central guiding principles have remained much the same. In exchange for training and education, we provide inexpensive labor for hospitals. We work most of our waking hours and are paid only about $12 an hour for an 80-hour week, even though nearly half of us owe more than $200,000 in educational debt.

There have been important regulations put in place to improve residents’ working conditions, mostly as a result of patient tragedies. An example is the death of Libby Zion in 1984, which led to the passage of a 1989 New York State law restricting resident work hours to 80 hours per week. Unfortunately, the recommendations were not adopted nationwide until 2003. Meanwhile, in 2017, the Accreditation Council for Graduate Medical Education (ACGME), which oversees residency training, raised the maximum number of hours an intern can work consecutively from 16 to 24. Unsurprisingly, many of these protections have been difficult to maintain in recent months. Residents have been asked to take on the lion’s share of additional work, often in capacities outside their area of training and specialization, during the COVID-19 pandemic.

More senior doctors will rightfully point out that residency training has always been demanding and, in some ways, exploitative. But even if overwork contributes to resident burnout, depression, and suicide, it cannot explain why the problem seems to be growing. In recent years, numerous academic studies have sought to characterize the problem of burnout more specifically, investigating risk factors, rates across medical specialties, and its 

 Medicine is not the only profession that involves rigorous training, long hours, and a stressful work environment. Moreover, we enter residency with foreknowledge of its difficulty and having already demonstrated the ability and dedication to endure it. In fact, physicians actually score higher on resilience scales than individuals in other professions, suggesting that physician burnout occurs in spite of the 

 My sense is that the current resident burnout is not merely one caused by overwork and insufficient attention on resident wellness, although these undoubtedly contribute, but rather due to a professional identity crisis.

Time Constraints and Patient-Doctor Interactions

Even before the coronavirus pandemic began, today’s hospitals were vastly different from the ones our teachers and mentors staffed when they were residents a generation ago. With improved medical knowledge and treatment over the last half-century, patients now can receive care in ambulatory (and even virtual) settings and survive conditions that would have likely been lethal a few decades ago. As a result, residency training, which remains predominantly hospital-based, involves caring for ever-sicker and more complex patients. The number of 

, for example, has doubled in the last 3 decades, as has the number of intensive care unit beds, even as the number of hospitals has decreased across the country.

 Sicker patients have more medical emergencies, and over the last 10 years, the rates of cardiac arrest in hospitalized adult patients has increased by more than 20%.

 Due to a combination of improved treatment and increased pressure to reduce health care costs, today’s patients spend roughly half as many days in the hospital per admission compared with those in the 1970s.

 As a result, in addition to managing more complicated and stressful clinical situations, residents contend with more rapid patient turnover and increased administrative burden than ever before.

Young doctors may have entered medicine to tend compassionately to patients, but they end up with woefully insufficient time to spend with those in their care. Contrary to the popular image of the young, white-coated physician intently examining a patient with a stethoscope, residents actually spend most of their time in cramped workrooms managing patients’ care from behind a computer. In recent studies at Stanford University and Columbia University, residents in their first 2 years of training spent almost half their working hours at computers, using the electronic medical record to gather information and write notes; less than 10% of their day was spent with patients.

 As an intern working in internal medicine, the 5 to 10 minutes a day I spent with each patient was sometimes more time than the more senior residents on my team had—they did not always have time to even meet the patients.

Even before the COVID-19 pandemic, which has accelerated this trend by forcing residents to minimize all face-to-face interactions with patients, pressing time constraints required residents to spend only enough time with patients to obtain necessary information, a dissatisfying experience for doctor and patient alike. We also save time by talking about patients primarily in terms of their basic demographics, diagnoses, and test results—a dehumanizing characterization that can make it difficult to see patients as actual individuals. The breakdown of the doctor-patient relationship presents an existential threat to resident professional identity, especially now, when patient interactions occur behind the impersonal veil of fogged face shields and voice-muffling N95 masks. If we are unable to spend meaningful time with patients, we are not learning to function as doctors, but merely as technicians for the human body.

While the combination of punishingly long work hours and limited time with patients may be demoralizing for residents, it is potentially disastrous for patients. My colleagues acknowledge that, as a result of feeling overwhelmed, they have made mistakes that have impacted patient care and wasted resources, such as requesting redundant laboratory tests, requiring an additional blood draw, or accidentally ordering an expensive imaging study on the wrong patient. When I did night shifts as an intern, I cared for up to 40 sick patients each night and was exhausted—sometimes somewhat delirious from sleep deprivation—and focused on trying to keep track of which emergency I needed to respond to first. Occasionally I would be notified of a patient’s request for pain medication, and despite my best efforts, would sometimes be too busy to respond promptly, or worse, might even forget. Experiences like these are not tracked by the ACGME when looking for links between resident exhaustion and clinical errors, as any resident will shrug and tell you that “it happens every day.” But ask anyone who has been a patient in a hospital, and they will tell you about a time they suffered while waiting for the help of a doctor whom they did not even know.

Addressing the Social Safety Net, Without a Net

Another way in which hospitals have changed is that they increasingly care for the most 

 in our society, those who cannot receive assistance anywhere else.

 Residents must not only treat the immediate medical problem at hand but, very often, also address the social determinants of patient health, including poverty, violence, exposure to the criminal justice system, systemic racism, illiteracy, immigration trauma, and homelessness. We enter residency training to become doctors, but we are asked to function as part of the social safety net, an impossible task that often leaves us feeling helpless, exhausted, and overextended.

I had this very experience when I spent a month working on an inpatient HIV service. Although patients with HIV can lead healthy lives thanks to antiretrovirals, the patients in this unit were gravely ill with severe complications, primarily because their lives were too unstable and chaotic to stay regularly engaged in treatment. Despite no formal training in social work, we spent hours each day in interdisciplinary meetings strategizing the provision of services to support patient well-being, like housing, nursing services, financial support, and psychological counseling. These patients needed assistance in almost every aspect of their lives, far more than we could accomplish during their short hospital stay.

In extreme cases known informally as “social admissions,” patients are hospitalized because they cannot be safely discharged due to the absence of sufficient support or care at home—not because of medical necessity. Throughout residency, I have encountered patients on nearly every hospital service who have remained hospitalized for months, even years, without an acute medical issue, simply because they were awaiting a safe discharge plan. I dreaded waking these patients on my early morning rounds, ashamed of how little we could do on their behalf and frustrated by how seemingly irrelevant my medical training was to their care.

Medical Records and Bureaucratic Nightmares

Another dispiriting change in residency is a result of health care systems’ goals to become more efficient and standardized. As a result, residents are often constrained by hospital bureaucracy. A close friend of mine training in neurosurgery routinely works 100-hour work weeks caring for critically ill and dying patients. The worst part of residency, he shares, is the round-the-clock nonurgent patient updates, nonclinical requests, and digital notifications, often triggered automatically by electronic record systems. Every resident knows what it is like to be startled awake in the middle of the night by seemingly pointless notifications, like a slightly higher than normal blood pressure reading, or a request to renew a routine order that has been in place for days. I was once sent an urgent notification to change the order for a patient’s protein drink from chocolate to vanilla. My friend explains, “Someone on the outside might think [these middle-of-the-night notifications are just] annoying and not a big deal, but multiply over years and countless hours of lost sleep…[and] it’s like psychological torture.”

Changes in modern medicine that burden house staff continue to affect doctors when they become attending physicians. In fact, attending physicians and residents have similarly alarming rates of depression and suicide,

 and this problem may be even more challenging to address since attendings are not under centralized oversight as residents are in training programs. While addressing the deeper systemic issues in American health care that undermine physician professional identity will ultimately require a radical reevaluation and overhaul of the American medical system, there is good news: Medical schools, residency programs, and hospitals can still take steps now to help residents by cultivating and preserving their emerging sense of professional identity. The first priority should be to protect residents’ time with patients, whether virtually or in person. Interpersonal skills are critical for fostering effective doctor-patient interactions and should be prioritized in training alongside other technical skills. Just as hospital-based residents spend the early part of their day in rounds that provide time for teaching and discussion, residents should have time built into the later part of their day to spend time with patients, reassessing their needs, providing education, and getting to know them as individuals. I kept sane in my intern year despite the 70- to 90-hour workweeks by managing to find a half hour at the end of the day to circle back to a patient. I would sit at their bedside, so they could introduce me to their spouse or show me a cherished picture of a vacation or wedding. Hospitals can be difficult places to feel human, both as a patient and as a doctor, and moments like these helped me feel like the work I was doing mattered.

Residents also need protected time with each other. Residency is life-changing in a way friends and family may not fully understand, and residents need time to process their experience with their colleagues and consolidate their emerging professional identity. Ideally, to facilitate trust and honest disclosure, such process groups should be small, consistent, and run on a weekly basis without the involvement of program administration or leadership. Furthermore, if a resident does need additional mental health treatment, hospitals should ensure that they have protected time for such. It is not sufficient or reasonable to simply refer residents to external mental health resources and ask them to address their mental well-being on their own time.

Young doctors need to be educated during medical school and residency about health care and social systems, so as to better function within an interdisciplinary health care team. Just as medical students learn about anatomy and physiology, they also need basic information about hospital payment structures, insurance reimbursement, and social systems such as public housing, homeless shelters, criminal justice, child protective services, and geriatric long-term care. Without an understanding of how their work fits into a broader social and health system, residents cannot advocate on their patients’ behalf. Similarly, residents’ day-to-day experience should facilitate direct and close collaboration with nonphysician team members, including nurses, social workers, and case managers.

Finally, doctors in training should be spending as much of their time as possible being doctors. Using residents as underpaid labor to perform tasks better suited to administrators, nurses, social workers, and other members of the health care team is not only inefficient, but it interferes with resident training and devalues their professional identity. Hiring additional staff would require additional hospital spending, but it would dramatically improve productivity and well-being.

Unfortunately, residents are not in a strong position to promote these changes themselves, especially changes that would involve reducing resident workloads. Hospitals have little incentive to make the financial commitment necessary to improve resident work conditions, especially since they have been primarily paying for resident salaries since the 1960s with set funds from Medicare and Medicaid. Moreover, overworked residents do not have time to organize and advocate for necessary reforms, nor do they have sufficient bargaining power to do so, as they are dependent on their residency programs for their future careers in medicine. Unsurprisingly, although residents have the legal right to unionize, only about 10% of them do so. However, residents are not the only individuals negatively impacted by the current burnout crisis. Patients also deserve higher quality and more personalized care from the residents who treat them. They, too, can lobby for increased access to their doctors by advocating for changes in how residencies are funded and structured.

Even with these changes, residency will still be demanding and difficult, just as it has been since its inception. To navigate and build expertise in dealing with high-stakes, emotionally intense situations—situations that are intrinsic to the practice of medicine—it is necessary to see large numbers of patients. Neither I nor my colleagues are looking to do less work, but we want to be allowed to direct our efforts in service of our professional mission: to become the physicians we envisioned when we started this transformative journey.

graduated from the psychiatry residency program at Columbia University Medical Center in June 2021.

She is a research fellow at Columbia University's Zukerman Mind Brain Behavior Institute.

Prevalence of depression and depressive symptoms among resident physicians: a systematic review and meta-analysis.

2. Rotenstein LS, Torre M, Ramos MA, et al. 

Prevalence of burnout among physicians: a systematic review.

3. Kannan L, Wheeler DS, Blumhof S, et al. 

Work related post traumatic stress disorder in medicine residents.

4. Jackson T, Provencio A, Bentley-Kumar K, et al. 

PTSD and surgical residents: everybody hurts… sometimes.

Web-based cognitive behavioral therapy intervention for the prevention of suicidal ideation in medical interns: a randomized clinical trial.

6. Yaghmour NA, Brigham TP, Richter T, et al. 

Causes of death of residents in ACGME-accredited programs 2000 through 2014: implications for the learning environment.

7. Martin KL. Medscape residents salary & debt report 2019. July 17, 2019. 

8. Chaukos D, Chad-Friedman E, Mehta DH, et al. 

Risk and resilience factors associated with resident burnout.

9. Martini S, Arfken CL, Churchill A, Balon R. 

Burnout comparison among residents in different medical specialties.

The relationship between resident burnout and safety-related and acceptability-related quality of healthcare: a systematic literature review.

11. Dyrbye LN, Burke SE, Hardeman RR, et al. 

Association of clinical specialty with symptoms of burnout and career choice regret among US resident physicians.

12. West CP, Dyrbye LN, Sinsky C, et al. 

Resilience and burnout among physicians and the general US working population.

13. Organ donation statistics. Health Resources & Services Administration. Updated April 2021. Accessed January 27, 2021. 

Hospital-level changes in adult ICU bed supply in the United States.

15. Holmberg MJ, Ross CE, Fitzmaurice GM, et al; American Heart Association’s Get With The Guidelines–Resuscitation Investigators. 

Annual incidence of adult and pediatric in-hospital cardiac arrest in the United States.

Trends in length of stay for Medicare patients: 1979-87.

Trends in inpatient admission comorbidity and electronic health data: implications for resident workload intensity.

19. Wang JK, Ouyang D, Hom J, Chi J, Chen JH. 

Characterizing electronic health record usage patterns of inpatient medicine residents using event log data.

How do residents spend their shift time? a time and motion study with a particular focus on the use of computers.

21. Health Research & Educational Trust. Social determinants of health series: housing and the role of hospitals. 

. August 2017. Accessed January 27, 2021. 

Suicide rates among physicians: a quantitative and gender assessment (meta-analysis).

A former resident's reflection on burnout, physician PTSD, and their consequences for patient care. 

A Generation in Crisis?

 is a perplexing question with elusive answers. Because it is impossible to ask the individual who died, those left behind may never find solace or closure. Instead, they may torture themselves with feelings of confusion, anger, guilt, and sadness, wondering what, if anything, they could have done to prevent the death.

In their search for answers, family members may turn to the psychiatrist or therapist who treated their loved ones before their untimely death. In some cases, family members may lash out and even blame clinicians for not doing more. Yet, this is an important part of our job, one that requires some reflection and preparation.

Losing a patient to suicide is an occupational hazard that can be particularly painful for a psychiatrist. For many, it is not a matter of if a patient will commit suicide, but when; 51% of psychiatrists have experienced the loss of a patient to suicide, and this can create significant disruptions in their professional and personal lives.

 True grieving for a clinician often comes only after the family has been consoled and the institutional procedures have been completed. Even then, it can be hard to process.

 are as unique as the patients who commit the act. But promising research is shedding light on what makes some individuals feel that death is the only solution to the overwhelming emotional pain they feel.

 in the United States. Between 1999 and 2019, suicide rates increased 33%, making it the 10th leading cause of death. In 2019, there were 47,500 suicides in the United States, or roughly 1 death every 11 minutes. About 12 million American adults seriously thought about suicide, 3.5 million planned a suicide attempt, and 1.4 million attempted suicide.

Suicide affects all ages, races, and ethnicities. In the US, it is the second-leading cause of death for individuals aged 10 to 34, the fourth leading cause among 34- to 54-year-olds, and the fifth leading cause for ages 45 to 54.

 Those who commit suicide are more likely to be older and male, have an 

, comorbid health problems, severe suicide ideation, and familiarity with highly lethal methods.

American Indian/Alaska Natives and non-Hispanic Whites have the highest rates of suicide deaths, along with veterans, those living in rural areas, and workers in industries such as mining and construction. Young individuals who identify as lesbian, gay, bisexual, or transgender are more likely to experience suicidal ideation and behavior than their peers.

Researchers have long speculated about the steps that lead someone to 

, and there are a number of theories that seek to explain the process. In his 1990 article, social psychologist Roy Baumeister, PhD, described suicide as a chain of events designed to “escape from aversive self-awareness.” According to Baumeister, the path to suicide begins when events fall grossly short of one’s expectations. Self-blame for these events quickly follows, along with an almost painful sense of self-awareness and self-loathing.

 This creates a negative feeling so powerful that an individual will do anything to avoid it. It may drive them to a state of cognitive deconstruction, generally characterized by concrete thinking, cognitive rigidity, and a rejection of meaning. Pushing aside any meaningful self-awareness and emotion, a person can become irrational and disinhibited. Anything is possible, and suicide is seen as a natural step to escape one’s self and the pain they are feeling.

, Thomas Joiner, PhD, identifies 2 contributing factors that comprise the suicidal mind. First, a person who is suicidal believes they are a burden to others, a perception often clouded by feelings of depression and anxiety. Second, they experience a sense of “thwarted belongingness,” expressed by withdrawing from social ties. This could include the loss of family, friends, and colleagues, whether through death, divorce, separation, or conflict.

What pushes these factors toward suicide is the acquired capacity to follow through on the desire. Marked by a fearless attitude toward death, there are 3 factors that can lead to acquired capacity.

First, acquired capacity can come from a tendency towards natural risk-taking, such as those in law enforcement, thrill-seekers, or emergency department doctors. Second, acquired capacity can also be learned, often through 

, such as exposure to violence, abuse, life-threatening situations, repeated suicide attempts, injuries, and illness. The third involves how knowledgeable and comfortable an individual is with the lethal means to kill themselves, such as knowing how to fire a gun.

None of these factors on their own means someone will commit suicide. Rather, if they ever had the desire to do so, their lack of fear of death and pain gives them the ability to overcome any hesitation. Individuals who are severely suicidal may sometimes lack the ability to understand how their death might impact family and friends. One study observed older adults who had previously attempted suicide expressed a blunted response to empathy scenarios.

For a closer look on warning signs, risk factors, and protective factors of suicide, see 

Evidence From Suicide Notes and Brain Imaging

Notes left behind can provide insight into the mind of an individual before they commit suicide. One study examined a collection of suicide notes in an effort to identify and create prevention strategies. Of the notes, 74% expressed apologies or shame, 60% expressed love “for those left behind,” 48% shared that life was “too much to bear,” 36% provided instructions on how to handle postmortem affairs, and 21% respectively described “hopelessness/nothing to live for” and dispensed advice for others left behind.

In a 2017 study, Yale University researchers studied the brains of 

, aged 14 to 25, to try and determine who would be more likely to follow through on suicidal thoughts. While the sample size was small, 26 had bipolar disorder and had previously attempted suicide, 42 had bipolar but had not attempted suicide, and 45 had no diagnosis of a mental illness, nor had they attempted suicide.

 Researchers used a specialized machine to combine 3 imaging techniques—structural and functional MRIs and diffusion tensor imaging—in 1 sitting, a first for this kind of research.

They discovered 3 indicators linked to suicidal behavior. First, the connective wiring, or white matter, in the areas of the brain that regulate emotion was decreased in those who had attempted suicide. Second, they noticed less gray matter in the frontal-limbic system and frontal cortex. And third, by studying real-time blood flow between different areas of the brain, researchers noticed less connectivity between the limbic amygdala and the frontal cortex.

Understanding how suicide looks on the inside is vital to our understanding of the mind considering suicide and can inform valuable treatment methods. Studying commonalities among victims of suicide is another way to discover ways to provide intervention and support. For more on ways to support someone considering suicide, see 

There are more suicide attempts on New Year’s Day than on any other holiday during the year. Sundays and Mondays are the most common days for adults to attempt suicide, while Mondays and Tuesdays tend to be favored by those under age 19.

 These are just some of the trends that influence suicide rates.

Spring and summer are likely to have the highest number of incidences compared to the winter season.

 One theory explains this by pointing out that symptoms of depression tend to worsen during wintertime. Feelings of listlessness may deflate any interest in forming a plan for suicide. Springtime, on the other hand, can act as an energizing motivator. Another theory suggests that the arrival of spring is regarded with the expectation that gloomy feelings during winter may dissipate. If this does not occur, someone may give up all hope and turn to suicide.

Suicides tend to be contagious. In 1774, Johann Wolfgang von Goethe launched his career with the publication of the novel, 

. In the story, Werther kills himself with a pistol in an act of unrequited love. The book became so popular that young men around Europe started dressing like the main character and killing themselves in a similar fashion. Government officials sought to have the book banned. Thus began the phenomenon of copycat suicides, also referred to as the Werther Effect.

Copycat suicides, or clusters, can occur after a famous person or celebrity kills themself. The media—and their portrayal of the death—usually get blamed for copycat suicides, and it is why many publications have policies on how suicides are reported.

Copycat suicides are a particular problem in South Korea. Since 2003, the country has had one of the highest suicide rates, and suicide is the leading cause of death among young adults. Just a day after a famous suicide is reported, suicides in the area tend to increase by 16.4%. After popular Korean actress Choi Jin-sil committed suicide in 2008, suicides in the country increased by 162.3% in the 3 weeks thereafter. News of Choi’s suicide dominated the media during this time. South Korea’s top 3 newspapers published 905 articles about her death in just 3 weeks, complete with graphic details and photos of the scene.

Copycat suicides are not always linked to real events. Similar to Goethe’s fictional story, the television series 

 among adolescents 3 months after the show’s release date. In the show, a series of audiotapes describe the role various individuals played in the suicide death of one of the characters. Suicide prevention organizations were quick to criticize the show for not portraying suicide in a socially responsible way.

Austria provides an example of a country that has taken steps to curb the Werther Effect and reduce the number of suicides and suicide attempts in the subway systems of Vienna. In 1987, the country launched a suicide-preventive experiment and issued guidelines on how the media can responsibly report suicide. Within 6 months, the number of suicides and attempts dropped by more than 80%.

The World Health Organization has released guidelines for the media when reporting on suicides. These include suggestions to avoid prominent placement and undue repetition of stories about suicide, avoid detailed information about the site and method involved, and caution in using photos and video footage.

While copycat suicides can be an alarming trend, there is another phenomenon that can affect suicide rates, thankfully, in a positive way. Known as the 

, suicide rates tend to dip after major events that are shared by large groups. It helps to explain why there are fewer suicides on Super Bowl Sundays, when groups of family and friends gather for a shared purpose. It is a powerful example of how the feeling of belonging and connectedness can be strong enough to stave off suicide.

 The most recent example of this was in 2020 when the world was gripped by the 

. Provisional suicide mortality rates dipped by 5.6% compared to 2019.

 This experience was similar to the aftermath of the 9/11 terrorist attacks when suicide rates in New York declined “significantly” for 180 days after the event.

This connection to others is a powerful tool that psychiatrists can use to discourage patients from suicide. But we need to understand that ultimately, the decision to end one’s life belongs solely to the patient. Our job as psychiatrists is to help patients recover to the best of our abilities. Even if we do everything right, we may still lose our patients to suicide. And if we are not prepared to fully accept this, true healing can elude the best of us.

After a patient’s suicide, 65% of psychiatrists reported stress levels on par with those who seek treatment after a parent dies. Younger, less-experienced clinicians were less prepared to deal with the effects than older, more experienced clinicians.

While all psychiatrists receive training on prevention and intervention, there is less discussion of how a clinician might react should a patient commit suicide. In the aftermath of a suicide, attention to self-care often falls by the wayside, which can lead to chronic problems related to stress, anxiety, anger, and depletion.

 Clinicians are often overwhelmed with other duties, such as speaking with the patient’s family to provide comfort and answers. They have to manage institutional inquiry procedures and engage in various risk management-driven procedures. There are many questions to consider: Should you reach out to family? How can you communicate tactfully? Should you attend the memorial service or funeral? Are you worried about a lawsuit? What will your colleagues think of you?

For some clinicians, there is a process of grieving that takes more time than they, or their colleagues, anticipate. Some professionals have symptoms similar to posttraumatic stress disorder, including flashbacks, survivor guilt, and nightmares about losing the patient. Other clinician reactions can include shock, disbelief, a feeling of numbness; guilt about not doing enough; reviewing notes to see what they missed; professional humiliation; doubt in one’s skills as a doctor; a sense of defeat; feelings of fear, anger, or sadness; and crying spells that can occur days, months, and even years afterward, often catching them off guard.

To help counterbalance these effects, psychiatrists and the organizations they work for can take the following measures:

Explaining the suicidal mind and helping to provide closure to family/friends left behind is no small feat. 

Suicide

Suicide: Myths, Media, and Difficult Discussions

When Suicide Is Not a Suicide: An Epilogue

Hopelessness to Help

A Generation in Crisis?

Exploring Thoughts and Feelings Inside a Suicidal Mind

Afghanistan Veterans Struggling With Mental Health

Phone Numbers to Know for National Suicide Prevention Month

5 Studies Aimed at Reducing Suicide Among Teens

Suicide: The Lesser-Known Hazard for Construction Workers

In the Wake of 9/11: Mental Health Statistics of First Responders