Psychiatric TimesVol 41, Issue 4

Suicide is a word that conjures a wide range of intense emotions.



In considering titles for this editorial, the word suicide seemed to capture all that needed to be written. Suicide is a word that conjures a wide range of intense emotions. Each medical specialty enriches for causes of death related to the disorders treated. Death by myocardial infarction, massive stroke, congestive heart failure, and so many others have a higher likelihood of filtering into a specific medical subspecialty than others. For us in psychiatry, it is death by suicide. Fortunately, suicide is not the most common cause of death in our patients or it would be difficult to go to work every day.

During my 33 years of clinical practice, I can recall 9 patients whom I was actively treating when they suicided. The suicide method was different for 7 of these 9 patients. I had considered only 3 of them to be at risk for suicide at some point, but none acutely. I learned of the suicides in 6 of these patients within 24 hours of their deaths, after 1 week in 1 patient, and after a month in the other 2. I felt a psychic jolt when I was informed of each, followed by a surreal sadness and grief.

My mind went back to our last appointment, and I read my last treatment notes. That same day, after reflecting on this information and regaining my clinical balance, I called my deceased patient’s closest support. I offered my condolences and then simply listened to their response. I always ended our call by offering to meet in person to process this life-changing event.

Unsurprisingly, the surviving support often describes raw emotions of confusion, disbelief, grief, loss, and guilt. My patient’s support met me in person in only 3 cases. It seemed to benefit them to talk about the suicide and whatever memories they chose to share. For me, these meetings provided more closure to my treatment of my patient and I felt privileged to discuss the suicide with one of the individuals who was most impacted by their death.

Four of these suicides were by patients at the community mental health center where I have worked for the past 17 years. For 2 of these patients, I was the only mental health treatment provider at our clinic, seeing them monthly for psychopharmacological management, with both patients also in treatment with a psychotherapist in private practice. In addition to speaking with a primary personal support, I also called and processed the suicide with the therapist involved in the treatment.

Two of the patients had been in treatment at our mental health center for years and worked with many other members of our treatment team. In these cases, we scheduled a postsuicide meeting and invited all clinical staff involved in the treatment, clinicians of various specialties, and some administrative staff, which allowed for a comprehensive, systemwide review of the patient’s treatment and the events leading up to the suicide. I found these debriefings extremely helpful, as they created a safe environment to explore the “what-ifs,” discuss possible signs or symptoms that in retrospect may have been red flags of distress, and bond as a treatment team that was recovering from our most feared patient outcome.

Achieving closure for 1 patient’s suicide was particularly frustrating for me, as we could not conclude that her death was by suicide or by accidental overdose until the state coroner completed their autopsy and made a determination. This patient had died of respiratory depression from an overingestion of prescription opioids. In cases like this, body fluids, including stomach content and cerebral spinal fluid, are sent to a specialty laboratory for a comprehensive analysis by liquid chromatography and mass spectroscopy. This analysis can take several months and the information obtained can greatly increase the coroner’s confidence in determining the cause of death.

The process of understanding, processing, and accepting a person’s death by family, friends, and clinicians is very different if the cause of death is “accidental overdose” vs “suicide.” A monthslong delay in receiving this determination changes the emotional energy of the process and delays the ability to fully integrate the loss for all involved.

Suicide is a complex phenomenon that we remain poorly equipped to predict and prevent. As the authors of our accompanying articles have nicely written, we know a lot, but we don’t know even more. Medicine has implemented screening tools and education with the noble goal of understanding the risk factors that may predict a person at high risk of suicide, but we still fall short. With more than 50% of US suicides completed by firearms, providing education about safe firearm storage and enacting policies to limit firearm access to high-risk individuals are actionable steps that would likely decrease the number of deaths by suicide. “Red flag” laws have shown to have a positive impact, as our cover story describes.

Death by suicide is as old as humanity itself. However, cultural, behavioral, and social factors are still understood as predictive or protective, and using this knowledge to modify public policy is essential. The 988 mental health crisis hotline, implemented in July 2022, provides a simple, streamlined access point to activate emergency intervention systems. Following a patient’s suicide, it is clinically imperative for the patient’s family, supports, and clinicians to engage in open, supportive dialogue, which should help facilitate acceptance, understanding, and, hopefully, closure.

If you are attending the American Psychiatric Association Annual Meeting, you can meet Dr Miller and the editorial team at booth #1417!

Dr Miller is Medical Director, Brain Health, Exeter, New Hampshire; Editor in Chief, Psychiatric Times; Staff Psychiatrist, Seacoast Mental Health Center, Exeter; Consulting Psychiatrist, Insight Meditation Society, Barre, Massachusetts.

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