A Psychiatrist Copes With Her Patient's Suicide

John Watson


March 18, 2019

Dinah Miller

Over the past two decades in the United States, the rate of suicide has risen by nearly 30%.[1] The devastating toll of this national healthcare crisis is measured in lives lost, with over 47,000 last year alone,[2] and the emotional fallout for their family, friends, and colleagues. Less frequently discussed, however, is the difficulty that physicians can experience when a patient in their care takes their own life.

In a recent article in the New England Journal of Medicine (NEJM),[3] Dinah Miller, MD, coauthor of Committed: The Battle over Involuntary Psychiatric Care and an assistant professor at the Johns Hopkins School of Medicine, Baltimore, Maryland, sought to shed light on this overlooked topic by describing the loss of her own patient to suicide, the first in a three-decade career as a psychiatrist.

Medscape spoke with Miller about the shock and grief that accompanied this experience, and the ways in which medicine may be ill-equipped to help practitioners deal with such feelings.

A Commonly Experienced Tragedy, Rarely Discussed

Medscape: What led you to want to share your experience in the form of this article?

Miller: As psychiatrists, we go through our careers worrying that a patient will commit suicide. We all know colleagues who have lost patients, so logically we know that this is something that can and does happen, and obviously it's horrible. And while it's certainly predictable that a suicide would leave any doctor feeling awful, I had never considered how long that might last, or the ways it might affect me. For a while after, I was anxious about seeing new patients, and I still sometimes find it a bit more difficult to trust some patients.

I'm someone who talks about how I feel. With my closer friends, I may have worn them down a bit, because this is all painful to hear; and frankly, for those of my psychiatrist friends who have had patients die, it's a lot to relive. For those who haven't had a patient die of suicide, listening to another doctor's distress probably adds to the fear that it might happen to one of their own patients. What I found was that other psychiatrists had also had a rough time, yet this is really not a topic we discuss or even write about. I decided that it might help some other doctors if I shared what I had gone through.

Medscape: You write that although there is open discussion of the toll of suicide on families and loved ones, there are no comparable discussions taking place for doctors. What do you think has prevented that conversation from taking place?

Miller: People come to psychiatrists so that terrible things won't happen. When there is a suicide, our tendency is to feel that we've failed, even if everything we have done was medically reasonable. In medicine, it's shameful to fail, and it's not a culture that encourages discussion of shameful things.

It was hard for me writing the NEJM article. In the first draft, the subtitle was "The Physician as Silent Victim." But "victim" is a loaded word in our society, and it occurred to me that it would be wrong to refer to the physician as a victim, especially when the family and the immediate people in that person's life are left so injured and so traumatized.

A second reason why we don't discuss the emotional aftermath of suicide on the physician is because we really don't feel entitled to grieve; it almost feels selfish to hurt so much when you think of all the pain your patient was in, and all the pain their family and friends are left to bear.

Coping With the Loss of a Patient

Medscape: Given the training and experience of psychiatrists, I imagine that many people believe they're well equipped for processing the feelings of guilt and despair that accompany a patient committing suicide.

Miller: There is that perception that as a psychiatrist you should be able to process it better, but I don't know that that's true; we may just be human!

One of my colleagues sent me an article by Michael Gitlin, MD, from the American Journal of Psychiatry.[4] He described a patient's suicide that occurred shortly after he finished residency. He shared how it affected him, describing a profoundly miserable experience with his own emotions. I was struck by the fact that this is one of the few articles I've seen on the topic, and it was from 1999.

I thought to myself, Is it easier or harder if you're just out of residency? Maybe if you're just out of residency you figure that suicides happen and it's something you'll need to get used to. But I don't think it really works that way. One of my younger colleagues had two patients commit suicide, and she was really devastated by it. I decided that no matter how you look at it, having a patient die of suicide is terribly distressing.

Medscape: What has the reaction to your piece been by your psychiatrist colleagues?

Miller: Everyone has been very supportive. My chairman shared it in his weekly email to the department, and from that I've received a number of emails and texts from people saying that this happened to them too. I've gotten very moving letters from strangers, including a young psychologist who told me that my article made her feel less alone. People have written with their own stories, expressed condolences, or thanked me for writing about the experience.

Medscape: Did you receive advice from colleagues who had been through this?

Miller: Yes. Several people have told me that going to the funeral and talking with the family helps. In the case of my patient, I didn't go to the service because I wasn't invited, and as psychiatrists, we don't typically go to public events unless we're specifically asked because of concerns about the patient's confidentiality.

Medscape: Did you find anything in your own process of recovery that other clinicians in similar situations may want to apply?

Miller: Am I recovered? I'm still working on that one. I find that writing is a wonderful release for me, and when I submitted the NEJM article—even before it was accepted—I felt some relief.

People have different ways of handling difficult emotions, so I would tell someone in a similar situation to do what has worked in the past to help them process these feelings.

Time has helped. I had a patient recently who was grieving an unexpected death in their family and was looking at me, wondering what to do with this. You just grieve; there's no great answer.

And certainly, I'd suggest to any doctor who has lost a patient, that if the emotions become overwhelming or disabling, then it would be wise to seek treatment. We can't forget that in this suicide epidemic, physicians are very vulnerable.

Improving Interventions for Patients and Physicians Alike

Medscape: As you note, healthcare professionals do not have adequate means of dealing with the loss of a patient to suicide. Are there any steps you think the field of psychiatry should take towards addressing that?

Miller: It begins with having a discussion. I think it would be nice if we had some set of rituals to deal with suicide. Certainly, if a suicide occurs in an inpatient setting, there may be a morbidity and mortality conference, but I'm not always sure that those are about healing.

At the annual meeting of the American Psychiatric Association (APA), there is an annual workshop for physicians who have lost a patient to suicide.

(Editor's note: The APA's website also offers guidance for residents on coping with a patient suicide.)

Medscape: We are in the midst of a substantial increase in the rate of suicide in the United States. Yet, as you write in your piece, "Insurers often require that patients be a danger to themselves or others as the standard for admission, making psychiatry the only specialty in which an illness must be deemed life-threatening for the patient to obtain hospital care." Has this situation gotten worse since you began practicing?

Miller: It has become ingrained in us that if somebody is not dangerous, then we can't admit them to inpatient units. I don't know if this has changed over the past couple of decades. I remember when I was first out of residency and one of my colleagues went to admit a suicidal patient from the ED, the insurance company asked her if the patient's gun was loaded!

It remains difficult to get inpatient treatment authorized, and we don't have enough beds for the patients who are in danger. Access to inpatient care is an enormous issue in our country.

Yet, it's also true that we have much easier access to antidepressants and there are more therapists. So there is increased access to lower levels of care and there are more people than ever getting treatment, yet we haven't contained the suicide rate.

Medscape: Are there any other aspects of how patients with suicidal ideation are traditionally approached that your own experience has made you reconsider?

Miller: I was recently listening to a talk[5] about how suicidal ideation is not a predictor for suicide, yet our measure for assessing risk is to ask the patient about their thoughts and intentions. The discussant, Dr Igor Galynker, noted that people kill themselves when they feel entrapped.

For years, patients have assured me that they would never harm themselves because of how much it would hurt their family members, and for years, that seemed like a reasonable predictor—no one else who said this has ever died before.

Many people have suicidal thoughts, and not many of those people go on to die. It would help so much if we had crystal balls or could read minds.

This interview has been edited and condensed for clarity.

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