You are on page 1of 5

Acad Psychiatry

DOI 10.1007/s40596-014-0083-1

EMPIRICAL REPORT

Helping Psychiatry Residents Cope with Patient Suicide


Deepak Prabhakar & Richard Balon & Joan Meyer Anzia & Glen O. Gabbard &
James W. Lomax & Belinda ShenYu Bandstra & Jane Eisen & Sara Figueroa &
Garton Theresa & Matthew Ruble & Andreea L. Seritan & Sidney Zisook

Received: 22 December 2012 / Accepted: 19 April 2013


# Academic Psychiatry 2014

Abstract suitability for the profession. This study evaluates a patient


Objective Every clinical specialty has its own high risk patient suicide training program aimed at educating residents about
challenges that threaten to undermine their trainees profes- patient suicide, common reactions, and steps to attenuate
sional identity, evolving sense of competence. In psychiatric emotional distress while facilitating learning.
training, it is patient suicide, an all-too frequently encountered Methods The intervention was selected aspects of a patient
consequence of severe mental illness that may leave the suicide educational program, Collateral Damages,video
treating resident perplexed, guilt-ridden, and uncertain of their vignettes, focused discussions, and a patient-based learning
exercise. Pre- and post-survey results were compared to assess
D. Prabhakar (*) both knowledge and attitudes resulting from this educational
Henry Ford Health System, Detroit, MI, USA program. Eight psychiatry residency training programs partic-
e-mail: dprabha1@hfhs.org
ipated in the study, and 167 of a possible 240 trainees (re-
R. Balon sponse rate=69.58 %) completed pre- and post-surveys.
Wayne State University, Detroit, MI, USA Results Knowledge of issues related to patient suicide in-
creased after the program. Participants reported increased
J. M. Anzia
Northwestern University Feinberg School of Medicine, Chicago, IL, awareness of the common feelings physicians and trainees
USA often experience after a patient suicide, of recommended
next steps, available support systems, required documenta-
G. O. Gabbard : J. W. Lomax tion, and the role played by risk management.
Baylor College of Medicine, Houston, TX, USA
Conclusions This patient suicide educational program in-
B. S. Bandstra creased awareness of issues related to patient suicide and shows
Stanford University School of Medicine, Stanford, CA, USA promise as a useful and long overdue educational program in
residency training. It will be useful to learn whether this pro-
J. Eisen
Brown University, Providence, RI, USA
gram enhances patient care or coping with actual patient sui-
cide. Similar programs might be useful for other specialties.
S. Figueroa
University of Michigan, Ann Arbor, MI, USA
Keywords Patient suicide . Psychiatry residents . Curriculum
G. Theresa
Oklahoma University Health Sciences Center, Oklahoma City, OK,
USA Regardless of clinical specialty, bad outcomes happen. In
psychiatry, the most serious and tragic bad outcome of the
M. Ruble
Cambridge Health Alliance, Cambridge, MA, USA serious and chronic conditions psychiatrists treat, patient sui-
cide, is also one of the most difficult to accept and cope with in
A. L. Seritan all medicine [1, 2]. Patient suicide has been called an occupa-
UC Davis, Sacramento, CA, USA
tional hazard for psychiatrists: an event almost all psychiatrists
S. Zisook in practice encounter, often many times. It is difficult to deal
University of California, San Diego, CA, USA with at any period of a psychiatrists career, but is especially
Acad Psychiatry

during residency [3-5]. Residents often blame themselves and (ACGME) competencies as a means to stimulate discussion;
may be too riddled with self-doubt, shame, and guilt about self- and (4) pre- and post-questions.
perceived omissions or commissions to seek help. Yet, resident
physicians are an especially vulnerable population whose early Sample
experiences with patient suicide may shape their future beha-
viors and coping skills [6]. This situation is compounded by the Immediately after the Collateral Damages curriculum was pre-
nature of psychiatric training, which generally emphasizes sented as a workshop at the 2010 Annual meeting of the
inpatient rotations, with the most ill and potentially suicidal American Association of Directors of Psychiatry Presidency
patients, for the most junior trainees [6]. And, although all Training (AADPRT), participating training directors were asked
training programs emphasize teaching suicide risk assessment if they wanted to volunteer their programs to pilot test the
and procedures to mitigate risk, few provide training aimed at curriculum. They were told a DVD and a users guide would
helping residents cope with the aftermath of patient suicide be provided and that they would have to agree to present the
when all attempts at treatment and prevention fail [4-10]. In a curriculum to residents and obtain pre-session surveys and
survey of chief residents of psychiatry training programs across immediate post-session surveys during the next academic year.
the USA, only 19 % of the respondents reported feeling pre- Eight residency training programs volunteered. The programs
pared for the aftermath of patient suicide [11]. The aim of this represented different regions of the USA: Midwest (Northwest-
study is to pilot test a new curriculum aimed at helping psychia- ern University, University of Michigan, Wayne State Universi-
try residents learn more about suicide, common reactions to ty), Northeast (Brown University, Cambridge Health Alliance),
patient suicide, and useful resources and actions as a first step South (University of Oklahoma), and West (Stanford Universi-
towards helping trainees adaptively cope with this tragic event. ty, University of California at Davis). The dedicated didactic
sessions occurred between November 2010 and October 2011.
Respective Institutional Review Boards approved the study for
Methods each site. Attendance at the program and completion of the
survey instrument implied informed consent.
Development and Contents of Curriculum
Teaching Session
As previously described [7], a group of senior investigators,
along with residents and recent graduates, developed a highly Although we presented a structured users guide describing
interactive curriculum, called Collateral Damages, aimed at the way the curriculum was to be implemented at the coordi-
providing psychiatry training programs tools to help trainees nating site, Wayne State University, each program was
learn: (1) suicide is often the result of serious mental illness; instructed to use the program according to their individual
(2) even experienced, highly-acclaimed psychiatrists have needs and adjust the content as deemed necessary. We allowed
patients who die by suicide; (3) anger, blame, guilt, shame, this flexibility considering that individual programs may al-
relief, and myriad other grief-related reactions are common; ready have some pieces of the educational curriculum in place.
and (4) departmental and institutional guidelines focused on The users guide suggested the curriculum could be given as a
dealing with patient suicide may ultimately enhance healthy one-time, 90-min workshop, to include the following:
coping. The Collateral Damages curriculum is contained in a
DVD that consists of (1) a video program that includes intro- 1. Pre-test survey to be distributed and collected during the
ductory comments; five brief vignettes from clinicians (two first few minutes.
from senior faculty, two from junior faculty, and one from a 2. A 15-min segment from the Collateral Damages
trainee) on their patients who killed themselves and their DVDopening remarks by Dr. Glen Gabbard and two
immediate emotions, thoughts, and behaviors; a panel discus- senior clinician narratives.
sion of the five psychiatrists who have provided their narra- 3. Open floor discussion for 10 min.
tives plus two senior training directors that focuses on univer- 4. A second 15-min segment from Collateral Damagesa
sal themes, processes, and procedures to follow after a patient resident narrative and closing remarks from Dr. Glen
suicide, principles of dealing with families, critical incident Gabbard.
review, risk management, and the roles of counseling/ 5. Open floor discussion for 10 min
supporting trainees and colleagues; and closing comments; 6. A patient-based learning exercise to be discussed for
(2) a PowerPoint presentation emphasizing suicide-related 30 min. This exercise included core issues related to
basic epidemiological facts, emotional reactions to patient patient suicide such as the importance of collateral infor-
suicide, and a brief overview of resources available to grieving mation, risk of suicide in patients with schizophrenia,
individuals; (3) a patient-based case learning exercise cover- impact of case load, medical knowledge, and risk man-
ing Accreditation Council for Graduate Medical Education agement procedures.
Acad Psychiatry

7. Open floor discussion for 10 min to answer any queries, in the event of patient suicide before the session, the percent-
highlight key take home points and discuss possible age rose to 85.1 % after the workshop. Compared to this, a
follow-up or next steps. higher percentage of the respondents reported very likely or
8. Distribution, completion, and collection of the post-test likely to consult with supervisor/mentor both before
survey. (96.4 %) and after (97.6 %) the session. Prior to the session,
62.7 % reported very likely or likely that they would
consult with surviving family members, and this percentage
Survey Instrument and Implementation improved to 75.6 %; however, the difference was not statisti-
cally significant. At the baseline, 23.1 % reported very like-
In addition to basic demographic information contained in the ly or likely to attend the patients funeral; this changed to
pre-test survey, the pre- and post-test surveys were composed of 35.5 % after the session. When asked about the improvement
items measuring the trainees awareness and understanding of in understanding of issues related to patient suicide as a result
issues related to patient suicide such as common facts, aware- of attending this program, 85.7 % reported improvement with
ness of common feelings, steps to take after completed patient 22.6 % reporting much greater understanding. Table 1.
suicide, support systems, documentation and risk-management,
and likelihood of consultation with surviving family members,
mentors, supervisors, department chair, and training director.
Surveys were completed anonymously. Differences between Discussion
pre- and post-test surveys were compared using linear trend
chi-square for ordinal variables and chi-square for nominal This 90-min interactive curriculum appears to be a viable
variables. Because the surveys were completed anonymously, strategy to help psychiatry trainees enhance their knowledge
it was not possible to match individual pre- and post-test of several important aspects of patient suicide; (1) self-
responses; therefore, independent tests were used. Statistical reported global knowledge of issues related to patient suicide;
significance was defined as a two-sided p value <0.05. (2) increased awareness that most suicides do not occur at
predictable times and places; (3) more knowledge that feelings
such as guilt, anger, shame, helplessness, and bitterness are
Results frequently experienced by psychiatrists after a patient suicide;
and (4) heightened appreciation of the availability and impor-
One hundred sixty-seven of a possible 240 trainees (69.58 % tance of next step procedures, support systems, documenta-
response rate) completed pre- and post-test surveys. Almost tion requirements, and risk management participation.
one in five (19.2 %) had already experienced at least one In the closing remarks on the Collateral Damages DVD,
patient suicide. One hundred three (61.7 %) of the respondents Dr. Gabbard emphasized doing what is right and responding
were female; 124 (74.3 %) were American medical graduates. to a patients suicide with compassion and humanness. That
Forty-seven (28.1 %) were in PGY1 of training, 43 (25.7 %) this suggestion influenced participants may have been reflected
in PGY2, 41 (24.6 %) in PGY3, 28 (16.8 %) in PGY4, and 8 by the increased number of residents reporting that they would
(4.8 %) in PGY5. be likely to consult with the surviving family members after a
As the attached table shows, residents self-perceived patient suicide or to attend the funeral. Several studies have
knowledge of issues related to suicide significantly im- found that families of patients who complete suicide wish to be
proved from 44.0 % rating themselves as very knowledge- contacted by physicians taking care of their loved ones, but
able or knowledgeable before the workshop to 68.9 % after psychiatrists are often reluctant to reach out because of their
the session. Before the intervention, 17.0 % believed that own insecurities, self-blame, or fear of being blamed [12]. We
suicides occur at predictable times; this rate dropped to are hopeful that participation in this curriculum might help
7.2 % after the session. Most participants (88.0 %) reported psychiatric trainees to be more responsive to the needs and
that the feelings of guilt, anger, shame, helplessness, and wishes of the deceased patients family in the future.
bitterness are common after a patient suicide, and this aware- This program also points to strengths of already existing
ness increased to 95.8 % post-session. Using a Likert scale of curricula at the participating institutions. Even before the
awareness, only 13.2 % reported knowing the steps to take in workshop, the majority of participants already knew that
the event of a patient suicide; this rate improved to 45.5 % suicides do not tend to occur at predictable times and places
post-session. Awareness about support systems improved and that physicians are vulnerable to feelings of guilt, anger,
from 28.1 to 57.5 %, documentation improved from 5.4 to shame, helplessness, and bitterness after losing a patient to
19.2 %, and risk management improved from 11.4 to 37.1 %. suicide. Thus, it is clear that this workshop was only one piece
While 75.3 % of the residents reported it was very likely or of a broader training program educating psychiatry trainees
likely for them to consult with their chair or training director about patient suicide.
Acad Psychiatry

Table 1 Survey questions and results

Survey items Pre Post Chi-square (p)


N (%) N (%)

How would you rate your knowledge of issues related to patient suicide? 26.52 (0.000)
Very knowledgeable 7 (4.2 %) 21 (12.6 %)
Knowledgeable 66 (39.8 %) 94 (56.3 %)
How many competent psychiatrists lose patients to suicide? 8.74 (0.003)
Less than half 26 (15.7 %) 10 (6.0 %)
More than half 133 (80.1 %) 154 (92.2 %)
Studies have consistently found that most suicides occur at predictable times and places? 7.39 (0.007)
True 28 (17.0 %) 12 (7.2 %)
False 137 (83.0 %) 154 (92.8 %)
Are feelings of guilt, anger, shame, helplessness, and bitterness common after a patient suicides? 5.52 (0.019)
Absolutely 147 (88.0 %) 160 (95.8 %)
Probably 19 (11.4 %) 6 (3.6 %)
Do you know what steps to take next if you hear about one of your patient completing suicide? 68.89 (0.000)
Yes 22 (13.2 %) 76 (45.5 %)
No 42 (25.1 %) 7 (4.2 %)
In the event of patient suicide would it be important for you to understand why the patient did it? 1.33 (0.248)
Yes 87 (52.1 %) 83 (49.7 %)
No 3 (1.8 %) 6 (3.6 %)
How responsible are you likely to feel if your patient completed suicide? 0.45 (0.499)
Very 54 (32.3 %) 52 (31 %)
Some 105 (62.9 %) 104 (61.9 %)
In the event of patient suicide are you aware of the support system available to you at 36.94 (0.000)
your training program?
Yes 47 (28.1 %) 96 (57.5 %)
No 30 (18.0 %) 8 (4.8 %)
In the event of patient suicide are you aware of the required documentation pertaining 60.57 (0.000)
to the investigative process?
Yes 9 (5.4 %) 32 (19.2 %)
No 95 (56.9 %) 34 (20.4 %)
In the event of patient suicide are you aware of the role played by risk management? 57.38 (0.000)
Yes 19 (11.4 %) 62 (37.1 %)
No 61 (36.7 %) 19 (11.4 %)
In the event of patient suicide how likely are you to consult with the surviving family members? 3.47 (0.062)
Very likely 36 (21.7 %) 36 (21.4 %)
Unlikely 14 (8.4 %) 7 (4.2 %)
In the event of patient suicide how likely are you to consult with your mentor or supervisor? 0.218 (0.640)
Very likely 134 (80.7 %) 137 (81.5 %)
Unlikely 2 (1.2 %) 1 (0.6 %)
In the event of patient suicide how likely are you to consult with your training director or chair? 7.02 (0.008)
Very likely 74 (44.6 %) 97 (57.7 %)
Unlikely 7 (4.2 %) 4 (2.4 %)
In the event of patient suicide how likely are you to attend the patients funeral? 4.26 (0.039)
Very likely 9 (4.9 %) 12 (7.1 %)
Unlikely 50 (29.8 %) 40 (23 %)
Please rate how much you feel your understanding of issues related to patient suicide have changed after attending this workshop
Much greater understanding 22.6 %
Improvement bit better understanding 63.1 %

This study has several limitations. These results are based on programs may not be reflective of all the training programs in
responses from a convenience sample. Although programs from the USA. The study did not have a control group for comparison
different geographical regions participated, results from eight and participants might have been biased towards answering in
Acad Psychiatry

socially desirable manner. One may also question the validity of Acknowledgments The authors would like to thank Cynthia L. Arfken,
Ph.D. for her invaluable assistance with statistical analysis, Glen
the pre- and post-test surveys utilized to ascertain the effective-
Gabbard, M.D., Emily Gray, M.D., Nicholas Hatzis, M.D., Nicole
ness of this program. Further, the immediate application of post- Lanouette, M.D., James Lomax, M.D., and Paul Puri, M.D. for coura-
test survey may not be a true measure of long-term changes in geously providing their personal narratives on Collateral Damages and
knowledge and awareness of issues related to patient suicide. the John A Majda, MD Foundation for its support of the production and
dissemination of Collateral Damages.
Even more important, this study does not provide information
on whether actual behavior was altered or whether the increased Disclosure Dr. Seritan is the PI of a student wellness grant from the
knowledge would, in fact, translate into improved coping skills Substance Abuse and Mental Health Services Administration
in any future events of this tragic outcome. (SAMHSA). The other authors have no disclosures.
Even though overall knowledge of patient suicide-related
issues did improve, changes were not always statistically sig-
nificant or as robust as we would like to have seen. This begs
the question of how to improve the curriculum. Some immedi- References
ate thoughts are to devote more time to the curriculum, perhaps
presenting the workshop in two or three 60-min sessions in- 1. Gitlin M. A psychiatrists response to patients suicide. Am J
stead of one 90-min session, to include the PowerPoint presen- Psychiatr. 1999;156(10):16304.
tation provided with the DVD which contains key background 2. Ruskin R, Sakinofsky I, Bagby RM, Dickens S, Sousa G. Impact of
patient suicide on psychiatrists and psychiatric trainees. Acad
and factual data, to use all of the resident vignettes contained Psychiatry. 2004;28(2):10410.
in the DVD, to include the group discussion of the psychia- 3. Chemtob CM, Hamada RS, Bauer G, Kinney B, Torigoe RY.
trists and training directors that also is contained in the DVD, Patients suicides: frequency and impact on psychiatrists. Am J
and to supplement the curriculum with targeted readings and Psychiatr. 1988;145(2):2248.
4. Fang F, Kemp J, Jawandha A, Juros J, Long L, Nanayakkara S, et al.
opportunities for small group breakouts, personal reflections, Encountering patient suicide: a residents experience. Acad
and narratives from the experiences of participants at each site. Psychiatry. 2007;31(5):3404.
These limitations notwithstanding, this patient suicide ed- 5. Balon R. Encountering patient suicide: the need for guidelines. Acad
ucational program appears to be a feasible and effective pro- Psychiatry. 2007;31(5):3367.
6. Brown HN. The impact of suicide on therapists in training. Compr
gram to increase knowledge of issues related to patient suicide Psychiatry. 1987;28(2):10112.
and to at least initiate the process of helping residents better 7. Prabhakar D, Anzia J, Balon R, Gabbard G, Gray E, Hatzis N,
cope with this tragic, but probably unavoidable occupational Lanouette N, Lomax J, Puri P, Zisook S. Collateral damages:
hazard. Similar programs, featuring testimonials of expert preparing residents for coping with patient suicide. Academic
Psychiatry. In press
clinicians and patient-based case discussions may also be
8. Coverdale JH, Roberts LW, Louie AK. Encountering patient suicide:
applicable to other clinical specialties; each of which must emotional responses, ethics, and implications for training programs.
train residents to deal with their unique set of bad outcomes Acad Psychiatry. 2007;31(5):32932.
including unexpected death of a patient [13-16]. 9. Lerner U, Brooks K, McNiel DE, Cramer RJ, Haller E. Coping with a
patients suicide: a curriculum for psychiatry residency training pro-
grams. Acad Psychiatry. 2012;36(1):2933.
Implications for Educators 10. Pilkinton P, Etkin M. Encountering suicide: the experience of psy-
& Factual information about suicide should be paired with an chiatric residents. Acad Psychiatry. 2003;27(2):939.
opportunity for personal reflections and narratives in a small group 11. Melton BB, Coverdale JH. What do we teach psychiatric residents
format. about suicide? A national survey of chief residents. Acad Psychiatry.
2009;33(1):4750.
& Patient-based case discussion can be used to emphasize key clinical 12. Brownstein M. Contacting the family after a suicide. Can J
concepts in helping trainees to cope with patient suicide. Psychiatry. 1992;37(3):20812.
& Responsiveness to the deceased patients family should be 13. Schwartz AC, Kaslow NJ, McDonald WM. Encountering patient
encouraged. suicide: a requirement of the residency program curriculum.
Academic Psychiatry. 2007;31(5):3389.
14. Engel KG, Rosenthal M, Sutcliffe KM. Residents responses to
Implications for Academic Leaders
medical error: coping, learning, and change. Acad Med.
& Patient suicide curricula should be introduced in the early phase of 2006;81(1):8693.
residency training. 15. Meier DE, Back AL, Morrison RS. The inner life of physi-
& Exploring collaborative opportunities with other clinical specialties is cians and care of the seriously ill. JAMA. 2001;286(23):3007
helpful. 14.
& Issues pertaining to risk management should be included as part of any 16. Khaneja S, Milrod B. Educational needs among pediatricians regard-
patient suicide curricula. ing caring for terminally ill children. Arch Pediatr Adolesc Med.
1998;152(9):90914.