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By: Paul Garfinkel Special to the Star, Special to the Star
Published on Fri Oct 03 2014
Psychiatrists are often unprepared when their patients take their own lives, writes Dr. Paul Garfinkel of CAMH in an excerpt from A Life in Psychiatry
This is the story of a woman named Debbie, a patient of mine. A kind, sensitive soul, Debbie struggled to overcome anorexia nervosa and then depression. She worked hard to manage her illnesses, and for a few precious years she carved out a life for herself, with a job and nights out at the movies. She even found a sensitive boyfriend to escape the loneliness that had plagued her since childhood. But then the monster that is depression reclaimed her. Debbie ended her life by jumping off a balcony at age 36.
Debbie’s death shocked and deeply saddened me. It was one of the most emotionally devastating moments of my professional life, and I was just not prepared for it. I had worked hard to free her, first from the vice-like grip of anorexia and then from the pit of depression, and we had made real progress together, or so I thought.
I felt guilty. Could I have done more? Had I been distracted? Debbie’s suicide had happened while I was focusing on the creation of CAMH, and I had cut back my practice during this time, but some patients I felt that I had to continue to see, and Debbie was one of them. Could someone else have done a better job? Could someone else have saved her? Why jump rather than take the medicines she had in her apartment? The hopelessness and determination to die must have been so awful for her.
As these questions circled in my mind, I noticed my grief was turning to anger, as if I had been betrayed. I had worked so hard for so long, and she had been succeeding. She had carved out a life for herself. I thought she would be okay. Why this?
The hospital did a psychological autopsy and found that the care Debbie received was appropriate. I had tried a variety of the newer antidepressants, saw her regularly, engaged the family, and attempted many rehabilitation techniques. At one point I asked for, and received, a second opinion regarding Debbie’s depression. Debbie’s parents were tremendously saddened but grateful for all we had done, and I attended the funeral, albeit awkwardly. I told myself not to feel defensive. I could learn from this, but that didn’t make it right. I didn’t recover for a very long while.
I tell this story because it is a not uncommon experience for psychiatrists. Although suicide is a relatively rare event, half of all psychiatrists will endure the suicide of a patient sometime during their career. It is not surprising: we’re dealing with patients who have depression and schizophrenia and other serious mental illnesses that vastly heighten the risk of suicide.
Even as psychiatrists we are not prepared for its impact. We are not prepared as human beings, in part because of our religious and cultural attitudes to suicide, and in part because medical schools and professional associations have not adequately tackled this sensitive topic.
Many more people die of suicide than in wars. For example, in 2000 over 800,000 people committed suicide, versus just over 300,000 who died as a direct result of armed conflict. In Canada, 4,000 people die of suicide each year, and 400 of these are youth. Suicide is the second leading cause of death for Canadians between the ages of 10 and 24, and the fourth leading cause of death for Canadians between the ages of 15 and 44.
When I was a student, medical school did nothing to prepare future psychiatrists for the impact of patient suicide. We were taught how to assess suicide risk. We learned the individual risk factors (male, older, alone, white, a medical condition, no religion), and we were told to watch out for a plan and any previous attempts. We learned that a suicide in the family greatly increases risk, as does a physical illness or history of trauma. We learned that loss or a drop in self-esteem can precipitate a suicide, and we learned about the related factors, such as the presence of substance abuse. We were taught to ask whether the patient had the means to carry out the plan, such as having a gun in the house or a large supply of medicines. We took seminars on the Mental Health Act, so that we could understand what our responsibilities were to patients in danger and the limits of those responsibilities.
We were also taught to be prudent: if in doubt, admit the person to a safe hospital bed. In Toronto I would soon learn, though, that people with some forms of personality disorder, even though chronically suicidal, are often better treated out of hospital if at all possible.
The emotional impact is severe. Most of the young psychiatrists experienced a devastating emotional impact on first learning of the suicide in a Toronto study conducted by Dr. Ron Ruskin and his colleagues. For 33%, the emotional turmoil lasted up to one month. For 7%, the disturbance lasted longer than three months. For many, it can be an isolated, lonely time. Some doctors feel they can no longer treat potentially suicidal patients. I have heard some psychiatrists describe an identification with the dead patient in their dreams; one spoke of how, for her, identification manifested in being accident-prone for some weeks after the death.
Many of the young psychiatrists said the suicide had a profound and enduring effect on them as individuals and as physicians. They experienced frequent and powerful feelings of fear related to their clinical practice, often feeling helpless, and with recurring images and feelings of horror. To get a better picture of the emotional impact, Ruskin asked respondents to fill out a questionnaire, the Impact of Events Scale. The results were striking: 20% of the psychiatrists who had a patient commit suicide met the clinical criteria for post-traumatic stress disorder.
For beginning therapists, the sense of shock is intense. Wayne Fenton, a psychiatrist at the National Institute of Mental Health, treated a young schizophrenic patient in his first year of residency. The patient had started taking the antipsychotic drug clozapine, an experimental treatment at that time, and he seemed to improve remarkably. When Fenton met with him late on a Friday afternoon, they spent the session discussing the future, including the possibility that the young man could return to college. At seven thirty that evening, the hospital called to say his patient had not arrived at the outpatient program, where he was supposed to spend the evening. A few hours later, there was another call: the police had found a body and wanted to show Fenton photographs to identify it.
“This suicide was unexpected by everyone,” Fenton said. “Particularly insofar as there was a feeling that here was a patient who was really improving tremendously.” For years after the death, Fenton indicated that he became anxious every time the telephone rang at night, with “the feeling of your heart going into your throat, when you’re afraid it’s the worst.”
I think psychiatrists have a harder time dealing with the death of a patient than other specialists, like cardiologists or oncologists, when the death is by suicide. Skilled therapists tend to develop intense, close relationships with their patients. They care deeply about their progress and survival. A therapist may take it upon himself or herself to act as the saviour of a particular patient. This can set the therapist up for a devastating personal loss should the patient choose death over life.
Excerpted from A Life in Psychiatry: Looking Out, Looking In by Dr. Paul Garfinkel. Reprinted with permission of Barlow Books Publishing.