Preparing for a suicidal patient

The death of a patient from suicide is heartbreaking and can be a traumatizing experience for healthcare providers. It can create an insurmountable amount of personal and professional distress and guilt, and may even trigger healthcare providers to leave medicine.

A troubled patient

A 53-year-old man came into my office saying he was exhausted and had no appetite. I learned he was a high-level executive who recently lost his job. He was a devoted husband and father of three young adult children.

He met all the criteria for depression and was devastated over his job loss, as his career was his pride and joy. He denied any suicidal or homicidal thoughts, or use of drugs or alcohol.

We had a long conversation about the benefits of antidepressants in conjunction with therapy. I wrote him a prescription for Lexapro and referred him to a therapist. I asked him to follow up in my office every 2 weeks, and call if he experienced any side effects.

Six weeks later, a woman with the same last name came in. She said her husband shot himself in the head while sitting in his car in the garage. She asked if he was one of my patients.

I was profoundly shocked and sad, and told her everything I knew. I told her about the prescription and referral. She wasn’t aware of him taking antidepressants or going to therapy. I called the pharmacy and learned he never filled his prescription.

In the aftermath, I withdrew from coworkers, spent hours reviewing notes, and experienced doubt, anger, sadness, and defeat.

Suicide: A look at the numbers

Disturbing statistics indicate a growing number of physicians and healthcare providers will lose patients to suicide.^[][][]

• Suicide is a leading cause of death in the US, with 45,979 deaths from suicide in 2020—approximately one death every 11 minutes.

• In 2020, an estimated 12.2 million American adults seriously thought about suicide, 3.2 million planned an attempt, and 1.2 million attempted suicide.

• In 2020, suicide was among the top nine leading causes of death for people ages 10–64, and was the second leading cause of death for people ages 10–14 and 25–34.

• A mental health disorder is one of the primary predictors of suicide.

While the link between suicide and mental health disorders (in particular, depression and alcohol use) is well established, many suicides occur in impulsive moments of crisis with a breakdown in ability to deal with life stresses such as financial problems, job loss, divorce, or chronic pain and illness.

Unfortunately, many healthcare providers are unprepared for the emotional and professional devastation that can follow.

Assessing risk

Suppose your patient comes into your office complaining of signs and symptoms of a mental health or substance use disorder, or a traumatizing event such as job loss or a relationship breakup. You must evaluate their suicide risk.

Before starting a suicide assessment, create a safe place for your patient to trust you to share their struggles. Allow them to open up without trying to "fix” them.^[]

Instead, listen to your patient, empathize and talk about painful emotions without coming to a conclusion or offering reassurance. Having an open, honest relationship with patients allows them to tell you what’s going on while you ask questions to assess risk.

Asking these tough questions does not put your patient at greater risk of committing suicide. You can ask:

• About severity of their symptoms

• Whether they have a plan

• If they have access to a firearm

• About specific events or triggers

• The most important question: Are you thinking of killing yourself?

If you identify an at-risk patient:

• Take the risk seriously.

• Help them remove any lethal means in their possession, such as drugs or firearms.

• Avoid minimizing their problems.

• Assure them you care.

• Encourage them to seek mental health treatment and offer referrals.

• Escort them to mental health services, or an ER if necessary.

Reporting a patient for suicidal risk 

You may face the challenging task of deciding whether or not the situation constitutes enough risk to report the patient and breach their confidentiality.

Most states have laws that either permit or require all health professionals to disclose information about patients who may be suicidal.

This usually includes the legal right to initiate a 24-to-72-hour involuntary "hold" for inpatient mental health assessment if an imminent risk of suicide is present. You should know how to access emergency psychiatric services and hospitalization, and also understand relevant legal guidelines for involuntary hospitalization.

If suicide risk is not imminent, establish a plan with the patient that targets the underlying mental health disorder, and begin treatment immediately.