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
challenges that threaten to undermine their trainees profes-
sional identity, evolving sense of competence. In psychiatric
training, it is patient suicide, an all-too frequently encountered
consequence of severe mental illness that may leave the
treating resident perplexed, guilt-ridden, and uncertain of their
D. Prabhakar (*)
Henry Ford Health System, Detroit, MI, USA
e-mail: dprabha1@hfhs.org
R. Balon
Wayne State University, Detroit, MI, USA
J. M. Anzia
Northwestern University Feinberg School of Medicine, Chicago, IL,
USA
G. O. Gabbard : J. W. Lomax
Baylor College of Medicine, Houston, TX, USA
B. S. Bandstra
Stanford University School of Medicine, Stanford, CA, USA
J. Eisen
Brown University, Providence, RI, USA
S. Figueroa
University of Michigan, Ann Arbor, MI, USA
G. Theresa
Oklahoma University Health Sciences Center, Oklahoma City, OK,
USA
M. Ruble
Cambridge Health Alliance, Cambridge, MA, USA
A. L. Seritan
UC Davis, Sacramento, CA, USA
S. Zisook
University of California, San Diego, CA, USA
suicide training program aimed at educating residents about
patient suicide, common reactions, and steps to attenuate
emotional distress while facilitating learning.
Methods The intervention was selected aspects of a patient
suicide educational program, Collateral Damages,video
vignettes, focused discussions, and a patient-based learning
exercise. Pre- and post-survey results were compared to assess
both knowledge and attitudes resulting from this educational
program. Eight psychiatry residency training programs partic-
ipated in the study, and 167 of a possible 240 trainees (re-
sponse rate=69.58 %) completed pre- and post-surveys.
Results Knowledge of issues related to patient suicide in-
creased after the program. Participants reported increased
awareness of the common feelings physicians and trainees
often experience after a patient suicide, of recommended
next steps, available support systems, required documenta-
tion, and the role played by risk management.
Conclusions This patient suicide educational program in-
creased awareness of issues related to patient suicide and shows
promise as a useful and long overdue educational program in
residency training. It will be useful to learn whether this pro-
gram enhances patient care or coping with actual patient sui-
cide. Similar programs might be useful for other specialties.
Keywords Patient suicide . Psychiatry residents . Curriculum
Regardless of clinical specialty, bad outcomes happen. In
psychiatry, the most serious and tragic bad outcome of the
serious and chronic conditions psychiatrists treat, patient sui-
cide, is also one of the most difficult to accept and cope with in
all medicine [1, 2]. Patient suicide has been called an occupa-
tional hazard for psychiatrists: an event almost all psychiatrists
in practice encounter, often many times. It is difficult to deal
with at any period of a psychiatrists career, but is especially

during residency [3-5]. Residents often blame themselves and
may be too riddled with self-doubt, shame, and guilt about self-
perceived omissions or commissions to seek help. Yet, resident
physicians are an especially vulnerable population whose early
experiences with patient suicide may shape their future beha-
viors and coping skills [6]. This situation is compounded by the
nature of psychiatric training, which generally emphasizes
inpatient rotations, with the most ill and potentially suicidal
patients, for the most junior trainees [6]. And, although all
training programs emphasize teaching suicide risk assessment
and procedures to mitigate risk, few provide training aimed at
helping residents cope with the aftermath of patient suicide
when all attempts at treatment and prevention fail [4-10]. In a
survey of chief residents of psychiatry training programs across
the USA, only 19 % of the respondents reported feeling pre-
pared for the aftermath of patient suicide [11]. The aim of this
study is to pilot test a new curriculum aimed at helping psychia-
try residents learn more about suicide, common reactions to
patient suicide, and useful resources and actions as a first step
towards helping trainees adaptively cope with this tragic event.
Methods
Development and Contents of Curriculum
As previously described [7], a group of senior investigators,
along with residents and recent graduates, developed a highly
interactive curriculum, called Collateral Damages, aimed at
providing psychiatry training programs tools to help trainees
learn: (1) suicide is often the result of serious mental illness;
(2) even experienced, highly-acclaimed psychiatrists have
patients who die by suicide; (3) anger, blame, guilt, shame,
relief, and myriad other grief-related reactions are common;
and (4) departmental and institutional guidelines focused on
dealing with patient suicide may ultimately enhance healthy
coping. The Collateral Damages curriculum is contained in a
DVD that consists of (1) a video program that includes intro-
ductory comments; five brief vignettes from clinicians (two
from senior faculty, two from junior faculty, and one from a
trainee) on their patients who killed themselves and their
immediate emotions, thoughts, and behaviors; a panel discus-
sion of the five psychiatrists who have provided their narra-
tives plus two senior training directors that focuses on univer-
sal themes, processes, and procedures to follow after a patient
suicide, principles of dealing with families, critical incident
review, risk management, and the roles of counseling/
supporting trainees and colleagues; and closing comments;
(2) a PowerPoint presentation emphasizing suicide-related
basic epidemiological facts, emotional reactions to patient
suicide, and a brief overview of resources available to grieving
individuals; (3) a patient-based case learning exercise cover-
ing Accreditation Council for Graduate Medical Education
Acad Psychiatry
(ACGME) competencies as a means to stimulate discussion;
and (4) pre- and post-questions.
Sample
Immediately after the Collateral Damages curriculum was pre-
sented as a workshop at the 2010 Annual meeting of the
American Association of Directors of Psychiatry Presidency
Training (AADPRT), participating training directors were asked
if they wanted to volunteer their programs to pilot test the
curriculum. They were told a DVD and a users guide would
be provided and that they would have to agree to present the
curriculum to residents and obtain pre-session surveys and
immediate post-session surveys during the next academic year.
Eight residency training programs volunteered. The programs
represented different regions of the USA: Midwest (Northwest-
ern University, University of Michigan, Wayne State Universi-
ty), Northeast (Brown University, Cambridge Health Alliance),
South (University of Oklahoma), and West (Stanford Universi-
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
each site. Attendance at the program and completion of the
survey instrument implied informed consent.
Teaching Session
Although we presented a structured users guide describing
the way the curriculum was to be implemented at the coordi-
nating site, Wayne State University, each program was
instructed to use the program according to their individual
needs and adjust the content as deemed necessary. We allowed
this flexibility considering that individual programs may al-
ready have some pieces of the educational curriculum in place.
The users guide suggested the curriculum could be given as a
one-time, 90-min workshop, to include the following:
1. Pre-test survey to be distributed and collected during the
first few minutes.
2. A 15-min segment from the Collateral Damages
DVDopening remarks by Dr. Glen Gabbard and two
senior clinician narratives.
3. Open floor discussion for 10 min.
4. A second 15-min segment from Collateral Damagesa
resident narrative and closing remarks from Dr. Glen
Gabbard.
5. Open floor discussion for 10 min
6. A patient-based learning exercise to be discussed for
30 min. This exercise included core issues related to
patient suicide such as the importance of collateral infor-
mation, risk of suicide in patients with schizophrenia,
impact of case load, medical knowledge, and risk man-
agement procedures.
Acad Psychiatry
7. Open floor discussion for 10 min to answer any queries,
highlight key take home points and discuss possible
follow-up or next steps.
8. Distribution, completion, and collection of the post-test
survey.
Survey Instrument and Implementation
In addition to basic demographic information contained in the
pre-test survey, the pre- and post-test surveys were composed of
items measuring the trainees awareness and understanding of
issues related to patient suicide such as common facts, aware-
ness of common feelings, steps to take after completed patient
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
pre- and post-test surveys were compared using linear trend
chi-square for ordinal variables and chi-square for nominal
variables. Because the surveys were completed anonymously,
it was not possible to match individual pre- and post-test
responses; therefore, independent tests were used. Statistical
significance was defined as a two-sided p value <0.05.
Results
One hundred sixty-seven of a possible 240 trainees (69.58 %
response rate) completed pre- and post-test surveys. Almost
one in five (19.2 %) had already experienced at least one
patient suicide. One hundred three (61.7 %) of the respondents
were female; 124 (74.3 %) were American medical graduates.
Forty-seven (28.1 %) were in PGY1 of training, 43 (25.7 %)
in PGY2, 41 (24.6 %) in PGY3, 28 (16.8 %) in PGY4, and 8
(4.8 %) in PGY5.
As the attached table shows, residents self-perceived
knowledge of issues related to suicide significantly im-
proved from 44.0 % rating themselves as very knowledge-
able or knowledgeable before the workshop to 68.9 % after
the session. Before the intervention, 17.0 % believed that
suicides occur at predictable times; this rate dropped to
7.2 % after the session. Most participants (88.0 %) reported
that the feelings of guilt, anger, shame, helplessness, and
bitterness are common after a patient suicide, and this aware-
ness increased to 95.8 % post-session. Using a Likert scale of
awareness, only 13.2 % reported knowing the steps to take in
the event of a patient suicide; this rate improved to 45.5 %
post-session. Awareness about support systems improved
from 28.1 to 57.5 %, documentation improved from 5.4 to
19.2 %, and risk management improved from 11.4 to 37.1 %.
While 75.3 % of the residents reported it was very likely or
likely for them to consult with their chair or training director
in the event of patient suicide before the session, the percent-
age rose to 85.1 % after the workshop. Compared to this, a
higher percentage of the respondents reported very likely or
likely to consult with supervisor/mentor both before
(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
improved to 75.6 %; however, the difference was not statisti-
cally significant. At the baseline, 23.1 % reported very like-
ly or likely to attend the patients funeral; this changed to
35.5 % after the session. When asked about the improvement
in understanding of issues related to patient suicide as a result
of attending this program, 85.7 % reported improvement with
22.6 % reporting much greater understanding. Table 1.
Discussion
This 90-min interactive curriculum appears to be a viable
strategy to help psychiatry trainees enhance their knowledge
of several important aspects of patient suicide; (1) self-
reported global knowledge of issues related to patient suicide;
(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
frequently experienced by psychiatrists after a patient suicide;
and (4) heightened appreciation of the availability and impor-
tance of next step procedures, support systems, documenta-
tion requirements, and risk management participation.
In the closing remarks on the Collateral Damages DVD,
Dr. Gabbard emphasized doing what is right and responding
to a patients suicide with compassion and humanness. That
this suggestion influenced participants may have been reflected
by the increased number of residents reporting that they would
be likely to consult with the surviving family members after a
patient suicide or to attend the funeral. Several studies have
found that families of patients who complete suicide wish to be
contacted by physicians taking care of their loved ones, but
psychiatrists are often reluctant to reach out because of their
own insecurities, self-blame, or fear of being blamed [12]. We
are hopeful that participation in this curriculum might help
psychiatric trainees to be more responsive to the needs and
wishes of the deceased patients family in the future.
This program also points to strengths of already existing
curricula at the participating institutions. Even before the
workshop, the majority of participants already knew that
suicides do not tend to occur at predictable times and places
and that physicians are vulnerable to feelings of guilt, anger,
shame, helplessness, and bitterness after losing a patient to
suicide. Thus, it is clear that this workshop was only one piece
of a broader training program educating psychiatry trainees
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
the pre- and post-test surveys utilized to ascertain the effective-
ness of this program. Further, the immediate application of post-
test survey may not be a true measure of long-term changes in
knowledge and awareness of issues related to patient suicide.
Even more important, this study does not provide information
on whether actual behavior was altered or whether the increased
knowledge would, in fact, translate into improved coping skills
in any future events of this tragic outcome.
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-
ate thoughts are to devote more time to the curriculum, perhaps
presenting the workshop in two or three 60-min sessions in-
stead of one 90-min session, to include the PowerPoint presen-
tation provided with the DVD which contains key background
and factual data, to use all of the resident vignettes contained
in the DVD, to include the group discussion of the psychia-
trists and training directors that also is contained in the DVD,
and to supplement the curriculum with targeted readings and
opportunities for small group breakouts, personal reflections,
and narratives from the experiences of participants at each site.
These limitations notwithstanding, this patient suicide ed-
ucational program appears to be a feasible and effective pro-
gram to increase knowledge of issues related to patient suicide
and to at least initiate the process of helping residents better
cope with this tragic, but probably unavoidable occupational
hazard. Similar programs, featuring testimonials of expert
clinicians and patient-based case discussions may also be
applicable to other clinical specialties; each of which must
train residents to deal with their unique set of bad outcomes
including unexpected death of a patient [13-16].
Implications for Educators
& Factual information about suicide should be paired with an
opportunity for personal reflections and narratives in a small group
format.
& Patient-based case discussion can be used to emphasize key clinical
concepts in helping trainees to cope with patient suicide.
& Responsiveness to the deceased patients family should be
encouraged.
Implications for Academic Leaders
& Patient suicide curricula should be introduced in the early phase of
residency training.
& Exploring collaborative opportunities with other clinical specialties is
helpful.
& Issues pertaining to risk management should be included as part of any
patient suicide curricula.
Acknowledgments The authors would like to thank Cynthia L. Arfken,
Ph.D. for her invaluable assistance with statistical analysis, Glen
Gabbard, M.D., Emily Gray, M.D., Nicholas Hatzis, M.D., Nicole
Lanouette, M.D., James Lomax, M.D., and Paul Puri, M.D. for coura-
geously providing their personal narratives on Collateral Damages and
the John A Majda, MD Foundation for its support of the production and
dissemination of Collateral Damages.
Disclosure Dr. Seritan is the PI of a student wellness grant from the
Substance Abuse and Mental Health Services Administration
(SAMHSA). The other authors have no disclosures.
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