No life remains untouched by suicide. In the United States, there are more than 31,000 suicides each year, with a national rate of 11 deaths per 100,000 people. This is roughly double the death rate by homicide and by alcohol-induced deaths. In comparison with patterns related to physical illnesses, it is more than twice the rate of deaths each year by AIDS and brain cancer, the same death rate as ovarian cancer and pancreatic cancer, and half the death rate by breast cancer, pneumonia, and Alzheimer’s disease (¹). The personal and intergenerational impact of suicide is immense, and the lost years of contribution by those who take their lives represent a tremendous, perhaps immeasurable loss to our society. As specialists in mental illnesses which are most highly associated with death by suicide, psychiatrists are called upon to provide distinct expertise and effective clinical services in relation to this highly significant public health issue. A corollary, then, is that academic psychiatrists must help prepare psychiatrists-in-training for the responsibility of caring for people at risk for suicide and learning how best to respond as a professional to the tragedy that suicide always is.

In this issue, Fang et al. (²) reviewed the literature concerning residents’ experiences and psychiatry training program responses when a patient dies by suicide. One impetus for their review was a recognition that psychiatry residents are likely to experience the suicide of at least one patient during training, with estimates ranging from around 32% to 61% (³—⁸). Fang et al. noted that there are few studies informing residency training programs about how to prepare residents for the possibility of a patient’s suicide or about how to support residents afterward. One of their goals was to encourage the profession to develop guidelines to support residents in their work with suicidal patients and for managing the aftermath.

Because of the importance we attributed to this topic, we invited members of the editorial board to respond to Fang et al.’s review and received several commentaries (⁹—¹¹). Schwartz et al. (⁹) recommended that psychiatry residency directors take the lead by instituting comprehensive programs that will help residents understand and address their personal feelings related to patient suicide. Balon (¹⁰) advocated for the development of guidelines, one for a brief course in suicidology, and one for a post-patient suicide intervention by supervisors. Sudak (¹¹) proposed that psychiatry departments create ad hoc resident and/or staff-only survivors of suicide groups.

One goal for this editorial is to add comments about residents’ emotional responses to the suicide of a patient, in relation to the associated ethical and policy issues. We will not, however, focus on more content-related processes following a suicide, including psychological autopsies or quality assurance reviews. The overarching goal of this editorial and accompanying manuscripts is to underscore the importance of a renewed focus on this area. This focus should include developing research, policies, and supportive and educational interventions for residents when managing suicidal patients and when encountering the suicide of a patient.

The suicide of a patient is one of the most stressful adversities in training (¹²). According to Fang et al. (²), and in light of the limitations of the data (²), there are a range of possible distressing psychological consequences following the suicide of a patient. Most residents experience an initial shock and disbelief (⁸, ¹³), which in some cases can last up to 1 month or longer (⁸). This initial response can be accompanied by depressive ruminations when residents search for the "fatal mistake," and by anger, shame, and guilt (¹³). Physical health, personal and professional relationships, and professional ambitions might also be affected, although the impact on residents’ emotional health exceeds that on all other domains (⁷). Other possible responses include alienation, loss of confidence, and recurrent feelings of horror (⁸). In addition, longer term distressing psychological consequences similar to posttraumatic stress are possible (⁶, ⁸).

We are not, however, aware of any studies that compare residents’ emotional responses to the death of a patient by suicide to the death of patients by other causes. Nevertheless, it is reasonable to assume, as suggested by Balon (¹⁰), that a resident’s reaction to the suicide of a patient will likely be more traumatic than to an unanticipated death by other means. One factor that may contribute to psychological distress is that residents, especially junior residents, are forming their identity as psychiatrists and will be especially concerned about how a suicide reflects on their competency and professional status. Recognition of this factor should add to the priority of programs to prepare residents for the possibility of the suicide of a patient.

In addition, several authors have called for a staged response to a suicide depending on the time that has elapsed since the event. Brown (³), for example, divided the key stages into "acute" (hours to 8 weeks), "clarification and initial working through" (2 to 6 months), and "reorganization characterized by relative resolution versus ongoing doubt" (6 to 18 months). Similarly, Little (¹⁴) described a stage of disbelief and a sense of loss of control (up to 1 week), followed by a sense of turmoil, exhaustion, and demoralization (over 2 months) and by growth or prolonged disability (2 to 6 months).

It should be appreciated that these stages are not empirically validated with a rigor that has been achieved for testing the stages of grief (¹⁵). Nevertheless, both Brown and Little emphasized the importance of a program’s responses that take account of expected emotions at different times over the months following a suicide. Brown, for example, called for the training director to meet with the resident almost immediately after a suicide in order that the resident not bear the experience alone (³). Little recommended different roles for staff meetings at the different stages with an early emphasis on support (¹⁴). He thought that formal review of the circumstances related to the suicide should only occur at a time when the intensity of the emotional turmoil had substantially lessened.

Prevention at an individual level, or the provision of care commensurate with standards of excellence for identifying and managing potentially suicidal patients, is a central ethical concern. Prevention includes treatment of the underlying mental disorder and intervention to protect against suicide when suicide is judged to be imminent (¹⁶). This is absolutely not to say, however, that all suicides are preventable. First, prediction is inherently probabilistic and never certain (¹⁶). Second, psychiatric hospitalization in particular does not ensure safety.

A number of authors have commented that residents react to a suicide by doing more to prevent the possibility of a subsequent suicide. Sacks et al. (¹³), for example, postulated that residents would become preoccupied with ensuring that another suicide does not occur. Tillman (¹⁷) commented that some of the clinicians in her small sample of psychoanalysts and trainees were more prone to "managing" their patients or, in one case, to hospitalizing patients. A single response in this vein has been described in this edition (²). This notion has received empirical support in that residents who had encountered suicide reported that this affected their assessments and thresholds for admission of patients (⁷). On the other hand, in one possibly underpowered study, experience with suicide was not significantly associated with residents’ decisions to seek involuntary commitment of patients (¹⁸).

Even without having experienced the suicide of a patient, the management of suicidal patients can evoke intense feelings. Residents might fear being viewed as incompetent and might fear damage to their reputation and a malpractice suit should a suicide occur (¹⁹). A sense of foreboding may understandably contribute to these concerns about risk. This, in turn, can create a sense of frustration when the patient makes decisions that are not in line with the resident’s clinical judgment about the patient’s ability or willingness to act safely.

The ethical concern here is that such potentially strong feelings, as in other circumstances of managing safety and risk (²⁰, ²¹), can unhinge clinical judgment. This can lead to an overzealous protection of patients at risk or, alternatively, to an avoidance of assessment or discussion of circumstances of risk or even to an avoidance of potentially suicidal patients. Outright avoidance of potentially suicidal patients has been thought to occur when a resident has previously experienced a suicide (¹³). When managing chronically suicidal patients capable of resisting suicidal impulses, too much concern about safety or an overly aggressive management of circumstances of risk may undermine a patient’s preference for how risks are managed (²²). On the other hand, when patients are acutely suicidal, respect for patients’ preferences without due care to identification and management of risk can result in suicide.

There are three primary considerations for preventing feelings or emotional responses to the possibility of a suicide from unhinging clinical judgment and undermining clinical care. These include acknowledging those same feelings, reasoned justification of decision-making, and basing clinical judgment on evidence. First, acknowledgment of feelings necessarily precedes efforts to thwart those same feelings from negatively influencing clinical outcomes (²³). Second, given the probabilistic character of decision-making in managing suicidal patients and given that an absolute ranking of the various benefits and harms associated with hospitalization in particular is not possible (²⁴), therapeutic choices require reasoned justification. Reasoned, ethically justified judgments can be supported by the provision of routine opportunities to discuss challenging cases with clinical teams and by establishing clear lines of responsibility. Similarly, Brown (³) called for supervisors to help residents think through possible influences of a suicide on attitudes that occur during the clarification stage. The third strategy for responding to strong feelings is to base clinical judgment on evidence when available. These strategies together should help medical students and residents learn from these challenging situations by supporting the provision of excellent clinical care.

It is instructive to see how we fare in course design and evaluation now that 21 years have elapsed since Lomax (²⁵) proposed a curriculum of the requisite knowledge, attitudes, and skills for suicide care. As noted by Fang et al. (²), there are few studies on what specific topics related to suicide care are taught and how they are taught (²⁶). There are also few, if any, examples of research shaping curriculum design in accordance with standard models for developing the curriculum (²⁷). According to a 1994 national survey (²⁶), the vast majority of psychiatry residency training programs provided some form of didactic training in the treatment of suicidal patients, although the specific forms of that training were quite variable. Methods utilized included supervision, journal clubs and seminars, case conferences, required readings, and workshops.

Because a sizable minority of residents (³, ⁴, ⁶, ⁸), or even more (⁵, ⁷), encounter the suicide of their own patient, programs should also prepare for this possibility. This preparation should begin early, since about half of the resident respondents who had experienced a suicide in one study did so within the first postgraduate year (⁸). Brown (³) proposed that the training program and department collaborate to establish policies and a structural context that aid in this preparation. Such a policy could provide faculty oversight of residents’ clinical work and a review of residents’ case assignments (⁴). Training programs, however, have not affirmed that training activities routinely include specific instruction or manualized policy on steps to follow should a patient commit suicide (²⁶).

Similarly, a more recent survey of training directors found that only one-third of residency program directors had a policy in place for resident debriefing in the event of a suicide, and only one-third of residents had received education about the possible impact of a suicide (⁷). These results suggest that requirements for training in suicide care as well as policy in the event of a suicide should be established. Requirements for training and policy should be developed and revised according to their utility and efficaciousness.

It should also be noted that in Ruskin et al.’s study (⁸), one-quarter of residents found themselves to be unable to ask for help after the suicide of a patient. Programs must be ready to support individual residents. Given the possible development of longstanding and distressing psychological consequences of a suicide (⁶, ⁸), this support should continue over months and years (³, ⁸).

It is also instructive to learn from residents what they found to be helpful and less helpful in the way of support received. For one, it is important for the program to inculcate a culture of support between residents and to provide opportunities for supporting all residents in need. Fellow residents have been judged to be the most helpful supports for those dealing with the loss of a patient by suicide (⁷, ⁸). In addition, most residents would use a mentor, supervisor, therapist, or critical incident debriefing (⁷). Cursory comments or cursory responses by colleagues, even if intended to assuage blame, have limited utility (¹⁰, ¹¹). Little (¹⁴) cautioned about meetings that focus exclusively on feelings, in case these accentuate guilt and shame. Alternatively, feeling prematurely reassured that the clinician had done nothing wrong is not always helpful (¹⁷). Support should be tailored individually and optimized to maximize the potential for growth in a way that respects individual adaptive styles (³) and avoids an undue focus on emotional responses and personalities (¹⁴).

APA is now collecting materials as resources for clinicians who experience the suicide of a patient (Deborah Hales, personal communication). We welcome this initiative. We also refer readers to the helpful Web sites provided by Sudak (¹¹).

Residency programs should teach suicide care as an early component of residency training and prepare for the possibility of the suicide of a patient treated by a resident. Furthermore, in the event of a suicide, supportive interventions should account for expectable emotions at varying time periods and account for individual needs. The associated clinical ethical issues warrant ongoing attention through training. Frustration and foreboding can unhinge clinical judgment in the care of suicidal patients, which, in turn, can be countered by open discussion of feelings, clear delineation of responsibilities within a team, support by supervisors, and reasoned judgment based on the available evidence.

We wholeheartedly support the calls of the authors published here (², ⁹—¹¹) for ongoing development and evaluation of suicide care programs supported by policy. These programs should also be extended to include medical students (²⁸). In addition, we should assist our colleagues in other specialties in their efforts to provide more robust training in the recognition and management of suicidal patients (²⁹). We thank Fang et al. (²) for bringing the topic of suicide care to our renewed attention, and look forward with enthusiasm to the further development of research, scholarship, and policy in this critically important and relatively neglected area.