In this commentary, I will focus on the role of residents and practitioners as survivors of suicide, describe some of my personal and professional encounters with suicide, and provide some medico-legal advice.

Family members and close friends of people who have committed suicide are termed "Survivors of Suicide" (rather than this term being applied to those who have attempted suicide and survived the attempt). SOS is a nonprofit organization with chapters in every major city (Appendix 1 ). Meetings are generally held once or twice a month and are usually led by other survivors of suicide than by mental health professionals, and are based on self-help principles and the concept that those trying to come to grips with such a tragedy in their own lives feel better understood by those who have shared such an experience and will feel less hopeless about eventually recovering by being with others who have moved along in the recovery process. In contrast, a shocked resident survivor generally receives a frightening critical incident review, which adds to the resident’s anxiety and guilt, coupled with little help from senior staff or a tacit departmental silence (outside of the "review"), which adds to the atmosphere of something shameful having taken place.

Obviously, what the resident/clinician feels following a suicide (in terms of shock, denial, guilt, anger, shame, anxiety, preoccupation with the death) will be quantitatively less than what immediate family will undergo, but will be qualitatively quite similar. It will also have the added element of "professional" concerns, such as, "What will my supervisors or colleagues think of me?" These similarities mandate that we should do more than hold "what went wrong inquiries" in our departments; we should create ad hoc resident and/or staff-only SOS groups and also designate a supportive, trusted, nonthreatening faculty member who makes him/herself available to meet with trainees and other staff following the suicide of a patient. This is the least we can do—a patient’s suicide is the trauma for the mental health professional (both intrapersonally and legally) and few of us escape it. A few medical schools have created model programs along these lines (¹).

I have had four patients commit suicide. My first was in my fourth postgraduate year. He was an art student from a devout Italian-American family in outpatient treatment with me for anxiety symptoms. I learned about the suicide in a Cleveland, OH, newspaper I had with me while en route to my first APA annual meeting. I received about as much support from the newspaper article as from my supervisor upon my return to work (a curt, "It was not your fault," was it). I learned little from the experience.

My next experience was at the National Institute of Health when I, as the weekend on-call physician, was asked to routinely screen another doctor’s inpatient for whom a pass had been ordered. He "seemed fine" to me, I let him go, and he killed himself that day. Ditto for learning (except I became more cautious).

The third was a woman with dysthymia (in those days "a depressed character") whom I had been seeing in outpatient therapy for approximately 2 years when she killed herself. I was in analytic training then and at least had the benefit of talking about it in my personal analysis.

The last suicide had been recently discharged from inpatient and partial programs, a middle-aged bachelor whom I had started to see in outpatient therapy. He came from a close-knit Eastern European-American family, and his widowed, chronically ill sister was his primary support. During the sister’s rare and well-deserved 4-day vacation in Florida without him, he killed himself. The beloved sister had accompanied him and was seen with him (each separately and together) in all of our sessions except the last. I made a home visit following the death because I knew I would be away on the day of the funeral. Interestingly, I never attended the funerals of any of the others nor made condolence calls, although in general I believe it is a good idea. For all four of these deaths I went through the feelings the authors of "Encountering Patient Suicide: A Resident’s Perspective" (²) poignantly describe.

Certainly, my most personal encounter with suicide is one that, fortunately, most mental health clinicians do not undergo—the suicide of one’s spouse. Although attenuated by the fact that, at that time, my wife and I were living in separate cities and were in the process of divorce, my guilt, grief, and shame have, not surprisingly, made this my life’s worst experience. My relationship to my grown children and my old friends has been permanently altered—as have my own self-image and view of the world. My new wife and family have helped enormously, and my participating as a survivor (rather than in my former role as a group leader or resource person) in SOS groups has also made me a believer in their efficacy and the comfort they provide. This is why I believe that facilitating comparable groups for providers should be a departmental imperative. I also believe that the SOS movement should have special groups for provider survivors, when they have national or regional meetings for survivors with small break-out group meetings for various categories of survivors (e.g., parents, spouses, children, siblings).

What is key to keep in mind is that although wrongful death is the most common malpractice claim against psychiatrists (boundary violations are next), decisions about lawsuits are based not on failure to predict suicide but failure to properly evaluate the risk of suicide. No one can predict suicide with statistical accuracy, but everyone can and should evaluate the known risk factors and warning signs of suicide (³) and must document that they have done so. If it is not written, it does not exist—at least in the courtroom. This risk appraisal is the most relevant standard of care. You cannot write everything down, but you at least need to write down the essentials, and this is one of them. The same is true for a full mental status record; a past and family history; a description of past attempts, their lethality and likelihood of discovery, and the "most-serious-ever attempt"; an alcohol and substance abuse history; and an inquiry into the availability of guns (for every depressed patient and every suicidal patient—depressed or not). If you are discharging or transferring a patient for some reason but you feel there remains significant risk of suicide, you should document your awareness of this in the chart along with an explanation of why you feel taking this risk is clinically justified. Note that a lack of insurance may not suffice in court as the justification. It can be legally very helpful to have a consultant add a note agreeing with your plan (because the standard of care also cites practicing in the manner of a "reasonably prudent psychiatrist" and a second opinion at the least shows you are not alone). Another suggestion for residents and other clinicians is "why now in and why now out"—that is, document in the chart not just what had changed in the patient’s life to precipitate the admission but also how these factors had been ameliorated during the admission to make it safer to discharge him or her (e.g., family meetings to heal some rift, a reconciliation with a spouse, a pending legal charge). Be certain, also, to ensure that you have followed your hospital’s policies and procedure manuals carefully, and do not alter your patient’s chart following a suicide no matter how anxious the suicide has made you.

A much-debated issue on the lawsuit topic is "Who gets sued?" Do the worst doctors get sued the most and the best the least? Although that is the way it ought to be, I suspect that lawsuits are engendered more by poor doctor-patient relationships than by the quality of care. I have seen numerous examples of otherwise very competent doctors who alienated their patients’ families, who then initiated suits following a suicide. Do not unduly hide behind confidentiality concerns and the patient’s refusal to divulge information to his or her family. Confidentiality can be waived if keeping it may endanger the patient, and if all else fails, the physician can always receive information from the family even if he or she is prevented from providing information. I, thankfully (and luckily), have never been sued, but with each patient suicide of mine, I was terrified that I would (should?) be.

Thank you, resident-authors, for opening this typically closed door and, I hope, for helping your seniors create a little light (and a lot of support) for every clinician facing this ordeal.

The nine resident authors of "Encountering Patient Suicide: A Resident’s Experience" (²) are to be commended for speaking out on a topic too often minimized by training programs, for their research on the topic, and for their helpful suggestions.