Suicide remains the 11th leading cause of death in the United States (1). Furthermore, an estimated 8 to 25 suicides are attempted for each death by suicide (2). Although all physicians should be trained in suicide prevention and intervention (3), psychiatrists are especially likely to encounter suicidal behaviors. In one survey (4), 51% of psychiatrists reported having had a patient who committed suicide. Also, as many as an estimated 31%–61% of residents in psychiatry have had a patient commit suicide (5–8). The suicide of a patient has been described as a very stressful adversity in training (6–8).
Treating suicidal patients includes addressing any self-destructive behavior, regardless of its lethality or underlying psychopathology. As proposed by Lomax (9), teaching the requisite knowledge, attitudes, and skills to manage any suicidal patient should be a core component of psychiatric residency training. However, there are few studies on the teaching of how to treat suicidal patients. Ellis and Dickey’s (10) 1994 national survey of training directors in general and child psychiatry achieved a response rate of 56%. The vast majority of responding programs reported some form of didactic training in the treatment of suicidal patients, but there was considerable variability in how this was taught. The majority of programs also offered suicide-related training in contexts less specifically devoted to the topic of suicide, such as therapy supervision, seminars on general topics, and case conferences (10). In Pilkinton and Etkin’s 2003 survey (6), about one-third of psychiatric residents reported having received education on the impact of patient suicide. Little is known about which specific topics on caring for suicidal patients are taught in U.S. psychiatry training programs.
Because there have been no recent surveys, and in light of the lack of information regarding which specific topics are taught, we surveyed chief residents in general psychiatry training programs regarding how and what was taught about suicide care. Additionally, we inquired about the residents’ views on which topics deserved more formal attention. Because encountering suicide can be so stressful to the affected residents (6–8), we also inquired whether the chief residents were aware of any residents in their programs whose patients had committed suicide and whether they felt sufficiently prepared as chief residents for managing the aftermath.
This study received formal approval from the institutional review board. Questionnaires were mailed in August 2004 to February 2005 to all 183 chief residents. We surveyed accredited psychiatry programs as identified from the Accreditation Council for Graduate Medical Education (ACGME) web site (http://www.acgme.org) for the 2004–2005 academic year (11). One chief resident from each program was asked to anonymously complete a four-page survey about the program’s teaching on suicide and suicide-related events. Residents who failed to respond were mailed a second questionnaire in October 2004 and a third in February 2005. A numbering system was used to keep track of the returned questionnaires while maintaining the anonymity of respondents. One survey was returned because the program did not exist at the time of the study.
The four-page questionnaire included eight sections and was developed in part from earlier surveys (8, 10). This survey is available from the first author upon request. Chief residents were first asked to describe how suicide care was taught by choosing which of six possibilities applied: formal training settings, such as by planned discussion in a seminar, lecture, or course; case conference on a potentially suicidal patient; morbidity and mortality conference; quality assurance/risk management meeting; grand rounds; and journal club.
The next section was answered only if the program taught suicide care formally (by planned discussions) in a seminar, lecture, or course. Residents identified the specific topics taught by answering “yes,” “no,” or “do not know” to each of 25 listed topics, which were generated by the authors. They then indicated the approximate number of seminars or lectures provided within each year, the titles of courses or description of seminars, and texts or materials provided.
For programs that provided a case conference on the potentially suicidal patient or a morbidity and mortality conference, residents identified the year of training, topics covered, and whether or not faculty provided supervision. Residents identified barriers to teaching about treatments for suicidal patients in their own programs by checking those that applied from a list, including a lack of skilled teachers, audio or videotapes, texts or materials, or a lack of emphasis on the topic, emotional difficulty of the topic, legal barriers, and “other.” Residents also indicated which topics (from the same list of 25 earlier provided) warranted more formal attention by planned discussion during residency training. Finally, a set of questions concerned whether the chief resident was aware of any residents within the program whose patients had committed suicide, how well the chief resident felt prepared in managing the aftermath, what could have been improved, and the adequacy of the training program’s response. Percentages of responses to each question were completed with the number of individuals responding as the denominator. The denominator varied according to the number responding to each question.
Following the three separate mailings, 106 of the 181 programs responded, yielding a response rate of 58.6%. The mean number of residents in training programs was 29; 86 programs were adult and 19 were combined with another specialty. The majority of programs (64 of 106 respondents, 60%) had 16–30 residents in their program; 31% (n=33) had 30 or more residents, and 7% (n=8) had fewer than 15 residents.
As shown in Table 1, the majority of the responding programs (91%) offered formal teaching to the residents. Grand rounds and case conferences were the most common teaching methods utilized, whereas quality assurance meetings, including morbidity and mortality conferences, were utilized by less than half of the responding programs. The average number of seminars or lectures taught by the programs was 3.6 with a range from 2.8 to 4.1. The majority of the teaching occurred in the first 2 years of the programs. Texts and the materials used included audiovisual materials, books or book chapters, and journals. Kaplan and Sadock’s Comprehensive Textbook of Psychiatry and APA’s Practice Guidelines were those most frequently used (by 9 programs each).
The programs that taught the management of suicide by formal methods, through planned discussions such as seminars, lectures, or courses, were queried about the specific topics taught. As summarized in Table 2, topics related to suicide assessment, such as suicide risk factors, early warning signs, and recognition, were the most commonly covered subjects in formal didactics. The least commonly taught topics, such as suicide in schools or prisons, family based therapies, and postvention of suicide (a form of psychological autopsy following suicidal behavior) (12), were those most likely perceived to require more attention. However, many residents thought that many of the topics required more attention and made suggestions for additional support, supervision, and teaching.
As many as 74 chief residents (71%) were aware of a resident in their programs whose patient had committed suicide, based on the chief resident’s knowledge of patient suicide during his or her training years. Only 19% of chief residents reported that they personally felt prepared for the aftermath of a patient suicide, although 69 (71.8%) reported that their programs’ response was adequate.
The most commonly reported barriers to teaching on suicide care were lack of audio or video teaching materials and relevant texts (n=44, 44%). The emotional nature of the topic was also described as a barrier (n=11, 11%). Only 10% of the chief residents reported that a lack of skilled teachers constituted a barrier to teaching.
As was the case in 1994, when the first national survey on teaching in suicide care was conducted (10), we found that around 90% of all responding programs formally teach suicide care by planned discussion in seminars, lectures, or courses. In addition, programs almost always teach by more than one method, such as grand rounds, case conferences, and journal clubs.
One of our primary goals for this survey was to identify the specific topics taught. Recognizing risk factors and early warning signs was taught by all or nearly all programs. Nevertheless, managing risk factors and warning signs warranted further attention in the view of many respondents, as did many other topics. We did not identify what topics were taught in grand rounds or other formats or determine the depth of coverage of individual topics. However, the opportunity to cover such a wide range of topics in depth was constrained by time, because on average, only four seminars or lectures were dedicated to suicide care.
Nearly half of the programs utilized a quality assurance program or morbidity and mortality conference. The use of case conferences was reported by 81% of the programs in Ellis and Dickey’s (10) national survey. Discussion and retrospective review of the facts of suicide in a safe and supportive environment might constitute an important learning experience for residents. Although managing personal reactions associated with suicidal potential or behavior was commonly taught, postvention was taught by only one-quarter of programs. Because as many as 71% of chief residents were aware of the suicide of a patient cared for by a resident in their own program, and because few had felt adequately prepared for the aftermath of a suicide, training programs should further prepare residents for the possibility of a patient suicide (13–17).
Our data should be understood in the light of the response rate of close to 60%, which limits the generalizability of the findings. Further, for programs that had more than one chief resident, we do not know how the one respondent was selected and whether this process of selection biased the results in any way. Nor did we inquire about the teaching sites within each program for the care of the suicidal patients. The recall of specific components of programs might be limited as well. Additionally, while the survey instrument was built from earlier instruments, the reliability of the chief resident responses was not determined. Program directors were also not surveyed in order to check the accuracy of the residents’ responses. The survey did not cover the different types of teaching, training, and support that occur in the postsuicide context. Nor was an assessment of competence in treating suicidal patients included.
The results of this survey and others (7, 10) nevertheless should assist in the development of suicide care programs. Suicide care topics were routinely taught, although the chief residents surveyed suggested that still more attention was warranted. To this end, the perceived lack of suitable teaching materials and texts and the other identified barriers to teaching should be addressed. We also need to learn more about how teaching about suicide influences relevant knowledge, attitudes, and skills, and how specific skills can be most efficaciously taught. These are challenges yet to be met.
Manuscripts authored by an editor of Academic Psychiatry or a member of its editorial or advisory board undergo the same editorial review process, including blinded peer review, applied to all manuscripts. Additionally, the editor is recused from all editorial decision making.
At the time of submission, the authors disclosed no competing interests.