New Study Sheds Light on Patient Suicide and the Emotional Toll It Takes on Healthcare Providers

More than half of healthcare professionals (HCPs) and approximately 75% of psychiatrists will lose a patient to suicide at some point in their career. Despite their ubiquity, these events can have devastating consequences for clinicians, many of whom find themselves wholly unprepared to manage their ensuing grief and self-doubt. For some, the suicide will precipitate depression, anxiety, burnout, posttraumatic stress disorder, and even suicidal ideation.

Although most clinics and hospitals have explicit protocols for managing suicidal patients, few have created deliberate guidelines for assisting HCPs after a patient suicide, explains Cleveland Clinic psychiatrist Akhil Anand, MD. As a result, providers often find themselves on an “emotional island” in the wake of these events.

Led by Dr. Anand, a new literature review published in Psychiatric Services aims to address the problem by examining the professional and emotional effects of patient suicide on clinicians and assessing the prevalence and availability of postvention support resources.

“This study is a potent reminder of how deeply affecting these situations are for providers,” says Dr. Anand, who lost a patient to suicide early in his career. "I know firsthand how painful and consuming these experiences can be. Those of us in healthcare have a responsibility to mitigate the profound reverberations of these events by understanding how best to meet providers’ needs.”

Eager to understand the effect of patient suicide on HCPs and the availability of formal and informal support networks, Dr. Anand and his team conducted an integrative, systematic review of more than 270 peer-reviewed articles on the topic.

“To our knowledge, this is the most inclusive review of the prevalence and impact of patient suicide across diverse HCPs and practice settings,” says study author Madison Jupina, DO, who participated in the research as a psychiatry resident at Case Western Reserve University. “Our findings make it clear that these events can be quite traumatic, particularly for our most vulnerable colleagues, including trainees and those who are isolated within their system of care.”

Long-lasting repercussions

The reviewed articles highlight the heavy personal and professional toll that patient suicide can exact on providers, says Dr. Anand, 4%-52% of whom were found to be clinically stressed and 3%-14% of whom met the criteria for post-traumatic stress disorder. Common reactions included shock, sadness, guilt, anger and helplessness following a patient’s suicide. Some clinicians also described nightmares, decreased sleep, severe distress, acute grief reactions and existential angst. For as many as 74%, the emotional impact continued for longer than 1 month. In the severest cases, suicidal ideation was reported.

Trainees, providers who identify as female, those in private practice, and those who had a close therapeutic bond with the patient were most vulnerable to severe or prolonged emotional distress. Furthermore, increased despair was reported when an investigation into the suicide was initiated or when a suicide screening had not been performed. Notably, providers who believed that suicide is a human right were less likely to experience severe emotional turmoil than their counterparts.

In many cases, a patient’s suicide prompted significant changes to a provider’s professional practice, including an increased tendency to hospitalize suicidal patients, heightened cautiousness, increased use of consultations, avoidance of or refusal to treat at-risk patients and greater diligence in the keeping of patient records.

Another common finding was decreased self-confidence in the HCP following a patient’s suicide. For some providers, the event prompted a major career change, early retirement or an extended leave of absence. The articles reviewed also described an increased attention to – and anxiety about – the legal aspects of practice and internal performance inquiries or disciplinary proceedings.

Interestingly, 52%–77% of clinicians reported a desire to make more affirmative practice changes following a patient suicide, even using the death as a learning experience. These events reportedly inspired some HCPs to engage in suicide research, seek additional training, use more detailed suicide risk assessments and develop better relationships with their patients. A number of HCPs reported that their clinical teams became more cohesive after the event, holding more regular meetings with open dialogue and an increased emphasis on suicide education.

Finding help

Most HCPs reported feeling that they received sufficient support after a patient suicide, with 83%–100% rating these interventions as helpful. Clinicians appeared to derive greatest comfort from colleagues and supervisors who were willing to share their own personal experiences. Of those surveyed, 42%–94% received training on suicide prevention, yet only 10%–47% received education on what to expect after such an event. Respondents were largely critical of formal support groups, which they felt were focused on assigning blame and scapegoating.

Several benefits were linked to postventions, including better acceptance of the patient’s death and milder emotional reactions. Those who received professional counseling after a patient suicide reported significantly fewer intrusive and hyperarousal symptoms. Conversely, clinicians who received insufficient support had more-pronounced emotional responses and stress reactions.

The study also identified several barriers to obtaining desired support, particularly a fear of judgment. In one study of psychiatrists, only 27% felt they could ask for help. In five studies, respondents explicitly expressed the need for nonjudgmental, stigma-free postventions. Notably, the literature suggests that trainees may receive less support and increased public scrutiny than their more-experienced colleagues and are especially likely to be perceived as unprofessional when expressing strong emotions.

Moving forward

Because so little data exists on how to support HCPs after a patient suicide, the development of best practices is a logical next step, says Dr. Anand.

“I hope professional and regulatory bodies will consider widespread, mandated training and support services – both before and in reaction to patient suicide,” he says. “It’s crucial for organizations to understand that the best way to protect patients and their providers is to develop an evidence-based framework for screening, assessing and mitigating the risk of suicide. Above all, it’s essential to prioritize the creation of a psychologically safe work environment that destigmatizes patient suicide and eliminates fear of blame in the workplace.”

Dr. Anand also emphasizes the utility of informal support systems, which HCPs described as particularly beneficial. He encourages healthcare organizations to provide time off for clinicians to grieve and commune with family and friends and endorses the development of peer-led grief and process groups in the workplace. In addition, he stresses the need for prediction tools designed to anticipate provider distress and burnout.

“When the experience happened to me, it quickly became clear that my residency program wasn’t equipped to provide me with any formalized assistance,” he explains. “This review shows that providers are hungry for this kind of help – and as much as they treasure support from friends and family, most would welcome professional counseling and the opportunity to hear the lived experiences of their healthcare colleagues.”

In the wake of a patient suicide, Dr. Jupina also urges HCPs to ask for – and offer – support.

“I hope our review will empower medical professionals to speak freely about patient suicide and reach out to those who have experienced this unique loss,” she says. “Research shows that even small gestures – like asking a grieving colleague if they’d like to talk – can make a life- and career-sparing difference.”